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Dr K K Aggarwal

Diclofenac associated with increased risk of cardiovascular events

By Dr K K Aggarwal
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Diclofenac, used for the treatment of pain and inflammation caused by arthritis, is associated with a significantly increased risk of cardiovascular complications and should be removed from essential–medicines lists.

It is listed on the EML of 74 countries, increased the risk of cardiovascular events between 38% and 63% in different studies. The increased risk with diclofenac was similar to the COX-2 inhibitor rofecoxib, a drug withdrawn from worldwide markets because of cardiovascular toxicity.

Dr David Henry at Institute for Clinical Evaluative Sciences, Toronto who conducted the review along with Dr Patricia McGettigan at London School of Medicine and Dentistry said that its use is much more common in other non–Western countries.

Science behind Shiva the Neelkanth

By Dr K K Aggarwal
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The blue neck Shiva called Neelkanth symbolizes that one should neither take out the vices or negative emotions nor suppress them. Instead one should alter or modify them.

The blue colour in mythology symbolizes slow poison that includes attachments, anger, greed, desires and ego. Blue neck means to hold on the negative emotions temporarily so that it can be neutralized at appropriate time.

Suppressed anger releases chemicals which can lead to acidity, asthma, angina, future heart attacks and diarrhea etc. Similarly expressed anger can cause social unhealthiness and acute heart disease.

The only way to mange anger is to take the right and not the convenient action. One should neutralize anger by willful cultivation of opposite, positive of different thoughts.

Anger is a known risk factor for heart blockages. Anger can evoke physiological responses that are potentially life threatening in the setting of underlying heart blockages. It has a dominant influence on the severity, frequency, and treatment of angina.

This Vedic message of Shiva is being validated by many western scientists.

Anger has many phases

1. Anger Expression Inventory
2. Assesses anger frequency (trait anger)
3. Anger intensity
4. Anger expression (anger–out)
5. Anger suppression (anger–in)
6. Anger recall.

Both anger–in and anger–out are associated with heart blockades.

a. Dr. C. Noel Bairey Merz, from Women’s Health at Cedars–Sinai Medical Center has shown women who outwardly express anger (anger–out) are at increased risk especially if they also have other risk factors like age, diabetes and high cholesterol levels. The findings are a part of Women’s Ischemia Syndrome Evaluation Study, a multi–center, long–term investigation sponsored by the National Heart, Lung and Blood Institute.

b. Anger–in is also related to severity of blockages. Dr. TM Dembroski in 1985 has shown that potential for Hostility and Anger–In are significantly and positively associated with the heart blockages disease severity, including angina symptoms and number of heart attacks. Suppressed anger is also associated with increased carotid arterial stiffness in older adults, a condition making them prone to future heart attacks and paralysis.

c. In univariate correlational analysis by Anderson DE from National Institute on Aging, Baltimore, Maryland in 2006 has shown a significant positive association of anger–in with artery stiffness.

d. Suppressed anger has also been shown to increase blood pressure by Thomas and group from University of Tennessee.

e. Recall of suppressed anger has been shown by Dr D Jain in 2001 from Yale University to be associated with angina, heart LV dysfunction and rise in upper blood pressure.

f. G Ironson and colleagues from Department of Psychology, University of Miami in 1992 has shown that anger recall produces more stress than the actual stress in a treadmill. Intensity of anger was associated with severity of angina. In the study vasoconstriction only occurred with high levels of anger. There also showed that there was no narrowing of non–narrowed arteries indicating that anger recall produce coronary vasoconstriction in previously narrowed coronary arteries.

IBD linked to heart disease

By Dr K K Aggarwal
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Inflammatory bowel disease is associated with increased risks for stroke, myocardial infarction and ischemic heart disease, particularly in women.

A meta–analysis and systematic review has shown that increased odds for cerebrovascular accidents including ischemic and hemorrhagic stroke –– and for ischemic heart disease according to Siddharth Singh, MD, of the Mayo Clinic in Rochester, Minn., and colleagues.

