Tuesday, 27 June 2017

IMA stresses on the importance of reviving family physicians

IMA stresses on the importance of reviving family physicians The need is imminent in the wake of a rising shortage of doctors, establishments, and beds in the country New Delhi, 26th June 2017: According to statistics, India has one doctor for every 1700 people against the WHO recommended norm of 1 doctor for every 1,000 people. With a population of more than a billion, India is facing a shortage of doctors, establishment and beds. There are not enough doctors to take care of the health needs of all. Adding to this, is the issue of unqualified quacks who dupe people in the name of medical practice. Research shows that about 80% of the population in India turns to private caregivers and more than 75% of their health care spending is out of their own pocket. All this makes it imperative to bring back the concept of a 'family physician'. Family doctors can help restore the faith of patients in medical professionals, which currently is seeing a downward trend. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "In earlier days, family physicians looked after all the health needs of a family, even many generations of a family, regardless of their specialization. They treated and provided preventive health care to a family as a whole because they were aware of the family history and served as a link between the patient and the specialist. The situation is different today: lack of communication has fostered distrust among patients which is evident in the form of rising litigations or often violence against doctors. The need of the hour, therefore, is to reintroduce the family physician system. They are the first link in health care delivery for the population and play a pivotal role in preventive health, early diagnosis, and timely referral including maintaining health details of all family members." A physician should be aware of the social determinants of health such as the conditions in which people are born, grow, work, live, and age, for good health outcomes. An organized chain of qualified family doctors will help in substantially easing the burden on large hospitals by detecting primary-stage ailments, and reducing cases that require complicated procedures. The society should be educated on the benefits of getting treatment through a family doctor. Adding further, Dr Aggarwal, said, "Family physicians offer several advantages. Some of them are familiarity, trust, and ease of communication. As a result, the patient is more likely to open up about his/her problems and adhere to the treatment prescribed. Family physicians provide a continuum of care at all levels of care, including emergency care. While specialization is required today keeping in mind the medical advancements, the psychological impact of a family doctor on the patients is invaluable, particularly due to the stressful and busy life people lead today." As part of its efforts to update the older lot of general practitioners (aged 45 years and above) with the latest medical advancements, the IMA is already offering a series of continuing medical education programmes with short courses in diabetes, ECG, oncology, etc. to keep them abreast of the latest developments. It is important to encourage more practitioners to undertake the diploma courses in family medicine so that they no longer deal with mundane and routine health issues.

Genesis of medical accidents

Genesis of medical accidents Patient safety is of prime concern in day-to-day practice. But despite, all precautions, medical accidents do occur. Medical accident is an unforeseen or an unintended occurrence. Most medical accidents are preventable. Hence, it is important for us to analyse why medical accidents occur. Several factors contribute to medical accidents. Fatigue, sleep deprivation, poor communication, inadequate preoperative planning are some common reasons for medical accidents. Distraction is another very important factor in medical accidents. Smart phones are a major source of distraction for the operating team in the OTs including the anesthetists or in critical care areas. Doctors may talk and attend to their mobile phones during a surgery and may communicate through a nurse or a junior who works as a bridge between the surgeon and the caller or may check or send e-mails or text messages. Mobile phone distractions adversely affect the performance of the entire team with greater likelihood of accidents that otherwise would not occur. E.g. an accidental injury to the intestine during an appendicectomy. Hands-free phone can be as distracting as talking on a hand-held mobile phone. The role of the navigator or the person who sits in the front passenger seat of a car can be an apt analogy here. It is a rule that he or she should not sleep or talk on the phone but stay alert. Besides navigation, he has to stay awake with the driver, especially on long drives, and also help the driver stay awake. Majority of car accidents are caused by human errors and are a result of distracted driving. It is important to concentrate on the task at hand and not let distractions take away the focus and cloud one’s judgement. Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award, Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

Monday, 26 June 2017

Lack of awareness impediments treatment of Parkinson's disease

Lack of awareness impediments treatment of Parkinson's disease Disease causes 60% to 80% of dopamine-producing cells to become damaged New Delhi, 25 June 2017: According to a report published in the International Journal Of Nutrition, Pharmacology, Neurological Diseases out of every 1, 00,000 people in India, 70 have Parkinson’s disease. What is alarming is that the brain has already lost more than half of its dopamine-producing cells, by the time the characteristic symptoms develop in patients. The symptoms of this disease are so subtle that it can remain undiagnosed for years. Parkinson's disease is a neurodegenerative disorder that is chronic and progressive. It occurs when the nerve cells in the brain stop producing dopamine, a chemical which helps in controlling movement. Dopamine helps in the smooth transmission of messages to different parts of the brain and regulates body movements in healthy adults. When a person develops this disease, about 60% to 80% of the dopamine-producing cells get damaged. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "The main impediment to managing Parkinson's is the lack of awareness about this condition. This disease generally affects those who are above the age of 60 and the risk increases with age. The symptoms can vary from person to person. Some early stage symptoms include very slight shaking of hands, difficulty in walking and/or postural imbalance. The four key motor symptoms of Parkinson’s disease include tremors (hands, arms, legs, jaw); stiffness or rigidity (arms, legs, trunk); slowness of movement; and postural imbalance (poor balance and coordination). This is a progressive disorder but not life threatening. However, people with Parkinson’s disease may be unable to perform daily movement related functions and eventually stop working due to progressively disabling symptoms." Diagnosis of Parkinson's can be done through a 99mTc-TRODAT-1 SPECT scan of the brain. Early detection is very important in minimizing dopamine loss in the brain and maintaining muscle function. Adding further, Dr Aggarwal, said, "While there is no cure for Parkinson's disease as yet, treatment can definitely help people live a good quality life, provided the diagnosis is done at the right time. The decision to start taking medicine, and which medicine to take, varies from person to person." Tips for people with Parkinson's disease • Simplify daily tasks and set realistic goals. • Plan activities such as household chores, exercise, and recreation well in time. Distribute them throughout the day. • Take some rest before and after any activity. • Do not plan activities right after a meal. Rest for 20 to 30 minutes after each meal. • Divide your work among friends and family. Do not hesitate to ask for help. • Get proper sleep and elevate your head when sleeping. Avoid extreme physical activity or lift heavy objects.

