Tuesday, 26 December 2017

Why should everyone oppose the National Medical Commission Bill 2017?

Composition of the National Medical Commission
One of the sections of the proposed Bill provides for the composition of the National Medical Commission, which will have a) a chairperson b) 12 Ex-officio Members c) 11-part time members d) an Ex-Officio Member Secretary. Thus, it would have an effective membership of 25 along with the Chairman of which only 5 members will be elected (Part Time Members who will be elected by the registered medical practitioners from among themselves from such regional constituencies and in such manner as may be prescribed.
Therefore, the proposed commission will have 1/5th members (20% elected members and 80% appointed / nominated members). It is for this reason it will not have a desired ‘representative character’ with reference to ‘elected and nominated / appointed members’
The composition of the four autonomous boards (Ethics and Medical Registration [EMR] Board, Medical Assessment and Rating [MAR] Board, Postgraduate Medical Education [PGME] Board, Undergraduate Medical Education [UGME] Board) prescribed under the Bill does not include any elected member there under.  Each board will have only three nominated members, one president and two members and that to with full powers to recognize or derecognize a medical college, powers today vested with 130 members.
The present MCI is a representative body with representatives from central government (8), state representatives (one from each state), state council’s professional doctors (one each), representatives from each health university etc. covering all stake holders.
Functions of the Commission
The functions vested with the Commission under the Act are generic, advisory and cosmetic in character. There under it is to exercise appellate jurisdiction with respect to decisions of the autonomous boards except that of the EMR Board as brought out in the proposed Bill. However, in one of the sections, it is stated that a medical practitioner or professional who is aggrieved by the decision of the EMR board may prefer an appeal to the Commission within 60 days of the communication of such decision, which is contradictory.
One of the sections of the proposed act provides an appellate jurisdiction exclusively to a medical practitioner or professional to prefer an appeal with the commission if aggrieved with the decision of the EMR Board. However, the said clause is absolutely silent in regard to providing appellate jurisdiction to the complainant, which is a substantial omission with reference to equity and providence for justice.
Functionally commission would be framing guidelines for determination of Fee in respect of such proportion of seats not exceeding 40% in the private medical institutions and deemed universities which are governed under the provisions of this Act. This operationally means that the fee regulation would be limited to a maximum of 40% seats in the private medical institutions and deemed universities, which is difficult to understand as to why such a ceiling and furthermore it could be anything from nil up to 40% which is paradoxical in nature. This will also have political implications and can be a root cause of future corruptions.
Separate National Register
The Bill states that the EMR Board shall maintain a separate National Register including the names of licensed Ayush Practitioners who qualifies the bridge course referred in one of the sections in such manner as may be specified by Regulations. By an explanation, Ayush Practitioner has been defined as a person who is a practitioner of Homeopathy or a practitioner of Indian Medicine as defined in Clause (e) of Sub-section 1 of section 2 of the Indian Medicine Central Council Act, 1970.
One of the sections of the proposed Bill contemplates bridge courses even for the practitioners of homeopathy to enable them to prescribe such modern medicines at such level as may be prescribed. This is materially inconsistent with the definition of the word ‘medicine’ as depicted in one of the sections wherein it is defined as ‘medicine means modern scientific medicine in all its branches and include surgery and obstetrics but does not include veterinary medicine and surgery’.
As such these are the flood gates that have been opened up in terms of the statutory provisions for backdoor entry into medical profession entitling practicing modern medicine.
Dismantling Screening Test
In one section, the proposed Bill clearly stipulates that ‘no person who has obtained medical qualification from a medical institution established in any country outside India and is recognized as a medical practitioner in that country shall, after the commencement of this Act and the National Licentiate Examinations becomes operational, be enrolled in the National register unless he qualifies the National Licentiate Examinations.
It is strange that, a filter in the name of screening test, was placed to ensure that the degree holders from medical institutions outside country are tested in regard to their required level of knowledge and upon clearance of the screening test were required to do one-year internship for the hands-on training under supervision in a recognized medical college to ensure that he is capable of rendering healthcare services to the people at large in the Indian context. Upon the promulgation of the National Medical Commission Bill 2017, the Indian Medical Council Act, 1956 would stand repealed and therefore the clause 13 thereat prescribing screening test would be rendered to nullity.
The proposed bill stipulates in one of the sections that “The National Licentiate examination shall become operational on such date, within three years from the date of commencement of this act, as may be appointed by the Central Govt., by Notification. This operationally means that till such time the National Licentiate examination is notified, the Indian possessing foreign Medical qualification would be entitled to seek permanent registration and practice medicine without any screening rider or filter. As such, during the interregnum a vacuum would be created, and the same would be filled in what manner is not provided for anywhere in the proposed Bill. This may amount to backdoor entry of over one lakh foreign graduates.
It is imperative to note that there are several students who have sought admission to medical institutions outside India after procuring eligibility certificate by the Medical Council of India and therefore, are legitimately entitled to appear for the screening test after acquiring foreign graduate medical qualification. Further, the foreign qualifications which are there in the existing schedule in a limited number appended to the Indian Medical Council Act, 1956, with the annulment of the said Act would also become redundant.
