Supine hypertension–orthostatic hypotension

SH/OH is a form of autonomic dysfunction characterized by hypertension when patients are supine and a clinically significant drop in blood pressure when they assume an upright posture. Treatment of this group of patients can be very challenging.

Orthostatic hypotension (OH) is a condition that is relatively common in elderly patients and those who suffer from diabetes mellitus and Parkinson’s disease. Some patients with OH will also develop concurrent supine hypertension (SH). This results from a defect in the functioning of the baroreceptors that normally maintain appropriate blood pressure upon assuming an upright posture.

OH and SH should be treated separately, and that non-pharmacological interventions should be employed first. For OH, these include smaller, more frequent meals and increasing water intake, along with other physical maneuvers to increase blood pressure (such as squatting).

As SH or OH becomes more severe, pharmacological measures should be taken, such as adrenergic agonists for OH or short-acting antihypertensives for SH.

These medications must be strictly monitored to minimize any undesired side effects that may worsen SH or OH.

They strongly recommend the use of 24-hour blood pressure monitoring as a means to identify the timing and magnitude of daily fluctuations. This practice can further help to guide treatment.

Building Indian Consensus

WHO advise on screen time for children under five?

1.That for children under one-year sedentary screen time (such as watching TV or videos, playing computer games) is not recommended and that when sedentary, engaging in reading and storytelling with a caregiver is encouraged.

2.That children under two years of age should have no screen time whatsoever

3.For those aged two years, sedentary screen time should be no more than one hour; less is better.

4.That three and four-year-olds should not play with iPads or watch television for more than an hour a day ( less is better).

5.WHO recommends at least 180 minutes in a variety of types of physical activities for three-to-four-year olds.

6.Improving physical activity, reducing sedentary time and ensuring quality sleep in young children will improve their physical, mental health and wellbeing

E-cigarettes more effective in facilitating smoking cessation

Bangladesh the daily star: Proponents of electronic cigarettes often advocate use of e-cigarettes (“vaping”) to facilitate smoking cessation.

In a recent U.K. study, researchers identified 884 adult smokers who chose a quit date and were randomized to either e-cigarettes or nicotine-replacement therapy. Those in the e-cigarette group were given starter kits; those in the nicotine-replacement group were permitted to choose from various products (e.g., patches, gum, lozenges); many used combinations of products. All participants were given multisession behavioral support.

The rates of abstinence from smoking at 1 year were 18% in the e-cigarette group and 10% in the nicotine-replacement group (P<0.001). Among abstainers in the e-cigarette group, 80% still were using e-cigarettes at 1 year; among abstainers in the nicotine-replacement group, only 9% were still using nicotine-replacement products at 1 year.

E-cigarettes were more effective than nicotine replacement in facilitating smoking cessation; however, many participants in the e-cigarette group who stopped smoking combustible tobacco continued to use e-cigarettes at 1 year. This study’s 1-year abstinence rates in the 10% to 20% range are typical for pharmacologic smoking-cessation interventions.

Bangladesh government is committed to tobacco control. Prime Minister Sheikh Hasina hopes it will be possible to make Bangladesh a tobacco-free country within 2040 in order to achieve the Sustainable Development Goals (SDGs). Vaping could be instrumental to reach that target.

Current Temperature Status and Warning for next five days

Heat Wave and Temperature Observed Yesterday (Past 24 hours from 0830 hrs IST of 27 April to 0830 hrs IST 28 April, 2019)

Heat Wave:

Yesterday, heat wave conditions were observed at many places over Vidarbha; at some places over Saurashtra & Kutch and in isolated pockets over West Madhya Pradesh, Marathwada and Madhya Maharashtra (Annexure 1 & 2).

Maximum Temperature

Maximum temperatures were markedly above normal (5.1°C or more) at a few places over Gujarat state; appreciably above normal (3.1°C to 5.0°C) at many places over Nagaland, Manipur, Mizoram & Tripura and Vidarbha; at a few places over Himachal Pradesh, Uttarakhand, Assam & Meghalaya, Jharkhand, Odisha, Madhya Pradesh, Madhya Maharashtra and Marathwada; at isolated places over West Bengal & Sikkim, Bihar, Chhattisgarh, Telangana and Tamilnadu & Puducherry; above normal (1.6°C to 3.0°C) at most places over East Uttar Pradesh; at many places over East Rajasthan, Rayalaseema, South Interior Karnataka and Andaman & Nicobar Islands; at a few places over West Uttar Pradesh, West Rajasthan, Punjab and Kerala; at isolated places over Haryana, Chandigarh & Delhi.Yesterday, the highest maximum temperature of 46.7°C was recorded at Akola (Vidarbha) (Annexure 1 & 2).

