MINUTES OF THE MEETING TAKEN BY SH. NARESH DAYAL, SECRETARY (H&FW WITH THE PARTICIPATING UNITS OF CHS REGARDING CADRE REVIEW OF CHS held on 12.3.2007.

MINUTES OF THE MEETING TAKEN BY SH. NARESH DAYAL, SECRETARY (H&FW WITH THE PARTICIPATING UNITS OF CHS REGARDING CADRE REVIEW OF CHS.
A meeting was convened at 10.30 A.M on 12.3.2007 under the chairmanship of Sh. Naresh Dayal, Secretary (H&FW) with the Participating Units of Central Health Service in Room No 249 'A', Nirman Bhawan, New Delhi to discuss the issues relating to cadre review of CHS. List of participants is enclosed at Annexure-I..
Secretary (H&FW) expressed concern that the information for framing a proposal for cadre review had not come from many of the participating units of CHS. He informed that the major review of CHS took place in 1991 based on the report of Tikku Committee and subsequently a part cadre review was undertaken in 2005 on the basis of recommendations of Hariharan Committee. He also mentiord that recently a Committee headed by Sh. Javed Chowdhury, former Health Secretary had gone into the working of CHS and pointed out the need for restructuring of service.
DGHS underlined the importance of Cadre Review and urged all delegates to make earnest efforts to complete the information in the prescribed format after a deep assessment of growth in next 5 years.
After a lengthy discussion, the following decisions were taken: 1
The participants Units will submit requisite proposals with proper justification in one month's time to Ministry.
2. The Ministry will firm up the proposal of Cadre Review in additional one month for submitting to the 6th Central Pay Commission.

3. DGHS/Addl. DGHS will monitor the progress of the participating units with regard to submission of the detailed proposal with the justification within prescribed time of one month.
4. The officers of the CHS Division will be available to the participating units in Delhi for any kind of help whenever they discuss a cadre review proposal among their staff before finally sending their proposal.
The meeting ended with a vote of thanks to the Chair.

Z. 1 6023/9/2005-CHS-V
Government of India
Ministry of Health & Family Welfare
(CHS-V Section)
Ninnan Bhawan,New Delhi

Dated 9th April, 2007

 

OFFICE MEMORANDUM

Subject:-Minutes of the meeting held on 12.3.2007 under the Chainnanship
of Secretary(HFW) regarding Cadre Review of CHS-Reg
Please find enclosed a copy of the Minutes of the meeting taken by Sh Naresh Dayal, Secretary (HFW) in the Ivlinistry of Health & Family Welfare on 12.3.2007 at 10.30 AJVI regarding Cadre Review of CHS, for infonnation and necessary action.

(S .CHAKRAVARTHY)
UNDER SECRETARY TO THE GOVT OF INDIA (Ph:2306 1203)

All participants
Copy to: 1
JS(VC)
2. DS(CHS)
3. PPStoDGHS
4. US(RL)/US(MP)
5. SO(CHS -I,II,III,IV &VI)

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Dr Marwah

What additional monitoring does the doctor do?

What additional monitoring does the doctor do?

Blood Glucose: The American Diabetes Association has the set the recommendations for health care providers on what they should be doing and what should be available for the optimal care of patients with diabetes. Among these recommendations are the monitoring of blood glucose either by fingerstick or through a venipuncture and lab testing. It should be used to supplement the information obtained from the patients regular home blood glucose readings, and used if the provider feels the patients is currently too high to too low in the office. Office testing also allows the physician to see if the patient's results at home are accurate.

Continuous Glucose Sensors (CGMS): There are also currently available Continuous Glucose Sensors (CGMS). These devices function similar to a Holter monitor of the heart. A small cannula is inserted into the superficial tissue of the abdomen (the subcutaneous tissue). The needle is removed and the sensor remains. It is taped in place and connected to an external device about the size of a pager. This records glucose values at an interval of roughly 20 minutes over a 72 hour period. At the end of that period, the recorded glucose values are down-loaded, and information is reviewed. Patients usually keep a log over the 72 hour period of how they feel, what they eat, and what their fingerstick readings are to compare with the sensor. This data is especially great for athletes, patients who are unpredictable in their highs and lows, and those who can't seem to find a pattern to their finger stick glucose readings. While a fascinating device for patients, the CGMS has not be proven to actually improve blood sugar control, though it does help to provide insight.

Hemoglobin A1C Testing: The hemoglobin A1C test is very important in the monitoring of blood glucose control in diabetes. In brief, hemoglobin A1C is a term used to describe a series of chemical reactions which occur when red blood cells are exposed to glucose. A red blood cell lives for about 3 months, so this reading is an average of 3 months worth of blood sugar control. Many different types of methods are available in the lab to determine the A1C levels. Regardless, the A1C level has been shown to predict the risk for developing complications of diabetes, much in the same way that cholesterol levels are predictive of heart disease. The A1c test should be performed routinely in all patients with diabetes, first to document the degree of glycemic control at initial assessment then to follow the patient as part of their diabetes management. It should be performed at 3 month intervals.

A blood sample can be obtained through a usual venous blood draw (through the vein) and sent to a laboratory for A1C measurement. Alternatively, many physicians who specialize in diabetes now have A1c machines in their office, which will read a fingerstick blood sample within a few minutes.

There are a few conditions in which the A1C values may be inaccurate, and these mostly are a result of problems with the red blood cells. For example, if the red cells are too few (as with anemia, which may be due to many different causes, see "Anemia"), results may be falsely low. Similarly, in conditions where the red blood cells loose their spherical shape (as in thalassemias, sickle cells disease and spherocytosis), falsely low readings can occur. The A1C is a valuable tool in helping to individualize patient care so that glycemic goals can be achieved.

--
Dr Marwah

How is diabetic treatment monitored at home?

How is diabetic treatment monitored at home?

The goal of diabetic therapy is to control blood glucose levels and prevent the complications of diabetes. Glucose levels are lowered into a normal range, if possible, but it is important not to reduce the levels to abnormally low levels which can cause symptoms such as sweating, increased heart rate, and even loss of consciousness. Therefore, it is necessary not only to treat the diabetes but to monitor the effects of treatment on blood glucose levels to avoid overtreatment or undertreatment of the diabetes.

