Friday, May 31, 2019

WHO decision on burnout should translate into better working conditions




We should all welcome the decision by the World Health Assembly to include work-related burnout as a problem that influences health status of an individual.

The decision was taken during the World Health Assembly in Geneva.

Burn-out has been included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. It is not classified as a medical condition. It is described in the chapter: ‘Factors influencing health status or contact with health services’, which includes reasons for which people contact health services but that are not classed as illnesses or health conditions.

Burn-out has been defined as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”.

It is characterized by:

·         Feelings of energy depletion or exhaustion;
·         Increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and
·         Reduced professional efficacy.

Burnout among physicians has been largely ignored by everyone for a long time.

Emotionally exhausted doctors are a danger to patients and a danger to themselves. The number of suicides among doctors resulting from burnout is a significant problem.

This World Health Assembly’s decision should lead to a new approach that addresses multiple factors including working conditions for doctors around the world’.

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


Thursday, May 30, 2019

E coli from flour and crypto from recreational pools


USA: The Centers for Disease Control and Prevention (CDC) has said that 17 people in eight states have been sickened with a strain of E. coli. The reports of the illness started on December 11, 2018, to April 18, 2019 and affected people ages 7 to 86. Epidemiologic and laboratory evidence indicates flour is a likely source of this outbreak. 

Symptoms of E. coli can vary in people, but often include severe stomach cramps, diarrhea (often bloody), and vomiting, according to the CDC. Most people get better within 5 to 7 days and sustain a mild infection, but others can be severe or life-threatening. Some people with Shiga toxin-producing E. coli (STEC) infection may get a type of kidney failure called hemolytic uremic syndrome.

In the US, from 2000 to 2014, close to 500 outbreaks of waterborne illnesses were reported in recreational venues in 46 states and Puerto Rico, causing 27,219 cases of sickness and eight deaths. Pool chemicals can take care of many problems, but not always. Getting optimal results for safety comes down to having the right balance. It comes down to having the right users, those who adhere to the proper pool etiquette.

Most of the illnesses in pools, hot tubs and water playgrounds are caused by Cryptosporidium, a parasite that causes Cryptosporidiosis, which  leads to diarrhea.

Crypto is spread by swallowing water that has been contaminated with fecal matter. Most germs are killed within minutes by common pool disinfectants like chlorine or bromine, but Crypto is a germ that can survive in properly chlorinated water for more than seven days. The diarrhea it causes can last for up to three weeks. And the number of Crypto cases have been steadily rising, with twice as many in 2016 as in 2014.


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

Pharm D degree holders can use ‘Dr’ prefix



The Pharmacy Council of India (PCI) has said that the candidates getting the Doctor of Pharmacy degree (Pharm D) from recognized universities will be authorized to use the ‘Dr’ prefix reports TOI.

In a letter issued to director of board of examination and evaluation of Sant Gadge Baba Amravati University, the registrar-cum-secretary of PCI Archana Mudgal has informed that the university should use the prefix ‘Dr’ before the names of the candidates while awarding the degree certificates to those who clear Pharm D course.

As universities in the state were not issuing degrees with ‘Dr’ prefix till now, members of Doctor of Pharmacy Association of Maharashtra had approached the PCI for a clarification.

The council had issued a circular that Pharm D candidates can use Dr before their names.

So as on today who all can prefix their name as Dr?

·                     A person who has completed the doctoral academic research when awarded with a PhD prefix Dr to his name
·                     MBBS are also addressed as doctors and they also use Dr prefix.
·                     Practitioners of AYUSH systems of medicine and are also referred as doctors even though they have their own appropriate terms for alternative medicines like Vaidya (Ayurveda), Hakim (unani), Naturopath, Yogacharya and Homoeopath
·                     Universities also facilitate eminent individuals for their contribution in many field such as literature, science, sports, music, cinema, social service etc with doctorate degrees. They also prefix Dr
·                     Now, Pharm D (Doctor of Pharmacy) will be granted a certificate with a Dr prefix.
·                     Physiotherapists also has been asking for Dr as a prefix
·                     Tomorrow Nurse practitioners ( once started) will also start writing Dr as prefix
·                     All quacks are prefixing Dr in from of their name
·                     Health products are also writing Dr for example Dr Morpen, Dr Fixit
·                     Practitioners of unrecognised systems of medicine are also prefixing Dr

So what is the answer?

