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).
• For most patients with chronic HBV infection who initiate therapy with tenofovir give tenofovir alafenamide rather than tenofovir disoproxil fumarate (tenofovir DF). Those initially started on tenofovir DF switch to tenofovir alafenamide (33-35).

References

1. http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/(Accessed on October 19, 2017).
2. 7th International Workshop on HIV and Women. Seattle, WA. February 11-12, 2017.
3. N Engl J Med 2017.
4. Lancet Haematol 2017; 4:e524.
5. Am J Gastroenterol 2017; 112:988.
6. Blood Cancer J 2017; 7:e599.
7. N Engl J Med 2017; 377:1022.
8. N Engl J Med 2017; 377:1033.
9. N Engl J Med 2017; 377:1011.
10. Eur J Cancer 2017; 70:87.
11. JAMA 2017; 318:132.
12. 52nd Annual Meeting of the European Association for the Study of the Liver (EASL), Amsterdam, The Netherlands, April 19-23, 2017.
13. Lancet Infect Dis 2017; 17:1062.
14. American Association for the Study of Liver Diseases Liver Meeting, Boston, MA, November 11-15, 2016.
15. N Engl J Med 2017; 377:1448.
16. N Engl J Med 2017; 376:2134.
17. Leukemia 2017.
18. N Engl J Med 2016; 374:2605.
19. Blood Advances 2017; 1:1159.
20. N Engl J Med 2017; 376:2211.
21. N Engl J Med 2017; 377:829.
22. Lancet 2017; 390:29.
23. WCLC 2016; PL03.07.
24. Radiology 2017; 284:228.
25. Lancet 2017.
26. Lancet Neurol 2017; 16:505.
27. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm557102.htm(Accessed on May 09, 2017).
28. N Engl J Med 2017; 376:1540.
29. N Engl J Med 2017; 376:209.
30. JAMA 2017; 317:596.
31. JAMA 2017; 317:606.
32. Ann Allergy Asthma Immunol 2017; 118:28.
33. www.gilead.com/news/press-releases/2016/11/us-food-and-drug-administration-approves-gileads-vemlidy-tenofovir-alafenamide-for-the-treatment-of-chronic-hepatitis-b-virus-infection
34. Lancet Gastroenterol Hepatol 2016; 1:185.
35. Lancet Gastroenterol Hepatol 2016; 1:196.

More than half of the allopathic doctors in India lack medical qualification

More than half of the allopathic doctors in India lack medical qualification
IMA urges people to beware of quacks and have faith in qualified doctors

New Delhi, 18 December 2017: As per a study published by the WHO, only 58.4% of doctors have a medical qualification in urban India. The condition is worse in rural areas with only 18.8% having a proper medical qualification. India has lakhs of quacks and about 60,000 work out of Delhi alone. Additionally, the study also indicates that 57.3% allopathic doctors do not have a medical qualification and another 31.4% are educated only up to the secondary school level.

A quack or charlatan, as defined by the Supreme Court in 1996,is anyone practicing modern medicine without proper training in the discipline. The large number of quacks in both the rural and urban areas of India are a threat to the people and society at large. What exacerbates the situation is that if anything goes wrong, only few have the resources to file a complaint against them. Many just accept it as fate, particularly in the rural areas.

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, “In many parts of India, the sick are first taken to the ‘so-called’ faith healers offering treatment in the garb of doctors, before they are brought in to a hospital for actual treatment. It is a settled law that quacks are untrained and cannot diagnose or treat routine and emergency situations. They will invariably miss diagnosis of acute heart attack, paralysis, meningitis, early cancer, early rheumatoid arthritis, appendicitis, acute abdomen, acute pregnancy situations, dissection of aorta, pulmonary embolism etc. leading to a high mortality and morbidity. Their modus operandi is based on referral practice to corporate set ups with a desire of getting commissions.”

The IMA has taken a strong stand against quackery. This was also one of the issues raised by the association in a movement called Dilli Chalo conducted in June this year.