These risks are specifically elevated in women versus men, with women having a 28% increased odds of cerebrovascular events and a 26% increased odds of ischemic heart disease.

The study was presented in a poster presentation at the American College of Gastroenterology meeting in San Diego.

The Spiritual Meaning of Lord Shiva

By Dr K K Aggarwal
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Most of us worship Lord Shiva without understanding the deeper meaning behind him. In Hindu mythology, Shiva is one of the three forms of God (Brahma, Vishnu & Mahesh).

The Parmatama or spirit or GOD can be equated to a mixture of three forces representing Generator, (Creator or Brahma); Organizer; (Maintainer or Vishnu); Destroyer (Winding up or Mahesh or Shiva).The same three forces are also present inside our body to perform any work, which can be linked to create or generate an idea, maintain or organise the contents of the idea, and then destroy or wind up so that new work can be undertaken through Ganesha – the Lord of new happenings.

For day to day life, one has to understand and implement the principles of Lord Shiva which can be known by understanding the meaning of Shiva.

Shiva is worshipped in the sitting meditating pose, sitting on a deer’s skin at white Himalaya in the background of blue sky. Shiva is also depicted in the form smeared with the ash of graveyard, having a snake on neck, Ganga coming out of his matted hairs, three eyes, blue neck, trishul on one hand and damru on his other hand.

All these symbolic representations have a deep spiritual meaning and tell us about Shiva’s principles of success.

Shiva’s third eye means thinking differently or using the eyes of our mind and the soul. The message is, whenever you are in difficulty, use your intelligence and wisdom or think differently for getting different options. The third eye opening also represents the vanishing of ignorance (darkness or pralaya).

Shiva sitting in an open–eye meditating pose indicates that in day–to–day life one should be calm as if you are in the meditation rose. Calmness in day–to–day practice helps in achieving better results. In allopathic language it is equivalent to mindfulness living.

The snake around the neck represents one’s ego. One should keep the ego out and control it and not let it overpower you. The downward posture of the head of the snake represents that ego should be directed towards the consciousness and not outwards.

The blue neck (Neelkanth) represents that one should neither take the negative emotions out nor suppress them but alter or modify them. The blue color indicates negative thoughts.

The same in the neck indicates that negative slow emotions akin to negative emotions are neither to be drunk nor to be spitted out but to be hold temporarily and with continuous efforts (matted hairs) with cool mind (moon) and with positive thoughts (Ganga) should be directed towards the consciousness keeping the ego directed towards it (sheshnag).

Suppressed anger or any other negative emotions will release chemicals in the body causing acidity, asthma, angina and diarrhea. Expressed anger on the other hand will end up into social unhealthiness.

The ash on the skin of the body of Shiva reminds that everything in the universe is perishable and nothing is going to remain with the person. The message is that ‘you have come in this world without anything and will go back without anything, then why worry’.

The Trishul in one hand represents control of three factors i.e. mind, intellect and ego. It also represents controlling your three mental gunas i.e. Sattva, Rajas and Tamas. The damru, the hollow structure, represents taking all your ego and desires out of the body.

The blue sky represents vastness and openness and the White Mountain represents purity and truthfulness.

If one adapts to Shiva’s principles in day–to–day life, one will find no obstacles both in his routine life as well as to one’s spiritual journey.

On the Shivratri day, the custom is to fast. The fast does not just indicate not eating on that day, but its deeper meaning signifies fasting of all bad things in life like – “seeing no evil, hearing no evil and speaking no evil”. Fasting also indicates controlling the desires for eating foods (like fermented, sweet, sour and salt) and control the negative thoughts both in the mind, deed as well as actions.

Honey excellent for Cough

By Dr K K Aggarwal
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A spoonful of honey can quieten children’s’ night time cough and help them — and their parents — sleep better.

When compared to the cough syrup ingredient dextromethorphan or no treatment, honey came out on top. As per a study from Archives of Paediatrics and Adolescent Medicine, the results are so strong that one is able to say that honey is better than no treatment and dextromethorphan was not. There is currently no proven effective treatment for cough due to an upper respiratory infection like the common cold. While dextromethorphan is widely used, there is no evidence that it works, and it carries risks.

