October 18   2015, Sunday
Dr KK AggarwalDr KK Aggarwal
IMA demands amendments to the PCPNDT Act

The PNDT Act came into being in 1994 with the purpose of improving the altered sex ratio in India. It was further amended in 2003 as the PCPNDT Act to regulate the technology used in sex selection. The Act banned preconception and prenatal sex determination. Its intent was to curb the actual act of sex selection and female feticide by regulating the use of ultrasound technology. WHO in its recent publication has clearly declared that restricting technology was not the way forward.

However, despite the Act having been in existence for over 20 years, the altered sex ratio in India has not changed. Instead, it has had two major negative consequences:

• In its current form, the implementation of the PCPNDT Act has deprived the community of life-saving and essential ultrasonography which has now become an extension of clinical practice for all specialties globally, being a well-known non-invasive, cost-effective and accurate diagnostic tool.

• The current PCPNDT Act has made it extremely difficult for ultrasound clinics to ensure complete enforcement. Doctors and other medical professionals are being put to extreme hardship while performing routine and essential scans. Due to this, many qualified doctors are opting not to do PNDT scans, thus creating a shortage of experts trained in ultrasonography.

As the PCPNDT Act has not resulted in the improvement of the falling sex ratio, social rather than medical interventions will be required to handle this issue effectively. The Act is being used to punish doctors for minor offences such as clerical errors in the filling of forms, thereby resulting in doctors being prosecuted and ultrasound machines being seized and sealed.
IMA demands the following amendments:

• The Act needs urgent modification to allow unambiguous and easy interpretation. The “Rules” need to be simplified and implemented uniformly across the country, and adhoc changing of rules by each local authority should be strictly prohibited. New rules must be logical and should apply to the entire country only after due discussion with the representative bodies. Time should be given for implementation of the new rules.

• The Act is to be directed only towards Obstetric Ultrasound and not any other applications of ultrasonography.

• The word “Offence” under this act has to be clearly defined. The word Offence should only mean the “actual act of sex determination or female feticide”.

• All other clerical/administrative errors should be classified as non-compliance (and not an offence). Strict penalties can only be imposed for the actual act of sex determination or female feticide and not for other errors. There is a need to redefine “what amounts to sex determination” as mere evidence of clerical error does not amount to sex determination. “Imprisonment” rules should be for the offence (of sex determination or female feticide) & not for non-compliance.

• Inspections should be conducted yearly instead of every 90 days. No NGO can conduct “raids” on doctors’ premises and there should be no impediment to doctors doing their practice during inspections.

• Ultrasonologists should not be restricted to working in only two centers.

• The doctors should have the right to report on those seeking sex determinations and action must be initiated against them immediately.
Breaking news
FDA Okays first novel oral anticoagulant reversal agent

The FDA has approved the first reversal agent for a novel oral anticoagulant (NOAC) -- this one for dabigatran.

Idarucizumab, which works by binding to dabigatran in the blood when given via intravenous injection, will be indicated for emergency situations prompting the need to reverse the drug's blood-thinning effects, the FDA said in a press release. The FDA warned that reversing the effects of dabigatran exposes patients to the risk of blood clots and stroke from their underlying disease, and the product's labeling recommends that patients get back on their anticoagulant as soon as their healthcare provider determines that it's medically appropriate to do so. (Medpage Today)
Dr Good Dr Bad
Specialty Updates
• Immune cells are more active in the brains of people at risk of schizophrenia, as well as those already diagnosed with the disease, suggests a study published in the American Journal of Psychiatry.

• Using a device designed to close the patent foramen ovale (PFO) in patients who have had a cryptogenic ischemic stroke may reduce their risk of having another stroke, suggest new 10-year data from the RESPECT trial, presented at the Transcatheter Cardiovascular Therapeutics (TCT) 2015.

• In a large, retrospective, cohort study of mainly middle-aged, obese women who had bariatric surgery, the patients had a 20% higher risk of a fracture after the operation, and the fractures usually occurred after a few years. The results were presented at the American Society for Bone and Mineral Research (ASBMR) 2015 Annual Meeting.

• A prospective cohort study published in the October 15 issue of the New England Journal of Medicine suggested that neonatal hypoglycemia does not increase the risk for poor neurological outcomes when infants receive treatment to keep their blood glucose concentration at a minimum of 47 mg/dL.

