The four keys to prevent cardiovascular disease

An estimated 80% of all CVD cases — heart disease, heart attack, heart failure, and stroke — can be prevented. The key is to control high blood pressure and high cholesterol and to maintain healthy habits, such as exercising regularly, eating a plant-based diet, getting enough sleep, and not smoking.

Exercise: Guidelines recommend 30 minutes of moderate-intensity exercise five times a week. "Doing more is better.

·         Walk for 5 minutes every 2 hours. Do a set or two of push-ups either on the floor or against the kitchen counter.

·         Perform up to 10 repetitions of stand-and-sit exercises, where you rise from a chair not using your arms and then sit down again.

·         Find opportunities to do extra movements. For example, park farther away from the grocery store, take the stairs, and do simple yard work like weeding, planting, and raking. Every bit of everyday movement can count toward your overall exercise requirements.

Diet: Focus on plant foods; minimize intake of red meat, especially processed meat.

Sleep: Guidelines from the American Academy of Sleep Medicine and the Sleep Research Society recommend adults get at least 7 hours of sleep per night on a regular basis. Studies have found that getting less than this amount is associated with heart disease risk factors like higher stress, increased inflammation, high blood pressure, and weight gain. Sleep apnea can also increase the risk. According to a study published online Feb. 12, 2018 in the Journal of Sleep Disorders & Therapy, people with sleep apnea are more likely to also have heart failure, an irregular heartbeat and diabetes

Numbers: Keep the lower BP, LDL cholesterol, abdominal circumference and fasting sugar < 80

(Source: Harvard Health Watch)

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

Who is a specialist?

In the Allahabad High Court

Petition

The petitioner Dr N 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.

That the specialised qualification DGO has been incorrectly construed not to be based on a valid certificate. The Diploma was obtained in 2007. There is no requirement of any additional registration of recognized and registerable degrees. He cited a decision of the Apex Court in case of Dr. B.L. Asawa Vs. State of Rajasthan and others, (1982) 2 Supreme Court Cases 55.  

Defence

The petitioner was not holding any specialisation or registration of the additional qualification of Diploma as claimed, which is required as per Section 26 of the Indian Medical Council Act, 1956. The petitioner got her registration in relation to the said certificate admitted much later. On the date of the incident, which obviously happened in the year 2012, the petitioner was not holding any specialisation qualification as per 2002 Regulations and she was not entitled to claim to be a specialist as per Regulation 7.20.

Judgment

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

Dr. Neetu Rastogi is MD from Ukraine i.e. equivalent to MBBS. She did her DGO from College of Physician and Surgeon, Mumbai, which is not a recognized and registerable degree in the State of U.P. Thus, she is simply MBBS and not the specialist as she claimed.

Hence, she is guilty u/s 7.20 of the Indian Medical Council (Professional Conduct, Ethiquette and Ethics) Regulations, 2002, “A Physician shall not claim to be specialist unless he has a special qualification in that branch.”

Claim of the petitioner being a Specialist on the strength of the Diploma certificate also cannot be sustained on the ground that the said Diploma stands derecognised w.e.f. 2.12.2009. It is correct that the certificate of the petitioner is prior to that but at the same time, the petitioner did not get this additional qualification registered when this surgery was performed in the year 2012. The registration is stated to have been obtained much later. Thus, the petitioner did not have any such authority to claim the specilisation and this defect therefore negatives the argument on behalf of the petitioner.

The judgment that has been relied upon by the learned counsel for the petitioner in the case of Dr. B.L. Asawa (supra) is in relation to recruitment to the post of lecturer in an University as per the terms and conditions of the Act and Ordinances as was involved therein. Learned counsel for the petitioner has stressed on the words used in paragraph 11 of the judgment to urge that it has to be ipso facto regarded as a valid diploma once it is contained in the Schedule of the Medical Council of India. This argument cannot be accepted inasmuch as the aforesaid judgment is not in relation to the registration of the additional qualification as per Section 26 of the Medical Council Act and as such, the said judgment does not come to the aid of the petitioner.

  

Judgement based on:

Who is a specialist? Two clauses in Medical Council of India Act, viz., 7.20 and 1.42 have to be read together for this. DGO should have been considered to be a valid specialisation degree.

