September 26   2015, Saturday
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Lowering BP of No Help in Acute Stroke
Dr KK Aggarwal According to findings from China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) published in the Journal of the American Medical Association, use of antihypertensive drugs to lower systolic blood pressure by close to 13% as part of acute treatment of ischemic stroke did not reduce early mortality or disability compared with patients who did not receive antihypertensive therapy.

At 14 days after randomization, there were 683 events among patients who received early aggressive antihypertensive therapy versus 681 events in the control group and at 3 months, there were 500 additional events in the treatment arm versus 502 among controls, said Jiang He, MD, PhD, of Tulane University School of Public Health in New Orleans. (MedPage)
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30th CMAAO General Assembly and 51st Council Meeting in Yangon, Myanmar
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CSI Cardiac Prevent 2015
Welcome to CSI Cardiac Prevent 2015

Welcome to the 2nd CSI Cardiac Prevent, being held at Hotel Taj Palace, New Delhi from 25th to 27th September 2015. The motto of the conference is 'Innovation for CVD prevention'.

India is rapidly racing towards earning the unpropitious title of the 'CVD capital of the world.' The economic costs and the loss from this disease to the enviable demographic advantage of the country are likely to be immense. This is especially worrying since the disease strikes early and portends far worse outcomes among Indians. Moreover, the disease now is known to affect all classes of people, sparing none. Thus the time for action is NOW!

As CVD throws a challenge to us, it also presents an opportunity to converge our resources to mitigate this epidemic. In light of this there has been an international call to reduce CVD and other non-communicable diseases by 25% by 2025. Indian participation in this arena is imperative to achieve these goals. The Cardiology fraternity in India has excelled in interventional and clinical care of patients with heart ailments running abreast with the best in the world. It is in this context that the time has come for us to rise to the challenge and raise the emphasis on preventive cardiology, which has remained somewhat below the radar for this community. The beauty of prevention is that very small changes across large populations transcends to massive gains for society. A successful preventive program for a country like India needs to combine conventional and innovative strategies to have a lasting impact. The cardiologists need to partner with the community at large. It is important that the CSI be the flag bearer for prevention of CVD in India.

About 800 delegates from India and neighboring countries are participating in this conference. And, more than 100 experts from world over are here to attend the conference, making it one of the largest meetings in the discipline of preventive cardiology. The schedule of the first day of the meeting has public lectures, awareness camps and other public activities.

Our endeavor has been to provide a stimulating and memorable scientific program, which includes interactive educative sessions and workshops apart from conventional plenary sessions, featured symposia, breakout sessions and oral presentation sessions for abstracts. Renowned international and national faculty who are the leaders in the field of preventive cardiology have been invited. These experts with active audience participation will formulate strategies in tackling problems which are peculiar to our country with its myriad cultures, customs and languages.

We sincerely hope that the blend of pleasant weather, warm hospitality and revitalizing social evenings will make the scientific environment richer.

Your participation will go a long way in making this mega event a success, and further the cause of CVD prevention in India.
Dr H K Chopra
President, CSI
Dr Santanu Guha
President-Elect, CSI
Dr Ashok Seth
Organizing Chairman
Dr K Venugopal
Imm. Past President
Dr Mrinal Kanti Das
Secretary, CSI
Dr Kewal C Goswami
Chairman, Reception Committee
Dr Geevar Zachariah
Convenor, Prevention Council, CSI
Dr S Ramakrishnan
Organizing Secretary
Highlights of CSI Cardiac Prevent 2015
Introducing Save Your Heart Tour Bus- What the bus is going to do??
  • To inform the community of the problems that individuals can face by being a Heart Patient.
  • To provide guidelines for dealing with situations which may arise by the disease.
  • To solicit the voluntary help of the community in addressing these situations.
Introducing Save Your Heart Mobile Application- What the app is going to do??
  • Engagement
    Attract and engage the target audience towards a Healthy Heart
  • Promotion
    Spread Awareness about Heart and related topics
  • Utility App
    Mobility to calculate ASCVD, other cardiac metrics, & stay updated through phones
  • Location
    To provide location of nearby Cardiac Centers in emergency
  • To be available in 3 versions, IOS, Android & Web-app
    Attempting for the Most Blood Pressure Checks World Record on 25th September 2015-
  • CSI cardiac Prevent 2015 is attempting to hold a Record in Guinness World Records, United Kingdom & Limca Book of Records, India for Most Blood Pressure Checks in a given time.
Joint Workshop of CSI & WHF

Dr HK Chopra, New Delhi,President CSI
Target reduction of premature morbidity by CVD by 25% by 2025…

Dr HK Chopra said that India is already the world capital of diabetes and CAD, it is soon going to be the world capital of HT, obesity (dyslipidemia), smoking and air pollution.

