mediscene january 2013

Vol. : 11 Issue : 3 JANUARY - 2013

Ph. : (C) 0261-2760982 Mo. 98253 22298E-mail : [email protected]

We are

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Please do read interesting cases, M.C.Q.S., Medi Cross Words & Chess Quiz.

Born : 17 February 1781 Quimper, France

Died : 13 August 1826 Ploaré, France

Nationality : French

Known for : Invented the Stethoscope

studied medicine in Paris under several famous

physicians, including Dupuytren and Jean-Nicolas Corvisart-Desmarets. Laennec is said to have seen schoolchildren playing with long, hollow sticks in the days leading up to his innovation.[4] The children held their ear to one end of the stick while the opposite end was scratched with a pin, the stick transmitted and amplified the scratch. His skill as a flautist may also have inspired him. He built his first instrument as a 25 cm by 2.5 cm hollow wooden cylinder, which he later refined to comprise three detachable parts.

Alma Mater : CHARITE, PARIS

Born : March 10, 1917

Hartford, Connecticut

Died : April 14, 1984 (aged 67)

Hope Town, Bahamas

Nationality : American

Known for : Nephrology, Kidney TransplantDr. John P. Merrill (left) explains the workings of a then-new

machine called an artificial kidney to Richard Herrick (middle)

and his brother Ronald (right). The Herrick twin brothers were

the subjects of the world's first successful kidney transplant,

Ronald being the donor.

Alma Mater : Peter Brent Brigham Hospital

Harvard Medical School

Ph.: 0261-2429797 Mo. 98241 93588E-mail : [email protected]

- Mo. 98251 13715

- Mo. 98251 27353

- Mo. 98252 68575

- Mo. 98795 19702

- Mo. 93747 16006

- Mo. 98258 74341

Ph.: 0261-2470130 Mo. 98795 38800E-mail : [email protected]

Editor Dr Vinod Shah

Every year we celebrate 26th January and 15th August as Republic Day and Independence

Day respectively, to pay our sincere and honest tribute to our freedom fighters. We celebrate our

national events in various ways. Flag hoisting is a prime event amongst all of them. According to

recent supreme court ruling, every Indian citizen can enjoy their basic right of flag hoisting.

This year also IMA Surat celebrated our Republic Day and during flag hoisting ceremony

hardly 30 to 32 members remained present, most of them being our office bearers, IMA Surat

enjoys a status of having our own zone at IMA state level having membership strength 2265

doctors from different medical fraternity of Surat. What a sad state of affair! This is the scenario

since few years at IMA Surat. Our members enthusiasm is tapering. We demand respect from

citizens of our nation. Question arises how much respect do we have for our nation? How much

genuine efforts are made for betterment of our country & time we spend for national function.

If we introspect at large, flag hoisting ceremony is losing its integrity. It has become only a

government function, where our leading politician attend and care more for their popularity

through media, then the event it self.

Million dollar question we must ask ourselves is, why are we dull, idle, inert, not self

trained and having no patriotic awareness and feeling? Why has our attitude become so

commercial and selfish?

Are we not sincere and sensitive? We attend events where only commercial profits are

calculated and concerned. We compare ourselves with citizens of other countries and we are

proud of our social relations but have we ever compared the higher degree of morality and

enthusiasm of respective nation with our nation? Our graph of patriotism is declining to baseline

gradually. We have not changed ever since 1947 and have forgotten our freedom fighters and

freedom struggle completely.

What have we gained in last more than 68 years of independent India? Answer is clear.

Unemployment, over population, social indiscrimination, injustice, disparity in reservation quota,

corruption and so on. Our political gundaism has become a part of our political set up. We have

surpassed Lakshmanrekha of social limitation, values, virtues, morals, principles, culture and so

on. People with highest negative values enjoys status, position and respect in the society.

We are marching in the era of globalization and internet, but we have lost our morality,

identity, confidence and virtues. Shall we get that confidence back which we had in our mind at the

time of freedom? We Indians love holidays, union activites, leisure hours and gossips are our part

time pleasure. Work less and demand more has become our routine attitude.

Friends wake up now, if we don't wake up we are the losers, be united and set an example of

citizen with principles, virtues, disciplines and patriotism for our future generation. Involve

yourself and motivate others actively, boost up your morale. Remember what J. F. Kenedy said

"Ask not what your country can do for you but ask what you can do for your country." It's is ineed of

the hour. Jai Hind, Bharat Mata ki Jai......