Adding further, Dr Aggarwal, said, “It takes over a decade for a modern medicine doctor to acquire sufficient knowledge to decide which antibiotic should be prescribed in a certain situation and which should be avoided. It’s not mathematics. One cannot learn medicine via Google or following the prescriptions of modern medicine doctors. Every case is different; hence, we say individualize treatment according to that particular patient. Most preventable deaths can be traced to ignoring warning signals or self-prescriptions or relying on medicines by quacks or chemists.”

IMA urges one and all to beware of quacks as they indulge in cuts and commissions, will never refer the patient in time, invariably give steroids in every case, and will over investigate the patient to appear genuine. On the other hand, people should have faith in registered and qualified doctors as they do not indulge in unethical practices, do not take or give commissions, work with the primary aim and dharma of healing and not financial gain, believe in Karma and not Kriya, and will always guide patients with the best of interest.

Straight from the Heart: National Medical Commission - After the storm

The Union Cabinet has effectively ended the era of Medical Council of India.
The citadel of modern medicine which initiated every young man and woman to the noble profession to alleviate the pain and suffering will now cease to exist.
The glorious era of MCI, which produced doctors of international caliber to serve the humankind as global doctors will come to an end. It will be replaced by a near total Government department called National Medical Commission.
IMA has been opposing NMC in its present form.
Devoid of federal character, this non-representative half non-medical body will be a poor substitute for the MCI. NMC will not represent the medical profession of India.

1. Anywhere in the world, medical profession is bestowed with reasonable autonomy. Patient care and Patient safety are the main benefits of such autonomy. 
2. Regulators need to have autonomy and be independent of the administrators.  The National Medical Commission will be a regulator appointed by the administrators under their direct control.      
3. It abolishes Medical Council of India and along with it possibly the section 15 of IMC Act, which says that the basic qualification to practice modern medicine is MBBS.
4. It takes away the voting right of every doctor in India to elect their medical council. Medical Council of India is a representative body of the medical profession in India.  Any registered medical practitioner in the country can contest the election and every qualified doctor can vote.Abolishing a democratic institution and replacing it by a body in which majority are nominated by the Government is certainly a retrograde step.
5. It allows the private medical colleges to charge at free will nullifying whatever solace NEET brought. The Government can fix the fee for only 40 percent of the seats in private medical colleges.
6. Instituting a Medical Licentiate exam after qualifying in final MBBS exam is an injustice. It is highly insensitive to the plight of medical students who even otherwise must undergo a long and tortuous academic career chequered with highly competitive exams.
7. The federal character of MCI is not found in NMC.All the state Governments have representation in MCI. Only 5 states in rotation will have representation in NMC. It will take two decades for a state to re-enter NMC.
8. All universities teaching medicine are members of MCI. This has been abolished in NMC.
9. All state medical councils, which are sovereign bodies constituted by state legislatures have been made subservient to NMC striking a blow to the federal nature of the nation.
10. Professional organizations like IMA are registered under Societies Act. In no way their independence and freedom of action could be subjected to Government control. In fact, they remain the only whistle blowers, being the voice of voiceless in the issues of Health. Such corrective forces are part and parcel of the democratic forces in the country. NMC has been vested with powers to control all professional bodies.
11. IMA has a representative in DNB board but not in NMC.
12. It inducts non-medical people into the highest body of medical governance changing its perspective and character forever.
13. It introduces schedule IV to allow AYUSH graduates to get registration in Modern Medicine.
14. It opens the floodgates of PG seats in modern medicine to AYUSH graduates in future by providing registration to them in schedule IV.
15. It directly affects Patient Care and Patient Safety by allowing graduates of other systems to practice modern medicine.
16. This is not the first time that the Government has made such a move. In 2005, the then Union health minister, Dr Anbumani Ramadoss, tried unsuccessfully to bring in a legislation to dissolve the MCI and set up another council under the control of the Health Ministry. The parliamentary standing committee rejected it because any regulatory body should be devoid of Government control or else it would lose its independent regulatory mechanism. It is pertinent to note that in its exhaustive report, the standing committee took exception to the attempt by the Government of India to centralize the powers with it and reduce a Body of Experts created for a distinct purpose by a Parliamentary enactment into a Department working under the Government of India.

