September 24   2015, Thursday
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Walking 2000 steps extra lower cardiovascular risk
Dr KK Aggarwal Walking 20 min at a moderate pace each day is associated with improved cardiovascular outcomes in patients with impaired glucose tolerance, according to a study in The Lancet.

People who walked 2,000 steps more per day at baseline had a 10% lower risk of cardiovascular death, paralysis or heart attack during an average follow–up of 6 years according to Thomas Yates, PhD, of the University of Leicester in England, and colleagues.

And those who increased the amount they walked by 2,000 steps per day from baseline to 1 year had a similar reduction in risk of cardiovascular events.

The findings from NAVIGATOR trial support both the promotion of increased ambulatory activity, and the avoidance of decreased ambulatory activity irrespective of the starting level, as important targets in the prevention of chronic disease.
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CMAAO meeting held in Yangon, Myanmar.
News
Neurology / Nutrition

Consumption of an unhealthy Western diet that includes meat, hamburgers, chips, and soft drinks, may reduce the volume of the left hippocampus, whereas a healthy diet of fresh vegetables and fish may increase hippocampal volume, suggests new research published online in BMC Medicine.

Infectious diseases

For patients infected with methicillin-susceptible Staphylococcus aureus (MSSA), outcomes with cefazolin are similar to those with nafcillin, the recommended first-line therapy, suggested a new study presented at the Interscience Conference of Antimicrobial Agents and Chemotherapy 2015.

Rheumatology / Anesthesiology

Patients with fibromyalgia show deficiencies in red blood cell magnesium and insulin-like growth factor 1 (IGF-1), reported a small study presented at the American Academy of Pain Management (AAPM) 2015 Annual Meeting.

Smoking/Addiction

Clinicians should ask all adults about their tobacco use, advise them to quit if they do smoke, and provide evidence-based behavioral therapies and medications to help them quit, advised the US Preventive Services Task Force (USPSTF) in its final recommendation statement on smoking cessation in adults. The final recommendations were published online September 21 in Annals of Internal Medicine.

Diabetes

A new meta-analysis published online in Lancet Diabetes & Endocrinology demonstrated that current smokers and people exposed to secondhand smoke have a significantly increased risk of developing type 2 diabetes, and this risk decreases in quitters over time.
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Cardiology eMedinewS
  • Pregnancy complications appear to be a significant sign of heart disease to come later in life, suggests a long-term study published in the American Heart Association's journal Circulation.
  • Stroke risk associated with carotid artery occlusion was found to be much lower than risk associated with carotid artery stenting (CAS) or carotid endarterectomy (CEA) in patients with ACS receiving intensive medical management, suggested a study published in JAMA Neurology. Researchers noted that neither severity of stenosis before occlusion nor the presence of an earlier contralateral carotid occlusion predicted stroke.
Pediatrics eMedinewS
Pediatrics / Addiction

Girls who hit puberty early are at sharply higher risk of abusing alcohol as teens if their parents do not keep tabs on them, suggests new research published online in Pediatrics.

Pediatrics / Urology / Cardiology

A recent study published in the Journal of Pediatrics has identified a link between kidney stones in children and thickened or hardened arteries - precursors to a range of cardiovascular diseases.
Pulmonary Embolism
Although some conditions, such as pneumothorax and pneumonia, can be identified by chest radiography or CT scan, pulmonary embolism (PE) can coexist with other conditions, and, therefore, the presence of an alternate diagnosis does not completely exclude the diagnosis of PE.
Dr KK Spiritual Blog
Direct all your energy towards the soul and not the ego

The epic Mahabharata can also be understood as a science of inner Mahabharata happening in everybody’s mind.

Lord Krishna symbolizes the consciousness and the five Pandavas, the five positive qualities of a person namely, righteousness (Yudhishthir), focus (Arjuna), power to fight injustice (Bheem), helping others (Sahdev) and learning to be neutral in difficult situations (Nakul). Panchali indicates the five senses, which can only be controlled when these five forces are together.

Dhritarashtra symbolizes ignorance, Duhshasan negative ruling quality (dusht while ruling) and Duryodhana (dusht in yudh) one who is not balanced in war.