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Vol.: 11 / Issue: 3 / January - 2013 1

Determine to Change : We & Our Nation

President WritesDr Bhupesh Chawda

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ltbtmfth, rvt{gt ztpfxh rbt*ttu, CtdtJttltltt yrm;t;Jt vth rJtatthe hngttu Awk !!! Ntwk CtdtJttlt suJtw fkE Au ? BJtltbttk ;tu Ntwk ytvtKtltu htn ct;ttJtu Au? ytvtKttk 'w&Ft ''obttk yulte Ntwk ntshe ntugt Au ? mtwFt Ntwk yultt vth rltCtoh Au ? Ntwk yultt (CtdtJttlt) Jtdth attjt;twk s lt:te? 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CT Scan yltu yltwctkr"t;t xumx fhtJgtt 48 fjttf nturmvtxjtbttk vtKt htFgttu. ct"twk lttubtojt...!! yltu vttkat r'Jtmt vtnujttk sultu nwk btÉgttu. Jtzejtu btltu Ctuxeltu fÏwk ztu³xh ;tbtu bttk'dtebttk:te WXeltu ytxjtt sj'e vt{tudt{tbtbttk ytJgtt btltu yltu ybttultu Ftqct ytltk' :tgttu. btltu vtKt Ftqct dtbgtwk rbt*ttultu ytxjttu sj'e btGJttlttu ytltk' n;ttu. ctu r'Jtmt vtAe Ftcth vtze fu NtrNtftl;tCttE vtxujtltu attjtw vt{tudt{tbtu ntxo ctk"t :tgtwk. btntJteh ftzegttf nturmvtxjt jtE dtgtt bttu;t rzfjtuh fgtwok. yt"twrltf rJt|ttltu mtthJtth ytvteltu ntxo attjtw fgtwok. ctu r'Jtmt BJgtt yuJtwk fne Ntftgt...... vthk;tw btdts lt attjgtwk ;tu lt s attjgtwk, rJt|ttltu btNtelttu Ftmtuzgtt yltu Ftujt Ft;tbt .....!!! nsw ;ttu btltu Ctuxujtt ;tultwk mbthKt btthtbttk Au yltu ytJtt mtbttatthlttu Jts{Dtt;t btuk yltwCtJgttu f'tat nwk ftatt Ç'gtlttu ntu;t ;ttu....!!! *teswk Ç'gt ctk"t :tt;t!!! Jttkf ftulttu ? ltmtectbttk su jtFgtwk ntugt ;tu :ttgt !!! 21 bte mt'ebttk yuf cttsw su mtkvtqKto mttSu Au ;tultu ;Jtrh;t HtKtu bttu;t!!! ytbttk Ntwk mtbtsJttltwk? CtdtJttltltt yrm;t;Jt rJtNtulte fgtt rJtatthu Jtt;t fhJte? bttltJtwk fu lt bttltJtwk! Ntwk ytrm;tf rJtatthNtu yus lttrm;tf rJtatthNtu Fthtu! yuxjtu fu CtdtJttltltt ntuJtt lt ntuJtt mtt:tu cteB rltmct;t :tE ltmtectlte Jtt;t. ltmtect mtt~ fu ltmtect Fthtct ntuJtwk? yuJtwk fnuJttgt Au, fu ltmtectltu vtw~Mtt:to yltu ftbt vt{;gtulte jtdtlt:te ct'jte Ntftgt Au. ;ttu vtAe ltmtectltu s vttu;ttltwk jtHgt ctlttJtltthltu mtwFt 'w&Ft vtKt ltmtect vth s yJtjtkctu Au ;tuytu nkbtuNtt fthKttu mtt:tu BJtu Au. btGu Au ;ttu CtdtJttltltt yltu mtt:tu ltmtectltt mt:tJtthtlttu ytltk' jtu Au yltu lt:te btG;twk ;ttu CtdtJttlt:te rJt~} ctkz vttufthu Au yltu ltmtectltu ftuMtu Au yltu 'w&Ft yltwCtJtu Au. ;ttu Ntwk CtdtJttlt Au? JtGe vttAe yuf s Jtt;t vth ytJteyu .... btthe YrMxyu CtdtJttlt ntuJtwk yltu lt ntuJtwk ctkltu mtbttk;th Jtm;tw Au vthk;tw yuxjtwk attu²mt Au fu su:te ytvtKtu ytvtKtt BJtltlttu mtkvtqKto ytltk' jtE Ntfeyu Aeyu. yultt vth ct"tw rJt#tmtvtqJtof Atuze 'Eyu Aeyu. yu fhNtu yu mtt~k s fhNtu. yltu f'tat ctw~ :tE vtKt sNtu ;ttu yu f'tat nJtu mtt~k fhNtu s yuJte ̀ }t yltu ytNtt attu²mt ctk"ttE Sgt Au. yu s f'tat BJtlt yltu B'kdteltu attu²mt, mtwYZ yltu btsctw;t Eht't:te mtCth fheltu BJttgt Sgt Au. BJtltbttk ftuEvtKt ftgto ytltk' mtt:tu fheNtwk, mtt:tu Waat "gtugt, mtFt;t vtrh`bt yltu mtkvtqKto;tgt ̀ }t rJt#tmt:te vtqKto fheNtwk ;ttu yubttk CtdtJttlt htB Au yu rJt#tmt fuGJteNtwk. 22 JtMto vtnujtt sgtthu nwk btntJteh ntumvtexjtbttk ICCU bttk lttufhe fh;ttu n;ttu. ;gtthu y;gtthltt suJte mtwrJt"ttltt lttbtu btekzwk n;twk. rJt'uNt:te ftrzogttf ztpfxhlte xebt rNtgttGtbttk ytJtu, ytuvthuNtltlttu mttbttlt vtKt jttJtu ct"tw §ebttk :ttgt. nJtu ytuvthuxeJt ztufxhtultt btwFtu mttkCtGujte Jtt;t ....... ynegttk ftuEvtKt mtdtJtz yt"twrltf lt:te vthk;tw ynekltt ''eoytu bttuxtk ytuvthuNtlt vtAe mttS :tE Sgt Au. ybtthu ;gttk ;ttu mtkvtqKto mtdtJtz;tt ntuJtt A;ttk ftubvtjtefuNtlttu :ttgt Au! Ntwk ynekltt CtdtJttlt s yt ct"ttlte ftGB jtu;tt ntuJtt SuEyu.....!!! ytxjtt JtMttuo vtnujttlte Jtt;t ytsu btltu gtt' ytJte sgtthu btltu ftuEvtKt S;tlte ;tfjteV Jtdth nwk mttbtu:te mttulttudt{tVe fhtJtJtt dtgttu yltu yuf bttuxt xulNtltbttk:te ctnth ytJgttu. ytbttk Ntwk CtdtJttlt y:tJtt ;ttu rJt# vthbtf]vttGwlttu bttht vthlttu ytNteJtto' mtbtsw Awk! su Au ;tu!!! su fhtu ;tu mtJttuo@tbt fhtu! ytltk' :ttgt ;tubt fhtu! cteS rbt*ttultu mtt:tu htFttu! ytvtKte subtltu s~rhgtt;t Au ;tultu bt'' fhtu! mtbttsjtHte ftgttuo fh;tt hntu! su FthuFth BJtltltwk mtwFt Au. ytvt mtJtuo rbt*ttulttu Ftqct Ftqct ytCtth! ;tbttht ;thV:te btGujt vt{ubtltu nwk bttht BJtltlte mtJttuo@tbt Ctux mtbtswk Awk. mtt:tu CtdtJttlt, vthbtf]vttGwk vthbtt;btt, yltu fw'h;tltt frhNbttltu vt{Kttbt mtt:tu mJteft~ Awk. yltu f'tat ftuE dtCthtEltu vtKt rJt#tmt btqfe mJtefth fhu ;ttu fkE dtwbttJtJttltwk ;ttu lt:te s lt:te s...... ctmt ytJtu ;tultu mJtefth;tt NteFtJttltwk Au!!!! SuEjttu vtAe ytltk' s ytltk' !!!

