Sunday, 20 August 2017

Govt. move to fix ceiling prices of knee implants: The need of the hour

Govt. move to fix ceiling prices of knee implants: The need of the hour Dr KK Aggarwal Early this week, the National Pharmaceutical Pricing Authority (NPPA) fixed and notified the ceiling prices (inclusive of trade margins) of orthopedic implants used in knee surgeries, both primary knee replacement surgery as well as revision surgery, under para 19 of Drugs (prices control) order (DPCO 2013) with immediate effect. In 2005, orthopaedic implants were notified as ‘drugs’ by the Ministry of Health and Family Welfare vide its S.O. 1468 dated 6th October 2005. Consequent to this, Drug (Prices Control) Order (DPCO) 2013 became applicable to these implants, which also came under the purview of the NPPA, which is mandated to monitor the prices of all notified drugs including notified devices. An estimated 1.5 to 2 crores patients require arthroplasty; however, out of these which only about 1 lakh plus well off patients are in a position to pay for it every year because of the very high cost of orthopedic implants (NPPA Notification, August 16, 2017). As per WHO estimates, osteoarthritis will be the fourth leading cause of disability by the year 2020. The ceiling price of different materials and components used in the implant in primary knee replacement system has been fixed between Rs. 4,090/- to Rs 38,740/-. Similarly, the ceiling price of different materials and components used in the implant in revision knee replacement system has been fixed between Rs. 4,090/- to Rs 62,770/-. As per the notification, “All manufacturers/marketers of knee implants having MRP lower than the ceiling price specified plus goods and services tax as applicable, if any, shall continue to maintain the existing MRP in accordance with paragraph 13 (2) of the DPCO, 2013”. The earlier average MRP of cobalt chromium, the most commonly used knee implant has reduced by an average of 65%. The MRP has been capped at Rs. 54,720/- now Wfrom the earlier 1,58,324/-Knee implants made up of special metals like titanium and oxidised Zirconium has been capped at Rs 76,600/- with price reduction by 69%. The price of high flexibility implants have been capped at Rs. 56,490/-, again with a price reduction by 69% (Press Information Bureau, August 16, 2017). All hospitals/nursing homes/clinics performing orthopedic surgical procedures using knee implants are now required to comply with the ceiling prices notified. The patients cannot be charged any additional charge over and above the ceiling price notified “except applicable goods and services tax, if any, paid or payable”. The Indian Medical Association (IMA) welcomes this move of the govt. to fix the ceiling price of knee implants as now these implants have become more affordable and within reach of the common people. Many more patients will now be able to undergo the procedure, which earlier they could not because of the very high costs of the implants. Earlier this year, the Govt. had fixed the ceiling prices of coronary stents, which also came as a relief to the general public. Disclaimer: The views expressed in this write up are entirely my own.

Collective action a must to prevent mosquito-borne diseases

Collective action a must to prevent mosquito-borne diseases • On World Mosquito Day, IMA encourages people to indicate that their premises are free of mosquitoes • This is only possible if there is community participation in the efforts made by the government New Delhi, 19 August 2017: Statistics indicate that mosquito-borne diseases are prevalent in more than 100 countries. Mosquitoes infect about 300 to 500 million people, causing 1 million deaths every year around the world. More than 40 million people suffer from mosquito-borne diseases annually in India alone. According to the IMA, on World Mosquito Day, the need of the hour is to take collective action to prevent the breeding of mosquitoes, both on a larger scale and at an individual level. Malaria, filaria and dengue are the most prevalent diseases spread by mosquitoes in India with over 2 million cases of malaria alone reported in the country. The mosquito that transmits dengue fever and chikungunya is also responsible for spreading Zika. All these diseases result in high fever and excruciating joint pains, which have been a common occurrence in the country over the last two decades. 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, “Failure to control the mosquito menace is a collective failure and therefore, the mosquitoes transmitting diseases are still at large around the country. The Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs, Private sector, and individuals must act together to prevent mosquitoes from breeding. A mosquito container index above 5% requires a community-integrated cluster approach to reduce mosquito density together with effective anti-larval measures. On World Mosquito Day, it is time to remind ourselves that we need to act against all the mosquitoes, be it Aedes, Culex, or Anopheles. Action against only the Aedes mosquito will not work.” Rain water is the most important source for mosquito breeding and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with rain water collections providing an ideal atmosphere for mosquito breeding. Adding further, Dr Aggarwal, said, “A community approach that involves 100% of the society needs to be adopted. Every house and establishment must indicate that their premises are mosquito-free. When you are invited to somebody’s place, you should ask ‘I hope your premises are mosquito-free’ and when you invite somebody, write ‘Welcome to my house. It is mosquito-free’.” IMA’s approach is a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); scrubbing clean the utensils. One should not clean their premises once a week. Rather, it should become a habit to look for the breeding places daily. Here are some tips to follow. • Avoid stagnation of water in and around the house to prevent mosquitoes from breeding. • Cover all containers that have water stored in them. • Use mosquito screens, nets, meshes and insect repellent screens regularly. • Do not venture out immediately after dusk. If you need to go out, make sure to wear full-sleeved clothing and apply a mosquito repellent cream. • If you are affected by any of these diseases, ensure that you are hydrated and well rested. • Follow the doctor’s advice completely and do not compromise on any checkups, etc.

Saturday, 19 August 2017

Gorakhpur Tragedy: Findings of the IMA Inquiry Committee

Gorakhpur Tragedy: Findings of the IMA Inquiry Committee Dr KK Aggarwal National President, IMA The Gorakhpur tragedy, where many innocent lives were lost, has shaken the nation and stirred a debate in the country. Taking cognizance of the seriousness of the situation, Indian Medical Association (IMA) HQs constituted an Inquiry Committee comprising of Prof KP Kushwaha, Former Principal & Head, Dept of Pediatrics, Medical College Gorakhpur; Dr Ashok Agarwal, National Vice President IMA and Dr BB Gupta, President IMA Gorakhpur Branch. The committee also asked the following doctors to appear before it to present their case. • Prof Dr Rajiv Mishra, Principal BRD Medical College, Gorakhpur at the time of the incident • Prof Dr Satish Kumar, Head, Dept. of Anaesthesia, Medical College, Gorakhpur • Dr Mahima Mittal, Associate Prof, Dept. of Paediatrics, Medical College, Gorakhpur • Dr Kafeel Khan, Asst. Prof and Nodal Officer, Encephalitis Ward, Dept. of Paediatrics, Medical College, Gorakhpur • Dr AK Shrivastava, Superintendent in Chief, Nehru Hospital, Medical College, Gorakhpur But, the above doctors failed to appear before the Inquiry Committee, which then decided to visit the Dept. of Pediatrics in the Medical College. People there were hesitant to speak. The scope of the Committee was to only examine the working of the doctors as other issues such as lack of oxygen, inadequate staff and any structural deficiency were being investigated by the Chief Secy, UP Govt. The committee also took note of the various reports published in the newspapers and other media. The following conclusions were arrived at: • Oxygen supply was interrupted for a short time on the night of August 10, 2017. • The liquid oxygen supplier had not been paid his dues since last 5-6 months. • Cleanliness of hospital and ward was unsatisfactory. Presence of dogs and rats in hospitals is not acceptable by any standards in the hospital premises. • The hospital was handling these cases and other critically ill patients much more than its capacity. • There is no facility in Gorakhpur and nearby districts to manage encephalitis. • There is a lack of staff – paediatricians, nurses and other paramedical staff – in PHCs/CHCs. • ICUs in 10 districts of Poorvanchal area are not functioning because of lack of staff and other resources. • No alert was issued by the hospital administration regarding shortage of oxygen, The traeting doctors should have been alerted seven days before the fresh oxygen supply was not received. According to the IMA, although there is no evidence of medical clinical negligence against Dr Rajiv Mishra and Dr Kafeel Khan, prima facie it appears that a case of administrative negligence against them cannot be ruled out. Hence, administrative inquiry and action may be taken against them. The recent movie ‘Airlift’ was based on the true story of evacuation – airlifted - of several hundreds of Indians from Kuwait during the first Gulf war and brought back to the country. Similarly, we read about ‘green corridors’ without any traffic disruptions being set up to transport harvested organs like heart to reach another hospital, where there is a patient waiting to receive the organ. It’s an emergency where time is of utmost importance. Why can’t the same be done in situations such as the Gorakhpur tragedy, where an epidemic of encephalitis recurs every year and, many children lose their lives every year because of the illness? In view of this tragedy, IMA has suggested the following to avoid similar situation in the future. • There should be a state policy to airlift such critically patients in a timely manner to nearby best facilities. • All patients denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at pre-defined rates. • All hospitals should have back up of one-week supply of all essential drugs, investigations and oxygen. • IRDA has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups. • Essential drugs and investigations, not non-essential drugs and tests, should constitute the bulk of the expenditure of the allocated budget to reduce the cost of treatment. • All payments for health care services should be made either in advance or in time. • Doctors are clinicians as well as administrators. It is important to make a distinction between clinical medical negligence and administrative negligence. Disclaimer: The views expressed in this write up are entirely my own