Inform your patients before traveling

Inform your patients before traveling The doctor-patient relationship is a sacred relationship. This relationship is initiated when the patient comes to the doctor, who in turn agrees to treat him. This ‘implied contract’ imposes on the doctor a legal duty to exercise due skill and care in providing medical treatment. Once a doctor takes on the care of the patient, he also has a duty to provide continuity of care when he is traveling or is unable to attend to the patient. The ‘fiduciary’ nature of the relationship, one that is based on trust, which the patient reposes in his doctor also places an ethical obligation on the doctor to always put the interests of the patient first. Patients rely on doctors for help in their time of need. Regulation 1.2.1 of MCI Code of Ethics requires that “…Physicians should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion.” So, before you undertake a case, if you are planning a visit out of town or a vacation, you still need to take care of your patients. Communication is the key to developing and nurturing the trust in a doctor-patient relationship. So, if you are going to be away on a vacation or for a conference etc. also convey the same to your patient. Inform them about the duration of time you would be away and the dates of your departure and return. If you have arranged for another physician to take care of your patients in your absence, then share the names, along with his or her credentials and training, with your patients also. This enables the patient to make an informed decision, whether to continue with you as his doctor. Before doing a surgery, the patient must know that you would not be there for his postop care. Take an informed consent of the patient, otherwise avoid doing the surgery. A physician is required to be “diligent in caring for the sick” (MCI Regulation 1.1.2). Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family (MCI Regulation 2.4). Failing to do so might put you at risk for a medical malpractice claim. Dr KK Aggarwal National President IMA & HCFI Dr K K Aggarwal Recipient of Padma Shri, Vishwa Hindi Samman, National Science Communication Award, Dr B C Roy National Award & FICCI Health Care Personality of the Year Award National President IMA Vice President Confederation of Medical Associations of Asia and Oceania Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

Sunday, 25 June 2017

Family physicians are the need of the hour

Family physicians are the need of the hour With a population of more than a billion (~1.32 billion), India is facing a shortage of doctors, establishment and beds. Presently, India has one doctor for every 1700 people against the WHO recommended norm of 1 doctor for every 1,000 people. There are not enough doctors to take care of the health needs of all. This is the time to bring back the age-old concept of ‘Family physician’. Unlike a General Practitioner, a family physician looked after all the health needs of a family, even many generations of a family, regardless of his/her specialization. They not only treat, but also provide preventive health care to the family being aware of the family history and was the link between the patient and the specialist. Considered a part of the family, he was an integral part of all important family functions and events. All in all, he was a ‘friend, philosopher and guide’ of the family. For good health outcomes, a physician has to be aware of the social determinants of health i.e. the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. It is important to know the socio-economic circumstances of a patient, because these influence outcomes. Family physicians address the social determinants of health. Family physicians also offer several advantages; most important are familiarity, trust, and ease of communication due to a long-lasting relationship. As a result, patient is more likely to open up about his problems and adhere to the treatment prescribed. Family physicians provide a continuum of care at all levels of care, including emergency care. Medicine has become highly specialized today leading to isolation among different specialties as well as from patients. Lack of communication has fostered distrust among patients becoming evident as rising litigations or often as violence against doctors. Hence, instead of destroying the family physician system, re-introducing the ‘traditional concept’ of family physician is the need of the hour. They are the first link in health care delivery for the population and play a pivotal role in preventive health, early diagnosis and timely referral including maintaining health details of all family members. Their services can be used on a retainership basis. One of our demands in the Dilli Chalo Movement on 6th of this month was that we need more than 25,000 additional PG seats in Family Medicine. Dr KK Aggarwal National President IMA & HCFI

Timely diagnosis of congenital heart disease imperative for right treatment

Timely diagnosis of congenital heart disease imperative for right treatment About 1.8 lakh babies in India are born with congenital heart disease, which may occur due to genetic factors New Delhi, 24 June 2017: About 8 out of every 1000 children in India are born with a congenital heart disease (CHD) resulting in about 1.8 lakh babies born every year with a CHD. Of these, about 60,000 to 90,000 have critical CHD, which requires an immediate intervention. Children with high-risk CHD can die if not diagnosed in time and this makes early diagnosis extremely important. Some chhildren with uncorrected heart defect may survive into adulthood and require intervention later. Congenital heart disease is a result of a defect in the formation of the heart. Care should be taken to avoid medications or alcohol etc. that are likely to interfere with organ formation in the fetus to lower the risk of CHD. Newborns with critical CHD exhibit symptoms that can be identified soon after birth. However, in some cases diagnosis is not possible till a later time. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said "Certain medications such as retinoic acid for acne, alcohol or drug abuse during pregnancy, and poorly controlled blood sugar in women who have diabetes during pregnancy increase the risk of CHD in the baby. Although the exact cause is not known, CHD may be genetic and get passed down through families. Although not entirely preventable, it is possible for children with CHD to lead active and productive lives with timely diagnosis and the right treatment. Though there is a good success rate for treatments, it is important to diagnose this condition early enough and reach the hospital on time. However, most of the times babies are diagnosed much later and reach the hospital in a critical stage. This reduces the efficacy of treatments." It is possible to detect any structural abnormalities in the fetus, including in the heart, with the help of a level-II ultrasound in the second trimester. Adding further, Dr Aggarwal, said, "It is imperative to make testing for CHD a standard practice in hospitals before babies are discharged. As a part of the efforts to save lives of children with CHD, the HCFI under its flagship project, the Sameer Malik Heart Care Foundation Fund, has saved over 500 lives in the past two years. This fund was initiated towards ensuring that no one dies of a heart disease just because they cannot afford treatment." Though it is not possible to prevent the likelihood of CHD in babies, there are some precautions that mothers can take during pregnancy. • Get vaccinated against rubella and flu • Avoid drinking alcohol or taking drugs • Taking folic acid supplement during the first trimester relatively lowers the risk of giving birth to a baby with CHD or any other birth defects. • Do not take any over the counter (OTC) medication including herbal remedies without consulting your doctor. • Avoid contact with people who have any infection. • Women with diabetes should try and keep the condition under check. • Avoid exposure to organic solvents, such as those used in dry cleaning, paint thinners, and nail polish remover.

