Intranasal esketamine may improve symptoms of Treatment-resistant depression and fibromyalgia, reports study

Intranasal esketamine may improve symptoms of Treatment-resistant depression and fibromyalgia, reports a paper presented at American Psychiatric Association (APA) 2024 Annual Meeting.

Treatment-resistant depression with intranasal esketamine was linked to improvements in major depressive disorder (MDD) symptoms and fibromyalgia pain, a patient case showed. The US Food and Drug Administration approved esketamine (Spravato) for treatment-resistant depression and depressive symptoms in adults with MDD who had acute suicidal ideation in 2019. Since then, the FDA warned using a compounded ketamine nasal spray to treat psychiatric disorders puts patients at risk. Esketamine may be derived from racemic ketamine, but it is safe to treaty psychiatric disorders. Although esketamine is approved for treatment-resistant depression, research suggests it can help other conditions, too. After intranasal esketamine, a 40-year-old female on intranasal esketamine had incident improvements for both MDD and chronic fibromyalgia pain. She wasn’t the first patient to experience pain relief after esketamine. Another patient with treatment-resistant depression the investigators studied received remission for their chronic migraine headaches through 6 months of treatment. Other patients with treatment-resistant depression on esketamine experienced pain relief from pain syndromes such as diabetic peripheral neuropathy, lower back pain, and sciatica, on the day of dosing.

A study earlier this year found low dose esketamine improves acute postoperative pain in patients undergoing thoracoscopic surgery without increasing adverse events. Investigators of the study suggest the underlying mechanism may be linked to postoperative inflammation. In this study, the esketamine group had no decreased depression scores after the surgery. However, for fibromyalgia pain, intranasal esketamine demonstrated to lessen the discomfort, as demonstrated by one patient’s case presented at the annual American Psychiatric Association (APA) 2024 conference. The patient had treatment-resistant depression, as well as anxiety, irritable bowel syndrome (IBS), dysesthesia, poor concentration, low energy, and weight gain. She tried many oral antidepressants and augmentation agents to alleviate depressive symptoms. Antidepressants helped symptoms a bit, but they were still inadequate. Before her esketamine treatment, she took bupropion extended-release 450 mg and venlafaxine extended-release 225 mg daily. Her esketamine regimen started with an initial 56 mg dose on the first day to establish tolerability. Afterward, she received esketamine 84 mg intranasal twice weekly for 4 weeks and followed by once weekly for 4 weeks. The patient’s depressive symptoms improved within days of beginning esketamine. The treatment also improved her sleep. Since depressive symptoms returned after switching to a biweekly dosing, she returned to weekly dosing. Along with reducing depressive symptoms, esketamine provided pain relief from fibromyalgia pain. She rated her baseline pain as 7 – 8 daily on a 10-point scale with aggravations to 9 or 10. After esketamine, she rated her pain as 2 – 3, except for a score of 4 on day 6 and a score of 7 on the 1-week inter-dose interval. The response lasted over a 10-month course of treatment. When doses were 11 or 9 days a part, the patient rated her breakthrough pain as 6 – 7.

Reference:
Fichtner, Christopher. Incident Pain Relief with Esketamine for Depression: Sustained Benefit in Fibromyalgia and Migraine. Paper presented at: American Psychiatric Association (APA) 2024 Annual Meeting. New York, NY. May 4-8, 2024.

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Second-generation supraglottic airway device effective intubation tool even for emergency airway management: Study

Recently published study aimed to assess the Ambu® Aura-i™ as an independent ventilatory device and conduit for fiberoptic-guided endotracheal intubation in adults. The Ambu® Aura-i™ is designed as a second-generation supraglottic airway device and is compatible with standard cuffed tracheal tubes, phthalate-free, and MRI-compatible. A descriptive observational study was conducted with 80 patients to evaluate the efficiency of the Ambu® Aura-i™ in various aspects.

Following the induction of general anesthesia, the Ambu® Aura-i™ was inserted, and fiberoptic examination of the glottis was conducted. The ease of insertion, time for insertion, glottic view grading, ease of intubation, success rate, time for fiberoptic-guided intubation, and removal duration were recorded. The Ambu® Aura-i™ was found to be easy to insert, with negligible variation in insertion and intubation times between different patient groups.

