October 17   2015, Saturday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal
IMA calls for quality drugs to be made available to the public at affordable costs

As it was clearly established through various studies and as reported by the Planning commission’s High Level Expert Group Report (HLEG) report on Universal Health Coverage for India, almost 70% of out of pocket expenses incurred in health care is directly due to the cost of drugs and this is more among the poorest quintile. Therefore, the government should spend more resources in making drugs affordable to the population-at least to the tune of 0.5% of GDP. Government should open more Jan Aushadi stores and establish a drug distribution system catering to both public sector and private sector hospitals

Essential drug list should be revised and published periodically. Drug manufacturing and distribution should be guided by the essential drug list. Very strict laws and penal provisions should be in place to curb irrational combinations and preparations. More drugs should be brought under the price control mechanism. Mechanism of adverse drug reaction monitoring should be made more effective. All companies should market the drugs in generic name.

Government should return to the old system of cost-based drug pricing and should do away with the current system of market-based pricing. This will rationalize the cost of majority of the drugs and will also help to avoid cartel formation.

Govt should ensure the quality of each batch of medicine, and this requires adequate funding to establish more testing labs in the country. Drugs should not be allowed to move to the market before the quality is tested for each batch.

Govt policy should be to facilitate domestic drug manufacturing companies to undertake drug research and innovation, to invent new molecules to preferentially address diseases, which are predominantly prevalent in our country. Just like techno parks, govt should invest and facilitate common facilities for drug research and quality control

Govt should also take steps to open and functionalize the closed down vaccine manufacturing units in the public sector and also sick drug manufacturing units in the public sector.
Breaking news
FDA warns of infection risk with Heater-Cooler devices

The US FDA has warned that the use of heater-cooler devices has been associated with nontuberculous mycobacterium (NTM) infections, mainly in patients undergoing cardiothoracic surgeries. (Heater-cooler devices are used during medical and surgical procedures to warm or cool a patient, as required. These devices include water tanks that provide temperature-controlled water to external heat exchangers or warming/cooling blankets through closed circuits. Contaminated water may enter other parts of the device or transmit bacteria through the air, via the device's exhaust vent, into the environment and to the patient, even though the water in the circuits does not come into direct contact with the patient. The FDA says it is "actively" monitoring the situation and will provide updates as appropriate. The safety communication is posted on the FDA website. (Medscape)
Dr Good Dr Bad
IMA,IJCP,HCFI
Specialty Updates
• Working in a highly stressful job may raise the risk for stroke, particularly for women, suggests a meta-analysis published online October 14 in Neurology.
• Enterovirus D68 (EV-D68) seems to be a more virulent pulmonary pathogen than rhinovirus or other enterovirus strains, suggests a study conducted in children, published online October 13 in the Canadian Medical Association Journal.
• For patients undergoing transcatheter aortic-valve replacement (TAVR) via the femoral artery, the use of bivalirudin did not significantly reduce the risk of bleeding, nor did it reduce the risk of ischemic events compared with the use of heparin, suggested the BRAVO 3 study, presented at TCT 2015 and published simultaneously in JACC: Cardiovascular Interventions.
• Prognosis for human epidermal growth factor receptor 2 (HER2)-positive patients with lymphocyte-predominant breast cancer (LPBC) was significantly better following treatment with chemotherapy alone than chemotherapy plus trastuzumab, reported an exploratory analysis of the North Central Cancer Treatment Group-N9831 trial published in JAMA Oncology.
• Data on women who received denosumab, in some cases for up to 10 years in the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every Six Months (FREEDOM) study and its extension phase, show that the drug produced a persistent reduction in bone turnover, continued increases in bone density without an apparent plateau so far, and low incidences of fracture. The data were presented at the American Society for Bone and Mineral Research (ASBMR) 2015 Annual Meeting.
• Midtrimester short cervix interventions to prevent preterm delivery appear to be effective only in the setting of intra-amniotic inflammation, suggests a new report published online in the American Journal of Obstetrics and Gynecology.
• As add-on therapy to metformin in type 2 diabetes, dipeptidyl peptidase-4 (DPP4) inhibitors are associated with fewer adverse outcomes than sulfonylureas, suggested new research published online October 13 in the Annals of Internal Medicine.
• Although rates are dwindling, yet serious complications are possible with local anesthesia for cataract surgery, suggested a new study published in the British Journal of Ophthalmology.
• Injured patients were evaluated and received medical imaging tests 30% faster after an innovative performance improvement project was enacted at one hospital. Results of the project, which involved multidisciplinary simulation training and feedback from actual trauma survivors, was tested at the Wake Forest Baptist Medical Center, were presented at the American College of Surgeons Clinical Congress 2015.
• Airway narrowing in parallel airways is more heterogeneous and airway closure is greater in asthma patients than in people without the condition, according to a small high-resolution CT study reported online in the journal Thorax.
IMA,IJCP,HCFI
Media
IMA,IJCP,HCFI
eSPIRITUAL
5th Navratri (Skanda Mata Worship)
Spiritual Significance: One should gain knowledge of detached attachment as the main principle of spirituality.