Saturday, 24 June 2017

Cellulose-based capsules to replace gelatin capsules

Cellulose-based capsules to replace gelatin capsules Capsules are a very widely used dosage form. They are easy to administer, mask the odor and taste of drugs, which may be unpleasant to some patients. Due to rapid disintegration, the drug is rapidly released in the stomach. Hence, they are a necessary form of drug. However, one aspect that is of concern is their storage. Capsules should be stored in airtight containers and in a cool and dry place to avoid degradation. They need to be protected from light and moisture. Gelatin has been commonly used to manufacture capsules, which is derived from animal sources, including bones. But now, the Govt has recommended a proposal to replace gelatin capsules with vegetable capsules. The sources of these vegetable capsules are plant in origin. In March this year, an Expert Committee was constituted to address all technical issues pertaining to the replacement of gelatin (non-vegetable) capsules with cellulose-based capsules. According to notice from the Directorate General of Health Services (DGHS) office dated June 2, 2017, the proposal is open to suggestions/comments within 21 days. The Bureau of Indian Standards (BIS) has formulated Draft Indian Standards for cellulose based vegetable capsule shells. Hydroxypropyl methyl cellulose (HPMC), most commonly known as hypromellose, is used in the manufacturing of the cellulose-based capsule shell. India is a land of diverse religious and cultural beliefs and traditions. A vegetable alternative should be available. On account of religious and cultural sentiments, patients may prefer the cellulose-based capsules over gelatin capsules. Additionally, personal preferences may influence the choice of the vegetable capsules. We have to respect these choices. Patients should be conveyed that the capsule is non-vegetable. In addition their safety and stability, the most important concern to be addressed is affordability to the patient. If the cost comes out to be the same as gelatin capsules, then the gelatin capsules can be replaced with cellulose-based capsules. But, if these capsules would cost more than the gelatin capsules, then both the options should be made available, leaving it to the patient to choose his preference. Another issue that comes up is the manufacturing capacity. More than a billion capsules are manufactured in India every year. Do we have the production capacity to match and then meet the growing demands? How do we differentiate the vegetable capsules from gelatin capsules? Will they be identified by the green and maroon circles in a square as used on food items? A maroon dot indicates the presence of non-vegetarian ingredients, while a green dot identifies vegetarian food. In May last year, the Drugs Technical Advisory Board (DTAB) had rejected the proposal to label the cellulose-based capsule with green dot to indicate its vegetarian origin to differentiate them from the normally available gelatin-based capsules stating that “unlike food, drugs are not taken by choice but are prescribed by the doctors to save lives and marking them vegetarian or non-vegetarian origin is not desirable”. DCGI is the regulatory authority, which provides the standards and quality of manufacturing, selling, import and distribution of drugs in India. Any drug approved by the Drugs Controller General of India (DCGI) is safe and a quality drug. But, there are issues that need to be addressed. Dr KK Aggarwal National President IMA & HCFI

Lack of awareness about gluten intolerance in India

Lack of awareness about gluten intolerance in India About 10% of the Indian population suffers from this disease, impacting both children and adults New Delhi, 23 June 2017: Consumption of wheat-based products is a common phenomenon in a majority of Indian households. However, if you happen to feel lighter and less bloated by skipping wheat for few days, chances are you may be suffering from gluten intolerance. According to studies, about 10% of the Indian population suffers from gluten intolerance. Research shows that if left untreated, this condition can further lead to a heart disease or even intestinal cancer. Gluten intolerance occurs when gluten, a protein found in wheat, provokes an adverse reaction from the cells lining the stomach. Based on the severity, type, and genomic predisposition of this disease, a person may have a wheat allergy or celiac disease (a condition in which a person is completely gluten intolerant). This condition can impact both children and adults. It can also be passed on genetically if either parent suffers from this condition. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said "Indians mostly perceive gluten insensitivity as a Western disease, one reason why it has never been taken seriously in India. There is also a lack of awareness about this disease due to which it remains undiagnosed for the major part. Gluten allergy, unlike traditional allergies, cannot be pinned down as its onset is gradual with symptoms that may resemble other conditions: headaches, stomach cramps, bloating, anxiety, depression, and so on. Gluten can gradually erode the villi in the small intestine and prohibit the body from absorbing nutrients from food. Unlike olden days, we consume new strains of wheat today and modern hexaploid wheat has highly antigenic glutens, which is capable of introducing celiac disease." According to research, gluten intolerance has also been found to worsen asthma, skin irritation, and rashes, as also affect menstrual cycles in women. It is imperative to recognize these symptoms and opt for a gluten intolerance test in time to prevent future complications like cancer and other chronic diseases. Adding further, Dr Aggarwal, said, "Two genes in the body, DQ2 or DQ8 of the HLA molecules, can help in identifying gluten intolerance or the risk for celiac disease. DNA test analysis can help in improving the understanding of symptoms, their triggers, and food habits that need to be changed to prevent the disease from aggravating. It is a good idea to identify the risk early so that corrective measures can be taken in time and one can live a healthier life with fewer problems." Having gluten intolerance does not mean one cannot enjoy wheat-based product ever again. It is possible to slowly reintroduce several wheat products over time so long as they are not part of the staple diet. Switching to a gluten-free diet is a big change and can take some time for a person to get used to. There are many naturally gluten-free foods which are also healthy and delicious. Some of these include the following. • Beans, seeds and nuts in their natural, unprocessed form • Fresh eggs • Fresh meats, fish and poultry (not breaded, batter-coated or marinated) • Fruits and vegetables • Most dairy products