1. Clause 7.20 states: “A physician shall not claim to be a specialist unless he has a special qualification in that branch.” 

i.        This clause is applicable only after 2003 and is not applicable for those who are practicing before 2003.

  ii.        The clause talks about special qualification and does not say anywhere MCI recognized qualification.

iii.        Also clause 7.20 does not differentiate a specialist from a super specialist. Though "The Postgraduate Medical Education Regulations 2000 (3) talks about a super specialist and specialist “the Postgraduate Medical Education in broad specialities shall be of three years duration in the case of degree course and two years in the case of Diploma course after MBBS and in the case of super specialities the duration shall be of three years after MD/MS with the exceptions wherever indicated”.

2. What is a special qualification? This has to be read in the Regulation 1.42, which states, “physicians shall display as suffix to their names only recognized medical degrees or such certificates/diplomas and memberships/honours which confer professional knowledge or recognizes any exemplary qualification/achievements”. A qualification is decided by the suffix allowed to the person.

a.    The clause is very clear. It adds “or such certificates/diplomas” only after the recognized medical degrees. It means that any doctor who displays specialty as suffix to his name, he or she can even put certificate/diploma, and membership/honour as long as that confers professional knowledge or recognizes any exemplary qualification/achievement. That means a person can suffix all society memberships, medals received, special certificates, training or diplomas. For example, if a person has received a certificate in IVF or a diploma in cardiology, he or she can suffix that to their names. Regulations 1.42 and 7.20 read together clarify that a person cannot claim to be a specialist unless he has a special qualification in that branch as mentioned in clause 1.42.

b.     The word ‘or’ gives it a wider perspective.

c.     Physician, cardiologist, neonatologists etc. are also suffix.

3. IMC Act: 26 “1 If any person whose name is entered in the Indian Medical Register obtains any title, diploma or other qualification for proficiency in sanitary science, public health or medicine which is a recognized medical qualification, he shall, on application made in this behalf in the prescribed manner be entitled to have any entry stating such other title, diploma or other qualification made against his name in the Indian medical register either in substitution for or in addition to any entry previously made. The entries in respect of any such person in a State Medical Register shall be altered in accordance with the alterations made in the Indian Medical Register.” “Shall” means mandatory.

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.

4. Under P&DT Act, an ultrasonologist is defined as “(3) (1) Any person having adequate space and being or employing: (a)  Gynaecologist having experience of performing at least 20 procedures in chorionic villi aspirations per vagina or per abdomen, chorionic villi biopsy, amniocentesis, cordocentesis foetoscopy, foetal skin or organ biopsy or foetal blood sampling etc. under supervision of an experienced gynaecologist in these fields, or  a Sonologist, Imaging Specialist, Radiologist or Registered Medical Practitioner having Post Graduate degree or diploma or six months training or one year experience in sonography or image scanning, or.  (c)     A medical geneticist: may set up a genetic clinic/ultrasound clinic/imaging centre.

5. Under MTP Act, a gynecologist is defined as: The medical termination of pregnancy act, 1971 (Act No. 34 of 1971), (10th August 1971), An Act to provide for the termination of certain pregnancies by registered Medical Practitioners and for matters connected therewith or incidental thereto. Be it enacted by Parliament in the Twenty-second Year of the Republic of India as follows: 2D: (d) “registered medical practitioner” means a medical practitioner who possesses any recognized medical qualification as defined in clause (h) of section 2 of the Indian Medical Council Act, 1956, (102 of 1956), whose name has been entered in a State Medical Register and who has such experience or training in gynaecology and obstetrics as may be prescribed by rules made under this Act.

6. Rule 4 defines the specialization: Experience and  training under clause (d) of Section 2:- For the purpose of clause (d) of section (2), a registered medical practitioner shall have one or more of the following experience or training in gynaecology and obstetrics, namely;  (a) In the case of a medical practitioner, who was registered in a State Medical Register immediately before the commencement of the Act, experience in the practice of gynaecology and obstetrics for a period of not less than three years;  (b) in the case of a medical practitioner, who is registered in a State Medical Register:-  (i) If he has completed six months of house surgency in gynaecology and obstetrics; or (ii) unless the following facilities are provided therein, if he had experience at any hospital for a period of not less than one year in the practice of obstetrics and gynaecology ; or (b) if he has assisted a registered medical practitioner in the performance of twenty-five cases of medical termination of pregnancy of which at least five  have been performed independently, in a hospital established or maintained or a training institute approved for this purpose by the government.

7. Under PNDT Act 2003:  Who is a specialist in genetics counseling? The qualifications of the employees, the requirement of equipment etc. for a Genetic Counseling Centre, Genetic Laboratory, Genetic Clinic, Ultrasound Clinic and Imaging Centre shall be as under: 1) Any person being or employing i) a gynaecologist or a paediatrician having six months experience or four weeks training in genetic counseling or  (ii) a medical geneticists, having adequate space and educational charts/models/equipments for carrying out genetic counselling may set up a genetic counselling center and get it registered as a genetic counselling center. 