Temperatures Recorded at 1430 Hours IST of Today, the 28 th April, 2019

• Akola (Vidarbha) recorded the maximum temperature of 46.7°C each (Annexure 3).
• Temperatures recorded at 1430 hours IST of today have risen by 1-3°C at at many parts of Jammu & Kashmir and; at a few places over West Bengal and North Interior Karnataka and at one or two pockets of Himachal Pradesh, Uttarakhand, Madhya Pradesh, Bihar, Odisha, Bihar, Konkan & Goa and Meghalaya (Annexure 4).

Healthcare News Monitor

India sets 2030 as target to eradicate malaria

Deccan Chronicle

Dr K.K. Aggarwal, president elect Confederation of Medical Associations in Asia and Oceania (CMAAO) says an investigational drug DM1157 is a modified form of the anti-malarial drug chloroquine which is found to interfere with the metabolism of the parasite. “This inhibits the parasite’s ability to expel the drug and drug resistance is avoided. A phase 1 trial to evaluate the safety of the drug began in September 2018. These new inputs are helping to deal with the resistance to drugs that has been noted.” But the major challenge before researchers is the sudden spike in the incidence of malaria in 2016-17. In 2017, there were an estimated 219 million cases of malaria worldwide and approximately 4,35,000 deaths due to the disease, according to the WHO.

Eyeing Profits

India Legal

Medical devices have often come under the scanner for being overpriced. A PIL filed in the Delhi High Court late last year challenged such overpricing with a specific plea that intraocular lenses, among the essential medical devices, be listed under the National Pharmaceutical Pricing Authority. India has for long been known as the “blind capital” of the world. Around 15 million people here are blind, which is 50 percent of the world’s blind population. According to the data published by the National Programme for Control of Blindness and Visual Impairment, cataract alone accounts for 62.6 percent of all causes of curable blindness in India. The cataract surgery rate is pinned at above one percent of the total population of the country every year. That means millions of people are getting intraocular lenses implanted each year. But there is a huge gap between the cost of procuring these lenses and the price a patient has to pay for correcting his vision.

Pharma News

Serdia Pharma launches nationwide campaign for angina awareness

Business Medical Dialogues

SERDIA Pharmaceuticals (INDIA) Pvt Ltd, a leader in cardiology, conducted a nation-wide campaign to raise awareness on angina. The campaign urged people to not ignore symptoms of angina-like clutching pain, heaviness or tightness in the chest, pain in neck/shoulder, fatigue, backache and breathlessness and to consult a doctor at an early stage. The field force also reached out to thousands of doctors through their in-clinic awareness drive. Angina is often the initial manifestation of coronary artery disease (CAD), the most frequent cause of death worldwide today, and has been shown to double the risk of major cardiovascular diseases. Approximately one-third of the outpatients with chronic CAD suffer from angina, while 30 per cent of patients continues to experience angina symptoms as early as one month after revascularization.

India trashes US report, calls it attack on cheap generic drug

The Times of India- Sushmi Dey

India has outrightly rejected allegations in a US report about the country being a chief source of counterfeit medicines to the world and said it is an attack on low cost generic drugs— crucial to make healthcare affordable. The ‘Special 301 Report’ by United States Trade Representative (USTR) slammed India and China as leading sources of counterfeit medicines distributed globally with 20% of all pharmaceutical products sold in the Indian market estimated to be counterfeits. We strongly disagree with the observations made by USTR. We do not know the genesis and methodology of their findings. Instead, we view this as opposition to low cost generics and the thriving Indian drug manufacturing industry which is the ‘Pharmacy of the world’,” health secretary Preeti Sudan told TOI.