Friday, 23 June 2017

Adopt a code of conduct while posting on social media

Adopt a code of conduct while posting on social media Recently, Indian Medical Association (IMA) received an email regarding a doctor at Kosmopolitan Charitable Dialysis Center (Mumbai) threatening to "chuck out" Hindu patients and letting them die in a post on social media (Facebook). We asked Team IMA Maharashtra to immediately form a three member committee and visit the dialysis center to find out the details and credentials of Aneeqa Ghani. The said person is not a member of the IMA or registered with the Maharashtra Medical Council. An inquiry needs to be conducted to establish if the person is a genuine doctor or a quack and whether the person is a qualified Allopathic doctor or an Ayush doctor? If not, then in what capacity is she working in the Dialysis center? View IMAGE - http://emedinews.org/2017/122.jpg The matter has been referred to the Maharashtra Medical Council and the Medical Council of India (MCI). Our laws do not allow discrimination on the grounds of religion to anybody and have made it a punishable offence. As doctors, we have a duty to treat all patients equally. Regulation 7.15 of the MCI Code of Ethics Regulations has said as follows: “The registered medical practitioner shall not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of Pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so.” Doctors are expected to abide by the Declaration signed at the time of making an application for registration under the provisions of the Indian Medical Council Act, which says, “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient (d).” Freedom of religion is guaranteed under Article 15 ‘Prohibition of discrimination on grounds of religion, race, caste, sex or place of birth’ and also Article 25 ‘Freedom of conscience and free profession, practice and propagation of religion’ of the Constitution of India. The Indian Penal Code (IPC) also has provisions pertaining to offences relating to religion under Section 153A and Section 295A. Section 153A IPC. “Promoting enmity between different groups on grounds of religion, race, place of birth, residence, language, etc., and doing acts prejudicial to maintenance of harmony. (1) Whoever— (a) by words, either spoken or written, or by signs or by visible representations or otherwise, promotes or attempts to promote, on grounds of religion, race, place of birth, residence, language, caste or community or any other ground whatsoever, disharmony or feelings of enmity, hatred or ill-will between different religious, racial, language or regional groups or castes or communities, or (b) commits any act which is prejudicial to the maintenance of harmony between different religious, racial, language or regional groups or castes or communities, and which disturbs or is likely to disturb the public tranquillity,… shall be punished with imprisonment which may extend to three years, or with fine, or with both.” Section 295A IPC. “Deliberate and malicious acts, intended to outrage religious feelings or any class by insulting its religion or religious beliefs. Whoever, with deliberate and malicious intention of outraging the religious feelings of any class of citizens of India, by words, either spoken or written, or by signs or by visible representations or otherwise, insults or attempts to insult the religion or the religious beliefs of that class, shall be punished with imprisonment of either description for a term which may extend to three years, or with fine, or with both.” Individuals who impersonate as ‘doctors’ endanger the lives of people who trust them with their care. This is why IMA is demanding a stringent Central anti-quackery law and punishment for quacks. As a doctor, such statements violate the spirit of the ethics of the medical profession. Beneficence i.e. for the benefit of others; for doctors ‘others’ means our patients, and nonmaleficence (do no harm) are the basic principles of bioethics that govern the practice of medicine. Regulation 1.1.2 of the MCI Code of Ethics Regulations says, “… Who- so-ever chooses his profession, assumes the obligation to conduct himself in accordance with its ideals. A physician should be an upright man, instructed in the art of healings. He shall keep himself pure in character and be diligent in caring for the sick; he should be modest, sober, patient, prompt in discharging his duty without anxiety; conducting himself with propriety in his profession and in all the actions of his life.” In addition to the legal implications, this story also underscores the importance of etiquettes or adopting a code of conduct while posting on social media. One should refrain from posting personal or derogatory comments on public online platforms such as Facebook. Post any story or comments responsibly using sound judgement. Despite the existence of privacy options, many items published in social media are publicly accessible. Assume that no sites are fully private. Be polite and respectful of others opinions, especially when discussions become heated. Also, be aware that inappropriate conduct can negatively affect your reputation and put you in legal trouble. Before posting any story or comment, always ask yourself “Is it the truth; is it necessary and will it bring happiness to me and the others”. If the answer to any of these questions is no, then do not post it.