• The majority of gonorrhea and chlamydia infections are missed when only urine is used to screen HIV-positive men, suggests new research presented at IDWeek 2015.

• New research has discovered that statins can help prevent kidney injury, and has uncovered how the drugs exert their protective effect. The findings are published in the Journal of the American Society of Nephrology (JASN).

• A pilot study of 23 adults with newly diagnosed type 2 diabetes reported that early insulin therapy is as effective as 15 months of oral therapy and may improve the body's ability to produce insulin. The findings were presented at American Osteopathic Association (AOA) Osteopathic Medical (OMED) Conference 2015.

• The use of a diagnostic strategy with fractional flow reserve (FFR) derived from computed tomography (CT) not only significantly reduced the number of patients requiring invasive coronary angiography compared with usual care, but also reduced resource consumption and costs, suggested a new analysis presented at TCT 2015 and published simultaneously in JACC: Cardiovascular Interventions.

• A new study published in Mucosal Immunology suggests that human breast milk serves as a reservoir for bio-molecules that help to resolve inflammation and combat infection.

• Functional magnetic resonance imaging (fMRI) may help identify patients in remission from major depressive disorder (MDD) who are most apt to experience relapse, according to a new study published online October 7 in JAMA Psychiatry.
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.

The top right hand is positioned in a gesture of providing courage and the other hand is positioned in a gesture of rendering a boon. The top left hand is holding a sword and the other holding a lotus.
In Yoga Shastra she represents the Ajna Chakra and AUM bija mantra. AUM chanting helps to attain success in religion, wealth, passion and salvation and removing fear and sorrows.

On the 6th day one should control aggression (lion), help and protect others (mudras) and practice detached attachment (lotus) using the sharp intelligence (sword). AUM chanting is one of the most powerful mantra and should be done concentrating on the Ajna chakra on this day.
Legal Quote
Jacob Mathew v. State of Punjab SC / 0457 / 2005: (2005) 6 SCC 1 (iv)

“A private complaint may not be entertained unless the complainant has produced prima facie evidence before the Court in the form of a credible opinion given by another competent doctor to support the charge of rashness or negligence on the part of the accused doctor. The investigating officer should, before proceeding against the doctor accused of rash or negligent act or omission, obtain an independent and competent medical opinion preferably from a doctor in government service qualified in that branch of medical practice who can normally be expected to give an impartial and unbiased opinion applying Bolam’s test to the facts collected in the investigation.”
Asset protection – Personal Residence

There are two equity stripping techniques. One way to strip out the equity is by obtaining a bank loan. Even if, we assume that a bank would lend an amount sufficient to eliminate 100% of the equity, the cost of this asset protection technique is staggering. A Rs 1 crore loan bearing a 10% interest rate, costs Rs 10 lakhs/year. Another way to strip out the equity is to encumber the residence by recording a deed of trust in favor of a friend. This avoids the carrying costs of an actual bank loan. With this technique it is important to know the intelligence and the aggressiveness of the creditor. Some creditors may stop trying to collect when they realize that there is no equity in the residence. Others may dig deeper, and if the debtor cannot substantiate the transaction as an actual loan, the deed of trust will be set aside by a court as a sham.

(Source: IJCP)
Industry News
Sweden may become world's first cashless nation: A study from the KTH Royal Institute of Technology in Sweden finds that Sweden is on its way to becoming the world's first cashless society, thanks to the country's embrace of information technology as well as a crackdown on organized crime and terror. According to Niklas Arvidsson, a researcher at the KTH Royal Institute of Technology, widespread and growing embrace of the mobile payment system, Swish, is helping hasten the day when Sweden replaces cash altogether. "Cash is still an important means of payment in many countries' markets, but that no longer applies here in Sweden. Our use of cash is small, and it's decreasing rapidly," he said… (Deccan Herald).

