uterus-fibroids-causes-risk-and-treatment

Sat Jul 29 16:17:43 IST 2023

Uterine fibroids, also known as leiomyomas, are noncancerous tumours that can be found in the uterus and the uterus lining. Although the tumour might seem a serious threat, the fact that the fibroids are not likely to develop into any form of cancer is a relief. The smaller fibroids don’t pose any serious threat and don’t require treatment; they are often asymptomatic and will go away. Larger fibroids, however, come with a possibility of complication as they are likely to create issues in the menstrual health and complications in pregnancy in the long term.

When the fibroids seem to have outgrown the uterine capacity, they need to be treated with proper medication or surgery. Symptoms of fibroids include heavy menstrual bleeding, back pain and frequent urination.

The fibroids are diagnosed either through the routine pelvic examination or through ultrasound and other imaging tests. It is usually detected as the size of the uterus seems irregular.

TYPES OF FIBROIDS

The uterine fibroids are classified into three major types, primarily on the basis of location.

1 Submucosal: They are found in the uterine cavity. These fibroids hang in the cavity.

2 Intramural: They grow and develop in the muscles of the uterine walls. On the basis of positioning inside the uterine walls they are further classified into anterior, posterior and fundal fibroids.

3 Subserosal: They project themselves outside the uterine walls. The growth of the fibroid goes beyond the uterus.

CAUSE OF FIBROIDS

One of the major challenges in successfully preventing the growth of uterine fibroids is that the actual cause for the condition is yet to be understood in absolute possibility. But through years of diagnosis we have been able to pinpoint a few factors that increase the risk of uterine fibroids. Fibroids are diagnosed in women of reproductive age. The drastic hormonal change in the body is said to be the cause of the growth of fibroids in the uterus. They usually shrink when hormone production slows down during the menopause stage.

RISK FACTORS

Fibroids can vary in size, number and location within or on your uterus, so the chances of risk caused by the fibroids will vary. Fibroids can be seen as a single nodule or as in clusters or even larger. The issues caused by fibroids will vary depending when the fibroid was formed in the uterus. The common risk factors for fibroid formation are:

History of fibroids: A family history of fibroids increases the risk by three times. The growth of fibroids is seen in older women as they have a higher risk than younger women.

Obesity: Obesity is another risk factor for fibroids in menstruating women. If the woman is considered obese it will result in the growth of fibroids.

Lifestyle: Eating red meat increases the risk of developing fibroids, which can be only reduced by eating plenty of green vegetables. Having a proper diet plan with plenty of fibre-rich food and liquids helps in the reduction of fibroid growth in the uterus.

TREATMENT

Over-the-counter pain medications: These medications are given only to manage the discomfort and the pain caused by the fibroids, as these medications include acetaminophen, which is used to relieve the pain and reduce the fever. Also, ibuprofen is given to relieve inflammation, swelling and pain.

Gonadotropin-releasing hormone (GnRH) agonists: These medications are taken via nasal spray or injection that help in shrinking the fibroids. These medications are also used before the surgery to remove the fibroids.

Oral therapies: Elagolix is a new oral therapy indicated for uterine bleeding in people who haven’t experienced menopause with symptomatic uterine fibroids. Advice from a medical professional is required as these medications are to be used for up to 24 months. Iron supplements will be given if there is heavy bleeding, which makes them anaemic.

Surgery: The sustenance of the fibroids for a long period of time can cause complications for women during pregnancy and also while conceiving. If the size of the fibroids present in the woman’s uterus is large, doctors will suggest surgical removal of the uterus through laparoscopic myomectomy. This is suggested in specific cases only and is performed by a team of experts in laparoscopic surgery.

CONCLUSION

Uterine fibroids are treated with both medication and surgery. The doctor will suggest surgery as the final resolve to treat fibroids that outgrow the size of the uterus as they can cause severe complications than smaller fibroids. The surgical method also varies based on the size and location of the fibroids. Medication is advised when early detection of small fibroids is found in the uterus.

The writer is senior consultant obstetrician and gynaecologist, Apollo Cradle & Children’s Hospital, Jayanagar, Bengaluru.

interview-with-dr-sachdev-sidhu-professor-anvil-institute

Sat Jul 29 15:51:14 IST 2023

Canadian scientist Dr Sachdev Sidhu has been actively engaged with the groundbreaking field of antibody therapeutics. It involves the creation of synthetic antibody libraries featuring artificially designed antigen-binding sites. His work extends to various areas such as cancer, infectious diseases and many chronic disorders. Dr Sidhu and his team are instrumental in creating therapeutics for challenging conditions like Covid-19 and also treatment-resistant cancers.

Excerpts from an exclusive interview:

Q/ Could you give an overview of your research on antibody therapeutics and its applications?

We develop proteins called antibodies that can be injected into the body, which can fix problems with natural proteins. Almost every disease, including cancer, diabetes and arthritis, is caused by problems with some proteins. So, we put in new proteins that can correct the diseased proteins. And the big advantage is that we do it on a very large scale. We make new drugs rapidly and then test them in animals and then, hopefully, move on to people.

Q/ Over the past 20 years, your group has been developing this advanced frontier in antibody therapeutics, called synthetic antibody library. What are its advantages?

It is much faster [to create antibodies] now because we are doing it synthetically and at a much quicker rate. That also makes it much cheaper. And you can make the drugs much better because you are designing them. Things in nature are nice, but they are not precise, so we can quite literally make them perfectly well-suited to what we are doing. We engineer them to be very, very potent, which means they can work very well and be very selective.

Q/ What is antibody library?

We have over 10 billion different antibodies. And we can search through those in days and find the ones that are perfect for what we want. So that is why it is a library. It is literally 10 billion different antibodies. And we have ways of finding among those antibodies the one that is a perfect drug.

Q/ You build this library so that you can deal with any kind of disease.

Exactly. And it is already built. So within days, we can look through that library with our methods and find the one or two antibodies that can do exactly what we want, and that can be a drug.

Q/ Will the world be in a better position to deal with another pandemic because of the kind of research you are doing?

Yes, definitely. Now we can make, within months, drugs that can hit the virus and neutralise it. And importantly, they can also deal with different versions of the virus. The virus mutates. But we can make our drugs so good that they can deal with that as well. So, you can hit many different viruses and you can make the drugs much quicker than before.

Q/ Was your research used by other companies during the pandemic?

No, because we were just getting into the field. Until Covid struck, our main focus was on cancer and other things. After Covid came, we got involved with that. We are starting to work with companies now.

Q/ Are you looking at solutions for other infectious diseases?

We are looking at dengue, we are looking at RSV (respiratory syncytial virus), which afflicts newborn children. We are still looking at Covid. Our technology can be applied to any virus.

Q/ You spoke about the rapid discovery of antibodies. Earlier it took a lot of time to defend against many diseases. So how did you achieve this rapid discovery?

Well, that is too complicated to get into. It is synthetic. So, we are not relying on animals. We don't have to work with mice. We don't have to grow things, because it is engineered in a test tube it is much quicker to do.

Q/ How cost-effective are these?

It is cost-effective. People are making drugs much more cheaply. I think Biocon is making Herceptin for a few hundred dollars, rather than thousands of dollars. That is a cancer drug. And the better they are, the lesser you have to take those drugs. The big goal is to make it more accessible.

Q/ Another focus area of your research is protein inhibitors and potential therapeutics. Could you please elaborate?

So for cancer, where certain proteins are overactive, we develop antibodies that target those in human cells and turn them down. In breast cancer, HER2 causes the cells to grow, and Herceptin binds that protein and turns it off. So we are looking for new proteins―if their activity causes cancer to grow, and if you turn that off, then the cancer should die.

Q/ Is there any particular kind of cancer or other disease that was not curable earlier, but can be cured now because of this new domain you are working on?

Many companies are doing this and every year there are new drugs, which are antibodies. So yes, there are some things for lung cancer and various other cancers. Then there are the immune checkpoint inhibitors that have cured melanoma.

Q/ What opportunities does India have in exploring these advanced technologies? Where does India stand in this particular segment of therapeutic antibodies?

Well, it should be in a very good position. It already is the biggest producer of vaccines, which is another protein. It makes a lot of antibody drugs that are biosimilars. So India already knows how to make these. You just have to invest in the new drugs that are coming. So we want to partner with India.

thyroid-hormones-effect-on-bone-health

Sat Jul 29 15:48:19 IST 2023

The thyroid, a butterfly-shaped gland in the front of our neck, produces the hormones T4 (thyroxine) and T3 (triiodothyronine). These hormones are regulated by the thyroid stimulating hormone, which is synthesised by the pituitary gland (situated at the base of the brain). The thyroid hormones help in the regulation of fat, protein and glucose metabolism, modulating body temperature and maintaining overall equilibrium.

The often-discussed functions of the thyroid hormones are related to body weight, energy levels, cardiac fitness, digestion and gut motility, skin and hair quality, sleep and mental wellbeing, and sexual health, fertility and pregnancy. An important aspect which is often overlooked is their role in regulating bone health.

The thyroid hormones are essential for normal skeletal development and play an important role in the maintenance of bone structure and strength. The skeletal system is one of the largest systems of our body and its important components include structural proteins like collagen, minerals like calcium-phosphorous, and cells like osteoclasts (responsible for bone dissolution) and osteoblasts (responsible for bone formation and replacement). Any disturbance in thyroid hormone levels disrupt the balance of bone dissolution and replacement.

Therefore, bone health can be adversely affected in various states of thyroid dysfunction. Dysfunction can be excess functioning of thyroid hormones―hyperthyroidism―or under functioning―hypothyroidism. Both situations can have detrimental effects on musculoskeletal fitness.

Impact of hyperthyroidism: The activity of osteoclasts increase and there is rapid bone dissolution. The bone replacement by osteoblasts cannot match-up, leading to net bone loss. Additionally, in hyperthyroid individuals, there is more calcium loss via the urine and inefficient calcium absorption via the gut, leading to negative calcium balance. These factors eventually lead to low bone density and osteoporosis, a condition associated with fragile bones. Osteoporosis itself has no obvious symptoms, unless fracture occurs.

People with untreated hyperthyroidism have 12 per cent to 20 per cent reduction in bone density and three to four times increased risk of hip and spine fractures. This is more evident in the elderly and post-menopausal women. Even treated hyperthyroidism is known to have residual negative effect on bones―increasing the risk of fractures up to two times.

Impact of hypothyroidism: Reduced activity of the osteoclasts and osteoblasts lead to low bone turnover. The decreased bone metabolism affects children more than adults. Childhood hypothyroidism causes delayed skeletal development, impaired mineralisation of bones and slowing of normal growth. Delayed eruption of teeth, hip dislocation and abnormal curvature of the spine can be other manifestations in children. Congenital hypothyroidism in India varies from one in 750 to one in 2,500 newborns, depending on the geographical location.

In adults with hypothyroidism, the overall quality of bones may become poor with time, although, there is no direct correlation between osteoporosis and low thyroid hormones. Hypothyroidism often affects muscles, causing pain, cramps, weakness and lethargy, which, in turn, can lead to increased tendency to fall and fracture. Also, people with hypothyroidism on thyroxine treatment should have regular blood tests to ensure that their hormone levels are not too high, as it can lead to treatment-induced hyperthyroidism.

Bone care in patients with thyroid dysfunction: Early identification and proper treatment of thyroid dysfunction is important as the bone involvement can be asymptomatic in the initial stages.

People with typical symptoms-cluster, like unexplained weight loss, tremors, palpitations, heat intolerance, anxiety, nervousness and protruding eyes, should get evaluated for hyperthyroidism.

Those with weight gain, fatigue, lethargy, constipation, dry and brittle nails, hair fall, cold hands and feet, puffiness of the feet and infertility, should get assessed for hypothyroidism.

Those with goitre (a swelling at the front of the neck caused by an enlarged thyroid gland) or a strong family history of thyroid disorders should consult an endocrinologist or a physician for further evaluation.

Patients on treatment for thyroid disorders should comply with the medicines, and be regular with their tests and medical follow-ups. In hyperthyroid patients, apart from the prescribed treatment, general measures for fall-prevention should be followed. Regular physical activity, balance exercises and yoga, properly fitting and sturdy footwear, proper lighting of living spaces, especially bathrooms and hallways and use of assistive devices like handrails can go a long way to prevent falls.

High impact exercises like jogging and power-walking help strengthen bones and muscles.

Eating a well-balanced diet of calcium and protein rich food, maintaining normal vitamin D levels, and avoiding smoking and alcohol help keep the bones healthy. Supplements are recommended for populations where diet does not provide adequate calcium.

Adequate vitamin D production occurs from frequent, mid-day sun exposure―10 to 30 minutes for three to five days a week. However, repeated, long-duration exposure can cause sunburns, eye problems and heat strokes. It is thus easier to consume vitamin D supplements as per your doctor’s advice. Some patients with osteoporosis, especially elderly women, may also need specific anti-osteoporosis therapy.

Screening for thyroid dysfunction in each new-born should be done, so that thyroid insufficiency is identified at the earliest. Consult paediatricians regarding children with delayed growth, inappropriate weight gain, deteriorating scholastic performance, slower reaction time and sluggishness, irritability and constipation.

Maldar is consultant endocrinologist, P. D. Hinduja Hospital and Medical Research Centre, Mahim.

ai-based-clinical-documentation-software-augnito-working

Sat Jul 29 15:43:25 IST 2023

Until about nine months ago, Dr Shreesha Maiya from Bengaluru would type into his computer the case history, diagnosis and prescription once the patient consultation was over. It was a dreary task, as most doctors would attest to.

Recently, though, Maiya has been using Ambient, an AI-powered app that compiles, in real time, the conversation between doctor and patient. With this, the patient's electronic medical record, which contains their health history, is ready the moment the consultation is over.

Maiya, a consultant cardiologist and electrophysiologist at Narayana Institute of Cardiac Sciences, said he could now speak more freely and without care for structure. “Earlier, it was a tedious job,” he said. “Most often, patients do not remember 70 per cent of the content that was discussed,” said Maiya. “It is really good that they can now read it after going home. It looks professional.”

Ambient, which comes from Augnito, an innovative voice AI service provider, also claims to reduce burnout in doctors. “The time I spend with the patient has reduced significantly as I do not have to type things out,” said Maiya. “Most important, I can continuously keep eye contact with the patient, which is crucial. Earlier, I also needed to look at the computer screen.”

