Sunday, March 31, 2019

“Any and all movements” improve heart health in older women

Even light physical activity such as gardening, strolling through a park, and folding clothes might be enough to significantly lower the risk of cardiovascular disease among women 63 and older. While the risk of stroke or heart failure is reduced by up to 22%, the risk of heart attack or coronary death, is reduced by as much as 42%.

In the five-year prospective study published March 15, 2019 in JAMA Network Open, researchers followed a racially and ethnically diverse group of 5,861 women aged 63 to 97 years to find out if higher amounts of light physical activity were associated with reduced risks of coronary heart disease or cardiovascular disease. None had a history of myocardial infarction or stroke. The women were part of the NHLBI-funded Objective Physical Activity and Cardiovascular Health (OPACH), a sub-cohort of the Women’s Health Initiative.

The movements of the participants were tracked with hip-mounted accelerometers 24 hours a day for seven consecutive days. Cardiovascular disease events such as heart attacks and strokes were tracked for the five years of the study.

According to the study author Andrea LaCroix, Ph.D., chair of the Division of Epidemiology and director of the Women’s Health Center of Excellence at the University of California, San Diego, the higher the amount of activity, the lower the risk. And the risk reduction showed regardless of the women’s overall health status, functional ability or even age.


Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Consent of both husband and wife is needed in an operation which may result in sterility

In the Allahabad High Court: Dr Neetu Rastogi vs Union of India and 4 Others; WP 4369 of 2017, dated 31/01/2017

Petition: The petitioner Dr Neetu Rastogi has filed this writ petition challenging the order dated 16.01.2017 passed by MCI holding the petitioner to be guilty of professional misconduct, and her name has been directed to be removed from the State Medical Register and Indian Medical Register for a period of one year.

Regarding consent, before performing surgery on the wife of the respondent, during the process of laparoscopy it was found necessary to remove the uterus for which the consent of the husband had been obtained.


·         Firstly, no consent was taken from the wife and any consent obtained from the husband was contrary to the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Regulation 7.16 urges that the consent from both wife and husband was necessary.
·         The petitioner hastily without following the due procedure has violated the Regulations and there is a provision of an appeal as per Regulation 8.8 of the 2002 Regulations, hence the entire arguments advanced on behalf of the petitioner do not hold water.


MCI Ethics Committee on 30th June, 2016/29-30, November 2016

Further she has obtained consent neither for laparoscopy nor for bilateral oophorectomies, which is a major procedure which rendered the patient Smt. Mehreen sterile for her whole life and this caused marital dispute between patient and her husband. Thus, this is a violation of Section 7.16 and 7.20 and serious medical misconduct under Ethics Regulations.

After considering the expert opinion of Dr Gita Radhakrishnan, UCMS and other available documents, the Ethics Committee is of unanimous opinion that Dr. Neetu Rastogi is guilty of severe professional misconduct. Therefore, the Ethics Committee recommends to remove the name of Dr. Neetu Rastogi from the Indian Medical Registration for a period of 3 years.

Executive Committee at its meeting held on 23.08.2016: Approved with the modification that the period of removal of name from IMR would be 01 year as originally decided by Ethics Committee on earlier two occasions.

No consent having been taken from the wife is concerned; the petitioner did not proceed ethically and after putting the patient under GA has taken a plea that since the patient was under the influence of anesthesia, therefore, the consent could not be taken. We cannot accept this plea in the background of the findings recorded based on the strength of the Expert Committee opinion and the recommendations. Thus, consequently there was no consent of the wife as per Regulation 7.16 of the 2002 Regulations.

Maintainability of the appeal before the MCI: This argument need not detain us inasmuch as the 2002 Regulations are applicable and there is no challenge raised to the vires of Regulation 8.8 thereof so as to entertain any such of the argument on behalf of the petitioner. So long as the Regulations are intact then the same having been framed under Section 20-A read with Section 33(m) of the Medical Council Act, 1956, would prevail and the appeal would be very much maintainable as it is statutorily available and is a substantive right of the aggrieved person. The argument that there is an appeal before the State authorities which would preclude proceedings of appeal before the Medical Council of India cannot be accepted as the said Regulations are not contrary to it but in addition to any other provision.

