You need not always complete full course of antibiotics: Doctors

NEW DELHI: Is it important to complete a full course of an antibiotic? Yes, according to conventional wisdom, which says stopping a course mid-way could lead to drug resistance. But several scientists have now challenged this claim.

In many situations, stopping antibiotics sooner is a safe way to reduce antibiotic overuse, said a paper published in the British Medical Journal. "Patients are put at unnecessary risk from antibiotic resistance when treatment is longer than necessary," said the authors from Brighton and Sussex Medical School in the UK.

Dr Randeep Guleria, director, AIIMS, however, warned patients against stopping antibiotics on their own.

Stopping or extending a course of antibiotics "is a clinician's call", the AIIMS director said, while agreeing that there was a need to critically look at prescription patterns.

Dr Suranjit Chatterjee, senior consultant, internal medicine at Apollo hospital said an antibiotic course need not be treated as sacrosanct. "It can be de-escalated or stopped if patient's condition improves," he said.

Chatterjee said antibiotics are prescribed to many patients on an empirical basis if they have high fever or diarrhea. "If tests reveal he or she does not have typhoid or other serious infections as suspected and this is reflected in his clinical condition, antibiotic course can be altered," the doctor said.

Guleria and Chatterjee said in diseases such as tuberculosis and typhoid, a patient may feel better after a few days but the antibiotic course still needs to be completed because not doing so increases the risk of relapse and emergence of resistant bacteria.

Traditionally, antibiotics are prescribed for recommended duration or courses, say for five to 10 days or more, depending on the condition.

The BMJ article argued that fundamental to the concept of an antibiotic course is the notion that shorter treatment will be inferior. But the scientists pointed out that studies to identify minimum effective treatment duration have simply not been performed for most conditions.

"For example, pyelonephritis (inflammation of kidney due to bacterial infection) has historically been treated for two weeks. Trials have shown shorter courses of quinolones are effective (seven days for ciprofloxacin and five days for levofloxacin), but no such data exist for B-lactams which are the main antibiotic class used," the BMJ study said. It added that current international guidelines recommend 10-14 days' treatment with B-lactams, based purely on absence of data for shorter courses.

The experts also argued that the concept of an antibiotic course ignores the fact that patients may respond differently to the same antibiotic, depending on diverse patient and disease factors.

Many bacteria, for example Staphylococcus aureus, live harmlessly in our body (the gut, skin or mucus membranes). When a patient takes antibiotics for any reason, species and strains sensitive to it are replaced by resistant species and strains ready to cause infection in the future. "The longer the antibiotic exposure these opportunistic bacteria are subjected to, the greater the pressure to select for antibiotic resistance," the BMJ article explains.

Dr Anoop Mishra, chairman, Fortis C-Doc, said concerns about antibiotic resistance due to overuse are important but they shouldn't be allowed to prejudice the minds of patients to unilaterally alter the antibiotic course. "The compliance rate of medicine prescription is already very low in India. It is a major cause of emergence of drug-resistant tuberculosis, for example," he said.

Non-alcoholic hepatitis, a growing health issue’

Jaipur: Non-alcoholic liver disorder causing hepatitis is growing as a new health concern. A 56-year-old person who was never looked obese but his BMI index was higher than normal reached Sawai Man Singh (SMS) Hospital on Wednesday with complaints of blood vomiting. He was diagnosed with non-alcoholic hepatitis, which is known as Nonalcoholic Steatohepatitis (NASH).

Earlier, majority of the cases of fatty liver reported were of alcohol-induced hepatitis. But, now with population with obesity has increased, the cases of NASH has also increased significantly. Obesity is a major risk factor for NASH. Over the past 10 year, the population among women with (BMI ≥ 25.0 kg/m2) has increased from 8.9% to 14.1% and among male, it has increased from 6.2% to 13.2%, shows the latest National Family Health Survey 2015-16.

“This patient belongs to Didwana of Nagaur. He never had any disease. His BMI index and blood glucose was slightly higher than normal. During diagnosis, it was found that he had NASH. We conducted endoscopy to stop bleeding immediately. He has liver cirrhosis but it is not terminal cirrhosis, which require liver transplant as final treatment. In his case, his condition can be managed with endoscopic treatment and medicine,” Dr Ashok Jhajharia, assistant professor, gastroenterology department, SMS Hospital said.