Rustom Lawyer, cofounder and CEO of Augnito, said a few hospitals, including Apollo, Fortis, Max, Aster and Narayana Health, are currently using the app, and claimed that it could be a game-changer. When the data is accurate, a lot can be done in clinical research and also in the insurance sector, he added. Augnito is talking to a few state governments; Lawyer said something could materialise in about six months. The national push for digitisation would only help onboard such apps.

As for how it works, the doctor need only open the app and start talking to the patient―no note-taking required. Ambient catches the doctor's voice even when the patient is being examined and the report comes out at the press of a button. “It is like a copilot doing the job for you,” said Lawyer. Voice, he added, is the next level of interface; graphical interface is old.

Ambient currently recognises accented Indian English and 10 Indian languages; the team is working on adding Arabic as Augnito primarily caters to India and the Middle-East.

Dr Binod Kumar from Apollo hospital, Kolkata, who also uses Ambient, said it works best if one uses headphones, but in the same breath added that doctors cannot do that. He was also open to the idea of government hospitals using the app, but added that the benefits you get from technology depend on how you use it.

Ambient is among a bouquet of apps that Augnito has put out over the past several years. These apps cater to more than 50 medical specialities in diagnostic centres, laboratories and out-patient departments.

Augnito is part of Scribetech, the UK’s first medical transcription BPO and a leading provider of software and services to the National Health Service. Lawyer, who is also a cofounder and CEO of Scribetech―he started there at 19, ―said a team of around 100, including 40 from the engineering and product team, worked on Ambient.

Though currently used by hospitals, the app can also help those in private practice. “It is a good clinical practice and the history is accurate when the patient goes to some other doctor for some other ailment,” said Lawyer.

There are a couple of competitors for Augnito in the US market, but Lawyer claimed that, in India, they are the leader. He also said that their association with the hospitals did not end with providing the app. “We have had good experiences in the past,” he said. “We are partners in the customers’ success and keep taking feedback from them about how the app is functioning.”

study-by-japanese-scientists-about-avoiding-frightening-visual-stimuli

Sat Jul 29 15:23:23 IST 2023

This year marks the golden jubilee of The Exorcist, the iconic American supernatural horror film that left countless people terrified, so much so that they covered their eyes during numerous scenes. The act of avoiding frightening or disturbing visual stimuli is a shared experience among both humans and animals. However, the underlying reason for averting our gaze from these fearful things has long intrigued researchers. Now, a group of Japanese scientists has found some interesting clues in the brains of fruit flies.

The researchers discovered a neuronal process that governs visual aversion in the brains of fruit flies when they experience fear. This mechanism involves a specific cluster of 20-30 neurons responsible for regulating their vision during fearful situations. The researchers assume that since fear affects vision across species, including humans, this mechanism must be present in all those species.

As per their study published in Nature, the researchers employed bursts of air to create a sense of physical threat, observing that the fruit flies' walking speed increased when subjected to these puffs and gradually returned to its baseline level afterwards. This response indicated that the flies perceived the air bursts as threatening or, at the very least, preferred to steer clear of them. To further explore this aversion behaviour, the team introduced a small black object, similar to the size of a spider, positioned either 60 degrees to the left or right of the fly. Interestingly, the object alone did not prompt any notable changes in behaviour. However, when presented with the puffs of air, the flies avoided looking at the object and positioned themselves to keep the object behind them.

Seeking to delve into the molecular mechanisms underlying this aversion response, the researchers introduced CRISPR-generated neuropeptide-null mutant flies, with altered activity in specific neurons. Despite maintaining their visual and motor abilities and still managing to avoid the air puffs, the mutated flies did not display the same fear-driven reaction when it came to visually avoiding the black object. This finding indicated a crucial link between the identified neurons and the flies' aversion behaviour towards perceived threats.

The researchers found that a cluster of neurons that releases the chemical tachykinin was necessary for activating visual aversion. The team is currently investigating how these neurons integrate into the broader brain circuitry. Despite identifying these neurons within a recognised visual region of the brain, the researchers are yet to determine the sources of inputs they receive and the targets they transmit to, which ultimately regulate visual responses, guiding the avoidance of perceived threatening objects. Once they unravel the mechanisms of visual information transmission in the brain, they will be able to construct a comprehensive circuit diagram illustrating how fear influences vision. This discovery holds the potential to offer insights into the treatment of psychiatric disorders associated with exaggerated fear, such as anxiety disorders and phobias in humans.

innovations-in-medical-diagnostics-and-treatment

Sat Jul 01 18:21:58 IST 2023

Improvements in our knowledge of human biology at the molecular and genetic levels have opened avenues to a potential golden era of cancer care―where identification of a tumour’s unique signature is a reality, and where personalised therapies can be easily crafted using innovative diagnostic solutions.

Cancer continues to be a leading cause of mortality across the world. In India, there were more than 14 lakh cases in 2022. As per the National Cancer Registry, one in nine people are likely to develop cancer in their lifetime. Moreover, the incidence of cancer is estimated to increase by 12.8 per cent in 2025 as compared to 2020. How will we meet the challenge that cancer poses to future generations?

Advances in technology are reshaping health care, offering patients the means to track their health and giving clinicians deeper insights into the causes of cancer and its management. Technologies and innovations like CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats), artificial intelligence, tele-health, cryo-electron microscopy, and robotic surgeries are accelerating the fight against cancer. Here, diagnostics tools play a crucial role. Innovative diagnostics technologies such as next-generation sequencing, liquid biopsies and artificial intelligence powered image analysis algorithms are facilitating an evolution in personalised cancer care.

For instance, the implementation of next generation sequencing (NGS) has improved our understanding of cancer and opened avenues for patients with personalised treatment options. We can use NGS to detect genomic alterations driving tumour development and provide insights to inform tailored care plans, including targeted treatment and immunotherapy. Moreover, through comprehensive genomic profiling (CGP), we can analyse hundreds of cancer-related genes and determine the specific genomic profile of an individual tumour.

Second, advances in computation and artificial intelligence in digital pathology have improved access to new treatment options for patients with solid tumours. AI in digital pathology is showing promise to meet the demand for more accurate and comprehensive assessment of pathology results to enable improved patient outcomes. These can help support clinical trials in the investigation of targeted therapy options. Expanding access to innovative tools will enable precise diagnoses, improved clinical decision-making, and lead to more personalised treatment strategies.

However, in India, the cancer burden is compounded by socioeconomic disparities and fragmented care provisions. Access to appropriate cancer care, including basic diagnostic tools, is still sparse in many parts of India.

Cervical cancer is the second most common women-related cancer in India, afflicting more than 1.23 lakh women each year. Despite being the most preventable and treatable cancer, around 77,000 women die of it each year, as per the Globocon 2020 statistics. According to the WHO, cervical cancer can be eradicated by 2030 by the implementation of a global strategy involving the vaccination of young girls against human papillomavirus (HPV), screening 70 per cent of women from 30 to 69 years of age, and treating 90 per cent of women with precancerous lesions. The WHO recommends HPV testing as a primary screening modality over pap testing and visual inspection with acetic acid. However, there is a lack of awareness around this effective screening tool.

India requires a digital roadmap designed to comprehensively address preventive and curative cancer management and deliver care that is of higher quality, more timely and precise, in an equitable manner across India.

Here is where efforts like the First Cancer Care (FCC) initiative can be instrumental. FCC envisages practical solutions for reshaping how millions of patients are treated and for improving efficiencies in cancer care. The recommendations are laid out in three cancer care value pathways: population health, capacity building and data pathways. This includes an independently implementable segment of the cancer care value chain, comprising digital and physical processes for a continuum of care.

Using digital tools to support screening will give millions the opportunity for early detection and treatment, leading to better health outcomes. These initiatives will be run in alignment with Ayushman Bharat Digital Mission (ABDM). A two-year pilot will be rolled out by the government of Meghalaya in association with the Union health ministry in East Khasi Hills district. It covers oral, breast, cervical, oesophageal and lung cancers.

The other area that can be explored is telemedicine. SARS-CoV-2 has highlighted the potential use of this tool effectively. Telemedicine can be utilised across the cancer care continuum including prevention, screening, diagnosis, treatment, rehabilitation and palliative care.

Likewise, innovative mHealth solutions can provide remote access to health care services. It can be used to provide cancer education, preventive measures, and counselling services to patients and their families. This can help to reduce the burden of travel for patients.

Sewlikar is head of medical and scientific affairs, Roche Diagnostics India & Neighbouring Markets.

regular-diagnostic-tests-women-must-take-to-keep-diseases-at-bay

Sat Jul 01 17:49:56 IST 2023

BIOLOGICALLY, WOMEN are prone to disease earlier in life because of several factors that include hormonal and menstrual issues, childbearing and multitasking. Women’s health is generally ignored because of lack of time, awareness, and the many responsibilities a woman has. Also, regular screening is still not a priority.

A woman's immunity starts to diminish noticeably as early as age 30, and she is likelier than men to be affected by bone density loss, anaemia, thyroid issues, malnutrition, diabetes, hypertension and other lifestyle disorders.

One way for women to ensure a healthy life is through early diagnosis. For this, regular checkups and screenings are beneficial. Though most health risks are present throughout life, women should get some routine checkups after they turn 20.

Prescribed tests for women in their early 20s:

PCOD/PCOS screening: This ovarian condition occurs because of hormonal imbalance. It is important to understand that polycystic ovary disease and polycystic ovary syndrome are different conditions. In PCOD, the ovaries release immature eggs that leads to hormonal imbalance and swollen ovaries; in PCOS, endocrine issues cause the ovaries to produce excess androgens (male sex hormone), which makes eggs prone to becoming cysts.

The conditions, in their early stages, can be treated with a healthy and active lifestyle. If one is facing symptoms along with menstrual irregularities, the gynaecologist will suggest screening. This includes a pelvic examination, blood tests and ultrasound. A followup test is recommended only if the symptoms persist.

The cost ranges from Rs200 to Rs3,300, based on various factors.

Pap smear: This is a test to identify cancer of the cervix before it becomes symptomatic. It also identifies precancerous changes and helps identify high-risk populations for cancer. An instrument called a speculum is used to collect cells from the cervix that are later tested. One needs to take a pap test at 21; if the results are normal, the patient should follow up with the test, once every three years, till they reach 65.

The cost ranges from Rs500 to Rs1,400.

Thyroid function test: A thyroid function test is prescribed to check the functioning of the thyroid gland in case of symptoms like weight gain, hair fall, dry skin, fatigue, mood swings, irregular periods and infertility. These could be because of thyroid disorders. Hyperthyroidism and hypothyroidism are detected through a series of blood checks. One is advised to take thyroid tests once a year or as frequently as advised by the doctor.

The average cost is between Rs300 and Rs700.

Apart from this, women are expected to get routine checkups for lipid profile and blood pressure, and mammograms at regular intervals as suggested by doctors.

Prescribed tests for women in their 50s:

Bone density test: This is to diagnose osteoporosis, which can cause fractures. Especially in women going through menopause or post-menopause. The bone density checkup should be done every two years. The test is performed through special X-ray beams called a DEXA scan.

The test costs between Rs1,500 and Rs6,000.

Blood glucose tests: Most diabetes cases go unnoticed because of a lack of screening and awareness. The delay in testing can cause vision impairment and kidney issues in women. One should get the glucose level tested as often as the doctor suggests, based on the risk factors.

The test costs around Rs200.

Complete urine exam: Urinary tract infection (UTI) is a common condition among older women because of the physical structure of the urethra and the hormonal changes during menopause and post-menopause. It occurs because of the bacteria in the urinary tract. CUE not only helps detect UTIs, but also any hidden health complications in the kidney before it become serious. The frequency of the test depends on the doctor's recommendation.

The test costs between Rs100 and Rs300.

Another test women above 50 should frequently take is one for various vitamin deficiencies as that is quite common among older women.

Conclusion

Apart from the above-mentioned health risks, women are comparatively at a higher risk for conditions like hypertension and heart attack. One needs to get routine checkups to keep a lookout for any health complications, and to help with better treatment. Most conditions are difficult to prevent as the actual causes are not known. However, early detection of the conditions helps the doctor and the patient fight the illness effectively.

The writer is part of the obstetrics and gynaecology department, Apollo Cradle and Children’s Hospital, Koramangala, Bengaluru

entrepreneur-and-biotech-adviser-sam-santhosh-interview

Sat Jul 01 17:46:59 IST 2023

Sam Santhosh, who spearheaded India's genomic revolution through the incubation and launch of many companies that harness the power of sequencing and bioinformatics, holds a positive outlook on India's advancement in the bioeconomy. In an exclusive interview, he sheds light on India's potential as well as the areas where it needs to improve in genomics and drug research. Excerpts:

What are the advancements in bioeconomy in India?

The bioeconomy encompasses a wide range of industries, primarily in the life sciences, but also bio-manufacturing. Numerous advancements are occurring, with the genomics revolution being particularly influential. Genome sequencing, in particular, serves as a cornerstone for this revolution. The breakthrough began in 2008-2009 with the emergence of new technologies enabling faster and more affordable sequencing.

It is a remarkable transformation where sequencing projects that used to take months can now be completed in a few days. This change has revolutionised the field of biology, as it has become digitised. The key element in the bioeconomy is biology itself, and, fortunately, the source code of life is universal across all living organisms. Consequently, the technologies for genomic sequencing and the necessary tools for analysis are applicable to all living organisms. Many advancements have emerged, including the retrieval of ancient DNA from bones that are thousands of years old. These breakthroughs have significantly enhanced our understanding of evolution and the shared genes across all species. To comprehend evolution, it is crucial not only from a scientific perspective but also for gaining insights into diseases and potential improvements in life.

We are significantly behind the US and China in spite of the advancements. The US holds the leadership position, but China has made remarkable strides in the past 20 years, particularly in pushing the bioeconomy applying genomics. They have invested substantial funds and effort in its development, making them a close second to the US. China has also produced a considerable number of publications and made significant advancements in real-life applications, surpassing the progress of both the US and India. In a democratic environment, certain limitations exist in pushing some of these advancements, whereas China, being a more dictatorial regime, can effectively implement new initiatives across the country. In terms of research and applications, China is currently ahead of India, but India has shown promise primarily in applications, albeit lagging in pure research. It is reasonable to expect India to catch up in about 20 years.

What major innovations can we anticipate in genomic research in this decade? How will these advancements change how we deal with human health and diseases?