IMA appeals to the Prime Minister to recall the Bill and rectify these anomalies.
The Parliament has a larger role to protect the interest of the medical profession of the country. The welfare and the independence of the profession are linked to the welfare of the people.
Dr K K Aggarwal- National President, IMA
Dr Ravi Wankhedkar- National President-Elect
Dr RN Tandon - Hony Secretary General IMA
Dr R V Asokan - Chairman Action Committee

Criminal prosecution of medical negligence unacceptable, says IMA

Criminal prosecution of medical negligence unacceptable, says IMA A fair judgment will help in retaining the nobility of the medical profession New Delhi, 29 May 2017: Highlighting another pertinent issue faced by the medical fraternity, the IMA has expressed its disagreement over the criminal prosecution of medical negligence and clerical errors and called it unacceptable. This is one of the many issues leading up to the Dilli Chalo movement being organized by the IMA on 6th June 2017. To be joined in entirety by the medical fraternity, the march will be undertaken by over a lakh doctors in the country, both digitally and physically, and followed by deliberations on issues ailing the medical profession. According to a judgment passed by the Supreme Court in 2004, it had stated that the medical man cannot be proceeded against for punishment for every mishap or death during treatment. Without adequate medical opinion, criminal prosecutions of doctors would amount to great disservice to the community. 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, "To prosecute a doctor for criminal medical negligence, any medical action taken by him/her, should have been done with an intention to harm or with the knowledge that it can cause harm and the patient is not informed about the same. However, this is not the case in medical practice. We never treat with an intention to harm or treat without an informed consent. Then why are doctors again and again subject to criminal prosecution? Criminal prosecution of doctor should be an exception and not a routine. The situation today is that doctors now are being prosecuted in various special acts for non-professional activities like not wearing apron, not displaying a defined board or not keeping a copy of PC PNDT Act. Doctors are also being prosecuted for minor violations of privacy, confidentiality of patient information and data and violations of minor clauses in surrogacy, IVF and HIV_AIDS acts. This is not acceptable to the medical profession." Earlier, doctors from the IMA had also opined that many medical negligence cases took place in government hospitals. However, their comparatively lower bills kept such establishments out of the purview of the authorities. Adding further, Dr Aggarwal, said, "While it would be reasonable to cancel the registration of a doctor or a clinical establishment, booking a doctor under criminal charges will no longer result in this being called a noble profession. Justice has been denied to the medical fraternity on a number of accounts and this movement is a clarion call against all these issues." IMA is also initiating a signature campaign on the issues at hand on social media and has urged all doctors to join and collect hundreds of thousands of signatures to demand justice from the government.