Honey is used around the world as a home remedy for cough, and might provide a safe, effective alternative to cough medicine. To investigate, the researchers compared buckwheat honey, a honey–flavoured dextromethorphan preparation, and no treatment in 105 children who had sought treatment for night time coughs due to colds. Among the three groups, children given honey had the greatest reduction in cough frequency and severity, and the most improved sleep, as did their parents. Its sweet, syrupy quality may be soothing to the throat, while its high antioxidant content could also be a factor. Honey also has antimicrobial effects. Honey is not recommended for infants younger below one year of age because of the risk of botulism spores.

Should doctors detach themselves?

By Dr K K Aggarwal
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In dealing with patients the traditional Patient–Doctor relationship model has been that doctor should remain cool, calm and collected at all times.

Doctor’s approach needs to be strictly scientific, logical, objective, methodical precise and dispassionate. This model has been since the era of William Osler, the father of modern medicine. The term used is imperturbability which means coolness and presence of mind under all circumstances.

Osler said a rare and precious gift to doctor is right of detachment. The right of detachment insulates the doctors and protects them from the powerful emotions that patients display in their presence like anger, frustration, grief, rage and bewilderment. It also insulates patients from the rolling emotions that doctors may at times feel towards them.

However, a detached attitude also insulates doctors from empathizing with patients. A detached doctor may talk in a language that is over patient’s head.

Detachment is not like a light switch that you can turn on and off to suit the situation. Detachment as a practice cannot be in isolation if it becomes your personal style of distracting from the world, it may not be just for the patients but also from your colleague, family friends and even yourself.

I recall when I joined by hospital the first lesson given to me by my boss was not to get unduly attached with patients. As etiquette, we were taught not to socialize with patients. Even today the new American Guidelines talk that doctors should not socialize with their patients on social media including Facebook. Even doctors are human beings and their personal life should not be known to the patients. As far as law suits are concerned, it is equally true that known close patient’s file a law suit much more than unknown people because over a period of time they know your weakness. One should learn to empathize with the patients and yet be detached from its results. Doctors who follow Bhagwat Geeta understand this concept very well.

Fecal Microbiota Transplantation (FMT)

By Dr K K Aggarwal
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Fecal Microbiota Transplantation (FMT) has emerged as highly effective treatment of C. difficile. FMT as emerged as a highly effective treatment for recurrent C. difficile infection. The transplantation refers to the infusion of a suspension of fecal matter from a healthy individual into the GI tract of another person to cure a specific disease through a colonoscopy. It is based on the concept that stool is a biologically active, complex mixture of living organisms with great therapeutic potential for C. difficile infection. Most patients with C. difficile infection respond to metronidazole, vancomycin but 15–35% may have recurrence. Patients who have one recurrence have 45% chances of a second recurrence, and after a second recurrence, 65% will have a third recurrence. The current treatment of recurrence is additional course of metronidazole, oral vancomycin, or prolonged oral vancomycin. FMT is commonly performed by colonoscopy but doctors have used nasogastric tube or nasoenteric tube, gastroduodenoscopy and enema.

Leverage your strengths

By Dr K K Aggarwal
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• Know your strengths
• According to a British study, only about one–third of people have a useful understanding of their strengths.
• If something comes easily, you may take it for granted and not identify it as a strength.
• If you are not sure, ask someone you respect who knows you well, by noticing what people compliment you on, and by thinking about what comes most easily to you.
• Strengths which most closely linked to happiness are gratitude, hope, vitality, curiosity, and love.
• Strengths are so important that they’re worth cultivating and applying in your daily life, even if they don’t come naturally to you.

Smell check, scratch and sniff, a new test for Parkinson’s disease

By Dr K K Aggarwal
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Olfactory dysfunction presenting as odor detection, discrimination, and identification is a common finding in patients with early non vascular Parkinson’s disease.