Dear Member Friends,

Greetings from IMA Surat.

I feel happy to communicate with you once again through the official mouth pieace of IMA Surat”

MEDISCENE”.

thThis month we had little deviation from academic CME to non academic seminar. On 20

January,2013 we had seminar on “Finance Management with Health Insurance”. This seminar was

jointly organized by IMA in collaboration with FPA,FWS and SMCA. It was attended by more then th75 delegates. On the occasion of 64 Republic day we had flag hoisting function at the IMA Surat

office. Though it was attended by more then 35 members, friends when large number of

members can turn up to IMA office for the election purpose, why not to salute our national flag? I thwish that in the next flag hoisting function on 15 August at least we shall have presence in three

digits.

In the up coming events we have a CME on Endocrinology,

IMA Surat

I appeal you to join in

large number and make is success.

In the service of IMA Surat.

“Self Defense” training for females-

our members, spouses, daughters etc and a drama show for the entertainment of members,

their family members and to raise fund for IMA Surat. Another upcoming event of IMA Surat

for which I had announced in the previous issue is “ Sports Carnival2013”. The

enthusiastic and able sports committee members are working hard to make it most enjoyable

event. The details of the mega event is published in this bulletin elsewhere.

Secretary's reportDr. Digant Shastri

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OBITUARY? Dr. Jivanbhai C. Patel (Pediatrician) passed away for heavenly journey on 19-12-2012

? Dr. S. N. Srivastav (Ophthalmologist) passed away for heavenly journey on 19-01-2013

? Dr. Navinchandra Nagarsheth (Anesthetist) passed away for heavenly journey on 23-01-2013

? Mr. Navinbhai M. Parikh F/O Dr. Sudhir N. Parikh (Family Physician) passed away for heavenly journey on 11-01-2013

? Mrs. Sudhaben P. Choksi M/o. Dr. Bimal Choksi (Dermatologist) passed away for heavenly journey on 21-01-2013

? Hemlataben mother of Dr. Dhiren Mahida Passed away for heavenly journey on 31-01-2013

May their soul rest in heavenly Peace.

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Westerners going to India to do business find out pretty soon that India is a culture where it is absolutely impossible to just drop in to conduct business and then fly away unaffected.

The pace of life, the vivacity of the teeming masses, the mêlée of sounds, the richness of colors and smells, the tenacity of the unpredictable to surface like an ubiquitous spook amidst all attempts on both sides to make business smooth and manageable - all this is India. Trying to understand the astonishing diversity of this ancient yet vibrant culture and yet finding rules for behaving in an effective manner is a daunting challenge for anyone.

In India you would discover thriving matriarchal societies, a group of people utterly convinced that they are one of the lost tribes of the Jews, signs of democratic forms of governments 2000 years before the Athenians, aboriginals who shun `civilization' and shoot poisoned arrows at anyone going near them etc. India is not a monolithic culture but the kaleidoscopic variety also contains underlying streams of unity. One mentor gives you a valuable piece of advice on business etiquette and then you notice that people behave exactly the opposite in some contexts.