The prevalence of CAD is rising steeply in our country. It was 1% in 1960, 11% in 2003 and 14% now in 2015, in the urban population. “To be an Indian is itself a risk for premature coronary artery disease” because of genetic predisposition, uncontrolled HT, obesity, diabetes, tobacco consumption and faulty lifestyle such as high levels of stress, inability to cope with negative competition, ego, arrogance and cynical behavior, sedentary lifestyle, erratic consumption, malnutrition (salt excess, fried food etc.), eating the wrong food, at a wrong time, in wrong place, in a wrong manner, in wrong dose, in wrong environment. The CAD is thus the globe’s biggest slayer claiming about 17.5 million lives every year. The disease is more extensive, diffuse, multivessel and more premature in Indians (10 times more) in young individuals more as compared to their counterpart in the Western and European world.

HT, diabetes, dyslipidemia, smoking and air pollution causing more deaths in India as per the 25 years long study published in Lancet. Between 1990 and 2013, (data was collected by analysis of 79 risk factors in 188 countries), the study conducted by International consortium of researchers led by University of Washington and representatives from the Public Health Foundation of India. Deaths due to hypertension were 76 lakh in 1990, which is increased by 106% in 2013. It is “Red Alert” for Indians with 139 million suffering from high BP equal to 14% of global burden of uncontrolled HT. This is as compared to WHO data 1980 showed 87 millions of Indians suffering from HT. High cholesterol in India has more than doubled, air pollution has increased by more than 60% and deaths from alcohol have increased by 97%. It is very clear from the study that the metabolic risk factors such as high BP, high blood sugar, high blood cholesterol, poor diet and excess of alcohol abuse have doubled in India over the past quarter of century.

The preventive strategies should focus equally on primordial, primary, secondary and tertiary prevention as they are interrelated. However, our focus of this joint workshop is on “Secondary Preventive Strategies” for control of HT, diabetes, dyslipidemia, smoking and air pollution as PPP Model. These should be controlled effectively nationally, regionally, locally and focally. Enhancing awareness campaign, advocacy and policy emphasis by print and electronic media, health promotion in digital way, use of apps, alliance of various GO, NGOs, Indian societies, federations etc.

Preventive Cardiology is the only method to halt the rising menace of CVD, HT, obesity, smoking and air pollution in India.

The theme of World Heart Day is “Healthy Environment, Healthy Heart”. We must create Healthy Environment to have healthy Heart, healthy heart to have healthy India (Swasth Dil, Swasth Bharat). The aim of the road map is to reduce the premature deaths from NCDs by 25% by 2025.The structured model for its propagation has to be coordinated efforts by government, NGOs, policy makers, various cardiac and health-related societies, trade, agriculture, food safety, taxation, education, federations, corporate, industry, media, community organization, academia and other relevant entities.

We must create a white paper policy document of CSI and WHF Healthy Heart Initiatives, create Wellness Centers in every colony with the help of welfare societies, corporates etc., create HT, diabetes, obesity, anti-smoking awareness campaigns by print and electronic media (Social media - Whatsapp, apps, Facebook, Twitter, YouTube, adv. in a digital way etc.), organize weekly HT, diabetes, obesity check up camps in the welfare centers, corporates, school, colleges. MNCs, PSUs, federations, NGOs and GOs in alliance with rotary, Lions, Inner Wheel etc., create National Hypertension, Obesity care days, work on implementation of appropriate Advocacy and Policy decisions for Heart Protection Pill (HPP) after the age of 55 under medical supervision, organize lectures, symposia, seminars, conferences on HT, diabetes, obesity, smoking and air pollution control periodically in public interest, create a Health Channels (Wellness Channels) round the clocks. Messages on FM Radio, Wellness Columns in the newspapers, magazines etc. working together, we can win and achieve, what we want.

CVD Protection is our Right. We should act locally and impact globally. Dr Chopra complimented both CSI & the World Heart Federation for this joint workshop to crystallize the mission, vision and action plan for the road map to reduce the premature CVD mortality by 25% by 2025.

