ACC and AHA Release New PCI Checklist

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The American College of Cardiology and American Heart Association along with several other organizations have released new performance and quality measures for percutaneous coronary intervention. The report is published in December 23 issue of Journal of the American College of Cardiology and Circulation.

Written in collaboration with the Society for Cardiovascular Angiography and Interventions, Physician Consortium for Performance Improvement, and National Committee for Quality Assurance, the group highlights 11 performance and quality metrics that should be recorded for patients undergoing PCI, as follows.

Documentation of the reasons for PCI.
Appropriate reason for elective PCI (safety vs benefit trade–offs).
Prior to PCI, evaluation of the patient’s ability to take dual antiplatelet therapy.
Use of embolic protection devices in the treatment of saphenous vein graft disease.
Renal function assessment prior to PCI and documentation of the amount of contrast used.
Documentation of the amount radiation used during the procedure.
Prescription of optimal medical therapy post–PCI.
Referral to an outpatient cardiac rehabilitation clinic.
Participation in a regional or national PCI registry.
Average annual volume of PCIs performed by physician in the last two years.
Average annual number of PCIs performed at the hospital in the last calendar year.

These measures, according to the writing committee, can help serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice.

Complex, determining procedural appropriateness with PCI requires documenting the presence and severity of angina symptoms, use of anti–anginal medications, and presence and severity of stenosis, according to the new report.

The present PCI performance measure set represents the first time in the cardiology literature that a specific performance measure has been constructed to address procedural appropriateness.

88TH National IMA Conference and 74th Annual Meeting of Central Council @ Rajahmundry AP, 27.12.2013

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N.V. Ramana, C.J
We have not lost faith, but we have transferred it from God to the medical profession. (George Bernard Shaw)

So declared our ancient rishis! The doctor is verily the Lord Narayana Himself! When I see the galaxy of Doctors today I am engulfed with an ecclesiastical feeling, because the Narayana Himself is present in His Virat Swaroopam.

No wonder, I deem it a singular honour to address you. I stand before you not with any authority to speak but with humility, bowing down to you in the most ancient order of the spiritual culture of India chanting Namo Narayana!

In fact all religions hold the doctor in high esteem. Gautama Buddha said that a doctor is like a mother to each of his patients. As the mother with only child showers all her love and compassion on the child, so the doctor should do the same.

Thus, an exceptionally venerable position is given to the doctor in all societies. It is but natural that greater the veneration given greater is the responsibility attached to live up to such privilege.

I feel privileged to be the Guest today and to inaugurate the 88th National Conference of Indian Medical Association and 74th Annual Meeting of IMA Central Council, to be held today and tomorrow. I thank the organizing committee for inviting me and making me a part of this august gathering.

History of Rajahmundry:

Rajahmundry is a historic city situated on the bank of river Godavari. Its rich heritage and history dates back to 191 AD. Distinctly located, Godavari Districts are known as the rice bowl of A.P. The first Telugu poet Adi Kavi Nannawa is born here and he was the first who translated the epic Mahabharatha into Telugu. Several freedom fighters belonging to this land sacrificed their lives and properties for our freedom struggle against the British Rule. The great Kandukuri Veeresalingam was born here who was an active social reformer, and a huge supporter of widow remarriages in our history. He has encouraged education for women, established a Telugu journal and also was the first among the few writers to write prose for women. Godavari people are known for their hospitality.

Introduction:

The two important things we value are life and health. Doctors have the knowledge and skills that put them in a position to improve our health, treat our illness and prolong or save our lives. The treatment of the patient and the medical information relating to his disease was once privity to the doctor and the medical professions, the advances in technology have made medical information available to any member of the public through internet.
Once the relation of the doctor and patient was that of trust, but today due to high expectations of the patients and non-meeting of such expectations by the doctors is straining their relationship.

We witnessed a pace of commercialization and globalization on all spheres of life and medical profession is no exception to this phenomenon. New advances in medicine and technology have improved health care for both patients and doctors.

Dr. B.M. Hegde, a renowned cardiologist and former Vice Chancellor of Manipal University, in one of his articles, sets out several ills of the present day medical system. One of the main complaints about the present medical system is that it has become money oriented, with service to humanity taking the back seat. This is a serious complaint which we all have to think about. Another complaint is about excessive or unnecessary treatment and in certain cases even wrong treatment. Dr. Hegde quotes Sir William Osler saying “one of the first duties of the physician is to educate the masses not to take drugs”. Further quoting Napoleon Bonaparte who said “Medicine is a collection of uncertain prescriptions the results of which, taken collectively, are more fatal than useful to mankind”.

Medical Profession and Laws:

The doctor-patient relationship has undergone a sea change in the last two decades. The patient considered himself to be a consumer of the doctor for his professional service. The Consumer Protection Act, 1986, was enacted with the objective of safeguarding the interest of citizens who access health care. Section 2(1) (0) provides services means service of any description, the definition is not “exhaustive” but inclusive. However, it does not include rendering of any service free of charge or under a contract of personal service.

