Cover en Sun Sep 25 14:49:06 IST 2022 a-doctor-demystifies-bipolar-disorder <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.</p> <p>&nbsp;</p> <p>These iconic words by Charles Dickens in A Tale of Two Cities summarise the state of mind of a person having a complex neuropsychiatric disorder called bipolar disorder.</p> <p>&nbsp;</p> <p>Previously referred to as manic-depressive illness, the disorder is characterised by dramatic shifts in mood, energy and activity levels that affect a person’s ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs experienced by everyone. Manic depressive illness was defined by Emil Kraepelin in 1898, and was characterised by recurrent mood episodes of any kind, either depression or mania. The current definition differs from the Kraepelinian one—bipolar disorder is said to have both depression and mania.</p> <p>&nbsp;</p> <p>Bipolar disorder is frequently missed because of the nature of the disorder itself. More often than not, it starts with periods of depression, and sometimes a decade may elapse, until the person has a manic episode. Merely treating depression in such persons will not result in the relief of symptoms. This is why psychiatrists keep an eye out on uncovering underlying bipolar tendency in persons (a) who present with early-onset (20-25 years) of multiple periods of depression (b) who have a family history of bipolar disorder (c) who have been diagnosed with ADHD (d) who engage in substance misuse (d) in whom the onset and offset of depression is abrupt (e) whose depression refuses to get better despite treatment (f) whose depression worsens with antidepressants.</p> <p>&nbsp;</p> <p>Natasha (name changed) had hard-to-treat depression. She had consulted a host of doctors and mental health professionals. Her depression refused to abate despite years of treatment. I vividly remember her exasperation at not being able to find a solution to her vexing medical problem. During the clinical interview, upon careful probing of her symptoms, her mother confirmed that Natasha had periods of mildly elevated mood wherein she was found to be more excitable, happier than usual and as though filled with more energy. These symptoms were never severe enough to disrupt her professional, personal or social spheres. Over the course of her illness of 15 years, she had four such distinct periods. Unfortunately, these were hard to pick during the initial clinical interviews. Hers was a case of bipolar II disorder, which is characterised by depression and hypomania. Bipolar II disorder is generally hard to pick during a single clinical interview, and requires clinical probing of symptoms, in the presence of a good informant. Missing periods of hypomania in the person’s history completely changes the management of the disorder, and has therapeutic implications.</p> <p>&nbsp;</p> <p><b>Prevalence</b></p> <p>Studies have reported that the lifetime prevalence of bipolar disorder I varied from 0.3 per cent to 1.5 per cent. More recent studies have reported that the lifetime prevalence rates are 1 per cent, 1.1 per cent and 2.4 per cent for bipolar disorder I, bipolar disorder II, and subthreshold bipolar disorder respectively. The prevalence of bipolar disorder I is similar in men and women while it is consistently more in women in bipolar disorder II.</p> <p><b>Risk factors</b></p> <p>There is a dynamic interaction between the constructs of ‘nature’ (genes) and ‘nurture’ (environment) in the causation of bipolar disorder. In determining the risk factors for lifetime vulnerability, genes play a pivotal role. For the onset of an episode of depression or mania, adverse life events such as bereavement, divorce, financial distress, relationship difficulties, may have some role to play. Factors such as stress, sleep disruption, substance misuse may also trigger mood episodes in genetically vulnerable individuals. Many women have their first episode of depression or mania in the postpartum period. Disruption of normal biological rhythms may precipitate the onset of manic or depressive episodes. This has been documented in relation to international journeys involving east-west or west-east travel with disruption of the body’s biological clock.</p> <p>&nbsp;</p> <p><b>Age of onset and course of illness</b></p> <p>Bipolar disorder is highly heritable, which means 70-80 per cent of persons with this disorder have a relative with either bipolar disorder or unipolar depression. The mean age of onset of bipolar disorder varies from 17 to 30 years. European data suggest a mean age in the late 20s, whereas the United States data suggest a mean age in the early 20s.</p> <p>&nbsp;</p> <p>Most individuals (85 per cent) with bipolar disorder present to the clinician with an initial episode of depression. The duration of these episodes is typically between two and five months. Ten per cent of patients present with mania and this lasts around two months. Ninety to 100 per cent of individuals with bipolar I disorder will develop more mood episodes after the first manic episode. Some may develop a few episodes while some others may develop many. The general rule of the thumb is that previous episodes increase the risk of recurrence for future episodes. Over the course of the illness, 80 per cent of individuals have depressive mood episodes while the rest have a manic or mixed episode.</p> <p>&nbsp;</p> <p><b>Undiagnosed bipolar disorder and health care utilisation</b></p> <p>Bipolar disorder is a clinical diagnosis, and in that it is frequently missed. This is because hypomanic or manic episodes do not frequently come to the attention of the clinician. A person in hypomania may even enjoy the slightly elevated mood and refuse to count it as a part of the illness spectrum. Likewise, periods of intense anger and irritation, which may reflect irritable mania, may get missed altogether. Persons in hypomania and mania frequently lack insight into their illness for them to get a clinical consultation.</p> <p>&nbsp;</p> <p>Added to this, there is often an interval between the onset of mood episodes and seeking help (on average 8-10 years), and it may sometimes take a decade for a bipolar patient to receive the right diagnosis. An overwhelming 20 to 40 per cent of bipolar patients are initially misdiagnosed to have unipolar clinical depression, and are administered antidepressant medications. This can worsen the longitudinal course of the disorder, and can result in poor long-term outcomes. When antidepressants are given without the cover of a mood-stabiliser in a person with undiagnosed bipolar disorder, a depressed person shifts to the opposite pole, and manifests extreme manic symptoms. This clinical phenomenon is called ‘switching’, and reflects in worsening of the person’s mood state.</p> <p>&nbsp;</p> <p><b>Solutions</b></p> <p>Bipolar disorder symptoms improve with treatment. Medication is the cornerstone of bipolar disorder treatment in conjunction with talk therapy. Talk therapy can help persons learn about their illness, increase their adherence to medications, and consequently prevent future mood episodes. Non-drug approaches include Interpersonal and Social Rhythm Therapy (IPSRT), Family Focused Treatment (FFT) and psychoeducation.</p> <p>&nbsp;</p> <p>IPSRT is based on the premise that symptoms of bipolar disorder are triggered by disruptions in daily routines and sleep-wake cycles, and stabilisation of these routines is essential to mood stabilisation. IPSRT begins following an acute period of illness and focuses on stabilising daily and nightly rhythms as well as resolving interpersonal problems that may have preceded the acute episode. Patients learn to track their routines and sleep-wake cycles, and identify events (for instance, job changes) that may provoke changes in these routines.</p> <p>&nbsp;</p> <p>Medications known as ‘mood stabilisers’ like lithium and dopamine-receptor blockers like risperidone are the most commonly prescribed type of medications for bipolar disorder. These medications are thought to correct imbalanced brain signalling. Since bipolar disorder is a chronic illness with frequent recurrences, ongoing preventive treatment is recommended. Psychiatrists frequently individualise the treatment, and this involves a process of trial and error to determine the best fit.</p> <p>&nbsp;</p> <p>In case the person is suicidal or if medications have resulted in a suboptimal response, a highly effective brain stimulation modality called electroconvulsive therapy (ECT) may be used. While the person is under anaesthesia, a brief electrical charge is applied to the person’s temples or frontal bone, leading to a short-controlled seizure. This remodels brain signalling pathways and results in immediate relief. ECT has saved many a suicidal person from the clutches of imminent death.</p> <p>&nbsp;</p> <p>Ruchi (name changed) has been a longstanding patient of mine. After recently having recovered from a depressive spell, she remarked, “Doc, do you think people will see me as a person or as someone who alternates between mania and depression?” I was at a loss of words for a moment, and then gathered myself to assure that, in all of her suffering, her individuality had remained intact. She was much more beyond her periods of mania and depression. She had been a wonderful daughter, a caring wife and an extraordinary mother.</p> <p>&nbsp;</p> <p>The stigma surrounding this complex yet common neuropsychiatric disorder is immense. As a result, many people do not seek help. Lack of awareness also delays people from seeking help. With the right treatment, people with bipolar disorder can lead productive and fulfilling lives. Mental health is an inalienable right, and every person with bipolar disorder has the right to seek timely care.</p> <p>&nbsp;</p> <p><b>Kulkarni is senior consultant psychiatrist, Manas Institute of Mental Health, Hubballi.</b></p> Sun Sep 25 14:54:04 IST 2022 finding-peers-and-support-on-bipolarindia-com <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>When was launched in 2013, it was merely a website with information to raise awareness about bipolar disorder. Gradually, the site saw conversations happening. This led to the formation of the peer support community, perhaps a first-of-its-kind in India.</p> <p>&nbsp;</p> <p>In 2016, on World Bipolar Day—March 30— hosted the first national conference that saw people coming in from all parts of the country. “Our community is virtually connected 24x7 on the Telegram app,” says Vijay Nallawala, founder of “The support that is provided is in the form of suggestions drawn from lived experience, recommendations from mental health professionals and crisis intervention.” Nallwala, 60, was diagnosed with bipolar disorder at 40, after struggling with depression for two-and-a-half decades.</p> <p>&nbsp;</p> <p>Peer-led intervention can vary from someone from the community connecting over the phone to try and help a person in distress to a much more direct degree of intervention, says Nallawala.</p> <p>&nbsp;</p> <p>“For instance, a member needed emergency hospitalisation, and our community crowdfunded almost the entire hospital bill for the month's treatment there,” he says. Peer support meets are held online and offline several times a month for its members who are based across India, he adds. The community also offers guidance on health insurance for mental illness and on how to apply for a disability certificate.</p> <p>&nbsp;</p> <p>“The mere presence in the community leads to a person feeling less isolated,” says Nallawala.</p> <p>&nbsp;</p> <p>, an initiative by, is focused on providing livelihood for persons with mental health conditions.</p> <p>&nbsp;</p> <p>“This platform has already attracted 30 CVs and we are in negotiations with companies that have inclusive policies,” says Nallawala. Significantly, the core team at the helm of this initiative is drawn mainly from the community.</p> Sun Sep 25 14:56:41 IST 2022 when-the-mood-swings-wildly <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Anshul Shukla, 27, from Lucknow talks about his turbulent past almost dispassionately.</p> <p>&nbsp;</p> <p>While doing his graduation, he had bouts of depression and changed his major four times. He started with engineering—first mechanical and then electronics—and later switched to humanities—English and Economics. During his graduation in Economics at Shiv Nadar University, he was suspended for violence, and he dropped out of college. “I had just come back from a month-long trip from northern Thailand, and I was feeling upbeat, energetic and very happy. It was showing in my behaviour,” recalls Shukla. “Earlier, I was feeling very depressed. I got into a fight and unfortunately I became a bit violent.”</p> <p>&nbsp;</p> <p>The incident changed the course of his life. At 21, he was diagnosed with bipolar disorder (BD) by the&nbsp;psychiatrists at the university. He has had a bipolar&nbsp;depression crash twice following manic episodes (a state of mind characterised by euphoria, high energy and excitement). “During the manic phase of bipolar, I would feel on top of the world,” says Shukla. “My confidence was unshakable and I felt I could achieve anything. This would be followed by a state when I would feel suicidal and empty. Like everything was being taken away from me.”</p> <p>&nbsp;</p> <p>Sometimes he would experience psychosis (a severe mental disorder wherein the patient loses touch with reality) and have delusions about his parents trying to harm him. “Things got so bad that the police had to be called in and I was taken in an ambulance to hospital. Such incidents have happened twice or thrice,” says Shukla.</p> <p>&nbsp;</p> <p>Shukla finally completed his graduation and did his masters in Political Science from Indira Gandhi National Open University. But he is still struggling to keep a job. He never disclosed his ailment at any of his previous organisations for fear of discrimination and losing the job. “I still didn’t manage to stay at a job for more than three months,” he recalls. “I’m finding it difficult to focus on work or further education, because I can’t seem to stick to anything.”</p> <p>&nbsp;</p> <p>The world is often unkind to people with mental health issues. At times, the hostility begins at home. “Most of my relatives don’t even think that this is a real thing,” says Shukla. “They think I’m lazy and don’t want to work and that is why I am making up such excuses. But my family supports me a lot.’’</p> <p>&nbsp;</p> <p>Shukla’s maternal grandfather supposedly had bipolar disorder. “He used to take lithium,” says Shukla. “He used to get manic and sometimes come back home without clothes as he would give them away to strangers who needed them more.”</p> <p>&nbsp;</p> <p>Shukla is currently on lithium and a long-acting depot injection. He had been on different medicines earlier. He switched to the current combination after the previous medicines stopped working for him.</p> <p>&nbsp;</p> <p>The term ‘bipolar’ refers to the way one’s mood can change pathologically between two very different states of excessive happiness and sadness—mania and depression, explains Dr Muralidharan K., medical superintendent and professor of psychiatry at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. “In manic episodes, someone might feel very happy, irritable, or ‘up’, and there is a marked increase in the activity level,” he elaborates. “In depressive episodes, someone might feel sad most of the time, indifferent or hopeless, in combination with a very low activity level.” The mood changes that people with bipolar disorder experience are different from the usual mood swings. “It is a brain disorder that causes unusual pathological shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks, that last a few weeks to months, continuously,” says Muralidharan.</p> <p>&nbsp;</p> <p>People with bipolar disorder swing between both ends of the spectrum, that too without any apparent reason or trigger. “These changes are episodic in nature,” says Dr Preethi V. Reddy, assistant professor of psychiatry at NIMHANS. “The range of mood changes can be extreme, with the episodes being of two opposite polarities.”</p> <p>&nbsp;</p> <p>Abhishek Mehta, 28, from Gandhinagar, is a worried man these days. He is unemployed, not for lack of trying. “I tried as many as 12 jobs, but couldn’t survive anywhere,” says the business management graduate. He tried his hand at varied jobs like customer service, finance, IT recruitment, but had no luck. “I used to get panic attacks and repeated bouts of depression and anxiety,” says Mehta. “I would have bipolar mania and paranoia (irrational suspicion, mistrust of people and a fear that someone is out to get you and conspiring against you) as well. All these took a toll on my professional life.” He has had panic attacks but never mania with psychosis at work.</p> <p>&nbsp;</p> <p>People with bipolar disorder may experience psychotic symptoms in depressive as well as manic phases. Mehta had false beliefs that he held persistently. Delusions happened mostly in the manic phase of bipolar disorder, he says. Occasionally, he had hallucinations, too. “I would feel the ground was shaking,” he recalls. “Once, I saw my shadow moving while I was standing still. But mostly, it was delusions and paranoia.”</p> <p>&nbsp;</p> <p>Mehta has no family history of bipolar disorder. Looking back, he says the turbulence of adolescence scarred him for life and perhaps acted as a trigger for his bipolar episodes. “There was a lot of bullying and abuse. I used to get teased for being overweight,” he says. “All that trauma kept building up. I was very sensitive and there was no way I could express my emotions. The brain and body can take only a certain amount of stress.”</p> <p>&nbsp;</p> <p>Mehta then became quiet and withdrawn. He would often feel sad and dejected, and had a major breakdown in 2015. The bipolar depression with psychotic symptoms lasted two months. “I had delusions and I felt very impulsive,” he recalls. “I remember I lost a lot of weight prior to that…. Prior to the episode, I felt dizzy, too.” His mother—his pillar of support—took him to a psychiatrist and he was diagnosed with bipolar disorder. With medication, he is stable right now.</p> <p>&nbsp;</p> <p>Mehta wants to work and be independent, but doesn’t know how. He thinks he would be a misfit in the corporate world. Bipolar disorder could affect every aspect of one’s life, says Mehta. “My girlfriend left me as I was not financially stable, though she knew about my mental health issues,” he says.</p> <p>&nbsp;</p> <p>Bipolar disorder peaks between 17 and 30 years of age, says Dr Alok Kulkarni, senior consultant psychiatrist, Manas Institute of Mental Health. Even among the elderly diagnosed with bipolar disorder, it is very likely that the disorder would have started in young adulthood. It is quite rare to find new-onset bipolar disorder in the elderly, he says.</p> <p>&nbsp;</p> <p>Across the world, the prevalence of bipolar disorder is equal in men and women. The National Mental Health Survey (NMHS) 2015-16 identified the prevalence to be 0.6 per cent in men and 0.4 per cent in women in India. The NMHS found that the prevalence was more in the urban population when compared to the rural population.</p> <p>&nbsp;</p> <p>Prevalence of bipolar disorder in India is between 0.5 to 1.5 per cent, says Kulkarni. This means that, at any given point in time, 60-70 lakh Indians are living with bipolar disorder. These are staggering numbers for a country that has less than 9,000 psychiatrists for a population of 1.3 billion.</p> <p>&nbsp;</p> <p>Access to psychiatric care had been a major challenge for Krishna, 25, from Uttar Pradesh. “There are very few psychiatrists in tier 2 and tier 3 cities,” he says. He now opts for online consultation.</p> <p>&nbsp;</p> <p>Krishna, who works as a tutor for an EdTech company, was diagnosed with bipolar disorder at 17. He had his first manic episode while preparing for his IIT entrance exam. He had scored 91 per cent in his class 12 exams. “I was under tremendous pressure to prove my worth,” he says. He believes that people suffering from bipolar disorder or any mental illness can have a successful career if people around them are empathetic and have proper awareness. A huge fan of Dr A.P.J. Abdul Kalam, he dreams of launching a startup that will help students pursue their passion.</p> <p>&nbsp;</p> <p>There are mainly two types of bipolar disorder—bipolar I and bipolar II. Bipolar I is when a person has one or more episodes of mania with an episode of depression in the past or vice-versa. In bipolar II, the patient will have episodes of hypomania, a less severe form of mania, with episodes of depression. People with hypomania tend to be cheerful and energetic. Hypomania is characterised by a decreased need for sleep. Even if the individual sleeps for just three or four hours, he/she will be fresh and active in the morning. There are no socio-occupational impairments or psychotic symptoms. Irritability is less common among people with hypomania. However, the depressive episodes in bipolar II episodes could be as severe as in bipolar I, says Dr Johann Philip, a consultant psychiatrist in Kochi.</p> <p>&nbsp;</p> <p>Avantika B., 19, from Mumbai was diagnosed with bipolar II when she was 17. She experiences hypomania. “I sleep less, I eat less, and I think I am being productive but it is just a feeling. Being hyper makes me feel I am more productive but I’m not,” says Avantika, an undergraduate student of psychology at NMIMS, Mumbai. “I would be working 10 hours straight but it wouldn't really be as productive as when I am working 7 hours during my maintenance phase. I am able to work longer hours though because I tend to commit myself to more things when I am in hypomania.”</p> <p>&nbsp;</p> <p>Avantika tries to go slow when she is in her depressive phase. “During depression, just making it to college is enough sometimes. It can get really suffocating and draining at times,” she says.</p> <p>&nbsp;</p> <p>While there are other types of bipolar disorders like cyclothymia—highs and lows are not as extreme as in bipolar I and II—and unspecified bipolar disorder, they are relatively uncommon. “What we see in clinical practice conforms to bipolar I and II only,” says Dr Gagan Hans, associate professor of psychiatry at the All India Institute of Medical Sciences, Delhi.</p> <p>&nbsp;</p> <p>Veena Malik, a 26-year-old filmmaker, musician and writer who grew up in Pune, describes hypomania as “an intense, elevated state where you can be extremely sharp, creative, and productive but can also be extremely angry, irritable and impulsive”. Malik, who has had recurring depressive episodes, was on medication for a year and a half.</p> <p>&nbsp;</p> <p>It is important to differentiate between unipolar—characterised by either depressive or (more rarely) manic episodes but not both—and bipolar disorders to initiate the right treatment. Both disorders have strikingly different medication regimes and treatment approaches.</p> <p>&nbsp;</p> <p>Varsha Verma, an engineering student from Kochi, would often fail to submit her assignments on time and perform poorly in her semester exams. She kept dropping out of her course as she was experiencing decreased energy levels, low mood, loss of appetite and poor sleep. Over 18 months, she approached several mental health experts, who put her on various antidepressants, but there was no slowing of symptoms. “On detailed evaluation, it was found that several past episodes of hypomania—discrete episodes of marginally elevated mood during which the patient was excessively upbeat, talkative, pleasant and spending too many hours in study without much sleep—were missed on her previous clinical evaluations. That changed her diagnosis from unipolar to bipolar depression,’’ says Philip, who treated her. He started her on a mood stabiliser and concurrent psychotherapy, which, he says, has helped her.</p> <p>&nbsp;</p> <p>Antidepressants alone don’t work for most people with bipolar depression, explains Philip. “If antidepressants are given to a patient with bipolar depression, he or she may switch from depression to mania,” he says. “So it is very important to go through a clear history because the treatment approaches and medications are different for bipolar and unipolar depression.”</p> <p>&nbsp;</p> <p>Bipolar disorder is more genetic than unipolar disorder, says Philip.</p> <p>&nbsp;</p> <p>Long-term bipolar disorder can result in cognitive impairment leading to reduced cognitive functioning.</p> <p>&nbsp;</p> <p>Bipolar disorder is rarely seen in children and adolescents compared to older adults. However, when it is present in this cohort, the elevated mood, restlessness and agitation associated with bipolar disorder is often mistaken for hyperactivity and wrongly diagnosed as Attention Deficit Hyperactivity Disorder, says Philip.</p> <p>&nbsp;</p> <p>Ashik Raj, 12, from Chennai had a diagnosis of ADHD that had worsened with medication before he consulted Philip. “On multidisciplinary assessment and after evaluating his symptom profile, we realised the diagnosis is not ADHD but childhood-onset bipolar disorder, which is now known to have a poor prognosis without early intervention and treatment,” says Philip. “ADHD is sometimes treated with stimulants that often worsen the symptoms of bipolar affective disorder. It is therefore prudent to accurately identify and treat bipolar illnesses as early as possible for improved overall treatment outcomes.”</p> <p>&nbsp;</p> <p>Substance abuse is quite rampant among people with bipolar disorder. That complicates things in terms of treatment, says Philip. Individuals with bipolar disorder are also at an increased risk of suicide, possibly because of impulsive behaviour.</p> <p>&nbsp;</p> <p>The mainstay of diagnosis in psychiatry is case history. There are no brain scans or lab tests to detect bipolar disorder. “We don’t have any diagnostic tests to confirm it. So we rely on a carefully taken history from the family members,” says Hans. Clinicians often use diagnostic manuals like the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases to diagnose bipolar disorder. “At the end of the day, the diagnosis is made based on clinical experience looking at the diagnostic criteria,” says Philip. Hans also observes the patient over a period of time. “If the symptoms are not clear, we insist the patient gets admitted so we can observe his/her behaviour and record the illnesses and problems,” he says.</p> <p>&nbsp;</p> <p>Bipolar disorder is basically a mood disorder. “What we look at is a change in mood from the baseline,” says Philip. The baseline could be different for different people. “What is baseline for me could be mania for you. So it is important to look at the individual’s baseline,” he says. Assessment scales are also helpful for diagnosis and treatment. Young Mania Rating Scale, a 11-item interviewer-rated scale, is widely used to assess manic symptoms. Beck’s Depression Inventory, a 21-item inventory, is useful for evaluating the severity of depression. Philip uses these scales mostly to see whether the symptoms have subsided after starting treatment.</p> <p>&nbsp;</p> <p>Compliance with medication is necessary to manage bipolar disorder. “Psychiatric medications take 4-6 weeks to have their effects,” says Hans. “Taking medicines on long-term basis is very repulsive for most patients. They take medications for a few days and the moment they feel better they stop. The effect of medications goes away in a few weeks and they may have a relapse. The more episodes you have, your prognosis worsens.”</p> <p>&nbsp;</p> <p>Mehta is currently on medication. “I take anti-psychotics and antidepressants. They cost Rs500 a month. At one point I used to take 13 medicines. Back then, my parents spent around Rs3,000 a month on my medication”, he recalls.</p> <p>&nbsp;</p> <p>Anti-psychotic medications decrease symptoms of mania and psychosis. “The right mix of medicines can help treat the symptoms really well and live a stable life. I see my doctor every month. And I’m also doing therapy,” says Mehta. Therapy costs around Rs1,500 an hour. “Medicines help with the chemical imbalance in the brain while therapy helps with the psychological aspects like thoughts, mindfulness and behaviour and coping mechanisms,” he says.</p> <p>&nbsp;</p> <p>Even people who experience just mania and no episodes of depression need treatment, says Hans. There is no cure for bipolar disorder. It is a chronic condition. “There can be multiple relapses,” says Hans. “You cannot say for sure which patients will have repeated episodes. It depends on several factors. There are patients who have had just one episode. At the onset, you cannot foretell whether other episodes will occur or not.”</p> <p>&nbsp;</p> <p>Treatment-resistant depression often turns out to be bipolar depression. “One of the biggest controversies in psychiatry today is whether to prescribe antidepressants in bipolar depression or not,” says Philip. “Sometimes we do have to give a little antidepressant because they just don’t come out of depression otherwise.”</p> <p>&nbsp;</p> <p>People process drugs differently depending on their genetic profile. White people seem to tolerate higher dosages than Asians, observes Philip. He recommends Transcranial Magnetic Stimulation for patients with treatment-resistant bipolar depression. TMS stimulates the left prefrontal cortex—responsible for mood regulation and positive emotions—and inhibits the right prefrontal cortex, associated with negative emotions.</p> <p>&nbsp;</p> <p>For Malik, talk therapy has done wonders. She vented a lot before she learned to find some peace and stability.</p> <p>&nbsp;</p> <p>Over the years, Avantika has learnt to live with bipolar disorder. She has made a lot of changes not just in her lifestyle but also at a cognitive level. Avantika believes it is really important to have a strong emotional support system and professional help to work through bipolar disorder. Her friends have been her pillars of support ever since she was diagnosed. “Sometimes it can get difficult to keep up with certain relationships when I have a depressive episode because not everyone understands it well; I wouldn't expect them to,” she says. “But sometimes it makes me feel invalidated or misunderstood. It's really important to have a strong emotional support system.” With therapy, she has been able to manage her life pretty well.</p> <p>&nbsp;</p> <p>Therapy has been beneficial for Mehta, too. He feels more aligned with himself. He is part of Bipolar India, an online community that offers support for people with bipolar disorder.</p> <p>&nbsp;</p> <p>Mehta feels bipolar disorder has made him a better human being. He now wants to spend the rest of his life helping others. “I love helping people going through mental health issues,” he says. “Even lending an empathetic ear helps keep their spirits up. I do it every day and it gives me immense joy.”</p> <p>&nbsp;</p> <p><b>Some names have been changed.</b></p> Mon Sep 26 10:59:02 IST 2022 the-amazing-journey-of-dr-sarthak-kamath <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><i>Ruk jaana nahin tu kahi haarke…. Kaaton pe chalke milenge saaye bahaar ke</i> (Do not stop even if you feel lost, you will meet the shadow of spring even as you walk on thorns.)</p> <p>&nbsp;</p> <p>Anybody meeting Dr Sarthak Kamath would tend to recall this song from Imtihaan (1974).</p> <p>&nbsp;</p> <p>Sarthak was diagnosed with a rare disease called Duchenne muscular dystrophy (DMD)—a genetic disorder that causes muscular weakness, mostly in boys—at three that left him wheelchair-bound. Today, the 30-year-old spirited, bright-eyed Bengaluru resident is the first person with DMD to become a doctor and an MD in psychiatry.</p> <p>&nbsp;</p> <p>His mother, Sneha, says that when Sarthak was three, he would fall repeatedly and his calf muscles had become prominent, medically known as compensatory hypertrophy of the calf muscles. “When we got him examined by our paediatrician, initially his condition was diagnosed as ‘flat foot’,” recalls Sneha. “Hence, special shoes with ‘insoles’ for the plantar aspect of the feet were provided.” But there was no improvement in Sarthak’s condition. At times, he would walk on his toes because his sole muscles were weak. “When he was five, special diagnostic tests like CPK (creatinine phosphokinase) and genetic tests were carried out at NIMHANS, Bengaluru,” says Sarthak’s father, K.N. Kamath, an engineer from Manipal Institute of Technology. The tests confirmed DMD. His parents were shocked. “We had to gulp down the bitter news like a ghora visha (horrible poison), since we could not discuss it with either of our parents,” says Kamath.</p> <p>&nbsp;</p> <p>Till the age of 12, Sarthak somehow managed on his own, walking on toes and sitting down at frequent intervals. But then one day at school, he could not get up from the bench and he became wheelchair-bound. That was also the time when a repeat PCR (Polymerase Chain Reaction) test and a muscle biopsy re-confirmed his DMD diagnosis.</p> <p>&nbsp;</p> <p>Sarthak was in class seven, and half the academic year was already over. The school said that they could not make arrangements for one student and asked his “parents to take the transfer certificate”. “The school did not even allow me to appear for my class seven final exams,” recalls Sarthak. “It was emotionally quite devastating for me.”</p> <p>&nbsp;</p> <p>But his mother was not one to give up. Sneha kept looking for a school near home that would take Sarthak in without complaints and some compromise. “We owe it to Parvathy Vishwanath, principal of Acharya Shree Maha Prajna School, who, for Sarthak’s sake, got all class seven students shifted to the ground floor,” she says. “Though Sarthak had to repeat an academic year, we were happy to see him in a school environment, that too in our neighbourhood itself.”</p> <p>&nbsp;</p> <p>Sneha, too, joined the school as a class teacher on the principal’s advice. That way, she could help Sarthak with his washroom needs and during lunch hour. When Sarthak was in class eight, a security guard would carry him to the second and third floor for certain classes, says Sneha. When Sarthak was 15, he underwent a minor surgical procedure to prevent tightening of calf muscles.</p> <p>&nbsp;</p> <p>A challenge that Sarthak had to tackle on his own was the change in syllabus, from Central board to state board. But he took on the challenge with élan—he scored 91 per cent in his class ten exams. But it was not just academic books that he read in high school. Since he could not be part of the physical training/sports period, he took to reading novels, especially those by Dan Brown. A classmate who loathed the PT period would stay with him for those 45 minutes.</p> <p>&nbsp;</p> <p>Sarthak decided to take science [Physics, Chemistry, Maths, Biology] in college despite people advising him against it. “Many people advised me not to pursue science, considering my condition, but I was determined to become a medical doctor,” he says.</p> <p>&nbsp;</p> <p>Sarthak was especially fascinated by neuroscience, thanks to Dr Subbarao Belawadi, a general physician. He was in class nine then, and Dr Belawadi was teaching him to cope with his physical disability without letting it affect him emotionally. “Dr Belawadi used a method called ‘Modified Visualisation Therapy’, wherein I had to imagine what I wanted to achieve in my life, and simultaneously brush aside all negative thoughts associated with DMD, which used to creep in quite often,” says Sarthak. “His advice helped me manage my temper and focus on my ambition. I was also tremendously influenced by the story of Dr David Hartman, who became the first blind psychiatrist in the world.” He also counts theoretical physicist Stephen Hawking, paralympic Deepa Malik and Australian-American motivational speaker Nick Vujicic, born without arms and legs, among his role models.</p> <p>&nbsp;</p> <p>While in high school, Sarthak learnt to play chess under the guidance of chess master Raja Ravi Sekhar. He also started playing music on the keyboard. In college, he won several prizes in quiz and debate competitions. “I even won a prize in the ethnic wear competition,” he says.</p> <p>&nbsp;</p> <p>Sarthak took tuitions for his medical entrance exam, and got admission at M.S. Ramaiah Medical College in Bengaluru in the physically challenged category. He had secured fourth rank in the said category. Though his ranking in the general category (below 2,000) got him a seat in two colleges, he did not consider them as they were both outside Bengaluru.</p> <p>&nbsp;</p> <p>When Sarthak joined the medical college in 2011, Dr Saraswathi Rao was the principal. When Sarthak’s parents came to meet her, she had asked them why Sarthak wanted to pursue a tough course like MBBS. “But the 19-year-old boy was very focused and single-minded about his career option,” she says. “His parents and paternal grandmother were equally committed to nurture his aspirations. We allowed him to make use of a helper for his washroom needs and for taking the lift. He did very well in his studies.” She remembers Sarthak playing popular songs on his keyboard at college functions. “Though always on wheelchair, he is a great motivator for many. M.S. Ramaiah Medical College has recorded his name with pride as a notable alumnus.”</p> <p>&nbsp;</p> <p>During his second year in medical college, Sarthak underwent a neuro-regenerative rehabiliataion therapy at NeuroGen Brain and Spine Institute in Mumbai. “The therapy is a holistic treatment consisting of stem cell therapy in combination with a personalised rehabilitation programme, including physiotherapy, occupational therapy and psychological intervention,” says Dr Nandini Gokulchandran, deputy director and head of medical services and clinical research, NeuroGen Brain and Spine Institute. “Sarthak had shown improvement a week after starting the therapy. The range of movement in upper extremity had improved so that he could move his wheelchair. He could not repeat the therapy, as he became busy with his studies.”</p> <p>&nbsp;</p> <p>It was the brain and its workings that kept Sarthak busy. During the anatomy class in his first year, he would find himself drawn towards the table where the brain was being dissected. “I was always curious and intrigued by the complex neuronic structure of the brain and its unique way of mega functioning,” he says. “During my internship, when my wheelchair could not fit through the door of the general surgery operation theatre, I was allowed to watch the surgery in the specialised neurosurgery OT. That again, in a way, provided more and more connection for me with the brain.” No wonder he specialised in psychiatry.</p> <p>&nbsp;</p> <p>After his internship at M.S. Ramaiah Medical College, Sarthak did one year of senior residency in psychiatry at Victoria Hospital, Bengaluru. For his MD in psychiatry, he got admission in Kempegowda Institute of Medical Sciences (KIMS), Bengaluru, in 2017 under the general category and procured eighth rank in the Rajiv Gandhi University of Health Sciences, to which KIMS is affiliated. He took the assistance of a scribe only for his final year MD exams, he says. “Sarthak’s resilience is beyond his disability,” says Prof Dr Raghuram, who headed the psychiatry department at KIMS when Sarthak did his MD. “He has an untiring quest to achieve greater things in life. We ensured that he was always accompanied by a helper, especially when he had to move on the wheelchair to the outpatient wing of psychiatry.”</p> <p>&nbsp;</p> <p>One’s school and college years are not just about education; they are also about the connections we make.</p> <p>&nbsp;</p> <p>“Not everyone used to be friendly with me,” says Sarthak. “There were sympathetic stares from people who kept asking one another, ‘Ayyo paapa (what a pity), what is this guy on a wheelchair going to do?’ I would have preferred if people were empathetic instead of being sympathetic. Even [in junior college], there were grumblings from a few parents that students appearing for IIT entrance exam may not be able to focus because of my wheelchair. If I had studied psychiatry by then, I probably would have diagnosed the condition as ‘wheelchair-induced anxiety’ or ‘wheelchair-induced psychosis.”</p> <p>&nbsp;</p> <p>But he did find some friends for life. Dr Siddarth Baindur, an ophthalmologist at the Maulana Azad Medical College, New Delhi, studied with him in his first school and saw how Sarthak struggled to get to the class on the higher floors. “But he never exhibited any remorse or sadness despite his physical disability,” he says. “He was very studious, hardworking and intelligent.”</p> <p>&nbsp;</p> <p>Baindur later met him at inter-collegiate festivals and remembers him excelling at the quiz competitions. “He has a sharp intellect,” he says. “Now, being a psychiatrist, I am sure he will be far more empathetic to his patients than any one of us.”</p> <p>&nbsp;</p> <p>Agrees Dr Aneeha, who was Sarthak’s batchmate in medical college, “Dr Sarthak’s ‘never give up’ attitude is his strength. He never allowed DMD to suppress his intellect.”</p> <p>&nbsp;</p> <p>Sarthak recently got through his first level of Member of the Royal College of Psychiatrists, the UK. Since January 2022, he has been working as an assistant professor (psychiatry) at Ambedkar Medical College in Bengaluru. He also counsels four to five patients in a day.</p> <p>&nbsp;</p> <p>Sarthak’s day begins at 7am. His helper assists him in his bath and with getting dressed for work. His breakfast consists of only two-three bananas and a protein-enriched beverage. He has no diet restrictions and eats both vegetarian and non-vegetarian food. His favourites though are Mexican chips and Konkani dal tadka.</p> <p>&nbsp;</p> <p>Sarthak travels to college in a car with a driver. He keeps his attire simple: dark-coloured woollen or cotton pants and light-coloured shirts, either plain or striped. His father says work has become his priority and he seldom travels for leisure with the family. He had visited London along with his parents and younger sister Sanmita, who is an interior designer, when he was 12. But the good doctor does find time to unwind, watching movies on television and documentaries on OTT platforms, genre no bar. A geography buff, he is obsessed with the online game ‘Worldle’, where one has to guess the country based on its outline.</p> <p>&nbsp;</p> <p>Sarthak undergoes physiotherapy at home for an hour every evening for about an hour. He is currently on steroid medication. Recent evaluation has revealed a good functioning of his heart and lungs. Most complications in DMD occur because of cardiac and respiratory deterioration, says Gokulchandran. “Sarthak’s cardiac output has been good and his respiratory condition has also been well maintained,” she says. “Continued physiotherapy, good care by parents and Sarthak’s optimism have all improved his quality of life and prolonged his lifespan.”</p> <p>&nbsp;</p> <p>Sarthak's name means ‘fulfillment’ or ‘justification’, and therefore his motto is: Har pal yahaan, jee bhar jeeyo (Live every moment to your heart’s content). He just has one advice for people: “Do not view the person afflicted with DMD as disabled. Try to understand that the disease is a disability.”</p> Sun Sep 04 13:59:05 IST 2022 working-towards-realistic-treatment-option-for-dmd-says-expert <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>When was DART established?</b></p> <p>&nbsp;</p> <p>In 2012 with the idea of initiating research leading to treatment that would provide support to children affected by DMD (Duchenne muscular dystrophy) and their families.</p> <p>&nbsp;</p> <p><b>What is the role of DART in DMD research? What scientific strides have happened in recent years, with respect to finding a cure or treatment?</b></p> <p>&nbsp;</p> <p>DART is the first research laboratory in India focusing on DMD research. We are working towards a realistic treatment option to alleviate and reverse the dystrophy condition at the genetic level, thereby enhancing the quality of life of affected children. The research programmes have been partially funded by state and Union government agencies, including ICMR (Indian Council of Medical Research).</p> <p>&nbsp;</p> <p>DART is a DSIR (department of scientific and industrial research, Union ministry of science and technology) recognised research lab. In February 2017, Hanugen Therapeutics was started as a spin-off of DART with the aim to make the skills and technology of antisense oligonucleotides (AOS: small pieces of DNA that can modify the production of protein by cells) available to those suffering from genetic disorders.</p> <p>&nbsp;</p> <p>Currently, Hanugen Therapeutics has obtained the manufacturing licence from the Indian Drug Licensing Authority for the upcoming clinical trials of DART.</p> <p>&nbsp;</p> <p><b>What is the strategy behind the process of exon-skipping?</b></p> <p>&nbsp;</p> <p>In human genes, there are non-coding sequences (introns) and the protein coding sequences (exons). In patients with disease-causing mutations, skipping or masking the non-functional exons can work to establish a situation where cells can produce a shortened but functional form of the dystrophin protein (which is deficient or undergoes mutation in DMD).</p> <p>&nbsp;</p> <p>An estimated 80 per cent of DMD patients have genetic mutations (alterations in gene) that are amenable to exon-skipping.</p> <p>&nbsp;</p> <p>In DMD, an exon or exons are deleted. This interferes with the rest of the gene being pieced together. For the dystrophin protein to work, it must have both the ends of the protein. Hence, whenever there is a mutation, it results in a completely non-functional dystrophin protein and severe symptoms of DMD.</p> <p>&nbsp;</p> <p>In exon-skipping, AOS are used to mask the exons that need to be skipped.</p> <p>&nbsp;</p> <p>In the future, the targeted next generation sequencing (NGS) may become a single platform to detect all types of mutations in the DMD gene. NGS could provide precise genetic information for emerging gene therapies.</p> <p>&nbsp;</p> <p><i>(DART was founded by Movin Anand and Ravdeep Singh Anand whose son Karanveer Singh is afflicted with DMD. Karanveer, 22, is wheelchair-bound. He is currently pursuing his Bsc.)</i></p> Sun Sep 04 13:44:56 IST 2022 hookup-lie-and-stinker <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Why do people join dating apps? To find a romantic partner? For casual hookups? A rebound relationship? Plain distraction? Or, to fill some gaping void?</p> <p>&nbsp;</p> <p>For 35-year-old Sreejita Basu, a Delhi-based communications professional in the development sector, it was simply a sense of curiosity to see what was out there. While waiting for a Delhi-bound train to arrive at Pushkar station at the end of her solo trip in May 2018, Basu downloaded OkCupid on a whim. She had heard her friends rave and rant about apps like Tinder and OkCupid. But after Basu's long relationship had ended in 2016, she did not take recourse to a dating app like a painkiller or a heart replacement therapy. Instead, she took a year and a half off to coast around on her own, quietly recovering in the company of people, places and things that gave her joy. So when she finally did download a dating app for the first time, Basu did not want, need or expect anything to happen. “I had good conversations and the men I met were all decent. No one acted like a creep or a stalker. My husband was the third guy I spoke to and met,” recalled Basu, who married Saurav in a lockdown wedding in November 2020. “I spent a good deal of time focusing on my life. And the apps worked more like a confidence booster before I met the right one.” Her age with its attendant wisdom in priority-setting also helped her attract the right person, she added.</p> <p>&nbsp;</p> <p>Basu's happy happenstance on a popular dating app, however, is hardly the norm. Of the several respondents THE WEEK spoke with to gauge levels of satisfaction on dating apps, more than 80 per cent attested to being unhappy, tired, cynical or sad. The pandemic surely added wings to online dating. According to research firm Sensor Tower, use of Tinder, Bumble and Hinge together grew by 17 per cent in January 2022 when compared to 2019, and first-time downloads grew from 91 million in 2019 to 106.4 million in 2021. Research will also tell you how more and more parents now approve of their children finding partners on dating apps. But precious little has been studied to understand the negative health impact born out of a culture of “choice overload”, “over abundance”, and “unlimited swipes” that dating apps engender. And how it breeds a “rejection mindset”, leading to swipe fatigue and dating burnout. A 2019 study in the journal Social Psychological and Personality Science found that more profiles, more searching, more scrutiny and a reluctant satisfaction with the final choice has often led people to gradually “close off” to mating opportunities.</p> <p>&nbsp;</p> <p>In the March 2022 issue of the peer-reviewed journal Body Image, the authors of a paper titled ‘Love Me Tinder: The Effects of Women’s Lifetime Dating App Use On Daily Body Dissatisfaction, Disordered Eating Urges, And Negative Mood’ paint an unflattering image of mate-selection strategy via dating apps, which kicks off an endless cycle of hope and hurt. One-third of the participants from close to 300 women from age 18 to 48 offered a link between lifetime dating app usage and daily urges for binge-eating or purging and negative mood.</p> <p>&nbsp;</p> <p>The reason why we are quoting research from the west is because it has wisened up to the ways in which dating has ushered in a strange anti-utopia for seekers of romantic or real human connections. Dating is something we have imported from the west (especially with the coming of Tinder), like several other lifestyle choices. And while we can only be thankful that these apps exist in the way it allows us encounters worth remembering, few are talking about the way it affects our brains, bodies and behavioural patterns with prolonged use.</p> <p>&nbsp;</p> <p>“I call it Big Dating because it’s like Big Pharma in the sense that they’re more interested in selling you pills than curing what’s really wrong with you,” said Nancy Jo Sales in a Vox interview last year for her memoir—Nothing Personal: My Secret Life in the Dating App Inferno. “Dating happens 24/7 now, whereas there used to be times when we dated,” she said.</p> <p>&nbsp;</p> <p>Sraboni Bhaduri, a Delhi-based psychologist, said that dating apps work more like “arranged marriages on steroids”, in the way it perpetuates a highly evaluative culture, with women and people from the LGBTQIA+ spectrum facing its worst pitfalls. “Our societal structure is a disaster right now,” she said. “People are not meeting each other situationally or running into each other the way they used to. Work is remote or hybrid, there is hardly any catching up over drinks after work or hanging out without an agenda. Normal friend circles are disrupted. And then dating apps make you market yourself in a way that you get chosen by someone on the basis of pictures and profiles. What does that do to your self-worth? It is a recipe for disaster, heightening feelings of stress, anxiety, loneliness. The very problem it seeks to solve is intensified.” Most people join dating apps at a moment of crisis in their lives, said Bhaduri, when something is not going right or one wants to break out of a toxic thread for a fresh start. “Women who are not so conventionally attractive will go out of their comfort zone to keep a date going,” she said. “They give in to men who might simply be predators. The result is a lot of casual, unprotected sex. These inexperienced, idiotic sexual encounters usually end up quite badly, including transmission of diseases. I know of cases, for both heterosexual and gay couples, where a bout of app-facilitated rough sex needed urgent medical attention.”