Medicine Update 2009 (2 Parts) AK Agarwal, DG Jain, Pushpa Yadav, Ashok Kumar
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1Medicine Update 2009: Part I
Editor A. K. Agarwal Executive Editors D. G. Jain Pushpa Yadav
2
For Private Circulation Only
MEDICINE UPDATE
(Part I and Part II)
(Proceedings of Scientific Sessions, APICON 2009, Greater Noida)
Vol. 19, January 2009
Editor: Dr. A.K. Agarwal
© All Rights Reserved.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher.
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Published by
Dr. A. K. Agarwal
President-Elect, Association of Physicians of India,
Chairman, Scientific Committee, APICON 2009
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SCIENTIFIC COMMITTEE, APICON - 2009
A. K. Agarwal
Chairman, Scientific Committee
S. K. Bichile
President, Association of Physicians of India (API)
A. K. Das
Dean, Indian College of Physicians (ICP)
B. B. Thakur
Dean-Elect, ICP
Sandhya Kamath
Honorary General Secretary, API and ICP
Shashank R. Joshi
Honorary Editor, Journal of Association of Physicians of India (JAPI)
N. K. Soni
Organising Secretary, APICON - 2009
Members - Scientific Committee
R. K. Singal
Surendra K. Sharma
Samar Banerjee
Shyam Sundar
Principal Advisors
Y. P. Munjal
B. K. Sahay
Siddharth N. Shah
Members - Advisory Board
S. Arulrhaj
T. Kadhiravan
J.M. Phadtare
Amal Kumar Banerjee
O.P. Kalra
Prashant Prakash
B.R. Bansode
Ulka Kamble
A.N. Rai
Subhash Chandra
Umesh Kansra
Y. Satyanarayan Raju
Anil Chaturvedi
Ram Kapoor
B.B. Rewari
S. Chugh
V.N. Kaushal
Anita Sharma
Naveen Garg
Navin Kumar
N.K. Singh
P.S. Ghalaut
Rajat Kumar
N.P. Singh
Anil Gomber
Sanjiv Maheshwari
Rita Sood
Vinay Gulati
Lt. Gen. S.R. Mehta
Dinesh Srivastava
B. Gupta
Vipin Mendiratta
B.K. Tripathi
B.B. Gupta
Adhip Mitra
Rajesh Upadhyay
Pritam Gupta
Alladi Mohan
A.K. Vaish
Rohini Handa
Ashutosh Mohan
A.K. Varshney
4Medicine Update 2009: (Volume 19, Part I and Part II)
Editor A.K. Agarwal (New Delhi) Executive Editors D.G. Jain (New Delhi) Pushpa Yadav (New Delhi) Associate Editors Ashok Kumar (New Delhi) M.P.S. Chawla (New Delhi) Assistant Editor Sumeet Singla (New Delhi) Principal Editorial Advisors Y.P. Munjal (New Delhi) Surendra K. Sharma (New Delhi) R.K. Singal (New Delhi) Members - Editorial Board Samar Banerjee (Kolkata) S.K. Bichile (Mumbai) S. Chugh (New Delhi) A.K. Das (Puducherry) B. Gupta (New Delhi) Pritam Gupta (New Delhi) Rohini Handa (New Delhi) Shashank R. Joshi (Mumbai) Sandhya Kamath (Mumbai) Rajat Kumar (Canada) Alladi Mohan (Tirupati) Ashutosh Mohan (Ghaziabad) B.B. Rewari (New Delhi) Siddharth N. Shah (Mumbai) N.K. Soni (Ghaziabad) Shyam Sundar (Varanasi) Members - Advisory Board Amal K. Banerjee (Kolkata) Sanjiv Maheshwari (Ajmer) Subhash Chandra (New Delhi) Anil Chaturvedi (New Delhi) Naveen Garg (Lucknow) Vinay Goel (New Delhi) S.K. Goyal (Kota) B.B. Gupta (New Delhi) Navin Kumar (Ghaziabad) A.P. Misra (New Delhi) J.R. Sankaran (Chennai) S.C. Sharma (New Delhi) N.P. Singh (New Delhi) R.S.K. Sinha (New Delhi) Kamlesh Tewary (Muzaffarpur) Rajesh Upadhyay (New Delhi)
5
Medicine Update 2009
(Volume 19, Part I and Part II)