Hyderabad-based CCMB to back traditional Indian medicine

Telangana Today- M. Sai Gopal

Traditional Indian medicine was long criticised for its inability to showcase proper scientific validation of drugs developed under Ayush. Though Ayurveda, Unani and Siddha are extremely popular among Indians, the traditional medicine systems struggled against Allopathy which is backed by scientific evidence. But, this could be a thing of the past with the country’s premier institute, Centre for Cellular and Molecular Biology (CCMB), deciding to makes it foray into research and documentation of plant-based medicines in India. CCMB has now entered into a MoU with Ghaziabad-based Indian Pharmacopeia Commission (IPC) to take up documentation, validation and characterisation of Indian herbal drugs. “Scientific validation and characterisation of herbal drugs will not only help authentication of such drugs but, also bring credibility to the industry and solidify the traditional Indian knowledge of thousands of years,” CCMB Director Dr RK Mishra said.

Integrating Traditional And Modern Medicine To Achieve Health For All

Business World-S R jindal

Across the globe, two divergent medical systems, one traditional and the other modern, are almost equally popular and in use even in the most developed countries. It is therefore important to understand the precise difference between the two. The origin of modern medicine can be traced back to the Greek physician Hippocrates, who introduced a scientific approach towards treatments more than 2000 years ago. Thereafter, the system started evolving side by side with scientific discoveries in the society, and finally, the industrial revolution in Europe, completely isolated the system from subjective to objective, making it a scientific product. It is now understood to be a research- oriented, demonstrative; strongly evidence based medical system which is evolving continuously. On the other hand, a number of traditional and natural medical systems have existed and flourished across the world for thousands of years before the advent of modern medicine. India’s traditional system Ayurveda and Yoga, for instance, have existed for 5000 years. All these natural healthcare systems are empirical, holistic and have the backing of cumulative medical wisdom of centuries. These too are evolving with time, albeit at a slower pace.

No country for generic medicines

The Hindu-Bindu Shajan Perappadan

Laws in India specify that all medical prescriptions should give generic medicines and all pharmacies must make them available to patients. But aggressive marketing by private pharma companies, cut-throat competition and ignorance of the customers coupled with weak enforcement of rules allow private manufactures of branded medicines to make a killing through your “friendly pharmacy”. About 85% of total health expenditure in India is financed by household out-of-pocket expenditure (according to government figures) and medicines constitute 20% to 60% of total healthcare expenditure. Understanding the strain medical expenditure has on the common man, the central government has been working on “aggressive” marketing of generic drugs by opening pharmacies that sell these medicines, and asking pharmacies to display availability of these medicines.

Ayush Min, CSIR join hands for herbal drug research

The Pioneer- PNS

With increasing demand for alternate traditional medicines and therapy in domestic and global market, Union Ministry of Ayush and countrys premier research agency, Council of Scientific and Industrial Research (CSIR), have joined hands for cooperation in research and education in areas of herbal drugs and its integration with modern science for their wider acceptance. As per the pact inked between the two organisations, stress will be on to pursue R&D covering fundamental research; ayush specific diagnostic tools; linking micro-biome, gene expression and prakriti; multi-ingredient herbal formulations, including their standardisation; exploring modern scientific methods for integration with traditional drugs and linking disease signatures among others. The collaboration in preserving and protecting traditional knowledge related to the Indian systems of healthcare will also be strengthened, through the existing TKDL platform and development of international standardized terminologies (disease-morbidity codes) in Ayurveda, Siddha and Unani (ASU), database on medicinal plants, foods, etc, said a senior official from the Ministry.

In India, Ayurveda Is A Booming Business

NPR-Furkan Latif Khan

Outside a barn in a jungle north of Mumbai, dozens of cows roam in the shade of mango trees and palm fronds. Theyre doted on by the farms caretaker, a Hindu monk draped in white robes. Cows are sacred to Hindus. Saved from slaughter, they live out their days in tranquility at shelters like this across India, courtesy of donations made by worshipers at temples. Many Hindus believe cow excrement has healing powers. So every morning, when the cows awake, farmhands line up with buckets to collect the cows urine. Dung gets scooped up and spread out to dry in the sun in an even layer or in patties. Soni believes this drying process eliminates bacteria. This is where entrepreneur Umesh Soni, 35, sources ingredients for his Cowpathy line of cosmetics. At a factory nearby, employees mix cow urine and dung with natural fragrances and oils to make soap, shampoo, face wash — even lip balm. Soni sells the products on Amazon, and has a tiny boutique in downtown Mumbai.

