July 6  2015, Monday
eMedinewS
editorial
Sunlight can reduce weight
Dr KK AggarwalA new Northwestern Medicine study has reported that the timing, intensity and duration of your light exposure during the day are linked to your weight.

People who had most of their daily exposure to even moderately bright light in the morning had a significantly lower body mass index than those who had most of their light exposure later in the day.

"The earlier this light exposure occurred during the day, the lower individuals’ body mass index," said co–lead author Kathryn Reid, research associate professor of neurology at Northwestern University Feinberg School of Medicine. "The later the hour of moderately bright light exposure, the higher a person’s BMI."

The influence of morning light exposure on body weight was independent of an individual’s physical activity level, caloric intake, sleep timing, age or season. It accounted for about 20 percent of a person’s BMI.

"Light is the most potent agent to synchronize your internal body clock that regulates circadian rhythms, which in turn also regulate energy balance," said study senior author Phyllis C. Zee, M.D. "The message is that you should get more bright light between 8 a.m. and noon." About 20 to 30 minutes of morning light is enough to affect BMI. (Science Daily)
IMA,IJCP,HCFI
National EMEDINEWS
• MEERUT: In a shocking scam, a sting operation done by a team of anti-corruption activists has revealed that workers in some Uttar Pradesh hospitals who assist doctors in conducting post-mortems have been removing organs from human bodies and selling them to tantriks who use them for black magic. A liver went for Rs 5,000. But a heart could go up to as much as Rs 20,000. [TOI]

South Africa ION News 2-013: The practice of selling human organs from the mortuary at Raleigh Fitkin Memorial Hospital in the central commercial hub of Manzini is an open secret. A human brain costs R1,000. Other parts, from internal organs to body fat, fetch from R400 to R1,000.
Body parts are roasted and pulverised into an ash, and mixed with herbs for a potion that is either drunk, ingested or in some cases rubbed into the blood through a razor cut to the skin. The user is then endowed with supernatural power, according to belief.
Even the water used to wash corpses in the hospital mortuary is being sold to traditional healers.
On the other hand vampire, only drink fresh blood.


• The Pune District Consumer Disputes Redressal Forum (PDCDRF) has received 209 cases of medical negligence since 1988, of which 193 have been disposed of by the forum while 16 are still pending. [SAKAL TIMES]

• Indore : Death of a mental retarded patient at MY Hospital has sparked speculations about alleged medical negligence. The patient died after ripping off a urine catheter that was left behind at the time of his discharge [FREE PRESS JOURNAL]

• The All India Organisation of Chemists & Druggists (AIOCD), a representative body of nearly 5.5 lakh members engaged in pharmaceuticals retail and wholesale trade, has demanded to the Drug Controller General of India (DCGI) to take immediate measures to notify to stop the indiscriminate internet drug trade and save the public from its probable harmful effects. [PHARMABIZ]

• To further tighten noose on the import of cosmetics tested on animals and ensure that such products do not enter the country the Drug Controller General of India (DCGI) Dr G.N. Singh has made it mandatory for the importers to submit an undertaking stating that the products have not been tested on animals for getting their consignments cleared at the port offices. [ASIAN AGE]
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Doctor’s Day Celebration by IMA Branch on 01 / 07 / 2015
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TRENDO 2015
The 3rd Annual meeting of the Endocrine Society of Tamil Nadu and Puducherry will be held in Kodaikanal on 11th and 12th of July 2015. TRENDO 2015 is proposed to address latest updates, emerging concepts, clinical applications and controversies in diabetes, thyroid disorders, gonadal problems, pituitary disorders, metabolic bone disease and adrenal diseases.
News
  • Brief treatment with antifungal medication does not increase the rate of fungal resistance in mycotic corneal ulcers, suggested findings from the Mycotic Ulcer Treatment Trial I (MUTT I) published online in JAMA Ophthalmology.
  • Breast-specific gamma imaging has high sensitivity and specificity for identifying invasive lobular carcinomas, reported an imaging registry study published online in JAMA Surgery.
  • Researchers have created an implantable "artificial pancreas" that may eliminate the use of insulin injections and pumps for people with type 1 diabetes. The details are published in the journal Industrial & Engineering Chemistry Research.
  • Intervening immediately after a lapse in hand-hygiene practice is an effective way to correct bad habits and can help achieve greater compliance with best practices, according to results from a new study presented at the Association for Professionals in Infection Control and Epidemiology (APIC) 2015 Annual Meeting.
  • Experts recommend that the treatment of athletes showing signs of acute hyponatremia should be guided by the severity of neurological symptoms on presentation, rather than by laboratory measures of blood sodium levels. The guidelines for exercise associated hyponatremia are published in the July issue of the Clinical Journal of Sport Medicine
Cardiology eMedinewS
  • A review published in the Journal of the American Heart Association suggests that while exercise appears to affect total cholesterol, lowering LDL cholesterol for at least some people and raising HDL for most, the proportion of CVD risk that could have been reduced by exercise via effects on total cholesterol and LDL cholesterol is much lower than what has been observed previously.
  • The American College of Cardiology, Heart Rhythm Society and Society for Cardiovascular Angiography and Interventions have released a new overview on the implantation of left atrial appendage occlusion devices. The devices may lower the risk of stroke in patients with atrial fibrillation. The paper is published in the upcoming issues of the Journal of the American College of Cardiology, Heart Rhythm, and Catheterization and Cardiovascular Interventions.
Pediatrics eMedinewS
  • A new study published in the journal Current Biology has identified differences in the way children with autism respond to smells, suggesting a "sniff test" could be used for early diagnosis of the condition.
  • The American Society of Human Genetics (ASHG) Workgroup on Pediatric Genetic and Genomic Testing has issued a position statement on Points to Consider: Ethical, Legal, and Psychosocial Implications of Genetic Testing in Children and Adolescents. The statement is published July 2 in The American Journal of Human Genetics.
Dr KK Spiritual Blog
Why do we Offer Food to God in Every Pooja?

