Friday, 20 June 2008
Wednesday, 18 June 2008
Progression of Mild Cognitive Impairment Visualized on PET
The use of molecular imagining might help clinicians monitor the progression of mild cognitive impairment (MCI) and help to identify people at risk for Alzheimer's disease (AD), according to a study presented here at the Society of Nuclear Medicine 2008 Annual Meeting.
"We can now visualize in vivo changes in the brain that correlate with clinical testing. Not all patients with MCI progress to AD. We think we will eventually be able to determine which persons will," Chester Mathis, PhD, professor of radiology at the University of Pittsburgh, in Pennsylvania, told Medscape Radiology.
He and his colleagues evaluated molecular changes in the brains of people with MCI using positron-emission tomography (PET) and the Pittsburgh compound-B (PiB) radiotracer. PiB binds to the beta-amyloid plaques believed to be responsible for the development of AD. PiB levels above a cut-off threshold of 1.44 to 1.48 distribution volume ratio, depending on the brain region affected, were considered to be elevated (that is, PiB positive).
The longitudinal study included 23 people diagnosed with MCI (mean age, 70 years). The study also included 5 mild- to moderate-AD patients and 33 elderly controls. Subjects underwent baseline PiB scans and were followed for 2 to 4 years, either clinically or with repeat scans.
"Our hypothesis was that MCI subjects with amyloid plaque (based on PiB elevations) would develop AD, and those without plaque would not," Dr. Mathis said.
At baseline, 13 of 23 (57%) MCI subjects were PiB positive, and 10 of 23 (43%) were PiB negative. Among the 13 PiB-positive patients, 5 progressed to AD. None of the PiB-negative patients progressed; in fact, 6 remained stable and 4 actually reverted to normal. "This was probably because there were other reasons for their MCI, such as depression or drug use, which change over time," he explained.
Amyloid Plaque Burden and AD
"We found that about 60% of the MCI subjects already had plaque loads comparable to AD subjects, whereas about 35% had no detectable plaque," he said. "This means that about 15% of MCI subjects per year converted to AD."
"These are slow changes in the amyloid plaque burden from year to year, barely above the test/retest variability. The changes conform to the hypothesis generated by postmortem studies, which is that the full transition from a situation of very little plaque to substantial plaque occurs over the course of about 10 years. This is exactly what our imaging told us," he said in his presentation.
In the elderly control group, about 25% had significant plaque deposition but were asymptomatic, which indicates future risk for AD. Of the 5 people with established AD (all PiB positive at baseline), only 2 had further increases in PiB levels, indicating that "there may be a ceiling to plaque deposition," he added.
Diagnostic Value of PiB
Daniel H. Silverman, MD, head of the neuronuclear imaging research group at the UCLA School of Medicine, in Los Angeles, California, and moderator of the session, told Medscape Radiology that he has concerns about the diagnostic and prognostic utility of PiB in MCI, as opposed to fluorodeoxyglucose (FDG), which has been found to be highly sensitive, even in young adults. Although there is "overwhelming evidence" that imaging with FDG-PET can accurately identify and assess people with MCI and dementia, the role of PiB is less established, he said.
For one thing, PiB depends on the presence of extracellular amyloid plaque, which can also be observed in cognitively intact people. Furthermore, most PiB studies have not been confirmed with postmortem findings, unlike those with FDG-PET, he pointed out.
"When you try to compare the diagnostic accuracy of PiB and FDG-PET without autopsy confirmation, you are not only on shaky ground, you have buried yourself under the rubble of the ensuing earthquake," he commented, adding that, for prognostic purposes, shorter follow-up, as in this study, is acceptable. In addition, the investigators remained appropriately conservative in terms of their conclusions, he noted.
"So far, the data are insufficient to determine whether this test has prognostic utility, let alone whether it is better than FDG-PET," he said. "But PiB could expedite the development of agents aimed at reducing the amyloid plaque burden, and be useful in monitoring in this setting."
Society of Nuclear Medicine 2008 Annual Meeting: Abstract 139. Presented June 16, 2008.
Dermoid and Epidermoid, Oral Cavity
Dermoids and epidermoids most commonly involve the floor of mouth in the submandibular space (SMS), sublingual space (SLS) or root of tongue (ROT).