Hand washing imperative to prevent infections and diseases

Hand washing imperative to prevent infections and diseases Hand hygiene an important part of infection prevention in hospital settings as well New Delhi, 22 June 2017: According to a recent study, only 53% of the people in India wash hands with soap after defecation. Apart from this, only 38% and 30% wash their hands with soap before eating and preparing food, respectively. Washing hands after a visit to the washroom or before eating is a no-brainer. However, it is also an activity often ignored. Many people even do it wrong without understanding the health risks that contaminated hands can invite. Diarrhoea and respiratory infections are the number one causes for child mortality in India. Research suggests that hand washing with soap can reduce the incidence of diarrhoeal diseases by about 40% and respiratory infections by 30%. Poor hand hygiene is responsible for a plethora of infections and diseases. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said "Poor hand hygiene can cause many other problems as we tend to touch other body parts too with the unclean hands. From common cold to an eye sty, one never knows what damage unclean hands can do to health. Contaminated hands can trigger feco-oral diseases like cholera and typhoid. This is more so during the rainy season when sanitation is poor and there are flies abound. Unclean hands can also lead to gastroenteritis, worm infestations, and jaundice. Hand washing with soap, inside out for about 10 to 15 seconds can guard you against various viral and bacterial diseases."
Unwashed hands are also a significant factor behind the high incidence of hospital-acquired infections. The IMA 5 Moments for Hand Hygiene approach define the key moments when health-care workers should perform hand hygiene. This evidence-based, field-tested, user-centered approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. Adding further, Dr Aggarwal, said, "Hand hygiene is an important aspect of infection prevention and control programmes in hospital settings. It not only prevents patient infection but also reduces an avoidable burden on health systems. All medical practitioners should ensure proper hand hygiene while attending to their patients. Even the nurses, attendants, and other staff working with them should wash their hand before dealing with the patients. This simple activity can help prevent over 50% hospital acquired infections.”
How should you wash your hands? • Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. • Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. • Scrub your hands for at least 20 seconds. • Rinse your hands well under clean, running water. • Dry your hands using a clean towel or air-dry them.

Thursday, 22 June 2017

Thank you, my patients

Thank you, my patients One of the reasons for the widening gap and the mistrust between doctors and patients is the increasing patient expectations. Patients today are aware of their rights – Right to safe medical care of good quality, right to be informed about the their disease and the treatment prescribed, right to ask questions and seek clarifications, right to privacy and confidentiality, among others. They expect the doctors to answer all their questions and want to be equal partners in decisions regarding their care. In addition to the professional care, patients expect their doctors to be compassionate and courteous to them. It may come as a surprise to many but the seeds of the doctor-patient relationship were sowed when the Consumer Protection Act (CPA) was introduced. In this consumer and shop relationship, the patient is “God”. The patient is considered your asset. Every effort must be made to keep the patient happy and satisfied and maintain the relationship. In a survey conducted by the Indian Medical Association (IMA) on expectations of patients from their doctors, a paradigm shift was observed. About 40% of patients expected their doctors to thank them. This is a fact that we need to accept and acknowledge. The doctor-patient interaction is a major factor that influences patient satisfaction. Remember, a satisfied patient will talk about you to 10 more people but an unsatisfied patient will talk to 100 people against you. And the easiest way to get new patients is to look after your existing patients well. Always meet your patients personally, greet them shake hands with them and try to call them by name. And, at the end of the consultation, say Thank you to the patient. This is courtesy. He has trusted you with his health needs. He has reposed his faith in you by selecting you to be his doctor and treat him. So, starting from Doctor’s Day this year, we want our doctors to start saying ‘Thank you’ to their patients. Always strive to improve your CGR (character, goodwill and reputation)... Remember, success in life as a journey and not a destination. Dr KK Aggarwal National President IMA & HCFI

Rotavirus, one of the leading causes of diarrheal infections in India

Rotavirus, one of the leading causes of diarrheal infections in India • Accounts for about 40% of all diarrhea cases • Rotavac introduced to combat the spread of this infection among infants and young children New Delhi, 21 June 2017: Statistics indicate that one of the leading causes of moderate-to-severe diarrhea in India is Rotavirus and accounts for about 40% of all diarrhea cases requiring treatment. More children across India die due to diarrhea than AIDS, malaria, and measles combined. It has also been estimated that India alone contributes to 22% of all global diarrheal deaths in children below 5 years. Among those more vulnerable include malnourished children and those with poor access to medical care. Between 80,000 to 1,00,000 children die in India annually due to Rotavirus diarrhea and another 9 lakh are admitted to the hospital with severe diarrhea. A highly contagious disease, Rotavirus is spread when a child comes in contact with infected water, food, or hands. This is known as the fecal-oral route. This virus can survive for long periods of time on hands and various surfaces. This condition also increases the risk of dehydration in very young children. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Rotavirus attacks the villus tip cells of the small intestine, obstructing digestion and absorption. Once the villi become blunted, the malabsorption of carbohydrates leads to diarrhea. In young infants and children, this infection can further cause severe diarrhea, dehydration, electrolyte imbalance, and metabolic acidosis. The virus is shed in high concentration in the stool of the infected children. They can easily catch an infection by touching something that is contaminated and then putting their hands in the mouth. The risk of infection is more in hospitals and day care settings." Last year, the health ministry launched India's first, indigenous rotavirus vaccine called Rotavac. Developed indigenously under a public-private partnership between the Ministry of Science Technology and the Health Ministry, this vaccine is expected to significantly reduce hospitalization and other conditions associated with diarrhea due to Rotavirus infection. Adding further, Dr Aggarwal, said, "Making this vaccine free of cost is indeed a great move by the government. It is immensely important for the health and well-being of children in the country. Apart from vaccination, it is important to create awareness on maintaining adequate hygiene and sanitation and also ensure access to clean drinking water to avoid any such infections from spreading." Here are some tips to prevent Rotavirus infection from spreading. • Maintain proper hygiene around the house. Clean all surfaces and the floor thoroughly. • Wash your hands after you change the infant's diaper or use the washroom. • Practice food safety at home. • Drink clean water and keep all containers closed.

