Medicolegal Aspects Of AIDS,

Doctors face various medicolegal and ethical questions regarding Acquired Immunodeficiency Syndrome (AIDS), as there is no legislation integrating all issues concerning Human Immunodeficiency Virus (HIV) and AIDS. Thus, it is essential for doctors to handle this sensitive issue with care as they play a central role maintaining patient dignity and providing compassionate care to HIV patients. This article provides medicolegal guidance to doctors regarding practice, confidentiality, HIV testing, etc. for AIDS patients.

Doctor’s Duty Of Care

It is unethical on part of a doctor to refuse treatment or investigation to a person infected with HIV. A doctor may be held guilty of professional misconduct for this unethical behavior.

Confidentiality

Doctors may have to face civil and criminal penalties for unlawful disclosure of HIV positive status. The physician should not reveal confidential communications or information without the consent of the patient unless provided for by law or due to the need to protect the welfare of individual or in public interest.

Medical Records

When patients have undergone tests for HIV, doctors must maintain separate records to prevent test results from being inadvertently disclosed with other records. They can be guided by existing regulations for medical termination of pregnancy concerning the custody of consent forms and maintenance of admission registers.

Informed Consent For HIV Testing

A physician must obtain an informed consent before performing any invasive procedure on a patient so that the patient has sufficient knowledge about the procedure to make an informed decision.

• Patients should be given full disclosure of the nature of HIV disease, nature of the proposed test, implications of a positive and a negative test result and the consequences of treatment prior to taking consent.
• The consent must be voluntary, and the patient must be competent to give consent or to refuse. Informed consent for testing and disclosure must be in writing.
• In case of marriage, if one of the partners insists on a test to check the HIV status of the other partner, such tests should be carried out by the contracting party to the satisfaction of the person concerned.

National AIDS Control Organization (NACO) Guidelines For Physicians

• HIV testing should be carried out on a voluntary basis with appropriate pre- and post-test counseling
• Disclosure of HIV status of the person should not affect his rights to employment, the position at the workplace, right to medical care and fundamental rights in any way.
• The result of HIV test must be kept confidential and even health care workers who are not directly involved in the care of the patient should not be told about the result.
• Surveillance of HIV positive cases in the country does not require reporting of the identification data of the patient.
• HIV positive woman should have complete choice to make decisions about pregnancy and childbirth.
• Women should be advised to avoid pregnancy as there are chances of infecting the child.
• There should be no forcible abortion or even sterilization.

Partner Notification (Partner Counseling/Contact Tracing)

It is necessary to notify and counsel the sexual partners of an HIV patient about their exposure to HIV. Approaches to partner notification are as follows:

• Patient referral: HIV positive person is encouraged to notify partners about their possible exposure to HIV, without the a direct involvement of health care providers.
• Provider referral: HIV positive person provide their partner’s names to health care providers who then confidentially notify the partners directly. There are again two approaches to informing third parties:
  • Contact tracing: It is based on patients’ voluntary cooperation in providing the names of contacts. It occurs during sexual disease awareness programs.
  • Duty to inform: This approach comes in a clinical situation where the physician knows the identity of the person at risk of exposure. Here, physician should disclose the endangered person without the consent of the patient due to his moral duty to warn.

Overall, the basic principle of ethics dictates that individuals with HIV should be treated with respect and their dignity should not be violated. It is the moral duty of physicians to provide compassionate care and maintain the dignity of HIV patients.

Reference

Mathiharan, K. HIV And AIDS: Some Legal And Ethical Implications For The Medical Profession. Issues In Medical Ethics 2002, 10 (4), 79-82.