We follow a ritual of offering ‘bhog’ to the deity we worship. The ritual also involves sprinkling water all around the place where we sit down to eat food. Many people have advocated that the sprinkling of water is related to preventing ants and insects from approaching the food. But in spiritual language there is a deeper meaning of these rituals.

Bhagwad Gita and Yoga Shastras categorize food into three types corresponding to their properties termed as gunas. Depending upon satoguna, rajoguna and tamoguna, the food items are categorized as satwik, rajsik or tamsik.

Satwik food provides calmness, purity and promotes longevity, intelligence, strength, health, happiness and delight. The examples of satwik food items are fruits, vegetables, leaves, grains, cereals, milk, honey, etc. These items can be consumed as they are. One can also live on satwik food for life.

Rajsik food items possess attributes of negativity, passion and restlessness. Hot, spicy and salty food items with pungent, sour and salt taste promote rajas qualities.

Tamsik food has attributes of inducing sleep, ignorance, dullness and inertia. The examples of tamsik food are meat, onions, garlic, leftover food, etc.

Only satwik food is offered to God. Rajsik and tamsik food is never offered as Bhog. The only persons who were offered tamsik and rajsik food in Ramayana are Ahi Ravana and Kumbhkaran. Both had an evil nature. Kumbhkaran signified tamas and Ahi Ravana, rajas or aggression. Tamsik and rajsik food can be converted into satwik by slow heating, sprouting or keeping them in water overnight. The examples are sprouted wheat and chana (chickpeas), etc.

A mixture of honey, milk, ghee, curd and sugar is called panchamrut and is a routine offering to the God. All the five components have satwik properties and their consumption promotes health.

In Ayurveda, there is a saying that any food item, which grows under the ground, is tamsik in nature and one, which comes from the top of the tree or plant like leaves, flower and fruits are satwik in nature. Satwik food is usually fresh, seasonal and locally grown.

Human beings are made up of body, mind and soul and soul is equated to consciousness or God. Whatever offered to external God if offered to the internal God or consciousness leads to inner happiness. The ritual, therefore, of offering food to God before eating forces us to either eat only satwik food or to include a substantial portion of satwik food in our meals. It helps a person convert his meal into a pure satwik one or at least adding satwik items.

Sprinkling water around the plate is considered an act of purification.

Many people confuse bhog with chadhava or offerings to the deity. While bhog is shared with God, chadhava is the offering of your illness or negative thoughts to the God and you go back with prasada of inner happiness. Many people counter the above argument by saying that alcohol is offered to Bhairon, viewed as a demon God, which means alcohol, is good for health. I personally feel that alcohol is offered to Bhairon not as a bhog but as an offering which means that people who are addicted to alcohol go to Bhairon and give their share of alcohol to him so they can de–addict themselves.
Inspirational Story
A Wise Donkey

One day a farmer’s donkey fell down into a well. The animal cried piteously for hours as the farmer tried to figure out what to do. Finally he decided the animal was old, and the well needed to be covered up anyway; it just wasn’t worth it to retrieve the donkey.

He invited all his neighbors to come over and help him. They each grabbed a shovel and began to shovel dirt into the well. At first, the donkey realized what was happening and cried horribly. Then, to everyone’s amazement, he quieted down. A few shovel loads later, the farmer looked down the well, and was astonished at what he saw.

As every shovel of dirt hit his back, the donkey did something amazing. He would shake it off and take a step up. As the farmer’s neighbors continued to shovel dirt on top of the animal, he would shake it off and take a step up. Pretty soon, everyone was amazed, as the donkey stepped up over the edge of the well and trotted off!

Life is going to shovel dirt on you, all kinds of dirt. The trick to getting out of a hole is to shake it off and take a step up. Each of our troubles is a stepping stone. We can get out of the deepest holes just by not stopping, never giving up! Shake it off and take a step up!
Wellness Blog
Cinnamon in Nonalcoholic Fatty Liver Disease

Cinnamon (dalchini) helps improve lipid profiles and improve nonalcoholic fatty liver disease (NAFLD), according to a new Iranian trial reports Medscape. The report found that 12 weeks consumption of 1.5 gm cinnamon per day plus a balanced diet improved insulin resistance and NAFLD characteristics. The study by Dr. Azita Hekmatdoost is published in the journal Nutrition Research.

