Malpractice fears are the chief reason that doctors overtreat

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  • NEET-PG 2018 is being conducted on 7th January 2018 (Forenoon Session)

Number of Cities 147

Number of Centers 364

Number of Candidates 1,33,435

Security Features: Finger prints and digital photograph capture, CCTV surveillance, frisking with handheld metal detector, provision of jammers at all centers and seating of candidates and room allocation of invigilators

  • India reported more over 1.5 lakh cases of dengue in 2017 and 250 deaths; 60,000 cases of Chikungunya were reported across the country. The data from the National Vector Borne Disease Control Programme (NVBDCP) under the Union Health Ministry showed that maximum dengue deaths were reported from Tamil Nadu (63 deaths out of the total 23,035 cases). Tamil Nadu was followed by Maharashtra, where 41 people died from dengue out of the total 7,442 cases reported. As many as 37 deaths were reported from Kerala while the disease claimed the lives of 28 people in Uttar Pradesh.
  • Haryana Health Minister Anil Vij has indicated the private hospitals to make self-regulatory rules after the state government cancelled the licence of the blood bank and pharmacy of the Fortis hospital at Gurugram. “With the action against Fortis Hospital, corporate-type hospitals should get a message that they make self-regulatory rules. Only minting money should not be the aim of hospitals,” Vij told ANI on Sunday.
  • Chikungunya virus (CHIKV) infection leaves about one quarter of those infected with persistent arthritis, according to data from the Chikungunya Arthritis Mechanisms in the Americas (CAMA) study. The joint symptoms, however, do not appear to be associated with persistent infection, suggesting it is safe to treat patients with regimens used for other types of inflammatory arthritis. Chronic joint pain after CHIKV is present in 30% to 70%. The most commonly affected joints are wrists, ankles, and fingers, and initial joint pain lasts a median of 4 days. With a median follow-up of 20 months, 25.4% of participants report that they had persistent joint pain. Factors associated with persistent pain included initial symptoms of headache or joint pain, 4 or more days of initial symptom, 4 or more weeks of initial pain, missed work, missed normal activities, and college graduate status. At follow-up, most patients had only one swollen joint, but also had tenderness in three more joints, with a mean global pain score of 47. The authors write in an article published online December 20 in Arthritis & Rheumatology.

“If persistent CHIKV infection is responsible for ongoing arthritis, immunocompromising disease modifying agents may be improper and potentially dangerous treatments. Alternatively, if CHIKV does not persist in the joint, then evaluation of immunomodulating arthritis agents could be useful,” they write. CHIKV causes arthritis through induction of potential host autoimmunity suggesting a role for immunomodulating medications in the treatment of CHIKV arthritis or that low-level viral persistence exists in synovial tissue only that is undetectable in synovial fluid.”

  • Malpractice fears are the chief reason that doctors overtreat. As per a research published in journal PLos One, physicians across a wide range of specialties and practice settings reported that, in their estimation, 20.6% of all medical care was unnecessary, including 22% of prescription medications, 24.9% of tests, and 11.1% of procedures. An overwhelming 84.7% of the 2106 survey respondents identified malpractice fears as the chief reason that doctors overtreat. Fear of litigation was followed in descending order by: Patient pressure/requests (59%); difficulty accessing prior medical records (38.2%); borderline indications of disease (37.7%); inadequate time to spend with patients (37.4%); lack of adequate information/patient history (36.7%) and pressure from the institution or management (20.8%). Significantly, only 9.2% of respondents identified “financial security of physicians” as the reason for overtreatment. 70.8% said that physicians are more prone to provide unnecessary procedures “when they profit from them.”

Only 2-3% of patients harmed by negligence pursue litigation, of whom about half receive compensation. But about 55% of physicians are being sued. But no matter what the outcome of the suit, the preparation, time spent, anxiety, and harm to ones reputation weigh heavily on physicians minds.