Dr HK Chopra, President CSI voiced the CSI Mission “Save a Heart” to have healthy and powerful India, on the occasion of Public Conference being organized by CSI Cardiac Prevent

Dr Chopra said that “Save a Heart Mission” is the only way to halt the rising menace. He congratulated Dr Ashok Seth, Organizing Chairman, and Dr S Ramakrishna Organizing Secretary for launching the mission “Healthy Heart, Healthy India” Swastha Dil, Swastha Bharat focusing all the four components of prevention - primordial, primary, secondary and tertiary.

Optimization of lifestyle right from the childhood is the need of the hour.

Say No to 6 Ss: Salt, Sugar, saturated fat, sedentary lifestyle, stress and smoking

Say Yes to Healthy Lifestyle, exercise daily for 30 min, walking, jogging, swimming, cycling, use treadmill more, consuming more fruits, vegetables and nuts (walnut and almonds), adequate sleep for 7-8 hours, mange stress, regular practice of yoga including the all the eight limbs of yoga Yama, (do and don’ts), Niyama (self-discipline), asana (Postures), Pranayam (breathing exercise), Pratihara (contemplation), Dharna (concentration) Dhyana (meditation), Samadhi (transcendence) and meditation, control HT, diabetes and have your BMI to less than 25.

He firmly believes that the “Longer the waist line, shorter is the heart line”, “What you eat definitely matters but what is eating you matters more”, “Healthy heart is a matter of our own choices”, “Healthy Heart, Healthy India”, “Swastha Dil, Swastha Bharat”.

Dr. Chopra appealed to all the members of the public that the CSI mission “Save a Heart” can create a healthy and powerful India.

Dr Chopra concluded his talk by integrating optimization of lifestyle and science in the following ways

The thoughts that we think
The stresses that we face
The words that we utter
The exercise that we undertake
The morsel of food that we eat
The yoga that we do
The salt and the trans fats that we eat
The hours that we sleep
The water that we take
The cigarette that we smoke
The environment that we live in
The alcohol that we drink
The actions that we perform
Get metabolized by 60 trillion cells, six trillion chemical reactions and 60 neuropeptide and becomes the health of our heart.


Dr Aashish Contractor
Mumbai

Role of cardiac rehabilitation in secondary prevention

• Cardiac rehabilitation (CR) is an essential part of secondary prevention for CVD (Class IA recommendation).

• CR programs have shown to have a significant impact in reducing cardiac, and all-cause mortality.

• The benefits of CR include greater patient adherence to lifestyle modification and risk factor reduction.

• CR can be implemented in a variety of settings, including hospital, fitness centers and home-based.

Dr Tiny Nair
Trivandrum

Sugar, not salt is the cause for hypertension

• Salt is responsible for genesis and progression of hypertension and salt restriction has shown to reduce CV event rates in both animal and epidemiological studies.

• But over the last 20 years, salt intake in communities have not increased (as measured by urine sodium excretion)

• Prevalence of hypertension has increased over the last 20 years.

• Processed food not only contain salt but also have a high fructose content.

• High fructose in soft drinks, fast foods and most processed foods increase blood pressure by increasing uric acid, producing more metabolic syndrome, stimulating sympathetic system as well as RAS axis.

• Epidemiological studies prove that fructose sugar is as important as salt in genesis and progression of hypertension.

Dr Denis Xavier
Bangalore

Spreading the message of secondary prevention

• First research project in India to test if trained community health workers can help to improve outcomes after acute coronary syndrome (heart attacks).

• Conducted in 14 cities across India among 806 patients and followed up for one year with indigenously developed tools (calendar and diary).

• Community health workers discussed with patients and helped to identify barriers to take medications regularly and modify lifestyle.

• At one year, the test group had better adherence to medications, lower rates of smoking, better diets, physical activity and lower blood pressure.

• This project demonstrated that health workers can help to improve care and thereby outcomes. This experience can now be scaled up for implementation across the country.
Dr KK Spiritual Blog
How to Remove Negative Thoughts

Darkness is absence of light and similarly negative thoughts are absence of positive thoughts. The answer to negative thoughts is to bring back positive thoughts. An ideal mind is a devil’s workshop and will always think negative.

Here are some ways by which you can remove negative thoughts.

• Think differently as taught by Adi Shankaracharya. Once Menaka approached Arjuna with lust and said that she wanted to have a son like him with him. Arjuna said that why wait for 25 years consider me as you son from today.

• Think opposite as taught by Patanjali. For example, if you are having a though to steal, silently start thinking of charity.

