CME INDIA Sunday ECG Academic Each wave on ECG tells a tale so preciseIn pulmonary disorders it adds to our surprise …. By Dr. DURGA PRASAD KHAITANMD (MEDICINE) FCGP (IND) FIAMS (MEDICINE) FICP FICCMD FIACM 70 years old male admitted for cough , fever , breathlessness of 5 days duration ; history of recurrent LRTI; no h/o DM , CAD ; stopped smoking recently ECG findings : Over the limb leadso Lead I sign : isoelectric P being merged with the baseline combined with QRS complex of <1.5 mm and T wave <0.5 mm (also consistent with Schamroth modified lead I sign) o Rightward P axis at +900 Over the precordial leads o Clockwise rotation : R/S <1 in chest leads including V5 and V6 both.o R wave <0.5 mV in lead V6.Discussion : As per Chou’s criteria , two P wave changes (lead I sign + rightward shift of the P wave) and two QRS changes (R/S ratio <1 in lead V5 and V6 + R wave <0.5 mV in lead V6) are in favour of COPD Take Home Low voltage QRS complexIn all limb leads <0.5 mV (5mm) / <1 mV (10 mm) in all the precordial leads Clockwise rotation with pushing of the right ventricle anteriorly and the left ventricle somewhat posteriorly (R/S ratio <1 over the chest leads even upto V5/V6).  Pulmonary hypertension on ECG is reflected as through RVH.  RVH Right axis deviation + R/S ratio <1 in V5/V6 (the most reliable sign) RSR’ or qR pattern in lead V1 with + inverted T waves in right precordial/ inferior leads. The SI, SII, SIII pattern in standard leads I , II and III Right atrial enlargement (RAE) : Indirect evidenceP>0.25 mV (p-pulmonale the most common ECG abnormity) in leads II, III ,aVF / P as a +ve initial wave in V1>0.15 mV.P axis deviation towards the right side over the frontal plane(Normal P axis =00 to 750) Associated arrhythmias Multifocal artial tachycardia is almost pathognomonic of the presence of pulmonary insufficiency. Other arrhythmias are – atrial fibrillation (most common arrhythmia in COPD) , atrial tachycardia , atrial flutter (less often).  Ventricular ectopi observed during sleep in the presence oxygen desaturation.  Miscellaneous ECG findings  Lead I sign (Schamroth’s sign) : Minimum deflection of P-QRS-T in lead I, compared to the other limb leads // Also to note SV1,SV2, SV3 pattern on ECG. Prominent atrial repolarization : sagging of PR segment with somewhat ST segment dragging downward reflects atrial repolarization to be prominent.

Dr Shambo S Samajdar, Tropical School Of Med ,Kolkata: We are humbled to share our today’s article, "The Cosmic Dance of Nataraja: Bridging Neuroscience, Movement Therapy, and Consciousness Research," published on CME India. This piece explores the profound symbolism of Nataraja, the cosmic dancer, as a metaphor for the intricate interplay between movement, consciousness, and neural processes. We delve into how rhythmic patterns in dance can influence neural activity, offering insights into therapeutic applications for various neurological conditions. By integrating ancient wisdom with contemporary scientific understanding, we aim to foster a holistic approach to neuroscience and consciousness studies. We invite you to read the full article and share your thoughts and feedback. Your insights will be invaluable as we continue to explore the intersections of art, science, and human experience.

Useful in Clinical Practice

Shared by Dr Suresh Kumar Infectious disease consultant ,Apollo hospital ,Chennai 🚨 Preventing Ventilator-Associated Pneumonia (VAP) – Key ICU Strategies! 🚑 🔹 Elevate the Head of the Bed (30°-45°) – Simple, effective, and life-saving! 🔹 Strict Hand Hygiene – Essential to stop infections! 🔹 Minimize Ventilator Time – Early extubation reduces risk. 🔹 Oral Care with Toothbrushing – Avoid routine chlorhexidine use. 🔹 Early Mobilization – Movement lowers infection risk. 🔹 Antibiotic Stewardship – Know local AMR trends for better treatment. 🔹 Use Prevention Bundles – Structured care can cut VAP rates by 66%! 🔹 Avoid Routine CHG & Probiotics – Evidence suggests re-evaluating their use. 🔹 Train, Monitor, Prevent – ICU teams play a crucial role! 📢 Spread the word—VAP prevention saves lives!

Proton pump inhibitors (PPIs) are widely prescribed for gastric acid-related disorders but are often overused. Long-term use is linked to potential risks, including fractures, nutritional deficiencies, myocardial infarction, infections, gastric neoplasia, renal impairment, and dementia. While causality is unproven, PPIs should be used only for appropriate indications and durations. Further research is needed to clarify these associations.

Hyperuricemia in Chronic Kidney Disease: Strategies for Management When to treat? CKD and symptomatic hyperuricemia should be offered uric acid–lowering intervention. Consider initiating uric acid-lowering therapy for people with CKD after their first episode of gout. How to treat? Prescribe xanthine oxidase inhibitors in preference to uricosuric agents. Acute gout: Low-dose colchicine or intra-articular/oral glucocorticoids are preferable to NSAIDs. Avoid: Alcohol, meats, and high-fructose corn syrup intake. Recommended: Low-fat dairy, high-fiber, and plant-based diets. When not to treat? Do not use uric acid-lowering agents in people with CKD and asymptomatic hyperuricemia to delay CKD progression. Source: KDIGO 2024 Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease. @anuja_java @NephJC @drniranjanmr2 @priti899

Non Pharmological management hardly discussed in HF This review highlights the importance of nonpharmacologic interventions in heart failure (HF) management alongside standard medical and device-based therapies. It emphasizes the role of diet, exercise, sleep-disordered breathing, mood disorders, and substance use in improving symptoms, quality of life, and reducing hospitalizations and mortality. The article provides evidence-based recommendations on optimizing these factors for comprehensive HF care.

