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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

 

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  Editorial …

24th August 2011, Wednesday

WMA Declaration of Malta on Hunger Strikers

  1. Physicians must assess individuals’ mental capacity. This involves verifying that an individual intending to fast does not have a mental impairment that would seriously undermine the person’s ability to make health care decisions. Individuals with seriously impaired mental capacity cannot be considered to be hunger strikers. They need to be given treatment for their mental health problems rather than allowed to fast in a manner that risks their health.
  2. As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing conditions should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimised or delayed by, for example, increasing fluid intake. Since the person’s decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences of fasting is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient to repeat back what they understand.
  3. A thorough examination of the hunger striker should be made at the start of the fast. Management of future symptoms, including those unconnected to the fast, should be discussed with hunger strikers. Also, the person’s values and wishes regarding medical treatment in the event of a prolonged fast should be noted.
  4. Sometimes hunger strikers accept an intravenous saline solution transfusion or other forms of medical treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care, such as treatment of infections or of pain.
  5. Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confidentiality.
  6. Physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike.
  7. If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or artificial feeding, the physician should make this clear at the outset and refer the hunger striker to another physician who is willing to abide by the hunger striker’s refusal.
  8. Continuing communication between physician and hunger strikers is critical. Physicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. These findings must be appropriately recorded.
  9. When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual’s wishes regarding medical intervention to preserve life. Consideration needs to be given to any advance instructions made by the hunger striker. Advance refusals of treatment demand respect if they reflect the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual’s intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because the situation in which the decision was made has changed radically since the individual lost competence.
  10. If no discussion with the individual is possible and no advance instructions exist, physicians have to act in what they judge to be the person’s best interests. This means considering the hunger strikers’ previously expressed wishes, their personal and cultural values as well as their physical health. In the absence of any evidence of hunger strikers’ former wishes, physicians should decide whether or not to provide feeding, without interference from third parties.
  11. Physicians may consider it justifiable to go against advance instructions refusing treatment because, for example, the refusal is thought to have been made under duress. If, after resuscitation and having regained their mental faculties, hunger strikers continue to reiterate their intention to fast, that decision should be respected. It is ethical to allow a determined hunger striker to die in dignity rather than submit that person to repeated interventions against his or her will.
  12. Artificial feeding can be ethically appropriate if competent hunger strikers agree to it. It can also be acceptable if incompetent individuals have left no unpressured advance instructions refusing it.
  13. Forcible feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.

(Adopted by the 43rd World Medical Assembly, St Julians, Malta, November 1991and revised at the 44th WMA Marbella, Spain, September 1992and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006)

Preamble

Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are often a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, they usually hope to obtain certain goals by inflicting negative publicity on the authorities. Short–term or feigned food refusals rarely raise ethical problems. Genuine and prolonged fasting risks death or permanent damage for hunger strikers and can create a conflict of values for physicians. Hunger strikers usually do not wish to die but some may be prepared to do so to achieve their aims. Physicians need to ascertain the individual’s true intention, especially in collective strikes or situations where peer pressure may be a factor. An ethical dilemma arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. An added difficulty arises in custodial settings because it is not always clear whether the hunger striker’s advance instructions were made voluntarily and with appropriate information about the consequences. These guidelines and the background paper address such difficult situations.

Principles

  1. Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy. Whatever their role, physicians must try to prevent coercion or maltreatment of detainees and must protest if it occurs.
  2. Respect for autonomy. Physicians should respect individuals' autonomy. This can involve difficult assessments as hunger strikers’ true wishes may not be as clear as they appear. Any decisions lack moral force if made involuntarily by use of threats, peer pressure or coercion. Hunger strikers should not be forcibly given treatment they refuse. Forced feeding contrary to an informed and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker’s explicit or implied consent is ethically acceptable.
  3. ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to benefit those they treat. This is the concept of ‘beneficence’, which is complemented by that of ‘non–maleficence’ or primum non nocere. These two concepts need to be in balance. ‘Benefit’ includes respecting individuals’ wishes as well as promoting their welfare. Avoiding ‘harm’ means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other values.
  4. Balancing dual loyalties. Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. Physicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient.
  5. Clinical independence. Physicians must remain objective in their assessments and not allow third parties to influence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non–clinical reasons.
  6. Confidentiality. The duty of confidentiality is important in building trust but it is not absolute. It can be overridden if non7nd disclosure seriously harms others. As with other patients, hunger strikers’ confidentiality should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm. If individuals agree, their relatives and legal advisers should be kept informed of the situation.
  7. Gaining trust. Fostering trust between physicians and hunger strikers is often the key to achieving a resolution that both respects the rights of the hunger strikers and minimises harm to them. Gaining trust can create opportunities to resolve difficult situations. Trust is dependent upon physicians providing accurate advice and being frank with hunger strikers about the limitations of what they can and cannot do, including where they cannot guarantee confidentiality.

