September 17   2015, Thursday
eMedinewS
5 steps to lower Alzheimer’s risk (HealthBeat)
Dr KK Aggarwal
  • Maintain a healthy weight.
  • Check your waistline.
  • Eat mindfully. Emphasize colorful, vitamin-packed vegetables and fruits; whole grains; fish, lean poultry, tofu, and beans and other legumes as protein sources; plus healthy fats. Cut down on unnecessary calories from sweets, sodas, refined grains like white bread or white rice, unhealthy fats, fried and fast foods, and mindless snacking. Keep a close eye on portion sizes, too.
  • Exercise regularly. Aim for 2½ to 5 hours weekly of brisk walking (at 4 mph) or try a vigorous exercise like jogging (at 6 mph) for half that time.
  • Keep an eye on important health numbers. In addition to watching your weight and waistline, keep a watch on your cholesterol, triglycerides, blood pressure, and blood sugar numbers.
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Heart Care Foundation of India (HCFI) trains school children on the importance of healthy eating, hygiene and sanitation
News
Psychiatry
Eating fish may protect against depression, suggests a new meta-analysis published online in the Journal of Epidemiology and Community Health.

Neurology
Cardiac-based monitoring for an impending epileptic seizure and subsequent vagus nerve stimulation (VNS) has the potential to decrease seizure severity and duration and improve overall quality of life, suggested a study presented at the 31st International Epilepsy Congress (IEC).

Diabetes
New data on a needle-free nasal delivery system for glucagon, presented at the European Association for the Study of Diabetes (EASD) 2015 Meeting, for use in severe hypoglycemia appear promising. Researchers noted that needle-free nasal delivery of glucagon was faster and had a much higher success rate with fewer errors than delivery of glucagon via injection.

Critical Care
Clinicians can now refer to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), a new tool to help them determine when and how to use peripherally inserted central catheters (PICCs) and related venous access devices. The guide is published as a supplement to the Annals of Internal Medicine.

Oncology
A Mediterranean diet (MeDiet) appears to protect against breast cancer, suggest results from the randomized controlled Prevención con Dieta Mediterránea (PREDIMED) trial. The findings were published online September 14 in JAMA Internal Medicine.
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Cardiology eMedinewS
  • The European Society of Cardiology (ESC) has released new guidelines for the management of acute coronary syndrome (ACS) patients without persistent ST-segment elevation MI (STEMI), providing new guidance on the use of high-sensitivity troponin assays, dual antiplatelet therapy (DAPT), and the optimal time to start P2Y12 inhibition. The guidelines were published in the European Heart Journal.
  • Updated guidelines issued by the US Preventive Services Task Force recommend daily low-dose aspirin for the prevention of heart attack and stroke among adults aged 50-59 who are at high risk for cardiovascular disease.
Pediatrics eMedinewS
Pediatrics
Ophthalmology

Increasing the amount of time spent outdoors at school significantly reduced the progression of myopia in children over the course of 3 years, suggested a new randomized controlled trial published in the September 15 issue of JAMA.

Pediatrics
Neurology

In an extensive literature review, experts provide insights on the valuable role of genetic testing in the diagnosis and care of pediatric epilepsy. In the study published in Epilepsia, researchers suggest that if a genetic disorder is suspected as the cause of treatment-resistant epilepsy, timely diagnosis with appropriate genetic tests may reduce costs, limit anxiety to families, and optimize treatment and care.
Pulmonary Embolism
Pulmonary Embolism can be complicated by recurrent thrombosis, chronic thromboembolic pulmonary hypertension (CTEPH) and death.
Dr KK Spiritual Blog
Why are most temples located in faraway places?

Most temples represent God or the spirit, as the deity located in the temple or mandir situated in an area on the outskirts of the city. A spiritual atmosphere is devoid of pollution and anything which promotes rajsik or tamsik behavior. The silence of the spiritual atmosphere reduces the internal noise and helps us in our inner journey. The inner journey of being in touch with one’s consciousness requires detachment from worldly pleasures and withdrawal of the five senses of the body.

To be in touch with one’s consciousness, one needs to bypass the disturbed state of consciousness controlled by emotion, memories and desires, through mind, intellect and ego.

This bypass usually requires a prolonged period of persistence and undertaking the inward journey devoid of external stimuli. The parikrama, which means "the path surrounding something", incorporating many long walks helps to detoxify the mind and thus shifts the consciousness from a disturbed state to an undisturbed, calm state.

