October 4   2015, Sunday
EDITORIAL
Dr KK AggarwalDr KK Aggarwal
Single common entrance test for MBBS and PG courses

In its annual general body meeting, the Medical Council of India (MCI) has decided to conduct a single common entrance test for all students appearing for MBBS and MD examinations. This recommendation has been sent to the Ministry of Health.

Presently, institutions across India have around 70,000 seats for MBBS and 21,000 seats for MD. Each state conducts its own entrance examination for the undergraduate and postgraduate seats. Private medical college associations, deemed universities and minority institutes who offer medical education also hold their own common entrance examination. Students generally take all these entrance tests, leaving nothing to chance.

An amendment to MCI Act Section 33 has also been proposed on empowering them to decide on the common test. The Centre had implemented National Eligibility-cum-Entrance Test (NEET) for admission to all under-graduate medical colleges in 2013. But, the MCI notification was challenged by 115 petitions following which the Supreme Court revoked the MCI notification. A three-judge bench by a 2:1 verdict held that the MCI notification was ultra vires of the Constitution. (DNA))

This has been the stand of the IMA too as also the MCI. The MCI lost its case in the Court last time on technical grounds. If adopted, it would be of immense help to all – students, doctors and check unethical practices.
Breaking news
Lexington Health Lab fined half a million dollars for bribing doctors

A Lexington health laboratory was fined half a million dollars for bribing doctors who referred patients to the lab. Strata Pathology Laboratory, now known as StrataDx, agreed to pay $558,793 as part of a settlement. “Billing arrangements like Strata’s, which provide a financial incentive to physicians to refer Medicare and Medicaid patients to a particular lab are unlawful,” said United States Attorney Carmen Ortiz. “When a company prioritizes profit, it disregards laws that are intended to protect patient health and the integrity of the healthcare system. Settlements like this serve to deter illicit kickback schemes.” (patch.com)
Dr Good Dr Bad
Situation: A 40-year-old male developed dyspnea for the first time in life.
Dr. Bad: It is an attack of asthma.
Dr. Good: Get an ECG done.
Lesson: First onset of breathlessness after the age of 40, unless proved otherwise, is cardiac in nature.