</p> <p>&nbsp;</p> <p>For women in smaller, tier-2 cities, matches do not go beyond a few chats. Antara Jha from Ranchi got on Tinder and Bumble to look for a like-minded friend after her marriage fell through the cracks. “But I would only come across men who wanted to know your ‘stats’; they would keep insisting on meeting without forming any connections,” said Jha, who then switched to an app for extramarital affairs to find a friend.</p> <p>&nbsp;</p> <p>Two years ago, Abhishek Ghosh, a 27-year-old art consultant from Kolkata, was exceedingly happy to have landed in Delhi for work. Always keen on finding a job in Delhi, his short visit occasioned several networking opportunities. “I was also hoping to find better quality matches on Grindr (a social networking app for gay, bi, trans, and queer people). The dating pool for queer men in Kolkata leaves much to be desired,” said Ghosh, who continued to chat with matches in Delhi without intending to really meet anyone. He was happy socialising with friends and industry folks and spending his evenings exploring the city’s dining scene. But on the last day of his stay, he couldn’t resist and invited a rather good-looking man he had been chatting with to his boutique hotel in south Delhi. “I really wasn’t expecting him to show up on such short notice,” said Ghosh. “But he did and rang the bell in my room. When I opened the door, I found a completely different man who did not look like anything in the profile picture. He was middle-aged with a paunch and an unshaven face. He tried to forcefully enter my room. When I resisted, he fished out a knife from his pocket. That day I lost the 04,000 I had in my wallet and an expensive watch I was wearing. I could not call for security, fearing my identity as a gay man would be revealed to everyone in the hotel.” Ghosh left for a meeting with a client with a straight face immediately after. Back in Kolkata, he couldn't sleep for weeks before he sought help from a therapist and friends.</p> <p>&nbsp;</p> <p>While dating applications have been a boon for same-sex couples in the way it allows exploration of intimacies in complete privacy, it can also be a bewildering, terrifying ride. Arjun Chandra, an advertising professional in Gurugram, found his partner on Hinge after years of trial and error on dating apps. He lists the number of ways he has been shortchanged. “I met a married man who wanted to have some serious BDSM style sex; another time I met a lesbian faking to be a man so that she could marry me and we both could live our own lives once married; the number of times I have been asked to pay for sex on these apps and the number of times I have been told to do drugs,” recalled Chandra. The way these social apps allow us to be whoever we want to be always acts as a double-edged sword, he said.</p> <p>&nbsp;</p> <p>Informal dating relationships which end abruptly without any intimation, explanation or closure is called ghosting. It has variations like icing, simmering and bread-crumbing—all pointing towards sporadic, intermittent interest and disappearance. Ghosting is the most commonly cruel aspect of dating apps. Seema Hingorani, a Mumbai-based psychologist and relationship expert, said the lack of closure that comes with ghosting has become a bane of existence for young dating individuals. It goes on to trigger traumatic memories of childhood experiences and related attachment injuries. “Repeated ghosting can lead to a unregulated nervous system, where one loses control over their emotions—they can't focus at work or sleep at night, they don't eat well and have bad headaches,” she explained. “I had a client who literally had large chunks of hair falling off her head because of the stress that came with not being able to find the right match or running into people who could not commit.” The only protection one can have, according to Hingorani, is to be mindful of red flags from the start, because they are always there. “And you need to decide if you are looking for a date or a parent on these apps. Because parental issues and subsequent flawed belief systems from childhood first need to be resolved with a therapist,” she said.</p> <p>&nbsp;</p> <p>Debanjan Banerjee, consultant psychiatrist, Apollo Hospitals, said that to understand how dating app addiction exactly affects the brain, we need three types of investigation. It can be obtained either through imaging—CT or MRI—or we need a neurophysiological study to measure blood pressure and heart rate variability, or an electroencephalogram (EEG) to track sweating and adrenaline rush. All of this entails putting electrodes on to an individual in a controlled environment which will violate the privacy one requires to form an emotional or intimate connection. And that is an obvious bias. But there is, in fact, sketchy data on how the gamification of dating apps gives us the unexpected, dopamine hit, said Banerjee, formerly with the National Institute of Mental Health and Neurosciences (NIMHANS). “There is an unpredictable reward in dating apps. So that unpredictability can actually hit your brain with a significant amount of adrenaline and dopamine,” he said. “So if someone is suddenly using, let's say Tinder, when they are sad or lonely or just bored, and they find something even for a few days, the experience is like a vodka shot or a snort of cocaine. This unpredictable hit to the brain is the same as a rapid rush of substance when the reward pathways of our brains are activated.”</p> <p>&nbsp;</p> <p>Banerjee pointed to a recent study done at the Donders Center for Cognitive Neuroimaging in The Netherlands on the science behind brain activity while using Tinder. It specifically situates all the action in nucleus accumbens, an area in the brain which is most actively engaged in reward processing, especially while flipping through attractive faces. And the paper argues that the principle on which Tinder really operates is much like a casino slot machine. “Because you never know when you will hit the jackpot or when it will be a loss,” noted the paper.</p> <p>&nbsp;</p> <p>Shreya Banerjee, a 32-year-old research professional, logged out of dating apps just before the pandemic started. Disappointed and disheartened, she reached out to old friends, family members and neighbours for shooting the breeze. “I didn't want to make cursory connections or flirt on apps,” she said. She continues to meet people the more old-fashioned way. But she knows there is no way out of apps. “Can you really blame the intention of technology for bringing people together?,” she asks. “We live in an unhealthy age where no one owes each other anything, be it an apology, an explanation or a decent farewell. The apps can add multiple filters to offer the perfect match, but how will they regulate human nature?”</p> Mon Aug 01 12:07:54 IST 2022 how-an-indian-woman-revolutionised-the-way-couples-hook-up <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The place is anything but romantic: a tinted-window skyscraper rising among highways bordered with malls in Dallas, the business capital of Texas. Yet it was there, on the 15th floor, that Shar Dubey decided on the sentimental and sexual lives of a growing part of the planet.</p> <p>&nbsp;</p> <p>When we met her in mid-January, she was the CEO of Match Group, which owns Tinder and another dozen dating apps including Meetic, OkCupid and Hinge. (She stepped down in May after two years at the helm, but continues to be director and adviser.) That Friday, Dubey had been hustling on her standing desk since 8am, following a video conference at 6.30am with the Korean teams. These early morning slots are necessary for the 52-year-old: her company revolutionises the way couples get together not only in the US but also in Europe and Asia. According to the analytics firm, Match Group is ranked second among mobile app editors whose users spend the biggest amount of money in the world after Google and before Tencent, video games aside.</p> <p>&nbsp;</p> <p>The leader in online dating has grown considerably since the 1995 launch of the website. These past five years, its income rose from $1.3 billion to $3 billion in spite of Facebook’s entry on the dating market in 2018. But the group remains more private than other tech giants. So does Dubey: she has no Twitter or Instagram accounts.</p> <p>&nbsp;</p> <p>Dubey is also wary of the Californian habit of letting societal debates infiltrate the company. Last fall, she nonetheless spoke up to denounce the new Texan law that bans abortion after six weeks by creating a fund to cover the expenses her female employees might have to pay if they abort in a different state. “I am not an activist and I don’t think it is usually the CEO’s job to take political stances. But I was asked what I think of this law and I couldn’t imagine replying ‘no comment’,” she says.</p> <p>&nbsp;</p> <p>Dubey, however, doesn't hesitate to share her career history and the obstacles she faced because of her gender. Raised in Jamshedpur, by her father—an engineering school professor—and her stay-at-home mother, she was the only woman to be accepted at the Indian Institute of Technology (IIT) among a hundred male students. “My father was delighted that I got into the IIT, but in my distant family the first reaction was to tell me no one would marry me,” says Dubey.</p> <p>&nbsp;</p> <p>She then flew off to pursue a masters at Ohio State University and she became the first woman engineer and the first foreigner to be hired by a Pennsylvanian aerospace manufacturer. “Many employees had been there for years when, suddenly, this girl with a thick accent turned up and told them what to do,” she recalls. Dubey is working on her accent by watching tons of sitcoms, and to fit in she shortens her first name from Sharmistha to Shar.</p> <p>&nbsp;</p> <p>At that time, she was dating a former co-worker from India who had also moved to the US. “It was the first time someone married for love in my family,” she says.</p> <p>&nbsp;</p> <p>When Mandy Ginsberg called her in 2006 looking for someone to manage Chemistry, the second brand launched by to compete with eHarmony, Dubey had never laid a finger on a dating website. And yet she decided to apply. She got along well with Ginsberg, whom she had met while working for a supply chain software producer. They formed a duo that would last for almost 15 years and transform the company. “It became obvious that Shar had some sort of magical comprehension of monetisation and of its balance with user experience,” says Ginsberg. She chose Dubey as president when she became CEO in 2017.</p> <p>&nbsp;</p> <p>The Texan group transformed itself to address people of every age and demographic category. “The idea is to exploit the users’ earnings for a long time: young people start with Tinder, move on to Hinge, then Plenty of Fish, then Match and OurTime,” says Jason Helfstein, senior analyst at Oppenheimer &amp; Co. The company also rides on the rise in divorces: “The average relationship lasts eight years in the US and in Europe. If our apps work out the first time, the user will come back,” says Match Group Americas CEO Amarnath Thombre, who also graduated from IIT.</p> <p>&nbsp;</p> <p>In 1999, Match Group was bought by the holding company IAC. Ten years later, Match Group bought People Media and its 27 targeted dating websites. These brands are now outdated but the segmentation strategy still prevails on the US market. In the last four years, Match Group created BLK for African Americans, Chispa for Latinos and Upward for Christians. Match then bought the French group Meetic, which allowed them to extend their markets to Europe, and OkCupid, a popular startup among hipsters.</p> <p>&nbsp;</p> <p>“The first generation of apps was closer to the way arranged marriages work, that is you think you know what you’re looking for,” says Dubey. “But it often turns out to be wrong: on our platforms we have the advantage to see that even if you say you like tall men, that is not such an important criteria for you.”</p> <p>&nbsp;</p> <p>While Match, Chemistry and Meetic required payment to send a message, OkCupid and Plenty of Fish (bought in 2015) innovate with a freemium model: sending messages is free, but users have to pay for certain features. This model boosts these websites, notably for young people, erasing little by little the “loser” image associated with using them.</p> <p>&nbsp;</p> <p>“The internet has become the most popular way for heterosexual couples to meet in the US, even ranking better than mutual friends for the first time in 2013,” says sociologist Michael Rosenfeld. The use of dating apps has increased since. “When I first started at, 3 per cent of marriages in the US were born from an online encounter. Today it’s 40 per cent,” says Hesam Hosseini, CEO, Match and Match Affnity.</p> <p>&nbsp;</p> <p>The use of dating websites is also developing outside of the west: Japan became Match Group’s second biggest market after the US two years ago, after the acquisition of the wedding-focused app Pairs. “Japan has a declining population and a Loneliness Ministry, to such an extent that the government is beginning to consider dating apps as a solution,” says Match Group Asia CEO Alexandre Lubot.</p> <p>&nbsp;</p> <p>And the pandemic sped up this process: “In the post-Covid world, the places where you’d meet people physically have disappeared. After #MeToo, it has also become harder to meet people at university and at the workplace,” says Dubey.</p> <p>&nbsp;</p> <p>Jessica Pidoux, a postdoctoral researcher who wrote a thesis about dating apps, says that the Tinder mindset is exporting itself beyond smartphones. “People evaluate others in an algorithmic manner, saying whether they like someone or not very early on,” she says.</p> <p>&nbsp;</p> <p>Tinder did change it all. The app was created in February 2012 by entrepreneur Sean Rad and the developer Joe Muñoz. It was free and inspired by Grindr, the 2009 dating app for LGBTQIA+ men which switched complex questionnaires for a higher focus on pictures. But Tinder added the “double opt-in”, the need to mutually swipe right to start a conversation. “Tinder’s big input is that it solves the problem of rejection,” says Dubey.</p> <p>&nbsp;</p> <p>A decade later, Tinder has become Match Group’s driving force: the app generates 55 per cent of its sales revenue against 31 per cent five years ago, thanks to a threefold increase in the number of users—now more than 10 millions.</p> <p>&nbsp;</p> <p>Dubey strongly contributed to the transformation of the startup into a cash machine. In 2017, she travelled every week to Los Angeles to launch Tinder Gold, a paid feature that allows users to know who swiped right on you, inspired by Who Likes You on OkCupid. “This company knows how to take a brand’s best recipes over to another one,” says Helfstein. Since 2015, Tinder had already limited free swipes to 50 a day per person, offering a paid subscription to those who would want to go beyond that limit, and the possibility to buy 30-minute profile “boosters”.</p> <p>&nbsp;</p> <p>But Tinder Gold takes monetisation to the next level, with prices of over 30 euros a month. The company launched an even more expensive formula last year and does not plan on stopping there. “Most of the monetised functionalities that we have created until now aim to render male users’ experience more efficient, since they do not want to be restrained by a certain number of swipes,” admits Dubey. “One of the things we are working on is finding what we can offer to make women pay, like getting a better control of who they see and who can see them.”</p> <p>&nbsp;</p> <p>Romantic people are protesting against this transformation of the quest for love into a supermarket where everyone is pitted against thousands of others. And many users feel like the algorithm puts them at a disadvantage. In 2019, journalist Judith Duportail found a patent mentioning a “desirability score”: if someone with many likes swipes right on your profile, you will get more visibility. Tinder assures it doesn’t use this system anymore, but has never explained what it replaced it with.</p> <p>&nbsp;</p> <p>“Algorithms are not very smart, but they improve with the time you spend on the app, and what you do on it. On Hinge, if you keep liking pictures of people in nature, we will deduce that you are more attracted to this kind of people,” says Thombre. Hinge is Match Group’s new gem. Dubey says it is “about to become the second biggest dating app in the world in a few years”.</p> <p>&nbsp;</p> <p>Thombre orchestrated the buyout of Hinge in 2017. Here, people who are interested in someone can only contact them by giving short answers to three questions or liking their pictures, so they can break the ice more easily. Hinge only exists in English for now, but the platform counts 8 lakh users and its sales revenue increased sixfold in three years.</p> <p>&nbsp;</p> <p>Newcomers in the dating app market are “limited by the more important companies’ possibility to patent popular functionalities,” says lawyer Evan Michel Gilbert. Before Match Group tried to buy out Bumble, the company had sued its rival for infringing their “swiping” patent. They also sued Muzmatch, a dating app for Muslims, for the same reason, as well as for also using “match” in their name.</p> <p>&nbsp;</p> <p>“We only sue other companies to preserve our brand and our patents,” says Dubey. She prefers talking about her efforts to remain at the forefront of innovation, her new mission being to “make sure users do not pick someone merely because of a picture”.</p> <p>&nbsp;</p> <p>Last October, she launched Tinder Explore, a tab giving access to interactive experiences. Last year, she also bought Hyperconnect, a Korean company with a strong interest in the metaverse. “They launched a beta experience in Seoul, Single Town, in which your avatar can go to clubs or to the beach and make unexpected encounters,” says Dubey.</p> <p>&nbsp;</p> <p>Flirting may have disappeared in real life, but Match Group is desperately seeking to revive its appeal.</p> Sat Jul 30 16:12:05 IST 2022 how-myra-saad-and-brian-mccarty-use-art-to-heal-children-in-war-affected-areas <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Myra Saad was born when her country, Lebanon, was in turmoil. “We lived amid conflict, with fear of bombs and tanks and shootings,” says Saad. Today, she is helping children affected by war with art therapy. “It can heal the trauma that generations have felt and also promote empathy,” she says. “Those are the best ways to prevent another war.”</p> <p>&nbsp;</p> <p>Saad—who holds an MA in expressive therapies with a specialisation in art therapy and mental health counselling from Lesley University in Cambridge, Massachusetts—first came in touch with California-based photo artist Brian McCarty in 2014. The latter had been documenting the stories of children from war zones through his toy photography for a few years. Since then, the two have collaborated to heal war-affected children and have helped articulate their stories. “The idea of working with children from conflict zones and collaborating with them through an art-based process for developing a photo series germinated after I made a trip to Croatia in 1996. It was in the aftermath of the Croatian war of independence,” says McCarty. “[I realised that] it is important to make people share their stories with their children, with the next generation, to stop the cycle of violence. Over the next 15 years, I learned about art therapy and play therapy, and formulated a project to gather the stories of children and articulate them through locally found toys.”</p> <p>&nbsp;</p> <p>McCarty worked in the toy industry, with top brands like Mattel, Hasbro, Disney and Nickelodeon, and simultaneously fine-tuned his war idea taking guidance from art therapy experts like Judy Rubin and Julia Byers. In 2011, he started the 'War Toys' series. Three years later, he met Saad, who, in McCarty’s own words, had a “unique skill-set” for healing children.</p> <p>&nbsp;</p> <p>“Over the past eight years, Saad and I have developed a methodology that works,” says McCarty. “And we have travelled to war-torn countries like Iraq and worked with children who have been displaced. We meet them at UNHCR (United Nations High Commissioner for Refugees) camps or schools or whatever had been set up to support them. We assemble groups of 10 to 15 children, and conduct what Myra calls ‘art-based interviews’. However, we are careful not to call it ‘art therapy’. Therapy happens over multiple sessions over multiple visits. And that is not something we have had the budget or resources to do very often.”</p> <p>&nbsp;</p> <p>Both Saad and McCarty say that the stories they would hear in these interviews were just heart-breaking. “There are rapes, murders, children being forced to watch people being stoned to death, all these things,” he says. “But even though they share these traumatic experiences, they leave the sessions with smiles and hugs and it just blows my mind—and that is the power of art. Also, it is the power of someone who knows and understands how to manage these emotions responsibly.”</p> <p>&nbsp;</p> <p>McCarty says that a regular art-based interview session lasts over three hours. “The first part is just to get the children to relax and feel safe and help them open up,” he says. “This part will have a lot of physical activities, play activities and some art activities. We then move on to the actual interview part. It is designed in such a way that the children are asked to draw a story from their life that they want to share with the world. It need not be necessarily about war or conflict. Sometimes we get to hear stories of a cat that comes by the window at night or a child's sister taking a toy truck or whatever. But nine out of ten times, we get to hear war-related stories. In the last part of the session, Myra brings the children out of that [traumatic] space.”</p> <p>&nbsp;</p> <p>Saad points out that this last session is crucial. “We did not want to meet the children, open up their wounds and leave,” she says. “We use art therapy approaches to empower them. The children get the chance to share their stories and be listened to in a safe environment.”</p> <p>&nbsp;</p> <p>McCarty recalled the story of an Iraqi girl who came to a session in 2017. “She came home after spending a day at her grandmother’s place to discover that her father, mother and sister had been executed by Islamic State,” he says. “She even drew very specifically where each one had been shot. She drew herself crying at the sight of them. Myra then brought her out from that traumatic mind space, and even after sharing the drawing, she had a beautiful smile on her face. When asked what she wanted to become in the future, she said she wanted to be Myra. She left the session with other children, but then she returned to give her a hug.”</p> <p>&nbsp;</p> <p>In 2019, McCarty founded NGO War Toys to “give future generations a better chance at peace and to envision a cultural paradigm shift in how we think about war as a society and how we encourage our children to play.”</p> <p>&nbsp;</p> <p>Currently, the NGO is lending support to First Aid of the Soul, a grassroots organisation founded by Ukrainian art therapist Nathalie Robelot. It is also building its programme to help children in conflict zones of Ukraine. “The challenge has been finding actual Ukrainian-speaking art therapists; there just are not a lot,” says McCarty. Untrained and unequipped therapists can cause more harm than good, he says. “This is a big problem... there is a lack of legitimacy and accreditation in many places,” he says, “and too many folks just call themselves art therapists.”</p> Fri Jun 24 17:50:20 IST 2022 scientific-studies-are-unravelling-the-link-between-art-and-healing <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>When Aleena Ali and Tanushree Sangma first came to her with an “art cart”, five-year-old Tushara Gaur showed little interest. But when Ali started taking out items from the cart and asked the little one to choose, Tushara's face lit up with a beautiful smile; she pointed to a water-colour brush.</p> <p>&nbsp;</p> <p>Tushara has blood cancer, and has spent most of the last nine months in various hospitals. She is currently an in-patient at the Fortis Memorial Research Institute (FMRI), Gurugram.</p> <p>&nbsp;</p> <p>Both Ali and Sangma, expressive art therapists, encouraged her parents to join Tushara. The mother sat next to her on the hospital bed, and the duo started drawing. The mood in the room changed. Sangma tied balloons to the IV stand and Ali introduced a DIY clay extruder. Her effort to shoot clay from it made Tushara laugh. By the time they left, the therapists had built a rapport—and thereby begun a therapeutic relationship—with Tushara. Through the session, the child had not spoken a word. But she did communicate through non-verbal ways and “art”.</p> <p>&nbsp;</p> <p>There is no general agreed-upon definition of the term “art”. Russian writer Leo Tolstoy called it an indirect means of communication between people. Some others say it represents the expression of thoughts, emotions, intuitions and desires. “When you are creating art, you are freeing yourself,” says Bose Krishnamachari, painter, curator and co-founder of the Kochi Biennale Foundation. “As an artist, I would say that when I am working, I am in my space. Being yourself is one of the most beautiful things.”</p> <p>&nbsp;</p> <p>For thousands of years, humans have used idols, charms, sacred symbols, chants and music in healing rituals. Professional “art therapy”, though, was only established in the mid-20th century. A unique therapeutic approach, it incorporated elements of movement, music, visual art, theatre, poetry and psychodrama in healing. It started as a way to treat veterans of the world wars who were suffering from post-traumatic stress disorder and to help children and teens with special needs.</p> <p>&nbsp;</p> <p><b>What is art therapy?</b></p> <p>Art therapy is essentially an umbrella term we use to define different art modalities or expressive capacities,” says Aditi Kaul, who leads the expressive arts therapy programme at FMRI. “The idea is not that a person [undergoing therapy] should be good at a particular art form. He should just be able to use an art form as a language to express himself, process things and work through that to get to a place where he would feel the healing.”</p> <p>&nbsp;</p> <p>Dr Christianne Strang, an art therapist with over 30 years of experience and a professor at the University of Alabama at Birmingham, says anybody can use art for healing, but when it comes to art therapy, there are specific treatment goals. “And those goals are arrived at with the client—art therapy is not something we do ‘to a client’, but something we do ‘with a client' in a therapeutic relationship,” she says. “And then the art materials in the process become part of that relationship.”</p> <p>&nbsp;</p> <p>Dr Samir Parikh, director of the department of mental health and behavioural sciences, Fortis Healthcare, says that art therapy is used to treat a range of mental health issues such as depression, substance abuse, anxiety and schizophrenia. However, the scope of art therapy goes beyond mental health care, he says. “We provide art therapy sessions to all children and teens admitted at Fortis,” he says. “We also provide art-based sessions to patients who are suffering from conditions like cancer, trauma, dementia and stroke.”</p> <p>&nbsp;</p> <p>He adds that art therapy should be used to supplement conventional methods of treatment. “For example, in a stroke case, the patient might be receiving physiotherapy and counselling,” he says. “Along with that, he may receive an art therapy session to improve his motor skills, cognitive functioning and movement. We also use art therapy sessions and workshops to facilitate self-discovery and growth.”</p> <p>&nbsp;</p> <p><b>The emergence of modern art therapy</b></p> <p>British artist Adrian Hill is said to have coined the term “art therapy” in 1941. While undergoing treatment for tuberculosis at King Edward VII sanatorium in Sussex, Hill had started drawing to pass the time. He found that the process improved his mood and aided in his recovery. The war painter then started exploring how he could help other patients with this discovery. “Hill published his theories in his book Art Versus Illness, which later was mandated for nursing staff in hospital units,” says Kaul. Hill also found that merely looking at art had some positive effect, and asked hospitals to hang artwork on their walls. “The hospitals were sad, white, dull places,” says Kaul. “Thanks to Hill, colour exists in hospitals across the world now.”</p> <p>&nbsp;</p> <p>Rishi Taneja, 35, found the healing power of art just like Hill did—accidentally. “I have always been an artist; in fact, I went to an art school called Camberwell College of Arts in London,” says the Delhi-based fashion photographer. “But the first time I experienced the true value of art is when I dealt with grief.”</p> <p>&nbsp;</p> <p>Taneja lost his mother in 2010 and his father the next year. “Though I have been on a lot of medication for anxiety and depression ever since, and attended many therapy sessions, painting has helped the most in terms of dealing with grief,” he says.</p> <p>&nbsp;</p> <p>American psychoanalyst Margaret Naumburg played a crucial role in developing art as a therapeutic modality backed by scientific study. Between 1941 and 1947, she worked at the New York State Psychiatric Institute and published a series of case studies in which she used art for diagnosis and therapy. “Naumburg brought together psychotherapeutic concepts and visual art and a little bit of movement [therapy] and gave it that art therapy stamp,” says Kaul. A major question art therapists faced was how to decide the appropriate media for their patients, and under what circumstances an art-based activity using that media could be therapeutic. The answer came in 1978, in the form of a theoretical framework called expressive therapies continuum (ETC). Developed by art therapists Sandra Kagin and Vija Lusebrink, ETC helped therapists identify which part of the brain and which brain functions were affected, and to choose a therapy plan accordingly. “ETC looks at the neuroscientific aspects of art therapy,” says Kaul. “For a long time, it was believed that the brain remained plastic only during childhood and adolescence. But research shows that the brain has neuroplasticity (the ability of neural networks in the brain to change) throughout lifetime. So, the brain decides what pathways and connections need strengthening, and which ones do not. New studies show that people engage both sides of the brain when they use creativity and engage in an art-based activity. So, creativity can be used to develop new neural pathways and to replace or bypass problematic neural pathways in the brain.”</p> <p>&nbsp;</p> <p>Girija Kaimal, assistant dean for Special Research Initiatives, Drexel University in Pennsylvania, says the human brain is like a prediction machine. “Every day, we are taking in information from our senses, our memories, and from things we learn, know and have experienced to prepare for an uncertain future,” she says. “Art helps us try out different scenarios for the future in creative ways. In the process, different neurobiological systems come into play.”</p> <p>&nbsp;</p> <p>Being creative, she says, is a natural state as the brain is constantly figuring out solutions to problems that inevitably come to us every day. “Now the tricky thing is if we overestimate negative outcomes, we get things like anxiety,” she says. “If we see no hope for the future, we get depressed. If our imagination sort of loses touch with reality, we go to psychosis or schizophrenia. So, neurobiologically, when we create, we activate reward pathways in our brain. Reward pathways are dopaminergic pathways. Dopamine is released when we create something that makes us feel good. It is activated when we use our motor systems as well as our imagination system.”</p> <p>&nbsp;</p> <p>Kaimal adds that when we communicate our inner state in an art therapy session with a compassionate and non-judgmental therapist, our stress level goes down. “You will see levels of [stress hormone] cortisol going down,” she says. “Our studies have shown that.”</p> <p>&nbsp;</p> <p>Also, as per a study published in the Journal of the American Medical Association in 2020, art therapy is found to have produced better outcomes in treating PTSD among military servicemen compared with popular verbal psychotherapies.</p> <p>&nbsp;</p> <p><b>Common therapy techniques</b></p> <p>Kaul and Sangma performed a mock “mirroring game”—a common exercise in dance/movement therapy and drama therapy—for THE WEEK team at Sukoon Health, a psychiatric hospital governed by FMRI. It started with Sangma raising her right hand and moving her body to her right. Kaul imitated her. Then Sangma moved to the left. Kaul did, too. Soon, their moves became like a dance. This was followed by a discussion about their emotional states while doing the “dance”.</p> <p>&nbsp;</p> <p>The mirroring game, say experts, enhances communication, empathy and understanding of others’ emotional intentions. Kaul recalled the case of a couple. “They were struggling with their relationship,” she says. “Their core issue was that they could not consummate their marriage for three years. There was a lack of communication. We initially tried conventional talk therapies. But none of them worked. So we decided to employ dance movement therapy techniques like mirroring, in addition to some visual art techniques. This was highly effective in making them understand each other’s patterns and mental states. Communication also became smoother. Their sessions lasted for around nine months and now they have a baby girl.”</p> <p>&nbsp;</p> <p>Arts therapists use various techniques like the mirror game to create treatment protocols best suited for their patients. To deal with emotional issues like anger, therapists may ask clients to make a “stress painting” by choosing the colours representing their stress, design a postcard that the patient will never send, make sock puppets to act out stressful situations or put together a journal. Likewise, for patients in distress, one of the most commonly used techniques is to ask the patients to draw a “safe space” and place the people and things that make them comfortable in it.</p> <p>&nbsp;</p> <p>Art therapy techniques are also used together with cognitive behavioural therapy to treat victims of sexual abuse. Expressive arts therapist Avantika Malhautra spoke of a case where she worked with a young woman who had body image issues and low self-esteem. “Because of a history of sexual abuse, she had not accessed certain parts of her body, as she felt numbness in those parts,” says Malhautra. “Over four months, and after several sessions of working together, art, movement and drama techniques became a container for her to express her true feelings, which she had not felt safe to express earlier. This created a shift in her and brought back a sense of agency and belonging to her body.”</p> <p>&nbsp;</p> <p><b>Art-based therapies for different outcomes</b></p> <p>Therapists say that play therapies are effective with children. A trained therapist can use this time to gain insight into a child’s problems and can help him deal with unresolved trauma. “I have worked with children who experienced a lot of guilt, anger and confusion on the separation of their parents,” says Malhautra. “I found that creating a story using angry or sad masks, or projecting their home life through drawing or clay using metaphors of animals was helpful in self-expression and asking for what they need.”</p> <p>&nbsp;</p> <p>There is growing awareness that art-based therapies can supplement cancer care, too. “Cancer is a physical illness, of course. But it is one of those unique illnesses that really forces people to reevaluate life,” says Kaimal. “So when people engage in artistic practices, they often talk about life and getting a second chance and doing things they might not have thought of.”</p> <p>&nbsp;</p> <p>A 2017 study conducted by Kaimal’s team, studying 22 cancer patients, found that participants felt more positive and more confident after they had 45-minute sessions of colouring or free art-making with an art therapist.</p> <p>&nbsp;</p> <p>Art can also help athletes, says mental conditioning and peak performance coach Dr Swaroop Savanur. “Athletes are generally goal-oriented people,” he says. “Therefore, their mind is always focused on goals and performance. And, that can trigger a lot of thoughts that can affect their focus. So, the principle for helping them is to be calmer, to be in the present. Art can help them get away from these thoughts and be mindful.”</p> <p>&nbsp;</p> <p>Savanur, who has been the mental conditioning coach for the IPL team Punjab Kings, says he uses art mainly in team-building sessions. “Last year, when our players were in quarantine, I had used art to make them more creative. I built some kind of team-building activity around it, which they enjoyed.”</p> <p>&nbsp;</p> <p>Art can also help players from different countries and backgrounds communicate. “These team-building activities are created to ensure that they can understand each other not just as a player, but as a person,” says Savanur.</p> <p>&nbsp;</p> <p>Sudha Meiyappan, who founded the NGO Parivartan For Parkinson’s Foundation, says that art-based therapies are effective in improving the quality of life of those affected with PD. “Parkinson’s disease is caused by reduction in dopamine secretion,” she says. “The disease affects the motor skills from the beginning itself. As the disease progresses, it will become worse. The reduction in dopamine would affect the patient’s mental wellbeing also. It is known to cause depression in over 50 per cent of population affected with PD. It is proven that art practices are helpful not only in dealing with the reduction in dopamine levels, but also in improving the cognitive and motor skills of patients. That’s why we are conducting art-based sessions.”</p> <p>&nbsp;</p> <p>S. Sudandra Babu, 62, a PD patient, agrees. “The disease started in 2018 with tremors in the hands,” he says. “After that, I started feeling anxiety and dizziness. I started attending the art sessions in Parivartan last year. I felt comfortable while drawing in the sessions. In my childhood, I used to draw pictures. After around 50 years I am back into drawing.” Babu says that it is not easy for him to hold the drawing materials tight, or to draw continuously. But drawing for three to four hours is part of his daily routine now. “Every day, it is a daunting task to start drawing. I have to wait till the tremor stops,” says Babu. “But still, I will do it. Because I feel good when I draw.”</p> <p>&nbsp;</p> <p>Smita Vinchurkar, 46, a Mumbai-based photographer, says that she used to think of art-based therapeutic intervention as a sham. But her own experience, specifically after she started taking pottery lessons, made her a believer. “I lost my job during the pandemic,” she says. “And, I was affected with a lot of negative feelings. That is when I decided to attend a one-day trial session at a pottery studio. I found that the tactile experience of pottery was meditative. It also connected me to my childhood. It gave me a new perspective in my life.” She now wants art education to be made compulsory in schools as it will help children be better equipped to cope with stressful situations in future. “Art,” she says, “is for everyone; art heals.”</p> <p>&nbsp;</p> <p>Some names changed on request and for privacy</p> Sun Jun 26 18:03:31 IST 2022 sight-support <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>A BENGALURU-BASED</b> software solutions company and an NGO are offering what is perhaps the best solution so far for the visually challenged in India. Smart Health Global, led by IIT Kanpur alumnus Ramu Muthangi, and Vision Aid have come out with Smart Vision Glasses (SVGs) customised for Indian users.</p> <p>&nbsp;</p> <p>These spectacles are loaded with Artificial Intelligence aids—camera and sensors, and software to translate these visual inputs into audio ones to help the user ‘see’ what is immediately around her.</p> <p>&nbsp;</p> <p>The easy-to-use spectacles have a small panel, the size of a small pen drive on the side, with Braille-coded options. The user simply needs to press for the option she wishes to use. For instance, if she opts for ‘things around me’, the spectacles scan all around and give inputs on what the immediate surrounding is like. It thus makes for a good mobility assistant, as it alerts the user about obstacles ahead.</p> <p>&nbsp;</p> <p>The glasses also have a face recognition feature, by which over a hundred faces can be stored in its memory. So the next time a known face is before the user, she will get the voice input about it.</p> <p>&nbsp;</p> <p>The reading assistant feature helps the user ‘read’. She has to bring the page near the camera, which takes a picture and then reads out the text, even instructing the user to go to the next page at the end of the text.</p> <p>&nbsp;</p> <p>Another interesting feature is the helpline; pressing this option connects the user to the Smart Health Global team. Thus, it gives the user more autonomy; she does not have to depend on another person for simple troubleshooting. The spectacles can be connected to a smartphone via an app.</p> <p>&nbsp;</p> <p>Sonia Srivastava, assistant manager, low vision services at Dr Shroff's Charity Eye Hospital, said that the device, which was being released through the manufacturer's partner hospitals, would be a game-changer for the visually challenged in India. “We have never had such a device,” she said. “The smart glasses from the west are exorbitantly expensive, costing several lakhs of rupees (SVGs cost a little above Rs25,000). Also, their voiceovers were in foreign accents, which were difficult for Indian users to understand. These SVGs are adapted for Indian languages, whether it is reading text in various Indian scripts, or whether it is in the ‘speaking out’, which is again in an Indian accent.”</p> Sun May 29 12:04:01 IST 2022 mind-the-rehab-gap <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>VISUALLY IMPAIRED</b> persons, whether from birth or those who lost sight later in life, can lead extremely productive and independent lives, given the right training and assimilation into the mainstream, says Dr Umang Mathur, executive director, Dr Shroff's Charity Eye Hospital.</p> <p>&nbsp;</p> <p>While there are traditional ways of using audio and tactile inputs to help “see”, artificial intelligence solutions today provide game-changing opportunities. However, access to these aids and training are important.</p> <p>&nbsp;</p> <p>Mathur recalled the case of a patient who had congenital cataract. His cataracts were removed and he was discharged from hospital. However, since the child had lost out on early schooling, no school was ready to enrol him at a later stage. He ended up as a manual labourer. “We came to know about this when he reported to hospital with some other problem,” said Mathur. The rehabilitation team then intervened, and helped the boy out. He later appeared for his board exams through the National Institute of Open Schooling.</p> <p>On the other hand, Mathur cites the case of a visually challenged man who is running a successful travel agency, not just making a good living for himself but also providing employment to around a dozen people.</p> <p>&nbsp;</p> <p>Smartphones are an accessible aid to almost everyone now. The TalkBack feature on Android (VoiceOver on iPhone) allows users to navigate their way through the phone's various features and apps with voice assistance. Smartphones, when connected to other devices like Smart Vision Glasses (see page 32), can bring about a very high level of independence to the user. Audiobooks and tactile models can complement Braille in providing a rich educational experience to children.</p> <p>&nbsp;</p> <p>Today, technology is not that expensive. The missing link is the dearth of trainers and rehabilitation experts who will identify a person's need and also help that person get assimilated into the mainstream. Most eye experts, for instance, are concentrated in the bigger metro cities. Patients often visit these centres only when their condition has deteriorated rather substantially, and then, there is not much that can be done by way of mitigation.</p> <p>&nbsp;</p> <p>Dr Sima Das, head of oculoplasty and oncology services at the hospital, says she sees so many cases of eye tumours among children at a stage when the disease has already metastasised, and it is a matter of saving the life, not the organ. In the west, she says, this condition is detected so early that in most cases it is treated before the vision gets impaired.</p> Fri May 27 16:15:34 IST 2022 life-is-beautiful <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>As Khatera Hashmi smoothed the creases from her new salwar kameez—a confection in red and gold that she got for Eid—and arranged her daughter on her lap for a family portrait, a small frown appeared on her smooth brow. “I had told you, hadn't I? That you should wear a good dress, too, we will be having our pictures taken,” she said. “But you don't listen to me.”</p> <p>&nbsp;</p> <p>Her husband, Mohammad Nabi, shrugged helplessly. “You are looking pretty, little Bahar has a new dress on, why bother about how I am looking?” replied Nabi.</p> <p>&nbsp;</p> <p>Khatera, however, was not pacified. She knows he is wearing a faded tee and shabby shorts—his home clothes. She has smelt and felt them. Nabi looked at us sheepishly, as his wife gave him that wait-till-we-get-home expression.</p> <p>&nbsp;</p> <p>Khatera is very image-conscious. How she appears to the world is very important for her, even though she can no longer see the world.</p> <p>&nbsp;</p> <p>India came to know of Khatera's existence when she came to Delhi in 2020, a living testimony of the Taliban's brutality. The young woman in her thirties, who only months earlier had finished her training and joined the police force in Ghazni town, had immediately come on the Taliban's radar. At that time, the Taliban was a guerrilla force, the US troops were still in Afghanistan and Ashraf Ghani was heading the country.</p> <p>&nbsp;</p> <p>They threatened her against continuing her job—it was not right for a woman to be working. The threats were dire enough for her superiors to suggest she take a transfer to Kabul. Nabi, who owned a cloth shop in the market, headed to Kabul, looking for an accommodation to rent. “It was the afternoon of June 6, 2020. I was walking back from my shift at the police station, which was very close to my house,” recounted Khatera in perfect Hindi. “Suddenly, three men emerged from a narrow lane—two were on a motorcycle, one was on foot. They began hitting me and the scarves they wore around their faces loosened, even as I fell to the ground. I had seen their faces.” That was the last thing Khatera ever saw. She blacked out in pain. The men, ostensibly afraid they would be identified, simply gouged out her eyes with some sharp weapon—no one knows what it was.</p> <p>&nbsp;</p> <p>“I was reading the namaz when I got a call from Khatera's friend, saying she was attacked,” recalled Nabi, his Hindi heavily accented and liberally sprinkled with Pashto. “I thought it was a joke and went back to reading the namaz. But then I began feeling uneasy and I called her again. And my world crashed around me.”</p> <p>&nbsp;</p> <p>Khatera was shunted from hospitals in Ghazni to Kabul. She had injuries all over, but her face was the most battered. “I didn't think she would survive,” said Nabi. She did, however. And as she recovered, her family dreaded telling her the truth. Around 12 days later, when her injuries were healing, she realised that as the bandage slipped from her eyes, her lids seemed stuck together—they weren't opening. “I realised I couldn't see,” she recalled that moment in a surprisingly composed voice. “Vo din mere liye bahut sakth tha [it was a very difficult day for me].”</p> <p>&nbsp;</p> <p>What Khatera was not to know was that even her eyelids were mutilated. It has taken several painstaking surgeries by the doctors at Dr Shroff’s Charity Eye Hospital in Delhi's Daryaganj to bring back the beauty of her face. Only, the light they haven't been able to restore.</p> <p>&nbsp;</p> <p>However, they have taught her to “see” her world in so many different ways. “With the right rehabilitation, a blind person can be extremely productive,” explained Umang Mathur, executive director of the hospital. Mathur has a soft spot for Afghanistan—he did the end part of his schooling (class nine and ten) there. That was in the 1980s, when Afghanistan, under Russian occupation, was a different world—a place where women sported haircuts and where cabarets were happening.</p> <p>&nbsp;</p> <p>Khatera resumed her story. “I was plunged into the world of darkness, but there was more trouble awaiting,” she said. Her story was being told and retold in Kabul, and this brought her on the Taliban's radar again. Amid all the bleakness, however, there was one more development. Doctors discovered she was pregnant. “I wanted to kill myself so many times since the attack,” she said. “But when I came to know I was going to have a child, I got fresh hope.”</p> <p>&nbsp;</p> <p>Hope has been a shifty companion for Khatera. It has kept her going during the worst times, but it has also crashed the world around her as many times. Hope then took the form of an American charity worker—Stephanie K. Hanson—who came to know of her. Through charitable foundations Orbis and Seva, which work for eyesight restoration and rehabilitation of the blind, she reached out to Dr Shroff's hospital in India. “With the Taliban focusing on my case, even the government recommended we should go to India for treatment and safety,” said Khatera. Thus, Khatera came to India in December 2020, in the thick of lockdowns, leaving her home, perhaps, forever.</p> <p>&nbsp;</p> <p>India, for many Afghans, is a land of dreams. It is the solution to their problems. It brims over with possibilities. Khatera came over, clinging on to a hope that the miracle of vision would happen in India. “As of today, we can only do corneal transplants to restore vision. In her case, both the eyes had been mutilated,” explained Dr Sima Das, head of the hospital's oculoplasty and ocular oncology services. In the months before she was shifted to Delhi, the local doctors had anyway removed all the eye tissue. Mathur said that the practice these days was to retain as much of the original tissue, because, sometimes, despite the worst trauma, miracles happened. It could only be a perception of light and dark, but for a patient, even that small perception is a huge empowerment. “The Israeli doctors always recommend saving original tissue,” he explained, but added that ground realities are often very different, and doctors have to take on-the-spot decisions. In Khatera's case, the mutilation was so bad that she even required reconstructive surgery on the eye sockets.</p> <p>&nbsp;</p> <p>The months that followed were a series of surgeries and recoveries as doctors rebuilt her face. She even had hearing loss in one ear because of the injuries, which has been improved vastly.