Editor A. K. Agarwal MD, FRCP (Edinburgh), MAMS, FICP, FIACM, FIMSA, FIAMS, FGSI President-Elect., API and Chairman, Scientific Committee-APICON 2009 Chief Consultant, Professor and Head Department of Medicine Post-Graduate Institute of Medical Education and Research, Dr. R.M.L. Hospital New Delhi - 110 001, India Executive Editors D. G. Jain MD (Pune), FRCP (Edin.), FRCP (Ire.), FRCP (Glasg.), FICP, FNCCP (Ind.), FIMSA, FIACM, FCPS Honorary Affiliate Professor of Medicine Manipal University, Karnataka, India Pulmonologist and Honorary Physician, Fortis Jessa Ram Hospital New Delhi - 110 005, India Pushpa Yadav MD, FICP, FIACM Consultant in Medicine and Associate Professor Department of Medicine Post-Graduate Institute of Medical Education and Research, Dr. R.M.L. Hospital New Delhi - 110 001, India Associate Editors Ashok Kumar MD Senior Physician and Associate Professor Department of Medicine Post-Graduate Institute of Medical Education and Research, Dr. R.M.L. Hospital New Delhi - 110 001, India M. P. S. Chawla MD, FIACM Chief Medical Officer Department of Medicine Post-Graduate Institute of Medical Education and Research, Dr. R.M.L. Hospital New Delhi - 110 001, India Assistant Editor Sumeet Singla MD, DNB, MNAMS Deputy Manager (Medical) Air India, Palam, New Delhi - 110 034, India
6
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Medicine Update 2009 (Volume 19, Part I and Part II)
© 2009, AK Agarwal for the Association of Physicians of India (Delhi State Chapter)
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
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7Contributors 19Foreword
“Education is an ornament in prosperity, and a refuge in adversity.”
– Aristotle (300 b.c.)
The Science of Medicine is a continuously progressing and advancing procession unlike other sciences that remain static for long periods, and hence have only jerky progress. Moreover, this wondrous Science of Life - unlike Physics, Chemistry, and other related sciences - does not conform to rigid laws discovered or created by scientists. For example, what proves to be beneficial for patient ‘A’ (e.g., any drug, advice, or regimen) may or may not be beneficial for another patient ‘B’ presenting under similar circumstances and with similar symptomatology. On the other hand, it may turn out to be harmful! This indicates the variance, the vastness, and the depth of medicine, its unlimited flexibility and unpredictability. Consequently therefore, along with this vastness, depth, and flexibility, the knowledge of a clinical scientist has to be equally vast and deep. There are hundreds of instances in the lifetime of every practicing physician when he or she has been baffled by the success or failure in managing a patient. For example, on certain occasions, a patient proclaimed that hopeless has come out as a winner, whereas on the other hand, a patient declared ‘recovered’ today, died the next day. Here, thus, lies the importance of ‘CME - Continuing Medical Education’ programmes, and books like this Medicine Update by the Association of Physicians of India, which I consider as priceless academic gifts for the large army of hard-working internists striving relentlessly to alleviate human suffering.
I believe that medicine - by itself - is neither a science alone nor an art. It is, in reality, a sacred confluence of both. The ‘art’ and ‘science’ have to co-exist simultaneously for the success and advancement of the practice of medicine. Medicine practised alone as a cold science will certainly be a total failure both for the physician and the patient. Likewise, the art of medicine - without the application of updated knowledge, technique, and ability provided by current global advancements in science - will also be a crippling failure.