Conscious-based decisions need to be taken to kill the negativity in the mind. Every action, if directed towards the consciousness or the soul, is the right action. To kill all the 100 Kauravas (the 100 negative tendencies a person can have) controlled by Duryodhan and Duhshasan along with Shakuni (the negative power of cunningness), positive qualities have to be redirected towards consciousness and then take right decisions.

The five Pandavas (positive qualities) made soul (Lord Krishna) as their point of reference (Sarthi) and won over the evils (Kauravas).

Bhishma Pitamah, Karna and Dronacharya, individually all had winning powers; but, they all supported negative thoughts and made Duryodhana as their point of reference and ultimately had to die.

The message is very clear, if one directs his or her positive powers towards ego as the reference point in long run, they will be of no use and, in fact, will be responsible for one’s destruction.

Ravana too was a great scholar but he directed all his energies and powers towards his ego and ended up in misery.

Therefore, one should cultivate a positive mental attitude, positive thoughts instead of directing them towards desire, attachment or ego and should direct them to soul/consciousness for a positive outcome.
Inspirational Story
Sometimes your biggest weakness can become your biggest strength

Take, for example, the story of one 10–year–old boy who decided to study judo despite the fact that he had lost his left arm in a devastating car accident. The boy began lessons with an old Japanese judo master. The boy was doing well, so he couldn’t understand why, after three months of training the master had taught him only one move.

"Sensei," the boy finally asked, "Shouldn’t I be learning more moves? This is the only move I know"

"But this is the only move you’ll ever need to know," the sensei replied.

Not quite understanding, but believing in his teacher, the boy kept training. Several months later, the sensei took the boy to his first tournament.

Surprising himself, the boy easily won his first two matches. The third match proved to be more difficult, but after some time, his opponent became impatient and charged; the boy deftly used his one move to win the match. Still amazed by his success, the boy was now in the finals. This time, his opponent was bigger, stronger, and more experienced. For a while, the boy appeared to be overmatched. Concerned that the boy might get hurt, the referee called a time–out. He was about to stop the match when the sensei intervened.

"No," the sensei insisted, "Let him continue." Soon after the match resumed, his opponent made a critical mistake: he dropped his guard. Instantly, the boy used his move to pin him. The boy had won the match and the tournament. He was the champion. On the way home, the boy and sensei reviewed every move in each and every match.

Then the boy summoned the courage to ask what was really on his mind. "Sensei, how did I win the tournament with only one move?" "You won for two reasons," the sensei answered.

"First, you’ve almost mastered one of the most difficult throws in all of judo. And second, the only known defense for that move is for your opponent to grab your left arm."

The boy’s biggest weakness had become his biggest strength.
Wellness Blog
First Aid in Burns
  • Patients with severe thermal burns are at significant risk of death and major morbidity.
  • Look for evidence of respiratory distress and smoke inhalation injury, a common cause of death in the acute burn victim.
  • Laryngeal edema can develop suddenly and unexpectedly.
  • Burn depth and size determine fluid resuscitation and the need for transfer.
  • Vascular collapse from burn shock is a critical component.
  • Rapid, aggressive fluid resuscitation to reconstitute intravascular volume and maintain end–organ perfusion is crucial.
  • The fluid requirement during the initial 24 hours of treatment is 4 mL/kg of body weight for each percent of TBSA burned, given IV. Superficial burns are excluded from this calculation. One–half of the calculated fluid need is given in the first eight hours, and the remaining half is given over the subsequent 16 hours.
  • Monitor urine output is important
  • Hourly urine output should be maintained at 0.5 mL/kg in adults.
  • Carbon monoxide and cyanide – Burn patients may be exposed to carbon monoxide, requiring immediate treatment with high–flow oxygen.
  • Cool and clean wounds, but avoid inducing hypothermia.
  • Remove any jewelry and any hot or burned clothing and obvious debris not densely adherent to the skin.
  • Irrigation with cool water may be used.
  • Topical antibiotics are applied to all non superficial burns.
  • Give opioids (morphine) to treat pain and give tetanus prophylaxis.
Scientific awareness on personal hygiene and prevention from obesity among school going children, N P Co. Ed. Sr. Sec. School, Laxmi Bai Nagar, New Delhi-21-9-15
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Make Sure
Situation: A patient with dengue fever developed shock.