Early stage VC investments cross $1 billion mark: Early stage investments in the first nine months of 2015 crossed the $1 billion mark, as per a report by Venture Intelligence. As many as 323 deals worth $1,438 million have been made in the first nine months, compared to 304 investments worth $1,170 million across 2014. Venture Capital (VC) firms invested $536 million over 111 deals in India during the past three months, record numbers for a single quarter. The investment activity in the third quarter this year was 41% higher compared to the same period in 2014. The activity level was 9% higher than the previous quarter. The main action was concentrated in seed, first and second round investments. (Business Standard)

Walmart arm scouts for acquisition in Indian start-ups space: WalmartLabs, engineering arm of Walmart that drives its e-commerce business, is engaged in discussions with around 10 IT start-ups. Jeremy King, chief technology officer of Walmart Global eCommerce and head of @WalmartLabs said, “I am pretty much interested in companies in areas like supply chain, ad tech, analytics and anything that has to do with mobile shopping.” (Business Standard - Bibhu Ranjan Mishra & Alnoor Peermohamed)

New online start-ups bring employers, jobseekers closer: Finding a suitable job for themselves is an area of concern for the jobseeker. A host of websites such as Hiree, ZenRadius, Babajob.com have come up that cater to the needs of the candidates. (Business Standard - M Saraswathy & Sohini Das)
Inspirational Story
The Man in Trouble

A man was caught and thrown into a pit of about "40 feet" deep, just because he was a stranger. He struggled trying to get out of the pit, but the more he tried, the weaker his muscles became. He said to himself, "I don’t know how to get myself out of this. Maybe I should just die instead of enduring these miserable struggles and pains." Just then, he heard a voice screaming, "Help! Help!! Help!!!" The shouts were coming from another pit, which was 10 feet deeper than the one he was in.

He thought to himself, "Wow, so there is somebody else like me trapped here too". Listening carefully, he heard some cracking and sand dropping from the wall of the pit of the other victim. Immediately he summed up his courage and with his last bit of strength, started crawling little by little until he made it out of his pit.

Moral of the story: That pain you think you are passing through, there are people worst off than you. Always say something sweet to yourself. Always smile at your pains. Let them be; they are just there for a while and also to challenge you. Today may be your darkest hour, but your joy will come in the morning. Try to encourage yourself. Look at yourself in the mirror, beat your chest and say, "I can make it and I can stand the test of time."

Always try to face your worst fear because nothing good comes easy. You must be uncomfortable to get to your comfort zone.
IMA leaders at the World Medical Association (WMA) 2015 Assembly meeting in Moscow
MTNL Perfect Health Mela 2015.

Pls click here for details
IMA Digital TV
The son of a general practitioner had recently qualified in medicine, and his father took him into partnership. A few months later, the old doctor went away on holiday, leaving the youngster to look after the practice. On his return his son informed him smugly that during his absence he had affected a complete cure of the back pains which has troubled an elderly private patient for years. "You did a grand job there, son," smiled his father. "Especially as it was those back pains which put you through medical school."
The nerve commonly damaged during McBurney's incision is:

1. Subcostal
3.11th Thoracic.
4.10th thoracic.

Yesterday’s Mind Teaser: The blood vessel related to the paraduodenal fossa is:

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

Answer for Yesterday’s Mind Teaser: 4. Inferior mesenteric vein.

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

Answer for 16th October Mind Teaser: 3. Left common carotid artery arising from brachiocephalic trunk

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

This dilemma touched a raw nerve. As doctors we are always expected to be ‘healthy’ and when we fall ill, the remarks used to be ‘how can a doctor fall ill’? We received a number of interesting replies to this dilemma. Those who wrote in were:
Sreenivas Vishnubhatla
Sudhakar Bhat
Ravindra Ghooi
Ved Mahla
Sheela Jaywant
Rohit Bansal
Pooja Sharma
Vihang Vahia
Rakesh Biswas
Naresh Vadlamani,
Sabina Rao
Padma Sudhakar
Thatikonda, Tirupati
Sarvesh Chandra
Vivek Kirpekar
Rema Devi
Vihang Vahia
Dr. Valan
Anil Nischal, KGMU,
Satish Malik
R Hari Kumar

Here is a summary of what they all said

One Professor (Vihang Vahia) wrote- what does UNESCO think? To answer, this dilemma was adapted from the UNESCO Casebook series referenced above. The legal position was stated in that reference. But we would like to know what the learned readers of this column think, and hence the dilemma. Ethics is also a product of culture, legalities and many other factors and individuals need to consider these aspects for an ethical dilemma, which may have no black or white answers.