Epidermoid and dermoid cysts are benign lesions encountered throughout the body, with 7% occurring in the head and neck area. The orbit is the most common site in the head and neck for these congenital lesions. They rarely occur within the oral cavity, representing less than 0.01% of all oral cavity cysts.
These congenital cysts are dysembryogenetic lesions that arise from ectodermal elements entrapped during the midline fusion of the first and second branchial arches between the third and fourth weeks of intrauterine life. Acquired cysts may be derived from traumatic or iatrogenic inclusion of epithelial cells or from the occlusion of a sebaceous gland duct.
The cysts can be classified as epidermoid when the lining presents only epithelium, dermoid cysts when dermal appendages are found, and teratoid cysts when other tissue such as muscle, cartilage, and bone are present. The teratoid type is the only variety that may have a malignant change.
Anatomically, these oral cavity cystic lesions most commonly involve the floor of mouth and may occur in the root of tongue (ROT), submandibular space (SMS) or sublingual space (SLS). Dermoid cysts generally present with slow and progressive growth, and even if they are congenital, the diagnosis is usually possible in the second or third decade of life. Midline cysts of the floor of the mouth present as painless subcutaneous or submucosal lesions. When large, they can displace the tongue and result in dysphagia, dysphonia or dyspnea.
Epidermoids present on imaging as low density, unilocular, well circumscribed simple cystic lesion. Dermoid cysts are usually more heterogeneous with fatty internal material and possibly calcification.
The treatment of dermoid cysts of the floor of the mouth is extracapsular excision with an intraoral or external approach, depending on the size of the lesion and the position relative to the mylohyoid muscle. The entire cyst must be removed to prevent recurrence.
Preventing Contrast Induced Nephropathy
Michael Smith
Overview
Contrast induced nephropathy (CIN) is a serious concern for today’s emergency physician when ordering contrast enhanced imaging. CIN is usually defined by an increase in serum creatinine by 0.5 mg/dL or 25% from baseline that usually occurs 2-3 days after contrast administration.[1] The incidence of CIN is estimated to be 1-2% in the general population, but the relative risk is greatly increased in diabetics, the elderly, and those with intrinsic renal disease, congestive heart failure, and dehydration.[1,2] It is the duty of the emergency physician ordering the study to assess risk of developing CIN, as other care providers may not adequately identify patients at risk.[3] Careful selection of patients for contrast imaging is paramount especially in this day of frequent and profuse imaging of both medical[4] and trauma[5] patients.
Prevention
The first step in preventing CIN is determining if a contrast enhanced study is actually clinically indicated. For example, a reasonable starting point might be to employ judicious use of CT scans in trauma patients, a group in whom contrast-enhanced CT scanning is routinely ordered and whole body scanning has become rampant.[6] Screening with ultrasonography may facilitate a decrease in CT scans in both medical and trauma patients. Finally, contrast administration may prove unnecessary for certain patients. For instance, data indicates that the lack of contrast does not alter the sensitivity of an abdominal CT for appendicitis.[7]
Once it has been determined that contrast enhanced imaging is clinically indicated, a few preventative measures can be initiated. Sodium chloride hydration remains the mainstay of choice for CIN prevention.[8] Studies have also demonstrated benefit to administering sodium bicarbonate for preventing CIN.[9] Controversy remains regarding the minimal benefit of adding n-acetylcysteine (N-AC) to the treatment regimen.[10] The use of both theophylline and high dose ascorbic acid has been proposed, but no methodologically or statistically sound studies exist, making the measurement of efficacy of ascorbic acid and theophylline in preventing CIN uncertain. Unfortunately, the majority of studies address CIN induced as a result of coronary angiography. There is some thought that ED CT contrast might be slightly safer than angiography contrast, but we are only able to extrapolate based on the available data.
Application to Emergency Medicine
Prevention of contrast induced nephropathy remains as a significant challenge for today’s emergency physician. Sound clinical judgement regarding the actual need of a contrast enhanced study is essential. The responsibility of risk stratification to assess for potential development of CIN remains that of the emergency physician ordering the study. Sodium chloride and sodium bicarbonate hydration, while not risk free, remain fairly safe and reasonably effective means of preventing CIN. The utility of N-AC, ascorbic acid and theophylline is unproven at best. Most studies reflect the incidence and treatment of CIN induced by angiography contrast, rather than CT contrast. However, some extrapolation and application of the above principles may be useful.