By removal of the said filter and in the teeth of the liberal provision incorporated one of the sections of the Bill, it will open floodgates for the compromised degree holders to practice without they being tested for the desired levels and country will be flooded with half- baked and ill-equipped medical practitioners playing havoc with the health of Indian population at large.
UG-NEET exam will be in English or other languages with common counselling.  There will be a uniform National Licentiate Examination operational within three years with no PG NEET and with common counselling.
Licentiate exam will be a hindrance to students who have passed MBBS from North East States and or who belong to SC/ST or other backward classes. They will never be able to pass such common exams. Also, there is no provision for AYUSH doctors practicing modern medicine to undergo licentiate exam.  This amounts to restricting post MBBS students to practice and allowing half-baked AYUSH doctors to start practicing modern medicine with a ‘bridge course’.
Composition of Autonomous Board
One of the sections of the proposed Act stipulates that each autonomous board shall consist of President and two members. The composition does not provide for inclusion of any elected member therein which goes to indicate that the membership of the said Boards would be totally appointed / nominated without any representation of an elected member and thus they would not have any representative character as is desired and warranted.
Discretionary Powers for relaxing prescribed regulatory conditions
In one of the sections of the Bill, a proviso is provided, which entitles the MAR Board to relax the criteria for opening of the medical colleges at its discretion with the previous approval from the Central Government which yields not only a wide authority but also provides adequate scope for availing the discretion for extraneous considerations. More so the regulatory stipulations which are mandatory in nature and binding in character cannot be open for any concession or condonation vide discretionary authority.
The said discretionary authority is not only vested with the autonomous board but also is with the Central Govt. as well. Such dual / double discretions to waive the applicability of statutory stipulations governing prescribed requirements per seis bad in the eyes of the law.
Permission to practice without qualifying the National Licentiate Examination
Proviso to one of the sections stipulates that ‘the commission may permit a medical professional to perform surgery or practice medicine without qualifying the National Licentiate Examination, in such circumstances and for such period as may be specified by regulations’. This operationally means that without ascertaining of the required levels and certification thereto the commission would be permitting people to practice surgery and medicine is nothing less than legalizing quackery in an operational sense.
Removal of embargo on Foreign Citizens practicing in India
‘A foreign citizen who is enrolled in his country as a medical practitioner in accordance with the law regulating the registration of medical practitioners in that country may be permitted temporary registration in India for such period and in such manner as may be specified by a Regulation’ as clearly stipulated in a proviso to one of the sections. An uninhibited permission to practice medicine by a foreign citizen without any reasonable restrictions is harboring intrinsic dangers in itself.
Imposition of Penalty
The Bill provides in one of the sections that MAR Board take such measure, including imposition of monetary penalty, against a medical institution for failure to maintain the minimum essential standards specified by the UGME Board or the PGME Board, as the case may be, in accordance with the regulations made under this Act.
It is further provided that the “medical institution which has been imposed a first-time monetary penalty fails to take any corrective action, the MAR Board may impose a second-time monetary penalty for continued failure which shall be higher than the first- time penalty and on continued failure, impose a third-time monetary penalty which shall be higher than the second-time penalty:
Provided further that all the three monetary penalties imposed under the first proviso shall not be less than one-half, and not more than ten times, the total amount charged, by whatever name called, by such institution for one full batch of students of undergraduate course or postgraduate course, as the case may be:
Provided also that even after the imposition of third-time penalty, if the failure continues, the MAR Board shall forward its report to the Commission recommending to withdraw the recognition granted to the medical qualification awarded by that medical institution.
The material point for consideration is that all the three monetary penalties are not to be less than one half and not more than ten times the total amount charged by such a institution for one full batch of students of undergraduate course or postgraduate course as the case may be. Apart from the heavy computation the contemplation of batch of students of undergraduate course or postgraduate course fall short of indicating required specifics.
For example, the penalty can range from 5 crore to 100 crore, enough variation to have political implications or root cause for corrupt practices.
Also, a medical college which has not been compliant for want of financial resources how will the college pay the fine and if closes down what will happen to these students admitted for these three years.
Central Govt. empowered to issue directions
Although, autonomy is expected to be a hallmark of the National Medical Commission Bill, 2017 and the Boards there under are called as, “Autonomous Boards” in reality the same is a misnomer as under one of the sections in the said proposed Bill the Central Govt. would be entitled to give directions to the Commission and autonomous boards on all the questions of policy which would be binding for the commission and autonomous Boards to comply.
Further it is clearly stipulated that the decision of the Central Govt. whether question is one of the policy or not would be final and is not open for any require of any type.
In one of the sections, the proposed bill further stipulates that the Central Govt. would be within its rights to give such direction it may deem necessary to the State Govt. for carrying out all or any of the provisions of this Act and State Govt. shall comply with such directions is also undermining the authority of the State Govt. and is inconsistent with the cardinal principles governing the federal polity as stipulated in the Constitution of India.
The proposed Bill takes away the autonomous status of state medical councils “(d) promote, co-ordinate and frame guidelines and lay down policies by making necessary regulations for the proper functioning of the Commission, the Autonomous Boards and the State Medical Councils; and (f) take such measures, as may be necessary, to ensure compliance by the State Medical Councils of the guidelines framed and regulations made under this Act for their effective functioning under this Act.