Hyderabad: Gates-funded malaria drug gets big break

Deccan Chronicle

Development of the drug tafenoquine is a major breakthrough in the treatment of malaria. No drug has been developed in the past 30 years to deal with malaria. It was approved for use by the USFDA last year but is still not available in India. Tafenoquine or Krintafel is used to treat p.vivax malaria. This malaria parasite continues to be dormant in the body even after treatment, and there is a relapse in at least 30 per cent of cases, even without new mosquito bites, which this drug prevents. Dr Hari Kishan B., senior general physician at Apollo Hospitals explained, “The use of tafenoquine is found to have the same effect as primaquine which has been in use for a long time. While tafenoquine is claimed to be more effective, it is still not available in India. Approval was given by the US Food and Drug Administration in September 2018, and it will take some time for the drug to be available in India.”

Homeopathy no longer a second choice of treatment

Gulf News- Suchitra Bajpai Chaudhary

Homeopathy is no longer a second choice when it comes to getting a health problem addressed, a leading homeopath, who opened his fifth clinic to cater to the growing demand in the UAE, has claimed. Speaking to Gulf News, Dr Mukesh Batra, chairman and founder of Batra’s Health care group, said homeopathy was earlier a second choice after allopathy failed to address health issues, but now most people resort to homeopathy first. He said: “In allopathy, antibiotics are widely used. We know that Antibiotic Microbial Resistance (AMR) is a very dangerous trend as these medicines destroy the healthy gut flora along with the harmful ones. "Homeopathy works through nerve endings and that is why our pills are kept under the tongue which has the maximum nerve endings for best absorption. Our treatment is easy to follow and helps strengthen the immune system. It works wonders in the area of child health.”

2,500 kg of drugs seized in crackdown on illegal medicines

Hindustan Times- Rhythma Kaul

The Central Drugs Standard Control Organisation (CDSCO) has been raiding and seizing medicines procured without following the registration and licensing process, officials said. This is a part of a crackdown on illegal import and sale of drugs. About 2,500 kg of drugs were seized in the latest raid carried out in Chennai on Thursday, the officials said. The raid was carried as the drugs were imported without registration certificate and import license, they added. The CDSCO’s intelligence cell had gathered the information that certain drugs were being imported illegally without a registration certificate and import license. The drugs seized included erythromycin stearate (235 kg), verapamil hydrochloride (155 Kgs), megestrol acetate (70 kg), trimetazidine dihydrochloride (1,344 kg), folic acid (125 kg), silymarin (175 kg) and calcium D-pantothenate (250 kg).

Dr Reddys, Cipla arm recall drugs in US market

The Times of India- PTI

Drug major Dr Reddys Laboratories is recalling 33,958 bottles of Divalproex Sodium Extended-Release tablets, used to treat seizure disorders, from the American market, as per a report by the US health regulator. Besides, InvaGen Pharmaceuticals Inc, a subsidiary of Mumbai-based drug maker Cipla, is recalling over 7.8 lakh vials of Testosterone Cypionate injection, used to treat low testosterone levels in men. Dr Reddys Laboratories Inc, a subsidiary of the Hyderabad-based Dr Reddys Laboratories, is voluntarily recalling the affected lot of bottles on account of certain deviations from the Current Good Manufacturing Practice (CGMP) regulations. As per the latest enforcement report by the US Food and Drug Administration (USFDA), the firm is recalling the product as it has been exposed to above 50 per cent relative humidity levels during packaging operations. The product was supplied to major distributors and retailers who may have further distributed the product throughout the US, the report added. Meanwhile, InvaGen Pharmaceuticals Inc is recalling its product in various strengths due to the "presence of particulate matter", the report said. The vials were manufactured by Cipla at its Verna facility in Goa for Cipla USA Inc.

Healthcare News

This 91-Year-Old Indian Doctor’s Research Raised Awareness About Breastfeeding In The UK

Indiatimes

Television commercials emphasising the importance of mother’s milk flash on screens frequently. Breastfeeding provides ideal nutrition for babies, reduces disease risk and promotes healthy weight as well. However, this was not known to many, especially in western countries until Annapurna Shukla did her pioneering research. The 91-year-old doctor from Varanasi is not only the proposer of Prime Minister Modi’s candidacy but also a successful researcher. Times of India reported that Dr Shukla did her research on the importance of breast-feeding babies between 1969 and 1972. The research was carried out in the United Kingdom and published in the British Medical Journal. She along with three other researchers studied parameters such as body weight, calorie intake, feeding pattern in infants and their correlation with obesity.`

Is Delhi Govt Doing Enough to Protect its Doctors from Disgruntled Kin of Patients?

