February 13  2015, Friday
These are draft guidelines for implementation by IMA. Kindly give suggestions.
editorial
Five practices that should be avoided by cardiologists
Dr KK Aggarwal 1. Coronary CT angiography should NOT be used as a “screening” test in asymptomatic individuals without clinical suspicion of CAD

2. Cardiac stress testing is NOT indicated in asymptomatic individuals at low risk of coronary events.

Non-invasive testing in patients with suspected coronary artery disease (CAD) should be based on the assessment of their pre-test probability of having disease determined from clinical evaluation (e.g., presence of symptoms and risk factors). Patients with an intermediate pre-test probability (15- 85%) of having CAD should undergo stress testing.1 Coronary CTA may sometimes be considered as an alternative to rule out significant CAD in patients in the lower range of intermediate pre-test probability.1 Neither stress testing nor coronary CTA is useful in patients with a low pre-test probability of CAD.1,2 Asymptomatic patients may be further stratified by the risk of future CAD events using either the QRISK2, ASCVD, or other validated scores. Patients who are categorized as having a 10-year risk <10% will not benefit from stress testing or coronary CTA.3

Indiscriminate use of stress testing with imaging and coronary CTA expose patients to the risk of radiation and iodinated contrast, and the anxiety, costs and harms of the resulting downstream invasive testing and interventions, which may not be indicated.

3. Annual cardiac stress testing should NOT be performed as part of routine follow-up evaluation of asymptomatic individuals or those with stable symptoms

Periodic stress testing in asymptomatic individuals or patients with stable disease (i.e., testing not prompted by changes in symptom status) are considered inappropriate.3 The widely prevalent annual health check-ups involving stress testing should be discouraged.

4. Patients undergoing non-cardiac surgery, who have moderate to good functional capacity (=4 METs), OR have no risk factors for CAD, should NOT undergo echocardiography or stress testing as part of routine pre-operative evaluation

Patients who are active and have moderate to good functional capacity (i.e., they can exercise =4 METs) and those without risk factors for CAD are unlikely to benefit from routine assessment of left ventricular or function stress testing.3 On the contrary, such an approach may cause more harm by delaying elective surgery.

5. Patients presenting late (>72 hours) after STEMI should NOT have angioplasty for an occluded infarct related artery without evidence of ischemia or viability

Patients with an occluded infarct related artery do not benefit from a strategy of systematic percutaneous coronary angioplasty performed after 72 hours of an ST elevation MI.2 Decisions about revascularization should be made based on the presence of symptoms, evidence of ischemia/viability in the infarcted territory.

References
  1. Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003.
  2. Authors/Task Force m, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014;35:2541-619.
  3. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014;63:380-406.
Corrigendum
eMedinewS regrets its editorial on DNB vs MD. It was inadvertently published. Clarification has already been issued

Editor
eMedipics
IMA,IJCP,HCFI
Dermacon 2015
News Around the Globe
  • New data from the National Center for Complementary and Integrative Health (NCCIH) show that from 2002 to 2012, the use of yoga doubled among adults. Overall, 34% of adults used any complementary approach in 2012, of whom about 21 million, about 10% of the population, reported using yoga, according to the most recent complementary health questionnaire, conducted by the National Institutes of Health's NCCIH and the Centers for Disease Control and Prevention's National Center for Health Statistics..
  • Rates of treatment failure and death are lower in patients who receive a kidney transplant than in those treated with intensive home hemodialysis, according to a study presented here at the American Society of Nephrology 35th Annual Dialysis Conference.
  • Smartphone pedometer applications can accurately measure steps and may be more precise than some wearable devices, according to a new study by Mitesh Patel, an assistant professor of medicine and healthcare management at Perelman School of Medicine and the Wharton School, University of Pennsylvania in Philadelphia, and colleagues published February 10 in JAMA.
  • Treatment with cognitive behavioral therapy (CBT) may help relieve insomnia and pain among patients with knee osteoarthritis (KOA), according to a new double-blind, randomized placebo-controlled clinical trial. The study findings were published online January 26 in Arthritis and Rheumatology.
  • According to a new study in the Journal of Clinical Endocrinology & Metabolism, brief 30-min daytime naps might protect you against the harmful health effects of a poor night's sleep. Specifically, naps appeared to restore hormones and proteins involved in stress and immune function to normal levels in the study.
Dr KK Spiritual Blog
How to Be Happy and Healthy

Somebody once asked Lord Buddha, “After meditating for years, I have not been able to gain anything.” Then Lord Buddha asked, “Did you lose anything?” The disciple said, “Yes, I lost my anger, desires, expectations and ego.” Buddha smiled and said, “That is what your gain is by meditating.”