There are two types of tests for blood glucose monitoring in the home. The first type uses a reagent strip, and the second type uses a reagent strip and a glucose meter.

Glucose also can be measured in the urine. Ketoacidosis is a complication of the inadequate treatment of diabetes. This condition can be identified by testing the urine for ketones.

Blood Glucose Reagent Strips: Reagent strips are saturated with glucose oxidase, an enzyme that interacts with glucose. When a drop of blood is placed on the strip, the glucose oxidase chemically reacts with the blood glucose and the resultant reaction produces a color change on the strip. The higher the glucose level, the greater the reaction and the more dramatic the color change. The blood glucose level can be determined by comparing the color of the strip with a color chart. For accurate results, test strips should be stored at room temperature and away from moisture. To protect the strips from moisture, bottles should be closed after use.

The disadvantage of reagent strips alone is that they do not give an exact glucose measurement. They are accurate enough, however, to alert patients to seriously high or low levels of glucose. Examples of reagent strips that are available over-the-counter (OTC) are Chemstrip bG and Glucostix. For an accurate blood glucose level, the reagent strip must be combined with a meters. (See below.)

Blood Glucose Meters: Self-monitoring of blood glucose is the most important tool a patient has to determine their level of glycemic control. This is simple to perform. It involves taking a small lancet, poking the finger (usually it's the tip of the finger, just off to the side, though now there are meters that allow for blood glucose testing to be performed at other sites, such as the forearm). Then a small quantity of blood is placed on a testing strip which is then inserted into a meter where the glucose value is read.

The meter reads the blood glucose level from the reagent strip. Results that are obtained using a glucose meter are more accurate than those obtained without the meter, that is, with reagent strips alone. However, the results using a meter are about 10-15% lower than the more accurate values determined in a clinical laboratory. Meters are accurate enough, however, for home monitoring and adjustment of insulin doses.

It is important to know that reagent strips are calibrated for specific meters. Most meters need to be calibrated once a new box of test strips is used. Inappropriate calibration will lead to errors in glucose readings. Using the wrong strip with a meter is also a source of error in glucose readings. Erroneous results can occur when:

• Meters are improperly calibrated;
• The meter is dirty;
• The battery in the meter is dead;
• Reagent strips are stored improperly;
• The reagent strips have expired;
• Not enough blood is applied to the reagent strip;
• Blood is not left on the reagent strip long enough or is left too long before reading;
• The test is performed under the wrong conditions of temperature and humidity; or
• Patients are dehydrated.

The main advantage of the self-monitoring of blood glucose is that it gives immediate feedback. Diabetics who are educated can make a decision in terms of insulin, diet, and exercise that immediately affects the glucose results. This, in turn, may give them more of a sense of control over their diabetes and may allow them to adapt the diabetes treatment plan to their life style rather than vice versa. Providing regular results to a physician allows for more frequent and accurate adjustments of the medication. This can result in improve symptoms and diabetic control more effectively, especially in an outpatient setting.

The main disadvantages of the self-monitoring of blood glucose are cost, discomfort, and inconvenience (such as having to interrupt one's usual activities to do it). In addition, some patients experience a feeling of frustration at seeing high blood glucose results when they expected lower readings. "The good thing about blood testing is that I know what my sugar is, and the bad thing about glucose testing is that I know what my sugar is."

The information obtained from self-monitoring of blood glucose is valuable to all patients with diabetes, even those controlled with diet and exercise, and those who required oral mediation. Many physicians routinely give all their patients with diabetes a glucose meter, along with an individualized schedule of when to test. This ranges from once a day up to 6 times a day, depending on what the patient needs. Introducing the self-monitoring of blood glucose in conjunction with diet education is very useful.

There are many meters available on the market to choose from that differ in attributes. They may vary in the amount of blood that is used, the speed at which results are displayed, the size of font of the displays, their ability to sore readings in memory, and down load capabilities. Newer meters function as a health PDAs, allowing the patients to enter other lab values, and dates and results of health visits. Newer meters may also store the strips right in the meter, thereby allowing the patient to avoid handling the strips. Examples of glucose meters available OTC are Accu-Chek III, Glucometer Elite XL, and One Touch Basic.

Urine Glucose Tests: The role for home urine glucose testing has faded with the easy use of fingerstick blood glucose monitoring. For those few patients who choose to do home urine glucose testing, they need to realize the limitations. It is only a rough estimate of blood glucose values. Also, it provides no information unless the kidney is spilling glucose, and that usually occurs at a blood glucose level of greater than 180mg/dl. Below that, the urine glucose values are negative.

Urine glucose levels should not be confused with checking microalbumin levels and protein levels. These test are performed in the doctor's office at least on an annual basis, and provide necessary information about kidney function, and provide the basis for obtaining information to see whether certain medications should be added.

Urine glucose tests also do not indicate the current blood glucose level but rather the glucose level during the period of time between the collection of the urine and the previous urination. In many patients, the level of blood glucose must be very high in order for glucose to appear in the urine. Therefore, the urine may be free of glucose, but blood levels of glucose still may be unacceptably high. Thus, results from urine glucose tests should not be used to adjust insulin doses.

There are two types of urine glucose tests. Both types rely on a chemical reaction that produces a color change. The tests use either tablets or strips. Generally, the test strip or tablet is placed in urine. The resulting color change is matched against a color chart provided by the manufacturer which shows the different colors produced by different levels of glucose.

The first type, called the copper reduction test, uses cupric sulfate (e.g., Clinitest). In the presence of glucose, cupric sulfate, which is blue, changes to cuprous oxide, which is green to orange. The reaction should be observed closely and the manufacturer's instructions closely followed. The copper reduction tests can react with substances other than glucose in the urine and lead to false positive results, meaning the test shows glucose when it is not present. Examples of these other substances include aspirin, penicillin, isoniazid, vitamin C, and cephalosporin-type antibiotics. Tablets and solutions utilizing copper reduction may damage the skin and are poisonous if ingested. They should be handled carefully and kept out of the reach of children.

The second type of urine glucose test, called the glucose oxidase test, uses the chemical toluidine and the enzyme glucose oxidase (e.g., Clinistix). Glucose oxidase converts the glucose in urine to gluconic acid and hydrogen peroxide. The interaction of the hydrogen peroxide with the toluidine causes a change in color. False negative results, meaning the test shows no glucose when glucose really is present, may occur in patients taking vitamin C, aspirin, iron supplements, levodopa, and tetracycline-type antibiotics. Glucose oxidase tests are more convenient to use and less expensive than copper reduction tests. The strips should be kept away from moisture.