Most professionals felt that it was for the regulatory agencies to lay down the rules and for the doctor to inform such agencies, especially if his medical judgment is not affected and the disease/disorder is under treatment and control including HIV (IMC or state medical council or NHS, the hospital where he works from etc.) (Sreenivas Vishnubhatla, Sheela Jaywant, Pooja Sharma, Sabina Rao, Sarvesh Chandra, Rema Devi, Dr. Valan, Sudhakar Bhat, R. Hari Kumar). Many doctors over 50 suffer from some ailment and are on multiple medications which may affect their performance (Naresh Vadlamani). NV felt that a fitness certificate should 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 practice when not fit. Many were of the opinion that the doctor’s health was his own private concern and there was no need to discuss with an individual patient.

Padma Sudhakar Thatikonda pointed out that the epilepsy was well under control, surgery is a team effort. If the surgeon is fit (Sudhakar did not say if a certificate would be mandatory) then the questions of disclosure should not arise. Sarvesh Chandra felt the psychological status of the surgeon was as important an issue as his physical status. The doctor himself should assess his own ability to operate (Rema Devi). Some warned about consequences with failure to disclose - doctors should not only be open but be seen to be open too (Ravindra Ghooi).

Some felt that doctors should not develop a ‘God like aura’ and must satisfy basic universal ethical and legal criteria of functioning and not harm the patient (Rakesh Biswas). Others pointed out the danger of a surgeon with epilepsy performing a procedure (Rohit Bansal). Anil Nischal wrote that medicine rests on ‘primum non nocere’- do no harm, so 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. The doctor 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. Technically too this is unfitness for job.

Vivek Kirpekar told of a relative- a surgeon- who was shifted to a teaching job after he developed scar epilepsy from a small superficial infarct. Some opined that the bigger issue of monitoring doctors at the time of license issuing and hospitals doing due diligence before hiring, especially in India (Sabina Rao). Ved Mahla felt that this world is all about managing to survive (rather cynical I felt!) while Satish Malik felt that the surgeon should refrain from active surgeries as he can put the others life at risk. Sudhakar Bhat felt that 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. 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 (Olinda Timms).

At the end, Olinda presented two dilemmas of her own: 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?

Does anyone has information on any directives from MCI/ Min Health &FW regarding this ethical dilemma? What do YOU think? What would you have done- if you were the doctor, or if you were the patient?
Breaking news
Fractional facilities for blood banks

With a view to ensure access to safe blood to patients requiring blood transfusions, the Union health ministry has decided permitting transfer of blood units and blood components between blood banks. For optimal utilization of blood and its components, it is also decided to send surplus plasma available with blood banks for fractionation. While, the fractionation facilities are so far either available in private sector in India or the country is dependent on imports. In consonance with the Prime Minister’s make in India ideology, the health ministry has taken a step forward to improve the availability of these products in the country.

In a recent meeting of governing body of National Blood Transfusion Council, it has been decided to implement these measures for improving optimal utilisation and minimising wastage. The council under the Union health ministry is the policy formulating apex body for all matters pertaining to the standards and training of a sustainable and safe blood transfusion in the country. Earlier, even though the Drugs and Cosmetics Act 1940 and rules did not debar bulk transfer of blood between banks, they also did not have an enabling provision. Officials said that this often led to expiring of blood in one bank and not being available in another and patients being asked to shuttle between banks to source blood, when required. (Asian Age – Teena Thacker)
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?
WMA News
WMA urges end to healthcare attacks in Turkey

The World Medical Association has called for an end to recent attacks on healthcare personnel, patients, and health care facilities in Turkey.

At its annual Assembly in Moscow, the WMA supported an emergency resolution deploring recent attacks in which healthcare personnel have been killed, wounded or threatened with guns. Delegates from more than 50 national medical associations heard that a physician, a nurse and an ambulance driver had been killed within the last two months.

Dr. Bayazit Ilhan from the Turkish Medical Association told the meeting that the wounded were being impeded from getting to hospital and preventable deaths were occurring because of the absence of health care. ‘There are indications that these attacks are being used as a deliberate political instrument to intimidate people, depriving them of their democratic rights. Parties in armed conflict have the obligation to protect health care provision to the wounded and sick and to prevent attacks such as these.'