News18- Rakhi Bose

A doctor is always the saviour. But what about the times when a doctor needs saving? For the most part, medical practitioners are viewed with respect and even revered as anthropomorphised Gods who heal the sick and bring back loved ones from the jaws of death. But sometimes, grief of losing a family member, inability to change the course of fate is debilitating enough for families of patients undergoing treatment to lose their cool. And the same God-like doctors end up facing the wrath. In fact, the assault on doctors is an important issue that often does not get the attention it deserves, especially in the capital where doctors in government hospitals often face violence and harassment at the hands of disgruntled relatives or misbehaving kin of the patients.

Doctors talk on treating patients with haemophilia

The Tribune

World Haemophilia Day is observed across the globe on April 17 every year and the month is dedicated for haemophilia awareness. Christian Medical College, Ludhiana, along with patients, observed this day today. More than 200 patients and their relatives attended the function. Director Dr William Bhatti encouraged the patients. Faculty members Dr Narinder Singh from GMC, Amritsar, and Dr Gursharan Singh from GMC, Patiala, shared their experience in treating patients with haemophilia at their centres. Dr Chepsy Philip from CMC elaborated on the World Haemophilia Federation theme for 2019, which is ‘outreach and identification’.

How voice technology can disrupt healthcare

eHealth

Doctors have been reluctant in stepping away from their core job of attending to patients and filling bulky documentation as a part of their daily routine. The general consensus amongst healthcare providers is that doctors hate extensive typing that is a part of any HMIS. They are tech-savvy but prefer using speech to convey their instructions, prescriptions and other paper work. This gap can be filled by using technology. The burden on doctors can be reduced significantly. Errors can be minimized and each system can be personalized to suit the personal preference of the user. Voice technology can bridge the yawning gap between the reluctance of the doctor to adapt to new technology and the need of the market. Voice technology can include conversion of speech to text, and could have tremendous impact in the area of data localization or regional languages. The demonstrated ability of the voice to text technologies to create documents, reminders, flag issues and predict suggestions has been a boon for doctors.

Be cautious of water-borne ailments, heat strokes: Experts

Telangana Today

With mercury levels in Hyderabad being on the higher side of 40 degree Celsius, district health authorities and senior public health experts have urged the public to take precautions from water-borne ailments and heat strokes. Experts in seasonal ailments have urged individuals and families to be alert for the next month, when temperatures are expected to rise further in the month of May, which could even trigger heat stroke cases. “During summer, usually we see a spurt in cases of water-borne ailments, food poisoning cases and heat stroke cases. All these are preventable and precautions must be observed by all, including individuals and families,” advises Superintendent, Fever Hospital, Dr K Shankar. While water-borne ailments are usually associated with lack of access to potable drinking water, heat strokes are due to exposure to high temperatures of over 40 degree Celsius. “A healthy person can withstand heat stroke. Complications arise in persons with co-morbid conditions like chronic kidney and heart ailments and diabetes,” Dr Shankar pointed out.

Renal transplantation, more action needed

The New Indian Express

March 14 was celebrated as ‘World Kidney Day’. This year, the focus was to promote educational awareness programmes on kidney diseases, its disastrous consequences, especially End Stage Renal Disease (ESRD), among others. In various hospitals, congregations of living donors and recipients were arranged to prove the safety of organ donation and the need to propagate the same through social, visual and print media. The longest surviving transplant patient is reported to be Johanan Ramphel, 69 years, from Canada. Other longest living recipients are from the USA and South Africa. This raises a very prominent question. In India, why is kidney transplantation rare and not progressing effectively?

Cases of skin diseases on the rise in Delhi as temperature soars

India Today- Priyanka Sharma

In Delhis hospitals, around 40 to 50 per cent of OPD patients are those suffering from skin illness, sun burn, fungal and bacterial infections. t is hot outside! Not just summer related gastrointestinal diseases, sweltering heat also brings along skin diseases. As temperature is set to further increase in the coming days, the autoimmune skin disease called skin lupus and fungal infections, allergies, sun burn, tanning, rashes and pigmentation will also start to shoot up. Theres been an alarming increase of skin diseases in the city. In hospitals, around 40 to 50 per cent of OPD patients are those suffering from skin illness, sun burn, fungal and bacterial infections. At the rheumatology department All India Institute of Medical Sciences (AIIMS), doctors are witnessing many patients suffering from Lupus or Systemic lupus erythematosus (SLE).