Reaction: Oh my God! Why was the blood pressure 90/80 ignored?

Lesson: Make sure that a pulse pressure of less than 20 is not ignored; it is an impending sign that the patient is going into shock.
Dr Good Dr Bad
Situation: A patient with diabetes wanted to join aerobics.

Dr. Bad: It is bad for you.

Dr. Good: At least do it three times a week.

Lesson: According to the results of a randomized, controlled trial, patients with type 2 diabetes improved in fasting blood sugar, low-density lipoprotein, high-density lipoprotein, and quality of life following 8 weeks of aerobic exercise training for 30 minutes, at 50%-75% of maximum heart rate three times weekly (Int J Gen Med 2011;4:723-7).
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Quote of the Day
Shame occurs when you haven’t been able to get away with the ‘who’ you want people to think you are. Carl Whitake
eMedi Quiz
When should you have your first colonoscopy to screen for colon cancer?

A. At age 35.
B. At age 40.
C. At age 45.
D. At age 50.
E. At age 55

Yesterday’s Mind Teaser: What is the number one cancer killer of women?

A. Colon cancer.
B. Breast cancer.
C. Lung cancer.
D. Cervical cancer.
E. Esophageal cancer.

Answer for Yesterday’s Mind Teaser: C. Lung cancer.

Correct answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr K Raju, Dr Avtar Krishan.

Answer for 22nd September Mind Teaser: B. Their eggs have begun to degenerate

Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, B R Bhatnagar, Dr K V Sarma, Dr Shangarpawar, Dr K Raju, Dr Avtar Krishan.
Reader Response
Dear Sir, Very informative news. Regards: Dr Karan
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Rabies News (Dr A K Gupta)
What is the role of monoclonal antibodies in Rabies?

Monoclonal antibodies against rabies virus have been widely used in the diagnosis and immunological analysis of rabies. Human monoclonal antibodies to rabies virus G protein are also expected to be used as a replacement for rabies immunoglobulin (RIG) in the post–exposure treatment of rabies. In 1978, Wiktor reported the preparation of rabies virus monoclonal antibodies. Since then, rabies virus monoclonal antibody (mAb) technology has been more and more widely used in basic research and diagnosis of rabies.
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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
eIMA News
News
  • The Union Minister for Health Shri J.P. Nadda released the National Health Profile 2015 along with officials of the Ministry, the Directorate General of Health Services and the Central Bureau for Health Intelligence (CBHI) reports The Hindu, dated September 22, 2015. New official data shows that every government hospital serves an estimated 61,000 people in India, with one bed for every 1833 people. In undivided Andhra Pradesh, every government hospital serves over 3 lakh patients while in Bihar, there is only one bed for every 8800 people. India now has cumulatively 9.4 lakh allopathic doctors, 1.54 lakh dental surgeons, and 7.37 lakh AYUSH doctors of whom more than half are Ayurvedic doctors. India’s 400 medical colleges admit an estimated 47,000 students annually.
  • The new American College of Gastroenterology guidelines, on the diagnosis and management of small bowel bleeding and published in the American Journal of Gastroenterology recommend that when patients have negative upper and lower endoscopy, second-look tests may be warranted and if repeated tests do not reveal a bleeding source, capsule endoscopy should be the next step. In patients with symptoms suggestive of potential obstruction or suspected stricture, CT enterography is recommended as the next test.
  • Patients with diabetic peripheral neuropathy who used a capsaicin 8% patch (Qutenza, Astellas Pharma) had more relief from pain and better sleep quality than those who received a placebo patch, according to a phase 3 study reported at the European Association for the Study of Diabetes (EASD) 2015 Meeting.
  • M. Arfan Ikram, MD, PhD, of Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues report online in JAMA Neurology that atrial fibrillation is associated with an increased risk of dementia, independent of clinical stroke. The association was strongest for younger participants who had the longest duration of atrial fibrillation.
  • Chances of impaired safe driving went up twofold when someone who had been drinking alcohol had to deal with a distraction such as a text message or changing a radio station while driving. This was true even for people whose alcohol levels were below the legal limits for drunk driving. The study is reported in the journal Psychopharmacology.
  • A small study published recently in Circulation: Heart Failure has found that beet juice, with its high concentration of nitrates, may help boost muscle strength among heart patients.
  • Pain relief is a greater concern than mobility for people with a common form of lower back pain known as lumbar spinal stenosis. In a study published recently in Neurology, nearly 80 percent of the patients said they would rather have relief from their pain than greater mobility.
  • A complicated pregnancy may increase a woman's risk of dying from heart disease later in life. The risk is particularly high for women who've had more than one health problem during pregnancy, said senior study author Barbara Cohn, director of child health and development studies at the Public Health Institute in Berkeley, Calif. (online Sept. 21 in Circulation)
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Bioethical issues in medical practice
A patient’s right to information