Pay More Attention to Menopause

Here's what doctors need to know about this condition that affects all women 

                                                     by Diana L. Bitner MD

There is a health condition that all women experience and is the single most dramatic risk factor for heart disease, stroke, diabetes, obesity, and osteoporosis. This health condition is well understood and can be managed with evidence-based treatments.
However, this condition is rarely discussed, adequately screened, or sufficiently treated. Women feel confused, ignored, and minimized when they complain of symptoms leading up to and during the most burdensome years. Many women are told "it is just a phase, (essentially) deal with it" and even the most ardent brain thermostat gives up over time, and hot flashes go away. Vasomotor symptoms act as alarm bells telling us that cholesterol levels, blood sugars, and inflammatory markers are rising, bone is wasting, and the corpus colosseum is shrinking.
But since menopause might seem too murky and confusing, hormone treatment too confusing and scary, and women being only 50% of the population, it is often dismissed as something to be accepted like Tom Cruise telling Brooke Shields on National TV that postpartum depression was in her mind and she should exercise more.
Menopause needs to be seen for what it is -- the cessation of ovarian function. Loss of estrogen causes metabolic derangement. There's no controversy about that.
Menopause is an opportunity for the healthcare system to do the right thing -- whether for a 16-year-old after life-saving chemotherapy, a 35-year-old after an unexpected BSO, or a 51-year-old experiencing natural menopause and told her rising waistline, sleeplessness, and pain with sex is natural and to "watch her diet."
The effects of loss of estrogen are lifelong. As healthcare providers, I believe we are obligated to inform women of life-altering irreversible changes, and best practices to alter their diet, exercise, and other habits as well as perhaps consider hormone medication options to mitigate physiologic changes.
A study that stands out in my mind showed that peritoneal fat cells change their phenotype in menopausal women. With loss of estrogen, the cells produce significant amounts of inflammatory agents such as CRP and IL-6 versus the pre-menopause state. The KEEPS trial showed women taking transdermal estrogen have less insulin resistance, and JoAnn Manson at Harvard showed that women undergoing a BSO before age 45 had a significant increase in risk for cardiovascular disease if not given hormone replacement. These are just a few examples of the width and breadth of data demonstrating how hot flashes are alarm bells for what is happening under the surface.
In the years of my uphill battle to develop a whole service line for midlife and menopause in a large healthcare system, I have gained a thorough understanding that even if a clinical program is a good idea, buckets of money do not exist for implementation. I have learned that clinical programs require strategy, planning, and a positive business proforma. And, many champions must speak loudly for coveted dollars to be invested.
In the process to help my healthcare system understand the opportunity of menopause, I strategized for and got a meeting in the C Suite with several system business leaders. In this meeting, a very well respected executive, near retirement, leaned back in his chair, steepled his fingers, asked me the question that had been a consistent barrier for leadership: "Menopause Clinic? Isn't menopause just something women have to deal with?"
Thank goodness he wanted open discussion of that question and I was able to present the solutions we would be solving and the clinical as well as business case for the program. The result of that meeting was health system support, and I am forever grateful he listened and that our Midlife and Menopause Health Services Clinic now exists.
Take Marcie (not her real name) as an example. She waited 3 months to see me. Her chief complaint in EPIC was "menopause symptoms" and as I reviewed her history, I saw she was 54, had never been pregnant, was 16 months from her last period, and had gained 12 pounds in the last 8 months.
Her prior physical with her PCP covered all the screening basics, but the standardized form did not allude to menopause status or treatment options. In the annual visit HPI there was mention of night sweats, and in the plan was "refer to Midlife and Menopause." Victory No. 1, high referral rate from our PCPs as a result of many "lunch-n-learns," and happy patients.
I walked in the room, laptop in hand, and sat down across from her. I shook her hand, closed my computer, and asked, "what is hard?" She quickly answered, "the fatigue, the fatigue is really hard." Her night sweats started 1 year prior to her LMP and ever since, she had been waking up tired and she felt moody. She also talked about how sex hurt, and was no longer enjoyable. She used to initiate sex with her husband, but now neither did because fear outweighed desire.
Over time as she felt worse, she exercised less, and ate more simple carbs. Because of the weight gain, she felt unattractive to her husband, and was frustrated every morning because her clothes did not fit. Victory No. 2, she was sharing personal details, which would lay the foundation for a trusting doctor-patient relationship.
I then took the driver's seat, opened my computer, and walked her through a symptom inventory, including questions about sexual health as well as lifestyle habits. I asked what she took in for each meal and snack, and how much alcohol she consumed. I gained many data points, which would allow for risk stratification, and help me understand opportunity for risk-reducing change. We reviewed her medical history, including potential risk factors such as DVT, which could preclude safe use of hormone therapy. We discussed the components of sex drive, and why her libido had changed. She visibly perked up and was involved. Victory No. 3, potential partner in preventing her premature heart attack.
After a pelvic exam that revealed low estrogen demonstrated by flat rugae and a pH of 7.0, and tight tender pelvic floor muscles, she got dressed, and we talked. I explained how her ovaries had stopped producing estrogen, progesterone, and testosterone, and loss of these hormones caused many of her symptoms. While she had minimal healthcare knowledge and only a high school education, I saw a light bulb turn on as I explained the physiology of where the hormones work on the brain, skin, vagina, uterus, breast, and bones. I explained how triggers such as sleep deprivation, weight gain, and a diet high in sugar could also trigger symptoms. A tear rolled down her face as she said, "I am not crazy?" Victory No. 4, the tear. Now, opportunity was palpable.
Next we discussed options for treatment, starting with lifestyle. I have created a list of seven habits I call the SEEDS, or "Seven Essential Elements of Daily Success" including water, vitamins, food groups, fiber, exercise, sleep, and gratitude. We put together how the habits could help, leading to a discussion of her barriers. Victory No. 5, starting her process to healthy change.
The discussion about hormone replacement therapy ensued, and I informed her of the basic findings of studies such as ELITE, WHI, KEEPS, NHS, and Vital. I explained the likely benefits of HRT, how to take it, and guidelines, giving the menopause.org website. She was a perfect candidate to trial HRT, and chose to accept a prescription. Victory No.6, a balanced discussion leaving her knowing there were hormone medication options.
I then asked her to follow up in 3 months, and to have blood work done, including an HbA1c and a DEXA bone density test. Because of her not having children and a history of dense breasts, I offered her an appointment at the high-risk breast clinic for advanced screening. Also, because of her fatigue, I sent her to the preventive cardiologist, and for her tight pelvic floor, to the Pelvic Floor Physical Therapist. Victory No. 7. Total health understood, valuable healthcare resources being utilized.
After 8 months, Marcie lost and kept off 20 pounds, worked to drop her HbA1c from 6.1 to 5.5, and lowed her blood pressure and cholesterol. She is happy on her 0.05 mg estrogen patch and micronized progesterone. Her stress echo was negative, and she had only mild osteopenia. Her fatigue was gone, her moods happy and coping skills improved, her exercise regular, and she felt normal. Victory No. 8. Heart attack prevented until age of 106 (dramatized, but you get my point).
Yes, menopause visits can be lengthy, and not well reimbursed. In a Work Relative Value Unit (WRVU) based system, moving from an ob/gyn salary to that of a card-carrying NAMS Certified Menopause Practitioner is not the best personal financial move. However, the results of such work is priceless. If more healthcare systems were to embrace mid-life and menopause health as the front-line of wellness care for women, engaged patients would flood the gates to join and everyone wins.
Menopause is an opportunity, not a just a condition or group of symptoms to be tolerated. Menopause needs to be embraced for the gift it gives us, a chance to save lives and reduce preventable illness

