June 21  2015, Sunday
Exit exam for medical graduates passing out from Indian Universities
Dr KK Aggarwal
  • Indian medical association understands that the government has a proposal to have an exit test for all medical graduates passing out from Indian universities. IMA strongly oppose this move. The major responsibility of the medical council itself is to ensure uniform standards in medical education by having inspection before recognition is given to any new medical college, periodic inspection of standards of education in existing medical colleges, fixing uniform syllabi and curriculum for MBBS. If the medical council is doing its responsibility correctly, there is no scope for differences in the standards of medical graduates coming out of our medical colleges.
  • If it is not feasible for MCI to fulfil this responsibility, an accreditation council similar to the one which is existing with regards to arts and science colleges (NAAC) is to be established.
  • It is not the fault of the medical graduate, that he happens to study in an institution which is below par. It is the Government through the process of counseling which is admitting him in different colleges. For no fault of his, a medical graduate cannot be penalised in the pre-text of lack of uniform standard and subject him to an exit test.
  • If it is for the uniformity in standards of graduates passing out of Indian universities, then exit test should be applied for all the graduates, e.g. B. Tech, LLB, BSc etc
  • There is contradiction in the government policy. When the government propose exit test for modern medical graduates, in the name of maintaining high standards, the government is also contemplating bridge courses for Ayurveda,Homeo graduates to practice modern medicine, e.g. the Maharashtra government’s GO to give one year training in pharmacology for homeopathy graduates and allowing them to prescribe modern medicine
  • Government is also contemplating 3 year BRHC course to serve the rural population
  • So there is so much of dilution and disparities in the standards of various streams of practitioners who would practice modern medicine. To insist on exit test for MBBS graduates one is not able to find a genuine reason.
  • Suppose the medical graduates fail in the exit test, then what will be their fate? Government accepts that three year graduates are enough to practice in rural areas, government accepts that a crash course or a bridge course is enough for AYUSH doctors to practice modern medicine
  • At the same time, government feels that modern medical graduates (MBBS) are not competent to practise modern medicine without an exit test
  • The logic behind this policy is not understandable.
  • IMA is strongly against bridge courses, crash courses and three year courses for practising modern medicine.
  • If the intention of the government is to have ‘international standard’ for our medical graduates, then our graduates should be allowed to practice in other countries without their compiling tests like PLAB, USMLE. But in spite of the exit test every medical graduate will have to undergo the competency exams of individual countries.
  • IMA strongly feels that there is no need for an exit test if the MCI is performing its responsibilities properly. If at all there is a feeling that the standards of MBBS graduates are not to the mark, what is required is timely revision of curriculum and syllabi for MBBS course and introducing a system of accreditation for evaluating the standards of medical education apart from the periodic inspection like the NAAC for art and science graduates by MCI.
Hence IMA request the Government to reconsider this proposal and take urgent steps to institution of an accreditation body as is in vogue for arts and science and engineering colleges. IMA also requests the government to revise the syllabi and curriculum of MBBS course at least once in five years

Thanks in anticipation
Warm regards

Prof Dr A Marthanda Pillai           Dr KK Aggarwal
National President                      Honorary Secretary General
Today is International Day of Yoga
Patients can practice yoga but with precautions

Yoga is a science, which shifts one from sympathetic to parasympathetic mode. It is a combination of Hatha Yoga (asanas or postures), breathing and meditation. Meditation means concentrating on the object of concentration and giving preference to the object of concentration over thoughts. Mindfulness meditation, breathing awareness can shift from sympathetic to parasympathetic mode.

Breathing exercises in yoga can be both slow & deep breathing and fast breathing. Kapalbhati and bhastrika are fast breathing exercises.

In modern system of medicine, every movement in an exercise is accompanied by the opposite movement. The same is true for yoga. For every movement, there is a reverse movement.