Final judgment

MCI has taken a lenient view in the matter by only imposing the punishment of removal of the name from the Medical Register for one year even though the Ethics Committee had made recommendations for three years.  We do not find any error in the impugned decision of the Medical Council of India. There is no merit in the writ petition which is hereby dismissed.

Judgment is rightly based on the fact that the consent of wife was not taken, which is required unless it is a life-threatening situation.

This is also specified in Regulation 7.16 of the MCI Code of Ethics Regulations, which states as follows: “Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.”

This was also the position held by the Supreme Court of India in the matter of Samira Kohli vs Dr. Prabha Manchanda & Anr on 16 January, 2008 Appeal (civil) 1949 of 2004, where the Apex Court held,

Consent given only for a diagnostic procedure, cannot be considered as consent for therapeutic treatment. Consent given for a specific treatment procedure will not be valid for conducting some other treatment procedure. The fact that the unauthorized additional surgery is beneficial to the patient, or that it would save considerable time and expense to the patient, or would relieve the patient from pain and suffering in future, are not grounds of defence in an action in tort for negligence or assault and battery. The only exception to this rule is where the additional procedure though unauthorized, is necessary in order to save the life or preserve the health of the patient and it would be unreasonable to delay such unauthorized procedure until patient regains consciousness and takes a decision (32)(iii).

There can be a common consent for diagnostic and operative procedures where they are contemplated. There can also be a common consent for a particular surgical procedure and an additional or further procedure that may become necessary during the course of surgery (32)(iv).”

The law recognizes the rights of the woman in deciding to continue a pregnancy or not.

As per guidelines from the Health Ministry and UNFPA India on female sterilization issued in 2005, the permission of the husband is not required for tubectomy “The surgeon should verify that the client has signed the informed consent form before beginning the procedure. Although the purpose of signing the form is to document informed consent, the principle focus should be on confirming that the client has made an informed choice of tubal occlusion as a contraceptive method.”

Similarly, as per Section 3(4)(b) of the MTP Act 1971, “No pregnancy shall be terminated except with the consent of the pregnant woman”, which means that the consent of the husband is not required for an abortion; only the consent of the pregnant woman undergoing the termination of pregnancy is required. Form C (form of consent) requires the signature of only the wife under the Medical Termination of Pregnancy Rules, 2003.

The courts have also affirmed these rights of the woman.

“Whether the express consent of the husband is required for unwanted pregnancy to be terminated by a wife?” This issue was examined by the Punjab and Haryana High Court in 2011 in the matter of Dr. Mangla Dogra and Ors vs Anil Kumar Malhotra and Ors. The Court noted that under Section 3(4)(b) of the MTP Act, only the Court recognised the personal right of a woman to continue with the pregnancy or abort the foetus given that it is her who must be to mentally prepared to carry out a pregnancy. “It is the free will of the wife to give birth to a child or not. The husband cannot compel her to conceive and give birth to his child.”

This decision of the Punjab & Haryana High Court was upheld by the Supreme Court in October 2017 in Anil Kumar Malhotra v. Ajay Pasricha, where the Supreme Court held that the woman has the right to decide about the abortion and that consent of the husband is not required as per the Act and dismissed the appeal filed by the husband against the judgement of the High Court.

MCI has powers

IMC Act: 33. The council may, with the previous sanction of the Central Government, make regulations generally to carry out the purposes of this Act…. (m): the standards of professional conduct and etiquette and code of ethics to be observed by medical practitioners; and (m a the modalities for conducting screening tests under sub-section (4A), and under the proviso to sub-section (4B), and for issuing eligibility certificate under sub-section (4B), of section 13.

20.A The Council may prescribe standards of professional conduct and etiquette and a code of ethics for medical practitioners. Regulations made by the Council under sub-section (1) may specify which violations thereof respect, that is to say, professional misconduct, and such provisions shall have effect notwithstanding anything contained in any law for the time being in force.

“8.8 Any person aggrieved by the decision of the State Medical Council on any complaint against a delinquent physician, shall have the right to file an appeal to the MCI within a period of 60 days from the date of receipt of the order passed by the said Medical Council: Provided that the MCI may, if it is satisfied that the appellant was prevented by sufficient cause from presenting the appeal within the aforesaid period of 60 days, allow it to be presented within a further period of 60 days.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Saturday, March 30, 2019

From "Formula of 80" to "Section 80". Invest wisely for a healthy future

India is the midst of an epidemic of lifestyle diseases or noncommunicable diseases (NCDs) such as type 2 diabetes, hypertension, heart disease, obesity, the genesis of which lies in an unhealthy lifestyle.

