November 13   2015, Friday
Dr KK AggarwalDr KK Aggarwal ACP New Policy Paper focuses on ethical aspects of ‘Concierge’ Medicine

The American College of Physicians (ACP) has released a policy position paper on the effect of concierge" medicine or direct patient contracting practices (DPCPs) on patient care in terms of medical quality, cost, access and workforce with a focus on ethical practice and makes recommendations to mitigate any adverse effect on the underserved patient.

ACP has defined concierge medicine as "any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care."

Robert Doherty, the ACP's senior vice president for governmental affairs and public policy said that the ACP does not take a position on whether such models are good for medicine. It supports the physician and patient choice of practice but has specified pros and cons if physicians choose the model. Factors in favor of this mode are that physicians can spend more time with patients, patients can see their physicians any time they like, and physicians are more satisfied. But there are drawbacks too such as potential of excluding low-income patients, who may not be able to pay the fees up front, and reducing the number of patients especially when primary care demand is expanding, issues which are important ethical considerations.

Few key recommendations are:

• Physicians in all types of practice arrangements must be transparent with patients and offer details of financial obligations, services available at the practice, and the typical fees charged for services.

• Physicians in all types of practices must honor their professional obligation to provide nondiscriminatory care, serve all classes of patients who are in need of medical care, and seek specific opportunities to observe their professional obligation to care for the poor.

• Policymakers should recognize and address pressures on physicians and patients that are undermining traditional medical practices, contributing to physician burn-out, and fueling physician interest in DPCPs.

The position paper is published online November 10 in the Annals of Internal Medicine.

Concierge medicine is yet to make a major impact in India, but it is becoming popular in the west.
Mr. Nilesh Aggarwal
We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
NPPA revises prices of 6 formulation packs under DPCO, 2013
The National Pharmaceutical Pricing Authority (NPPA) has fixed/ revised the prices in respect of 6 formulation packs under DPCO, 2013. In its notification/order dated 9.11.2015, the NPPA has revised the formulations based on bulk drugs Chloroquine Phosphate, Ibuprofen and Metronidazole. Chloroquine Phosphate injection 40mg/ml, Ibuprofen tablet 200mg, Ibuprofen tablet 40mg, Metronidazole injection 500 mg/100ml, Metronidazole tablet 200 mg, Metronidazole tablet 400 mg are the six formulations whose prices have been capped by the national drug price regulator. (Pharmabiz)

India eases testing norms for new drugs

Mumbai: India has taken a series of steps that eases norms for testing and clinical trials needed for introduction of drugs already approved in other countries. The move places greater responsibility on the Ethics Committees - that vet clinical trials - and is expected to cut timelines for launch of new medicines, including biologics. The Central Drug Standard Control Organization, through a Nov. 10 circular, said if a new drug was already approved outside India after conducting pre-clinical/toxicological studies on animals, such studies are not required to be repeated while approving their proposal for import or manufacture in India unless some specific concerns are raised. The recommendations to ease the norms for additional tests were made by the Investigational New Drug Committee and Drug Technical Advisory Board… (ET Bureau - Vikas Dandekar)
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Specialty Updates
• Deficits in sense of smell may help predict response to cholinesterase inhibitors in patients with mild cognitive impairment (MCI) due to Alzheimer's disease (8th Clinical Trials Conference on Alzheimer's Disease).

• Dr William C Cushman (VA Medical Center, Memphis, TN), lead author of ACCORD trial says that new results from long-term follow-up of the ACCORD trial support the position that the benefits of intensive blood-pressure lowering to a target of <120 mm Hg systolic for patients at high cardiovascular risk, as shown in the new SPRINT trial, should be extended to diabetic patients.

• People with type 2 diabetes fall into three distinct groups, say researchers who have analyzed genotypes and data pulled from electronic health records. Those in group 1 were younger, more obese, and had higher relative risk for diabetic nephropathy and retinopathy; group 2 had higher risk for cancer and cardiovascular disease; risk in group 3 was associated most strongly with cardiovascular disease, neurological diseases, allergies, and HIV infections (October 28 in Science Translational Medicine).

• Two new studies presented at the American College of Allergy, Asthma & Immunology 2015 Annual Scientific Meeting suggest that food allergy and atopy might be underlying factors in some patients with irritable bowel syndrome (IBS).

• The American College of Rheumatology (ACR) has sidestepped the controversy over biosimilar drugs in its 2015 guidelines for the treatment of rheumatoid arthritis. Advice on this new category of drug, as well as some other hot potatoes, has been deferred.

• Three months of clopidogrel given on top of aspirin was associated with a reduced frequency of migraine in patients who had undergone transcatheter closure of an atrial septal defect (ASD) in the CANOA study presented at the recently concluded American Heart Association (AHA) 2015 Scientific Sessions.