Often when patients come to us for consultation or follow up, they ask if it is safe for them to do yoga. Yes, patients can do yoga but they should do it under the guidance of a trained yoga instructor. Teaching yoga is the job of an expert. In the hands of an untrained person, yoga may be risky. Also, it is important that patients observe specific precautions pertaining to their illness while doing yoga. They should practice yoga slowly and take care to not overdo any asana and avoid some postures that may aggravate their health problems

Here are some precautions, which patients should follow while doing yoga:
  • Yoga is not included as an aerobic exercise.
  • Fast breathing exercises stimulate the sympathetic system. Slow breathing stimulates the parasympathetic system. Therefore, cardiac clearance needs to be taken for all breathing exercises.
  • In three situations in Hatha Yoga (headstand, handstand, shoulderstand), the total body weight is put on head, wrist and shoulder. This requires medical clearance, especially for heart patients.
  • When you get up from a sitting position, nine times weight is put on the knees. Hence, patients of osteoarthritis should avoid sitting down, low height bed or chair or Indian toilets. Yoga may prevent osteoarthritis, but once developed, Hatha Yoga practices need to be modified.
  • The Lotus position, forward and backward bends need orthopedic clearance in selected patients.
  • Forward spine exercises may require orthopedic clearance in selected cases as they may precipitate sciatica, if done incorrectly.
  • Painful and/or difficult yoga postures should be avoided
  • Patients with cervical disc disease, glaucoma should avoid doing inversion postures (head stand, shoulder stand).
  • In case of worsening pain or paresthesia, stop and consult a doctor
IMA Uttarakhand Branch celebrated “World Blood Donor Day” on 14th June, 2015
Cardiology eMedinewS
  • Individuals who suffer from panic disorder, or panic attacks, may be at much higher risk of heart attack and heart disease later in life, suggests a new study published in the journal Psychological Medicine.
  • A small study of patients free of hypertension symptoms or left ventricular (LV) hypertrophy revealed that those with a high systolic blood pressure reading in a clinic measurement had a higher LV ejection fraction (LVEF) than those with a normal systolic blood pressure reading. The findings were presented at the European Society of Hypertension (ESH) 2015 Scientific Sessions.
Pediatrics eMedinewS
  • Migraine associated with concussion seems to be more prevalent among young athletes than is currently appreciated, suggest two new studies conducted among children and adolescents. The findings were presented at the American Headache Society (AHS) 57th Annual Scientific Meeting.
  • Older mothers may have babies who grow up healthier and better educated than infants born to women in their twenties, suggests an international study published in the Lancet Global Health.
Dr KK Spiritual Blog
Spiritual Prescription: Yoga Nidra

Many people in the East and the West are attracted to yogic practices, for they think they can find a solution to every problem therein, be it physical, mental, emotional or spiritual. Hence, much importance is attached to relaxation techniques that one thinks might help a person in easing the tension caused due to chronic stressful lifestyle. Yoga Nidra is one such wonderful technique, not only for physical or mental relaxation but also for preparing the mind for spiritual discipline. It concerns mainly with pratyahara (withdrawing senses from sense-objects) and dharana (concentration).

It is to be understood that ordinary sleep is not complete relaxation, for tension and stress cannot always be resolved completely in ordinary sleep. Yoga Nidra is qualitatively different relaxation. It is a ‘sleep’ where all the burdens are thrown off to attain a more blissful state of awareness, and hence it is a relaxation much more intense than ordinary sleep.

As Swami Satyananda Saraswati (Preface to “Yoga Nidra”, 1982, Bihar School of Yoga, Monghyr, Bihar, India) says: ‘When awareness is separate and distinct from vrittis - mental modifications, when waking, dreaming and deep sleep pass like clouds, yet awareness of Atman remains, that is the experience of total relaxation. That is why, in Tantra, Yoga Nidra is said to be the doorway to samadhi!’


Yoga nidra helps in restoring mental, emotional, and physical health by way of relaxation, and makes the mind more conducive to pratyahara - (withdrawing senses from their objects), dharana - (concentration), and meditation. Such a practice helps to harmonize two hemispheres of the brain and the two aspects of autonomous nervous system viz. sympathetic and parasympathetic. The impressions in the subconscious are brought to the surface, experienced and removed. Thus, the fixation of awareness to the body is replaced with the awareness linked to subtler aspects of Prana and spiritual dimensions.

(Source: http://www.boloji.com/
Make Sure
Situation: A patient with dengue fever developed shock.