Wednesday, 21 June 2017

Picture Abhi Baki Hai, Mere Dost…

Picture Abhi Baki Hai, Mere Dost… The “Dilli Chalo” movement organized by the Indian Medical Association on the 6th of this month was a resounding success. The capital witnessed a huge nation-wide participation of doctors. More than one lakh doctors were connected to each other that day and achieved the required critical mass of 1% of collective consciousness. I will here try to elucidate on what is “collective consciousness”. Some of you would be familiar with the term. Consciousness is an energized field of information with powers to do everything in the universe. Collective consciousness is the internet of the collective souls of many people in a group and is the strongest superpower ever available in the universe. As per the Vedic texts, whatever is the intent of collective consciousness will become a reality. Scientifically speaking, collective consciousness is based on the principle of critical mass, which is 1% of the defined population under study. The origin of the critical mass comes from “100th monkey phenomenon”. “Long ago in Japan a monkey called Emo used to eat dirty apples everyday picked up from the ground. One day by accident the apple fell down in a river, the dirt got washed off and he ate the washed apple. Obviously it tasted delicious. The monkey started washing the apple thereafter every day before eating. His fellow monkeys started following the same. The process of following went on. When the 100th monkey washed the apple and ate it, a strange phenomenon was noticed. All monkeys in and around that state started washing the apple before eating.” This 100thmonkey was the critical mass. Once this mass is crossed, the information will spread like a wild fire and the intent becomes a universal reality. The Merriam Webster English Dictionary gives the meaning of critical mass as “a size, number, or amount large enough to produce a particular result”. We are not criminals and no criminal prosecution clause should be made applicable to medical professionals as also in the West Bengal Clinical Establishments (Registration, Regulation and Transparency) Bill 2017 and now in the recently passed Karnataka Private Medical Establishments Amendment Bill 2017. We need to remain true to the spirit of “IMA 1 Voice”. Our focus should not shift. We should not weaken in our resolve to achieve justice for the medical fraternity in the country. Today “Dilli Chalo” has proven our strength as IMA 1 Voice. Now is the time to sustain and further strengthen the IMA 1 Voice movement. I ask all those who attended or participated digitally in the movement to become IMA brand ambassadors and speak out about IMA all across the country. We achieved the required critical mass of 1% of collective consciousness on 6th June. People have been sensitized. But, this is not the end of the road for us. Lot more needs to be done. What decisions we take now will be crucial. Here I am reminded of that iconic line from the Shahrukh Khan movie ‘Om Shanti Om’… “Picture abhi baki hai, mere dost… Yes, picture abhi baki hai, mere dost… Our next slogan is “Do not force us to go to a nation-wide strike from 18th August”.

IMA votes against amendment to the KPME Bill

IMA votes against amendment to the KPME Bill Another movement in the making to protest against fixing rates for procedures in private hospitals New Delhi, 20 June 2017: The IMA has come out against another draconian amendment, this time by the Karnataka government, which seems to follow on the lines of West Bengal. The amendment to the Karnataka Private Medical Establishments (KPME) Act entails fixing of rates for various procedures in private hospitals and penalty for flouting these. The Bill, when passed, will enable the government to regulate private hospitals in all aspects. It also entails setting up of an expert committee to classify private medical establishments and recommend the state government to fix the cost of treatment for different medical services. Condemning the amendment as a very disturbing trend with the CEA Karnataka trying to follow West Bengal in forming grievances cell and fixing rates, the IMA has called for quick action to be able to fight this act and other such acts at the anvil as soon as possible. The Association has called the fixing of rates as irrational and unacceptable. The IMA recently concluded the Dilli Chalo movement protesting against the atrocities faced by the medical fraternity. Speaking on this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "It is unfortunate that the government, instead of providing a favorable and secure environment for doctors, is trying to create severe hurdles even for their day-to-day activities. The KPME (amendment) Bill, 2017 should be stalled to save the doctor-patient relationship. Rates for procedures can be fixed only through scientific calculations. No one can predict the cost in patients with comorbidities and neither for complications and the associated expenditures. It is a fact that small and medium level hospitals are already vanishing due to financial non-viability. The government can bring down costs only by a process of empanelment which is further possible by fixing rates for below poverty line people and allowing hospitals to charge reasonably to those who can afford. Every hospital is either already providing or forced to give free service. Hospitals should not be in a position to file cases to get money back from relatives. This will only make the existing doctor-patient relationship even worse." The Association has further asked for clarity on the fact that if the government has decided to fix rates, will it pay for those who do not pay the hospital bills. It has also called for an answer on whether the government will bear the responsibility of paying up in the unfortunate circumstance of a patient dying and the relatives being unable to pay the bill. Adding further, Dr Aggarwal, said, "The medical fraternity has been doing its best to provide healthcare, utilizing all the latest technologies and treatments, at most affordable rates. It is only due to this that Karnataka has the best of health indicators such as IMR and MMR. With the failure of the government to improve its own hospitals, the private healthcare establishments have shouldered the responsibility with their own investments and expenses. The IMA is in the process of fixing up a meeting with the Karnataka government and convince them to change the law after the protest, failing which it will be only prudent to shut down the hospitals and fight legally." There is no law in the world that allows anyone to complain about and punish a doctor for merely asking questions to the patient. Creating new regulatory authorities under the alibi that the medical councils, consumer fora, and civil and criminal courts are ineffective, is not only an affront to these institutions, but also a dangerous phenomenon. It will only lead to further expenses, open the doors for more corruption and will certainly cripple each and every doctor.

