The Facebook Suicide: Who is to blame?

Following the suicide of the 22 year old girl after herboyfriend dumped her, much debate has followed. I find that most of the commentators have joined either of the two camps; one side believes that the boyfriend is to be blamed for being an utter jerk while the other side thinks that at least some part of the blame lies with the girl for being immature. I was prompted into thinking about this by this post over at the Just The Way I Like blog and the comments there in. Let me quote –

“I just can’t figure out why people today are so sensitive, to the extent that they are unable to tolerate when someone blames them or points a finger at them. Why are we not able to take criticism in the right spirit from others?  Have we lost the ability to be resilient, instead call it a day, once and for all and give up? The World is fast paced, but why are we impatient and look for quick results? Why do we get into bouts of depression just because we failed at one point? Where has the virtue of patience gone? Has optimism and Positive thinking; despite being stressed repeatedly; become a thing of the past? When we should be giving a lot of room for positive thoughts and withstand the negative forces which trying their best to hamper our progress, we are unable to digest that one negative setback?”

What I can’t figure out is why people have become so insensitive today? Why is all the talk about being so strong? I think it reeks of Social Darwinism. “Hey there! You are weak, that’s why you committed suicide but look at me, I am strong, and I can face everything.” Well guess what, there is nothing called strong willed or weak willed. When someone suffers from diarrhea do we ask them to go and strengthen their stomach by doing ab crunches? Then why all the non-sense about being “strong” for those who are suicidal? Is it just a way to shift the blame?

Why can’t they take criticism? There is a distinction between constructive and destructive criticism. Sadly, most of the criticism is destructive. We all like to snub others, it makes us feel superior. The world is fast paced, we are expected to show performance or get the boot. If I ask my boss to be patient and wait for the day when I succeed, will he listen? Will the so called “market” looking for quick results listen if I am not fit for the rat race? When the worth of a human is being judged by money and success can we blame any one if they despair on failing to achieve success?

There is an amazing lack of education regarding suicide and this doesn’t help any one. Let me start off with some definitions (from Medscape) –

• Suicide – The act of killing one self.
• Suicide attempt - This involves a serious act, such as taking a fatal amount of medication and someone intervening accidentally. Without the accidental discovery, the individual would be dead.
• Suicide gesture - This denotes a person undertaking an unusual, but not fatal, behavior as a cry for help or to get attention.
• A suicide gamble - For example, to ingest a fatal amount of drugs with the belief that family members will be home before death occurs. Patients gamble their lives that they will be found in time and that the discoverer will save them.
• Suicide equivalent - In this situation the person does not attempt suicide. Instead, he or she uses behavior to get some of the reactions their suicide would have caused. For example, an adolescent boy runs away from home. He wants to see how his parents respond. Do they care? Are they sorry for the way that they have been treating him? It can be seen as an indirect cry for help.

In almost all the cases the person is just crying out for help. After being repeatedly ignored, he/she feels that this is the only way that they can get someone’s attention, that they can get someone to care for them. The blame squarely lies with us, the friends and family of the suicidal – if only we had listened, if only we had seen the signs, if only we had given some time, if only we had showed some compassion.

Depression is one of the most important risk factor for suicide. The thing we have to understand is that if someone is unable to open up, to share their feeling this doesn’t mean it’s their fault. It’s part of the disease, we can’t blame them instead we need to help them. For example, do you blame a child for throwing up if he is suffering from stomach upset? Then why we blame the suicidal? Almost 95% of those committing suicide have some form of mental illness but this is such a taboo topic in India that we never discuss it, instead we blame the suicidal which makes it easy for us to shirk our responsibilities. Being depressed is like drowning in a sea of despair from which one can never arise unless one gets help but they are unable/unwilling to seek help. This is a part of the disease.

