November 17   2015, Tuesday
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Dr KK AggarwalDr KK Aggarwal Cancer drugs, stents at 60% discount soon

Over 200 cancer drugs, 186 medicines to treat cardiovascular diseases and 148 stents and cardiac implants will now be available at central government hospitals at prices 50-60% lower than the open market.

The health ministry has launched a programme called AMRIT (Affordable Medicines and Reliable Implants for Treatment), under which the government will run pharmacy retail stores to sell medicines in hospitals like All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital and Ram Manohar Lohia Hospital.

The idea is to make treatment of critical diseases more affordable by bringing down the cost of medicine, which constitute a major part of the total health expenditure, mainly in case of tertiary care.

The government is exploring the possibility of scaling up the facility and also making it accessible to larger number of people in various parts of the country

Since the incidence of cancer and heart diseases is high and rapidly increasing in India, the government has chosen these two therapeutic categories for initial focus of the pragramme.

The project has been floated in partnership with the government-owned HLL Lifecare Ltd. The company will set up AMRIT stores and also run them across the country. Prices will be negotiated with the companies by the government for bulk procurement.

Amit sharma and Nilesh aggarwal

We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
Blood-brain barrier breached to treat cancer

For the first time, scientists have successfully breached the human blood-brain barrier non-invasively to effectively deliver cancer-fighting drugs into the brain of a patient. Each person has a protective blood barrier lining the blood vessels in the brain to restrict the passage of large toxic substances from the bloodstream into the brain. Dr Todd Mainprize, principal investigator of the study and Neurosurgeon at Sunnybrook Health Sciences Centre in Canada said, “The blood-brain barrier (BBB) has been a persistent obstacle to delivering valuable therapies to treat disease such as tumors. We are encouraged that we were able to temporarily open this barrier in a patient to deliver chemotherapy directly to the brain tumor.” (ET Healthworld)
Dr Good Dr Bad

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Specialty Updates
• Being pleasantly or unpleasantly surprised by the taste of something can change a person's mood, suggested new research published in Food Research International. Researchers noted that eating vanilla yogurts made people feel happy and that yogurts with lower fat content yielded a stronger positive emotional response.

• Macrolide antibiotic use is associated with a 2.42-fold increased risk of sudden cardiac death and ventricular tachyarrhythmias, suggests new research published online in the Journal of the American College of Cardiology.

• Mindfulness meditation can bring greater pain relief than a placebo, reported new research published in the Journal of Neuroscience. Mindfulness meditation appears to affect the brain in ways that reduce pain.

• Ranibizumab, a vascular endothelial growth-factor (VEGF) inhibitor, may be the first major treatment advance in 40 years for proliferative diabetic retinopathy, suggested new research presented at the American Academy of Ophthalmology (AAO) 2015 Annual Meeting.

• A new study, presented at the Liver Meeting 2015: American Association for the Study of Liver Diseases (AASLD), suggested that obeticholic acid maintains reduced levels of key biomarkers for primary biliary cholangitis (previously known as primary biliary cirrhosis) for up to 5 years. As a long-term therapy, both as monotherapy and in combination with ursodeoxycholic acid, the response is good.

• Data presented at the 14th International Kidney Cancer Symposium (IKCS) suggest that patients with metastatic renal cell carcinoma (mRCC) have variable clinical outcomes to treatment, and identifying the underlying molecular markers may help predict response to therapy.

• Results from the phase 2b DARWIN 1 study suggest that filgotinib is safe and effective for patients with rheumatoid arthritis who have an inadequate response to methotrexate therapy. The findings were presented at the American College of Rheumatology (ACR) 2015 Annual Meeting.

• A new study, published in the December issue of Sleep, suggests that lead exposure in early childhood is associated with increased risk for sleep problems and excessive daytime sleepiness in later childhood.
Why do we Ring the Bell in a Temple?