To be happy, one must learn to let go the following:
  • One should let go of the desires. In Amarnath Yatra, Lord Shiva firstly let go of the Bull, which represents the sexual desires. In Hanuman’s Lanka yatra, desires are represented by Samhiki, a creature who used to catch birds by their shadow. Hanuman killed the desires. So, it is possible to kill your desires. Again in Ramayana, desires are linked to Rajsik mind and in mythology, Meghnath represents the Rajsik mind. Meghnath was killed by Lakshman, the determined mind. Therefore, one should let go of the desires by killing them by focused concentration of the mind on the desires.
  • Let go of your expectations. In Amarnath Yatra, the second thing which Lord Shiva discarded was the moon, which in mythology symbolizes letting go of expectations.
  • Let go of your ego. In mythology, ego represents Kansa in Krishna era and Ravana in Rama era. Both were killed by Krishna and Rama respectively, who symbolize the consciousness. Ego can never be killed by the mind and can only be killed by the consciousness (conscious-based decisions).
  • Ego is also represented by Sheshnaag and we have Lord Shiva and Lord Vishnu both having a Sheshnaag each with a mouth downwards indicating the importance of controlling one’s ego.
  • One should let go of his or her ego but also remember never to hurt somebody’s ego. Hurting somebody’s ego in terms of allegations of sexual misconduct, financial corruption or abusing one’s caste is never forgotten and carries serious implications.
  • In Hanuman’s Lanka Yatra, ego is represented by Sursa; Hanuman managed her by humility and not by counter ego. On Naag Panchami, we worship Naag, the ego, by folded hands and by offering milk.
  • Let go of your inaction. One should learn to live in the present. In Hanuman’s Lanka Yatra, Hanuman first meets Menak Mountain, which indicates destination to rest. One should never do that and willfully divert his or her mind towards action.
  • Let go of your attachments. Let go of your attachments to your close relatives and the worldly desires. In Amarnath Yatra, Lord Shiva first leaves Bull (desires), moon (expectations), sheshnaag (ego) and then he gives up Ganesha and worldly desires (five elements). In mythology, this is practiced as detached attachment and in Bhagavad Gita is equated to Lotus. In Islam, detached attachment is practiced in the form of Bakra Eid.
  • Let go of your habit of criticizing, complaining and condemning people. One should always practice non-violent communication and speak which is truth, necessary and kind. One should not criticize, condemn or complain about people, situation and events. Wayne Dyer said, “The highest form of ignorance is when you reject something you do not know anything about.”
  • Most of us often condemn people without knowing their capabilities and label them as unmatchable to us. One should also let go habit of gossiping as it is a form of violent communication.
  • Let go of your habit of blaming others: One should learn to take the responsibilities and people believe in team work. Good leader is the one who learns to be responsible in life.
  • Let go of your need to be always right: It is a form of ego. Remember, in arguments either you can win arguments or relationships. Always try to win relationship and not arguments.
  • Let go of your need to control situations, events and people: Learn to accept people as they are. The world is won by those who let this habit go.
  • Let go of your habit and the need to impress others: This is also a type of ego where we always seek appreciation.
  • Give up your belief that you cannot do it: Remember ‘IMPOSSIBLE’ is ‘I M POSSIBLE’. A belief is not an idea held by the mind but it is an idea that holds the mind. (Elli Roselle).
  • Give up your resistance to change: Remember change is the only constant which will happen and always welcome it. Joseph Campbell once said that one should follow one’s bliss and will open doors to your where there are only walls.
  • Let go of your fear and all negative thoughts: Remember, the mind is a superb instrument if used rightly. It becomes very destructive if used badly. (Eckhart Tolle).
  • Let go of your habit of giving excuses.
  • Let go of always being in the past.
IMA,IJCP,HCFI
Cardiology eMedinewS
  • In patients with acute ischemic stroke patients who have confirmed large vessel anterior circulation occlusions treated with thrombolysis, rapid treatment with the Solitaire FR (Flow Restoration) stent retriever (Covidien) reduced poststroke disability and increased the proportion of patients alive and independent at 3 months, in the SWIFT PRIME trial presented at the International Stroke Conference (ISC) 2015 and published simultaneously in the New England Journal of Medicine.
  • Rapid endovascular treatment improved functional outcomes and halved mortality in ischemic stroke patients with a proximal vessel occlusion in the ESCAPE trial. The study was presented at the International Stroke Conference (ISC) 2015 on February 11 and published online simultaneously in the New England Journal of Medicine.
Pediatrics eMedinewS
  • Trends from multiple studies suggest preschoolers in the United States may be bridging a caloric gap, researchers report in a commentary published online February 9 in Pediatrics. The results suggest the recent decline in obesity rates in 2- to 5-year-olds may continue. The caloric gap estimates how many calories children must eliminate from their daily diet to bring obesity rates down to the 1970s pre–obesity epidemic levels. Among children aged 2 to 5 years, the gap is about 30 kcal daily.
  • Premature birth is associated with an increased use of prescription asthma medication through adolescence, but this tendency disappears by young adulthood, according to a Danish National Cohort Study published in PLoS One 2015.
Make Sure
Situation: A terminally ill patient who developed bed sores is prescribed only systemic antibiotics.