• Think positive as taught by Buddha. Make a list of positive actions to be done today as the first thing in the morning and concentrate on that list. Divert your mind to the pending works. It’s a type of behavioral therapy.
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Great attitude

Once a Bird asked a Bee, after a continuous hard work, you prepare the honey..........

But a man steals the honey.

Do you not feel sad?"

Then the Bee replied, Never......

Because a man can only steal my honey, not the art of making honey....
Scientific awareness on personal hygiene and prevention from obesity among school going children
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Make Sure
Situation: A patient on amlodipine developed severe gum hypertrophy.

Reaction: Oh my God! Why was amlodipine not stopped?

Lesson: Make sure that all patients on amlodipine are watched for gum hypertrophy as its side effect.
Dr Good Dr Bad
Situation: A diabetic patient with TB came with treatment failure

Dr Bad: Diabetes has nothing to do with it

Dr Good: It is due to uncontrolled diabetes

Lesson: Diabetes is associated with poor prognosis of tuberculosis infection: early microscopic negative conversion rate in diabetic patients is lower than that in normal control. Treatment failure rate of 6-month's medication in diabetic patients was also significantly higher than that in normal control. (Diabetes Metab J. 2013 Aug;37(4):249-51)
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Reader Response
Dear Sir, very informative news. Regards: Dr Kripa
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The Leave Application

A leave letter to the headmaster: "As I am studying in this school I am suffering from headache. I request you to leave me today."
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Can IDRV be given in private hospital?

The ID route has been permitted to be used in selected anti–rabies clinics having an adequate number of patients (at least 5/day) seeking post–exposure prophylaxis against rabies every day to make IDRV viable and cost–effective.
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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
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News
  • A meta-analysis published online September 21 in the journal Pediatrics found that 19% of children who underwent adenotonsillectomy experienced a postoperative complication, with 9.4% experiencing respiratory compromise, the most frequent complication, and 2.6% having secondary hemorrhage, according. Children with obstructive sleep apnea (OSA) were 4.9 times more likely to suffer respiratory complications than children without OSA.
  • The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have jointly recommended that clinicians should not use the Apgar score to predict neonatal outcomes or to diagnose asphyxia, and should use the expanded Apgar score form whenever possible. (Pediatrics and Obstetrics & Gynecology)
  • Delayed orthostatic hypotension is an earlier, milder form of orthostatic hypotension. Data from a 10-year follow up study show that 54% of patients with DOH progressed to OH over 10 years of follow-up and the 10-year mortality of patients who progressed to OH was 50%. (Neurology)
  • SHIVA, the first randomized trial to compare personalized cancer care based on molecular characteristics of the tumor vs conventional therapy has yielded rather disappointing results. No difference in progression-free survival between the two treatment groups was observed. (Lancet Oncology)
  • Exposure to secondhand smoke nearly doubles the risk for hospitalization for an asthma exacerbation in children with asthma. This twofold difference in hospitalization risk is clinically important because hospitalizations for asthma have been linked with increased mortality and poorer disease control. (Annals of Allergy, Asthma and Immunology).
  • Use of the terms "breakthrough" or "promising" in US Food and Drug Administration (FDA) press releases on new drugs may make the public think the drug is more effective than it actually is, hints a new study.
  • Patients with inflammatory bowel disease (IBD) are at slightly increased risk of invasive pneumococcal disease as reported in The American Journal of Gastroenterology by Bjørn Kantsø of Statens Serum Institut in Copenhagen and colleagues.
  • The TEXT ME (Tobacco, Exercise and Diet Messages) trial showed that compared with the participants who received usual care only, those who received usual care + four motivational texts (offering support and advice on how to make lifestyle modifications) weekly for 6 months had greater improvement in low-density lipoprotein cholesterol (LDL-C), the primary end point, as well as decreases in body-mass index (BMI) and smoking status and an increase in physical activity. (Journal of the American Medical Association)
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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?

Here are the responses received

• 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 behavior, but rather to delineate the ethical conduct prescribed under the extant rules and regulations, including Code of Ethics Regulations, 2002 http://www.mciindia.org/ Rulesand Regulations/ Codeof Medical Ethics Regulations 2002.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, Prof & 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

• The patient has to be told about his health problem. The doctor can also inform his (friend) the son. The patient, as he has enquired, has the right to know about himself and that may help himself to prepare for the inevitable. Rema Devi, St. John's Medical College, Bangalore
IMA IPMO Initiative
Kindly go to http://module.ima-india.org/ipmo/
and pledge your organs. Unless we do it, the public will not listen to us.