Cinnamon has antioxidant and insulin–sensitizer properties.

In the study, 50 patients were randomized to two 750 mg capsules of cinnamon or placebo daily for 12 weeks. All patients were given advice on a balanced diet and physical activity. In both groups, LDL cholesterol dropped significantly but there was no significant change in serum HDL cholesterol levels. After 12 weeks, LDL levels were 55.8 mg/dL in the treatment group and 90.3 mg/dL in the placebo group (p=0.032).

In the active treatment group there were also significant decreases in the HOMA (Homeostatic Model Assessment) index, fasting blood glucose, total cholesterol, triglyceride, SGOT and SGPT levels. This was also true of gamma GT and hs–CRP.
Events
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Make Sure
Situation: A patient with 105 degree fever was not responding to the paracetamol.

Reaction: Oh my God! Why was IM paracetamol given?

Lesson: Make sure to remember that when the fever is greater than 105 degree, giving only fever medicines will not work. The answer is tap water sponging to lower the temperature.
Dr Good Dr Bad
Situation: A patient with high blood pressure was found to have low vitamin D levels.

Dr. Bad: Vitamin D has nothing to do with high blood pressure.

Dr. Good: It may be the cause of your high blood pressure.

Lesson: A study published in Lancet Diabetes Endocrinol. 2014 Sep;2(9):719-29 has suggested a causal relationship between low vitamin D levels and high blood pressure. Increased plasma levels of 25(OH)D might reduce the risk of hypertension.

(Copyright IJCP)
eMedi Quiz
An anxious mother brought her 4 year old daughter to the pediatrician. The girl was passing loose bulky stools for the past 20 days. This was often associated with pain in abdomen. The pediatrician ordered the stool examination which showed the following organisms. Identify the organism:

1. Entamoeba histolytica

2. Giardia lamblia

3. Cryptosporidium

4. E. coli

Yesterday’s Mind Teaser: Haemorrhage secondary to heparin administration can be best corrected by administration of:

1. Vitamin K

2. Whole blood

3. Protamine

4. Ascorbic acid

Answer for yesterday’s Mind Teaser: 2. Whole blood.

Correct Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Raju Kuppusamy, Daivadheenam Jella

Answer for 4th July Mind Teaser: 3. Atherosclerosis.

Correct Answers received: Dr Jainendra Upadhyay, Dr Avtar Krishan
eMedinewS Humor
Will I live longer?

Patient: Doctor, if I give up wine, women, and song, will I live longer?

Doctor: Not really, it will just seem longer.
IMA,IJCP,HCFI
Rabies News (Dr A K Gupta)
Is there any role of systemic antibiotic treatment for animal bites infections?

Treatment with prophylactic antibiotics for 3 to 7 days is appropriate for dog bite wounds, unless the risk of infection is low or the wound is superficial. If frank cellulitis is evident, a 10– to 14–day course of treatment is more appropriate. Amoxicillin–clavulanate potassium is the antibiotic of choice for a dog bite. For patients who are allergic to penicillin, doxycycline is an acceptable alternative, except for children younger than eight years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance. Other acceptable combinations include clindamycin and a fluoroquinolone in adults or clindamycin and trimethoprim–sulfamethoxazole in children. When compliance is a concern, daily intramuscular injections of ceftriaxone are appropriate.
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Total CPR since 1st November 2012 – 101090 trained
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
IMA,IJCP,HCFI
Quote of the Day
Every great and commanding movement in the annals of the world is the triumph of enthusiasm. Ralph Waldo Emerson.
Reader Response
Dear Dr Aggarwal, I enjoy reading eMedinewS daily & also share it with others. Thank you very much. - Dr S N Tripathi
Media
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IMA Videos
News on Maps
IMA in Social Media
https://www.facebook.com/ima.national 28505 likes

https://www.facebook.com/imsaindia 46540 likes

https://www.facebook.com/imayoungdoctorswing 1681 likes

Twitter @IndianMedAssn 1027 followers

http://imahq.blogspot.com/ www.ima-ams.org

http://www.imacgpindia.com/

http://www.imacgponline.com/

http://www.ima-india.org/ima/

www.indianmedicalassociation.info
Press Release
Blood sugar goals

Correction and prevention of low blood sugar is beneficial to hospitalized patients, Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Hony Secretary General, Indian Medical Association.

For most non–critically ill hospitalized patients with diabetes, one should have a target blood sugar of <180 mg/dL.

In non–critically ill hospitalized patients, lower blood glucose levels may decrease the risk of poor clinical outcomes, but also increase the risk of hypoglycemia.

