Letters to the Editor
Pharmaceutical companies as the funding sources for continuing medical education Sir, Continuing medical education (CME) is essential to keep medical practitioners abreast with the latest research and developments in their specialties, and thus, updating their knowledge. The debatable issue however is about the source of funding to attend these CMEs and the expectations arising out of that. A recently published paper by Venkataraman et al.[1] and a follow‑up correspondence[2] on funding sources for CME make some very interesting observations and thus, are useful additions to the literature. The sources and extent of funding may vary in different setups and are subject to the prevailing regulations. Thus, it becomes essential to highlight on the prevailing regulations with regard to the funding by pharmaceutical companies for attending conferences, seminars, workshops, and CME programs in India. The Medical Council of India (MCI), is a statutory body that is entrusted with the responsibility of establishing and maintaining high standards of medical education and to ensure quality medical care to the citizens in India. To achieve its aim, the MCI lays down rules and regulations from time to time that are subject to periodic amendments. The amendment notification from the MCI adds certain regulations to amend the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. These Regulations called the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2009 ‑ Part‑I” makes additions in Chapter 6 that deals with unethical acts. The newly added clause 6.8 mentions about “Code of conduct for doctors and professional association of doctors in their relationship with pharmaceutical and allied health sector industry,” and in the sub clause 6.8.1 (b) clearly states that “A medical practitioner shall not accept any travel facility inside the country 186
or outside, including rail, air, ship, cruise tickets, paid vacations etc., from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CME program etc., as a delegate.” Sub clauses 6.8.1 (a) and (c) also discourages a medical practitioner from receiving any gifts and hospitality respectively. A medical practitioner is expected to follow and adhere to the stipulations mentioned in the amendments, or else his/her actions will be construed as unethical.[3] These regulations came into force from the date of their publication in the Official Gazette on December 14th, 2009. Just like CMEs and workshops are the sources for recent advances, well‑read journals such as Indian Journal of Critical Care Medicine are not far behind in dissemination of latest research and information in the field. Many of the rules, regulations, guidelines and amendments associated with the practice of medicine are likely to be missed by the medical practitioners at large and thus, a need to increase awareness on these important issues as well. Ignorance about such amendments can unnecessarily pose problems for the medical practitioners. This correspondence is thus, aimed at increasing the awareness regarding the aforementioned specific amendments and guidelines for the elite readership of the journal.
Tanuj Kanchan
Department of Forensic Medicine, Kasturba Medical College, (A constituent college of Manipal University), Mangalore, Karnataka, India
Correspondence: Dr. Tanuj Kanchan, Department of Forensic Medicine, Kasturba Medical College, (A constituent college of Manipal University), Mangalore, Karnataka, India. E‑mail: [email protected]
References 1. 2. 3.
Venkataraman R, Ranganathan L, Ponnish AS, Abraham BK, Ramakrishnan N. Funding sources for continuing medical education: An observational study. Indian J Crit Care Med 2014;18:513‑7. Walsh K. Funding sources for continuing medical education: A different perspective. Indian J Crit Care Med 2014;18:762. Medical Council of India, Amendment Notification, New Delhi, the 10 th December, 2009. Available from: http://www.mciindia. org/RulesandRegulations/CodeofMedicalEthicsRegulations2002. aspx. [Last accessed on 2014 Nov 08].
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3 Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152778
Methyl alcohol poisoning causing putamen necrosis Sir, I read with great interest the article by Singh et al. published recently in your journal. [1] The authors described a 50‑year‑old male who presented to the emergency department with chief complaints of giddiness, vomiting, abdominal pain, and blurred vision. On examination, altered sensorium was found, and high anion gap metabolic acidosis was detected in arterial blood gas (ABG) analysis. According to the suggestive history, chief complaints, and the ABG reports, methanol poisoning was considered in the absence of definitive diagnostic facilities. On the follow‑up, patient suffered bilateral basal ganglia damage. I would like to address some points in this paper. Consumption of home‑distilled alcohol or country liquor may cause sporadic or mass methanol poisoning, especially in some countries such as Iran and India where poverty‑ridden population exists or production and dispersion of illegal, nonstandard or adulterated alcoholic beverages remain widespread.[1,2] Gas‑liquid chromatography is not available in most of the poison centers in these countries to determine serum methanol levels, but the combination of metabolic acidosis, visual problems and abdominal pain should always suggest methanol poisoning as was the case in this report.[3] Moreover, putamen necrosis stated in this case can occur in methanol poisoning even with normal ABG analysis.[4] However, one point about this patient is of concern. Was hemodialysis performed in this patient? If not, what was the reason? As you know, hemodialysis for treatment of methanol poisoning appears ideal because methanol, owing to its low molecular weight, is easily dialysed, as are its toxic metabolic products.[5] Furthermore, this method facilitates the correction of metabolic acidosis
and other metabolic derangements that may have a role in the neurologic sequelae including putamen necrosis.[4] Pappas and Silverman recommended that hemodialysis be instituted promptly, independent of the initial serum methanol level, if one of the following features is present: (a) Metabolic acidosis, (b) visual disturbance or (c) a history of ingestion of more than the accepted minimum fatal dose (30 ml of absolute methanol).[6] Two of them (a and b) were evident in this case. By the way, a recent study conducted by Hekmat et al. showed that when the antidote fomepizole is not given for any reason, physicians should lower the threshold level for initiating conventional hemodialysis in acute methanol poisoning.[7] Indeed, when aggressive intervention such as hemodialysis is not available or feasible, only new antidote fomepizole would benefit the patients and may withdraw the hemodialysis from treatment strategy. Thank you very much for your interesting case report.