References
Pucelikova T, et al: Contrast-induced nephropathy. Catheter Cardiovasc Interv. 2008 Jan 1;71(1):62-72. 17975790
Wong GT, Irvin MG: Contrast-induced Nephropathy. Br J Anaesth. 2007 Oct;99(4):474-83. 17681968
Reddan, D, Fishman, EK: Radiologists' knowledge and perceptions of the impact of contrast-induced nephropathy and its risk factors when performing computed tomography examinations: a survey of European radiologists. Eur J Radiol. 2008 May;66(2):235-45. 17728089
Broder J, et al: Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006. Emerg Radiol. 2007 Sep;14(4):227-32. 17505849
Beck D, et al: Prospective study of the clinical predictors of a positive abdominal computed tomography in blunt trauma patients. J Trauma. 2004 Aug;57(2):296-300. 15345975
Aucar J, et al: If a picture if worth a thousand words, what is a trauma computerized tomography panel worth? Am J Surg. 2007 Dec;194(6):734-9; discussion 739-40.
Tamburrini S: Accute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol. 2007 Aug;17(8):2055-61. Epub 2006 Dec 16. 17180324
Van Praet J, et al: Prevention of contrast-induced nephropathy: a critical review. Curr Opin Nephrol Hypertens. 2007 Jul;16(4):336-47.
Masuda M: Comparison of usefulness of sodium bicarbonate versus sodium chloride to prevent contrast-induced nephropathy in patients undergoing an emergent coronary procedure. Am J Cardiol. 2007 Sep 1;100(5):781-6. Epub 2007 Jun 13.
Brigouri C: Renal insufficiency following contrast media administration trial (REMEDIAL): a randomized comparison of 3 preventive strategies. Circulation. 2007 Mar 13;115(10):1211-7. Epub 2007 Feb 19. 17309916
The Incidental Adrenal Mass on CT
Julie H. Song; Fakhra S. Chaudhry; William W. Mayo-Smith
Am J Roentgenol. 2008;190(5):1163-1168.
Abstract and Introduction
Abstract
Objective: The purpose of our study was to determine the nature and prevalence of adrenal lesions identified on CT in patients with no known malignancy.
Materials and Methods: A computer search of abdominal CT reports using the term "adrenal" was performed in 65,231 consecutive patients with examinations performed from January 2000 to December 2003. An adrenal mass was identified in 3,307 (5%) patients. Patients with no known malignancy and no suspicion for a hyperfunctioning adrenal mass were further isolated. Nine hundred seventy-three patients with 1,049 adrenal masses fulfilled the study criteria. The nature of each lesion was determined by histopathology; imaging characterization with CT, MRI, or washout; a minimum of 1 year of stability on follow-up imaging; or clinical follow-up of at least 2 years.
Results: One thousand forty-nine adrenal masses were characterized with the following methods: histopathology (n = 12), imaging characterization (n = 909), imaging follow-up (n = 87), and clinical follow-up (n = 41). There were 788 adenomas constituting 75% of all lesions. There were 68 myelolipomas (6%), 47 hematomas (4%), and 13 cysts (1%). Three pheochromocytomas (0.3%) and one cortisol-producing adenoma (0.1%) were found incidentally. One hundred twenty-eight lesions (12%) were presumed to be benign by imaging or clinical stability. No malignant adrenal masses were found, even among the 14 patients who later developed malignancy elsewhere.
Conclusion: In 973 consecutive patients with an incidental adrenal mass and no history of cancer, no malignant lesions were identified. Adenomas (75%) and myelolipomas (6%) were the most common lesions.