Comparison of Insertion and Intubation

Both groups experienced similar ease of insertion, with average insertion times being around 13-14 seconds and fiberoptic-guided intubation times averaging about 14 seconds. The success rate for the first attempt intubation was around 75-87.5% in both groups, and the removal duration of the Ambu® Aura-i™ from the tracheal tube was comparable in both groups.

Study Findings and Conclusion

No significant adverse events were reported, and the device was found to be suitable for various age groups and compatible with MRI machines. The study concluded that the Ambu® Aura-i™ is an effective and appealing ventilatory device and intubation tool for both normal and emergency airway management.

Overall Assessment and Limitation

Overall, the study demonstrated that the Ambu® Aura-i™ is an efficient and cost-effective ventilatory device and intubation tool, making it both anesthetist- and patient-friendly, and has potential use in fiberoptic-guided airway management in both operating theaters and the ICU. However, a limitation of the study was the restriction to only sizes 3 and 4 of the Ambu® Aura-i™, limiting its use to patients weighing up to 70 kg.

Key Points

– The study assessed the Ambu® Aura-i™ as a ventilatory device and conduit for fiberoptic-guided endotracheal intubation in adults, concluding that the device is easy to insert, with negligible variation in insertion and intubation times between different patient groups. The average insertion times were around 13-14 seconds, and fiberoptic-guided intubation times averaged about 14 seconds. The success rate for the first attempt intubation was around 75-87.5% in both groups, and the removal duration of the Ambu® Aura-i™ from the tracheal tube was comparable in both groups.

– The study found no significant adverse events and concluded that the Ambu® Aura-i™ is an effective and appealing ventilatory device and intubation tool for both normal and emergency airway management. It is considered suitable for various age groups and compatible with MRI machines. The research suggests that the device is efficient, cost-effective, anesthetist- and patient-friendly, and has potential use in fiberoptic-guided airway management in operating theaters and the ICU.

Reference –

Mishra N, Sinha N, Kharwar R K, et al. (April 20, 2024) Clinical Assessment of the Ambu® Aura-i™ as an Independent Ventilatory Device and Conduit for Fiberoptic-Guided Endotracheal Intubation in Adults. Cureus 16(4): e58629. DOI 10.7759/cureus.58629

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Multi-Ingredient Supplement Shows Promising Results for Dry Eye Disease in Clinical Trial

USA: Dry eye disease (DED) affects millions worldwide, causing discomfort and impairing vision quality. However, a glimmer of hope emerges from the latest research findings published in the Frontiers in Ophthalmology. A novel multi-ingredient supplement has demonstrated remarkable efficacy in alleviating ocular symptoms and improving tear production among patients with DED, according to results from a rigorous randomized, placebo-controlled clinical trial.

The study showed that a novel nutritional supplement of lutein, zeaxanthin isomers, curcumin, and vitamin D3 (LCD) demonstrated therapeutic potential as a once-daily treatment for patients with dry eye disease.

“Once-daily LCD supplementation significantly improved tear production, quality and stability, improved participants’ symptoms, and reduced ocular surface damage and inflammation,” the researchers reported. They suggested that LCD supplementation could offer a useful adjunct to artificial tears for patients with DED.

The multi-ingredient supplement is formulated with a synergistic blend of nutrients and compounds that support ocular health, including omega-3 fatty acids, antioxidants, and essential vitamins. This unique combination targets multiple pathways involved in DED pathogenesis, providing comprehensive relief from symptoms and promoting long-term eye health.

While artificial tears are the traditional mainstay of treatment for DED, addressing the underlying pathophysiology could relieve symptoms and prevent progression. Considering this, Neda Gioia, Integrative Vision Corp, Shrewsbury, NJ, United States, and colleagues evaluated the safety and efficacy of a proprietary blend of lutein, zeaxanthin isomers, curcumin, and vitamin D3 as a daily supplement in adult participants with DED.

The study Participants were randomized to receive one LCD supplement capsule (zeaxanthin isomers 4 mg, lutein 20 mg, curcumin 200 mg curcuminoids, and vitamin D3 600 IU) or placebo per day for eight weeks (LCD, n=77; placebo, n=78). Primary outcomes were changes in ocular symptoms (Ocular Surface Disease Index [OSDI] and tear volume (Schirmer’s test).