Reaction: Please change the position of the patient frequently and keep the skin clean and dry.

Lesson: Make sure that good nursing care and maintenance of skin hygiene is advised first to patients with bed sores, along with topical antibiotics.
Medicolegal
(Padma Shri, Dr. B C Roy National Awardee & DST National Science Communication Awardee, Dr. K K Aggarwal, Editor eMedinewS and President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association)

Choosing the best option in the judgment of the doctor is not medical negligence


In the case of Charan Singh vs Healing Touch Hospital And Ors on 24 April, 2003 (III(2003) CPJ 62 (NC)), the National Consumer Disputes Redressal Commission observed “it is a settled law when two choices are available, exercise of one, which is the best in the judgment of the doctor and anything else is available to contradict this, doctor in such circumstances cannot be held negligent.
Dr Good Dr Bad
Situation: A patient with skin diseases needed circumcision and wanted to know whether mediclaim covers it or not.

Dr. Bad: It will not be covered.

Dr. Good: It will be covered.

Lesson: Circumcision is excluded unless it is necessary for treatment of a disease.

(Copyright IJCP)
IJCP Book of Medical Records
IJCP’s ejournals
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Twitter of the Day
Dr KK Aggarwal: Chew a tablet of water soluble aspirin if you suspect heart attack
Dr Deepak Chopra: A God worthy of faith must actually matter. He needs to start performing instead of disappointing
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Rabies News (Dr A K Gupta)
Can a rabies patient make a valid will?

A rabies patient can make a valid will. Section 59, Indian Succession Act, 1925: Person capable of making will:
  • Every person of sound mind not being a minor may dispose of his property by will.
  • A married woman may dispose by will of any property which she could alienate by her own act during her life.
  • Persons who are deaf or dumb or blind are not thereby incapacitated for making a will if they are able to know what they do by it.
  • A person who is ordinarily insane may make a will during interval in which he is of sound mind.
No person can make a will while he is in such a state of mind, whether arising from intoxication or from illness or from any other cause that he does not know what he is doing
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh,

SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund,

Post CHD Repair


Deepak, SM Heart Care Foundation Fund,

CHD TOF
About the Editor
National Science Communication and Dr B C Roy National Awardee, Honorary Secretary General IMA, Immediate Past Senior National Vice President IMA, Professor of Bioethics SRM University, Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand, President Heart Care Foundation of India, Chairman Legal Cell Indian Academy of Echocardiography, Editor in Chief IJCP Group of Publications & eMedinewS, Member Ethics Committee Medical Council of India (2013-14), Chairman Ethical Committee Delhi Medical Council (2009-14), Elected Member Delhi Medical Council (2004-2009), Chairman IMSA Delhi Chapter (March 10- March13), Director IMA AKN Sinha Institute (08-09), Finance Secretary IMA (07-08), Chairman IMAAMS (06-07), President Delhi Medical Association (05-06)
IMA NEWS
5 Orthopedic tests you don't need
  1. Imaging studies are not indicated for acute back pain: There is no indication for performing Plain X rays or MRI for patients with acute onset low back pain. Imaging studies do not contribute to majority of cases in general and MRI, on the other hand may show normal age related findings which may be interpreted as abnormal. Moreover, most of these episodes are self-limiting. MRIs and x-rays are seldom needed to diagnose nonspecific back pain of less than 12 weeks duration, and usually are only performed if “Red Flag Signs” suggesting infection, fracture, malignancy or cauda equina syndrome are present, or, the standard back pain treatments are not effective.
  2. MRI is unnecessary for diagnosing osteoarthritis: Weight bearing or standing anteroposterior, lateral and skyline view x-rays are adequate to diagnose osteoarthritis of the knee joint. Knee x-rays give much more useful information about the alignment, bone quality, and the extent of any degenerative changes within the knee. Patients with knee pain should have x-rays before an MRI is considered, unless there is suspicion of a more serious or uncommon condition. X-ray should come before MRI in the majority of knee osteoarthritis cases.
  3. MRI is unnecessary for acute Tendo Achilles Rupture: Tendo Achilles rupture may occur in middle age persons. Diagnosis can be made easily by history and physical examination. MRI is time consuming, expensive, and can lead to treatment delays. Clinicians should rely on the history and physical examination for accurate diagnosis of the acute tendo achilles rupture. MRI should be reserved for ambiguous presentations and subacute or chronic injuries for preoperative planning.
  4. Bone Densitometry assessment by DXA is not indicated in low risk patients: Bone densitometry can diagnose osteoporosis by measuring areal bone density and expressing it as number of Standard Deviations more or less than the expected (Peak) Bone Mass in healthy young adult (T –Score). Bone density measurement by T- Score is meant to diagnose osteoporosis in postmenopausal women and is not applicable to premenopausal women or men under 50 who are assessed by the Z score. Z score is bone density of the person tested expressed as the number of standard deviations more and less than the expected bone density of the age, sex, size, weight and ethnicity /race matched healthy individual.

    Several risk assessment tools are available to quantify the risk of osteoporosis in postmenopausal women. Those at low risk of osteoporosis do not need assessment of bone density. On the other hand, there are specific criteria that are used to determine when bone density test is appropriate. Moreover, once a patient is on treatment for osteoporosis, the bone density measurement should not be repeated before 2 years unless specifically indicated as for example, in patients on high doses of steroids.
  5. Routine Blood investigations are unnecessary for patients with acute trauma
    • In patients with mild to moderate injury: If airway, breathing and circulation are stable and not predicted to deteriorate, no blood tests are required in these patients unless there are specific medical indications.
    • In patients with serious injury: Airway or breathing may be compromised. Circulation is stable with less than 2 liters fluid requirement. Such patients are advised for full blood count and blood grouping. Kidney Function Tests (KFT) are needed only if the injured is >60 years age or has known pre-existing co-morbidity.
    • In patients with serious injuries requiring blood transfusion: Patients with poor perfusion and ongoing hemodynamic instability; such patients need Complete Blood Counts, Kidney function tests and cross matching.
Coagulation studies are not indicated in acute trauma unless the patient is taking oral anticoagulants; if so, INR should be done.

Liver Function Tests (LFTs) are to be done only if hepatic injury is suspected.

References
  1. Grover F Jr, et al. Is MRI useful for evaluation of acute low back pain? J Fam Pract 2003;52(3):231-2.
  2. Wilk V, et al. Evidence and practice in the self-management of low back pain: findings from an Australian internet-based survey. Clin J Pain 2010;26(6):533-40.
  3. Boden SD, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72(3):403-8.
  4. O'Shea KJ, et al. The diagnostic accuracy of history, physical examination, and radiographs in the evaluation of traumatic knee disorders. Am J Sports Med 1996;24(2):164-7.
  5. Garras DN, et al. MRI is unnecessary for diagnosing acute achilles tendon ruptures. Clin Orthop Relat Res 2012;470(8):2268–73.
  6. Lane JM, et al. Osteoporosis: current modes of prevention and treatment. J Am Acad Orthop Surg 1999;7(1):19-31
  7. Emergency Department Orientation Handbooks for RMO/Interns and Registrars, Liverpool Hospital, 2002.
  8. Blood Testing Guidelines for Trauma Patients, Liverpool Hospital Policy and Procedure Manual, 2000.
Medical Emblem
Indian Medical Association is looking for a new emblem for the medical profession. We do not have one. We only have IMA logo. We cannot use the Red Cross emblem. Our emblem should be able to differentiate us from doctors from other pathies. Kindly suggest and send your ideas.