Indian Penal Code & Criminal prosecution of medical doctors

Indian Penal Code & Criminal prosecution of medical doctors According to the provisions of Indian Penal Code 1860 (IPC) any act of commission or omission is not a crime unless it is accompanied by a “guilty mind” or mens rea. If it can be established without reasonable doubt that death was the result of malicious intention/gross negligence or with the knowledge that the act could cause harm and patient was not informed about the same, only then can a doctor can be charged with criminal negligence. No doctor treats a patient with an intention to harm or without taking an informed consent. Doctors must be aware of the Indian Penal Codes, under which they can be charged for negligence. They should know whether the act undertaken by them amounts to rash or gross negligent action under the provisions of the law of the country. This is very relevant today, where doctors are increasingly being subject to criminal prosecution. Is the act done in good faith with proper consent? IPC 88: Act not intended to cause death, done by consent in good faith for person’s benefit Nothing which is not intended to cause death, is an offence by reason of any harm which it may cause, or be intended by the doer to cause, or be known by the doer to be likely to cause, to any person for whose benefit it is done in good faith, and who has given a consent, whether express or implied, to suffer that harm, or to take the risk of that harm. Illustration A, a surgeon, knowing that a particular operation is likely to cause the death of Z, who suffers under a painful complaint, but not intending to cause Z’s death and intending in good faith, Z’s benefit performs that operation on Z, with Z’s consent. A has committed no offence. Has the consent taken by frightening the patient or without scientific data? IPC 90: Consent known to be given under fear or misconception A consent is not such a consent as it intended by any section of this Code, if the consent is given by a person under fear of injury, or under a misconception of fact, and if the person doing the act knows, or has reason to believe, that the consent was given in consequence of such fear or misconception; or Consent of insane person.—if the consent is given by a person who, from unsoundness of mind, or intoxication, is unable to understand the nature and consequence of that to which he gives his consent; or Consent of child.—unless the contrary appears from the context, if the consent is given by a person who is under twelve years of age. Is there any violation of a special act? IPC 91: Exclusion of acts which are offences independently of harm caused: The exceptions in sections 87, 88 and 89 do not extend to acts which are offences independently of any harm which they may cause, or be intended to cause, or be known to be likely to cause, to the person giving the consent, or on whose behalf the consent is given. Illustration Causing miscarriage (unless caused in good faith for the purpose of saving the life of the woman) is an offence independently of any harm which it may cause or be intended to cause to the woman. Therefore, it is not an offence “by reason of such harm”; and the consent of the woman or of her guardian to the causing of such miscarriage does not justify the act. Was the act done without consent? IPC 92. Act done in good faith for benefit of a person without con¬sent: Nothing is an offence by reason of any harm which it may cause to a person for whose benefit it is done in good faith, even without that person’s consent, if the circumstances are such that it is impossible for that person to signify consent, or if that person is incapable of giving consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for the thing to be done with benefit: Provisos—Provided— (First) — That this exception shall not extend to the intentional causing of death, or the attempting to cause death; (Secondly) —That this exception shall not extend to the doing of anything which the person doing it knows to be likely to cause death, for any purpose other than the preventing of death or grievous hurt, or the curing of any grievous disease or infirmi¬ty; (Thirdly) -— That this exception shall not extend to the voluntary causing of hurt, or to the attempting to cause hurt, for any purpose other than the preventing of death or hurt; (Fourthly) —That this exception shall not extend to the abetment of any offence, to the committing of which offence it would not extend. Illustrations (c) A, a surgeon, sees a child suffer an accident which is likely to prove fatal unless an operation be immediately performed. There is no time to apply to the child’s guardian. A performs the operation in spite of the entreaties of the child, intending, in good faith, the child’s benefit. A has committed no offence. How was the patient communicated? IPC 93: Communication made in good faith: No communication made in good faith is an offence by reason of any harm to the person to whom it is made, if it is made for the benefit of that person. Illustration A, a surgeon, in good faith, communicates to a patient his opin¬ion that he cannot live.The patient dies in consequence of the shock. A has committed no offence, though he knew it to be likely that the communication might cause the patient’s death. Was it a culpable homicide? Was there any intention or knowledge? IPC299: Culpable homicide: Whoever causes death by doing an act with the intention of causing death, or with the intention of causing such bodily injury as is likely to cause death, or with the knowledge that he is likely by such act to cause death, commits the offence of culpable homicide. Explanation 1.—A person who causes bodily injury to another who is labouring under a disorder, disease or bodily infirmity, and thereby accelerates the death of that other, shall be deemed to have caused his death. Explanation 3.—The causing of the death of child in the mother’s womb is not homicide. But it may amount to culpable homicide to cause the death of a living child, if any part of that child has been brought forth, though the child may not have breathed or been completely born. What is the punishment for culpable homicide? IPC 304: Punishment for culpable homicide not amounting to murder: Whoever commits culpable homicide not amounting to murder shall be punished with [imprisonment for life], or imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine, if the act by which the death is caused is done with the intention of causing death, or of causing such bodily injury as is likely to cause death, or with imprisonment of either description for a term which may extend to ten years, or with fine, or with both, if the act is done with the knowledge that it is likely to cause death, but without any intention to cause death, or to cause such bodily injury as is likely to cause death. IMA View: This penal code is not applicable to doctors unless there was intention to harm in the treatment provided or there was knowledge that the treatment can harm but the patient was not informed about the likely harm. Was it a case of gross negligence? IPC 304A: Causing death by negligence: Whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.] Who certified the gross negligence? Statutory Rules or Executive Instructions incorporating certain guidelines need to be framed and issued by the Government of India and/or the State Governments in consultation with the Medical Council of India (MCI). So long as it is not done, we propose to lay down certain guidelines for the future which should govern the prosecution of doctors for offences of which criminal rashness or criminal negligence is an ingredient. 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. A doctor accused of rashness or negligence, may not be arrested in a routine manner (simply because a charge has been levelled against him). Unless his arrest is necessary for furthering the investigation or for collecting evidence or unless the investigation officer feels satisfied that the doctor proceeded against would not make himself available to face the prosecution unless arrested, the arrest may be withheld. [Jacob Mathew vs State of Punjab & Anr on 5 August, 2005: Author: R Lahoti: Bench: Cji R.C. Lahoti, G.P. Mathur, P. K. Balasubramanyan: Case No.: Appeal (crl.) 144-145 of 2004] Dr KK Aggarwal National President IMA & HCFI