The genomic revolution progressed through three phases. The first phase involved reading the genetic code through sequencing technology. The genetic code consists of four letters, A, G, C, and T, representing the four chemicals that make up DNA. All living organisms are based on these four letters, although their order and length vary. For instance, the human genome consists of approximately three billion letters in each of our cells, while other organisms may have larger or smaller genomes. The size of the genome does not necessarily indicate the complexity or development of an organism, but it provides insights into the evolution and specific traits exhibited by the organism.

Genes play a crucial role in determining an organism's traits, and genes from one organism can often function properly in another organism. However, transferring genes between organisms requires extensive work to ensure they work correctly within the new host. From a gene's perspective, it operates like a part of a software program and is compatible across organisms. The understanding of these concepts was made possible through gene sequencing.

As the cost of sequencing decreased and the speed and power of sequencing technology increased, vast amounts of data became accessible. This data offered valuable insights into the causes of diseases and why certain individuals are more prone to them, and facilitated the development of new targets for medicines. The Covid-19 pandemic highlighted the significance of sequencing as it enabled the rapid identification of the virus and played a vital role in developing vaccines within a remarkably short period. These advancements and discoveries characterise the first phase of the genomics revolution.

With the vast amount of genomic data available, we can now begin to manipulate it through editing. This process is similar to how language develops, starting with learning words and gradually developing the ability to converse and write. Similarly, we can now edit the genetic code. Editing plant genomes has progressed rapidly, though they are more complex yet present fewer ethical concerns. In the US, for instance, more than 60 per cent of food consists of genetically modified plants. This technology allows for improved crop yields, reduced pesticide and fertiliser use, increased shelf life, and enhanced nutrition. Unfortunately, many countries, including parts of Europe and India, have expressed fears about genetically modified organisms, despite these fears being unfounded. However, the Indian government has relaxed regulations now and categorised genetically modified food into three categories, allowing for more genetically modified food to emerge in the second wave of the genomic
revolution.

Genomic editing is also being explored for human applications. The first human trial for a genome editing medicine is currently underway in the US by Verve Therapeutics, with successful completion of the first phase of clinical trials and plans for Phase 2. They aim to find a solution for high cholesterol through gene editing. High cholesterol levels contribute to heart disease, and while there are existing medications, they often require lifelong use and have side effects. The researchers are focusing on a specific gene called PCSK9 that, when altered by changing a single letter, prevents cholesterol increase. Previous evidence shows that altering this gene does not cause other problems since many individuals naturally lack the gene. The goal is to administer a single injection to modify this specific letter in the gene through a process known as base-pair editing.

When genome editing gained popularity, CRISPR technology received significant attention. This approach involves cutting the desired region of the genome and introducing desired changes. While it is easy to use, it can have unintended consequences due to the cutting and reattachment process. In contrast, base-pair editing provides greater control as it targets specific letters for modification, minimising potential side effects.

Gene and cell therapies have gained significant attention in the last decade. However, the current processes are expensive and inaccessible to the average Indian.

They are very expensive. Even in the US, they cost like a million dollars per patient. So even there very few people can afford it. For instance, CAR T-cell therapy involves modifying T-cells, which are our immune fighters, to recognise and target cancer cells. Typically, cancer cells evade our immune system, allowing them to grow unchecked. By extracting T-cells from the body, modifying them to specifically recognise cancer cells, and reintroducing them, the immune cells can effectively eliminate the cancer. However, this process is time-consuming and costly. Lowering the cost of CAR T-cell therapy poses significant challenges.

Researchers are exploring various approaches to make allogenic CAR T-cell therapies more feasible and affordable. Allogenic therapies involve using T cells from a few donors and modifying them to be suitable for anyone with specific cancer and gene mutation. By leveraging sequencing data, the specific line of modified T-cells can be quickly administered to patients. If mass manufacturing can be achieved, the cost of these therapies could be significantly reduced. However, the challenge lies in overcoming the complexities of the immune system, as each person's immune response is unique. Despite the challenges, efforts are being made in this direction to reduce costs.

Another avenue of exploration is the use of different immune-related cells in the body, such as NK cells (natural killer cells). Researchers are investigating these alternative cell types for potential therapeutic applications. Additionally, there are ongoing advancements in other technologies related to cell therapy and gene therapy. It's worth noting that the current CAR T-cell therapies primarily target liquid cancers, as solid tumours present greater challenges due to their heterogeneous nature. Unlike liquid cancers, solid cancers like lung cancer can have multiple mutations and different types of cancer cells within them. Developing CAR T-cell therapies that effectively address solid cancers remains an ongoing area of research.

Numerous companies are actively working on various diseases, including rare diseases that carry a significant burden in India. Many of these rare diseases are caused by single gene mutations, often involving just a single letter in the genetic code. The use of base pair editing technology, as mentioned earlier, holds great potential for addressing these diseases by making precise fixes. Over the next 10-20 years, we can expect significant advancements in gene editing that will contribute to the treatment of many diseases.

The third phase of the genomic revolution will involve synthetic biology, which encompasses the creation of new genomes and the manipulation of genes to manufacture a wide range of products, from fertilisers to cosmetics to medicine. This will entail using cell lines, yeast, and other microbes to produce desired substances, scaling up production in large fermenters. Various forms of sugar, biomass, and even waste materials can serve as inputs, enabling environmentally friendly and sustainable production processes. The bioeconomy will bring forth a plethora of products that are safe for the environment and free from toxic by-products. The potential impact of this development is immense, and it will far exceed the current target of a $300 billion market.

CUT, PASTE, CURE

Genetic code

The genetic code consists of four letters, A, G, C, and T, representing the four chemicals that make up DNA (adenine, guanine, cytosine and thymine). The two strands of DNA are held together by bonds between these bases.

All living organisms are based on these four letters, but their order and length vary. The human genome, for instance, consists of around 3.3 billion letters in each of our cells, while a dog genome has around 2.8 billion.

Gene editing

It is now possible to edit the genetic code. Editing plant genomes has progressed rapidly. In the US, more than 60 per cent of food consists of genetically modified plants.

The first human trial for a genome editing medicine is under way in the US, looking for a solution for high cholesterol. The researchers are focusing on a specific gene called PCSK9 that, when altered by changing a single letter, prevents cholesterol increase. The goal is to administer a single injection to modify this specific letter in the gene through base-pair editing.

CRISPR gene editing vs base-pair editing

Clustered Regularly Interspaced Short Palindromic Repeats gene editing involves cutting the desired region of the genome and introducing desired changes. It can have unintended consequences due to the cutting and reattachment process. In contrast, base-pair editing provides greater control as it targets specific letters for modification, minimising potential side effects.

computer-vision-syndrome-symptoms-treatment

Sat Jul 01 17:40:35 IST 2023

When 30-year-old Manju began seeing floaters and dark zigzags, she put it down to tiredness and ignored it. After a few months it became a regular occurrence. She also began seeing bright flashes. Still, she ignored it. But, after a year it became more frequent and, at times, she was unable to see or focus on objects. Finally, Manju (name changed) decided to consult an ophthalmologist and was referred to a neurologist.

Dr Sudhir Kumar, senior consultant neurologist, Apollo Hospital, Hyderabad, diagnosed her with smartphone vision syndrome. Manju, who was a factory employee, quit her job after she had a baby. Her husband would return from work late and Manju would stay awake till he was back. While waiting for him, Manju would switch off the lights, lie down beside her baby and watch videos on her smartphone for hours. She never thought the screen brightness, changing colours and the darkness in the room would do her harm.

Manju is among 1.8 crore people in India affected by dry-eye syndrome or computer vision syndrome (CVS). In one year, at least 30,000 children under five complain of blurred vision. While malnutrition and consanguineous marriages are two of the reasons for the increasing cases of blurred vision in children, another major reason is prolonged smartphone screen time.

The symptoms include floaters and zigzags, burns around the eye, non-stop tears or complete, momentary blindness. Additional symptoms could be pain in the head and neck. CVS, according to ophthalmologists and neurologists, does not lead to permanent vision loss but causes vision disturbance. There could also be redness, pain or watering in the eyes.

“The only reason for this is more screen time and the brightness on the screen,” says Dr Niveditha Narayan of Sankara Nethralaya in Chennai.

Dr Ravindra Mohan of Trinethra Eye Care, Chennai, says we have to learn to live with it because the cause is lifestyle related. “The job of the eye is to convert light impulse into electrical impulse, which will travel along the nerves to the brain,” says Mohan. “This is the system which is used to touch and feel the real image. This is called the eye-nerve-brain coordination.” He says that digital screens lead to people of all ages stressing out their eyes and nervous systems.

“The longer the use, the more the stress,” says Narayan. Sankara Nethralaya has a dedicated CVS clinic. Patients who walk in every day for treatment range from five year olds to 80 year olds. “The footfall in the clinic has been increasing day by day, sounding an alarm,” says Narayan. She says that most patients do not blink enough when they do visually strenuous work. “That is a natural phenomenon,” she adds. “When somebody is keenly listening to or watching something, they do not blink and the eyes get bulged.” The blinking rate comes down by 50 per cent in such situations. The reduction in blinking and the air in air conditioned rooms cause dehydration, leading to dryness in the eyes.

In the case of Manju, CVS occurred because she used her phone with the lights off. Looking at the bright screen in the dark room caused her retina to be under the maximum pressure. “I advised her to reduce screen time,” says Sudhir Kumar. “She was anxious, but, with counselling she was alright. She [reduced] her phone usage. After one month, the symptoms started subsiding. She is fine now.”

He cites the case of another patient who used to cover one of her eyes with a bed sheet and look at her phone with just one eye. “This is even more dangerous,” he says. “We tell patients to split work into portions and not to use digital screens during breaks.” The usual advice is 20-20-20―every 20 minutes, look 20 feet away for 20 seconds. However, with the increase in use of digital screens, ophthalmologists say CVS cannot be eliminated, only managed.

research-studies-to-tackle-obesity-and-high-cholestrol-issues

Sat Jul 01 17:28:48 IST 2023

Obesity is a multifaceted condition, not yet fully understood by the scientific community. A recent study published in Nature Metabolism has revealed that obesity can potentially modify an individual's brain activity, leading to an impact on how the brain responds to food, particularly in terms of satiety signals. These changes in brain function persist even after significant weight loss among obese individuals. Consequently, researchers suggest that this could be a contributing factor to the weight regain experienced by many. Moreover, they argue that since obesity causes structural alterations in the brain, it warrants being recognised as a disease.

Individuals with a body mass index (BMI) exceeding 30 are classified as obese, while a BMI between 18 and 25 is considered within the normal range. The recently released 2023 atlas by the World Obesity Foundation presents a worrying prediction: if significant action is not taken, over half the global population―more than 4 billion―will be overweight by 2035. The report also reveals a startling projection for childhood obesity―the number of affected boys could more than double from 2020, reaching 208 million by 2035, while the number of affected girls may reach 175 million. According to the federation's estimates, addressing health conditions associated with obesity will require an annual expenditure of over $4 trillion by 2035 globally.

In the context of combating obesity, a recent discovery has gained significance. A team of scientists from the University of Barcelona has unveiled an innovative approach in the form of ex vivo gene therapy―gene modifications done outside the body―to combat obesity. Gene therapy involves the introduction of genetically modified cells to target a specific disease. The study, which was recently published in Metabolic Engineering, asserts that it is a first-of-its-kind approach to employ ex vivo gene therapy to generate and implant cells that produce the CPT1AM protein―an enzyme found in the mitochondria that plays a crucial role in the development of metabolic disorders, including obesity.

Adipose tissues―connective tissues in the body―predominantly consist of adipocytes or fat cells. These adipocytes function as energy-storing cells, provide cushioning for organs and produce hormones. Researchers in Barcelona aimed to generate adipocytes capable of expressing an active variant of the CPT1A enzyme responsible for mitochondrial fatty acid oxidation. Their findings revealed that this active form, known as CPT1AM, effectively facilitated the burning of excess fat and improved metabolism in obese mice. CPT1AM was found to reduce weight, hepatic steatosis (fatty liver), as well as cholesterol and glucose levels in mice.

While the study is yet to be conducted on humans, researchers suggest that this preclinical investigation may pave the way for advanced therapeutic solutions in the coming years to tackle obesity and high cholesterol issues.

can-chatbots-replace-the-connection-between-a-patient-and-a-human-healer

Fri Jun 02 18:52:37 IST 2023

Joseph Weizenbaum, a renowned German-American computer scientist and former professor at the Massachusetts Institute of Technology, is widely recognised as a pioneer of artificial intelligence. During the 1960s, he developed an AI program called ELIZA, which employed word and pattern recognition techniques along with natural language programming to simulate responses similar to a psychotherapist. According to a recent article by Elisabeth Rosenthal, a senior contributing editor of KFF Health News, the success of ELIZA actually “terrified” Weizenbaum. In an interview with Rosenthal, Weizenbaum disclosed that his students would engage with the machine as if it were a genuine therapist. Although he had foreseen the rise of powerful AI tools, he maintained the belief that they could never truly excel as therapists.

In today's cyber world, there is an overwhelming presence of self-help apps focused on mental health. According to a market analysis by Grand View Research, the global market for mental health apps touched $5.2 billion in 2022, with a projected compound annual growth rate of 15.9 per cent from 2023 to 2030. Over the past few years, around 20,000 apps have emerged in the mental health space.

However, clinicians, researchers, and government authorities have raised concerns regarding the effectiveness of these apps. The lack of comprehensive research and expert consultation during the app development process has been a major factor contributing to these concerns. A study published in JMIR Mental Health in 2020 examined 293 apps offering therapeutic treatment for anxiety and/or depression. Of these, only 162 claimed to have an evidence-based theoretical framework in their app store descriptions, and a mere 10 had published evidence supporting their efficacy.

Most mental health apps provide what can be called “structured therapy”, generating workbook-like responses tailored to specific patient problems. However, there are concerns about the potential for unempathetic responses and the harm they may cause, particularly in cases involving suicidal tendencies.

Three years ago, the Journal of the American Medical Informatics Association featured a study highlighting concerns with consumer-facing apps. The study reviewed 74 reports on safety issues related to health apps and identified 80 safety concerns, with 67 of them relating to the quality of information presented and inappropriate responses.