As per a study of 2,267 men published in the Annals of Neurology, an impaired sense of smell could be an early indicator of Parkinson’s disease, occurring up to four years before motor skill problems appear.

In the study, decreased odor identification was associated with older age, smoking, more coffee consumption, less frequent bowel movements, lower cognitive function and excessive daytime sleepiness, but even after adjusting for these factors, those with the lowest odor identification scores had a five time greater risk of developing Parkinson’s disease than those with the highest scores.

Nerve loss and the formation of Lewy bodies –– abnormal clumps of proteins inside nerve cells that are thought to be a marker of the disease –– are known to take place in the olfactory structures of patients with the disease.

An impaired sense of smell could also be caused by impaired sniffing, which may be another motor symptom of Parkinson’s.

Early indicators of Parkinson’s disease are olfactory abnormality, constipation and sleep disturbances.

Besides Parkinson’s disease, obesity, diabetes, hypertension, malnutrition, Alzheimer’s disease, multiple sclerosis and Korsakoff’s psychosis are all accompanied or signaled by smell disorders.

Definition of Health

By Dr K K Aggarwal
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Health is not mere absence of disease; it is a state of physical, mental, social, spiritual, environmental and financial well being. All aspects of health are not defined in allopathy.

During MBBS, medical students are taught more about physical health. Social and mental healthcare is covered only in few lectures. Community health is a separate subject but is never given its due importance. Spiritual health is not defined at all and financial health is hardly covered.

Yet, in day–to–day practice, it is the social, financial, spiritual and community health which is the most important during patient–doctor communication. It is incorporated in the four basic purposes: dharma, artha, kama and moksha.

Dharma and artha together form the basis of karma which is righteous earning. You are what your deep rooted desires are. Most of the diseases today can be traced to a particular emotion, positive or negative. Anger and jealously are related with heart attack, fear with blood pressure, greed and possessiveness with heart failure. Unless the mind is healthy, one cannot be free of diseases.

The best description of health comes from Ayurveda. In Sanskrit, health means swasthya, which means establishment in the self. One is established in the self when there is a union of mind, body and soul. Most symbols of health are established around a shaft with two snakes and two wings. The shaft represents the body, two snakes represent the duality of mind and the two wings represent the freedom of soul.

Sushrut Samhita in Chapter 15 shloka 10 defines the Ayurvedic person as under:

Samadosha, samagnischa,
Samadhatumalkriyah,
Prasannatmendriyamanah,
Swastha iti abhidhiyate.

From Ayurvedic point of view, for a person to be healthy, he⁄she must have balanced doshas, balanced agni, balanced dhatus, normal functioning of malkriyas and mind, body, spirit and indriyas full of bliss and happiness.

Human body is made up of structures (Kapha) which have two basic functions to perform; firstly, metabolism (pitta) and movement (vata). Vata, pitta and kapha are called doshas in Ayurveda. Samana dosha means balance of structures, metabolism and movement functions in the body. Agni in Ayurveda is said to be in balance when a person has normal tejas and a good appetite.

Ayurveda describes seven dhatus: rasa, rakta, mamsa, medha, asthi, majja, shukra and they are required to be in balance. They are equivalent to various tissues in the human body.

Ayurveda necessitates proper functioning of natural urges like urination, stool, sweating and breathing and that is what balance in malakriya means.

Ayurveda says for a person to be healthy he⁄she has to be mentally and spiritually healthy, which will only be possible when his or her indriyas are cheerful, full of bliss and devoid of any negativities. For indriyas to be in balance, one has to learn to control over lust and desires, greed and ego. This can be done by learning regular pranayama, learning the dos and don’ts in life, living in a disciplined atmosphere and learn to live in the present.

Regular pranayama shifts one from sympathetic to parasympathetic mode, balances the mind and thoughts and helps in removing negative thoughts from the mind. For living a disabled life one can follow the yama and niyama of yoga sutras of Patanjali or dos and don’ts taught by various religious gurus, leaders and principles of naturopathy.

Living in the present means conscious or meditative living. This involves either learning meditation 20 minutes twice a day or learning subtle mental exercises like mind-body relaxation, yogic shavasana, self–hypnotic exercises, etc.