The first thing for Westerners to learn about business etiquette in India is:

You need to be sensitive to the context at all times.

Focus of Business

One of the major blunders Western people make in India is to forget people and concentrate on schedule, contracts, results, facts and issues.

Western Business = End Results

Indian Business = Process of Interaction, Relationships

The credibility and trustworthiness of a business partner are critical in securing cooperation so these have to be built up over time.

Orientation to time

West: Time = Scarce commodity

India: Time = Expression of eternity

In India everything takes time. Indian business people like to be on time but in real life things don't work like clockwork. Keep a lot of margin in your schedules for the unexpected events. A Western person likes to concentrate on one thing at a time while his Indian counterpart is poly chronic and attends to many things at the same time. Be prepared for lots of interruptions all the time.

Personal space

Indians keep very small bubbles of personal space around them and there is so much touchy cuddly walking hand in hand behavior all around. However:

1 Men don't touch women in public and vice versa.

Superiors pat subordinates on their shoulders and there is much collegial backslapping. The handshake is practiced everywhere in cities. The traditional Indian greeting is the "Namaste," which you do with hands pressed together, palms touching and fingers pointed upwards, in front of the chest with a slight nod or bow of the head. This has a spiritual basis in recognizing a common divine essence within the other person.

1 Always be polite, although you need to be firm.

1 Never lose your temper, even when it is to your advantage to show anger.

Conversation

All meetings start with some small talk. Indians are very curious and like to exchange views even with total strangers. Be prepared for Indians talking about matters which would be considered an

Business Etiquette in India Compiled by Dr Mitesh Bhatt

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invasion of privacy in the west.

Learn to recognize the "NO" as Indians don't say NO directly, unless it is a crucial issue.

Don't point out poverty, dirt, and social ills to Indians as they might interpret it as condescending coming from a foreigner. Indians are proud of their rich history and appreciate intelligent discussions with mutual respect, so avoid preaching about democracy and women's rights etc.

Addressing others

Indian businesses are hierarchical. Titles such as Mr, Mrs or Professor are used almost always unless the other person asks you to go on a first name basis.

Get used to people always calling you Mr this or Madam this or saying "yes, Sir" or "yes, Madam" all the time.

Find out how you should address the other person - naming and addressing practices vary across the country.

Giving Gifts

Gifts are not opened in the presence of the giver. If your Indian host insists on your opening the gift, do so and show appreciation for his/her choice. If you are invited to an Indian home for dinner, take some small gift, like a box of chocolates or flowers or a gift for the children (if they have any). Wrap in red, yellow, green or blue colored wrapping paper. White and black colors in wrappings are considered inauspicious. A small gift from your culture or a framed photograph with the host or colleagues would be valued as a gift. If your Indian host drinks and keeps alcoholic drinks at home, a bottle would be an appreciated gift.

Meetings and Negotiations

Meetings and negotiations are spaced over time and there are many digressions. Give background information such as who is involved, who else has implemented such a proposal or who higher up has endorsed - Indians understand matters in their overall context and such information is vital for them. Don't get nervous over frequent interruptions, digressions or bargaining in negotiations. Keep buffers, which you can cut in your offers as Indians interpret fixed offers as inflexible thus unsuitable for their needs. Don't expect quick commitment as all decisions take time and may involve people not present in meetings.

Business Dress

Business attire varies in different parts of India. Decency and decorum is the guiding principle here. It is better to dress slightly more conservatively than too casually. In India position in the hierarchy of business dictates formality of dress. Use common sense in dressing

Visiting Cards

The visiting card ritual is not so formal as in China or Japan but you should always carry decent and presentable cards with you. Cards in English are fine. You don't need to print them in local languages.

Never use the left hand to give and receive cards.

Appointments

Appointments must be fixed well in advance. Always confirm beforehand to make sure nothing has changed meanwhile. Traffic is always unpredictable so leave a lot of margin. Be prepared to be kept waiting when visiting government officials.

Invitations

Foreigners visiting India might receive many social invitations. A direct refusal to an invitation (e.g., "Sorry, I can't come.") would be seen as impolite or arrogant.

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Use "I'll try" or "I will confirm with you later," etc. when declining social invitations.

When refreshments/ snacks or beverages are served, it is customary, though not compulsory, to refuse the first offer, but to accept the second or third. Accept what is offered to you even if you don't want to eat or drink everything. Leave some on the plate or all of it untouched. If you eat all, it is a sign you want more.

What people consider taboo in food or drinks varies greatly among people in India:

Generally Muslims don't eat pork and Hindus shun beef.

Chicken, mutton or fish suit most people.

All vegetable menus are safer choices for everyone.

Be very sensitive to customs and preferences when hosting invitations.

Never use your left hand for eating, serving, or taking food or in fact handing over or accepting things. The left hand is considered the toilet hand and thus taboo.