There are a few signs that we can look out for in our friends or relatives to see if they have suicidal tendencies (from Medscape) –

• Making a will
• Getting the house and affairs together
• Unexpectedly visiting friends and family members
• Purchasing a gun, hose, rope, drugs, knifes etc.
• Writing a suicide note
• A preoccupation with death
• A sense of isolation and withdrawal
• Few friends or family
• An emotional distance from others
• Distraction and lack of humor: They often seem to be "in their own world" and lack a sense of humor.
• Focus on the past: They dwell in past losses and defeats and anticipate no future. They voice the notion that others and the world would be better off without them.
• They are haunted and dominated by hopelessness and helplessness. They are without hope and therefore cannot foresee things ever improving. This is a terrible feeling. They also view themselves as helpless in 2 ways. First, they cannot help themselves. All their efforts to liberate themselves from the sea of depression in which they are drowning are to no avail. Second, no one else can help them.
• There are signs of suicide attempts, for example, cuts on the wrist, rope burns in the neck etc.
• They have unkempt, disheveled appearance, unclean room or cloths.
• Recent life experiences – death of a family member, losing a job, being dumped, failing an exam etc

If you do find this in someone, understand that they need your help even if they deny it. Don’t leave them alone. Get them help and may be you can save a life. For more information please visit here.

Hepatosplenomegaly with fever in a child

Yesterday I got into a discussion with one of my friends about a case. He had examined a 7 year old male child who presented with fever for the last 7 days. The fever was of mild grade, continuous in type. The fever was not associated with any chills, rigor or sweating. There were no complaints of headache, vomiting, visual disturbance or convulsions. There was no history suggestive of any upper respiratory tract infection , urinary tract infection or any rash. The child complained of dark colored stool but on further inquiry it was not judged to be melaena. There was a history of mild abdominal pain, non colicky and possibly dull aching in nature (one can only get so much out of a child).

On examination the vitals were normal. There was mild, soft tender hepatomegaly and mild splenomegaly. There were no visible veins over abdomen. There was no lymphadenopathy. There was no jaundice. Rest of the examination findings were within normal limits.

Hepatomegaly - from NIH

Based on the history and examination findings the differential diagnosis consisted of

·        Acute viral hepatitis

·        Acute leukemia

·        Malaria

·        Acute hemolysis

·        Enteric fever

·        Lymphoma

·        Disseminated tuberculosis

My friend was of the opinion that the child had malaria. I disagreed.  My argument was that for a child to have malaria with hepatosplenomegaly, the duration needs to be pretty long. More over there is a correlation between jaundice and hepatomegaly in patients of malaria (1). Here the child did not have jaundice. I thought that enteric fever or acute leukaemia fits better. Mind you, neither of us had any test results at that point.

The test results came back positive for malaria and the child was started on chloroquine therapy. However, I still think based on the clinical picture, it would have been inappropriate to come to a provisional diagnosis of malaria, as there was no jaundice, the rapid course of the disease and mild grade of the fever, though certainly it was in the differential.

Interestingly, jaundice and hepatomegaly is associated with increased risk of acute renal failure in children suffering from malaria (1) but not an increase in the risk of cerebral malaria. However, in this case there was clinical finding of any abnormal renal function and the test results were within normal limits. There were also no features of CNS involvement (no headache, vomiting, visual disturbance, irritability or sleepiness), CSF examination was within normal limits.

1.  Nacher M, Treeprasertsuk S, Singhasivanon P, Silachamroon U, Vannaphan S, Gay F, Looareesuwan S, & Wilairatana P (2001). Association of hepatomegaly and jaundice with acute renal failure but not with cerebral malaria in severe falciparum malaria in Thailand. The American journal of tropical medicine and hygiene, 65 (6), 828-33 PMID: 11791981

Taking on non-sense about exercise

I lost my cool today when I opened the newspaper in the morning. Predictably there was an ignorant nonsensical article published in the T2 by a fitness expert. Normally I would not have bothered but this one touched a nerve.

“Strength coach Charles Poliquin had coined the term ‘chunky aerobics instructor’ (CAIS) to describe women aerobics and step-class instructors who spend almost two to three hours every day on aerobic exercise, yet carry 22-24 per cent body fat. Compare these figures to female sprinters who carry only 12-13 per cent body fat and the punchline is clear: stay away from aerobic exercise!”

Comparing apples to oranges are we? Normal women compared with sprinters? Even then this is a pathetic comparison. He seems to imply that 22 -24% body fat is bad for women. On the contrary 21-24% body fat is considered to be fitness level for women and 25 to 31% body fat is acceptable for women (Diabetes India). So he is wrong there. May be he should have Googled properly before shooting his mouth off.

“Forget what doctors tell you about aerobic exercise based on research done on treadmill running of rats. Humans are not rats.”