Many of these apps carry disclaimers stating that they are not intended to replace medical or behavioural health services. However, they are still marketed with claims of treating conditions such as anxiety and depression and predicting suicidal tendencies. Hence, it is prudent to refrain from replacing a qualified therapist with a mobile application since the current evidence is inadequate to support the notion that a chatbot can replicate the empathetic connection between a patient and a human healer.

governance-system-fails-to-keep-medical-workers-safe

Fri Jun 02 18:50:27 IST 2023

Since the funeral of her daughter, Vasanthakumari has retreated into the darkness of her room, rarely venturing outside. Despite persistent pleas by family members and relatives, she skips meals and refuses to switch on the lights in her room. She and her husband, K.G. Mohandas, suffered the biggest tragedy of their lives on May 10, when their daughter, Dr Vandana Mohandas, was killed by a patient she was attending to at the government-run taluk hospital at Kottarakkara, in Kerala's Kollam district.

It was Vasanthakumari’s dream to see her daughter become a doctor. And, Vandana, who did her MBBS at Azeezia Medical College in Kollam, was so close to getting a registration to practise and fulfill that dream. But the systemic failure to prevent violence against health care workers culminated in the young doctor’s death at the hands of a violent man.

Vandana joined the MBBS course in 2016. She was doing her house surgency with her junior (2017) batch. The 2017 batch was the first regular batch in Kerala that was required to do three months of community medicine posting in district or taluk hospitals as part of their 12-month compulsory rotating medical internship (CMRI)―which is required to become a registered doctor. Vandana was fulfilling this requirement when she was attacked by S. Sandeep, a 42-year-old school teacher.

On that fateful day, Vandana and another house surgeon, Dr Muhammad Shebin, were assisting the duty doctor in the casualty section. At around 4:30am, the police brought an injured Sandeep to the hospital. As he was being treated, Sandeep turned violent, and went on a stabbing spree with a pair of scissors he took from the nursing room. He stabbed Vandana multiple times inside the observation room. According to the forensics report, she suffered 17 injuries, including four deep cuts in the body. Unfortunately, the police failed to anticipate the attack or to stop it.

Vandana’s tragedy shook the entire state’s conscience, and led to vehement protest from the medical community―not the first time, though―about the violence they face and the lack of security at their workplace. The Kerala Government Medical Officers’ Association (KGMOA), the Indian Medical Association (IMA), the Kerala Medical Post Graduate Association (KMPGA) and the Kerala House Surgeons Association went on a flash strike.

At the protest site of the KMPGA in front of the secretariat in Thiruvananthapuram, THE WEEK met Dr Merry Francis Kallely, a neurosurgery resident at the Thiruvananthapuram Government Medical College, who shared the story of an attack she faced. The 31-year-old was kicked on her abdomen by a bystander a few months ago. “I was on ICU duty that day,” she said. “A 49-year-old patient with brain tumour, who was operated on by doctors in the neurosurgery department, died. I was not part of the team that did the surgery, but I went to communicate the patient’s death to her husband. But then he kicked me. I filed a complaint and an FIR was registered. But then the public and the media said he was in pain because of the death of his wife. So far, nothing has happened in this case.”

According to the IMA, in the last three years alone, doctors faced around 200 attacks in Kerala, and none of the perpetrators was convicted. In March, Dr Sulphi Noohu, president of the Kerala chapter of the IMA, said the rising attacks on health care workers would soon result in a death. “One person will be murdered soon! It could be me. It could be anyone. A health worker will be killed in Kerala,” he wrote on Facebook. And, on May 10, that prediction became a shocking reality.

A 2015 study by the IMA showed that 75 per cent of the doctors in India have faced some kind of violence at their workplace, with 12 per cent being physical attacks. The study found that escorts of patients committed nearly 70 per cent of such acts, and almost half of such violence was reported from intensive care units or post-surgery units. And, the death of a relative was the most common trigger.

For Dr L.K. Tiwari, a former civil surgeon at Panna district hospital in Madhya Pradesh, the memories of getting mobbed and slapped and later cyber shamed for the death of a patient is still afresh. It happened in September 2022 when he had to rush to the hospital after being informed about the victim of a major road accident. By the time the patient was brought to the hospital, he was dead. But a crowd, including the relatives of the victim, started abusing the medical staff, alleging negligence. Amid the ruckus, one person slapped Tiwari, and the video of it went viral on social media. Angered over the abuse and assault, doctors of the district hospital went on an indefinite strike. An FIR was registered three days later, but a counter FIR, too, was filed under the SC/ST (Prevention of Atrocities) Act against five doctors, including Tiwari, for allegedly abusing the victims’ relatives.

Tiwari, who is now posted as chief medical and health officer at Satna district hospital, told THE WEEK that although an FIR was registered, a compromise with the accused was reached after the case went to court.

Dr Madhav Hasani, president of the Madhya Pradesh Medical Officers’ Association, explained why such compromises are reached and why such cases were underreported. “The person who is assaulted feels that if they go ahead with the complaint, they might be made to feel like a culprit [as in the case of Tiwari] and are often forced to withdraw the complaint,” he said. “So the doctors prefer a compromise. After all, they have to work in the public sphere to earn their livelihood.”

There is no uniform law in the country to protect health care workers from violence at their workplace. In June 2019, the country saw massive protests by doctors after two junior doctors at Kolkata’s NRS Medical College were attacked. Two months later, a 73-year-old doctor in Assam’s Jorhat district was lynched by a mob accusing the doctor of medical negligence in the death of a plantation worker. All these prompted the Union ministry of health and family welfare to propose the Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019, which was intended to criminalise violence against health care personnel.

However, the bill did not become an Act as the Union home ministry opposed the proposal, saying that a separate law covering medical professionals could not be considered. The ministry reasoned that the enactment of a special law to deal with violence against members of a specific profession was not required since existing provisions of the Indian Penal Code were sufficient to deal with it. However, in April 2020, with the growing threat of Covid-19, the government came up with the Epidemic Diseases (Amendment) Ordinance, to include protections for health care personnel.

In February this year, Union Health Minister Mansukh L. Mandaviya confirmed in Parliament that the Union government would not enact any separate legislation to prohibit violence against health care professionals. “Since law and order is a state subject, state/Union territory governments also take appropriate steps to protect health care professionals/institutions under provisions in the Indian Penal Code/Code of Criminal Procedure,” he said.

Currently, 25 states and Union territories have laws penalising violence against health care workers. In most of these states, violence against health care workers is a cognisable and non-bailable offence with a fine of Rs50,000 and three years of imprisonment. But doctors and experts from several states have confirmed that these laws are not being implemented properly. Also, these laws predominantly emphasise punitive measures rather than provide comprehensive protection for health care establishments.

The Kerala Healthcare Service Persons and Healthcare Service Institutions (Prevention of Violence and Damage to Property) Act, 2012, was in place in the state. On paper, it offered protection to registered and provisionally registered medical practitioners, registered nurses, medical students, nursing students and paramedical staff working in health care institutions.

“However, this Act was absolutely toothless,” said Noohu. “That is why we demanded an amendment to this Act or a new Act. It has been before the government for quite some time. The government had agreed to implement our recommendations. But the process was going at a slow pace. They did not feel the urgency.”

Finally, a young doctor had to pay the price with her life for the government to understand the urgency. On May 17, a week after Vandana’s death, the Kerala government approved an ordinance to amend the law. The new ordinance will extend the protection under the law to the paramedical students and staff, security guards, managerial staff, ambulance drivers, helpers posted in health care institutions and health workers notified in the official gazette from time to time. Under the ordinance, anyone found guilty of causing grievous bodily harm to any health care worker or professional would be punished with imprisonment ranging from one year to seven years and a fine up to 05 lakh. Verbal attacks will also be brought under penal provisions.

A major demand from the health care community is to raise the security on hospital premises. “There should be 24x7 posting of police personnel. Currently, some not-so-fit personnel are posted at hospitals as a mere formality. They just sit in the room provided to them and appear only when the incident has already occurred. The system should be that as soon as emergency or critical cases enter the hospital and the care providers rush out with stretchers, the police should immediately appear on the scene and control the situation as emotions tend to run high in such cases,” said Tiwari.

After Vandana's death, the Kerala government has decided to strengthen the security systems by dividing hospitals into multiple categories. Police outposts will be established in medical colleges, district hospitals, general hospitals and women's and children's hospitals, which come under the first category. Full police surveillance will be ensured in other hospitals as well. The decision has also been taken to establish closed-circuit cameras in all hospitals, ensure proper surveillance and conduct a security audit every six months in all hospitals.

“We demand that security should be provided by ex-servicemen under 50. There should be postings from the Central Industrial Security Force,” said Noohu. He said the IMA was thinking of forming a security force of its own. “It is not to make them armed bouncers. The hospital is a special kind of place. So, there should be a two-way approach. They should be able to do crisis management,” he said.

The new ordinance by the Kerala government envisages the setting up of fast-track courts to ensure quick trial and conviction within one year in cases involving violence against health care workers. An officer of inspector rank or above will investigate the cases, and the investigation should be completed within 60 days from the day the FIR is registered.

Shreya Shrivastava, a senior resident fellow with Vidhi Centre for Legal Policy, who had studied violence against health care workers, however, said there were deeper issues that could not be effectively resolved through criminal punishments alone. “According to the theory of criminal law and deterrence, punishment serves its purpose when individuals consciously consider the consequences of their actions, leading to deterrence. However, when examining violence against health care professionals and the circumstances under which relatives of patients initiate such acts, it becomes crucial to comprehend the context,” she said. “Often, these incidents are triggered by strong emotions, such as the loss of a patient or unexpected and prolonged waiting time. In such situations, individuals may not have the opportunity to premeditate their actions or contemplate the repercussions. Therefore, relying solely on criminal punishments may not be the best approach.”

Shrivastava called for holistic safeguards for health care professionals, encompassing aspects such as occupational health and safety regulations, employer obligations, post-incident interventions, insurance coverage and compensation.

Shrivastava also called for deeper structural changes. She said all stakeholders must acknowledge the “trust deficit” between doctors and patients, which were exacerbated by various factors. “This deficit exists not only in private health care, but also in the public sector, where patient grievances often go unresolved," she said. "Additionally, during the pandemic, exorbitant bills were imposed on patients for ICU costs, ventilators and medications, further contributing to the erosion of trust. In some cases, doctors and hospitals have affiliations with pharmaceutical companies, which adds to the complexities. Consequently, patients respond in a manner influenced by all these factors."

To tackle this problem, the first measure that should be taken is the introduction of provisions that promote transparency and accountability among health care providers. By doing so, a significant portion of the trust deficit can be addressed. Second, health care establishments should have greater obligations towards their employees, particularly doctors who bear the brunt of patient aggression. Implementing routine assessments of incidents, establishing internal grievance redressal processes, ensuring accessible management and facilitating open communication channels between doctors and patients are essential.”

Another area of concern is the medical education sector which ignores how crucial effective communication is, especially during crises. “Currently, the curriculum does not adequately address these aspects. Enhancing communication skills within the medical curriculum can contribute significantly to reducing the trust deficit,” said Shrivastava.

KMPGA president Dr Ruwise E.A., however, said it was important to look at the overburdened house surgeons and postgraduate residents. “The National Medical Commission says that PG scholars have to work 60 hours per week. But most of us work anywhere between 90 to 120 hours a week. After working 48 to 60 hours straight, one may not even have the capacity to speak patiently,” he said. “Such work schedule is also the reason why so much violence happens in hospitals. And, we face different types of people, from drunks to drug addicts. How much tolerance should we be showing?”

Dr Suresh T.N., who heads the KGMOA, said the doctor-patient ratio in India was severely inadequate, resulting in an overwhelming burden on doctors. “The permanent solution is to reduce the doctor-patient ratio and actively work towards overcoming the shortage of medical professionals.”

Shrivastava said it was crucial to prioritise health care, as its neglect had been evident across different governments. “Allocating sufficient budgetary resources towards health care is essential. There is a need for greater determination and political will to make health care a top priority.”

―With inputs from Sravani Sarkar

ai-model-that-can-diagnose-cold-from-a-person-s-voice

Fri Jun 02 18:44:37 IST 2023

The Covid-19 pandemic and the recent outbreaks of influenza have seen many infected people not showing symptoms associated with cold. They needed blood tests to confirm the infection. Soon pathbreaking research at Sardar Vallabhbhai National Institute of Technology in Surat might change that. The researchers have been able to recognise from a person's voice if she has a cold or not.

Surat-based researcher Professor Suman Deb and students Pankaj Warule and Siba Mishra collaborated with Jarek Karjewski of RFH Koln in Germany to develop an algorithm that can distinguish between the voice of a person with cold and one without.

The AI model was fed voice recordings of people with cold and those without, provided by Karjewski. Those who participated for the study were asked to read short stories like 'The North Wind and the Sun' and the German passage ‘Die Ostergeschichte’.

Deb said they achieved 70 per cent accuracy, and the model would detect voices in Indian languages as well. It will initially be available for English and Hindi speakers. Other Indian languages are being developed.

Warule said, after recording the voice, a harmonic peak extraction was done by calculating the Fourier transform of speech, followed by NHPF, NHPM and SHPR feature extraction. NHPF and NHPM stand for normalised harmonic peak with respect to the first harmonic peak and normalised harmonic peak with respect to the maximum value of the harmonic peak, and SHPR is successive harmonic peak ratio. Then comes the prediction of cold or healthy speech using machine learning or deep learning classifier. This is done using python (a computer language) and an AI model, and it involves mathematical and signal processing calculation. The speech spectrum amplitude and frequency of a healthy person's speech, and that of a person with cold, are different.

The Indian researchers had begun work in 2015 and published a paper in 2019. The work then continued and their latest study, 'Sinusoidal model-based diagnosis of the common cold from the speech signal', has been published in the journal Biomedical Signal Processing and Control.

At the SVNIT, Surat, the researchers are building a sound-proof room. Deb said a sound-proof room would increase the accuracy to 80 per cent to 90 per cent, and help deduce which parameters were affected by noise and to what extent. They are also trying to develop a mobile app, which would be a signal-based non-invasive diagnostic technique that can work remotely.

The use of the technology would mostly be for remote areas that do not have easy access to doctors and labs, said Deb. In future, we might also be able to detect lung and heart disease from a person’s speech.