WMA President Sir Michael Marmot said: ‘Physicians and other healthcare personnel should not be prevented from performing their duties. Such attacks constitute a blatant violation of international human rights law and undermine fundamental medical ethics principles. ‘We call for all parties involved to respect the professional autonomy and impartiality of healthcare staff, and to comply fully with international human rights law and other relevant international regulations. We also want to see all violations documented and the perpetrators prosecuted.

Physician leaders urge health care for refugees

It is essential that countries receiving refugees establish systems to provide them with health care, the World Medical Association said today.

In an emergency resolution adopted at their annual Assembly in Moscow, delegates from more than 50 national medical associations said that governments and international agencies including the United Nations must make more effort to reduce the pressures of the current global refugee crisis. This included rapidly providing extensive relief and making more effort to stop the armed conflict.

The meeting commended those countries that have welcomed and cared for refugees, especially those currently fleeing Syria, and called on other countries to improve their willingness to receive refugees and asylum seekers. It pointed out that most countries have signed international treaties giving them binding obligations to offer aid and assistance to refugees and asylum seekers.

WMA President Sir Michael Marmot said: ‘It is important we make the point that refugees are people who are suffering, and that we as doctors understand that suffering that has led them to become refugees. These are desperate refugees from Syria escaping the effects of armed conflict including bombing, lack of access to utilities, clean water, and the destruction of their homes, schools and hospitals. ‘So we urge all governments to provide immediate help to countries facing the effects of what has become the largest mass movement of populations in over 70 years.

‘This should include safe passage for refugees, and appropriate support after they enter countries offering refuge. Governments must seek to ensure that refugees and asylum seekers are able to live in dignity within their country of refuge and make every effort to enable their integration into their new society. ‘But above all the international community must work to get a peaceful solution in Syria under which the population can either stay at home safely or, if they have already left, safely return home.'

The emergency resolution passed by the Assembly also calls on the global media to report on the refugee crisis in a manner ‘that respects the dignity of refugees and displaced persons, and to avoid bigotry and racial or other bias in reporting'.
Lesion-directed skin tumor screening is feasible
A study published online in JAMA Dermatology suggests that lesion-directed screening (LDS) had a similar detection rate for overall skin cancers compared with total body examination (TBE) and was dramatically less time consuming. It also had lower costs per detected skin cancer. The detection rate for LDS was 3.2% vs 2.3% for TBE (P=0.40), and the average time per exam was 232 seconds (SD 70) for TBE vs 41 seconds (SD 67) for LDS.

According to Lieve Brochez, MD, PhD, University Hospital Ghent in Belgium, and colleagues, when performed by dermatologists, LDS is an acceptable alternative screening method in health care systems with limited budgets or long waiting lists. Compared to naked-eye examination, dermoscopy has been shown to increase melanoma detection by at least nine times. The authors of this dermatologist-driven, population-based screening study suggest that community-based sensitization campaigns and personal invitations to participate, as well as screening teams with dermatologists experienced in using dermoscopy, are important for skin cancer screening.
(Medpage Today)
MCI Code of Ethics Regulations, 2002
3.4 Statement to Patient after Consultation

3.4.2 Differences of opinion should not be divulged unnecessarily but when there is irreconcilable difference of opinion the circumstances should be frankly and impartially explained to the patient or his relatives or friends. It would be opened to them to seek further advice as they so desire.
Over 20,000 annual ED visits linked to supplements, says CDC
CDC researchers have reported in the New England Journal of Medicine that dietary supplements are involved in some 23,000 visits to emergency departments (ED) every year in the US. Even though this figure constitutes less than 5% of the figure for pharmaceutical drugs, dietary supplements are regulated and marketed under the presumption of safety. According to Andrew Geller, MD, of the CDC in Atlanta, and colleagues, cardiac symptoms from weight loss and energy supplements accounted for more ED visits than prescription stimulants, which actually contain warnings about sympathomimetic adverse events, while supplements are not required to identify adverse effects. The authors suggest that these findings should be used to "help target interventions to reduce the risk of adverse events associated with the use of dietary supplements."