Dr Jhajharia said that such cases with NASH are now frequently being reported. “Even in vegetarian population and those people who do not drink liquor, are being diagnosed with fatty liver, which is a bad sign. Over the past few years, the consumption of food which helps building up of fat in the liver has increased,” Dr Jhajharia said.

Health experts say that the biggest cause of NASH is building up of fat in the liver. “Fatty liver is common among those who drink a lot of alcohol. But, now we can see that the trend is changing now. We can see that 10% of all the cases of fatty liver are non-alcoholic in the hospital. It was not so in the past,” Dr Sandeep Nijhawan, senior professor and head of gastroenterology department, SMS Hospital, said.

He said that NASH is common in America and European countries but now India has also reporting increased number of cases. “Those with diabetes, obesity and heart problems are also vulnerable to NASH. It happens because of consumption of food rich in carbohydrates and with not much of protein. Such junk food is quite common, which is one of the reasons of NASH. Also, people are doing job sitting at one place without doing any physical work,” Dr Nijhawan said.

Doctors say that those with NASH should avoid food with fat. They should do lifestyle modification by reducing weight and do a lot of exercise.

The doctors conduct liver biopsy for final diagnosis of the disease. They also do Fibro Scan to find out if the liver has fibrosis and stiffness.

Apart from hepatitis due to non-alcoholic fatty liver and alcohol-induced fatty liver disease, there are Hepatitis A, B, C, D and E causing liver disorders.

“Hepatitis B and C virus stay in our system for a long time, they become chronic and can result long term adverse conditions. Hepatitis has a tendency to remain undetected, so it is important that people should take their symptoms seriously and should take consultation for better treatment and living. “Dr Vijay Sharma, Gastroenterologist, of a private hospital said.

Apart from chances of developing into chronic diseases, people with undiagnosed viral hepatitis are also accountable for unknowingly transmitting their infections to others and adding to the disease burden. “The fact that till date we do not have any vaccine for hepatitis C, which is an equally perilous infection as hepatitis B, prevention becomes even more crucial. On one hand while safe blood transfusion practices at blood banks and hospitals can prevent the spread of infection, on the other, it is the use of safe injection practices which needs to be ensured,” Dr Dinesh Agarwal, Gastroenterologist of a private hospital said.

No more underreporting of infections: Hospitals to upload patient details online

CHENNAI: Come August, civic bodies in the state can no longer throw a cloak over an outbreak as the government readies a software that will require hospitals to upload patients’ details online.

As part of the initiative, hospitals in 12 corporations will have to notify the government, if patients walk in complaining of fever, diarrhoea, jaundice or encephalitis, even before an infectious disease is confirmed. Subsequent reports should also be uploaded online. This, officials say, will not give them an early warning of outbreaks and do away with underreporting by civic bodies.

Public health officials are in the process of mapping hospitals. At present, 2,972 of all the hospitals and labs in the state have been asked to intimate the health department on a daily basis if they receive patients with symptoms of infections that are epidemic prone. Of this, approximately one-third are located within the limits of these corporations, said director of public health K Kolandaisamy. While bigger hospitals notify the health department, health officials manually collect data from smaller ones. “There is at least a 24-hour lapse before we get a patient’s details and this is conveyed to the health inspector on the field to take action,” said Kolandaisamy. In the new system, the health inspector will receive an SMS the minute a hospital feeds a patient’s particulars. At least 23 ailments, including cholera, dengue and typhoid, have been declared as notifiable diseases. Through the online notification system, officials hope to pick early signs of diseases like dengue, typhoid, chikungunya, leptospirosis and H1N1 flu.

The system will also ensure cross notification. For example, a health inspector in Virudhunagar will receive an alert if a patient from his or her jurisdiction is admitted to a hospital in Madurai. Undiagnosed and mistreated cases are often cited as reasons that push infections to epidemic proportions in the state. While access to patient details will be restricted to officials and hospitals, public will be able to view overall infection hotspots in the state.