All the major lifestyle disorders or NCDs share common lifestyle-related risk factors like physical inactivity, unhealthy diet, tobacco and excess alcohol intake, which are modifiable. Hence, patients should be advised a common lifestyle that will prevent all lifestyle disorders and not just one.

I have devised a ‘Formula of 80’, which I teach all my patients to maintain a healthy lifestyle. I have chosen the number 80 as common to all risk factors - as most recommendations are to keep the values below 90 - so that it is easy for patients to remember.

Here is my Formula of 80 to live up to the age of 80.

·         Keep lower BP, LDL ‘bad’ cholesterol levels, resting heart rate, fasting sugar and abdominal girth levels all less than 80.
·         Walk 80 minutes a day, brisk walk 80 min a week with a speed of 80 steps (at least) per minute 
·         Eat less and not more than 80 gm or ml of caloric food each meal. 
·         Observe cereal fast 80 days in a year.
·         Do not smoke or be ready to shell out Rs. 80,000/- for treatment.
·         Do not drink alcohol; if you do, do not consume more than 80 ml per day for men (50% for women) or 80 grams per week. Ten grams of alcohol is present in 30 ml or 1 oz of 80 proof liquor.
·         If you are a heart patient, consider 80 mg aspirin and 80 mg atorvastatin a day.
·         Keep kidney and lung functions more than 80%.
·         Avoid exposure to PM 2.5 and PM 10 levels < 90 mcg/m3.
·         Avoid exposure to >80 dB of noise.
·         Take vitamin D through sunlight 80 days in a year.
·         Do 80 cycles of pranayama (parasympathetic breathing) in a day with a speed of 4 per minute.
·         Spend 80 minutes with yourself every day (relaxation, meditation, helping others etc.).

Health has been defined by the WHO as “not just the absence of disease, but a state of complete physical, mental and social well-being”. 

This means that “the social contexts of health and disease” including socioeconomic status also influence our health.

Stress is one such factor that has an adverse impact on health and well-being. Excessive stress can interfere with your productivity and performance, impact your physical and emotional health and also affect relationships and domestic life.

Financial insecurity can be stressful for the body and the mind.

It physically hurts to be economically insecure, concluded a study published in April 2016 in the journal Psychological Science (Psychol Sci. 2016 Apr;27(4):443-54). Those who reported extremely stressful money or work-related events were at greater risk of metabolic syndrome (Diabetes Care. 2010 Feb;33(2):378-84)

Yet another study published in August 2013 in the journal Social Science & Medicine observed that “high financial debt relative to available assets is associated with higher perceived stress and depression, worse self-reported general health, and higher diastolic blood pressure” (Soc Sci Med. 2013 Aug; 91: 94–100).

People often try to cope with stress by adopting unhealthy behaviors such as overeating or eating unhealthy food, substance or alcohol abuse, tobacco use, social withdrawal; they skip exercise. All these behaviours are linked to lifestyle diseases. Hence, stress is recognized as a risk factor for NCDs.

But, this is not the right way to deal with stress.

Management of stress involves either removing the known situation or changing one’s interpretation or preparing the body in such a way that the stress does not affect mind and the body. Our needs and wants are not synonymous; it’s important to understand the difference between the two.

Section 80 of the Income Tax Act is most commonly used to save income tax legally. By choosing to invest in certain tax-saving options, the tax burden can be reduced.

Here is a summary of various provisions under section 80.

Deduction on
Allowed Limit (maximum) FY 2018-19
Investment in PPF
– Employee’s share of PF contribution
– NSCs
– Life Insurance Premium payment
– Children’s Tuition Fee
– Principal Repayment of home loan
– Investment in Sukanya Samridhi Account
– Sum paid to purchase deferred annuity
– Five year deposit scheme
– Senior Citizens savings scheme
– Subscription to notified securities/notified deposits scheme
– Contribution to notified Pension Fund set up by Mutual Fund or UTI.
– Subscription to Home Loan Account scheme of the National Housing Bank
– Subscription to deposit scheme of a public sector or company engaged in providing housing finance
– Contribution to notified annuity Plan of LIC
– Subscription to equity shares/ debentures of an approved eligible issue
– Subscription to notified bonds of NABARD
Rs. 1,50,000
For amount deposited in annuity plan of LIC or any other insurer for a pension from a fund referred to in Section 10(23AAB)
Employee’s contribution to NPS account (maximum up to Rs 1,50,000)
Employer’s contribution to NPS account
Maximum up to 10% of salary
Additional contribution to NPS
Rs. 50,000
Interest Income from Savings account
Maximum up to 10,000
Exemption of interest from banks, post office, etc. Applicable only to senior citizens