(Copyright IJCP)
Specialty Updates
  • "Our findings provide reassurance that vaccinations do not increase stroke risk, and may even reduce risk," Heather Fullerton, MD, MAS, of the University of California San Francisco and colleagues reported online in Neurology.
  • A salmonella outbreak that has been linked to contaminated cucumbers imported from Mexico has now caused 671 illnesses in 34 states, U.S. health officials said Tuesday.
  • People with type 2 diabetes may benefit from a higher-protein diet, but it likely depends on whether or not they have a particular gene related to vitamin D metabolism, new research suggests. The study is published online Sept. 29 in the journal Diabetologia.
  • Among patients scheduled for coronary CT angiography, those with "uncomplicated" hypertension had higher levels of pericardial-fat volume, coronary artery calcium (CAC) scores, extracoronary calcification, and Gensini scores (an indication of severity of coronary artery disease) than patients with no hypertension (European Society of Cardiology (ESC) 2015 Congress, Dr Azza Abd El Moneim Farrag (Cairo University, Egypt))
  • More than 3 million children in the United States who are severely obese may be at a higher risk of developing heart disease and diabetes than overweight children, according to a study published in the October 1 issue of the New England Journal of Medicine. The study found that children with the more severe forms of obesity showed early signs of heart disease and diabetes, with the differences most notable in boys.
  • Use of assisted-reproduction technology increases the risk of gestational diabetes by about 30%, although the prognosis for these women is similar to that of those who have normal pregnancies, suggests new research presented at the European Association for the Study of Diabetes (EASD) 2015 Meeting.
  • The US Food and Drug Administration (FDA) approved the programmed death (PD-1) inhibitor pembrolizumab for use in lung cancer. Pembrolizumab has become the second immunotherapy available for this tumor type.
  • An interleukin 17 (IL-17) receptor antagonist, brodalumab, achieved a 100% reduction in plaque psoriasis symptoms in twice as many patients as the commonly used antibody ustekinumab, suggested a phase 3 multicenter trial published in the October 1 issue of the New England Journal of Medicine.
  • The later a teenager or young adult goes to bed on weekdays, the more likely they are to gain weight over time, suggests a new study published in the journal Sleep.
  • Most people with tennis elbow recover without physical therapy and steroid injections, according to a study by researchers in Norway. (BMC Musculoskeletal Disorders)
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Media
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eSPIRITUAL
Mindfulness meditation
  • Sit on a straight–backed chair or cross–legged on the floor.
  • Focus on an aspect of your breathing, such as the sensation of air flowing into your nostrils and out of your mouth, or your belly rising and falling as you inhale and exhale.
  • Once you’ve narrowed your concentration in this way, begin to widen your focus. Become aware of sounds, sensations and ideas.
  • Embrace and consider each thought or sensation without judging it good or bad. If your mind starts to race, return your focus to your breathing. Then expand your awareness again.
Medicofinance
Components of financial planning process
  • Capital needs and survivor income analysis: Analysis and recommendations.
  • Retirement income: Analysis and recommendations inflation, qualified plans and increasing net cash flow.
  • Financial organizer file: For all documents, policy records.
  • Income tax organizer file: Used each year to accumulate and store vital records to support tax returns.
  • Master implementation checklist: To monitor your financial progress and be aware of advisor performance.
  • Periodic review sessions: Verify progress evaluation of investments, benefit plans and document completion.
(Source: IJCP)
Industry News
  • Aadhaar now most widely held ID with 92 crore holders: New Delhi: The Aadhaar card is now the most widely held identification document in the country with a voluntary enrolment of 92 crore people. It is also perhaps the sole ID for many of its holders, including many families below the poverty line. In comparison, 5.7 crore people have passports, 17 crore people PAN cards, 60 crore voter ID cards, 15 crore ration cards and 17.3 crore driving licences. Aadhaar has helped effect savings of Rs 2,600 crore by eliminating bogus claims in welfare schemes besides engendering greater transparency and consequently reducing corruption, reports from states and Union Territories show. (Rajeev Deshpande – Economic Times)
  • PM launches mudra for entrepreneurship: Prime Minister Narendra Modi launched MUDRA (Micro Units Development & Refinance Agency) scheme under which a loans of Rs 26,000 crore will be distributed among 42 lakh people to start business, in Dumka on Friday. He inaugurated the distribution of loans and free LPG connections to families that are below poverty line in Jharkhand. “MUDRA Yojana will lift the standard of life of the people after several years of negligence and exploitation by usurers,” Modi said after the inauguration of the twin benefits. (The Pioneer – PTI)
  • Government working on plans for major thrust to startups: New Delhi: The government is taking steps that will exempt new startups from various rules and regulations till they achieve a particular turnover. Lots of start-ups are coming up in the country and there is a need to provide them a conducive environment for their growth, Secretary in the Department of Industrial Policy and Promotion (DIPP) Amitabh Kant said. (ET Retail – PTI)
  • What startups can learn about entrepreneurship from Mahatma Gandhi: When an entrepreneur embarks on a new venture, it is a journey that is rife with struggles - sweat and tears, heartbreak and toil, failures and disappointments, losses and bankruptcies, even in the face of insurmountable barriers. This journey not much different from that Mahatma Gandhi took, to free India from the British rule, which at that time was a seemingly impossible task. (Inc42.com- Shweta Modgil)
eMEDIPICS
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Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
Medicolegal
Achieving Privacy and confidentiality in day to day practice- an ethical dilemma

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

Doctors in busy settings face an ethical dilemma. Maintenance of confidentiality and privacy becomes problematic due to the use of shared rooms. At times, the patient hesitates to share medical information due to this fact. More funds and better infrastructure may not always be possible. What is your preferred solution in such circumstances?

a) Ignore the issue as sharing information is culturally acceptable in India

b) Acknowledge overcrowding, try to make the patient comfortable within the shared setting

c) Extend work hours, push back appointments to ensure one patient per room at a time

d) Whisper/ talk in low voices

Do write in with your views and solutions.