Monday, 25 December 2017

IMA policy is to prescribe quality drugs at affordable cost

IMA policy is to prescribe quality drugs at affordable cost
Bioequivalence studies are an important aspect of making medicine affordable

New Delhi, 24 December 2017: In what can be called a long overdue move, the Ministry of Health and Family Welfare amended the law to make bioequivalence studies compulsory for certain classes of generic drugs manufactured in India this year. The Drugs & Cosmetics Rules, 2017 was formally amended through a notification on April 3 to incorporate the change. The new law required bioequivalence studies to be performed on drugs with low solubility.

Bioequivalence studies are studies conducted to establish that two medicines, normally the original patented drug and a generic version, have the same biological equivalence – that is, that they work the same way, to the same extent and for the same purpose.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “The most important characteristics of any drug is its Bioequivalence to the innovator product to prove its safety, clinical efficacy equivalence and cGMP compliance on continuous basis for sustainable supply. The BE of any drug depends on its formulation process, choice of excipients, dissolution profile, stability under different conditions to prove its claimed shelf life, in process manufacturing and quality controls, packaging, storage conditions, transportation, validation studies, annual stability data review, analytical testing validated procedures, continuous engineering maintenance of every equipment in the plant, continuous training and development of people, reviewing regularly manufacturing/plant/site data, taking action on deviations e.g. Out of Specifications, Out of Limit, batch specific deviations, change control, presence of impurities and mode of release of the drug etc. to name a few.”