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

A doctor’s healthy father suddenly started complaining of weakness, dyspnea and loss of appetite. A chronic smoker for many years, he was diagnosed with pulmonary cancer with few weeks to live.Keeping in mind his father’s happy go lucky nature, total ignorance of health issues and his own sadness for his father, the doctor did not disclose the diagnosis to his father. He asked the treating doctor not to tell his father either. One day the father came for consultation alone and asked the treating doctor point blank- what is wrong with me? What should the treating doctor do?

a. Tell the entire truth and betray his friend’s trust?
b. Tell a white lie to his patient?
c. Any other choice?

Which is the way you would prefer and why? Can you suggest some other solution and why?

Do write in with views and your suggestions!
  • I am surprised by the method by which some of the respondents have arrived at their answer, rather than by their answers themselves. The query posed is not directed towards eliciting personal opinion on ideal physician behaviour, but rather to delineate the ethical conduct prescribed under the extant rules and regulations, including Code of Ethics Regulations, 2002 http://www.mciindia.org/
    RulesandRegulations/Codeof
    MedicalEthicsRegulations2002.aspx
    prescribed by the MCI on the duties of the Physician. Hence, it may be appropriate to start by identifying the rules/regulations applicable to the fact-situation, and then infer the answer. I find that the following clauses of the above regulations are applicable:

    1.3.2. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

    2.3 Prognosis: The physician should neither exaggerate nor minimize the gravity of a patient’s condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family.

    7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession except –

    1. in a court of law under orders of the Presiding Judge;

    2. in circumstances where there is a serious and identified risk to a specific person and / or community; and