Skanda Mata is worshipped on the fifth day of Navratri. SHE is holding her son ‘Skandaa or Kartikaya’ on her lap. SHE has three eyes and four hands. Two of her hands hold lotuses while the other two hands respectively display defending and granting gestures. SHE is the ocean of knowledge and rides on a lion.

In Yoga Shastra she represents the Vishuddha chakra and HAM bija mantra. SHE also dignifies motherhood, fertility and mother-child relationship.

Skanda means the one with six heads corresponding to the five senses and the mind. Or the one who has a control over the six demonic vices: kama (sex), krodha (anger), lobha (greed), moha (passion), mada (ego) and matsarya (jealousy).

Kartikeya carries a spear in one hand; his other hand is always blessing devotees. His vehicle is a peacock, a pious bird that grips with its feet a serpent, which symbolizes the ego and desires of people. The peacock represents the destroyer of harmful habits and the conqueror of sensual desires.
Legal Quote
Samira Kohli vs Dr. Prabha Manchanda and Anr, SCI, Civil Appeal No. 1949 of 2004, 16.01.2008

“Consent given only for a diagnostic procedure, cannot be considered as consent for therapeutic treatment. Consent given for a specific treatment procedure will not be valid for conducting some other treatment procedure. The fact that the unauthorized additional surgery is beneficial to the patient, or that it would save considerable time and expense to the patient, or would relieve the patient from pain and suffering in future, are not grounds of defence in an action in tort for negligence or assault and battery. The only exception to this rule is where the additional procedure though unauthorized, is necessary in order to save the life or preserve the health of the patient and it would be unreasonable to delay such unauthorized procedure until patient regains consciousness and takes a decision.”
Medicofinance
Asset Protection - Personal Residence

Personal residences represent the bulk of many people’s fortunes, and have great sentimental value. A doctor’s personal residence is thus the most important asset which needs to be protected from creditor claims. Creditors do not pursue the residence itself, but the equity in the residence that can be converted into money through a foreclosure sale of the residence.

(Source: IJCP)
Industry News
Design as a long-term advantage for startups: It is not just technology or a business model but a solid foundation of design that will help startups scale and incumbents reinvent themselves, according to a range of speakers at the Design Summit of NASSCOM’s National Product Conclave 2015. “Without good design, technology companies cannot connect with the people. Many companies do not pay adequate attention to detail in design,” cautioned Muki Regunathan, Founder and CEO, Pepper Square. (Yourstory)
The 7 most active investors in India this year: 2014 was a watershed year for fund flows into India’s startup ecosystem: a billion dollar funding round, the entry of Japanese giant SoftBank with big ticket investments, and the emergence of Bangalore as one of the fastest growing startup hubs in VC deals. This fund flow has gathered even more momentum this year. According to Nasscom, the country is on course in 2015 to see a doubling of the previous year’s funding level for startups incorporated since 2010 – from US$2.2 billion to US$4.9 billion. (Techinasia.com)
Funding into tech startups surging despite bubble fears: Washington: According to a survey by by CB Insights and KPMG, investors poured increasing amounts of cash into startups in the third quarter, defying fears of a bubble in the tech sector. A total of 1,799 venture-backed startups around the world pulled in $37.6 billion in funding in the quarter, the highest since 2001. About 77% of the funding went to technology startups. (The Economic Times- AFP)
Inshorts acquires app startup BetaGlide: Bengaluru: Content distributor app Inshorts has acquired Palo Alto/Bengalurubased BetaGlide, a startup that builds technology to optimise mobile applications. "The acquisition will be helpful in improving mobile experience for customers," said Azhar Iqubal, cofounder of Inshorts, who started up along with IIT-Delhi alumnus Anunay Arunav and IIT-Kharagpur alumnus Deepit Purkayastha. (The Economic Times- Malavika Murali)
eMEDIPICS
IMA,IJCP,HCFI
World Medical Association (WMA) 2015 General Assembly meeting at Moscow
MTNL Perfect Health Mela 2015.