A long walk not only provides physical benefits, one also gets the benefits of nature as the inner stimuli are exposed to the outer stimuli during the parikrama. The person is often required to walk bare foot on natural ground, inhale pure air and concentrate and listen to the sounds of the nature, birds and trees. This proximity of nature helps in the inward spiritual journey and shifts one from the sympathetic to parasympathetic mode described by lowering of blood pressure and pulse rate and rise in skin resistance.

The final happiness invariably comes from within us at the time of final darshan when a person invariably closes his eyes and experiences God within his heart.

Most temples today are being constructed in residential colonies and provide a holy atmosphere to people right at their doorstep. However, this does not have the same spiritual significance and benefits as a temple located at the outskirts of a city.

There is no way a person can go to a temple in the vicinity of his house and detoxify his mind as this can hardly be achieved in minutes unless you are a siddha yogi, and if you are one, you need not go to a temple as the temple is within you.

In Vedic texts, it has been clearly mentioned that the rishi-munis were also required to do tapasya for months and years together to acquire powers and inner happiness.

This tells us that spiritual well–being is acquired over an extended period of time as the process of detoxification is a long-drawn process.

Cars and other vehicles should not be allowed near temples as the basic motive is to have a pollution–free atmosphere and to give time and space for the mind to detoxify.
Inspirational Story
Everybody Needs Someone

People need people and friends need friends, And we all need love for a full life depends Not on vast riches or great acclaim, Not on success or on worldly fame, But just in knowing that someone cares, And holds us close in their thoughts and prayers For only the knowledge that we’re understood, Makes everyday living feel wonderfully good, And we rob ourselves of life’s greatest need, When we "lock up our hearts" and fail to heed The outstretched hand reaching to find, A kindred spirit whose heart and mind Are lonely and longing to somehow share, Our joys and sorrows and to make us aware That life’s completeness and richness depends, On the things we share with our loved ones and friends.
Wellness Blog
Tomato reduces prostate cancer risk

Consumption of lycopene–containing foods, especially tomato and its products is prostate friendly. A prospective study published in J Natl Cancer Inst 2014;106(2):djt430 by Zu et al in a cohort of over 50,000 men from the Health Professionals Follow–up Study suggests that dietary intake of lycopene is associated with a lower incidence of prostate cancer and a decreased risk of lethal prostate cancer. These effects may be mediated through inhibition of tumor angiogenesis.
Scientific awareness on personal hygiene and prevention from obesity among school going children, Sarvodaya Bal Vidyalaya, Khajoori Khas, Near Thana-16-9-15
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Make Sure
Situation: A patient died after receiving penicillin injection.
Reaction: Oh my God! Why was anaphylaxis not suspected?
Lesson: Make sure that each time a patient is given penicillin injection, anti anaphylaxis measures are available.
Dr Good Dr Bad
Situation: A patient with fever and low TSH had ESR > 100.
Dr Bad: This is TB.
Dr Good: This is thyroiditis.
Lesson: Thyroiditis typically has a very high ESR and low TSH.

(Copyright IJCP)
eMedinewS Humor
On Trial

After a trial had been going on for three days, Finley, the man accused of committing the crimes, stood up and approached the judge’s bench. "Your Honor, I would like to change my plea from ‘innocent’ to ‘guilty’ of the charges."

The judge angrily banged his fist on the desk. "If you’re guilty, why didn’t you say so in the first place and save this court a lot of time and inconvenience?" he demanded.

Finley looked up wide–eyed and stated, "Well, when the trial started I thought I was innocent, but that was before I heard all the evidence against me."
eMedi Quiz
What percentage of your diet should fat make up?

A. About 10 percent of your daily calories.
B. About 20 percent of your daily calories.
C. About 30 percent of your daily calories.
D. About 40 percent of your daily calories.
E. There is no recommended amount of fat; you should strive to eat as little of it as possible.

Yesterday’s Mind Teaser: LE cell is a

a. Neutrophil
b. Macrophage
c. Histiocyte
d. Dendritic cell

Answer for Yesterday’s Mind Teaser: a. Neutrophil

Correct answers received from: Dr Jainendra Upadhyay, Dr J Daivadheenam, Dr Avtar Krishan.