The vibrations of the ringing bell also produce the auspicious primordial sound ‘Om’, thus creating a connection between the deity and the mind. As we start the daily ritualistic worship (pooja), we ring the bell, chanting:

Aagamaarthamtu devaanaam
gamanaarthamtu rakshasaam
Kurve ghantaaravam tatra
devataahvaahna lakshanam

"I ring this bell indicating the invocation of divinity, So that virtuous and noble forces enter (my home and heart); And the demonic and evil forces from within and without, depart."
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Legal Quote
Martin F. D'Souza vs Mohd. Ishfaq SCI: 3541 of 2002, dated 17.02.2009

“Full record of the diagnosis, treatment, etc. should be maintained.”
Developing an Investment Portfolio: Responsibility of Financial Advisors

• Revise the portfolio to respond to changes in the marketplace and in the securities within the portfolio.
• Coordinate tax and cash flow planning, estate planning and risk/reward planning.
• Revise the portfolio in response to changes in the client’s objectives or financial circumstances.

(Source: IJCP)
22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Dear friends

National Health Scheme has decided after Kovalam CWC to enrol both parents of husband and wife. Please utilize this facility and propagate the benefits of National Health Scheme. More liberal benefits are on the way provided membership growth is sufficient.

Dr Alex Franklin
Hon. Secretary
IMA N H Scheme
HeartBuds will make your smartphone as accurate as a stethoscope
Stethoscopes might soon be replaced by a new device powered by smartphones. The upstart technology is called 'HeartBuds' and it takes the form of a small circular gadget, placed on the chest to listen to a heartbeat. But unlike a stethoscope, you or your doctor don't listen through a tube in your ears. Instead you plug it into your smartphone, where an accompanying iOS app plays the heartbeat aloud, as well as recording it and showing rhythmic blips that correspond with each sound. This allows both the patient and the doctor to hear the heartbeat and also means the doctor can easily play it back later or share and discuss it with colleagues… (ETHealthworld)
Physicians Urged to Green their Offices

As Paris prepares to host thousands of delegates to the United Nations Climate Change conference, the World Medical Association is urging physicians to look to their own offices and surgeries.

It is announcing the availability of a service to help doctors to adopt environmental practices and to share these ideas with their patients. My Green Doctor is a free website ( that guides physicians to make changes in their offices that can save money for the practice and create both a healthier office and healthier community.

Dr. Otmar Kloiber, Secretary General of the WMA, said: ‘Doctors understand that the health of their patients is determined in part by how resources are used in their country, resources such as energy, water, chemicals and foods. For example, most of the world’s electricity and transportation requires burning fossil fuels, which contributes to air and water pollution, and to diseases such asthma and cancer.

‘My Green Doctor is a free service that is suitable for any outpatient medical setting—a clinic, an office, an imaging center or other facility. It teaches the staff members who work in the office how to form an office Green Team which would meet regularly to make changes in the office.’

My Green Doctor offers more than 140 action and education steps that the team can choose to adopt. The topics include energy and water conservation, climate change, renewable energy, solid waste and recycling, chemicals in the office and home, landscape management, transportation choices and healthy foods.

Dr. Kloiber added: ‘The website is comprehensive and easy to use. Part of its purpose is to show doctors how they might share wise environmental practices with their patients by teaching their patients and by providing information brochures in waiting rooms. In this way, doctors can improve the quality of the natural environment and improve the physical health of their communities.’

The WMA’s 112 national medical organizations now can use My Green Doctor and offer this free service to doctors in their countries. Doctor offices and clinics can fulfill the requirements of this program to qualify for the Green Doctor Office Recognition certificate.