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WMA Declaration of Malta on Hunger Strikers

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    Photo Feature (from the HCFI Photo Gallery)

23rd Bharat Nirman Award function

Celebrity guests who graced the occasion of the 23rd Bharat Nirman Award function on 21st August 2011.

 
Dr K K Aggarwal
 
    National News

National Conference on Insight on Medico Legal Issues – For the First time any conference was posted live on Facebook & Twitter

http://blogs.kkaggarwal.com/?p=1134
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Rajya Sabha passes Juvenile Justice Bill

The Rajya Sabha on Friday passed the Juvenile Justice (Care and Protection of Children) Amendment Bill, 2010, which will end the segregation of disease–hit children from other occupants of juvenile homes. Replying to a brief debate on the Bill, Women and Child Development Minister Krishna Tirath said segregation of children afflicted with leprosy, sexually transmitted disease, Hepatitis–B, tuberculosis and unsound mind was not required anymore. "In the opinion of experts too, segregation is not necessary for the treatment of such children." Ms. Tirath said the Delhi High Court had also held that there was a need to amend discriminatory legislation and to ensure that those afflicted with leprosy enjoyed equal rights. The Bill seeks to omit and amend certain sections of the original Act, which had provisions for removal of such children from juvenile homes to treatment centres.
(Source: http://www.thehindu.com/news/national/article2373387.ece, Aug 19, 2011)

For Comments and archives

Certificate courses in 2D and 3D Echocardiography/Fellowship Diploma in non invasive cardiology Contact Dr KK Aggarwal, Moolchand Medcity, email: emedinews@gmail.com

 
    International News

(Dr Monica and Brahm Vasudev)

Metabolic Syndrome Associated With Kidney Disease.

People with metabolic syndrome are at 55% increased risk for kidney disease (reduced kidney functions), according to a study to appear in the Clinical Journal of the American Society of Nephrology.

For comments and archives

Minocycline–EDTA Solution to Reduce Catheter–Related Bacteremia

Dialysis patients had significantly fewer catheter–related infections when minocycline – EDTA was used as a catheter–lock solution instead of heparin," according to a study in the Journal of the American Society of Nephrology. The catheter–related bacteremia rate was one per 1,000 catheter days, a three–fold decrease compared with use of a heparin lock.

For comments and archives

Changes In Cabin Pressure May Affect Insulin Pump Function.

According to a study published online Aug. 4 in the journal Diabetes Care, changes in airliner cabin pressurization during take–off and landing may affect how much insulin is delivered by an insulin pump. Pumps should be disconnected during take–off and landing and during any flight situations in which a loss of cabin pressure results.

For comments and archives

 
    Fitness Update

(Contributed by Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com)

Eating fat when sad really does lift mood

There may be more to the term ‘comfort eating’ than we realize – however, consuming fat appears to be the mood–lifter, rather than any other food ingredient. Researchers from University of Leuven, Belgium, reported on a study in the Journal of Clinical Investigation. The authors explained that humans have an intimate relationship between their emotional state and what they eat. When we feel tired, stressed, anxious or overworked we tend to grab the chocolate bar, rather than an apple – in other words, comfort foods. Lukas Van Oudenhove, MD., PhD. and team charted areas of the brain with functional magnetic resonance imaging (MRI) scans – specific areas of the brain are seen to light up when a person is sad. They recruited 12 healthy individuals, none of them was obese. They were then given an infusion of fatty acid or saline via a feeding tube. Fatty acid was used because most comfort foods have a high fatty acid content.

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@DrKKAggarwal: #AJPP FDA Panel gives okay to pediatric use of LVAD An FDA advisory committee has recommended in favor of a… fb.me/FjTM9F6l

@DeepakChopra: While you go looking for trinkets, the treasure house awaits you in your own being––Rumi

 
    Dr KK Answers

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

How common is multiple radiation exposure?

Multiple medical tests involving radiation exposure lead to high cumulative doses of radiation. In one study, in a 20–year period a heart patient may end up with 15 procedures involving radiation exposure. Of these four may be high dose procedures (≥3 mSv). The cumulative estimated effective dose from all medical sources exceeds 100 mSv in 31.4 percent of patients.