A reasonable sugar goal to avoid low blood sugar is to achieve fasting blood glucose concentrations not less than 90 to 100 mg/dL.
eIMA News
IMA – UNICEF Initiative: Child Sexual Abuse
(Dr K K Aggarwal, Dr Jagadeesh N, Dr A Marthanda Pillai)
  1. The age of a Child for the purpose of Child Sexual Abuse is up to 18 years.
  2. Children represents 42% of Indian population. Upto 50% of the children face child sexual abuse during childhood and 21.9% of children face severe child sexual abuse (penetrative) during childhood.
  3. About 50 to 90% of the children are sexually assaulted by someone known to the child.
  4. According to NCRB, 2265 cases of child rape were reported in 2001 and 6371 cases were reported in 2010.
  5. Incidence of child sexual abuse has remained the same but reporting is increasing.
  6. The virtual word (e-world) is also responsible for child sexual abuse (e-crime).
  7. There is a sizeable number of teachers and doctors among the child sexual abusers. They should be punished. There is no role of suspending or transferring them as doing so will be exposing them to new group of children.
  8. Youngsters too are indulging in child sexual abuse.
  9. Adultification of kids (parents pushing kids for reality shows on TV) is a problem.
  10. Every institution must have child protection policy.
  11. Always suspect child sexual abuse in a situation with non accidental fracture or non accidental burns.
  12. Child Sexual Abuse is mainly a social problem, an act of violence which is intentional and the intention is to hurt, humiliate the child. Perpetrator enjoys power in the society and feels can get over the situation easily without being caught and punished.
  13. Various laws governing child sexual abuse: POCSO (2012); CLA (2013) (Amendment), Indian Penal Code; CrPC; IEA (Indian Evidence Act); 2014 MoHFW Guidelines'; 2013 WCD Guidelines and Various Court judgment, The Protection of Women From Domestic Violence Act, 2005
  14. Medical management of a case of child sexual abuse is a medicolegal emergency.
  15. Child sexual abuse is a process (and not a one off incident). Grooming in takes place.
  16. Rule 5 OF POCSO mandates discussion about HIV prophylaxis.
  17. All decisions by a health care provider should be scientifically, ethically and legally correct.
  18. The Criminal Law (Amendment) Act 2013, section 357(C) CrPC states that all hospitals public or private should provide first aid or medical treatment and shall inform the Police immediately.
  19. POCSO Rule No. 5: As per this rule medical care has to be provided within 24 hours and child should be taken to the nearest hospital
  20. POCSO Rule No. 27 mandates that medical examination should be done as per Section 164 (A) of the code of criminal procedure 1973.
  21. Section 19 POCSO mandates informing the police even if one suspects child sexual abuse.
  22. When two Laws are applicable to a situation, whichever has higher punishments will prevail over the other (either POCSO or IPC)
  23. Presence of lubricant, use of contraceptive being reported in a sexual crime, does not mean consensual sex. (Remember people use gloves for murder)
  24. There is no time bar for mandatory reporting in a case of child sexual abuse.
  25. Absence of Medical evidence (absence of injury, absence of any trace evidence) does not mean sexual crime has not taken place.
  26. Comments on section 375 IPC - Where a prosecutrix is a minor girl suffering from pain due to ruptured hymen and bleeding vagina depicts same, minor contradictions in her statements they are not of much value, also absence of any injury on male organ of accused is no valid ground for innocence of accused, conviction under section 375 I.P.C. proper; Mohd. Zuber Noor Mohammed Changwadia v. State of Gujarat, 1999 Cr LJ 3419 (Guj). Penetration Mere absence of spermatozoa cannot cast a doubt on the correct¬ness of the prosecution case; Prithi Chand v. State of Himachal Pradesh, (1989) Cr LJ 841: AIR 1989 SC 702."
  27. There may not be injuries on the victim in sexual violence cases, when under fear; overpowered; unconscious due to drugs/trauma; also, injuries can heal within hours.
  28. Evidence may be lost by passing urine, stool, washing local area or bathing.
  29. No medical evidence does not mean no sexual offence.
  30. Even in a consensual sexual act, one cannot tell the correct sequence of events; BUT the society expecting a victim to repeat verbatim the exact sequence of events of a forced sexual act and repeat the same exactly each time when asked by different agencies is totally unacceptable.
  31. Two finger test has been banned by the Hon’ble Supreme Court of India
  32. There is a MYTH that in a well-built female, sexual abuse cannot occur without her consent.
  33. Explanation 2 of section 375 IPC states that on mere absence of physical resistance offered by the woman it should not be construed as if the woman has consented for the act.
  34. Section 42 of POCSO states ?Alternate Punishment – Where an act or omission constitutes an offence punishable under this Act and also under sections 166A, 354A, 354B, 354C, 354D, 370, 370A, 375, 376, 376A, 376C, 376D, 376E or section 509 of the Indian Penal Code (45 of 1860), then, notwithstanding anything contained in any law for the time being in force, the offender found guilty of such offence shall be liable to punishment under this Act or under the Indian Penal Code as provides for punishment which is greater in degree.”
  35. Section 42A states ?Act not in derogation of any other law - The provisions of this Act shall be in addition to and not in derogation of the provisions of any other law for the time being in force and, in case of any inconsistency, the provisions of this Act shall have overriding effect on the provisions of any such law to the extent of the inconsistency.”
  36. Copy of medical records should be given free of cost to the victim immediately.
  37. In Delhi, rape kits are made mandatory as per Delhi High Court order.
  38. There is an obsession over the use of kits; health systems should be careful about this overemphasis. MOHFW guidelines provide a list of materials which are required for medical examination of sexual assault/rape. Each hospital can assemble and put together such materials.
  39. Potency examination in an accused of sexual crime is not necessary.
  40. Section 164 A of Cr. P. C.- Medical examination of the victim of rape: (2) The registered medical practitioner, to whom such woman is sent shall, without delay, examine her and prepare a report of his examination giving the following particulars, namely:- (iii) the description of material taken from the person of the woman for DNA profiling;
  41. MTP act does not allow abortions/terminations of pregnancy after 20 weeks, even if the pregnancy is a result of rape or gang rape. (Gujarat High Court Judgment " dated 16 April, 2015: R/SCR.A/1919/2015: SPECIAL CRIMINAL APPLICATION (QUASHING) NO. 1919 of 2015: JUSTICE J.B.PARDIWALA)
Media handling of a child sexual abuse victim