The best state branch of IMA whose emblem will be selected by the IMA will get a prize of 25K.The deadline is one month so that the same can be passed in the working committee.
IMA initiative for safe sound
Chairman: Dr. K.A. Seethi
National Co-ordinator: Dr. C. John Panicker

Noise
  • Any abnormal sounds that irritates human beings is called noise.
    • Unwanted
    • intolerable
  • Undesirable byproduct of technological advance.
  • Nuisance and health hazard too.
India
World capital of noise
Metropolitan cities > 90 dB
(Decibel is the unit of sound pressure expressed in logarithmic scale.)

Sources of noise pollution
  • Traffic (Automobiles, Trains, Aero planes).
  • Loudspeakers.
  • Religious and social ceremonies. (Studies by SOCLEEN in Bombay during Ganapathi festival in 1980 showed that noise levels were 97 dB)
  • Industrial: Factories, construction activities, machineries.
  • High decibel music.
  • Home noise: TVs, Radios, music players, high speed fans, air conditioners, home appliances.
Effects of noise pollution
  • Humans
    1. Systemic Effects
    2. Effect on Hearing
    3. Emotional
    4. Mental
    5. Social
  • Animals
  • Inanimate Things
Clinician – Patient Communication
Vinay Sharma, New Delhi
The Art of Asking Questions

Closed Questions
  • Where is the pain?
  • Who is your doctor?
  • When did you get these symptoms?
  • Are you depressed?
  • What is your name?
  • How many children do you have?
  • Are you happier now?
Open ended Questions
  • What did you do then?
  • How did you feel when that happened?
  • How are you feeling right now?
  • What is happening at the moment?
  • Why do you think it is related to what you ate?
  • What is your major concern now?
Medscape Family Physician Lifestyle Report 2015

Family Physicians Marijuana Use by Age

According to the 2014 Gallup poll, the youngest and oldest age groups had the lowest percentages of reported marijuana use (36% and 17%, respectively). Just about half (49%) of Americans ages 30-49 years and slightly less than half (44%) of those 50-64 have used it. Among family physicians in our survey, the highest usage (29%) is among the baby boomers, ages 56-65. It drops considerably in the next two younger age groups, with only 18% of those 46-55 and only 15% of those 36-45 reporting use. That number rises again among the youngest family physicians (under 35) to 23%.
Media
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Inspirational Story
The Tale of Two Pebbles

Many years ago in a small Indian village, a farmer had the misfortune of owing a large sum of money to a village moneylender. The moneylender, who was old and ugly, fancied the farmer’s beautiful daughter. So he proposed a bargain. He said he would forgo the farmer’s debt if he could marry his daughter.

Both the farmer and his daughter were horrified by the proposal. So the cunning money-lender suggested that they let providence decide the matter. He told them that he would put a black pebble and a white pebble into an empty money bag. Then the girl would have to pick one pebble from the bag.

If she picked the black pebble, she would become his wife and her father’s debt would be forgiven. If she picked the white pebble she need not marry him and her father’s debt would still be forgiven. If she refused to pick a pebble, her father would be thrown into jail.

They were standing on a pebble strewn path in the farmer’s field. As they talked, the moneylender bent over to pick up two pebbles. As he picked them up, the sharp-eyed girl noticed that he had picked up two black pebbles and put them into the bag. He then asked the girl to pick a pebble from the bag.

Now, imagine that you were standing in the field. What would you have done if you were the girl? If you had to advise her, what would you have told her? Take a moment to ponder this. What would you recommend that the girl do?

The girl put her hand into the moneybag and drew out a pebble. Without looking at it, she fumbled and let it fall onto the pebble-strewn path where it immediately became lost among all the other pebbles.

“Oh, how clumsy of me!” she said. “But never mind, if you look into the bag for the one that is left, you will be able to tell which pebble I picked.” The moneylender dared not admit his dishonesty. The girl changed what seemed an impossible situation into an extremely advantageous one.