  • Nurses fill shoes of striking doctors at Beawar hospital (TNN). Jaipur: With the doctors on strike, nurses have stepped in their shoes at a hospital in Beawar district. The 300-bed Amrit Kaur District Hospital saw at least 1,500 outpatients every day, which has drastically come down 500 after the strike began on December 16. Principal medical officer Dr MK Jain said, “We have issued orders empowering nurses to see the patients. At least 30 doctors are on strike and only three of us are on duty currently.” He added that once the nurses prescribe the medicine, one of the three doctors verify it and sign the prescription card.
  • CDC urges shingles vaccination for patients 60+. If you’ve ever had chickenpox, there’s a good chance you’ll develop shingles — −a viral infection that causes a painful rash and blisters. The CDC estimates 1 in 3 people will get shingles in their lifetime, and risk increases significantly after age 50. The CDC currently recommends the vaccine Zostavax. It cuts the risk of developing shingles by half and is given in one dose as an injection. This recommendation is likely to change as a result of a recently approved vaccine that reduces the risk of shingles by as much as 90 percent. The new vaccine, called Shingrix, isn’t available to the public yet, but is expected to be this year.
  • Dr D Nageshwar Reddy was honored with the prestigious Dr MG Garg All Time Achievement Award by the Indian Medical Association (IMA). Dr Reddy who is currently the chairman of Asian Institute of Gastroenterology, Hyderabad and President of World Endoscopy Organization was shortlisted for this award in recognition of his distinguished contribution to medical services in India and globally. Speaking about the achievement Dr Reddy said, “It is heartwarming to be recognized for all that youve done. This is just the beginning, theres still a long way to go when it comes to medical advances”. Dr Reddys main area of research interest has been in G.I. Endoscopy particularly in Therapeutic Pancreatio Biliary Endoscopy and Innovations in Transgastric Endoscopic Surgery.
  • You cannot buy happiness. Current research is confirming what many of us have heard from our elders and spiritual leaders: satisfaction comes with being engaged, doing good and focusing on the present.
  • Continuously moving while sitting at a desk may boost metabolic rate more than sitting or standing at a desk. Using a desk fitted with a movable footrest raises metabolic rate more than sitting or standing at a desk as per a report published in the journal Work. Using a desk fitted with the moving device raised metabolic rate 7% more than standing and 17% more than just sitting. Movement while sitting had no impact on the cognitive function of participants.

Dr KK Aggarwal

Padma Shri Awardee Vice President CMAAO Group Editor-in-chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

IMA Policy on Antibiotics

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At the Antimicrobial Resistance Conference held in New Delhi yesterday to discuss the IMA Antibiotic Policy the following decisions were taken. Doctors should write the antibiotic in a box to differentiate it from other drugs in the prescription. The role of antibiotics should be discussed in an informed consent. When prescribing antibiotics clear instructions should be given to the patient about no refill of antibiotic prescription without signature of the doctor. No antibiotic cover or prophylactic antibiotic should be given without a high degree of clinical suspicion. No antibiotics should be prescribed in following conditions o Small bowel diarrhea o Fever with cough and cold o Dengue o Chikungunya o Malaria o Fever with rash Early initiation of antibiotics is the rule in suspected sepsis bacterial pneumonia meningitis and confirmed TB. Food Safety and Standards Authority of India FSSAI should make it mandatory for food companies to label all poultry and agriculture products as Antibiotic free . IMA will be writing to the Health Ministry to formulate clear guidelines about safer disposal of left over antibiotics.