The following were the study’s key findings:

  • The study met its primary endpoints: the LCD group demonstrated significantly better Schirmer’s test scores, and improvement in overall OSDI score, versus placebo, at Day 56.
  • Scores for total OSDI, and symptoms and vision domains, significantly improved by Day 14 for LCD versus placebo, and were maintained to Day 56.
  • In addition, the LCD group demonstrated significantly improved tear film break-up time (TBUT) and tear film osmolarity, versus placebo, by Day 56, along with significant improvements in corneal and conjunctival staining, and inflammation (matrix metalloproteinase-9).
  • Total Standard Patient Evaluation of Eye Dryness (SPEED) score, and scores for the frequency and severity domains were significantly improved by Day 14 for LCD versus placebo and maintained to Day 56.
  • There was no difference between groups for artificial tear usage. The supplement was well-tolerated.

In conclusion, the trial highlights the benefits to patients with DED of anti-inflammatory and antioxidant nutritional support with this proprietary supplement by addressing the characteristic loss of tear homeostasis, improving their experience of symptoms, and ameliorating the ocular inflammation and damage that are the basis of DED pathophysiology.

Reference:

Gioia N, Gerson J, Ryan R, Barbour K, Poteet J, Jennings B, Sharp M, Lowery R, Wilson J, Morde A, Rai D, Padigaru M and Periman LM (2024) A novel multi-ingredient supplement significantly improves ocular symptom severity and tear production in patients with dry eye disease: results from a randomized, placebo-controlled clinical trial. Front. Ophthalmol. 4:1362113. doi: 10.3389/fopht.2024.1362113

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Dequalinium Chloride Matches Metronidazole in Efficacy for Treating Bacterial Vaginosis: JAMA

Researchers have found that dequalinium chloride, a broad-spectrum antiseptic, is as effective as oral metronidazole for treating bacterial vaginosis (BV) with better tolerability and fewer adverse events. This phase 4, multicenter, triple-blind, double-dummy, noninferiority randomized clinical trial suggests that dequalinium chloride could be a promising non antibiotic treatment option for BV. This study was published in the journal JAMA Network Open by Raba G. and colleagues.

Bacterial vaginosis is a common cause of vaginal infection, with metronidazole and clindamycin being the first-line treatments. Due to rising concerns about antibiotic resistance, the need for effective non antibiotic treatments is growing. Dequalinium chloride, a broad-spectrum antiseptic, has been examined to determine if it is noninferior to oral metronidazole for treating BV.

The trial, conducted from July 29, 2021, to August 25, 2022, included 147 premenopausal women aged 18 years or older diagnosed with BV from 11 gynecologic practices and one hospital in Poland, Slovakia, and the Czech Republic. Participants were randomized to receive either dequalinium chloride vaginal tablets (10 mg once daily for six days) or oral metronidazole (500 mg twice daily for seven days). Double-dummy medication kits contained both vaginal and oral tablets with either placebo or active medication.

The main outcome was the non-inferiority margin of 15 percentage points in the absolute difference in clinical cure rates between dequalinium chloride and metronidazole 7 to 11 days after starting treatment (visit 1). Noninferiority was achieved if the lower 95% confidence interval for the difference in clinical cure rate was less than 15 percentage points.

The key findings of the study were as follows:

  • At visit 1, the clinical cure rate was 92.8% for dequalinium chloride and 93.2% for metronidazole in the intention-to-treat population.

  • The treatment differences confirmed the noninferiority of dequalinium chloride, with a difference of −0.5 percentage points (95% CI, −10.8 to 9.8 percentage points; P = .002) in the intention-to-treat population and 2.5 percentage points (95% CI, −9.4 to 14.4 percentage points; P = .001) in the per-protocol population.

  • Dequalinium chloride was rated as very good by 60% of patients compared to 38.9% for metronidazole.

  • Three patients in the metronidazole group suspended treatment due to adverse events.

Given the similar high cure rate and improved tolerability, dequalinium chloride could be considered as a first-line treatment for BV, offering an alternative to antibiotics and helping to reduce antibiotic consumption.

The trial demonstrates that dequalinium chloride is noninferior to oral metronidazole for treating bacterial vaginosis. It provides similar efficacy with better tolerability and fewer adverse events, making it a potential first-line treatment option for BV.

