October 15   2015, Thursday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal
IMA seeks increase in budgetary allocation for health

It is the obligation of the state to provide free and universal access to quality health-care services to its citizens. India continues to be among those countries of the world that have a high burden of diseases. The various health program and policies in the past have not been able to achieve the desired goals and objectives.

High-level expert group (HLEG) on Universal Health Coverage (UHC) constituted by Planning Commission of India submitted its report in Nov 2011 for India by 2022. The recommendations for the provision of UHC pertain to the critical areas such as health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation. Planning commission has estimated that 3.30 lakh crores has to be spent in 12th FY period (2012-2017) to achieve the goal of UHC by 2022. We are already into the third year of the 12th FYP and yet only a meager proportion of this amount has been budgeted so far on an annual basis

It is believed that an important factor contributing to India‘s poor health status is its low level of public spending on health, which is one of the lowest in the world. In 2007, according to WHO’s World Health Statistics, in per capita terms, India ranked 164 in the sample of 191 countries. This level of per capita public expenditure on health was less than 30 percent of China’s (WHO, 2010). Also, public spending on health as a percent of Gross Domestic Product (GDP) in India has stagnated in the past two decades, from 1990–91 to 2009–10, varying from 0.9 to 1.2% of GDP

Government should increase the public expenditure on health from the current level of 1.1% GDP to at least 2.5% by the end of the 12th plan and to at least 3% of GDP by 2022. Government should ensure that a minimum of 55% of health budget is spend on primary, 35% on secondary and a maximum of 10% on tertiary care services (as proposed by National Health Policy 200), as against the current levels of 49%, 22% and 28% respectively.

The Twelfth Finance Commission provided grants to selected states for improving health indicators, but in effect, they recommended that the grants cover only 30% of the gap between the state‘s per capita health expenditure and the expenditure requirements assessed by them for each of the state. This should go up to at least fifty percent of the gap. Additional transfers from the central government to selected states have to be directed toward primary care and the first level of secondary care by strengthening the related health infrastructure and personnel. This is important not only to facilitate basic primary and secondary care but also to reduce the burden and expenditure share at the tertiary level.

The estimated additional expenditure requirement just to provide subcenters, health centers, and community health centers according to the norms is estimated at 0.6% of GDP. There are additional administrative expenditures and requirements for providing health facilities in urban areas, and these could add up to another 0.4%. Thus, a minimum of one percent of GDP will be required in the medium term (next 1 to 2 years) to ensure minimum levels of health care as per the norms.

There should be an increase in spending for public procurement of medicines from 0.1% to 0.5% of GDP. Government should bring in legislation to discourage pharmaceutical firms from using trade names in marketing. Drugs should be available only in chemical name; which will help to bring in uniformity. At the same time there should be strict mechanism to monitor and ensure that drugs available in the market are of good quality. Government should invest in establishing drug-testing laboratories in each state. In addition, government should support and rejuvenate the existing public sector drugs and vaccines manufacturing units

General taxation plus deductions for health-care from salaried individuals and taxpayers as the principal source of health-care financing should be used, and no fees of any kind be levied for the provision of health-care services under UHC. Insurance is not a panacea and government should refrain from promoting health insurance as the best solution for health care problems in the country.

Government should introduce a health cess (0.5%) as a component of the existing VAT system and the new Goods and Services Tax (GST) that is proposed. There should be additional health cess for sweetened beverages, tobacco, alcohol and cars. This will raise revenue for the government and at the same time will also act as a measure to discourage the use of these products

Water, hygiene and sanitation are the cornerstones for effective public health protection. Government should not only increase allocation to these areas, but also ensure that the money is spend properly and time-bound Government should move to a system of ‘purchasing’ secondary care services from private sector until it can provide these services by itself. This will help to prevent out-of-pocket expenses for a large section of population and also can reduce the burden on tertiary care.

The reimbursement scheme for health care should be extended to all people working in organized sector and not just to central government employees. This will help to relieve some pressure on the public health systems on one side, and will help to give more options for people in the organized sector.

The present schemes such as JSBY, RSBY, JSY etc. are run by different ministries and departments. The Budget should facilitate convergence among the various stakeholder ministries/departments so that we can evolve a comprehensive social security package

Public and private sectors should not move as parallel systems, but should complement each other. Public private partnership in health should be promoted. At present, the facilities in private sector are underutilized at one end, whereas public sector lack in facilities to cater to the needs. Government should design special programs in discussion with professional associations like IMA to optimally utilize the resources- both in the public and private sector. This will include sharing of the resources in private sector like CT, MRI scans etc. for patient care in public sector.