Dengue Revisited

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Mosquito Menace: How to win over our collective failure Napoleon Hill once said that “Most great people have attained their greatest success just one step beyond their greatest failure.” Its time for all of us to convert our biggest failure, to control mosquito menace, into success. Today dengue is in alarming condition in Kerala, West Bengal, Karnataka and a mysterious illness in Indore (? Zika ? Alpha Virus) with arthritis. We all must agree that collectively we have failed in controlling the mosquito menace. Any mosquito container index above 5% requires community integrated cluster approach for mosquito density reduction together with effective anti-larval measures. Mosquito repellent impregnated mosquito nets are not available to patients. Anti-larval measures such as temephos (an organophosphate larvicide) and mosquito fish or Gambusia (a freshwater fish) also are not available to a common man. Then what is the answer? We need a paradigm shift in our thinking. We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act during monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society. We need to act on all mosquitos – Aedes, Culex and Anopheles. Acting only on Aedes will not work. The campaign that “Aedes is a day biter and only breeds in indoor fresh water” will not work. Even if this is true, then by killing Aedes you may end up increasing the density of Culex and malaria causing Anopheles mosquito. But the fact is that Aedes can breed and bite in the evening or night also. Culex mosquito, which causes filarial and Japanese encephalitis, is already rampant in many states. Aedes, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female Aedes aegypti (indoor) or A. albipecto (outdoor) mosquito. It is true that Aedes aegypti are more dangerous because they can fly up to 200 m and only feed on human blood whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 m and feed on animal blood other than human blood. However, the outdoor Aedes cannot be ignored. The entire campaign until now has focused on Aedes being a day biter, wear long sleeved clothing during the day and no need to use night mosquito nets. But precautions need to be taken all through the day. The mosquito only recognizes the light and not day or night. That the mosquito only breeds in clear water also needs to be re-learnt. Aedes breeds in stagnant water anywhere inside or outside the house. Rain water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rainy water collections providing ideal atmosphere for mosquito breeding. It is true that disease-spreading mosquitoes do not make noise but noise-producing nuisance mosquitoes unless addressed will not create a public movement. The law says that dengue and Chikungunya are notifiable diseases, but one can notify within seven days of diagnosis. Aedes mosquito takes up to three meals in a day and by seven days will bite over 21 people in the vicinity. Municipal anti-mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspected cases. All suspected cases must be reported without waiting for confirmation of the diagnosis. We have failed because the government has been insisting on notification of only ELISA confirmed cases. An SMS should be sent to all doctors practicing in that PIN code area with a case so that they can become a part of the public health action chain. All public health measures should start right when the first case is suspected in a state, colony or house. An SMS should go to the local councillor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts. It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and causes only platelet deficiency with thinning of blood and dengue 2 and 4 strains are dangerous as they lead to platelet destruction along with thickening of blood due to capillary leakage and rise in hematocrit. Platelet transfusion is not required in absence of active bleeding and thickening of blood. Timely fluid resuscitation is more important and not platelet resuscitation. Remember a raid fall in platelets along with a rapid rise on hematocrit is dangerous and not rapid fall of platelets alone. Dengue becomes serious when fever is subsiding. We admit dengue cases with high fever and always are in an urgency to discharge them when fever was subsiding. Now we know that the machine reading of platelet count can be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean that the platelet count is actually 50,000. Hospital beds should be reserved only for severe dengue and severe Chikungunya cases. Just because one can claim reimbursement in Mediclaim or PSU, one should not be admitted. If it was the US, Medicare by now would have come out with admission guidelines. The message has been going that fogging has no answer. But at this stage of container index of > 40, we need not just ground fogging, but also aerial fogging. When Zika threat came up Brazil, they deployed army to join and made it a public movement. All political parties reach every house during election process then why can�t each one of them reach every house and make the anti-mosquito and anti-larval measures more effective. Breeding checkers are only with Municipal Corporation and they also have regulatory powers to put fine. We need breeding checkers in private sector also. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises. Community approach means that 100% of the society talks about dengue. Every premise must write that their premises are mosquito free. When you are invited to someone you should ask �I hope your premises are mosquito free� and when you invite somebody write �Welcome to my house and it is mosquito free�. Even today most hospitals do not provide mosquito nets to dengue or Chikungunya patients. It is true they may be having anti- larval mesh doors or mesh windows but for secondary prevention of dengue or Chikungunya we need to ensure that medial establishments are certified as mosquito-free. In flats or apartments, the mosquitoes may be breeding in the roof top belonging to one of the owners and if he is out of station for a holiday, the anti-larval measures may remain deficient. The RWAs may use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises. One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today�s era our roofs, verandas and courtyards are full of left over tires, utensils, plastic utensils etc. We buy a new car tire and keep the old one on our roof top. We need to change this habit. We have forgotten to plant Tulsi and Peepal in our premises and stopped the daily Yagna, all which have anti-mosquito properties. The new strategy must focus on small collections of water like in bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house roof tops, verandas and inside the rooms, including unused toilets accessories. Also, the slogan to check your house once a week needs a change. One needs to be alert every day. It should be a part of your daily routine. You do not clean your premises once a week. Make it a habit to look for the breeding places every day. The innovative approach should be a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; in small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); rub cleaning the utensils Indian Medical Association (IMA) and Heart Care Foundation of India (HCFI) slogan is �Katwayega to nahi� i.e. whenever you someone ask �I hope your premises are mosquito free�. Also, when you invite somebody at home say, �You are invited at my home and I have checked there are no mosquitos�. Remember the slogan: �Ghar ke andar or ghar ke bahar; din me or rat me, deewaron ke niche or upar, chote pani or bade pani ke collection me, eggs larve or mosquito, teeno ko maro.�

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