Immunization in infants and children a must to avoid hearing disabilities

Immunization in infants and children a must to avoid hearing disabilities Childhood hearing loss goes undetected mostly due to lack of awareness and appropriate interventions New Delhi, 18 August 2017: As per recent reports, about 5% of the world's population suffers from disabling hearing loss, of which 32 million are children. About 6.3% of the Indian population suffers from hearing impairment and this percentage includes roughly 50 lakh children. As per the IMA, most of these hearing problems can be prevented through immunization against various diseases, by controlling noise pollution, and regulating the use of certain medicines. Deafness is primarily of two kinds. Nerve deafness is caused due to sound pollution and problems during birth. Conductive deafness is a result of socio-economic factors such as poor hygiene and lack of treatment, leading to chronic infection and deafness. 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, “It is alarming to note that the number of infants and youngsters with hearing impairment has increased substantially over the last few years. Hearing impairment is not recognizable easily during infancy and therefore is highly neglected. The need of the hour is to educate people and create awareness that hearing loss can be combated through early identification and appropriate intervention. Apart from congenital defects, hearing loss can also be the result of external factors. It is imperative to control these with support from a good healthcare system and control over noise levels.” Universal Newborn Hearing Screening (UNHS) is a medical test for early detection of congenital hearing loss. India still lacks such a system that can identify congenital hearing problems in infants. Adding further, Dr Aggarwal, said, “There is a lack of communication, low awareness, and lack of understanding about the importance of early diagnosis and intervention in case of a hearing loss. Delay in identifying this condition can affect language acquisition, social interaction, emotional development, and education in children. Neonatal hearing screening for every newborn is a must and highly recommended.” Here are some ways to prevent hearing loss in infants. • Avoid any shock and trauma to the ears as it can cause severe damage to the ear drums resulting in loss of hearing. • Ensure that water does not enter the infant’s ears while bathing. • Get them medically tested as early detection can lead to better treatment outcomes. • Never insert any sharp object in the infant’s ears. • Keep them away from loud music or other sounds as this can impact their hearing capability. Loud music causes acoustic trauma. • Make sure that children are immunized against infections like measles, mumps, rubella, and meningitis as per schedule. These infections can also cause hearing loss in children.

Friday, 18 August 2017

Will we be ready to tackle future epidemics?

Will we be ready to tackle future epidemics? In the public debate on the Gorakhpur tragedy, several reasons were put forth as to why these deaths occurred. That several factors collectively led to this tragedy is the undeniable truth. Rather than trying to pinpoint who is to be blamed, our focus instead should be preventing further outbreaks in the future. Dealing with the aftermath of a tragedy is important as also, how we choose to deal with it. And the question that we all should be asking ourselves in this regard is “what can we do to prevent future epidemics” and not “what should have been done and was not done”. Will we be ready to tackle future epidemics? The answer to this depends on what corrective measures we take today. A long-term strategy needs to be formulated to deal with such outbreaks. A well-planned surveillance and response system should be in place, which can be mobilized quickly when needed. We need better investment in preparedness. We have to work together to stop the next outbreak, not only in Gorakhpur, but also any epidemic in the country. Dengue, for example, occurs in epidemic proportions every year. The Indian Medical Association (IMA) has suggested the following to avoid more incidents like the Gorakhpur tragedy. • There should be no shortage of staff – doctors, nurses and other supporting staff. Staff deficit affects patient care. Shortage of staff should be supplemented with the services of locum doctors. • Private doctors can be hired, but only for locum jobs, not as regular doctors. • The practice of “moonlighting” as is prevalent in the US should be allowed in India. • There should be a uniform system for Govt. doctors: either practice is allowed or it is not allowed. • All patients who are denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at predefined rates. • All hospitals should have back up of at least one-week supply of all essential drugs, investigations and oxygen. • To reduce the cost of treatment, essential drugs and investigations - not non-essential drugs and tests - should constitute the bulk of the expenditure of the allocated budget. • All payments for health care services should be made either in advance or in time. • Insurance Regulatory and Development Authority (IRDA) has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups. • Every death should be audited to find out the probable cause of death and whether it was a preventable death so that future such deaths can be prevented from occurring. • In any case of negligence, one should differentiate between administrative negligence and medical negligence. Disclaimer: The views expressed in this write up are entirely my own. Dr KK Aggarwal

Smoking increases the chances of acquiring an erectile dysfunction

Smoking increases the chances of acquiring an erectile dysfunction Lifestyle changes and quitting smoking can go a long way in reducing the risks New Delhi, 17 August 2017: Studies indicate that men who smoke more than 20 cigarettes a day have 60% higher risk of erectile dysfunction (ED). About 15% of past and present smokers experience an ED. Other important factors that contribute to this condition include diabetes, high blood pressure, and high cholesterol, all of which can also get further exacerbated by smoking. As per the IMA, smoking also leads to reduced volume of ejaculation, low sperm count, sperm shape, etc. ED is defined as a persistent difficulty achieving and maintaining an erection. The causes for this disorder can be both medical and psychological. Frequent ED is usually the sign of health problems which may require treatment. 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, "Sexual arousal in males is a complex process involving the brain, hormones, emotions, nerves, muscles, and blood vessels. ED can occur when there is a problem with any of these associated factors. Stress and mental health concerns have been known to worsen the condition. Sometimes, ED is the result of a combination of physical and psychological issues such as a minor physical condition that slows a person’s sexual response leading to anxiety. This anxiety can lead to or worsen ED.” There are various risk factors which can contribute to ED. These include medical conditions, being overweight, certain medical treatments such as prostate surgery or radiation treatment for cancer, injuries, medications such as antidepressants, psychological conditions, and drinking. Adding further, Dr Aggarwal, said, “Many men with ED have been able to improve their sexual function through lifestyle changes. It is imperative to give up smoking, lose weight, and exercise which will all help in improving blood flow. In case a medication seems to be the contributing factor, it is a good idea to speak to a doctor about adjusting the dosage or switching to another drug.” The following steps can reduce a person’s risk of acquiring ED. • Start walking: At least 30 minutes of walking a day is linked with a 41% drop in risk for ED. • Eat right: Eating a diet rich in fruit, vegetables, whole grains, and fish can decrease the likelihood of ED. • Pay attention to vascular health: High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the male organ. Low levels of HDL (good) cholesterol and an expanding waistline also contribute. • Get slim and stay slim: Obesity raises risks for vascular disease and diabetes, two major causes of ED. Excess fat interferes with several hormones that may be part of the problem as well. • Build pelvic muscles and not biceps: A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein.

Thursday, 17 August 2017

AES Update: This is not the time for a “blame game”

AES Update: This is not the time for a “blame game” The recent tragic deaths of children due to encephalitis in Gorakhpur medical college have hit the headlines in the last few days. These deaths also generated a lot of debate on the issue. Unfortunately much of the debate centered on “finger pointing”. This is not the time for a “blame game”. This is not the first outbreak of acute encephalitis syndrome (AES) in the region. Many such outbreaks have been occurring for several years now and each epidemic has taken a heavy toll of lives. By now there should have been a state of the art hospital to manage AES patients. There should have also been a research facility to examine why the area is vulnerable to AES, establish effective surveillance systems, plan a response plan, predict future outbreaks etc. This is the time to look to the future and not talk of the past or even the present outbreak. Drawing from the lessons of the past years, we must be able to anticipate such local outbreaks and be ready to respond to them systematically and in a timely manner to contain them. A research center focusing on AES will help to identify early warning signals for such impending outbreaks. Anticipation and preparedness will enhance efforts to control and prevent future outbreaks of AES. All stakeholders have equally important roles to play in prevention of any epidemic. Some key points on AES • Encephalitis is inflammation of the brain parenchyma. It presents clinically as neurologic dysfunction (altered mental status, behavior, or personality; motor or sensory deficits; speech or movement disorders; seizure) • Viruses are the most commonly identified infectious causes of encephalitis. Around 10% cases may be due to Japanese encephalitis, scrub typhus and herpes simplex each. Enterovirus and other viruses also cause AES. Bacteria, fungi, and parasites may also cause encephalitis. In many cases of encephalitis, the etiology remains unknown despite extensive evaluation. • The WHO’s guidelines for JE surveillance recommend syndromic surveillance for JE meaning that all AES cases should be reported (NVBDCP, 2009). • The NVBDCP 2009 guidelines on management of AES have recommended classification of a suspected case as follows: o Laboratory-confirmed JE: A suspected case that has been laboratory-confirmed as JE. o Probable JE: A suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak. o Acute encephalitis syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified. o Acute encephalitis syndrome (due to unknown agent ) A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate. • The incidence is highest among infants <1 year. • Status epilepticus, cerebral edema, fluid and electrolyte disturbance, and cardiorespiratory failure are some of the complications of AES. • ICU care is essential for patients with severe encephalitis (i.e., those with seizures, cardiorespiratory compromise, coma, or severe neurologic compromise) with close cardiorespiratory monitoring and careful attention to neurologic status, fluid balance, and electrolyte status. • Prognosis of viral encephalitis depends upon the age of the patient, neurologic findings at the time of presentation and the etiopathogen. • The case fatality and morbidity is very high among various viral encephalitis especially in JE or enterovirus encephalitis. • Survivors of childhood encephalitis should be monitored for long-term sequelae. • Scrub typhus encephalitis: Curable with doxycycline or erythromycin if diagnosed early. Look for fever, rash, local black eschar in the legs with enlarged, lymph nodes. • Japanese encephalitis: Mortality is 20% in the best of the centers. Preventable by vaccination. • Herpes simplex encephalitis: Can be diagnosed due to temporal lobe localization and can be managed with antivirals. • Lichi encephalitis is manageable with intravenous glucose. • Enteroviral encephalitis has limited therapeutic options. Intravenous immunoglobulin (IVIG) is often administered despite a lack of convincing evidence for efficacy. • All children who present with suspected encephalitis should be treated with acyclovir pending viral studies. • Empiric treatment for bacterial meningitis pending bacterial cultures also may be warranted if bacterial meningitis cannot be excluded. • Empiric treatment with doxycycline or erythromycin should be given till scrub typhus is ruled out. • Prevention strategies include hand hygiene, appropriate management of pregnant women with active herpes simplex virus lesions, routine childhood immunizations, JE vaccine, traveling immunizations, and insect control and avoidance measures. Control of culex mosquito. • All children who are hospitalized with encephalitis should be placed on airborne, droplet, and contact precautions at the time of admission, pending identification of a pathogen. Disclaimer: The views expressed in this write up are entirely my own. Dr KK Aggarwal