Services of family doctor/single man private clinics should be optimally used on a retainership basis, at least in places where government doctors are not available at PHCs, until government is able to recruit and sustain regular doctors.

Government should increase the allocation for health awareness programs. A repository on health information should be created and disseminated using the social media. Non-communicable diseases and health needs of the elderly need urgent attention. Government should increase the allocation to these areas significantly. National programs for NCD and care of elderly should be introduced in all the districts within the next two years. Telemedicine should be given importance, with simultaneous investment in increasing the availability of trained and qualified human resources.
Breaking news
New biomarkers found that can now predict HIV relapse

New biomarkers have been identified, which may help predict the relapse of HIV virus in some patients after they discontinue with their treatment.

In a recent research published in the journal Nature Communications, researchers analyzed data from a randomized study of 154 patients with primary HIV infection from Europe, Brazil and Australia involved in the SPARTAC trial who were taken off their ART after 12 or 48 weeks. Three specific biomarkers (PD-1, Tim-3 and Lag-3) were found to be associated with the destruction of immune cells called T cells and were statistically significant predictors of HIV viral rebound. High levels of these biomarkers, attached to 'exhausted' T-cells prior to patients started ART, were associated with earlier rebound of the virus following treatment interruption. Researchers are hopeful that these findings may open up new avenues for understanding the mechanisms underlying post-treatment control, and HIV-1 eradication in due course.

SPARTAC (Short Pulse Anti Retroviral Therapy at HIV Seroconversion), is the largest randomized controlled trial ever undertaken in primary (recent) HIV infection and was conducted between 2003 and 2011 across eight countries.
Dr Good Dr Bad
IMA,IJCP,HCFI
Specialty Updates
• Stimulant medication for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children with congenital heart disease (CHD) does not affect heart rate or blood pressure and can be safely administered in this patient population, suggests new research presented at the Society for Developmental and Behavioral Pediatrics 2015 Annual Meeting.

• Contrary to previous research, a new study suggests that prolonged sitting is not damaging to health if one engages in regular exercise. The findings are published in the International Journal of Epidemiology.

• A protein-restricted diet among young women leads to significant decreases in calcium absorption, suggests new research presented at the American Society for Bone and Mineral Research meeting. This could have implications for women's skeletal health later in life.

• The process for screening for type 2 diabetes or those at high risk of the condition needs careful re-evaluation, suggested the first study on the effectiveness of testing methods published in the journal PLos One.

• A new study comparing the dietary patterns of cancer survivors to federal guidelines indicates that they often have poor diets. The findings, published online October 13 in the journal Cancer, underscore the need for dietary interventions in this vulnerable population.

• In a head-to-head trial, a new version of an HIV drug had efficacy similar to its older rival; however, a single-pill regimen based on the investigational tenofovir alafenamide had a better safety profile than a similar regimen based on the older tenofovir disoproxil fumarate. The data were presented at the annual IDWeek meeting.

• Minocycline may have a role to treat patients with possible multiple sclerosis (MS), suggests a new study showing that minocycline reduced the absolute risk of developing MS by 27.4%, and the relative risk by 44.6%, compared with placebo in patients with clinically isolated syndrome. The findings were presented at the Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2015.

• New research suggests that pre-pregnancy exercise can help reduce pelvic girdle pain during pregnancy. The findings are published in the British Journal of Sports Medicine.

• A head-to-head comparison of the everolimus-eluting stent with a bioresorbable scaffold against a conventional everolimus-eluting cobalt-chromium stent showed the two devices yielded similar rates of target lesion failure (TLF) at 1 year. The findings were presented at Transcatheter Cardiovascular Therapeutics (TCT) 2015 and published simultaneously in the New England Journal of Medicine.

• Patients who underwent gastric bypass surgery were at a much higher risk of self-harm than before the surgery as reported in a longitudinal cohort analysis published in JAMA Surgery.
IMA,IJCP,HCFI
Media
IMA,IJCP,HCFI
eSPIRITUAL
On the 3rd Navratri control your fire and negative energies
Chandraghanta is worshipped on the third day of Navratri. SHE is shown with golden skin and riding a tiger. She is depicted with 10 hands and 3 eyes with a crescent moon on the head. Eight of HER hands display weapons. The rest two are in the mudras or gestures of giving a boon/blessing and stopping harm (Varada and abhay mudra) indicating protection.

