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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; National Vice President Elect Elect, Indian Medical Association; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group & Hony. Visiting Professor (Clinical Research) DIPSAR

For updates follow at www.twitter.com/DrKKAggarwal     www.facebook.com/Dr KKAggarwal

    Health Videos …

eMediTube (videos), eMedipics, eMediSlide, eMediLaw

  Editorial …

18th April 2013, Thursday

Does the money charged by hospital from their consultants for providing consultancy come under service tax?

Recently, Service Tax Department has issued notices to various hospitals under the provisions of the Central Excise Act 1944/Central Excise Rules2002/Chapter 5 of the Finance Act 1994 (Service Tax).

  1. Under this, they have asked the details of fee charged from patients in respect of such specialists/visiting doctors/consultants, an amount for such specialist/visiting doctors/consultants against fee charged for the period 01.04.2007 to 31.03.2012 in the given format. Amount received from patient Amount paid to the consultant or doctors Difference Service tax paid, if any
  2. Under these summons, for example, a doctor is attached to a hospital; the hospital charges Rs. 1000/- consultation on his behalf and deducts Rs. 250/- and pays Rs. 750/- to the doctor. For this Service Tax Department has asked hospital or medical establishment to pay service tax on Rs. 250.
  3. As per Mega Exemption 25/2012 dated 25.04.2011, Service Tax dated 20.06.2012, Ministry of Finance Government of India “Health Care Services at clinical establishments, an authorized medical professional or paramedics is exempted under service tax.
  4. As per Delhi Medical Council Nursing Home and Medical Establishment Forum chairman Dr. V K Monga, once the clinical establishment is exempted as a whole for being the provider of health care services, individual activities for the same should not be considered for applicability of service tax. Also no exception for this has been given in the exemption dates.
  5. As per Dr. Monga, Service Tax is not applicable to the medical services as medical establishments are providing service to the patients and not to the doctors and consultants.
  6. As per Dr. Monga, if Rs. 1000 is charged by the hospital from the patients, the doctor is paid Rs. 750 for his services and Rs. 250 are charged by the hospital from the patients for providing ancillary services which include nursing care, infrastructure facilities, paramedic care, emergency mishaps, checking of temperature, weight, blood pressure etc.

Views

If the agreement between the hospital and the consultant is such which reflects money charged for providing services to the doctor, then service tax would be applicable. If the agreement is such where the amount of doctor’s fee is fixed, then the hospital is free to charge more amount of money from the patients or providing non-doctor services then service tax is not applicable.

In the agreement, it should be shown that the hospital is not deducting any money from the doctor’s consultations for providing services to the doctor.

In reality most of the hospitals charge 20-25% money from the doctor’s consultation fee under the head providing services to the doctors.

In the doctor’s income tax records also, it comes under income and expenditure. This means that if a doctor is charging Rs. 1000/- as fee, his income in his personal income returns is Rs. 1000/- out of which Rs. 250/- retained by the hospital comes under expenses.

The only solution is that the hospital should not deduct any money from the consultation fee or they should charge the fee under two headings – consultation fee and non-medical infrastructure fee.

For More editorials…

Dr KK Aggarwal
Group Editor in Chief

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Stay Tuned with Padma Shri and Dr BC Roy National Awardee Dr KK Aggarwal

Vitamin D intake associated with reduced risk for Crohn’s disease

Audio PostCard
    Photo Feature (from the HCFI Photo Gallery)

WHO Day Celebrated

Over 11459 people were trained in Hands Only Cardiopulmonary Resuscitation (CPR 10) in one day

 
Dr K K Aggarwal
    National News

This happens only in India

Dr K K Aggarwal

This is what happens when senior residents or attending consultants are not there in hospital. Following is the email I received from one of my friends who got treated in one of the metro cities in India.