Answer for 15th September Mind Teaser: a. Hemiplegia

Correct Answers received from: Daivadheenam Jella, Dr Poonam Chablani, Viswanatha Sarma, Dr Avtar Krishan.
Reader Response
Dear Sir, Very informative news. Regards: Dr Karan
Media
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Rabies News (Dr A K Gupta)
What are the precautions to be taken while administering RIGs?
  • Patient should not be on an empty stomach.
  • The RIG vial should be kept outside for a few minutes, after taking it out of the refrigerator, to warm it to room/body temperature.
  • While infiltrating RIG into the bite wound, care must be taken to avoid injecting into blood vessels and nerves.
  • While injecting into the finger tips, care must be taken to avoid compartment syndrome.
  • All emergency drugs and facilities for managing any adverse reactions must be available.
  • For ERIG, keep the patient under observation for at least one hour after ERIG administration and then send home.
  • RIGs can be infiltrated even to already sutured wounds without disturbing the sutures.
IJCP Book of Medical Records
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CPR 10
Successfully trained 113241 people since 1st November 2012 in Hands-only CPR 10
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
Platelet transfusion is not the solution to the increasing incidence of dengue in the Capital

Can do more harm than good and transfusion is only needed in patients whose count is less than 10,000 and there are signs of active bleeding

Dengue cases are at an all-time high causing immense panic and chaos in the city. Every family member of patients diagnosed with dengue is found to be worrying about how to arrange the necessary platelets for transfusion. It is crucial that the public is educated about the fact that platelet transfusion is not the only solution and is not required in most of the dengue cases.

Speaking about this issue, Padma Shri Awardee Dr. A Marthanda Pillai, National President IMA & Padma Shri Awardee Dr. KK Aggarwal Hony. Secretary General IMA and President HCFI in a joint statement said, “What most people are not aware of is that most dengue cases are preventable and manageable. The risk of complications is in less than 1% of dengue cases and if the public knows warning signals, all deaths from dengue can be avoided. One must however always remember it is a myth that all dengue patients require platelet transfusion. In fact unnecessary transfusion causes more harm and puts the patient at risk of complications such as sepsis, transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), alloimmunization and allergic and anaphylactic transfusion reactions. Transfusion must only be done if a person’s platelet count is less than 10,000, and he has active bleeding.”

It is also important to remember that platelet counts acquired by machine readings are not reliable, and a discrepancy of up to 40,000 can be found. Instead, the doctor must opt for a hematocrit test. Most dengue cases can be managed without testing by only measuring the difference between the upper and lower blood pressure. The pulse pressure should be kept over 40 mm Hg. The public must not pressurize the doctors to hospitalize patients whose illness can be managed at home. The beds should be made available for severe dengue patients instead.

The typical symptoms of dengue are fever, vomiting, headache, nausea, pain behind the eyes and severe joint and muscle pain. Most dengue virus infections in adults are symptomatic (86%) and in children under the age of 15 years are asymptomatic or minimally symptomatic.
Classic dengue fever is an acute febrile illness accompanied by a headache, retro-orbital pain, and marked muscle and joint pains. Symptoms typically develop between 4 and 7 days after the bite of an infected mosquito. The incubation period may range from 3 to 14 days. Fever typically lasts for five to seven days. The febrile period may also be followed by a period of marked fatigue that can last for days to weeks, especially in adults. Joint pain, body aches, and rash are more common in females.

Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue fever, the treatment is directed toward relief of the symptoms. The acute phase of the illness with fever and myalgia lasts about one to two weeks.

In dengue, most complications occur within two days of the fever subsiding and most people are casual during this period. A doctor should attend to any abdominal pain, giddiness or weakness after the fever has subsided. Dengue complications during this period are due to a shift of blood volume and patients require a rapid infusion of oral or intravenous fluids in large quantities during this time.

If a person has suffered from dengue in the past year, they must take additional precautions to prevent the disease because a second attack of dengue may be more dangerous than the first attack. There are four different types of dengue, and one can, therefore, suffer from dengue four times in his or her lifetime. The second or subsequent dengue infections tend to be more serious. A person with dengue can also simultaneously suffer from malaria. Malaria and dengue together can lower platelet counts to a dangerous level leading to complications.