Straight from the heart: The plight of the medical profession today

Straight from the heart: The plight of the medical profession today IMA is the voice and represents the collective consciousness of the medical profession in the country. It practically covers all the doctors in India directly through its membership of 3 lakhs, spread over 30 States and 17 Local Branches, and indirectly through federation of medical associations to the rest of the medical professionals in the country. IMA also is connected to every medical professional in the world through the Confederation of Medical Associations in Asia and Oceania (CMAAO) & the World Medical Association (WMA). The medical profession is going through its toughest time with the nobility and dignity of medical profession at stake. Some black sheep amongst us are taking away the entire nobility and dignity of the medical profession. They must be exposed at the earliest. Medical profession was, is and will always remain noble. First and foremost, it is important for us to understand that we are medical professionals and not a business house. To run a business, a businessman does not require a registered degree or follow a professional code of conduct. But we, professional doctors, are being controlled by corporate houses whose ethics differ from that of ours. They can market, distribute commissions and advertise their services, which is unethical for professional doctors and is a professional misconduct as defined by the MCI Code of Ethics Regulations. Bureaucrats and legislators must look into this matter and allow only professionals to own, manage and/or run medical establishments. Have we ever heard of law firms and legal arbitrators owned by business houses? To prosecute a doctor for criminal medical negligence, any medical action taken by him/her, should have been done with an intention to harm or with the knowledge that it can cause harm and the patient is not informed about the same. But, this is not the case in a medical practice, we never treat with an intention to harm or treat without an informed consent. Then why are doctors again and again subject to criminal prosecution? Criminal prosecution of doctor should be an exception and not a routine. The situation today is that doctors now are being prosecuted in various special acts for non-professional activities like not wearing apron, not displaying a defined board or not keeping a copy of PC PNDT Act. Doctors are also being prosecuted for minor violations of privacy, confidentiality of patient information and data and violations of minor clauses in surrogacy, IVF and HIV-AIDS Acts. This is not acceptable to the medical profession. Doctors provide subsidy to the patients. Doctors, whose consultation fees may be more than Rs. 2,000/-, constitute only a small percentage. Most GPs in metro cities charge less than Rs. 200/- as their consultation fee; often this also includes dispensing medicines along with professional consultation. To err is human. Doctors are bound to make mistakes and are covered for the same under indemnity insurance. But the compensation awarded for negligence cannot be in crores. There are more than six cases on record, where the compensation awarded against the doctors have ranged between 1 and 12 crores. Also, the method used for calculation of compensation is based on the income of the patient and not the seriousness of the illness. For the same amount of fee charged by a doctor and for the same illness depending upon the income of patient, the compensation awarded may be in lakhs or crores. The formula 70 - age x annual income + 30% - one third should not be acceptable to medical profession as it discriminates a poor from the rich. The formula of compensation calculation for drug trials as defined by the Drugs and Cosmetic Act may be the best alternative. This formula depends on age and the seriousness of the patient. Doctors are professionals and professional autonomy is their right. It is the duty of the doctor to provide rational treatment, which includes rational use of drugs and investigations. No one can take away this autonomy from a doctor. The job of a doctor is also to provide affordable, quality and safe health care. Today, most doctors are not informed about any new drug launched in the country, drug/s banned in the country, drugs found to be substandard quality or fake/spurious drugs. Similarly, any drug labelling changes, whether deletions or additions, are not communicated to the doctors. So, all doctors today depend on the industry to update their knowledge. The government allows the same salt to be sold by the same company at three difference prices as