September 25   2015, Friday
eMedinewS
Do heavier heart failure patients live longer?
Dr KK Aggarwal A higher BMI was associated with decreased mortality in certain subsets of patients with acute decompensated heart failure, according to an intercontinental study that supports the existence of a global "obesity paradox." Overall, a higher BMI was associated with decreased 30–day and 1–year mortality (11% decrease at 30 days; 9% decrease at one year per 5kg/m2; P<0.05)¸ after adjustment for clinical risk‚ wrote James L‚ Januzzi Jr‚ MD‚ of Massachusetts General Hospital, and his co–authors in the Journal of the American College of Cardiology. Further analysis showed that the protective association was confined to older individuals (>75; HR=0.82‚ p=0.006)‚ decreased cardiac function (ejection fraction < 50%; HR=0.85‚ P<.001)‚ non diabetics (HR=0.86‚ P <.001) and de novo HF (HR = 0.89‚ P = 0.004).
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30th CMAAO General Assembly and 51st Council Meeting in Yangon, Myanmar
News
Anesthesiology/Neurology

A clinical profile of chronic back pain accompanied by a specific report of severe pain upon standing for too long and leg tremors may suggest an often overlooked diagnosis of arachnoiditis, suggests new research presented at the American Academy of Pain Management (AAPM) 2015 Annual Meeting.

Oncology

A new study advises to think carefully about adding androgen-deprivation therapy (ADT) to radiation therapy when treating men with unfavorable-risk localized prostate cancer who also have a "moderate to severe" level of comorbidity. Researchers reported that ADT might speed death from all causes or from heart attack. The findings are published online September 22 in JAMA.

Sleep Disorders / Psychiatry

More than 70% of people with sleep apnea experience symptoms of depression, suggests a new study published in the Journal of Clinical Sleep Medicine. Researchers noted that the findings indicate a possibility that the sleep condition could be misdiagnosed as depression.

Infectious Diseases / Urology

High cure rates can be achieved with fosfomycin in patients with chronic prostatitis, many of whom are resistant to the current first-line treatment of fluoroquinolones, suggests a new study presented at the Interscience Conference of Antimicrobial Agents and Chemotherapy 2015.

Obstetrics and Gynecology

An updated committee opinion from the American College of Obstetricians and Gynecologists urges healthcare providers to increase access to long-acting reversible contraception (LARC) for all appropriate patients and encourage patients to consider implants and intrauterine devices. The committee opinion is published in the October issue of Obstetrics & Gynecology.
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Cardiology eMedinewS
  • An analysis of more than 76,000 participants in the prospective Cohort of Swedish Men and Swedish Mammography Cohort showed that, although there were more than 7000 cases of atrial fibrillation (AF), there was no association with coffee consumption. The findings were published online September 23 in BMC Medicine.
  • Empagliflozin, a sodium glucose cotransporter 2 (SGLT2) for treating type 2 diabetes, has been found to significantly cut risk of cardiovascular death and death by all causes without significantly increasing risk of side effects, except for genital infections, reported a study presented at the European Association for the Study of Diabetes (EASD) meeting.
Pediatrics eMedinewS
Pediatrics / ENT

Nineteen percent of children who underwent adenotonsillectomy experienced a postoperative complication, with 9.4% experiencing respiratory compromise, and 2.6% having secondary hemorrhage, reported a meta-analysis published online September 21 in Pediatrics. The researchers also noted that children with obstructive sleep apnea (OSA) were 4.9 times more likely to suffer respiratory complications than children without OSA.

Pediatrics / Gastroenterology

New research found that some infants gained tolerance to cow's milk after being treated with probiotic formula, while others did not. Researchers reported that structural differences in gut bacteria may be the reason why some children do not acquire tolerance. The findings are published in The ISME Journal.
Dr KK Spiritual Blog
Music as a Drug