IMA is for affordable, accessible and quality healthcare. IMA policy is to prescribe quality drugs at affordable cost. IMA promotes usage of drugs from NLEM (National List of Essential Medicines).
Adding further, Dr Aggarwal, said, “To promote Pradhan Mantri Bharatiya Jan Aushadhi Pariyojana, IMA has opened a Pradhan Mantri Bharatiya Jan Aushadhi Kendra (PMBJK) in the premises of its headquarters and recommends such Kendras should be opened in all the IMA buildings in India. Doctors are committed to the welfare and safety of patients. Economy of drugs is only one dimension of the issue. IMA shall remain the voice of voiceless and continue its service in nation building diligently.”

Seven steps for Government of India.
·         Raise the Government expenditure on Health to 2.5 % of GDP from the current abysmal 1.1%.
·         Strong overview and monitoring by DCGI and State Drug Controllers on compliance to cGMP practices in drug industry.
·         Strengthen the quality assurance infrastructure to the required level so that the quality of every batch of drugs is assured.
·         Deploy adequate regulatory manpower to enforce the laws regarding drugs.
·         Stop over-the-counter (OTC) sale of prescription drugs without a prescription and do not allow a company to market same drug in different prices under different brands.
·         Prevent quacks and alternative system from using modern medicine drugs.
Initiate awareness movement amongst doctors and patients to buy quality affordable drugs. 

Straight from the Heart: IMA ICMR Initiatives - Annual Round Up

 Straight from the Heart: IMA ICMR Initiatives - Annual Round Up

IMA endorses National Guidelines for Stem Cell Research (NGSCR): The NGSCR-2013 covers only stem cell research, both basic and translational, and not therapy as the same is experimental as on date. Any stem cell use in patients, other than that for hematopoietic stem cell reconstitution for approved indications, is investigational and must only be done within the purview of an approved and monitored clinical trial. Every use of stem cells in patients outside an approved clinical trial is malpractice.

Points about stem cell therapy every IMA member must know

·         There are no approved indications for stem cell therapy other than the hematopoietic stem cell transplantation (HSCT) for haematological disorders. Stem cell therapies other than HSCT are investigational and can be conducted only in the form of a clinical trial following ICMR guidelines for clinical research after obtaining necessary regulatory approvals. Use of stem cells for any other purpose outside the domain of clinical trial is unethical (Clause 10.3.1)

·         Any violation of ICMR Clinical Research Guideline are actionable professional misconduct under “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 7.22 “Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.”

·         One dealing with pharmaceuticals and or allied industry one also need to follow 6.8.1 e regulation of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations:” Medical Research: A medical practitioner may carry out, participate in, work in research projects funded by pharmaceutical and allied healthcare industries. A medical practitioner is obliged to know that the fulfilment of the following items (i) to (vii) will be an imperative for undertaking any research assignment / project funded by industry – for being proper and ethical. Thus, in accepting such a position a medical practitioner shall:- (i) Ensure that the particular research proposal(s) has the due permission from the competent concerned authorities. (ii) Ensure that such a research project(s) has the clearance of national/ state / institutional ethics committees / bodies. (iii) Ensure that it fulfils all the legal requirements prescribed for medical research. (iv) Ensure that the source and amount of funding is publicly disclosed at the beginning itself. (v) Ensure that proper care and facilities are provided to human volunteers, if they are necessary for the research project(s). (vi) Ensure that undue animal experimentations are not done and when these are necessary they are done in a scientific and a humane way. (vii) Ensure that while accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research in the greater interest of the society by inserting such a clause in the MoU or any other document / agreement for any such assignment”

The MCI ethics violation will attract “First time censure, and thereafter removal of name from Indian Medical Register or State Medical Register for a period depending upon the violation of the clause.”