Deb has already found a common application for the new technology. On a lighter note, he said it would be the quickest and easiest way to catch those who call in sick faking cold.

how-doctors-at-sankara-eye-hospital-saved-the-vision-of-a-toddler-with-retinoblastoma

Fri Jun 02 18:34:58 IST 2023

Aadharv was like any toddler—cheerful and playful. But then his mother Shanthamma, like any mother attuned to her child’s needs, noticed him having trouble locating his toys. He would also ram into the walls and doors of his home in Kolar, some 65km from Bengaluru. Based on Shanthamma’s hunch, Aadharv (name changed) was taken to an eye specialist. A medical examination revealed a white reflection or glint in Aadharv’s eyes. He was referred to the Sankara Eye Hospital in Bengaluru, where he was diagnosed with retinoblastoma—a rare cancer of the retina (that sense light) that mostly occurs in children below six. Aadharv was only two.

At the hospital’s ocular oncology centre, a staging of the tumour was done as per the International Classification for Intraocular Retinoblastoma. Aadharv’s tumour was group E, and so large that there is little chance of saving the eye. Since the cancer had affected both his eyes, he was started on chemotherapy. But his left eye was not responding to the chemotherapy, and the doctors were forced to remove the tumour and his left eye to prevent the cancer from spreading to other parts of his body.

“When the patient came to us, he was blind as both his eyes were severely affected,” said Dr Mahesh Shanmugam, head of ocular oncology and vitreoretinal diseases, Sankara Eye Hospital. “The right eye responded well to both chemotherapy and radiation therapy and the sight was restored. But the child lost vision once again as he developed bleeding inside the eye. We performed vitrectomy (removal of the vitreous humor—the transparent jellylike tissue filling the eyeball behind the lens) to restore the vision. It is a rare surgery as incisions are done into the eye, which poses the risk of metastasis (tumour cells spreading outside the eye). The procedure took 45 minutes under general anaesthesia; the child was treated in the outpatient department.”

Shanmugam warns of possible complications of retinoblastoma, like a detached retina, metastasis and loss of eyesight. Then there are the side effects of chemotherapy such as tiredness, bruising and bleeding, mouth sores, infections, vomiting and diarrhoea and also bleeding or infection from surgery. So, a regular followup is necessary to rule out any complications. Glasses are prescribed to help the child have normal vision.

Retinoblastoma is a curable cancer, if detected early. The cancer may be passed on from parents (inherited) or it may occur by chance (sporadic). The cancer is caused by a mutation in the RB1 gene. It also increases the risk of bone and soft tissues cancer and skin cancer. The most common symptoms are an abnormal white reflection in the retina and misaligned or squint eyes, said doctors.

“At least 60 per cent of retinoblastoma cases are sporadic and 40 per cent familial,” said Shanmugam. “If it is familial, the chances are both eyes could be affected and the child is prone to other tumours later on in life as the gene that protects against developing tumours is missing in the patients.”

Retinoblastoma can be detected at 12 months in genetic retinoblastoma and between 18 and 24 months in sporadic retinoblastoma. But early detection has remained a challenge, said doctors. “Newborns can be tested by examining the pupil,” said Shanmugam. “But since the incidence of the disease is one in 10,000 live births, the cost versus benefit is low and it is not part of routine screening in hospitals.” Also, regular health screening programmes in schools pick up cases of poor vision and squint eyes, but that screening is not helpful to detect retinoblastoma as it affects the pre-school age group (below six years).

The treatment for retinoblastoma is a combination of surgery, chemotherapy, brachytherapy (placement of radioactive implant close to the base of the tumour), laser therapy and cryotherapy (freezing the tumour). In Aadharv’s case, the treatment involved six cycles of chemotherapy, brachytherapy and surgeries to remove the tumours, vitreous humor and the left eye. The treatment cost depends on the number of cycles of chemotherapy required and the services of specialists availed as it demands team work—from an ophthalmologist, paediatrician, paediatric surgeon, paediatric oncologist to retina specialist, radiation oncologist and anaesthetist.

Shanthamma had never heard of retinoblastoma before Aadharv’s diagnosis. She has three daughters, and none of them has the rare disease. But she has put the ordeal behind her and is happy with Aadharv’s recovery. He is six now. “He is in class 1 and wears glasses,” she said. “He uses eye drops before going to bed. I take him for a followup once in three months.”

mosquito-control-india-s-biggest-challenge-to-eliminate-malaria-by-2030

Fri Jun 02 18:31:36 IST 2023

It’s a bright afternoon. Anil Mishra, 60, is enjoying a cup of tea with his family at their Ghaziabad home when one of them notices a mosquito buzzing. “All Out jala do (light the repellant),” shouts his mother, who is in her 80s. “Batao, din mein bhi machhar dikh rahe hain, itni safaai rakhne ke bawajood (There are mosquitoes even during the day, despite us keeping the house so clean).” She is scared for the children in her joint family—Mishra has had malaria twice, 20 years apart. “In 1993, I had high fever and the situation was grim,” he says. “I used to visit the district hospital every week and the doctors kept recommending test after test. It took them two months to find out that I had malaria. Till then, they kept transfusing blood every three to four days because I was so weak that I could not go to the bathroom on my own.”

His father, who is reading a newspaper, suddenly gets a bit emotional. “We faced a lot of difficulties, especially for blood transfusion,” he says. “While he was admitted, a friend of mine went to the hospital and gave him blood. My son was brave. His zeal for life helped him fight.”

When Mishra got it again, in 2013, he was not scared. He had returned home from an official tour and felt feverish; he was weak and also had headache. He took paracetamol for three days, but when there was no change in the temperature, he went to a clinic near his home. Within three days, the doctor diagnosed malaria. “I was sure I would be fine within a week or 10 days,” he says. “Even the doctor had said that there was nothing to worry about. I recovered completely in 15 days. Since then, I have been absolutely fine.”

Like Mishra, Shreya Sharma (name changed), who lives alone in Bhopal, also had malaria, in 2008. She had to be hospitalised for a week and became anaemic; it took a month for her to recover fully. “Today, I am so cautious about mosquitoes that I shut my doors and windows in the evening itself, and make sure to use a repellant before sleeping, because prevention is better than cure. I don’t want to take any risk.”

According to Professor P.K. Rajagopalan, former director of the Vector Control Research Centre (VCRC) at the Indian Council of Medical Research, and former World Health Organization expert committee member on malaria, “[The disease] endangers one in every six Indians, and costs the economy $2 billion in lost productivity each year.”

There has been progress, though. Since 2014, India has reduced malaria cases by over 80 per cent. However, pockets of the country require increased attention because 90 per cent of the cases are concentrated in states with a significant tribal population. The hotspots are Chhattisgarh, Madhya Pradesh, Jharkhand, Odisha, Karnataka, parts of Rajasthan and Haryana, and West Bengal. As per the National Center for Vector Borne Diseases Control (NCVBDC) website, the country had 1.6 lakh malaria cases and 90 deaths in 2021.

India has set a deadline to eliminate malaria by 2030. It may be easier said than done. “We cannot eliminate malaria in India because of the populations that live alongside water,” said Dr Manoj Kumar, who has a PhD in biochemistry. “In places near rivers, the presence of mosquito larva is quite high, and people don’t know how to take care of such places because they are not at all aware of it. Perhaps we can eliminate malaria on paper, but not practically.”

Dr Rakesh Gupta, who was a member of the five-year national strategic framework for malaria in 2018, agreed that it will not be a cakewalk. He said that malaria involves three components—host (human beings), agent (mosquitoes) and environment—and conceded that the number of hosts is reducing through awareness, medication and testing. “But, what is being done for the agent? How will the vector be eliminated? Where is the testing being done?” he asked.

The National Institute of Malaria Research (NIMR) in Delhi is conducting insecticide-resistant studies every two years and the results are being incorporated in the national programme for malaria elimination. The researchers at NIMR go to the field in different districts to collect the mosquitoes and cultivate them inside the lab. Trials are then conducted to understand the impact of the insecticides.

Among the deep-rooted problems in eliminating the disease, said VCRC director Ashwani Kumar, is poor reporting of cases by the private health care sector and poor capacity for direct interventions against vectors. “There used to be entomologists, insect collectors and field workers manning the 72 entomological zones of the country. Although the number of these zones has increased to 103, there are no trained entomologists in most of them. To eliminate malaria, killing the vector and preventing the formation of mosquito larva is important. If that is not done, malaria will remain prevalent.”

Amita Chhebi, executive vice president for advocacy and programmes at Asia Pacific Leaders Malaria Alliance—consisting of 22 governments—said that in 2017, the national programme reported 8.4 lakh cases and 194 deaths, whereas WHO estimated 96 lakh cases and 16,700 deaths in the same year.

There is an incomplete understanding of the actual malaria burden because all cases do not go to hospitals. Moreover, people going to hospital are not fully investigated. A live reporting system through a digital platform is a good option to clear the mess. “There must be guidelines on how to diagnose malaria and to give anti-malarials after diagnosis only,” said Sushila Kataria, senior director, internal medicine, Medanta, Gurugram. “The reporting should be seamless to save a clinician’s time on reporting cases. A proper followup and surveillance in areas where cases are detected can lead to smooth reporting. Even the labs should be involved to make a central reporting system.”

Eliminating the vector is a primary concern for public health experts. “There are maximum number of malaria cases in eastern Uttar Pradesh because there is water-logging in paddy fields, drains remain open and riversides are not clean,” said Dr R.C. Gupta, a consultant at a district hospital in Uttar Pradesh and a core member of the polio-elimination programme for five years. “How will a mosquito larva not be found at such places? Who has got a solution for this? Uttar Pradesh is just one example. We have such spots across India.”

In India, P vivax and P falciparum are the two prevalent parasites for malaria. Years ago, there used to be nearly two lakh malaria cases a year in India and DDT, before its use was restricted, was sprayed to kill the mosquitoes. “You kill the mosquitoes rigorously and don’t give them time to mutate, or you forget about malaria elimination,” added R.C. Gupta. “Also, the lab technicians are not skilled enough. There have been several cases when I sent patients for blood tests assuming they have malaria because of the symptoms. But their reports never show them as malaria-positive.”

VCRC runs a master's course in public health entomology and organises hands-on training workshops for entomologists and conducts molecular xenomonitoring (testing of mosquitoes to detect the DNA or RNA of a parasite) to strengthen vector surveillance in the country. It also generates disease risk maps using Geographic Information System (GIS) mapping-and-modelling approaches, carries out insecticide susceptibility studies, and evaluates in-house developed vector-control products such as larvicides, insecticides and Long Lasting Insecticidal Nets (LLINs).

“The VCRC field station at Koraput (Odisha) is the only place in India with 13 experimental huts where insecticide residual spray candidates and LLINs are evaluated in real-life situation,” said Ashwani Kumar. “Besides, VCRC conducts simulated trials on larvicides/bio-larvicides and evaluates industry-formulated products in different parts of the country to check their efficacy.”

A District Malaria Officer (DMO) said that to control mosquito breeding, use of repellents is being promoted through campaigns. In addition, larvicidal sprays are being used in urban areas once a week.

Under the Urban Malaria Scheme, the control of the disease lies primarily in the implementation of urban bylaws (that govern how planned urban development is done in cities) to prevent mosquito breeding. Environmental methods of controlling breeding include source reduction works like filling ditches, pits and low-lying areas; streamlining, de-silting and de-weeding drains; water disposal and sanitation; emptying water containers once a week and observing weekly ‘dry day’.

For the past three years, 30-year-old Nitin Sharma has seen filthy water pooling in Delhi's Naraina industrial area. Last year, there were 21 cases of malaria here. “During monsoon, the mosquitoes keep buzzing and I always keep extra repellants in my office and make sure the doors and windows are closed,” he said.

Malaria inspectors even hold the power of prosecution if mosquito larva is found at a construction site or around commercial or institutional properties. They kill the larva through fumigation and insecticide sprays, which is a primary step towards preventing malaria cases.

“At first, we give a notice to the defaulters,” a malaria inspector told THE WEEK. “If there isn’t any improvement, we issue them challans that range from Rs2,000 to Rs1 lakh. For severe violations, we also file a case against them as per section 269 of the Indian Penal Code. We make sure that there is no mosquito breeding anywhere.”

China, which the WHO recently declared malaria-free, adopted a 1-3-7 model—case reporting within one day after diagnosis, investigation within three days, and action within seven days—to eliminate the disease.

While India plans to eliminate malaria by 2030, it perhaps requires extensive brainstorming to find ways to stop the mosquito from buzzing. That is the bigger fight.

malaria-no-more-india-director-pratik-kumar-interview

Fri Jun 02 18:27:42 IST 2023

Malaria No More is a nonprofit that aims to eradicate the disease. Founded in 2006 in the US, the organisation has affiliates in India, Japan and the UK, and has mobilised political commitment, funding and innovation to rid the world of malaria. In an interview, MNM's India director Pratik Kumar talks about where the country stands vis-a-vis malaria eradication.

Q. What are the avoidable mistakes that could lead to the breeding of malaria-causing mosquitoes?

A. There are two types of people. One is the well-educated class, which knows of preventive methods but continues to do things that lead to proliferation of mosquitoes. We see them keeping their houses clean, but outside it can be as dirty as possible. In high societies, you don’t see stagnant water, but there are enough places—the corner of an AC or some patch somewhere or something that is constantly leaking—to cater to the egg-laying.

Then there are tribals, migrant workers, people who sleep in the open, or have lived in such conditions that if they get bitten by a mosquito, it is not going to impact them. That is because, at a young age, if you get exposed to mosquitoes, that buzzing sound doesn’t bother you, and even if it bites, you manage to sleep through it.

So one has to be alert about the mosquito density in a place and the ways to protect oneself. Anopheles mosquitoes [that transmit malaria] can smell a person from 100 feet. People have to create barriers for it using coils, sprays and other repellants.

Q. You have worked on the ground. How has your experience been?

A. People who have low access to quality health care are the ones who suffer. There are hills, forests and other inaccessible terrains where health workers find it difficult to go and test people. By default, the chances of malaria being eliminated in these areas are low.

Q. What needs to be done to eliminate malaria by 2030?

A. The biggest challenge is that we don’t even know who all are carrying the parasite. There are two reasons for this. The first is the way the country accumulates data around malaria, which is through the public health system. Second, the private sector does not report data because there is no system wherein it can notify this. In India, on average, the national family health survey says that 70 per cent of people go to the private sector for treatment.