Our body is the largest pharmaceutical group in the world and has the capacity to heal each and every disease. The very fact that there is a receptor for every drug in the body means that the body has the capacity to produce that drug. Music is one such modality, which can heal by initiating various chains of chemical reactions in the body.
  • Chanting vowels produces interleukin-2 in the body, which works like a painkiller.
  • Chanting nasal consonants produces tranquilizers in the body.
  • Sounds like LUM are associated with fear, VUM with attachments, RUM with doubt, YUM with love, HUM with truthfulness and AUM with non–judgmental.
  • Various chemicals can be produced in the body by chanting of various vowels and consonants.
  • Nasal consonants are vibrant sounds and produce vibrations of the autonomic plexus causing balance between sympathetic and parasympathetic states. More the nasal consonants in music, the more will be its relaxing healing power.
  • Listening to overtone chanting in music can also heal people in the vicinity of the music.
  • Recitation of music can also increase or decrease the respiratory rate of the singer. Lyrics, which reduce respiratory rate will lead to parasympathetic healing activity. The respiratory rate of a listener too can increase and decrease if he is absorbed in the song.
  • Listening to a song word by word and by understanding its meaning can also change the biochemistry of the listener. A song can create an excitement or a feeling of depression.
  • A song can also work like intent by speaking in the form of prayers. Group prayers can have powerful affects and convert intent into reality through the concept of spontaneous fulfillment of desire.
  • Music is often linked with dance, both classical and western, which provides additional healing.
  • Gestures, mudras, bhavs and emotions associated with songs produce parasympathetic state in both the singer and the listener.
Inspirational Story
Human value

Life is full of ups and downs. It is easy to lose hope and confidence. This little story helps us to realize that no matter what happens, we remain valuable as individuals.

A well-known speaker started off his seminar by holding up a $20 bill. In the room of 200, he asked, “Who would like this $20 bill?” Hands started going up.

He said, “I am going to give this $20 to one of you but first, let me do this.” He proceeded to crumple the dollar bill up. He then asked, “Who still wants it?” Still the hands were up in the air.

“Well,” he replied, “What if I do this?” And he dropped it on the ground and started to grind it into the floor with his shoe. He picked it up, now all crumpled and dirty. “Now who still wants it?” Still the hands went into the air.

“My friends, no matter what I did to the money, you still wanted it because it did not decrease in value. It was still worth $20.

Many times in our lives, we are dropped, crumpled, and ground into the dirt by the decisions we make and the circumstances that come our way.

We feel as though we are worthless. But no matter what has happened or what will happen, you will never lose your value. You are special – Don’t ever forget it!”
Wellness Blog
Give BP drugs at night

Blood pressure drugs should be taken at night.

Uncontrolled blood pressure can lead to heart attacks, paralysis and heart failure. Most such attacks occur in the early morning hours. Pulse, blood pressure and thickening of platelets are all higher in the early morning hours.

Controlling early morning blood pressure can reduce cardiovascular mortality.

According to a study published in the Journal of the American Society of Nephrology, among patients with chronic kidney disease and high blood pressure, taking at least one antihypertensive drug at bedtime significantly improves blood pressure control, with an associated decrease in risk for cardiovascular events.

The study included 661 patients with chronic kidney disease who were randomly assigned either to take all prescribed anti-BP drugs on awakening or to take at least one of them at bedtime. Patients were followed for a median of 5.4 years; during that time, patients who took at least one BP–lowering drug at bedtime had approximately one third of the cardiac risk compared with those who took all medications on awakening.

A similar significant reduction in cardiac deaths, heart attacks and paralysis was noted with bedtime dosing. Patients taking their medications at bedtime also had a significantly lower mean BP while sleeping.

For each 5 mmHg decrease in mean sleep–time systolic upper BP, there was a 14% reduction in the risk for cardiovascular events during follow–up.

Potential explanation for the benefit of night time treatment may be associated with the effect of night time treatment on urinary albumin excretion levels. Urinary albumin excretion is significantly reduced after bedtime, but not morning, treatment.
Scientific awareness on personal hygiene and prevention from obesity among school going children, Salini Public School, Meet Nagar, 23rd September, 2015
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Make Sure
Situation: An elderly patient with unstable angina presented with upper respiratory infection and tested positive for C. pneumoniae infection.

Reaction: Start macrolides immediately.

Lesson: Make sure to remember that erythromycin 2 g/day for 10–14 days reverses the increased risk of atherosclerosis. Seroepidemiological studies have shown a strong association between C. pneumoniae infection and atherosclerosis in patients with cardiovascular disease.
Dr Good Dr Bad
Situation: A patient of coronary artery disease (CAD) developed dengue.

Dr Bad: Start paracetamol.

Dr Good: Start paracetamol and stop low–dose aspirin.

Lesson: In dengue, low–dose aspirin should be stopped.
Media
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Quote of the Day
Idleness is an inlet to disorder, and makes way for licentiousness. People that have nothing to do are quickly tired of their own company. Jeremy Collier
eMedi Quiz
What is not true for HNPCC?

a) It is the most common hereditary colorectal cancer syndrome in USA

b) It is associated with MMR gene mutation

c) It is associated with APC mutation

d) It is associated with carcinoma colon and extraintestinal cancers

Yesterday’s Mind Teaser: 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

Answer for Yesterday’s Mind Teaser: D. At age 50.