Private hospitals in the city have welcome the initiative, saying they are often harassed by corporation officials, especially when there is an outbreak of dengue. “They refuse to believe our lab results and discredit us. So we just keep sending them figures,” he said. Public health officials, on the other hand say one of the main challenges for surveillance of infectious diseases is lack of reporting from the private healthcare sector, which delivers healthcare to close to 60% of the population.

S K Roy, former secretary general of Indian Public Health Association, said other states could also follow Tamil Nadu’s initiative as it would also ensure standardisation of lab tests. “In the long-run it could check indiscriminate prescription of antibiotics as the portal bares the entire treatment process,” he said.

State seeks tough law against ‘cut practice’ by doctors’

The state (Maharashtra) government is set to introduce a Bill against the cut practice by doctors in the upcoming monsoon session of the state legislature which will begin on Monday. The government wants to make provisions for punishment under the Prevention of Corruption Act, 1988, to be applicable to doctors and others who are found guilty of the practice. If passed, the guilty will face minimum imprisonment of six months, extending up to five years.

Speaking to Mumbai Mirror, a senior official from the state’s medical education department said, “The state government has appointed a committee under former Director General of Police Praveen Dixit to draft the law. The state will be receiving the draft very soon and once the cabinet approves it, it will be tabled in the monsoon session of the state assembly.”

Cut practice is the act of accepting favours, cash, gifts or free trips from other doctors, hospital chains or diagnostic laboratories for referring patients to them. The practice is known to have originated in the United Kingdom where it started at 5 per cent. But according to recent government data, in India the rate has reached up to 40 per cent. Experts say, this is mainly due to increasing competition and one-upmanship.

Under the proposed Act, receiving gratification for referring patients to specialist doctors or ordering medical tests from one particular lab will be considered a criminal act.

Similarly doctors receiving expensive gifts from pharmaceutical companies, diagnostic laboratories or hospital chains on special occasions like birthdays, marriage anniversaries, children’s weddings etc. will be also considered a crime. Besides this, junkets sponsored by pharma companies will be also considered against the law.

A senior official from health department said, “Whether a particular test or procedure recommended by the doctor was necessary or not has been kept out of the proposed law’s purview. However under the law, investigating agencies will only examine whether a doctor or a hospital received material benefits for referring patients to another organisation or doctor.”

Dr Praveen Shingare, director medical education and research said, “The basic aim of the Act is to end the cut practice and if we succeed in doing so, it will bring down the cost of treatment by almost 30 per cent.”

A publicity stunt?

Medical sector activists are not convinced if the Act will be fool proof. An activist, Dr Arun Bal said, “The so-called bill against the cut practice is nothing but a publicity stunt. How is the government going to procure proofs of these payments and gifts? Most of these are done off the books. And even if they do, how are the authorities going to establish a pattern of these payments to prove their guilt?”

“We have built our health care system in such a way, that a young medical practitioner entering the profession will not survive unless he joins the menace of cut practice. Unless we change the system, we won’t be able to curb this,” he added.

According to Dr Bal, doctors constitute just 25 per cent of the health sector, big corporate hospitals, diagnostic centres and pathological labs constitute the major chunk of 75 per cent.

Dr. Shivkumar Utture, treasurer of the Maharashtra chapter of Indian Medical Association said, “We have made several representations to the government that one of our representatives should be included in the drafting committee. We should at least be given a hearing by the committee.”

“We would also like to request the government to not provide investigating agencies with sweeping powers under the proposed law. The doctor should be arrested only if he or she is found guilty by the court. Otherwise if the doctor is arrested today and found not guilty after five years, he stands to lose both his practise and his reputation,” he added.

PBT PRESIDENT ARGUES IN COURT AGAINST TOP KOLKATA HOSPITAL FOR A VICTIM OF BOTCHED SURGERY BY DOCTOR AGAINST WHOM SEPARATE CHARGES OF UNLAWFUL “STEM CELL THERAPY” IS PENDING IN STATE MEDICAL COUNCIL FOR PAST 4 YEARS

Division bench of West Bengal State Consumer Disputes Redressal Commission headed by president Justice Mr. Ishwar Chandra Das issued notice against Belle Vue Clinic, a premier private hospital in Kolkata, and Dr. Niranjan Bhattacharyya for a botched surgery that nearly took the life of wife of Mr. Partha Datta, a retired income tax deputy commissioner. 