The Accredited Social Health Activists (ASHAs) and Auxiliary Nurse and Midwives (ANMs) report malaria. If one has fever, he/she can go to an ASHA, who will potentially run a malaria test on the person. It’s possible only when the ASHA has a rapid test kit, and some of these blood samples are taken to labs for further information. This whole system is quite weak. If someone tests positive, ASHAs and the labs report, and then, from the ground report, the system collates data at various levels—up to district, state and national level. ASHAs record the findings using pen and paper, and by the time it comes to district level, it potentially becomes computerised. There is a huge lag. If we have to address an immediate malaria outbreak, we cannot afford this lag. At present, we have a monthly reporting system. So we are just trying to control malaria right now, not eliminate it. It is a disease for which even the government is not willing to take enough action.

Q. How do you report malaria cases and deaths?

A. Our reporting goes to the primary and community health centres. India is a big country; we have worked in only 263 villages, but we do get a lot of information. We have heard about a lot of deaths, but those do not get reported because there are administrative issues involved in the system.

Another thing that needs attention is asymptomatic malaria, because the parasite inside one’s body causes all the damage—from breaking off the red blood cells to making a person anaemic, malnourished and so on. This is a huge problem that the Centre does not even recognise.

Q. With such few resources, how can malaria be eliminated?

A. Every November, the WHO comes out with a World Malaria report, in which the number of cases are five-to-10 times higher than the number the Indian government reveals. The government usually trashes the WHO report. We, as civil society, have the figures for rapid diagnostic test (RDT) kits, and the medicines sold for malaria. The medicines sold are 100 times the number of cases. So the sales figures tell a different story, WHO says something else and the government doesn’t say much.

Interestingly, the health ministry recognised that the private sector reporting is good for HIV and tuberculosis, but no heed is being paid to malaria.

So far, we haven’t got the sense that the government has really shown the urgency to achieve the goal of ensuring zero malaria cases. All sectors also have to come forward together to eliminate malaria. It has to be a people’s movement.

how-you-should-deal-with-severe-asthma

Fri Apr 28 17:34:27 IST 2023

Our bodies are finely tuned machines and need oxygen to produce energy. Atmospheric air enters our body through the airways. Upon reaching the lungs, the inhaled oxygen diffuses into the blood and is exchanged for carbon dioxide, which is thrown out of the body. The smooth running of the airways and other parts of the respiratory system is crucial for the process.

Patients with asthma, however, suffer from hypersensitive airways, which become inflamed and narrow when they encounter allergens like smoke, tobacco and pollen. Asthma-related inflammation results in symptoms, which vary from person to person, from one season to another, and at any time of the day. Some of the key symptoms that make it difficult for the patient to breathe include:

Wheezing―a high-pitched sound while breathing.

Coughing can be accompanied by mucus and worsens at night, disturbing sleep.

Tightness in the chest―a feeling that something is squeezing or sitting on one’s chest.

Breathlessness―inability to catch one’s breath or feeling out of breath.

Uncontrolled asthma can result in severe attacks, which can even lead to hospitalisation. Though it cannot be cured, doctors can help manage asthma symptoms with two types of inhaled medications―reliever inhalers that offer short-term instant relief, and maintenance inhalers that help prevent subsequent attacks.

In case asthma symptoms worsen or asthma attacks are more frequent in spite of treatment, it is essential to reach out to a respiratory specialist. These doctors may recommend other types of medications after assessing the patient.

Severe asthma can be life-threatening

Nearly 1.9 million Indian asthmatic patients suffer from severe asthma. In such patients, the symptoms persist even after they are treated with the highest possible dose of inhalers, and other modifiable factors that may interfere with control (such as triggers, coexisting conditions and inaccurate use of inhalers) are ruled out.

Though the symptoms remain the same, patients with severe asthma suffer from more intense episodes and often do not obtain instant relief from reliever medication. The unpredictability of the severe asthma symptoms interferes with day-to-day activities, considerably impacting the quality of life.

Severe asthma attacks can constitute a medical emergency and may require immediate hospitalisation. Life-threatening attacks can lead to:

◆ Lack of speech

◆ Chest tightness

◆ Loss of consciousness

◆ Exhaustion and confusion

◆ Extremely low levels of oxygen in the blood

◆ Death

Respiratory specialists diagnose severe asthma based on the patient’s symptoms, their frequency, and the need for hospitalisation due to flare-ups. They may also use specific tests such as pulmonary function tests (spirometry), peak flow meter and fraction of exhaled nitric oxide to confirm the diagnosis. Research has shown that the underlying inflammation patterns differ in patients with severe asthma, and it could be allergic, eosinophilic, or non-eosinophilic. The doctor may prescribe a simple blood test to confirm the type of severe asthma.

Severe asthma can be managed

With the advent of more specific therapies, doctors can manage severe asthma more successfully, providing patients with much-needed peace of mind to carry out their normal activities.

The doctor may also ask the patient to check their asthma control with the help of a simple questionnaire called the Asthma Control Test (ACT). If the patient’s score is less than 20, it is not well controlled. Those who suffer from unpredictable and persistent bouts of asthma must reach out to the doctor for a complete assessment.

Inhaled medication taken correctly is the backbone of asthma therapy, and any modification in treatment should be made in consultation with the doctor. Moreover, avoid going to places with bad air quality (especially during festivals) to reduce the aggravation of asthma symptoms.

The writer is an assistant professor in the department of pulmonary medicine, critical care medicine and sleep disorders, at Vardhman Mahavir Medical College & Safdarjung Hospital, Delhi.

diabetes-and-varicose-veins-impact-on-health-treatment-prevention-methods

Fri Apr 28 17:31:28 IST 2023

Varicose veins and diabetes are not really interdependent. Diabetes per se does not cause varicose veins. They are caused by the inability of veins and veinous valves to push blood on to the path back to the heart. When the push is insufficient, gravity takes over and causes pooling of blood.

Diabetes can influence one's health in many ways and make one susceptible to severe health conditions. The same is true for varicose veins. And both conditions together can have a bigger impact on health.

Although the two conditions are not severely interdependent, diabetes increases the risk of varicose veins. High blood sugar damages and weakens veins. Diabetes also causes a delay in blood circulation and aids the formation and retention of plaque in blood. This, in turn, could lead to varicose veins. And, diabetes is a major cause of chronic venous insufficiency, which could cause varicose veins.

Diabetes and varicose veins are commonly seen in elders. This is because ageing has a negative impact on immune efficiency and venous health. Pregnancy is a major risk factor for both diabetes and varicose veins. The veins and valves are weakened because of the major changes that the body is going through. Also, hormonal imbalance during pregnancy leads to high blood sugar levels resulting in gestational diabetes, which, in turn, can damage blood vessels. One needs to keep the leg elevated if there are slight symptoms of varicose veins.

Body weight is another factor which has a connection with the possibility of diabetes. It also puts additional pressure on the veins, which could lead to varicose veins. Genetics, too, play a vital role in diseases like diabetes and varicose veins.

As both varicose veins and diabetes are caused by the same risk factors, the treatments and prevention methods are similar. Making healthy lifestyle choices and opting for a healthy diet is the most effective non-medical approach. One needs to increase fibre intake and reduce salt intake. An improvement in the blood sugar level can help improve vein health. If one has only diabetes and no symptoms of varicose veins, it is recommended to regularly check blood sugar levels and always check for any changes to the veins.

Nyapathi is interventional radiologist and vascular surgeon, Apollo Spectra Hospital, Bengaluru.

the-experience-benefits-and-stigma-of-eating-with-hands

Fri Apr 28 17:28:51 IST 2023

The recent Rani Mukerji-starrer Mrs Chatterjee Vs Norway, based on a true story, stirred many conversations and debates. Among them, was the debate on how eating with hands has often been viewed as “uncivilised, uncultured” by the west. But, is it a practice prevalent only in third world countries? Of course not. The art of eating with hands is not simply about “polite” or “impolite” eating habits that grew out of cultural, climate and civilisational changes. And, as more people turn to it today citing scientific, practical and even sensual benefits, it is clear that it is here to stay.

Hot dal or sambhar poured over rice, mixed with a generous helping of vegetables, some pickle thrown in, papad crushed, an occasional helping of curd poured over. This amalgamation is then mixed with the finger tips, rolled into a bite-sized ball and pushed into the mouth. As the flavours release on the tongue, it satisfies the senses. Rice and curries in Kolkata, vada pav in Maharashtra, yakhni pulao in Kashmir, and khakras, bhakharis and handvos in Gujarat are all best enjoyed with bare hands. Sri Lankans, Malaysians, Indonesians, Pakistanis and Nepalis feast with hands. Further away, people in the Middle East, Africa and South America, too, eat with hands.

The experience

The art of eating with hands can be compared to the art of drinking wine, which, like food, is a sensual experience. Art historian, academic, author and museum curator Alka Pande believes that for Indians, it is about the flavour and taste. “Our body and our food are related,” she says. “We are a sensual lot―the touch, taste and smell of the food are related. We believe in pressure points in hands and the physicality of food is important for us. Flavour of rice or roti is enhanced when had with hands. Where is the flavour in having it with knife and fork?” She adds that cold materials of cutlery take away the warmth of food.

Pande, whose husband is in the services, recalls coming across a high-ranking officer eating a paratha with a knife and fork. “I was so ashamed back then that I could not eat my paratha with bare hands,” she says. “But, even today, I cannot have my paratha with a knife and fork. Indian food and street food like golgappas, puris and curries are such that you cannot pick up a knife and fork for it.”

Chef and restaurateur Kunal Kapur believes that food is the only art that requires all the senses. “From the sound of cooking to its aroma, touch and feel, visual appeal and taste, food requires all senses,” he says, adding that touch is important as it allows you to feel what you are about to put in your mouth. “That is why the Indian way of eating is through touch, wherein you break the bread, dip it in aachar, break a little papad, put in onion, dip it in curry and savour it,” he says.

The benefits

The science behind the art of eating with hands lies in traditional Indian scriptures and ayurvedic practices. According to ayurveda, the five fingers symbolise the five elements―the thumb represents fire, the index finger represents air, and the middle finger, ring finger and little finger represent sky/space, earth and water, respectively. Hence, eating with hands is known to stimulate the five senses and the nerve endings on the fingers stimulate digestion.

Experts also suggest that when eating with hands, one eats in controlled proportions and hence overeating can be avoided. Some even believe that with the tactile sense being put into use, the food's taste is enhanced. According to ayurvedic practitioners, the best way to eat is with hands, after washing them thoroughly, using only fingers (without soiling the palm), while sitting on the floor cross-legged to aid digestion. Kapur says the fingers must not enter the mouth while eating, but must push the food into the mouth. “It brings one close to the meal experience,” he says. “Indian food is about playing with the senses.” He adds that eating with hands with friends brings people closer.

According to Payal Kothari, gut health nutritionist and wellness coach, eating with hands is the perfect way to connect with one's culture and heritage and has several benefits. “It improves digestion as you are more likely to chew your food properly,” she says. “Hands and eyes can also detect the temperature and texture of the food, helping your body prepare for digestion.” Kothari also feels that eating with hands can help you eat more mindfully and be more present during meals. Additionally, it can be more hygienic than using cutlery, she says.

The stigma

In the western, ‘polite’ culture, eating with hands may often be taboo. This leads to instances of discrimination. Moreover, the way people eat with hands also differs from geography to geography. In northern India, for instance, licking fingers after the meal might not be a popular practice, but down south, it symbolises a sumptuous meal.

Within India, Covid-19 raised concerns about eating with hands in public spaces. But, academic, food critic and historian Pushpesh Pant says there is no guarantee that the cutlery is hygienic. “I have rarely seen even five-star hotels offering sealed packs of cutlery that has been cleaned,” he says. “We do not know if it has fallen on the floor or has been touched with dirty hands.” He argues that post Covid, there is no way to know if a person has washed his hands for 40 seconds before cooking or offering a meal.

While Pant does not believe that food can taste different when had with hands, he, too, says that from India to Nepal and Sri Lanka, the food is such that one cannot always use cutlery. “You cannot eat a motichoor laddoo or a papad with knife and fork,” he says.

On the other hand, the way one eats is influenced by the geographies, the climatic conditions, and the availability and type of food. For instance, in European countries and in the US, it becomes hard to eat a steak, a roast lamb, baked vegetables, soups, noodles or salads with hands. Additionally, in cooler climates, eating with hands also means washing hands more often in extremely cold water. Before water heaters were widely available, this was, at times, an impossible task.

However, despite such challenges, the knife-and-fork 'revolution' seems to have happened fairly recently in human history―after the 16th-17th centuries. The table knife is said to have been invented by French statesman and clergyman Cardinal Richelieu in 1637. While two-pronged forks had existed since the 8th-9th centuries, a proper fork was introduced in Europe in the 10th century by Emperor Otto’s wife Theophanu. It became popular in France only after Catherine de’ Medici’s marriage to King Henry II.

Before that the Italians and French ate with hands, according to food writer, television show host, restaurant consultant and author Karen Anand. “[It was] only after Catherine de’ Medici influenced the culinary cultures of Italy and France and introduced the fork that the French started to be considered the pinnacle of good taste and manners,” says Anand. “Before that, in medieval England, and all over Asia, people ate with hands and, in Europe, used knives to cut big pieces of meat.”

drug-price-hike-in-india-details

Fri Apr 28 17:02:52 IST 2023

In January 2022, Gurugram resident Rajni Sahdev, 63, underwent a bypass surgery. While her heart is healthier now, it sinks every time she sees her medical bill. “Her medicines cost between 12,500 and 12,800 per month,” says son Manish, an HR professional. “There cannot be any compromise in matters of health, but the cost of medicines seems like a burden at times.”

Running out of funds every month is a constant worry for Manish, 35, as he juggles several responsibilities including taking care of his two-year-old son. “Everything is getting expensive,” he says. “My mother needs to undergo a knee replacement surgery as well, but since the costs involved are too high, we are not rushing into it. We don’t know when we will be able to get the procedure done.”

Rajni’s current prescription includes Udiliv, Bemdac and Roseday 10 to lower cholesterol and reduce the risk of heart disease, Emildap to control high blood sugar and Razo to relieve acidity. None of these falls under the Union health ministry’s list of essential medicines, the prices of which are regulated by the National Pharmaceutical Pricing Authority (NPPA). The World Health Organization (WHO) has a list of essential medicines to meet health care needs around the world. Likewise, the NPPA, which comes under the Union ministry of chemicals and fertilisers, too, has a national list of essential medicines (NLEM). The NPPA caps the ceiling price of essential medicines under schedule I of the Drugs (Prices Control) Order (DPCO), 2013. The DPCO provides for an annual hike in drug prices based on the Wholesale Price Index (WPI), which represents the price of goods sold in bulk by trade organisations and is used as a measure of inflation in some countries.