generic-generic, generic-trade or generic-branch. Why does the government not adopt ‘one drug - one company - one price’ policy? How can the government grant a license to companies to sell drugs at different rates, but then forces doctors to choose only the cheaper drugs? It’s like giving licenses to open five star hotels, but simultaneously issuing an advisory to the public to not to go these hotels. Medical profession is not against accountability, but violence at any cost is not acceptable. Disturbing a doctor while he/she is on duty in the critical area, either verbally, mentally or physically, is not acceptable. Any act of violence against doctors should be made a punishable, non-bailable offence with imprisonment of up to 14 years. The doctors posted in critical areas are on a sensitive duty, where they look after critically ill patients and violence can endanger multiple lives. A stringent central law is the only answer. Every critical area in the hospital must have voice activated CCTV camera and adequate doctor-to-patient ratio. The government policy of allowing four minutes per patient needs to be changed. Doctors also want single window accountability for registration for license to practice and registration of their medical establishment. Let doctors concentrate on their professional work and not divert their energies in permissions and administration matters. MBBS doctors are the need of the hour. They need to be cultivated and empowered. They should be involved under retainership in all national health programs. More than 25,000 postgraduate seats need to be introduced in family medicine. There must be a simpler way for them to get PG after completing their MBBS. It does not make sense for them to appear in another exam (NEXT) to get license to practice. As per the government, there is a shortage of doctors in rural areas. A rural posting is challenging and a difficult posting. Therefore, doctors posted in rural areas must be given income tax-free double income compared to a person practicing in an urban area. The professional autonomy must also be respected for specialists and for regulatory bodies. Consultants cannot be given targets to achieve and the government cannot take away the autonomy of the regulatory body ‘Medical Council of India (MCI)’ and bring a nominated national medical commission in its place. A knife in the hands of a monkey and modern medicine in the hands of quacks, chemists and doctors of other systems of medicine can kill a person. The general public has right to get the best of the treatment. Every citizen has a right to receive affordable or free preventive and emergency health care. If the government cannot provide this, then it shall ensure its availability through private sector for which the government should reimburse the same. But all this is not possible without increasing the health budget to 5% of GDP. At present, the government is looking after only 20% of population in the government sector for which 1% of budget may seem reasonable to them. All our doctors in service, residents and medical faculty must get uniform conditions of service, may it be with regard to retiring age, salary, or other service conditions etc. No way doctors can be kept on contracts and not made permanent for decades. Doctors are often blamed of being in a nexus with chemists, industry, hospitals and laboratories. One must not forget that for any unethical act, the ethical act needs to be defined first. If a pharma company is updating my knowledge free of cost and if I choose a drug of that company out of over 50 brands available in the market, I cannot be blamed of being partial. Anyone can criticize me but not the MCI or the ministry as pharma companies are doing their job of updating my knowledge. Similarly, any referral with a service involved is not a cut or a commission. If I refer a patient to a specialist and make a detailed summary, then I am entitled for my services to be paid by the patient. Let the government not forget that they are supposed to look after 100% of the population and not differentiate the poor from the rich. Today the private sector is forced to cater to 80% of the health care and is overburdened. But at what cost? The private sector should in fact be provided with all possible subsidies for the same. All this is possible and not difficult to achieve. IMA is willing to spend two hours every day at Nirman Bhawan and work hand in hand alongside the government. To our fellow colleagues, I say, all doctors are good. Let us not criticise each other and defame the medical profession. I hope this “straight from the heart” reaches the “Mann ki Baat” of the Prime Minister