  1. A patient is discharged on Tuesday afternoon.
  2. Operating (tracheostomy closure) ENT surgeon leaves station without informing primary physician.
  3. Patient gets worse in the night. Relations do not know what to do.
  4. Primary physician gets call from family as ENT surgeon not available.
  5. Physician call up ER that patient is coming (at 4.29 and 4.30 am.)
  6. Emergency room informs the physician about the condition at 5.23 and 6.13 AM
  7. Physician USA Son calls up: 6.59 am (about his concern)
  8. ICU resident calls up about update at 6.20, 6.25 and 6.45 am.
  9. Call from Son in USA to physician at 4.22, 4.28, 6.15 and 6.59 am about the concern for not getting assuring answers from the doctors.
  10. Husband calls up at 2.32, 2.34, 2.35, 2.54, 2.55, 2.58, 3, 3.07, 3.20, 3.22, 3.23, 3.24, 3.48, 3.59, 4.01, 4.20, 4.21, 4.47, 5, 5.33, 6.38
  11. The primary physician receives total 32 calls between 2.32 am and 6.59 am ( till he reaches the hospital) in a matter of 4 ½ hours out of which 17 calls occurring with hospital in communication and 5 calls communication with the patient as the ENT surgeon was not available. Ten calls were missed calls.

Issues

Husband’s concerns

  1. Patient is sick what to do, ENT surgeon not available who operated.
  2. Whom to meet in hospital, where to go, where is ER.
  3. I have Rs. 25,000/-, but the hospital is asking Rs. 750000/- for advance
  4. The ICU doctors are saying that while intubating, the patient can die
  5. Husband says not satisfied with assurance given

ICU doctors’ concerns

  1. Patient has come
  2. Informs ABG report
  3. Which ENT to call
  4. One of the other ENT doctors says he has left the hospital
  5. Other one says call the anesthetist
  6. Relations are not giving consent for intubation

ER doctors’ issues

  1. Patient has
  2. Patient has been admitted
  3. Informs about update
  4. Permission for admission has been taken from ICU in-charge.

Son in USA calls every time a fear is warned

  1. The patient has been taken to hospital
  2. Why are the doctors saying that she is serious?
  3. Why is ENT doctor not available?
  4. Why has anesthetist been called?

For comments and archives

DD Programme “Take Care Holistically”, Dr KK Aggarwal as an Anchor, Telecast every Wednesday 9 AM in DD National

DD Programme “Take Care Holistically”, Dr KK Aggarwal as an Anchor, every Thursday 4:30 PM in DD India

Medical mistakes in Indian movies

Dear all, eMedinewS is starting a special series on ‘Medical mistakes in Indian movies’. We invite all our readers to share with us the following information:

  1. Scene/s where the image of the medical profession has been maligned in an unrealistic manner, or
  2. Scene/s where medical care and approach has been depicted incorrectly, or
  3. Scenes where the medical profession has been portrayed correctly.

Send us the clippings or description of the scenes. This would be a start to a special campaign to rebuild the image of the medical profession.

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

    Be Human Stop Child Abuse (Team IMA for CMAAO)

(http://behumanstopchildabuse.emedinews.in/)

Sexual Harassment and Punishment

A person is said to commit sexual harassment upon a child when such person with sexual intent,—

  • utters any word or makes any sound, or makes any gesture or exhibits any object or part of body with the intention that such word or sound shall be heard, or such gesture or object or part of body shall be seen by the child; or
  • Makes a child exhibit his body or any part of his body so as it is seen by such person or any other person; or
  • Shows any object to a child in any form or media for pornographic purposes; or
  • Repeatedly or constantly follows or watches or contacts a child either directly or through any means; or
  • Threatens to use, in any form of media, a real or fabricated depiction through electronic, film or digital or any other mode, of any part of the body of the child or the involvement of the child in a sexual act.

Explanation: Whoever commits sexual harassment upon a child shall be punished with imprisonment of either description for a term which may extend to three years and shall also be liable to fine.

For comments and archives

 
    Valvular Heart Disease Update

Progressive fibrocalcific stenosis requiring surgery eventually occurs in over 75 percent of patients with bicuspid aortic valve.