8. DNB for family medicine is not recognized by MCI yet a person is a family medicine consultant.

9. DNB in maternal and child health is not recognized by MCI yet people can suffix as DNB maternal and child health and practice as specialist in that specialty.

10. PGDM, PGDMCH are IGNOU courses and not recognized by MCI yet a person writes as specialist in that specialty.

11. Dip Card is a diploma in Cardiology recognized by IGNOU only and once a person has done Dip Card he or she is practicing as a cardiologist.

12. MRCP, FRCS, FRCR are not recognized by MCI and yet they are specialists and practice. 

13. The Indian Armed Forces has a well-defined modality of how doctors would be classified as specialists and super specialists as per their TGC (Training, Grading & Certification) Rules: Graded Specialists : After obtaining PG degree ; Classified Specialists ( eq. to super specialists) : 4-5 yrs. Experience after PG or Grading + 1 months of satisfactory  observatory working under a Sr. Advisor. You are also classified as a Sub Specialist for which you are granted 2 years study leave and have to acquire training (not qualifications) in a reputed institute of that Sub specialty. 

14. The eligibility for being a medical teacher in a particular super-speciality is also based on the above as per MCI Act.

15. MCI does not recognise any Fellowship from any institution from anywhere in the world, including India. 

16. There are so many courses run by Annamalai University that are definitely not recognised by MCI. If one has to use only MCI recognised degrees, then how has MCI allowed a Deemed University like Annamalai to run these courses while not recognising them? Contradictory, isn't it?

17. MCI does not differentiate between specialist and super specialist as far as working is concerned. 

Minutes of the meeting of the Ethics Committee held on the 11th & 12th December, 2008 at 10.30 a.m: Application by Sh. Amit Karkhanis for seeking information under RTI Act, 2005 to be read with regards to application by Sh. Amit Karkhanis for seeking information under RTI Act, 2005.

The Ethics Committee considered the matter with regards to application by Sh. Amit Karkhanis for seeking information under RTI Act, 2005 and decided to answer as under:

Q.(i) I want to know whether a medical doctor registered with you with additional qualification of MD (Gynecology) / DNB (Gynecology) can perform gynecology related sonography / endoscopic surgery? 

Ans.: As far as the work relating to the Specialty of Gynecology is concerned – yes.

Q.(ii) What is the difference in the scope of work of MD(General Medicine) and those possessing qualifications such as DM(Cardiology)?

Ans.: No specific information is available in the Council’s Regulations enacted under IMC Act, 1956.

18. MCI has limited specialists and super specialist courses in medical and surgical fields.  One is not negligent in practicing a field in India in which no such recognized course is available.  For example no course is available in noninvasive cardiology, preventive cardiology, cardiodiabetology, and echocardiography. A person who has acquired proficiency in any of the above either by foreign training or experience over a period of time will be justifying in writing a specialist in that field 

(Dr Neetu Rastogi vs Union of India and 4 Ors; WP 4369 of 2017, 31/01/2017)

My views

Anybody who has a valid recognized medical degree or has certificates/diplomas, memberships/honours, which the Council feels that they confer professional knowledge or recognizes any exemplary qualification/achievements can practice and be called as a specialist or super specialist. 

Examples

• After 2003 when the MCI Ethics Regulations Act was enacted, MD Medicine cannot write Cardiologist but can write Physician and Cardiologist, or Physician and Gastroenterologist etc. Same is true for MS Surgery or MD Gynaecology.
• MD Gynaecology can write Onco Gynaecologist if she has a certificate or an experience in the field
• ENT people can write based on their experience e.g. specialist in Cochlear transplants etc
• MD pathologist can write histopathologist, cytologist, onco-cytologist depending on training or certificate.

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

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.