Here are the responses received
  • I will go for a) Ignore the issue, as sharing information is culturally acceptable in India unless someone specifically asks for not sharing a small part of information. Saranya Devanathan, Psychiatrist
  • I think we cannot see 2 or 3 patients in one room. The patient’s right of privacy cannot be compromised for any reason. Each patient should be interviewed in a single room, and the patient and the family members should also be seen separately at least once and as and when needed. Infrastructural issues cannot be the excuse for inefficient treatment. Prof. Anil Agarwal, Psychiatrist
  • Lack of infrastructure is not an excuse for not observing privacy and confidentiality Patients should be seen alone as well as with family members. Prof. Satish Malik
  • Explain that the other person too is a doctor like me and assure that she would maintain confidentiality. Sudhakar Bhat, Psychiatrist
  • It is very difficult to provide a separate place and extending work hours may not be possible for doctors. They can talk in low voices and make the patient as comfortable as possible. If the issue really demands confidentiality like HIV or any other which patient is not at all confident to discuss in overcrowded situations, then extra time can be given after the crowding hours. Respecting the privacy of the patient is very important. Triptish Bhatia, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • Firstly, we can have cabins or space with glass partitions, which prevent the sound from reaching other places. Secondly, if we are to be economical then probably the patients, of course depending upon their problem and certainly alongside giving him assurance and confidence about confidentiality, can be asked to record their voices in their phones and then ear phones can be used as a medium to listen to the voice recorded by the patient. These ear phones shall be inserted/worn by both - the patient as well as the client so that they are on the same track of conversation. But, this can be done only at the time of case history taking. If the client is educated, he can write and the doctor can ask and clarify. Enquiry questionnaires could be used. Structuring the room accordingly can help. I don't know how much do we support online counselling and case history taking. However, people (doctors and patients) who are ready for the online case history-taking, shall be taken separately by doctors at say a particular day and they must be given facility and services of the same with helpers available around in a particular room Or can be done in a booth placed to be able to communicate with the doctors in any given area within the compound. Parul
  • Lack of rooms is a fact in mental health care. But mental health service cannot and should not be stopped due to this fact only. Privacy is definitely an important issue but when infrastructure is not adequate then also treatment means a lot. When any country does not have adequate infrastructure then decision should be taken according to what is available in nearby surrounding. So treatment comes first as per hierarchy of decision criteria. So the clinician should explore the possibility of privacy if possible. S/he may evaluate himself/herself, the nature of information forthcoming during the interview and take decision accordingly whether to ensure privacy or not. However privacy of any nature should be given due respect. But this suggestion is for setting where rooms are not available in adequate number. So the clinician may also ask the patient and family about their comfort level. However it has been observed that people do not care that much in a hospital outpatient department as they have their mind made up for such crowded places. And again people feel a kind of security being stranger in the crowd. If there are not too many patients then privacy must be secured for the patient. But during a rush this issue should be dealt by considering the nature of the problem and the sensitivity of the patient and the family. Ranjita Thakur
  • Having interned at Sion Hospital in Dept of psychiatry department, this dilemma was an everyday problem. However, practitioner skills made huge difference. Doctors who were able to successfully get history and provide details at the same time respecting confidentiality showed the following:
    • Apologize to the patient for the overcrowding but saying at the same time that all these people require a doctor so we have to work with this.
    • Telling that other professionals in this room are competent and caring doctors and will not make fun of (most men who were hesitant came with premature ejaculation issues); instead can actually assist in solving the problem.
    • Allowing them to speak softly if it is a sensitive detail.
Therefore if we really want to keep patient’s interest at the fore, a way can always be found to do so. Sadaf Vidha
Breaking news
India promises 33-35% cut in carbon emissions by 2030

