Sonia Gandhi to undergo surgery in US

Health Care, Medicine, Social Health Community 359 Comments

UPA chairperson Sonia Gandhi will underg  successful surgery in the United States for an undisclosed medical condition. Not disclosing her condition is her right. Her doctors also cannot disclose her condition. Health bulletins are not allowed in the US.Can a doctor disclose the medical condition of the patient?(1998) 8 SCC 296: Supreme Court of India: CIVIL APPEAL NO. 4641 OF 1998JUDGMENT S. SAGHIR AHMED. J.1.    Principle of “duty of care”, as applicable to persons in medical profession, includes the duty to maintain confidentiality.
2.     Duty to maintain confidentiality has its origin in the Hippocratic Oath, which is an ethical code attributed to the ancient Greek physician Hippocrates, adopted as a guide to conduct by the medical profession throughout the ages and still used in the graduation ceremonies of many medical schools and colleges. Hippocrates lived and practiced as physician between third and first century BC. He has referred to by Plato as a famous Asclepiad who has philosophical approach to medicine. His manuscripts, the Hippocratic Collection [Corpus Hippocracticum], contained the Hippocratic Oath which is reproduced below:
“I swear by Apollo the physician and Aesculapius and health and all-heal and all the gods and goddesses that according to my ability and judgment I will keep this oath and this stipulation – to reckon him who taught me this art equally dear to me as my parents, to share my substance with him and relieve his necessities if required, to look upon his offspring in the same footing as my own brothers and to teach them this art if they shall wish to learn it without fee or stipulation and that by precept, lecture, and every other mode of instruction I will impart a knowledge of the art to my own sons and those of my teachers and to disciples bound by a stipulation and oath according to the law of medicine but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked nor suggest any such counsel, and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my art. I will not cut persons laboring under the stone but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption, and further, from the seduction of females or males, of freeman and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad. I will not divulge as reckoning that all such should be kept secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times, but should I trespass and violate this oath, may the reverse be my lot.”
3.    The Hippocratic Oath consists of two parts. The first, or covenant, is the solemn agreement concerning the relationship of apprentice to teacher and the obligations enjoined on the pupil. The second part constitutes the ethical code.4.     It is on the basis of the above that the International Code of Medical Ethics has also laid down as under: “A Physician shall preserve absolute confidentiality on all he knows about his patient even after his patient has died.”
5.     The Indian Medical Council Act controls medical education and regulates the professional conduct. Section 20A, which was inserted by the Indian Medical Council (Amendment) Act 1964 provides as under: Professional Conduct: 33: Code of ethics: “Do not disclose the secrets of a patient that have been learnt in the exercise of your profession. Those may be disclosed only in a Court of Law under orders of the presiding judge.”
6.     In the doctor-patient relationship, the most important aspect is the doctor’s duty to maintain secrecy. A doctor cannot disclose to a person any information regarding his patient which he has gathered in the course of treatment nor can the doctor disclose to anyone else the mode of treatment or the advice given by him to the patient.
7.     Hippocratic Oath as such is not enforceable in a court of law as it has no statutory force.
8.    Medical information about a person is protected by the code of Professional Conduct made by the Medical Council of India under Section 33(m) read with Section 20A of the Act.

Cognitive impairment and dementia update

Health Care, Medicine, Social Health Community 283 Comments

 Suresh Kalmadi is suffering from dementia. This has given us an opportunity to revise the subject of dementia.

What is dementia?

Dementia is a disorder characterized by impairment of memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.

What are cognitive functions?

The cognitive functions are: Memory, reasoning, language, calculations and spatial orientation.

How common is dementia?

About 5 % of individuals over age 65 years and 35-50 % of persons over age 85 years have dementia; the pretest probability of dementia in an older person with reported memory loss is estimated to be at least 60 %.

What are dementia syndromes?

The major dementia syndromes include

  • Alzheimer’s disease
  • Dementia with Lewy bodies
  • Frontotemporal dementia
  • Vascular (multi-infarct) dementia
  • Parkinson’s disease with dementia

What is Alzheimer’s disease?

Alzheimer’s disease is the most common form of dementia in the elderly, accounting for 60-80 % of cases.

What is DSM-IV definition of dementia?

Evidence from the history and mental status examination that indicates major impairment in learning and memory as well as at least one of the following:

  • Impairment in handling complex tasks (e.g., balancing a checkbook)
  • Impairment in reasoning ability (e.g., unable to cope with unexpected events)
  • Impaired spatial ability and orientation (getting lost in familiar places)
  • Impaired language (word finding)

The cognitive symptoms must significantly interfere with the individual’s work performance, usual social activities, or relationships with other people. There must be a significant decline from a previous level of functioning. The disturbances are of insidious onset and are progressive. The disturbances are not due to delirium (a major psychiatric diagnosis), systemic disease or another brain disease.

Patients with dementia may also have difficulty with

  • Learning and retaining new information (e.g., trouble remembering events)
  • Behavior

Who reports dementia in a patient?

Most patients with dementia do not present with a complaint of memory loss; it is often a spouse or other informant who brings the problem to the physician’s attention.