We need to differentiate ourselves from others
Use IMA patented emblem for modern medicine




  











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

Wednesday, May 29, 2019

Diet for high uric acid: Focus shifts to healthy diets


Patients with high uric acid levels were earlier advised by their doctors to avoid eating foods high in purine. By itself, it has not been shown to be very helpful; hence, this approach is changing.  The focus is shifting to following a healthy diet instead of making a list of foods to be avoided along with maintaining a healthy body weight. Losing weight can lower uric acid levels.

·         Drink plenty of fluids but limit intake of sweetened drinks and alcohol, which can increase uric acid levels.

·         A healthy diet emphasizes plant-based foods, such as vegetables, fruits and legumes. Whole grains are preferred over processed grains. Reduce intake of fat, especially saturated fat (found in red meat). Lean sources of protein, including chicken, turkey, fish and tofu, are better choices than beef or pork.

·         A study published in 2016 in the journal Arthritis & Rheumatology in 2016 found that people who followed the DASH diet for 30 days lowered their uric acid levels 0.35 mg/dL on average. The higher the starting uric acid level, the greater the decline.

·         Fish are a source of omega-3 fatty acids, which is healthy but some seafood also contains high amounts of purines. However, gout patients do not need to totally avoid eating fish. They should limit their intake of shellfish, sardines, and anchovies as they have the highest amounts of purines. They should instead choose flaky white fish, such as cod, tilapia, or flounder.

·         Consume low-fat dairy products. These products, which contain calcium, may help lessen gout attacks as well as protect your bones

·         Vitamin C may lower uric acid levels. Gout patients may add citrus fruits and other foods rich in vitamin C (such as strawberries and peppers) to their diet.

·         Eating cherries can reduce gout attacks and improve pain.


(Source: Harvard Health)


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


Can estrogen help treat women with schizophrenia?



Findings of a systematic literature review conducted at the University of Maryland in Baltimore show that addition of estrogen reduced schizophrenia symptoms in women with schizophrenia in a dose-dependent, and statistically significant, manner compared with stand-alone antipsychotic treatment.

According to the findings presented at the 2019 annual meeting of the American Psychiatric Association (APA), young women typically develop symptoms 3 to 4 years later than their male counterparts. Also, symptoms in women can develop at times of hormonal change, including during the postpartum or postmenopausal periods.

Schizophrenia affects about 1% of the population. Evidence has shown that although the prevalence of schizophrenia is similar in men and women, the presentation differs.

Overall the levels of estrogen are typically lower in women with schizophrenia than their counterparts without the disorder. Estrogen enhances dopamine antagonists in animal models and may serve as a “natural antipsychotic agent”. It may also have a protective role in neuronal injury by promoting neurogenesis and re-myelination.


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

Tuesday, May 28, 2019

How to deal with leftover food: Tips from the Cleveland Clinic



1.      For cookouts and barbeques, when you’re thinking about your leftover food, anything that’s been sitting out for more than 2 hours, you probably shouldn’t save
2.      Avoid letting foods get into the ‘temperature danger zone’, which ranges from
40-140oF.  When food has been sitting out in that temperature range, it will begin to grow bacteria, and there’s a higher likelihood of getting sick from eating it.
3.      There are some food items that are likely able to be saved such as snacks like nuts or pretzels.
4.      If you have a vegetable tray, you can probably save most of it.
5.      Items which cannot be saved include pasta salad and potato salad. Those items are more likely to grow bacteria, so you can discard them.
6.      If you’re having a large gathering, stick with smaller serving dishes, but have your backup in the fridge to pull out half way through, so that you can keep things at a good, healthy temperature
7.      If you are serving things such as salads with dressings, put the dressing on the side, and let people decide how much they want to use. This will help keep moisture out of the dishes, because moisture is where bacteria likes to grow.
8.      When the party is over, be mindful not only of what you can save, but how you pack it up.
9.      If you’re storing foods, use shallow containers, and bring the food to room temperature before you put them in the refrigerator
10.    Once the food is in the refrigerator, you have a window of about 2-3 days to eat leftovers.
11.    If you’re not sure if something is still good to eat – use your senses. Inspect it for visible mold and smell it to see if it smells right; if in doubt, throw it out.

(Source: Cleveland Clinic)

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

Drug Formulations: Banking on Brands





Retaining the brand name in a new formulation is misleading and harmful for patients and state drug controllers can crack down on companies which do so

Dr KK Aggarwal

The central government has ordered state drug controllers not to allow pharma companies to market drug formulations in which the composition has been tweaked while retaining the old brand name. With this in place, certain companies will not be allowed to retain the brand name in medicines that have undergone a change in raw material or active pharmaceutical ingredient.