Pls click here for details
IMA Digital TV
Humor
Doctor, doctor, I keep thinking I’m a dog." "Sit down and tell me all about it."

"I can’t, I’m not allowed on the furniture."
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.
• The balance to be struck is between the surgeon's autonomy (desire and will to operate and right to livelihood) and the greater public good. The greater public good will be served if he continued operating. Unless he had a seizure in the past few weeks when the odds of him having one while actually operating would be significant. A utilitarian perspective. The patient has no right to any personal information unless it is likely to harm him directly a la Tarasoff. Dr T Madhusudan
• Physical illnesses catch the attention of every one and one can draw conclusions regarding outcome and the procedure adopted by the doctor. Surgical procedure carry glamor as well as defamation, which can be affected by physical as well as psychological status of surgeon. Can anybody attribute the mishap during surgery to psychological status of surgeon readily? The hallmark of fitness of surgeon should be his own assessment of physical as well as mental state and if surgeon thinks that he can perform the procedure with reasonable thinking and competence, need to disclose the health information. After all no one Is 100% healthy. Dr Sarvesh
• You have raised a very interesting and thought provoking issue. My thoughts about it are as follows. Anil Nischal

o All of Medicine and its practice rests on the principle of “No harm first”. Whatever the practicality of world says I think ethically and morally the patient has the right to know if his treating Doctor suffers from any condition, which may be threatening to his life.

o The doctor in such a case should arrange for a reliable back up strategy and inform and assure the patient of the same. The decision of undergoing surgery in hands of such a surgeon even when back up is available still rests with the patient.

o Will we not feel cheated if a pilot or a train/bus driver in who operates a transport has such a condition which can endanger our life is in command? Do we not have the right to decide whether we want to take a risk? Things may not really work this way in the world but what is wrong is wrong. No amount of justification can make it right.

o Technically too, this is unfitness for job. Such a surgeon in my opinion should voluntarily opt for an assisting role rather than be the primary surgeon.

• I don't think that the doctor has to discuss his health concerns to his/her patients, so as the patient chooses the doctor based on this. It is the primary responsibility of the doctor to manage his/her health problem, without that coming in the management of the patient. If, as mentioned in this case, the disease is well under control, it is even beyond the means of the attending doctor that an emergency crisis develops at the doctor's side. The doctor has all rights to enjoy his privacy with regard to his/her health or personal life. In case there was an error in judgment/ treatment, the doctor should be honest enough to disclose the same to the patient/ bystander. Rema Devi
• Ethically the surgeon is not bound to disclose the illness to the patient if the disease is under control. Even in the case of infections like HBV, HCV, HIV many countries allow doctors and nurses suffering from HIV to choose the speciality they wish to work as usual if the disease is under control.(http://www.theguardian.com/lifeandstyle/2013/
aug/18/nhs-guidelines-doctors-nurses-hiv;
http://bma.org.uk/news-views-analysis/news/2013/
august/ban-lifted-on-hiv-positive-doctors-practising-surgery).
Does anyone has information on any directives from MCI/ Min Health & FW regarding this ethical dilemma? Dr Valan, India EIS officer, NCDC, New Delhi.

• The health issues of the treating doctors are not the concern of the patients, it is only the capabilities and capacities that will affect the treatment procedures. As told by Dr Valan, a doctor with serious health issues that are not under control should restrain from treating patients, especially diseases like epilepsy, which may affect if not under control. If the patient died of lack of minimum capacities due to his illness, it is unethical to treat or do surgeries. In the case mentioned here the doctor is ethically correct. Dr R Hari Kumar, Scientist 'E' (Deputy Director), Division of Community studies, NIN, Hyderabad
• In the case described, it is unclear whether the surgical mishap was linked at all to the surgeon’s medical condition. As other have pointed out, unfortunate complications and medical errors can happen even when the doctor is in the best of mental or physical health. I fully agree that doctors are entitled to privacy and confidentiality regarding their own health status. And are subject to the usual work, family and social stress. However, there is a professional responsibility to ensure that patient care is in no way compromised by any underlying health condition of the doctor. Doctors should avail sick leave, take tests and treatment regularly and excuse themselves from clinics and surgeries when ill-disposed. But this is left to the integrity of the doctor (as with many other situations in patient care) and therein lies the crux of the problem.