We learnt long ago that in a large number of diseases the aetiology is multifactorial; some of the factors are obvious, yet some remain elusive, and it is these elusive factors that are responsible for the variance in the course of management and unpredictability in prognosis. Here, the ‘art’ and not the ‘science’ of medicine would play an important role. The art of history-taking, listening carefully to the patient, followed by an artful clinical examination will go a long way in arriving at a proper working diagnosis, management strategy, and prognosis. During history-taking, the physician ‘enters the mind’ of the patient and unravels many a secret. And this is of paramount importance both for the physician and the patient.
“In the sick room, ten cents' worth of human understanding equals ten dollars worth of medical science.”
– Martin H. Fischer.20
Everyday experience tells us that a patient with a ‘positive frame of mind’ responds positively to treatment and has a greater chance of recovery, whereas a patient with a nervous temperament could respond poorly to treatment, and consequently would have lesser chances of recovery. Here, I quote Professor B.M. Hegde, a renowned physician and medical teacher:
“Every disease begins in the mind and ends in the mind.”
How true! Various studies conducted over long periods of time have arrived at the conclusion that from common cold to cancers, every malady is influenced by one's temperament and attitude, i.e., the mind. Moreover, it has been observed that one's sustained and prolonged worries and tensions, over a period of time, take the form of some disease or the other - nervous disorders, cardiopulmonary ailments, diabetes mellitus, degenerative disorders, and many more.
The human nervous system directly affects the hormonal secretions which in turn affect the multitude of biochemical reactions occurring incessantly in the cells which act as messengers that give out and receive signals from different parts of the body. A ‘negative frame of mind’ disturbs all these hormonal secretions and biochemical reactions by damaging the intracellular protein components in the cells’ DNA, thereby causing ‘gaps’ in inter-cellular communications. These unique intercellular communications are essential for the optimal functioning of the human body. In effect, the health of the individual suffers with the interruption of these intercellular links and messages. This whole ‘mind - body’ process is at the root of this unpredictability and variance that we are talking about.
Thus, we have still to go a long way till we discover the cause of a disease, the course it could follow, its management, and its prognosis. Yet, more importantly, if and when we are able to prevent a disease happening, only then will we be able to consider ourselves winners in this mysterious game that nature plays with the human body.
The fascinating world of clinical medicine demands further search and research to arrive at the root of the problems of ill health and disease. It is here that publications like this Medicine Update compiled by India's top brains in medicine are of profound importance. Since the last several years now, API's annual Medicine Update is considered as the flagship of all CME programmes in internal medicine. This flagship has been further polished and brightened by the dedication and concentrated devotion of its captain and editor, the incoming President of the API - Professor A.K. Agarwal - and his indefatigable editorial team. Himself an astute and renowned clinician, Professor Agarwal has organised each chapter very ably, and his selection of the scientific material is indeed praiseworthy. His editoral team comprising Professor D.G. Jain, Dr. Pushpa Yadav, Professor S.K. Sharma, Dr. Y.P. Munjal, Dr. R.K. Singal, and Dr. Sumeet Singla, is among the who's who of Delhi's medical fraternity. They have done a yeoman task in meticulously editing these two volumes with ability and sincerity. This all is reflected in the pages of these precious volumes of Medicine Update. The Scientific Committee of APICON-2009, Dr. Sandhya Kamath (Honorary General Secretary, API), and Professor Shyam Sundar deserve special thanks for their unlimited efforts and support in this daunting task of designing a delectable scientific programme.
The Association of Physicians of India - API, has, over the decades, been at the forefront of medical education activities not only for the benefit of physicians, but the medical students as well. The latest 8th edition of the API Textbook of Medicine published in 2008, is one such shining example. Edited by the dynamic Dr. Siddhartha N. Shah, this book is a must-read for all medical students. I congratulate Dr. Shah, Dr. M. Paul Anand, and their bright team of authors and editors for bringing-out an impeccable textbook of international standards. The monthly Journal of the Association of Physicians of India – JAPI, currently edited by Dr. Shashank R. Joshi, is another reputed and widely read publication.