Tests For Urinary Ketones: Ketone testing is an important part of monitoring in type 1 diabetes, and it is a tool that is often also used in pregnancies that are complicated by diabetes.

Ketones are formed when the body goes into starvation mode when there is a profound lack of insulin. When the body produces an insufficient amount of insulin, the cells are unable to remove glucose from the blood, and the level of glucose in the blood rises. The cells respond to what appears to be a lack of glucose by stimulating the body to produce larger amounts of glucose, and the blood glucose level rises further. In addition, ketones are produced by the cells. The presence of ketones signals a condition in diabetics called ketoacidosis. Ketoacidosis signifies that the cells are not getting enough glucose.

Severe diabetic ketoacidosis is a medical emergency since it can result in loss of consciousness and even death. There is a correlation between high blood glucose levels and ketones. The higher the glucose level, the more likely it is that there are ketones. Therefore, diabetics with blood glucose levels of 240 mg/dl or greater should test for urinary ketones. Patients with type 1 diabetes should test for ketones during acute illness and if they are in severe stress. Also, the urine ketones should be checked if any symptoms of ketoacidosis (nausea, vomiting, abdominal pain) are present.

Ketones can normally be found in the urine. For example, after an overnight fast, ketones can be seen in up to 30% of non-diabetic people. However, these levels of ketone production are usually below the threshold of measurement by the ketone test strips. The strips can also give false positive results when patients are on drugs such as captopril. False negative readings may be seen if the test strips are old, exposed to air, or if the urine is very acidic (such as after drinking a lot of orange juice, which is high in vitamin C).

Tests for ketones are based on the color change that occurs when ketones react with sodium nitroprusside or similar compounds. The tests are performed in a manner similar to that of urine glucose testing. There are different tests for the different types of ketones. For example, Acetest detects two ketones, acetoacetic acid and acetone, but does not detect another ketone, beta-hydroxybutyric acid. Ketostix detects only acetoacetic acid and, therefore, produces false negative results if only acetone and beta-hydroxybutyric acid are present in the urine. Ketone tests are supplied as strips or tablets.

The American Diabetes Association advises that ketone testing materials be available in the office setting and that physicians should prefer using blood ketone measurements over urine ketone measurements if possible. Home testing for blood ketones is also available, though not often used.

--
Dr Marwah

Diabetic Home Care and Monitoring At A Glance

Diabetic Home Care and Monitoring At A Glance

• Diabetes mellitus is a chronic condition associated with abnormally high levels of their sugar glucose in the blood.

• The two types of diabetes are type 1 (insulin dependent) and type 2 (non-insulin dependent) diabetes.

• Diabetes treatment depends on the type and severity of the diabetes.

• Type 1 diabetes mellitus is treated with insulin, exercise, and a diabetic diet.

• Type 2 diabetes mellitus is first treated with weight reduction, a diabetic diet, and exercise. When these measures do not control the elevated blood sugar, oral medications are used and, if need be, insulin.

• The main goal of diabetic therapy is to control blood glucose levels and to prevent the complications of diabetes.

• Glucose levels should be lowered into the normal range, if possible, but not to abnormally low levels. It is very important to monitor the effects of treatment on blood glucose levels to avoid overtreatment or undertreatment.

• There are two types of tests for blood glucose monitoring in the home. The first type uses a reagent strip, and the second type uses a reagent strip and a glucose meter. Use of the glucose meter has become more common.

• Glucose also can be measured in the urine. However, the role of home testing of the urine for glucose has faded in recent years.

• Ketoacidosis is a complication of the inadequate treatment of diabetes. This dangerous condition can be identified by testing the urine for ketones.

• People with diabetes should discuss monitoring in detail with their physicians and have clearly defined goals for blood sugar control.

• The choices for blood glucose meters should be discussed and the best meter chosen, taking into account visual impairment, tremors, and other factors which may influence usability.

• People with diabetes should visit their physician every 3 months to monitor their hemoglobin A1C levels.

• Good diabetes home care and monitoring together with a few physician visits make diabetes much more manageable.

--
Dr Marwah

Hypertensive emergency / Hypertensive urgency

 A hypertensive emergency is a condition in which elevated blood pressure results in target organ damage. The systems primarily involved include the central nervous system, the cardiovascular system, and the kidneys. Malignant hypertension and accelerated hypertension are both hypertensive emergencies, with similar outcomes and therapies. In order to diagnose malignant hypertension, papilledema must be present. Accelerated hypertension is defined as a recent significant increase over baseline blood pressure that is associated with target organ damage. This is usually vascular damage on funduscopic examination, such as flame-shaped hemorrhages or soft exudates, but without papilledema.

Hypertensive urgency must be distinguished from emergency. Urgency is defined as severely elevated blood pressure (ie, systolic >220 mm Hg or diastolic >120 mm Hg) with no evidence of target organ damage.
Hypertensive emergencies require immediate therapy to decrease blood pressure within minutes to hours. In contrast, no evidence suggests a benefit from rapidly reducing blood pressure in patients with hypertensive urgency. In fact, such aggressive therapy may harm the patient, resulting in cardiac, renal, or cerebral hypo perfusion.
--
Dr Marwah

Autism At A Glance

Autism At A Glance

 

    * Autism is characterized by impaired development in social interaction, communication, and behavior.

    * The degree of autism varies from mild to severe.

    * Severely afflicted patients can appear to have a profound intellectual disability.

    * The cause of autism is unknown.

    * The optimal treatment of autism involves an educational or vocational program that is suited to the developmental level of the child or adult, respectively.