As emphatically argued by PBT president, Dr. Kunal Saha, while doing a routine hysterectomy, Dr. Bhattacharyya also cut the left ureter of the patient and even worse, it was not disclosed to the patient or her husband. After patient’s condition deteriorated rapidly and a second opinion was sought, it was found that urine was leaking into the abdomen as the patient went into a serious condition. A number of follow-up surgeries were performed as the patient was transferred to a different hospital to save the life of the patient who still suffers from persistent medical problems. The long medical fiasco also caused a serious dent in Datta’s financial situation as the family had to pay a hefty hospital bill of over Rs. 20 lakh. The lawsuit has sought a compensation of about Rs. 45 lakh including the hospital cost for treatment of the patient. The matter will be listed for contested hearing on January 10, 2017.

Ironically, the same Dr. Bhattacharyya was also involved with unlawful and unethical “stem cell therapy” on a poor and unsuspecting patient in 2013. PBT lodged a formal complaint against this doctor with the West Bengal Medical Council seeking cancellation of medical registration of Dr. Bhattacharyya for his unlawful and dangerous medical experiment. While WBMC listed PBT’s complaint on their website, not a single hearing was held till now as the devious medical council stays on a slumber for the past 4 years as the accused doctor (see below).

The Real Returns from Real Estate Have Been Very Low

Vivek Paul's Diary

The best way to challenge myths is to look at data. The trouble is that India's real estate sectoris very opaque and does not give us enough data points to do a proper job of analysing it. In the process, the myth that any real estate investment yields massive amounts of returns at all points of time, continues to persist.

Thankfully, now we have some data which we can use. Sometime back, the National Housing Bank (NHB), the regulator of housing finance companies, launched a revamped RESIDEX, a housing price index. The index claims to offer home prices of 50 cities across the nation though I could find data for only 49. In this column, I look at data referred to as HPI@Assessment Prices based on the information furnished by banks and other lending agencies regarding home prices.

This should help us get some idea about which way the real estate prices have gone over the last few years. And for the first time we should be able to calculate the actual city wise returns. This should give all the real estate bhakts out there some idea of how their investments have done over the years.

As I said at the beginning, the NHB RESIDEX has price data for 50 cities. Let's take a look at Table 1. It shows the per year returns of these cities between June 2013 and March 2017. It also shows the one-year return between March 2016 and March 2017. While the NHB RESIDEX claims to have data from 50 cities, I could find data only for 49 cities.

Also, even though it has data from 50 cities, it can't claim to be a pan India index given that many of the cities represented separately are essentially the satellite cities of some of the bigger cities like Mumbai, Delhi and Kolkata. Further, some of the bigger cities in states haven't found representation in the index. These include Jamshedpur in Jharkhand, Madurai in Tamil Nadu, Jalandhar in Punjab, Allahabad and Varanasi in Uttar Pradesh.

Nevertheless, the index is a good start which can give us a good sense which way the real estate market in India is headed. Also, it will give us a good idea of how well or badly has the real estate market in India performed, over the last few years. Typically, this sort of information is rarely available in the public domain and will allow us to settle once and for all, how good an investment real estate has been over the last few years.

Table 1:  