Dr Awadhesh K. Singh, DM endo. Kolkata: Some of the highlights of this article through figures. This article cut neck to neck both molecules head on. Hope you will like it 🙏🏽 @DrAmbrishMithal @AskDrShashank @DanielJDrucker @kamleshkhunti @banshisaboo @singhak_endo

Salt Substitution and Recurrent Stroke and DeathA Randomized Clinical Trial A cluster-randomized trial (SSaSS) in 15,249 stroke patients across 600 Chinese villages found that using a salt substitute (75% NaCl, 25% KCl) vs. regular salt over 61 months led to: 14% lower recurrent stroke risk (RR: 0.86, P = .005), with 30% fewer hemorrhagic strokes. 12% lower mortality (RR: 0.88, P = .003), including 21% fewer stroke-related deaths. 2.05 mmHg lower systolic BP. No increased hyperkalemia risk. Conclusion: A safe, low-cost intervention with significant stroke prevention benefits.

RT @deepduttaendo: Early initiation of SGLT2 inhibitors like Dapagliflozin & Empagliflozin in ACUTE MYOCARDIAL INFARCTION (HEART ATTACK) is…

@singhak_endo @akritimilisingh @kamleshkhunti @AmarPut @DrAmbrishMithal @AskDrShashank @drmohanv @docanoopmisra @docchennai Very interesting and a must read

2025 AACE Clinical Practice Guideline on Pharmacologic Management of Adults With Dyslipidemia This guideline update includes 13 evidence-based recommendations for the pharmacologic management of adults with dyslipidemia focused on patient-important outcomes of atherosclerotic cardiovascular disease (ASCVD) risk reduction.

Dr. Suresh Kumar, ID Specialist, Apollo Hospital, Chennai 🔥 Poll: PrEP vs. PEP in Rabies Prevention ❓Which approach is more effective in preventing rabies? 1️⃣ PrEP (Pre-Exposure Prophylaxis) – Protection before exposure 2️⃣ PEP (Post-Exposure Prophylaxis) – Treatment after exposure 3️⃣ Both – A combined approach 4️⃣ Dog Vaccination – Targeting the source of infection Let us Learn 💰 Cost-Effectiveness of Routine Childhood Rabies PrEP 🌍 Rabies Burden: ~59,000 deaths/year worldwide, India leads (~20,847 deaths/year). 💉 PrEP vs. PEP: Limited PEP access in rural areas; PrEP offers preemptive protection. 📊 Cost-Effectiveness Analysis (ICER – Incremental Cost-Effectiveness Ratio): ICER < $1000/QALY if rabies incidence ≥3/100,000/year & PrEP ≤$5/child. ICER < $500/QALY if PrEP efficacy is ≥50% over 15 years. Even at lower incidence (~0.3/100,000), ICER remains < $3000/QALY. 📈 Decision-Tree Model: Assesses cost, efficacy, and rabies risk. 🦠 Public Health Impact: PrEP should complement PEP & mass dog vaccination 🐕. Most effective in rural settings with poor PEP access. Single-dose PrEP & integration into routine immunization improve feasibility. ✅ Conclusion: PrEP is a cost-effective intervention in high-burden areas and should be considered for childhood immunization programs. 🚀

Anti obesity drug MariTide is administered monthly and 20% average weight loss over 52 weeks appears to be sustainable even after discontinuation of the drug This could be 2025 best bet for obesity? MariTide, developed by Amgen, represents a significant advancement in the field of weight-loss maintenance, particularly due to its unique mechanism of action. MariTide Overview: Mechanism of Action: MariTide is a bispecific molecule that activates glucagon-like peptide-1 (GLP-1) receptors while simultaneously antagonizing glucose-dependent insulinotropic polypeptide (GIP) receptors. This dual action differs from other GLP-1 agonists like semaglutide and tirzepatide, which only activate GLP-1 receptors. Dosing: It is administered monthly via injection, which could be more convenient for patients compared to weekly injections required by other treatments. Efficacy: In clinical trials, MariTide has shown to achieve up to 20% average weight loss over 52 weeks. Notably, this weight loss appears to be sustainable even after discontinuation of the drug, which is a significant point of differentiation from other drugs where weight regain is common post-treatment. Phase III Trials: Amgen is planning to initiate Phase III trials for MariTide, which will further validate its efficacy, safety, and durability for weight loss maintenance. Expert Opinion: Randy Seeley, an expert in obesity treatments, has noted MariTide's potential to maintain weight loss even after treatment cessation.

[07/02, 19:55] Drnksingh: [07/02, 19:57] Drnksingh: Tafamidis, the only approved drug for ATTR-CM, stabilizes transthyretin (TTR) and reduces amyloid formation but remains costly. ATTR-CM, once considered rare, results from TTR misfolding and amyloid deposition, leading to heart failure. Noninvasive diagnostics have increased recognition and driven new therapies. SGLT2 inhibitors in ATTR-CM showed benefits for heart failure symptoms, renal function, and mortality, though randomized trials are needed.

Interesting Finding Sleep deprivation impairs intracellular lipolysis by KynA, leading to lipid droplets accumulation in colon cancer cells. This process ultimately promotes colon cancer liver metastasis. @onco @OncoNetworks @OncoViews Sleep deprivation enhances liver metastasis of colon cancer. Kynurenic acid, a gut microbiota metabolite, is reduced in sleep-deprived mice. Sleep deprivation activates the P4HA2-HIF-1α signaling pathway and promotes lipid droplet accumulation. Kynurenic acid treatment suppresses colon cancer liver metastasis in sleep-deprived mice.