Tuesday, 20 June 2017

Revised WMA Declaration of Delhi on Health and Climate Change: For comments

Revised WMA Declaration of Delhi on Health and Climate Change: For comments Document no: SMAC 206/Climate Change REV2/Apr2017 Original: English Title: Revised WMA Declaration of Delhi on Health and Climate Change Destination: Constituent Members Action(s) required:For Comments Note: The Associate Members submitted this proposed statement to the General Assembly in Taipei (October 2016), under the initiative of the Junior Doctors Network (JDN). The General Assembly passed it to the 204thCouncil Session, which decided to circulate it to the members for comments. The Council in Livingstone (April 2017) considered the compromise version based on the comments received and decided to return the draft to the rapporteur for further work in view of the discussion during the meeting, before a new circulation. Suggested Keywords: Climate change, air pollution, environment, Paris Agreement, Marrakesh Agreement, COP, mitigation, heat waves, flooding PREAMBLE 1. Compelling evidence substantiates the numerous health risks posed by climate change, which threaten populations of low, middle and high-income countries. These include more frequent and potentially more severe heat waves, droughts, flooding and other extreme weather events including storms and bushfires. The resulting climate change, especially warming, is already leading to changes in the areas in which disease vectors flourish. There is reduced availability and quality of potable water, and worsening food insecurity leading to malnutrition and population displacement. Global warming is universal but its effects are unevenly spread and many of the areas most strongly affected are least able to manage the challenges it poses. 2. Tackling climate change offers opportunities to improve health and wellbeing both because of the health co-benefits of low carbon solutions and because mitigation and adaptation allow action on all the social determinants of health. Transition to renewable energy, the use of active transport, dietary change including a reduction in consumption of red meat, may all contribute to improving health. Mitigation actions, such as those on reducing indoor and outdoor air pollution, will reduce health harms suffered predominantly by poorer people. 3. The social determinants of health are those factors that adversely affect health through exposure before and after people are born and as they grow live, and work. They are worse in the poorest populations of all countries and also vary between countries. Those with generally the poorest health and lowest life and health expectancy will be least able to adapt to deal with global warming exacerbating adverse social determinants of health. Assisting these countries is a common but differentiated responsibility. 4. Climate change research and surveillance is important and the WMA supports studies seeking to describe the patterns of disease that are attributed to climate change, including the impacts of climate change on communities and households; to quantify and model the burden of disease that will be caused by global climate change including emergent diseases; to describe the most vulnerable populations. 5. The Paris Agreement highlights a transition to a new model of global collaboration to address Climate Change and represents an opportunity for the health sector to contribute to climate action. It includes a series of actions to be undertaken in each nation to attempt to limit the global increase in average temperature to less than 1.5 C. RECOMMENDATIONS 6. The World Medical Association and its Constituent Members: 6.1 Urge national governments urgently to recognize the serious health consequences of climate change and to adopt strategies to adapt to and mitigate the effects of climate change; 6.2 Urge national governments to work to ensure fulfillment of national commitments to the Paris Agreement, including both mitigation and adaptation measures as well as action on losses and; 6.3 Urges national government to ensure that climate financing must include designated funds to support the strengthening of health systems, and health and climate co-benefit policies and through this, to ensure the availability of sufficient global, regional and local financing for climate mitigation, adaptation measures, disaster risk reduction, and the attainment of the Sustainable Development Goals (SDGs); 6.4 Urge national governments to engage with health sector representatives in developing and implementing climate change plans and emergency planning and response on local, national and international levels; 6.5 Urge national governments to provide for the health and wellbeing needs of people displaced by environmental causes both within their countries and others including those becoming refugees due to the consequences of environmental changes. 7. National Medical Associations and their physician members should: 7.1 Advocate for sustainable, environmentally responsible low-carbon practices across the health sector to reduce the environmental impact of health care facilities and practices. 7.2 Prepare for the infrastructure disruptions that accompany major emergencies, in particular by planning in advance for the delivery of services during times of such disruptions and increased patient care demands; 7.3 Encourage and support advocacy for environmental protection and greenhouse gas emissions reductions including through emissions trading systems and/or carbon taxes. 8. The WMA and its Constituent Members should: 8.1 Encourage sustainable low-carbon living including active lifestyle, low-carbon agricultural and food production processes and diet, and sustainable production and consumption patterns; 8.2 Seek to build professional and public awareness of the importance of the environment and global climate change to personal, community and societal health; 8.3 Work towards the integration of key climate change concepts and competencies in undergraduate, graduate and continuing medical education curricula; 8.4 Collaborate with WHO and other organizations as appropriate, to produce educational and advocacy materials on climate change for national medical associations, physicians, other health professionals, as well as the general public; 8.5 Work towards increasing resilience including by preparing physicians, physicians’ offices, clinics, hospitals and other health care facilities for the infrastructure disruptions that accompany major emergencies, in particular by planning in advance the delivery of services during times of such disruptions; 8.6 Seek to ensure that physicians are involved in the planning and delivery of primary ill-health prevention strategies in relation to climate change, working with NGOs, IGOs and governments; 8.7 Advocate for their respective governments adequately funded climate change research and collaborate with governments, NGOs and other health professionals to develop knowledge about the best ways to address health impacts of climate change; 8.8 Work collaboratively with government and NGOs to develop systems for event alerts in order to ensure that health care systems and physicians are aware of climate-related events as they unfold, and receive timely accurate information regarding the management of emerging health events. 9. The WMA urges National Medical Associations to: 9.1 Work with health-care institutions, and individual physicians to adopt climate policies and act as role models by striving to reduce their carbon emissions, for instance by adopting more sustainable travel policies and increasing the use of on-line meetings. 9.2 Recognize environmental factors as a key element inherent within the social determinants of health (SDH) agenda, and encourage governments to foster collaboration between the Health and non-health sectors in addressing these determinants. Dr KK Aggarwal National President IMA & HCFI