For comments and archives

 
    Spiritual Update

Lage Rahon Anna Bhai: The science behind what makes a wave?

As we have been witnessing over the last few days, there is an ‘Anna wave’ in the country. People of all ages, from all walks of life have come out on the streets in large numbers in support of Anna. Till about few months back, Anna was a relatively unknown name to most people. Since then, he has become the biggest name in the country. A new term has been coined. Just like Gandhigiri, Annagiri is the talk of the town.

For comments and archives

 
    An Inspirational Story

(Ms Ritu Sinha)

Always remember those who serve

In the days when an ice cream sundae cost much less, a 10–year–old boy entered a hotel coffee shop and sat at a table. A waitress put a glass of water in front of him. "How much is an ice cream sundae?" "Fifty cents," replied the waitress. The little boy pulled his hand out of his pocket and studied a number of coins in it. "How much is a dish of plain ice cream?" he inquired. Some people were now waiting for a table and the waitress was a bit impatient. "Thirty–five cents," she said brusquely.The little boy again counted the coins. "I’ll have the plain ice cream," he said. The waitress brought the ice cream, put the bill on the table and walked away. The boy finished the ice cream, paid the cashier and departed.

When the waitress came back, she began wiping down the table and then swallowed hard at what she saw. There, placed neatly beside the empty dish, were two nickels and five pennies – Her Tip

For comments and archives

 
    Gastro Update

(Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta – The Medicity)

Gastroesophageal reflux disease in children

Warning signals or the ‘red flag’ signs that require investigation for GERD in infants are:

  • Regurgitation or vomiting
  • Bilious vomiting
  • Consistently forceful vomiting
  • Gastrointestinal bleeding – Hematemesis, Hematochezia
  • Onset of vomiting after 6 months of life
  • Failure to thrive
  • Diarrhea
  • Constipation
  • Fever
  • Lethargy
  • Hepatosplenomegaly
  • Bulging fontanelle
  • Macro/microcephaly
  • Seizures
  • Abdominal tenderness or distension
  • Documented or suspected genetic/metabolic syndrome
  • Cough and anorexia or feeding refusal are common in 1 to 5 years of age than in older children.

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  Lab Update

(Dr Arpan Gandhi and Dr Navin Dang)

Magnesium

  • Increased: Renal failure, hypothyroidism, severe dehydration, lithium intoxication, antacids, Addison’s disease.
  • Decreased: Hyperthyroidism, aldosteronism, diuretics, malabsorption, hyperalimentation, nasogastric suctioning, chronic dialysis, renal tubular acidosis, drugs (aminoglycosides, cisplatin, ampho B), hungry bone syndrome, hypophosphatemia, intracellular shifts with respiratory or metabolic acidosis.

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    IJCP Special

Dr Good Dr Bad

Situation: A patient with visceral obesity had episodes of night chest burning.
Dr Bad: its acidity.
Dr Good: Rule out CAD.
Lesson: Nighttime acute coronary syndrome occurs more often in patients with visceral fat accumulation and sleep–disordered breathing (Nakagawa Y, Kishida K, Mazaki T, et al. Impact of sleep–disordered breathing, visceral fat accumulation and adiponectin levels in patients with night–time onset of acute coronary syndrome. Am J Cardiol 2011; Aug 12. (Epub ahead of print)

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Make Sure

Situation: A patient with prosthetic heart valves (bioprosthetic) developed infective endocarditis.
Reaction: Oh my God! Why was he not given infective endocarditis prophylaxis?
Lasson: Make sure that all patients with prosthetic heart valves (bioprosthetic or homograft) are given infective endocarditis prophylaxis.

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What you get by achieving your goals is not as important as what you become by achieving your goals.

 
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(Ms Ritu Sinha)

Drive someone up the wall: To irritate and/or annoy very much.

 
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Streptomycin can be given IV or IM (1.0 gm 5 times a week).