IMA SURAT SPORTS CARNIVAL

DATE:th17 Feb 2013

To th24 Feb 2013

VENUE:

Civil Hospital

Ground

(PLAYERS ARE ONLY ALLOPATHIC DOCTORS)

Match fees : ` 251 per teamKNOCKOUT TOURNAMENT

3 SETS MATCH

EACH SET : 15 POINTS

TIME : 08:00 PM TO 12:00 MIDNIGHT

YL

VOLLEBA

LI

ECR CK

TMatch fees : ` 501 per teamKNOCKOUT TOURNAMENT

TENNIS BALL MATCH

BL TENNIS

TAE

Match fees : ` 51 per team

KNOCKOUT TOURNAMENT

SINGLE PLAYER MATCH ONLY1 SET MATCHEACH SET : 21 POINTSTIME : 06:00 PM TO 12:00 MIDNIGHT

th

B

24 FE 2013

FIL

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CRICKET :st

1 SEMIFINAL : nd 2 SEMIFINAL :

FINAL : VOLLEY BALL FINAL :

TABLE TENNIS FINAL : PRIZE DISTRIBUTION :

08:00 AM TO 10:00 AM11:30 AM TO 01:30 PM03:00 PM TO 05:00 PM 05:30 PM TO 06:30 PM06:00 PM TO 07:00 PM07:00 PM TO 09:00 PM

DINNER : 09:00 PM ONWARDS

OVERS :: GROUP MATCH : SEMIFINAL & FINAL MATCH :

POWER PLAY :: GROUP MATCH : SEMIFINAL & FINAL MATCH :

12 OVER 16 OVER 4 OVER 5 OVER

DR CHANDRESH JARDOSH - 98791 32526

DR HIREN MAKWANA - 99795 80681

DR DIGANT SHASTRI - 98795 38800

DR HIRAL SHAH - 98251 06352

CONTACT

TIME : 06:30 AM TO 06:30 PM

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IAP IMMUNISATION SCHEDULE

6 Polio : [1] All doses of IPV may be replaced with OPV if former is unaffordable /unavailable.[2] additional doses of OPV on all supplementary immunization activities (SIAs).[3] Two doses IPV instead of 3 for primary series if started at 8 weeks and 8 weeks interval between

the do6 Rotavirus : 2 doses of RV-1 and 3 doses of RV-5 (1st dose to be started before 15 weeks, last dose to be g i v e n

before 32 weeks.)6 Typhoid : Typhoid revaccination every 3 years, if Vipolysaccharide vaccine is used.6 Varicella : The 2nd dose can be given at anytime 3 months after the 1st dose.6 HPV : Only for females, 3 doses at 0, 1-2 (depending on brands) and 6 months.6 *Influenza : 1st dose after 6 months of age and 2nd dose at 1st month interval and then 1 dose once a year.

(In a special circumstances as per advice by doctor.)

Age(Completed

Weeks / Months / Years)

Vaccines Due Date Given On

Birth

6 Weeks

10 Weeks

14 Weeks

6 Months

7 Months

9 Months

12 Months

15 Months

16 to 18 Months

18 Months

2 Years

4.5 to 5 Years

10 to 12 Years

BCG / OPV 0Hep-B1

DTwP 1/ DTaP 1IPV 1 / Hep-B 2

Hib 1 / Rotavirus 1PCV 1

DTwP 2/ DTaP 1IPV 2 / Hep-B 2

Hib 2 / Rotavirus 2PCV 2

DTwP 3/ DTaP 3IPV 3 / Hib 3

Rotavirus 3 / PCV 3

OPV 1Hep-B-3 / Influenza 1 *

Influenza 2 *

OPV 2Measles

Hep-A-1

MMR 1 / Varicella 1

PCV Booster

DTwP B1/DTaP B1IPV B1 / Hib B1

Hep-A-1

Typhoid 1

DTwP B2/DTaP B2OPV 3 / MMR 2

Varicella 2 / Typhoid 2

Tdap / TdHPV

Vaccination Wizard Compiled by Dr Nirmal Choraria

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Acute lower limb Deep Vein Thrombosis (DVT): Changing Concepts in Treatment

Indians were once believed to be affected very rarely by this dreaded problem of DVT.

However, over the past 10 15 years, numerous studies have found that DVT is a common

occurrence in our Indian patients. Another peculiar finding is that in our country, we often

encounter idiopathic acute extensive lower limb DVT in young, otherwise healthy people.

According to pooled data from multiple vascular centers across India, 10 20 % of patients of DVT

belong to this group.

These young and mobile patients with DVT have no other obvious risk factor for DVT. The

thrombus involvement is also extensive often involving iliac, common femoral, superficial

femoral, popliteal & tibial veins. Hematologic work up can identify thrombophilic

(hypercoagulable) state in many of these patients.

Till recently, heparin or low-molecular weight heparin (LMWH) followed by oral

anticoagulation using Warfarin was considered the only treatment option. Despite using the same

treatment methods, the response to treatment is noted to be significantly different in patients. A

large majority of these young patients with DVT end up with persistent swelling of limbs. In the

long term, post-thrombotic syndrome (edema, pigmentation, ulcers, lipodermatosclerosis) would

be detected in more than 50 60 % of these patients due to chronic thrombosis of veins or

associated valvular damage within the veins and incompetence or reflux of blood.