--
Dr Marwah

PROCEDURE OF LOCAL PURCHASE INDENT

LOCAL PURCHASE INDENT

(a) The Storekeeper will prepare the local purchase indent daily as per necessity and put up to Chief Medical Officers In charge for checking / signature along with his initial. (b) The total No. of prescriptions being sent is to be noted on the body of the indent and the prescriptions shall be recounted on receipt of stores from authorised chemists. (c) The Sl. No., quantity indented and date should be noted by the Chief Medical Officer In charge on the body of prescription so that the same medicines once supplied are not re indented by mistake or otherwise. (d) The quantity received should be specifically mentioned by the Storekeeper in the receipt column and necessary certificate is to be endorsed about the items received (total items received) and the items not received (Sl. Nos. to be mentioned) and to be countersigned by the Chief Medical Officer/Medical Officer In charge. The Chief Medical Officer In charge should also physically verify the items. (e) The medicines which are not supplied by the Chemist may be authorized to be purchased from open market in the same city/town. The beneficiary should be advised to claim the bill within the month from the date of indent. The Store-keeper will fill up the form in duplicate and endorse the same along with the cash memo to the Chief Medical officer In charge for counter signature. (f) The non-formulary medicines should be issued after obtaining dated signature and address of the beneficiary. (g) No chits required for the listed and non listed medicines. (h) The local purchase indent should be prepared as per standing instructions. Before sending the indent the following shall be ensured.

• The local purchase indent bears the rubber stamp of Chief Medical Officer In charge..
• Prescriptions bear the rubber stamp of the prescribed Specialist/Hospital.
• Out of list items have not been included unless prescribed by Consultant / Specialist / Head of Unit.
• Non-admissible items have not been indented.
• Prescription is valid for the period of indent.
• Quantity indented as per the prescribed quantity.
• Prescriptions are arranged serially.
• Prescription is indented after registration.

(i) The medicines issued to the patient should be noted on the body of prescription (1) Name of medicines; (2.) Quantity; (3) Date of issue: and (4) Signature of Storekeeper. A rubber stamp may be suitably made for the purpose. (j) The local purchase medicines shall be issued by the Store-keeper. (k) The local purchase medicines if not collected by the beneficiaries within 15 days should be taken into stock ledger. (m) The medical officer concerned will sign against each serial No. of medicines indented. (n). The chemist must mention the batch number and name of manufacturers while supplying local purchase medicine, must be checked by storekeeper and Chief Medical Officer In charge before accepting the medicine. (0) Medicines available in Medical Store Depot / Dispensary: No medicine should be indented for local purchase if it is available in Medical Store Depot / Dispensary.
--
Dr Marwah

PENALTIES as per the Chemist agreement

PENALTIES

7.1 In case of indent for specific brand of medicines, the same shall not be substituted. If any such case is noticed during subsequent scrutiny after or before the payment, then supplier will be penalized for Rs.1000 + cost of the specific brand of medicines for each such default.

7.2 The delivery of supplies in full will be made on the next working day by 8.30 a.m. or at the opening hours of unit/dispensary, whichever is later, at the premises of the dispensaries indenting the supplies or in case of emergency at the residence of the patients as directed by CMO I/c of the dispensary/unit. In the event of non-supply of indented medicines in time as aforesaid, Rs. 500/- will be deducted from the bill of the Chemists for each delay.

--
Dr Marwah

Chemist agreement General Conditions SECTION – II

SECTION – II

General Conditions

1 SUPPLY OF MEDICINES

1.1 Sufficient stock of standard quality of medicines at all times will have to be maintained by the supplier, to avoid inconvenience to the Government/CGHS beneficiaries.

1.2 In case of failure or refusal on supplier's part to supply the medicines to the purchaser / beneficiaries within the time as provided in clause 17 hereunder, the contract is liable to be terminated /cancelled at supplier's risk and cost. Any extra cost involved in arranging supply from alternative source will be recovered from the supplier. It is in addition and without prejudice to the deduction in clauses 17 & 18 hereunder.

1.3 The supplier will indicate batch number, name of manufacturer, date of expiry in the indents at the time of supplying the drug to the concerned CGHS Units/Dispensaries.

1.4 (a) The medicines/drugs to be supplied will be of standard quality. In case it is found that any particular medicine's date is expired, found not of standard quality, substandard or spurious, supplier's (Appointed Authorized Chemist) firm will be liable to be blacklisted for a period of 5 years besides other legal action that may be initiated. In case the supplier fails to supply indented drugs/medicines, the purchaser will be entitled to procure the same from other chemist and the supplier will be liable to reimburse in full the price paid by the purchaser. However the supplier will be allowed to claim what would be payable to him for the medicines as per agreed terms and conditions.

(b) In case of indent for specific brand of medicines, the same shall not be substituted. If any such case is noticed during subsequent scrutiny after or before the payment, then supplier will be penalized for Rs.1000 + cost of the specific brand of medicines for each such default.

1.5 Indented medicines for the beneficiaries to be supplied in individual packets by the designate local chemist.

1.6 The payment for NA items to be made to the beneficiaries on a fixed date / day by the local chemist / their representative, at the Dispensary.

1.7 Short supplied medicine to be sent through courier at the residence of the beneficiary at the cost of the local chemist.

2 AUTHORITY SLIP

In case an Authorized Medical Attendant of the Dispensary concerned gives any 'By

Hand' Authority Slip to a beneficiary, the medicines will be supplied immediately to the beneficiary for a period as mentioned in the slip or for 7 days, whichever is less.

-

3. LIFE PERIOD OF MEDICINES

Every medicine has its own shelf life period mentioned on the label of medicine. The shelf life of article supplied should not have passed more than half of its shelf life at the time of supply.

4. PACKED SUPPLIES:

Supplies are required to be made in original packing of manufacturer. The packing should approximately be nearest to the total quantity demanded of any particular medicine/drug on any particular day.

5. COLLLECTION OF PRESCRIPTION FOR SUPPLY

The Authorized Chemist or his representative should collect local Purchase Indent on the basis of which supplies are to be made, from the unit allotted at the closing hours of unit/dispensary on every working day.

6. PERIOD UPTO WHICH SUPPLY ORDERS WILL BE PLACED:

Supply orders will be placed against the contract up to the last date of the contract.

Orders received even on the closing date should be honored in accordance with the terms of contract even though the last date of the contract may have expired on the date of supply of articles.

7. DELIVERY OF SUPPLIES

The delivery of supplies in full will be made on the next working day by 8.30 a.m. or at the opening hours of unit/dispensary, whichever is later, at the premises of the dispensaries indenting the supplies or in case of emergency at the residence of the patients as directed by CMO I/c of the dispensary/unit. In the event of non-supply of indented medicines in time as aforesaid, Rs. 500/- will be deducted from the bill of the Chemists for each delay.