It is always said that prevention is better than cure, and it applies to the case of dengue as well. What most people must remember while taking necessary precautions is that dengue mosquitoes only bite during the day and breed in clean, fresh water. Often people remain unaware of these facts and protect themselves from bites during the nights by using mosquito nets and repellent creams. They also feel that they are the safest when in clean urban environments, not realizing that mosquitoes could be breeding in the clean water filled bucket kept in their backyard.
eIMA News
News
  • In the United States, nearly 138.5 million people—almost 44% of the population—currently live in areas where levels of air pollution are deemed dangerous to heath, according to the "State of the Air 2015" report issued by the American Lung Association (ALA).
  • There is an association between acute and chronic exposure to ambient air pollution and an increased risk for respiratory disease (asthma, chronic obstructive pulmonary disease, lung cancer) and cardiovascular disease (myocardial infarction, heart failure, stroke), diabetes, obesity, cognitive decline, and anxiety. Prenatal exposure has been associated with preterm birth. People living in areas with poor air quality have consistently been shown to be at increased risk for premature death from cardiopulmonary and other diseases. Number of preterm deaths linked to reduced air quality caused by road transportation exceeds the number of fatal accidents by up to 30%. (Medscape)
  • An article by Anupam B. Jena, MD, PhD, from Harvard Medical School in Boston, Massachusetts, and colleagues published in the September 15 issue of JAMA reports that although women make up half of all medical school graduates, 30,464 women are medical faculty members vs 60,609 men in a cohort representing about a tenth of physicians in the United States.
  • The FDA has "clarified and enhanced" prescribing information for clozapine to better explain how to monitor patients for neutropenia and manage clozapine treatment, and it approved a new, shared risk evaluation and mitigation strategy (REMS), called the Clozapine REMS Program. (Medscape)
  • A scoring system based on five "easily and readily available" clinical and laboratory variables, called the GLOBE score, was better able than existing criteria to predict the transplant-free survival of patients with primary biliary cirrhosis (PBC) who were treated with ursodeoxycholic acid (UDCA), as reported by Willem J. Lammers, MD, of the Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues in Gastroenterology. These variables include: Age, bilirubin level, albumin, alkaline phosphatase and platelet count.
11 Things Gastroenterologists Think Hospitalists Need to Know
  1. Fluid resuscitation is crucial for pancreatitis patients
  2. Gastrointestinal bleeding decisions
  3. Endoscopy has very low yield for diagnosis of reflux
  4. In cases of acute diarrhea, order a stool sample right away
  5. When—and how—to test the stool
  6. Gastroenterologists do not need to be consulted for every C. difficile infection
  7. For Patients with a possible GI bleed and black stools, do an exam before calling in the gastroenterologist.
  8. Minimize CT scans in early evaluation and management of acute pancreatitis patients
  9. Actively bleeding patients?
  10. Don't be too quick to order barium studies, especially in patients with dysphagia
  11. Gastric-emptying studies should be outpatient
Turkish government urged to restore basic health care to cities in conflict: WMA
15.09.2015

An appeal to all parties of armed conflicts occurring in south-eastern cities of Turkey to restore basic health care has come from the World Medical Association.

According to the Turkish Medical Association, the cities of Diyarbakir, Cizre, Varto, Yuksekova, Semdinli, Lice, Silvan and Silopi have been the centre of fierce fighting between the military and militants for two months. This has provoked attacks on healthcare workers and ambulances, and has led the Turkish Government to curtail the movement of citizens as well as their basic health care during the curfews.

Dr. Xavier Deau, President of the WMA, said: ‘We are receiving alarming reports from the Turkish Medical Association about ambulances not being allowed to tend to those killed and wounded in the fighting in the city or take them to hospital. The Government curfew prevented people from going out to buy food and water and no outside observers are being allowed to visit the city to investigate the situation. This lack of basic healthcare and the failure to allow health professionals to move freely in the city is a scandal that must end.

‘We urge the Turkish Government to bring a halt to this inhumane situation and to allow health professionals to care for the sick and wounded.'
Dengue cases on a rise but Indian Medical Association says nothing to panic about
Tuesday, 15 September 2015 - 10:15pm IST | Agency: DNA Webdesk

Dengue is known to have four serotypes out of which type four and type two are supposed to be most dangerous. The capital this year is said to be exposed to type four dengue although it is not as fatal as the one which was detected in 2013.

Severe dengue type is prevalent in Delhi this year Severe dengue type is prevalent in Delhi this year Representational Image Indian Medical Association in New Delhi on Tuesday released guidelines to avoid dengue and also said that people had no reason to panic as everything was under control.