Worldwide, vascular specialists dealing with acute DVT and its acute as well as chronic

problems evaluated newer methods to improve vein recanalisation and also reduce the

occurrence of vein valve damage and thus the incidence of post-thrombotic syndrome. Catheter

directed treatment methods are now considered to be most effective in achieving these goals.

The method of treatment is as follows:

1. Ultrasound/ doppler guided access (puncture) of popliteal or posterior tibial vein.

2. Placement of large sheath (7 or 8 Fr) in to the vein.

3. Thromboaspiration of thrombus material from the vein by guiding catheter.

4. Venography to detect residual thrombus

5. Placement of multi-hole infusion catheter within the thrombosed vein segment &

infusion of thrombolytic agent ( Urokinase/ rTPA) for 12- 36 hours. (Regional

thrombolysis)

6. Check Venography at 12/ 24/36 hours to confirm dissolution of thrombus & vein patency.

7. If there is vein stenosis/ narrowing noted in common iliac vein or IVC, angioplasty with

stent placement may also be required.

8. After procedure is over, switch over to LMWH & Warfarin.

The rationale behind this modern treatment method is that “Heparin is only an anticoagulant- it

can prevent thrombus propagation, but it cannot lyse or dissolve established thrombus”. Hence

Dr Sumit Kapadia (MS, DNB, MRCS), Vascular & Endovascular Specialist

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the eventual response to treatment of DVT depends not on the medicine, but the body's own

fibrinolytic system to dissolve the thrombus. Catheter directed removal of thrombus & infusion

of thrombolytic agent regionally would aid in better recanalisation of thrombosed vein.

Newer technical advances for catheter directed treatment methods which would be

available in India by the next year include Mechanical thrombectomy devices to pulverize the

thrombus and ultrasound enhanced thrombolysis to ensure maximum penetration of

thrombolytic agent within the thrombus.

We have an experience of managing DVT by catheter directed methods in 42 patients over the

past 3 years. Our early results have shown that adequate recanalisation (more than 75 % of

thrombus clearing) had been achieved in 37 patients (88 %). Also, we noted that iliac vein stenosis

or narrowing or occlusion was present in 12 patients (28 %). These patients underwent

angioplasty with stenting to treat these stenoses. Long stents were required in 3 of these patients.

Another noticeable finding is that we have used IVC filters very selectively only in 3 patients who

had evidence of large floating thrombus in iliac vein or IVC. So despite the assumption that

pulmonary embolism would be very common in DVT interventions, we found that the occurrence

is fortunately rare. We also noted reoccurrence of thrombosis in 2 patients with stents and both

were managed by re-treatment by aspiration & thrombolysis.

So, in summary, newer management methods for DVT aim at regional catheter based

techniques to achieve better early & late results. These methods should be increasingly

considered for young, mobile patients who wish to live a better and active life ahead. Vein

angioplasty and stenting may also be required in 20 30 % of these patients who have vein

stenosis or compression (May Thurner syndrome)

These results have been presented at Vascular Society of India Annual Conference and VIVA

(Vascular & Interventional Vascular Advances) 2012 at USA.

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Erectile Dysfunction : Who, When, What TreatmentSIGNIFICANCE OF THE CLINICAL PROBLEM

Erectile dysfunction (ED) the persistent inability to obtain or maintain an erection satisfactory

for sexual intercourse is a common clinical condition. Estimates of prevalence of ED in US adult

men range from 10 to 20 million men, or up to 50% - of men age 40 or older. As age is probably

the strongest risk, factor for ED, the prevalence of ED can be expected to increase as the

population ages. ED also associates with diabetes and other cardiovascular risk factors. thus

endocrinologists will likely see a population of men enriched in the prevalence of ED The

relationship between hormonal disorders, particularly hypogonadism and ED is controversial

Endocrinologist will likely see men with ED referred for evaluation of "low normal" or "mildly

low" testosterone replacement therapy. Given the high prevalence of this condition, it is

important that physicians follow a rational approach in the evaluation of ED in order to avoid

excessive, unnecessary and expensive testing and inappropriate therapy.

While not all men with ED desire treatment. Many do. In some instances, ED may be the

complain that first brings an adult man to medical attention. thus providing an opportunity to

screen tor important conditions that associate with ED particularly hypertension, cardiovascular

disease, diabetes, smoking and hyperlipidemia.

There are a number of therapies for the treatment of ED While most men with ED who desire

treatment will be candidates for one or more therapies there are risks and costs associated with

treatment. Therefore, it is important that physicians who are evaluating men for ED have an

understanding these treatment options and issues.

BARRIERS TO OPTIONAL PRACTICE

Although there has been a marked change in the openness in US society regarding issues of

sexuality and sexual function over the past decade, some patients and physicians may remain

uncomfortable or hesitant to broach this subject. There is also a lack of strong evidence based

medicine to guide physicians in the areas of appropriate evaluation of men with ED and

therapeutic options, particularly as related to long term efficacy and outcomes.

LEARNING OBJECTIVES

As a result of participating in this sessions, learners should be able to:

1. Identity major risk factors and medical conditions associated with erectile dysfunction.

2. Formulate a rational and appropriate plan for the clinical evaluation of men presenting with a

complaint of erectile dysfunction.