What is age-related cognitive decline?

The normal cognitive decline associated with aging consists primarily of mild changes in memory and the rate of information processing, which is not progressive and does not affect daily function. Learning or acquisition performance decline uniformly with age. Delayed recall or forgetting remains relatively stable. Aging is associated with a decline in the acquisition and early retrieval of new information but not in memory retention.

What is mild cognitive impairment?

Mild cognitive impairment is the presence of memory difficulty and objective memory impairment but preserved ability to function in daily life. These patients appear to be at increased risk of dementia.

Should these patient be screened for B12 levels?

The American Academy of Neurology  recommends screening for B12 deficiency and hypothyroidism in patients with dementia.

Should MRI be done in all cases?

Neuroimaging rules out patients who might have reversible causes of dementia that can be diagnosed with imaging studies (subdural hematoma, normal pressure hydrocephalus, treatable cancer). Structural neuroimaging with either a non-contrast head CT or MRI should be considered in the initial evaluation of all patients with dementia.

Is there a role of biopsy?

Brain biopsy has a very limited role in the diagnosis of dementia.

What is the association with depression?

Screening for depression in patients with dementia is recommended because depression is a common treatable co-morbidity that may also masquerade as dementia.

What is Mini-Mental State Examination?

Mini-Mental State Examination (MMSE) is the most widely used cognitive test for dementia. The examination takes approximately 7 minutes to complete. It tests a broad range of cognitive functions including orientation, recall, attention, calculation, language manipulation, and constructional praxis.

The MMSE includes the following tasks:

  • What is the date: (year)(season)(date)(day)(month) – 5 points
  • Where are we: (state)(county)(town)(hospital)(floor) - 5 points
  • Name three objects: Ask the patient all three after you have said them. Give one point for each correct answer. Then repeat them until he/she learns all three. Count trials and record. The first repetition determines the score, but if the patient cannot learn the words after six trials then recall cannot be meaningfully tested. Maximum score – 3 points.
  • Serial 7s, beginning with 100 and counting backward: one point for each correct; stop after five answers. Alternatively, spell WORLD backwards: one point for each letter in correct order. Maximum score – 5 points.
  • Ask for the three objects repeated above: one point for each correct answer. Maximum score – 3 points.
  • Show and ask patient to name a pencil and wrist watch – 2 points.
  • Repeat the following, “No ifs, ands, or buts.” Allow only one trial – 1 point.
  • Follow a three stage command, “Take a paper in your right hand, fold it in half, and put it on the floor.” Score one point for each task executed. Maximum score – 3 points.
  • On a blank piece of paper write “close your eyes;” ask the patient to read and do what it says – 1 point.
  • Give the patient a blank piece of paper and ask him/her to write a sentence. The sentence must contain a noun and verb and be sensible – 1 point.
  • Ask the patient to copy a design (e.g., intersecting pentagons). All 10 angles must be present and two must intersect – 1 point.

A total maximal score on the MMSE is 30 points.

A score of less than 24 points is suggestive of dementia or delirium.

Using a cutoff of 24 points, the MMSE had a sensitivity of 87 % and a specificity of 82 %.

The test is not sensitive for mild dementia, and scores may be influenced by age and education, as well as language, motor, and visual impairments.

For research purposes, some investigators use a cutoff score of 26 or 27 in symptomatic populations in order to not miss few true cases.

Are we ready for a terror attack : Bomb blast update

Health Care 1,617 Comments

The Mumbai terrorist attack update: Bomb blast injuries are always hollow organ injuries

How do bomb blast cause injuries? It is crucial that we know this to handle the aftermath of bomb blasts.

Primary blast injuries are the injuries to the hollow gas-filled organs like the lungs, ear drum or intestines leading to their rupture. These occur as a direct result of the impact of the over pressurized blast wave on the body.

Secondary blast injuries occur due to flying debris and bomb fragments leading to penetration or penetrating injuries such as to the eyes.

Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures as a result of the fall.
Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important triage to manage blast injuries is not to waste energies and resources on patients with non-serious injuries.

The first thing is to check for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non-serious injury.

All patients exposed to a blast must have eardrum examination as the first step. If the ear drums are intact, the patient can be discharged with first-aid treatment. If ear drum is ruptured, an X-ray chest should be done immediately. All such patients should be observed for eight hours as primary blast injuries are notorious for delayed presentation.

Doctors should therefore focus only on two exams: Otoscopic ear exam and pulse oximetry. Blast lung injury is unlikely without tympanic or ear membrane rupture. This is used as a screening procedure for admitting a patient. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.

Half of all initial casualties seek medical care over first hour. Double this number after one hour and you will know the total casualties. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.

Always expect upside down triage as the most severely injured arrive after the less injured who self-transport to the closest hospitals.

The Government should take all steps so that blasts do not occur. With the increasing use of explosives in terrorist events in our country in recent times, doctors, especially Emergency Doctors, should undergo orientation training every six months so that they are prepared and better equipped to manage several casualties all at one time. There is a need for constant updation. Govt. should formulate guidelines, which should be available on their website and can be followed by all.

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