Correct answers received from: Dr Avtar Krishan, Dr B R Bhatnagar, Dr K V Sarma, Dr K Raju, Dr J Daivadheenam, Dr Lopa Dalal.

Answer for 22nd September Mind Teaser: C. Lung cancer.

Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr K Raju, Dr Avtar Krishan.
Reader Response
Dear Sir, Thanks for the updation. Regards: Dr Kastur
eMedinewS Humor
God vs. Satan

And God populated the Earth with broccoli and cauliflower and spinach and green and yellow vegetables of all kinds, so Man and Woman would live long and healthy lives.

And Satan created McDonald's. And McDonald's brought forth the 99-cent double cheeseburger.

And Satan said to Man "You want fries with that?" And Man said, "Super size them". And Man gained pounds.

And God created the healthful yogurt, that woman might keep her figure that Man found so fair.

And Satan froze the yogurt, and he brought forth chocolate, nuts and brightly colored sprinkle candy to put on the yogurt. And woman gained pounds.

And God said "Try my crispy fresh salad."

And Satan brought forth creamy dressings, bacon bits and shredded cheese.

And there was ice cream for dessert. And Woman gained pounds.

And God said "I have sent you heart healthy vegetables and olive oil with which to cook them."

And Satan brought forth chicken-fried steak from Cracker Barrel so big it needed its own platter. And Man gained pounds, and his bad cholesterol went through the roof.

And God brought forth running shoes, and Man resolved to lose those extra pounds.

And Satan brought forth cable TV with remote control so Man would not have to toil to change channels between ESPN and ESPN2. And Man gained pounds.

And God said "You are running up the score, Devil." And God brought forth the potato, a vegetable naturally low in fat and brimming with nutrition.

And Satan peeled off the healthful skin and sliced the starchy center into chips and deep-fried them. And he created sour cream dip also. And Man clutched his remote control and ate the potato chips swaddled in cholesterol. And Satan saw and said "It is good."

And Man went into cardiac arrest. And God sighed and created quadruple by-pass surgery...

And Satan created HMOs
HCFI Videos
Rabies News (Dr A K Gupta)
How to approach a case of irregularities in treatment schedule, e.g., if patients missed the doses as per the due dates, i.e. dose schedule is broken?