The MCI Regulations 2002 do not specifically mention this aspect of ethical practice, but doctors who are HIV positive or who have a psychiatric illness may have to make tough choices, even abandoning practice or relocating to non-clinical departments until they are cured or stabilized on medication. Hospitals can design policy to require doctors to share health conditions that can compromise patient safety. Medical colleagues also have a responsibility to report or counsel doctors who are obviously at risk of medical lapses, in the interest of patient care. We only have to ask ourselves....would we be comfortable to have our child treated by a doctor who is unwell, overworked, HIV-positive or is on anti-TB medication? But who will take the call on when it is safe to resume practice? Do we have any policies on this? Two related questions: If a patient who is scheduled for surgery asks the surgeon directly if he is HIV positive...is the doctor obliged to reveal the truth? Does the patient have a right to know?

We see many senior doctors practicing way beyond retirement. It is not age that is in question here but physical and mental abilities. When hand tremors, loss of memory and other health issues have set in but the doctor refuses to retire from practice, what is our response? Do we have a duty to the patient in this regard? Dr Olinda Timms
Breaking news
FSSAI to notify junk food guidelines for schools

The Food Safety and Standards Authority of India (FSSAI), the regulating authority of food standards in India, has issued draft guidelines to monitor the consumption of junk food by school children following an order by the Delhi High Court in July. These recommendations titled ‘Guidelines for making available wholesome, nutritious, safe and hygienic food to school children in India’ are available on FSSAI website. The July judgment was in response to a public interest suit moved in 2010 by the Uday Foundation, an NGO, which had raised the issue of easy availability of junk food and carbonated drinks to children and had sought a ban on these food items in schools.

Under the draft guidelines, foods high in fat, salt or sugar such as chips, ready-to-eat noodles, pizzas, burgers, sugar-sweetened carbonated and non-carbonated drinks, potato fries (commonly called French fries) and confectionery items will not be sold within 50 meters of the premises of a school. The guidelines also recommend formulation of a canteen policy and school health education programs to make students and parents aware about the harmful effects of unhealthy food habits. (Business Standard)
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?
AHA updates CPR and emergency cardiovascular guidelines
The AHA has released revisions to its “Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Guidelines”. These revised guidelines have highlighted the role of the public and 911 dispatchers in reducing time to chest compression in cardiac arrest occurring outside the hospital setting. Quick action among bystanders, increased training of emergency personnel, and greater use of cell phones and other technology could bolster dismally low survival rates among cardiac arrest patients, the AHA stated. Marking a first, these revised guidelines have also addressed response to cardiac arrest caused by opiate drug overdoses among lay rescuers, noting that administration of the opioid-reversing drug naloxone by bystanders may be considered. For lay rescuers, the guidelines highlight the importance of recognizing the signs of cardiac arrest, as well as the importance of calling 911 and providing immediate hands-only CPR at a rate of between 100 and 120 compressions per minute. Also, Dispatchers should instruct bystander rescuers who call 911 to place their mobile phone on speaker and remain on the line. These guidelines are published in the November issue of journal Circulation. (MedPage Today)
Supreme Court suggests a ban on commercial surrogacy
The Supreme Court of India has expressed serious concern over India becoming a top destination for surrogacy tourism. It has suggested a ban on commercial surrogacy and directed the government to re-examine the policy to allow import of human embryo. A notification issued by the Central Government in 2013 allowed import of human embryos for artificial reproduction making it easy for foreign couples to bring in frozen human embryos and rent a surrogate womb in India. A bench comprising of Justices Ranjan Gogoi and N V Ramana observed that the surrogacy issues were not covered by any law and the government must take a holistic view and bring in a legislation. They said, "Commercial surrogacy should not be allowed but it is going on in the country. You are allowing trading of human embryo. It is becoming a business. It has evolved into surrogacy tourism."