Maximum up to 50,000
For rent paid when HRA is not received from employer
Least of :
– Rent paid minus 10% of total income
– Rs. 5000/- per month
– 25% of total income
Interest on education loan
Interest paid for a period of 8 years
Interest on home loan for first time home owners
Rs 50,000
Rajiv Gandhi Equity Scheme for investments in Equities
Lower of
– 50% of amount invested in equity shares; or
– Rs 25,000
Medical Insurance – Self, spouse, children
Medical Insurance – Parents more than 60 years old or (from FY 2015-16) uninsured parents more than 80 years old
– Rs. 25,000
– Rs. 50,000
Medical treatment for handicapped dependent or payment to specified scheme for maintenance of handicapped dependent
– Disability is 40% or more but less than 80%
– Disability is 80% or more
– Rs. 75,000
– Rs. 1,25,000
Medical Expenditure on Self or Dependent Relative for diseases specified in Rule 11DD
– For less than 60 years old
– For more than 60 years old
– Lower of Rs 40,000 or the amount actually paid
– Lower of Rs 1,00,000 or the amount actually paid
Self-suffering from disability :
– An individual suffering from a physical disability (including blindness) or mental retardation.
– An individual suffering from severe disability
– Rs. 75,000
– Rs. 1,25,000
Contribution by companies to political parties
Amount contributed (not allowed if paid in cash)
Contribution by individuals to political parties
Amount contributed (not allowed if paid in cash)
Deductions on Income by way of Royalty of a Patent
Lower of Rs 3,00,000 or income received

Lifestyle changes should start right in childhood. Similarly, a person should start planning for a secure financial future, the day he or she starts working.

Invest wisely...from Formula of 80 to Section 80 for healthy finances and a healthy you...

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Friday, March 29, 2019

Adolescent psychotic experiences linked to air pollution

The adverse impact of air pollution on heart and lungs are well established. Air pollution has now emerged as a major environmental risk factor for health.

Here is another adverse impact of air pollution.

A study of more than 2000 UK-born children says that adolescents exposed to high levels of outdoor air pollution were more likely to report psychotic experiences; though, this is not a cause and effect association. 

In the study published online March 27, 2019 in JAMA Psychiatry, a total of 623 (30%) of the adolescents reported at least one psychotic experience between ages 12 and 18.

Adolscents exposed to top-quartile levels of nitrogen dioxide (NO2), nitrogen oxides (NOx) and particulate matter (PM2.5) had 71%, 72% and 45% greater odds, respectively, of psychotic experiences compared with those exposed to the lowest-quartile levels.

Urbanicity is a well-established risk factor for clinical (e.g, schizophrenia) and subclinical (e.g, hearing voices and paranoia) expressions of psychosis.

Taken together, NO2 and NOx explained 60% of the association between urbanicity (urban residency) and adolescent psychotic experiences. According to the authors, this observation could partly be the answer for the association between urban residency and adolescent psychotic experiences. 

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Hon’ble Delhi High Court directs social restaurant to provide wholesome meals and sanitary napkins to children of 10 orphanages and 10 foster care homes

In a yet another exemplary move, on 27th March, 2019 the Hon’ble Delhi High Court has directed Impresario Entertainment and Hospitality, owner of the ‘SOCIAL’ restaurant chain, to provide wholesome meals to children in ten orphanages and ten foster care homes in Delhi for two years.

The restaurant chain will continue providing one meal per day to the children lodged in these centres until the expenditure incurred by it becomes equal to the punitive costs of Rs 20 lakh imposed on it by the Court.

The owner of the SOCIAL chain will also provide sanitary napkins to adolescent girls at these centres.
The order was passed by a Single Judge Bench of Justice Najmi Waziri in a contempt case filed against Impresario Entertainment.