·         Stem cells clinical trials for conditions other HSCT will require approval from Institutional Ethics Committee (IEC) and Institutional Committee for Stem Cell Research (IC-SCR) and CDSCO. The IEC should be registered with Central Drug Standards Control Organization DSSCO and IC-SCR with National Apex Committee for Stem Cell Research and Therapy (NAC-SCRT). Only registered entities are permitted to conduct these trails. Stem cells used for intervention should be processed/developed under CDSCO certified GMP facility.

·         Clinical trials using human stem cells should be in compliance with Schedule Y of Drugs and Cosmetics Act and GCP Guidelines of CDSCO (www.cdsco.nic.in) as well as ICMR-Ethical Guidelines for Biomedical Research involving Human Participants (http://www.icmr.nic.in/ethical_guidelines.pdf). All clinical trials on stem cells shall be registered with Clinical Trial Registry India (CTRI). (Clause 10.2)

o    Any violation will be a professional misconduct as per MCI ethics regulation 1.9  to be read with regulation 7.1

o    1.9: “Evasion of Legal Restrictions: The physician shall observe the laws of the country in regulating the practice of medicine and shall also not assist others to evade such laws. He should be cooperative in observance and enforcement of sanitary laws and regulations in the interest of public health. A physician should observe the provisions of the State Acts like Drugs and Cosmetics Act, 1940; Pharmacy Act, 1948; Narcotic Drugs and Psychotropic substances Act, 1985; Medical Termination of Pregnancy Act, 1971; Transplantation of Human Organ Act, 1994; Mental Health Act, 1987; Environmental Protection Act, 1986; Pre–natal Sex Determination Test Act, 1994; Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954; Persons with Disabilities (Equal Opportunities and Full Participation) Act, 1995 and Bio-Medical Waste (Management and Handling) Rules, 1998 and such other Acts, Rules, Regulations made by the Central/State Governments or local Administrative Bodies or any other relevant Act relating to the protection and promotion of public health”.

o    MISCONDUCTThe following acts of commission or omission on the part of a physician shall constitute professional misconduct rendering him/her liable for disciplinary action
o    7.1   Violation of the Regulations: If he/she commits any violation of these Regulations. 

·         The physician/scientist engaged in stem cell research shall avoid any activity that leads to unnecessary hype, or unrealistic expectations in theminds of study participants or public at large regarding stem cell therapy. The study participant and other responsible family members must be given adequate and unbiased information about the trial protocol, its limitations and potential adverse effects. (Clause 7.5). The same is also actionable under The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954.

o    Promotional advertisements by private banks offering storage of cord blood for possible- future use are misleading. As there is no scientific basis for preservation of cord blood for future self-use at present, this practice is not recommended. The only exception is when there is a child with a haematological disease curable by HPSC and the mother is pregnant. In such situation storage and release of stem cells from cord blood of the new-born sibling,  subject to HLA match shall be recommended. On the other hand, parents should be encouraged for voluntary donation to public cord blood banks for allogeneic transplantation and research purposes. (Clause 12.2)

o    "Disclaimers / Qualifiers" the advertisements should carry so that there is a standard declaration which is unambiguous to a lay consumer?

·         The IC-SCR and IEC shall ensure that the patients/participants recruited under clinical trial shall not be charged including hospital stay and laboratory based investigations. (Clause

·         Prior to enrolment of subjects in clinical trials or procurement of stem cells for research, it is mandatory to obtain informed consent from thedonor. (Clause 4.1)

·         Independent informed consent in advance should be obtained for termination pregnancy and for donation of the foetal material for research.  There should be no inducement for donation of gametes/embryos/somatic cells by way of payment or in of lieu of medical services, except for reimbursement of reasonable expenses for travel and loss of wages incurred by the person (amount to be decided by IC-SCR/ IEC). (Clause 13.1.2)

·         Use of Umbilical cord blood stem cells (except when the HPSCs are used for conditions approved for bone marrow HPSC transplantation) , HSC or MSC is experimental at present and shall be permitted only under conditions of controlled clinical trial by the IC-SCR/IEC (Clause 12.2)

o    In most of the haematological/genetic disorders, child’s own stored cord blood stem cells cannot be used for the same child as those will carry the same defect. 