First of its kind national study by IMA, HCFI & Eris Lifesciences through the ABPM method reveals high incidence of hypertension amongst the medical fraternity

First of its kind national study by IMA, HCFI & Eris Lifesciences through the ABPM method reveals high incidence of hypertension amongst the medical fraternity Record attempt of collecting 20,000 ambulatory blood pressure readings of over 500 doctors in 1 day Over 50% physicians found to be suffering from uncontrolled hypertension despite taking hypertensive medicines; 56% from irregular BP at night and 21% from masked hypertension New Delhi, May 16, 2017: In what can be called as a massive feat, the Indian Medical Association, in partnership with the Heart Care Foundation of India(HCFI) and Eris Lifesciences in the form of an unconditional educational grant attempted to record the maximum number of ambulatory blood pressure readings amongst the medical fraternity in a single day. About 20,000 readings were taken of 533 doctors including those of the IMA leadership spanning 33 Indian cities. The aim being to raise awareness about the benefits of ambulatory blood pressure monitoring (ABPM) in the timely and correct diagnosis of hypertension on the occasion of the World Hypertension Day 2017. Hypertension is one of the most common lifestyle diseases prevalent today with one in three Indian adults suffering from it. The incidence of hypertension is equally high amongst the medical fraternity owing to high-stress levels. Often hypertension is misdiagnosed given the difference in blood pressure readings at home and in a clinic. Ambulatory Blood Pressure Monitoring (ABPM) can help in getting a more accurate picture of a person's BP pattern in a span of 24 hour. “The IMA National study on ambulatory blood pressure measurement amongst doctors conducted in partnership with HCFI and Eris Lifesciences revealed that 21% of the doctors surveyed had masked hypertension or isolated ambulatory hypertension. In simple terms, their BP readings were normal when evaluated through the conventional clinic measurement technique but high through the ABPM technique. Masked hypertension is associated with an increased long-term risk of sustained hypertension and cardiovascular morbidity. In addition to this, 56% of the doctors evaluated suffered from irregular BP pattern at night making them prone to future adverse cardiac events. 37% doctors had nocturnal hypertension, which can never be diagnosed through in clinic BP measurement. Over 50% physicians had uncontrolled hypertension despite taking hypertensive medicines,” said 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. Evaluating both daytime and nighttime blood pressure is crucial for predicting all cardiovascular events. It is a fact that a blood pressure reading obtained during one’s sleep is more accurate in helping predict all causes of mortality when compared to those obtained during waking hours. Ambulatory Blood Pressure Monitoring is globally accepted as the gold-standard method towards detecting hypertension. It evaluates the patient's BP continuously over a period of 24 hours and helps diagnose masked or white coat hypertension, conditions in which a patient's BP readings are inaccurate due to certain environments. Dr Shashank Joshi, President Hypertension Society of India opined, "Your doctor may suggest ABPM for the following reasons: to find out if your blood pressure readings are higher in the clinic than at home; to see the efficacy of your medicines in controlling blood pressure throughout the day, or to note whether your blood pressure increases at night. Since there are no visible signs of masked hypertension, it is always good to let your doctor know if you have a family history of high blood pressure. I congratulate IMA, HCFI and Eris on this initiative and believe that a collaborative effort towards raising mass level awareness on the prevention of hypertension, it's timely diagnosis and management is crucial in our country where every third person has high BP”. ABPM involves attaching a small digital blood pressure machine to a belt around your body. This is in turn is connected to a cuff around the upper arm. It does not cause any inconvenience, as it is small enough for you to carry on with your routine. This machine notes blood pressure readings at regular intervals during a 24 hour period: typically, every 15 to 30 minutes during the day and 30 to 60 minutes at night. Increasing your intake of fresh fruits, vegetables, olive oil, and omega-3 foods can help lower your high blood pressure levels. It is also a good idea to consume sprouted or 100% whole grains. Try to reduce your sodium intake, which does not necessarily come only from table salt or salt added while cooking. Processed and ultra-processed foods are the real culprits behind increased sodium intake. Disclaimer: This project is undertaken by the IMA under an unconditional education grant from Eris Lifesciences Ltd. Contents of this program are a copyright of IMA and are not influenced by any third party.