Reaction: Oh my God! Why did you ignore the blood pressure of 90/70?

Lesson: Make sure that a pulse pressure of less than 20 is not ignored. It is an impending sign that the patient is going into shock.
Dr Good Dr Bad
Situation: A diabetic patient was found unconscious.

Dr Bad: He has suffered a stroke.

Dr Good: First rule out hypoglycemia.

Lesson: In diabetics, sudden loss of consciousness is hypoglycemia unless proved otherwise.

(Copyright IJCP)
eMedi Quiz
A case of Gestational Trophoblastic Neoplasia belongs to high risk group if disease develop after:

1. Hydatidiform mole.
2.Full term pregancy.
3. Spontaneous abortion.
4. Ectopic Pregancy

Yesterday’s Mind Teaser: Which of the following is not a post transcriptional modification of RNA?

1. Splicing.
2. 5' Capping.
3. 3' polyadenylation.
4. Glycosylation.

Answer for yesterday’s Mind Teaser: 4. Glycosylation.

Correct Answers received from: Dr Poonam Chablani, Dr K Raju, Daivadheenam Jella, Dr Avtar Krishan.

Answer for 19th June Mind Teaser: 2. Corticosteroid

Correct Answers received: Daivadheenam Jella, Dr Avtar Krishan.
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
Press Release
Precautions for diabetic patients during Ramzan fast

“Patients with type 1 diabetes should avoid fasting. However, those type 2 diabetes can fast,” said Padma Shri, Dr B C Roy & DST National Science Communication Awardee Dr K K Aggarwal, President, Heart Care Foundation of India and Hony. Secretary General, Indian Medical Association (IMA).