References
Hedeland H, Ostberg G, Hokfelt B. On the prevalence of adrenocortical adenomas in an autopsy material in relation to hypertension and diabetes. Acta Med Scand 1968;184:211–214
Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally discovered adrenal masses. Endocr Rev 1995; 16:460 –484
Lee MJ, Hahn PF, Papanicolaou N, et al. Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size and observer analysis. Radiology 1991;179:415–418
Korobkin M, Brodeur FJ, Yutzy GG, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR 1996; 166:531 –536
Boland GW, Lee MJ, Gazelle GS, Halpern EF, McNichols MM, Mueller PR. Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature. AJR 1998;171:201–204
Mitchell DG, Crovello M, Matteucci T, Petersen RO, Miettinen MM. Benign adrenocortical masses: diagnosis with chemical shift MR imaging. Radiology 1992;185:345–351
Outwater EK, Siegelman ES, Radecki PD, Piccoli CW, Mitchell DG. Distinction between benign and malignant adrenal masses: value of T1weighted chemical-shift MR imaging. AJR 1995;165:579–583
Mayo-Smith WW, Lee MJ, McNicholas MM, Hahn PF, Boland GW, Saini S. Characterization of adrenal masses (< 5 cm) by use of chemical shift MR imaging: observer performance versus quantitative measures. AJR 1995; 165:91 –95
Korobkin M, Brodeur FJ, Francis IR, Quint LE, Dunnick NR, Londy F. CT time–attenuation washout curves of adrenal adenomas and nonadenomas. AJR 1998; 170:747 –752
Szolar DH, Kammerhuber FH. Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. Radiology 1998;207:369–375
Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology 2000; 217:798 –802
Abeshouse GA, Goldstein RB, Abeshouse BS. Adrenal cysts: review of the literature and report of three cases. J Urol 1959; 81:711 –718
Blake MA, Kalra MK, Sweeney AT, et al. Distinguishing benign from malignant adrenal masses: multi-detector row CT protocol with 10-minute delay. Radiology 2006;238:578–585
Caoili EM, Korobkin M, Francis IR, et al. Adrenal masses: characterization with combined unenhanced and delayed enhanced CT. Radiology 2002;222:629–633
Herrera MF, Grant CS, van Heerden JA, Sheedy PF, Ilstrup DM. Incidentally discovered adrenal tumors: an institutional perspective. Surgery 1991; 110:1014 –1021
Leifer DM, Middleton WD, Teefey SA, Menias CO, Leahy JR. Follow-up of patients at low risk for hepatic malignancy with a characteristic hemangioma at US. Radiology 2000;214:167–172
Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest 2006; 29:298 –302
Gajraj H, Young AE. Adrenal incidentaloma. Br J. Surg 1993; 80:422 –426
Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol 2003; 149:273 –285
Mantero F, Terzolo M, Arnaldi G, et al. A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. J Clin Endocrinol Metab 2000; 85:637 –644
Bülow B, Ahrén B; Swedish Research Council Study Group of Endocrine Abdominal Tumours. Adrenal incidentaloma: experience of standardized diagnostic programme in the Swedish prospective study. J Intern Med 2002;252:239–246
Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y, Bornstein SR. The clinically inapparent adrenal mass: update in diagnosis and management. Endocr Rev 2004;25:309–340
Benitah N, Yeh BM, Qayyum A, Williams G, Breiman RS, Coakley FV. Minor morphologic abnormalities of adrenal glands at CT: prognostic importance in patients with lung cancer. Radiology 2005; 235:517 –522
Heinz-Peer G, Hönigschnabl S, Schneider B, Niederle B, Kaserer K, Lechner G. Characterization of adrenal masses using MR imaging with histopathologic correlation. AJR 1999;173:15–22
Paulsen SD, Nghiem HV, Korobkin M, Caoili EM, Higgins EJ. Changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies. AJR 2004;182 :1033 –1037
Lam KY, Lo CY. Adrenal lipomatous tumours: a 30 year clinicopathological experience at a single institution. J Clin Pathol 2001; 54:707 –712
Olsson CA, Krane RJ, Klugo RC, Selikowitz SM. Adrenal myelolipoma. Surgery 1973; 73:665 –670
Mayo-Smith WW, Boland GW, Noto RB, Lee MJ. State-of-the-art adrenal imaging. RadioGraphics 2001;21:995–1012
Sevitt S. Post-traumatic adrenal apoplexy. J Clin Pathol 1955; 8:185 –194
Burks DW, Mirvis SE, Shanmuganathan K. Acute adrenal injury after blunt abdominal trauma: CT findings. AJR 1992; 158:503 –507
Rana AI, Kenney PJ, Lockhart ME, et al. Adrenal gland hematomas in trauma patients. Radiology 2004;230:669–675