Out of her eight hands, five hold:

• Bow and arrow in two hands (to bend, focus, one point determination. The bow and arrow also represent energy. Holding both the bow and arrow in one hand indicates control over both potential and kinetic energies)

• Trishul (balance)

• Sword (sharp intelligence)

• Mace (power to destroy the evil).

Rest three hands hold:

• Rosary (tapas)

• Lotus (detached attachment)

• Kamandalu (acceptance).

In Ayurveda, SHE represents the control over the fire element. In Yoga Shastra, SHE represents the solar or Manipura Chakra with the Bija sound RAM.

Sound of her bell terrifies demons as well as all enemies. SHE represents protector and bravery.

Spiritual mantra on the 3rd Navratri

One should continuously (beaded rosary) control the fire (solar plexus) within by using our sharp intelligence (sword) and balancing the mind (Trishul) by focusing on one point (arrow and bow), practicing detached attachment (lotus), accepting things as they are (Kamandalu) and killing the negative energies by using gada (power) when needed.
Legal Quote
Jacob Mathew v. State of Punjab SC / 0457 / 2005: (2005) 6 SCC 1 (iv)

“Deviation from normal practice is not necessarily evidence of negligence. To establish liability on that basis it must be shown (1) that there is a usual and normal practice; (2) that the defendant has not adopted it; and (3) that the course in fact adopted is one no professional man of ordinary skill would have.”
TB Fact
Prior TB disease is associated with an increased risk of subsequent TB disease.
Medicofinance
Once the plaintiff obtains a legal judgment against the doctor in a malpractice lawsuit, the plaintiff becomes a creditor of the doctor, and the doctor becomes a debtor. The plaintiff can now use the judgment to collect and attach almost any and every personal and business asset of the doctor. Consequently, the purpose of all asset protection planning is to remove the debtor-doctor from legal ownership of his assets, while retaining the doctor’s control over and beneficial enjoyment of the assets.

(Source: IJCP)
Industry News
India takes the third spot in the global startup space: India has overtaken Israel to become the third largest startup base after the US and the UK with more than 4,200 startups. The country also becomes the youngest startup nation in the world, where more than 72% founders are 35 years age. There has also been a 50% increase in female entrepreneurs this year compared to 2014. As per a report published by Nasscom in association with research firm Zinnov, around 1,200 tech startups were born in the year 2015, out of which more than 50 per cent focus on e-commerce, consumer services and aggregators business. Bengaluru continued to be the favourite destination and was placed 15th globally. (The Hindu - Pradeesh Chandran)

'mSehat' launched in UP: A mobile Health Solution, ‘mSehat’ was launched in Uttar Pradesh by the Chief Minister Akhilesh Yadav to help health workers to record maternal infant data in real-time. It is a cloud-hosted solution to facilitate remote access and enrolment from across the region through 2G-enabled mobile devices This mobile app developed by Kellton Tech selected as the technology partner for this initiative by SIFPSA (State Innovations in Family Planning Services Agency). (NDTV Gadgets- PTI)

Indian start-ups to see funding worth $5 billion by year end: A report by Nasscom states that the Indian start-up ecosystem will see funding worth $5 billion by the end of this year. The number of active investors grew from 220 in 2014 to 490 in 2015, while number of incubators or accelerators grew to 110, 40% higher over last year. (Mint- Moulishree Srivastava)

Poll puts India as most favored investment destination: India has been named the most attractive country for investment in a survey of more than 500 global investors published by accounting firm Ernst & Young. Thirty-two percent of the 505 executives questioned said India was their favored market for investment, with China second on 15% of the vote, followed by Southeast Asia, Brazil and North America. Mark Otty, EY area managing partner for Europe, Middle East, India and Africa said, “There is no doubt that interest in India has increased. Investors increasingly see the potential and understand the fundamentals.” (Live Mint)
eMEDIPICS
IMA,IJCP,HCFI
Dr A Marthanda Pillai National President IMA, Dr KK Aggarwal Hony Secretary General IMA and Dr Sudipto Roy at the World Medical Association meeting in Moscow
MTNL Perfect Health Mela 2015.