All diabetic patients who fast should be aware of certain facts if they fast during Ramzan, he further added.
  • All patients with diabetes should consult with their family physician regarding the Ramzan fast and learn the warning symptoms.
  • Type 2 diabetes will be controlled by diet and may require no special precautions.
  • Patients at risk of diabetes should avoid overeating to prevent post meal high blood pressure, after the predawn and/or sunset meal.
  • The exercise program for patients with diabetes on diet control should be modified to avoid lower blood sugar level. Exercise should be done 2 hours after the sunset meal.
  • Food restriction and dehydration may cause some cardiac risk in the elderly.
  • The choice of drugs in diabetes may require consultation with a doctor. Drugs that act by increasing the production of insulin are to be preferred. Some patients on metformin may fast safely with minimal complications. However, two-thirds of the total daily dose should be given just before the sunset meal and rest one-third before the predawn meal. Patients on pioglitazone may require no change in dose. Patients on sulfonylureas may require medical clearance before commencing fast.
  • Insulin dose also needs to be modified during the fast. Usually two doses of insulin, one before each meal, are sufficient.
  • If the blood sugar falls below 60, then the fast should be immediately broken.
  • Fast should also be broken if blood sugar rises to more than 300.
  • Patients should avoid fasting on sick days.
eIMA News
Prescribing medicine in generic name
Dr PillaiIndian Medical Association has always supported prescription in generic name provided the government can ensure quality of the drugs manufactured or available in our market. The generic drug prescription is a complex issue.
  1. The quality control mechanism in our country is very weak. When India has more than 67,000 drug formulations, the quality control mechanism in our country can ascertain the quality of only 15753 drug annually (Combined testing capacity of all the Central Drugs Testing Laboratories)(1)
  2. The bioavailability of any drug depends on its concentration, presence of impurities and mode of release of the drug , the concentration of the drug in the blood and storage conditions
  3. A 2014 study(2) found that 10.9 percent of the products were of poor quality-that is, they either contained none or less than the required dosage of active pharmaceutical ingredients. Of this 10.9 percent, 7 percent contained less than the required dosage of active ingredients, while 3.9 percent were duds without any of the necessary active ingredients. Drugs without or with less than the required pharmaceutical ingredients will be ineffective, and therefore potentially harmful since they won’t treat the condition they’re meant to address.
  4. There is no mechanism in our country to ensure all these factors related to quality of the drug.
  5. In fact, time and again, major adverse events including death occur due to poor quality of drug or contaminated drugs. e.g one of the major reasons for number of deaths that has occurred in the sterilisation camp held in Chhattisgarh have been due to contaminated drug used as antibiotics
When generic prescriptions are insisted, in our country anybody can buy any medicine from drug stores even without prescription. In fact the sale of drugs in a medical store is more off the counter than through prescription. How these can be regulated?
The cost of same molecule (drug) varies considerably in our market. The price control mechanism is not enforced to cover even the essential drugs.
If you look at the ground reality, even if a doctor writes prescription in generic name/trade name, either way in the government hospital, the pharmacy will give only those drugs available there. In a private hospital, the management decides on which drugs is3 to be purchased and issued. In both situations, the prescribing doctor is helpless Even if doctors prescribe in the generic name, while dispensing it will be the sales person in the medical store who has no knowledge about drugs who is going to decide which brand of drug is to be given. (Medical store, although registered under a pharmacist, it is the salesman who deals with the dispensing of medicine and not the pharmacist.) This situation will be more dangerous and detrimental to the patient where the right and responsibility of prescribing a particular brand of drug is entrusted with the salesperson in the medical store, and if a adverse reaction or death occurs due to spurious drug, the doctor will be legally responsible and not the salesperson.
By shifting the responsibility of choosing the brand to the salesperson in the drug store, the objective of reducing the cost of drug is not going to be achieved.
If the government is serious about making drugs cheap and affordable, government should insist on the pharmaceutical manufacturers to market drugs in generic name. Without curbing the issue at the manufacturing level, putting the onus of prescribing cheaper drugs on the doctors is not a wise decision
When the government allows manufacturing of combination drugs, even irrational combinations, it is not easy and practicable to write generic names. Government will have to ban combination drugs in that case.
AYUSH drugs are also being used by our population. No quality control mechanism of these drugs is in place. In fact AYUSH drugs are much more expensive than many of the modern medicine drugs. No effort on the part of the government to encourage ‘generic prescription’ for cost control is visible.
Even our day to day commodities carry ISI mark before they come into the market. But no batch of drugs available in the market carries the seal of quality. Only when life is lost, the drug is sent for quality assessment.
Although the government’s intention in insisting on generic name is to make drugs cheaper and affordable, just putting the onus on the doctors alone will not help the purpose. The root cause of the problem has to be analysed and solved by a multi-pronged approach like;
  1. Government to strengthen the quality control mechanism in drug manufacturing and to ensure that each batch of drug available in the market is quality checked
  2. Government to enforce that all manufacturers may use only generic name for labelling their products.
  3. Government to see that the cost of the same drug is uniform across all manufacturers, which in itself will make drugs cheaper
IMA is prepared to use generic names once the government is able to fulfil all the above. Till then, IMA strongly object to generic prescription in the interest of public health and patient safety.

  1. Website of central drugs standard control organisation, India. Available on www.cdsco.nic.in/forms/contentpage1.aspx?lid=1425, accessed on June 10, 2015
  2. Study by University of Maryland, the University of Ottawa, and the American Enterprise Institute. Bate, Roger and Jin, Ginger Zhe and Mathur, Aparna and Attaran, Amir, Poor Quality Drugs and Global Trade: A Pilot Study (September 2014). NBER Working Paper No. w 20469 Available at SSRN: http://ssrn.com/abstract=2492979
Thanks and regards