    3. notifiable diseases

    Therefore, I would say that the doctor has to disclose the true condition of his health to the patient. If he is applying 2.3, he has to personally ensure that such disclosure would not harm the patient. The opinion or recommendation of the patient's son in this matter is irrelevant, just as if the son had not been a doctor himself. Swapna Sundar
  • I instinctively seem to agree with Swapna, any agreement to treat is between the patient and the doctor-most compassionate and empathetic way to tell him must surely be found, but he needs to be told. Pooja
  • As he has a right to know, I would give him part truth with hope (e.g a tumor that could be treatable) and tell him not to disclose it to his son as it could upset the son. This will ensure that the son does not feel betrayed by me. While he may have a right to know all, the full knowledge is not going to save his life or even improve his quality of life in any way. On the contrary it can cause major damage and make the rest of his life miserable. He has a right to happiness in the terminal stages of his life. I would not lie as that can jeopardize the doctor-patient relationship. Prof. Dr U Gauthamadas, Professor & Head, Dept. of Psychiatry, MAP Institute of Medical Sciences & Research, Chennai
  • Howsoever it may appear unethical and unlawful but in this case I would suggest "If a person has lived with dignity let him die with dignity a few weeks later" Don't tell him anything. Dr BB Singh, IPR Attorney & Scientific Advisor and Advocate, High Court, Mumbai
  • The doctor first should give an answer to the patient that they are working to get to the bottom of things and it is a serious problem but every problem will have some solution. Important is QOL. And that he would talk in detail once he and his son would get the diagnosis. Must reassure him. The doctor then must talk to his friend about his father's wishes and that every patient in sound mind must know his condition. It gives him time and chance to do important things. Dr Pratibha Pereira
  • As you know disclosing bad news is an art too. Let us do it properly. I would opt the third choice in your MCQ. Dr Ajithkumar K
  • C. The patient undergoing the problem knows the treating doctor is a friend of son and may be keeping the report confidential. His coming to the doctor alone and wanting to know the result is a matter of his right. The doctor should tell his friend’s father about the result to enable him take decisions about his health and related issues. For health matter his doctor son’s friend was there but other matters the patient had to make decisions. In case this doctor is busy he can take help of a counsellor to help the patient in disclosing the report confidentially who would opportunity to overcome patient's anxiety at the stage of disclosing and help in decision making. Nita Mawar
  • I see two issues. 1. To tell father or not? 2. Regarding treatment. I am sure the father, an intelligent person, will know that things are hidden hence he came alone to find out. There must be full disclosure. No less. Regarding treatment, it is the adult patient's right to decide what he wants, not his children. He should decide it. There is no ambiguity about it. I know of people in the same predicament and I have seen the difference in opinion between the children and the sick parent. It is often that the children do not want to see their parent in a difficult state and not want to handle it. If there are financial issues it is a different context altogether. Saradha Suresh
  • This is a glaring example of ethical dilemma! There are two issues here to be weighed 1. Right to information and 2. QOL. If the doctor finds the father to be sound and strong to understand the situation as he is willing to know, so breaking the bad news can be the next step ...of course it requires expertise! This can help in his further decision making process. QOL issues (according to his son) also need to be taken care of. Final goal of looking into ethical dilemma is to analyze risk and benefit, which is to be assessed on case to case basis. So a doctor's judgment on analyzing that situation is the main step, keeping his friend also into confidence. Finally the answer goes for (C) in the MCQ. Thanks for bringing up such issues. Looking forward for more such. Dr Barna Ganguly, Prof & Head, Dept. of Pharmacology & Head, UNESCO Bioethics Unit, Gujarat International Network of UNESCO Bioethics Chair.
  • Option C: We have to tell the truth to the patient. It need not be a sudden disclosure as it may have negative impact and add to the suffering of the patient. It can happen in multiple sessions after preparing him for coping up with the bad news and counsel him. It may be time consuming but the patient has all rights to know about the illness he is suffering from. If the doctor finds it difficult to disclose the result, he may seek the help of a professional counselor and the same may be discussed his colleague who is the son of his patient. Dr AS Valan, India EIS officer, NCDC, New Delhi.
  • It has two components: content and the method. Both are equally important, whether we see it through ethical perspective or legal perspective or human rights perspective or humanitarian perspective, (or some other) the person should get a decent deal. First thing is how much and how he would like to know, why he wants to know, what are his concerns, what other help he would like to get, what is the relationship with the son, how much the patient wants to involve him in the process, how much help he wishes to have in planning his own future and treatment, and lot more. I would prefer the doctor (if necessary a team) will be able to develop a therapeutic relationship to disclose and counsel him comprehensively through his sickness/ illness and death if it happens. Let us give importance to the patient not the son. Dr Ajith
  • It has been already reiterated by most that the father has a right to know about his illness. I agree totally with that. The treating doctor can call his friend, the patient's son, explain the dilemma, and if possible disclose the diagnosis in the son's presence. But if the son is still not in favor of disclosure, the doctor has to over-rule him and tell the patient, even if it is at the cost of a friendship. The doctor, since he is a friend may also garner the support of someone else in the patient's family-his wife or other offspring. In fact, what about the wife? Shouldn't she know? Dr. Ratinder Jhaj, Associate Professor, Dept. of Pharmacology, AIIMS, Bhopal, MP.