	Name of the city	Return per year between June 2013 and March 2017 (in %)	One-year return between March 2016 and March 2017 (in %)
1	Mumbai	6.7	2.8
2	Delhi	-2.6	5.8
3	Bengaluru	7.3	7.5
4	Kolkata	6.5	2.9
5	Chennai	7.1	10
6	Pune	7.2	9.5
7	Nagpur	5.6	11.2
8	Nashik	2.5	-0.25
9	Kalyan Dombivali	8.6	7.4
10	Mira Road-Bhayander	5.11	2.9
11	Navi Mumbai	3.4	-8.9
12	Panvel	2.9	-7.1
13	Thane	7.1	2
14	Vasai Virar	3.2	2.3
15	Chakan	6	0.7
16	Pimpri Chinchwad	5.2	3.5
17	Coimbatore	-0.8	-10.5
18	Ahmedabad	0.5	6.8
19	Surat	3.5	3.6
20	Vadodra	1.6	7.9
21	Rajkot	2.5	0.3
22	Gandhinagar	-7.8	-11.1
23	Kanpur	8.3	11.3
24	Lucknow	4.7	1.9
25	Meerut	13.5	6
26	Ghaziabad	2.9	9.7
27	Greater Noida	4.3	0
28	Noida	2.7	0
29	Howrah	10.5	15.6
30	New Town Kolkata	4.2	-7.8
31	Bidhanagar excluding Rajarhat	5.4	-1.8
32	Chandigarah(Tricity)	2.1	-5.4
33	Ludhiana	4.8	0
34	Faridabad	3.7	12.3
35	Gurugram	4.8	7.4
36	Jaipur	5.2	-1.5
37	Bhiwadi	1.6	-14
38	Indore	6.2	6.9
39	Bhopal	3.2	0.4
40	Vizag	10.3	24.7
41	Vijaywada	8.8	1.2
42	Kochi	6.8	4.1
43	Thiruvananthapuram	7.7	-0.5
44	Hyderabad	4.1	2.2
45	Patna	2.6	-7.1
46	Guwahati	4	8.2
47	Dehradun	0	4.8
48	Ranchi	-2.6	-17.7
49	Bhubaneswar	1.5	7.5

Source: Author calculations on data obtained from https://residex.nhbonline.org.in/NHB_Residex.aspx

Table 1 makes for a very interesting reading. If we look at returns per year across different cities from June 2013 onwards, very few cities have given a return of greater than 10 per cent year, which is what is needed, in order to meet the regular expenses for upkeep of real estate, along with beating the rate of inflation. Regular expenses would include the maintenance charge that needs to be paid to the housing society every month and a property tax that needs to be paid every year. Of course, the home could be put on rent, the rental yield would work out to around 2 per cent per year. (rental yield is essentially annual rent divided by the market price of the home). If you had bought the home on a loan, then interest would have to be paid on the loan. But a tax deduction would also be available.There are only three cities which have given a return of greater than 10 per cent per year (Meerut, Howrah and Vizag), since June 2013.

In fact, the median rate of return on real estate investment across the 49 cities is 4.3 per cent per year. As John Allen Paulos writes in Beyond Numeracy: "The median of a set of numbers is the middle number in the set."

Hence, it is easy to see that unless a massive amount of black money has been invested in real estate, the returns have been meagre across the country since June 2013. This is the point from which the NHB RESIDEX data is available, in case you are wondering, dear reader, as to why have we taken this as a cut off.

The situation has gotten worse in the one-year period between March 2016 and March 2017. The median rate of return has fallen to 2.8 per cent. In fact, if we remove Vizag where one year return has been close to 25 per cent return during this period, the median rate of return falls to 2.55 per cent. Money in a savings bank account would have yielded more.

This basically means that real estate returns across the country have been subdued lately. In fact, between March 2016 and March 2017 prices have fallen in 13 out of the 49 cities under consideration. This is if we just look at prices. If we take other expenses into account (maintenance charges, property tax, interest paid on a home loan after adjusting for the tax benefit and inflation etc.) into account, the real returns would be negative in many other cases.

Of course, this logic works on weighted average prices for cities and individual experiences may have been different. Also, the logic could have been completely different if black money was being invested to buy real estate.

Hence, real estate as an investment hasn't gone anywhere in the last four years and the situation has only worsened in the last one year. Having said that prices are not falling. This, despite the sales crashing in the aftermath of demonetisation.

Recently, the real estate consulting firm PropEquity released some interesting data. As per the data, for the period between January and May 2017, the housing sales fell by 41 per cent to 1.1 lakhs, across 42 major cities. During the same period in 2016, the housing sales had stood at 1.87 lakh.