Fatty liver can lead to liver cancer in the long run

Fatty liver can lead to liver cancer in the long run It is important to follow a healthy diet free of alcohol to prevent build-up of fat in the liver New Delhi, 16 August 2017: Studies indicate an alarming increase in the number of people suffering from fatty liver. As per available statistics, 1 in 5 people in India have excess fat in their liver and 1 in 10 have fatty liver disease. This is a cause of concern as fatty liver can lead to liver damage and even liver cancer if undiagnosed and untreated. As per the IMA, about 20% of those with non-alcoholic fatty liver disease (NAFLD) are likely to get liver cirrhosis in 20 years. This percentage is akin to that among alcoholics. NAFLD is caused due to a build-up of fat in liver cells. The first stage of this disease is called simple fatty liver. Although excess fat builds up in the liver in this stage, it remains harmless and has no evident symptoms unless it develops into inflammation or damage. The second stage is called non-alcoholic stea to hepatitis (NASH) which is similar to alcoholic liver disease. However, those affected drink little or no alcohol. 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, “NAFLD may progress to cirrhosis and is likely an important cause of cryptogenic cirrhosis. As little as two drinks per day in those who are overweight (and one drink per day in those who are obese) is associated in hepatic injury. Liver cancer is associated with cirrhosis due to NAFLD and heart disease is the most common cause of death among patients with this condition. NAFLD is not caused by alcohol but its consumption can make the condition worse. The disease can stop or reverse, especially in the early stages. Once it progresses to cirrhosis, the liver becomes unable to function causing symptoms like fluid retention, muscle wasting, internal bleeding, jaundice (yellowing of skin and eyes), liver failure.” Some symptoms of NAFLD that emerge in the long run include fatigue, weight loss or loss of appetite, weakness, nausea, confusion and impaired judgment, pain in the centre or right upper part of the abdomen below the ribs, an enlarged liver, and patchy or dark skin on the neck or underarm. Adding further, Dr Aggarwal, said, “NAFLD is often diagnosed after liver function tests produce an abnormal result and other liver conditions such as hepatitis are ruled out. However, NAFLD can be present even when routine liver blood tests are normal. One needs to make certain lifestyle changes to prevent the disease from progressing to a more serious stage and lower the risk of having a heart attack or stroke.” Here are some simple lifestyle changes one can make to avoid this condition. • Maintain a healthy weight. • Consume a healthy diet rich in fruits and vegetables. • Get minimum of 30 minutes of physical activity every day. • Limit alcohol intake or avoid consuming it at all. • Only take medicines that are required and follow dosage recommendations.

Wednesday, 16 August 2017

Should a learning curve be allowed in medical education today?

Should a learning curve be allowed in medical education today? For a doctor, it’s not enough to just know facts; application of that knowledge into clinical skills is even more important. Traditionally, medical students have relied on acquiring these skills by learning on real patients during their clinical postings as undergraduates and then as part of postgraduate training. In this hands-on, often experimental, way of learning, raises ethical and legal concerns. Mistakes are bound to occur during the learning process. We learn from our mistakes more than our successes. But patients today are empowered and enlightened. They are unwilling to accept this experimentation on their body. Primum non cere – “above all, do no harm” is fundamental to the practice of medicine. We do cadaveric dissections to learn anatomy. But, surgical procedures are learned on live cases. When we learn something new, performance improves with experience... as also with a surgical procedure, where complication rates depend on the experience of a surgeon. There is therefore a learning curve. An expert surgeon is defined by the number of similar surgeries done; complication rates, success rates, re-hospitalization rates are all factors that also define an expert surgeon. Patients today can ask the doctors to disclose these numbers before consenting to a procedure. A single center study published in the year 2013 in the journal Circulation reported that 75-125 minimally invasive mitral valve surgeries were required to be performed by an average cardiac surgeon to gain mastery in the procedure. And, more than one such surgery per week was required to maintain good results. In this age of digitization, all procedure-based skills should now be learnt via simulation lab. Although they are not a replacement for the actual patient-based operative experience, simulation labs provide a safe environment for learning. Practicing on a simulator, which has all possible simulations of a variety of real life clinical scenarios, ranging from low to high fidelity, shortens the learning curve and avoids “preventable” errors. Learning by trial and error is no longer a feasible approach in this age of patient-centric medicine, where doctors have to work with patients as equal partners. Simulation-based training is the need of the hour in both undergraduate and postgraduate studies and even continuing medical education, when students and doctors can refine their knowledge, skills, without compromising patient safety. Disclaimer: The views expressed in this write up are entirely my own. Dr KK Aggarwal

Measles needs a vaccination strategy like polio

Measles needs a vaccination strategy like polio It is a deadly disease and still a cause of major child mortality in the country New Delhi, 15 August 2017: Statistics indicate that about 1,34,200 children, mostly under the age of five years, died due to measles around the world in the year 2015. In India, it killed 49,200 children. As per the IMA, measles is a deadly disease and one of the main causes behind child mortality in the country. Eliminating measles will help achieve Sustainable Development Goal’s target 3.2, which aims to end preventable deaths of children under 5 years by 2030. Measles is a highly infectious illness caused by the rubeola virus. As many as 21 strains of the virus have been identified to date. The virus takes about 1 to 3 weeks to establish itself. While there is no specific treatment for this, getting vaccination at the right time can be affective. Pregnant women are advised taking the vaccine. 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 rubeolavirus lives in the mucus of the nose and throat of an infected child or adult. The disease is contagious for 4 days before the rash appears. It then continues to be contagious for about 4 to 5 days after.A person can get infected through physical contact with an infected person, being near an infected people when they cough or sneeze, touching a surface that has infected droplets of mucus. When the virus enters the body, it multiplies in the back of the throat, lungs, and the lymphatic system. The infection then replicates in the urinary tract, eyes, blood vessels, and central nervous system.” The symptoms of measles include runny nose, dry hacking cough, swollen eyelids, and inflamed and watery eyes, sensitivity to light, sneezing, a reddish-brown rash, Koplik's spots, and generalized body aches. Adding further, Dr Aggarwal, said, “A highly contagious disease, measles spreads like wildfire in communities where children are unvaccinated. Since the virus reduces immunity, children who have had measles - especially those who are undernourished - may die of pneumonia, diarrhea and encephalitis later on. India should build on its polio eradication campaign experience to ensure more children get vaccinated against measles. Awareness needs to be created about the need and safety of measles vaccination.” Some tips to ease the symptoms of measles include the following. • Get adequate rest and avoid heavy activities. • Drink plenty of water, fruit juice, and herbal tea to replace fluids lost by fever and sweating. • Seek respiratory relief and use a humidifier to relieve cough and sore throat. • Rest your eyes by keeping the lights low, and avoid reading and watching the television.