</p> <p>&nbsp;</p> <p>Khatera recalled the day when her last hope shattered. The technicians were taking her measurements for artificial eyes. “I knew then that this is my reality.” Khatera's new eyes may be sightless, but they are beautiful works of art, painstakingly hand-painted to replicate what her actual eyes must once have been like. She wears them proudly, they give her confidence in her looks. She “sees” things in different ways, however.</p> <p>&nbsp;</p> <p>Sonia Srivastava, assistant manager, low vision services, was the messiah who brought a new light to Khatera's life, guiding her through a rehabilitation process that helps her use hands, ears and nose as her new visual aids. The process is slow, often frustrating, but the results are game-changers. “I used to be so scared to be alone,” recalled Khatera. “I would not allow my husband to leave the room. I could not even turn on an electric switch. I used to be scared I would get an electric shock.”</p> <p>&nbsp;</p> <p>Nabi has loyally stood by her side, taking on every setback with a brave front, and rejoicing in every small progress. Blessed with a daughter last year, he has two demanding women to take care of. “He is also learning a lot,” said Khatera with a warm smile. “Initially, when he would go to the kitchen, he would pester me about how much salt to put, how long to stir a dish and so many other annoying questions. You should taste his cooking now. He makes such delicious chicken.” Nabi smiled shyly at the compliment.</p> <p>&nbsp;</p> <p>Theirs was a love match. Romance blooms even in the most forbidden environments. Khatera's father was a tailor; she did some sewing, too. She would often go to the market to purchase new material. Soon, the shopkeeper was as much an attraction as the latest bolts of textile, mostly imported from India. “I remember giving him my phone number, so that he could alert me when something new arrived,” said Khatera. Numbers exchanged, the romance bloomed further, till the couple got married four years ago. He has an earlier wife, and several children, all of whom have been left behind as they made their journey to India. “We always thought we would go back, or the family would come to meet,” said Nabi. But first there was Covid-19, then the Taliban takeover in Afghanistan. A reunion seems impossible in the foreseeable future, at least.</p> <p>&nbsp;</p> <p>The last two years have been trying on their relationship, but Khatera said it helped her “see” people through. “My husband did not give up hope,” she said. “My mother-in-law would nag him constantly to leave me—I was useless and blind. He did not give up on me.” Nabi tugged at his hair. “See all these whites, the last two years have brought them on. The day Khatera was attacked was the worst day of my life,” he said, an involuntary shiver passing over him. He has battled her suicidal thoughts, her struggles with re-learning every little thing, the endless visits to the hospital—it can be intimidating for the well-trained caregiver, let alone someone who has no experience and is himself battling loss at various fronts. But the day Khatera demanded he get a “big speaker” for her to listen to music, he knew that the darkest hour was past. “Such a big speaker she wants,” he said, spreading his hands theatrically. “She always wants loud music.”</p> <p>&nbsp;</p> <p>Khatera was born when her family lived as refugees in Pakistan, so she speaks and understands Hindi. Even on return to Ghazni, she spoke in Hindi and Urdu with her siblings, watched Bollywood films and listened to Hindi songs.</p> <p>&nbsp;</p> <p>She is back to humming songs as she manages the few chores she has learnt at home. I ask her to sing. She is shy. But we know there is music bubbling within her. Her husband urges her on with some suggestions. She has a choice of songs from Hindi and Pashto now, and she deliberates, before settling on a Hindi number. It is about loyalty and fidelity. As she began singing, her toddler daughter left the sliced cake she was eating, and listened to her mother in rapt attention. Nabi wore an indulgent look.</p> <p>&nbsp;</p> <p>There is a new spring in Khatera's life. Recently, she had started attending classes at the National Association for the Blind (NAB) centre in the city, thanks to Srivastava's interventions. “I was so hesitant initially,” she confessed. “I thought, ‘Others will see me spill food, or drop something, it will be so embarrassing’. Then I realised they, too, were sightless. They are also learning, like me.” Khatera has learnt to cook again. She can boil milk and make tea and instant noodles. “I spread my hands over the pot like this,” she says, gesturing with her hands over an imaginary pot. “The temperature changes tell me how far the boiling is progressing.” However, Nabi is lord of the kitchen. “Someone has to take care of Bahar, too,” they said.</p> <p>&nbsp;</p> <p>Khatera is happy she can do that part. “I can massage, bathe and change her clothes, too,” she said. “I like going with my husband to the market to buy new clothes for her.”</p> <p>&nbsp;</p> <p>NAB is opening up a whole new world of possibilities for her. Her impoverished living in Ghazni did not give her access to a smartphone, let alone a computer. At the centre here, she is learning to use a computer through voice commands. Srivastava is also teaching her to operate a smartphone with the help of voice commands. Once she is proficient, she will be equipped with a special set of spectacles. These spectacles will have cameras fitted on to them, and will be synced with the phone. They will be a navigation aid, conveying what is before her through voice messages. But the most interesting feature of these spectacles is that they will be able to do a face scan of the person before her. If that person's details match with the entries on her phone, the spectacles will recognise the person, and tell her who is approaching.</p> <p>&nbsp;</p> <p>Khatera always wanted to see India. “When I got my police job, I had told myself I will save for a trip to India,” she said. “I didn’t know I would be coming here like this. But I am glad I am in India. This is a wonderful place, the people are so good, and they work different miracles here.”</p> <p>&nbsp;</p> <p>The path ahead is not easy. She still has terrible headaches. There are more surgeries left to repair the damage around the eye orbits and she has only just started down the road of rehabilitation. At some point, Nabi has to think of getting some employment, too. They have got refugee cards, so at least they can stay here without worry. But as Bahar grows up, there will be newer cares to deal with.</p> <p>&nbsp;</p> <p>Khatera, though, has regained her zest for living, and for taking up challenges, with her love at her side. “Zindagi abhi achchi lagne lagi hai (life is looking good again),” she said.</p> Sun May 29 12:05:02 IST 2022 recurrent-fusion-genes-found-in-60-to-70-per-cent-of-prostate-cancers <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>Dr Arul Chinnaiyan</b> was awarded this year’s Sjoberg Prize in cancer research for establishing that the fusion gene is responsible for more than half the prostate cancer cases in the world. In an exclusive interview, Chinnaiyan talks about fusion gene and how it is going to help in treating prostate cancer. Excerpts:</p> <p>&nbsp;</p> <p><b>What is fusion gene?</b></p> <p>&nbsp;</p> <p>A fusion gene occurs when two genes, which normally reside in different parts of the genome, come together and get fused. The fusion of genes can initiate the development of cancers in which they are found.</p> <p>&nbsp;</p> <p><b>Why is it important in prostate cancer?</b></p> <p>&nbsp;</p> <p>It is important in prostate cancer because recurrent fusion genes are found in upwards of 60 to 70 per cent of prostate cancers. The most common gene fusion we discovered is called TMPRSS2:ERG, which is found in about 50 per cent of patients. These prostate cancer gene fusions are typically regulated by male hormones and cause increased levels of cancer driver genes. When recurrent gene fusions are discovered for a particular cancer type they are considered the molecular cause of the cancer. In addition, to serving as a therapeutic target in prostate cancer, these gene fusions are exquisitely specific for prostate cancer and thus can be used as diagnostic biomarkers.</p> <p>&nbsp;</p> <p><b>How is it going to help with diagnosis and treatment?</b></p> <p>&nbsp;</p> <p>The TMPRSS2: ERG gene fusion that we identified is an exquisitely specific biomarker of prostate cancer that can be detected in prostate needle biopsies and non-invasively in the urine of men with prostate cancer. In terms of treatment, the gene fusions in prostate cancer are under the control of male hormones, and blocking male hormones is already an established treatment for prostate cancer. Investigations are underway to target the gene fusion product directly or indirectly using a variety of approaches.</p> <p>&nbsp;</p> <p><b>Is it relevant in other cancers?</b></p> <p>&nbsp;</p> <p>Before the discovery of recurrent gene fusions in prostate cancer, it was thought that gene fusions and translocations were major drivers of liquid cancers and rare soft tissue tumours, but we had found these gene fusions in high prevalence in a common solid tumour, that being prostate cancer. After our discovery, a number of recurrent gene fusions were identified in subsets of other common solid tumours including lung cancer, breast cancer, and melanoma, among others. Perhaps, the most famous being the EML4-ALK gene fusion in lung cancer which can be directly targeted with drugs.</p> <p>&nbsp;</p> <p><b>What is your current focus of research?</b></p> <p>&nbsp;</p> <p>My research, in general, is focused on precision oncology with a heavy focus around prostate cancer. Since I was awarded this prize for the discovery of recurrent gene fusions in prostate cancer, I plan to use the funds from this award to fuel our efforts in therapeutically targeting the products of these gene fusions—which are oncogenic transcription factors. We will develop direct and indirect approaches to target oncogenic transcription factor in cancer.</p> <p><b>Dr Arul Chinnaiyan is director of the Michigan Centre for Translational Pathology and SP Hicks endowed professor of pathology and urology at the University of Michigan</b></p> Sun May 01 10:50:09 IST 2022 a-cancer-no-one-really-talks-about <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>John Smith is a healthy 56-year-old with no family history of cancer. Other than the occasional social drinking, he followed a healthy lifestyle, with regular exercise and a balanced diet. He never smoked.</p> <p>&nbsp;</p> <p>Lately, he started getting up at night to urinate. He did not make much of it. But when he started noticing blood in the urine, he consulted a urologist. Following the prostate examination, which showed a hard nodule, the urologist ordered a blood prostate specific antigen test (PSA) test. The blood test revealed that his PSA level was very high. After an ultrasound, the urologist recommended a prostate biopsy.</p> <p>&nbsp;</p> <p>A week later, Smith and his wife were sitting in the urologist’s office listening to alien terms like Gleason score, radical prostatectomy, radiation and hormonal blockade. The only word Smith heard and registered was prostate cancer.</p> <p>&nbsp;</p> <p>Prostate cancer is a disease in which malignant cells develop in the prostate gland. The prostate is a small walnut-shaped gland that is a part of the male reproductive system. It produces some of the fluid that is a part of the semen that transports sperm during ejaculation. It is located just below the bladder and in front of the rectum. “Testosterone, the male hormone, acts like a food for prostate cancer,” explains Dr Jatin Bhatia, consultant-radiation oncology, Jupiter Hospital, Pune. “Testosterone gets converted into various chemical forms, and the form that acts as a feeder for prostate cancer increases. Meanwhile, the other forms decrease.”</p> <p>&nbsp;</p> <p>Prostate cancer is the second most common cancer in men worldwide and the fourth most common cancer overall, after breast, lung and colorectal cancers. According to the World Health Organization, there were about 1.41 million newly diagnosed cases of prostate cancer in 2020.</p> <p>&nbsp;</p> <p>Prostate cancer is less prevalent in Asia. It is more common in North America, northwestern Europe, Australia and on the Caribbean islands. While more intensive prostate cancer screening in many of the developed countries could probably be the reason, lifestyle factors such as diet and exercise could also play a role. For instance, while Asian Americans have a lower risk of prostate cancer compared to white Americans, their risk is greater compared to men of similar ethnic backgrounds living in Asia.</p> <p>&nbsp;</p> <p>In India, one in every 10,000 men is diagnosed with prostate cancer, says Dr Ramakrishna Vangara, consultant-radiation oncologist, Manipal Hospitals, Vijayawada. According to data from national cancer registries, prostate is the second leading site of cancer among men in cities like Delhi, Kolkata and Pune and the third leading site of cancer in cities like Bengaluru and Mumbai. “With the increase in life expectancy, the incidence of prostate cancer has gone up phenomenally,” says Dr P.P. Singh, senior consultant and head of department of urology, PSRI Hospital, New Delhi.</p> <p>&nbsp;</p> <p>Despite the increase in numbers, prostate cancer remains one of the least talked about cancers, at least in India. “Hence, there remains a great deal of misinformation about the disease and sometimes the symptoms are attributed to something else,” says Dr Ramesh Kinha, vice president and head of lab operations at Medall Healthcare in Chennai.</p> <p>&nbsp;</p> <p>The exact aetiology of prostate cancer is unclear. Prostate cancer is caused when the DNA of a normal prostate cell starts to change. These gene changes can cause the cells to grow out of control and form tumours. Certain well-established risk factors for prostate cancer include advancing age, family history and certain genetic mutations.</p> <p>&nbsp;</p> <p>“As we know, any cancer is from chronic inflammation. Inflammation could be caused by prostatitis. It could be even related to viral infections,” says Dr B.S. Ajaikumar, chairman and CEO, HCG Group of Hospitals, Bengaluru. “Over a period of time, these can cause prostate cancer. It can also be ethnic-based. It is also an ageing process.”</p> <p>&nbsp;</p> <p>All men are at risk for prostate cancer, and the risk increases with age. About one in eight men will be diagnosed with prostate cancer during their lifetime in the US. Prostate cancer is rare in men younger than 40. About 60 per cent of cases are diagnosed in men 65 or older. The average age of men at the time of diagnosis is 66.</p> <p>&nbsp;</p> <p>Prostate cancer can run in families. Having a first-degree relative (father, brother) with prostate cancer more than doubles a man’s risk of developing this cancer. The risk is also higher if several family members have had a diagnosis. That is one reason why Salil N.S., 52, a senior law officer at South Western Railway headquarters in Hubli, was not shocked when he was diagnosed. “This was not something alarming to me as I had other members in the family who had it, like my paternal uncle who has been living with prostate cancer for more than 15 years without any treatment,” he says. “The only difference was that he was diagnosed after the age of 65, whereas my diagnosis was before I turned 51.”</p> <p>&nbsp;</p> <p>Several inherited gene mutations can also raise prostate cancer risk. Inherited mutations of the BRCA1 or BRCA2 genes, which are linked to an increased risk of breast and ovarian cancers, can also increase prostate cancer risk in men. Salil had a genetic profiling done, which indicated some mutations that could be the cause for his disease. Men with Lynch syndrome also have an increased risk for prostate cancer. Other contributing factors may include obesity, diet, hormones, smoking and alcohol consumption.</p> <p>&nbsp;</p> <p>In general, prostate cancer grows very slowly and often does not cause any symptoms in its early stages. Symptoms of prostate cancer include problems with urination like difficulty starting urination, slow or interrupted urinary stream, frequent urination, especially at night, difficulty emptying the bladder, painful or burning urination, blood in the urine or semen and painful ejaculation. Symptoms of a more advanced prostate cancer that has spread outside of the prostate gland may include pain in the hips, back, pelvis, chest or other areas if the cancer has spread to bones, swelling or weakness or numbness in the legs or feet, weight loss, fatigue and loss of bladder or bowel control.</p> <p>&nbsp;</p> <p>Prostate cancer often does not have any warning signs or symptoms. That is why screening and early detection are important. Cancer that is detected early, when it is still confined to the prostate gland, has the best chance for successful treatment.</p> <p>&nbsp;</p> <p>The two most commonly used tests to screen for prostate cancer are PSA test and the digital rectal exam (DRE). Prostate-specific antigen test is a blood test that measures PSA levels in a person’s blood. The possibility for a cancer diagnosis increases as the PSA level goes up. Prostate cancer is commonly detected by elevated levels of prostate-specific antigen (PSA &gt;4 ng/mL), says Dr Kirti Chadha, chief scientific officer and consultant onco-pathologist at Metropolis Healthcare, Mumbai. Men with a PSA level between 4 and 10 have about a 25 per cent chance of having prostate cancer. The chances of having prostate cancer are over 50 per cent if the PSA level is more than 10. But PSA levels alone cannot determine a cancer diagnosis. The PSA level could also be elevated due to other conditions that affect the prostate.</p> <p>&nbsp;</p> <p>While screening can identify cancer early, the benefits may not always outweigh the risks. Both the PSA and DRE tests can yield false negative (a person may actually have cancer) and false positive test results (a person may not actually have cancer) and can often lead to unnecessary tests, like a biopsy of the prostate, as well as cause anxiety and confusion.</p> <p>&nbsp;</p> <p>Screening can also lead to over-diagnosis and treatment. Since prostate cancer grows very slowly, some men with prostate cancer would never have had symptoms from their cancer nor would they die from it. Treatment of cancer that would never have caused a problem can lead to unnecessary complications from treatment like surgery and radiation, such as urinary incontinence, bowel problems and erectile dysfunction that can ruin a person’s quality of life, with no added benefit.</p> <p>&nbsp;</p> <p>“The US National Cancer Institute does not have screening recommendations for prostate cancer. Prostate cancer screening should be done only after discussions with one’s doctors of the uncertainties, risks and potential benefits of screening,” says Dr James L. Gulley, chief of genitourinary malignancies branch and director of medical oncology service, National Cancer Institute, US.</p> <p>&nbsp;</p> <p>If the PSA and DRE tests are abnormal, a prostate biopsy is often recommended. Prostate cancer is assigned a grade if the biopsy results show cancerous cells. The higher the grade the greater risk that the cancer is more likely to be aggressive and spread quickly.</p> <p>&nbsp;</p> <p>A Gleason score is the most common scale used to determine the grade of prostate cancer cells. The score ranges from 2 to 10. A Gleason score of 6 or less indicates a low-grade prostate cancer; a score of 7 indicates an intermediate-grade cancer; and scores from 8 to 10 indicate high-grade cancer.</p> <p>&nbsp;</p> <p>Once prostate cancer is diagnosed, other tests such as bone scan, ultrasound, CT scan, MRI or PET scans are done to determine if the cancer cells have spread to other parts of the body. This will help determine the stage of the cancer. Stage I means the cancer is confined to the prostate, while stage IV indicates the cancer may have spread to other areas of the body.</p> <p>&nbsp;</p> <p>Treatment options depend on several factors, including the patient’s age, Gleason score, stage of the cancer, how aggressive the cancer is, whether it is confined to the prostate or has spread to other parts of the body, overall health of the person, as well as the potential benefits vs side effects of the treatment.</p> <p>&nbsp;</p> <p>“We experience an unprecedented era of rapid new developments in the field of prostate cancer therapeutics, including radiopharmaceuticals/'theranostics' (using one radioactive drug to diagnose and another to deliver therapy), targeted therapies for selected patients (eg, PARP inhibitors) and novel immunotherapy strategies,” says Dr Petros Grivas, professor and clinical director, genitourinary cancers program, Fred Hutchinson Cancer Research Center, Seattle. “The advent of novel imaging, for eg Prostate Specific Membrane Antigen (PSMA) Imaging or fluciclovine/axumin PET, represents another great opportunity for more accurate prostate cancer staging. However, the clinical utility, impact and practical implications on decision making need to be better defined in clinical trials.”</p> <p>&nbsp;</p> <p>Early stage, low-grade prostate cancer, especially in older men, may need minimal or even no treatment. Doctors may recommend active surveillance or watchful waiting. Active surveillance involves closely monitoring the prostate cancer by performing PSA tests and prostate biopsies regularly and opting for treatment if the cancer grows or causes symptoms. In watchful waiting, fewer tests are done. The patient is treated only if he has any symptoms. This is usually recommended for older patients with low-grade tumour.</p> <p>&nbsp;</p> <p>But prostate cancer in younger patients and cancer that is aggressive need multidisciplinary treatments. A radical prostatectomy involves removing the prostate gland as well as some surrounding tissue and a few lymph nodes, an option for cancer that is confined to the prostate. Jitendra Yadav, 58, from Mumbai did a PSA test as part of his executive health check-up. Thanks to that, his cancer was detected early. “Also, the cancer was localised to prostate with no spread elsewhere in the body,” recalls Dr Shrikanth Atluri, uro-oncologist and robotic surgeon, Sir H.N. Reliance Foundation Hospital, Mumbai. “He was treated with robotic radical prostatectomy where the entire prostate was removed by surgery.” Yadav has been disease free for seven years.</p> <p>&nbsp;</p> <p>Novel surgical technologies such as laparoscopic and robotic surgeries to remove the prostate gland can potentially offer faster recovery and less complications. According to Dr Ashwin Tamhankar, consultant, uro-oncology and robotic surgery, Apollo Hospitals Navi Mumbai, surgeons prefer robotic surgery because it gives the advantage of better precision, control, 3D vision, negligible blood loss, quick recovery and early discharge.</p> <p>&nbsp;</p> <p>Another treatment option is radiation therapy, which uses high energy rays to kill the cancer. There are various types of radiation therapy approaches like external beam radiation therapy, wherein a patient lies on a table, and a machine moves around the body, directing radiation at the cancer cells; brachytherapy (internal radiation therapy) involving small radioactive seeds or pellets that are surgically placed into or next to the tumour to destroy the cancer cells; and proton beam radiation therapy—a type of high-energy, external radiation therapy that uses streams of protons to kill tumour cells. There have been rapid advances in radiation therapy, like the CyberKnife device, which results in less damage to surrounding tissues when compared to conventional radiotherapy.</p> <p>&nbsp;</p> <p>Apart from chemotherapy and immunotherapy, there are other therapies like cryotherapy, which uses extremely cold temperature to freeze and kill cancer cells, and hormone therapy that uses medications or surgery to reduce the levels of male hormones, called androgens, that fuel the growth of cancer cells in the body. There is also targeted drug therapy that uses drugs to target specific proteins that control the growth of the cancer cells. Bisphosphonate therapy has drugs, such as clodronate or zoledronate, that reduce bone disease when cancer has spread to the bones and reduce the risk of fractures. High-intensity focused ultrasound uses high-energy ultrasonic beams to kill cancer cells. And, photodynamic therapy uses a drug and a certain type of laser light to kill cancer cells.</p> <p>&nbsp;</p> <p>Since Salil’s cancer had spread to the lymph nodes, he had a combination of therapies at HCG Bengaluru. His PSA levels were brought under control with hormone therapy. “Initially, surgery was being planned,” he says. “However, the decision was left to an interdisciplinary medical board. As the disease had responded well to hormonal treatment, the medical board advised to go for radiotherapy through CyberKnife.” His treatment lasted six weeks. “There is no significant weakness or other problems related to this radiation therapy,” says Salil. “It is a painless outpatient process. I was at the hospital alone during the treatment; no bystanders were needed.” The PSMA PET scan was repeated after the treatment. The results were heartening. However, Salil is still on hormonal therapy. “The treatment, particularly the hormonal therapy, has adverse effects on sexual life. Apart from that, life goes on as normal,” says Salil.</p> <p>&nbsp;</p> <p>Novel treatments and technologies are changing the landscape of prostate cancer management. PARP inhibitors, such as Olaparib and rucaparib, are found to be highly effective in patients with genetic mutations such as BRCA1 and 2.</p> <p>&nbsp;</p> <p>“PSMA PET scans are one of the most exciting recent developments in prostate cancer,” says Dr Rahul Tendulkar, clinical director and residency program director for the department of radiation oncology, Cleveland Clinic, US. “By detecting early recurrences while they are small in size and number, we can offer patients treatment with stereotactic body radiation therapy and hopefully eradicate their visible disease.”</p> <p>&nbsp;</p> <p>Ramlal Sahu, 85, from Nagpur was suffering from frequent urination, difficulty in passing urine, back pain and pain in his left leg because of which he was unable to walk. He was admitted in a critical condition to HCG NCHRI Cancer Centre, Nagpur, and was diagnosed with prostate cancer. Sahu had multiple comorbidities such as diabetes and hypertension and he also suffered from cardiac-related issues, which prevented him from being a candidate for chemotherapy.</p> <p>&nbsp;</p> <p>“We started him on targeted therapy and tested for genetic mutations and he tested positive,” says Dr Nikhil Pande, medical oncologist, HCG NCHRI Cancer Centre, Nagpur. “He is now on second-line treatment with Olaparib, a form of targeted therapy and is doing well.”</p> <p>&nbsp;</p> <p>Chadha is thankful for scientific advances. “The gland’s location on the neck of the urethra by the bladder means that whole-gland treatments like radical prostatectomy or radiation therapy often leave men with incontinence and erectile dysfunction,” she says. “However, developments in MRI are enabling more targeted treatments to the prostate without damaging surrounding structures.”</p> <p>&nbsp;</p> <p>Researchers are now testing the use of artificial intelligence to recognise suspicious areas in a prostate MRI that should be biopsied, says Chadha. “AI tools also help pathologists who aren’t prostate cancer experts to accurately assess prostate cancer grade,” she says.</p> <p>&nbsp;</p> <p>Can prostate cancer be prevented? There is no absolute way to prevent prostate cancer. Risk factors such as age, genetics and family history cannot be modified. While several drugs and supplements are being studied, there isn’t enough evidence to make conclusive recommendations on prostate cancer prevention.</p> <p>&nbsp;</p> <p>Maintaining a healthy weight, staying physically active, eating a balanced diet and avoiding smoking are all factors that could improve your overall health and lower your risk of prostate cancer.</p> <p>&nbsp;</p> <p>Some studies have suggested that high consumption of dairy products may increase the risk of prostate cancer. Limiting dairy products and calcium intake could be beneficial.</p> <p>&nbsp;</p> <p>A couple of studies have suggested that men with a higher frequency of ejaculation may have a lower risk.</p> <p>Since prostate cancer tends to grow slowly, most men diagnosed with prostate cancer will live a long, normal life and do not die from it. The 10-year survival rate is about 98 per cent. Many of the elderly men detected with prostate cancer die with prostate cancer rather than because of it, says Bhatia.</p> <p>&nbsp;</p> <p>There are hundreds of clinical trials in different phases related to prostate cancer treatment that are in progress around the world. These trials will help the medical community better understand how to diagnose, treat and prevent prostate cancer and improve patient outcomes.</p> <p>&nbsp;</p> <p>“While significant strides have been made in treating localised and advanced prostate cancer, understanding the disparities in prostate cancer outcomes by age, stage, race and ethnicity is crucial to decreasing global incidence of prostate cancer, especially in developing countries” says Dr Shilpa Gupta, director of genitourinary oncology program, Cleveland Clinic.</p> <p>&nbsp;</p> <p><b>Some names have been changed.</b></p> Sun May 01 10:53:12 IST 2022 philanthropy-could-transform-iisc-bangalore-into-a-health-care-hub <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>IISC BANGALORE HAS</b> entered into an MoU with Ajit Isaac, founder and chairman, Quess Corp, and his wife Sarah Isaac, to establish a centre for public health. The couple has committed Rs105 crore towards the centre, which will be called the Isaac Centre for Public Health and will be a part of the upcoming IISc Medical School. The centre is expected to be operational by 2024 and is aimed at encouraging aspirants to pursue careers in clinical research to develop new treatments and health care solutions.</p> <p>&nbsp;</p> <p>The centre will be located in the medical school’s academic and research block and span one floor spread over 27,000sqft. It is expected to create postgraduate education and research programmes in public health and will offer dual-degree programmes such as master of public health plus doctorate (MPH-PhD), which would be five-six years. The centre will also host high-end biomedical research computing infrastructure to host the data, and develop and test big data analysis methods tailored for public health.</p> <p>&nbsp;</p> <p>IISc director Govindan Rangarajan said there was an acute need for India to have a centre for clinical and academic research in public health to be able to make quicker and more impactful strides in realising the goal of quality health care for all. “The proposed centre will be an interface between all the departments of the IISc Medical School, and also other science and engineering departments of IISc in the context of public health research,” he said. “In particular, the centre will create a niche for health data science and analytics through collaboration with the existing computer science and data science departments at IISc, putting it on par with international counterparts like the Johns Hopkins Bloomberg School of Public Health.”</p> <p>&nbsp;</p> <p>Isaac said the humanitarian crisis created by the pandemic will take several years to recover from and has exposed the lacuna in public health systems. “This needs to be addressed systematically and consistently,” he said. “A strong nation is not only built on education and employment, but good, sound public health. And the onus of building a healthy future cannot lie on the government alone.”</p> Wed Mar 23 12:19:43 IST 2022 md-phd-programme-will-open-up-new-avenues-for-students <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>DR NATASHA DESHPANDE,</b> based in Belagavi, Karnataka, recently completed her MBBS from the Jawaharlal Nehru Medical College in the city and is now planning to pursue MD in the US. She feels that the proposed MD-PhD five-year course that will be offered by the upcoming IISc School of Medicine and Bagchi-Parthasarathy Hospital, Bengaluru, will be a big help to medical students.</p> <p>&nbsp;</p> <p>“To get both MD and PhD, it generally takes seven years after MBBS,” she said. “Also, in the proposed MD-PhD programme, the student has to submit just one thesis. Now, it is one during MD and one during PhD.” She added that an MD and PhD together will provide more options to choose from for the thesis and will also make more topics available for research.</p> <p>&nbsp;</p> <p>At present, she said, students who are keen on research have to look for opportunities abroad and this may contribute to brain drain. “The initiative taken by these philanthropists at IISc Bangalore will bring everything under one roof and will make a great difference in the lives of the students as well as the future of India,” she added. “Post MD-PhD, there would be multiple career paths that would open up for a student. They can pursue advanced research, they can become an academician, or they can become a practitioner. This programme will open up new possibilities to students who were interested in research but could not afford to go abroad.” Such a programme will increase the research mindset of the new generation of students who pass out of medical colleges, said Deshpande.</p> Wed Mar 23 12:16:57 IST 2022 wealth-for-health <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Decades ago, Subroto Bagchi, the co-founder of IT major Mindtree, and his wife Susmita, an acclaimed writer, used to travel to the US quite a lot for various projects. The couple spend considerable time there. They observed a sense of obligation towards the community among people there and were deeply influenced. The couple was awed by the ability of many moneyed people to write a cheque and walk away from it.</p> <p>&nbsp;</p> <p>“There is a misconception that in the west it is all about me, myself and I,” said Bagchi. “Take the example of the funding of Stanford, Harvard or Yale. People exhaust their life’s savings and simply go away, often anonymously. That spirit is what funds long-term research. That is one of the things that creates academic freedom and flexibility to pursue nebulous, but potentially life-altering ideas. Though many of them do not materialise, if one or two do, they turn out to be inventions that save humanity.”</p> <p>&nbsp;</p> <p>With this in mind, the Bagchis and Mindtree co-founder N.S. Parthasarathy and his wife Radha joined hands with the Indian Institute of Science Bangalore and donated Rs425 crore to help build a not-for-profit, 800-bed multispeciality hospital on the IISc campus in Bengaluru. It is the single largest private donation ever received by IISc and the hospital, which will be set up as part of a postgraduate medical college (the IISc Medical School), will be named the Bagchi-Parthasarathy Hospital.</p> <p>&nbsp;</p> <p>“This will be the first large-scale effort to integrate engineering, science and medicine in the lap of an institution that has the culture of research,” said Bagchi. The medical college being located alongside the IISc's science and engineering departments is expected to lead to greater interactions and synergy between the disciplines. Bagchi added that breakthroughs in health care require engineering, science and medicine to coalesce. “The intersecting area becomes the space for path-breaking innovation,” he said.</p> <p>&nbsp;</p> <p>He said that both he and his wife had great admiration for what IISc does, how it does it and its ability to stay the course with regards to the cause for which it was created. However, they had not imagined that they would get the opportunity to collaborate with the Institute of Eminence. Then, they heard, from the Parthasarathys, about IISc director Govindan Rangarajan's vision of creating an IISc medical college.</p> <p>&nbsp;</p> <p>The Parthasarathys had met Prof Rangarajan on December 30, 2021 and were interested in the project, but they were nervous about engaging with an institution of the stature of IISc and about the scale of the idea. They decided to discuss the idea with the Bagchis. “Susmita is the cautious one among the two of us, but within minutes, her eyes lit up,” said Bagchi. “To Partha’s surprise and joy, we told him on the spot that he had made a great choice and that we also wanted to come on board. The very next day (December 31, 2021), we met Dr Rangarajan. We saw in him a leader driven by purpose.”</p> <p>&nbsp;</p> <p>Rangarajan said that the Parthsarathys had seemed keen on being involved in the project even during the first meeting. This combined with the fact that they returned with the Bagchis the next day was a good sign. But, Rangarajan was still unsure whether the meeting would be fruitful. After all, he had made hundreds of presentations to large institutions to no avail. But after the meeting that lasted an hour, the prospective donors told him that they were not thinking in terms of “whether or if”, but how and when. “During our discussions, we discovered that our visions were closely aligned and it was a real joy for me to interact with them,” said Rangarajan. They also met Prof Navakanta Bhat, dean, division of interdisciplinary sciences, IISc.</p> <p>&nbsp;</p> <p>On January 5, the Bagchis and the Parthasarathys said they would jointly donate Rs425 crore for the construction of the hospital. “I was accompanied by Prof Bhat during this meeting and both of us literally jumped in joy,” said Rangarajan. Bagchi said that they were blown away by how much homework the two professors had done. “It did not feel like we were dealing with an academic institution because of the clarity, the collaborative spirit and the unbelievable response time of IISc,” he said.</p> <p>&nbsp;</p> <p>The Bagchi-Parthasarathy Hospital will provide advanced facilities for diagnostics, treatment and research. Facilities for genome sequencing, robotic surgery and organ transplant will be available. A comprehensive bio-repository will be created in the hospital for retrospective and prospective analysis of patient samples such as blood, tissue culture and lung lavage.</p> <p>&nbsp;</p> <p>Prof Bhat said that the hospital is envisioned to be a “digital hospital”, implementing technologies and solutions to enhance operational efficiency. Moreover, for training, simulation platforms will be made available. “For instance, the operation theatres will have live feed to the seminar halls so that the postgraduate students and researchers can have real-time exposure to complex surgeries,” he said. The latest augmented reality and virtual reality tools will be available to enhance the educational experience.” He added that a telemedicine suite with haptic interfaces will be provisioned for remote follow-up and long-term care delivery to patients in peri-urban (immediately adjacent to urban) and rural settings. “Given the evolving research on mind-body connection on healing, the hospital will have an integrative medicine wing with yoga and meditation facilities,” he said.</p> <p>&nbsp;</p> <p>Rangarajan said the larger vision of the project was to establish the best medical school in India and one of the best in the world. He added that this can be achieved by conducting high-impact clinical research, which leverages the IISc's existing strengths in science and engineering. Another important aspect is to train a new cadre of “physician-scientists” who will be highly knowledgeable both in basic research and clinical studies. “In the MD-PhD programme, MBBS graduates will spend time in the hospital performing clinical studies and in the science or engineering labs performing basic research,” said Rangarajan. “Combining both these aspects, they will submit a single thesis at the end of five-six years and will be awarded both an MD and PhD. These students will spend around six months in the best medical schools abroad, further enhancing their training.” Students of other courses on the IISc campus will also benefit by interacting with the medical faculty and by being able to do projects oriented towards clinical research.</p> <p>&nbsp;</p> <p>The architect for the project, Archi Medes Consultants, was finalised after a rigorous selection process involving more than a dozen firms specialising in hospital design. They came up with the final design of three interconnected blocks for the hospital, a utility block and an academic block. The architecture, the modularity of design and the equipment are all geared towards world-class standards. IISc plans to hire faculty for the medical school from 2024.</p> <p>&nbsp;</p> <p>Rangarajan took over as director, IISc, in August 2020, months into the pandemic. Therefore, he felt that the immediate priority for IISc should be establishing a postgraduate medical school so that it can help the country in preparing for and mitigating future health care crises. “Given my own interdisciplinary background, I had seen first hand the advantages of collaborating with other disciplines,” he said. “Hence, I wanted the integration with science and engineering. When this idea was proposed to our senate and governing council in early 2021, they fully supported it.”</p> <p>&nbsp;</p> <p>For the Bagchis, philanthropy is not new as they have funded a cancer hospital and a palliative care unit to be set up in Bhubaneswar by Sri Shankara Cancer Foundation and Karunashraya, respectively. The two projects together will have an outlay of 0340 crore. The government of Odisha has given 20 acres of prime land to each institution, free of cost. While researching for these two projects, they had looked at many global institutions for ideas and had come across something inspirational.</p> <p>&nbsp;</p> <p>“We all know about the Sloan Kettering Hospital in the US,” said Bagchi. “It is at the forefront of cancer treatment and research. What many do not know is that this started relatively small, as Marshall Hospital. And then came Alfred Sloan and Charles Kettering, auto-industry executives who came to Marshall Hospital, wrote fat cheques, and walked away. How did they do that? It couldn’t have been a decision based on kneading excel sheets. It was a work of heart.” Humankind, he added, needed such works of the heart more than ever before. “We saw IISc presenting us a platform to help build an institution that may turn out to be something like a Sloan Kettering or a Mayo Clinic or the Harvard Medical School,” said Bagchi.</p> <p>&nbsp;</p> <p>He said that he and his wife have shared vision, values and objectives all their lives. “When Mindtree happened, all the founders had emptied their life’s savings into the initial equity, even before the venture capital was raised,” said Bagchi. “When it became successful and over the years it became apparent that we will be rewarded with more money than we needed, Susmita and I called our daughters Neha and Niti. We asked ourselves what our approach to wealth should be. We needed our children to be decision makers as well. Susmita and I suggested that a substantive part of the wealth must go into serving larger causes, helping build institutions. Our daughters listened. But they had a caveat: 'Keep what you need for your own future and please spend the rest of the money for causes you find dear to you. But please, do that in your own lifetime'.”</p> <p>&nbsp;</p> <p>For Parthasarathy, Covid-19 provided a moment of clarity. His mother was hospitalised during the peak second wave. Because of the rush and scarcity of beds, it had taken hours of anguish before she finally got into a hospital. “We could not go in,” he said. “We didn’t know what would happen next. We were standing on the road for hours and then we realised we were hungry. This was during the complete lockdown and there were no restaurants open. We called a friend, who was kind enough to bring us some food. We sat on the road outside the hospital and gratefully ate the food. Sometimes, you can have all the money you want but it cannot even buy you food. Eating on the road that day, in that moment of distress when a loved one was inside the hospital, we were seized by the urgency of the situation.”</p> <p>&nbsp;</p> <p>He and Radha strongly believe that philanthropy must take its rightful place in supporting and enhancing India's outstanding public institutions. “People with money are not necessarily the best people to build and run world-class institutions,” he said. “And we should be comfortable donating and leaving it to the institution. Radha and I come from ordinary backgrounds and studied in ordinary schools,” he added. “We believe that destiny has placed resources in our hand for a purpose and we have to fulfil that purpose. We have the full support of our daughter and son-in-law for using these resources for the common good. Our intention was to fund education and health care and the IISc project presented us with this opportunity.”</p> <p>&nbsp;</p> <p>The philanthropists hope that one day IISc will give humankind the next great thing, like insulin or a Covid-19 vaccine. But equally important, they hope it will make breakthroughs in medicine and health care delivery that will lead to equity and access. “The professors at IISc keep using a phrase we like,” said Bagchi. “They talk about medicine 'for the next 6 billion people'. At the core of this gigantic vision is the need to breed the scientist-physician and this can happen through the proposed focus on the MD-PhD programme.” He added that the dream to make IISc a breeding ground for med-tech was equally significant. “Med-tech entrepreneurs will flourish,” he said. “These youth will come from many disciplines and co-create medicine, devices and systems for delivery. The silicon valley of medicine will come up here.”</p> Wed Mar 23 12:14:14 IST 2022 helping-the-heroes <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Kinjal Gathani has a master's in applied positive psychology and coaching psychology. She is certified by the International Coaching Federation and the European Mentoring and Coaching Council. She finds her role at Aster holistic, with equal focus on supporting well-being and resolving grievances.</p> <p>&nbsp;</p> <p>“Employee well-being is a complex, multidimensional concept, being defined by the International Labour Organization as an aggregation of an employee’s physical environment, social environment, health and safety,” she said.</p> <p>&nbsp;</p> <p>Gathani says her job involves multiple interventions, from individual well-being coaching and counselling to group activities. “Well-being is not a one size fits all panacea and hence we cater to varying and diverse employee needs,” she said. “While partnering with employees in their journey from grievances to well-being, we endeavour to first understand where the need lies and eventually tailor unique and relevant solutions.”</p> <p>&nbsp;</p> <p>She added that there was a lot to be done with regards to the well-being of health care workers in India. “Indian health care organisations need to explore ways to support well-being programmes aimed at raising the levels of happiness and contentment at the workplace, invariably resulting in higher productivity,” she said.</p> Sun Feb 27 11:54:53 IST 2022 caring-through-coding <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Anubhav Anand, like most Indians, experienced the chaos of the health care system during the pandemic. “From finding the right hospital near you to dealing with paperwork, insurance claims, bills.... Doing all this while your dear one is on IV with scary looking machines beeping is a test,” he said.</p> <p>&nbsp;</p> <p>Through his job, he tries to make the experience better. “I was attracted by the novelty of challenges which the company was taking on, like consistent clinical outcomes, pricing transparency and patient accessibility,” he said. “Most of the time, people just Google the nearest hospital, without knowing if it is equipped to handle the problem. Our team at Ayu Health is empowering our medical officers with an in-house tool, with which they can filter information, categorise it and recommend the nearest and the best-suited medical help.”</p> <p>&nbsp;</p> <p>Anand, who works on automating large parts of the process, joined as a trainee in September 2021 and was offered a full-time role two months later. “The human body does not show concise error codes like software, so codifying it remains a challenge that we like working on,” he said. “However, our team is more than equipped to navigate this. I feel that India has moved up a rung in the pyramid of needs and is looking for seamless experiences everywhere.”</p> Tue Feb 22 16:12:26 IST 2022 trust-builders <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It was “trust issues”that made three young entrepreneurs—Himesh Joshi, Arjit Gupta, and Karan Gupta—think about building a new tech-powered health care model for India. And by the time they unveiled their model via their startup Ayu Health, the pandemic hit the country and made it apparent how unreliable the country’s existing health care system is for a large section of the population.</p> <p>&nbsp;</p> <p>“During our research, we found that there were only a few trusted hospital brands in the country,”says Joshi, CEO, Ayu Health. “But these top brands are often out of reach for most patients. For an average person, differentiating between hospitals is often a challenge. Earlier, we used to have a system of the family doctor. People had trust in him, and he would suggest which hospital they should go to. We do not have this system anymore, and patients do not know which hospital is good and which is not.”</p> <p>&nbsp;</p> <p>This made the tech-trio think about offering clear information to the public on the number of available beds, doctors, surgeons and medicines in each of the hospitals near their location. They observed that by providing adequate information, people will have more trust in the hospital facilities—and also would help them take timely decisions.</p> <p>&nbsp;</p> <p>Thus, the tech-trio decided to build a branded private hospital chain that an average Indian can trust and afford for its transparency and quality. “We thought this trust must be built on three broad pillars—consistently good clinical outcomes, transparent and affordable pricing, and quality experience,”says Joshi. “Our mission is to make quality health care accessible to everyone, everywhere.”</p> <p>&nbsp;</p> <p>Ayu Health started operations in 2019 making a Chandigarh hospital its partner. The hospital started using the technology platform built by the startup for patient management. Ayu Health digitised the entire consultation, medicine prescription and payments procedure to offer a better experience to customers. It also helped its partner hospital to create a more “asset-light”network, where Ayu Health manages end-to-end administrative operations and the medical faculty concentrate on clinical outcomes. This partnership model soon attracted many other small and medium-sized hospitals. Now, this unique model has 40-plus hospitals in Bengaluru and 20-plus hospitals in Chandigarh as part of its chain.