Most problems do have a solution, sometimes we just need to think in a different way.
Event
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Wellness Blog
Tips for getting the rest you need
  • Reserve your bedroom for sleep and intimacy.
  • Banish television, computer, smartphone, tablet, and other diversions from that space.
  • Nap only if necessary.
  • Avoid caffeine after noon, and go light on alcohol.
  • Get regular exercise, but not within three hours of bedtime.
  • Plan a vacation with a light schedule and few obligations.
  • Avoid backsliding into a new debt cycle. Try to go to bed and get up at the same time every day, at the very least, on weekdays. If need be, use weekends to make up for lost sleep.
Quote of the Day
Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it. David Starr Jordan
IMA in Social Media
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Twitter @IndianMedAssn 789 followers

http://imahq.blogspot.com/ www.ima-ams.org

http://www.imacgpindia.com/ http://www.imacgponline.com/

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Reader Response
  1. In terms of the Indian Medical Council Act, 1956 there are no such powers vested with the Medical Council of India to prescribe any such equivalence or issue any such clarification suo moto at their own level and without any prior sanction of Government of India. The equivalence of qualification for teaching purpose is laid down in TEQ Regulations, which is notified by Medical Council of India u/s 33 with prior approval of the Govt. of India. As per the IMC act, the Govt. of India has a final say in the matter and is the final authority to adjudicate upon or decide upon the issue. Ministry of Health & Family Welfare, Govt. of India in terms of the powers vested has already clarified and upheld the position that such decision of Medical Council of India is void abinitio and is not permissible. Dr Alexandar Thomas
  2. These two Govt orders clearly restate the equivalence of DNB against MD and MS.
    Dr. Manvendra Gaur
  3. Dear Dr KK Aggarwal, My sincere thanks for issuing the clarification. Medical graduates and post graduates are national assets and I believe that under your dynamic and able leadership IMA will work for the interest of all medical students. Regards: Anurag Nbe
IMA Videos
News on Maps
IMA Humor
I'll trust you that you paid

A man walks into a bar and has a couple of beers. Once he is done the bartender tells him he owes $9.00.

"But I paid, don't you remember?" says the customer.

"Okay," says the bartender, "If you said you paid, you did."

The man then goes outside and tells the first person he sees that the bartender can't keep track of whether his customers have paid.

The second man then rushes in, orders a beer and later pulls the same stunt.

The barkeep replies, "If you say you paid, I'll take your word for it."

Soon the customer goes into the street, sees an old friend, and tells him how to get free drinks.

The man hurries into the bar and begins to drink high-balls when, suddenly, the bartender leans over sand says, "You know, a funny thing happened in here tonight. Two men were drinking beer, neither paid and both claimed that they did. The next guy who tries that is going to get punched right in the nose."

"Don't bother me with your troubles," the final patron responds. "Just give me my change and I'll be on my way."
eMedi Quiz
A hemodynamically stable nulliparous patient with ectopic pregnancy has adnexal mass of 2.5 x 3 cms and beta-hCG titre of 1500 mIU/ml. What modality of treatment is suitable for the patient?

1. Conservative management.
2. Medical management.
3. Laparoscopic surgery.
4. Laparotomy.

Yesterday’s Mind Teaser: A 55-year-old lady presenting to outpatient department (OPD) with postmenopausal bleeding for 3 months has a 1x1 cm nodule on the anterior lip of cervix. The most appropriate investigation to be done subsequently is:

1. Pap smear.
2. Punch biopsy.
3. Endocervical curettage.
4. Colposcopy.

Answer for yesterday’s Mind Teaser: 2. Punch biopsy.
Correct Answers received from: Dr KV Sarma, Dr Avtar Krishan.
Answer for 11th Feb Mind Teaser: 3. Borrelia recurrentis is the etiological agent.
Correct Answers receives: Daivadheenam Jella, Dr Avtar Krishan.
Press Release of the Day
MEDICAL PROFESSION TO HAVE ITS OWN EMBLEM

Indian Medical Association will be coming out with an Emblem for medical profession which will differentiate doctors from modern system of medicine from doctors of other systems of medicine.

Giving the details Padma Shri Awardee Dr (Prof) M Marthanda Pillai, National President and Padma Shri Awardee Dr K K Aggarwal, Hony Secretary General IMA said that there is an urgent need for a new medical Emblem which can be used by all doctors who practice modern medicine so that public is not confused about the pathy they are approaching for treatment.

Today, doctors from all system of medicine prefix their name with the word “Dr” which cannot differentiate the system of medicine they practice. Even unqualified persons and quacks have also started using the prefix “Dr”.

The Association has asked all its 30 branches to send their suggestions and a suggested Emblem. The Association will also award a prize of Rs. 25,000/- for best selected Emblem.

Once selected by IMA, the Emblem will be sent to the Ministry of Health and Family Welfare, Govt. of India and Medical Council of India for approval, added Dr Aggarwal.

Letters are also being issued to all medical colleges to involve their students in designing the same.