  • The patient has the right to know about his illness. In any case he has come to inquire about his illness shows that he has some doubt and hiding may affect him psychologically also. He might have to prepare himself for the inevitable, may be writing a will, saying goodbye to his close friends and relatives. These are very important issues and he may not get time when he finally gets to know. The friend should be told about all these issues and may plan some other happy moments for his father to go peacefully. Triptish Bhatia, PhD, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • This scenario is not uncommon in our Indian context, where family members request the doctor to refrain from sharing the diagnosis with the patient. The intention is usually to protect the patient from the emotional impact of the unfavorable diagnosis or prognosis. However, this 'collusion' is not always in the best interest of the patient. The primary responsibility of the doctor is to the patient and honesty with the patient is critical to preserve trust in the relationship. The doctor should use his judgment to decide whether the patient has the capacity to deal with the bad news. Breaking bad news can be postponed in cardiac cases or certain phases of psychiatric illness, where the emotional response may worsen the condition. Breaking bad news is a communication skill that can be learned. The concerns of the family members must of course, be taken into account and evaluated. Family may even need to be counseled on the benefits of truth telling and respect for the patient’s right to information about his body and health. It will enable the patient to participate in decisions about treatment and end of life. Patients usually have a well developed sense about their state of health and some may wish to prepare for death; denying them information can only lead to distress and confusion. In the example above, the doctor's request to withhold information appears emotional due to the distressing circumstances, and the treating doctor would have to take the lead in advising appropriate disclosure to the patient. More so, since the patient is clearly asking for the truth. Olinda Timms
  • My answer is 'c'. The patient is already aware that there is something wrong and his family is hiding that from him, so keeping him ill informed still may not be the right thing even if it is for a few weeks (again it may be months and is difficult to predict with a lung cancer)? This scenario (and the previous one) hints at a traditional dyadic informational relationship between son and patient, doctor and son, patient and doctor slowly breaking down to make way for a newer pluralistic informational infrastructure? (More here: http://www.ncbi.nlm.nih.gov/pubmed/26123908). In my own practice I believe in a metaphorical approach to communicating with patients who have terminal illnesses (more here: http://annals.org/article.aspx?articleid=715632) and I often ask patients (such as the one under discussion) to look out of my office window and notice the upcoming concrete buildings where previously green forests and river streams reigned (my office actually overlooks a slowly dying Kaliasot forest and river). After that I inform them that this is exactly what is happening inside their body and it is possible that in time all the greenery will be eventually wiped out. No one can really predict how soon: weeks, months or years. All of us have this process going on within us and all of us will have to one day come to terms with dealing with the same dilemma and will need to face our imminent departure and provide for our loved ones before that. (More disease metaphors here: offline full text: http://searchworks.stanford.edu/view/7929525). Dr Rakesh Biswas, Professor, Medicine, LN Medical College, Bhopal
  • The nature of illness has to be told to the patient. The disclosure has to be done in such a way that the patient receives the information that is his right and at the same time discussing the concerns and feelings of his son. Although I believe the son should have taken his dad into confidence and told him and also the treating doctor should have impressed upon the son that his father is entitled to know the truth. Dr Tribhuvan Pal Yadav, Prof of Pediatrics. PGIMER, Dr RML hospital, New Delhi.
  • The autonomy of the patient has taken precedence over beneficence and nonmalfeasance nowadays. Paternalism is no more advocated. It is believed that withholding pertinent information violates a patient's autonomy rights and violates the fundamental duties of a physician. First of all the physician should have offered the advice to reveal the truth to the doctor friend. Considering his father’s happy go lucky nature he might have taken it as an inevitable & might have accepted it with courage. Even if physician doesn’t revealed the truth, in this modern era patient will try every bit to find it from another source. And he may come to know the fact sooner or later, that may have a deep scarring effect on him to the extent that father-son, patient-doctor relations may get strained. Explaining the truth about diagnosis, prognosis, and treatment options to the patients is needed for a good professional relationship and for exercising informed choices by patient. Now the only plausible thing to do is communicating the ugly facts and here the experience, attitude, skill of physician & timing of communication will be of utmost importance. So I think the best possible resolution for this dilemma is to ask the patient to come other day with his doctor son and then revealing the truth. Dr Manik S. Ghadlinge, Assistant Professor, Dept of Pharmacology, PGIMER & Dr RML Hospital, New Delhi
  • The trust of the patient is more important than the trust of the doc's friend. So I consider option A is more relevant for the doctor. Sreenivas Vishnubhatla, Professor of Biostatistics, All India Institute of Medical Sciences, New Delhi
  • It depends upon the condition of his illness and accordingly doctor will disclose. Because doctors have to speak truth to their patients. NN Mishra, Asstt Prof & Head/Bioethics Consultant. Dept. of Psychology, LS College, Muzaffarpur, BRA Bihar University, Muzaffarpur, Bihar.
  • In my view, the doctor should first consult his friend and then tell his father the truth about his illness. Because if he knows the truth, he will then be able to take care of himself in a better way. Dr Shalini Makkar, Asst. Prof. Forensic Medicine, PGIMER-Dr. RML Hospital, New Delhi
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Patients with uncontrolled diabetes and heart disease are more prone to dengue fatality