Prof Dr A Marthanda Pillai           Dr KK Aggarwal
National President                      Honorary Secretary General
  • Higher intake of trans fats, commonly used in processed foods to improve taste, texture and shelf life, has been linked to worse memory function in men in their prime earning years, according to a study published online June 17 in PLoS One.
  • A case series, published online in Diabetes Care, has shown an association between sodium-glucose cotransporter 2 (SGLT2) inhibitors and a serious side effect of euglycemic diabetic ketoacidosis (DKA) in nine patients; seven of these patients had type 1 diabetes and two had type 2 diabetes.
  • The US Food and Drug Administration (FDA) has approved a device that helps blind people read letters of the alphabet and recognize objects through electrotactile signals on their tongue. The BrainPort V100 converts video images taken with a glasses-mounted camera into electrical signals which are transmitted to a small, flat, lollipop-like device placed on a person's tongue.
  • Getting enough good quality sleep is essential for maintaining health and quality of life, and not getting enough is dangerous to individual health and public safety, suggests a new policy statement by the American Thoracic Society (ATS). The statement is published online in the American Journal of Respiratory and Critical Care Medicine.
  • A novel recombinant vaccinia virus kills hepatocellular carcinoma (HCC) in human cells in vitro, suggests a new study published online in Surgery.
  • The Indian Medical Association (IMA), Kozhikode branch, is planning to move court against the Indian Homoeopathic Medical Association (IHMA) for allegedly misleading the public by publishing false information on communicable diseases. The complaint is based on a report published in a popular Malayalam daily on Wednesday which claimed that excess use of medicines was a major reason for the increase in fever deaths in the State. The report, based on a statement issued by the IHMA, also says that the use of Paracetamol would reduce the blood platelet count thus leading to death. President of IMA Kozhikode Ajit Bhaskar said the IHMA was trying to mislead the public through such statements. He also pointed out that the IHMA had no right to comment on practices in modern medicine. (The Hindu)
  • The recent US Preventive Services Task Force (USPSTF) recommendation for intensive behavioral counseling interventions in adults at high risk of cardiovascular disease is cost-effective for individuals who are overweight or obese and have impaired fasting glucose, according to a new modeling study.
  • In August 2014, the USPSTF recommended referring adult patients who are overweight or obese and who have additional cardiovascular risk factors (hypertension, dyslipidemia, impaired fasting glucose [IFG], or metabolic syndrome) for intensive behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular-disease prevention.
  • e-pharmacies: The national general secretary of Indian Medical Association (IMA) India, Dr. K K Aggarwal, voiced several concerns. “Doctors, patients and pharmacists have a relationship based on trust. If a website were to display cheaper variations to the medicine I prescribe, without offering an explanation, this relationship suffers. Quality comes at a cost,” he said. He added that verification of doctors could be a problem as medical licenses could easily be forged. SOURCE: Live Mint| 19th June 2015
B12 and vegetarians: eMedinewS responds
Millennium Post published a story that “strict vegetarians are at a high risk of developing nutritional vitamin B12 deficiency, which can lead to neurologic abnormalities. The usual western diet contains 5 to 7 micrograms of cobalamin (Cbl) per day, while the minimum daily requirement is 6 to 9 micrograms daily. Total body stores of Cbl are 2 to 5 mg and one-and-a-half of this is in the liver. It takes years to develop vitamin B12 deficiency, after absorption of dietary B12 ceases.”

This comment should not be taken as a statement that vegetarians should start eating meat to cover for B12 deficiency. Literature has shown that pure vegetarians and pregnant women on Mediterranean diets (e.g., fresh fruits and vegetables with little in the way of animal-source foods) are at risk of developing vitamin B12 deficiency and require vitamin B12 supplementation.

Pregnant women who plan exclusive breastfeeding for their infants also need supplementation, as these infants are at much greater risk of vitamin B12 deficiency than their mothers.

It is correct "Animal products (meat and dairy products) provide the only dietary source of Cbl for humans." Remember the word used here is strict vegetarians, which means those who do not take dairy products also.
Letter to Editor
Dear Dr Aggarwal


On 13 June, 2015 Ad Melkert, former Special Representative of UN Secretary General for Iraq participated in a convention in Paris where he proposed a 6 point plan to resolve the current stalemate at camp liberty residents medical and logistics blockade and to preserve their full legal rights under international law.