But as we have seen the median price hasn't really fallen between March 2016 and March 2017. While, real estate hasn't made for a great investment for a while now, it hasn't reached a stage where those actually wanting a home to live in, can buy one, in most cities. What are the reasons for the same?

a) Those who have already invested in real estate have a substantial amount of black money invested in it. The trouble is that if they sell right now, there isn't much they can do with the black money that they will get in the form of cash after the sale. This is because black money generated by real estate finds its way into real estate all over again. But given the very low returns that real estate has given over the last few years, there is no point in doing that.

b) In some cases, the investors are sitting on losses and they are waiting for prices to rise before they will sell. As Richard Thaler writes in Misbehaving-The Making of Behavioural Economics: "Roughly speaking, losses hurt about twice as much as gains make you feel good." This basically leads to a tendency among investors who are facing losses on their investment to continue to hold on to the losses, until they reach the positive territory again. This leads to a slow correction in prices.

c) In some other cases, investors are anchored on to the high returns that their friends, relatives and acquaintances, had made during the go goyears of real estate between 2002 and 2011. They are waiting for that era to return. We wish them luck.

d) Up until last year, home loans taken to finance self-occupied homes, were allowed a deduction of up to Rs 2 lakh for the interest paid on the home loan against taxable income.

For home loans taken to finance non-self-occupied homes, any amount of interest on the home loan could be deducted to arrive at taxable income. This was allowed as long as the real rent (if the home was rented out) or the notional rent (if the home wasn't rented out, but the rent the home owner was likely to earn if he would rent it out), was adjusted against it.

Typically, given the high home prices, the interest paid on a home loan these days, is many times the rent a home is likely to earn, if rented out. This essentially ensures that by buying a second home (or a third or a fourth or fifth home...), individuals could create a massive tax deduction and bring down their taxable income dramatically. The corporate crowd used this anomaly with great success by buying second and third homes, as they went up the hierarchy.

This basically ensured that even if the investment was not yielding any returns in terms of price increase, the tax arbitrage available was good enough to stay invested.

In his budget speech, the finance minister Arun Jaitley limited all such deductions (for self-occupied as well as other homes financed through home loans) to Rs 2 lakh. This has basically ensured that the market for homes to be create a tax deduction has now effectively come to an end. Whether this has an impact on prices remains to be seen.

To conclude, without a genuine price correction the mess in the real estate sector is likely to continue. Investors have sustained the sector for many many years now. It's time the real estate companies realised this. If they want to continue to make money in the years to come, it's time they addressed the genuine home buyers as well.

Until that happens, we don't see any acche din for this sector.

No more ‘idol worship’ at SAT hospital premises

Thiruvananthapuram: As the superstitious practice of turning a statue into a ‘divine idol’ continues unabated, the Medical College authorities finally decided to act. The sculpture of a mother breast feeding an infant erected in front of the SAT Hospital has been used by bystanders and patients of the hospital as a prayer spot for quite some time.

On Saturday that the hospital authorities erected a board with a statement from Medical College superintendent M S Sharmad that warns against practice of lighting candles and burning incenses and forming crowds in the area as the statue is close to the oxygen plant and casualty. The board also clears superstitions by stating that the statue was erected as part of beautification process.

The mother and child sculpture was made by sculptor Aryanad Rajendran for SAT hospital.

“The mother and child sculpture was erected as part of the campus beautification process back then. Now, people consider it as a religious idol and pay tributes to it. This will create distraction for other people who visit the hospital for various medical needs. We have concerns about emission of fumes and lighting of the candles due to proximity of liquid medical oxygen tank to the statue,” said Sudhakaran C, sergeant of security wing in SAT hospital.

However, the board could do little to diminish the beliefs of the patients and bystanders.

“It is the belief that the statue holds a spiritual power that made us to consider it as an idol. My daughter, who was admitted in the maternity ward, was affected with fever two days back. I prayed for her speedy recovery and now the medical reports show that she is perfectly alright,” said Ponnamma, a resident of Nedumangad.

Sulochana, a resident of Kottarakkara, too narrated how the idol was her support at the time of her daughter’s operation.

Lizy, a resident of Pathanapuram, said that she sought apology to the statue as she could not light a candle due to the new directive from hospital authorities. She wanted to light a candle for her daughter admitted in the maternity ward.