Lee JE, Evans DB, Hickey RC, et al. Unknown primary cancer presenting as an adrenal mass: frequency and implications for diagnostic evaluation of adrenal incidentalomas. Surgery 1998; 124:1115 –1122
Caplan RH, Strutt PJ, Wickus GG. Subclinical hormone secretion by incidentally discovered adrenal masses. Arch Surg 1994; 129:291 –296
Motta-Ramirez GA, Remer EM, Herts BR, Gill IS, Hamrahian AH. Comparison of CT findings in symptomatic and incidentally discovered pheochromocytomas. AJR 2005;185:684–688
Grumbach MM, Biller BM, Braunstein GD, et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med 2003;138:424–429
Bernini GP, Moretti A, Oriandini C, Bardini M, Taurino C, Salvetti A. Long-term morphological and hormonal follow-up in a single unit on 115 patients with adrenal incidentalomas. Br J Cancer 2005; 92:1104 –1109
Tuesday, 17 June 2008
Now US radiology jobs for India
Arvinder Kaur in New Delhi | PTI | March 28, 2006 | 13:51 IST
With a large pool of well-trained doctors and high-tech infrastructure, India is fast emerging as a tele-radiology hub, providing offshore X-ray reporting services to the United States, Europe, Singapore and the Middle East.
In fact, with tele-radiology, there are no geographic boundaries!
According to estimates, the US is facing a shortage of radiologists with 20 per cent of vacancies going unfilled in hospitals.
"There is worldwide shortage of qualified radiologists and tele-radiology counters this by providing services from one area to another. It can be used to cover the night shift from another geographic zone or to cover remote areas where there are CT (computerised tomography) or other scanners but no radiologists to interpret the results," said Sunita Maheshwari, director, Telerad Solutions, Bangalore, which is pioneer in tele-radiology.
Outsourcing and India: Complete Coverage
"India has an optimal time advantage with the US in terms of providing emergency night shift services to the American hospitals. We also possess high technology infrastructure base, a large pool of well-trained doctors, skilled manpower and a lower cost of living," Maheshwari told PTI.
Tele-radiology means electronic transmission of radiological images, such as X-Rays, CTs and MRIs from one location to another for the purpose of interpretation and consultation.
The doctors here are thus providing diagnostic interpretation of all emergently and non-emergently performed non-invasive imaging studies, including compound tomography, MRI (Magnetic Resonance Imaging), ultrasound, X Ray, nuclear medicine studies and conventional plain films. In emergency setting, these services are provided with a turnaround time of less than 30 minutes.
"The scope of tele-radiology is enormous. One doctor sitting in a centralised reading facility can cover several hospitals at the same time making this a very efficient use of a radiologists time and skill," said Maheshwari.
However, Yatish Agarwal, a medical specialist at Safdarjung Hospital in New Delhi said "The scope has become limited because of certification problems. Only those doctors who have relocated from the US, can do offshoring to America. Such restrictions also exist in many European countries."
"Thus Indian doctors who have relocated from these countries can only do this job, which is limiting the scope of this work. However, as said tele-radiology knows no boundaries. It has immense scope even in Indian conditions. A doctor sitting in a remote area can discuss the results of an MRI or CT scan with a specialist in Mumbai or Delhi," points out Agarwal.
Agrees Maheshwari, but said "the US has around 20 per cent Indian doctors. And with telemedicine becoming popular, they can easily come back and start working from here. Five Indian radiologists from the US will be back in Bangalore by this year end."
Licensing barriers are there but they can be easily overcome. American doctors too come here and apply for a working licence. There are many FRCS (Fellow of the Royal College of Surgeons) doctors practising here. They all can work for the UK and countries, which recognise British degrees. Singapore has recently awarded recognition to our doctors, she added.
Within India also, the scope of tele-radiology is immense. The remote areas have limitations of infrastructure. There it can make the greatest impact. If a patient gets right diagnosis, he can be treated in the right manner, she said.