Infografics Voilence against Women

 WHO launched a new manual for health managers and policy-makers to strengthen health systems to deliver better quality of care to women who are subjected to violence,
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Manage Stress To Prevent Diabetes Complications

Daily life is already filled with demands and decisions—diabetes adds another heavy layer over all of it. But there are healthy ways to handle tough situations, whether it’s a traffic jam, an argument with a loved one, or taking control of your blood glucose numbers.

A Mindful Approach

Mindfulness can help you manage stress. With history in Buddhist traditions, mindfulness encourages judgment-free observations of what you are thinking and feeling in the present moment.
Wondering how to begin reaching a more mindful state? Try these ideas:

• Observe your thoughts and emotions from an outsider’s perspective. This pulls reflection into the mix, allowing you to think about what is going on and why thoughts are happening.
• Keep a nonjudgmental attitude about blood sugar monitoring. It’s simply information—how you react to the numbers determines failure or success.
• Add time in your routine to practice mindfulness and improve your mindset. Whether it’s every day or week, choose a distraction-free time that fits in your schedule.
• Seek out a supportive network. You’re not in this alone. Find comfort in sharing with and learning from loved ones, health care providers, diabetes educators, and other people with diabetes.
• Realize it’s normal to feel stressed about managing diabetes. Set goals with your health care professional or diabetes educator, and take it day by day.
• Learn what triggers you. Is it going too long without reaching out to your support group? Or not logging your meals? Define the cause, and use trial and error to discover how you can stop stress in its tracks.
• Take advantage of educational opportunities. Diabetes management tips and strategies can arm you with know-how to maintain a mindful perspective.