Towards March end, the NPPA notified that prices of medicines will increase by 12.12 per cent as per the WPI rate for pharmaceuticals set by the government for 2022. The revised prices of drugs came into effect from April 1, causing worry, especially among middle class families like the Sahdevs. Then on April 3, the drug pricing authority released another notification, clarifying that 651 of 870 essential medicines like paracetamol (fever), metformin and glimepiride (diabetes) and amoxicillin along with clavulanic acid (bacterial infections) would actually see an average price reduction of 6.73 per cent. Health Minister Mansukh Mandaviya further clarified that the government had revised the list and prices of essential medicines in November 2022, and that the ceiling price of 651 drugs was brought down by an average of 16.62 per cent. So, even with the revised annual hike, the average reduction in the ceiling prices of 651 medicines was estimated to be 6.73 per cent, he said.

While the string of notifications caused confusion, there is no denying that the pharmaceutical industry has witnessed unprecedented price rise in raw materials, packaging and transportation in the last two years. This cost escalation―it is unclear whether it was induced by Covid-19― has had a severe impact on the entire pharmaceutical value chain. The surge in input and transportation costs has particularly been acute in the last one year, impacting the industry. “This (annual) increase comes as a respite for a sector grappling with high cost of active pharmaceutical ingredient and losses caused by decline in prices of essential medicines a few months ago,” said Nikkhil K. Masurkar, CEO of Entod Pharmaceuticals.

The WPI rate for the new fiscal is the highest in five years. It was 10.7 per cent in 2021, which came into effect on April 1, 2022. In 2020, it was 1.88 per cent, 4.26 per cent in 2019 and 3.43 per cent in 2018. “Since 2015, the prices of drugs have either been consistent or have seen an increase of hardly two to three per cent,” said Daara Patel, secretary general of the Indian Drugs Manufacturers’ Association. The current price rise, he said, is a fallout of an increase in manufacturing costs in the last few years, putting pressure on drug manufacturers. “Various input costs that go into manufacturing of medicines increased tremendously,” he said. “Hence, this cannot be considered as a price increase, but a mere reimbursement for the increase in input costs. If medicine manufacturers are not compensated, at least partially, manufacturing medicines would become unviable, resulting in stoppage of large-scale manufacturing, which will be against the interest of patients.”

Agreed Dr Girdhar Gyani, director general of the Association of Healthcare Providers of India, who said that the rise in prices also ensures quality control. “If we do not increase the prices, the quality will take a back seat, and that may be detrimental to the health of consumers,” he said.

Despite the drug price conundrum, Gyani said there was good news for lakhs of people registered under the Ayushman Bharat scheme. “People registered under this scheme will not be impacted,” he said. “However, hospitals can be affected unless the government increases the reimbursement rates for various packages.” But even under the scheme, he said, it may not be prudent to correlate the existing reimbursement rates with the fresh increase in prices as no study has been done yet on how the rates of many procedures can be impacted. “The cost of some procedures may even be low. We will have to wait and watch,” he said.

The NPPA, meanwhile, is cracking down on illegal means of hiking prices, which can cause further grief to patients. It has set up Price Monitoring and Research Units in some states and Union territories to tackle drug price ceiling violations. States like Gujarat, Uttar Pradesh, Kerala, Haryana, Rajasthan, Madhya Pradesh, Jharkhand, Chhattisgarh, Odisha, Andhra Pradesh and Karnataka have already started showing results.

“If the NPPA has fixed a price for a medicine, and a pharmaceutical company sells it at a price higher, we can notify the NPPA,” said Hemant Koshia, commissioner at Food and Drug Control Administration in Gujarat. “The NPPA has the powers to ask the manufacturer to share the number of units manufactured of that particular product and if any discrepancies are found, action is taken. The illegal money is recovered from the manufacturer with interest, and if they refuse, criminal proceedings can be initiated.” The money is then distributed to seven National Institutes of Pharmaceutical Education and Research―Mohali, Ahmedabad, Guwahati, Hajipur, Hyderabad, Kolkata and Raebareli―for development, education and research work. In the last decade, over 3,500 cases of DPCO violations have been referred to the NPPA, helping recover more than 180 crore.

But state governments are questioning the Centre’s dilly-dallying over drug price regulation. Ripan Mehta, assistant drug controller of Haryana, wondered why price of every medicine cannot be regulated by the NPPA. “Any drug that is not a part of [NLEM] will be vulnerable to rise in cost,” he said. “Therefore, a regulation is required not only for essential medicines, but for the remaining ones as well.” He said that if this is not possible, then at least trade margins (the difference between sales and cost price) should be capped.

The issue was flagged by the Alliance of Doctors for Ethical Healthcare in its letter to NPPA Chairman Kamlesh Kumar Pant last year. Dr G.S. Grewal, former president, Punjab Medical Council, told The WEEK that former health minister Dr Harsh Vardhan had attempted to resolve the problem but to no avail. “He had suggested that it must be mandatory for all pharmaceutical companies to mention the factory price (the price quoted for manufactured goods) along with the maximum retail price,” said Grewal. “The government was in the process of preparing a draft note, but it was not notified to the pharmaceutical companies.”

The government might have drawn applause for capping the price of essential medicines, but it remains to be seen whether it can effectively regulate the prices of hundreds of remaining drugs.

brachytherapy-treatment-procedures-right-equipment-and-training

Sat Mar 25 15:43:40 IST 2023

A 62-YEAR-OLD patient was diagnosed with stage 1 breast cancer. After careful clinical examination, followed by an MRI, it was seen that she had a tumour of 1.5cm in the left breast without any swollen lymph nodes in the armpit. In consultation with the tumour board and medical physicist, it was decided that they could be managed with perioperative brachytherapy.

Brachytherapy, a form of radiation therapy, treats the patient from within. It has proven to be precise and effective in the management of cancer associated with the head and neck, breast, skin, prostate, cervix, rectum and uterus.

It is a tailored approach to provide precise radiation to the cancer tissues and it minimises damage to the healthy tissue around it.

The patient and caregivers were advised about the treatment benefits and demerits, and consent was obtained. The patient underwent a lumpectomy and, in the same sitting, plastic catheters were placed in and around the tumour bed. Simulation and planning for brachytherapy were done on the third day; from the following day, the plastic catheters were connected to a brachytherapy machine and radiation was delivered twice a day for five days. Other radiotherapy techniques require about five weeks.

Planning brachytherapy includes a careful clinical examination to understand (1) the size and location of the tumour and its correlation with the surrounding tissue (2) diagnostic measures to get a 3D picture of the tumour (3) strategy and approach to access and put applicators that are in the form of plastic catheters or tubes and (4) selection and placement of the radioactive material and dose calculations.

Some of the patient benefits include short treatment cycles and faster recovery time, and they might not even require hospitalisation.

For an oncologist, saving as many patients and their families from cancer is a life goal. Experience has shown that cancer not only affects the patient, but also the family. Therefore, management of cancer has to be done not only with a focused multimodal approach that includes radiotherapy, chemotherapy, and surgery, but also with a psychological support system for patient and family.

The 2020 WHO ranking on cancer burden placed India third in terms of new cases every year. Latest data from the National Cancer Registry Programme of the Indian Council of Medical Research shows around 14.6 lakh patients in 2022; this is estimated to go up to 15 lakh by 2025. There is a chance that the actual patient load could be 1.5 to 3 times higher than this. This number shows the immediate need to provide the best holistic care in cancer management.

With technology providers and doctors coming together, more clinicians are getting trained in brachytherapy. Hospitals with access to the right equipment and training provide better clinical outcomes for patients. Such measures will collectively support the fight against cancer.

The writer is former dean, AIIMS Rishikesh.

troubling-layers-of-shopping-addiction

Sat Mar 25 15:39:59 IST 2023

Add to cart, proceed to checkout, complete order. This was, and is to an extent, 39-year-old brand consultant Divya Singh's routine each time she got her paycheque. “My shopping addiction began when Flipkart was the major player—way before Amazon came along,” she says. “It initially started with ordering books. It then became about finding deals online. When you are earning and have money at your disposal, you are tempted to buy things. It began with an original Calvin Klein watch I bought when I got a new job. I spent 012,000 on it. When you get great brands for a great deal, it is so tempting. It kind of gives one self-confidence. Moreover, it is convenient—you can pay by card or avail of cash on delivery.”

Just like Singh, the convenience of online shopping tempted a lot of us to buy things; things we may not even have needed. Singh says she once spent 080,000 in three months. “I bought books, shoes and many other things,” she says. “It was a craze, it was also greed.” Singh confesses that her tendency to shop was more when she had a bad day. “When something went wrong, my go-to comfort would be shopping,” she says. “I amassed over 1,000 things. A lot of them are locked in a room.”

Singh says she definitely overspent—maxing out her debit and credit cards. “Paying bills became difficult,” she says. “I still find it difficult to control the urge to shop as the offers keep coming.”

Bengaluru-based psychotherapist Aji Joseph says compulsive shopping can be a result of pending anxiety disorder. “It has layers—it could be a comorbid condition and not just a habit,” he says. “In my experience, compulsive shopping has been seen in people with a traumatic experience. Or those who have insecurities or have faced rejection.” Compulsive shopping, according to him, is an extreme symptom of an underlying condition. “The trauma or the rejection could have taken place between the ages of one and 10,” he says. “This usually manifests in adolescence. Shopping here can provide the same relief as a painkiller.”

The pain or trauma can be anything from parental abstention, abuse (emotional or physical) or even financial or social insecurity. “The presumption that compulsive shopping is predominantly a female problem is wrong,” says Joseph. “It can affect men, too.” There are also shoppers who buy the product, return it and do this on a loop, he says.

“Getting help is crucial,” adds Joseph. “Psychotherapy can help identify the underlying problem, find the root cause and help address it. One could also turn to parents or a trusted friend. Tell them about why you shop, how you feel when you shop; talk about it in detail. You could also ask them to keep a check on you—make it so that you need their permission to shop. Or, let them handle your debit/credit cards for a while. This will create a delay and help cut the urge.” Joseph also suggests writing down the trigger. “Write down what you intend to buy and why you need it,” he says. “Wait for two days and decide whether you need it. Most of the time, you would not buy it.” Most important, he says, seek help.

Aliya Nazeer, 30, a Kochi-based IT employee says the shopping craze caught up with her during the lockdown. “You could not step out; it felt restrictive and so my solace was shopping,” she says. “It was not just clothes or make up. I was shopping for nearly anything and everything from books to home decor to household items like cleaning supplies. Many a time, the things I bought did not serve any purpose. I would not look for deals as such. I would shop every time I felt out of sorts, which was a lot.”

She says a lot of her buying was after watching reels on Instagram. “I would see a beautifully done room and think, I want that!” she says. “The need to be perfect, the need to look put together, drove me to buy cosmetics, clothes, accessories.” Nazeer says that initially she never thought about the money—so much so that she does not recall how much she spent on shopping during the pandemic. “Even when I felt I was overspending, I would buy what I wanted,” she says. “I am quite sure I overspent on items I did not need.”

“Currently when you look at influencers on social media, it is a combination of many things,” says Joseph. “Shopping behaviour is a combination of one or two things like impulsivity and peer pressure. Often, it is not a well-thought decision. It just gives immediate gratification. It becomes a weakness because a lot of these purchases are made when one is stressed—it could be termed a disorder. It gets difficult to resist when there are inviting tag lines like 'complete your life' or 'boost your confidence' and so on. This causes more damage than benefit to shopaholics. Another factor is the visuals—they are attractive. What we see, we imprint and buying it generates a gratifying feeling. As a result, the shoppers get into huge credit card debt.”

Chennai-based chartered accountant and personal finance expert Lavanya Mohan says that shopping for discretionary items should be done only after essential spends and debt have been taken care of. “Saving cannot come after spending,” she says. “Allow yourself to spend only after you have allocated for savings.”

At the same time, Mohan adds that everyone deserves some “fun money” that they can spend on whatever they want. It just should not come at the cost of savings or essential spends. “Today with the popularity of BNPL (buy now pay later) it becomes easier than ever to shop for the items you want,” she says. “However, if consumers are not careful, they can easily slip into a very expensive trap and a vicious cycle of interest payments and late fees.”

Influencer marketing today, says Mohan, is bigger and more legitimate than it has ever been. “It is a $14 billion business, globally,” she says. “In India, it is estimated to be around Rs900 crore and is predicted to grow to Rs2,200 crore by 2025. The marketing argument for influencers is that they drive revenue. While this makes sense, it is superficial to an extent,” she adds.

Mohan recommends the 50-30-20 rule when it comes to budgeting—50 per cent for your needs, 30 for savings and 20 for wants. “The key is simply staying consistent,” she says. “It is not a one-time exercise, but a habit. So take time every day to record all the transactions you make.”

So, maybe head to the cart and hit delete!

COPING WITH SHOPPING ADDICTION

Recognising the problem is the first step. “Accepting that you have a problem is key,” says Kochi-based consultant and clinical psychologist Anita Rajah. She suggests the following methods to cope with shopping addiction:

* Tell yourself that it is not a necessity, it is not a requirement. This requires a lot of self-awareness

* Quitting cold turkey is another option. This might be hard, but you can achieve it by keeping your credit card away and identifying your trigger. Are you shopping because you are bored or because you are stressed? Do you tend to have an affinity towards discounts? Identify which sites you tend to visit frequently—is it Amazon, Myntra? What time do you tend to shop? In the morning, during the lunch hour or before bed time? Identifying the patterns help you break it

* Keep an amount aside for spending. Let us say the amount is Rs10,000. Put the rest of the amount in another account or in a joint account with your spouse or partner or parent, someone who will hold you accountable. Ask a trusted family member to ensure that you do not touch your phone after a certain time, so that you are not tempted by social media

* Try delayed gratification. For example, if you have goods worth Rs10,000 in your cart, do not buy it immediately. Revisit it a day later, assess if you really like the colour of the clothes you have chosen. The next day, assess whether you will wear it on day-to-day basis. Such assessment will help reduce the number of items in the cart and you will probably spend Rs2,000 instead of Rs10,000

* Practise meditation and deep breathing. This, to an extent, will help control your impulses

danish-chef-rene-redzepi-anger-management-lessons

Sat Mar 25 15:20:38 IST 2023

When he opened Noma, chef René Redzepi gave it ten years before he moved on. That was in 2003. Now, as the Copenhagen restaurant—named the world’s “best” multiple times and credited with revolutionising Nordic food—approaches its 20th birthday, with a new book to boot, the 44-year-old has no plans to walk away.