Dengue is known to have four serotype out of which type four and type two are supposed to be most dangerous. The national capital this year is said to be exposed to type four dengue although it is not as fatal as the one which was detected in 2013. AIIMS has said that the type four strain of the disease has emerged as the dominant type for the first time in New Delhi, along with dengue type two, both of which are said to be dangerous.

IMA's guidelines also mention the symptoms of type four dengue which include fever with shock and a drop in platelets while type two causes a severe drop in platelets, hemorrhagic fever, organ failure and dengue shock syndrome. While type 4 also carries the risks of hemorrhagic fever, the severity of dengue is higher in type two. The classic dengue fever which is common during the season has symptoms like headache, retro orbital pain, and marked muscle and joint pains. The symptoms are seen to develop between four and seven days after the bite of an infected mosquito and the incubation period typically remains for three to 14 days while the fever lasts for five to seven days. Adults will be shown having symptoms like fatigue that will last for days to weeks. And among females, joint pain, body aches, and rashes will be prevalent.

Though, complications rise after the fever is over. Doctors say that the two days after the last episode of the fever are crucial and during this period, a patient should be encouraged to take plenty of oral fluids mixed with salt and sugar as the main complication is leakage of capillaries and collection of blood outside the blood channels which leads to intravascular dehydration which is why giving fluids orally or by intravenous at the right time can save complications.

As doctors continue to make people aware of the cause and precautions to be taken, Dr K K Aggarwal, Padma Shri Awardee and Honorary secretary General IMA said in New Delhi that only suspected severe dengue cases should be given medical attention and admission and that others can be managed as OPD care. For this reason, IMA has refused platelet transfusion unless the patient has active bleeding and a platelet count less than 10,000.

IMA has said that the reliable test for the disease is haematocrit and not platelet count as platelet counts by machine readings are not reliable and can have an error of up to 40,000. They have also said that most cases can be managed without testing and by only measuring difference between upper and lower blood pressure, which should be kept over 40 mm Hg.

Appeals have been made to the public to not panic and not force doctors to admit them unless it is important. "Do not fill beds with patients not requiring admission. Make beds available for severe dengue cases” added Dr Aggarwal. Dr V K Monga and Dr R N Tandon from IMA said that most dengue patients can be managed with oral fluids and so unnecessary admissions and overcrowding of hospitals could end up infecting the hospital itself.

The rise of type four dengue cases has even shocked the doctors as strains of it were not found in Delhi except for a few cases in 2003 after which it wasn't even actively circulating in the national capital. Doctors have said that if a dominant strain remains for a long period, it will be seen that a significant population will get immune to the disease, however type four was not seen in Delhi.

AIIMS lab is also suspecting the birth of a new serotype this year in addition to the four. Researchers who collected samples during an outbreak in Malaysia's Sarawak state in 2007 found that this serotype is different from the other four and that the antibodies produced against the new type are also different from those used in the previous treatments. But the occurrence of this type was found only once in humans.
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Bioethical issues in medical practice
Privacy and confidentiality

Dr Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

A 17-year-old student of a premier school, studying in Class 12, came to see his family doctor alone and in confidence. The doctor had seen this boy grow up and knew him as shy and studious. Although the doctor did not know his family very well he was aware that it was a large joint family where both parents were busy.

The boy told the doctor his story. After his girlfriend broke up with him the boy was disconsolate and considered suicide. His family had no idea about his relationship or breakup. He is unable to study and tells the doctor that his parents are extremely worried about his condition, but forbids the doctor from informing about his condition to his parents.

What should the doctor do?
  • Do nothing and treat the boy as per his usual practice
  • Inform the parents behind the boy’s back
  • Insist that the boy bring his parents when he visits next
  • Inform the police or child protection services?
We have had an encouraging response (as below) from our readers to the questions posed in the Case 1 scenario. Do write in with your views and solutions!
  1. I think the doctor should first try to persuade the boy to let him/her tell his parents. But if he doesn't agree, the doctor should inform the parents after letting the boy know that he is going to do so. As a doctor, an Ethics committee member and most importantly as a mother I would definitely want to know! Dr Ratinder Jhaj, Associate Professor, Dept. of Pharmacology, AIIMS, Bhopal
  2. I think the boy should be counseled and treated in confidence. However, as he is a minor, the parents need to be taken into confidence to protect the doctor from claims of medical negligence or malpractice. Herein lies the dilemma. What will be the case if an adolescent like him was found to be HIV positive? Dr Saradha Suresh
  3. With reference to Dr Saradha’s important comment on HIV testing of adolescents, WHO has issued a guidance note, which may be reviewed at: http://apps.who.int/adolescent/hiv-testing-treatment/page/Informed_consent_and_HIV_testing. The position of NACO in this regard is as follows: The law gives paramount importance to the best interests of the child. In the context of HIV/AIDS, the best interests of the child are served by promoting access to information and services including counselling and testing services. Whenever possible, minors are encouraged to involve their parents/guardians in supervising their health care. However, unwillingness to inform parents/guardians should not interfere with the minor's access to information and services. Access to ICTC (Integrated Counselling and Testing Centre) services should be available to children and young people under the age of 18 years based on an assessment of their evolving capacities and their ability to comprehend the nature and implications of HIV/AIDS and an HIV test result. It is the role of the trained counsellor to assess these abilities. However, the informed consent of parents/guardians is required prior to testing minors for HIV.” (Source: Operational guidelines for integrated counseling and testing centers, NACO, July 2007:p.40) Ganesh Aylur Kailasam
  4. The doctors should keep the following aspects in mind. Boy is a minor so parents need to be involved; helpline is accessible. Because, if the boy takes any rash action, the parents could blame the doctor. They need to be counselled to understand their son and in present times, such situations do occur but timely action and with understanding, the smaller family unit should be helped to deal with this crisis. Kamal Hazari
  5. Even if legally a minor, a 17-year-old should be able to give consent for treatment. I think it would make his life miserable if his family were to be informed. Treatment first, in my opinion, and close monitoring. Sheela Jaywant
  6. Take the adolescent in confidence and inform the parents. Suicidal ideation expressed by the boy puts the doctor in a situation, where he/she is legally bound to inform parents. Hence, inform parents anyway. I am waiting for alternate opinion, debate and some refs to how legal overtakes moral/ethical considerations. RK Baxi
  7. If the doctor believes that the patient intends to go through with suicide or is a risk to himself, s/he is bound to inform the parents, and other agencies, to prevent it. If the doctor believes that the patient is depressed and is expressing himself by stating that s/he is considering suicide, but is not likely to go through with it, the doctor has to preserve and ensure confidentiality. The doctor is also bound to treat the patient. As the patient is a 'minor', within the meaning of the law, consent is required for any procedure or specific treatment involving even a marginal risk to the patient including prescription of potentially toxic medication. The doctor in order to protect her/himself professionally must maintain accurate and confidential records of the meetings and the decisions s/he takes. This will help in a case brought either by the parents or the patient. Swapna Sundar, CEO, IP Dome Strategy Advisors Pvt. Ltd., Chennai
  8. First and foremost this case highlights and emphasizes the importance of an important institution in our society, that of a "Family Practitioner". Unfortunately in modern day practice, the concept of a family physician is commonly downplayed so much so that a fresh medical graduate opts for it only if he does not get admission to any of the sought after PG courses!! It is very important to understand and realize that a shy and reserved 17-year-old considered it comfortable and fit to open up his problem with his family doctor. This adds to the responsibility of the doctor to take him into confidence and assure him that his views and problems will be dealt with confidentially.

    The boy's problem is more psychological and hence needs to be tackled emotionally rather than pharmacologically. Hence, the concerned doctor needs to spare some time from his busy practice and be ready to spend some hours supporting and comforting this 12th standard boy so that he gives up the idea of a grave step like suicide and diverts his mind and attention to his studies and career. A ‘Family doctor’ is the best person to convince the boy as he has seen him grow up since his childhood. In the course of his discussions the doctor has to inform the boy subtly that he would need to speak to his parents / family, NOT about his affair with a girl, but to know their apprehensions about his condition and allay their fears and concerns about his studies and health. It would also be important to understand that who in the joint family the boy feels close to, his parents or any other relative? If so, the doctor can initiate some dialogue with the relative which would make things more comfortable for the boy at home. Such a soft approach can yield at least the following goals:
    • The doctor can presumably dissuade the boy from an extreme and ghastly step like suicide.
    • The boy would be more comfortable at home as the family member closest to him would slowly spill the beans to his entire joint family and by that time he would have tided over his crisis and this would work even if he does not have the best of his relations with his parents.