3. Understand the options for treatment of erectile dysfunction.Erectile Dysfunction(ED): the

persistent inability to obtain or maintain an erection satisfactory for sexual intercourse. ED=low

libido=ejaculatory disorders(i.e. premature ejaculatior, anejaculation)=anorgasmia.

I. Epidermiology

Estimate appear stable over time : 1970's

15% men average 40: 1990's national Health & Social

Life Survey, 10-20% in men age 40-60; Mass Male Aging Study (MMAS) -25% moderate impotence,

10% complete impotence in men age 40-70. Common risk factors:

Compiled by Dr Ajay JainEndocrinologist

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! AGE (MMAS moderate or complete impotence was - 20% at age 40,45% at age 70)

! Diabetes - onset 10-15 yrs earlier compared to men without diabetes

! ASCVD (esp. smokers), HTN (esp.smokers)

! Depression

! Medications - HTN, hypoglycemics, antidepressants (causal vs. associational?)

II. Physiology of erections.

Neurogenic pathways -

! Psychogenic ! Reflexogenic ! Nocturnal (REM sleep)

Dynamics-

! Increased arterial flow. ! Cavernosal smooth muscle relaxation.

! Decreased venous drainage.

Neural mediators -

! Sympathetic - alpha adrenergic mediated smooth muscle constriction - inhibitory,

! Parasympathetic - cholinergic inhibition of sympathetic tone and stimulation of

vascular and cavernosal smooth muscle relaxation via non-ad renergic, non-

cholincrgic (eg, nitric oxide) pathways - facilitative,

III. Pathophysiology

Psychogenic -

! Probably minority of cases (10-30 %)

Organic-

! Vascular: atherosclerosis (smoking, diabetes, heart disease, hypertension,

hyperlipidemia), trauma, pelvic surgery, radiation, medications.

! Neurogenic: spinal cord lesions, diabetes, trauma, pelvic surgery, central

mechanisms (Parkinsonism, stroke, chronic disease), medications.

! Cavernosal (venous leak): aging, diabetes, atherosclerosis, smoking, Peyronie

disease, trauma, congenital.

STRATEGIES FOR DIAGNOSIS HISTORY -

Diagnosis of ED is primarily based on history; there is no gold standard diagnostic test. Elements of

the history to consider include: nature of the problem - lifelong/acquired, problem obtaining

erections, maintaining, both; pain with erections, penile curvature; chronicity -

chronic/progressive vs. acute; history of known risk factors or symptoms of

unrecognized/undiagnosed risk factors (e.g. symptomatic diabetes, heart disease, peripheral

vascular disease, cerebrovascular disease, depression, neurologic disease); symptoms of clinically

significant endocrinopathy - esp. hypogonadism (e.g. decreased libido, change in beard/ body

hair, breast development, fertility history); history of pelvic/penile trauma or injury; relationship

Life Survey, 10-20% in men age 40-60; Mass Male Aging Study (MMAS) -25% moderate impotence,

10% complete impotence in men age 40-70. Common risk factors:

! AGE (MMAS moderate or complete impotence was - 20% at age 40,45% at age 70)

! Diabetes - onset 10-15 yrs earlier compared to men without diabetes

! ASCVD (esp. smokers), HTN (esp.smokers)

Physical exam - Particular focus on: signs or evidence of undiagnosed cardiovascular risk factors,

such as blood pressure, cardiac exam, peripheral pulses: signs of neurologic disease; signs of

androgen deficiency female habitus, loss of hair in androgcn-dependent areas, gynecomastia,

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small testes; penile exam fibres is/plaque.

Laboratory - May not be necessary for men up to date on routine screening for diabetes, lipids. For

other men, appropriate screening for diabetes, cardiovascular risk factors (Ale or fasting glucose,

lipid panel); if clinical suspicion for renal or liver disease, creatinine and/or liver function tests, as

this may influence treatment decisions or medication dosing. If clinical suspicion of

endocrinopathy based on history or exam - e.g. hypogonadism, thyroid dysfunction - total

testosterone, TSH.

Exercise testing - Consider in men with symptoms of unstable or exertional angina who might be

at risk for cardiac is chemia during the physical exertion of sexual activity (2-5 METS). Men who can

exercise to 5-6 METS are at little risk for ischemia during sex.

The above evaluation is Likely sufficient in most cases, especially for middle-aged or older men

with conventional history and risk factors.

Optional - Non-invasive testing - nocturnal penile tumescence testing via portable home monitor

or formal sleep lab.

Invasive testing - duplex ultrasound before/ after penile injection of vasodilator (eg, PGE,),

cavernosometry/ cavernosography, arteriography).

Rarely necessary: consider in young men, particularly those with significant anxiety desiring

reassurance, medical-legal cases, atypical history such as lifelong ED, history suggesting possibility

of surgically treatable lesion. To be continued.....THERAPY.....

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Name of Scheme Previous No. New Member Total MemberL. M.S. S. S.N. S. S. S.H. S.P. P. S.F. W. S.

22651370704443

10131060

162-124

22811372704444

10151064

White to play and mate in three.

?Rain Corner

Please send your answer to President,

Secretary or Editor before 25-02-2013.

Answer - December, 2012

1.

2.