Seyed Mostafa Mirakbari
Department of Forensic Medicine and Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Iran Correspondence: Dr. Seyed Mostafa Mirakbari, Department of Forensic Medicine and Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, 34137 86165, Iran. E‑mail: [email protected]
References 1. 2. 3. 4. 5. 6. 7.
Singh Y, Jain G, Singh DK. Methyl alcohol poisoning causing putamen necrosis. Indian J Crit Care Med 2014;18:698‑9. Shadnia S, Rahimi M, Soltaninejad K, Nilli A. Role of clinical and paraclinical manifestations of methanol poisoning in outcome prediction. J Res Med Sci 2013;18:865‑9. Burkhart KK, Kulig KW. The other alcohols. Methanol, ethylene glycol, and isopropanol. Emerg Med Clin North Am 1990;8:913‑28. Srivastava T, Kadam N. Bilateral putaminal hemorrhagic necrosis with rapid recovery of sensorium in a patient with methanol intoxication. J Postgrad Med 2013;59:243‑4. Erlanson P, Fritz H, Hagstam KE, Liljenberg B, Tryding N, Voigt G. Severe methanol intoxication. Acta Med Scand 1965;177:393‑408. Pappas SC, Silverman M. Treatment of methanol poisoning with ethanol and hemodialysis. Can Med Assoc J 1982;126:1391‑4. Hekmat R, Samini F, Dadpour B, Maghsudloo F, Mojahedi MJ. Should guidelines for conventional hemodialysis initiation in acute methanol poisoning, be revised, when no fomepizloe is used? Iran Red Crescent Med J 2012;14:743‑5.
Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152780
187
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Pharmaceutical companies as the funding sources for continuing medical education Sir, Continuing medical education (CME) is essential to keep medical practitioners abreast with the latest research and developments in their specialties, and thus, updating their knowledge. The debatable issue however is about the source of funding to attend these CMEs and the expectations arising out of that. A recently published paper by Venkataraman et al.[1] and a follow‑up correspondence[2] on funding sources for CME make some very interesting observations and thus, are useful additions to the literature. The sources and extent of funding may vary in different setups and are subject to the prevailing regulations. Thus, it becomes essential to highlight on the prevailing regulations with regard to the funding by pharmaceutical companies for attending conferences, seminars, workshops, and CME programs in India. The Medical Council of India (MCI), is a statutory body that is entrusted with the responsibility of establishing and maintaining high standards of medical education and to ensure quality medical care to the citizens in India. To achieve its aim, the MCI lays down rules and regulations from time to time that are subject to periodic amendments. The amendment notification from the MCI adds certain regulations to amend the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. These Regulations called the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2009 ‑ Part‑I” makes additions in Chapter 6 that deals with unethical acts. The newly added clause 6.8 mentions about “Code of conduct for doctors and professional association of doctors in their relationship with pharmaceutical and allied health sector industry,” and in the sub clause 6.8.1 (b) clearly states that “A medical practitioner shall not accept any travel facility inside the country 186
or outside, including rail, air, ship, cruise tickets, paid vacations etc., from any pharmaceutical or allied healthcare industry or their representatives for self and family members for vacation or for attending conferences, seminars, workshops, CME program etc., as a delegate.” Sub clauses 6.8.1 (a) and (c) also discourages a medical practitioner from receiving any gifts and hospitality respectively. A medical practitioner is expected to follow and adhere to the stipulations mentioned in the amendments, or else his/her actions will be construed as unethical.[3] These regulations came into force from the date of their publication in the Official Gazette on December 14th, 2009. Just like CMEs and workshops are the sources for recent advances, well‑read journals such as Indian Journal of Critical Care Medicine are not far behind in dissemination of latest research and information in the field. Many of the rules, regulations, guidelines and amendments associated with the practice of medicine are likely to be missed by the medical practitioners at large and thus, a need to increase awareness on these important issues as well. Ignorance about such amendments can unnecessarily pose problems for the medical practitioners. This correspondence is thus, aimed at increasing the awareness regarding the aforementioned specific amendments and guidelines for the elite readership of the journal.