The court asked the government to take a stand whether a woman who donates her egg in commercial surrogacy can be said to be the only mother or both surrogate and genetic mother can be said to be mothers of the child and also raised concerns such as whether commercial surrogacy amounts to economic and psychological exploitation of the surrogate mother and whether the practice is inconsistent with dignity of womanhood; whether import of human embryo amounts to commoditization of human life and whether human rights of a surrogate child are violated as such a child would face psychological and emotional problems and what would be the fate of the surrogate child if the if the commissioning couple refuses to take child in case he/she is physically and mentally challenged. The Court asked the government to include provisions for such issues in the proposed law. (Times of India – Amit Anand Choudhary)
India flags off 'climate Change Special' science express train to create awareness on climate change
India has launched an awareness drive on climate change and it did so in a unique way. The environment and climate change minister Prakash Javadekar, railway minister Suresh Prabhu and science & technology minister Harsh Vardhan jointly launched a 16-coach 'Climate Change Special' science express train at the Safdarjung railway station. During its journey in the next seven months, the train will cover about 19,500 km and halt at 64 locations, spread over 20 states. The official statement of the ministry of science stated, “The state-of-the-art exhibition aboard SECCS aims to create awareness among various sections of the society, especially students, about various issues & challenges associated with Climate Change and how it can be combated through mitigation and adaptation.” Eight coaches have been assigned specific themes on various aspects of climate change; a discussion centre-cum-training facility is also provided in a coach for orientation of teachers; the other coaches will house exhibits, Kids zone, and the Joy of Science (JOS) Hands-on Lab. It will be open to visitors from 10 am to 5 pm. (Economic Times - Vishwa Mohan)
WMA News
Turkish government urged to restore basic health care to cities in conflict

(15.09.2015) An appeal to all parties of armed conflicts occurring in south-eastern cities of Turkey to restore basic health care has come from the World Medical Association.

According to the Turkish Medical Association, the cities of Diyarbakir, Cizre, Varto, Yuksekova, Semdinli, Lice, Silvan and Silopi have been the centre of fierce fighting between the military and militants for two months. This has provoked attacks on healthcare workers and ambulances, and has led the Turkish Government to curtail the movement of citizens as well as their basic health care during the curfews.

Dr. Xavier Deau, President of the WMA, said: ‘We are receiving alarming reports from the Turkish Medical Association about ambulances not being allowed to tend to those killed and wounded in the fighting in the city or take them to hospital. The Government curfew prevented people from going out to buy food and water and no outside observers are being allowed to visit the city to investigate the situation. This lack of basic health care and the failure to allow health professionals to move freely in the city is a scandal that must end. ‘We urge the Turkish Government to bring a halt to this inhumane situation and to allow health professionals to care for the sick and wounded.’

World physicians urged to speak up about health inequity

A rallying call to physicians of the world to speak up about inequality and the causes of ill health was delivered today (Friday) by Sir Michael Marmot in his inaugural speech as the new President of the World Medical Association.

Speaking at the WMA General Assembly in Moscow, Sir Michael, Director of the Institute of Health Equity at UCL, University of London, said he had spent his research life showing that the key determinants of health lay outside the health care system in the conditions in which people were born, grow, live, work and age and showing that inequities in power, money and resources gave rise to the inequities in conditions of daily life.

‘The way we organise our affairs, at the community level or, indeed at the whole societal level, are matters of life and death. As doctors we cannot stand idly by while our patients suffer from the way our societies are organised. Inequality of social and economic conditions is at the heart of it.'

Now, Sir Michael wanted the world's doctors to get involved. He said: ‘The World Medical Association upholds the highest ethical standards of the practice of medicine. It speaks out fearlessly when the right of doctors to pursue their noble calling is threatened. As President, I want the WMA to use the same moral clarity to be active against the causes of ill-health and what I call the causes of the causes - the social determinants of health.'

In his speech to delegates from more than 50 national medical associations, Sir Michael declared: ‘We can, we do and we should speak up about inequity in social conditions that damage the health of the populations that we serve.

‘We should not whisper at the gross inequities in the world that give rise to health inequities. In fact, so close is the link between social conditions and health that, I argue, health equity is a good measure of social progress; much better than income growth. Health and health equity are not only worthwhile in themselves but they reflect much else that makes life worthwhile: the freedom to lead lives we have reason to value. As doctors, at our best, we flourish in the cause of social justice.'

There is a great deal of money sloshing about. But great inequality between and within countries stops the money being spent in ways that benefit the poor and the needy. Sir Michael illustrated his point by saying that if the top 25 US hedge fund managers gave up their combined income for one year, around $23 billion, it would double the income of Tanzania.