Pls click here for details
IMA Digital TV
Medicolegal
Bioethical issues in medical practice

A Physician’s right to privacy

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

The case concerns a lady who underwent hysterectomy. The surgeon used to suffer from epilepsy, which was currently well under control. While the surgery went off well and the surgeon did not have any health issues during surgery, the patient died due to an inadvertent cystotomy during surgery.

a) Should the surgeon have disclosed his health information with the patient and allowed her to choose?

b) How much privacy should a physician enjoy in disclosing health issues to the patient?

c) When a surgeon suffers from periodic health issue such as epileptic seizures or unstable diabetes, should s/he discuss them with patients, especially if the health condition is under control? Should such a surgeon undertake surgeries without disclosing his health condition?

Adapted and shortened from: UNESCO, 2011. Casebook on Human Dignity and Human Rights, Bioethics Core Curriculum Casebook Series, No. 1, UNESCO: Paris, 144 pp.

Do write in with views and your solutions!

Here are some of the responses received

• Do pilots tell passengers what they're suffering from? It's for the competent authorities to make sure the professional is fit to deliver. No need for the client to know the details. Sheela Jaywant

• I believe this is not something that mandates disclosure, a conflict of interest would perhaps need disclosure, but epilepsy/diabetes really do not, until they impact the doctor’s daily living. An apparently healthy surgeon can have a heart attack in the middle of a case, a hospital building can collapse, a cautery can electrocute/cause burns –these are all out of the realm of ‘expected’ but they are possible –does it mean we should inform about all of those as well? Additionally there is personal/private information of a surgeon –that should not need to be shared. Doctors and surgeons are all humans and have all the limitations of being one. He should definitely inform of the inadvertent cystotomy and manage that to the best of his ability /refer. Dr Pooja Sharma, MD (Obs and Gynae), Senior Scientist Medanta - The Medicity, Cankids patient advocacy group leader (Hon)

• He should refrain from active surgeries as he can put the others life at risk. Satish Malik

• Let’s suppose the patient had a comorbidity, which was not initially declared, would the surgeon use the information to absolve himself/herself of all responsibility? We must consider whether this would have been the stand of the surgeon even if the comorbidities played no role in the patient's death. There are some more questions that this case study brings to the forefront. How many doctors declare substance abuse or dependence? Psychiatric disorders? Such as OCD or even other debilitating or minor disorders? Every patient has a right to know the qualifications of the doctor (MCI Code of Ethical Regulations), they also have a right to know the drawbacks of their doctor. I agree that the code is hardly followed in letter or spirit, but that is one of the reasons for the sorry state which medical practice finds itself in. I think both sides need to be open. In the hypothetical case you describe, a good lawyer would have a field day if the patient's relatives decide to sue. They should not only be open but be seen to be open too. I believe this debate could open a can of worms. Ravi Ghooi

• The case in example is not specific to only medical ethics, but ethics in public life in general. I remember some 2-3 years back, a neurologist colleague of mine discussed with me about one of her epilepsy cases, who was a school bus driver of a Public school in Delhi. She came to know about his profession after persistent inquiry. We discussed the possible consequences of such a school bus driver and on probing the case further, the driver admitted that he did not reveal his status to the school authorities. She took the pains of contacting the school and saw to it that the said driver was rehabilitated as a gardener, removing him from driving duties. Another similar case is the aircraft pilot of one of the recent air crashes, where the pilot was suspected to be a case of depression. So I consider this issue a more generic one. Coming to the case of the unfortunate surgeon, I reckon that such professionals need not discuss their health issues with individual patients they deal with. Instead they should disclose their health problems that might impinge their professional activities to their regulatory authorities. It is for the regulatory authorities (such as IMC or state medical council or NHS etc.) to consider the issue at length and advise the individual professional as deemed fit. If such a surgeon should disclose his health problem to his individual patients, then the questions such as consent form, its appropriateness, video recording of the consent etc. will compound the issue further. Dr V Sreenivas, Professor of Biostatistics, AIIMS, New Delhi