3.

Q x f7 +

R x f7

Re 8#

Dear IMA friends,

this is the Third CHESS QUIZ exclusive for

IMA Surat members. Those who will send correct

answers for all the issues, from them three Lucky

Winners will get the Prize at the end.

1st Prize Rs. 1001/-,

2nd Prize Rs. 751/-

3rd Rs. 501/-

Dr. Chandresh Jardosh

Congratulation! Himali Munshi got 1st rank in her college (Electronics and Communication, SCET) in 2nd sem

and in whole GTU 5th rank.

! Parth Jinwala son of Dr Jyoti Jinwala and Dr Ketan Jinwala for achieving 1st rank at state level

and 16th rank at international level in national cyber olympiad . Now he is eligible for level 2

examination.

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Vol.: 11 / Issue: 3 / January - 201346

Dear IMA friends,

From this month onwards we are starting CROSS WORDS CONTEST exclusive for IMA Surat members.

Those who will send correct answers for all the issues, from them three Lucky Winners will get the Prize

at the end. 1st Prize Rs. 1001/-, 2nd Prize Rs. 751/- & 3rd Rs. 501/-

Dr. Neeta RanaSMIMER

Medi Cross Words

Answer Medi Cross Words December-2012

1 2 3 4

5 6

7

8 9

10

11

13

12

15

14

18

22

16

17

20

21

19

23

Across

1 the change in the type of adult cells in a

tissue to a form that is not normal for the

tissue

5 pertaining to the ileum and cecum

7 excessiva amt of cholestrol in blood

8 the part of the pharynx that lies above the

level of the soft plate

10 abnormal multiplication or increase in the

number of normal cells in normal

arrangement in a tissue

11 formation of white spots or patches on the

mucous membrane of the tongue or cheek

13 unable to control excretory functions

15 local and temporary deficiency of blood

supply caused by obstruction of the blood

flow to the part

16 pertaining to or compromising the skeleton

and the muscles

17 formation of an area of coagulation

necroses in a tissue caused by local

ischemia

20 a transparent slightly yellow liquid of alkaline

reaction, found in the lymphatic vessel and

derived for the tissue fluid

21 pertaining to the myocardium

23 irrigation or washing out of an organ such as

the stomach or bowel

Down

2 disease of the lymph nodes

3 enlargement of the liver and spleen

4 pertaining to the neurology or the nervouse

system

6 excision of the posterior arch of a vertebra

9 elevated concentration of any or all of the

lipids in the plasma

12 roentgenography of the mammary gland

13 situated between the ribs

14 gliding

16 a mucous membrane

18 no known allergies

19 pertaining to loins

22 Intravenous pyelogram

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Dear IMA friends,

1. This is the CME of IMA- Surat for the year 2012-13. 2. Contestants will have to play the quiz for all the thmonths. 3. The answers should reach to any of the committee members on or before 30 of every month

without fail. Thereafter no entry will be considered. 4. The winner will be the one who sends all the answers

correct at the end of the year. 5. The answers of previous month quiz will be published in the next issue of

Medi-Scene every month. 6. The decision of the Quiz committee will be final and binding to all.

********************************************************************

Quiz 3. January 13

MEDIQUIZ MEDIQUIZ Committee : Dr. Tony Nicholas, Dr. Vijay Shah, Dr. Sonal Chavda

1. All of the following drugs may cause hirsuitism ,except a. Danazoleb. phenytoinc. norethisterone

d. flutamide2 . s t r e p t o k i n a s e a n d u ro k i n a s e a r e

contraindicated ina. intracranial malignancy

b. pulmonary embolismc. A V fistulad. thrombophebitis

3. Gluteus medius is supplied by a. superior gluteus nerveb. inferior gluteus nerve

c. nerve to obturator internus d. nerve to quadratus femoris4. insulin secretion is inhibited by

a. secretin b. epinephrine c. growth hormone d. gastrin5. vitamin K deficiency coagulation factors

includea. II & IIIb. IX & Xc. III & Vd. VIII & XII

6. Which of the following types of patients are not recommanded to have influenza immunization?a. hypertensionb. diabetes mallitusc. CRFd. >65 years of age

7. which of the following one is true for prostate cancer?a. 80%of the patients with cancer have non

aggressive formb. prostate cancer does not spread to bonec. is the 3rd commonest cancer (excluding

non melanoma skin cancer)in mend. PSA testing is effective in screening for

prostate cancer8. 38 years old teacher present with back pain.

which one of the following symptom would indicate a serious pathology and require immediate reference/further assessmenta. pain made worst by movementb. perineal anaesthesiac. aged between 20 to55 years at initial

presentationd. numbness in one leg

9. left sided superior vena cava drain in toa. right atriumb. left atriumc. coronary sinusd. pericardial space

10.patient with s.billirubin 8.0mg/dl & s.creatinine of 1.9 mg/dl is planned for surgery . what is the muscle relaxant of choice in this patient

a. vecuronium b. pancuronium c. atracurium d. rocuronium

ANSWERS : QUIZ-2 :DECEMBER-2012

1. c

2. a 3. d

4. d

5. a

6. c 7. b

8. a

9. a

10. a

mediscene january 2013

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