POCSO Act (Section 23) talks about how Media should handle reporting a case of Child Sexual Abuse
  1. No person shall make any report or present comments on any child from any form of media or studio or photographic facilities without having complete and authentic information, which may have the effect of lowering his reputation or infringing upon his privacy.
  2. No reports in any media shall disclose, the identity of a child including his name, address, photograph, family details, school, neighbourhood or any other particulars which may lead to disclosure of identity of the child: Provided that for reasons to be recorded in writing, the Special Court, competent to try the case under the Act, may permit such disclosure, if in its opinion such disclosure is in the interest of the child.
  3. The publisher or owner of the media or studio or photographic facilities shall be jointly and severally liable for the acts and omissions of his employee.
  4. Any person who contravenes the provisions of sub-section (1) or sub-section (2) shall be liable to be punished with imprisonment of either description for a period which shall not be less than six months but which may extend to one year or with fine or with both.
No Court or police permission is required for medical examination of a child sexual abuse victim
  • State of Karnataka Vs. Manjanna 2000 (CPL1031/SC/Civil (J3471/2006 (6) SCC188)
  • POCSO 27.(1) The medical examination of a child in respect of whom any offence has been committed under this Act, shall, notwithstanding that a First Information Report or complaint has not been registered for the offences under this Act, be conducted in accordance with section 164A of the Code of Criminal Procedure, 1973.
  • POCSO Rule 5 (3): No medical practitioner, hospital or other medical facility centre rendering emergency medical care to a child shall demand any legal or magisterial requisition or other documentation as a pre-requisite to rendering such care.
  • Criminal Law (Amendment) Act, 2013: 357 C: Treatment of victims: "All hospitals, public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall immediately, provide the first-aid or medical treatment, free of cost, to the victims of any offence covered under section 326A, 376,376A, 376B, 376C, 376D or section 376E of the Indian Penal Code, and shall immediately inform the police of such incident". (Only information is required and not permission)
  • POCSO is applicable to children (<18 years) and section 357C CrPC is applicable to all ages.
Compulsory Treatment (Who Pays?)
  • Rule 5 POCSO- Emergency medical care: (1) Where an officer of the SJPU, or the local police receives information under section 19 of the Act that an offence under the Act has been committed, and is satisfied that the child against whom an offence has been committed is in need of urgent medical care and protection, he shall, as soon as possible, but not later than 24 hours of receiving such information, arrange to take such child to the nearest hospital or medical care facility centre for emergency medical care: Provided that where an offence has been committed under sections 3, 5, 7 or 9 of the Act, the victim shall be referred to emergency medical care.
  • Rule 5 POCSO subrule (4) The registered medical practitioner rendering emergency medical care shall attend to the needs of the child, including -- (i) treatment for cuts, bruises, and other injuries including genital injuries, if any; (ii) treatment for exposure to sexually transmitted diseases (STDs) including prophylaxis for identified STDs; (iii) treatment for exposure to Human Immunodeficiency Virus (HIV), including prophylaxis for HIV after necessary consultation with infectious disease experts; (iv) possible pregnancy and emergency contraceptives should be discussed with the pubertal child and her parent or any other person in whom the child has trust and confidence; and, (v) wherever necessary, a referral or consultation for mental or psychological health or other counseling should be made.
  • Criminal Law (Amendment) Act, 2013: section 357 C: Treatment of victims: " All hospitals, public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall immediately, provide the first-aid or medical treatment, free of cost, to the victims of any offence covered under section 326A, 376,376A, 376B, 376C, 376D or section 376E of the Indian Penal Code, and shall immediately inform the police of such incident". (Only information is required and not permission)
  • Section 33(8) POCSO: “In appropriate cases, the Special Court may, in addition to the punishment, direct payment of such compensation as may be prescribed to the child for any physical or mental trauma caused to him or for immediate rehabilitation of such child.”
  • Rule 7 provides further details in relation to the payment of this compensation. It specifies that the Special Court may order that the compensation be paid not only at the end of the trial, but also on an interim basis, to meet the immediate needs of the child for relief or rehabilitation at any stage after registration of the First Information Report [Rule 7(1)). This could include any immediate medical needs that the child may have. Further, Rule 7(3) provides that the criteria to be taken into account while fixing the amount of compensation to be paid include the severity of the mental or physical harm or injury suffered by the child; the expenditure incurred or likely to be incurred on his/her medical treatment for physical and/or mental health; and any disability suffered by the child as a result of the offence.
  • Hence, the child may recover the expenses incurred on his/her treatment in this way.
  • Section 166 B of IPC: Non treatment of victim by hospital, Imprisonment for 1 year or fine or both. Non-Cognizable, Bailable (The Criminal Law (Amendment) Act-2013) " Whoever, being in charge of a hospital, public or private, whether run by the Central Government, the State Government, local bodies or any other person, contravenes the provisions of section 357C of the Code of Criminal Procedure, 1973, shall be punished with imprisonment for a term which may extend to one year or with fine or with both."
  • Supreme Court of India clarifies in a judgment delivered in May/June 2015 that treatment means till the person becomes normal. (A social justice bench of Justices Madan B Lokur and U U Lalit said hospitals must also provide free medicine, food and other facilities to such victims. The Supreme Court directed private hospitals to provide free treatment, including specialized surgeries, to acid attack victims and asked government authorities to take action against them if they fail to comply with its order.)
Mandatory reporting Versus Care of Treatment
  • Criminal Law (Amendment) Act, 2013: 357 C: Treatment of victims: "All hospitals, public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall immediately, provide the first-aid or medical treatment, free of cost, to the victims of any offence covered under section 326A, 376,376A, 376B, 376C, 376D or section 376E of the Indian Penal Code, and shall immediately inform the police of such incident".
  • The law mandates compulsory treatment under Rule 5 of POCSO. Rule 5 POCSO (4): The registered medical practitioner rendering emergency medical care shall attend to the needs of the child, including -- (i) treatment for cuts, bruises, and other injuries including genital injuries, if any; (ii) treatment for exposure to sexually transmitted diseases (STDs) including prophylaxis for identified STDs; (iii) treatment for exposure to Human Immunodeficiency Virus (HIV), including prophylaxis for HIV after necessary consultation with infectious disease experts; (iv) possible pregnancy and emergency contraceptives should be discussed with the pubertal child and her parent or any other person in whom the child has trust and confidence; and, (v) wherever necessary, a referral or consultation for mental or psychological health or other counseling should be made.
  • POCSO ACT: Reporting of offence to the SJPU or the local police (Section 19). In case, child is in need of care and protection, SJPU/ local police to provide such care within 24 hours of the report (Section 19(5)) SJPU/ local police to report the matter to CWC and Special Court within 24 hours (Section 19(6))
  • Compulsory treatment is only possible if the victim reaches the hospital. For fear of getting an FIR when police intimation under Section 357 C CrPC or under Section 19 POCSO - most of the victims may not seek care and treatment if they do not want to file a police case. And also in cases, if they have yet not decided to get into criminal investigation.
Mandatory reporting Versus MTP Act