Reference:

Raba, G., Ďurkech, A., Malík, T., Bassfeld, D., Grob, P., Hurtado-Chong, A., Botta, S., Sach, A., Golańska – Wróblewska, M., Paškala, M., Romanek-Piva, K., Sládičeková, R., Skřivánek, A., Sudek, P., & Fluomizin Study Group. (2024). Efficacy of dequalinium chloride vs metronidazole for the treatment of bacterial vaginosis: A randomized clinical trial. JAMA Network Open, 7(5), e248661. https://doi.org/10.1001/jamanetworkopen.2024.8661

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Preserving subacromial bursa in rotator cuff repair may improve patient outcomes, finds study

Over 500,000 surgeries are performed every year in the US to repair rotator cuff injuries, but a significant number of these procedures do not achieve the desired outcomes. A recent research published in the Science Translational Medicine journal suggests that a reevaluation of surgical practices like the routine removal of the subacromial bursa may be required.

The subacromial bursa is a synovial-like tissue located between the rotator cuff and the acromion. Traditionally, it has been removed during rotator cuff surgeries due to its perceived role in contributing to shoulder pathologies. However, this study utilized proteomic profiling of bursa samples from patients with rotator cuff injuries provides compelling evidence that the bursa actually plays a beneficial role in the healing process.

The study analyzed the response of bursa to tendon injuries in both human patients and a rat model and found that the bursa not only helped to maintain the mechanical properties of the intact infraspinatus tendon which lies next to the injured supraspinatus tendon, but also protected the underlying humeral head by preserving bone morphometry. This protective mechanism suggests that the bursa has a more complex and constructive role than previously understood.

Further experiments in the rat model revealed that the bursa stimulated an inflammatory response that is pivotal for wound healing in the injured tendon. This was marked by the initiation of genes associated with healing processes like the Cox2 and Il6. The positive influence of the bursa was also observed in rat bursa organ cultures by reinforcing the findings from live animal models.

This study involved the use of polymer microspheres loaded with dexamethasone which were delivered to intact bursae of rats after a tendon injury. The release of dexamethasone from the microspheres effectively reduced the expression of inflammatory markers like Il1b in the injured tendon. This research highlights the potential of the subacromial bursa as a novel target for drug delivery systems to enhance the healing process by modulating inflammation directly at the injury site. Overall, the study suggest that preserving the subacromial bursa during rotator cuff repairs could improve patient outcomes by utilizing the natural protective and healing properties of bursa. 

Reference:

Marshall, B. P., Ashinsky, B. G., Ferrer, X. E., Kunes, J. A., Innis, A. C., Luzzi, A. J., Forrester, L. A., Burt, K. G., Lee, A. J., Song, L., Lisiewski, L. E., Soni, R. K., Hung, C. T., Levine, W. N., Kovacevic, D., & Thomopoulos, S. (2024). The subacromial bursa modulates tendon healing after rotator cuff injury in rats. In Science Translational Medicine (Vol. 16, Issue 744). American Association for the Advancement of Science (AAAS). https://doi.org/10.1126/scitranslmed.add8273

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Justify dose and rationality: CDSCO Panel Tells Dr. Reddy’s Lab on Sacubitril-Valsartan tablets 25 mg

New Delhi: Noting that the proposed protocol is insufficient to prove the clinical relevance of the lower strength of Sacubitril/Valsartan (12mg/13mg), the Subject Expert Committee (SEC) functional under the Central Drug Standard Control Organisation (CDSCO) has opined the drug major Dr. Reddy’s Lab to submit a revised protocol with more justification on the proposed dose and its rationality for further evaluation.

This came after Dr. Reddy’s Lab applied for the manufacture and market of Sacubitril and Valsartan tablets 25mg (as additional strength) indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction with bioequivalence (BE) and clinical trial (CT) waiver.

However, in light of an earlier SEC recommendation held on 09/01/2024 on a similar proposal deliberated for another firm wherein the committee opined that the firm should provide more justification on the proposed dose and its rationality.

In line with the above, the firm submitted a Phase II clinical trial protocol titled “A double blind, multicentre, comparative, Phase II study to evaluate the efficacy and safety of low dose sacubitril/valsartan (12mg/13mg) twice daily of Dr. Reddy’s Laboratories Limited in comparison to sacubitril/valsartan (24mg/26mg) twice daily in adult patients with heart failure and reduced left ventricular ejection fraction” and presented their proposal before the committee.