(Experts: Dr Ganesh K Mani, Dr Yugal Mishra, Dr Deepak Khurana, Dr Rajesh Kaushish, Dr K S Rathor, Dr Sandeep Singh and Dr KK Aggarwal)

 
    International News

(Contributed by Dr Monica and Brahm Vasudev)

Fecal microbial transplantation may treat ulcerative colitis

Fecal microbial transplantation (FMT) via enema may be effective, tolerable, and feasible for treating children with ulcerative colitis (UC), according to findings from a phase 1 pilot study published online March 29 and in the June issue of the Journal of Pediatric Gastroenterology and Nutrition. FMT involves infusion of human stool from a healthy adult donor into the patient's intestine. (Source: Medscape)

For comments and archives

Prostate biopsy triggers Tx in older men

Prostate cancer screening and biopsy declined as age increased, but most older men who underwent biopsy received aggressive treatment, a review of a large Veterans Affairs population showed. (Source: Medpage Today)

For comments and archives

New guidelines to reduce 'alarm fatigue'

planning, training, and basic machine maintenance were some of the recommendations made by the Joint Commission last week in a report that tackles the chronic problem of medical device alarm safety. The commission's Sentinel Event Alert also advised healthcare facilities to establish guidelines for alarm settings on medical monitoring devices, such as electrocardiogram machines and blood pressure monitors, and to tailor them for individual patients. (Source: Medscape)

For comments and archives

Boston bombing a lesson in prep for hospitals

The Boston Marathon bombing serves as yet another tragic reminder that American healthcare must be prepared to deal with terrorist attacks that result in the injuries typical of the wide-ranging damage caused by explosive devices, experts said Tuesday. Injuries like those incurred in Boston are similar to those inflicted in bombings around the world, Hunt said: Primary damage comes from the force of the blast. But projectiles intentionally built into the device, like nails, or from surrounding material -- like flying glass, concrete, and metal -- gain force in the explosion. Internal injuries result from compression. Blood loss is extreme. (Source: Medpage Today)

For comments and archives

New social media guidelines issued for physicians

A new social media policy urges doctors to "pause before posting" and to not "friend" patients online. The position paper, issued by the American College of Physicians (ACP) and the Federation of State Medical Boards, was released at ACP Internal Medicine 2013 in San Francisco, California, and was simultaneously published online April 11 in the Annals of Internal Medicine. (Source: Medscape)

For comments and archives

An economic crisis triggered by the Soviet Union’s fall saw a 50% drop in death rates from diabetes in Cuba during the late 1990s.

Deaths from heart disease declined by a third. Reason: The average Cuban lost 5kg in the crisis years (1990-95), says an international team of researchers. Food and fuel shortages resulted in millions going hungry and having to abandon their vehicles and walk. Farmers had to work the fields manually and the government issued one million cycles to keep people on the move. By late 1990s, however, Cuba and its waistlines began to recover. By mid-2000s, death rates were back to pre-crisis levels. The Cuban experience, said researchers, shows that within a relatively short period, modest weight loss in a population can have a profound effect.

(Dr Tripta Gupta)

 
    Twitter of the Day

@DrKKAggarwal: Smell check, scratch and sniff, a new test for Parkinson’s disease http://bit.ly/11elruD #Health

@Dr Deepak Chopra: I highly recommend reading Science Set Free: 10 Paths to New Discovery by @RupertSheldrake http://amzn.to/171iNxi

 
    Spiritual Update

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

On 6th Navratri chant AUM

Mata Katyayani is worshipped on the sixth day of Navratri. SHE has three eyes and four hands and rides on a Lion.

For comments and archives

 
    Infertility Update (Dr Kaberi Banerjee, IVF expert, New Delhi)

In how many cycles does the hair grow?

Hair growth occurs in cycles. While some grow, others rest, and still other are shed. Hormonal changes, such as those associated with oral contraceptives (birth control pills) or pregnancy may synchronize hair growth and make it appear to grow and shed more than usual. However, hair growth patterns usually return to normal within 6 to 12 months.