An irresistible urge to move your legs could be a sign of RLS

An irresistible urge to move your legs could be a sign of RLS Adequate physical activity and avoiding caffeine can help counter this condition New Delhi, 19 June 2017: Are you one of those who finds your legs jerking uncomfortably in the evening or at night and getting a disturbed sleep as a result? If yes, you are not alone. You may be suffering from Restless Leg Syndrome (RLS), which is a disorder causing a strong urge to keep moving the legs. This is a common disorder affecting many today. Occurring mostly in middle-aged or older people, RLS also causes distress or impairment in social, occupational, educational, and academic behaviour. RLS is a neurological movement disorder of the limbs and is often associated with a sleep complaint. Those with RLS have an almost irresistible urge to move their legs. Though it is not painful, this condition can be quite bothersome and lead to significant physical and emotional disability with the symptoms showing up at least thrice a week. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "A strange and unpleasant feeling in the legs can result in a constant urge to move them. The feeling is very creepy-crawly with pulling of muscles, itching, tingling or burning sensation, aches or even electric-like shocks at times. The syndrome strikes when a person is at rest or inactive and can worsen in the evening or at night. This in turn can leave one tired and sleepy during the day and affect daily activities. Many people even find it difficult to understand the abnormal sensation in their legs." While primary RLS can have a genetic cause, secondary RLS may be due to peripheral neuropathy, iron, folate, magnesium, or Vitamin B12 deficiency, rheumatoid arthritis, Parkinson's disease, kidney failure, diabetes, venous disorder, thyroid disorder, or a neurological disorder. Few things that can further worsen this condition include antidepressants, painkillers, alcohol, and caffeine. Exercise and avoiding certain things such as caffeine can help bring relief for those with RLS. Adding further, Dr Aggarwal, said, "One can use compression stockings, which come in various sizes and shapes, as a relief measure for this condition. Stockings with strong elastic can make your legs feel lighter and improve blood flow from the lower limbs to the upper limbs." Here are some other tips to counter RLS. • Reduce or avoid consumption of coffee, tea, soft drinks and other caffeinated foods. • Avoid taking any form of stress and practice meditation techniques. Daily stretching and meditation can promote relaxation. • For those in a job that requires sitting at a place for long hours, it is a good idea to go for short walks in between work. Choose the stairs instead of the lift. • Make dietary changes and eat food that is rich in iron.

Monday, 19 June 2017

Proposed Revision of the World Medical Association Declaration of Geneva: For comments and inputs

Proposed Revision of the World Medical Association Declaration of Geneva: For comments and inputs

Document no:
MEC 207/DoG/Oct2017
Original:
English
Title:
Proposed Revision of the WMA Declaration of Geneva

Destination:
Constituent Members
Action(s) required:
For Comments
Note:
This revised version (as of 7 June 2017) is proposed by the DoG Workgroup who considered the comments from the
public consultation which was conducted for all experts and stakeholders by 29 May 2017. This is now open for the Constituent Members to comment no later than 31 July 2017.
Keywords
Geneva, Oath, Pledge, Conduct, Discrimination, Non-Discrimination, Conscience, Dignity

No
Text of current version of the Declaration of Geneva
Revised draft (as of 7 June 2017)
Additions: bold/underlined
Deletions:  lined-out
Comments only: [italic]
Comments

WMA DECLARATION OF GENEVA
WMA DECLARATION OF GENEVA

New

The Physician’s Oath


Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948
and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968
and the 35th World Medical Assembly, Venice, Italy, October 1983
and the 46th WMA General Assembly, Stockholm, Sweden, September 1994
and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 
and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006
Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948
and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968
and the 35th World Medical Assembly, Venice, Italy, October 1983
and the 46th WMA General Assembly, Stockholm, Sweden, September 1994
and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 
and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006
and the

1.
AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:
AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:

2.
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I SOLEMNLY PLEDGE to consecrate dedicate my life to the service of humanity;

3.
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;



I WILL FOSTER MAINTAIN by all means in my power, the honour and noble traditions of the medical profession;  (Moved from line 7)

4.
I WILL PRACTISE my profession with conscience and dignity;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;

5.
THE HEALTH OF MY PATIENT will be my first consideration;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

New

I WILL RESPECT the autonomy and dignity of my patient;

6.
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;

7.
I WILL MAINTAIN by all means in my power, the honour and the noble traditions of the medical profession;
Moved between lines 3 and 4 – see above

8.
MY COLLEAGUES will be my sisters and brothers;
MY COLLEAGUES will be my sisters and brothers;

New

I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

New

I WILL FOSTER my own health and ability to provide care of the highest standard;

9.
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;

10.
I WILL MAINTAIN the utmost respect for human life;
I WILL MAINTAIN the utmost respect for human life;

11.
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

12.
I MAKE THESE PROMISES solemnly, freely and upon my honour.
I MAKE THESE PROMISES solemnly, freely and upon my honour.




https://ssl.gstatic.com/ui/v1/icons/mail/images/cleardot.gif



Dr KK Aggarwal
National President IMA & HCFI