</p> <p>&nbsp;</p> <p>Joshi says that there are plenty of multispeciality and super-speciality hospitals in India with good health care outcomes, but are not doing very well on the business front. “We found that these hospitals are lagging in terms of managing the procurement of drugs and consumables, insurance and continuously evaluating technology to improve patient experience,” he says. “So, we co-branded these hospitals, gave an operating system to run the hospital, [and deployed] technology to improve patient conversion and patient experience. We also helped them procure drugs and other equipment at better prices, and have better insurance partnerships.”</p> <p>&nbsp;</p> <p>Before diving into the health care sector, Joshi, Arjit and Karan were into e-commerce. Their refurbished goods marketplace, Zefo, was acquired by online classifieds platform Quikr in 2019 for 0200 crore in an all-stock deal. Karan comes from a family of doctors. And that connection was crucial in the trio’s shift to health tech.</p> <p>&nbsp;</p> <p>“Karan’s father had set up this 100-bed super speciality hospital—something into which he had invested a lot of money and effort,”says Joshi. “He had been running it for the last three to four years, but the hospital was not doing that well [on the business side]. [After Zefo was acquired], Karan’s plan was to go and help his father [with the business]. And, that is where his—and later our—research about the problems faced by unbranded hospitals started.”</p> <p>&nbsp;</p> <p>The trio launched the startup after five months of research. Joshi says that the pandemic has been a hindrance to their growth. “We would have probably grown more in the last two years [if there was no pandemic],”says Joshi. “But one silver lining of the whole pandemic was that it accelerated the adoption of technology in the Indian health sector. And, we were always available for our partners [to provide solutions demanded by the Covid phase]. For instance, we launched a telemedicine application for our partners within 24 hours after the government released the new telemedicine guidelines.”</p> <p>He is hopeful that the digitisation push will make the patients more informed and demanding about the quality of medical care they receive. And he is confident about Ayu Health’s unique health care model.</p> <p>&nbsp;</p> <p>In September 2021, the company raised $6.3 million in funding for expanding its hospital network and building new technology solutions for hospital management. The startup expects to grow its business ten-fold in the financial year 2022. It also aims at 5,000 additional beds in six cities by December.</p> Thu Feb 24 18:41:29 IST 2022 solution-squad <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Low doctor-to-patient ratio, acute shortage of trained professionals, ill-equipped ICUs, inadequate medical infrastructure—India faced the Covid-19 pandemic with all these vulnerabilities. But this once-in-a-lifetime global crisis became the fuel that ignited a makeover of the Indian health sector. Dramatic changes happened in patient care, patient management processes and allied services in the last 24 months.</p> <p>&nbsp;</p> <p>“One major structural change could be seen in intensive care units in hospitals,”says Dr Swami Subramaniam, a clinical pharmacologist and neuroscientist who has been in leadership roles in various health care companies. “Hospitals are investing big time in expanding not just intensive care unit capacity, but also to train more intensivists. The normal beds to ICU beds ratio changed; hospitals added more ICU beds in this phase.”</p> <p>&nbsp;</p> <p>Medical experts point out that during the first and second waves of the pandemic, the system focused primarily on Covid-care. A vast majority of hospitals had stopped or postponed elective surgeries. But postponing emergency surgeries and procedures was not an option. The situation had forced many leading hospitals to turn to robot-assisted surgery to clear the backlog.</p> <p>&nbsp;</p> <p>Robotic surgery allowed social distancing with fewer people around the patient and the robot. It also allows fast recovery of patients. “All of a sudden, the number of open surgeries came down, and robotic surgeries went up,”says Prof Dr Somashekhar S.P., chairman and HoD, surgical oncology, Manipal Comprehensive Cancer Centre. Somashekhar, one of the pioneers of robotic surgery in India, has done over 2,800 robotic surgeries in his career. “We did 536 robotic surgeries during the pandemic, which was much more than in any of the last 10 years,”he says.</p> <p>&nbsp;</p> <p>Though robotic surgery was introduced many years earlier in India, its usage has been limited. However, fear of the virus infection from prolonged hospital stay—a requirement for most open surgeries—made patients demand robotic surgery. And this demand created a new crop of robotic surgeons in India who perform minimally invasive surgery using advanced surgical systems like Da Vinci.</p> <p>&nbsp;</p> <p>Created by Intuitive, a global technology leader in minimally invasive care, Da Vinci is the most used surgical robotic system in the world. The country currently has more than 75 Da Vinci systems installed across major public and private hospitals. “There are over 500 trained robotic surgeons in India now,” says Mandeep Singh Kumar, vice president and general manager, Intuitive India. Intuitive has three centres in India to train robotic surgeons. Last year, the company started collaborating with top government medical colleges to familiarise future surgeons with robotic-assisted surgery. In January, the company launched India’s first remote surgical case observation technology, Intuitive Telepresence, to enable those undergoing training to learn from expert robotic surgeons remotely.</p> <p>&nbsp;</p> <p>It was not just global players like Intuitive, desi health-techs also came up with innovative solutions—and even shortcuts—to deal with India’s systemic shortcomings. Take, for instance, the case of qXR of, an AI-based chest X-ray analysing solution repurposed to screen the Covid-infected population in slums and remote villages. “Our application helps to interpret X-rays faster and better,” says Prashant Warrier, founder and CEO, Built with deep learning, qXR can detect abnormalities in lungs, bones, diaphragm and heart with great precision, in less than one minute.</p> <p>&nbsp;</p> <p>During the first and second waves of Covid-19, RT-PCR or antigen testing facilities were not available in many parts of the country. Even if they were available, two to three days were required to get the test result. “But X-ray centres are there in almost every corner,” says Warrier. “The qXR, on analysing X-rays, would tell whether there is lung damage or lung infection because of Covid. Lung abnormalities were a major indicator of Covid infection.” Warrier, however, notes that X-rays were not always accurate in detecting Covid. “You might miss [Covid-positive] cases in which there is no lung damage visible,”he says. The Brihanmumbai Municipal Corporation adopted this technology for rapid screening of Covid-positive cases in Mumbai slums. The qXR utilises the scalability and agility offered by cloud computing technology to deliver its services.</p> <p>&nbsp;</p> <p>It was during the pandemic that a large section of Indian hospitals moved their IT operations from legacy systems to the cloud. This led to wide-scale implementation of Software as a Service (SaaS)-based health care solutions across India. And, the result was a heightened demand for techies in the health care sector.</p> <p>&nbsp;</p> <p>“The sudden acceptance of the digital ecosystem to meet the patient demands during the pandemic has resulted in the need for health care providers to become digitally savvier,”says Himesh Joshi, who co-founded Ayu Health which had become a technology partner for over 60 private hospitals during the pandemic. According to data from employment website, job postings under the tag of Indian health care, biotechnology and life sciences, and the pharmaceuticals industry witnessed a 9 per cent year-on-year growth in January 2021. Software developers and artificial intelligence and machine learning professionals are in high demand capturing almost 40 per cent of the health care jobs listed. Job roles related to telemedicine, digital marketing and clinical research also have seen a boom in the sector compared to pre-pandemic levels. “There have been several acquisitions and huge investments lately in the health-tech domain, which has led to a rise in hiring demand in the sector,”said Chandra Sekhar Garisa, CEO, “The sector is expected to grow at a 39 per cent compounded annual growth rate over FY2020-FY2023.”</p> <p>&nbsp;</p> <p>Adarsh Natarajan, CEO and founder of health startup AIndra Systems, points out that technology can become a force multiplier to bring down the inequities in the Indian health care segment. AIndra’s flagship work is in pathology—one of the fastest advancing health care segments. Their AI platform Astra is built to detect critical illnesses such as cancer. Natarajan points out that the platform can be extended to build diagnostic tools for several critical illnesses. Both and AIndra are winners of the prestigious India-Sweden Healthcare Innovation Centre Challenge.</p> <p>&nbsp;</p> <p>“The increased digitisation and AI in the health care sector will result in an uptick in tech-influenced jobs taking away from jobs having repetitive tasks,”says Runam Mehta, CEO, HealthCube, a point-of-care technology-enabled diagnostics services provider. “Candidates who have a good understanding of domain-specific business process management, along with knowledge in AI and robotics, will be highly coveted by any health care solutions company.”</p> <p>&nbsp;</p> <p>Covid-19 has dramatically changed the way hospitals deliver outpatient care. In the initial phase, several patients—including many who needed emergency care—avoided hospital visits because they did not want to leave their homes and risk exposure. This situation prompted health care providers to start telemedicine and home care services. Kalappa K.B., country head HR at Aster DM Healthcare, says demand for telehealth services had seen a slow decline as Covid-19 lockdowns were lifted. “Because of the wider acceptance for home health care segment during the pandemic, we increased the hiring of nurses and paramedics to suit the job roles in this segment,”he says. “Another job that became hot during this phase was that of a mental health consultant. The work-from-home conditions and the varied clinical issues that arose because of Covid infection created a mental imbalance in many people. Hence the job of mental health consultants became more crucial.”</p> <p>&nbsp;</p> <p>Ranjan B. Pandey, the chief human resource officer at Fortis Healthcare, says home care professionals were in high demand especially in the elderly care segment. The renewed focus on the ageing population and preventive care led to increased demand for skilled professionals like phlebotomists (technicians who collect blood from patients and prepare samples for testing), lab assistants and diagnosticians.</p> <p>&nbsp;</p> <p>“Home collection of samples for lab testing also gained prominence,”says Pandey. Medical recuperation professionals who offer post-Covid treatment and nutritionists are some of the other job profiles that gained prominence in the post-pandemic phase.</p> <p>&nbsp;</p> <p>Covid has provided India with a unique opportunity to burnish its credentials as a global leader in vaccine manufacturing and drug development. Subramaniam, who is currently serving as the CEO of Ignite Life Science Foundation—a Bengaluru-based non-profit scientific research institute, says that the government is now considering policy directions to increase funding for research in domains like epidemic diseases. “So, we expect that in the next few years, we will see more centres dedicated to investigating pandemics and developing a response to pandemics,”he says.</p> <p>&nbsp;</p> <p>In July 2021, the Ignite Life Science Foundation announced its first grant award for “pandemic preparedness”research to a team led by Raghavan Varadarajan, a professor at the Indian Institute of Science, Bengaluru. The team will use the three-year grant to develop platform technologies for mRNA vaccine development.</p> <p>&nbsp;</p> <p>Varadarajan works on stabilising and engineering proteins. “In the late 1990s, the three-dimensional structure of one of the HIV [human immunodeficiency virus] proteins came out,”he says. “And, we thought it would be interesting to use what we knew to work on this sort of problem.”And that is how he got initiated into vaccine research.</p> <p>&nbsp;</p> <p>During the pandemic, Varadarajan’s team, in collaboration with a Bengaluru-based startup Mynvax, had worked on developing an indigenous thermo-tolerant vaccine—that can be stored at room temperature. They saw promising results in animal trials with their vaccine formulations. Their initial findings were published in the American Society for Biochemistry and Molecular Biology’s journal, Journal of Biological Chemistry, in 2020. However, progress to clinical development has been delayed because of funding constraints.</p> <p>&nbsp;</p> <p>Varadarajan says that as part of their Ignite-funded project, his team will first create a normal mRNA vaccine. “As we get more experience, we will try to make it thermotolerant,”he says. All the currently available mRNA vaccines need to be stored at very cold temperatures.</p> <p>&nbsp;</p> <p>“It has become clear that mRNA is an efficacious technology,”says Varadarajan. “Before the pandemic, mRNA was fairly untested. But there are still many things to be resolved in this segment. mRNA vaccines are not cheap, and they have storage issues. Also, a lot of intellectual property [rights] are held by a few companies. This is a major challenge in this field.”Varadarajan says that substantial and timely government funding to both academia and industry is required to catalyse research in this frontier area and to better prepare the country for future pandemics.</p> <p>&nbsp;</p> <p>The pandemic was a time when the country witnessed an explosive rise in biomedical waste—masks, personal protective gears, syringes, vaccine vials. And, lakhs of biomedical waste managers worked 24x7 to keep the country’s health infrastructure clean and safe. The service they offer to society often went unrecognised in the past. But the pandemic made people recognise the heroic work they do behind the scenes, says Masood Mallick, joint managing director of Ramky Enviro Engineers Limited, a leading biomedical waste management firm. “The way our people stepped up, it was like a soldier who waits his entire life for that one war,”he says. “Most of the country’s Covid waste was treated by our frontline staff. We took waste from everywhere—not just from hospitals, but also from commercial institutions converted into isolation centres, and airports. We even handled waste from competitors who could not cope. We serve about 45,000 hospitals in India. We have facilities for collection, transport, treatment and disposal of waste in 23 cities.”</p> <p>&nbsp;</p> <p>Mallick says Ramky used its industrial waste managing facilities to augment and supplement its industrial waste management capacity. The company gave special monetary support to its biomedical waste handlers. It also started a comprehensive employee assistance programme to protect the families of frontliners in case of a Covid casualty. “Just 48 hours after the start of the national lockdown, we had 100 per cent attendance. And that happened just because our people felt that it is their duty, it is their time to serve,&quot; says Mallick. “It is a matter of pride that our biomedical waste management team did not have a single fatality to date. After the pandemic began, we started a campaign, #OutThereForYou, to tell our communities that we are out there for them. And, there were some instances where our waste collection teams had received flower showers or were garlanded with money. Hard times bring the best out of people; the pandemic was a life-changing experience for our team.”</p> Mon Feb 28 14:06:12 IST 2022 india-pig-heart-doctor <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The first recorded xenotransplant in India was performed in January 1997. Dr Dhani Ram Baruah, a cardiothoracic surgeon from Assam, transplanted a pig's heart and lungs into Purna Saikia, a 32-year-old farmer with ventricular septal defect (hole in the heart). The transplant that took 15 hours was carried out at Baruah’s clinic in Sonapur, a small town on the outskirts of Guwahati. Baruah, a fellow of the Royal College of Surgeons, London, performed the procedure along with Dr Jonathan Ho Kei-Shing, a surgeon from Hong Kong.</p> <p>&nbsp;</p> <p>Saikia had failed to respond to conventional surgery and the xenotransplant was performed as a last resort, with consent from the patient and his family. The transplant went awry. A week after the surgery, Saikia died of multiple infections and hyperacute rejection. “Certain genes and proteins in the tissues of an animal are recognised by the human immune system and this leads to hyperacute rejection,”said Dr Sonal Asthana, lead consultant, hepato-pancreato-biliary and liver transplant surgery, Aster CMI Hospital, Bengaluru. “It is the reason for death in most cases of xenotransplantation. Initial strategies to deal with hyperacute rejection involved profoundly suppressing the host immune system, which left the patient vulnerable to infections.”</p> <p>&nbsp;</p> <p>Both Baruah and Kei-Shing were arrested under the Transplantation of Human Organs Act, 1994, and imprisoned for 40 days. During the trial, Baruah argued that the act did not cover transplantation of organs taken from other species. Baruah, who is now 72, had a stroke in 2016 that left him unable to speak. People close to him said he was not greatly moved by the Maryland surgeon’s feat.</p> <p>&nbsp;</p> <p>If Baruah were to perform a xenotransplant now, the chances of survival of the patient would be much higher thanks to the evolution of technology. “Gene editing technologies have made it possible to remove the genes that cause interspecies hyperacute rejection, and insert genes that improve human compatibility,”said Asthana. “Also, CRISPR-Cas9 genome editing [employed to modify the pig heart used in Maryland] has made it easier to create animal organs that are less likely to be attacked by human immune systems.”</p> <p>&nbsp;</p> <p>As a transplant surgeon, Asthana looks at Baruah’s work objectively. He feels it is important for us to draw lessons from the opprobrium that Baruah had to endure. “To go beyond, India has to create the research and innovation mindset that allows physicians to test new ideas that can save untold numbers of lives,”he said. “Without innovation, there is no progress.”</p> Tue Jan 25 13:16:14 IST 2022 a-shot-in-the-dark <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>He was getting closer to death, which made him say “yes”to a risky medical experiment. David Bennett Sr, the first human to receive a heart transplant from a genetically-modified pig, thus became part of the history of medical science.</p> <p>&nbsp;</p> <p>The 57-year-old Maryland man had uncontrolled cardiac arrhythmia, a condition that would result in irregular heartbeat. Doctors did not consider him a good candidate for human heart transplantation because his medical records said he had often missed appointments and not filled prescriptions. Statistics show that those patients who are not good at following doctors’orders usually do not survive long with a donor heart. Bennett was also too sick to qualify for a human donor heart. The condition that he had exhausted all treatment options and would die anytime without a new heart, made him gamble on the experimental transplantation.</p> <p>&nbsp;</p> <p>Dr Bartley P. Griffith, professor of surgery at the University of Maryland School of Medicine (UMSOM), led the January 7 transplantation procedure on Bennett. Dr Muhammad M. Mohiuddin, professor of surgery and director of the cardiac xenotransplantation programme at UMSOM, was another crucial member of the team. Dr Griffith and Dr Mohiuddin reportedly spent three decades fine-tuning the surgical techniques for this transplant they conducted on Bennett.</p> <p>&nbsp;</p> <p>Dr Griffith told Bennett about the experimental method in December. “We can’t give you a human heart; you don’t qualify. But maybe we can use one from an animal, a pig,”he told his patient, according to The New York Times. To that Bennett replied: “Well, will I oink?”</p> <p>&nbsp;</p> <p>When Bennett discussed his decision to be a pig heart recipient with his son David Bennett Jr, he became perplexed. The younger Bennett initially thought his father was experiencing delirium because of his continuous hospital stay. But he soon realised that his father was telling the truth.</p> <p>&nbsp;</p> <p>Pigs offer a great choice for organ procurements. Transplanting pig heart valves into humans is common now. In 2013, Bennett Sr had undergone surgery to implant a pig valve in his heart. The valve was implanted after removing the pig cells, so he didn’t have to take immunosuppressants then.</p> <p>&nbsp;</p> <p>Gene editing and cloning are the two technologies used to yield genetically-modified pig organs that won’t be rejected by the human body. In September 2021, doctors at New York University Langone Health had transplanted kidneys from genetically-modified pigs into a legally dead person with no perceptible brain function. The procedure was done with the permission of the patient’s relative. He was sustained on the ventilator, and his body did not reject the organ for more than two days.</p> <p>&nbsp;</p> <p>The January 7 procedure by the University of Maryland Medical Centre (UMMC) doctors on Bennett Sr marks the first time a pig organ is being transplanted into a human being who still holds a chance to recover and survive.</p> <p>&nbsp;</p> <p>His condition was so bad before the transplant; he was on extracorporeal membrane oxygenation (ECMO) machine—which pumps and oxygenates a patient's blood outside the body—for almost two months. Because he had irregular heartbeats, he was not fit to have a mechanical heart pump, too.</p> <p>&nbsp;</p> <p>The United States Food and Drug Administration rejected the initial applications for human trials of pig heart transplantation by the UMMC. The FDA asked them to transplant hearts into 10 baboons before trying it on humans. However, on New Year’s Eve, the agency authorised the surgery under its “compassionate use”provision.</p> <p>&nbsp;</p> <p>The surgery encountered some major challenges. The anatomy was a little problematic and the doctors had to do plastic surgery to make everything fit.</p> <p>&nbsp;</p> <p>Bennett Sr saw the experiment as an “either die or give it a try”kind of situation. “I want to live. I know it’s a shot in the dark, but it’s my last choice. I look forward to getting out of bed after I recover,”he told the doctors at the UMMC before the surgery. His faith in medical science and his doctors saved him. So far, his body has not rejected the pig heart. But he still faces a long road to complete recovery.</p> <p>&nbsp;</p> <p>Within days after the news of the historic surgery came to the public domain, Bennett Sr’s “worthiness”to receive a new heart was questioned. In 1988, he was convicted for stabbing a man named Edward Shumaker. According to the Washington Post, Bennett Sr., attacked Shumaker during a bar game after his then-wife sat on the latter’s lap. The attack left Shumaker paralysed from waist down. Bennet Sr was sentenced to ten years in prison. He was released from jail in 1994, after serving six years. Questioning the ethics of the second chance, Shumaker’s sister Leslie Shumaker Downey told the Washington Post: “He gets a second chance with a new heart—but I wish, in my opinion, it had gone to a deserving patient.”</p> <p>&nbsp;</p> <p>The transplant team reacted to the controversy by saying that a patient’s criminal past could never be grounds for refusing medical care. “It is the solemn obligation of any hospital or health care organisation to provide lifesaving care to every patient who comes through their doors based on their medical needs,” the UMMC officials said.</p> Tue Jan 25 13:10:59 IST 2022 heart-of-the-matter <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The news of a man getting a pig’s heart took the cardiology world by surprise. We had been hearing about xenotransplant (transplantation between different species) for a while now, but it was relegated to snide talk, rather than anything realistically achievable. In the die-hard (no pun intended) xenotransplant world, however, scientists have achieved a slow but definite progression of the science that led to the unique surgery.</p> <p>&nbsp;</p> <p>So, how did the seemingly impossible come to fruition?</p> <p>&nbsp;</p> <p>The heart is essentially a pump and, like any pump, it needs a supply of fuel and electricity to function. It is self-sufficient—there is an intrinsic pacemaker to generate electricity and wiring that conducts the electricity to different areas of the heart. The fuel supply is through tubes called arteries, which supply the blood through which the heart generates energy to function. Any abnormalities of the electrical system, or of the fuel supply, causes the heart muscle to dysfunction—a condition commonly referred to as heart failure.</p> <p>&nbsp;</p> <p>There are also diseases that affect the heart muscle directly, and any malfunction of the valves (doors that separate the chambers) can cause a pressure load, causing it to weaken and result in a similar condition. The end result is decreased pump function and a reduced output, which affects the rest of the body. Every intervention done on the heart is essentially to preserve the pump function.</p> <p>&nbsp;</p> <p>In the initial stages of heart failure, medications to improve the pump function generally work well. Pacemakers to control electrical issues, and stents and bypass surgery to improve the blood flow to the heart, helps keep the pump going. Unfortunately, sometimes because of either delayed treatment or progression of the underlying condition, the pump function continues to deteriorate, causing a condition called end-stage heart failure. This is the space where technology has made a huge impact in the past five years. From devices that stimulate the nerve supply of the heart to make it a more efficient pump, to a partial mechanical heart—a pump that is called a left ventricular assisted device (LVAD)—to a total mechanical heart.</p> <p>&nbsp;</p> <p>The mechanical takeover because of organ shortage has gone from a temporary approach (LVADs were used as a bridge to heart transplant) to what is known as destination therapy, or a permanent approach instead of heart transplant. The LVAD is a mechanical pump that is inserted into the chest and takes over the function of the left side of the heart, which is responsible for pumping blood to the rest of the body. The device is powered by a driveline that comes out of the body and can be connected to power. There is also a battery pack that lasts 17 hours, making patients ambulatory. These patients do not have a pulse or the usual blood pressure (we love to watch the reaction of medical students and new nurses come running out of the room), as these pumps provide a continuous flow, unlike the pulsatile heart. Ironically the continuous pumps have been found more durable than the pulsatile pumps.</p> <p>&nbsp;</p> <p>The survival for patients with an LVAD is about 70 per cent two years out. The good part of the mechanical pumps is that they are inert and patients do not have to be immunosuppressed, the bad part is they tend to clot off and lifelong blood thinners are the tradeoff. The total mechanical heart has not been as promising, and is still a bridge or a temporary solution, for patients awaiting a complete heart transplantation.</p> <p>&nbsp;</p> <p>In what is arguably the biggest covered medical event in history, Dr Christiaan Barnard and his team performed the first human-to-human transplant in Cape Town on December 3, 1967. The patient survived for only 18 days, but the first step to the journey in transplantation was taken. With his rugged good looks, Barnard soon became an international celebrity and got a whole generation interested in cardiology. He built on the animal lab transplant research at Stanford University and was able to overcome the ethical issues about declaring patients brain dead. (There was a disagreement in the US about when a patient was truly dead. District attorneys in the US had threatened to arrest surgeons who harvested organs from “brain dead” patients.)</p> <p>&nbsp;</p> <p>Today, cardiac transplantation is standard of care. There are 250 transplant centres in the US alone. There are two issues with transplantation. The first is procuring the heart from the donor and transplanting it before there is damage to the donor heart. The second is managing the rejecting response of the receiving body. The heart can be used for approximately four hours after it is explanted, cooled and placed in a solution, before irreversible injury sets in, and the immune response to the donor heart is suppressed by using immunosuppressive medicines. Since 2000, the median survival with heart transplant has been 12 years.</p> <p>&nbsp;</p> <p>The limited donor heart availability has led researchers to pursue xenotransplantation, which would potentially give us an unlimited supply of organs. The problems with xenotransplant have been combating the immunity differences in different species, different blood groups and, of course, different infections. We have pretty much tried all possible animals, including apes, monkeys and baboons, but due to ethical concerns, availability, expense, slow breeding and infectious issues, we settled on the pig. Not just any pig, but a genetically modified pig. In 2016, researchers were able to delete all 62 copies of pig genes that code for porcine endogenous retrovirus by a process called CRISPR-based gene editing. There is only one company in the world, Revivicor, that breeds these pigs in a facility near Birmingham, Alabama. The pig heart used in this transplant had three genes that trigger attacks from the human immune system knocked out. They also added six human genes that help the body accept the organ by promoting normal blood clotting and preventing blood vessel damage. A final 10th modification prevents the size of the pig heart from growing.</p> <p>&nbsp;</p> <p>These models have been tested by transplanting the pig’s heart into baboons- with survival two years out. Each baboon experiment costs approximately $5,00,000. Researchers are unclear on whether all these modifications are needed in pig to human transplants. In addition to the gene modifications, the patient is given a super strong immunosuppressant—an experimental antibody drug called KPL-404—which shuts down production of antibodies completely by binding to a receptor called CD40. The team from Maryland also used a novel nutrient solution to preserve the pig heart after it was harvested. The solution was developed by a Lund University surgeon, Stig Steen, and is composed of water, hormones such as adrenaline and cortisol and—get this—dissolved cocaine. The last ingredient as expected posed some legal issues to the team.</p> <p>&nbsp;</p> <p>The US Food and Drug Administration granted humanitarian exemption for this one patient. The result of the surgery so far has been positive, though these are early days. While the unlimited supply of organs from animals seems to be an exciting concept (we are talking about other organs, too, such as kidney, liver and lungs), the ethical and regulatory steps still need to be in place. We may be opening a whole new can of worms with new infections that could mutate and transmit to the general population and a whole new set of cancers, not to mention the creation of a new genetically modified species to suit our needs.</p> <p>&nbsp;</p> <p>We really don’t know what the future of xenotransplant is, but it does offer a ray of hope to the terminally ill. The advancement of science to the extent of altering another species is always fraught with risk, as we have come to painfully realise with the gain of function virology research. While these two areas are completely different, the fact remains that we are messing around with the natural order of things—something that, at the very least, needs a robust public debate.</p> <p>&nbsp;</p> <p>While there has been a significant evolution on the mechanical aspect of heart failure treatment, the machines do not mimic the action of the heart, not to mention the mobility aspect for a patient. Apart from the immunosuppression, heart transplant patients live a normal life. There are a limited number of donors and healthy hearts available for transplantation. I have been called in the middle of the night to do an angiogram on a brain-dead patient, when there is a question of donor heart viability. There is a section on our license that qualifies us for donors in the event of a heart transplant.</p> <p>&nbsp;</p> <p>Despite this, there is a huge shortage of donors, given the number of patients with end-stage heart disease. If (and it is a big if) we can use hearts from pigs, the supply of hearts could be potentially unlimited. Patients who are otherwise deemed borderline can be considered for heart transplantation and a second shot at life.</p> <p>&nbsp;</p> <p>The human heart, apart from being a pump, is also responsible for secreting hormones that help regulate the functioning of the circulation. Whether a pig heart, albeit genetically modified, will be able to perform these functions in a human milieu is uncertain. The fact that the FDA green-lighted the first transplant is a sign that there has been extensive discussion about an upcoming clinical trial. These decisions do not happen overnight in a vacuum.</p> <p>&nbsp;</p> <p>In an ideal world, we will be able to overcome the infectious and immunological barriers of xenotransplantation and there will be an endless supply of organs-hearts, kidneys and possibly lungs. But we don’t live in an ideal world, do we?</p> Tue Jan 25 13:09:11 IST 2022 how-david-bennett-sr-became-the-first-pig-heart-transplant-recipient <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>In a medical first, a 57-year-old heart patient in the United States received a heart from a genetically modified pig. The pioneering procedure, performed by surgeons at the University of Maryland Medical Center on January 7, could offer hope to thousands of patients who are waiting for organ transplants.</p> <p>&nbsp;</p> <p>According to the US federal government's Health and Services Administration, 17 people die each day waiting for an organ transplant and another person is added to the waiting list every nine minutes. “About 20 per cent of patients on the heart transplant waiting list die while waiting for a transplant or become too sick to be good candidates for the complex procedure,”the American Heart Association said in a statement. In India, about 50,000 people suffer heart failures annually, but only 10 to 15 transplants are performed every year, as per the Union health ministry's Directorate General of Health Services.</p> <p>&nbsp;</p> <p>“There are simply not enough donor human hearts available,”said Dr Bartely P. Griffith, who transplanted the pig heart into the recipient. He added that the breakthrough brings us one step closer to solving the organ shortage crisis. David Bennett, the recipient of the pig heart, is doing well and is being closely monitored.</p> <p>&nbsp;</p> <p>Bennett was suffering from terminal heart failure and had been bed-ridden for six weeks leading up to the surgery. He was connected to a heart-lung bypass machine called extracorporeal membrane oxygenation (ECMO), which kept him alive. The transplant of porcine heart was the only option for the patient as he was ineligible for a traditional human heart transplant and for an artificial heart pump because of his life-threatening arrhythmia. “It was either die or do this transplant,”Bennett said.</p> <p>&nbsp;</p> <p>The US Food and Drug Administration gave emergency approval for the procedure through its compassionate use programme. The programme gives a patient with a life-threatening medical condition access to an experimental drug or medical device outside of clinical trials when no satisfactory treatment options are available.</p> <p>&nbsp;</p> <p>If successful, this could be a watershed moment in xenotransplantation—the use of animal organs, tissues or live cells for human transplants. Attempts at xenotransplantation date back to the early 1900s. There have been several failed attempts with pig, goat, sheep and monkey organs over the years. In 1963, Dr Keith Reemtsma, an American transplant surgeon, transplanted chimpanzee kidneys into 13 patients. Twelve of the patients died within four to eight weeks of the transplant; one patient survived for nine months. The first heart xenotransplant was performed by Dr James Hardy in 1964, using a chimpanzee heart, but the patient died within hours. In 1984, a baboon heart was transplanted into an infant girl known as Baby Fae, born with a fatal cardiac defect, but she died 20 days later.</p> <p>&nbsp;</p> <p>However, pig heart valves have been successfully used to replace heart valves in humans for years. Pigs are considered a better choice for xenotransplantation than primates for several reasons. They are easier to raise, have large litters and achieve adult size within about six months. Pig organs are anatomically similar to human organs, and they are viable for genetic engineering. But the clinical use of these organs has been impeded because of the significant risk of xenozoonosis—the transmission of disease from an animal to a human through transplantation. Transplanting animal organs into the human body can also trigger severe immune reactions and immediate rejection of the organ, which can be potentially deadly.</p> <p>&nbsp;</p> <p>However, newer technologies like cloning and gene editing have yielded tremendous success, making it more viable. “This is the culmination of years of highly complicated research to hone this technique in animals,” said Dr Muhammad M. Mohiuddin, a professor of surgery at the University of Maryland School of Medicine who established the cardiac xenotransplantation programme with Griffith and is its scientific/programme director. “The FDA used our data and data on the experimental pig to authorise the transplant.” Mohiuddin has more than 30 years of experience in xenotransplant research and has been successfully experimenting and transplanting pig hearts into baboons for years. In recent experiments, the primates have survived up to nine months and died from lung infection unrelated to the transplant.</p> <p>&nbsp;</p> <p>The genetically modified pig that was used for the heart transplant was provided by Revivicor, a regenerative medicine company that is working to develop pig organs to transplant into humans. Revivicor is a US firm that spun off from PPL Therapeutics, the UK company that helped to clone Dolly the sheep, the first mammal to be cloned from an adult cell. “This transplant is groundbreaking, and is another step in the investigation of xeno organs for human use," said David Ayares, PhD, chief scientific officer, Revivicor.</p> <p>&nbsp;</p> <p>The researchers modified 10 genes in the pig heart that was used for the transplant. Four genes were removed: three of them were responsible for producing antibodies that cause rejection and the fourth one to control the growth of the pig heart tissue once implanted, Mohiuddin explained. Six human genes that would make the immune system accept the new organ were inserted into the genome of the donor pig.</p> <p>&nbsp;</p> <p>The research team also used an experimental drug developed by Mohiuddin and Kiniksa Pharmaceuticals, along with conventional anti-rejection drugs, to suppress the immune system and prevent the body from rejecting the new pig heart. Once removed, the pig’s heart was preserved until transplant in a new perfusion device. The device, developed by medical technology company XVIVO, preserves the donor heart at 8 degrees Celsius while continuously pumping an oxygenated “proprietary solution”through the organ.</p> <p>&nbsp;</p> <p>Griffith told The New York Times that the “anatomy was a little squirrelly”. “We had a few moments of ‘uh-oh’and had to do some clever plastic surgery to make everything fit,”he said. “It creates the pulse, it creates the pressure, it is his heart. It’s working and it looks normal. We are thrilled, but we don’t know what tomorrow will bring us. This has never been done before.” The pig heart has been performing well so far after the experimental eight-hour procedure, without any immediate signs of rejection. Bennett is off ECMO; his new heart is pumping, and he is breathing on his own. He talked to his son who visited him. David, Bennett’s son, told the Associated Press: “He realises the magnitude of what was done, and he really realises the importance of it. He could not live, or he could last a day, or he could last a couple of days. I mean, we’re in the unknown at this point.”</p> <p>&nbsp;</p> <p>Calling the procedure a game changer, Mohiuddin said: “If this works, there will be an endless supply of these organs for patients who are suffering. We have the technique of genetically modifying and if there is more tweaking required for modifying the genes, we will be able to do that and even customise the heart or other organs for the patient. The successful procedure provided valuable information to help the medical community improve this potentially life-saving method in future patients.” The heart transplant follows the efforts of surgeons in New York, last October, who temporarily attached the kidney of a genetically engineered pig, provided by Revivicor, to a brain-dead person who was being sustained on a ventilator. The organ functioned normally.</p> <p>&nbsp;</p> <p>While most of the medical community is excited about the procedure’s potential for reducing wait times and easy availability of animal organs for human transplants, some have raised ethical questions as well. Animal rights groups like PETA oppose xenotransplants and the use of animal organs for human transplants. PETA condemned the surgery both on the grounds of animal cruelty and the potential to transmit animal viruses to humans. “Animal-to-human transplants are unethical, dangerous, and a tremendous waste of resources that could be used to fund research that might actually help humans,”the organisation said. “The risk of transmitting unknown viruses along with the animal organ are real and, in the time of a pandemic, should be enough to end these studies forever. Animals aren’t tool sheds to be raided but complex, intelligent beings.”</p> <p>&nbsp;</p> <p>This is unknown territory, and the doctors are not sure how well the pig's heart will survive in the human body. The one-year survival rate of human heart transplants is 91 per cent, according to the American Heart Association. On average, heart transplant recipients live another 12 to 13 years. “Rejection of the organ can occur any time after transplant,”Griffith told STAT, a leading medical news website. The immunosuppressive medications used to prevent rejection also carry risks. “The intensity of immune system suppression required is higher with a xenotransplant than with a traditional transplant from a human donor,”he said. “We are proceeding cautiously, but we are also optimistic that this first-in-the-world surgery will provide an important new option for patients in the future.</p> Thu Jan 27 14:33:57 IST 2022 eye-on-the-enemy <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Nature wants you dead. Not just you, but your children and everyone you have ever met and everyone they have ever met; in fact everyone”. British researcher John S. Tregoning’s Infectious: Pathogens and How We Fight Them is a book that starts with this scary statement. And, as we proceed with its pages, we would encounter some scary science facts, too. However, Tregoning, who is currently a reader in respiratory infections at Imperial College, London, makes sure to explain these hard ideas in simple language—with abundant use of witty analogies—for the readers.</p> <p>&nbsp;</p> <p>The book is a product of the pandemic. Tregoning started working on it in March 2020—a stage when total deaths from Covid-19 were less than 3,000. By the time he reached the last chapter, the toll reached 2,230,000. This pandemic timeline from March 2020 to January 31, 2021, could be seen in the book.</p> <p>&nbsp;</p> <p>“I have been working as a research scientist studying infectious diseases for the last 20 years. I have spent a lot of that time trying to understand how and why we get sick from airborne pathogens. However, it was only in 2020, at the beginning of the Covid-19 pandemic, that I really appreciated the thirst for knowledge about viruses and infections,” says Tregoning. “This was an opportunity to share what I have learned with a wider audience to help people understand what has just happened and what they can do to protect themselves against future outbreaks.”</p> <p>&nbsp;</p> <p>The book rightly notes that we are in a far better position to fight infections compared with our past generations. “As a result of science’s success, even during a full-blown pandemic most of us will die of non-infectious causes, in stark contrast to a hundred years ago, when many more people died of infections than other causes. The tipping point came somewhere in the 1950s when the cumulative effect of access to clean water and increased vaccine coverage changed our relationship with microorganisms,” it says. And, the book celebrates this massive success of the medical field in the past 100 years.</p> <p>&nbsp;</p> <p>Infectious is broadly divided into two parts. Part 1 discusses the science behind infections and how the body’s immune system fights them. It also discusses the various diagnostic tools used to identify the culprits behind infections. In part 2, Tregoning offers bits of advice for the prevention, control and treatment of infections.</p> <p>&nbsp;</p> <p>One long chapter in part 2 is about how vaccines work. Tregoning notes that vaccines are based around the simple principle that our immune system can remember things it has seen previously. And, along with explaining the impact of vaccination drives, Tregoning offers a commentary on the problem of misinformation campaigns against vaccines. “I think it is important not to over-promote anti-vaxxers; they are highly vocal, but are a very low proportion of the population,” he writes. He also explains how Covid-19 vaccines were brought out in record-breaking time. “This was achieved through massive investment, both in the research to generate the new candidates and in the manufacturing,” says the book. The vaccine makers took a huge financial risk, too: “To coordinate the delivery of the vaccine with the end of the clinical trials, doses of vaccines were made even before it was known if they were safe or effective, some of which will no doubt end up going down the drain.” He ends the chapter saying that vaccines are “a success story of human science and innovation, up there with the moon landing, Swiss army knives and the internet”.</p> <p>&nbsp;</p> <p>It will be wrong to tag Infectious as a book about medical facts alone. It offers some very relevant sociological observations, too. For instance, it talks about “the sorry state of affairs surrounding the Covid-19 pandemic” in some quarters. The writer says that the fear factor, the absence of actual information about the virus (at least in the first phase) and the disruption the world had witnessed in a short span led to the deluge of fraudulent theories about the Covid-19 pandemic.</p> <p>&nbsp;</p> <p>The book offers some interesting historical anecdotes, too. For instance, Tregoning unearths a rare connection Nobel Prize-winning British chemist Dorothy Hodgkin had with the Iron Lady of Britain–Margaret Thatcher was once a student in Hodgkin’s lab.</p> <p>&nbsp;</p> <p>The book also talks at length about the development of antibiotic, antimicrobial, anti-viral and anti-parasitic drugs, and also about an impending “post-antibiotic apocalypse”. Says Tregoning: “With climate change and the changes in the way that people live and interact with the environment, it is certainly possible that there will be more pandemics in the future. We are living through another, slower-burning pandemic—that of antibiotic-resistant bacteria. These are pathogens that are not treatable with our existing drugs.”</p> <p>&nbsp;</p> <p>The researcher notes that continued investment in basic research and understanding how the body fights infections are vital to deal with these threats. “We also need investment in national-level manufacturing for vaccines and drugs, which will help achieve greater equality in how infectious diseases are controlled,” he says.</p> <p>&nbsp;</p> <p><b>Infectious: Pathogens and How We Fight Them</b></p> <p>Dr John S. Tregoning</p> <p>Publisher: Simon &amp; Schuster</p> <p>Pages: 374</p> <p>Price: Rs699</p> Wed Dec 22 15:23:46 IST 2021 dr-monalisa-sahu-on-how-we-can-protect-ourselves-from-infections <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Infections and infectious diseases are a major burden to our society.</p> <p>&nbsp;</p> <p>Several microorganisms—from bacteria to viruses to fungi and parasites—are causative agents of these infectious diseases. Certain diseases are endemic to particular regions; others lead to an epidemic, affecting a large number of people during a certain period of time in a particular geographical area; and a few infectious diseases take the form of the pandemic, affecting several continents simultaneously, like Covid-19. There are several other agents, known as vectors, which serve as the means of spreading the pathogenic organisms among human beings and animals.</p> <p>&nbsp;</p> <p>To keep oneself protected from these diseases, one needs to have a clear idea about the various common infections prevailing in that area or region, more so during different times of the year.</p> <p>&nbsp;</p> <p>For example, during monsoons, one needs to be aware of infectious diseases during that time, like malaria, dengue, scrub typhus, leptospirosis; the agents causing the disease, their mode of acquisition, the disease manifestations, signs and symptoms so that they can suspect the disease early in its course, before the onset of complications and approach the health care facilities for timely management.</p> <p>&nbsp;</p> <p>They should also be aware of the measures to be taken to prevent the transmission of diseases and break the chain of disease transmission, like maintaining environmental cleanliness to protect against dengue, malaria, chikungunya; avoiding consumption of contaminated food and water to protect from diarrhoeal diseases, dysentery, typhoid; maintaining hygiene to protect against bacterial and fungal infections of the skin; following proper hand-washing and cough etiquettes to protect from respiratory illnesses like influenza, Covid-19 and TB.</p> <p>&nbsp;</p> <p>They should also keep themselves updated about the outbreak of any infectious diseases in their region and state so that they can take adequate measures as recommended by health authorities. And they should get vaccinated to protect themselves from diseases like hepatitis B, appropriate for their age and health conditions, after consultation with an infectious disease specialist.