Section 2(1) (9) defines “deficiency” which includes all forms of professional negligence including medical negligence.
Negligence is the failure to exercise reasonable care. Professionals like doctors are expected to exhibit wisdom as well as technical ability and reasonable care to patients.

Medical Negligence:

“Medical negligence” is the breach of reasonable care towards patients. Basically three pertinent issues evolve in cases of medical negligence, which are-

1) Whether the doctor, who was dealing with the patient at that particular point of time, was having proper medical skills?
2) Whether the doctor used medical skills and practices as responsible practitioner in the field?
3) Whether the standard of skill or knowledge and duty expected from the doctor was followed when the allegation of negligence occurred?

The Hon’ble Apex Court responding to the need of the hour developed and elaborated the jurisprudence of medical negligence. In Samir Kohli’s case, it was held that when the patient is adult and capable of giving consent, the doctor should obtain consent from him when there is no emergency.

In Jacob Mathews case, Supreme Court has laid down the principles on “Medical negligence” and held that it is not possible for every professional to have highest level of experience or skill, but it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular act and further the concept of negligence between civil law and criminal law was also discussed. The Apex Court in Martin F. D‘Souza’s case held that whenever a complaint for medical negligence is filed, the matter should be referred to a competent doctor or committee of doctors specialised in the relevant field, when such experts feel that there is prima facie case, then only notice should be issued to the doctor to avoid harassment to the doctor.

As you all aware, recently on 24th October 2013, in Balaram Prasad’ case, the Apex Court, while rejecting the plea of IMA that medical practitioners cannot be treated as service providers in term of Section 2(1)(0) of the Consumer Protection Act, held that hospitals and doctors are liable for negligence and enhanced the compensation from Rs.1.73 crores to Rs.5.96 crores.

In cases of medical negligence, the Courts in India are following two principles, one is limited liability and the second is based on the highest degree of care towards the patient and his relatives, as the professionals are responsible and accountable. In limited liability 1) mere deviation from normal professional practice is not negligence 2) An error in judgment on the part of professional is not negligence per se and 3) when patient does not respond favourably to a treatment given by a doctor, he cannot be held liable.

Although the field of medical negligence is a new emerging area of law in the context of corporatization of health care, yet what constitutes “medical negligence” has now been well-settled in view of a number of judgments of the Apex Court. I feel doctors practicing ethically and honestly should not have any reason to fear. Doctors claiming to adhere to ethics have always lamented that colleagues stooping to unethical practices have an unfair advantage because there is no control over those practices. The Consumer Protection Act will help in curbing these unfair advantages and the Act is definitely good for medical practitioners, who believe in principles and ethics. Therefore, the medical professionals need to update their understanding on Consumer Protection Act and its amendments which are on a legally safer side: If doctors would like fewer legal restrictions on themselves they must regulate through adherence to the principles of medical ethics.

Social responsibility and the Constitution:

Success in one’s career is certainly a goal to be pursued. We should however not lose sight of the fact that a large number of our less favourable brothers and sisters are in urgent need of help. Ideally all of us should devote a portion of our life to community service. The silent suffering of millions of people in our country cannot be ignored. India is one of the poorest countries in the world. Poverty in India involves poverty in every aspect of life. Inequality continues to destroy India like any other developing countries. The rich become richer while the poor becomes poorer. Without health, no progress is possible. Therefore, a duty is cast upon the State to provide to its citizens a good and healthy life. Article 21 of the Constitution provides for protection of life and personal liberty, which includes in its ambit, right to health and medical care to all its citizens. Article 47 of the directive principles of state policy ordains a duty on the State to raise the level of nutrition and the standard of living and to improve public health. Despite constitutional provisions, providing better health care to citizens was never a top priority in India. To meet the medical needs of millions, we must evolve an integrated system of medicine, which will best suit our country having regard to its geographical conditions and socio-economic needs and keeping in view its available limited resources.

In our country, we have the best physicians and surgeons. But we lack in terms of qualified medical technicians and supporting staff. Although India remained a major supplier of doctors and nurses to the developed countries over the years, domestic scenario looked bleak with the country ranking 67th amongst the developing nations in the case of doctor population ratio. A fees levying private health care sector comprises of 82% of overall health expenditure. While less than 1 % of population is covered by health insurances, the challenges are enormous.

According to the report by the United Nations, 75% of the health infrastructure in India, including doctors, specialists and other health resources are concentrated in urban area, where only 27% of Indian population lives. The rural population of India is around 716 million people i.e. (72%) yet there are no proper medical facilities for them. Today, rural India faces a shortage of more than 12,300 specialized doctors; there are vacancies for 3,880 doctors in the rural health care systems and a need for 9,814 health care centres. 66% of rural population of India lacks access to preventive medicine. 31% of the rural population in India has to travel 30 km. to get needed medical treatment.