Intensive medical treatment can reverse type 2 diabetes

Intensive medical treatment can reverse type 2 diabetes Type 2 diabetes can be reversed…Data from a study published in the Journal of Clinical Endocrinology & Metabolism show that a short course of intensive lifestyle and medical treatment using oral medications and/or insulin may lead to drug-free remission of type 2 diabetes, at least in the short term. Patients with type 2 diabetes of up to 3 years in duration were randomized to three groups: Standard diabetes care and intensive metabolic intervention: One group underwent the intensive metabolic intervention for 8 weeks, while the other was treated intensively for 16 weeks. • In the intensive metabolic intervention, the participants were provided with a personalized exercise plan and a suggested meal plan that reduced their daily calorie intake by 500-750 calories a day. Their progress was regularly tracked and they also were given oral medications and insulin at bedtime to tightly manage their blood glucose levels. • The control group received standard blood sugar management advice from their usual doctor along with standard lifestyle advice After the intervention, individuals in both groups stopped taking diabetes medications and were encouraged to continue with lifestyle changes Three months after the intervention was completed, 11 out of 27 individuals in the 16-week intervention group met HbA1c criteria for complete or partial diabetes remission, compared to four out of 28 individuals in the control group. Three months after finishing the 8-week intervention, six out of 28 individuals in that group met the same criteria for complete or partial diabetes remission. Natalia McInnes, MD, MSc, FRCPC, of McMaster University and Hamilton Health Sciences, in Hamilton, Ontario, Canada and the first author of the study said, “These findings support the notion that type 2 diabetes can be reversed, at least in the short term not only with bariatric surgery, but with medical approaches. Type 2 diabetes is a life-long progressive disorder and the findings of this study showing that the condition may be potentially reversible may motivate patients to adhere to the prescribed lifestyle changes and medications. The goal of managing a patient with type 2 diabetes could shift from achieving and maintaining glycemic control to inducing remission and then monitoring the patient for any signs of relapse (Source: Endocrine Society Press Release, March 15, 2017) Dr KK Aggarwal National President IMA & HCFI

ACP terms substance use disorders as chronic medical conditions

ACP terms substance use disorders as chronic medical conditions Substance use disorders related to illicit and prescription drugs, including opioids, are chronic medical conditions that are treatable through public and individual health interventions, says the American College of Physicians (ACP) in a new policy statement published online March 27, 2017 in the Annals of Internal Medicine. The new ACP policy statement includes public policy recommendations for the prevention and treatment of substance use disorders involving illicit and prescription drugs. Some of the key recommendations to combat the epidemic of prescription drug misuse are as follows: • Physicians should familiarize themselves with and follow as appropriate clinical guidelines related to pain management and controlled substances such as prescription opioids as well as non-opioid drugs and non-drug interventions • Expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel • Expansion of access to medication-assisted treatment of opioid use disorders • Improved training in the treatment of substance use disorders including buprenorphine-based treatment • Establishment of a national Prescription Drug Monitoring Program and improvement of existing monitoring programs. ACP also recommends public and individual health interventions rather than excessive reliance on criminalization and incarceration to prevent and treat substance use disorders. It proposes education and training of health care professionals to substance use disorders. Health insurance should cover mental health conditions including substance use disorders. (Source: ACP News release, March 28, 2017) Dr KK Aggarwal National President IMA & HCFI