It is mandatory to report any child sexual abuse under Section 19 POCSO and Section 357 C CrPC. This would include pregnancy arising out of the child sexual abuse. So any pregnancy, if it is an outcome of Rape or Sexual Assault will require mandatorily reporting to the police.

No such police reporting is required in the MTP Act, even if pregnancy is as an outcome of rape.

Grounds for termination of pregnancy: Sec.3: When pregnancies may be terminated by registered medical practitioner.

(i) Notwithstanding anything contained in the Indian Penal Code (45 of 1860) a registered medical practitioner shall not be guilty of any offence under that Code or under any other law for the time being in force, if any pregnancy is terminated by him in accordance with the provisions of this Act"

This makes it clear that the provisions of the MTP Act, so far as abortion is concerned suppresses the provisions of the Indian Penal Code. Sub-sec. (2) of Sec.3: "Subject to the provisions of sub-sec (4), a pregnancy, may be terminated by a registered medical practitioner.

(a) Where the length of the pregnancy does not exceed 12 weeks if such medical practitioner is, or

(b) Where the length of the pregnancy exceeds 12 weeks but does not exceed 20 weeks, if not less than 2 registered medical practitioners are of opinion, formed in good faith that

1: The continuance of the pregnancy would involve a risk to the life of the pregnant women; or

2: A risk of grave injury to her physical or mental health; or

3: If the pregnancy is caused by rape;

Sec 3(2) Explanation 1: where any pregnancy is alleged by the pregnant woman to have been caused by rape, the anguish caused by such pregnancy shall be presumed to constitute a grave injury to the mental health of the pregnant woman. Therefore, rape per se is not an indication. It is the mental anguish following pregnancy due to rape, which is the main indication. In other words, mental anguish is to be taken into consideration; proving rape and affecting her character is not necessary. Her allegation that she has been raped is sufficient. Further proof of rape like medical examination, trial, judgment is not necessary.

All these days this practice of doing MTP without asking for police complaint or FIR whenever a lady alleged that her pregnancy is as a result of Rape/Sexual assault.