Mindfulness training helped a group of U.S. veterans significantly lower their blood glucose and diabetes-related distress. A group of 28 veterans from Pittsburgh participated in the study. After three months, on average, diabetes-related distress decreased by 41 percent and A1C levels fell from 8.3 percent to 7.3 percent.
“We create so much suffering for ourselves when we add judgment and failure into our diabetes management,” says Heather Nielsen, a counselor and wellness coach in Portland, Oregon. But that negative thinking isn’t necessary and isn’t productive to better manage diabetes. Instead, give yourself a break, and think about how far you’ve come and the progress you’ve made.
Source  http://www.diabeticlivingonline.com/well-being

New Born Care Week. (National Health Portal)

New Born Care Week

New Born Care Week is celebrated every year throughout the country from15 to 21 November. The aim is, to generate awareness and suggest measures to improve health of new born and child survival.
In India out of every 1000 newborn babies, 70 die during the first year of life. Most crucial phase is the 0-4 weeks of life (called the neonatal period), since two third of all newborn deaths occur during the first week of life. Infant mortality has significantly dropped over the last one decade, but it is still very high.

Main Causes of Death among the Newborn

• Infection
• Lack of oxygen to foetus and new born baby
• Premature deliveries
• Complications at the time of delivery
• Birth defects

Care process of mother and child is divided in three phases :
Antenatal Care (Mother care during pregnancy) (1st Phase):

• Tetanus toxoid vaccination to mother
• Management of Anaemia and High Blood Pressure
• Infections and Nutrition of mother
• Preparedness of mother for delivery
• Identification of danger signs and prompts referral

Intra-partum Care (Mother care at the time of childbirth) (2^nd Phase):

• Clean delivery
• Skilled care during delivery
• Timely access to Emergency Obstetric Care
• Care during pregnancy and delivery

 Post-Partum Care/ postnatal care (Mother and newborn care after the childbirth) (^3rd Phase):

• Recognition of complications: Post-Partum haemorrhage, lacerations (injury of birth canal), Inversion of uterus (Uterus turns inside out after delivery).
• Counselling for Family Planning.
• Maintaining infant health and infant feeding

Suggestive measures

• Education of expectant mothers about various problems during pregnancy.
• Basic minimum care during pregnancy, nutrition counselling and supplementation of iron and vitamins.
• Institutional/Hospital deliveries to be encouraged, else these may be   conducted by trained personnel.
• Early diagnosis of problems in newborns and early referral to hospitals for optimum care and treatment.
• Proper and timely vaccination should be given to the newborn

Points to remember after childbirth

• Wash your hands with soap or use a hand sanitizer before handling your baby.
• Be careful to support your baby's head and neck.
• Start Breastfeed within an hour of the birth.
• Exclusive breastfeeding to the baby for the first 6 months and only after this solid food should be introduced.
• Child should be fed on demand or at least 8 times in 24 hours.
• Don’t feed honey, water or things other than breast milk in lieu of a ritual as it can be a source of infection to a baby.
• Cord Care-  Give baby a sponge bath until the umbilical cord falls off and the navel heals completely (1-4 weeks)
• Kangaroo Mother Care to low birth weight infants: The method involves holding the baby in a special way stuck with the chest to provide skin to skin contact with the mother and exclusive and frequent breastfeeding.

“Exclusive Care to Mother during pregnancy and after Delivery is the best possible care for the new born”

Respectful Maternity Care

Respectful Maternity Care from CONSULTANT IN OBGYN, ODISHA ,INDIA

Dangers of Too Much Sitting, They don’t call it sitting disease for nothing. Here’s how it can take a toll. web md

It Hurts Your Heart

Scientists first noticed something was up in a study that compared two similar groups: transit drivers, who sit most of the day, and conductors or guards, who don’t. Though their diets and lifestyles were a lot alike, those that sat were about twice as likely to get heart disease as those that stood.