Hopefully, this will not apply with retrospective effect as a new law ought to be prospective, not retrospective. Article 20 (1) protects individuals against ex post facto legislation and says that no person can be convicted for an offence that was committed before the enactment of the law. This immunity is only limited to criminal proceedings. However, it does not prohibit a civil liability retrospectively, i.e. with effect from a past date. So, a tax can be imposed retrospectively.

The Union health ministry on September 12, 2018, banned about 328 FDCs (fixed-dose combination drugs) after an expert panel was formed under the chairmanship of Dr Nilima Kshirsagar, professor of clinical pharmacology at GS Medical College, KEM Hospital, Mumbai. The panel had to review the safety, efficacy and therapeutic justification of these drugs and found them “irrational”. Citing safety issues and lack of therapeutic justification, it recommended the ban which includes pain­killers and anti-diabetic, respiratory and gastro-intestinal medicines.

Over 6,000 brand names were banned. Many companies which had created a known brand lost their market share overnight and had to create new brands with new preparations.

Take one example. Codeine-containing cough medicine was banned in India from March 14, 2016. Pfizer Ltd, the Indian subsidiary of US-based drug maker Pfizer Inc., discontinued the cough syrup Corex (codeine plus chlorpheniramine maleate) in its then form, changed the composition but decided to retain the brand name for its future respiratory products. The new formulation is now called Corex T (codeine plus triprolidine). It is being marketed for dry cough. Since February 1, 2018, all over-the-counter (non-prescription) codeine-containing medicines for pain relief, cough and colds can be bought by prescription only.

Retaining the brand name in a new formulation where an ingredient has been tweaked is misleading and harmful for patients. The issue had been discussed for years now and was deliberated in several drugs consultative committee meetings since 2008. The expert panel was of the view that medicines where the ingredient is tweaked by companies but the brand name retained is “not only misleading, but may result in undesirable pharmacological effects” as the consumer would take the formulation, assuming it was the earlier composition. This is especially so in India where even scheduled medicines can be bought without prescriptions.

Even Section 200 of the IPC (using as true such declaration knowing it to be false) and Section 415 (cheating, deceiving, fraudulently or dishonestly) may become applicable in such cases. The Supreme Court had held almost 18 years ago in Cadila Health Care Ltd vs Cadila Pharmaceuticals Ltd that there ought to be some coordination between the trademark registry and drug authorities. In this case, the Court had observed that “drugs are poisons, not sweets”.

Under the Drugs and Cosmetics Act, 1940, the Drug Controller General of India (DCGI) and state FDAs are vested with powers to supervise and overlook the manufacture and sale of drugs. Sections 17 and 17A of the DC Act deal with misbranded and adulterated drugs. Central and state governments are empo­wered to appoint inspectors who have vast powers as stipulated under Section 22.

The High Court of Delhi in the matter of M/s Curewell Drugs & Pharmaceuticals Pvt Ltd & Anr vs Ridley Sciences Pvt Ltd had issued an order on August 14, 2018, that the DCGI and state FDAs ought to implement an action plan in which drugs with identical or near identical brand names or marks are not given licences so as to ensure that no confusion is created among doctors, chemists and patients. Though the context in this case was different, the spirit of the judgment was not to create any confusion in the minds of people when it comes to brands.

The Supreme Court in the Cadila Health Care case had said: “Keeping in view the provisions of Section 17-B of the Drugs and Cosmetics Act, 1940, which inter alia indicates that an imitation or resemblance of another drug… likely to deceive being regarded as a spurious drug it is but proper that before granting permission to manufacture a drug under a brand name the authority under that Act is satisfied that there will be no confusion or deception in the market. The authorities should consider requiring such an applicant to submit an official search report from the Trade Mark Office pertaining to the trade mark in question which will enable the Drug Authority to arrive at a correct conclusion.”

Subsequently, in compliance with the order of the Delhi High Court, a meeting was held under the chairmanship of additional secretary and Director General (Central Government Health Scheme), Ministry of Health and Family Welfare, on November 13, 2018. At the meeting, it was discussed that the brand name/trade name in the case of pharmaceuticals is neither controlled by the licensing authority under the Drugs and Cosmetic Act nor the trademarks office at present. This allows scope for having the same trade names for different drugs manufactured and sold. Thus, the Drugs and Cosmetic Rules, 1945, may be amended to include provisions for regulating brand names/trade names by central and state licensing authorities.