Tuesday, 15 August 2017

“Nothing is impossible”: My philosophy of life

“Nothing is impossible”: My philosophy of life Dr KK Aggarwal I was given the name Krishan as the day I was born, 5th September, was the auspicious day of Krishna Janmashtami, the birthday of Lord Krishna. 5th September is also celebrated in our country as Teacher’s Day. Lord Krishna holds special significance for me…evidently so, because of my given name; but, more importantly, because he has helped me define my guiding philosophy of life. Lord Krishna is always depicted in blue color and with yellow clothes. He always holds a flute in his hands. The blue color, like the sky or the ocean, denotes vastness i.e. something which is much larger than what we can see or perceive. To me, this means nothing is impossible. His yellow clothes denote vigor or persistence. The flute in his hands denotes humility. “Take up challenging tasks because nothing is impossible. You can always win with humility.” This according to me is the message from Lord Krishna. This has been my constant endeavor all my life, including my years in the Indian Medical Association (IMA), particularly the last two years, first as the Honorary Secretary General and now as National President. I have always believed that we must try to develop habits and behaviors as befitting one’s given name. Name carries a lot of significance as Akshar in Sanskrit has a vibration and if that positive vibration matches with the vibrations of universe at the time of your birth, it helps in healing. On both my birthdays, Janmashtami and Teacher’s Day, as also today, I try to seek forgiveness from all my colleagues and friends. “Knowingly or unknowingly, if I have hurt your consciousness in my writings, speech, actions or thoughts, please forgive me.” Our medical profession is going through tough times. We are facing an onslaught of atrocities, violence both physical and mental, criminal prosecution, media trials, pubic defamation, to name a few. We need ‘azaadi” from these. We are fighting for the rights of the patients, community as well as our profession. On this Independence Day, let’s pledge to work together and speak together in “One voice” in the best interests of and towards betterment of the community and the fraternity. A Happy Janmashtami & Independence Day to you all! Disclaimer: The views expressed in this write up are entirely my own

Make changes at the personal level to ensure ‘freedom’ from diseases

Make changes at the personal level to ensure ‘freedom’ from diseases Independence Day should also be an occasion to pledge making healthy changes at the personal level and commitment towards eradicating the burden of lifestyle diseases New Delhi, 14 August 2017: As per statistics, India ranks very high among the nations affected by the rising wave of premature deaths due to non-communicable diseases (NCDs), which account for 60% of all deaths in India. About 5.8 million Indians die due to diabetes, cancer, stroke, heart, and lung diseases each year and 1 out of 4 Indians is at a risk of dying from an NCD before the age of 70. As per the IMA, this Independence Day, one should pledge to make lifestyle changes and take preventive healthcare measures at a personal level, to ensure freedom from the burden of NCDs. A healthy diet, regular physical activity, avoiding the use of tobacco and alcohol, and preventive screening can prevent at least 80% of premature deaths from heart diseases and strokes and 40% of cancer related deaths. 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, “Every year, 15th of August is celebrated as the day India got independence from the British rule. However, it is time that we work towards that day when we celebrate independence from diseases. The 15th of August should not just be a reminder of independence from the British but also a commitment on a yearly basis to eradicate one more disease or other problems faced by our country. And change begins at the personal level. It is important to keep a check on the body’s functioning by going for regular health checkups. This will help in assessing risk factors and diagnosing diseases at the right time which will further enable effective treatment and better management of the condition.” Although healthcare in India has undergone massive changes, there is a lot more that needs to be done. The challenge lies in enabling both the private and public sectors to work together and enable a healthy and disease-free India. Adding further, Dr Aggarwal, said, “The Father of Nation, Mahatma Gandhi was absolutely right when he said, ‘be the change you want to see in the world’. This change also applies to our lifestyle patterns, which will encourage others to follow suit and adopt a healthier lifestyle and in turn obtain freedom from diseases and ailments.” One can follow the Formula of 80 to prevent NCDs and live up the ripe age of 80. • It is important to keep your fasting sugar lower than 80 mg % • It is best to refrain from consuming alcohol. For those who still wish to drink, they should restrict it to not more than 80 ml of alcohol in a day or 80 grams in a week • To not consume more than 80 grams of caloric solid or liquid food in one meal, rather eat frequent but small meals • Restrict your soft drink consumption to 80ml in one go. The tip is to add soda and dilute it to make it 200 ml • Do not consume tobacco products otherwise you will end up with a surgery bill of over Rs 80,000 • It is important to keep one’s blood pressure lower than 80 mm Hg and heart rate lower than 80 per minute. • Do aerobic exercises for 80 minutes a week. • Do stretching exercises for 80 minutes in a week. • Consume at least 80 fruits and vegetables servings in a week. • Do not consume more than 80 ml/gram of ghee, oil and butter in a week.

Monday, 14 August 2017

Optimum Noise levels for class room teaching

Optimum Noise levels for class room teaching Everyday exposure to noise over time has an impact upon our ability to hear and on the degree of hearing loss that develops. Continuous exposure to sounds above 85 db can cause progressive hearing loss. Noise-induced hearing loss is the most common and obvious outcome of noise pollution. It is also an important occupational health concern due to high workplace noise levels. However, noise pollution has also been associated with other health problems such as stress, anxiety, high blood pressure, increases heart rate, heart disease. It may manifest as disturbed sleep/ insomnia, headache, fatigue, irritability, loss of concentration and decreased work efficiency. Noise levels are also an increasing concern in class rooms. The source of noise can be external such as street traffic, playground noise, airplanes, etc. The source of noise can be indoor, such as hallway noises, noise from other rooms etc. or noise within the classroom itself such as conversation, noise from fans, lights, paper, etc. Noise in a class room is not conducive to learning. Background noise in classroomsinterferes with auditory communication and adversely affects speech perception and speech recognition. It interferes with language and reading development and hampers academic performance. Attention and memory are also adversely affected. Speech intelligibility or understanding is determined by the signal to noise ratio, which should be at least 15dB i.e. the teacher should speak at least 15 db louder than the noise in the classroom for the student to optimally comprehend what he/she is hearing. For clear speech perception the background noise levels should not exceed 35 dB in schools as recommended by the WHO. The reverberation time in the classroom should be about 0.6 sec. Reverberation time is the length of time required for sound to decay 60 db from its initial level in a room. A longer reverberation time together with background noise increases noise levels and makes speech perception even more difficult. Hospitals are noisy and high stress work environment places. Because of high background noise, such as in emergency dept. and OTs, the conversation has to be conducted at higher dbs for clear speech communication (normal conversation is between 60-70 db). Noise can interfere with oral communication leading to mediation errors as a result of orders that are misunderstood. A noisy environment affects performance of any complex task in a hospital as it reduces concentration. It has been shown that “mental activities requiring a lot of working memory, such as paying attention to a variety of different cues or performing a complex analysis, are especially noise-sensitive”. Failure to hear a warning signal or alarm over the general background noise in an ICU may have potentially catastrophic outcome. Noise affects effectiveness of health care. Hence, hospitals too should have similar noise levels as educational institutes. Schools and hospitals are “silence zones”. Silence zone is an area comprising not less than 100 m around hospitals, educational institutions, courts, religious places or any other area as per the Noise Pollution (Regulation and Control) Rules, 2000. Every effort should be made to reduce noise levels in hospitals for optimum delivery of health care.

MDR TB should be declared a public health emergency

MDR TB should be declared a public health emergency Not adhering to prescribed medications can lead to MDR TB in existing TB patients New Delhi, 13 August 2017: As per available statistics, India accounts for one-fourth of the global TB burden of both TB and MDR TB. About 1.3 lakh incident multi-drug resistant (MDR) TB cases occur in India every year, including 79,000 MDR-TB cases among the notified pulmonary cases. As per the IMA, to prevent the epidemic of MDR TB, it should be declared a public health emergency. Multidrug resistant (MDR) TB is TB resistant to both isoniazid and rifampicin with or without resistance to other first-line anti-TB drugs. Extensive drug resistant (XDR) TB is TB resistant also to a fluoroquinolone (ofloxacin, levofloxacin or moxifloxacin) and a second-line injectable anti TB drug (kanamycin, amikacin or capreomycin). 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, “Tuberculosis (TB) is a major public health concern in the country. Despite advances in TB care, the disease continues to be a major cause of morbidity and mortality. And, it takes a heavy toll on the economy too. Emergence and spread of drug-resistant TB has become a major public health concern now. A person can acquire MDR TB in two ways. First is when a person does not take drugs as instructed by the health care provider or does not take the correct drugs. This situation is likely when the bacteria are resistant to more drugs than the health care provider has prescribed. One can also get MDRTB if they become infected with TB bacteria from another person who already has MDRTB. This is known as primary TB.” The symptoms of MDR TB are similar toregular TB: severe cough lasting for three weeks or more, bloody or discolored sputum, night sweats, fever, fatigue and weakness, pain in the chest, loss of appetite, pain in breathing or coughing, and weight loss. Adding further, Dr Aggarwal, said, “A person can develop XDR-TB if the treatment for MDR TB fails. The treatment for this acquired disease is lengthier, more complex, and expensive. At time, XDR TB can even be impossible to treat and be a death sentence. It is difficult to estimate the incidence of XDR-TB is as many laboratories are ill-equipped to detect and diagnose it. As a result, many of the cases go undocumented.” Here are some tips prevent TB. • Vaccination Newborns must be given the BCG vaccine to protect them against TB. • Keep your immunity high Vaccines may not be able to provide life-long protection. Thus, it is important to maintain a healthy lifestyle and consume a healthy diet rich in fresh fruits and vegetables. Quit smoking and drinking alcohol, exercise regularly, and stay fit. • Maintain good hygiene Certain simple hygienic practices such as covering the mouth while coughing, not spitting in public places, etc. are good ways to avoid infections from spreading. Wash your hands before eating and drink clean water. If you are around someone you know is suffering from TB, avoid direct contact with them. • Take medications on time This is one of the major reasons for acquiring MDR TB. People who have the infection are carriers of the disease. If they don’t adhere to the prescription, the TB bacteria can develop resistance to the drugs.

Sunday, 13 August 2017

IMA Updates

IMA Updates • Medical Council of India (MCI) with inputs from IMA has drafted a document for Indian Medical services. The same will be placed in the next executive committee meeting of MCI. • MCI with inputs from IMA has finalized a draft for Guidelines to govern the prosecution of medical doctors for offences of which criminal rashness or criminal negligence is an ingredient. The same will be placed in the next executive committee meeting of MCI. • MCI with inputs from IMA has drafted standard medicolegal check list so that doctor’s diary may be sufficient to be taken up as an evidence (based on Pt. Parmanand Katara vs Union of India & Ors on 28 August, 1989). • MCI with inputs from IMA is in process of drafting guidelines for deciding negligence (8.6 Professional incompetence shall be judged by peer group as per guidelines prescribed by Medical Council of India). Practice changing IMA policies IMA TB Initiative: GTN • GeneXpert (sputum diagnosis) • Treat and Trace (treat with daily fixed dose combination regimen and trace all contacts) • Notify @ Nikshay Organ transplant • Mandatory required request for organ donation at death • 100% IMA members should pledge their organs / tissues after cardiac or brain death Blood Transfusion • IMA blood donation camps should only be component donation camps IMA-PMSMA: 9th of every month • Provider antenatal care to all pregnant mothers on 9th of every month, for nine months, checking for nine parameters (blood tests, urine tests, blood pressure, ultrasound, weight, vaccination, high risk stratification, arrangements for institutional delivery, lifestyle counseling [diet, rest, breathing, relaxation]) and involving the paediatrician at ninth month IMA Aao School Chale • 5th of every month lets us sensitise school children Ao Gaon/Slum Chalen: On first Sunday of the Month, let us sensitize the community and the families (Aao Ghar Ghar Chale) IMA PvPI Initiative: Call and report any adverse event, side effect of treatment at 9717776514 Physicians’ Health First: All IMA members to have their annual check-up done between 30th July and 5th September. Dr KK Aggarwal

A big breakfast may be key to losing weight

A big breakfast may be key to losing weight Breakfast with a high glycemic index is harmful and can lead to cravings later in the day New Delhi, 12 August 2017: In a recently conducted study, sedentary, obese women lost almost 5 times as much weight on the “big breakfast” diet compared to women following a traditional, restrictive low-carbohydrate diet. As per the IMA, having a good breakfast made up of carbohydrates and lean protein, can help lessen cravings and hunger during the rest of the day, which can lead to significant weight loss. Eating breakfast with high glycemic foods may be harmful. After eating cereals or a doughnut, the blood sugar and insulin levels spike. Once this blood sugar is used up, the body will still have excess insulin circulating, which leads to hunger pangs and craving for carbohydrates. 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, “Treating obese people should entail treatment for carb cravings and hunger first. In the morning, the body is primed to look for food. Metabolism is revived and the levels of cortisol and adrenaline are at the highest. The brain needs energy instantly, and if one doesn’t eat or eats too little, the brain tried to find another fuel source. To do this, it activates an emergency system that pulls energy from muscle, destroying muscle tissue in the process. Then when you eat later, the body and brain are still in high-alert mode, so the body saves energy from the food as fat.” The levels of the brain chemical serotonin are highest in the morning. Craving levels are at the lowest and one may not feel like eating. As the day wears on, serotonin levels dip, and one craves for chocolate or cookies, and such similar foods. Adding further, Dr Aggarwal, said, “Eating processed food causes an increase in the serotonin levels, and the body begins to associate good feelings with them, making it an addictive cycle. A high protein-carbohydrate mix in breakfast gives the body the initial energy boost it needs in the morning. As protein is digested slowly, it reduces hunger pangs. If you crave chocolate, eat it in the morning as having a small piece of chocolate or candy when serotonin levels are high, won’t make it taste as good. The brain, thus, won’t feel the same serotonin boost, and this will eventually help cut down any cravings.” Here are some tips for smarter snacking. • Go for the grain Whole-grain snacks and whole-grain cereals can give you some energy with staying power. • Repurpose food Many breakfast foods can be repurposed as a nutritious snack later in the day. • Try a “hi–low combination” Combine a small amount of something with healthy fat, like peanut butter, with a larger amount of something very light, like apple slices or celery sticks. • Go nuts Unsalted nuts and seeds make for great snacks. Almonds, walnuts, peanuts, roasted pumpkin seeds, cashews, hazelnuts, filberts, and other nuts and seeds contain many beneficial nutrients and are more likely to leave you feeling full. • Snack mindfully Don’t eat your snack while doing something else like surfing the Web, watching TV, or working at your desk. • Carry healthy snacks Carry a small bag of healthful snacks in your pocket or purse to avoid unhealthy snacking at work.

Saturday, 12 August 2017

MDR-TB is a public health emergency

MDR-TB is a public health emergency Over the years, there has been an alarming increase in cases of drug-resistant TB in India. The prevalence of MDR TB is more than 2% in primary TB cases. India has the highest burden of TB patients, including drug resistant patients in the world. MDR-TB is a public health emergency, not only for patients but also for doctors, who are at risk of acquiring the infection from their patients. Control of TB should therefore be of immediate priority for all stakeholders including health care providers and policy makers. Inaccurate diagnosis and/or delayed diagnosis, especially detection of infected but asymptomatic patients (latent TB) as well as incomplete treatment are fueling this epidemic of MDR TB. The entire country is in a state of “angina” with an impending “TB attack”. GTN (glyceryl trinitrate) is used to relieve angina and prevent an anticipated heart attack such as before exercise. A similar “GTN” is needed to prevent “TB attack”. It’s time to adopt and implement an intensive strategy to control this preventable and curable disease. Yesterday, I had spoken about the IMA TB Initiative “DTR-C” “Diagnose, Treat, Report to track Contacts”. We received suggestions and inputs on this, following which, we have altered the message of our campaign to “IMA TB Initiative: GTN”. G: GeneXpert test (diagnose) T: Treat (patients) & Trace (contacts) N: Notify (mandatory) Dr KK Aggarwal

Varicose veins is a highly ignored condition

Varicose veins is a highly ignored condition • Timely treatment is imperative to avoid complications • It is better to avoid tight clothes and high heels New Delhi, 11 August 2017: According to a recent study, varicose veins are a growing concern in Indians with about 7% of India's youth suffering from this condition. Women are four times more likely to suffer from this condition than men. As per the IMA, some of the major reasons for varicose veins include a sedentary lifestyle and wearing tight clothes and high heels. Varicose veins are formed when the valves of the superficial veins of the lower limbs get damaged. As a result, blood flow from the lower limbs to the heart is decreased resulting in retention of blood in the veins. It is most commonly found in legs and feet, particularly calves. 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 legs contain multiple valves that help the blood to flow in the direction of the heart. Varicose ulcer can be found in both legs. Blood starts accumulating in the legs, when these valves get damaged, resulting in swelling, pain, fatigue, skin discoloration, itching, and varicosities. This a slow but progressing condition. Although the symptoms are mild in the beginning, people usually delay in getting themselves tested, which can lead to complications that become difficult to treat. It is imperative to treat this condition on time failing which it can develop a non-healing ulcer on the leg.” Some factors that influence the onset of varicose veins are age, sex, genetics, obesity, and the position of legs for longer periods. Ageing can also result in wear and tear of the veins. Pregnancy, pre-menstruation, and menopause are some factors influencing varicose veins in women. Adding further, Dr Aggarwal, said, “There is a lack of awareness in many people about this condition. What is alarming is that this is an under treated disease. Lack of timely treatment can lead to chronic venous insufficiency, venous ulcers, eczema, cosmetic disfigurement, and systemic hypertension. Provided the patient has no symptoms or discomfort, treatment should be accorded on time. Some patients may also undergo treatment for cosmetic reasons.” Certain self-help tips can help in preventing varicose veins. • Get moving Stimulate blood circulation in your legs by taking regular walks. • Control your weight and diet It is important to lose that excess weight to avoid pressure on the legs. Follow a low-salt diet to prevent swelling caused from water retention. • Wear comfortable clothes and footwear Low-heeled help exercise the calf muscles more and are hence, better for the veins. Avoid wearing clothes that are tight around the waist, legs, or groin. • Elevate your legs Take short breaks between work to elevate your legs above the level of your heart. You can lie down with your legs resting on three or four pillows. • Don’t sit or stand for a long time Change your position frequently to encourage blood flow.

Friday, 11 August 2017

IMA TB Initiative: DTR-C

IMA TB Initiative: DTR-C Tuberculosis (TB) is a major public health concern in the country. Despite advances in TB care, the disease continues to be a major cause of morbidity and mortality. And, it takes a heavy toll on the economy too. Emergence and spread of drug-resistant TB has become a major public health concern now. India accounts for one fourth of the global TB burden, both TB and MDR TB, as reported in Global TB Report 2016. Every year, about 1.3 lakh incident multi-drug resistant (MDR) TB cases occur in India, including 79000 MDR-TB cases among the notified pulmonary cases (TB India 2017 Report). The incidence of primary MDR TB may be higher in selected states like Maharashtra. To prevent the epidemic of MDR TB, it should be declared a public health emergency. Multidrug resistant (MDR) TB is TB resistant to both isoniazid and rifampicin with or without resistance to other first-line anti-TB drugs. Extensive drug resistant (XDR) TB is TB resistant also to a fluoroquinolone (ofloxacin, levofloxacin or moxifloxacin) and a second-line injectable anti TB drug (kanamycin, amikacin or capreomycin). Early and complete treatment is important to prevent emergence of drug-resistant cases. This year, there has been a shift in policy under the government’s Revised National TB Control Programme (RNTCP) from the “intermittent thrice weekly” regimen to a “daily fixed-dose combination (FDC) drugs” regimen for drug-sensitive TB to improve patient compliance to treatment, prevent relapse and minimize chances of developing drug resistance. All cases of TB, whether in the public and private health care sector, should uniformly adopt and follow these standards. Bedaquiline, a new anti-TB drug to be used in the treatment of MDR-TB and XDR-TB was added to the RNTCP, at six identified tertiary care centres across India. Reporting is important to trace contacts of the person with infectious TB. All contacts of the patient should be screened for TB and put on treatment if required. This cascade of screening of contacts, at home and workplace, identifies individuals at risk and prevents further spread of TB, including MDR TB. All GPs should focus on tracing the contacts of their TB patients and screen them for latent TB infection. Accurate diagnosis is important in this endeavor. The rapid diagnostic molecular sputum GeneXpert test should be used to diagnosing TB including drug-resistant TB. Contact tracing increases community awareness about the disease. Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment. Early diagnosis and complete treatment is important to prevent and control TB. To address the problem of rising drug resistance, TB is a notifiable disease. It was declared a notifiable disease in 2012. Every case of TB has to be notified to the local authorities. The approach to all notifiable diseases should therefore be based on DTR “Diagnose, Treat & Report”. • Diagnose early, using sputum GeneXpert test • Treat: Complete and effective treatment based on national guidelines, using FDC • Report: Mandatory reporting The Indian Medical Association (IMA) is launching a new campaign “IMA-TB Initiative: DTR-C” i.e. Diagnose, Treat, Report to track Contacts. IMA requests all its members to actively participate and support this initiative. It is only through a united and concerted effort that this public health menace can be controlled.

Urinary incontinence is a silent problem in many Indians

Urinary incontinence is a silent problem in many Indians Those with the disorder face much stigma, with people isolating such patients due to lack of awareness New Delhi, 10 August, 2017: Statistics indicate that as many as 24 million Indian adults suffer from urinary incontinence and another 27 million suffer from fecal or bowel incontinence. Although the loss of bladder and bowel control is common in people over the age of 40, it can start at the age of 20 as well. As per the IMA, people are not very kind towards those who lose bladder control and can even go to the extent of isolating such people. Old people, in particular, suffer much stigma due to this condition. Urinary incontinence is a condition in which a person suffers from leaking of urine especially while coughing or sneezing loudly. They may also have a strong urge to urinate, which leads to leakage. However, the condition can be managed or even eliminated altogether with some simple lifestyle changes or medical treatment. 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, “Urinary incontinence can be an outcome of many other conditions. In women, the causes could include weak bladder muscles, pregnancy, child birth, forceps delivery, and removal of uterus. Some general reasons are complications from surgery, stroke, or chronic diseases like diabetes, multiple sclerosis (MS), and Parkinson's disease. Diseases that weaken the bladder nerves or spinal cord can also lead to this condition. Incontinence is a disorder and can be treated and managed. Body shaming a person for this or isolating them can lead to embarrassment for them, and sometimes, even depression in the longer run. The fact, however, is that not many people are aware of this condition and need to be educated on the causative factors.” Urinary incontinence is more common among women than men. About 30%of women between the age of 30 and 60 are thought to suffer from it, compared to 1.5% to 5% of men. Two of risk factors for this condition are obesity and smoking. Adding further, Dr Aggarwal, said, “Treatment for urinary incontinence depends on factors such as the type of incontinence, patient's age, general health, and mental state. Bladder training can help people get back their bladder control. In some cases, medication is prescribed in combination with exercises for the pelvic muscle. Surgery is done if other treatments are not effective. Some simple steps can help maintain bladder and urinary health. • Behavioural therapies This includes educating patients about how urine is formed, stored, and expelled. • Pelvic floor muscles exercises These are called Kegels and they help strengthen the muscles that control urination. • Dietary changes Avoid caffeine, alcohol, and acidic drinks. Some things like chocolates, artificial sweeteners, and spices can irritate the bladder. • Weight control Excess weight can put added pressure on the bladder and surrounding muscles. Therefore, maintain an ideal weight or lose weight if you are overweight. • Fluid intake Drink at least eight glasses of water a day to keep the bladder healthy. Drinking less water makes the urine more concentrated and this can irritate the lining of the urethra and bladder.

Thursday, 10 August 2017

Difference between Wrong and Different: It’s not ‘wrong’ to be ‘different’

Difference between Wrong and Different: It’s not ‘wrong’ to be ‘different’ Dr KK Aggarwal We are all different as individuals given our diverse backgrounds, skills, thoughts, etc. Yet our actions or thoughts are often influenced by what the majority does or thinks... doing what the others are doing. This is the “herd mentality” that many of us are often guilty of. Herd mentality is a barrier to originality as it does not encourage independent thinking. It is easy to fade into the background or get lost in the crowd. ‘Fitting in’ may seem more safe and comfortable, yet it may not give you a sense of satisfaction, which you might be subconsciously seeking. Only when you think differently, can you be creative. But, creativity is not just about getting great and original ideas. Implementing these ideas is innovation. If you get an idea and you believe in it strongly, trust yourself and work to make it a reality, even if it does not conform to “accepted norms”. Children have vivid imaginations, free of set patterns. Their imaginations and creativity should be nurtured. Don’t be afraid of not doing “what is expected of you”. Successful people have challenged assumptions and popular practices on their journey to success. Being different is how innovations happen. It requires courage to be creative. Instead of trying to fit in, dare to be different from others. Keep an open mind and don’t be too ready to judge. This may be why very few original researches in medicine are being done in the country. We look to western data and accept them unquestioned. It’s not ‘wrong’ to be ‘different’… This is how you can make a difference. Disclaimer: The views expressed in this write up are entirely my own.

Platelet transfusion in dengue should not be done without proper assessment

Platelet transfusion in dengue should not be done without proper assessment It is imperative to carry out proper diagnosis to confirm dengue in patients with a low platelet count New Delhi, 09 August, 2017: Statistics indicate that India has recorded over 18,700 cases of dengue in 2017, thus far. Apart from other symptoms, dengue causes a drop in a person’s platelet count. However, as per international guidelines, unless the platelet count is below 10,000/or there is spontaneous active bleeding, no platelet transfusion is required in case of dengue patients. According to the IMA, the cause of death in dengue is capillary leakage, which causes blood deficiency in the intravascular compartment, leading to multiorgan failure. Many viral infections, which are not dangerous, can also lead to a drop in the platelet count. A proper diagnosis must be done to confirm whether it is dengue. 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, “At the first instance of plasma leakage from intravascular compartment to extra vascular compartment, 20 ml per kg body weight per hour of fluid replacement should be administered to the patient till the difference between upper and lower blood pressure is more than 40 mmHg or the patient passes adequate urine. Giving unnecessary platelet transfusion to the patient can harm the individual. The normal count of platelets is 1.5 lakh to 4.5 lakh per microlitre of blood. In dengue, this comes down to 20,000 or even lower, but reaches the normal once dengue is cured.” It is estimated that dengue causes about 50 to 100 million infections per year worldwide. It is a viral disease transmitted by mosquitoes. There is no vaccine for the disease yet and the most effective protective measure is to avoid mosquito bites. Adding further, Dr Aggarwal, said, “Family doctors should remember the ‘Formula of 20’ to understand the severity of dengue. Rise in pulse by 20,fall in upper blood pressure by 20 mmHg, pulse pressure lower than 20, hematocrit increase by 20%, platelet count less than 20,000, and more than 20 petechiae in the tourniquet test. Dengue takes on an epidemic form almost every year and creates panic among the public. It is a preventable disease and prevention is the first step in its management.” Human beings are primarily responsible for the presence of Aedes aegypti in their environment through poor sanitation practices; improper solid-waste disposal practices; unsafe water storage practices and poor pool management. The government cannot employ enough persons to search every backyard to identify and destroy breeding sites on a consistent basis to prevent this mosquito from breeding. At an individual level, the following measures can be taken to prevent dengue. • Avoid stagnation of water in and around the house to prevent mosquitoes from breeding. • Close all containers that have water stored in them. • Use mosquito screens, nets, meshes and insect repellent screens regularly. • Do not venture out immediately after dusk. If you need to go out, make sure to wear full-sleeved clothing and apply a mosquito repellant cream.

Wednesday, 9 August 2017

Opinion or judgement?

Opinion or judgement? Dr KK Aggarwal Doctors often tell their patients that “your disease has no cure”. They should never say that there is no cure for this illness. Instead, doctors should say “I have no cure for your disease.” Or an even better answer is “I have no cure for your disease in my system of medicine.” One of these statements is a judgement and the other is an opinion. What is the difference between opinion and judgement? One can have an opinion on any subject or issue. An opinion need not be based on facts or on evidence. Opinions are subjective as they are personal based on one’s beliefs or emotions. Others may agree or disagree with it. Judgement, on the other hand, is an opinion, about the subject or issue in question, expressed as a fact. Judgement is supported by evidence i.e. there is no room for any doubt. Hence, it implies authority and gives a sense of certainty and finality. “There is no cure for this disease” is a judgement. “I do not have treatment for this disease”, this is an opinion. There may be treatments available, which I may not be aware of. Patient care is foremost for the doctor. Hence, always express an opinion and not a judgement. Disclaimer: The views expressed in this write up are entirely my own.

Cerebral venous thrombosis is more common in women

Cerebral venous thrombosis is more common in women This condition can be cured in 80% of the patients, says IMA New Delhi, 08 August 2017: Cerebral (brain) venous thrombosis is an uncommon disorder and going by available statistics, it occurs in 1 per lakh of population. About 5% of those who suffer from this condition die of acute illness and 10% die over time. This condition is also more common in women than men. As per the IMA, complete recovery is possible in about 80% of the patients, and the rate of recurrence is about 2% to 4%. Cerebral venous thrombosis occurs when a blood clot forms in the brain’s venous sinuses. This prevents blood from draining out of the brain. This leads to breaking of blood cells and blood leaking into the brain tissues, forming a hemorrhage. The onset can be acute, subacute, or chronic. The mean age of onset of this condition in adults is 39 years. 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, “Thrombosis of cerebral veins or dural sinus leads to increased venous and capillary pressure, which in turn leads to brain swelling, venous hemorrhage, and/or ischemia with cytotoxic edema. Occlusion of dural sinus causes decreased brain cerebrospinal fluid absorption and elevated brain pressure. Although it is possible to cure majority of those diagnosed with this condition, a certain percentage may die, the reason for which is brain herniation. One of the most common symptoms in which occurs in about 25% of the cases is headache.” Some of the risk factors of this condition are hypercoagulable states, oral contraceptives, pregnancy, cancer, infection, and head injury.Symptoms may include focal neurologic deficits, focal or generalized fits, altered mental status, stupor, or coma. Adding further, Dr Aggarwal, said, “For diagnosis, doctors take a medical history and a physical examination. Description of the symptoms may help to a certain extent, particularly if the person who has had a stroke is unconscious. The final diagnosis is done basis how the blood is flowing in the brain. This is done through imaging tests that show areas of blood flow. Some such tests include MRI and CT scan, Venography, Angiography, Ultrasound, and Blood tests. There are few things that people can do to prevent this condition from occurring. • Consume a healthy diet It is good to follow a diet that is low in fat. Include a lot of fresh fruits and vegetables in your meal plan. • Get enough physical activity Exercising for about 30 minutes every day is not only beneficial in preventing this condition but also in keeping the body healthy overall. • Quit smoking Smoking increases the chances of cancer, which is one of the risk factors for cerebral venous thrombosis. • Keep chronic conditions under control It is important to keep conditions like diabetes under control by regulating daily lifestyle. This will help keep associated risks at bay.

Tuesday, 8 August 2017

A health journalist is a health worker too

A health journalist is a health worker too Dr KK Aggarwal Communication, as we know, is how we acquire information, how we disseminate information. Effective health communication is crucial for health promotion. Health journalists have an important role to play in health promotion by increasing health literacy. The reach of the media, whether print, radio, television and/or internet is phenomenal. In our country, people usually visit their doctors only when they fall sick. News reports on health and medicine are thus their major sources of information and influence health-related behaviors and attitudes. Health journalists increase the level of awareness and knowledge of the general public about any health issue and in this process, they often dispel myths and misconceptions prevalent in the society. It is via news reports that we come to know of the latest advances in medicine, be it drugs, devices, techniques etc. Particularly during times of outbreaks or epidemics, journalists can help to quickly deliver important health-related messages to the public about the disease in question, the Dos and Don’ts, so that people can take adequate measures to stay safe or when they should seek a doctor’s help. Diseases such as type 2 diabetes, once considered to be a disease of the affluent countries are now a major cause of morbidity and mortality in developing countries. India, as we know, has the second highest population of people with type 2 diabetes in the world. As diabetes is a lifestyle disorder, it is important that people are aware of the risk factors and how they can be modified. Health journalists can educate the general public about the need to adopt a healthy lifestyle to check the rising prevalence of the disease. When reporting stories related to health, journalists should ensure that the message should be clear, accurate, complete, factual and relevant as people often make important health care decisions based on what they read or see. The message has to be tailored to the needs of the public. Health journalists are an important link between the patient and the doctor. As health care communicators, they can be considered as health workers and therefore an integral part of health care delivery. Disclaimer: The views expressed in this write up are entirely my own.

Rural India lacks access to safe drinking water

Rural India lacks access to safe drinking water Need of the hour is to address the issue on an urgent basis and reduce the prevalence of water-borne diseases New Delhi, 07 August 2017: As per a global report released recently, about 63 million people in rural India lack access to clean water.[1]Add to this the fact that only about 26.9 million out of 167.8 million households (16%) in rural areas have access to piped water. Studies have also found the presence of iron in water supplied to 30% rural Indian households. As per the IMA, iron when mixed with water, can cause respiratory system hemorrhage. Lack of access to clean water can also lead to multiple diseases. Unclean water can increase the prevalence of diseases such as cholera, blinding trachoma, malaria, and dengue in the rural areas, not to mention other water-borne problems. India is one of the fastest growing economies and the need of the hour is to address the issue of water security on an urgent basis. 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, “There is a strain on our country’s water resources due to various reasons. Providing access to safe water is one of the sustainable development goals and the government must increase efforts towards meeting this goal. Diseases can become rampant if people drink water that is contaminated or unclean. The presence of contaminants can result in adverse health effects such as gastrointestinal illness, reproductive problems, and neurological disorders. Infants, young children, pregnant women, the elderly, and people with a weak immune system are particularly at risk of illness from some contaminants. Diseases such as amoebiasis, cholera, dysentery, and typhoid are all due to drinking unclean water.” It is alarming to note that about 140,000 children die from diarrheal diseases each yearin the country, as a result ofusing dirty water. There is “chronic underfunding” of vital water resources in the country and access to safe water is not necessarily the top priority in government agendas. Adding further, Dr Aggarwal, said, “There is a need to supplement access to safe water withthe necessary tools, infrastructure, and preparedness to deal with the effects of weather and climate change, particularly in rural India. Awareness must be created on the need to drink clean water and how unclean water affects the system. Schools are a good starting ground for awareness creation and the IMA is already undertaking efforts towards educating children on public health issues through the Aao School Chaleinprogramme.” Some tips to prevent water-borne diseases include the following. • Always ensure to drink boiled and filtered water. • Store water in clean containers and clean them every day. • Avoid consumption of uncovered and openly stored water outside. • Ensure that the pipes and tanks that supply water to your house are properly maintained and clean. • Using detergent and hot water, discard or flush any stool in the toilet.

Monday, 7 August 2017

Personal opinion vs official opinion

Personal opinion vs official opinion Dr KK Aggarwal As individuals we all have different opinions or viewpoints at the same time on any situation or a particular topic. At times, opinions may overlap when opinions are similar in some ways but not in every way. These are personal opinions. An official opinion is the opinion of any organization or association i.e. an organized body of authority. It is the collective viewpoint of all members who make up that body and reflects the policy. The National President or Hony Secretary General of the Indian Medical Association (IMA) usually voice the official stand of the association on any issue. But, they may have their personal opinion too or their own interpretation of a situation or issue. When they state that this is the opinion of IMA, it has to be based on the collective consciousness of IMA. The opinion of the house has to be unanimous i.e. everyone is in total agreement with the said opinion. I usually put a viewpoint on an issue/situation in public domain and invite suggestions. Once I receive all suggestions and comments then it becomes IMA's stand. All Spiritual and Mind Body blogs that I write are my personal columns and views and do not reflect the stand of IMA on the topics covered therein. Disclaimer: The views expressed in this write up are entirely my own.

Research underway to prove the effectiveness of stem cell therapy in cerebral palsy

Research underway to prove the effectiveness of stem cell therapy in cerebral palsy About 15% to 20% of physically disabled children suffer from this condition New Delhi, 06 August 2017: One of the most common childhood motor disabilities, statistics indicate that cerebral palsy affects about 15% to 20% of physically disabled children. Its estimated incidence is around 3/1000 live births in India. Though there is no cure for this condition, recent research speaks of the possibilities that stem cell therapy can provide in treating the disorder. Cerebral palsy is a term used to cover certain neurological conditions affecting movement. Children with this condition can find it hard to move certain parts of the body and the condition can vary in severity. Due to the damage to certain parts of the brain, both voluntary and involuntary movements can be affected. 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, “This condition is not contagious and does not affect a child’s intelligence or cognitive ability. It also does not become worse with age. Currently, research is underway to show the effectiveness of stem cell therapy in this condition. This involves two steps: one,taking the patient’s bone marrow and second, injecting it back after it has been multiplied in the lab. The therapy sessions begin after this process. Once the effectiveness of this therapy is established, there could be an effort towards taking up 'autologous' stem cell therapy. Studies have indicated that the progress is quick in children below the age of 10 and this procedure can also cure muscular dystrophy and autism.People with cerebral palsy have a normal lifespan and can lead a good quality of life as well.” Some common symptoms of cerebral palsy include overdeveloped or underdeveloped muscles, poor coordination and balance, involuntary movements, spastic paralysis, crawling in an unusual way, lying down in awkward positions, favoring one side of the body over the other, and limited range of movement. Adding further, Dr Aggarwal, said, “Though stem cell therapy is being spoken of, there is still time to prove its effectiveness in the treatment of this condition. However, other kinds of therapy can help children with this condition achieve their maximum potential in growth and development. As soon as it is diagnosed, a child can begin therapy for movement, and other areas that need help, such as learning, speech, hearing, and social and emotional development.” Some preventive measures can help reduce the risk of cerebral palsy in children. A woman who is planning to become pregnant should ensure that all her vaccinations are up-to-date. Additionally, it is important to: • Attend all antenatal appointments • Quit alcohol, tobacco, and drugs • Indulge in regular exercise • Eat healthy food

Sunday, 6 August 2017

Head of institutes or associations should avoid chairing routine meetings

Head of institutes or associations should avoid chairing routine meetings Dr KK Aggarwal Some days back I attended a function, where Prof NK Ganguly, Former Director General (ICMR) also spoke. He said something very interesting. He said that he tried to avoid chairing committee meetings as the head of the organization unless absolutely required to do so. “I preferred constituting expert committees instead as I can’t be an expert in all fields.” The reasoning behind this approach is clear. If the head of the institution is chairing an expert committee meeting, all those attending the meeting hesitate to speak up and they tend to defer to the views of the institute head. “I want their views, not just my views,” he said. It was a lesson for me. At IMA we have different committees, each with different assigned functions such as family welfare, medical education, medical ethics, anti-quackery, rural health and national plans, to name a few and each with a designated Chair. As National President, I have been chairing many meetings and now I personally feel that this may not always be the right way to look for ways to solve a problem or any issue. The more junior staff tend to defer to the Chair or more senior colleagues. The right way to do it is to involve experts. This is what we routinely follow in standing committees for finance and building. Diversity of ideas, even if dissenting views, can change the way we think. Brainstorming or ideas and viewpoints gathered from a group of people give different perspectives, different interpretations of any given situation and different ways of solving that particular situation. Diversity leads to creative and innovative thinking as ideas that come up are often original in thought. In the remaining term of my tenure, this is what I will try to do i.e. chair fewer meetings and attempt to gather more wide ranging ideas by letting experts take the chair and tap into their knowledge for the benefit of the Association and in turn the fraternity as well as the community. Disclaimer: The views expressed in this write up are entirely my own and do not represent in any way the official stand of the IMA.

Diabetic retinopathy must be detected on time to avoid loss of vision

Diabetic retinopathy must be detected on time to avoid loss of vision Many remain unaware till the issue reaches an advanced stage, where vision once lost cannot be regained New Delhi, 05 August 2017: India has already been accorded the status of the diabetes capital of the world, with about 65 million Indians suffering from this disorder. Statistics indicate that about 40% of those with diabetes will suffer from diabetic retinopathy at some point in time. As per the IMA, although diabetic retinopathy was always one of the associated complications of diabetes, its incidence has seen a rise in recent years. The condition can exacerbate if steps are not taken on time. Diabetic retinopathy occurs from damage to the tiny blood vessels that nourish the retina. They leak blood and other fluids and cause swelling of the retinal tissue thereby leading to clouding of vision. This condition usually affects both the eyes. 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, “Diabetic retinopathy is the major cause of blindness in patients with diabetes mellitus. However, it is largely a preventable or avoidable cause of blindness. Some factors that increase the risk of acquiring this condition include poor glycemic control, high blood pressure, and high cholesterol levels. In most patients, diabetic retinopathy is usually asymptomatic or may cause only very mild symptoms, to begin with. Due to this reason, many people living with diabetes remain unaware until the disease reaches an advanced stage and it becomes too late for treatment. Vision that has been lost cannot be restored. It is imperative that people with diabetes undergo regular screening to detect retinopathy. Early intervention is very important to prevent visual impairment and blindness.” Diabetic retinopathy is included in the list of eye diseases that can be prevented and treated if detected early under ‘VISION 2020: The Right to Sight’ global joint initiative of the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB). Adding further, Dr Aggarwal, said, “Although its symptoms become noticeable only once the disease advances, there are some common things one can look out for including sudden changes in vision / blurred vision, eye floaters and spots, double vision, and eye pain. Laser surgery is often used in the treatment of diabetic eye disease, but each stage of diabetic retinopathy can be treated in a different way.” Few steps can reduce the chances of vision loss due to diabetic retinopathy. Controlling blood sugar levels It is good to keep blood sugar levels in a target range through a healthy diet, frequent monitoring of blood sugar levels, and adequate physical activity Control blood pressure One of the associated complications of this disorder is macular edema which occurs in those with high blood pressure. Therefore, keep the levels in the right range. Get an eye examination regularly Get your eyes checked regularly. Though screening for diabetic retinopathy and other eye problems will not prevent diabetic eye disease, it can help you in timely treatment.

Saturday, 5 August 2017

Doctors and hospitals should be governed by a common code of conduct

Doctors and hospitals should be governed by a common code of conduct Recently, hoardings “Honest Opinion, No Commission to Doctors” put up by the Asian Heart Institute in Mumbai generated a lot of controversy, with many criticising it as casting a negative shadow over the entire profession. Giving and accepting Rebates and Commission are unethical in the medical profession as laid down in the MCI Code of Ethics under Regulations 1.7, 6.1.1, 6.4 and 7.19,. “1.7 Exposure of Unethical Conduct: A Physician should expose, without fear or favour, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession. 6.1 Advertising: Soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organizations is unethical (6.1.1). 6.4 Rebates and Commission 6.4.1 A physician shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment. 6.4.2 Provisions of para 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study / work. Nothing in this section, however, shall prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.” 7.19 A Physician shall not use touts or agents for procuring patients.” Where do doctors stand vis-à-vis the culture of corporate hospitals today? The MCI Code of Ethics are binding on doctors. However, the corporate hospitals are out of the purview of the MCI. Doctors cannot advertise. Hiring agents or touts to solicit is an unethical act on the part of a doctor, but all corporate hospitals have a marketing dept. It is also unethical for a doctor to give rebates and commissions but for a corporate medical establishment, there is no such bar. It is very unfortunate that doctors working in the corporate hospitals and who are bound by a code of conduct, work and report to corporate hospitals, who do not have to abide by a similar code of conduct. Doctors are under pressure to reach the “targets” given to them by the corporate hospitals. There should be a common code of conduct for doctors and hospitals and both should abide by it. Alternatively, hospitals should be owned only by doctors. According to me, there should not have been any controversy on this issue. The hoarding put up by the Asian Heart Institute very daringly showed that the hospital does not indulge in the unethical practice of cuts and commissions. In my opinion, all hospitals in the country should follow suit and declare that they respect the MCI Code of Ethics and will not allow the unethical “cuts and commissions” practice in their premises. Doing so will make their interactions with doctors transparent to the public. This will generate trust resulting in an effective doctor-patient relationship, which is in the interests of both the doctor and the patient. IMA is for “one code of ethics” for doctors and hospitals and had attempted to develop a common code of ethics in collaboration with the Association of Healthcare Providers India (AHPI) and Healthcare Federation of India (NATHEALTH). We undertook this initiative two years back and developed basic documents on code of ethics (as below) as guidelines for members as how to conduct themselves ethically and in a transparent manner in all their interactions with the patients and all others involved in healthcare. IMA & AHPI Code of Ethics for Healthcare Providers • “We comply with all the Regulatory and Statutory requirements. • We respect and uphold the Rights of Patients. • All our doctors abide by MCI code of ethics. • We do not accept expensive gifts, cash benefits or gratification from the drug & equipment suppliers, diagnostic centers or similar agencies. • We do not indulge in any activities that are unethical or illegal such as: o Unjustified admissions o Un-justified reporting or billing to the patient o Sheltering any criminal from the law o Pre natal sex determination o Improper entries in insurance forms o Giving cuts and commissions to any one for soliciting patients o Overbilling in claim cases” IMA & NATHEALTH Code of Ethics for Healthcare “We, the members of IMA and NATHEALTH and signatories to the Code of Ethics for Healthcare, do hereby solemnly declare that we have read and understood the Code of Ethics and shall abide by it to maintain ethical and transparent professional conduct and practices to ensure improved access to and better quality of the healthcare ecosystem in India. • A voluntary and collective commitment to follow ethical practices to ensure that patients are provided access to high quality, cost effective, safe and efficient technologies, products and services. . Comply with all applicable laws and members’ internal policies on the subject and create a mechanism to address violations appropriately. • Recognize and champion the sanctity of patient confidentiality. • Maintain accurate and complete records and ensure their safety and access. • Refrain from offering or accepting any payments/gifts with the objective of influencing a decision making process within the healthcare community. • Desist from engaging in any activity, practice or act which conflicts with, or appears to conflict with the interests of the healthcare community, end users or patients. • Maintain a safe and healthy work environment. • Provide donations only for charitable purposes and not with the intent to influence the healthcare community to purchase, lease or recommend the use of specific products and services or treatment modalities. • Meet all applicable quality standards and accreditations as may be required to provide the appropriate delivery of healthcare services. • Undertake appropriate dissemination of the Code for full applicability and accountability.” But, these apply only to those who are members or signatories as these are voluntary Code of Ethics. There should be a debate on this issue. The same can be adopted by the Govt. The Ministry of Health should discuss with all stakeholders and come out with an Advisory in this regard.