It Can Shorten Your Life

You’re more likely to die earlier from any cause if you sit for long stretches at a time. It doesn’t help if you exercise every day or not. Of course, that’s no excuse to skip the gym. If you do that, your time may be even shorter.

Dementia Is More Likely

If you sit too much, your brain could look just like that of someone with dementia. Sitting also raises your risk of heart disease, diabetes, stroke, high blood pressure, and high cholesterol, which all play a role in the condition. Moving throughout the day can help even more than exercise to lower your risk of all these health problems.

You’ll Undo All That Exercise

The effects of too much sitting are hard to counter with exercise. Even if you work out 7 hours a week -- far more than the suggested 2-3 hours -- you can’t reverse the effects of sitting 7 hours at a time. Don’t throw away all that hard work at the gym by hitting the couch for the rest of the day. Keep moving!

Your Odds of Diabetes Rise

Yup, you’re more likely to have it, too, if you sit all day. And it isn’t only because you burn fewer calories. It’s the actual sitting that seems to do it. It isn’t clear why, but doctors think sitting may change the way your body reacts to insulin, the hormone that helps it burn sugar and carbs for energy.

You Could Get DVT

Deep vein thrombosis (DVT) is a clot that forms in your leg, often because you sit still for too long. It can be serious if the clot breaks free and lodges in your lung. You might notice swelling and pain, but some people have no symptoms. That’s why it’s a good idea to break up long sitting sessions.

You’ll Gain Weight

Watch a lot of TV? Surf the web for hours on end? You’re more likely to be overweight or obese. If you exercise every day, that’s good, but it won’t make a huge dent in extra weight you gain as a result of too much screen time.

Your Anxiety Might Spike

It could be that you’re often by yourself and engaged in a screen-based activity. If this disrupts your sleep, you can get even more anxious. Plus, too much alone time can make you withdraw from friends and loved ones, which is linked to social anxiety. Scientists are still trying to figure out the exact cause.It Wrecks Your Back

The seated position puts huge stress on your back muscles, neck, and spine. It’s even worse if you slouch. Look for an ergonomic chair -- that means it’ll be the right height and support your back in the proper spots. But remember: No matter how comfortable you get, your back still won’t like a long sitting session. Get up and move around for a minute or two every half hour to keep your spine in line.

It Leads to Varicose Veins

Sit for too long and blood can pool in your legs. This puts added pressure in your veins. They could swell, twist, or bulge -- what doctors call varicose veins. You may also see spider veins, bundles of broken blood vessels nearby. They usually aren’t serious, but they can ache. Your doctor can tell you about treatment options if you need them.

If You Don’t Move It, You Could Lose It

Older adults who aren’t active may be more likely to get osteoporosis (weakened bones) and could slowly become unable to perform basic tasks of everyday life, like taking a bath or using the toilet. While moderate exercise won’t prevent it, you don’t have to go out and run a marathon or take up farming to stay mobile in your golden years. Just don’t plant yourself on the couch for hours at a time.

Your Cancer Risk Goes Up

You may be more likely to get colon, endometrial, or lung cancer. The more you sit, the higher the odds. Older women have higher odds of breast cancer. That doesn’t change if you’re super-active. What matters is how much you sit.

How to Take a Stand

Work more movement into your day: Stand up and stretch every half hour or so. Touch your toes. Take a stroll around the office. Stand at your desk for part of the day. Get a desk that raises or make your own: Set your computer on top of a box. Talk to your boss about a treadmill desk. All these things can help stop the negative effects of uninterrupted sitting and keep you on the road to good health.

Labor room teams to be financially rewarded by govt. "Lakshya initiative"

New Delhi, Nov 5 (PTI) Doctors and medical staff involved in the child delivery process will now be financially rewarded for following strict benchmarks in providing quality care to both mother and newborn, according to a new initiative by the Union Health Ministry.

The initiative -- Lakshya -- will be launched soon across the country to ensure proper implementation of the existing labor room protocols in order to reduce maternal and newborn mortality, a senior health ministry official said.