Luxury accessories and apparel label Hermes International had moved the Delhi High Court after discovering that Impresario Entertainment was violating its trademark, logo etc. Without going into the merits, the case was disposed of after Impresario Entertainment stated that it would not use the Hermes trademark or other intellectual property to its benefit.

Despite this undertaking, Impresario Entertainment’s Goregaon Social in Mumbai displayed a red watch-box with the Hermes logo and the word ‘Herpes’.

Aggrieved by the display, Hermes International moved the High Court. It was submitted that the word ‘Herpes’ was written in the same font style and size as ‘Hermes’. Therefore, an unsuspecting individual would ascribe some affinity to Hermes International, it was stated.

Further noting that the word ‘Herpes’ is associated with a skin disease, it was submitted that the display was in bad taste and reflected poorly on Hermes International.

Impresario Entertainment, on the other hand, argued that the element of humour was part of public life. The display on the red box was a word-play and it never intended any harm, it was submitted.

The owner of SOCIAL vowed to abide by any such terms and conditions that may be imposed on it by the Court, in larger public service. Hermes International also agreed to forego the sum imposed as costs on Impresario Entertainment.

Quantifying the punitive damages in the contempt proceeding at Rs 20 lakh, the Court directed Impresario Entertainment to provide one wholesome meal per day to children in ten orphanages and ten foster care homes in Delhi for two years against this amount.

The meal would be equivalent to a mid-day meal as provided by government schools, the Court said. The Court also directed Impresario Entertainment to file a compliance report every four weeks on the distribution of meals.

As per the order, Impresario Entertainment would also have to install a commercial water purifier at Delhi’s 150-year-old orphanage, Bhachhiyon Ka Ghar.

Additionally, it was also ordered to provide sanitary napkins to girls aged 6 to 18 years at these centres. The napkins would be procured by Impresario Entertainment from a Nagpur-based company which also provides sanitary napkins to the Delhi Government under the Kishori Shakti Yojna.

As a natural corollary to this judgement, the question arises “Why are doctors subject to criminal prosecution?”

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, no doctor chooses to become a doctor to harm a patient intentionally as was also observed by the Hon’ble Supreme Court in its landmark judgment in Jacob Mathew vs State of Punjab & Anr, which stated: “No sensible professional would intentionally commit an act or omission which would result in loss or injury to the patient as the professional reputation of the person is at stake. A single failure may cost him dear in his career… A medical practitioner faced with an emergency ordinarily tries his best to redeem the patient out of his suffering. He does not gain anything by acting with negligence or by omitting to do an act.” Also, no doctor practices without informed consent.

To err is human and despite all care, errors do happen inadvertently.

Difference of opinion, error of judgment, medical errors and medical accidents are not medical negligence. Experiencing a bad outcome does not always mean medical negligence. This has also been the position of the Supreme Court of India in its various judgements.

Doctors are professionals and are bound by the MCI Code of Ethics Regulations.

If there is a Code of Ethics for doctors, then why should they be charged under Penal Codes?

Justice Waziri is known to hand out punishments with a difference.

Earlier this month, Justice Waziri quashed an FIR against a couple, who had employed a minor for household work, and directed them to plant 100 trees and pay Rs 1.5 lakh to the victim. He also directed two other persons, who were agents and through whom the minor girl was employed at the couple's house, to offer manual labour for plantation and care of the trees (Outlook India).

In February this year, Justice Waziri had ordered 2G case accused - Swan Telecom’s promoter Shahid Balwa, the director of Kusegaon Fruits and Vegetables, Rajeev Agarwal, and three firms, namely Dynamic Realty, DB Realty, and Nihar Constructions - to plant 3,000 trees each in the Delhi’s South Ridge forest area. He also specified that the plants should be indigenous, three and a half years of nursery age and six feet in height. They will also have to submit photographic proofs in the court ensuring plants' good health (Business Today).

Why can’t the medical councils and courts follow suit and award punishments of a similar nature instead to erring doctors?

Why are they still being penalized and punished?

It is now becoming evident that more than the medical or clinical factors, it is the social factors that determine the health outcomes.

Doctors are not just clinicians; they are change agents and act as a catalyst for change and transformation in their patients as well as the community. 

Regulation 8.2 of the MCI Code of ethics clearly states “…If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner…”.

(Source: Bar and Bench)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA