September 18   2015, Friday
eMedinewS
Healthy obesity does not exist
Dr KK Aggarwal A research published in the Annals of Internal Medicine suggests that individuals cannot be simultaneously overweight and physically fit. As BMI rose, so did blood pressure, waist circumference and insulin resistance. As BMI increased, levels of HDL cholesterol, thought to protect against heart attack and stroke, decreased.

While participants who were either overweight or obese "may not yet have reached the points that define metabolic illness, they appeared to be on that road as their weight" increased.
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eMedipics
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Dr KK Aggarwal, Hony Secy General IMA felicitated by Team IMA for being awarded the Vishwa Hindi Samman at the recently concluded 10th World Hindi Conference held at Bhopal. Also in the picture is Dr Veena Aggarwal.
News
Diabetes
Higher HbA1c levels are associated with an increased risk of dementia among patients with type 2 diabetes, indicating potential for prevention of dementia with improved glycemic control, suggests the largest study of its kind presented at the European Association for the Study of Diabetes (EASD) 2015 Meeting.

Rheumatology
A new study suggests that yoga may improve symptoms of osteoarthritis and rheumatoid arthritis,. The findings are published in the Journal of Rheumatology.

Infectious Diseases
A new study, published in the Journal of Antimicrobial Chemotherapy, shows little significant difference between the bactericidal effects of plain soap and antibacterial soap when used under real-life conditions. Researchers noted that antibacterial handwash is no more effective against germs than plain handwash.

Hepatology
There is a link between sedentary behavior and nonalcoholic fatty liver disease, and doing high levels of moderate to vigorous exercise is unlikely to counter this effect, suggests a new study published in the Journal of Hepatology.

Oncology
The addition of cetuximab to standard chemotherapy failed to improve survival in patients with advanced non-small-cell lung cancer (NSCLC), suggested results from the large phase 3 SWOG S0819 trial presented at the 16th World Conference on Lung Cancer.
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Cardiology eMedinewS
  • New research suggests that β-blockers may prevent further cell death following a heart attack and could lead to better longer term patient outcomes. The findings are published in the journal Cell Death Discovery.
  • New research presented at the annual meeting of the European Association for the Study of Diabetes shows that diabetic women are more at risk than diabetic men of having a heart attack and other complications as they age.
Pediatrics eMedinewS
Pediatrics/Oncology
Children are put at the unnecessary risk of developing cancers when they are exposed to insecticides from sprays and foggers used in the home, suggests a new study published in the journal Pediatrics.

Pediatrics/Obesity
A novel study presented at the annual meeting of the European Association for the Study of Diabetes (EASD) suggests that no access to a garden at age 3-5 years is linked to an increased risk of developing obesity by age 7 years.
Pulmonary Embolism
Pulmonary embolism, if left untreated, has an overall mortality of up to 30 percent, which is significantly reduced with anticoagulation.
Dr KK Spiritual Blog
Ganesha, the Stress Management Guru

If Lord Krishna was the first counselor who taught the principles of counseling, Lord Ganesha taught us the principles of stress management.

We should worship Lord Ganesha and become like him whenever we face any difficulty or are stressed out.

The elephant head of Lord Ganesha symbolizes that when in difficulty, use your wisdom, intelligence and think differently. It can be equated to the Third Eye of Lord Shiva. Elephant is supposed to be the most intelligent animal in the kingdom. Here, wisdom means to think before speaking. Lord Buddha also said that don’t speak unless it is necessary and is truthful and kind.

The big elephant ears of Lord Ganesha signify listening to everybody when in difficulty. Elephant ears are known to hear long distances. Elephant eyes see a long distance and in terms of mythology, it denotes acquiring the quality of foreseeing when in difficulty. The mouth of Lord Ganesha represents speaking less and hearing and listening more.

The big tummy of Lord Ganesha represents digesting any information gathered by listening to people when in difficulty. The trunk denotes using the power of discrimination to decide from the retained information. It also indicates doing both smaller and bigger things by yourself. The elephant trunk can pick up a needle as well as a tree.

The teeth, broken and unbroken, signify to be in a state of balance in loss and gain. This implies that one should not get upset if the task is not accomplished and also not get excited if the task is accomplished. In times of difficulty, Ganesha also teaches us not to lose strength and control one’s attachments, desires and greed.

The four arms of Lord Ganesha represent strength. Ropes in two hands indicate attachment; Laddoo or Sweet in one hand represents desires and mouse represents greed. Riding over the mouse indicates controlling one’s greed.

Lord Ganesha is worshipped either when a new work is started or when one finds it difficult to complete a job or work. In these two situations, these principles of Lord Ganesha need to be inculcated in one’s habits.
Inspirational Story
Don’t change the world

Once upon a time, there was a king who ruled a prosperous country. One day, he went for a trip to some distant areas of his country. When he returned, he complained that his feet were very painful, because it was the first time that he went for such a long trip, and the road that he went through was very rough and stony. He then ordered his people to cover every road of the entire country with leather. Definitely, this would need thousands of cows’ skin, and would cost a huge amount of money.

Then one of his wise servants dared himself to tell the king, "Why do you have to spend that unnecessary amount of money? Why don’t you just cut a little piece of leather to cover your feet?"

The king was surprised, but he later agreed to his suggestion, to make a "shoe" for himself.

There is actually a valuable lesson of life in this story: to make this world a happy place to live, you better change yourself – your heart; and not the world…
Wellness Blog
Cinnamon in diabetes

A meta–analysis of 10 studies in patients with type 2 diabetes, published in the Annals of Family Medicine taking cinnamon supplements improved fasting blood glucose and cholesterol levels, but not HbA1c levels.

Small doses of a cinnamon supplement could be used along with traditional diabetes medication, Cinnamomum cassia, either as natural supplement powder or capsule, was the most common form of cinnamon that was studied in the trials, and 1 tsp of cinnamon is approximately 3 g. Cinnamon effect is attributed to its active component cinnamaldehyde.

The advantages of cinnamon are its cost, tolerability, and relatively safe profile. Long–term administration of high–dose cinnamon may possibly be unsafe due to the coumarin content of cinnamon, which has been associated with liver damage in animal studies.
Felicitation ceremony organized by Team IMA to honor Dr KK Aggarwal on being awarded with the Vishwa Hindi Samman
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Make Sure
Situation: A patient after sublingual nitrate developed fainting attack.
Reaction: Oh my God! Why was the systolic murmur missed on auscultation?
Lesson: Make sure that patient with left ventricular outflow tract (LVOT) obstruction are not given sublingual nitrates.
Dr Good Dr Bad
Situation: An obese diabetic patient was found to have high ESR and elevated CRP.
Dr Bad: You are suffering from an inflammatory disease.
Dr Good: This may be a part of diabetes.
Lesson: In diabetes, both ESR and CRP can be high at the same time and this can be due to IL–6 secretion by adipose tissue.

(Copyright IJCP)
eMedinewS Humor
Price you pay for being good

Three men were waiting to go to heaven. St Peter was at the gate and said, "However good you were to your wife that is the vehicle you will get in heaven".

The first guy comes up to the gate and says, "I never, ever cheated on my wife and I love her". So St. Peter gives him a Rolls Royce.

The next man comes up and says, "I cheated on my wife a little but I still love her." He gets a mustang and drives off into heaven.

The next guy came up and said, "I cheated on my wife a lot". He gets a scooter.

Next day the guy that got the scooter was riding along and he saw the guy who owned the Rolls Royce crying.

He asked, "Why are you crying you have such a nice car?!" and the man sobbed, "My wife just went by on roller skates".
Reader Response
Sir, Like the regular academic and organizational updates via eMedinewS; this is a good initiative to keep up with current technological advances! Best wishes and regards!! Dr Charu Mittal, Consultant Gynecologist, Medical College Baroda, Gujarat
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Rabies News (Dr A K Gupta)
Can the vaccine be injected in gluteal region?

Rabies vaccine must not be administered in gluteal region as the gluteal fat may retard vaccine absorption resulting in delayed and lower seroconversion.
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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
IMA, AHPI, CAHO & DMA Nursing Home Forum release a white paper on Dengue Management

Addressing a press meet at the Indian Medical Association today, representatives of IMA, Association of Health Care Providers of India (AHPI), DMA Nursing Home Form and CAHO (Consortium of Accredited Healthcare Organisation) released a white paper on the ongoing dengue menace in the country.

Addressing the press, Padma Shri Awardee Dr. KK Aggarwal–Honorary Secretary General IMA, Dr. Shubnum Singh - Advisor-AHPI, Dr. Girdhar Gyani (AHPI), Dr Vinay Aggarwal - Former President CMAAO, Dr C M Bhagat - Chairman, Delhi Nursing Home Form & Dr Vijay Aggarwal - CAHO, Dr. R.N. Tandon & Dr. V.K. Monga - Health care Experts in a joint statement said, “Instead of continuing to blame other associations, government officials, hospitals and doctors for the mismanagement of dengue cases in the country, we must all work together towards preventing and minimizing further dengue deaths, to stop the disease from spreading in other states, prepare ourselves for an outbreak of flu in the coming season and rationalize the charges, admissions and services of the medical profession”

The guidelines released by the organizations stated:
  • Delhi is at present going through a dengue outbreak although the government has not declared it as an epidemic.
  • The maximum dengue cases are recorded between 15th September and 15th October.
  • Dengue can be classified as dengue fever and severe dengue. A person is said to be suffering from severe dengue when there is capillary leakage. Patients who have dengue fever do not have capillary leakage.
  • Any person suffering from fever in this season with a headache, body ache, fatigue, nausea, vomiting is believed to have dengue fever unless proved otherwise.
  • Dengue fever can be managed on an outpatient basis and does not need hospitalization.
  • Out of the four types of dengue infections, which exist in our country, type 2 and type 4 dengue are more likely to cause capillary leakage. Type 2 dengue is considered to be more dangerous than type 4 dengue.
  • The present dengue outbreak is that of dengue 4 as against the outbreak in 2013, when type 2 dengue was more prevalent.
  • Given that this is the first time dengue 4 has occurred in Delhi on a large scale. a large number of cases are expected to occur and will continue to occur for next one month.
  • Cases of severe dengue are categorized by capillary leakage – (rapid fall of platelets, high liver enzymes with SGOT > SGPT, intravascular dehydration categorized by rise in haematocrit levels, and fall in pulse pressure which is the difference between the upper and lower blood pressure).
  • The best treatment for dengue is to administer large amounts of oral fluids to patients. For patients who are unable to take oral fluids, intravenous administration may be necessary.
  • Capillary leakage occurs when the fever starts settling down. It occurs a day before the fever comes back to normal and continues for the next one more day. The total duration of capillary leakage often lasts for up to 48 hours. Dengue is never serious when the fever is high.
  • Clinically capillary leakage presents with sudden onset of extreme weaknesses or restlessness.
  • At the onset of capillary leakage, the patient must immediately receive oral or IV fluids equivalent to 20 ml per kg.
  • No dengue patient should ordinarily die if he/she passes urine every few hours (a sign of adequate hydration) and difference of upper and lower blood pressure is kept > 40 mm Hg
  • A second occurrence dengue (secondary) is more serious than first infection (primary). In the primary infection, IgM or NS1 will be positive and in secondary infection IgG will also be positive.
  • Platelet transfusion is only required in the presence of active bleeding and platelet count less than 10,000.
  • In the absence of severe abdominal pain or tenderness, persistent vomiting, abnormal mental status or extreme weakness, the patient may not need hospital admission.
  • All medical establishment and doctors should attend to dengue suspected cases immediately.
  • Distinguish cases of dengue fever from severe dengue. · Give bolus 20 ml fluid per kg of body weight if capillary leakage is suspected.
  • In the absence of capillary leakage, stabilize the patient on oral fluids and observe as outpatient on a daily basis.
  • In the presence of capillary leakage or if high risk (pregnancy, age less than 5 years, uncontrolled diabetics, associated co morbid condition), hospitalize or arrange for safe transfer to nearest government hospital or private hospital as the case may be.
  • In the absence of a centralized bed management information system, it may not be possible for a private sector hospital to call all nearby private hospitals and arrange for a bed for the patient if bed is not available with them.
  • Hospitals should arrange their own ambulances or arrange empanelled ambulances for a safer transfer of the patient to the nearest designated government hospital.
  • Unnecessary admission should be avoided. No patient should be admitted to the hospital just because the family of the patient wants admission, or he/she has a reimbursement policy.
  • Platelet transfusion is not recommended in most patients and if given when not necessary may be harmful.
  • Machine platelet count reading may be less than the actual platelet count.
  • Inter-machine variability is also often found to be high while interpreting platelet count.
  • Admitting dengue patients on floor and filling more than 90% occupancies may increase the possibility of hospital-acquired infections
  • The health authorities should reimburse emergency care for all dengue patients at government entitled rates.
  • The chances of severe dengue reduce after the age of 11. Deaths are more common in children.
  • It is possible for a child or an adult to be completely healthy just a few hours before he or she develops capillary leakage.
  • Whenever a dengue patient’s fever is below 100 degrees, one should observe for capillary leakage.
  • With effective and timely treatment, severe dengue mortality can be reduced to <1% from 20% (as per the WHO guidelines).
  • According to data by the WHO, each year around 39 lakh people develop dengue every year, out of which five lakh develop severe dengue with 25,000 deaths. More than 80% of the patients are treated in the private sector.
  • Testing platelet levels alone does not account for complete and effective management of dengue.
  • A complete blood count (especially hematocrit) is needed to monitor prognosis and increased capillary permeability, which is the starting point of all complications.
  • Only PLATELET count requires manual dilution, charging of chamber and manual counting. It is extremely time-consuming and impractical to perform in periods of crisis like this. It is not possible to do a CBC for Rs. 50/-.
  • Rapid dengue testing is the need in any outbreak, it cannot be ignored.
  • For ELISA confirmatory test, one may send all cases to the designated government or private sector labs.
  • IMA has requested the media not go for a Media trial in every dengue case as even in the best of the centers, 1% of patients may not survive with severe dengue.
  • A patient who is clinically stable can become serious in a matter of minutes or hours and may succumb to complications even in the best of centers and that is the reason all dengue patients on OPD management are required to follow up daily with their doctors. The biological behavior of the disease leads to questioning of the care that was provided to a stable patient.
  • Medical doctors are under tremendous pressure and are at risk of violence at time of any dengue death and will require protection from appropriate authority.
eIMA News
News
  • Air pollution is killing 3.3 million people a year worldwide, according to a new study published Wednesday in the journal Nature, which also has a surprise observation: Farming plays a large role in smog and soot deaths in industrial nations. The study also projects that if trends don't change, the yearly death total will double to about 6.6 million a year by 2050. With nearly 1.4 million deaths a year, China has the most air pollution fatalities, followed by India with 645,000 and Pakistan with 110,000. The United States, with 54,905 deaths in 2010 from soot and smog, ranks seventh highest for air pollution deaths. (PTI)
  • Prolonged sitting time and reduced physical activity contribute to the prevalence of non-alcoholic fatty liver disease (NAFLD) as observed in a study of middle-aged Koreans, published in the Journal of Hepatology. These associations were also observed in patients with a body mass index (BMI) of less than 23. Researchers suggest that these findings support the importance of both reducing time spent sitting and increasing physical activity.
  • Dehradun: According to Global Nutrition Report 2015, India has made significant progress in reducing malnutrition, but experts have raised concerns over increasing obesity in the country as it will "double the burden" of diseases in the country as reported in TOI. Indian women have shown an increase of 1.1% in obesity — from 5.6% in 2010 to 6.7% in 2014. Similarly, the male population, too, has shown an increased trend in obesity from 2.5% in 2010 to 3.2% in 2014, an escalation of 0 .7%. Currently, India ranks third in number of obese people in a country after USA and China, one in five Indian men and women are either overweight or obese. Surprisingly, all 193 countries in Global Nutrition Report 2015 are "off course" for the World Health Assembly target of "no increase in adult overweight and obesity". Only one country in the world — Nauru — showed smallest decline in adult obesity. (Shivani Azad, TNN | Sep 16, 2015)
  • The CDC released recommendations on September 16 for prescribing antibiotics in long-term care facilities (nursing homes) and sparing residents the scourge of antibiotic-resistant infections. The agency is directing its guidance toward nursing-home medical directors and nursing directors, attending physicians, and pharmacists. According to the CDC, nursing homes are hotbeds of misprescribed antibiotics that breed dreaded superbugs, such as Clostridium difficile.
  • Lead author, Thomas House, PhD, a senior lecturer in applied mathematics at the University of Manchester, in the United Kingdom suggests that having sufficient friends with healthy mood can halve the probability of developing, or double the probability of recovering from, depression over a 6- to 12-month period on an adolescent social network. The study was published online August 19 in the Proceedings of the Royal Society of London Series B.
  • A multi-specialty panel led by Vineet Chopra, MD, of the University of Michigan in Ann Arbor, has designed a best practices guide for the "insertion, care, and management" of peripherally inserted central catheters (PICCs). Dr Chopra and colleagues reviewed published literature and 665 clinical scenarios to create the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) guideline. (Annals of Internal Medicine)
  • A smaller portion of Chinese children who had additional outdoor activity time developed myopia compared to children without that extra activity, report Mingguang He, MD, PhD, of Zhongshan Ophthalmic Center in Ghangzhou, China, and colleagues in the Journal of the American Medical Association. Children with an additional 40 min of outdoor activity per school day had a 30.4% incidence of myopia over 3 years vs 39.5% in a control group who continued with their usual pattern of activity.
  • In an effort to prevent foodborne illness, the FDA has finalized requirements for food production facilities to have preventive plans and controls. The move is one of the "most significant steps in decades" to prevent foodborne illness, it said in an announcement posted on the FDA website. The finalization of the two steps would be the first of seven major ones outlined in the FDA Food Safety Modernization Act (FSMA), which was signed into law in 2011 by President Obama.
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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
  14. My suggestions are:
    • Treat the boy as per his usual practice
    • Inform the parents behind the boy’s back. The boy is minor and concurrence with his desire to keep his parents in dark is not correct. But the Doctor should properly and adequately advise his parents not to disclose to the boy that they came to know through the Doctor; and let them find the way how to deal with the situation with above rider. Also advise the parents not to invoke a disciplinary conservative attitude to admonish him and restrict his freedom.
    • Advise the parents by sympathizing with him and by assuring him that they will not get angry to tactically get the admission from his mouth without giving him an idea that they know the reason for his behavior; and then properly counsel him to get away from that girl and come back to normal life. If their own counseling does not produce desired results, advise them to take him to an appropriate professional counselor. The parents have to behave with extreme sensitiveness and accommodativeness with the boy and not behave with prohibitive/retributive/punitive mindset for such love affairs. VA Savangikar
  15. As per my view, the doctor can do as follows: It seems that the boy is in an adolescent age. To identify precipitating events or to find true facts, doctor should explore carefully the boy’s life during last 48-72 hours. Doctor should also find the degree of premeditation and also evaluate response of the immediate family to suicidal attempt and assess the degree of ongoing family conflicts. Doctor should enter into a “No-suicide contract” with boy. Then he should notify the parents and should obtain psychiatric consultation (if he is not a Psychiatrist). Doctor should admit boy to the hospital for one day or more so that a detailed evaluation of the boy’s frame of mind and the family or environmental circumstances can be done. After careful follow-up steps could be taken for disposition, which might be fairly rapidly in case of supportive family. A hostile or angry family requires different disposition. Mr Prashant Shivgunde, Member Secretary, Ethics Committee, Maharashtra university of Health Sciences, Nashik
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eIMA Quiz
Since sunscreen awareness campaigns began, have skin cancer rates decreased?

A. Yes, fewer people are getting skin cancer.
B. No, skin cancer rates and deaths from the disease are on the upswing.
C. No, skin cancer is on the rise, but fatalities are down.
D. Skin cancer rates have been stable over the past decade.
E. Yes, but only among older women.

Yesterday’s Mind Teaser: 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.

Answer for Yesterday’s Mind Teaser: C, about 30 percent of your total calories should be from fat.

Correct answers received from: Dr Jainendra Upadhyay, Dr K Raju, Daivadheenam Jella

Answer for 15th September Mind Teaser: a. Neutrophil

Correct Answers received from: Dr Jainendra Upadhyay, Dr J Daivadheenam, Dr Avtar Krishan.
Quote of the Day
Fear less, hope more, eat less, chew more, whine less, breathe more, talk less, say more, hate less, love more, and good things will be yours. Swedish Proverb
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