Regulation of supplements in the U.S. has long been under fire for being too lax; critics note that while the Dietary Supplement and Health Education Act (DSHEA) doesn't allow supplements to be marketed as being able to cure disease, it makes it easy for a company to sell products with very little oversight. Products don't need FDA approval to come to market, and companies are only required to report serious adverse events to the agency. Since DSHEA was passed in 1994, the estimated number of supplement products rose from 4,000 to more than 55,000 in 2012, the CDC researchers said, amounting to some $15 billion spent each year on herbal or complementary nutritional products...(Medpage Today)
Vaccinations made friendly: WHO position paper
Recently, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) studied the feasibility of globally adapting Canada’s existing clinical practice guidelines for reducing pain and fear from vaccine injections. Based on SAGE’s thorough review of the evidence and issuance of recommendations, WHO published the first position paper, “Reducing pain at the time of vaccination,” which recommends the following measures be applied by national immunization programmes in all countries, across all age groups:

• Health-care personnel carrying out vaccinations should be calm, collaborative and well informed and use neutral words when administering the vaccine such as “here I go” instead of “here comes the sting.”

• Recipients of the vaccines should be positioned properly, according to age. Infants and young children should be held by their caregiver. Older populations should be sitting upright.

• Aspiration or pulling back of the plunger of a syringe prior to intramuscular injections should not be performed as this may increase pain.

• When multiple vaccines are scheduled to be injected in the same session, they should be given in order of painfulness – ending with the most painful.

For infants and young children, additional measures are recommended:

• Caregivers should be present throughout and after the vaccination procedure.

• Infants should be breastfed during or shortly before the vaccination session, if it is culturally acceptable.

• Distractions such as toys, videos and music are recommended for children under 6 years of age.

(Source: WHO)
IMA Digital TV
GP Tip: Simpler eye drop administration

Putting eyedrops in an uncooperative or frightened child. Have the child lie supine, with eyes closed. Place 1 or 2 drops of medication in the pocket by the medial canthus. When the eyes are opened, the drops flow in.
Lifestyle choices in controlling blood pressure

• Try lifestyle management for up to 6 months. It can alone control the high blood pressure if initial BP is <160/100 mmHg.

• Lifestyle interventions have effects similar to single drug therapy.

• Combinations of two (or more) lifestyle modifications can achieve even better results.

• Maintain normal body weight. A reduction of 5–20 mmHg of BP can be achieved for every 10 kg weight loss.

• Consume a diet rich in fruits, vegetables and low fat dairy products with a reduced content of saturated and total fat. It can reduce a blood pressure of 8–14 mmHg.

• Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). It can alone reduce blood pressure by 2–8 mmHg.

• Do regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). It can alone reduce blood pressure by 4–9 mmHg.

• Limit consumption of alcohol to no more than 2 drinks (1 oz or 30 mL ethanol; e.g., 24 oz beer, 10 oz wine, or 3 oz 80–proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter weight persons. It can alone reduce blood pressure by 2–4 mmHg.
Readers column
Very nice and informative endeavour. Dr Varsha Gupta.
Digital IMA
Press Release
Indian Medical Association seeks increase in budgetary allocation for the health sector

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.

The High-level expert group (HLEG) on Universal Health Coverage (UHC) constituted by the Planning Commission of India submitted its report for the year 2022 in Nov 2011. The recommendations made 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. The planning commission estimated that 3.30 lakh crores had 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).

Speaking about this, Padma Shri Awardees, Dr A Marthanda Pillai, National President Indian Medical Association (IMA) and Dr K K Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India in a joint statement said, “The 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. The Government should ensure that a minimum of 55% of health budget is spent 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.”

Recommendations shared by the IMA include

• 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 50% 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 will not only facilitate basic primary and secondary care, but also reduce the burden and expenditure share at the tertiary level.
• There should be an increase in spending for public procurement of medicines from 0.1% to 0.5% of GDP.
• The 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 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.
• 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 reduce out of pocket expenses and also reduce the burden on tertiary healthcare system.
• The reimbursement scheme for health care should be extended to all people working in organized sector and not just to central government employees.
• Public and private sectors should not move as parallel systems, but should complement each other. Public private partnership in health should be promoted.
• 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.