·         An institution or laboratory developing or processing stem cells for human use should obtain NABL accreditation for all laboratory procedures required for product development.

Presidential address on 28th December I spoke “IMA also wants the government to declare a special fund for rare diseases and orphan drugs.”

ICMR set up a registry of rare diseases. Apart from maintaining a database, the registry, set up on April 28 2017, will also help formulate policies on funding, treatment and more. A disease is defined as rare when it affects less than one in 2,500 individuals. Over 70mn Indians suffer from such disorders and live with them throughout their lives.   There are only 500 FDA-approved drugs for over 7,000 rare diseases globally.  There is often no cure, only supportive care. Treatment is extremely costly too, ranging from lakhs to crores a year.  The health ministry is currently discussing a draft policy for treatment of rare diseases.

In Gorakhpur issue IMA raised the absence of autopsies in such cases

The under-five mortality rate in India stands at 50 per 1000 live births. The pilot project that will begin in January, 2018, at New Delhi’s Safdarjung hospital, is a part of the global CHAMPS— Child Health and Mortality Prevention Surveillance, project, wherein tissue biopsies of the brain, liver, spleen and other tissues are taken in a minimally invasive way. This will benefit in districts like Gorakhpur where child deaths are high. For six months— January to June, all child deaths that take place at Safdarjung hospital will be examined. Informed consent will be taken from the parents.

IMA Women Life Time Achievement Award to ICMR DG

Other issues: C. auris ICMR advisory, AMR, NCD

May Measurement Month

Saturday, 23 December 2017

IMA re-emphasizes on the one drug-one price-one company policy

IMA re-emphasizes on the one drug-one price-one company policy
The word ‘Brand’ has nothing to do with the words ‘generic’ or ‘patented’ drugs.
New Delhi, 22 December 2017: More than 95% of the drugs available in India are generic with no patent. They are available in the market with a generic name, trade name, or brand name from the same company. Being with no patent, over one thousand companies can market a single molecule. The word brand means a way to differentiate various generic drugs from each other.
A generic drug is the same as a brand name drug in dosage, safety, strength, how it is taken, quality, performance, and intended use. Before approving a generic drug product, FDA requires many rigorous tests and procedures to assurethat the generic drug can be substituted for the brand name drug.
Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “The patented drugs are introduced in the market by the original company that researched the basic molecule. Let us take the example of Pfizer, which introduced two original molecules – Amlodipine and Sildenafil – and launched them in the international market as Amlogard (Amlodipine) and Viagra (Sildenafil). Being their research molecules, Pfizer had exclusive rights for 10 years based on their patent. These drugs are called patented drugs and the pharmaceutical company will have exclusive rights to them till the patent expires. After 10 years as the patent period expires, other companies can also market these molecules under their own brand name or as generic molecules. These are called non-patented generic version of the drugs.”
India is the largest exporter of generic versions of the drugs in the world as they can manufacture drugs at fraction of a cost compared to international brands. The word ‘Brand’ has nothing to do with the words ‘generic’ or ‘patented’ drugs.
Adding further, Dr Aggarwal, said, “In India, generic versions of drugs can be sold in the name of molecule (generic-generic) or brand (generic-brand).The only thing that the IMA wants is that all generic versions of drugs in India should be permitted to be sold only at one price by one company. At present, the generic versions are being sold at three different prices (generic-generic, trade-generic and branded-generic) by the same company.”
Medical Council of India Code of Medical ethics: 1.5 Use of Generic names of drugs: Every physician should, as far as possible, prescribe drugs with generic names and he / she shall ensure that there is a rational prescription and use of drugs. The interpretation is as follows.

  •  Use of Generic names of drugs: it’s not use of generic drugs
  • Every physician should: the word SHOULD makes it binding
  • As far as possible means to the best of his or her capacity
  • Prescribe drugs with generic names:  is not the same as prescribing generic drugs. It only means the name of the salt should also be written.
  • Shall ensure that there is a rational prescription: Rational means prescription of drugs which are evidence based and or with informed consent.
  • Rational use of drugs: means the same when dispensing. 