</p> <p>&nbsp;</p> <p>Earlier, there were limited diagnostic modalities for the diagnosis of various infectious diseases, but with advancement of medical science and technology, a number of newer diagnostic modalities are available. Many point-of-care tests are also available for a number of infectious diseases, which help us in the early detection of disease, even in remote areas. There are newer molecular diagnostic tests that help us in rapid detection of pathogens, in tracing the outbreaks, and in predicting future outbreaks. There are certain testing modalities, known as biomarkers, which help us in the early detection of diseases, and in monitoring the response to treatment.</p> <p>&nbsp;</p> <p>There has been a lot of advancement in radiological imaging, like CT scan, MRI, PET scan, which help in obtaining samples from remote, inaccessible areas in our body by interventional procedures which, in turn, helps to make an early diagnosis.</p> <p>&nbsp;</p> <p><b>Sahu is consultant, infectious diseases, Yashoda Hospitals, Hyderabad.</b></p> Thu Dec 23 15:09:25 IST 2021 how-the-body-responds-to-an-infection-has-changed-dr-rohit-shetty <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Infections across different parts of the body have seen considerable change in how a pathogen infects and creates challenges for the doctor.</p> <p>&nbsp;</p> <p>In the last decade or so, we have seen a change in dietary patterns like food poor in proteins, omega 3 fatty acids and fibre. New infections have crept in because of changes in our diet. Gut microbiome is one of the most important factors that controls inflammation in our body. It changes as a result of stress, changes in diet and irregular or poor eating habits. The body fighting externally because of a bacteria has changed because of the changes in your diet and gut microbiome. When the gut microbiome is altered, many things could change, from mood swings to immunity.</p> <p>&nbsp;</p> <p>Nowadays we are less exposed to sunlight. We stay indoors too long. That changes your body’s immune system.</p> <p>&nbsp;</p> <p>Because of the pandemic, our lifestyle has become more sedentary. We don’t exercise. There are a lot of changes happening in every part of our body, in every cell of our body. Our lifestyle alters the body’s immune response. If your body is strong and healthy, your response to a particular bacteria, virus or fungi is different. Black fungus was more prevalent in Covid-19 patients because their body’s immune response was weak. It is important that we all make changes to our lifestyle.</p> <p>&nbsp;</p> <p><b>Shetty is vice chairman, Narayana Nethralaya, Bengaluru.</b></p> <p>&nbsp;</p> <p><b>As told to Mini P. Thomas</b></p> Thu Dec 23 15:05:45 IST 2021 how-we-fight-the-many-infections-around-us <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Reenu Jennifer had a bad cold recently. “I had symptoms like sore throat, headache and stuffy nose, which made it hard for me to breathe,’’ recalls Jennifer, a teacher at St Joseph’s Boys High School, Bengaluru. She was unable to do her daily chores and was grumpy and cranky. “Due to the current pandemic situation, I chose to work from home until I recovered. I didn’t want to expose others around me to the infection,’’ she says.</p> <p>&nbsp;</p> <p>Homebound, Jennifer kept gargling and taking steam inhalation. She also tried home remedies like honey ginger tea, which helped ease her symptoms.</p> <p>&nbsp;</p> <p>Jennifer wonders why medical science is still not able to find a cure for common cold, the most common infectious disease among humans. Dr Swati Rajagopal, consultant, infectious diseases and travel medicine, Aster CMI Hospital, Bengaluru, has the answer. “Since common colds are caused by rhinoviruses, the challenge is the number of circulating strains or types of the virus. There are at least 160 aero types or strains of the virus, so unfortunately we do not have one master key to cure the virus. It is virtually impossible to create one vaccine or one drug against the 160 types.’’</p> <p>&nbsp;</p> <p>In the future, we can successfully evolve a method of targeting the immune response against the structure common to all subtypes, says Rajagopal. “That is when we can offer protection against all the subtypes,” she says.</p> <p>&nbsp;</p> <p>Infections have marched in lockstep with us in our race to modernity. The world is still reeling under a pandemic, and Omicron, the new Covid-19 variant, has cast a dark shadow on our hopes of returning to a normal life. “The vaccine is short-lived. The antibodies and protection do not last long and hence you have to keep taking the vaccine. Also, infection with the virus causes long-term problems in 40 per cent of those who got even a mild infection. We are going to live with this for a long time,’’ says a top Emory virologist. “The current viruses are not vaccine-escape mutants. They are coming. I hope I am wrong.’’</p> <p>&nbsp;</p> <p>India has a disproportionately high burden of infectious diseases. Common infections include upper respiratory infections, influenza, diarrhoea, pneumonia, urinary tract infections, worm infestations, infections affecting the skin and soft tissues like boils and abscesses, tuberculosis, dengue, malaria, chikungunya, typhoid fever and HIV/AIDS. It is estimated that drug-resistant infections will result in 10 million deaths a year worldwide by 2050, a significant portion of which will occur in India. Drug-resistant tuberculosis has already been a major public health concern in the country, despite the government’s efforts to eradicate TB by 2025.</p> <p>&nbsp;</p> <p>Veteran virologist Dr Jacob John is appalled with the way India deals with its infectious diseases. “Take, for instance, TB. How many people have TB in the country? WHO tells us the numbers. If you ask any doctor, he will say the numbers given by WHO are an underestimation. We don’t have a policy to control cholera or typhoid fever. India is home to infectious diseases and yet we don’t have a policy,’’ he says. “We are very tolerant. We tolerate filth, plastic, bacteria, viruses and diseases.’’</p> <p>&nbsp;</p> <p>In the west, if a person is infected with cholera, they make sure the system is cleared to control the infection, says John. “A patient with an infectious disease receives the same kind of treatment in India and the west. However, there is a huge difference in the way the public health system works. In European countries, that one patient will result in a community investigation. They trace the origins of the outbreak and take necessary measures to reduce the transmission. On the other hand, in India we will add one statistic point and move on,’’ says John, who describes himself as an unwelcome virologist who brings up inconvenient facts.</p> <p>&nbsp;</p> <p>The pandemic has changed everything. The changes in our susceptibility to infections are evident in the outpatient department of our hospitals. “People at large are using masks. As a result, respiratory infections have come down,’’ observes Dr Mahendra Dadke, head of department, internal medicine, Jupiter Hospital, Pune. “Usually the paediatric OPD is full of respiratory infections. But as schools were closed, the incidence of those infections came down.”</p> <p>&nbsp;</p> <p>But we can’t breathe easy, owing to Omicron. “Omicron is a mutating virus. It is an unusual mutational variant, having many mutations in one variant,” says John. “It is a leapfrog mutation, not step by step mutation. The mutations look as if the variant had been mutating for a long time.” The virus now is more virulent and spreads faster. Also, it escapes previous immunity.</p> <p>&nbsp;</p> <p>People who get Covid-19 are found to be more prone to other infections like fungal infection. The high incidence of mucormycosis in the country is attributed to the rampant use of steroids in Covid-19 patients. Moreover, Covid-19 affects pancreatic beta cells. So the incidence of diabetes or high blood sugar has gone up in the population, which, in turn, causes other infections like urinary tract infection and skin infections. “Sugar is a good medium for bacteria to grow,” explains Dadke.</p> <p>&nbsp;</p> <p>Even something innocuous as a spinach or lettuce salad can sometimes lead to infections. Eating unwashed or badly or improperly cooked food can cause neurocysticercosis, an infection of the brain and spinal cord. “Though the infection was considered to be common among non-vegetarians, especially those who eat pork, later we came to know that it is more commonly seen among vegetarians. That is possibly due to the use of vegetables that are contaminated with the eggs of tapeworms,’’ says Dr P. Satish Chandra, adviser and senior consultant, neurology, Apollo Hospitals, Jayanagar, Bengaluru. These eggs will get into the body through consumption of unhygienic food. It travels through the blood and could get lodged anywhere in the body. If it lodges in the brain or spinal cord, it is called neurocysticercosis, explains Chandra, who is also former director and vice chancellor, National Institute of Mental Health and Neurosciences, Bengaluru.</p> <p>&nbsp;</p> <p>Neurocysticercosis affects the nervous system in different ways and the manifestations may vary. The commonest manifestation is seizure. If it occurs in the spinal cord, the patient may experience weakness in limbs.</p> <p>&nbsp;</p> <p>But that is not as common as, say, urinary tract infections (UTIs) that affect both men and women. Women are at greater risk of UTIs than men. A recent study published in Therapeutic Advances in Urology says that 50-60 per cent of women experience UTIs at least once in their lifetime.</p> <p>&nbsp;</p> <p>Do not ignore symptoms of UTIs, warns Dr Prathima Reddy, director, lead obstetrician and gynaecologist at Sparsh Superspeciality Hospital for Women and Children, Bengaluru. UTI, if left untreated, could lead to inflammation of the kidneys and septic shock, a potentially fatal medical condition.</p> <p>&nbsp;</p> <p>Bond girl Tanya Roberts, fondly remembered for her performance in A View to A Kill as well as Charlie’s Angels died of a UTI in early 2021. Roberts developed sepsis after the UTI. The infection had spread to her “kidney, liver, gallbladder, and then bloodstream”, leading to her death.</p> <p>&nbsp;</p> <p>In pregnant women, UTI could result in complications that can affect both the mother and the baby. “UTI causes growth restriction and reduced weight of the baby. People often resort to self-medication for UTI, which in turn can lead to health complications. Most frequently, we find that people start antibiotics by themselves,’’ says Reddy.</p> <p>&nbsp;</p> <p>It is always better to see a doctor and get a urine culture and sensitivity test done, she says. “The urine culture report comes back to us in about three days,” says Reddy. “Meanwhile, if the symptoms are really bad, we start the patient on antibiotics and change the medicines later once we get the reports. The urine culture test will help the doctor know whether the antibiotics prescribed for the patient are the right ones. UTI can affect women of all ages—teenagers, middle-aged, pregnant and post-menopausal women.”</p> <p>&nbsp;</p> <p>Symptoms of UTI include a burning sensation and pain while passing urine, increased frequency of urination and presence of blood in urine. The patient may also experience chills with a fever. “If any of these symptoms start, drink plenty of water, see a doctor, get a urine test done and start an antibiotic prescribed by them,” says Reddy.</p> <p>&nbsp;</p> <p>Some infectious diseases like malaria and typhoid, though, share similar symptoms, making diagnosis harder. Manu Leen from Kochi had symptoms like fever, headache, nausea and diarrhoea. As her condition worsened, she was hospitalised. Malaria was suspected, and she was given anti-malarials. The test results took too long, she recalls.</p> <p>&nbsp;</p> <p>A diagnosis of typhoid was confirmed later. “I was going through tremendous pain—severe headache and body pain,” says Leen. “I would scream in pain and my family thought I wouldn’t survive. I couldn’t eat anything.”</p> <p>&nbsp;</p> <p>Leen survived the illness, but the misdiagnosis, medications and prolonged hospital stay took a heavy toll on her health.</p> <p>&nbsp;</p> <p>She had no relapse of typhoid, but she lost 20kg and had excessive hair fall. She also had persistent body aches that lasted around three months.</p> <p>&nbsp;</p> <p>Fever is a common symptom of most infections. It may or may not be associated with other manifestations such as cough, cold, diarrhoea, skin rash and body ache. Most infections are viral and are self-limiting. “Hence patients can take symptomatic therapy for the first 2-3 days with antipyretics, cough syrups, oral rehydration solutions (but never antibiotics) and seek medical help if they are not better by third or fourth day,’’ explains Dr Tanu Singhal, consultant, paediatrics and infectious diseases, Kokilaben Dhirubhai Ambani Hospital, Mumbai. “However, if there are risk factors such as extremes of age (very young or very old), immunocompromised state, underlying diseases or excessive fatigue, weakness, dizziness, lethargy, breathing difficulty, low urine output, persistent headache and vomiting, they should report to emergency services immediately.”</p> <p>&nbsp;</p> <p>Cancer patients undergoing chemotherapy and radiation are more susceptible to infections because of their immunocompromised state, says Dr B.S. Ajaikumar, chairman and CEO, HCG Group of Hospitals, Bengaluru. “They may have infections without any fever,” he says. “Their body's ability to fight infections is lower as their immunity levels are low. We usually do what we call immunity scoring. Based on that, we decide which patients are likely to get infections and we take lot of preventive measures, apart from normal hand washing and masking. We also make sure these patients get some oral antibiotics before we administer them chemotherapy.” The infection rate is higher in patients undergoing chemotherapy than radiation.</p> <p>&nbsp;</p> <p>Infections come through the water we drink, too. Parvathy, 37, from Thurputhallu, a coastal village in west Godavari district of Andhra Pradesh, earns a living by cleaning and selling the fish her husband catches.</p> <p>&nbsp;</p> <p>One day, she complained of fever, continuous vomiting and diarrhoea. Medical investigations by the village health care provider revealed that she had jaundice. “The likely cause was the water that she had been consuming,’’ says Dr Swati Subodh, cofounder of 1M1B foundation. The foundation’s Project Auxilia focuses on health care of fishermen in rural Andhra Pradesh.</p> <p>&nbsp;</p> <p>In Thurputhallu, clean water is still a luxury many cannot afford. Fetching water from a public tap has been part of Parvathy’s daily grind ever since she got married. Living on land surrounded by the sea, she always knew the water in her village was not fit for drinking. However, like most women in her village, she would use it for drinking and cooking. The smell and purity of the water bothered her, but she had no access to other sources.</p> <p>&nbsp;</p> <p>Parvathy’s long road to recovery took a heavy toll on the family’s income. She was not able to work for a month.</p> <p>&nbsp;</p> <p>“Since then Parvathy boils her water, as much as possible,” says Subodh. “However, the additional fuel cost incurred for boiling the water does not make this a likely long-term solution to her.”</p> <p>&nbsp;</p> <p>Infections add to rural India’s health woes. Water-borne diseases like cholera, jaundice, diarrhoea and hepatitis are high in coastal communities of west Godavari, says Subodh. Project Auxilia encourages fishermen to use cost-effective charcoal-based water filters.</p> <p>&nbsp;</p> <p>Infections don’t spare newborns either. Preterm or low birth weight newborns are at increased risk of infections. Pneumonia, sepsis, tetanus and diarrhoea are some of the leading causes of neonatal deaths in India. Infection in babies born less than 72 hours ago is usually caused by the maternal genital tract, says Dr Amit Gupta, chief neonatologist and paediatrician, Motherhood Hospital, Noida.</p> <p>&nbsp;</p> <p>“Genital tract infection is common during pregnancy and can result in neonatal infection,” he says. “Newborns can also get infected owing to contaminated hospital surroundings. Unhygienic hands play a major role in community-acquired infections.”</p> <p>&nbsp;</p> <p>Fortunately, breast milk comes to the rescue of infants as it contains antibodies that can fight infection. “Antibodies are present in high amounts in colostrum, the first milk that comes out of the breasts after birth,” says Gupta. “Breast milk is also said to provide other essentials like proteins, fats, sugars and contains white blood cells that work to fight infection in many different ways. It is also said that breastfeeding sets the stage for a protective and balanced immune system that helps recognise and fight infections and other diseases even after breastfeeding ends.’’</p> <p>&nbsp;</p> <p>Moreover, advancements in diagnostics and treatment offer much hope. For tackling infections, the need usually is quick diagnosis and accurate treatment, which, in general, reduces mortality, says Dr Neha Mishra, consultant, infectious diseases, Manipal Hospital, Old Airport Road, Bengaluru.</p> <p>&nbsp;</p> <p>“If we look at bacterial infections, it used to take as long as 72 hours to know the cultures (isolating bacteria in labs),” she says. Now, it is possible to not only classify the type of organism but also the type of mutation in much lesser time, thereby enabling a quick decision on the therapy to be provided. “Inventions like MALDI-TOF and BACTEC have made speciation easy and quick, while modalities like Carba gene XPERT give us an answer regarding mutation within an hour’s time,” she says.</p> <p>&nbsp;</p> <p>Techniques like PCR testing have made it easier to diagnose viral infection and that too on any type of sample, be it blood, cerebrospinal fluid, pleural fluid or urine, says Mishra. “Such PCR techniques have been used to diagnose bacterial and fungal infections as well,” she adds.</p> <p>&nbsp;</p> <p>Not only diagnostics, the treatments have also taken a leap. “For instance, in HIV, the type of drugs available—dolutegravir, bictegravir—now has made the disease easily manageable,” says Mishra. “The good news is that such changes have been implemented even in government programmes, making these drugs more accessible and available to all. These changes have taken HIV/AIDS from a universally fatal disease to a chronic health care issue.”</p> <p>&nbsp;</p> <p>A lot of advancements have taken place in treatments for lung infections, too, especially tuberculosis. Thirteen-year-old Shourya Akshata Mangaonkar from Mumbai experienced severe stomach ache during Diwali. “We discovered that she had TB,’’ recalls Akshata Mangaonkar, her mother. It was a highly complex and critical case, she recalls. Mangaonkar was treated at Kokilaben Dhirubhai Ambani Hospital, Mumbai. She is now recuperating at home.</p> <p>&nbsp;</p> <p>Earlier patients with TB used to be given blanket therapy or empirical medication. “We are getting the reports faster now,” says Dr Arvind Kate, chest physician and pulmonologist, Zen Multispeciality Hospital, Mumbai. “In the last two years, there are newer diagnostic modalities like respiratory BioFire that are available. They have made diagnosis faster and more accurate. We are more targeted now in terms of our therapies. We are more selective in our antibiotics. This helps to prevent antibiotic resistance. It helps save costs, too.”</p> <p>&nbsp;</p> <p>Giant strides have been made in biomarker science, too. “Biomarkers help us understand in what direction patients are going,” says Kate. “Some antibiotics are very costly and patients end up spending Rs10,000-Rs15,000 a day just on antibiotics. With biomarkers, we know whether the antibiotics work and if the infection is under control.”</p> <p>&nbsp;</p> <p>Abhishek Salagre, 29, a chartered accountant from Mumbai would vouch for that. He was diagnosed with TB on his 24th birthday. “I was doing my chartered accountancy course then. My schedule was so hectic that I barely had time to eat,” he says. “I would often skip my lunch and dinner and my immunity came down drastically.’’</p> <p>&nbsp;</p> <p>When TB manifested as chest pain, Salagre consulted a doctor. It was found that both his lungs had been affected. Salagre had a hard time managing his studies and fighting the potentially serious infection. To add to that, his treatment was delayed as the doctor was using traditional methods. “I took the TB medicine for 18 months. Then I met Kate and in three months, my treatment got completed,’’ says Salagre, who is getting married to his girlfriend.</p> <p>&nbsp;</p> <p>Antimicrobial resistance is a huge challenge in the treatment of TB. Bacteria and bugs which used to be easily treated with a certain level of anti-bacterials are now showing tremendous resistance to them. This is the world’s major challenge today, especially in ICUs, says Dr Rohit Shetty, consultant, cornea and refractive surgery and vice chairman, Narayana Nethralaya, Bengaluru. “We use the antibiotics so much that the bacteria become tolerant to them,” he says. “A huge chunk of antibacterials of the 1980s and 1990s are no longer sensitive to a lot of bacteria. We have to keep building new drugs. After a few years, the same drug won’t work because of the antibiotic abuse.”</p> <p>&nbsp;</p> <p>There has been a rise in multi-drug resistance over the last 10 years. “Bacteria that are resistant to certain types of antibiotics make treatment of TB all the more challenging. New medications are being introduced by the government to tackle this problem,’’ says Kate. Antibiotic misuse is common in outpatient practice, which contributes to antimicrobial resistance.</p> <p>&nbsp;</p> <p>Jael Varma has never taken antibiotics. The Bengalurean hardly falls sick. “I eat basic homemade food. I never take tablets unless it is a dire necessity,” says the poet. “I stay away from toxicity (both situations and people) and I always drink hot water.” Dancing and practising mindfulness keep her happy and healthy. Varma says our body is supremely intelligent. “It always tells us what is wrong,” she says. “All you have to do is pause and listen.”</p> <p>&nbsp;</p> <p>For Bengaluru-based media professional Barkha Chawla, science and nature go hand in hand. That is why she has no qualms in letting her two-year-old—Jeeana—play in the sand. Chawla believes that a little exposure to the environment helps children build a strong immune system. “I always allow her to go out in the nature,” she says. But she also abides by the ‘prevention is better than cure’ adage, and so adds that if there is enough scientific proof that “a vaccine will save my child from an array of infections and life-threatening diseases, I will immunise my child without a second thought”.</p> <p>&nbsp;</p> <p>Vaccines are the most powerful weapons in our arsenal in the fight against infectious diseases. Vaccine hesitancy, says John, is a major public health challenge, especially in rural India. “People don’t trust the system,” he says. “They think the government is covering up adverse reactions. The truth is we don’t have a system to monitor adverse reaction. It is a systemic failure.’’</p> <p>&nbsp;</p> <p>In the fight against infections, more dramatic than treatment advances are advances in prevention of infections through vaccination, says Singhal. “Small pox is the most striking example. Apart from smallpox, the incidence of polio, diphtheria, tetanus, whooping cough and measles have declined dramatically due to widespread immunisation,” he says. “On the flip side, we still await effective vaccines against tuberculosis, malaria and dengue.”</p> <p>&nbsp;</p> <p>We live in a world full of microbes. Pathogenic microbes are present in the air we breathe and the food we eat. Germs lurk in bathroom light switches, refrigerators, microwave handles and stove knobs. Public restrooms are breeding grounds for E. coli, streptococcus, hepatitis A virus and the common cold virus. Cash and pillows have more germs than we think. If you are reading this story on your phone, don’t forget to wash your hands before you snack. A study conducted by Insurance2Go, a gadget insurance provider in England, shows that smartphone screens have three times more germs than a toilet seat.</p> <p>&nbsp;</p> <p>Getting rid of germs in our environment is an insurmountable task though. All we can do is maintain hygiene, learn to coexist with bugs and protect our body against infections.</p> Sun Dec 26 11:42:47 IST 2021 christian-eriksens-cardiac-arrest-shows-risks-faced-by-overworking-athletes <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Denmark vs Finland. The Euro 2020 match this June between the Nordic countries was supposed to be one of the low-key fixtures of the group stages, and yet it turned out to be the most talked about.</p> <p>&nbsp;</p> <p>The world watched in horror as Danish star midfielder Christian Eriksen collapsed face first in the 43rd minute of the game and players of both teams rushed to revive him. He had suffered a cardiac arrest.</p> <p>&nbsp;</p> <p>German doctor Jens Kleinfeld was by his side within seconds, performing cardiopulmonary resuscitation (CPR). An electric shock from a defibrillator worked and Eriksen opened his eyes after 30 seconds.</p> <p>&nbsp;</p> <p>“Are you back with us?” Kleinfeld asked Eriksen.</p> <p>&nbsp;</p> <p>“Yes, I am back,” Eriksen responded feebly. “Damn, I’m only 29 years old!”</p> <p>&nbsp;</p> <p>The player’s words echoed what was on everybody’s mind: how could a fit athlete at the top of his game suffer a cardiac arrest mid-match?</p> <p>&nbsp;</p> <p>As Eriksen was transferred to a hospital and news trickled in of his health improving, possible reasons for the sudden attack were being spelled out by physicians.</p> <p>&nbsp;</p> <p>Eriksen was playing in his 66th competitive fixture in exactly one year since football restarted after a break because of the pandemic. Just a few hours before Denmark’s first Euro 2020 game, FIFPRO—a global union of professional footballers—had reiterated its long-standing view that players were under increasing pressure because of a congested schedule.</p> <p>&nbsp;</p> <p>The Dane’s former cardiologist, Dr Sanjay Sharma of St George’s University, London, had told The Mail that Eriksen had no prior history of heart issues. He had been screened regularly since 2013 at football club Tottenham Hotspur and the tests always returned normal.</p> <p>&nbsp;</p> <p>The doctor’s inference was that FIFPRO is right. The relentless schedule can take its toll on athletes, though it may not seem like it. The fatigue of extended periods in a bio-bubble with little rest between tournaments was also cited as one of the reasons for the Indian cricket team’s dismal show at the T20 World Cup, as players like Virat Kohli voiced the need to “manage his workload”.</p> <p>&nbsp;</p> <p>Six days after the unexpected attack, Eriksen walked out of the hospital. He is fitted with an implantable cardioverter-defibrillator in his chest, a device that addresses irregular heart rhythms. He has been undergoing rehabilitation in Denmark.</p> <p>&nbsp;</p> <p>Though he has been given the green light to resume light physical activity, his doctors have told him that it would take at least a year of monitoring him to decide if he can resume high-intensity training and competitive football.</p> <p>For now, the Italian league, where Eriksen plays domestic football, does not allow players to participate with devices like the ICD fitted to them. His club, Inter Milan, has since prohibited him from returning to action for the remainder of the ongoing season, which ends in May 2022.</p> <p>&nbsp;</p> <p>Doctors have told Eriksen that follow-up tests would tell whether the ICD would be a permanent fixture for him or whether it can be removed by next year. It is uncommon for footballers to play with ICDs, but not unheard of. Dutch defender Daley Blind was fitted with an ICD in 2019 after being diagnosed with heart muscle inflammation, but he has continued playing for both club (Ajax) and country.</p> <p>&nbsp;</p> <p>Eriksen might be back on the pitch next year, perhaps in a different domestic league where ICDs are allowed. But the concerns remain of overworking professional athletes as more competitions are squeezed into their calendar every other day.</p> Sun Nov 28 12:57:29 IST 2021 moderate-exercise-is-key-says-dr-aashish-contractor-reliance-foundation-hospital <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Over the past few months, there have been a number of sudden cardiac deaths in relatively young, and seemingly healthy individuals. This has caused great consternation, especially among those who exercise. The fear has been exacerbated, since many of these celebrities were regular exercisers. And that has raised the question of ‘excessive exercise’ and its potential harm, instead of benefit. As is the wont these days, social media has been on fire with advice from various sources, which have increased rather than allay the fears.</p> <p>&nbsp;</p> <p><b>Exercise and the heart</b></p> <p>Studies done over several decades have clearly shown the benefit of regular exercise and physical activity to reduce the risk of heart disease. Exercise can benefit the heart, directly and indirectly. Direct benefits include helping the heart muscles get stronger and pump more blood per heart beat as well as the ability to withstand abnormal heart rhythms better. Indirect benefits include control on blood pressure, sugar, cholesterol and body fat, all of which reduce the chances of a heart attack.</p> <p>&nbsp;</p> <p><b>Exercise and sudden cardiac death</b></p> <p>There is nothing more dramatic and scary than an athlete having a cardiac arrest during play, or immediately after exercise. It also generates more fear than the larger number of people who have the same event while, say, watching TV, working or even during sleep. Research has suggested that the commonest causes of these deaths differ in those who are young (below 35 years) versus those who are older. At this point, it is also important to distinguish between a heart attack and a cardiac arrest. A heart attack, or myocardial infarction, occurs when a blockage in the coronary artery ruptures and blood flow to the heart muscle is cut off. Usually, one third of heart attacks lead to cardiac arrest and death. As the name suggests, a cardiac arrest occurs when the heart stops beating. This can happen because of several causes, with heart attack being one of them. In the younger age group, a condition known as cardiomyopathy is the commonest cause of cardiac arrest and death, while in the older group, a heart attack is the commonest cause of death.</p> <p>&nbsp;</p> <p><b>Can you exercise too much?</b></p> <p>On social media, it is common to attribute some of the deaths in young and fit persons to excessive exercise. It is important to keep in mind that sudden cardiac death very rarely occurs in someone with a healthy heart. Exercise may be the trigger to have a cardiac event in individuals who have undetected or silent heart disease, but it is almost never the cause. In terms of a single episode of exercise, there is no absolute upper limit defined, and it all depends on the individual’s training level. One should avoid high levels of unaccustomed exertion, the rule of thumb being that any given bout of exercise should not be more than a ten per cent increase from previous bouts. Environmental conditions should also be considered, and outdoor exercise should be avoided in extreme weather conditions, as this is one scenario where even a healthy person can suffer serious consequences.</p> <p>&nbsp;</p> <p>Another way to look at ‘too much exercise’ is the overall volume of exercise accumulated over the years. Here, the research has shown that a very large volume of exercise over several decades might cause some changes in the heart muscle, as well as accumulation of calcium in the coronary arteries. At this point, the amount of exercise has not been defined, and the consequences of these changes have not been fully understood. However, it is well known that to reap optimum health benefits, moderate exercise is the way to go.</p> <p>&nbsp;</p> <p><b>How does one reduce the risk?</b></p> <p>1. Pre-participation health check</p> <p>2. Paying heed to warning signs</p> <p>3. Sensible and appropriate training programmes</p> <p>&nbsp;</p> <p><b>Pre-participation health check</b></p> <p>There is no definite testing protocol that can completely rule out risk, but we can certainly minimise it. The first step is to evaluate your cardiac risk factors, which include age, family history, smoking, high cholesterol, hypertension, diabetes and obesity. In my experience, if there is a cardiac death in a close family member, below the age of 60 years, we need to be more watchful. Review your cardiac risk factors with your physician, who will decide on the need for further testing. For most people, there should not be any need for further testing before starting with a moderate exercise programme, such as brisk walking.</p> <p>&nbsp;</p> <p><b>Warning Signs</b></p> <p>Several studies have shown that individuals who experienced cardiac events during exercise often had mild warning signs and symptoms prior to the event, which they ignored. The most important of these are:</p> <p>1. Chest discomfort, which may present as acidity or heartburn</p> <p>2. Increasing fatigue</p> <p>3. Unusual breathlessness with usual levels of exercise</p> <p>&nbsp;</p> <p><b>Appropriate training programmes</b></p> <p>All exercise programmes should progress gradually. Most arrests and deaths occur in individuals who participate without adequate preparation or those who ramp up their training exponentially. At the end of vigorous physical exertion, it is important to cool down appropriately, since reduced blood supply to the heart may be exacerbated by abrupt cessation of activity.</p> <p>&nbsp;</p> <p><b>Take-home message</b></p> <p>Regular exercise has great health benefits. It is important to start at a low level and progress gradually to a moderate level. If you would like to engage in vigorous exercise, it would be prudent to review your risk factor profile with your doctor, before doing so. During exercise, if you feel any discomfort or unusual symptoms, stop and get yourself evaluated.</p> <p>&nbsp;</p> <p><b>The writer is director of rehabilitation and sports medicine at the Reliance Foundation hospital, Mumbai.</b></p> Sun Nov 28 12:58:39 IST 2021 train-your-mind-says-grandmaster-akshar <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Staying healthy is a very important part of living. We may be able to forego a lot of other things, but health is something we need if we want to truly enjoy life. And when it comes to the topic of over-exercising, then you must be able to work your fitness routine also into a system. We all have different capacities in terms of stamina, strength, flexibility, and we should learn to slowly build our capacity.</p> <p>&nbsp;</p> <p><b>Rest and recover</b></p> <p>Looking at this from the perspective of yoga, there is an important point to keep in mind. Yoga covers all aspects of health, which includes the physical, mental as well as spiritual health. Therefore, while exercising it is important that you invest as much in your spiritual and mental health as you do in your physical fitness.</p> <p>Death is inevitable and no matter what you do you cannot escape it. Rest and recovery are an important process in fitness. Not only does your body need time to heal and recover, but you must also pay close attention to your mental wellbeing. Find enough time for relaxation and also indulge in activities that are good for the mind, body and spirit—whether it is reading a book or finding a hobby that helps you increase your creativity. These are all different ways to de-stress the mind, which then helps you to become a healthy individual.</p> <p>&nbsp;</p> <p><b>Do not suppress emotions</b></p> <p>If you carry stress, anxiety and any other form of repressed or suppressed emotions, this could harm you in the long run. This is because it spills over in any activity that you do. By finding enough time for relaxing, you are ensuring that the body and the mind are able to recharge and rejuvenate in order to continue with anything that you are pushing yourself to do.</p> <p>&nbsp;</p> <p><b>Self-awareness</b></p> <p>Most important, you must be aware of your own mental wellbeing and health. When you are happy and calm, this also translates into the physical body. If you perform any activity while holding a lot of stress within you, then it invariably affects your productivity and creativity. Most of us lead with the mind and the mind can be a tricky companion. The mind can lead us either towards goodness or towards harm. If we are able to maintain a state of mental wellbeing that is beneficial for us, then we can easily progress towards growth, prosperity and harmony. But if we are full of fear, worry or negative emotion, then all our actions will be led by these emotions, causing us harm and self destruction.</p> <p>&nbsp;</p> <p><b>Find what works for you</b></p> <p>Everybody deals with different kinds of situations in life, and there are no two people with the exact same problems. Therefore, the solutions also have to be different. Keeping this in mind, it is essential that you analyse how you deal with troubling situations or challenges that life throws at you. If you are a person that tends to hold everything inside you and are unable to express how you truly feel, then in the long run this builds up, causing a lot of physical problems, like lifestyle diseases. Thus, you must make a conscious effort to seek out people or activities that help you to open up and express yourself freely.</p> <p>&nbsp;</p> <p>Last but not the least, practise yoga and also consume a nutritious diet. Find a reasonable balance in your life with work and play. Rest as well as you push yourself hard.</p> Sun Nov 28 12:59:30 IST 2021 dr-rajeshwari-janakiraman-of-manipal-hospitals-on-our-biological-fitness <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Biological fitness goes far beyond just body weight. For instance, when someone is overweight, losing just 5 to 7 per cent of body weight can bring several benefits—metabolism moves into the normal range, blood sugar level comes down, there is reduced dependence on medicines, cholesterol drops, blood pressure is normalised and thyroid fluctuation is in control. So if we have a 100-kilo man whose ideal weight is 60 kilos, losing just 10 per cent of his weight might not make much difference to his appearance or physical fitness, but, biologically and metabolically, there will be tremendous benefit. One need not go to the same extremes to achieve biological fitness as one does to get a certain physique.</p> <p>&nbsp;</p> <p>Biological metabolism has to do with ensuring that the respiratory and cardiac parameters are in place, and breathing is normal. For instance, normal blood pressure is 125 and pulse is about 72. Maintaining a non-extreme exercise regime and a balanced diet goes a long way in establishing biological fitness. There is no shortcut. You cannot achieve it by drastic and sudden changes to your daily routine.</p> <p>&nbsp;</p> <p>The parameters for gauging biological fitness are fairly simple: an adult must be able to walk at a speed of 5 to 7kmph. If you can do that, you do not have to go overboard with exercise. Biological or metabolic fitness means being able to do everyday activities without any stress. There is no need for excess muscle building using weights or high-protein diets.</p> <p>&nbsp;</p> <p>A person might have abdominal obesity, but it might not hamper his day-to-day living. Having said that, it could also be damaging his biological fitness and he might not even know until it is too late. Ideally, adults must get around five hours a week of moderate exercise or two-and-a-half hours of more intense activity or a combination of the two. Going over that will not drastically increase one's health benefits. To give the most basic example, I would say that light to moderate runners have a lower risk of death (from fitness-related issues) than people who are sedentary, but those who run at an extreme pace many times a week have an increased risk compared with those who do not run at all. This is because an extreme endurance workout puts demands on the body's cardiovascular system. Too much intensity can undo some of the benefits gained from being active. After a round of workout, assess how you feel physically and emotionally, and you will know if you have been pushing it too hard.</p> <p>&nbsp;</p> <p><b>The writer is consultant endocrinologist, Manipal Hospitals, Bengaluru</b></p> Sun Nov 28 13:00:19 IST 2021 heres-why-experts-warn-against-going-overboard-with-exercising <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>In barely two months, India lost two very popular and celebrated actors—Puneeth Rajkumar from the Kannada film industry and Sidharth Shukla from the Hindi film industry and a Big Boss winner. Both were in their 40s, gym regulars and advocates of fitness. Yet, both died a sudden cardiac death; they died before they could be admitted to hospital. Neither of them suffered from pre-existing conditions. A similar death was that of Raj Kaushal, Bollywood director and husband of actor Mandira Bedi. Kaushal was 49 when he suffered a “sudden heart attack”. He, too, was known for his “active lifestyle”.</p> <p>&nbsp;</p> <p>Each of them had complained of “chest pain” a few hours after their workout, and that has led to several questions. Did the workout have anything to do with it? Did the body undergo exertion caused by 'over-exercising', which then led to a heart attack? How can someone in the prime of one’s life and a fitness buff die of heart attack, which was hitherto mostly seen in the older population and those leading sedentary lifestyles? Medical experts and scientists all agree that exercise in itself cannot be blamed for tragic clinical outcomes, and that it is mainly the “yearning for pushing the body undesirably to test its limits often as an outcome of social pressure” that is at the crux of the problem.</p> <p>&nbsp;</p> <p>According to Dr Vivek Jawali, chief of cardiothoracic vascular sciences, Fortis Hospitals, one thing that could have happened in Rajkumar’s case was that hardcore exercising could have ruptured his arteries. “For instance, if you have soft to moderate plaques in your arteries, then exercising very hard can lead to spiking of the heart rate, contractile force and blood pressure, which, in turn, can lead to friction of the fast-flowing blood on the arteries and rip them open,” he says. He, however, adds that in Puneeth’s case the heart attack did not come as a major surprise as he had a family history of heart disease. “His brother Raghavendra had come to us at 23 because of a heart attack. His father, Dr Rajkumar, was treated by us for many years for the same problem.”</p> <p>&nbsp;</p> <p>This June, Danish footballer Christian Eriksen suffered a cardiac arrest and collapsed on field during Denmark's opening Euro 2020 match. The footballer got a miniature defibrillator fitted to detect and correct heart rhythm disorders.</p> <p>&nbsp;</p> <p>A cardiac arrest, say experts, occurs when the heart stops completely, rendering the person unconscious. A heart attack, on the other hand, is a condition that slows down blood circulation, and the patient may stay conscious.</p> <p>&nbsp;</p> <p>“We have always had young patients coming to us due to heart attacks caused during and after physical exercises, and a lot of them have been extremely fit also,” says Dr Sudhir Pillai, consultant cardiologist, Hinduja Hospital. He explains that physical fitness may not always be the same as “biological fitness”. The body, he says, does not care about physical fitness, it is about how healthy you are metabolically. He cites three important reasons for young patients to get sudden cardiac arrest—one, owing to a heart attack when the arteries shut down; two, because of arrhythmia when the heart becomes very fast due to underlying heart disorder; three, arterial dissection, where because of the sheer physical or emotional stress, including sudden heavy exercises, the walls of the artery pop.</p> <p>&nbsp;</p> <p>The moment we cross the age of 20-25 years, says Pillai, we all have these small cholesterol deposits or plaques in our arteries, which may build up over time. Plaque rupture can happen because of extreme physical stress that one is otherwise not conditioned to, or owing to extreme emotional stress and biological stress such as acute infections.</p> <p>&nbsp;</p> <p>“It takes long years for fitness to be established,” says Pillai. “It is one that begins in childhood and goes on into adulthood. It is worth noting that these kinds of sudden cardiac deaths are not observed much in rural areas or in the labour class or farmers or tribals who have all been doing physical work for years.” For people who take up physical exercise in their 30s and 40s, Pillai’s advice is to give the body time to adapt. “One cannot suddenly start running marathons in short timelines by giving in to peer pressure,” he says. “That can lead to the plaque rupturing and sudden cardiac arrest. Also, those who may be into exercises and fitness for long, but decide to stretch their limits further, for instance, suddenly moving from 20km daily to 40km on a single day will sense trouble at some point. Sheer exhaustion can create either a plaque rupture or dissection of the artery. So please take it slow.”</p> <p>&nbsp;</p> <p>Mahesh Ambekar, a fitness trainer who runs a gym in Mumbai, narrates the tragic death of a 40-year-old owing to sudden cardiac arrest while working out in his gym. “He was a regular and was on top of his game,” he recalls. “On that particular day, he overdid it with weights and cardio. In his thrill for testing the limits of his body, he took up deadlifts that were close to 100kg, something he had never attempted before. I think that did it. It was just all of a sudden and we had no time to act.”</p> <p>&nbsp;</p> <p>‘Ego-lifting’, says Ambekar, is the cause of most injuries and even death inside the gym. “One of my clients was doing leg press, which helps in building the quadriceps and hamstrings of the thigh and buttocks,” he says. “He was a gym regular and knew his regimen well. Yet, he went overboard with the weights. While he ideally had to take 180-200kg, he took 350-400kg weights simply as a way of massaging his own ego and ended up with a broken shinbone, which carries the majority of the body's weight.”</p> <p>&nbsp;</p> <p>Experts agree that extreme exercise can be toxic to the heart. As per a 2018 research report titled, 'Characteristics and prognosis of exercise-related sudden cardiac arrest', published in Frontiers in Cardiovascular Medicine, while physical activity is an established protective factor for coronary heart disease, stroke and heart failure, and may also reduce the risk of sudden cardiac death in the general population, “those who suffer sudden cardiac arrest in association with physical activity tend to be younger and previously healthier”. As per the report, cycling and heavy physical labour were the most common types of physical activity related to sudden cardiac arrest. Reports have also emerged that say putting in excessive running miles, such as ultra marathons, may lead to conditions that may promote cardiac rhythm disturbances.</p> <p>&nbsp;</p> <p>Over-exercising effects go beyond the heart. Dr R.H. Chauhan, orthopaedic surgeon at Bhatia Hospital in Mumbai, says that he regularly gets patients with knee pains, backaches and muscle tears, either because they go overboard on the treadmill or lift excess weight or indulge in too much strength training in the gym too soon.</p> <p>&nbsp;</p> <p>Gym trainer and fitness enthusiast Snehal Thevan, who has been training at a gym in Mumbai's Kurla for over seven years now, cites the example of a “fitness freak who overdid it with squats” The man, in his early 40s, did squats with dumbbells weighing over 90kg. “He should have stuck to 40-50kg,” she says. “But because he went overboard, he got a slip disc when he tried getting back up.”</p> <p>&nbsp;</p> <p>Over-exercising or going overboard with workouts can mean different things to different people, says Chauhan. For somebody who has never exercised in his or her life, overdoing it can mean suddenly indulging in excess workout just for the kick of it. “The legs and the hands stop growing between the ages of 14 and 16 years and the spine stops growing at the age of 22,” says Chauhan. “So that is why any kind of weight-lifting exercise before the age of 18 is not recommended because it can affect one's growth. The most decisive indicator of overdoing it in a gym is the repetition level of a workout. How many times do you do the same exercise over and over again? And, is it too much too early? If the answer to that is a yes, then you are sure to experience muscle fatigue, muscle spasm and muscle tear, and laxity, looseness and injury to the ligaments.”</p> <p>&nbsp;</p> <p>Chauhan recounts the case of a man who started working out in his early 30s. “He began with 40 reps of every exercise in the gym, right from strength training to weights to squats, instead of taking it slow with 10 reps at the start,” he says. “That alone became the reason for soreness in his muscles and it had a major impact on his knees.”</p> <p>&nbsp;</p> <p>Also, while lifting very heavy weights, one can injure the body. “You can sprain any joint during weightlifting, starting from the ankle, lower spine, middle spine, upper spine and elbows,” says Chauhan. “A spinal vertebral fracture, resulting from excess weightlifting, is a high possibility, too.” He cites the example of his friend, also an orthopaedic surgeon, who recently fractured his spine and was bedridden for three days because of overdoing the bent-over-rows exercise.</p> <p>&nbsp;</p> <p>Another example of overdoing it among teenagers is going on a 12km hike with friends all of a sudden with no previous workout routine. Treadmill-related knee injuries that cause wear and tear of joints are the most common gym injuries, and long-term treadmill use in the wrong fashion can even increase the risk of arthritis, says Chauhan. Most of his patients are in the age group of 20 to 40 years who cannot wait to lose weight and build up their muscles and stamina. They want to see the results in a matter of days and that is exactly when things begin to go wrong, he says.</p> <p>&nbsp;</p> <p>So, just how much exercise is too much exercise? We cannot tell for sure, just yet. “There is no pre-defined limit because the science around over-exercising is simply not enough,” says Dr Aashish Contractor, director of rehabilitation and sports medicine at the Reliance Foundation Hospital, Mumbai. “We have not conclusively proven that too much exercise is bad and what the cutoff point is.”</p> <p>&nbsp;</p> <p>Aanchal Gupta, who runs the Arts in Motion studio in Mumbai that focuses on freestyle exercises, says that exercise, even if strenuous, will offer more benefits than risks and only a small minority of those who may be having underlying problems might experience arrhythmia.</p> <p>&nbsp;</p> <p>Agrees Pillai: “There is no doubt that pushing one's body to its maximum every day can stress the heart and raise the risk for arterial fibrillation, a type of abnormal heart rhythm that can lead to heart failure or stroke. But it is important to know that not exercising at all is far worse for the heart than overdoing it, because not getting the blood pumping can lead to clogged arteries and so moderation is key.” The Centers for Disease Control and Prevention recommends that adults get at least 150 minutes of moderate exercise per week to help ward off unhealthy weight gain and heart disease.