• By hiding information about themselves do physicians want to maintain a 'God like aura' and is this necessary to their practice and is this 'aura' beneficial for their patients? This could be permissible as long as the physician satisfies basic universal ethical and legal criteria of functioning and doesn't harm the patient? On the other hand, if the physician hides certain data about his/her own abilities (or disabilities as in this example) that may harm the patient (not very clear or definite from the given scenario, as also pointed out by others), I guess it would be unethical? Hiding information is a known mechanism of leveraging one's power base from time immemorial and primates too use it in jungles by not disclosing locations of trees where the figs have ripened (and hold the promise of better nutrition and subsequent power gains)? Apologies for posing more questions than offering answers. Dr Rakesh Biswas, Dept. of Medicine, LN Medical College, Bhopal

• If the symptoms were fully controlled for the duration which is used to decide on the competency of other professionals like drivers, the surgeon was not obliged to disclose his condition to the patient. The answer depends upon whether the health issue is likely to affect the medical judgment of the surgeon. If not, there is no need to disclose them. Do we disclose our current worries, stresses to the patient although we know they may affect our performance? Since surgery is always a team work, the surgeon may do well to let the other members know his health issues so that they can keep a watch and spot automatic behavior at the earliest moment. Sudhakar Bhat

• This is the simplest of a dilemma a doctor can answer (practically, theory is redundant here!): One tells the truth one faces the consequences; one doesn't tell it, one faces the consequences. This world is all about managing to survive. Ved Mahla

• When surgeon has a blade in hand during surgery and is also epileptic, it is really dangerous. Other medical illnesses in surgery or epilepsy in other medical branches are not dangerous to patient. Dr Rohit Bansal

• A relative of mine, a surgeon in UK was retired from active surgery after he developed scar epilepsy from a small superficial infarct. He was offered a teaching job. Vivek Kirpekar

• Most 'doctors' over the age of 40 have some illness or the other - heart disease, hypertension, diabetes, arthritis, cancers, GI diseases, renal disorders, Infections, UTIs, alcohol and other substance abuse/dependence disorders, mood disorders, anxiety disorders, other psychiatric disorders, other medical disorders, dental Problems etc. Most of them would be on medications and other necessary treatments.

Scenarios

o A 'doctor who is suffering from heart disease or other medical /psychiatric illness, while performing any surgery or invasive medical procedure or even performing ECT, has a myocardial infarction, hypoglycemic attack, epileptic seizure, blackouts, heart rhythm disturbances, delirium, other acute medical/surgical/psychiatric condition etc.

o Due to the side-effects of the medications the 'doctor' is taking, he could have sudden rhythm disturbances, hypotension, fainting spells, seizure, hypoglycemic attack etc.

The question is not whether the doctor is competent. The question is whether the doctor is currently suffering from the illness and is taking treatment and is he fit to practise or does he require rest till he is fit. A fitness certificate has to be provided/submitted by the concerned specialty treating doctor. The Hospital HR/administration is responsible for all these documentations. A doctor who is practicing in a hospital is deemed to be fit by any patient. If any procedure goes wrong due to the doctors illness and proven unfitness AND it is proven in the court of law, then the hospital is responsible for allowing the doctor to practise when not fit.

Fitness is taken for granted in India. In the US, according to recent statistics despite strict laws, their implementation, licensure exams and high quality care delivery, medical errors are leading to 400000 deaths (4 lakh deaths per year, YES 4 lakh deaths and innumerable increase in morbidity).

In India, with fake doctors flourishing, Homeopathy, Ayurveda, Allopathy, pharmacists, RMPs, Nurse practitioners, compounders and even health assistants practising however they like with scant regard to knowledge about standard care or Guidelines and no monitoring system, no accountability, it makes me believe, GOD is controlling India's population through these people. Dr Naresh Vadlamani, Hyderabad

• First of all, a surgery is a team effort led by a senior surgeon. Once you say epilepsy well under control, this means the hospital / organisation had accepted his capacity to operate. When the subject succumbs to some other cause (not because the surgeon having a PCS/GTCS at the time of surgery), the surgeon’s existing ailment which had been declared under control) the question of surgeons competence shall not arise. If you go by this yardstick, doctors with CAD /bronchial asthma etc. should declare themselves and tell the patients and the relatives that they suffer from these ailments which makes the disclosure ridiculous. That’s why the saying ‘go to an experienced physician, but to a young surgeon for treatment’. Probably in many elective procedures, our patients and caregivers are very clever as they choose who should perform it. Let’s not underestimate their selection. Probably you would remember about a senior surgeon in a prestigious institute who had a similar problem and it really happened. Unfortunately he himself was an administrator and the treating neurologist did not issue an advice about his ability to perform surgery. Dr Padma Sudhakar Thatikonda, Professor and head (Retd), Dept of Psychiatry, Sri Venkateswara Medical College, Tirupati.
Breaking news
Collaborative initiative on state-level disease burden estimation in India

The Ministry of Health and Family Welfare, Government of India has launched a collaborative initiative with the Indian Council of Medical Research (ICMR), the Public Health Foundation of India (PHFI) and the Institute for Health Metrics and Evaluation (IHME) at the University of Washington to estimate the state-level burden of disease in the country.