But now the new provisions of the Law deter those from seeking MTP when they are yet not decided to get into criminal investigation. That also forces them to get their termination of pregnancies by quacks and in nonhospital situations, which is again risky

Confidentiality, Privacy, Trust under MTP Act & Regulations Vs Mandatory reporting-

The MTP Regulations of 2003 – Regulation (6) guarantee Confidentiality, Privacy, Trust of the person getting MTP services.

"6. Admission Register not to be open to inspection, - The Admission Register shall be kept in the safe custody of the head of the hospital or owner of the approved place, or by any person authorized by such head or owner and save as otherwise provided in sub-regulation (5) of regulation 4 shall not be open for inspection by any person except under the authority of law :- Provided that the registered medical practitioner on the application of an employed woman whose pregnancy has been terminated, grant a certificate for the purpose of enabling her to obtain leave from her employer ; Provided further that any such employer shall not disclose this information to any other person"

But with Mandatory reporting laws in force for Rape/Sexual Assault any such person seeking MTP cannot expect Confidentiality of their information because the doctor has to mandatorily inform police before offering MTP services.

Criminal Law (Amendment) Act, 2013: 357 C: Treatment of victims: "All hospitals, public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall immediately, provide the first-aid or medical treatment, free of cost, to the victims of any offence covered under section 326A, 376,376A, 376B, 376C, 3760 or section 376E of the Indian Penal Code, and shall immediately inform the police of such incident".

Informed Consent Versus Mandatory reporting
  • POCSO 27.(1) The medical examination of a child in respect of whom any offence has been committed under this Act, shall, notwithstanding that a First Information Report or complaint has not been registered for the offences under this Act, be conducted in accordance with section 164A of the Code of Criminal Procedure, 1973.
  • Section 164 A CrPC subsection 7 says that it would be illegal if anything is examined without the consent of the person being examined. Section 164 A (7) CrPC: Nothing in this section shall be construed as rendering lawful any examination without the consent of the woman or of any person competent to give such consent on her behalf."
  • But 357 C CrPC mandates police information regardless of consent being taken or not. Criminal Law (Amendment) Act, 2013: 357 C: Treatment of victims: "All hospitals, public or private, whether run by the Central Government, the State Government, local bodies or any other person, shall immediately, provide the first-aid or medical treatment, free of cost, to the victims of any offence covered under section 326A, 376,376A, 376B, 376C, 376Dor section 376E of the Indian Penal Code, and shall immediately inform the police of such incident".
  • Section 19 POCSO Act seeks mandatory reporting to police even when there is no consent for that reporting.
  • POCSO Act: Reporting of offence to the SJPU or the local police (Section 19). In case, child is in need of care and protection, SJPU/ local police to provide such care within 24 hours of the report (Section 19(5)) SJPU/ local police to report the matter to CWC and Special Court within 24 hours (Section 19(6))
  • This puts the doctor in dilemma as the relatives may not want a criminal investigation. It’s a Catch 22 situation… which one to follow 164 A CrPC or Section 19 POCSO / Section 357 C CrPC.
Section 41 POCSO versus Section 375 IPC
  • Child above 12 but below 18 years.
  • Age for child consent for medical examination is 12 years.
  • Exceptions under Section 375 IPC: Any medical examination would not amount to rape
  • Under Section 41 POCSO, if the parents give consent for medical examination only then will such examination not amount to sexual assault and types

    Section 41 POCSO: " the provisions of sections 3 to 13 (both inclusive) shall not apply in case of medical examination or medical treatment of a child when such medical examination or medical treatment is undertaken with the consent of his parents or guardian."
  • Thus the doctor faces a dilemma in a situation of a child above 12 years and less than 18 years when conducting medical examination, If the child wants medical examination but the parents oppose, then parents can sue the doctor for violating Section 41 POCSO.
Section 164 A CrPC versus Section 27 POCSO
  • Under section164 A CrPC any registered medical Practitioner can examine the person with the consent of that person:
    164 A. “Medical examination of the victim of rape. – (1) Where, during the stage when an offence of committing rape or attempt to commit rape is under investigation, it is proposed to get the person of the woman with whom rape is alleged or attempted to have been committed or attempted, examined by a medical expert, such examination shall be conducted by a registered medical practitioner employed in a hospital run by the Government or a local authority and in the absence of such a practitioner, by any other registered medical practitioner, with the consent of such woman or of a person competent to give such consent on her behalf and such woman shall be sent to such registered medical practitioner within twenty-four hours from the time of receiving the information relating to the commission of such offence."
  • But section 27 POCSO insists for a lady doctor to examine when the victim is a girl that is less than 18 years. "POCSO 27 (4) In case the victim is a girl child, the medical examination shall be conducted by a woman doctor."
  • Rule 5 POCSO and Section 357 C CrPC mandates compulsory treatment.
  • The doctor faces a dilemma when there are no female doctors but requires immediate care and treatment.
  • The only solace now is the guidelines from the Central health Ministry which allow a male doctor to examine after making every possible effort to search for a female doctor.
  • The issue which remains is whether a Guideline can overtake a section of the Law.
Age estimation by Medical examination Versus Documentary proof of Age

Age estimation by Medical examination is compulsory under Section 164 A CrPC, Section 27 POCSO, Section 15 (5A) Immoral Traffic Prevention Act.
But the Supreme Court Judgment in Ashwani Kumar Saxena V State of Madhya Pradesh2013(I) OLR(SC)-214 says there is no need for such age estimation by medical examination unless in cases where those documents or certificates are found to be fabricated or manipulated.
All doctors face a dilemma whether to estimate age or not when the Investigating officer asks for age estimation in cases where there is a clear proof of Age by documents.