He stated that: “…the international community has not been able, has not endeavored, and simply has not dared to force a breakthrough in the five years of siege that is the real name of the game going on around Liberty…” He then emphasized:” Let me reiterate the immediate steps needed and possible to break the impasse:
  1. To have the US, EU member states and other interested countries accept quota for granting asylum to and pledge for the resettlements of Camp Liberty residents.
  2. To have the UNHCR engaged the government of Iraq on the status of Camp Liberty as a refugee camp under protection of international law.
  3. To encourage the government of Iraq to put in place of an impartial mixed committee to oversee the implementation of the Memorandum of Understanding of 2011 between the government of Iraq and the UN.
  4. To request UNAMI to appoint impartial liaison officers to reside in the camp and ensure independent reporting on the day-to-day living conditions.
  5. To insist that the government of Iraq should ensure access to medical services, and
  6. To urge the government of Iraq to ensure that the camp be connected without delay to the city’s electricity grid.”
…. Not ignoring their existence but bring them back into worlds of normal rights and recognition, not staying silent and standby, breaking the silence, that is what we need now. Putting the spotlights on injustice and turning that around, that is what we need now. Pushing the international community towards unambiguous action, that is what we ask here and now. …”

Best, Hassan
Baby stillborn, family alleges medical negligence
Bengaluru, June 19, 2015, DHNS

Family members of a woman have lodged a complaint of negligence against doctors at the State-run Vani Vilas Hospitals following the birth of a stillborn
IMA Uttarakhand State Branch
IMA Blood Bank of Uttarakhand celebrated “World Blood Donor Day” on 14th June, 2015 and organized various voluntary blood donation camps in different places. A total of 239 units were collected in the camps (146 units from the camp organized at Military Hospital, Lansdowne, 50 units in Inhouse Camp which was in association with Amarujala Foundation, 21 in Red Mobile Van, 22 in Yellow Mobile Van).
SMS of the Day
IMA Rise & Shine

After surgery, surgeons are expected to devote time for check up even on holidays. It is part and parcel of their duty. (NCDRC)

Dr Pillai                                                       Dr KK
Inspirational Story
Sand and Stone

It’s a story of two friends who were walking through the desert. In a specific point of the journey, they had an argument, and one friend slapped the other one in the face.

The one, who got slapped, was hurt, but without anything to say, he wrote in the sand: "Today, my best friend slapped me in the face".

They kept on walking, until they found an oasis, where they decided to take a bath. The one who got slapped and hurt started drowning, and the other friend saved him. When he recovered from the fright, he wrote on a stone: "Today my best friend saved my life".

The friend who saved and slapped his best friend, asked him, "Why, after I hurt you, you wrote in the sand, and now you write on a stone?"

The other friend, smiling, replied: "When a friend hurts us, we should write it down in the sand, where the winds of forgiveness get in charge of erasing it away, and when something great happens, we should engrave it in the stone of the memory of the heart, where no wind can erase it".
Wellness Blog
Do not replace saturated fat with refined carbohydrates: white sugar, white rice and white maida may be more harmful

It is wrong to say eat less fat; the real message should be eat more fresh fruits and vegetables.

White advocating low–fat diets it is easier for patients to understand advice given in terms of foods e.g., "Eat more fresh fruit" rather than nutrients or "Reduce your intake of fat to less than 30 percent of your total energy intake."

The message to reduce fat has been translated by food manufacturers and consumers into a potentially harmful set of food choices.

Instead of replacing high–fat foods with naturally low–fat foods with other benefits, such as fruits, vegetables, legumes, and whole grain foods, consumers have often increased their consumption of low–fat or "fat–free" varieties of naturally high–fat foods, such as fat–free snack or junk foods.

The result is an increase in refined carbohydrates which lower good HDL–cholesterol concentrations with a possible increase in the incidence of type 2 diabetes and obesity, and failure to gain the benefits of more.
Quote of the Day
By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest. Confucius
IMA in Social Media
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Twitter @IndianMedAssn 1002 followers
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IMA Humor
Interview with Chris Gayle’s son

Beta, which standard are you in?


And how far is your school?
– At a distance of 10 SIXES from home.

Okay, tell me how much is a dozen?

How many months are in a year?

How many days are in a month?

Umm… ok, I wanna talk to your father, can you give me his no.?
Reader Response
Dear Sir, Very informative news. Regards: Dr Kanchan
Rabies News (Dr A K Gupta)
Can a rabies vaccine be given to a pregnant woman?

Following animal bite, rabies vaccine can be given to a pregnant woman. Medical termination of pregnancy should not be done as a routine clinical practice.
IMA Videos
News on Maps