 
    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Doctor is a professional of Medical science with neutrality, and impartiality

  • When a doctor appears as medical witnesses in the court of law must strive to achieve respect, good medical understanding and biggest thing is credibility before the honorable judge as well legal counsel of both sides.
  • Doctor must give the appearance of being independent medical witnesses of truth based on medical science with neutrality, impartiality and authentic characteristics. Vagueness and theory has no place in legal medicine
  • Vagueness and theory have no place in legal medicine hence a Medical witness, should remain a man of science; you have no victim to avenge, no guilty person to convict, and no innocent person to save.
  • Doctor must bear testimony within the limits of medical/allied science". The attitude of a medical/clinician/scientific witness should be the same whether he is called by the defense or prosecution. The doctor really testifies neither for nor against the prosecution or the defense. The doctor’s expertise is in the application of science to a legal controversy and the proper interpretation of scientific findings.
  • Doctor sole obligation is to present the truth as he sees it, adding nothing, withholding nothing and distorting nothing mean revealing whole truth.
  • Doctor should not concern himself with the previous character of the accused or with other evidence in the case.
  • Doctor should not be influenced in any way by emotional consideration, such as sympathy or antipathy. The doctor must be honest, the honesty gives the confidence with enlightened conscience and the success in the court of law depends upon your confidence.
  • Honest perusal of medical science, confidence and medical ethics are tripods of this noble medical professional

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    Mind Teaser

Read this…………………

Which of the following is the most troublesome source of bleeding during a radical retro pubic prostatectomy?

1. Dorsal venous complex
2. Inferior vesical pedicle
3. Superior vesical pedicle
4. Seminal vesicular artery

Yesterday’s Mind Teaser: The most common cause of renal scarring in a 3 year old child is:

1. Trauma
2. Tuberculosis
3. Vesicoureteral reflux induced pyelonephritis
4. Interstitial nephritis

Answer for yesterday’s Mind Teaser: 3. Vesicoureteral reflux induced pyelonephritis.

Correct answers received from: Dr poonam Chandra, Dr Valluri Ramarao, Dr Muthumperumal Thirumalpillai, Dr Surendra Bahadur Mathur, Dr Pramod M Kulkarni, Dr Prabodh Kumar Gupta, Dr Chandresh Jardosh, Dr Anil Bairaria, Dr Jainendra Upadhyay.

Answer for 22nd August Mind Teaser: b.16,18
Correct answers received from: Dr Anil Bairaria, Dr Amit Vyas, Dr Sukanta Sen.

Send your answer to ijcp12@gmail.com

 
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(Dr. GM Singh)

Dana, you’ve been late to class ever since school started, why?
I can’t help it: the sign outside says ‘SCHOOL GO SLOW’.

 
    Drug Update

List of Approved Drug From 01–01–2011 to 30–06–2011

Drug Name

Indication

DCI Approval Date

Erlotinib HCl Tablet 150 mg (Additional Indication)

Monotherapy for the maintenance treatment of patients with locally advanced metastatic non–small lung cancer whose disease has not progressed after four cycles of platinum–based first–line chemotherapy.

04.01.11

 
    Public Forum

(Press Release for use by the newspapers)

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Opt for medical treatment for heart blockages with low left heart functions

For most patients with systolic left heart pumping function (LVEF) of 35 percent or less and coronary heart blockages amenable to bypass surgery one should first initiate optimal medical therapy alone rather than medical therapy plus bypass surgery, said Padmashri and Dr B C Roy National Awardee Dr K K Aggarwal President Heart Care Foundation of India and MTNL Perfect Health Mela.

Earlier view had been that compared with medical therapy, surgical bypass of viable heart muscle improves both survival and left heart function. This view was based on the fact that up to 50 percent of patients with left heart pumping dysfunction due to coronary heart blockages have a significant amount of viable heart muscles.

The results of Surgical Treatment for Ischemic Heart Failure (STICH), a randomized trial have shown that compared with optimal medical therapy alone, optimal medical therapy plus bypass surgery resulted in no significant improvement in the primary outcome of all–cause mortality at a median follow–up of 56.

The current recommendation that one should initiate optimal medical therapy alone rather than optimal medical therapy plus bypass surgery is based upon the significant morbidity associated with bypass surgery. Bypass surgery, however, is preferred by patients with ongoing anginal symptoms despite optimal medical therapy.

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    Readers Responses
  1. Dear sir, Lok pal bill and fight against corruption is getting momentum through Anna, but most corrupt people are trying to surround him under his banner in disguise even yogis who are most corrupt came to the forefront. It is the pity of all movements:– first started by Father of our country later it fell into the hands of hippocrates and finally to decoits who loot money regularly from our treasury. God alone knows, what will be end of this new movement of ANNA.
    Dr. Alex Franklin
 
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from Sept 29, 2011: A unique & highly educative Pre–Conference CME, International & National Icons in the field of Cardiology & Echocardiography will form the teaching faculty.

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