</p> <p>&nbsp;</p> <p>Jawali notes that heart attack cases among Indians below 50 years doubled in the last 20 years, and such cases increased by 25 per cent among those under 40. A similar trend is noticed among urban women, too. “The problem is a mixed bag of genetic predisposition toward heart attack, which is almost three times more among southeast Asians than among whites and blacks,” says Jawali. “This has been compounded by a dramatic change in lifestyle.”</p> <p>&nbsp;</p> <p>While in the US, a number of athletes and fitness enthusiasts die of sudden cardiac deaths resulting from heart attacks because of irregularity of heart rate, young Indians are dying because of accumulated plaque in their arteries and not irregular heart rhythms, explain doctors. These small plaque lesions collected over time due to sedentary lifestyles will become blocked by the time one is 60, say doctors.</p> <p>&nbsp;</p> <p>“It is not the exercise that is getting people into trouble,” says Pillai, “it is the manner in which the body is put to test during exercise which is the problem. One has to understand the limits of one's own body and follow a structured form of exercise and watch for signs of over-exercise. The most common way of finding it is [to check if your] heart rate is high and [if you] are not able to eat well [in the morning]. Take a break. For instance, after six weeks of good running, take one week off.”</p> <p>&nbsp;</p> <p>Another problem that Thevan has observed is fitness enthusiasts overdoing one particular workout. For instance, somebody who enjoys treadmill spends more than an hour on it while neglecting the other elements of the body. “This type of overtraining presents itself as knee pain, soreness in the legs and also a sort of exhaustion,” she says. The solution lies in diversifying one's workout routine, she adds.</p> Sun Nov 28 13:00:49 IST 2021 the-science-of-human-endurance <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Endurance is the ability to sustain an activity for an extended period. A muscle’s ability to resist fatigue and sustain the contraction is measured in terms of the number of repetitions. Muscle endurance and strength together constitute muscular fitness. Improving muscle fitness makes difficult activities easier and decreases the risk of injury.</p> <p>&nbsp;</p> <p>Endurance training programmes can produce small but measurable gains in muscular strength. Activities that require muscle endurance include sustained walking, running, cycling, resistance training, swimming, circuit training, aerobics, dance and rope jumping. In endurance training, the number of repetitions and the length of the muscle or group of muscles are more important than the resistance/load or intensity/speed at which the physical activity is performed.</p> <p>&nbsp;</p> <p>Endurance athletes desire to maintain an optimal lean muscle that will complement and not hinder performance. Protein contributes only 1 to 6 per cent to total energy costs during endurance exercises, so it is not the main dietary focus. The primary sources of energy are fat and carbohydrates. The main goal of endurance training is to increase the anaerobic threshold as this improves training efficiency.</p> <p>&nbsp;</p> <p><b>Improving performance</b></p> <p>&nbsp;</p> <p>The three factors that affect endurance are:</p> <p>&nbsp;</p> <p>1. The maximum capacity of a person to use oxygen during the exercise (VO2 max)</p> <p>2. Running economy</p> <p>3. Lactate (or anaerobic) threshold</p> <p>&nbsp;</p> <p><b>VO2 max</b></p> <p>Improving this can help the heart work more effectively, allowing more intense workouts and improving performance in events. It will also help the person call upon a wider range of speeds. VO2 max is largely genetically determined. Research has shown that whatever aerobic capacity an individual possesses can be improved with training by only about 25 per cent. Oxygen uptake in females is usually 65 to 75 per cent of those of males. VO2 max also declines with age.</p> <p>&nbsp;</p> <p>Altitude training causes an increase in the haemoglobin content in the blood. So the altitude-trained people, when competing at sea level, seem to have enhanced aerobic performance.</p> <p>&nbsp;</p> <p><b>Running economy</b></p> <p>This is a physiological measure of the amount of oxygen required to run at a specific pace. The more economical the runner, the less oxygen will be needed to run at that pace. Improving running economy leads to lowered perceived effort at your current race pace, increased endurance at the current race pace, and the ability to run faster than the current competitive speed. Resistance work enhances economy by eliminating wasted energy in excessive movement and by stabilising the running motion. Interval running, when done correctly, trains muscles to use oxygen more efficiently when working hard.</p> <p>&nbsp;</p> <p><b>The lactate threshold</b></p> <p>This is the running speed at which large amounts of lactate begins to build up in the blood. Higher lactate levels cause pain in the muscles, which causes an athlete to reduce the level of exertion or slow down pace. An elevated lactate threshold helps the athlete run faster with less discomfort. It is a good indicator of performance in endurance events. The accumulation of lactate usually occurs at just below 10kmph pace. One should always stimulate a degree of lactate buildup to familiarise the muscles with lactate clearance capabilities. When training, it is important to take at least one week in four very easy, so as to allow the muscles to recover. Tempo running involves running a specified distance (four to six miles) at a pace just below the threshold. It is ideal for building endurance and generating lactate buildup.</p> <p>&nbsp;</p> <p><b>Ultra-endurance sports</b></p> <p>Ultra-endurance competition is defined as events that take six hours or more. These events rely on long-term preparation, sufficient nutrition, accommodation of environmental stressors, and psychological toughness. Successful ultra-endurance performance is characterised by sustaining a higher absolute speed for a given distance than other competitors. This can be achieved through a periodised training plan and by following key principles of training. Periodisation is an organisation of training into large, medium and small training blocks referred to as macro-, meso-, and micro-cycles. When the sequencing of training is correctly applied, athletes can achieve a high state of competition readiness and avoid the overtraining syndrome during the months of hard training. A plan is executed in accordance with the following principles of training—overall development, overload, specificity, individualisation, consistent activity and structural tolerance. The training relies heavily on the athlete’s tolerance to repetitive strain.</p> <p>&nbsp;</p> <p>Today’s ultra-endurance athlete must also follow appropriate nutritional practices to recover and prepare for daily training and remain injury-free and healthy. Ultra-endurance events require energy contributions from all three macronutrients (carbohydrates, protein and fat) as indicated by the duration of the event and the lower intensity.</p> <p>&nbsp;</p> <p>The successful execution of an ultra-endurance event is dependent on preparation, and attention is given to nutritional requirements, injury prevention, tissue regeneration, and avoidance of acute tissue trauma and overtraining. The training required for ultra-endurance events is no different from that required for other sports, in terms of the underlying principles. The holistic approach can be expanded into five areas that, when combined, culminate in an integrated view of performance—physiology, biomechanics, psychology, tactics and health/lifestyle.</p> <p>&nbsp;</p> <p>The fundamental variables of physiologic stress are the intensity, duration and frequency of training. Within the training process, the correct balance of low-, medium-, and high-intensity movement is critical to the adaptation process. If too much moderate- or high-intensity training is undertaken, there is a significant risk of fatigue, leading to overreaching or overtraining. Training frequency refers to the number of training sessions within a given time frame, such as a day or a week. Training volume refers to the product of duration and frequency of training (usually in a week), and training load refers to the product of all three fundamental components—frequency, duration and intensity.</p> <p>&nbsp;</p> <p>Carbohydrate diets range from 5 to 7g/kg/d (gram/body weight in kilogram/day) to 7 to 10g/kg/d three to four days before the competition. The higher the intensity, the more reliance there is on carbohydrates. During prolonged running events, 40 to 80 g/h usage has been reported, whereas usage of more than 90 g/h is not uncommon during cycling events. Most endurance athletes report better performances and minor gastrointestinal discomfort using liquid carbohydrates. Research has shown that fluid ingestion of 30 to 70g of carbohydrates per hour can maintain blood glucose oxidation and delay fatigue. A 7.5 to 12 per cent solution has been shown to minimise the chances of hypoglycaemia and maximise performance.</p> <p>&nbsp;</p> <p>The modern ultra-endurance athlete requires sustenance to recover and prepare for upcoming training and racing. Rehydration and recovery of fluid balance after exercise, together with the timing and method of increased food intake to cope with heavy training, are essential for optimal performance.</p> <p>&nbsp;</p> <p>—<b>The writer is consultant, orthopaedics, Fortis Hospitals, Bannerghatta Road, Bengaluru.</b></p> Sun Oct 31 11:38:37 IST 2021 views-from-the-top-a-cardiologist-recounts-his-kilimanjaro-experience <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Mt Kilimanjaro is the largest free-standing mountain on the continent of Africa, standing at an impressive 19,200 feet. It is a dormant volcano and I have been scheming to climb it for a while now. I finally decided on it this February as I felt the pandemic was subsiding. I told my family about it at dinner, and was surprised when my older son, Rohan, 21, asked if he could tag along.</p> <p>&nbsp;</p> <p>He was never much of the athletic or outdoor type. He did play tennis for his school team, but after he went to college to pursue mechanical engineering, that dropped off, too. With Covid-19 hitting, the last year was pretty much spent at home with limited physical activity and a hefty dose of laziness. “Sure,” I said. But it was going to require a lot of training and sacrifices, not to mention taking three weeks off in the middle of the academic year, which he would have to make up. In addition, this could not be the reason for a fall in grades. He agreed, but I still thought that he had bitten off more than he could chew. He had never been above 8,000ft in his life, and that was during downhill skiing, which does not require much exertion at that altitude.</p> <p>&nbsp;</p> <p>How do you train for a mountain with that altitude living at sea level? The short answer is you don’t. There really is nothing that would mimic those conditions. Altitude sickness is a funny thing. It hits when you least expect it, and has nothing to do with age or previous fitness. Sure you could try an altitude gym, but there were none near us. We had a bridge that was about 50ft high. I suggested he wear a backpack weighing at least 30 pounds and keep going up and down the bridge, along with weight training. We would do a few practice climbs in the Rocky Mountains to test the strategy. We had six months to prepare.</p> <p>&nbsp;</p> <p>After three months of training, which I assumed he had done, we made a plan to climb Pikes Peak in Colorado, at an elevation of 14,100ft, by the end of May. It would be his first ‘fourteener’ as they are called. I thought we should do the climb over two days, but he insisted that we do it in one day. The plan was straightforward—we fly into Colorado Springs, which would be our base camp, acclimatise for a day to get our bodies adjusted to the low atmospheric pressure and climb the next day. That would be 7,600ft of climbing in one day, and take the train back down. As luck would have it, there was a storm moving in the day we flew in. We decided to climb without the day of acclimatisation to avoid the storm. There is a small camp halfway called Barr Camp, where you can rest, refill water from a stream (you have to carry your own water purification system) and even spend the night if you have reservations.</p> <p>&nbsp;</p> <p>We made it to Barr camp without an issue, but after that I saw him struggling. He didn’t complain, but we had slowed to a crawl at 11,000ft and we weren’t going to make the summit in time. I asked if he had a headache, and he said that it was going on for an hour and was pretty bad. I knew this was altitude sickness causing mild swelling of his brain—a condition called cerebral oedema—and we had to descend. He didn’t argue with the call. The route was snowed in, too, but the downside was that we had to hike back all the way down. The whole hike took us 12 hours and we were both barely able to walk back to our jeep.</p> <p>&nbsp;</p> <p>I thought that would deter him, but he said we should train harder and return. We did so after another two months, by the end of July. I used to get a text message at 3am most mornings, saying, “Let’s train.” He was away in college and going to the gym before his classes. This time we got smarter. We decided to spend a night at Barr camp at 10,500ft and attempt the summit the next day. He again struggled at 12,000ft. Pikes Peak has these notorious switchbacks—the zigzag route that seems to go on forever—but this time we kept pushing, with ibuprofen and steroids for his headache and finally reached the summit. It was euphoric for him—which consisted of a wry smile and a few animated words.</p> <p>&nbsp;</p> <p>In October, as we were flying to Doha en route to Kilimanjaro, we were seated separately. I went to check in on him and he was sleeping. The flight attendant told me he was shy and polite. We both envied his ability to sleep. We had learnt a lot about each other on the mountains. We were completely different people. He had grown into a young man who had few wants and minimal needs to be happy. The material world that I had strived for meant nothing to him. Socially, too, we were poles apart—he did not have a Facebook or Instagram account. The huge hulk of a mountain was waiting for us, but it suddenly seemed immaterial on whether we would summit. In my mind, we had already scaled a higher mountain.</p> <p>&nbsp;</p> <p><b>A shot at Kilimanjaro</b></p> <p>The alarm went off at 11pm on October 9, but I was already awake, thinking about everything and anything that could go wrong on summit night. Beside me, my son was fast asleep—boy, could he sleep! I woke him up and we got dressed in the cold tent with our flashlights. A hot cup of tea and biscuits awaited us at the food tent. While hiking, food is a lot of carbohydrate and protein-rich bars during the day, including rice, pasta, chicken and mutton—all prepared at camp by the local Tanzania support team. We had carried sleeping bags, rated to -30°F, sleeping pads and plenty of warm clothes. The key is to have multiple layers—a base layer, a middle layer and outer waterproof layer, if needed. On summit night, we needed all layers, gloves, two layers of woollen socks and hand warmers. We went through one last gear check, and went through the route plan again. At 12am, we went out into the cold and dark night making our bid to summit.</p> <p>&nbsp;</p> <p>Earlier that afternoon, we had rolled into base camp at 15,200ft. The last four days had been hiking six to eight hours a day as we made our way to the mountain through the modified Shira route and acclimatised to the altitude. The rule of climbing is to trek higher each day and camp lower, getting the body to adjust to the higher altitude. Contrary to popular perception, the amount of oxygen is unchanged—it is 21 per cent. But the lower atmosphere pressure causes the oxygen molecules to disperse, making for fewer molecules during each breath. The five days of hiking, sleeping out in tents, the poor toilet facilities, weather and altitude were beginning to take a toll. Luckily, despite the close quarters, and the constant fatigue, everyone was holding up reasonably well. We lost one of our colleagues, who recognised he was not adapting to the altitude and made the call to head back down to lower camp.</p> <p>&nbsp;</p> <p>It was pitch black with only the boot of the person in front visible to us through our headlamps. We had 18 doctors in our group, most of them serious and experienced hikers. There were two father-son combinations. Luke was a cute spunky 13-year-old with a Michigan baseball cap, dark glasses and a naughty smile. He was there with his father, an orthopaedic surgeon. Luke would lead the pack. On two occasions, he had issues with altitude sickness, but bounced back with medication. He was in the lead, behind the guide, this time as well. His backpack was being carried by his father to lessen the load on the final assault. Rohan was right behind Luke’s dad.</p> <p>&nbsp;</p> <p>The two keys to climbing are to avoid sweating and to avoid breathing too hard which would need you to stop more frequently. You need to stay on the cooler side, as sweat dampens your base layer. When you stop, you lose heat 25 times faster, as it takes a lot of body heat to warm the wet layer. When we got out of base camp, we were immediately into a steep ridge, causing me to overheat and jack up my heart rate. I thought the pace was too fast. I hung out at the back, shedding layers to get back to pace and after a while got my rhythm back. The group in front pressed on, and with two novice climbers in front, I thought we were headed for trouble.</p> <p>&nbsp;</p> <p>As we climbed higher, I could see Luke tiring. I asked him how he felt and he said he was trying to keep pace with the guide and was getting exhausted. Luke and Rohan were doing what kids do—keep up with the pace, taking it on as a challenge, rather than listen to their bodies and create their own pace. I got into a bit of back and forth with the guide. I told him he was going too fast and he politely told me he was the expert on the mountain and knew what he was doing. I politely reminded him I was the expert on the human body. And the matter was settled—we slowed down. We continued on the near vertical trudge, with quick stops to keep chewing on our bars for nutrition.</p> <p>&nbsp;</p> <p>At around 18,000ft, the group was in varying stages of disarray. The portable water that we carried on our backs was frozen. We were briefed on this and switched to drinking from Nalgene bottles. The sun was just beginning to come up and I took a minute to take in the beauty of the mountain. I was still feeling reasonably good and the altitude was not affecting me as much as I thought it would. The lead guide identified four of us to go ahead. Three of us were experienced hikers, and we let inexperienced Rohan lead us. He was surprisingly getting stronger the higher we went. The last 1,000ft seemed to take forever, and every time we crested a ridge, thinking we had reached the summit, we would realise that it was a false summit. The true summit seemed to be just out of reach, tantalisingly close, almost mocking us. We climbed false summit after false summit till the true summit was in sight. And, at 7.30am on October 10, after a 7.5-hour-long climb, the inexperienced non-hiker, with no previous high-altitude exposure, led us to the summit.</p> <p>&nbsp;</p> <p>There is nothing magical on a summit. It is just a piece of rock. The magic lies in the journey, the perseverance and the pain that you put yourself through. The mountain does not discriminate—it punishes everyone—and in the process always changes you. It may be subtle, but you are a changed person. The harshness makes a more kinder and gentler person out of you, as you realise how insignificant you are compared to nature. The kids got to learn this at an early age. The four of us were alone at the summit. It was serene, with breathtaking views. We sat down for a bit and just took in the moment. We were at the highest point on the continent and there was nowhere else to go, literally and metaphorically. Doing this climb with my son and spending time together and discovering each other has made this my most memorable climb.</p> <p>&nbsp;</p> <p>As far as physical endurance goes, I still think the Ironman endurance race is the toughest. This would count as a close second. I keep learning on how much I can push my body. I honestly feel more comfortable now, than when I was younger, about the extent to which I can ask my body to push without breaking down. The experience and the pace really helps. I know the body well as a doctor and it is interesting to see how far I can take it. This gives me a better perspective on how to advise my patients, my friends and family as I have experienced the situations I advise them about. It is different from pure academic knowledge. I think it helps me to be a better doctor and, more important, a better person. It also helps me focus on the more important things in life, like time and relationships. The time spent with my son was priceless.</p> <p>&nbsp;</p> <p>We took the obligatory pictures at the summit and commenced our descent. We had a long road ahead of us— we had to descend 14,000ft over the next day. We met the rest of the group, led by a determined Luke. Everyone made summit. The descent was uneventful, except for one part where I lost my footing and fell on to a rock. “You okay, Dad?” I heard a voice call and looked up to see Rohan with a quizzical half smile. I had been asking him that same question all week, so I guess it was payback. “Yes,” I replied sheepishly, as I got back on my feet. Luckily, nothing was hurt except for my self-esteem.</p> <p>&nbsp;</p> <p>On the first day as we were registering at the main gate, I saw a man sitting by himself. I introduced myself and my son as I thought he looked lonely. His name was Mick and he was from Amsterdam. Turned out, he had split from his wife and decided to climb Kilimanjaro on a whim. He was all lean muscle and in good shape, so this wasn’t his first rodeo. One of the things about the mountains is you meet people—strong people—and form relationships. For some reason we pour our hearts out to each other—complete strangers. Sometimes you only know first names, phone numbers are not exchanged and most of the time you never see each other again (if you are lucky on occasion you do), but you draw from each other at that point of time. We made friends with the local people. Our lead guide was a gentleman by the name of Festo. He spoke good English. We talked about everything, including our daily lives, ambitions, family and altitude climbing. The local people, well versed with the mountains, gave us a historical context as well as guided us every step of the way while climbing. It would be a very difficult, if not impossible, proposition to attempt the climb without their experience.</p> <p>&nbsp;</p> <p>I saw Mick coming down as I was getting into base camp after an hour and a half descent. “Amsterdam,” I shouted across the ridge. He looked up and smiled. “Dinesh,” he shouted back, raising his arm. “I saw Rohan up ahead, and he is looking strong.” “How was the summit?” I asked. He thought for a bit, and said, “I have never felt more physically broken and yet so mentally whole.” I was not quite so physically broken, but I did feel mentally whole.</p> <p>&nbsp;</p> <p>—<b>The writer is clinical assistant professor of medicine, Florida State University, and director, interventional and structural cardiology, AdventHealth, Daytona Beach, US.</b></p> Sun Oct 31 11:43:43 IST 2021 inside-the-world-and-work-of-anaesthetists <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Every time I visit a dental clinic, I say a little prayer of gratitude for Dr Karl Koller, the man who discovered local anaesthesia.</p> <p>Koller, an Austrian ophthalmologist and a colleague of Sigmund Freud, experimented with cocaine as a local anaesthetic for eye surgeries. He had earlier tried using morphine, bromide and chloral hydrate for local anaesthesia in laboratory animals, but failed.</p> <p>His experiment with cocaine was conducted on a frog. One of its eyes was treated with cocaine solution. The cocaine solution started to work a minute after it was administered. The frog did not show any signs of discomfort when Koller touched the cornea of its eye treated with the cocaine solution. But when he tried to touch the other eye, it got agitated.</p> <p>Koller repeated the tests on a rabbit and a dog, too, and the results seemed promising. He found that cocaine had pain-killing as well as tissue-numbing properties. Thereafter, cocaine was used as a local anaesthetic in different types of surgery. Cocaine, however, is no longer used as an anaesthetic, as it can damage the cornea and can be addictive. Today, there are a variety of anaesthetics that are being used in surgeries and procedures, which can be administered through inhaled gas, injected via shots or intravenously, applied topically in liquid form or as a patch or through spray. And, in the right hands, they put patients at ease, numbing their pain, and let surgeons and specialists work in peace.</p> <p>But those hands are rarely noticed, despite the fact that it requires high precision skill to administer anaesthetics. Anaesthesiology is among the most high pressure specialties in medicine, says Dr Sreeja Menon, associate director and head of department of anaesthesia at Max Hospital, Gurugram. “All our drugs act on various organ systems and need to be fine-tuned according to the patient and surgery for optimal results or can end up creating a disaster,” she says. “High-level skills are needed for an ideal outcome. A patient’s life is practically in the hands of the anaesthesiologist during a surgery. Even after 22 years, I must be very alert on the job, with no room for error.”</p> <p>There are different types of anaesthesia, including local anaesthesia to numb a small section of the body (generally used during cataract surgeries or dental procedures); regional anaesthesia to block pain from a larger section, say, a limb or below the hip (for example, epidural during a caesarean); and general anaesthesia to put the patient in a sleep-like/unconscious state (used during invasive surgeries). People usually associate anaesthesiologists or anaesthetists with operation theatres. Their job, however, begins way before the surgery and at times continues even after the patient leaves the operation theatre.</p> <p>An anaesthesiologist’s job starts when the surgeon sends a patient for surgery. He or she meets the patient and does a pre-anaesthetic check, which involves getting to know the patient in detail. “We try to understand whether the patient had any surgeries or anaesthesia issues in the past,” explains Muralidhar Thondebhavi S., consultant, anaesthesiology and pain medicine, Apollo Spectra Hospital, Koramangala, Bengaluru. Anaesthesiologists also take a look at the patient’s medical history, the medicines being taken and allergies, if any. They also check if any family member reacted badly to anaesthesia in the past. “Following this, we do a physical examination of the patient, which includes an examination of the mouth and oral cavity,” says Thondebhavi. “After that, we tell the patient what type of anaesthesia is given and what to expect after the surgery. This patient interview generally ends with obtaining an informed consent.”</p> <p>On the day of the surgery, the anaesthesiologist reviews the patient again. “We also need to prepare the operation theatre,” says Thondebhavi. “We check the anaesthesia machine every day for its proper functioning. We have to load all the drugs that are to be administered to the patient. We use a lot of checklists, very similar to how pilots use checklists while flying. The WHO surgery safety checklist is another valuable tool, which is used just before anaesthesia is given. We have checklists for checking the machine as well. The use of checklists enhances safety.”</p> <p>But not many are aware of the work that anaesthetists do, and several myths abound. One of the common myths people have is that anaesthesiologists are technicians. This is far from the truth. Anaesthesiologists are qualified doctors. They must finish the four and a half years of medical school (MBBS), followed by three years of specialisation. Next, they must pass the university or national board exam to become a certified specialist anaesthesiologist, says Dr Yash Javeri, critical care, anaesthesia and emergency medicine, Regency Superspecialty Hospital, Lucknow. After passing the exam, one can pursue a super specialisation in a field of his/her choice­—cardiac anaesthesia, paediatric anaesthesia, neuro-anaesthesia, intensive care, chronic pain management and emergency medicine.</p> <p>Menon, for instance, did her MD in anaesthesia from a government hospital. “It was for three years and involved postings in all branches of surgery like gynaecology, orthopaedics, neurosurgery, cardiac surgery, ENT and ICU,” she says. “I had to take an exam at the end of three years, both practical and written, and submit a thesis before being declared an MD in anaesthesia. I did a senior residency in AIIMS, Delhi, for another three years post MD.” Menon did her super specialisation in chronic pain management and started her practice as a consultant before working her way up to becoming the head of the department. The foundation of anaesthesiologists is formed by studying physiology, pharmacology, anatomy and physics, says Thondebhavi. “Physiology is the study of how the body functions. As anaesthesiologists, we see the complete spectrum of how the body works in health and disease,” he explains. “We need to know how gases, machines and electricity work. The drugs that we use are some of the most powerful ones. So an anaesthesiologist should have indepth knowledge in pharmacology and how anaesthetic drugs and gases work. Besides these, we need to know about all other specialities and associated comorbidities.”</p> <p>There are many myths about regional anaesthesia, too. “People don’t consider [regional anaesthesia] to be anaesthesia because they remain aware of the surroundings, though not about the surgery,” says Dr Madhujeet Gupta, senior consultant, anaesthesia, PSRI Hospital, New Delhi. Another myth is that anaesthesiologists leave the OT after administering anaesthesia. In fact, anaesthesiologists play a key role from the start of the surgery till the patient is shifted either to the recovery room, adjacent to the operation theatre, or an ICU. They are experts in dealing with post-operative pain and they ensure patients are as comfortable as possible.</p> <p>“Our main area of work lies in the operation theatres, conducting safe anaesthesia for all the surgeries being done,” says Gupta. “We have to ensure that the patient’s pain is well managed before and after the surgeries. Many patients are required to be kept on elective ventilator support and intensive care after critical surgeries. Such patients are kept under the constant monitoring and care of an anaesthetist till they recover.”</p> <p>There is a constant challenge till the surgery is over, especially in case of complicated surgeries. “Many unforeseen complications or events happen during the course of anaesthesia,” says Gupta. “Failing to address the situation at the right time could have grave consequences. So, vigilance and preparedness is the key to the successful conduct of anaesthesia.”</p> <p>Anaesthesia is calculated based on body weight, the age of the patient, the specific illness the patient has and the type of surgery he or she is undergoing. A drug error occurs when there is gross miscalculation or because of an ailment, like a weak heart, that the anaesthesiologist was not made aware of prior to the surgery. Unexpected allergic drug reaction can falsely be attributed as errors.</p> <p>Thondebhavi recalls a drug error that he made in the early days of his training. That incident turned him into a “safety-obsessed” anaesthetist. “We were operating on a child for a birth defect in the urinary bladder,” he recalls. “At the end of a procedure under general anaesthesia, we normally give a cocktail of drugs for the reversal. It reverses the chemically-induced muscle paralysis. That day, I picked up the wrong syringe. I injected the medicine that causes the paralysis.” Instead of waking up instantly, the child was unconscious for another 30 minutes. “It didn’t cause any harm,” says Thondebhavi. “But it made me realise the drugs loaded into the syringes should be labelled and read accurately.”</p> <p>An anaesthesiologist’s role is not restricted to the OT only. Anaesthesiologists dealing in critical care have to take care of sick patients in collaboration with other specialists looking after different aspects of the patient’s wellbeing. Many believe that pain after the surgery improves immunity. However, the truth is that pain increases the stress response in the body and can weaken it.</p> <p>Another popular misconception about spinal anaesthesia is that it causes back pain. Women who have undergone C-section may complain of back pain. Thondebhavi attributes it to poor posture among other reasons. Women do not get back to their normal posture after the C-section and they often blame the back pain on anaesthesia. “We use a fine needle and it generally doesn’t cause any trauma,” says Thondebhavi, who is a member of the national executive committee of the Academy of Regional Anaesthesia of India.</p> <p>The myths and misconceptions could be because anaesthesiologists come in contact with patients only briefly during their hospital stay. As doctors working in the background, their patient contact is minimal. Patients don’t recognise the vital role anaesthetists play, and their hard work often goes unnoticed and unacknowledged. Even during the pandemic, the largest group of frontline medical specialists were anaesthesiologists in different roles, says Javeri. Many of them worked for 24 hours or more without a break in the last one and a half years. “It could have been a lot more encouraging if the patients directly appreciate the pains we take to keep their sufferings at bay,” says Gupta.</p> <p>Being an anaesthesiologist can take a toll on one’s health as well. Anaesthesiologists, in general, lack control over their working hours. Some work with different hospitals as freelance anaesthesiologists. Erratic schedules lead to a poor work-life balance. Unlike other doctors, anaesthesiologists can hardly step out of the hospital. Spending long hours in artificial light can be detrimental to one’s physical and mental health. Night shifts are an inevitable part of their lives. A typical day in an anaesthesiologist’s life is filled with hours of boredom and moments of terror. “We do have occasions where decisions have to be made in a split second,” says Thondebhavi, who has brilliantly captured the life of an anaesthetist in his book <i>Think Like An Anaesthetist</i>. “When patients entrust their life with us, that itself is a demanding position to be in.”</p> <p>For Menon, juggling the responsibilities at home and work has never been easy. Between managing a home, two children, family and a full day at work, life has been hectic, she says. Her workday begins at 8am and on a lucky day ends at 5pm, but there are days that stretch into nights and she gets free only by 11pm. “Pressures of the job begin right from the days of training or residency,” she says. “Long duty hours, busy sleepless emergency nights, ICU duties and academics during training keep us on our toes.”</p> <p>Dr Darshan V. Pawar, consultant anaesthesiologist at Narayana Nethralaya in Bengaluru, will agree. For him, a typical workday begins the previous day itself. By late evening, he receives the list of patients scheduled for surgery the next day. This is followed by segregating the patients into different categories, depending on the severity of their medical condition and their general health. These preparations help the team prioritise high-risk patients with multiple health problems and comorbidities and tackle unforeseen eventualities, adverse effects or complications during the surgery.</p> <p>Family is his anchor, says Pawar. He loves to play table tennis with his son and helps his wife with household chores. “Watching movies is my greatest stress buster,” he says. “I like old Kannada movies. They are so entertaining.” Occasionally, he catches up with friends and colleagues over coffee. On Sundays, he goes cycling.</p> <p>From Monday, as always, duty calls and he readily answers.</p> Thu Sep 23 14:36:21 IST 2021 how-anaesthetic-drugs-and-gases-work <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes, says Dr V.S. Ravikanth, consultant cardiac anaesthetist at Yashoda Hospitals, Hyderabad. “Anaesthesia includes analgesia (pain relief), paralysis (muscle relaxation), amnesia (loss of memory) and unconsciousness. The purpose of anaesthesia is to keep an individual away from feeling pain during a procedure,” he says.</p> <p>Broadly speaking, there are two types of anaesthesia—local and general. A simple procedure like cavity filling can be done under local anaesthesia. “The patient will be given an injection to numb the area,” says Dr Muralidhar Thondebhavi S., consultant, anaesthesiology and pain medicine, Apollo Spectra Hospital, Koramangala, Bengaluru. “It blocks specific channels in the nerves called sodium channels. When these channels are blocked, the sodium ion cannot travel into the nerve. This stops conduction of nerve impulses. Local anaesthetics block the nerve sensation being carried through the nerves to the brain.”</p> <p>Local anaesthetics work on peripheral nerves, which can be in the arm or the spinal cord. Unlike local anaesthetics, general anaesthetics work on the brain and render a person unconscious.</p> <p>General anaesthesia is commonly used for major operations such as heart and brain surgeries. General anaesthetics may be divided into two types—intravenous and volatile. Intravenous anaesthetics are given into the blood stream and they render the person unconscious in 15-30 seconds. ‘’We understand to a certain extent how these medicines work,” says Thondebhavi. “They block certain receptors in the brain. The chemicals in the brain which we call as neurotransmitters are unable to act because general anaesthetic drugs block the receptors.” It gets unblocked later and the patient regains consciousness.</p> <p>Anaesthetic gases fall in the volatile general anaesthesia category. A volatile general anaesthetic can be used in the form of a vapour, which is breathed in by the patient. It goes to the lungs, from where it is taken up into the blood stream and then into the brain. “Once it reaches the brain, the exact mechanism by which it works is still not clearly discovered,” says Thondebhavi. “But we know that they dissolve in the fats. Therefore, we deduce they work at the level of nerve cell membrane, nerve junctions or some of the proteins in the cell membrane or receptors.”</p> <p>There are a wide range of gases that can produce a state of general anaesthesia—from xenon (used presently in research setting) to complex hydrocarbon agents used routinely (which are similar to ether). They produce a state wherein the conduction of impulses in the brain is stopped, causing the patient to go to sleep. Modern anaesthesia practice doesn't involve the use of chloroform or ether.</p> <p>Children undergoing a surgery are usually given the anaesthetic gas, as injections can be too traumatic for them. But for adult patients, anaesthesia is generally given intravenously. “Once the patient is asleep with the IV anaesthetic agent, the anaesthesia is maintained for the duration of the operation by continuing the IV anaesthetic agent or by giving them the volatile anaesthetic agent through the breathing tube,” says Thondebhavi. “This is given as a mixture with oxygen with or without nitrous oxide (laughing gas). It keeps the patient asleep for the entire duration of the operation.”</p> <p>At the end of the operation, the gas is switched off. The anaesthesiologist makes sure the gas washes out of the patient’s lungs. The brain concentration of the gas decreases and the patient wakes up.</p> Thu Sep 23 14:23:17 IST 2021 how-an-anaesthesia-error-put-a-french-footballer-in-coma <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>An anaesthesia error put him in a slumber he never woke up from.</p> <p>Former European football star Jean-Pierre Adams died on September 6 after remaining in a vegetative state for nearly four decades.</p> <p>The African-French footballer, with 22 international caps to his credit, was admitted to Lyon Hospital on March 17, 1982, for a knee surgery.</p> <p>The day he was operated on, many staff at the hospital were on strike and the anaesthetist was overburdened—she had to look after eight patients, including Adams. A trainee who supervised Adams later confessed, “I was not up to the task I was entrusted with.”</p> <p>Adams was starved of oxygen during the procedure, leading to a cardiac arrest and brain damage. Decoding what went wrong, a Bengaluru-based anaesthesiologist said, “The breathing tube that we normally put into the lungs for giving oxygen was not in the right place, or there was a condition with the patient that made giving oxygen difficult.” Back then, patient monitoring systems in the operation theatre were at a relatively nascent stage, he said. “Pulse oximetry was just coming around. Probably it wasn’t even available in France,” he says. “So the anaesthetist didn’t have a proper way of measuring oxygenation in the blood and hence the problem might have been picked up late and by then the damage was already done.”</p> <p>Born in Senegal, Adams had risen from humble beginnings. He was enrolled at a school in France at the age of 10 and was adopted by a French couple. He was in hospital for 15 months. Post his discharge, his wife Bernadette tended to him, changing his clothes, talking to him and even giving him presents like T-shirts, pretty bedsheets and scents. “No one ever forgets to give Jean-Pierre presents, whether it's his birthday, Christmas or Father's Day,” she told CNN.</p> <p>Bernadette never considered turning off his life support machine. “Jean-Pierre feels, smells, hears, jumps when a dog barks,” she said in 2007. “But he cannot see.” She believed he could recognise “the sound of her voice as well”.Adams met Bernadette at a dance when he was an amateur footballer. They started living together at a time “when a black man and a white woman being together wasn’t well-regarded.”</p> <p>Bernadette’s parents disapproved of the relationship. However, when Adams and Bernadette decided to get married and they broke the news to her parents, her mother invited them to dinner. “After that, everything was fine and he was seen in a better light than me: ‘Jean-Pierre, Jean-Pierre’—they only spoke of Jean-Pierre!’’ she said.</p> <p>After a legal battle that went on for 10 years following the mishap, the court ruled in Bernadette’s favour and she started receiving annuities. The anaesthesiologist and the trainee just received a one-month suspension and a fine of €750.</p> <p>Had Adams undergone the surgery in this decade, would things have been different? “Nowadays we have excellent monitoring systems in most of the places, even in the periphery,” says a senior anaesthesiologist. “We can monitor the oxygenation in the patient’s blood and ensure whether the tube is in the right place in the lung. These can be done on a routine basis. Anaesthesia-related deaths were significantly high in the 1980s, but they have dropped to probably one in two lakh surgeries now.”&nbsp;</p> Thu Sep 23 14:14:44 IST 2021 what-it-means-to-be-the-worlds-first-ivf-baby <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>She grew in a glass jar as an embryo and was later placed in her mother’s womb.</p> <p>Louise Brown, the world’s first baby conceived outside of the human body, celebrated her 43rd birthday this July 25. “I was subjected to more than 100 tests after my birth to ensure I was a ‘normal child’,” she told THE WEEK.</p> <p>Louise was a child of perseverance and relentless hope. Her parents—Gilbert John Brown, a truck driver, and Lesley—desperately wanted a baby. The couple, who lived in Whitchurch, England, tried to conceive for nine years without success. Lesley had fallopian tube blockages that made natural conception impossible. She had undergone failed operations in the past to clear her blocked tubes and was prepared to “put up with anything” to have a baby.</p> <p>On November 10, 1978, the couple underwent a procedure, wherein a mature egg extracted from one of Lesley’s ovaries was fused with John’s sperm in a laboratory under the direction of physiologist Sir Robert Geoffrey Edwards and gynaecologist Patrick Christopher Steptoe. Lesley was warned that there was only a “one in a million” chance of having a baby, but she clung to hope.</p> <p>The egg was fertilised and divided into two, four and then eight cells. Lesley got pregnant after the eight-celled embryo was implanted in her womb. Being the first woman to have conceived via in vitro fertilisation (IVF) and have a pregnancy that went beyond a few weeks, Lesley attracted a lot of media attention. Edwards and Steptoe found it hard to shield her from the media frenzy. She was hounded by the press so much that Steptoe hid her in his car and drove her to his mother’s place in Lincoln. Later, when Lesley was admitted to Oldham hospital for delivery, reporters entered her room posing as housekeeping staff.</p> <p>Louise ‘Joy’ Brown, weighing five pounds 12 ounces, was born by C-section at 11.47pm on July 25, 1978. The ‘Joy’ in her name was a suggestion from the two doctors. Her birth marked a milestone in modern medical science. It was described by <i>TIME</i> as “the most awaited birth in perhaps 2,000 years”. The baby offered a ray of hope to millions of childless couples across the world. Until then, for women with damaged fallopian tubes, it was impossible to conceive. Edwards won the Nobel Prize in 2010 for the development of IVF therapy, considered one of the most remarkable medical breakthroughs of the 20th century. Around eight million babies have been born in the last four decades through assisted reproduction technologies, including IVF.</p> <p>Louise realised she was an IVF baby only when she started going to school. Lesley showed her a video footage of her birth. IVF was unheard of in those days and people were curious about her unique birth. She had always been big-bodied and some would ask her how she managed to fit in the test tube.</p> <p>The Browns were in the spotlight for many years after Louise’s birth. They were criticised for allowing the doctors to film the birth. Soon after Louise’s birth, Lesley received a post bag full of letters splattered in red. Once, she received a box from the US that contained a broken test tube and a plastic foetus. Louise defended her mother, saying that letting the doctors film the birth was an act of gratitude for her.</p> <p>Things were no different for Edwards and Steptoe. They had a hard time breaking the taboo and stereotypes around IVF. The idea of fertilising an egg outside the body has always been controversial. The first such successful experiment was done at Boston in 1944 by Miriam Menkin, essentially a scientist at heart and mind but often relegated to a lab technician or research assistant to the better-known fertility specialist and contraceptive pill co-developer John Rock. The research got derailed with Menkin’s move to North Carolina, where IVF was considered scandalous, following her husband’s job loss. But it was Menkin’s initial research that eventually led to Louise’s birth through IVF.</p> <p>Edwards, Steptoe and nurse Jean Purdy, whose contribution was forgotten till recently, feared criticism from the church and the public and they kept their work under wraps. Only five of the 282 women who underwent IVF could get clinically pregnant and none of them had delivered a live baby. Many embryos died during the process. Unsurprisingly, the medical community refused them support for research. The UK Medical Research Council feared children born through IVF would run a risk of fatal abnormalities. IVF children, Louise said, are no different from normal children. “The only difference is the process of conception,” she said. “It is impossible to distinguish between an IVF baby and other children born naturally.”</p> <p>John and Lesley went for IVF again and had a second child—Natalie. The couple wanted a third child, but their attempts failed. Natalie was the 40th child to be born through IVF. She became the first IVF child to conceive naturally, easing concerns that women born through IVF cannot conceive naturally. Natalie now has five children.For the Browns, IVF changed their life in more ways than one. Lesley was John’s second wife; he had two daughters from a previous marriage. John and Lesley, who stayed in an abandoned railway carriage on the first night of their elopement, had a hard life. Homeless, penniless and unemployed, they struggled a lot until John got a job as a bus conductor.</p> <p>Infertility was an extremely frustrating experience for Lesley. In an interview to <i>Daily Mail</i> later, she said, “You feel you are not the same as ordinary wives. You don’t feel normal. You feel you are not a real woman. I said to John, ‘Go and find a proper wife.’”</p> <p>The couple couldn’t afford IVF until 1977, when John won £750, by betting on the outcome of a football match. That helped him pay for the IVF treatment.After Louise was born, the Browns earned money by doing exclusives. Louise’s birth was reported exclusively by <i>Daily Mail</i>. Associated Newspapers Ltd, the parent company of <i>Daily Mail</i>, secured exclusive rights to the story and pictures reportedly by paying $600,000. Lesley and John stayed positive amid the negativity that was directed at them. They went on speaking assignments around the world as advocates for IVF.</p> <p>Louise now lives in Oldham with her husband Wesley Mullinder, a nightclub bouncer. Interestingly, Mullinder first met Louise when she was just a few days old. Eight-year-old Mullinder lived across the street from the Browns and was among the crowd gathered to see the extraordinary baby. The duo later met when Louise was 24. Two years later, they were married. They have two boys—Cameron and Aiden. Cameron is 14 and has just begun with his General Certificate of Secondary Education exams; he will be applying for college in another two years. Aiden turned eight this August.</p> <p>All her life, Louise received media attention. And now she is consciously using the media glare on her to break the stigma associated with infertility and IVF treatments. “Couples suffer through a lot of emotional and psychological stress. I think no couple should be deprived of parenthood,” said Louise, who has shared the story of her extraordinary birth and its impact on her life in her memoir <i>My Life As The World’s First Test Tube Baby</i>. “Through my association with ART Fertility Clinics India, I will be working towards the mission of making IVF the wise choice of treatment, enabling couples to realise the dream of parenthood. Another purpose is to assert that all those who need IVF should have access to it.”