According to Yoga Sutras of Patanjali, a person who eats thrice a day is a rogi, twice a day is a bhogi and once a day is yogi. The take home message is: to live more one has to eat less.

Swar yoga defines the importance of respiration and longevity. According to this yoga shastra, everybody has a fixed number of breaths to be taken during the life span. Lesser the number a person takes in a minute more is the life. It also forms the basis of pranayama, which is nothing but longer and deeper breathing with reduced respiratory rate.

To be healthy one should follow the principle of moderation and variety in diet and exercise, regular pranayama and meditation and positive thinking.

Carbohydrates as substitute to saturated fats not the answer

By Dr K K Aggarwal
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More than 20 prospective studies have addressed components of diet and the risk of heart disease.

The type of fat consumed appears to be more important than the amount of total fat.

Trans fatty acids increase risk of heart disease while polyunsaturated and monounsaturated fats decrease risk.

There is controversy about whether it is optimal to substitute saturated fats with carbohydrate. An increase in carbohydrate tends to reduce the level of good high density lipoprotein (HDL) cholesterol in addition to total and low density lipoprotein (LDL) cholesterol. Thus, the reduction in heart disease risk may be less than predicted by the reduction of saturated fat alone.

Observational studies have consistently shown that individuals consuming diets high in vegetables and fruits (which are rich in antioxidant vitamins) had a reduced risk of heart disease.

Results of a number of randomized trials are now available and show largely no significant clinical benefits of antioxidant vitamins on heart disease.

Supplemental vitamin C, E, and beta carotene cannot be recommended in the primary prevention of CHD.

Taking supplements without clinical benefits could, in theory, increase the risk if individuals mistakenly avoid therapeutic lifestyle changes or drug therapies with proven benefits.

Why do we light a lamp during pooja?

By Dr K K Aggarwal
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Prayer
|| Deepajyothi parabrahma
Deepa Jyotir Janaardanah
Deepo harati paapaani
Sandhyaa deepa namostute ||

“I prostrate to the dawn/dusk lamp; whose light is the Knowledge Principle (the Supreme Lord), which removes the darkness of ignorance and by which all can be achieved in life.”

Light symbolizes knowledge, and darkness, ignorance. Knowledge removes ignorance just as light removes darkness. The purpose of any ritual is to remove internal darkness and attain knowledge.

Vedic scriptures recommend daily lighting of the lamp as a part of pooja. Some do it once at dawn, others twice a day – at dawn and dusk – and some keep a lamp that is always lit (akhanda deepa). No auspicious function can commence without the lighting of a lamp.

Knowledge is everlasting inner wealth by which all outer achievement can be accomplished. By lighting the lamp, we bow to knowledge as the greatest of all forms of wealth. Knowledge about the self is the greatest wealth. It goes around achieving inner happiness by burning the negativity of a mind that is full of lust and ego.

The traditional oil lamp defines this spiritual significance. The oil or ghee symbolizes our vaasanas (lust, negative tendencies) and the wick, the ego. When lit by spiritual knowledge, the vaasanas get slowly exhausted and the ego too finally perishes. The flame of a lamp always burns upwards signifying that the only that knowledge should be acquired, which takes us towards higher ideals.

All about death by hanging

By Dr K K Aggarwal
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  • Hanging is the simplest and yet highly effective method used by people who commit suicide.
  • It is the most common cause of suicide after poisoning in women and after gunshot injury in men.
  • Hanging accounts for 53% of suicides in males and 39% in females.
  • It has a high mortality rate up to 70%.
  • The materials required are easily available and of wide range and therefore it is difficult to prevent.
  • Hanging can be suspension hanging or drop hanging.
  • Suspension hanging is hanging of the body by the neck and drop hanging involves calculated drop to break the neck.
  • In suspension hanging, a person takes 10 to 20 minutes to die resulting into a painful death. Materials used are rope, bed sheet, shoe laces, telephone extension cables, thread of the chairs/mattresses.
  • Suspension hanging causes compression of carotid artery, jugular veins and the airway.
  • In suspension hanging, 5 kg of pressure is required to compress the carotid artery; 2 kg of pressure is required to compress the jugular veins and 15 kg of pressure is required to compress the airway. Unconsciousness occurs in 5 to13 seconds.
  • Full suspension is not necessary, even with partial suspension a person can die.
  • Near hanging is the term used for those who survive.