Never forget we are different

 Never forget we are different

Dr KK Aggarwal
National President

We are doctors, we are demi Gods, we are next to God, and so we cannot be inhuman. We not only need to be scientifically and legally correct but also morally and ethically correct. As doctors, we are supposed to follow two bioethics principles: non-maleficence (first do no harm) and beneficence (welfare of all).

Compassion is inherent to our profession as are compassionate doctors. Compassion should be demonstrated in practice as much as felt. A compassionate attitude in practice is more important than the science. Poor, inconsiderate and uncompassionate communication is the reason why most patients sue.

The etymology of "compassion" is Latin, meaning "co-suffering." Compassion involves "feeling for another" and is a precursor to empathy, the "feeling as another".

Compassion is considered in almost all the major religious traditions as among the greatest of virtues.
But, it is not the same as empathy or altruism. While empathy refers more generally to our ability to appreciate the perspective of and feel the emotions of another person, compassion is when those feelings and thoughts include the desire to help.

Altruism is the kind, selfless behavior often prompted by feelings of compassion, though one can feel compassion without acting on it, and altruism isn’t always motivated by compassion.

Today, everybody wants to regulate us. If we are demi Gods we do not need a regulator. God regulates others. We the medical professionals need to wake up and adopt and abide by the IMA self-regulation policies and also regulate policies for the corporate.

Friday, 22 December 2017

Straight from the Heart: Medical Uptodate Year Roundup 2017

  • Elvitegravir-cobicistat use during pregnancy: For HIV-infected women who become pregnant while on an elvitegravir-cobicistat-containing regimen switch to a different regimen (1,2).
  • Acetylcysteine IV or oral does not prevent contrast nephropathy(3).
  • Frequency for dosing of oral iron for individuals with iron deficiency should be every other day rather than every day (4).
  • Patients ≥60 years of age with new onset dyspepsia should undergo an upper endoscopy (5).
  • Patients <60 years with new onset dyspepsia upper GI endoscopy is reserved for those with clinically significant weight loss, overt gastrointestinal bleeding, more than one alarm feature, or rapidly progressive alarm features. These patients should be tested and treated for H. pylori infection (5).
  • For patients with suspected multiple myeloma do cross-sectional imaging (low-dose CT, PET/CT, or MRI scan), rather than a skeletal survey, as the imaging modality to detect bone involvement (6).
  • For patients age ≤60 years with an embolic-appearing cryptogenic ischemic stroke who have a patent foramen ovale with a right-to-left shunt detected by saline contrast bubble study go for percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone (8,9).
  • For patients with RAS/BRAF wild-type (wt) metastatic colorectal cancer (mCRC) and a left-sided primary tumor, treat with an antibody targeting the epidermal growth factor receptor (EGFR), rather than bevacizumab, when a biologic agent is chosen as a component of first-line therapy (10).
  • For most patients with RAS/BRAF wt mCRC and a right-sided primary tumor treat with bevacizumab rather than an anti-EGFR antibody in conjunction with first-line chemotherapy (10).
  • In mild to moderate treatment resistant major depression augment the initial antidepressant with a second drug and/or psychotherapy, rather than other strategies such as switching antidepressants or switching from pharmacotherapy to psychotherapy (11).
  • For patients with chronic HCV genotype 1 infection who have not been previously treated with sofosbuvir or an NS5A inhibitor give ledipasvir-sofosbuvir, sofosbuvir-velpatasvir, or glecaprevir-pibrentasvir (12-16).
  • For patients with advanced systemic mastocytosis give midostaurin for initial systemic therapy rather than imatinib or other cytoreductive therapies (17, 18).
  • In patients with a presumptive diagnosis of acquired TTP administer rituximab as a component of initial therapy (19).
  • For patients with cutaneous melanoma and a positive sentinel lymph node biopsy go for clinical observation and ultrasound surveillance of the positive nodal basin rather than immediate completion lymph node dissection [20].
  • For patients with newly diagnosed ALK-positive NSCLC go for alectinib as first-line treatment.For those without access to alectinib, appropriate alternatives include crizotinib or ceritinib. For patients with advanced anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), crizotinib has been administered as frontline therapy. However, newer agents have shown promising efficacy in advanced ALK-positive NSCLC (22,23).
  • For patients with an asymptomatic solid or subsolid (pure ground glass or part-solid) solitary pulmonary nodule (SPN) <6 mm, no routine follow-up is required. For patients with solid SPNs that have been stable on serial CT over a two-year period, or with subsolid SPNs that have been stable over a five-year period, we suggest no further diagnostic testing (24).
  • For women with postpartum hemorrhage diagnosed within three hours of delivery administer tranexamic acid as a component of overall treatment (25).
  • For patients with ALS who have a disease duration of two years or less, are living independently, and have an FVC ≥80 percent treat with edaravone and edaravone for patients with more advanced ALS (26,27).
  • For adults with acquired severe aplastic anemia who are not candidates for allogeneic hematopoietic cell transplantation treat with eltrombopag plus standard immunosuppressive therapy (IST) rather than IST alone (28).
  • For patients with primary progressive multiple sclerosis treat with ocrelizumab (29).
  • Scalp hypothermia can prevent chemotherapy-induced alopecia in women with breast cancer (30,31).
  • Do not give venom immunotherapy (VIT) to patients with reactions to stinging insects limited to cutaneous systemic symptoms and not involving other organ systems. However, VIT is effective in reducing the severity of future reactions and may still be offered in selected situations (32).
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Selfitis is now a real medical condition