Section	Deduction on	Allowed Limit (maximum) FY 2018-19
80C	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 – ULIPS – ELSS – 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
80CCC	For amount deposited in annuity plan of LIC or any other insurer for a pension from a fund referred to in Section 10(23AAB)	-
80CCD(1)	Employee’s contribution to NPS account (maximum up to Rs 1,50,000)	-
80CCD(2)	Employer’s contribution to NPS account	Maximum up to 10% of salary
80CCD(1B)	Additional contribution to NPS	Rs. 50,000
80TTA(1)	Interest Income from Savings account	Maximum up to 10,000
80TTB	Exemption of interest from banks, post office, etc. Applicable only to senior citizens	Maximum up to 50,000
80GG	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
80E	Interest on education loan	Interest paid for a period of 8 years
80EE	Interest on home loan for first time home owners	Rs 50,000
80CCG	Rajiv Gandhi Equity Scheme for investments in Equities	Lower of – 50% of amount invested in equity shares; or – Rs 25,000
80D	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
80DD	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
80DDB	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
80U	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
80GGB	Contribution by companies to political parties	Amount contributed (not allowed if paid in cash)
80GGC	Contribution by individuals to political parties	Amount contributed (not allowed if paid in cash)
80RRB	Deductions on Income by way of Royalty of a Patent	Lower of Rs 3,00,000 or income received

 (Source: https://cleartax.in/s/80c-80-deductions)

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

Do Not Ignore Chronic Constipation

Do not ignore chronic constipation, especially in the elderly as it may be a sign of underlying cancer, said Dr. Rajiv Khosla and Dr. Praveen Bhatia, in a joint statement. Panelists were Dr Ajay Kumar, Dr Rajiv Khosla, Dr SK Thakur, Dr  AK Jhingan, Dr Kailash Singla. The seminar was moderated by Padmashri & Dr. BC Roy National Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India, Dr KK Aggarwal.

They were participating in a seminar organized by Heart Care Foundation of India and eMedinewS at Constitution Club of India as part of 19th MTNL Perfect Health Mela celebrations. Over 200 doctors participated in the seminar which was supported by Win Medicare.

The doctors said that any abdominal pain associated with diarrhea should suspect one of inflammatory bowel disease but if the same appears for the first time in the elderly, one must conduct colonoscopy to rule out cancer of gut.

Constipation should not be treated with laxatives as they may be habit forming. Isabgol, triphala  and poly ethylene glycol are the commonest medicines used to treat constipation. Isabgol is a bulk laxative. Presence of rectal bleeding, constipation and diarrhea, unexplained abdominal pain should warrant one to undergo colonoscopy.

Facts about chronic constipation

1.    Constipation is the most common digestive complaint in the general population, and is associated with substantial economic costs

2.    Infrequently, constipation is the first manifestation of metabolic (diabetes mellitus, hypothyroidism, hypercalcemia, heavy metal intoxication), neurologic, or obstructive intestinal disease; more often, it occurs as a side effect of commonly used drug

3.    Constipation has been defined as a stool frequency of less than three per week

4.    An international working committee recommended diagnostic criteria (Rome III) for functional constipation. The diagnosis should be based upon the presence of the following for at least three months (with symptom onset at least six months prior to diagnosis).

a.    Must include two or more of the following:

·         Straining during at least 25 percent of defecations

·         Lumpy or hard stools in at least 25 percent of defecations

·         Sensation of incomplete evacuation for at least 25 percent of defecations

·         Sensation of anorectal obstruction/blockage for at least 25 percent of defecations

·         Manual maneuvers to facilitate at least 25 percent of defecations (eg, digital evacuation,  support of the pelvic floor)

·         Fewer than three defecations per week

b. Loose stools are rarely present without the use of laxatives

c. There are insufficient criteria for IBS.

5.     It often responds to dietary changes and various laxatives.

6.     Idiopathic constipation is associated with normal or slow colonic transit, functional defecation disorder, or both.

7.     Management of normal and slow transit chronic constipation includes patient education, behavior modification, dietary change, bulk forming laxatives, and the use of non-bulk forming laxatives or enemas

8.     Initial management of idiopathic constipation involve dietary fiber and bulk forming laxatives such as psyllium ormethylcellulose, together with adequate fluids

9.     For patients who do not tolerate bulk forming laxatives or respond poorly to fiber one should start with osmotic laxative

10.  Other options include stool softeners or stimulant laxatives (bisacodyl, senna, and sodium picosulfate).

11.  Management of severe constipation and functional defecation disorder may involve suppositories, biofeedback, botulinum toxin injections into the puborectalis muscle, or subtotal colectomy under specific circumstances.

12.  Various pharmacologic therapies (lubiprostone, misoprostol, colchicine) have been used to treat severe constipation with limited success.

13.  In patients over the age of 70 years warm water enemas rather than sodium phosphate enemas be used for the treatment of constipation

14.  The use of sodium phosphate enemas in older adults has been associated with complications including hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and EKG changes (prolonged QT interval).