Responsibility of Government:

The government on its part needs to take certain policy decisions by allocating sufficient budget for health care. It needs to strengthen public health care system. US, Australia, UK has strong provision for health care. Unfortunately, India being poor, its citizens are paying the price. Government should provide enabling environment and achieve universal health care. The country graduates 27,000 doctors each year, but all of them want to work in major cities or pursue higher studies abroad. I personally feel that there is nothing wrong. If a doctor chooses to work in a remote village with a service motto, he is handicapped because there is no infrastructure; there are no qualified medical technicians and supporting staff. Though the doctor has enough knowledge and skill, practically he is not able to serve the people to the best of his ability and ultimately he is left with dissatisfaction. Whereas his colleagues who are working in the cities and abroad are able to do a better job than him and able to prove themselves. Strengthening the public health care system is the need of the hour. Government should implement a uniform health care policy, wherein we should see a day when all the citizens of India, irrespective of their social status, receive equal medical facilities and no one is deprived of his fundamental rights guaranteed under the Constitution. I would like to appeal to the members that each and every one should make it a point to spend a day in a month in the service of under-privileged people of the society.

Duties of MCI:

The MCI and IMA should make joint effort and improve quality of medical education and effectively enforce medical ethics. The Institutions have failed miserably in curbing rampant quackery. The professional bodies like MCI and IMA need to work efficiently in coordination with each other towards restoration of public faith in the system. Another solution is to educate and empower patients as equal partners, important stakeholder towards delivery of patient centric care. The common man needs to be educated and enlightened on the basic health issues, hygiene, because it is said that “prevention is better than cure” An enormous responsibility is cast upon the doctors in educating the patients and making them understand about the basic precautions to be taken, hygiene and other issues, which will minimize the health related problems.

Expectations:

The modern medicine should aim at a holistic approach following the advice of Hippocrates which says” Cure rarely, Comfort mostly but Console always, With the advent of the corporate culture In the medical world the personal relation between doctor and patient is totally missing which is a vital component in the health care. Hardly anyone talks with the patients these days. Most of the big bosses make what they call the ‘chart rounds’ in the ward side rooms where all the details of patients including the scans and X-rays are kept. Little time is spent on the bed side.

It must be remembered that as professionals, you have the higher ideals and standards to uphold. The medical profession needs input from a belief in humanity and the ethics more than professionalism. There is no definition for a perfect doctor. A good doctor is one who is truly mindful of his/her personal and professional limitations, and treat the patient with utmost compassion and sheer humanity, regardless of who they are, and above all, a doctor should have a human touch, where they can perceive and understand the tone of human relations and their sufferings.

In spite of several issues, still people have lot of faith in doctors and they believe only doctor after God. I hope and trust that the Indian Medical Community, through this Conference, will take fruitful and deliberated discussions in tune with the mottos of the IMA, which are promotion and advancement of medical and allied sciences in all their different branches, Improvement of public health and medical education in India, and maintenance of honor and dignity of the medical profession, for which it was established.

The medical education has to be streamlined, teaching methodology and examination patterns need reforms. The archive methods of testing the talent of medical students have to be changed. As a Judge, I am coming across a vast number of cases from the student community about the harassment made in the hands of professors during awarding marks and so I request the IMA to sensitize the problems of medical students to the teaching community.

As Gurudev Rabindranath Tagore said “let life be beautiful like summer flowers and death like autumn leaves‘. The medical world should precisely aim at that, instead of prolonging a person’s life on a ventilator in a vegetative state.

I thank you one and all for your patient hearing. I wish you all the best and in advance, a happy new year 2014.
Dr K K Aggarwal on Zee TV

Noteworthy Advances in Basic Research

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Seeing into the brain

NIH–funded scientists developed a new technique to preserve the brain’s 3–D structure down to the molecular level with a hydrogel. It allows for study of the brain’s inner workings at a scale never before possible.

Structure of a potential diabetes drug target

An international team of researchers, funded in part by NIH, determined and analyzed the structure of the human glucagon receptor.

How sleep clears the brain

An NIH–funded study in mice suggests that sleep helps restore the brain by flushing out toxins that build up during waking hours though a special series of channels in the brain.

Technique forms working inner ear cells

Using an innovative 3–D culture system, NIH–funded researchers were able to coax mouse embryonic stem cells to form complex cells and structures seen in the inner ear.

Study reveals new targets for Parkinson’s disease

NIH scientists used a novel approach, involving a protein tied to Parkinson’s disease, to identify dozens of genes that may contribute to disorders that involve mitochondria.

Therapeutic nanoparticles from grapefruit juice

NIH–funded researchers made nanoparticles from grapefruits and used them to deliver targeted drugs to treat cancer in mice. The technique may prove to be a safe and inexpensive alternative.

Understanding how we speak

Scientists funded by NIH revealed the patterns of brain activity that produce human speech

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