All about depression

By Dr K K Aggarwal
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Depression is a major public health problem as a leading predictor of functional disability and mortality.
• Optimal depression treatment improves outcome for most patients.
• Most adults with clinical significant depression never see a mental health professional but they often see a primary care physician.
• A non–psychiatric physician 50% of times misses the diagnosis of the depression.
• All depressed patients must be enquired specifically about suicidal ideations.
• Suicidal ideation is a medical emergency
• Risk factors for suicide are psychiatric known disorders, medical illness, prior history of suicidal attempts or family history of attempted suicide.
• The demographic reasons include older age, male gender, marital status (widowed or separated) and living alone.
• About 1 million people commit suicide every year globally.
• Around 79% of patients who commit suicide contact their primary care provider in the last one year before their death and only one-third contact their mental health service provider.
• Twice as many suicidal victims had contacted their primary care provider as against the mental health provider in the last month before suicide.
• Suicide is the 10th leading cause of death worldwide and accounts for 1.2% of all deaths.
• The suicide rate in the US is 10.5 per 100,000 people.
• In the US, suicide is increasing in middle aged adults.
• There are 10–40 non–fatal suicide attempts for every one completed suicide.
• The majority of suicides completed in US are accomplished with fire arm (57%), the second leading method of suicide in US is hanging for men and poisoning in women.
• Patients with prior history of attempted suicide are 5–6 times more likely to make another attempt.
• Fifty percent of successful victims have made prior attempts.
• One of every 100 suicidal attempt survivors will die by suicide within one year of the first attempt.
• The risk of suicide increases with increase in age; however, young adults and adolescents attempt suicide more than the older.
• Females attempt suicide more frequently than males but males are successful three times more often.
• The highest suicidal rate is amongst those individuals who are unmarried followed by those who are widowed, separated, divorced, married without children and married with children in descending order.
• Living alone increases the risk of suicide.
• Unemployed and unskilled patients are at higher risk of suicide than those who are employed.
• A recent sense of failure may lead to higher risk.
• Clinicians are at higher risk of suicide.
• The suicidal rate in male clinicians is 1.41 and in female clinicians it is 2.27.
• Adverse childhood abuse and adverse childhood experiences increase the risk of suicidal attempts.
• The first step in evaluating suicidal risk is to determine presence of suicidal thoughts including their concerns and duration.
• Management of suicidal individual includes reducing mortality risk, underlying factors and monitoring and follow up.
• Major risk for suicidal attempts is in psychiatric disorder, hopelessness and prior suicidal attempts or threats.
• High impulsivity or alcohol or other substance abuse increase the risk.

Energy drinks may put heart at risk for sudden death

By Dr K K Aggarwal
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Energy drinks may raise blood pressure and prolong QT interval increasing the risk of sudden cardiac death.

In a meta–analysis by Sachin A. Shah at University of the Pacific in Stockton, Calif, with a pooled analysis of 93 people who consumed energy drinks, the QT interval on an ECG was significantly prolonged by 10 ms. The threshold level of regulatory concern is around 5 ms.

In another pooled analysis of 132 people by the same group, researchers found a significant increase in systolic blood pressure by 3.5 mmHg that was associated with the consumption of energy drinks.

Doctors are generally concerned if patients experience an additional 30 ms in their QT interval from baseline. QT prolongation is associated with life–threatening arrhythmias.

Most energy drinks have caffeine. Drinks such as Monster, Red Bull, Rockstar, Full Throttle and AMP have three times the amount of caffeine as colas. A 16–oz. can of Monster Energy, for example, contains 160 mg of caffeine, which is almost as much as 5 cans of soda.