Non communicable diseases are rapidly increasing in the country, while diseases such as respiratory infections, tuberculosis, diarrhea etc. continue to be very high. Due to a variation in disease burden across the country, national-level estimates do not provide enough detail for targeted-action. Hence, a reliable estimation of disease burden at sub-national level is necessary in order to formulate an informed health system response to improve population health. Estimates of all the major drivers of health loss at the state level in India will be generated by a global network of researchers coordinated by IHME using the methods employed for the Global Burden of Disease (GBD) study. The initiative plans to produce multilevel disseminations through policy-briefs, workshops and seminars to raise the discourse and monitor changing disease trends. State-of-the-art GBD interactive visualization tools will be used to bring to life the initiative findings, which will allow a variety of contrasts between states. This will help policy makers in understanding trends of disease and risk factor in order to plan further action. (Source: The Financial Express - Newsvoir)
MAKE SURE
IMA,IJCP,HCFI
IMA Satyagraha, suggested slogans
• Writing prescription drugs by a non-MBBS is injurious to health of the community.

• Writing prescription drugs by unqualified people can be dangerous.

• Allow doctors to treat patients irrespective of patients’ income.(If compensation is not capped, we can't do this)

• When there is capping of Rs 2 lakh for a sterilization death, why not for other procedures?

• When there is a compensation of Rs 30,000/- for a sterilization failure, why not for other procedures?

• Allow us to treat poor and rich equally.

• Non pelvic ultrasound providers should be out of PCPNDT Act.

• Unless caught doing sex determination, no criminal offence shall be registered.

• If any prospective parent asks for sex determination, they should be booked under a non bailable offense.

• More patients will die if doctors are not provided protection during duty hours.

• Death does not mean negligence.

• Money spent does not mean you will get a cure.

• Including single clinic and small establishments under Clinical Establishment Act will make treatment costly.

• How can we treat patients using outdated standard treatment guidelines made by government?

• How can government decide the charges of a clinical establishment?
MCI Code of Ethics Regulations, 2002
2.2 Patience, Delicacy and Secrecy: Patience and delicacy should characterize the physician. Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the State. Sometimes, however, a physician must determine whether his duty to society requires him to employ knowledge, obtained through confidence as a physician, to protect a healthy person against a communicable disease to which he is about to be exposed. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances.
ACR releases first guideline on ankylosing spondylitis
The American College of Rheumatology (ACR) has issued evidence-based recommendations for management of patients with either ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (SpA). These guidelines are simultaneously published online in Arthritis & Rheumatology and Arthritis Care & Research. The major include:

• NSAIDS for adults with active AS

• TNFis for adults with active AS despite NSAID treatment

• No specific TNFi preferred for adults with active AS, except for infliximab or adalimumab, rather than etanercept for adults with AS and inflammatory bowel disease

• No systemic glucocorticoids for adults with active AS

• Physical therapy for adults with active AS

• Total hip arthroplasty for adults with AS and advanced hip arthritis

• TNFi for adults with active nonradiographic axial SpA despite treatment with NSAIDs
IMA JIMA
IMA Digital TV
India's silent killers: Heart and respiratory diseases

The recent Global Burden of Disease Study lists heart and respiratory diseases as the major factors that will cut the life expectancy of Indians. High blood pressure, blood sugar, cholesterol, poor diet, alcohol use, air pollution and tobacco smoking have been the contributing factors. In 1990, the major causes of deaths in India were lower respiratory infections (58,575), diarrheal diseases (45,824) and preterm birth complications (43,528). But, in 2013, ischemic heart disease (36,913), chronic obstructive pulmonary disease (20,884) and lower respiratory infections (20,478) became the major diseases causing deaths in the country.