India has promised to cut the intensity of its carbon emissions by 33-35% by 2030 from 2005 levels and make its economy more energy efficient in a climate-change policy statement released ahead of a UN summit in Paris in December. In the pledges submitted to the United Nations Framework Convention on Climate Change (UNFCCC) late on Thursday, India also said it would target 40% cumulative installed power capacity from non-fossil fuel sources by 2030, though added this would require UN financial support. (Source: Hindustan Times)
MAKE SURE
Situation: A dengue patient with BP 100/90 developed shock.
Reaction: Oh my God! Why was rapid fluid challenge not given?
Lesson: Make sure that pulse pressure (upper minus lower blood pressure) is maintained above 40 in all patients with dengue.
IMA JIMA
IMA Digital TV
Updates
  • The petition by three toddlers complaining about Delhi's toxic air has resuscitated the issue, with amicus curiae and senior advocate in the Supreme Court's Green Bench, Harish Salve, seeking imposition of a hefty pollution tax to rid the city of trespassing trucks.
  • Showing remarkable progress, 89 lakh individual household latrines have been built in rural areas in the past one year. According to government figures, the big Swachh Bharat push in rural areas has increased the access of toilets to 46.9% from only 32.6% in 2011 across the country.
  • The National Institutes of Health announced its second wave of grants to support the goals of the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, bringing the NIH investment to $85 million in fiscal year 2015.
Swachchh Bharat mission gallops in villages

As Prime Minister Narendra Modi’s pet project Swachchh Bharat Mission — aiming to make the country open defecation free by 2019 — completes one year on Thursday, a reality check has shown that while the programme is yet to make expected impact in the urban areas, it is gradually picking up in the villages, reported The Pioneer on 2nd October 2015. As per the Government’s latest data, nearly 4.64 lakh toilets were constructed till September 4 against the target of 25 lakh till March 2016 in the urban areas. The project in urban areas is being implemented under the supervision of the Urban Development Ministry. However, the Ministry of Drinking Water and Sanitation, which is implementing the programme in rural areas, has surpassed the target of 60 lakh toilets for 2015-16 and built 80 lakh toilets so far. (Source: The Pioneer)
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Safety Alerts List of Drugs, Medical Devices and Cosmetics declared as Not of Standard Quality/Spurious/Adulterated/Misbranded for the Month of August 2015

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Fatty liver common in type 2 diabetes

Results of a cross-sectional analysis published in Alimentary Pharmacology and Therapeutics show that almost two-thirds of patients with type 2 diabetes in the primary-care setting have evidence of nonalcoholic fatty-liver disease (NAFLD) on noninvasive MRI, while over 7% of them have advanced fibrosis on magnetic-resonance elastrography. Rohit Loomba, MD, associate professor of clinical medicine, University of California, San Diego said, “Most patients have no idea that they have fatty-liver disease until they develop cirrhosis, and that's why it's a silent killer.”
GP Tip: Formula of 4-2, 4-2

The easy way to remember DOTS treatment is the formula 4-2, 4-2 which is 4 drugs for 2 months and 4 months with 2 drugs.
CDC awards $22,800,000 to increase colorectal cancer screening

The Centers for Disease Control and Prevention has awarded a total of $22,800,000 to 24 state health departments, as well as six universities, and one American Indian tribe to increase colorectal screening. The grants, awarded in a competitive process, are designed to increase colorectal (colon) cancer screening rates among men and women aged 50 to 75 years. Tom Frieden, M.D., M.P.H., director of the Centers for Disease Control and Prevention said, “Colorectal cancer is the second leading cancer killer of both men and women in the United States, but most colorectal cancer can be prevented. “Screening saves lives and funds we are providing the states will support doctors, nurses, and others to save lives.” (Source: CDC)
WHO Removes Nigeria from Polio-Endemic List

WHO announced today that polio is no longer endemic in Nigeria. This is the first time that Nigeria has interrupted transmission of wild poliovirus, bringing the country and the African region closer than ever to being certified polio-free. The Global Polio Eradication Initiative (GPEI), the public-private partnership leading the effort to eradicate polio, called this a 'historic achievement' in global health. Nigeria has not reported a case of wild poliovirus since 24 July 2014, and all laboratory data have confirmed a full 12 months have passed without any new cases. Polio, which can cause lifelong paralysis, has now been stopped nearly everywhere in the world following a 25-year concerted international effort. Polio remains endemic in only 2 countries – Pakistan and Afghanistan. (Source: WHO)
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Inspirational Story
The perfectionist sculptor

A gentleman once visited a temple under construction where he saw a sculptor making an idol of God. Suddenly he noticed a similar idol lying nearby. Surprised, he asked the sculptor, "Do you need two statues of the same idol?" "No," said the sculptor without looking up, "We need only one, but the first one got damaged at the last stage." The gentleman examined the idol and found no apparent damage. "Where is the damage?" he asked.