Team IMA
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Quote of the Day
Anger is a Wide ball, Leave it Fear is a No ball, Let it
Smile is a Sixer, Hit it
Friendship is a Wicket, Get it
Failure is Bouncer, Forget it
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Then you can rock the World Cup of Life…
Wellness Blog
Skin care
• Clean with soap and water.

• Moisturizers can make the skin dirty.

• Dryness is better than being dirty.

• No soap is a better soap.

• Glycerin is the safest moisturizer.

• Rub hard but take care to not cause bruises.

• Soap emulsifies, therefore, one should remove 100% of surface part.

• Killing the normal flora of the skin is a bad idea. So, do not use antiseptic soaps.

• Remember, the commonly used antiseptic solution Dettol does not kill pseudomonas infection.

Can creams and oils penetrate skin?
• The answer is no.

• Oil cannot be absorbed.

• Nutrition cannot be absorbed from the skin.

• Almond cannot be absorbed from the skin.

• Unless the skin is damaged, nothing can be absorbed.

• For absorption, an occlusive dressing has to be used over a patch with a bandage, only then the drug can be absorbed. The bandage damages the skin because of preparation of moisturizer and heat. Any agent, which is irritating, can cause inflammation, erosion and only then can a drug be absorbed.

• If the skin is damaged, it can cause inflammation and can cause dermal pigmentation.

• Ultrasound techniques can be used to increase absorption.

• Newer drugs are getting absorbed through nano techniques.
eIMA Quiz
What percentage of your diet should fat make up?
A. About 10 percent of your daily calories.
B. About 20 percent of your daily calories.
C. About 30 percent of your daily calories.
D. About 40 percent of your daily calories.
E. There is no recommended amount of fat; you should strive to eat as little of it as possible.

Yesterday’s Mind Teaser: 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

Answer for Yesterday’s Mind Teaser: c) It is associated with APC mutation

Correct Answers received from: Dr Poonam Chablani, Viswanatha Sarma, Raghavendra Chakurkar, Dr K Raju, Dr J Daivadheenam

Answer for 24th September Mind Teaser: D. At age 50.

Correct Answers received from: Raghavendra Chakurkar, Dr K Raju, Dr J Daivadheenam
Press Release
Dengue can cause heart problems

With the increasing incidence of dengue in the Capital, awareness must be created about its close association with heart disease

India has become the Dengue capital of the world with the maximum number of cases being reported in the country. The abundant presence of stagnant water and innumerable potholes acts as an ideal breeding ground for the Aedes aegypti mosquitoes, the vector responsible for spreading the infection. The time has come to take necessary preventive measures and decrease the incidence of the disease.

Dengue fever can affect the proper functioning and health of vital body organs such as the heart, liver and respiratory system. The reason for this is that it often reacts severely with commonly taken medicines such as aspirin and ibuprofen. It also causes a fluctuation in sugar levels, blood pressure and the pulse rate causing further complications in people with pre-existing morbidities. Some of the typical symptoms of dengue are fever, vomiting, headache, nausea, red rashes on the lower limbs and chest, pain behind the eyes and joint and muscle pain. The disease is characterized by a low platelet count, however transfusion is not needed until the platelet counts are less than 10,000 and there is active bleeding.

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, “Adequate hydration is key for effective dengue management. Patients with pre-existing morbidities such as heart ailments, hypertension, diabetes, and obesity must take extra care because dengue can turn life threatening for them. Capillary leakage is more common in patients with existing life-style disease and regular monitoring is required. ECG changes may occur. Accumulation of fluid around the heart, called pericardial effusion, if capillary leakage occurs, can cause further complications. Awareness must also be raised about the need to immediately stop consumption of aspirin in any form when dengue fever is suspected because it can cause internal bleeding.”

“In addition to this, we always suggest that patients must get their pulse rate checked immediately if they feel dizzy and transient unconsciousness. If the pulse rate is less than 40 to 45, the patients must seek early medical assistance” they further added.

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 less than 20

Start fluid replacement at 20 ml/kg/hour immediately in such patients, and shift to nearest medical center for observation

Everyone must take necessary precautions given that there is no definite vaccine available to prevent dengue until now. As they say, precaution is better than cure. Healthy living is possible only when you make the desired efforts to fight the Dengue disease.

The best way to reduce chances of getting the infection is to eliminate the places where the mosquito lays her eggs, 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.