The best time to start addressing health inequities is with equity from the start - good early child development across society. But intervention at any stage of the life course could make a difference. Enabling young people to become employed, relieving adult poverty, paying a living wage, reduction in fuel poverty, improving working conditions, improving neighbourhoods, and taking steps to reduce social isolation in older people saves lives.

Referring to the stratification of early child development Sir Michael said: ‘If this were caused by a chemical in food or water, we would clamour for its removal. Stop the injustice now. Unwittingly perhaps, we tolerate such an unjust state of affairs with seemingly little clamour for change. The pollutant is not only poverty, but also social disadvantage. It has profound effects on developing brains and limits children's intellectual and social development. There is a clear social gradient in intellectual, social, and emotional development—the higher the social position of families the more do children flourish and the better they score on all development measures.'

Sir Michael highlighted the issue of domestic violence. He said that empowerment of women through education was key to prevention. He added: ‘Evidence shows clearly: the greater the education of women the less the likelihood of being subject to domestic violence.' Sir Michael said that there is a great deal of injustice in the world, but he was optimistic that we can make a difference.
India to soon have first ever data on health of tribal population
An expert group constituted to review health situation and formulate guidelines to improve services among tribal population has compiled health data at the national level and is expected to submit its report to the government by end of 2015. "The expert group has conducted visits to various states to review the existing situation and has for the first time, compiled health data for tribal people at the national level. It is expected to complete its report and recommendations by the end of this year," the Union health ministry said on Thursday. The expert group on tribal health, constituted jointly by the health ministry and the Ministry of Tribal Affairs in October 2013, includes representatives from the central government, state governments, research organizations and the civil society. India has a tribal population of over 100 million with health problems ranging from malaria and maternal mortality to fluorosis and human resource constraints. (Times of India – Sushmi Dey)
Clues to opioid abuse from state prescription drug monitoring programs: CDC
Drug overdose is the leading cause of injury death in the United States – mostly due to abuse and misuse of prescription opioid pain relievers, benzodiazepines (sedatives/tranquilizers), and stimulants. Information from state prescription drug monitoring programs (PDMPs) can be used to detect and measure prescribing patterns that suggest abuse and misuse of controlled substances, according to a report released in the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR) Surveillance Summary. It is the first multi-state report from the CDC- and FDA-funded Prescription Behavior Surveillance System (PBSS), which analyzes data from state PDMPs. The eight states that submitted 2013 data—California, Delaware, Florida, Idaho, Louisiana, Maine, Ohio and West Virginia—represent about a quarter of the U.S. population. The study found that prescribing practices varied widely among states despite the fact that states are similar in the prevalence of the conditions these drugs are used to treat. There is an urgent need for improved prescribing practices, particularly for opioids – which in all eight states were prescribed twice as often as stimulants or benzodiazepines. (Source: CDC)
IMA JIMA
IMA Digital TV
MCI Code of Ethics Regulations, 2002

3.4 Statement to Patient after Consultation

3.4.1 All statements to the patient or his representatives should take place in the presence of the consulting physicians, except as otherwise agreed. The disclosure of the opinion to the patient or his relatives or friends shall rest with the medical attendant.
IMA,IJCP,HCFI
GP Tip: Can we talk?

Curious about patient satisfaction? A good time to call patients is the day after an office visit. This allows you to start by asking them if they have any questions. Patients often appreciate the follow-up.
Inspirational Story
Enjoy your coffee

A group of friends, highly established in their careers, got together to visit their old university professor. Conversation soon turned into complaints about stress in work and life. Offering his guests coffee, the professor went to the kitchen and returned with a large pot of coffee and assortment of cups – porcelain, plastic, glass, crystal, some plain looking, some expensive, some exquisite – telling them to help themselves to the coffee.

When all the students had a cup of coffee in hand, the professor said: “If you noticed, all the nice looking expensive cups were taken up, leaving behind the plain and cheap ones. While it is normal for you to want only the best for yourselves, that is the source of problems and stress. Be assured that the cup itself adds no quality to the coffee. In most cases it is just more expensive and in some cases even hides what we drink. What all of you really wanted was coffee, not the cup, but you consciously went for the best cups…..And then began envying each other’s cups.
Now consider this: “Life is the COFFEE; the jobs, money and position in the society are the CUPS. They are just tools to hold and contain Life, and the type of cup we have does not define, nor change the quality of Life we live. Sometimes, by concentrating only on the cup, we fail to enjoy the coffee God has provided us”. God brews the coffee, not the cups. NOTE: The happiest people don’t have the best of everything. They just make the best of everything. Live simply. Love generously. Care deeply. Speak kindly.
eWELLNESS
Weight gain precedes the onset of diabetes

Weight gain after age 18 years in women and after age 20 years in men also increases the risk of type 2 diabetes.