My Green Doctor was launched on-line in 2011 by the Florida Medical Association of Tallahassee, Florida, USA. My Green Doctor’s partner societies include the World Medical Association, the Florida Medical Association, and the Florida Academy of Family Physicians.
WHO launches campaign for better use of antibiotics
To improve the general public's awareness and understanding of this global phenomenon, while at the same time involving public authorities, health professionals and agriculture, the WHO has launched the first in an annual global campaign based on the theme Antibiotics: Handle With Care. The campaign will launch during the first World Antibiotics Week from November 16 to 22. The campaign highlights the importance of reducing antibiotic usage… (DNA)
Drug-resistant tuberculosis is difficult but treatable
Johns Hopkins Children’s Center specialists report they have successfully treated and put in remission a 2-year-old, now age 5, with a highly virulent form of tuberculosis known as XDR TB, or extensively drug-resistant TB. The case, researchers say, provides the first detailed account of a young child in the United States diagnosed and treated for XDR TB. Despite the successful outcome, the experts say the child’s case underscores the shape-shifting nature of a bacterium increasingly resistant to drugs, and the serious challenges of monitoring and treating pediatric TB. The study is published online in The Lancet Infectious Diseases… (Financial Express - ANI)
Smoking dads can pass cancer genes to kids
Research conducted at AIIMS has showed that men who smoke or consume tobacco in other forms are more likely to father children suffering from cancer. This is so because microelements present in smoke cause oxidative stress that affects the genetic integrity of the sperm. This can also lead to infertility. Professor Rima Dada, in charge of the laboratory for molecular reproduction and genetics at AIIMS, said sperm has minimal antioxidants and its DNA repair mechanism is also deficient, thus making it more vulnerable to oxidative DNA damage. Dr Dada said, "We found that the quality of sperm was poor among all tobacco users. However, the damage was extensive, almost irreparable, in fathers of children with eye cancer." The study is published in a recent issue of the Asian Pacific Journal of Cancer Prevention… (Times of India – Durgesh Nandan Jha)
Facts about noise pollution
• Permissible noise in industrial area is 75 dB in day time and 70 dB in night time.
• Permissible noise in commercial area is 65 dB in day time and 55 dB in night time.
• Permissible sound in residential area is 55 dB in day time and 45 dB in night time.
• Permissible sound in silence zone is 50 dB in day time and 40 dB in night time. Silence zone are areas up to 100 meters around hospitals, educational institutions and courts.
WHO warns against diabetes epidemic
Diabetes can be prevented and treated. World Diabetes Day, created in 1991 by the International Diabetes Federation and WHO, is focusing on “Healthy Living and Diabetes” as the theme for 2014 to 2016, and the importance of prevention in diabetes. To put the spotlight on the urgent need to act against diabetes, WHO has selected diabetes, as the theme for the World Health Day 2016. WHO South-East Asia Region is home to an estimated 91 million people affected by diabetes. Of these, nearly half go undiagnosed. WHO is supporting countries by advocating for and catalysing multi-sectoral policies for health promotion and strengthening national health systems for early detection and treatment of diabetes… (The Hindu – Bindu Shajan Perappadan)
Signals of heart failure

One of the commonest presentations is breathlessness on exertion, which is often confused as a part of aging or being obese. Not being able to climb stairs may be the earliest sign of hypertensive diastolic heart failure. Other signals are:

• Feeling extra tired even after a good night’s sleep. People with heart failure may limit activities they like to do or take naps to avoid feeling tired.
• Weight gain: Call your doctor if you gain weight for more than 2 days in a row or if you gain 2 or more pounds.
• Shortness of breath: Heart failure makes breathing harder, especially during exercise. Lying position may make it worse.
• Swollen ankles, legs, belly, and/or lower back, the swelling is often worse at the end of the day.
• Going to the bathroom more at night.
Bioethical issues in medical practice
Living wills

Smita N Deshpande

Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

This dilemma arises from two issues- living wills, and the problem of old couples living alone together.