</p> <p>IVF has come a long way. Scientists now pin their hopes on IVG (in vitro gametogenesis), which could make it possible to produce babies from skin cells. IVG seemed promising when tested in mice. In 2016, a group of researchers in Japan created embryos using skin cells from mice. The embryos were<br> implanted, and eight healthy mice were born.</p> <p>Scientists are now exploring the possibility of making human babies in the lab using skin cells. Imagine a couple wanting to have a baby walking in to a lab to give their skin biopsy samples. The cells from these samples will be transformed into stem cells, which, in turn, will be reprogrammed into sperms and eggs. The process involves creating embryos outside the womb and then transferring them into the woman’s womb for implantation, as in IVF. IVG holds much promise for people who cannot conceive naturally, especially menopausal women, gay and lesbian couples and men with abnormal sperm function or low sperm production.</p> <p>Dr Henry T. Greely, author of <i>The End of Sex and the Future of Human Reproduction</i>, said that in future, sex will no longer be a popular means of reproduction for people in developed countries. People will continue to have sex. But those who want to have a baby would prefer to go to a lab, said the Stanford professor of law and genetics. IVG for humans will be a reality within our lifetime, said Greely.</p> <p>Every woman has the right to have a child, said Louise. “Treatment for fertility problems is a right that should be made available to all women,” she said. IVF not only creates a child, but a family, she added. Despite her extraordinary birth, Louise lives an ordinary life. She worked in a nursery in her early 20s. Currently, she works for a freight company in Bristol. Her days begin with planning meetings with her team at National Fertility Society; her evenings are dedicated to her family. Home means a lot to Louise, who was a much loved and much longed for child. Her mother had carefully kept everything concerned with her birth, from hospital appointment cards and correspondence to letters from journalists and well-wishers and even a movie script by Carl Foreman, Oscar-winning Hollywood film producer. Louise donated them to the Bristol Archives. Among them is a letter from Edwards to Lesley, dated December 6, 1977, which reads:</p> <p><i>Dear Mrs Brown,</i></p> <p><i>Just a short note to let you know that the early results on your blood and urine samples are very encouraging, and indicate that you might be in early pregnancy.</i></p> <p><i>So please take things quietly—no skiing, climbing, or anything too strenuous including Xmas shopping!</i></p> <p><i>If you should wish to get in touch with me for any reason before seeing Mr Steptoe next week, my laboratory number is 0223 65069, and my home number is 0223 54019. Best wishes.</i></p> <p><i>Yours sincerely,</i></p> <p><i>Dr R.G. Edwards</i></p> <p>All these mementos were found in Lesley’s wardrobe following her death. She died due to complications of a gallbladder infection on June 6, 2012. She never regretted her choices.&nbsp;</p> Thu Aug 26 19:42:32 IST 2021 my-birth-was-a-ray-of-hope-to-millions-of-childless-couples <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>Tell us about the best and worst part of being the first human to have been born after conception by in vitro fertilisation (IVF).</b></p> <p>My birth is remembered for two reasons—a milestone in science and a hope to all the women yearning for motherhood. My parents were in the spotlight after my birth. It was also a bit sensational at that time and they received criticism due to debates related to the ethics of the IVF procedure. I feel people have an opinion and they are entitled to it. Infertility is a medical condition and if medical science can overcome it, I do not see any difference in trying to solve that with the help of medical treatment. Back then, I was subjected to more than 100 tests after my birth to ensure I was a ‘normal child’.</p> <p>&nbsp;</p> <p><b>You were a much longed-for child. What was your childhood like?</b></p> <p>I was born on July 25, 1978, at Lancashire. Barring the circumstances of my birth that my parents described as “bit different”, in all other sense I was a normal child, as normal as one can be. When I was born, the doctors suggested to my parents to keep my middle name as ‘Joy’. I am blessed to be the symbol of their joy on their hard work and their success story. While my parents kept me shielded from the criticism, they continued to receive it their entire lifetime. It motivated them to go on speaking assignments around the world as advocates for IVF.</p> <p>&nbsp;</p> <p><b>How did it feel when you first realised that you are an IVF baby?</b></p> <p>It was only when I started going to school that my parents told me that I was born through IVF. It was not a big deal for me as I always considered myself just like the other children around me. All my life, I have received media attention. While most of it has been positive, it surely has its own fatigue and strain—of being constantly followed around and having to constantly look over my shoulders. But as I grew older, I have been consciously using the media glare on me to be an advocate for IVF treatments.</p> <p>&nbsp;</p> <p><b>There is still a lot of stigma surrounding infertility and IVF. How does it affect women?</b></p> <p>Infertility is no more a condition associated only with women. Discussion around male infertility is always ignored. Couples suffer through a lot of emotional and psychological stress. I think no couple should be deprived of parenthood, and my birth was a ray of hope to millions of childless couples across the world. Through my association with ART Fertility Clinics India, I will be working towards the mission of making IVF the wise choice of treatment, enabling couples to realise the dream of parenthood. Another purpose is to assert that all those who need IVF should have access to it.</p> <p>&nbsp;</p> <p><b>Is an IVF child different from any other child?</b></p> <p>IVF children are as normal as other children. The only difference is the process of conception. It is impossible to distinguish between an IVF baby and other children born naturally. Despite being the first IVF baby, I gave birth to two young boys through normal pregnancy. Forty-three years of my life journey have been a testament of the success of IVF and how this medical intervention helped my parents enjoy the joys of parenthood, and me, my very life itself.</p> <p>&nbsp;</p> <p><b>What is your typical day like?</b></p> <p>A daily routine is honestly very hard to say. But I have always known I wanted to work for the cause of infertility and hence a typical day for me usually starts with planning meetings with my team at National Fertility Society. I do believe in work-life balance, and after a busy day I look forward to going back home to spend time with my husband and my two boys.</p> <p>&nbsp;</p> <p><b>Do you have a bucket list?</b></p> <p>I do not have a bucket list per se. But as an instant symbol of hope for couples across the world, my purpose is to assert that every woman has the right to have a child, and that treatment for fertility problems is a ‘right’ that should be made available to all women because IVF not only creates a child, but a family.&nbsp;</p> Thu Aug 26 19:21:07 IST 2021 fighting-covid-19-as-a-family <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Delhi-based writer and filmmaker Vandana Kohli's tryst with Covid-19 began last November when her husband Rajat Sethi, a corporate lawyer, tested positive. Four days later, she tested positive, too. Rajat, thinks Vandana, picked up the virus from his office conference room that was earlier used by a colleague who had conjunctivitis. The couple later learnt that conjunctivitis, too, could be a symptom of Covid-19.</p> <p>&nbsp;</p> <p>Vandana knew that time had come to manage everything on her own for at least a few months. She asked her domestic helps to stay home, while continuing to pay their salary. It was challenging to pull off daily household chores, coupled with their own work responsibilities, but the strategy was to immerse themselves in work to an extent that the emotional upheaval of living with Covid-19 day after day was kept at a minimum. Rajat had fever for five days, but he chose to continue working and also took up online classes for students from the National Law School in Bengaluru. Vandana, too, kept herself busy with the release of her book on emotional wellness, Hinge.</p> <p>&nbsp;</p> <p>While Rajat was battling fever that would keep fluctuating every evening, Vandana was struggling with brain fog. “I couldn't think clearly,” she says. She also went through bouts of terrible breathlessness. Delhi’s winter added to her misery. “I kept coughing like a maniac,” she recalls. A high resolution CT scan found a patch of mild pneumonia and she was prescribed Fabiflu and steroids for 25-30 days. What made it worse was the persisting weakness that lasted for months, making it “impossible to lift the body to do even the basic chores,” says Vandana. “But once you are in that situation, nobody thinks of cleaning. So even if no help is coming over for a week or more, it is fine. Every three to four days, I would do the basic [cleaning].”</p> <p>&nbsp;</p> <p>A couple of months later, as life was gradually crawling back to normalcy, Vandana's brother, Nalin, and her septuagenarian parents, Anupama and Amolak Rattan Kohli, tested positive. At the time, her brother and her parents were near Chandigarh. The family’s ordeal began when Nalin, who had first tested positive, had to isolate himself inside a room, leaving his aged parents to themselves. A recovering Vandana, who still hadn't gotten back her full sense of smell and taste and would be fatigued at the slightest exertion, now had the responsibility of catering to another house infected with Covid-19. A few days later, both parents, too, tested positive and the entire responsibility of managing the show fell on Vandana, who kept flitting between the two homes. “Whatever they would need, I would leave out at the doorstep, stand near the window and communicate three to four times a day,” says Vandana. “The neighbour, too, was extremely empathetic and sent lots of food home.” The family panicked when Anupama, a borderline diabetic, developed high fever and her oxygen levels dropped to 80 and pulse to 75. She couldn't stand and had to be rushed to the hospital. This happened twice. “It was crazy. It's not like once you catch the infection, you can simply go back to your couch and watch TV at home,” says Vandana. “The sheer anxiety of having Covid-19 and the fatigue it causes keeps you on tenterhooks at all times. As a family, our perspective on life changed.”</p> <p>&nbsp;</p> <p>In Mumbai, Charu Mehra, 39, “struggled to make sense of the world,” when she, along with her teenaged niece and sister-in-law tested positive four months ago. “It was as if the entire house had come to a standstill because it is essentially my sister-in-law and I who manage the show on a day-to-day basis. And with us stuck inside our bedroom, there was panic in the house,” says the homemaker. Though she has tested negative, she still feels fatigued.</p> <p>&nbsp;</p> <p>The seven-member Mehra family lives in a two-bedroom flat in Mumbai. Apart from the virus, Charu says she was also battling a sense of guilt on two counts. “That one of us would be blamed for getting it into the family or for passing it on to others,” says Charu. “And then that as daughters-in-law we were being served food in bed. What would the mother-in-law think? All of it was emotionally draining for me.”</p> <p>&nbsp;</p> <p>Also, Covid-19 brought the underlying fissures to the fore. “The interpersonal chemistry between all of us was rapidly undergoing a remarkable shift,” says Charu. “We had never spent so much time together and it was a testing time for us as a unit. There was bitterness, annoyance and frustration, mostly over the additional domestic workload that everyone had to bear. At one point we did shout at and blame each other, but then we have tided over it as one unit and that makes it memorable.”</p> <p>&nbsp;</p> <p>The pandemic has been an intensely challenging period for family life, uniquely affecting families by disrupting routines, changing relationships and roles. Additionally, with child care, school and recreational activities being closed and family gatherings limited, families are going through periods of emotional turmoil and fractured relationships. Stress from Covid-19 has been compounded by additional responsibilities for parents and grandparents, too, as they adapt to their new roles as educators and playmates for children, even as they cope with work-related stressors. At the same time, experts concur that family members are spending more time with one another, thereby knowing each other better and more importantly feeling empathetic towards one’s own.</p> <p>&nbsp;</p> <p>“Only after Covid struck did we all realise the significance of my mother's role in the house and the seamless manner in which she pulled off all familial duties, which we now found to be an enormous challenge,” says Surabhi Kumar, 26, a public relations consultant in Kolkata. The family of four, including her 19-year-old sister Subhangi, a law student, got infected with Covid-19 this March. “On knowing that we were all positive, the first few hours were spent panicking—how would we manage everything, get the essentials, do the household chores day after day—because until now nobody had ever given much thought to these things except for our mother,” says Surabhi. Surabhi and her father, a government employee in the excise department, had mild symptoms like fever and body ache. All four of them experienced “extreme fatigue”. “For a week post diagnosis, we could divide and distribute the chores between us. But post that, as fatigue took over, it became increasingly difficult to even get out of the bed,” says Surabhi. “None of us really wanted to do anything; not cook, wash or clean. We had so much weakness that getting up to get a glass of water was difficult. It was nothing less than a Big Boss challenge. The chemistry between us had become a bit stressed, too.”</p> <p>&nbsp;</p> <p>Says consultant pulmonologist Dr Lancelot Pinto of P.D. Hinduja hospital, Mumbai, “There is no doubt that it pushes one to the limits to have everybody in the house unwell, especially down with Covid-19.” He talks about heart-breaking situations where both the husband and wife are admitted in the hospital at the same time, and one passes away and the other remains oblivious to it. Or, families with just a single, healthy young member caring for three elderly people, especially when he himself is stressed and fatigued with excess work. He talks about the peculiar challenges faced by new mothers, with no outside help and having to juggle homely chores with the continuous attention demanded by a newborn. “Add to that, the stress of infection from Covid-19 and the challenges compound instantly,” says Pinto. He narrates an incident where a two-year-old child had nowhere to go as both his parents were Covid-positive, and his grandparents weren't sure of taking care of him as they, too, were vulnerable in terms of age and immunity.</p> <p>&nbsp;</p> <p>For Chaitali Pathare, 30, the challenge was to look after her 61-year-old father and 53-year-old mother, both of whom tested positive. Chaitali lives in a joint family of six with her parents, younger brother, an aunt and her daughter. They live in two 2BHK flats facing each other on the same floor of a society in Thane. Early morning on April 21, Chaitali’s mother informed her that her father was feeling uneasy and feverish. Chaitali assumed the worst and asked her mother to let him isolate. Given that her father was used to travelling around in Mumbai for work, she suspected it to be Covid-19, because otherwise, she says, he is “fit as a fiddle”. “At the time it was the peak of the second wave and so we immediately got in touch with those who had recovered from the first wave and they suggested a battery of tests and a list of medicines,” says Chaitali, who works in a private firm. “The very same day, we got him tested and the reports came the next morning. He had tested positive. We all isolated ourselves and my mother moved from the bedroom to the living room from day one. Three days later, she had fever. Next morning, she, too, tested positive.”</p> <p>&nbsp;</p> <p>Even as she was taking care of her parents, Chaitali worried that she, too, might contract the disease. But she tested negative thrice. Her father took medicines only for fever and from the seventh day of testing positive, he began feeling better. Her mother, however, had persistent fever, and on the eighth day, her oxygen levels dropped. She was hospitalised for five days.</p> <p>&nbsp;</p> <p>“What worked for us was that we assumed the worst from the very first symptom and started taking precautions,” says Chaitali. “We isolated ourselves, wore a mask at all times, even indoors, consulted a specialist who could guide us properly and had a backup plan ready—list of nearby diagnostic centres, hospitals and ambulances with their contact details.”</p> <p>&nbsp;</p> <p>Experts suggest having a network of trusted people one can talk to regularly and who can help during the situation. “It is really important to have the right doctor to guide you,” says Chaitali. “Many people from their personal experiences advised us to get CT scans done, which was discouraged by our doctor. We did a simple X-ray and that too only for my mother. Other than that, it was just the standard three blood tests—CBC, CRP and D-dimer—for monitoring the level of infection, and taking proper medication, if necessary.”</p> <p>&nbsp;</p> <p>What got to them though was the overload of information, be it from the media or well-wishers, says Chaitali. “It became tiring after a point because there was nothing else they were talking about,” she says. Her parents, too, kept talking about Covid-19, even on phone with relatives and friends.</p> <p>&nbsp;</p> <p>The extent of the impact of Covid-19 also depends on the resilience displayed by the family, says psychiatrist Dr Avinash De Sousa. “That has a lot to do with which family member is affected,” he says. “With the breadwinner, children and the elderly contracting Covid-19, the resilience of the family breaks down.”</p> <p>&nbsp;</p> <p>Severity of the disease also plays a role. “While mild symptoms won't matter, serious complications including hospitalisation and death can totally shake up the familial constellation,” says De Sousa. He lists coping mechanisms in such situations. First, one who is least affected takes charge and starts managing. Second, have a counsellor speak to them online. Third, a psychiatrist or mental health professional should be made part of the treating team, especially when entire families are affected. Fourth, speaking to survivors of Covid-19, especially other families that have been down that path and have emerged stronger together, will help. Fifth, neighbours also play a very important role here and it is important that they are sensitive towards the situation.</p> <p>&nbsp;</p> <p>De Sousa also cautions families who have members with a history of mental health issues. “If there is any family member who has had a previous history of a psychiatric problem, then they need to be extra cautious,” he says, “because the risk of them relapsing is high as they get surrounded by negative information on the disease.”</p> Thu Jul 22 17:17:52 IST 2021 the-tripathis-study-will-have-huge-impact-on-cancer-research <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The study by Dr Vinay Kumar Tripathi and others is exciting with interesting results. This blood test has potential for early cancer detection and to determine the response to therapy. The authors have highlighted the details of 10 cases in their article; it would have been better if more such cases were provided. Though the study included a large cohort of patients, a much larger sample size will validate the claim of [almost] 100 per cent sensitivity and specificity. It would be interesting to see if the result is applicable for the detection and prognosis of childhood cancers.</p> <p>&nbsp;</p> <p>Similar studies by other groups will validate the utility of this procedure, and based on the current report, this method may emerge as one of the easiest and robust ways to predict cancer prognosis.</p> <p>&nbsp;</p> <p>The study will have a huge impact on the field of cancer diagnostics. Given the ease of detection that requires a routine blood withdrawal, a centrifugation step, real-time PCR and the efficiency and specificity reported in the study, this test can be implemented with minimal technical expertise.</p> <p>&nbsp;</p> <p>Early cancer detection and diagnosis are very effective in fighting cancer, as the disease is best treated in its earliest stages. However, until now, not many techniques are available to detect cancer before the onset of symptoms. That is why this technique stands out. Moreover, unlike most methods of cancer detection, this technique is almost non-invasive.</p> <p>&nbsp;</p> <p>One other major advantage of this method is that it detects all cancers—from solid tumours to blood cancers—at all stages. This is a significant breakthrough. Moreover, with a continuous rise in cancer occurrence in India and all over the world, a technique like this is the need of the hour as tissue biopsies and sample collection from different organs are practically impossible before the onset of symptoms. Therefore, this technique can be utilised for large-scale cancer screening in populations with high cancer occurrences.</p> <p>&nbsp;</p> <p>Considering the disruptive innovation this technique brings to the field of cancer detection, a standardised protocol needs to be developed to isolate VSEL cells, which has been a subject of scientific debate. Several research groups have been unable to find these cells, and a few selected groups could detect and isolate them successfully. A standardised protocol will put this debate to rest and will validate the entire study at a broad scientific level.</p> <p>&nbsp;</p> <p>What is intriguing is that if VSELs are quiescent, how do they represent the mutation profile of cancer? Can these cells be detected in the tumour mass by any of the markers they express? Is it also possible that cancer patients have more VSELs than healthy individuals? How does increased Oct4A expression correlate with the mutation profile of these cells or does cancer-associated inflammation increase Oct4A levels in all stem cells? One must be careful in detecting Oct4A because it has several pseudogenes, isoforms, and transcript variants.</p> <p>&nbsp;</p> <p><b>As told to Pooja Biraia Jaiswal</b></p> <p>&nbsp;</p> <p><i><b>Dr Jaganathan is associate professor, department of biosciences and bioengineering, IIT Guwahati.</b></i></p> Fri Jun 25 17:25:17 IST 2021 how-a-mumbai-familys-research-can-help-detect-cancer-early <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Two weeks ago, Prerna Dhawan lost her life to stage IV lung cancer. Her husband and daughter Aarti, 20, are still in a daze as it all happened so fast. Dhawan, in her sixties, showed no symptoms. She went about her daily chores which included a walk in the park, reading books, doing the laundry and cooking elaborate meals. A month ago, she vomited blood. That is when the diagnosis surfaced—a tumour had been growing inside her body for years. It had already spread to both her lungs and nearby areas and even distant organs. The family was shocked and shaken. The doctor told them that it was “already too late for treatment”, and advised palliative care to ensure that her remaining days were pain-free. She was gone within a month of the diagnosis. Even today, as the family struggles to come to terms with her death, one question haunts them: would things have been different had she been diagnosed in time?</p> <p>&nbsp;</p> <p>As cancer continues to emerge as the number one killer worldwide, that question becomes increasingly significant as in most cases the tumours are detected only after they have taken a form or shape. And by the time the symptoms show up, the cancer may have advanced and spread, making it too lethal to be cured. This is true for almost all types of cancers. Take, for instance, ovarian cancer in which the symptoms can often be confused with those of other ailments or dismissed as menstrual cramps. Only regular screening helps in early diagnosis. Even then, the screening helps only after the cells have mutated to form a lump. The treatment begins after a PET scan or a CT scan shows imagery that confirms the tumour. Often scans do not spot tumours if they are very small, weigh less than a gram and are spread in micro particles in the blood.</p> <p>&nbsp;</p> <p>Experts concur that if we are to rein in this silent killer, it is pertinent to identify it in the blood right at 'stage zero' when it first becomes apparent, much before it begins to start forming or multiplying. And this is precisely what the latest research published in the April issue of SCRR (Stem Cell Reviews and Reports) talks about: a blood test to diagnose 25 types of cancer.</p> <p>&nbsp;</p> <p>Helmed by molecular medicine expert and scientist Dr Vinay Kumar Tripathi and his investment banker son, Ashish, the paper claims to have made the discovery of a unique gene marker that allows for early detection of all types of cancer when the disease is still in-situ, meaning it is still limited to the place it started without spreading to nearby tissues. If validated by additional trials, this discovery could mean that a basic blood test—named HrC—can not only detect cancer and its stage but also predict if one can get it in future. And all of this, the paper claims, is with almost 100 per cent accuracy.</p> <p>&nbsp;</p> <p>This discovery, says Ashish, CEO of Tzar Labs, is based on the principle of stem cells, which have the ability to regenerate and develop into other kinds of cells. But the type of stem cells that led the Tripathis and their team to come out with a diagnostic tool for cancer, are the VSELs (Very Small Embryonic-Like stem cells) that are ubiquitously circulating in the body. “We found a large number of VSELs in the circulating blood of patients with cancer as against those without cancer, and the expression of protein Oct4A within the cell showed variations according to the stages of cancer,” Ashish tells THE WEEK.</p> <p>&nbsp;</p> <p>The team developed a HrC test scale, based on observations in a group of 120 cancer patients and then re-tested it in a clinical trial with 1,000 people, half of whom were cancer patients. “Cancer patients and the stages they were at were identified with 99 per cent accuracy and we were also able to tell whether or not non-cancerous patients have the risk of developing cancer,” says Ashish.</p> <p>&nbsp;</p> <p>As per the paper, the HrC scale can detect cancer, predict and monitor treatment outcome, is superior to evaluating circulating tumour cells and can also serve as an early biomarker. An HrC score in the 6-10 range is categorised 'high risk', as it means that the number of VSELs in the bloodstream is significantly elevated as compared to the 'normal' range (0-2). This range precludes ordinary infection, organ inflammation or other disease states, as only cancer-causing gene mutations reflect in this range. The team postulates that a high-risk score might indicate the emergence of cancer stem cells and thereby the underlying proclivity of a person towards developing cancer. When the HrC score is in the 8-10 range, the team categorises it as “cancer imminent”. It signals that cancer-causing gene mutations have already occurred, hence the observed increase in levels of VSELs and the Oct4A biomarker. It also indicates that cancer cells have formed in the primary location. A score of 10-20 is indicative of stage I cancer, 20-30 of stage II, 30-40 of stage III and above 40 of stage IV. For instance, in a 49-year-old non-cancerous male patient, the HrC score was 7.20, indicating high risk. “The patient was an active user of pan masala and gutkha and a regular smoker. In-depth analysis revealed that the subject was at risk of developing oral cancer,” reads the paper. As against this, in a 68-year-old male patient with liver cancer, the HrC value was 40.15, indicative of fourth stage liver cancer. “HrC test was able to accurately detect the stage of cancer,” reads the paper. “A detailed mutational analysis revealed lymph node metastasis, primary and secondary organs like the liver and lung metastasis.”</p> <p>&nbsp;</p> <p>The HrC test, according to the Tripathis, is a non-invasive test that can predict, screen and diagnose cancer with absolute (&gt;99 per cent) specificity and sensitivity. Put simply, from a blood test, they try to extract a patient's DNA or genes and calibrate the mutations in the DNA to see if they point towards cancer. “The difference between the HrC test and the liquid biopsy techniques used by companies globally is that while the former tries to read a genetic signature it has found to correlate with cancer, the others depend on examining tiny particles of broken tumour, circulating in the blood, to make a diagnosis,” explains Ashish. “We are superior in that sense because we took a completely different approach.”</p> <p>&nbsp;</p> <p>The family has now filed for patents in the US, Japan, Europe, Singapore, South Korea, China and India. The HrC test has been co-developed by Epigeneres, a Mumbai-based firm that holds the exclusive licence for the test in India, and Singapore-based Tzar Labs that holds the intellectual property rights for the invention; the family is a majority stakeholder in both firms.</p> <p>&nbsp;</p> <p>But this is not what Epigeneres had initially set out to do. The finding of the biomarker “just happened” while the team was working on finding a cure for cancer. And, while they were debating on whether to delve deeper into this discovery or to continue on the path towards curative cancer medicine, the Tripathi family was going through a period of deep turmoil. Having lost four grandparents to cancer already, the three Tripathi brothers—Anish and twins Amish and Ashish—lost their only brother-in-law Himanshu Roy, who was former additional director general of police, Maharashtra, in 2018 after suffering from fourth stage renal cancer. At the time, Roy's death, widely reported in the media, steeled the family to aggressively pursue cancer research, especially diagnostics. With Roy, cancer had come knocking again 16 years after he first fell prey to it. Except a nagging pain in the calves, there were no symptoms. Roy and wife Bhavna, both gym regulars, initially thought it was a gym injury as Roy first experienced the pain after a workout session. “There was just no other symptom except for that pain,” says Bhavna, who reportedly quit the IAS to be with her boyfriend-turned-husband. “But at the time we thought it was just any other injury and did not take it seriously. He even showed it to a sports medicine expert who then suggested that he do an MRI because the pain just wouldn't subside. The MRI pointed towards a fully formed tumour in his fibula, which required an emergency surgery.”</p> <p>&nbsp;</p> <p>Bhavna says the family embraced his death. “He said that he did not want the disease to take away his dignity,” says Ashish. “Even in his death, he conquered cancer.” Amish, a renowned author who dedicated his recent books Suheldev &amp; The Battle of Bahraich and Dharma: Decoding the Epics for a Meaningful Life to Roy, talks fondly of him. “He had this strict, tough cop image for the outside world. Within the family, he was warm, kind, protective and loads of fun,” he recalls. “He had a wicked sense of humour, and would have us in splits in family get-togethers. Our social life was largely restricted to our immediate family; primarily eight of us—the four siblings and our spouses—with Himanshu da as our patriarch, our collective elder brother!” It was around 2018, sometime before Himanshu's death, that the Tripathis discovered the biomarker. “Dada knew we were working on this and he was very proud,” says Anish, COO of Epigeneres. “We only wish it could be of help to him. The tragedy became a collective trigger for us to bring out a diagnostic tool that could place the most stubborn, hidden tumours by way of a blood test.” And that is how the test got its name: HrC for Himanshu Roy Cancer.</p> <p>&nbsp;</p> <p>At present, with the exception of blood cancers, blood tests cannot absolutely tell whether you have cancer or some other noncancerous condition. But they can give the doctor clues about what is going on inside the body. In addition, noncancerous conditions can sometimes cause abnormal test results. But in other cases, cancer may be present even though the blood test results are normal. And it is in this context that the discovery of the HrC biomarker becomes even more significant.</p> <p>&nbsp;</p> <p>“There is no doubt that scientists are looking for the exact marker for cancer cells which can help us in detecting it at very early stages and can tell a person if he or she has cancer much before the disease can cause an impact,” says Dr Rama S. Verma, professor, Stem Cell and Molecular Biology Laboratory, IIT Madras. “But then, these VSELs are very difficult to catch hold of as they are extremely small, largely indistinguishable and widely spread in the body. If successful, this blood test will be a major breakthrough, but it needs thorough validation through additional research.” Agrees Professor Ajaikumar Kunnumakkara from the department of biosciences and bioengineering, IIT Guwahati. “This is a very important discovery, because till date we have not been able to find a specific marker for cancer and most of the cancers are asymptomatic, which makes it even more challenging. This discovery would lead to the diagnosis of cancer, to identify the susceptible population and importantly in the pre-cancer stage.”</p> <p>&nbsp;</p> <p>The discovery of Oct4A in itself is not novel, say experts. But it is the way in which it is interpreted by the Tripathis and their team that makes it unprecedented. “Oct4A is found in different stages of cancer, therefore this would help in treatment of different types of cancers. Also, it will keep away arbitrary diagnosis which is rampant now, by helping clinicians decide what treatment should be given to the patient,” says Kunnumakkara. “The expression of this protein in non-cancerous patients is very less, but in cancerous patients it is 40 to 50 times [more], which is huge. This is more accurate than others. However, what remains to be seen is if they can place it successfully across populations and places.”</p> <p>&nbsp;</p> <p>Agrees Dr Dilip Nikam, professor and head, radiation oncology department, Bombay Hospital, adding that a number of important issues regarding Oct4A remain to be addressed. “Vinay Kumar Tripathi et al showed us that Oct4A is a good marker and can be studied further,” he says. “Curiously, very little is known about it beyond its ability to regulate gene expression. The mechanism by which it specifies totipotency [ability of a single cell to divide and produce all of the differentiated cells in an organism] remains entirely unresolved. And an increased understanding of Oct4A function in stem cell biology could also lead to novel ways of detection and treatment of multiple malignancies.”</p> <p>&nbsp;</p> <p>Yet, the Tripathis are quick to point out that this does not mean the blood test alone will suffice in making a diagnosis; it has to be accompanied by a PET scan and a biopsy as well, they say. The family hopes to get approvals for further trials so as to speed up the process of making the test available as soon as possible. “We are not entirely ruling out a company buy-out,” says Ashish, “but as of now we can't wait for our first laboratory to come up in Mumbai.”</p> Fri Jun 25 22:20:55 IST 2021 can-rehab-for-sex-offenders-help-combat-sexual-violence <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Sexual violence and the fear of sexual abuse has a profound and devastating effect on not only individuals, but entire communities. According to the 2019 annual report of the National Crime Records Bureau (NCRB), 32,033 rape cases were registered across India; that is an average of 88 cases every day. Since the Nirbhaya gang rape in 2012, public outrage has led to more punitive measures to combat sexual violence, and keeping convicted sex offenders in prison for longer seems like an appealing resolve. However, in reality, this does not contribute towards reducing the risk of future reoffending and harm.</p> <p>&nbsp;</p> <p>There are many factors associated with reoffending such as social and emotional isolation, unemployment or not having something meaningful to do in life. India has 134 central jails, and at the time of my prison research of convicted rapists, Tihar alone had around 400 convicted male rapists serving sentences that ranged from five years to life. While it is a bitter pill to swallow for the public when it comes to rehabilitating sex offenders, the hardest fact that we must face is that the vast majority of sex offenders will one day be released and we need to provide support for their reintegration to avoid reoffending and to reduce future victimisation.</p> <p>&nbsp;</p> <p>Research has shown that rehabilitation of sex offenders is more effective in the community than in prisons, and programmes like Circles of Support and Accountability (CoSA) have been quite effective. In Minnesota, the risk of reoffending and rearrests had reduced by 88 per cent for those who were a part of the CoSA programme.</p> <p>&nbsp;</p> <p>Rob Turner (name changed), a one-time sex offender in the UK—now a close colleague—emphasises the need for greater acceptability of rehabilitation of offenders as a solution. Rob was convicted for the possession and distribution of indecent images and videos of youngsters. He received a sentence that included five years on the sex offenders register, which involves providing notifications regarding any changes in circumstance, any involvement with young people, checks on any necessary disclosures or job attainment and engagement with the public protection unit division of the police. He was also given a three-year community order that dictated his supervision under probation and put him in the Horizon rehabilitation programme. In addition, he also received a sexual harm prevention order, which outlined further restrictions around internet usage and electronic devices.</p> <p>&nbsp;</p> <p>To him, the official conviction does not even begin to explain the other 99 per cent of his identity, nor the complicated array of reasons why he committed the crime. "But, I felt very early on in this process that I was keen to hold myself to account and, in doing so, attempt to navigate ways to support others, too," he said.</p> <p>&nbsp;</p> <p>During my research with convicted rapists at Tihar jail, it was clear that the men actively rejected the label of “rapist”. One possible reason is the stigma attached to sexual crimes, particularly in the current Indian climate that is witnessing strong responses regarding sexual violence against women. This is their coping mechanism; an identity management technique. But this label continues beyond the prison walls.</p> <p>&nbsp;</p> <p>Rob explains how difficult it is to move away from the label of a “sex offender”, to not just being defined by that one mistake. "It is a complex question to surmise," he said. "A key component of the Horizon programme and any probation supervision is about understanding triggers to not only limit reoffending risk but also better grasp your identity beyond the offence and your navigation of choices in the future. We look back to move forward. Personally, I had an exposure to early sexualised experiences which I certainly struggled to both discuss openly and process inwardly."</p> <p>&nbsp;</p> <p>With the realisation of his homosexuality and the negativity around sharing that, Rob's teenage years were of sexual discomfort. According to him, a hidden, compartmentalised narrative began to grow in a shadow-self, one that manifested in a great reliance on pornography and communication in adult chat-rooms. Over time, this became his almost singular source of sexual gratification, one that was instantly available, and one that grew into addictive, habitualised patterns of behaviour. "As addictions often do, it became a vicious spiral in searching for more extreme and dangerous ways to meet the apparent need," said Rob.</p> <p>&nbsp;</p> <p>A healthy support system is extremely crucial in the effective rehabilitative journey of individuals with sexual convictions. Rob credits his support network, stating that its impact cannot be understated and that he considers himself lucky to have such a strong and loving one. "I always had hope that I now had some part to play in the journey of other men with sexual convictions, of passing on my experiences and new-found knowledge, of beginning to explore how this was a wider issue society has refused to discuss. My hope was in defining myself beyond this offence, as a person capable of good, as a person worthy of being a member of society, of paying back, of contributing again. I have spoken to so many organisations and tried to get so many projects off the ground and, though there has been a lot of doors slammed in my face, and society will struggle to have this debate, I hope we are getting there," said Rob.</p> <p>&nbsp;</p> <p>It is important to realise that sexual violence is a public health crisis as well as a human rights violation that the United Nations described as a “shadow pandemic”. But unfortunately, society does not see rehabilitation of sex offenders as a long-term solution. "Any person who commits a sexual offence is not inherently evil... nor should they necessarily be locked away for life," said Rob. He quotes a senior police officer, who said it is impossible to "arrest our way out of it" as the numbers are significantly high. Hence the need for conversation.</p> <p>&nbsp;</p> <p>As part of the Festival of Social Science 2020 (FoSS), I had the opportunity to organise a roundtable event on the need for continued rehabilitation and reintegration of men who have committed sexual offences in the UK. This stimulating event brought together the voices of experts from criminology, psychology, probation, charities sector and service users like Rob, in order to create a dialogue around the need for continued and sustainable rehabilitation.</p> <p>&nbsp;</p> <p>"A person who commits a sexual offence against a child or young person or an adult—whether this is an internet or contact offence—rarely receives any support or awareness of deeper issues before conviction," said Rob. "This experience can destroy one's world in an instant. The loss of work, family, friends, identity, reputation and freedom can lead to harrowing custodial ordeals or equally traumatic, ongoing, social judgement. This, while at the same time as taking responsibility, understanding victimisation, psychological processing and rehabilitation to understand behaviours, coping strategies and the dangers of reoffending can also lead to isolation, less confidence and huge challenges finding work. This can, in turn, lead to mental health issues, reoffending and self-destructive behaviours including suicide."</p> <p>&nbsp;</p> <p>I ask him about individuals who have not been convicted yet but are worried about their sexual thinking. The balance of sexualised thoughts and feelings is delicate and complex for any person, said Rob. He adds that the manifestation of these into criminal behaviours can be abhorrent and the need for law and punishment is obvious, but there is a need to educate our society in preventative pathways.</p> <p>&nbsp;</p> <p>There arises the need for better access to counsellors and psychologists, as well as initiatives to raise awareness on such behaviours, which we know stem from deeply rooted archaic and misogynistic ideas in society that normalise violence against women. There is a lack of research regarding harmful sexual behaviours involving children and young people in the UK—and in India, too—so it is important to design interventions from an early stage to distinguish between appropriate non-abusive behaviour and inappropriate or abusive behaviour. This can be a complex task that requires practitioners to have an understanding of what is healthy and informed consent and what is abusive or coercive.</p> <p>&nbsp;</p> <p>There is a general belief that sex offenders are monsters or predators. Although several recent, high-profile sexual assault and harassment cases have sparked a dialogue about “sexual predators”, the rise of predator discourse predates the series of events leading up to the #MeToo movement. In fact, over the past 15 years, predator discourse became central to how people conceptualise and discuss sexual violence, both constitutive and reflective of the expanding and increasingly punitive sex offender laws. Rob says that this kind of discourse poses some challenges in the effective rehabilitation of men with sexual convictions.</p> <p>&nbsp;</p> <p>"In media and societal opinion, anyone who commits a sexual offence is considered beyond 'inappropriate' and 'deviant', and there is a clamour to label all sexual offenders," said Rob. "This more often than not is factually inaccurate. It stunts any debate with a one-size-fits-all, lynch-mob mentality, not calling for greater understanding and nuanced approaches but simply more punitive convictions, creating and encouraging a rhetoric of hatred and ignorance.”</p> <p>&nbsp;</p> <p>According to the fifth edition of Death Penalty in India: Annual Statistics 2020 Report, even though the death sentences have decreased, the proportion of cases of sexual violence has steadily increased over the years. Of the total death sentences delivered in 2020, almost 65 per cent, or 50 sentences, were related to cases involving sexual violence. Of those, in 48 per cent of cases, the victims were below the age of 12. So, how can we even begin to think about rehabilitation or reintegration of these men in a country that clearly supports punitive measures?</p> <p>&nbsp;</p> <p>Rob is hopeful and draws inspiration from theatre, which he says stands as a tool that can powerfully lend itself to wider debate in creative and kinaesthetic ways. "If more could be done to respectfully, delicately and truthfully present and perform testimonies from those who have committed sexual offences and also those who are its victims, a platform of debate can be raised to balance more punitive measures, with a more reasonable rehabilitative practice," he said.</p> <p>&nbsp;</p> <p>Along with Rob and Andrew Fowler, former probation officer and currently a senior lecturer in criminology, I am working on a project funded by the National Organisation of Treatment of Abuse (NOTA) in the UK to highlight the voice of service users who have committed sexual offences and have completed the sex offender treatment programme in the country.</p> <p>&nbsp;</p> <p>Fowler and his colleagues recently researched community hubs across the UK. These are places where agencies share a premise and pool resources to holistically support service users like Rob. "The key ingredients to facilitate desistance-focused practice include the location and easy access to the hub, the hub's physical environment, ensuring the hubs include the co-location of support agencies, the cultural context of the hub and innovation to commission the hubs," said Fowler. "There are signs that community hubs link people into their communities better and create a support network that can last beyond the probation order."</p> <p>&nbsp;</p> <p>India also needs programmes that can utilise an offender’s conviction time effectively by challenging gender myths and stereotypes, addressing their misplaced notions of masculinity and providing them with a safe environment to not only speak about their crimes but to reflect on them.</p> <p>&nbsp;</p> <p>Professor Belinda Winder, director of the Centre of Crime, Offending, Prevention and Engagement (COPE) at Nottingham Trent University, advocates that people not be defined by the worst thing they have done. "It is about understanding the part of someone's character we never want to see again and making sure they put the right foot forward," said Winder, who is also the cofounder of The Safer Living Foundation that supports the needs of sex offenders released from prison. "This will support our existing research to understand and prevent sexual abuse. It will also go a step further in encouraging us to apply our findings so that we can have a real impact on improving the safety of the public and preventing sexual crime.”</p> <p>&nbsp;</p> <p><b>The writer is a lecturer in criminology at Sheffield Hallam University, UK.</b></p> Wed May 26 15:54:57 IST 2021 set-up-to-shelter-abused-women-one-stop-centres-are-not-fully-functional <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Allow me to open with a question: Do you know where your nearest one stop centre is? They were established to provide integrated support and assistance to women and girls affected by violence. This is a question I often ask my family and friends. On most occasions, even this group of educated and liberal individuals does not have the answer. Because they are not a marginalised group, perhaps they do not feel the need to know.</p> <p>&nbsp;</p> <p>However, the same cannot be said about the victims in the 4.06 lakh cases of crimes against women that were registered in 2019, and countless more that probably never reached a one stop centre or police station. Knowing the nearest one stop centre is not just for your personal benefit. As a conscious member of your community, you should also be in a position to provide assistance and aid to those who are more at risk of harm and victimisation.</p> <p>&nbsp;</p> <p>I first visited Gauravi, a one stop centre in Bhopal, in the summer of 2018 as part of the Helena Kennedy Centre for International Justice’s research on gender-based violence in India. Having never been to a centre of this nature, I did not know what to expect. As you enter the complex, the eye immediately goes to the vibrant murals promoting gender equality and awareness on combating violence against women.</p> <p>&nbsp;</p> <p>Gauravi, meaning pride, is India’s first One Stop Crisis Centre. It was opened in June 2014 in J.P. Hospital in Bhopal. The centre was inaugurated by Union Health and Family Welfare Minister Dr Harsh Vardhan, actor Aamir Khan and Madhya Pradesh Chief Minister Shivraj Singh Chouhan. Khan had discussed the centre and crimes against women on his TV show Satyamev Jayate. While the centre was set up by the Madhya Pradesh state health department, it runs in collaboration with ActionAid, an NGO that works in over 40 countries to combat poverty and injustice, coordinated by a global secretariat, based in Johannesburg.</p> <p>&nbsp;</p> <p>When Gauravi was located inside the J.P. Hospital, finding and accessing it proved to be a challenge for victims and their families. So it was moved into a single-storey structure in a little complex adjacent to the hospital. Being close to a hospital is one of the key requirements for one stop centres; so that immediate medical attention can be given to the victim. It is also important to note that medical examination plays a crucial role in the long run if the victim wants to pursue the case.