According to Dr K Srinath Reddy, President of Public Health Foundation of India (PHFI), the efforts of the State-level Disease Burden Initiative would help refine the understanding of these variations across India and would lead to formulation of appropriate strategies for the different states of India. Dr Soumya Swaminathan, Director-General of ICMR and Secretary, Health Research, said that this collaborative effort will be a first-of-its-kind that examines the extent, pattern, and trends of diseases and risk factors across the states of the country... (Source: Mail Today)
India could see a rise in new HIV infections

The United Nations envoy for AIDS in Asia and the Pacific, J.V.R. Prasada Rao has said that new HIV infections in India could rise for the first time in more than a decade because states are mismanaging a prevention program. The federal AIDS budget was cut by one-fifth in February and Prime Minister Narender Modi asked the states to fill the gap, even though the poorly-run bureaucracies were already slow in releasing the funds to their AIDS prevention units. This has led to slowing of prevention activities and delay in staff salaries. The decision was part of a wider strategy to decentralize social spending and focus central government resources on building roads and railways to boost economic growth. Under the new funding arrangement, states are given a larger share of federal taxes but are no longer obliged to allocate funds for social schemes

India's efforts to fight HIV have for years centered around community-based programs run for people at high risk of contracting the virus, such as sex workers and injecting drug users. India's free HIV/AIDS drugs program has been highly successful. According to a World Bank estimate, India's policy of targeting sex workers averted 3 million infections with HIV between 1995 and 2015. The results won praise globally - annual new infections fell consistently and, overall, were reduced by more than half between 2000 and 2011. Still, UNAIDS estimates India accounted for most of the 340,000 new infections in the Asia-Pacific region last year. Rao said the flow of funds has improved marginally in recent months after complaints from AIDS workers, but he urged states and politicians to do more. India's last nationwide AIDS estimates were released in 2012. Data for the next assessment is still being collected. (Source: Medscape)
IMA,IJCP,HCFI
GP Tip: Helping patients understand high blood pressure

As you measure a person’s blood pressure, inflate the cuff to just over the systolic pressure. Explain that this is how much pressure there is on the heart and in the blood vessels supplying the brain. This gives a hands-on example of what blood pressure means and may help patients understand why it is important to take their medication regularly. (Source: IJCP)
Inspirational Story
Sometimes ignorance is bliss

My classmate, Susan, and I are in the middle of our thesis rewrites for Johns Hopkins University. We only have two weeks left and we are both quite razzled at the prospect of doing more research in the remaining time.

Today Susan called me to say that she desperately needed more history about a small tribe of Native Americans that lives in the Grand Canyon But there’s only one telephone on the reservation and no one ever answers it.

As a matter of fact, the three times she visited the tribe’s Visitor Center while she was on vacation, she said no one ever opened up the building.

Being a computer geek, I said, "Have you checked the Internet?" She said, "No, what a great idea! Thanks." I did a quick check using Excite while she used Yahoo and she was astounded at the information available about this little-known tribe.

She thanked me profusely for the tip and hung up. Two hours later, she called me back sounding absolutely miserable. "Susan," I said, "What’s the matter?" "Well," she said, "You’re not going to believe it but they have their own Web page with all the information I could ever want about the tribe."

"That’s great," I said. "What more could you ask for?" "You don’t understand," she said. "My article is about how isolated the tribe is and how their only path to the outside world is a little dirt trail up the side of the canyon!

On their Web page, they even have a scanned photo of the helicopter that brought the donated PC into the canyon."

Moral of the story: Sometimes ignorance is bliss, especially when you’re trying to finish a thesis on time.
eWELLNESS
Diet is linked to the diabetes epidemic

A study published in the journal Diabetes Care, has highlighted the importance of the whole diet rather than focusing on certain foods or food groups that might be beneficial.

A diet rich in whole grains, fruits and vegetables (leafy green), nuts and low-fat dairy may help people lower their risk of type 2 diabetes by 15% over 5 years than those who ate the lowest amounts of these foods.

Also, a diet which contains high amounts of red meat, high-fat dairy and refined grains like white bread may boost the odds of diabetes development by 18%.

Type 2 diabetes is closely linked to obesity and it is well-known that maintaining a healthy weight through diet and exercise reduces the risk of developing the disease. Diet affects diabetes risk independent of a person’s weight.
Humor
History of Telecommunication

After having dug to a depth of 10 feet last year, Italian scientists found traces of copper wire dating back 100 years and came to the conclusion, that their ancestors already had a telephone network more than 100 years ago.