The Nurses’ Health Study, compared women with stable weight (those who gained or lost <5 kg) after the age of 18 years to women who gained weight. Those who had gained 5–8 kg had a relative risk of diabetes of 1.9; this risk increased to 2.7 for women who gained 8–11 kg.
Similar findings were noted in men in the Health Professionals Study.

Thus, the excess risk for diabetes with even modest weight gain is substantial.

Weight gain precedes the onset of diabetes. Among Pima Indians (a group with a particularly high incidence of type 2 Diabetes), body weight gradually increased 30 kg (from 60 kg to 90 kg) in the years preceding the diagnosis of diabetes.
IMA,IJCP,HCFI
eMEDI QUIZ
The blood vessel related to the paraduodenal fossa is:

1. Gonadal vein.
2. Superior mesenteric artery.
3. Portal vein.
4. Inferior mesenteric vein.

Yesterday’s Mind Teaser: The commonest variation in the arteries arising from the arch of aorta is:

1. Absence of brachiocephalic trunk.
2. Left vertebral artery arising from the arch.
3.Left common carotid artery arising from brachiocephalic trunk.
4. Presence of retroesophageal subclavian artery.

Answer for Yesterday’s Mind Teaser: 3. Left common carotid artery arising from brachiocephalic trunk.

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

Answer for 15th October Mind Teaser: 2. Ulnar

Correct Answers received from: Dr Poonam Chablani, Dr Jainendra Upadhyay, Dr K V Sarma, Dr K Raju, Daivadheenam Jella, Dr Avtar Krishan.
Readers column
Dear Sir, Everyday Morning like reading a newspaper, i read your article which gives me new insight. Keep up this good work. Regards, Dr KP Sharma
Digital IMA
Press Release
People who fast during Navratri are at an increased risk of food poisoning and diarrhea

Eating leftover and oily food can make you sick...Keep a check on your liquid intake to celebrate the festival of Navratri with all the enthusiasm

Starving and not eating for too long can make you feel weak. It is advised that you consume mini meals after an interval of every 2-3 hours


Have you ever wondered what is the reason behind the 9-day fast during Navratri? In addition to the religious reasons, fasts also help in the purification of the body by relaxing its metabolism. The consumption of low calorie and less spicy food items helps relieve the body of the extra work it has to do on a regular basis. However, this purpose gets defeated when people indulge in starchy and oily foods like potatoes and kuttu pakoras.

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 Heart Care Foundation of India said, “During Navratris, people have fewer food options, which are mostly restricted to kuttu and singhara flours. We advise that the people who are on a fast consume ample amounts of liquids to maintain energy levels and prevent dehydration. It is also strongly recommended that the kuttu or singhara flour left over from the previous year should not be used as they may be contaminated and result in diarrhea. Eat lot of fruits. Eating too much of very oily and high sugar food items like burfi, ladoo and potato fries may also cause diarrhea.”

Keep the following in mind in order to avoid the chances of food poisoning and diarrhea and help in maintaining a healthy fasting routine:

• Use singhara flour, it is not a cereal but a fruit as it is made from dried ground water chestnuts and hence a good substitute for a Navratri fast, where cereals cannot be consumed. It is an excellent source of energy and provides 115 kcal per 100g.

• Singhara plants bear ornately shaped fruits containing a single very large starchy seed. These seeds or nuts are boiled and eaten as a snack and can be eaten raw as well

• Chestnuts are relatively low in net carbs (total carbohydrate minus dietary fiber). It is included in many low carb diets. They do not contain the fat that regular nuts have. They also contain less carbohydrate than white flour.

• Avoid eating deep fried chestnut flour pooris or parathas.

• Buy only branded best quality flour as leftover flour from last year can lead to food poisoning.

• One should not use high trans fat vegetable oils to cook chestnut flour bread.

• You should consume as many fruits as you can, fruits are the best alternatives for the individuals who are on a fast.

• To keep your body hydrated, you should drink as much liquid as you can like in the form of water and juices.