 
    Tat Tvam Asi………and the Life Continues……

(Dr N K Bhatia, Medical Director, Mission Jan Jagriti Blood Bank)

Primary reasons for transfusing blood

  • To restore or maintain oxygen supply to body tissues
  • To prevent massive blood loss e.g. traumatic accidents
  • To treat blood disorders e.g. anemia
  • To treat hemolytic disease of the newborn (pregnant women develop antibodies that destroy the newborn’s red blood cells)

For comments and archives

 
    An Inspirational Story

The mother giraffe makes her child suffer

The mother giraffe gives birth standing up, so the first thing that happens to a new-born giraffe is a fall of about two meters.

Still dazed, the baby tries to stand up on its four legs, but its mother behaves very strangely: she gives the baby giraffe a gentle kick which sends it sprawling. It tries to get up and is again knocked down.

This process is repeated several times, until the new-born giraffe is too exhausted to stand. At that point, the mother kicks it again, forcing it to get to its feet. After that, she does not push the baby giraffe over again.

The explanation is simple: in order to survive predators, the first lesson a giraffe must learn is to get to its feet quickly.

The mother’s apparent cruelty finds support in an Arabic proverb: “Sometimes, in order to teach something good, you have to be a little rough.”

For comments and archives

 
    Cardiology eMedinewS

CV risk factors seen more often at younger age Read More

 
    Pediatric eMedinewS

Pneumonia, diarrhea plan may save 2 million children yearly Read More

 
    Rabies Update

Dr. A K Gupta, Author of "RABIES - the worst death", Joint Secretary, Association for Prevention and Control of Rabies in India (APCRI)

What is eight-site intradermal regimen (“8–0–4–0–1–1” regimen)?

One dose of 0.1 ml is administered intradermally at eight different sites (Either upper arms, lateral thighs, supra-scapular region, and lower quadrant of abdomen) on day 0. On day 7, four 0.1 ml injections are administered intradermally into each upper arm (deltoid region) and each lateral thigh. Following these injections, one additional 0.1 ml dose is administered on days 28 and 90. This regimen lowers the cost of vaccine administered by intramuscular regimens and generally produces a higher antibody response than the other recommended schedules by day 14. It does not result in a significantly earlier antibody response and in order to ensure optimal treatment, a passive immune product must be administered to patients presenting with severe exposures. However, it is not approved for use in India by DCGI.

 
    IJCP Special

Dr Good Dr Bad

Situation: A patient with albumin in the urine was to go for bypass surgery.
Dr Bad: There is no risk.
Dr Good: There is a risk of kidney injury.
Lesson: A simple urine test for presence of proteins before heart surgery can predict which patients may develop kidney–related complications, according to a study published in the Journal of the American Society of Nephrology.

Make Sure

Situation: A child with sore throat and enlarged lymph nodes developed fever.
Reaction: Oh my God! Why were antibiotics not given in time?
Lesson: Make Sure that all children with sore throat and enlarged lymph nodes are given antibiotics as such sore throats are Streptococcal unless proved otherwise.

 
  Quote of the Day (Dr GM Singh)

Many people love in themselves what they hate in others.~ E. F. Schumacher

 
    Mind Teaser

Read this…………………

A 2-month-old baby hasn’t received any immunizations. Which immunizations should Nurse Jess prepare to administer?

a. Measles, mumps, rubella (MMR); diphtheria, tetanus, pertussis (DTP); and Hepatitis B (HepB)
b. Polio (IPV), DTP, MMR
c. Varicella, Haemophilus influenzae type b (HIB), IPV, and DTP
d. HIB, DTP, HepB; and IPV

Yesterday’s Mind Teaser: Nurse Dave is conducting an examination of a 6-month-old baby. During the examination, the nurse should be able to elicit which reflex?

a. Babinski’s
b. Startle
c. Moro’s
d. Dance

Answer for Yesterday’s Mind Teaser: a. Babinski’s

Correct answers: Dr KV Sarma, Dr Ayyavoo, Dr BK Agarwal, Dr PC Das,
Dr BB Gupta, Tukaram Pagad, Tukaram Pagad, Dr Raghavendra Jayesh,
Dr (Brig) C H Gidvani, Dr Jainendra Upadhyay, Dr Pankaj Agarwal, Dr U Gaur,
Dr Sanjay Soni, Dr Jella, Dr Chandresh Jardosh, Raju Kuppusamy, Dr Thakor Hitendrsinh G, Dr PK Sahu, Dr Avtar Krishan, Dr Kanta Jain, Muthumperumal Thirumalpillai, Tukaram Pagad, Dr VM Kartha.