First three doses of modern rabies vaccine must be very timely and for the fourth and fifth, one or two days of variation is permissible.
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IJCP Book of Medical Records
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CPR 10
Successfully trained 113241 people since 1st November 2012 in Hands-only CPR 10
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
eIMA News
News
  • Analysis of a US database of in-hospital cardiac arrests reported online in the Journal of the American Medical Association showed that patients with do-not-resuscitate (DNR) orders had lower survival than those without DNR orders, even among those with the best prognosis.
  • Treatment with clomiphene, a standard therapy for couples with unexplained infertility, results in more live births than treatment with a potential alternative, letrozole, according to a study of more than 900 couples conducted by a National Institutes of Health research network and published in the New England Journal of Medicine.
  • The US Preventive Services Task Force (USPSTF) has recommended that 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.
  • Prostate cancer diagnoses decreased by 28% in the first year following the US Preventive Services Task Force (USPSTF) recommendation against regular prostate specific antigen (PSA) screening. Diagnoses of low-, intermediate-, and high-risk prostate cancers declined significantly during that period, although new diagnoses of nonlocalized disease did not change.
  • Women with genetic conditions should begin counseling prior to becoming pregnant, according to new recommendations released by the American College of Obstetricians and Gynecologists (ACOG) and published in Obstetrics & Gynecology as Committee Opinion 643.
  • According to the National Health Profile released by the health ministry on Tuesday, India witnessed 4,071 cases of diphtheria and 104 deaths in 2014, while among the states, Delhi had the highest number of cases at 1,418 and also the highest number of deaths at 60. Haryana recorded the second highest diphtheria cases at 663. However, it was West Bengal that saw the second highest number of deaths at 10. Assam recorded the third highest figure of cases at 506, followed by Maharashtra at 444. (TOI, Sep 23, 2015)
  • The prevalence of obesity among adults and children living in the United States continues to be alarming, but there are signs that weight is stabilizing among adults in many states, and even among children in areas where greater efforts are being made to keep kids healthy, according to the State of Obesity report released yesterday by the Trust for America's Health and the Robert Wood Johnson Foundation.
  • On Tuesday, the FDA announced that the combination of trifluridine and tipiracil, with the brand name Lonsurf, could be marketed for the colorectal cancer indication.
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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
  • The answer to this question is not an easy on as we are dealing with a living human being. As the patient is cheerful and happy-go-lucky by nature and does not take health seriously, it would be dangerous to hide information about cancer because it needs proper treatment. If patient would not have knowledge regarding his disease, then he never would be able to comprehend the seriousness of disease and essential treatment. And by hiding information we cannot stop the truth to come in the forefront eventually. The patient has every right to know about his illness, whatever his adaptation would be after knowing. But there are some ways in which adaptation may be better. First of all it is necessary to know the general attitude of the patient toward any illness. It is to be explored that why is he so casual towards health issues. A clinical psychologist may deal with this much appropriately. His orientation towards fatal illness and death may be explored. According to his attitude, information about the cancer should be revealed slowly. And while revealing the diagnosis, every verbal and non-verbal cues should be analyzed and way of giving information should be improvised accordingly. He should be properly educated about all the treatment available and its processes. He should be informed about the mortality rate due to this disease and chances of being treated also. Each and every fear should be addressed well. It would be better if family is present around him. The patient is definitely going to break down, and he should be reassured about the recovery chances. Such session should not be limited to one day only. Actually during any terminal illness, continuous counseling is beneficial to the patient and the family. As with the revealing of the truth about disease, a process of denial, anger, bargaining, depression and lastly acceptance would follow. Time duration of these stages vary person to person. So persistent counseling helps a lot. If the patient has few day left, then it’s more important to inform him about his illness. He needs to be prepared, educated about the death processes and lastly about the wonderful life he has lived. He may be helped by narrative therapy, diary writing techniques, music therapy and by many other methods. Main focus would be to help the person in spending the rest of his days peacefully. Ranjita Thakur
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Dengue fever is more difficult to treat in patients with pre-existing lifestyle diseases

Extra care must be taken in individuals who are suffering from pre-existing conditions such as diabetes, hypertension, heart disease and obesity

The National Capital is witnessing chaos and disorder amid the present dengue outbreak. Fatalities arebeing recordeddespite the best efforts of the medical fraternity to save lives. The primary reason for this is the spread of Type 4 dengue in the Capital at such a large scale for the first time. What complicates the situation is pre-existing lifestyle disorders that deter proper treatment and increase the severity of the symptoms. It is believed that at the rate at which lifestyle disorders such as obesity, hypertension, diabetes and heart disease are plaguing the 21st century Indians, soon the treatment of seasonal diseases such as dengue will only become more complex.

Hypertension, for instance, is characterized by blood pressure higher than the normal range. If a hypertensive patient suffers from dengue, a disease characterized by a drop in the blood pressure of the body, warning signs of complications may go un-noticed since his BP will still be within the normal range.

In addition to this, if a dengue patient suffers from obesity, he runs a higher risk of capillary leakage as compared to a person with a normal body mass index.

Speaking about this Padma Shri Awardees Dr A Marthanda Pillai National President Indian Medical Association (IMA) and Dr K K Aggarwal – Honorary Secretary General IMA and President HCFI said, “Dengue is of two types, dengue fever, and severe dengue. While dengue fever can mostly be managed on an outpatient basis through the administration of adequate fluids, severe dengue occurs when there is capillary leakage. In a situation where the body fluid leaks from the blood vessels into the surrounding tissues, extra care must be maintained, and regular monitoring is required. Patients who are obese, are on heart medications are more prone to capillary leakage. Heart patients on low-dose aspirin must stop its consumption immediately and consult their physician because of its anti-platelet effect.

Patients on hypertension medication might often not be aware that their medicine may contain a combination of aspirin, a statin and a blood pressure lowering agent, which may be life-threatening if taken when suffering from dengue.

"All patients who are suffering from lifestyle diseases must take extra care and consult their doctor for advice if they are suffering from fever for over 24 hours to rule out dengue. Instead of panicking, one must be aware of all facts and seek timely intervention and treatment. Only 1% of the dengue cases are life-threatening, and if managed properly, fatality can be eliminated", they further added.

People suffering from diabetes must also keep their insulin in check since dengue can cause a fluctuation in the sugar levels. Most dengue patients can be managed on an outpatient basis and do not need hospitalization. Being in constant touch with one's doctor is important.

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