Selfitis is now a real medical condition
Constant need for external appreciation and approval can lead to depression in the longer term
New Delhi, 21 December 2017: As per a recent study, clicking selfies is actually a medical condition that may require treatment. The condition is being called Selfitis. Researchers have also developed something called the 'Selfitis Behavior Scale' that can help determine the severity of one's addiction. Statistics indicate that India ranks number one in accidents related to selfies. About 60% of the total selfie accidents that happen throughout the world occur in India.
Selfitis has been classified at three levels: borderline, which involves clicking at least three selfies a day but not posting on social media; acute, which involves clicking at least three selfies a day but posting it on social media; chronic, where there is a constant urge to click selfies and posting at least six on social media.
Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “Today’s generation is constantly looking for external appreciation and approval. Youngsters want to show to the world that they have achieved a milestone that none or only a few others have achieved. The more daring a selfie, the more appreciation one gets. Such selfies help them in getting instant approval from their peers. We live in an age where mobile phones have penetrated our lives and actual human interaction is almost non-existent. Although technology has made life easier for everyone, there is a severe limitation of actual human empathetic interactions. We have begun to place more importance on what others think of us and how they perceive us. All of this can lead to anxiety and depression in the longer term.”
Those suffering from this condition typically seek to increase their self-confidence, seek attention, improve their mood, connect with the environment around them (to create a record of memories), increase their conformity with the social group around them, as well as being socially competitive.
Adding further, Dr Aggarwal, said, “n this digital era, the key to good health should be moderation – moderate use of technology. A lot of us have become slaves to devices that were really meant to free us and give us more time to experience life and be with people. Unless precautionary measures are taken at the earliest, this addiction can prove detrimental to one’s health in the longer term.”
Some tips for preventing problems caused due to overuse of mobile phones are as follows.

  • Electronic curfew means not using any electronic gadgets 30 minutes before sleep.
  • Facebook holiday: Take a Facebook holiday for 7 days every three months.
  • Social media fast: Avoid use of social media once in a week for the entire day.
  • Use your mobile phone only when mobile.
  • Do not use computer for more than three hours in a day.
  • Limit your mobile talk time to more than two hours in a day.
  • Do not recharge your mobile battery more than once in a day.
  • Mobile can also be a source of infection in the hospital setup; therefore, it is disinfected every day.