A 65-year-old man is brought to emergency with subarachnoid hemorrhage. With aggressive and timely treatment he is shifted to the ventilator. Over the next few days his condition deteriorates and he is declared brain dead. He has left a living will saying that if he is incapacitated or comatose, his life should not be artificially extended. His tearful wife however insists that the doctor keeps trying and ‘give him another chance’ as she has read about cases recovering from coma after years. The hospital too will not mind as the ventilator will be paying for itself. What should the treating doctor do in these circumstances?

a) Leave well enough alone, continue treatment as usual, and continue charging for his and the hospital’s services.

b) Insist on application of the living will in letter and spirit- in which case he may face action for shifting the patient to the ventilator in the first place

c) Involve the hospital ethics committee in the decision

d) Approach the court

Any other suggestions and solutions? Do write in!

Adapted from: Bioethics Case Studies (AUSN and EEI, November 2013):

Response received for the case scenario ‘Rights and duties of a parent’ published on 15th Nov

The pregnancy must be terminated before it is too late. An intellectually deficient woman may insist on continuation of pregnancy, but she is not medically fit to take any decision. She will be unable to take care of the new born and even of herself, who will bear the responsibility of both for whole life. Finding the person and holding him responsible is too theoretical an approach, a person of substance would not have done such a heinous crime, forget his owning and taking responsibility, and what if he is already married. Not terminating the pregnancy to save a life is too idealistic a view in this case. Why make the new arrival suffer punishment and live a cursed life, he/she will curse the father, pity the mother and pity the self, suffer a stigma and mental torture. Dr (Col) R N Kothari, Prof & Head, Dept of Ophthalmology, SBKS MI&RC, Vadodara
Inspirational Story
This is Good!

The story is told of a king in Africa who had a close friend with whom he grew up. The friend had a habit of looking at every situation that ever occurred in his life (positive or negative) and remarking, "This is good!" One day the king and his friend were out on a hunting expedition. The friend would load and prepare the guns for the king. The friend had apparently done something wrong in preparing one of the guns, for after taking the gun from his friend, the king fired it and his thumb was blown off. Examining the situation the friend remarked as usual, "This is good!" To which the king replied, "No, this is NOT good!" and proceeded to send his friend to jail.

About a year later, the king was hunting in an area that he should have known to stay clear of. Cannibals captured him and took them to their village. They tied his hands, stacked some wood, set up a stake and bound him to the stake. As they came near to setting fire to the wood, they noticed that the king was missing a thumb. Being superstitious, they never ate anyone that was less than whole. So untying the king, they sent him on his way. As he returned home, he was reminded of the event that had taken his thumb and felt remorse for his treatment of his friend. He went immediately to the jail to speak with his friend. "You were right," he said, "it was good that my thumb was blown off."

And he proceeded to tell the friend all that had just happened. "And so I am very sorry for sending you to jail for so long. It was bad for me to do this." "No," his friend replied, "This is good!"

"What do you mean, ‘This is good’? How could it be good that I sent my friend to jail for a year?" "If I had NOT been in jail, I would have been with you."

Situations may not always seem pleasant while we are in them, but the promise of God is clear. If we love Him and live our lives according to His precepts, even that which seems to be bleak and hopeless will be turned by God for His glory and our benefit.
eMedi Quiz
A vitreous aspirate has been collected in an emergency at 9 pm what advice you like to give to the staff on duty regarding the overnight storage of the sample.

1. The sample should be kept at 4° C.
2. The sample should be incubated at 37°C.
3. The sample should be refrigerated deep freezer.
4. The sample should be refrigerated for the initial 3 hours and then incubated at 37°C.

Yesterday’s Mind Teaser:  A 60-year-old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is:

1. Thymoma
2. Lung cancer.
3. Hodgkin's lymphoma.
4. Superior vena caval obstruction.

Answer for Yesterday’s Mind Teaser: 4. Superior vena caval obstruction.

Answers received from: Dr K V Sarma, Dr K Raju, Dr Avtar Krishan, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr B R Bhatnagar, Dr A C Dhariwal.

Answer for 15th November Mind Teaser: 3. Bone erosions.