Oh! Slandering doctors are we? Perhaps he should have read up a bit more. Isn’t there any human study showing the effect of aerobic exercise? Of course there is, the fitness expert is too lazy to even use Google. What a shame! So here are two studies (on humans m'Lord, not on rats, I swear) that show aerobic exercise is indeed good for you –

1. Effect of Exercise on Total and Intra-abdominal Body Fat in Postmenopausal Women: A Randomized Controlled Trial
– Whoa, an RCT! I can barely control my glee. Qouting the results –

“Exercisers showed statistically significant differences from controls in baseline to 12-month changes in body weight (–1.4 kg; 95% confidence interval [CI], –2.5 to –0.3 kg), total body fat (–1.0%; 95% CI, –1.6% to –0.4%), intra-abdominal fat (–8.6 g/cm2; 95% CI, –17.8 to 0.9 g/cm2), and subcutaneous abdominal fat (–28.8 g/cm2; 95% CI, –47.5 to –10.0 g/cm2). A significant dose response for greater body fat loss was observed with increasing duration of exercise.”

                    And the conclusion –

“Regular exercise such as brisk walking results in reduced body weight and body fat among overweight and obese postmenopausal women.”

    2 .Effect of Aerobic Training on Percentage of Body Fat,Total Cholesterol and HDL-C among Obese Women (PDF) – Quoting from the abstract –

“The results showed that there were significant changes in Percentage of Body Fat, TC and HDL-C.”

So Mr. Fruitness expert, you are demonstrably wrong. Maybe you should think again before slandering doctors and sprouting non-sense?

Edit - Can't believe I missed this nugget -

"Cortisol leads to adrenal fatigue, yo-yo-like fluctuations in blood sugar and completely throws your digestive system off gear."

Our fruitness expert is a total woo monger, peddling a fake disease!! From the brilliant people of Science based Medicine -

“Adrenal fatigue” is not a real medical condition. There are no scientific facts to support the theory that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms."

Irwin, M. (2003). Effect of Exercise on Total and Intra-abdominal Body Fat in Postmenopausal Women: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 289 (3), 323-330 DOI: 10.1001/jama.289.3.323

Writing at the doc2doc clinical blog

I have written a post on numbers needed to treat over at the doc2doc clinical blog of BMJ. Here is an excerpt, go ahead and have a read –

“The NNT or number needed to treat is a useful way to report binary outcomes of RCTs. NNT gives us an easy to understand statistic. It can also be used to present results of continuous variables by converting them to dichotomous variables. NNT can be defined as the reciprocal of the absolute risk reduction (ARR) or NNT=1/ARR. ARR is the difference between the absolute risk of the control group (AR_C) and the absolute risk of the treatment group (AR_T) or NNT=1/ (AR_C - AR_T). The value of NNT can lie between 1 to +∞ for a beneficial effect and -1 to -∞ for harmful effect.” Read more.

Novartis vs. Government of India

From 6^th September onwards, a very important case is being heard in the Supreme Court. It concerns two parties, the drug manufacturing giant Novartis and the government of India but the outcome of this case has huge implications for the people of India and of other low income countries.

Imatinib mesylate. From wikimedia

What is the case about?

Novartis wants to obtain a patent on imatinib mesylate, a salt of the drug imatinib used for the treatment of cancers like chronic myeloid leukaemia. Previously, Novartis appealed in the Chennai High Court and the Indian Patent Appelleate Board but the decision was not in their favour. In both the cases, section 3(d) of the Indian Patent Act was cited to show that imatinib mesylate did not show any significant efficacy than that of the original compound although Novartis claimed that it increased the bioavailability of the drug by 30%. Now Novartis is challenging the decision in Supreme Court to obtain a patent.

Why should you be bothered?

If Novartis does not have a patent on the drug, it allows generic manufacturers to produce the drug. Competition in the generic market drives the price of the drug down and you and I can afford to buy the drug should we need it. If Novartis succeeds in getting a patent, it gains a monopoly on the drug and no other company can produce it unless authorized by Novartis. This is a common tactic used by pharmaceutical companies to maximize their profit, called evergreening. If Novartis is successful in getting a patent, this will set a precedent, all the other companies too will file for patents and will ultimately drive up the cost of life saving medicines.

Médecins Sans Frontières, an international humanitarian organization has already spoken up against this, saying that this will drive up the cost of medicine in low income countries to whom they supply drugs which they buy from generic Indian manufacturers.