8. ITEMS NOT AVAILABLE WITH THE AUTHORISED CHEMIST

In case the Authorized Chemist for any reason fails to supply any item in time indented by the dispensary, the beneficiaries concerned shall be entitled to purchase the medicines from the open market. The Authorized Chemist will be liable to reimburse, in full on the spot, the amount incurred by the respective beneficiaries on production of

Cash Memo, duly certified by the M.O. In-charge of the dispensaries concerned. The

Authorized Chemist shall be entitled to claim the amount from the CGHS, which will be limited to the extent admissible in terms of contract on the basis of accepted offer and other conditions of the contract. The chemists shall enclose such cash memos with the bill and total discount/ deduction made on such cash memos should be reflected in the claim bill.

9. ITEMS REQUIRED IN EMERGENCY

When an emergency arises outside the working hours of the dispensary or on holidays, the Authorized Medical Attendant in the CGHS Dispensary may procure the items as required from the open market. The Authorized Chemist will be liable to reimburse, in full on the spot, the amount incurred by the respective Authorized Medical Attendant on production of Cash Memo, duly certified by the M.O. In-charge of the dispensary concerned. The Authorized Chemist shall be entitled to claim the amount from the CGHS, which will be limited to the extent admissible in terms of contract on the basis of accepted offer and other conditions of the contract. The chemists shall enclose such cash memos with the bill and total discount/ deduction made on such cash memos should be reflected in the claim bill.

10. PRESENTATION OF BILLS:

(i) The Authorized chemist shall present the bill to respective unit for the supplies made during each fortnight (1 to 15 & 16 to 30/31) within ten days of closing of each respective fortnight. The bill should clearly indicate the details of the supply made each day. The bill should clearly indicate the details e.g. Name of the item, Name of

Manufacturer, batch no., date of manufacture & expiry date, prescription slip no. with date, rate, discount as per contract etc. or any other information required by the purchaser.

(ii) The bill shall be supported by the following documents:

The original indent along with the certificate from the Medical Officer In charge of the dispensary under his/her signature, with date, seal of the office for receipt of the items indented giving names of the drugs, their quantity and rate charged, shall accompany the bill. The incomplete bills not equipped by any of the particulars mentioned above, will not be entertained.

11. MISCELLANEOUS

11.1 The Director, CGHS, New Delhi reserves the right to enter into parallel contracts simultaneously or at any time during the period of this contract, with one or more chemists.

11.2 One Chemist can quote for only one group/area as per list attached. Offers for multiple groups/areas shall be rejected out rightly.

11.3 The bidder should have its establishment within five (5) Kms. distances by shortest motor able route from the dispensaries/Hospital (Affidavit to be submitted). The suppliers, in the vicinity of the CGHS dispensary/Unit meeting all the requirements, may be preferred. However, this could not be considered as the only criteria for appointment. The CGHS reserves the right to appoint the chemist on the same terms and conditions for any other dispensary / hospital / Unit. (within five (5) kilometers distance by shortest motor able route from the establishment) if otherwise found eligible.

--
Dr Marwah

Treatment outcomes In RNTCP

Treatment outcomes In RNTCP,every patient registered has one of the following six outcomes.

• Cured: Initially sputum smear-positive patient who has completed treatment and had negative sputum smears, on at least two occasions, one of which was at the end of treatment.
• Treatment Completed:

1. A sputum smear-positive patient who has completed treatment, with negative smears at the end of IP but none at the end of treatment,
2. A sputum smear-negative patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment,
3. An EP TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment.

• Died: Patient who died during the course of treatment, regardless of the cause of death.
• Failure:

1. Any TB patient who is smear-positive at 5 months or more after starting treatment,
2. A patient who was treated with Category Ill but who becomes smear-positive during treatment.

• Defaulted: A patient who has not taken anti-TB drugs for 2 months or more consecutively after starting treatment.
• Transferred out: A patient who has been transferred to another TB Unit or district and for whom the treatment result (outcome) is not known.

-- Dr Marwah

Scientific Basis of DOTS

Scientific Basis of DOTS

In vitro experiments demonstrated that, after a culture of M. tuberculosis is exposed to certain drugs for some time, it takes several days before new growth occurs (the 'lag' phase). All the commonly used anti-TB drugs induce lag phases ranging from two days to forty days. Therefore these drugs can be given intermittently. Intermittent regimens make treatment observation more feasible and convenient for DOT providers and patients. They achieve high levels of treatment success with low relapse rates. As the quantity of drugs consumed is less, adverse reactions and costs are also lowered. In addition, intermittent dosing increases the efficacy of treatment by allowing organisms to re-enter the active metabolic phase in which the bactericidal drugs are more effective. Direct observation of treatment (DOT) ensures the best possible results in treatment of TB. Here an observer watches and assists the patient in swallowing the tablets, thereby ensuring that the patient receives the medication. Hence, by observing the patients during the entire course of treatment, one ensures that they receive the right drugs, in the right doses, at the right intervals and for the right duration. The bacillary sub-population in TB is of four kinds and different drugs act on different kind of bacteria. These are tabled below:
The phenomenon of 'persisters' explains to some extent why all bacilli are not killed during treatment. Relapse with drug-susceptible organisms after the end of treatment or endogenous reactivation may be due to bacilli that have persisted in residual lesions for a long time in a semi-dormant / dormant state.

Currently recommended treatment regimens aim to: Cure the patient

Type of TB Bacilli and Effective Drugs

• Extra-cellular rapidly multiplying :- Rifampicin,Isoniazid Streptomycin,Ethambutol
• Extra-cellular intermittently multiplying /semi- dormant:- Rifampicin
• Intra- and extra-cellular acidic environments intermittently multiplying/semi-dormant: -Pyrazina mide
• Dormant No drug

DOTS

• Prevent death from active disease or from its late effects
• Prevent the emergence and spread of drug-resistant organisms
• Minimise relapse
• Protect the community from continued transmission of infection

All treatment regimens consist of two phases:

Intensive Phase (IP) aims for a rapid killing of bacilli. This means a shorter duration of infectiousness ( 2 weeks), usually with rapid smear conversion (80% — 90%) after 2 to 3 months of treatment. Each dose in this phase should be directly observed to ensure adherence and involves 3 to 5 drugs depending on the category into which the patient has been placed.