The Drugs Technical Advisory Board after detailed deliberation recommended devising a mechanism under the Drugs and Cosmetics Rules, 1945, to include provisions for regulating the brand names/trade names of pharmaceutical products. With no system in India for the DCGI to inform every doctor about this, confusion is sure to persist.

As for companies, they prefer using popular brand names for new products containing different ingredients as it is easier to market them. Also, they would have spent a lot of money in building that brand name.

As long as the name is for the same indication and the company ensures safety by making a rational combination, it can justify it. Of course, extensive communication and information to every healthcare provider should be given.

Similarly, a name change of a drug under these circumstances should be communicated on a one-to-one basis to every doctor and not by an advertisement. This seems a difficult task as even the MCI does not have the records of all practising doctors in India.

All possible efforts should be made to avoid mistakes with brand names. Prescription errors are the number one cause of medical errors in the country.


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

Monday, May 27, 2019

Can emergent care be denied to a hospitalized patient if he cannot afford?


Quite often we see that a patient is being told by a hospital, especially in cases of coronary blockages, that your blockages are severe enough to be tackled immediately. You need a bypass or stenting without delay and any second opinion, transfer to another Centre will be at your risk.

In this way, they force the patient to get a surgery or an intervention done there and then irrespective of whether the patient can afford or not.


I recently saw a patient where the hospital did stenting without giving any time to relatives to think. They collected 2.8 lakhs, but the bill handed over amounted to Rs 5 lakhs.


What can be done in such cases?


I feel any emergency must be tackled by the hospital and if the patient cannot afford, then the hospital needs to provide free and safe transfer to another hospital or do a free intervention.


Many Supreme Court decisions have made it clear that in a life-threatening emergency the hospital cannot wash its hands off the situation and will need to provide emergent treatment (free if the patient cannot afford).


The emergent situation does not mean a patient in the ER but also means hospitalized patients, who develop an emergency during their hospital stay.


Emergency is a life-threatening condition, which requires immediate action; it’s not the same as urgency, which requires urgent care, but where you have time to decide.


Debate

·         This is a  common situation not only for coronary but also for so many medical situations. Issues bothering the patient would be: Do I really need stent as advised by a doctor; do I have time enough for the second opinion, can I afford it? I think in most cases there is adequate time for patient to have a second opinion, so attending physician must guide the patient properly. In life-saving and urgent situations, decision has to be taken on a case to case basis. Do whatever you can do, but patient should not die due to want of money. Dr Arun Gupta MD, President, Delhi Medical Council

·         I agree with you. The option to get treated elsewhere or redirected to a hospital where the treatment can be afforded by the patient e.g. a lower star facility or public healthcare facility, after understanding the paying capacity of patient needs to be politely explained to patient and courtesy ambulance provided after initial assessment and first aid and basic medical management. Forceful medical care being opted for a patient by some corporate hospitals for those who don’t have the buying power to avail that treatment in lakhs leads to ugly situations of non-payment, violence and breeding lack of trust with the historically respected medical profession. A defined code for urgency differentiated from a medical emergency and opting to treat these few patients under emergency under an insurance or Ayushman Scheme will ensure that the hospital gets some level of reimbursement and it’s not total cost is borne by the hospital for humanitarian treatment of some emergency cases. Rajiv Nath, Forum Coordinator, AiMeD 

·         The only solution is to bring all health care under the Clinical Establishment Act. Dr Jagdish Prasad, Professor (Cardiac Surgery), Director General of Health Services

·         In safe transfer, what is safe or really safe in all situations? The patient might become a shuttle cock between govt. hospitals and eventually die on road. Govt has to spend more money to treat all patients in govt. hospitals then it reimburses the private hospitals and patient gets timely attention. So "treat and not transfer" should be the policy but this can only be sustained by reasonable and timely hassle-free reimbursement. Dr Kamal Parwal

·         In some countries, such emergencies are immediately tackled and if the patient is very poor then the hospital subsidies it out of its fund....In India too, we must ask our hospitals to earmark some funds for this purpose (though most poor must be covered by HI in which case they should draw the amount from the HI agency and pay for the rest) ...and only after fully stable should or can they transfer for follow up to a more affordable centre as chosen by the patient.  Several systems like these need to be thought through and worked out. I am not sure what the NHA is doing in this regard. But it’s a major problem and needs attention. Sujatha Rao

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