• Trained first responders don't need to switch over to the chest compression-only version of cardiopulmonary resuscitation (CPR) recommended for untrained bystanders, a Resuscitation Outcomes Consortium trial suggested. Outcomes were at least as good for out-of-hospital cardiac arrest treated with continuous chest compressions (100 per minute, with 10 asynchronous breaths per minute) as with chest compressions interrupted for two breaths during a pause of less than 5 seconds after every 30 compressions.

• "Individuals with one first-degree relative with colorectal cancer (CRC) <50 years old or two first-degree relatives with CRC independent of age at diagnosis have a moderately increased risk of developing CRC and are referred to as familial CRC. In such cases, colonoscopy at intervals of six years is safe”, said Dr Hans FA Vasen, from Leiden University Medical Center.

• Fluoroquinolone labels need much stronger warnings about the risks for serious adverse events, including tendinitis and tendon rupture, prolongation of the QT interval, and peripheral neuropathy, according to a joint panel of the US Food and Drug Administration (FDA).

• Neurobehavioral effects of prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) extend beyond the first 7 to 10 days of life, as per a new study in the American Journal of Psychiatry.
The science behind Bhai Dooj

Bhai Dooj is celebrated two days after Diwali. Like Raksha Bandhan, it is a day dedicated to the sacred love between a brother and sister. Both Raksha Bandhan and Bhai Dooj fall in Chaturmas, one at the start and the other at the end of this four months of negative state of mind. The Jagannath Yatra (another festival of love between brother and sister where Krishna is worshipped with his sister Subhadra) is also held in Chaturmas. All three festivals also signifies purification of mind, getting it lust free and reminding the people a sacred relationship between men and women. The festival is known as “Bhav-Bij” in Marathi and “Bhai-Tika” in Nepal.

On Bhai Dooj, sisters pray for the wellbeing and prosperity of their brothers by putting tika/tilak (vermilion spot) on their forehead and offer sweets (healthy) and perform a ritual of taking their ‘Arti’. The brother offers gifts as an expression of love. Some sister observe fast on this day; gifts often involve rice, new grass, aab (a length of flax, knotted into a circular shape and dotted with sugar batashas) etc. Rice in mythology symbolizes with fulfilled desires and again this ritual on this day signifies a non lust based sacred relationship between a man and a woman.
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Legal Quote
Raghunath Raheja v Maharashtra Medical Council, AIR 1996 Bom 198

“We are of the view that when a patient or his near relative demands from the Hospital or the doctor the copies of the case papers, it is necessary for the Hospital authorities and the doctors concerned to furnish copies of such case papers to the patient or his near relative.”
Developing an Investment Portfolio

We need to have a balanced investment portfolio which will include a number of investment vehicles that together will contribute the needed characteristics. By spreading capital over many investments, an investor may be able to reduce the overall risk of the portfolio. Investment capital should be spread proportionally over several different investments and among several vehicles within an asset category. The result will hopefully be a portfolio that produces the sought-after investment results and helps the individual to achieve his or her goals and objectives.

(Source: IJCP)

22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Adverse reaction to aspirin is not aspirin allergy

With true aspirin allergy, you can expect angioedema, anaphylaxis, respiratory symptoms, and skin reactions. But abdominal pain, nausea, vomiting, and GI bleeds are adverse reactions and not allergy. (Dr Orgeron at American College of Allergy, Asthma & Immunology (ACAAI) 2015 Annual Scientific Meeting). GI symptoms are manageable by stopping aspirin temporarily or combining it with a proton pump inhibitor. It's not necessary to stop aspirin altogether. Aspirin is considered the cornerstone of treatment for patients with high to moderate risk for coronary artery disease, and therefore the findings have potentially wide-ranging implications.
Off-label drug use linked to more adverse events
A study published in JAMA Internal Medicine has suggested that the off-label use of prescription drugs is associated with more adverse drug events (ADEs) in adults than on-label use, especially when off-label indications are not backed by solid data. The authors, Tewodros Eguale, MD, PhD, an epidemiologist at McGill University, Montreal, Quebec, Canada, and associate professor in the School of Pharmacy at MCPHS University, Boston, Massachusetts and colleagues suggest that caution should be exercised in prescribing drugs for off-label uses that lack strong scientific evidence. (Medscape)
WMA News & Advocacy
• WMA Expert Meeting on Health Databases and Biobanks, 30-31 January 2016, Seoul, Korea

• War, Migration and Health Symposium, 26-27 February 2016, Istanbul, Turkey

• 203rd WMA Council Session, 28-30 April 2016, Buenos Aires, Argentina

• WMA General Assembly, 19-22 October 2016, Taipei, Taiwan

• 3rd edition of WMA Medical Ethics Manual written by Professor John Williams.

• WMA leaders have expressed concern about Government involvement in the election for President of the Order of Physicians of Albania by nominating its own candidate. When its candidate lost the election, the Government challenged the election result in court last month. The WMA, along with the Standing Committee of European Doctors (CPME) and the German Medical Association, has issued a press release and written to the Minister of Health asking the government to respect the independence of the Order of Physicians.

• The WMA has condemned the decision of a Turkish court to imprison two young doctors for giving first aid to people injured during the Gezi Park demonstrations in Istanbul two years ago.

• The partners of the Health Care in Danger Initiative (HCiD) have called for access to and the delivery of health care to be made safer in armed conflict and other emergencies.
One in five Indians walk to work
A survey has shown that more than one in five Indians walk to their work and less than 15% take public transportation. Some 33% use other modes of transport than buses and trains to reach their workplaces situated up to 20 km from their homes. Another 23% walk while 30% don't stir out of their houses but still work. These figures are based on recently released 2011 Census data on different modes of transport used by workers commuting to workplaces within 20km from their homes. Of the nearly 20 crore workers surveyed, 4.5 crore walked to their workplace. Agricultural workers and domestic helps were not considered in the survey. Shreya Gadepalli, Institute of Transportation and Development Policy regional director said, “In urban areas, a large number of people who walk to work are poor. They often walk long distances in spite of inconvenient and dangerous conditions because they cannot afford any other form of transport.” (Times of India - Sivakumar B)
Poorly cleaned flexible endoscopes that can spread antibiotic-resistant pathogens are the top health technology hazard that hospitals and clinicians should tackle in 2016, according to a new report from the ECRI Institute. (Medscape)
Facts on Noise pollution
• Noise pollution is a major health problem in India.
• Constant exposure to loud noise can lead to higher frequency sensorineural hearing loss.
• Exposure to noise greater than 120-125 dB can cause hearing loss or pain in the ears.
GP Tip
Glow-in-the-dark eye exam

To visualize the fundi of even very young children, secure a glow-in-the-dark sticker at about eye level a few feet away from the exam table. Turn the lights out and ask the child questions about the glowing object as you examine one eye and then the other.
Smoking makes you 5 years older

Men have a greater chance of dying then women, and smoking increases any adult's risk of death just as if five years were suddenly added to their age.

• For men who have never smoked, heart disease presents their greatest risk for death at any age, exceeding the odds of dying from lung, colon and prostate cancer combined.

• Male smokers face a lung cancer risk that is greater than the odds of heart disease taking their lives after age 60, and is tenfold higher than the chance of dying from prostate and colon cancer combined.

• The chances of dying from heart disease and breast cancer are similar for nonsmoking women until age 60, when heart disease becomes a greater risk.

• For female smokers, dying from lung cancer or heart disease is more likely than dying from breast cancer after age 40.
Bioethical issues in medical practice
Rights and duties of a parent

Smita N Deshpande

Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

A girl suffering from intellectual disability, serious enough so that she could not take care of herself became pregnant at the care home. By the time the pregnancy was discovered she was pregnant for over four months. The girl was admitted to a government hospital and assessed for MTP. The girl insisted- from the point of view of her limited understanding of the matter- that she wanted to keep the child and bring it up herself. Doctors at the hospital where she was admitted after the pregnancy was discovered were of the opinion that she was intellectually unfit to look after herself, what to say of a child. What should the doctors do?

a) Carry out MTP regardless of the girl’s wishes

b) Allow the pregnancy to continue possibly to the future detriment of the unborn baby.

c) Any other recourse such as going to court – but what if the court orders continuance of the pregnancy? Who will look after the baby?

Do write in with views and your solutions!

Responses received

• The pregnancy should be allowed to be continued. Efforts should be made to find out the father. He should be compelled to take care of the child and in case he is unable to take care of, he should be prosecuted for rape and child be sent to some social organisation along with the mother. Dr BR Bhatnagar

Inspirational Story
Love in action

One night a man came to our house and told me, "There is a family with eight children. They have not eaten for days," I took some food and I went. When I finally came to the family, I saw the faces of those little children disfigured by hunger. There was no sorrow or sadness in their faces, just the deep pain of hunger. I gave the rice to the mother. She divided it in two, and went out, carrying half the rice with her. When she came back, I asked her, "Where did you go?" She gave me this simple answer, "To my neighbors–they are also hungry."

I was not surprised that she gave, because poor people are generous. But I was surprised that she knew they were hungry. As a rule, when we are suffering, we are so focused on ourselves we have no time for others.
eMedi Quiz
All of the following conditions may predispose to pulmonary embolism except:

1. Protein S deficiency.
2. Malignancy.
3. Obesity.
4. Progesterone therapy.

Yesterday’s Mind Teaser:  A 20-year-old man complains of difficulty in reading the newspaper with his right eye. Three weeks after sustaining a gunshot injury to his left eye. The most likely diagnosis is:

1. Macular edema.
2. Sympathetic ophthalmia.
3. Optic nerve avulsion.
4. Delayed vitreous hemorrhage.

Answer for Yesterday’s Mind Teaser: 2. Sympathetic ophthalmia.

Answers received from: Dr K Raju, Dr J Daivadheenam, Dr B R Bhatnagar, Dr Avtar Krishan.

Answer for 11th November Mind Teaser: 4. Glycosylation

Answers received from: Dr Avtar Krishan, Dr Bitaan Sen & Dr Jayashree Sen, Dr Jainendra Upadhyay.
A traffic slogan: Don’t let your kids drive if they are not old enough–or else they never will be.
Readers column
Dear Dr KK Aggarwal, Hats off to your untiring work towards educating people about CPR 10. Regards: Dr Sushma
Press Release
Rapid increase in diabetes incidence is a time bomb that will destroy India’s future generations

In terms of the prevalence of the disease, India has around 65.1 million diabetic patients and 77 million pre-diabetes stage patients

If the disease incidence continues to rise and preventive steps are not taken it is predicted that India will be home to 100 million diabetics by 2030

The increasing incidence of Diabetes is growing to be a major healthcare concern amongst the medical fraternity in India. According to a report released by WHO, a majority of mortality cases are linked to diabetes. Additionally, diabetes is also a leading cause of heart disease and stroke in patients, increasing the risk of its incidence two – four times more than that of non-diabetics.

Our body turns foods into sugar or glucose after digestion. Once this process is complete, the pancreas release insulin, a substance that helps the cells absorb the glucose and produce energy. Diabetes occurs due to the body’s inability to produce adequate insulin causing a rise in the blood glucose levels. Patients with high blood sugar will typically experience polyuria (frequent urination), become increasingly thirsty (polydipsia) and hungry (polyphagia). While Type 1 and type 2 diabetes are the most common forms of the disease, there are other forms as well including gestational diabetes, which occurs during pregnancy and abdominal diabetes.

Speaking on the issue, Padma Shri Awardee Dr. K K Aggarwal, Hon Secretary General IMA and President, HCFI said, “Type 2 Diabetes can be prevented and managed if necessary precautions are taken. The epidemic nature of the disease is a major point of concern for the medical fraternity, and mass preventive awareness campaigns are a must. Losing a modest amount of weight — about 15 pounds — through a controlled diet and exercise can reduce your risk of getting type 2 diabetes by as much as 58 percent amongst people at high risk. Diabetes drastically increases a person's risk of developing heart, kidney, eye and nerve diseases. Diabetics must regularly consult their doctor and ensure that they get enough physical exercise, eat a healthy and balanced diet and keep their stress levels in check. For those suffering from diabetes for over ten years, a complete physical examination and an exercise stress test is recommended so that one can determine the best physical activity.”

Indians develop diabetes 10-15 years earlier than people in the West. The reasons for the epidemic nature of the disease in India and its early incidence a genetic disposition, diet containing high levels of sugar and trans fats and a predominantly sedentary lifestyle.

In addition to this, the following factors also contribute to its early incidence:

Family History: The chances of developing diabetes increases if one of the family members is already suffering from the disease. In such cases, the risk of a child developing diabetes with a parental history of the disease increases by 50 percent.

Obesity: The correlation between Type 2 diabetes and obesity is well known and warned about. Not only obesity but also weight gain can increase an individual’s risk of developing diabetes. Concentrated body fat present in excessive amount deposited in the abdomen can stimulate the chances of abdominal diabetes. It is advised that the desirable waist circumference should be 90 cm for males and 80 cm for females.

Unorganized lifestyle due to urbanization: Several reports have shown that physical inactivity, spoiled eating habits, and a predominantly sedentary lifestyle can act as prominent factors leading to the development of type-2 diabetes. An individual should always keep a watch on his/her daily lifestyle habits and routine. It shouldn’t only entail healthy eating habits and a balanced diet, but also a workout regime and outdoor physical activities.

Stress: Stress has been linked to a wide number of diseases like cardiovascular issues, type-2 diabetes and blood pressure fluctuations. Stress when coupled with physical and mental exertion along with lifestyle changes aggravates the incidence of type II Diabetes amongst individuals with a strong genetic background.

Given the widespread nature of the disease and associated risks, it is essential that the medical fraternity as a whole raise awareness about how Type 2 diabetes is preventable and Type 1 manageable through basic lifestyle changes.