</p> <p>&nbsp;</p> <p>It has been eight years since the gang-rape of a 23-year-old female physiotherapy intern in a private bus in South Delhi. There were six accused, including a minor, all of whom raped her and beat her friend who was accompanying her that night. Nirbhaya, meaning fearless, was the name given to the victim to symbolise her struggle and death. The Nirbhaya Trust was set up by the government a few months later with an allocation of 11,000 crore for the empowerment, safety and security of women and girls.</p> <p>&nbsp;</p> <p>The ministry of women and child development formulated a scheme for setting up of one stop centres across India, which are funded by this Nirbhaya fund. The centres provide the following services:</p> <p>&nbsp;</p> <p>* Emergency response and rescue</p> <p>* Medical assistance</p> <p>* Assistance in lodging a complaint</p> <p>* Psychological and social support/counselling</p> <p>* Legal aid and counselling</p> <p>* Shelter</p> <p>&nbsp;</p> <p>Research interviews with survivors of gender-based violence as well as members of staff at Gauravi revealed that there is still a lack of awareness and knowledge about women’s helplines, locations of one stop centres and accessibility to support services.</p> <p>&nbsp;</p> <p>Survivors shared how there was still a dearth of female police officers, and even when present, they were not helpful or supportive. They felt that the police could be more proactive and creative, especially with the help of technology. Sometimes, they said, no follow-up is done despite the availability of evidence. However, some survivors also expressed trust in the police.</p> <p>&nbsp;</p> <p>With respect to Gauravi, there are also challenges specific to Madhya Pradesh, like diverse ethnic groups, particularly various tribes and caste communities. Child marriage continues (especially in the tribal areas) and tribal norms act as a barrier to justice; in particular the jati panchayat process. Registering complaints continues to be an ordeal for the survivor and her family—court proceedings are another nightmare.</p> <p>&nbsp;</p> <p>There is no doubt that the staff at Gauravi have given their all to support survivors with the limited resources they have. But it takes a lot more than a building and a few members of staff to fully support victims and their families. Despite being a successful centre, I saw no presence of a female police officer on site during both my research visits.</p> <p>&nbsp;</p> <p>As per the one stop centre scheme, survivors are only provided temporary shelter. This was also the case with Gauravi, and some of the interviews highlighted the long-term challenges of the scheme, such as displacement of women, break in continued rehabilitation, and further harm and victimisation in women’s shelter homes. One of the survivors, who had spent time at both the temporary shelter provided by Gauravi and the women’s shelter home provided by the state, recalled with horror the living and working conditions which make the vulnerable feel more afraid.</p> <p>&nbsp;</p> <p>She said: “The centre is not safe at all. Sometimes, men come in at night; they are not stopped by the guard or the night duty manager. They then take sexual liberties with the women without worrying about the consequences.” In 2018, the state government of Madhya Pradesh had also ordered an inspection of women’s hostels in the light of a shelter home rape case in Bhopal.</p> <p>&nbsp;</p> <p>Since my research into Gauravi in 2018, the one stop centres across India have grown substantially in number. According to the Press Information Bureau, 728 one stop centres were sanctioned and 595 had started operations as of November 2019. Many news articles have also captured the ground realities of how “functional” these are.</p> <p>&nbsp;</p> <p>So, to answer my question, we certainly do not need more one stop centres. We also need the existing ones to become functional and accessible. This is a classic example of quality over quantity. Instead of prioritising a systematic inquiry into effectiveness of the existing centres, the focus is on highlighting the “progress” through the setting up of more diminutive, shoddy and inadequate centres. There is also a blatant absence of awareness drives that can inform the average citizen how to access their nearest one stop centre. A list of the one stop centres should be easily available in housing complexes, schools, university campuses and organisations in addition to being easily accessible online.</p> <p>&nbsp;</p> <p>While the UN Women also promotes multisector coordinated care models like the one stop centres, it provides a word of caution: the integration of such models by local governments can be the most challenging part of the process even in stable environments.</p> <p>&nbsp;</p> <p>Finally, do me a favour and find your nearest one stop centre today.</p> <p>&nbsp;</p> <p><b>The writer is a lecturer in criminology at Sheffield Hallam University, UK.</b></p> Thu May 27 19:59:33 IST 2021 the-adverse-effects-of-abuse-verbal-physical-or-mental-on-women <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>A self-confessed introvert, Pratiksha Chhetri found a haven in social media. “That was the only place I could talk to people openly and be who I am. It worked like a mask to cover my shyness,” says the 23-year-old from New Jalpaiguri who dreams to be a kindergarten teacher.</p> <p>&nbsp;</p> <p>It was fun for a while but the experience would soon be ruined. “I started receiving texts asking for nudes from people whom I assumed were nice. It felt creepy,” she recollects.</p> <p>&nbsp;</p> <p>Chhetri changed her password frequently, fearing someone would hack into her account and create trouble. “I did not want to be ashamed for something I did not do,” she says. “I still lose my peace of mind when I think about it, because creating a fake account is no big deal. Somebody, somewhere might be using someone else's picture to degrade them." Chhetri finally deactivated her account.</p> <p>&nbsp;</p> <p>For girls, danger lurks everywhere, even at home. “I had to face my abuser almost every day,” says one survivor of abuse. “We lived under the same roof. I had to cook and serve food to that person. I could not sleep at night. I wanted to talk to someone about it and when I finally did, I was silenced. I had seen abuse in TV shows, but I never thought I would [experience it]. It becomes scary when the person who abused you has good ties with your family. We even shut ourselves up from speaking about it. We are conditioned in such a way that by default we choose to keep quiet and continue like nothing happened.”</p> <p>&nbsp;</p> <p>Unlike this person, Dopdi Mehjen used her body to shame her perpetrators. The tribal woman in Mahasweta Devi’s short story Draupadi confronts Senanayak—a police officer who ordered his subordinates to rape her—with her bare body. Dopdi, who understands “she’s been made up right” walks towards Senanayak naked “in the bright sunlight with her head high”.</p> <p>&nbsp;</p> <p>“You can strip me, but how can you clothe me again? Are you a man?” she asks him. “There isn’t a man here that I should be ashamed. I will not let you put my clothes on me. What more can you do?”</p> <p>&nbsp;</p> <p>The story is a clarion call to a society where victim blaming is common and blatant. The activist writer tells us that it is the perpetrator and not the victim who should be shamed and scared. The protagonist “pushes Senanayak with her two mangled breasts, and for the first time, Senanayak is afraid to stand before an unarmed target, terribly afraid”.</p> <p>&nbsp;</p> <p>Violence against women is rampant in India. According to the National Crime Records Bureau, 4,05,861 cases of crimes against women were recorded in 2019. This was a 12.8 per cent rise from cases reported in 2017. “Patriarchy is at the root of the issue, perpetuating domestic violence,” says Aarthi Chandrasekhar, programmes coordinator, Resource Centre for Interventions on Violence Against Women, Tata Institute of Social Sciences, Mumbai. “Violence is often understood as being physical and sexual; there is a lot of emotional violence, too,” she says. “Financial and cyber violence are also prevalent. They take place concurrently. All these forms of violence have consequences on the physical and mental health of the survivor as both are linked.”</p> <p>&nbsp;</p> <p>Shedding light on the magnitude of abuse, Dr Kedar Tilwe, a consultant psychiatrist and sexologist at Fortis Hospital, Mulund, and Hiranandani Hospital, Vashi, says: “It is estimated that one in three women may be exposed to some sort of abuse (psychological, physical, sexual) during their life. Exposure to abuse makes them feel weaker and diffident. It can result in a loss of self-esteem and self-confidence.”</p> <p>&nbsp;</p> <p>Abuse can scar a girl for life, be it social media trolling, sexual harassment or domestic violence. Women often internalise their anxiety and stress.</p> <p>&nbsp;</p> <p>The health consequences of violence are usually perceived as severe injuries. “However, violence affects health in many ways including reproductive issues as a result of sexual violence, aches and pains, stress, anxiety and skin disorders,” says Chandrasekhar. “Women who reach the hospital with burns or consumption of poison are invariably experiencing violence. It is certainly a public health issue where health care providers have a key role and responsibility in identifying survivors through clinical inquiry and linking them to relevant support services.”</p> <p>&nbsp;</p> <p>Many women have developed certain traits that are shaped by our society’s patriarchal values. It took Vismaya Vishwa a long time to understand how language and dialogue are constructed to make the woman feel guilty or responsible for someone else's actions. “I have always observed the language people use in situations where a woman is harassed or sexually assaulted,” says the assistant professor of English at St Joseph’s Evening College, Bengaluru. “It is always 'Where were you going?' or 'Why were you alone?' or 'Why did you not do anything about it?' We all know words have power. These words put the onus on women to always be aware and battle ready.”</p> <p>&nbsp;</p> <p>It reflects in everyday incidents as well, says Vishwa. “I've heard more women than men apologise for being in the way, for jostling someone, for accidentally brushing past and making contact. The language used in these situations plays a major role in how women orient themselves in public spaces. Personally, it was this kind of language that made me question my role in situations where I was harassed.”</p> <p>&nbsp;</p> <p>What is stopping women from asserting their identities as part of society and reclaiming public places? Even empowered women living in metros like Bengaluru feel unsafe in public places. Chhetri, who is an undergraduate in Bengaluru, prefers to walk through a crowded place than take short cuts after sunset because she feels that even if something bad happens, there would definitely be one “good man who would reach out to help” or at least call someone for help.</p> <p>&nbsp;</p> <p>Having crossed 50, J. Devika, a historian, scholar and social critic, never thought she would be vulnerable. “No woman in this society is permitted such peace,” says the author of several articles and books on gender relations in early Kerala society. Two years ago, she found herself on the receiving end of a man’s sexually coloured insults in public.</p> <p>&nbsp;</p> <p>Devika was delivering a lecture at the Krishna Menon Memorial Government College for Women at Kannur, Kerala. A man walked in and sat in the audience of mostly women. “When I finished and the Q and A began, he stood up and asked a question in which insinuations against women authors were implicit,” says Devika. “I chose not to accelerate it, choosing my words carefully so as to not give him a pedal to push.”</p> <p>&nbsp;</p> <p>After a while, the man asked another question, this time accusing Devika of being a “man-hating feminist who attacked male intellectuals”. “Now this was a baseless and unwarranted assault on my right to criticise male intellectuals as a feminist scholar and public intellectual, and so I was quite shocked,” she says. “I tried to argue that he was wrong. When he did not stop, I grew angry. But it struck me that he might be mentally troubled. I went to pacify him but he refused to calm down. He continued grumbling and said, “As long I am sitting here with a penis between my legs, women like this one cannot be allowed to say these things.”</p> <p>&nbsp;</p> <p>Devika, who remained calm through the ordeal, broke down later when she came to know that the man was a member of the college faculty. “He had come deliberately to insult me in front of an audience. And he walked away coolly,” says Devika.</p> <p>&nbsp;</p> <p>She was so rattled by the incident that she would narrate it at every college she spoke at. “He is protected by his powerful brother and his colleagues,” says Devika. “I have no such protectors. For that reason, I cannot step down from the fight. I will carry on until this man is punished. Otherwise, what security can a woman student feel?”</p> <p>&nbsp;</p> <p>There is a lot that can be done to help women feel safer in the workplace or in public places. Surveillance cameras can improve women’s safety only to a certain extent. “Better street lighting, improved public transport that encourages mobility of women, and, above all, gender sensitisation,” says Chandrasekhar. “Unfortunately, women’s safety is often approached from a custodian point of view which in itself is patriarchal. Why do women need to constantly be ‘on alert’? If one has to think so much about it, can it be considered safe?”</p> <p>&nbsp;</p> <p><b>I AM AMONG THE 99% UNREPORTED CHILD ABUSE CASES</b></p> <p>&nbsp;</p> <p>Growing up is tough but growing up as a woman in India is tougher. I sometimes feel like my identity has been confined to a number in India—I am among the 20.3 per cent of working women; I am included in the 34 per cent women workforce in the IT sector; I am one among the 2.5 per cent of childless women; and I am among the 99 per cent unreported child abuse cases.</p> <p>&nbsp;</p> <p>So what defines me? All of the above. Everything I have been through has moulded me. Like most women in India, I was brought up in a patriarchal household. The irony is that this patriarchal thought process was not imposed on me by the men in my family, but by my mother. As a girl, I was told to talk, sit, laugh and eat in a particular way. The days I was on my periods, I was treated like an untouchable, locked up in my room. Let me remind you that I am not talking about the 17th century India, but the early 2000s.</p> <p>&nbsp;</p> <p>Like most victims, my abuser was a close relative; someone I trusted. However, when I told my parents, my mother blamed six-year-old me for what happened. I lost trust in relationships, and until recently, I felt guilty about it.</p> <p>&nbsp;</p> <p>Like Ambedkar, I thought education was the only way out, and I left home for higher education to regain my autonomy. And I have never gone back. Fifteen years on, I am on my own, content not bound by those restrictions. But is that enough? We fight prejudices and wrong perceptions every day. The moment you get a promotion or a raise, you hear the rumours: “Promoted, huh? She might be in really “good” terms with her manager.” It does not matter whether you worked more hours than others or led enough projects to prove yourself. Women even hesitate to ask for a raise or talk about what makes them remarkable.</p> <p>&nbsp;</p> <p>No matter what kind of upbringing you had, do not let that hold you back from claiming your place in this fast-paced world, because if you don’t talk for yourself, no one else will.</p> <p>&nbsp;</p> <p><b>The writer is programme manager at an MNC in Bengaluru.</b></p> Wed May 26 15:39:15 IST 2021 how-immunotherapy-gave-a-66-year-old-cancer-patient-a-fighting-chance <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>CANCER,</b> for Kanaklata Dugar, was like the unwelcome guest that refuses to leave.</p> <p>During her long and arduous battle, Kanaklata had three surgeries and six cycles of chemotherapy. But the cancer kept coming back. The 66-year-old resident of Rajarajeshwari Nagar in Bengaluru then underwent immunotherapy and is cancer free now.</p> <p>&nbsp;</p> <p>Kanaklata was diagnosed with breast cancer at 40. She was disease free for eight years, but had a relapse in 2004. She had another round of chemotherapy and surgery and was declared cancer free. But in 2017, she was diagnosed with carcinoma endometrium (a type of uterine cancer). She had her uterus and ovaries removed. In 2018, Kanaklata developed lung cancer. She was physically and emotionally drained.</p> <p>&nbsp;</p> <p>Chemotherapy was not very effective in her case. “Initially, she showed some improvement. But she had a relapse even after six rounds of chemo,’’ says Kanaklata’s daughter Monika, 40, who works as a senior financial analyst with Hewlett Packard Enterprise.</p> <p>&nbsp;</p> <p>The family prayed for a miracle. And so, when doctors suggested immunotherapy, the Dugars decided to give it a try. “We wanted our mom back desperately,” says son Anup, 47, a businessman.</p> <p>&nbsp;</p> <p>Monika consulted Dr Vijay Agarwal, senior consultant medical oncologist at Aster CMI Hospital. He recommended some tests. “The results were good to go ahead with immunotherapy,” recalls Kanaklata.</p> <p>&nbsp;</p> <p>Dr N. Aditya Murali, consultant-medical and haemato-oncology, Aster CMI Hopsital, and his team of doctors who treated Kanaklata found that she could be a good candidate for immunotherapy. “We looked for biomarkers that could predict response to the newer immunotherapy medications,” says Murali. “Upon genetic sequencing of the tumour, a genetic defect called microsatellite instability (MSI) was found, which would predict an excellent response to immunotherapy. Once this diagnosis was established, the patient was started on immunotherapy in late 2018.”</p> <p>&nbsp;</p> <p>Immunotherapy, which activates our immune system to fight the tumour cells, has given Kanaklata a new lease of life. But Murali does not recommend immunotherapy for everyone. “It works in patients whose tumours are positive for a marker called PD-L1 or MSI,” explains Murali.</p> <p>&nbsp;</p> <p>None of the traditional side effects associated with chemotherapy is seen in immunotherapy, says Murali. “There may be very rare side effects caused by an overactive immune system, but they are far less common and easier to manage than conventional chemotherapy side effects,” he says.</p> <p>&nbsp;</p> <p>Poonam Bhurat, Kanaklata’s daughter, agrees. “Mom didn’t have ulcers or mood swings after immunotherapy. Neither did she lose hair,” says the 43-year-old homemaker. “However, the first time she took immunotherapy, she got diarrhoea and she felt drowsy the next day. She also complained of fatigue for two days.”</p> <p>&nbsp;</p> <p>Kanaklata had treatment every three weeks and after a year, the doses were reduced. She underwent treatment for two years. “Though the treatment is a bit expensive, it worked wonders for my grandmother,” says Harshit, 21. “We are so relieved to know that there are no active cancer cells in her body.”</p> <p>&nbsp;</p> <p>Kanaklata is in excellent general condition, says Murali. “The battle that began in 1996 has led to a cure in 2021 with the ingenious use of immunotherapy, that too in the presence of a rare genetic abnormality,” says Murali.</p> <p>&nbsp;</p> <p>The cost of immunotherapy varies depending on the type of molecule used. It could be anywhere between Rs1 lakh and Rs4 lakh per dose. How many doses would a patient generally need? “Immunotherapy is generally given till the time the disease is in control or till the time the patient develops intolerable side effects,” says Murali. “On an average, patients on immunotherapy continue this drug for anywhere between a year or year and a half and sometimes a little longer.”</p> <p>&nbsp;</p> <p>Despite her trying tryst with cancer, Kanaklata has been a pillar of strength to the family. “Mom is a strong-willed lady,” says Poonam. “She doesn’t want to be dependent on others.” Adds Monika, “She is so calming to be around and she gives a great deal of support and comfort to us.”</p> Fri Apr 23 21:04:59 IST 2021 we-know-immunotherapy-works-but-we-need-to-find-out-why-it-doesnt-too <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>What changed for you after the Nobel?</b></p> <p>&nbsp;</p> <p>After the Nobel, several things changed for me. There came a sudden, not necessarily wanted, notoriety [laughs]. I couldn't go to a grocery store without people seeing me. I couldn't just be a person, you know. For a couple of months, my ability to work was affected because people would come up and see me. But it did all come back to normal, eventually.</p> <p>&nbsp;</p> <p>The positive thing that really happened was the fact that immunotherapy, which was so controversial for so many years—for long, it was considered 'voodoo', 'quack medicine'—[got recognised]. I didn't really get into the big argument for a long time, because to me it made sense to focus on my work and see how it really came out. We know now that it works. We know that a lot of people with cancer are getting cured now, and so, having it finally accepted as a way of treating cancers, that is really a positive thing. Now, I can actually sit down and have discussions with people who were like ‘you have to identify the causes of cancer and block the mutations instead of saying that we make the immune system work’.</p> <p>&nbsp;</p> <p>Besides the Nobel, the thing that really consolidated the whole result (of Allison's work on immunotherapy) was that the American Cancer Society released data saying that the mortality rate due to melanoma had fallen by 18 per cent, and this has largely been due to immunotherapy. It has made a difference in people's lives, and as a scientist, as someone who mostly wants to figure out how things work, being able to do something that helps people... that has been really great.</p> <p>&nbsp;</p> <p><b>It has worked for other cancers beyond melanoma, too.</b></p> <p>Yes, the checkpoint blockade—CTLA-4 or PD-1 (that came afterwards; they keep the body’s immune response in check)—have been approved now for several cancers besides melanoma, including lung cancer, head and neck cancers, kidney and bladder cancer, cancers of lymphoma, and on and on…. There are about 30 different kinds of cancers. The response rates are 25-40 per cent… so we have got a lot of work to do. We know it works, but we need to find out why it doesn't, too. We are still doing our lab work on that, trying to see what's missing in the cancers that don't respond better [to immunotherapy]… what makes it different from people who respond better…. The goal now is to get us close to 100 per cent [smiles].</p> <p>&nbsp;</p> <p>The good news in melanoma is that it is close to 60 per cent now; 55 per cent or so with a combination of CTLA-4 and PD-1 together. The five years of survival so far in a trial stands at 55 per cent. There is no reason why that wouldn't continue for ten years. If we just work hard, I don't see why we cannot get it over 55 per cent.</p> <p>&nbsp;</p> <p><b>For a therapy that has offered tremendous hope for cancer patients, how has the response from them been?</b></p> <p>&nbsp;</p> <p>There have been so many stories... so many letters that I have gotten from people, saying 'thank you, my wife was dying and was in hospice… and she got these drugs, and now, five years later, she's fine'. The most touching story is of Sharon Belvin, the first patient I met. In 2004, she was 22… and dying from metastatic melanoma. She had 31 metastases in her lungs, she had subcutaneous things on her skin, a half centimetre tumour in her brain. Sharon had failed every other therapy. But after she enrolled in one of the early trials, the tumour just went away! I hadn't seen her, but one day, her physician called and asked me to come down to his office. I said, ‘Why, I am busy.’ But he said, ‘No, no... come.’ He was with Sharon and her husband. Here was a woman who had been diagnosed with this disease when she had finished college, had just got married and started on with her life. Now, she has two kids. She has been in therapy for 16 years now. But her recovery was remarkable: the pathologist who was looking at her CT-scans was really amazed. He said, ‘Has there been some kind of mix up? Is this the wrong patient?’…. Over the years, I have seen [Sharon’s] kids grow up…. We have become friends now. It has been great.</p> <p>&nbsp;</p> <p><b>What would you recall as your most challenging experience in the journey?</b></p> <p>&nbsp;</p> <p>The question about the most challenging experience is an interesting one because science presents you with challenges all the time. You have to figure something out and know that you are right. If you have a sound belief that there are such things as facts, which is not necessarily universally felt these days, you could test them and come up with these ideas…. My work was designed to figure out how the immune system worked, not to discover a cure for cancer. But when we found this negative checkpoint, I had the idea that [if] we blocked it, that could cure cancer. We did the experiments and we could cure almost anything in mice….</p> <p>&nbsp;</p> <p>At that point, I wanted to, obviously, bring it to patients. But for three years or more, I had no luck. I was working at the University of California, Berkeley, in a basic science lab; I had no industry contacts. So I had to go out and try to find some company that would buy my idea, but they wouldn't do it. I ran into so many things that were just ridiculous. People said ‘immunotherapy has never worked, it will never work’. Or, ‘okay so you cured cancer in mice, anybody could cure cancer in mice’. First of all, that's not true! It is not a trivial achievement. Even in mice. My response as a scientist was always that how are you going to know if you don't try it. Let's do the experiment. If the massive data I have isn't sufficient to actually try a clinical trial, then, I mean, you are a moron [laughs]. I am a scientist, I have data and I could show you this; if you don't buy it, you don't do it. But the reasons that were given to me were not scientific, they were biases.</p> <p>&nbsp;</p> <p>Finally, we met with a company that wanted to make the antibodies, and we teamed up with them. They made this antibody that got approved by the Food and Drug Administration. It is called ipilimumab, or 'ippi'… kind of like a chewing gum, I don't know why they named it that [laughs]. In 2010, they completed a clinical trial that showed that little over 20 per cent of patients with melanoma were alive for almost five years with this treatment. No drug of any type had extended survival with melanoma. When we started this work, a diagnosis of metastatic melanoma meant a life expectancy of seven months, and almost nobody lived past five years. And here we had 20 per cent! It was disappointing [in a way], you know, why not a 100 per cent? That is what is we are working on now…. We need to make it work for everybody, that's my goal.</p> <p>&nbsp;</p> <p><b>What works in animals often fails in humans. What convinced you that this would work?</b></p> <p>&nbsp;</p> <p>I was sure it was worth taking a chance. You are correct in that everything that works in mice won't necessarily work in humans. But I had never seen data as strong as ours. It was not just in one kind of cancer or in one strain of mice. We tried with several different cancers and many different strains of mice, and it always worked. I was sure enough that it had a good chance to work. So I made my decision, and… I was betting the rest of my career on that, to just do whatever I had to do, to get people in the clinic and see if it worked on them, too. I couldn't stand, as a scientist, people saying that nothing like that has ever worked before. That's not science, that's just bias. How would we make progress if that's how we thought. We knew the prevailing attitude was wrong, and the only way to prove it was to challenge it.</p> <p>&nbsp;</p> <p><b>Within immunotherapy, what made you choose cancer?</b></p> <p>&nbsp;</p> <p>My decision to go to cancer was based, I suppose, on my family history. My mother died from lymphoma when I was ten. She had radiation therapy and that ravaged her. I was holding her hand when she passed away. That made a real impact on me. Two of her brothers also died—one from melanoma, and another from lung cancer. I think I just had it in the back of my mind if I could understand the immune system properly, then maybe I could really make a well-educated decision about how to go after cancer. I had read a lot of stuff about what people were doing and most of it was not based on solid science. Rather it was based on suppositions and assumptions that were wrong.</p> <p>&nbsp;</p> <p>I had dabbled in immunotherapy over the years occasionally, but then when we got CTLA-4, a lot of data that we had just came together in my head. We began doing this work with the mouse experiments. Jeff Bluestone was the other person who simultaneously discovered CTLA-4. After it was published, it was in the textbooks that it was not a negative [checkpoint], [but] a positive regulatory thing. And both of us said that that was wrong…. Jeff decided to take this work because he is interested in autoimmunity and diabetes. He went down that track. My family history took me to cancer.</p> <p><b>What are your thoughts about the potential of immunotherapy in areas other than cancer?</b></p> <p>I think the success [of immunotherapy] in cancer is leading to other applications as well. One of the things that we do is block the negative, but if we could somehow deliver the negative signals, you could treat autoimmune diseases, diabetes, multiple sclerosis and other nasty, debilitating diseases. There is accumulating data suggesting a really tight relationship between the nervous and immune system... suggesting that there may be ways to treat what we previously considered purely neurological diseases [with immunotherapy]…. So I have got someone in my lab who is now working on [understanding the connection with the immune system]. I think that it has led to answers to a lot of applications, a lot of understanding of how all the systems are really integrated.</p> <p>&nbsp;</p> <p><b>How hopeful are you of its use in these conditions?</b></p> <p>I do have hope. I think it is going to take time. You cannot just jump into it…. You got to see what the immune system is doing, understand the fundamental aspects of the science, before you can think about how to integrate, or maybe try. That is why immunotherapy in cancer didn't work for so long. You got to know the details, really study and understand exactly what's going on, before you could be at the right place at the right time.</p> <p>&nbsp;</p> <p><b>What are your current projects?</b></p> <p>&nbsp;</p> <p>Most of what we are doing now is cancer. It is what I call reverse translation. So we studied what happened in the mice and took it to the humans. Now if you want to understand it better, you got to study what is going on in the humans, generate hypothesis and take it back to the mice. Dr Padmanee Sharma, my wife and collaborator, [and I] run a lab, where we are involved in over a 100 clinical trials, where we get specimens from patients undergoing these therapies and analyse them [right down to the] molecular level to see what is going on. Our philosophy is that we should learn from every patient in the trial. If the therapies don't work on them, then we need to figure out why…. There are a lot of technologies that have come up in the last couple of years, enabling us to look at the genes that are expressed, the cells that are there and really build up a picture. We know what a successful response looks like now. So if it doesn't work all the way, we can identify what's missing. For instance, there are certain types of macrophages that can turn off T-cells, and so, we are working on ways of either eliminating them or turning them into other macrophages that won't inhibit T-cells, so that we can get a better response.</p> <p>&nbsp;</p> <p>Dr Sharma has a trial where we have learnt some things from the biopsies of prostate cancer patients.... Every company had given up on prostate cancers [because of not being able to find an] immunologically responsive target. We figured out why that was, put together a combination [to test in a] large trial to see if it works. Hopefully it will, we don't know yet.... That's what trials are about.</p> <p>&nbsp;</p> <p>The major companies shut down their work [on prostate cancer and immunotherapy]; they said that it won't work. We made some observations and showed them the data [and made some suggestions]. So, we did the trial and it worked somewhat, it didn't work in some ways. Now we are refining it, and we will see.</p> <p>&nbsp;</p> <p><b>Cancer is tough. But some cancers are more difficult than others.</b></p> <p>&nbsp;</p> <p>Oh yeah... unfortunately glioblastoma and pancreatic cancers are still pretty much resistant…. They take too many people. They are rapidly lethal. But we are studying biopsies, we are getting some ideas. Actually a lot of labs are studying... There are some studies with a combination of five different things... too early to say if they are curative. They seem to be slowing the diseases.... With other types of cancer like bladder and kidney, we get 30-40 per cent response rates, we need to get them higher. But then there are these other ones where we are nowhere, [and] need to get above zero. I am optimistic because we could begin to identify the barriers preventing immunotherapy from working. Now, it may take the help of chemotherapy, radiation, multiple modalities, where the idea is to kill some tumour cells and let the immune system take on from there.</p> <p>&nbsp;</p> <p><b>In what way is immunotherapy a paradigm shift in the range of options that are currently available to treat cancer?</b></p> <p>&nbsp;</p> <p>Earlier, surgery was the first pillar of cancer therapy, then came radiation with Madame Curie, then came chemo after World War II, and now immunotherapy.... But unlike the other three, immunotherapy can work with all of them because when you kill cancer cells, that will provoke immune responses, but mechanisms… will stop it before it can become effective enough. So if you got cancer… and may be you think… I don't have to kill every last cancer cell with chemotherapy, with radiation and shut down the immune system. All I need to do is kill enough tumour cells, and then let the immune system come in. It will require radical rethinking. People keep asking me, ‘is this the end of radiation, chemotherapy? Are we done with them?’ I say no, we are not, but that we are done with them as sole agents, because it is too hard to cure people with them most of the time. With a few cancers they work, but with a large majority, they don't work by themselves. We can use them with immunotherapy to have a synergistic effect, drop the exposure to radiation and chemo to a point where it is less toxic, your hair doesn't fall out, your immune system isn't destroyed, you are not susceptible to infections. It is going to take a while to figure out the balance; that's the other thing we are working on.</p> <p>&nbsp;</p> <p><b>What about Indian researchers? Do you think access to immunotherapy for cancer patients is an issue?</b></p> <p>&nbsp;</p> <p>I have had a number of Indian researchers in my lab, some of whom have gone back to India and done great work. They have been a rich source of intellectual vigour…. [I understand that] perhaps, support for science is not quite enough [there] and there might be a lot of reasons for that which are understandable, given other needs of the country. As far as access to drugs goes, without getting into too much details, I would say that they are highly overpriced, and ought to be given to people at a reasonable price. But that is a separate issue…. In terms of science, there is quite a lot of activity [among Indians], including those going back and people coming here. India is a valuable contributor.</p> <p>&nbsp;</p> <p><b>You exude a lot of hope when it comes to something as difficult as cancer. But a section of experts feel there is a lot of hype when it comes to treatment modalities in cancer.</b></p> <p>&nbsp;</p> <p>I understand the pessimism. It is really difficult to use the word 'cure' and 'cancer' without provoking doubt and suspicion. Not everybody can have a single round of treatment and be alive 20 years later. About 20 per cent are alive over a decade and so I think that qualifies as cured. There are hundreds of different cancer diseases—not one kind, one tissue, not one cause, but many different causes…. So, I don't think we will ever make cancer disappear, but we can do it a step at a time. We can reduce mortality from melanoma, which has already been done. And it will be soon so for lung, bladder and kidney cancers. We just need to keep working at it. We will never be able to totally defeat it…. But I have the optimism because I know that we are beginning to learn basic rules. We couldn't say that ten years ago; nobody could say I know how to cure any cancer, except maybe testicular and some kinds of leukaemia, but majority of cancers had no hope. Now we know there is. The message I would like to send out to everybody is that a cancer diagnosis is not necessarily a death sentence. We just got to work harder on it.</p> <p>&nbsp;</p> <p><b>Through this time, is it your music that has kept you going?</b></p> <p>&nbsp;</p> <p>[Smiles] That helps. I have been part of a couple of bands. Though lately, we haven’t been playing because of Covid-19. Besides, I love science, figuring things out. I like the fact that what I do, to some extent, helps people and that's important to me, too. It is important that what we do makes the world a better place, through science, through music, hopefully both.</p> <p>&nbsp;</p> <p>A few years ago, a physician told me that while he was curing one patient at a time, as a scientist, my work was curing hundreds of thousands at a time. There is a lot of work still to be done on different checkpoints. But we are looking at other things, too. Oncolytic viruses [for treating cancer], for example. Putting genes into viruses to help tumour cells express things, and attract the immune system better…. There is a lot of exciting work being done in immunotherapy.</p> <p>&nbsp;</p> <p><b>Do you still play music at home?</b></p> <p>Yeah some, not much. Now that you bring it up, I think I should play a little bit more [laughs].&nbsp;</p> Fri Apr 23 19:15:51 IST 2021 immunotherapy-hope-vs-hype <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Its work is often described as fascinating, even elegant. And for the most part, it does its job—fighting foreign invader pathogens with an army of antibodies and killer cells and keeping us disease-free. Sometimes though, all it takes is a microscopic entity, say, a SARS-CoV-2, to throw the elegant machinery of the human immune system into a tizzy. Managing this system that has now gone into a tizzy—aka a ‘cytokine storm’—has been keeping scientists, doctors and researchers across the world rather busy. Various methods such as suppressing the system through steroids and even using a cocktail of synthetic antibodies to attack the virus are being studied furiously. It is not the first time that medical science is banking so heavily on targeting the human immune system. Inside laboratories and hospital settings, evidence around targeting the immune system for new treatment modalities, or what is broadly known as immunotherapy, is mounting. The idea, say experts, is fairly simple—the root cause of several diseases lies in immune dysfunction. By stimulating or suppressing specific mechanisms within the system, zeroing in on specific targets, and even using synthetic, lab-generated antibodies, scientists, researchers and clinicians are hoping to find a cure for, or in many cases at least better manage, several diseases, ranging from cancers, autoimmune diseases and infections to heart disease and diabetes.</p> <p>&nbsp;</p> <p>“With immunotherapy, one can think of either 'stimulatory' immunotherapy, which is what is meant in discussions about cancer (or infectious diseases), or 'suppressive' immunotherapy, which is what is meant in conversations about autoimmune diseases,” says Dr Satyajit Rath, immunologist and adjunct professor, Indian Institute of Science Education and Research, Pune. Apart from cancer, therapy to activate the immune system against specific targets is being thought of in multi-drug-resistant infectious diseases, too. “But nothing is in or even near the market so far,” he says.</p> <p>&nbsp;</p> <p>When it comes to using immunotherapy in cancer, the last few years have seen much hope, and hype. Research—and limited application in clinical settings—on immune checkpoint inhibitors, adoptive T-cell therapy, targeted therapy and monoclonal antibodies has received a fair bit of attention. The turning point, of course, being the Nobel Prize for immune checkpoint inhibitors in 2018. “In cancer, the normal process of identifying and killing abnormal cancerous cells is thrown off gear,” explains Dr V.S. Negi, head of immunology department, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. “Cancer cells find ways around host immunity to survive and proliferate. They can have proteins on their surface, which switch off the immune activation, or release them in circulation to serve as a smokescreen for them to hide.”</p> <p>&nbsp;</p> <p>Immunotherapy has helped overcome these “evading mechanisms” of cancer cells. “The new class of drugs called immune checkpoint inhibitors work by releasing a natural brake or checkpoint in the immune system, so that certain immune cells [T-cells] can recognise and attack tumours,” says Negi. Monoclonal antibodies (manmade proteins that are clones of a white blood cell) that attach themselves to these checkpoints and thereby boost the immune cells against cancer have shown good response in solid tumours such as non-small cell lung cancer and melanoma (skin cancer). “In other cancers, such as metastatic renal cell carcinoma, metastatic urothelial cancers, head and neck cancers, and hepatocellular carcinomas, the benefit in overall survival has been only a few months. More work needs to be done to find out why these therapies work on a certain subset of patients, and not others,” says Dr T. Rajkumar, head, department of molecular oncology, Cancer Institute (WIA), Chennai. “Besides, stimulating the immune system also has its own risk in that the system could run amok, and you could unleash what is known as a cytokine storm, leading to death.”</p> <p>&nbsp;</p> <p>Cytokines are small proteins released by several different cells in the body, including those of the immune system, where their job is to coordinate the fight against infection and trigger inflammation. Sometimes though, excessive release of cytokines can cause hyperinflammation and lead to serious organ damage and even death.</p> <p>&nbsp;</p> <p>Other forms of “stimulating” the immune system to attack the cancer cells include the adoptive T-cell therapy. “Here, immune cells working against cancer are selected or trained in the laboratory to attack cancer cells (known as chimeric antigen receptor transfer, or CAR-T cell therapy). These selected or trained T-cells are grown in large numbers and injected in the patient with cancer to identify and kill cancer cells,” says Negi.</p> <p>&nbsp;</p> <p>Work is on to find other “brakes” that need to be released to help immune cells fight cancer better. One such target is indoleamine 2,3-dioxygenase (IDO), a protein that has immunosuppressive effects in tumours, says Rajkumar.</p> <p>&nbsp;</p> <p>The concept of curing disease by boosting the immune system itself is not new. According to Negi, it originated a century ago for infectious disease, where serum from the recovered patient of diphtheria was used to treat other patients with the same infection. “This form of transferring the serum with antibodies is known as passive immunotherapy,” he says. “Passive immunotherapy has also been available for tetanus, rabies and measles, neutralising the toxin or the micro-organism causing harm to humans.”</p> <p>&nbsp;</p> <p>Another form of therapy under development is the ‘oncolytic virus therapy’ that is being tried in melanoma. Here, the genetically modified virus invades the cancer cells and kills them. ‘Stem cell transplants’ as immunotherapy, too, have proven useful, especially in cancers involving blood cells such as leukaemia and multiple myeloma.</p> <p>&nbsp;</p> <p>If stimulating the immune system works, the corollary is also promising. Though broadly suppressing the immune system has been a standard treatment for certain ailments such as allergies—steroids work by suppressing an overactive immune response—work is on to be more specific so as to lessen the side-effects in treatment of autoimmune diseases, says Dr John Mathew, associate professor and head of department of clinical immunology, Christian Medical College, Vellore.</p> <p>&nbsp;</p> <p>Autoimmune diseases happen when the body's immune system starts to fight itself. “Adaptive immune system includes B-cells and T-cells that play a role in long-term immunity. But when that balance goes off, these cells turn against the body. T-regulatory or suppressor cells [a sub-type of T-cells] work to protect from autoimmune diseases. We need to further study these sub-types to understand their role in autoimmune diseases,” says Mathew.</p> <p>&nbsp;</p> <p>Research is on to that end in autoimmune diseases such as lupus and rheumatoid arthritis. “Such experiments [of finding and re-engineering these T-cells to suppress the immune response] have worked in animal models,” says Mathew. “So, what we have right now is biological plausibility. But since it hasn't been tried in humans yet, we can't be sure. What works in animals may not work in humans.”</p> <p>&nbsp;</p> <p>With autoimmune diseases, the risk threshold, too, is lower than, say, in cancer. Suppressing the immune systems comes with its own side-effects such as susceptibility to infections. “Cancer is life-threatening, so some side-effects may be acceptable. Not so in chronic diseases such as autoimmune diseases which are debilitating, but not life-threatening,” says Mathew.</p> <p>&nbsp;</p> <p>Monoclonal antibodies that work to suppress immune systems are also being worked on. Tocilizumab, which made headlines with Covid-19, is a humanised monoclonal antibody that suppresses IL-6 [a kind of cytokine] and helps control inflammation in the body. “Globally, the burden of immune-mediated inflammatory diseases [such as arthritis, inflammatory bowel disease, Type 1 diabetes, Alzheimer's and cardiovascular diseases] is growing. In India, though we have the twin burden of infectious and non-infectious diseases, the numbers of IMID are set to grow, and hence, immunotherapy in this area needs to be researched further in India, too,” says Mathew.</p> <p>&nbsp;</p> <p>In other treatment modalities such as organ transplants, targeting the immune system is being seen as a new area of hope. “The current strategy to prevent and treat rejection includes use of steroids and other immunosuppressive agents that are required to be given daily. These pose a definite risk of severe infections and other side-effects including hypertension, diabetes and osteoporotic bone fractures,” says Negi. “Use of immunotherapy may overcome these challenges by inducing ‘transplant tolerance’ by giving a cytokine IL-2 or infusion of regulatory T cells.” Eventually, they may help overcome the need for tissue matching during organ donation, and help to make a large number of organs available to deserving patients who die every year waiting for the organs, he adds.</p> <p>&nbsp;</p> <p>Resetting the immune dysfunction in case of autoimmune diseases could also be done through stem cell transplant, says Negi, who has worked on this treatment approach at JIPMER. “When patients with cancers and autoimmune diseases received stem cell transplants, it was observed that in addition to cancer, their autoimmune disease also went in remission. This paved the way for treatment with ‘stem cell therapy’ in autoimmune disease,” he explains. A heavy dose of immunosuppressants and/or radiation is followed by stem cells to restore order. “There is a definite role of stem cell transplant in the management of systemic sclerosis for which no treatment options were available till recently,” says Negi. “Occasionally, systemic lupus erythematosus (SLE), myositis (muscle inflammation) and vasculitis refractory (vascular disease) are also treated with this form of therapy. The major hurdle, of course, remains high cost and inadequate facilities for stem cell transplant in autoimmune disease in our country.”</p> <p>&nbsp;</p> <p>Costs remain a challenge for all forms of immunotherapy. With a price tag of about Rs75 lakh for the checkpoint inhibitors (one-two years of therapy) and Rs2.5 crore or above for the CAR-T cell therapies, cancer immunotherapies remain out of reach for over 99 per cent of the Indian population, says Rajkumar.</p> <p>&nbsp;</p> <p>Besides, the high costs also have to be seen in the context of how they work for patients. “What we ordinary people mean by a cancer therapy that 'works' is that it 'cures' cancer, implying that it goes away and never recurs. There are very, very, very few examples of that, and some of those examples seem to be in immunotherapies,” says Rath. “For drug companies, though, 'works' can simply mean (commonly) that it extends survival by a few weeks in many patients.” By either definition, most, if not all, cancer therapies, work only in a percentage of patients of any given cancer, he says. “Checkpoint immunotherapies which 'work' for many different kinds of cancers including many solid tumours, only 'work' in a minority of cases in most of these instances,” says Rath. “In some patients though, they seem to have 'worked' even in the sense that the cancers have gone away and not recurred. Many of these immunotherapies [including cancer vaccines, T-cell transfers (both tumour-infiltrating T-cells and engineered CAR-T cells) and the ubiquitous monoclonal antibodies] have not properly become regular treatments yet (with a few exceptions), although there have been successes, including with melanomas, in clinical trials. No treatment 'cures' most patients of a given cancer. So, in that sense, there is a fair amount of hype.”</p> <p>&nbsp;</p> <p>Monoclonal antibodies, like all biologics, too, remain very expensive even as generic medications, says Rath, in part because of precision manufacturing requirements. “Cell-based therapies require enormously more hospital-based technical resources that are much more expensive, so it seems quite unlikely to me that any of them will become feasible on any reasonable scale in India,” he says. “However, even in the upper middle classes, where this is financially practicable, the potential consumer numbers in India are very large, so private medical business is likely to boom steadily, and hype will keep pace with that.”</p> <p>&nbsp;</p> <p>More research to find ways to bring down costs by developing more affordable therapies, extensive government funding to support this research, and manufacturing biosimilars (a product very similar to one that is already approved) in the country are some ways to increase access to these therapies, says Rajkumar.</p> Fri Apr 23 18:41:09 IST 2021