Finally, a word to our dedicated and worthy teaching fraternity spread-out in medical colleges and institutions throughout 21the length and breadth of our country. Academic success and qualifications make only one-half of the doctor; to complete the other half, equal stress should be laid on the personality, behaviour, and bed-side manners of the student during his/her training period. On clinical rounds, the number of students should be less, so that the teacher can observe in detail and ‘nip in the bud’ there and then, any minor defects of behaviour or examination technique committed by the student while examining a patient. Academics apart, we need medical men and women who should, in addition to their medical expertise, be able to face the day-to-day challenges of a modern, ever-changing society. I feel that a teacher is both a mentor and a guide to students. We need to strive to bring-out the very best in each and every student. For this we have to encourage them to learn by guiding them as much as we can. Also, we must accept the reality that students are going to make mistakes every now and then. Only thus will they learn. We need not always reprimand them or be impolite to them, else they will gradually lose their self-esteem and confidence. We must appreciate that every student is different - each one hailing from a different social, cultural, and economic background. Each student deserves to be heard patiently and treated as a dignified and worthy member of the medical fraternity. Unfortunately, the experiences of medical students in the pre-clinical undergraduate years in India leave much to be desired - I have seen innumerable, intelligent and sincere students utterly disillusioned by the raw and insulting treatment meted out to them in their formative years. I feel that as medical teachers, we need to treat our ‘generation-next’ with due care and courtesy. This issue needs much thought and debate, followed by suitable remedial measures. I have seen that most medical students fear their teachers and are too scared to voice their grievances and all sorts of problems they face in their institutions, for fear of adverse grades in the professional examinations. To the heads of various institutions, my sincere advice is to amplify the facilities provided to medical students - whether in their colleges or living quarters/hostels and mess - and provide a congenial environment for study, research, dignified living, and recreation. The times are changing and now we cannot and should not adopt a complacent approach to the needs of students. Every head of an institution should study the systems and workings of institutions in other countries for a broader outlook towards the needs of the unique world of medical education. More than finances, good systems need a genuine will for effective implementation.
To conclude, I quote Professor Randal Hayes, examiner for the MRCP clinical examinations for over 25 years: “…during professional examinations, medical teachers and examiners should strive to find out what the student knows, and not what he/she does not know.”
We must not forget that as medical professionals - whether medical teachers or practising physicians - we too shall remain students always! Having said all this, I leave you with my thoughts and my best wishes for a successful conference and fruitful scientific deliberations.
“There are two outstanding wonders of God's creation - the starry heavens above, and the mind of man within.”
– Immanuel Kant (1724-1804), German idealist philosopher
Dr. G. B. JAIN
Barnala House
FRCP (Edinburgh), DTM and H (Liverpool), FICP, FICA
867, New Rohtak Road, New Delhi-110 005
Emeritus Physician and Trustee, Tirath Ram Shah Hospital,
Delhi
Founder-Fellow, National College of Chest Physicians (India)
January 15, 2009
Founder-Fellow, International Medical Sciences Academy
22Acknowledgements
In making this project viable, we immensely appreciate the initiative and generosity of the following:
  • Serdia Pharmaceuticals (India) Pvt. Ltd.
  • Grownbury Pharmaceuticals Pvt. Ltd.
  • Micro Labs Ltd.
  • Abbott India Ltd.
  • MSD Pharmaceuticals Ltd.
  • Cipla Ltd.
  • Course Director, AMI Course, Max Heart and Vascular Institute
  • Novo Nordisk India Pvt. Ltd.
  • Ipca Laboratories Ltd.
  • Aristo Pharmaceuticals Pvt. Ltd.
  • Abbott Vascular
  • Boston Scientific International BV
  • Intas Pharmaceuticals Ltd.
  • Sanofi Aventis
  • MASCOT Health Series Pvt. Ltd.
  • Eli Lilly and Company (India) Pvt. Ltd.
  • Johnson & Johnson Ltd.
  • USV Ltd.
  • Pfizer Products India Pvt. Ltd.
  • Novartis India Ltd.