Continuation Phase (CP) eliminates most residual bacilli and reduces failures and relapses. At the start of the CP, there are low numbers of bacilli and less chance of drug resistant mutants. Therefore fewer drugs are needed during this phase.


Dr Marwah

Points to Remember:-Pulmonary Tuberculosis

Points to Remember

• TB continues to be the leading killer disease for Indian adults amongst all infectious diseases
• One fifth of the world's TB incident cases are in India
• More than 80% of TB patients have pulmonary TB
• In developing countries, more than 75% of TB patients are in the economically productive age group of 15-45 years
• The WHO recommended DOTS strategy is the most effective tool for TB control
• The DTO has the overall responsibility of implementing the programme at the district level
• Involvement of all sectors of health care is necessary for the control of TB in India

• RNTCP has shifted the responsibility for cure from the patient to the health system
• Sputum microscopy is the recommended diagnostic tool for patients suspected to have pulmonary TB
• Directly observed treatment ensures the best possible results
• Intermittent regimen is as effective as daily regimen and causes lesser side effects
• All treatment regimens in RNTCP have two phases; an intensive phase and a continuation phase

• The most common symptom of pulmonary TB is a persistent cough for three weeks or more
• Sputum samples should be examined as soon as possible and not later than a week after it is collected
• Patients suspected to have pulmonary TB should have three sputum smears examined
• The role of chest X-rays in the diagnosis of pulmonary TB is only supportive
• 2—3% of new adult outpatients in a general clinic will be TB suspects and should be sent for sputum examination
• 10% of TB suspects are expected to have sputum smear-positive pulmonary TB

--
Dr Marwah

RESPONSIBILITIES OF THE BENEFICIARIES

RESPONSIBILITIES OF THE BENEFICIARIES


The smooth running of the CGHS dispensary depends on the support we receive from our beneficiaries.
Please try to appreciate the various constraints, under which the CGHS dispensary is functioning. Please do not cause inconvenience to other patients.
Please help us in keeping the CGHS dispensary and its surroundings neat and clean.
Please use the facilities of this CGHS dispensary with care.
The CGHS dispensary is a 'No Smoking Zone.'
Please refrain from demanding undue favours from the staff and officials.
Please provide useful feedback and constructive suggestions.

These may be addressed to the CMO In charge.

Dr Marwah

Frequently asked questions :- Hemophilia and website http://www.hfindia.org/

website http://www.hfindia.org/

Frequently asked questions :- Hemophilia

• What is the difference between hemophilia A and hemophilia B?
• There are two types of hemophilia: hemophilia A (sometimes called classical hemophilia) and hemophilia B (sometimes called Christmas disease). Both are caused by a low level or absence of one of the proteins in the blood (called factors) that control bleeding. Hemophilia A is caused by a deficiency of factor VIII, and hemophilia B is caused by a deficiency of factor IX.
• There is no difference between the two types of hemophilia, except that hemophilia B is about five times less common than hemophilia A.
• Are there other types of bleeding disorders?
• Yes, there are several other factor deficiencies that also cause abnormal bleeding. These include deficiencies in factors I, II, V, VII, X, XI, XIII and von Willebrand factor. The most severe forms of these deficiencies are even rare than hemophilia A and B.
• How does a person get hemophilia?
• Hemophilia is a genetic disorder, which is usually inherited. It cannot be caught or transmitted except through inheritance. The hemophilia gene is passed down from a parent to a child.
• About one third of new cases are caused by a new mutation of the gene in the mother or the child. In these cases, there is no previous history of hemophilia in the family.
• Is hemophilia lifelong?
• A person born with hemophilia will have it for life. The level of factor VIII or IX in his blood usually stays the same throughout his life.
• Does hemophilia only affect men?
• The most severe forms of hemophilia affect almost only males. Females can be seriously affected only if the father has hemophilia and the mother is a carrier. This is extremely rare. However, many women who are carriers have symptoms of mild hemophilia.
• Are there any precautions a carrier should take if she becomes pregnant?
• It is important that a carrier’s hematologist is involved in the supervision of the pregnancy and that there is some liaison with the obstetrician before delivery. It is not necessary to perform prenatal diagnosis just for management of the pregnancy. This is only done if termination of a pregnancy is being considered.
• The factor VIII level (but not factor IX) tends to rise during pregnancy but it should be checked sometime in the last couple of months of pregnancy.
• A normal vaginal delivery is perfectly acceptable even if the fetus is known to be male and at risk of hemophilia. Epidural anesthesia does not usually present a problem and is generally permissible if the patient’s factor level is 40 percent or more. A cord blood sample after delivery will be used to check if a male baby has hemophilia.
• How common is hemophilia?
• Hemophilia is quite rare. About 1 in 10,000 people are born with hemophilia A. About 1 in 50,000 people are born with hemophilia B.
• What are the signs of hemophilia?
• The signs of hemophilia A and B are the same.
• • Big bruises
• • Bleeding into muscles and joints, especially the knees, elbow, and ankles
• • Spontaneous bleeding (sudden bleeding inside the body for no clear reason)
• • Bleeding for a long time after getting a cut, removing a tooth, or having surgery
• • Serious internal bleeding into vital organs, most commonly after a serious trauma
• Are bruises dangerous?
• Bruises are very common in children with hemophilia. A bruise is not usually cause for alarm unless it is on the person’s head or neck, the person has a hard time moving, the bruise hurts, the lump in the bruise gets larger or does not go away, or there is numbness, or a tingling feeling along with the bruising. If any of these symptoms are experienced, a physician or local hemophilia treatment center should be consulted.
• Should people with hemophilia avoid aspirin?
• People with hemophilia should not take aspirin (ASA or acetylsalicyclic acid), or anything containing aspirin, because it interferes with the stickiness of the blood platelets and adds to problems with bleeding.
• Paracetamol (acetominophen) is a perfectly safe alternative to aspirin to relieve pain, for example, headaches.
• Should people with hemophilia exercise and play sports?
• Some people with hemophilia do not exercise because they think it may cause bleeds, but exercise can actually help prevent bleeds. Strong muscles help protect someone who has hemophilia from spontaneous bleeds and joint damage.
• Sport is an important activity for young people. It not only helps build their muscles, it helps them develop mental concentration and coordination, and learn about being part of a team. However, some sports are riskier than others, and the benefits must be weighed against the risks. The severity of a person’s hemophilia should also be considered when choosing a sport. Sports like swimming, badminton, cycling, and walking are sports that most people with hemophilia can safely participate in, whilst sports like American football, rugby, and boxing are not recommended for people with hemophilia.
• What are inhibitors?
• Inhibitors are antibodies to factor VIII or factor IX made by the body’s immune system that attack and destroy the factor VIII and IX proteins in clotting factor concentrates, making treatment ineffective. They appear almost exclusively in patients with severe hemophilia. There is some controversy over the precise incidence (number of new cases) of inhibitor development, but it is generally accepted that between 10 and 30 percent of people with severe hemophilia A will develop inhibitors at some stage. By contrast, inhibitor development in hemophilia B is very rare indeed, and seen in 1 to 3 percent of subjects. Most inhibitors emerge after relatively few treatments. In general, the more treatments a person has had without developing inhibitors, the less likely he is to develop an inhibitor.
• Treatments exist that can sometimes eliminate inhibitors. In other cases, they disappear naturally. In other cases, they continue for many years.
• What is prophylaxis?
• Prophylaxis is the regular use of clotting factor concentrates to prevent bleeds before they start. Injections of clotting factor are given one; two or three times a week to maintain a constant level of factor VIII or IX in the bloodstream. Prophylaxis can help reduce or prevent joint damage. In countries with access to adequate quantities of clotting factor concentrates, this is becoming the normal mode of treatment for younger patients, and can be started when the veins are well developed (usually between the ages of two and four years).
• What is a venous access device (port-a-cath)?
• A port-a-cath, or implantable venous access device (IVAD), is implanted under the skin, usually in the upper chest but there are models which can be inserted into the arm. It has a small metal reservoir with a rubber diaphragm, which is connected to a catheter, which is then threaded into a large vein in the chest or arm. The entire device is surgically implanted under the skin so there is no catheter that hangs out of the body. The device provides ready access to a vein for administering medications and fluids intravenously. It can also be used for drawing blood samples.
• The device is accessed by inserting a special needle through the skin and into the rubber diaphragm of the reservoir. The medication or fluid is injected into the device and it flows through the catheter into the vein.
• These devices have made prophylaxis in hemophilia much easier for families because the problems of "finding a vein" for infusion two to three times a week are eliminated. However, there are risks involved with their use, the most worrisome being that of infection. Studies differ but some show an infection rate as high as 50 percent. These infections can usually be treated with intravenous antibiotics but sometimes the device must be removed. Also, there are other studies that show a risk of clots forming at the tip of the catheter. Still, many families have chosen to use the device in spite of the risk because of the benefits. Like any other procedure, one must weigh the risks and benefits.
• Is there a cure for hemophilia?
• There is no cure for hemophilia yet but gene therapy remains an exciting possibility and holds out the prospect of a partial or complete cure for hemophilia. There are many technical obstacles to overcome, but it is encouraging to see the research efforts currently underway.
• What is the life expectancy of someone with hemophilia?
• The life expectancy of someone with hemophilia varies depending on whether they receive proper treatment. Without adequate treatment, many people with hemophilia die before they reach adulthood. However, with proper treatment, life expectancy for people with hemophilia is about 10 years less than that of males without hemophilia, and children can look forward to a normal life expectancy.