"There is a scratch on the nose of the idol." said the sculptor, still busy with his work. "Where are you going to install the idol?" The sculptor replied that it would be installed on a pillar twenty feet high. "If the idol is that far, who is going to know that there is a scratch on the nose?" the gentleman asked. The sculptor stopped his work, looked up at the gentleman, smiled and said, "I know it and God knows it!"

The desire to excel should be exclusive of the fact whether someone appreciates it or not. Excellence is a drive from inside, not outside. Excel at a task today – not necessarily for someone else to notice but for your own satisfaction.
eWELLNESS
5 ways exercise improves your quality of life
  • Wards off depression
  • Enhances sex life
  • Sharpens wits
  • Improves sleep
  • Protects mobility and vitality
eMEDI QUIZ
The nerve commonly damaged during McBurney's incision is:

1. Subcostal
2. Iliohypogastric.
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 K V Sarma, Dr K Raju, Dr Avtar Krishan, Daivadheenam Jella, Dr Poonam Chablani.
Answer for 2nd October Mind Teaser: 3.Left common carotid artery arising from brachiocephalic trunk.
Correct Answers received from: Dr Poonam Chablani, Dr K V Sarma, Dr K Raju, Dr J Daivadheenam, Shiva Reddy, Dr Avtar Krishan.
Humor
Jumping on Beds

Connie told her 4–year–old grandson, Dean, not to jump on the beds. After several warnings she punished him, explaining that should he fall, he would hurt himself badly. Several minutes passed and he was back to jumping on the beds. Connie said, "Dean, you weren’t jumping on the beds again, were you?" He stood with his little head dropped low and said, "I’m trying, but it’s so hard to quit."
Press Release
Timely vaccination is recommended for disease-free healthy ageing

Vaccination is one of the ways by which we can maintain our health and longevity by simultaneously reducing the risk of contracting any degenerative and chronic disease

The saying, "You reap what you sow", fits the best in case of an individual’s health. We often don’t calculate the aftermath of the ignorance we show towards our health while we are young. As a result, we end up facing all the health-related consequences when we get old and have low immunity and decreased body resistance. And sometimes, we think taking necessary precautions and vaccinations once is enough. But akin to health, the effect of these vaccinations and precautions fades away as we grow old.

Speaking on the issue, Padma Shri Awardee, Dr A Marthanda Pillai – National President IMA and Padma Shri Awardee Dr K K Aggarwal – Honorary Secretary General IMA and President HCFI, “The ageing mechanism leads to a health deteriorating effect on the immune system of elders. This makes them comparatively more susceptible to basic preventable and manageable diseases when compared to the younger individuals. When coupled with existing lifestyle diseases such as cardiovascular ailments, hypertension, diabetes, or obstructive pulmonary diseases, it runs the risk of becoming life threatening. Most commonly contracted diseases include flu, pneumonia and Hepatitis B. Given this scenario, it is essential that certain vaccinations be given to people post the age of 65. Children must ensure that their parents get these vaccines on time for a healthy and long life.”

Following points should be kept in mind when considering a vaccination course:
  • Annual influenza or flu vaccine is recommended for all elderly persons
  • Pneumonia vaccine should be given to all adults aged 65 years and older.
  • Tetanus Toxoid should be given to all irrespective of age after every 10 years.
  • A single dose of herpes zoster vaccine is recommended for adults aged 60 years and older regardless whether they have had a previous episode of herpes zoster. The vaccination begins at 60 years of age
  • Hepatitis B vaccine should be given to all if they have not been vaccinated earlier.
  • All diabetics aged 60 years or older should be vaccinated for hepatitis B. This recommendation is based on increased need for associated blood glucose monitoring in long-term care facilities.
  • All patients with chronic liver diseases should also be given the Hepatitis B vaccine.
Unfortunately, nearly 50 percent of the senior citizen population is still unaware of the benefits of vaccination and the consequences if not taken. These shots prove highly beneficial and protect thousands of people from getting afflicted by life-threatening diseases every year. Proper education and a little responsibility can reduce the health risk and chances of hospitalization in elders.
Digital IMA