Sacubitril and valsartan combination is used together with other medicines to treat chronic heart failure in adults and cut down on the number of hospital visits for heart problems. It is also used to treat symptomatic heart failure in children 1 year of age and older.

Sacubitril is a neprilysin inhibitor used in combination with valsartan as an adjunct to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.

Sacubitril’s active metabolite, LBQ657 inhibits neprilysin, a neutral endopeptidase that would typically cleave natriuretic peptides, which includes: atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and c-type natriuretic peptide (CNP). ANP and BNP are released under atrial and ventricle stress, which activate downstream receptors leading to vasodilation, natriuresis, and diuresis.

Valsartan is an angiotensin-receptor blocker used to manage hypertension alone or in combination with other antihypertensive agents and to manage heart failure in patients who are intolerant to ACE inhibitors.

Valsartan belongs to the angiotensin II receptor blocker (ARB) family of drugs, which selectively bind to angiotensin receptor 1 (AT1) and prevent angiotensin II from binding and exerting its hypertensive effects. These include vasoconstriction, stimulation, and synthesis of aldosterone and ADH, cardiac stimulation, and renal reabsorption of sodium among others. Overall, valsartan’s physiologic effects lead to reduced blood pressure, lower aldosterone levels, reduced cardiac activity, and increased excretion of sodium.

Sacubitril/valsartan’s combined action increases endogenous natriuretic peptides while inhibiting the renin-angiotensin-aldosterone system and exerting cardioprotective effects.

At the recent SEC meeting for Cardiovascular held on 21st March 2024, the expert panel reviewed the application presented by the drug major Dr Reddy’s Lab to manufacture and market Sacubitril and Valsartan tablets 25mg (as additional strength) and Phase II clinical trial protocol to evaluate the efficacy and safety of low dose sacubitril/valsartan (12mg/13mg) twice daily of Dr. Reddy’s Laboratories Limited in comparison to sacubitril/valsartan (24mg/26mg) twice daily in adult patients with heart failure and reduced left ventricular ejection fraction.

After detailed deliberation, the committee opined that the proposed protocol is insufficient to prove the clinical relevance of the lower strength of Sacubitril/Valsartan (12mg/13mg).

Hence, the expert panel suggested that the firm should submit a revised protocol with more justification on the proposed dose and its rationality for further review by the committee.

Also Read: Submit global regulatory status of Atezolizumab for IV, SC route: CDSCO Panel Tells Roche Products India

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NBE changes NEET PG 2024 exam pattern last minute, Doctors see red

New Delhi: With the last-minute changes to the NEET PG 2024 exam pattern, the doctors are concerned over the National Board of Examination (NBE) decision. 

Announcing modifications in the exam patterns in all MCQ-based examinations, such as NEET-PG, NEET-MDS, NEET-SS, FMGE, DNB-PDCET, GPAT, DPEE, FDST, and FET, the NBE recently introduced mandatory time-bound sections. However, doctors under the Federation of All India Medical Association (FAIMA) have expressed concern over these last-minute revisions in the NEET-PG 2024 exam pattern opining that such significant changes require adequate time for adaptation and preparation, which the current timeline does not afford.

Medical Dialogues recently reported that through a notice dated 04.05.2024, NBE had announced that it introduced time-bound sections as a measure to enhance the security and sanctity of the exams in light of emerging threats during the examination process. Releasing details of the mandatory timed sections in MCQ-based examinations, NBE mentioned that the question papers in the examinations mentioned above including NEET PG would be divided into multiple time-bound sections.

“For example, in NEET-PG 2024, if there are five time-bound sections (A, B, C, D & E) in the question paper, each section will have 40 questions and 42 minutes of time allotted. Candidates will be restricted from proceeding to the next section until they complete the allotted time for the previous section. Additionally, candidates will not be allowed to review the questions or modify their responses for a section after the completion of its allotted time. The questions for the next section will start automatically after the completion of the allotted time for the previous section,” NBE mentioned in the notice.