I came across a case of hemophilia so I thought of writing this blog.

Dr Marwah

World observes April 17 as Haemophilia Day

World observes April 17 as Haemophilia Day

Treatment for haemophilia costly, limited
Annie Samson in New Delhi |
As the World observes April 17 as Haemophilia Day, there is little awareness in the country about this inherited genetic disorder for which treatment is costly and difficult to get, experts say. Over one lakh people are estimated to be affected by haemophilia or the silent killer that is inherited through a defect in the genes and causes severe bleeding even from very small cuts and injuries, says Dr Uppal Roy, one of the founding members of Haemophilia Federation of India (HFI).

In a country with one billion that works out to be one in every ten thousand people, he says. "Out of the one lakh estimated population of haemophiliacs in the country the HFI has been able to register 12,844 patients so far," says Roy who informs that the foundation has 60 centres countrywide.
Haemophilia A commonly known as classical haemophilia is the most common form and is caused due to the inability of the blood to clot properly. When a normal person is injured his blood quickly clots to prevent further loss of blood. However, this does not happen in the case of people with haemophilia. The Anti Haemophilic Factor (AHF) that produces clotting in blood is not manufactured in the country but imported from abroad. "In India the HFI is the nodal agency that negotiates the prices of drugs with manufacturer linked with the Canada-based World Federation of Haemophilia," says Roy. "Each unit of the AHF costs Rs seven. The blood is dried and powdered and contained in a small vial and given to the bleeding person according to his body weight. So, a child weighing 20 kg needs at least 500 units to stop severe bleeding. A patient has to bear at least a cost of Rs 50,000 to Rs one lakh to lead a near normal life," he says. In order to form a blood clot the body uses several proteins and blood cells. Patients with Haemophilia A have a deficiency of clotting factor 8 and those with Haemophilia B are deficient in clotting factor 9. "Replacements of factor 8 or factor 9 made out of human blood are given to patients depending on their requirements. Apart from that if patients can provide a donor we give blood transfusions," says Dr Sumita Bhasin, Professor of Medicine, Safdarjung Hospital. The disorder usually transfers from father to daughter who then becomes a carrier of the gene with the chance of passing it on to her children. Bhasin points out there are at least three hospitals in Delhi other than Safdarjung that gives free medicines for treating the condition. "We provide free treatment for the poor people who come to our hospital. Obviously we are able to do so for only those patients who come to us in a critically ill condition and those who are involved in accidents and the like. For other patients we usually charge," she says. Anil Lalwani a severe haemophilia 8 patient and part of the HFI says, "There are very limited diagnostic facilities available for haemophiliacs. There is also not proper treatment available in the country." "In HFI chapters across the country, some preliminary treatment is available," says 48-year-old Lalwani who was diagnosed with the condition when he was one-and-a-half-years old. What compounds the treatment is the fact that most haemophiliacs are not unaware that they are suffering from this disorder. There is no specific cause for haemophilia as it is an inherited disorder. "We have the facility to check for the disorder and detect the carriers. Apart from HFIs chapters five other hospitals- AIIMS at Delhi, CMC at Vellore, KEM at Mumbai and CCMB at Hyderabad-have provisions to test and give free medicines," says Roy. "These hospitals give the factor constituent free of charge. Others like the HFI and the Lion's hospitals provide medicines at subsidised rates," says Bhasin. Other cures apart from replacement of the AHF are under progress worldwide. "Everything is in a trial stage and nothing can be said so far," says Bhasin. In the US and UK doctors have experimented with gene therapy to find a cure for haemophilia. In India, however, there is no such therapy. "Even in the west the therapy has not been very successful because it was found that it was always done for severe haemophiliacs to reduce their condition from severe to moderate or mild," says Roy. "If children affected with haemophilia are not given treatment then it can lead to disability and even death in some cases. Also since patients need frequent blood transfusions they are at the risk of contracting infections like HIV and hepatitis C virus," he says.