Diseases like diabetes and heart disease suppress the immunity of individuals, making them prone to complications

The increasing incidence of dengue in the Capital is becoming a threat for its large diabetic population. The reason being that dengue fever increases the body temperature and metabolic rate simultaneously. This causes blood sugar levels to fluctuate and can prove fatal for the patient if the blood sugar levels are not controlled in time. In addition to this, several prescription drugs used for the management of diabetes and heart disease act adversely in dengue patients causing further complications.

Dengue is transmitted by female Aedes Aegypti mosquitoes, which acquire the virus while feeding on the blood of an infected person. Dengue occurs in two forms: Dengue fever and dengue hemorrhagic fever or severe dengue. A person is said to be suffering from severe dengue when there is capillary leakage.

The disease is marked by the onset of fever, headache, vomiting and pain behind the eyes, and in muscles and joints. There is no specific treatment for dengue fever apart from early recognition and adequate hydration. However regularly monitoring vital parameters is a must in diabetics and heart patients given the risk they run of severe thrombocytopenia and are more likely to developing Dengue Hemorrhagic Fever and Dengue Shock Syndrome. Use of aspirin during dengue fever is not recommended as it may increase the bleeding tendency. So all heart patients on regular low-dose aspirin must stop taking it immediately and consult their doctor if dengue is suspected. For diabetics with dengue, ‘insulin therapy’ is suggested because oral medications like metformin and DPP-4 inhibitors may react adversely and cause multi-organ failure. Urine ketones should regularly be checked for in patients with type 1 and 2 diabetes if acid levels are up in body. The medications should be modified accordingly thereafter.

According to Padma Shri Awardee Dr A Marthanda Pillai National President Indian Medical Association (IMA) and Padma Shri Awardee, Dr K K Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India, “Those who are already suffering from one or the other morbidities are greater risk of developing complications if they contract dengue fever and must be closely monitored. For instance, a majority of dengue patients are unaware of the fatal consequences that drugs like aspirin can have on them due to its anti-platelet effect. Given that most heart and diabetic patients already have a low immunity, they must take additional precautions towards disease prevention. The best way to reduce chances of acquiring the illness is to eliminate the places where the mosquito breeds, like artificial containers that hold water in and around the home. Outdoors, one must regularly clean water containers like pet and animal water containers, flower planter dishes and keep water storage barrels covered.”

Other precautionary measures include keeping a lookout for standing water indoors such as in vases with fresh flowers and clean them at least once a week. One must remember that the adult mosquitoes like to bite inside as well as around homes, during the day and at night when the lights are on. To protect oneself, it is important to use mosquito repellents while indoors or out. When possible, people must wear long sleeve shirts and long pants for additional protection. Also, they must make sure that the window and door screens are secure and without holes. Sitting in air-conditioned rooms can reduce the incidence of the disease.

An easy to apply ‘Formula of 20’ that can be used to identify high risk patients with Dengue fever:
  • Rise in pulse by 20
  • Fall in upper blood pressure by more than 20
  • Rise in hematocrit by more than 20 percent
  • Rapid fall in platelets to less than 20,000
  • More than 20 hemorrhagic spots on the arm in one inch after tourniquet test
  • Difference between upper and lower blood pressure is less than 20
Start fluid replacement at 20 ml/kg/hour immediately in such patients, and shift to nearest medical center for observation.