  • Prochem India Pvt. Ltd.
For the elegant typesetting and excellent design of this book, we are highly grateful to Mr. Sanjeev Chaudhry of Initials, E-39, Flatted Factory Complex, Jhandewalan, New Delhi - 110 055, (E-mail: sanjeev.initials@gmail.com)
Finally, we wish to thank our supporting staff – Mr. Yashpal Satmukhi, Mr. Jai Prakash Vashisht, and Mr. Mohan Chand for all the miscellaneous backroom technical help which made our work hassle free.
23Preface
It gives me immense pleasure to present Medicine Update 2009 (Volume 19, Part I and Part II) on the occasion of 64th Annual Conference of the Association of Physicians of India - APICON-2009. There are rapid ongoing advances in internal medicine and it is difficult for most of us to stay abreast of the latest developments. These two volumes endeavour to fill this void. Most of the chapters of this publication are part of the ‘Scientific Programme’ of this conference, whereas the others find a place in this book especially so that a concise, yet clinically relevant text is made available to the practitioners of medicine. Adequate and possible efforts have been taken to minimise the errors.
The main focus of this ‘Update’ is to empower the internist who spearheads the day-to-day fight against disease, thereby strengthening the speciality of ‘Internal Medicine’ in India. The key issues related to internal medicine are discussed in a lucid fashion by the eminent faculty drawn from all over the country and also from overseas. Notable contributors include Professors Surendra K. Sharma, Rajat Kumar, Rohini Handa, Amal Kumar Banerjee, Nihal Thomas, Alladi Mohan, Randeep Guleria, Shyam Sundar, O.P. Kalra, Sanjay Jain, B. Vengamma, Nikhil Tandon, Anil Bhansali, Gautam Ahluwalia, and Lata Bichile. I am also extremely grateful to Drs. M.B. Agarwal, V. Mohan, Siddharth N. Shah, S. Arulrhaj, Shashank R. Joshi, B.B. Rewari, Govind K. Makharia, Keertan Dheda, Jai P. Narain, Gyanendra Sharma, Sameer Mehta, Arun K. Gupta, Yogesh K. Govil, Joseph Tibaldi, and many others for having given their time and expertise generously.
The Editorial Team consisting of Professor D.G. Jain, Drs. Pushpa Yadav, Ashok Kumar, M.P.S. Chawla, and Sumeet Singla have spared no efforts in making this endeavour a success - often yielding to my impossible deadlines.
This book would not have taken the present shape without the guidance, motivation, and inspiration provided by Dr. Y.P. Munjal and the immense day-to-day efforts of Dr. R.K. Singal and Professor Surendra K. Sharma. Both of them have been the pillars of this project. The Scientific Committee of APICON-2009, and all the Governing Body Members of API deserve my sincere thanks for their valuable advice and contributions. Dr. S.K. Bichile, Professors A.K. Das, Sandhya Kamath, B.B. Thakur, Samar Banerjee need particular mention.
Finally, I wish to thank Professor N.K. Chaturvedi, Medical Superintendent of Dr. Ram Manohar Lohia Hospital, Postgraduate Institute of Medical Education and Research, New Delhi, for all the encouragement, motivation and moral support. All the faculty members of Department of Internal Medicine at this institution have in one way or another contributed to make this academic venture a successful and memorable one.
The Editorial Board is pleased to place on record the deep appreciation of Mr. Sanjeev Chaudhry - artist, typesetter, and a close associate - who has worked tirelessly to bring this publication into its present shape. Shri Jitendar P. Vij (Chairman and Managing Director) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, is credited with the superb and expeditious printing of these volumes. I am convinced that these two books will be academically fulfilling as well as practically useful to the physicians, residents, and postgraduates.
Dr. (Prof.) A. K. Agarwal
MD, FRCP (Edinburgh), MAMS, FICP, FIACM, FIMSA,
FIAMS, FGSI
Chairman, Scientific Committee, APICON-2009
President-Elect, Association of Physicians of India