Steps to be taken to improve environment of natural delivery process include avoiding unnecessary induction, providing privacy to the mother during the intra-partum period, by way of separate labor room, or at least a private cubicle, use of labor beds instead of tables and a no-tolerance policy for any verbal or physical abuse of the woman.

Also, it should be ensured that the mother and the child bond immediately after birth, stressing a comfortable position during delivery rather than insisting on a universal "lying down" position.

Abolishing 'out of pocket expenditures (OOPE)' including demand by facility staff, for gratuitous payment by families for celebration of the baby's birth.

"All these are required to avoid undue stress in mothers," the official said stressing on the need to reorganize the labor room care processes to facilitate natural delivery process and to enable not only adherence to quality standards and clinical protocols, but also address issues such as respectful maternity care.

"Under the 'Lakshya', labor room teams will be financially rewarded if they meet the strict benchmarks and achieve targets in a time-bound manner as defined in the labor room guidelines," the official said.

The targets described include reduction of preventable maternal and new-born mortality, still birth rates, reductions in related morbidity such as obstetric fistula, puerperal sepsis, birth asphyxia and newborn sepsis, he said.

According to a Lancet study published in 2014, birth is the time of greatest risk of death and disability. The study highlighted that 40 per cent of still births, 25 per cent of under 5 mortality and 46 per cent of maternal deaths occur at the time of birth.

According to another health ministry official, there has been a substantial increase in the number of the institutional deliveries in the last decade of implementation of the National Health Mission (NHM).

"However, this increase in the numbers has not translated into commensurate improvements in the key maternal and new- born indicators such as maternal mortality and morbidity, still birth rates and early initiation of breastfeeding," the official said.

He said the available evidence shows that the first day of birth is the day of greatest risk for mothers and newborns.

Proper implementation of the guidelines and standards will ensure quality care of the mother and the new born by improving infrastructure with availability of functional equipment, robust supply system and competent human resource supported by adherence to clinical protocols and behavioral change towards ensuring delivery of respectful care.

There are 20,000 delivery points in the country and 2.64 crore deliveries happen (including the private sector) in India annually and 44,000 maternal deaths.

According to the Sample Registration System (SRS), Maternal Mortality Ratio (MMR) for the period 2011-13 was recorded at 167 per 100000 live births.

This translates into an estimated 44,000 maternal deaths in the country, every year. The infant mortality rate, as per the SRS 2016 stands at 34 per 1,000 live births in 2016.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

 • Preventable maternal morbidity and mortality is associated with the absence of timely access to quality care, defined as too little, too late (TLTL)—ie, inadequate access to services, resources, or evidence-based care—and too much, too soon (TMTS)—ie, over-medicalisation of normal antenatal, intrapartum, and postnatal care.
• Although many structural factors aff ect quality care, adherence to evidence-based guidelines could help health-care providers to avoid TLTL and TMTS.
• TLTL—historically associated with low-income countries—occurs everywhere there are disparities in socio-demographic variables, including, wealth, age, and migrant status. Often disparities in outcomes are due to inequitable application of timely evidence-based care.
• TMTS—historically associated with high-income countries—is rapidly increasing everywhere, particularly as more women use facilities for childbirth. Increasing rates of potentially harmful practices, especially in the private sector, reflect weak regulatory capacity as well as little adherence to evidence-based guidelines.
• Caesarean section is a globally recognised maternal health-care indicator, and an example of both TLTL and TMTS—with disparate rates between and within countries, and higher rates in private practice and higher wealth quintiles. Caesarean section rates are highest in middle-income countries and rising in most low-income countries. Although researchers partly attribute the increase and variable rates to a shortage of clear, clinical guidelines and little adherence to existing guidelines, multiple factors—economic, logistical, and cultural—affect caesarean section rates.
• Quality clinical practice guidelines need to be developed that reflect consensus among guideline developers, using similar language, similar strengths of recommendation, and agreement on direction of recommendations.
• Strategies for enhanced implementation and adherence to guidelines need multisectorial input and rigorous implementation science.
• A global approach that supports eff ective and sustained implementation of respectful, evidence-based care for routine antenatal, intrapartum, and postnatal care is urgently needed.