Huge response for cancer walk

The Hans India

To help build awareness on head and neck cancer among people, a walkathon was being organsied by Apollo Hospitals in association with the walkers associations at RK Beach on Sunday morning. Raising slogans and displaying banners and placards that highlighted preventive measures, a number of clubs and associations such as Madhavadhara Mahila Walkers Club, Three Star Walkers Club and SVLN Walkers Club teamed up for the walkathon. Flagged off by VIMS Director K Satya Vara Prasad, presidents of various walkers associations, Apollo Hospitals unit head Sami, among others, the walkathon began at Kali Mata temple and concluded at YMCA. Emphasising the need to identify symptoms of cancer early, the organisers said the walkathon aimed at dissuading people from consuming alcohol apart from smoking and chewing tobacco which are known risk factors for most head and neck cancers.

Medical fraternity rues bridge courses

Telangana Today- M. Sai Gopal

In order to meet the shortfall of practicing doctors, especially at secondary and primary healthcare level in districts and villages, policy-makers are increasingly leaning towards introducing bridge courses as a possible solution to meet the demand and supply shortfall. However, that has caused a lot of strife and unease among the community of qualified MBBS doctors at State and national level. Influential organisations of MBBS doctors such as Indian Medical Association (IMA) have roundly criticised and threatened to launch agitation over proposals to have such bridge courses. A majority of doctors see such bridge courses as a threat to their profession while others point out that if such ‘short-cuts’ are available, then what is the point in pursuing MBBS degree for over five years and later also struggle to complete a post-graduation, which will take away at least 8 years of their lives while they pursue academics.

Indian Army to train medical team of Six Sigma

millenniumpost

For the first time in the history of Armed Forces, Indian Army will impart high altitude training to private medical team of Six Sigma at High Altitude Warfare School, Gulmarg, Kashmir. Six Sigma is the only non-government organisation in India, which is trained by the maximum number of military and para Military Forces like Airforce, ITBP, BSF, CRPF and NDRF. Six Sigma Healthcare is famous for providing free Mountain Medicine Services at High Hills with donations at any time, any where, any weather, any height. The training includes exercises on mountain medicines, latest mountain equipment, rock climbing, river crossing, peak climbing, rappelling, basic life support, advance cardiac life support, communication on high altitudes, glacier and avalanche rescue etc. The exercise is being conducted for the first time in collaboration with Indian Army. These lifesaving skills will help them in better rescue management on high hills, said Dr Pradeep Bhardwaj, Medical Director – Six Sigma High Altitude Medical Rescue Services. The Mountain Medicines is the most difficult medical services. Every year millions of people travel to high-altitude for recreation. Twenty percent of those traveling to altitudes below 5500 m/18,000 ft are affected by some form of altitude illness, said Pradeep Bhardwaj, CEO – Six Sigma High Altitude Medical Rescue.

Doon medical college gears up for MCI inspection

The Times of India- Ishita Mishra

Dehradun: Government Doon Medical College & Hospital (GDMCH) is gearing up to face the Medical Council of India’s (MCI) inspection expected this week. The college is hopeful of getting the Letter of Permission (LoP) from MCI to start its academic session for the MBBS post the inspection. Dr Ashutosh Sayana, principal, GDMCH, recently inspected the wards and other facility centres to review preparations ahead of the MCI team’s visit. “We are ensuring that facilities like pathology, blood bank etc stay in good condition. MCI team will oversee the staff availability and make sure that the norms laid down by the medical board are being followed,” Dr Sayana told TOI. "The MCI had granted us the permission to enroll 150 MBBS students in first year in 2016. The renewal of the permission was done again in 2017 and ’18 and now in 2019, we expect to get the nod for our fourth batch of MBBS students," Dr Sayana added. The hospital administration has been directed to reopen TB and Chest ward and fix all ACs and coolers before the inspection. “The non-functional dialysis and MRI machines remain a cause of concern for administration. We have been asked to ensure their repairs before the visit,” said a staff member of GDMCH.