Tele-radiology is already working in Bijapur, Raipur and some backward areas also. "We have also started the service for a hospital in Kerala and remote areas in Karnataka," she said.
There are three main challenges facing healthcare -- quality, cost and time delivery. The goal of tele-radiology is to optimise the use of technology to tackle these challenges head on, said Maheshwari, noting, "We leverage technology every day as we work with hospitals that extend halfway around the world literally from Bijapur to Philadelphia."
Negotiating salary? 4 important tips
Meenakshi Subramaniam | BS | May 05, 2008 | 10:09 IST
When Sanjeev Verma took the offer to join a new company, he was quite happy with the cost-to-company salary that was offered to him.
However, after the first month, when the salary cheque came, he was shocked with the numbers. His actual take-home was slightly more than his previous salary. And,Verma is not alone.
There are many of us who get lured with the numbers that show in our CTC package, but when the actual take-home salary comes in our hand, it causes a lot of heartache. It is therefore very important that when you are negotiating the salary, you should have a clear idea about numbers. A good way to achieve this is by using tax saving strategies that would reduce your burden.
Ah! those slips that snip
The first thing to look for is the different heads in your salary package. Heads like performance incentive sound challenging, but they are always taxed. Special allowances, added with conveyance and phone reimbursement, also attract tax.
Often, there is a notion among salary-earners that a lesser basic pay and high allowances may bring down income tax burden. However, it is best if you avoid this approach. A reduced basic salary leads to a lower provident fund, which is a forced saving for your future.
Anyone who gets many allowances must combine all of them under a single head. Put car allowance, books reimbursement, house rent allowance, office travel allowance, phone, vehicle and staying in hotels under on head, which straight away lowers your tax bill. Call this consolidated allowance.
Allowances that help
Always go for conveyance allowance. A sum of Rs 800 a month is tax-free. Even if your office does not give conveyance allowance, you can ask for a reduced basic pay and additional conveyance allowance. This move can cut down tax outgo.
Daily allowance, wherever allowed, must be grabbed with both hands because it carries total tax exemption. Professional tax, up to Rs 2,500, is also unencumbered by tax. Also, office loans for car or personal reasons can be used to avoid taxation to a great extent.
Policies that pay
Employees State Insurance Scheme, if available, must be compulsorily availed. Unlike LIC schemes, the amount is absolutely free from income tax. Fidelity Guarantee Scheme is another insurance plan that is completely tax-free.
Even if you are contributing to a Public Provident Fund, a salaried individual must also opt for Employers Provident Fund, because this also doesn't attract tax. Many salaried people are unaware that a loan for medical treatment is exempt from income tax under Rule 3 A, but make sure that your medical insurance policy is not utilised.
Avoiding FBT
The fringe benefit tax can be avoided if you own a car and the company pays for maintenance and petrol bills. The most profitable way to claim HRA is to ask the company to take a house on lease, which is owned by any of your relatives. If it's your parents, who don't have any income, it works completely to your advantage.
It is because, on one hand, you claim HRA and they, having zero income, don't have to pay any tax. In fact, even if they have some income, but less than the stipulated base limit of Rs 220,000 a year (assuming they are retired), they would gain from the situation. The maximum benefit occurs when the rent is over 20 per cent of your salary.
When gift vouchers are given, insist on taking them under the employee welfare scheme.
Mobile phone bills are considered a perquisite and taxed, causing your office to fret a lot. You can again offer tax counselling by suggesting a simple trick.
The mobile phone bills can be placed under "recurring operative expenditure" head. All taxes are eliminated at one stroke. At home, leased phone landlines installed at the company's behest and cost, allows you to get rid of paying tax on calls.
Travel expenses and hotel stays are taxed under FBT. In fact, even a conference to discuss reducing tax incidence on perquisites will also be taxed! However, by not showing the expenditure as conference/seminar and calling it "convention" would remove the tax burden.
The office may want to give meals, breakfast or tiffin, but FBT fear precludes an employer from extending this perquisite to staff. Why not have an office "food and beverage" account? Show the claim in the income tax return.
The FBT will not apply, at all. Finally, soft furnishings for a house (such as curtains and table cloth), which give the abode a decent appearance for entertaining guests who drop in for official duties, can be shown as expenses. They also qualify for tax exemption.