      We thus could also make optimum use of this other fading but a wonderful institution of a joint family in the Indian context, thereby we would NEVER insist that the boy bring his parents along with him for any discussions in this matter. Information to the police or child protection services could be used only as a secondary measure or Plan 2 if the initial efforts do not give results. Moreover rather than a police team I would preferably refer him to a child psychologist or a friendly psychiatrist in the best interests of the boy so that he is saved from a taboo of a police referral particularly in our society. Dr PR Pandit, I/C Bioethics Unit, Dept. of Pharmacology, HBTMC & Dr RN CH, Mumbai
  9. This is an interesting case and a very common ethical dilemma, which practicing doctors - GPs or Consultants can face. I agree with most of the points made by Dr Pandit. The fact that this boy approached the family doctor indicates that he is aware that he needs help to come out of this miserable state. The boy is sensitive and is worried about his parents suffering due to his condition.
    • The doctor initially has to explain to him, treat with anxiolytics and get help from a professional counsellor for psychotherapy assuring confidentiality to him.
    • He/she should convince the boy to take his parents into confidence as educated parents are often aware of teenage problems and can help him cope. If parents are orthodox, they should still be consulted for his present condition of falling behind in studies and low feelings, without disclosing the real reason. This will ensure indirect support of parents in getting him out of this situation.
    • There is no need to inform police or child protection services. This option, I think would be necessary, if the child did not have parents or legal guardian. As the boy is a minor, parents should be informed by convincing the boy.
    • The boy could also be told that as he is a minor, not informing parents about this health condition (directly/ indirectly) is illegal and unethical for him as a doctor.

      Privacy to be protected completely in this case but confidentiality not with parents/ the closest family member since there is risk of harm (self) to the boy and parents should be watchful. Dr Padmaja Marathe
  10. Informed consent and confidentiality are important. However in this case, suicidal threats have to be taken seriously. In India, the consent is usually done by a team, mainly parents along with the patient (In India 'paternalistic' system prevails).When insight is present, the autonomy of the patient has to be respected. However, a person who has expressed suicidal ideas and who is still under the 'umbrella of parental care', the confidentiality issues get diluted and your social responsibility overrides. In this case, it appears that the family doctor has the authority to make an 'advanced directive', which I doubt, if not properly recorded, is valid. The boy/youth (17 years) has to be interviewed and his mental state assessed. Apart from the adjustment issues, is he harboring bipolar II depression? What is his personality -borderline/cyclothymic or otherwise? Is there a family history of depression or bipolarity? If the boy has good faith in the family doctor, he can psychoeducate the client about the situation and persuade him to get him involved with family members to take decisions. If the issue is 'status quo' (doesn't want the family to be involved) the issue has to be taken to ethical committee for a collective, judicious decision (has to be recorded).

    Legal formalities are a last resort. Good psycho-education can develop a good rapport, can negotiate issues through family doctor (if the client still wants), family members may be involved as per our culture and practice(if possible).The foremost aim is to help the client and bring him back to normalcy. Lastly, insight and judgment are difficult constructs, not static but dynamic. Mohandas Warrier
  11. The boy should be counseled and convinced to inform his parents and at least consent to doctor that he could tell the parents. The doctor can tell the parents as boy is minor but he should inform the boy before dong so to keep the trust and possibly in the presence of both parties. Counseling is very important here and matter should be handled with utmost sensitivity. Triptish Bhatia, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  12. The boy should undergo counselling. He should be talked to and with his permission, parents should be informed. Rema Devi
  13. Legally the doctor has to inform the parents as else he will be liable if anything happens. Psychologically the boy will need the support of the parents to come out of his depression, so anyway they need to be informed. Since the boy confided in the doctor, the doc obviously has his trust. The doctor needs to explain to the boy the need for telling his parents and make him understand that the parents are worried and so probably will want what's best for him. The doctor can assure the boy that he will tell the parents in his clinic in the boy's presence so that he is there to handle the parents' reactions. The boy will not feel alone. The parents can be told about the depression but not about the cause. The doctor can make them understand that the boy needs to tell them when he is ready and that if they insist it will only worsen the situation. I think the parents will understand. Astrid Lobo Gajiwala
IMA IPMO Initiative
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