The natboard further informed that the candidates would be given the option to mark any question, whether attempted or not, for review. This means that the candidates can go through these marked questions in a section again before the allotted time for that section ends.  As per the NBE notice, the questions marked for review will be evaluated according to the marking scheme as mentioned in the Information Bulletin of the respective examination and the actual number of time-restricted sections in an examination may vary based on the total number of questions in the question paper and operational feasibility in creating such sections.

However, expressing displeasure with the last-minute changes in the NEET PG 2024 exam pattern, FAIMA recently wrote to the NBE Executive Director. While the association acknowledged the importance of maintaining the security and sanctity of examinations and also appreciated the measures implemented to address the emerging threats, it also expressed concerns regarding the recent decision to introduce mandatory time-bound sections in NEET PG examinations.

“As you are aware, NEET PG aspirants already face Immense pressure and time constraints during the exam period. The sudden Introduction of mandatory time-bound sections adds an additional layer of stress and uncertainty, affecting the performance and well-being of the aspirants,” FAIMA mentioned in the letter.

“We believe that such significant changes require adequate time for adaptation and preparation, which the current timeline does not afford. Therefore, we respectfully request reconsideration of the decision to implement mandatory time-bound sections In the upcoming NEET PG examinations. Instead, we propose that these changes be implemented gradually, allowing aspirants sufficient time to adapt and prepare effectively. We trust that you will give due consideration to our concerns and take necessary steps to address them. Your prompt action in this matter is highly appreciated and will contribute to the welfare and success of NEET PG aspirants across the country,” it further added.

Meanwhile, sharing the NBE notice on X (formerly Twitter), the National Chairman of FAIMA, Dr. Rohan Krishnan also urged the authorities to cancel these changes. He wrote in an X post, “We are always against any kind of changes which are last minute. @NbeIndia should refrain from treating young aspirants who are graduates doctors like lab rats. @FAIMA_INDIA_ stands against this last minute modifications in exam/exam patterns. Requesting @NbeIndia to cancel this.”

Commenting on the matter, Dr. Rohan Krishnan told Medical Dialogues, “It is a very last-minute step. The examinees are already very stressed and we are always very particular about this because this is an exam which has 40,000 to 60,000 seats and more than 3-4 lakh doctors who are appearing for this exam. This exam happens only once a year, so it is a very important day and it is going to happen pan-India. So, obviously, it is a very important examination.”

“For any examination, the pattern should be declared before 6 months and after that, there should not be any changes. Now, the exam is going to happen in June itself and at present these changes are only going to create a lot of panic among the students and it is going to create more stress in the already stressful state of the NEET PG aspirants,” he further added.

Also Read: NEET PG 2024 exam pattern revised! NBE introduces time-bound sections in all its computer-based tests- NEET SS, NEET MDS, FMGE and more

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NBE introduces time-bound sections in all its computer-based tests- NEET PG, NEET SS, NEET MDS and more

NEET PG 2024 exam will now have time-bound sections. The announcement in the exam pattern was recently made by the National Board of Examination (NBE) which has decided to introduce mandatory time-bound sections in all its MCQ-based examinations, such as NEET-PG, NEET-MDS, NEET-SS, FMGE, DNB-PDCET, GPAT, DPEE, FDST and FET which are conducted on a computer-based platform.

According to the NBE notice, this measure has been implemented to enhance the security and sanctity of the exams in light of emerging threats during the examination process.
For more information click on the link below:

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Issue of non-payment of stipends to MBBS interns to be considered by SC

The issue of non-payment of stipends to MBBS interns and resident doctors at medical colleges across the country will be considered by the Supreme Court today i.e. on May 6, 2024.

During the hearing on the issue last month, the Apex Court directed the National Medical Commission (NMC) to submit the details of the stipend paid to the MBBS interns in all the medical colleges across all States within four weeks.
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5 Gujarat medical colleges gets NMC show-cause notice over faculty deficiencies

Taking serious cognizance of the massive faculty deficiencies, the National Medical Commission (NMC) has sent show-cause notices to 5 medical colleges in Gujarat.

According to the Ahmedabad Mirror report, at least five medical colleges and hospitals (MCHs) in Gujarat have received these show-cause notices. Observing severe shortages of medical teachers, tutors, and resident doctors across departments, the Apex Medical Regulator has warned to reduce the MBBS seats in these medical colleges and impose high monetary penalties on these institutes.
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