Not to be outdone by the Italians, in the weeks that followed, a Chinese archaeologist dug to a depth of 20 feet, and shortly after, a story in the China Daily read: ‘Chinese archaeologists, finding traces of 200 year old copper wire, have concluded their ancestors already had an advanced high–tech communications network a hundred years earlier than the Italian’s.

One week later, the Punjab Times, a local newspaper in India, reported the following: After digging as deep as 30 feet in his pasture near Amritsar, in the Indian state of Punjab, Dugdeep Singh, a self–taught archaeologist, reported that he found absolutely nothing. Dugdeep has therefore concluded that 300 years ago, India had already gone wireless.
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eMEDI QUIZ
Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve:

1. Musculocutaneous.
2. Ulnar
3. Radial
4. Median.

Yesterday’s Mind Teaser: In all of the following conditions neuraxial blockade is absolutely contraindicated, except:

1. Patient refusal.
2. Coagulopathy
3.Severe hypovolemia.
4. Pre-existing neurological deficits.

Answer for Yesterday’s Mind Teaser: 4. Pre-existing neurological deficits.

Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Daivadheenam Jella, Dr K V Sarma, Raghavendra Chakurkar, Dr K Raju, Dr Avtar Krishan.

Answer for 13th October Mind Teaser: 4. Protein folding

Correct Answers received from: Dr Poonam Chablani, Dr Jainendra Upadhyay, Dr K V Sarma, Dr K Raju, Daivadheenam Jella, Dr Avtar Krishan.
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Press Release
Individuals with existing lifestyle ailments should adopt healthy fasting practices this Navratri

Patients with existing chronic diseases like heart disease, diabetes and high blood pressure should take extra precautions when fasting

Skipping meals or eating an inappropriate diet can adversely affect your health if you are on continuous medications.

Diabetic patients should decrease their insulin intake up to 40 percent if they are fasting and consume only one meal a day


There is a lot of hustle bustle around, as the festive season is approaching. And we all know that Navratri, which is an auspicious 9-day period for Hindu devotees, marks the festive season. Fasting, worshipping and playing dandiya are a few important things that matter the most during this period. From kids to elders, you see almost everyone indulging in the 9-day fast schedule that is observed during the festival.

But sometimes, this fasting may culminate in people ignoring their health because they believe in strictly adhering to fasting norms like eating once a day, staying without water till the last meal, consuming salt once a day and only eating potato-based meals. These strict fasting practices do not suit individuals who are suffering from long-term chronic diseases like heart ailments, diabetes and high blood pressure or for that matter pregnancy. In such patients, life-threatening complications may occur and so, fasts must be observed with caution and post-consultation with the treating doctor.

Speaking on the issue, Padma Shri Awardees Dr A Marthanda Pillai National President Indian Medical Association and Dr K K Aggarwal Honorary Secretary General IMA and President HCFI said, “Fasting has many positive impacts on one's health if an optimum level of nutritional intake are maintained. For patients who have heart issues, we recommend that they don’t eat fried foods like potato pakoras, fried potatoes and processed potato chips. Diabetics must immediately end their fast if their blood sugar level falls below 60 mg. They must also drink ample amounts of fluid given that dehydration can lead to paralysis and heart attacks. The risks associated with fasting are low in patients with type 2 diabetes. Patients suffering from type 1 diabetes should not fast. Fasting in chronic patients must be done in strict consultation with the doctors since the dosage of regular medicines may need to be reduced by 40-50% during fasts.”

A few healthy fasting tips during the Navratri include

• Curd with lauki (bottle gourd) called ‘raita’ can be consumed instead of plain curd.

• One can eat almonds (badam) in between as snacks.

• Stuffed kuttu (buckwheat) roti with pumpkin (kaddu) vegetable should be consumed.

• Ample fruits should be consumed at regular intervals to maintain nutrient levels.

• Both chestnut flour and buckwheat flours can be combined as a healthy option.

• Singhara or water chestnut, is not a cereal but a fruit and hence a good substitute during a Navratri fast where cereals are not to be eaten.

• Chestnut flour, a gluten-free product, is an ideal food option for people with celiac disease or other gluten intolerances or allergies.