Answer for 16th April Mind Teaser: a. Hepatomegaly

Correct answers received from: Tukaram Pagad, Dr VM Kartha, Vineeta.

Send your answer to ijcp12@gmail.com

 
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    Laugh a While (Dr GM Singh)

The Football Player

There was a football coach that had a player on his team who was a bit slow.

The Headmaster told him that if the player could learn the formula for water, then he would be allowed to play in the big game.

The day of the big game came and the Dean called the player into his office and asked him to recite the formula for water.

The player grinned real big and said, 'H I J K L M N O.'

 
    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

The right to refuse medical interventions - The Nancy Vehicle Accident Case

The US Supreme Court declared that artificial hydration or nutrition is no different from medicines

Nancy Cruzan, a 31–year–old woman suffered severe brain damage in a vehicular accident that placed her in a persistent vegetative state, dependent upon a feeding tube.

  • After four years without improvement in her cognitive function, her family asked to have her artificial feeding and hydration stopped.
  • In its decision, the United States Supreme Court recognized that competent patients have a constitutional right to refuse medical care.
  • Using the Fifth Amendment’s guarantee that no person shall "be deprived of life, liberty, or property, without due process of law" the Supreme Court affirmed patients’ rights to refuse medical treatments. The Court declared that artificial hydration or nutrition is no different from other medical interventions. Although mentally incapacitated patients have the same right, the Supreme Court allowed states to impose restrictions on how explicit and specific the patient’s prior wishes had to be.
  • After this court ruling, some of Cruzan’s friends provided evidence that she had previously expressed wishes that she would want artificial feedings discontinued in such a scenario. As a result of this testimony, her feedings were terminated.
  • Mentally competent patients need not be terminally ill to exercise this right to refuse interventions they have the right regardless of health status.
  • The right applies equally to withholding proposed treatments and to discontinuing initiated treatments.
  • The right to refuse medical care does not imply a correlative right to demand treatment.

For comments and archives

 
    Public Forum

(Press Release for use by the newspapers)

Guidelines for hypertension

As per the guidelines published by the American Heart Association and published in Hypertension in patients with resistant hypertension, the blood pressure remains above the target level despite taking three medications to lower it. High blood pressure that's under control but requires four or more medications to treat it, is also considered resistant to treatment.

As many as 25 to 30% people with high blood pressure may have resistant hypertension in India said Padamshri & Dr. BC Roy National Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India & National Vice President Elect IMA.

Older age and obesity are two major risk factors for the condition. People with resistant hypertension have a high cardiovascular risk.

Successful treatment of resistant hypertension requires consideration of lifestyle factors, diagnosing and treating secondary causes, and using multiple drug treatments effectively.

Lifestyle factors include weight, salt intake and alcohol consumption.

  1. Losing weight can lower blood pressure and reduce the number of medications needed to control blood pressure.
  2. Reducing salt intake can lower blood pressure.
  3. Reducing alcohol consumption can help lower blood pressure.

Health conditions that can contribute to resistant hypertension include: obstructive sleep apnea, renal parenchymal disease, primary aldosteronism and renal artery stenosis. Treating these conditions may improve blood pressure control.

Drugs that increase blood pressure, such as non-steroidal anti-inflammatory drugs (NSAIDs), should be reduced or halted, if possible, in patients with resistant hypertension.

Diuretics are often underused in people with resistant hypertension. Patients may benefit from adding mineralocorticoid receptor antagonists (MRAs) to their treatment regimens. MRAs treat primary aldosteronism, which is found in about 20 percent of people with resistant hypertension.

 
    Readers Responses
  1. Dear Sir, Very informative newsletter. Regards: Dr Trishna
 
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