Tanuj Kanchan
Department of Forensic Medicine, Kasturba Medical College, (A constituent college of Manipal University), Mangalore, Karnataka, India
Correspondence: Dr. Tanuj Kanchan, Department of Forensic Medicine, Kasturba Medical College, (A constituent college of Manipal University), Mangalore, Karnataka, India. E‑mail: [email protected]
References 1. 2. 3.
Venkataraman R, Ranganathan L, Ponnish AS, Abraham BK, Ramakrishnan N. Funding sources for continuing medical education: An observational study. Indian J Crit Care Med 2014;18:513‑7. Walsh K. Funding sources for continuing medical education: A different perspective. Indian J Crit Care Med 2014;18:762. Medical Council of India, Amendment Notification, New Delhi, the 10 th December, 2009. Available from: http://www.mciindia. org/RulesandRegulations/CodeofMedicalEthicsRegulations2002. aspx. [Last accessed on 2014 Nov 08].
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3 Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152778
Methyl alcohol poisoning causing putamen necrosis Sir, I read with great interest the article by Singh et al. published recently in your journal. [1] The authors described a 50‑year‑old male who presented to the emergency department with chief complaints of giddiness, vomiting, abdominal pain, and blurred vision. On examination, altered sensorium was found, and high anion gap metabolic acidosis was detected in arterial blood gas (ABG) analysis. According to the suggestive history, chief complaints, and the ABG reports, methanol poisoning was considered in the absence of definitive diagnostic facilities. On the follow‑up, patient suffered bilateral basal ganglia damage. I would like to address some points in this paper. Consumption of home‑distilled alcohol or country liquor may cause sporadic or mass methanol poisoning, especially in some countries such as Iran and India where poverty‑ridden population exists or production and dispersion of illegal, nonstandard or adulterated alcoholic beverages remain widespread.[1,2] Gas‑liquid chromatography is not available in most of the poison centers in these countries to determine serum methanol levels, but the combination of metabolic acidosis, visual problems and abdominal pain should always suggest methanol poisoning as was the case in this report.[3] Moreover, putamen necrosis stated in this case can occur in methanol poisoning even with normal ABG analysis.[4] However, one point about this patient is of concern. Was hemodialysis performed in this patient? If not, what was the reason? As you know, hemodialysis for treatment of methanol poisoning appears ideal because methanol, owing to its low molecular weight, is easily dialysed, as are its toxic metabolic products.[5] Furthermore, this method facilitates the correction of metabolic acidosis
and other metabolic derangements that may have a role in the neurologic sequelae including putamen necrosis.[4] Pappas and Silverman recommended that hemodialysis be instituted promptly, independent of the initial serum methanol level, if one of the following features is present: (a) Metabolic acidosis, (b) visual disturbance or (c) a history of ingestion of more than the accepted minimum fatal dose (30 ml of absolute methanol).[6] Two of them (a and b) were evident in this case. By the way, a recent study conducted by Hekmat et al. showed that when the antidote fomepizole is not given for any reason, physicians should lower the threshold level for initiating conventional hemodialysis in acute methanol poisoning.[7] Indeed, when aggressive intervention such as hemodialysis is not available or feasible, only new antidote fomepizole would benefit the patients and may withdraw the hemodialysis from treatment strategy. Thank you very much for your interesting case report.
Seyed Mostafa Mirakbari
Department of Forensic Medicine and Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, Iran Correspondence: Dr. Seyed Mostafa Mirakbari, Department of Forensic Medicine and Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin, 34137 86165, Iran. E‑mail: [email protected]
References 1. 2. 3. 4. 5. 6. 7.
Singh Y, Jain G, Singh DK. Methyl alcohol poisoning causing putamen necrosis. Indian J Crit Care Med 2014;18:698‑9. Shadnia S, Rahimi M, Soltaninejad K, Nilli A. Role of clinical and paraclinical manifestations of methanol poisoning in outcome prediction. J Res Med Sci 2013;18:865‑9. Burkhart KK, Kulig KW. The other alcohols. Methanol, ethylene glycol, and isopropanol. Emerg Med Clin North Am 1990;8:913‑28. Srivastava T, Kadam N. Bilateral putaminal hemorrhagic necrosis with rapid recovery of sensorium in a patient with methanol intoxication. J Postgrad Med 2013;59:243‑4. Erlanson P, Fritz H, Hagstam KE, Liljenberg B, Tryding N, Voigt G. Severe methanol intoxication. Acta Med Scand 1965;177:393‑408. Pappas SC, Silverman M. Treatment of methanol poisoning with ethanol and hemodialysis. Can Med Assoc J 1982;126:1391‑4. Hekmat R, Samini F, Dadpour B, Maghsudloo F, Mojahedi MJ. Should guidelines for conventional hemodialysis initiation in acute methanol poisoning, be revised, when no fomepizloe is used? Iran Red Crescent Med J 2012;14:743‑5.
Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152780
187
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