Dr Marwah

Patient Education Series :- Safe Use of Prescription Medications

Patient Education Series

Safe Use of Prescription Medications

If you have already been taking some medications

· Please provide a written list and dose of medications that you have been taking during your consultation with the doctor.

· Knowing what medications you take helps your doctor select the best treatment for you.

· Also, please inform about your medication allergies or unpleasant reactions you may have experienced in the past.

Learn about the medication that you have been prescribed

· Find out which medicines are being advised and what they are for.

· Find out how to take the medication; especially the dosage, timings or foods to be avoided.

· Also, learn about the common side effects you might expect and what you should do about them.

Medication use

· Read the label every time you take a medicine to avoid mistakes.

· Check the expiry dates of medications and do not take expired medications.

· While taking a pill from a strip, tear off in such a manner so that the date of expiry is visible till the last pill on the strip.

· Do not chew, crush or break any capsules or tablets unless instructed. Some long-acting medications are absorbed too quickly when chewed, which could be unsafe.

· Be regular with the medication advised and do not miss doses.

· If you have missed a dose take as soon as possible.

1. However, if it is almost time for the next dose, skip the missed dose and return to your regular schedule.

2. Do not take a double dose or extra doses.

· Do not stop the course on your own without consulting your doctor.

· Report any allergies or untoward symptoms to your doctor immediately.

Storage

· Keep medications in their original packs, to avoid difficulty in identification.

· Don't store medications in the bathroom, kitchen, or in direct sunlight. Humidity, heat and light can affect the medications' efficacy.

· Some medications have specified storage requirements, please check these and store accordingly.

· Store medications where children can't see or reach them, for example, in a locked box or cabinet.

· Never share medications with anyone.

Dr Marwah

Fwd: NEWS LETTER Joint Action Council 3rd March, 2007

For the benefit of our colleages this NEWS LETTER Joint Action Council 3rd March, 2007 is posted with the permission of Dr D R Dey President Joint Action Council of Service Doctor Organisation.

Dr Marwah

Joint Action Council

of

Service Doctor Organisation

(Registration No. 19683)

CHS, CGHS, Delhi Admn., IRMS, IOFHS, ESIC, MCD, NIH & FW

Drs of Min. of AGR, DESU, WHS, DTC and allied Govt. of India Undertakings,

Dental Surgeons, Civilian Demonstrators of CUS and AFMC etc.

Dr. D. R. Dey Dr. Rajeev Sood Dr. K. K. Bhushan

President Chairman General Secretary

9871470029 9810005182 9868446233

Office: 586 Laxmi Bai Nagar, New Delhi-110023.

Address of Correspondence,: D-II/A-55, South Moti Bagh, New Delhi-110021.

VOL. VI Dated: 3rd March, 2007

NEWS LETTER

Dear Friends.

JACSDO is back in this News Letter after a period of six months.

The three vital issues are pending in front of us

1. Recommendations of Javed Choudhry Committee
2. Cadre Review of Central Health Service
3. VIth Central Pay Commission.

All of you are aware of that the two vital recommendations of Javed Choudhry Committee Report are under process and is in advance stage of implementation.

In this regard we want to inform you that two vital recommendations are (i) enhancement of retirement age of all CHS officers to 62 years (ii) to release stagnation at NFSG scale and put to SAG scale to those who have completed five years in NGSG scale till 31^st March, 2006. The retirement age in respect of Specialist Sub Cadre has already been implemented and also the same will be extended to GDMO Sub Cadre very soon as it is in the advance stage of implementation. Regarding promotion to SAG scale for the incumbents who are stagnating at NFSG scale for more than five years till 31^st March, 2006 is also in advance stage of implementation as necessary procedural formalities are being completed.

The other recommendations of Javed Choudhry Committee report is being pursued with VIth Central Pay Commission.

Our Association has prepared the document for VIth CPC on holistic manner and submitted to the Commission. We had audience with the Chairman and other Members of the VIth CPC on 14^th Jan. 2007 where all issues were presented in a logistic manner.

Out of several proposals submitted to VIth Pay Commission we have pinpointed two vital proposals e.g. (i) to put to SAG scale on 9^th year of service and 16^th year of service for Specialist and GDMO sub cadre respectively. (ii) To upgrade, 50% of existing SAG posts of Central Health Service is also going on and we hope it will be finalized at the feedback from the different participating units of CHS. We also appeal to all the Head of the Department of the participating units to reply to the Ministry of Health & Family Welfare which they have asked from the different organizations in a format regarding cadre structure and its proposal. Recently the DPC is conducted for 25 posts of Professor/ Director of teaching Sub Cadre and 108 posts of SAG of GDMO Sub Cadre. The order of promotion is expected to be issued within one month. The DPC for posts of Consultant for non-teaching Sub cadre and 12 posts of Additional DGHS for four sub cadre of CHS is still pending and JACSDO is pursuing with the Ministry of Health & Family Welfare & UPSC for fixing the date of DPC at the earliest.

JACSDO is running short of funds and every activity of the Association is cost effective. We appeal to all of you to contribute @ Rs.1000/- per head in the name of JACSDO New Delhi" at the earliest so that we can pursue all the issues vigorously.

LONG LIVE JACSDO.

DR.D. R. DEY DR. K. K. BHUSHAN

PRESIDENT GENERAL SECRETARY

Dr Marwah