Answers received from: Raju Kuppusamy, Dr Janiendra Upadhyay, Takaram Pagad, Dr Avtar Krishan.
Cab Drivers

Two cab drivers met. "Hey," asked one, "why did you paint one side of your cab red and the other side blue?" "Well," the other responded, "when I get into an accident, you should see how all the witnesses contradict each other.
Readers column
It is right that we have won the battle but if we are to win the war, we will have to be united and also introspect among ourselves and remove certain menace we all very well know I AM SURE ANY QUALIFIED doctor can do extremely well without any hanky panky I know my writing will not have any effect unless everybody amongst us pledges and senior people at every level keep a vigil and take strict actions so that we regain our old reputation Dr Aryan, Senior Physician, Aryan Hospital Pvt Ltd, Gurgaon.
Press Release
The Future of Concierge Medicines in India: Should physicians and patients consider it?

Concierge medicinal practices usually require patients to pay a certain amount as a fee or a retainer, paid weekly, monthly or annually, depending on a physician’s payment model in return of enhanced and personalized medical care provided by the physician that insurance policies don’t cover

The discipline of concierge medicine has become quite popular with more and more patients seeking individual and personalized medical care. Reacting to the increasing trend of concierge care practiced by doctors, the American College of Physicians (ACP) has released a policy position paper, which talks about the effect of concierge medicine or direct patient contracting practices (DPCPs) on patient care in terms of medical quality, cost, access and workforce with a focus on ethical practice and makes recommendations to mitigate any adverse effect on the underserved patient.

Elaborating the topic, American College of Physicians defines concierge medicine as "any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care."

In recent time, the concierge business model has attracted a lot of patients, especially medical tourists, as it aims at providing services holistically, from fixing appointments with doctors, planning a trip abroad to get medical treatments, email access, phone consultations, newsletters, prolonged visits, comprehensive wellness and evaluations plans, arranging the accommodation to even providing the contact details of the services providers and medical facilitators.

Speaking on the issue, Padam Shree Awardee Dr K K Aggarwal, National Hon General Secretary, IMA and President, HCFI said, “The future of concierge medicine in India depends upon the physicians and patient’s choice to take up the concierge model, as it has both pros and cons. While implementing the concierge business model, physicians get to spend more time with their patients and as a result they are able to communicate effectively with them. In addition to this, patients are able to see the doctor anytime they want. In such cases, patients are more likely to open up about their problems and discuss about their expectations giving enough time to a physician for managing a particular medical casualty. Although the idea of taking up a concierge plan might sound a bit expensive to some, the higher priced plans generally include services like x-rays, ultrasounds and lab tests as well. Not only this, the patients can also avail services like home visits in case of emergencies and expedited emergency room care anywhere in the world.”

While concierge medical practices serve as a source of satisfaction for both patients and doctors, it impacts low-income patients severely, as they cannot afford the fee charged by a doctor for personalized medical assistance and other benefits. In addition to this, this impacts a doctor as well, as the number of patients a doctor sees decrease exponentially.

Demands of Concierge practices:

• This business model can be successful only of physicians maintain a level of transparency with their patients. A doctor should make sure that the patients knows about the details of financial obligations, services offered and the fees charged for the serves provided

• Above everything, a doctor should honor their professional obligation to provide nondiscriminatory care to all his patients. Doctors in all kinds of arrangements should not differentiate between patients based on caste, creed or financial status when they are in need of immediate medical care

• Policymakers should identify and address the potential pressures on physicians like stress and burnout situations, which are ultimately pushing them towards adopting concierge practices or DPCPs

• Physicians should be careful while charging a patient for the services provided. The service provider cannot charge the insurance companies for the services the concierge fees already covers

• Shifting to concierge practices equals to a risk, as introducing patients to a new business model may require marketing with efficacy to achieve required results

• A physician’s earnings may see a downside, for a while as concierge medicine is more about improving the services a doctor provides, simplifying insurance hassles and delivering the best with lots of personalized care