Mandatory reporting when you only suspect CSA and not confirmed

Under Section 19 POCSO reporting is mandatory but many times, the doctor only suspects CSA and has not confirmed it.
But Section 19 includes both - offence likely to be committed or committed as to be mandatorily reported.
This puts the doctor in a dilemma in mandatory reporting those cases to police wherein CSA is just a differential diagnosis and not a definitive diagnosis.

Limitations of Medical Opinion

Though all stake holders expect the doctor to give a definitive positive opinion in every case of Rape / Sexual assault reported to hospital – nobody understands the limitations in giving medical opinion.
Due to delay in a case being reported to hospital (Social reasons); post assault activities (Washing, bathing, douching, urination, defecation) and in many cases of non penetrative sexual assault, the doctor may not be able to conclude a definitive positive opinion.

There are several Laws which are in force but not being followed:-
  • Section 357 C CrPC says victim can go to any Hospital (public or private) but several States are insisting on Designated hospitals to treat these cases.(Maharashtra, Delhi, etc)
  • Section 27 POCSO, Rule 5 POCSO and Section 357 C CrPC recognize voluntary reporting of a victim to any hospital that is even without police requisition or Court order but unfortunately in almost all States the doctors still are examining these cases only with the police requisition that means they are denying the right of the victim to reach hospital for care and treatment even without police requisition or Court order.
  • Section 164 A CrPC insists for reasoned opinion to be given by doctors but in reality the biggest allegation against doctors is furnishing of incomplete opinions and also without reasoning.
  • Section 357 C CrPC insists on free treatment by all hospitals in care and treatment of these cases which becomes difficult to be followed in all private hospitals. Though section 33(8) and Rule 7 POCSO allows the Special Court to award Interim compensation to cover medical expenses – not all States have got funds/ Budget to cover all these expenses in all cases without bureaucratic hurdles and delay. Note has to be taken that care and treatment is not a one off incident but a continuous process requiring several visits; and many a time you cannot exactly estimate the medical expenses before hand because of the unforeseen complications.
Consent or Informed Refusal

Age of Consent for sexual intercourse has been raised to 18 years. Age of consent for medical examination is 12 years.

Adolescent health care teaches them about general/sexual hygiene and emergency contraception. When there is not right to consent for sexual intercourse under 18 years, why teach them about all this?

Consent
  • Section-164 A of CrPC- Medical examination of the victim of rape: (7) Nothing in this section shall be construed as rendering lawful any examination without the consent of the woman or of any person competent to give such consent on her behalf.
  • Consent is required for examination, evidences collection, treatment, photography, police intimation.
  • Then Police intimation also requires consent as per section 164 A CrPC (but section 19 POCSO says mandatory reporting even when not consented).
  • In such cases Informed refusal should be noted as per MoHFW Guidelines and also reported to police to comply mandatory reporting laws.
International Day of older persons
To,
Presidents and Honorary Secretaries
All State and Local Branches of IMA

Dear Colleague,
Every year, October 1st is celebrated as the “International Day of older persons”. 2015 Theme Thursday: Theme of 2015 would be “Nothing for Us without Us!”

This year too, it has been decided to celebrate this Day in all IMA State and local branches in a big way through various community based health activities for our senior citizens.
You are requested to:-
• Compile a list of all doctors in your branch who are 80 plus and send it to head quarters
• Give awards to elderly persons in your branch over 80 years of age
• Organize health checkup camps for the senior citizens from 27th September Sunday to October Sunday 2015 in your Branch or in your clinical establishments
• Organize a Public lecture related to health issues of senior citizens.
• Organise a press conference on Thursday 1st October at 1pm ( all state of IMA will organize the press meet at the same tie).Necessary press material will be sent.
• Find out the oldest living MBBS doctor in India. He or she will be honored at national level.
• As per the working committee resolution, all elderly people needs to be offered 10% discount by IMA members
• Dedicate your bulletin on elderly care

On finalization of the programme, kindly let us know about the same so that participation of a national leader in your event can be planned.

On completion of the event, kindly send us a report of the activities carried out by you as above along with complete details of the beneficiaries for a comprehensive report.

The reports sent by the branches will be uploaded on the website of IMA.

Looking forward to your dedicated participation in the celebrations of the “International Day of older persons - 2015”

Prof (Dr) A Marthanda Pillai    Prof (Dr) K K Aggarwal
Padma Shri Awardee, Padma Shri, National Science Communication & National President, IMA Dr B C Roy National Awardee Honorary Secretary General, IMA

Dr V U Seethi                    Dr D R Rai
Chairman                         Convener