“I’ve often asked myself why I was so adamant in saying ten years,” he tells me over Zoom from the Noma test kitchen (which, from where I’m sitting, looks like a glass Portakabin being buffeted by the Danish winter weather). “My feeling was that after ten years you had to tear down the fortress you’d built. But I’m very happy right now. Twenty years in, we’re in the best place we’ve ever been—without a doubt. Including myself.”

Many chefs go through what in cringeworthy modern parlance might be called a “journey”, and Redzepi is no exception. It has been a decade since he first spoke about his temper in the kitchen, calling himself a “beast”. In 2015 he wrote an article in which he admitted: “I’ve been a bully for a large part of my career.”

That must have been hard to face, I venture. Redzepi shakes his head, his hair falling over one eye. “It wasn’t hard at all, because I was doing it every day,” he says. “When I came home at night I looked in the mirror and said to myself: ‘Why are these insignificant incidents in the kitchen disasters to you? It doesn’t make any sense.’ I would tell myself: ‘Tomorrow, I’m not going to do it’. And then I’d go back, and within an hour I would be furious. Those are some of the worst times of my life.”

Angry, self-loathing chefs are having a cultural moment, Ralph Fiennes playing one in The Menu. That film’s depiction of a destination restaurant where privileged diners come for the ultimate tasting menu has echoes of Noma. Fiennes’s description of his character as someone who “wants the power and the control, but at a deeper level… despises himself for it” could almost have been applied to Redzepi, from the sound of it. Although thankfully the Dane resolved his issues in a different way.

He has, he tells me, had “many, many, many, many hours of therapy” to deal with the wellspring of his anger—something it has taken years to pin down. “There’s a very specific moment, which I can’t talk about because it’s way too traumatic, when I started asking: ‘Where does all this anger come from?’” he says. “Finding that out was the hardest thing I’ve ever done. It’s something I’m still processing. Typically it comes from your childhood, and when I found that out, that’s when I could start really letting go of the anger and fear.”

His temper, he insists, was limited to “shouting and screaming”. “I never hit anyone, but we were in a very small kitchen. So I probably bumped into people in a way where it was, like, ‘Come on, hurry up.’ It’s hard not to be a little physical when you’re running around.”

Was he scared that he might cross that line if he didn’t deal with his anger? “Yes, I probably was,” he replies. “It’s an intense industry. I know everyone will have read it many times, but it is so much pressure, you guys have no idea. It’s just a machine that churns out young people. It’s not easy to fix, and it’s going to take a long time. We need much better management skills and teaching—that just doesn’t exist. But it has changed quite a lot, I’m happy to say, in the 30 years since I started.”

Redzepi and his twin brother, Kenneth, were raised by a Macedonian-Albanian father, who moved to Denmark in the 1970s and worked as a taxi driver, greengrocer and dishwasher to provide for his family, and a Danish mother, a cleaner. Childhood summers were spent foraging in rural Macedonia, but in Copenhagen Redzepi began to supplement the family income aged 11, delivering newspapers, beer and cigarettes.

He struggled to focus at school and left aged 15, following a friend to cookery classes on a whim and spending the next decade climbing the culinary ladder, with stints at El Bulli in Spain and the French Laundry in California, before being offered the head chef role at a new eatery in the Danish capital. If you were being lazy, you might say the rest is history. In fact, the rest is the result of his legendary 80-hour working weeks, leaving limited time to spend with his wife, Nadine, and three daughters, Arwen, 14, Genta, 11, and Ro, 7.

“Maybe it’s not 80 hours every week now, but it’s very damn close,” he says. “It’s hard for me to have a day where I’m not working. Mondays are what I call a half day—I might come in at 11am and leave at 5pm. And then on Sundays, there might be two or three hours of work to do. I also leave early once a week, between 6pm and 7pm.”

That’s not early, I say.

“It is very early to me.” Redzepi laughs, taking a bite of the dark rye bread and ham he has been eating while we talk. “Early enough to actually have dinner with my family anyway.” It helps that Nadine works at Noma. It’s where the couple met in 2005, when Redzepi was head chef and she was a 19-year-old student who had stepped in to cover a friend’s waitressing shift. Despite a rule (still in existence) that banned dating among staff, love blossomed.

“When I first saw her it was like an angel walking down the stairs. That’s really how I felt,” Redzepi tells me. Very romantic—but would he have thought twice about starting the relationship in this post-#MeToo era? “Of course, you would think even harder now whether it’s something that you’re serious about,” he says. “The imbalance between me being the boss and her being an hourly employee—could they feel pressured? I’m sure that would make me think differently today. Back then, I was blinded by love so I didn’t even consider it.”

The family is soon leaving on a month-long holiday to Mexico, their first break together since Covid, during which Noma pivoted to selling burgers to locals who queued around the block. And Redzepi makes time for an annual walking holiday with his closest friend and Noma co-founder, Mads Refslund, during which they stay in people’s homes or hostels, and eat simple meals and chocolate bars.

“Hiking is my passion. I’ve walked the Camino de Santiago twice, the Shikoku 88 in Japan twice and the Caucasus mountains of Georgia,” he says. “You can vacuum your mind of clutter. You switch off your phone and ground yourself by just walking. A lot of people say, ‘Well, I don’t have time,’ and I’m, like, ‘I don’t have time either!’ But it’s a part of your longevity plan. You make the time. I just cancel everything—doesn’t matter what it is, just cancel it.”

This “longevity plan”, it turns out, is rather calculated. “I am trying to plan for the long run,” he says, sipping lemon balm tea. “I have stuff I do for myself—workouts, hiking, vacations. I meditate every day. I would like to do what I’m doing until I’m 75 and stay motivated.”

That desire is what meant that, in 2017 and at the height of its powers, Redzepi closed Noma, reopening it a year later on a new site near the hippie enclave of Christiania, with a dining structure limited to a seafood season, game season and vegetable season. It paid off, and Noma was named the world’s best restaurant in 2021, having not held the title since 2014. The new menu is reflected in his latest book, Noma 2.0: Vegetable, Forest, Ocean. Redzepi tells me that it is intended to showcase the team’s work—a good job, since home cooks are likely to be intimidated by the lack of quantities on some recipes, while others demand industrial measures (5kg of sushi rice, anyone)?

In the acknowledgements he name checks each member of the team, including Stu, one of several chefs from the north of England to have cooked in Redzepi’s kitchen and whom he credits with his love of a Sunday roast. “Those potatoes cooked in beef fat? The best in the world,” he enthuses. “I’ve also learnt a little bit about your culture—watching a game at the weekend, and drinking pints. British people and Danish people are fairly similar.”

I’m starting to think that Redzepi may be a secret anglophile. During our interview his dog bounds into view—a border collie, no less. Then there’s his friendship with the British artist David Shrigley, whose whimsical illustrations feature in the book, with slogans such as “The new you is contained inside the old you” and “Release the negative gases”. “I started following his work 15 years ago after I went to a gallery and bought a print,” Redzepi says. “Then I asked if he would do one specially for Noma. I love his view of the world. They are words to live by. I’m very inspired by people who can keep doing what they’re doing for a long time and stay relevant.”

He won’t divulge the names of his other famous friends or diners, other than admitting that Raymond Blanc is coming to the restaurant in a few days’ time, about which he is “excited and quite nervous”. Did he have any of the Danish football team in, before the World Cup? Redzepi pauses. “No, but actually, we tried to get the Danish manager [Kasper Hjulmand] to give us a management session,” he replies. “Denmark is doing really well. There’s an incredible togetherness. He’s a leader who is clearly doing something to inspire this group of great footballers. I find that very inspiring—that the right team energy can really make a difference. He wants to come and do it, but he’s just a little busy right now.”

As is Redzepi, planning Noma’s next pop-up in Kyoto in the spring. He waves his phone in front of a flipchart, on which are scrawled 30 ideas (I can only make out the word “squid”) that must be turned into 20 dishes for a package that will cost €775 per person (around Rs78,000). And he’s already planning to tear down the Noma 2.0 fortress.

“We have a couple of years here, and then we’re going to have a big change,” he says. “When Covid happened, it was like a thunderclap at night—you can see everything clearly for a second. So, early on in the pandemic, we started some planning that will be put into effect over the next 18 months to two years. We could just keep raising the prices, but we need to do something different to actually get where we need to be.”

Redzepi seems satisfied that he is almost where he needs to be too. “I feel better now than when I was 35,” he says. “I’m healthier. I’m the same weight as when I was 18. And I never shout any more—I can honestly say that. That’s a done deal for me.”

sickle-cell-anaemia-causes-history-prevention-treatment-in-india

Sat Feb 25 15:35:34 IST 2023

Bhagwan Badole has the physical appearance of a six year old. He is actually 14 and gets uncomfortable when his age is discussed. A resident of Rehtiyawadi in the Jhirniya block of Khargone district, Madhya Pradesh, Bhagwan was irregular in school and reluctant to socialise till recently. He felt he was made fun of for his height. His poor health―he gets severe pain and breathing complications―kept him mostly at home.

His elder brother Kanu, 16, has a similar issue. The poor Barela tribe family, still recovering from the death of Bhagwan’s father, Rain Singh, four years ago, was too caught up in earning a living to focus on the health of the children.

Kanu, despite his poor health, has gone with his mother, Sabli Bai, and elder brother Bharat, 20, to Pune to work as labourers. Kanu cannot do any physical work, but he wanted to be with his mother. “Kanu and Bhagwan would remain sick a lot,” Dharmendra Badole, the eldest brother, told THE WEEK. “We would regularly take them to hospital and get blood transfusion done at least once a year, though we did not know what the disease was.”

Things changed a few months ago. Under a screening drive by the NGO Synergy Sansthan, Bhagwan and Kanu were diagnosed with sickle cell anaemia (SCA), the most common and most severe of the group of genetic blood-related disorders called sickle cell diseases (SCD).

SCA is widely prevalent in India, especially among disadvantaged groups like the tribals and the scheduled caste communities. There are some other forms of sickle cell diseases, but they are rarer and milder.

“Following the diagnosis, Kanu and Bhagwan were given family and individual counselling,” said Synergy Sansthan volunteer Sunita Rathod. “Their treatment was initiated and they are now better. They regularly take the medicines that we and the government hospital provide and we follow up on them regularly.” The NGO has taken up an intervention on sickle cell anaemia in Jhirniya block with support of SBI Foundation and the district administration.

“I feel better now and I try to ignore comments on my appearance,” said Bhagwan. “I want to study and be able to support myself and my family.”

Dharmendra, who is a sickle cell carrier but healthy, said that though they did not know it, their father might have had the disease as he, too, had similar problems as Kanu and Bhagwan. He was scrawny, though not short-statured, and died when he was just over 40.

Kanu and Bhagwan are among the more fortunate ones. “Mostly, because of a lack of awareness, adequate data and planned government intervention, the disease has continued unabated in different parts of the country,” said Vimal Jat of Synergy Sansthan. “This has caused a significant population to live painful and shortened lives, and has entailed a huge economic burden that few of them can afford.”

However, he hopes for a change now that the Union government has announced a mission to eliminate sickle cell anaemia by 2047. In her budget speech, Finance Minister Nirmala Sitharaman said: “It (the mission) will entail awareness creation, universal screening of seven crore people in tribal areas (most affected) and counselling through collaborative efforts of Central ministries and state governments.”

Health Minister Mansukh Mandaviya said after the budget speech: “The government will take up the eradication of sickle cell anaemia in a mission mode and conduct massive screening for early detection of cases. Going forward, the government will also issue cards after screening to (positive) tribal persons below 40 and also provide pre-marital counselling to make them aware of the effects of marrying another sickle cell anaemia patient and giving birth.”

The Union health ministry, in collaboration with the ministry of tribal affairs and states, has prepared a roadmap to screen the seven crore people under the age of 40 in 200 districts (in 17 states). The screening will be done using the rapid “point of care” histological test, for which a person will just have to give a blood sample, said Mandaviya.

What is SCA?

“SCA is a genetic disease caused by a point mutation of the beta-globin expressing gene... that gives rise to a type of haemoglobin named Haemoglobin Sickle (HbS). This mutation deforms the disc-shaped red blood corpuscles into sickle-shaped cells,” read a note on the website of the Council of Scientific and Industrial Research-Indian Institute of Integrative Medicine. “The sickle-shaped cells lose flexibility with reduced oxygen carrying capacity and induce dehydration in the cells. Individuals suffering from sickle cell disease show symptoms such as body pain, clotting, dyspnea (shortness of breath), anaemia, jaundice, pneumonia and repeated infection. Their lifespan is usually reduced to 42 to 48 years, with 50 per cent of children dying before five. A major cause of premature mortality in sickle cell disease patients is infection. The disease management is usually symptomatic and hydroxyurea is the major therapeutic agent (medicine) available for treatment. Hence, early and affordable detection, treatment as well as preventive measures are important in managing this disease.”

A ‘Handbook on Sickle Cell Disease’ by the Sickle Cell Institute, Chhattisgarh, said, “Abnormal beta globin genes from both mother and father are required to be inherited in offspring to cause SCD. If a person has only one abnormal gene inherited either from mother or father, it is referred to as sickle cell trait (carrier) and is usually asymptomatic. However, they can pass the abnormal beta globin gene to their progeny (children).”

Lack of data

There is little holistic data available on the extent of the disease in India, let alone state-level data. A December 2018 study called 'The spatial epidemiology of sickle-cell anaemia in India', published in Nature, said, “The global burden of SCA is increasing with the annual number of SCA newborns expected to increase from around 300,000 to more than 400,000 between 2010 and 2050. India has been ranked the second worst affected country in terms of predicted SCA births, with 42,016 babies estimated to be born with SCA in 2010.”

It further noted that, “Scheduled populations (ST and SC) show carrier frequencies ranging from 1 to 40 per cent. Carrier frequencies up to 12 per cent have also been reported in non-scheduled groups, although frequencies of less than 5 per cent are more commonly observed.”

The highest frequency of the disease has been found in the belt stretching through central India from south-eastern Gujarat to south-western Odisha.

The paper said the scheduled population is more vulnerable to the disease because of genetic mutation to safeguard these groups from malaria, high rate of endogamy (marriage within community and inbreeding) and “evolutionary exclusion of the sickle cell gene in non-scheduled groups by beta-thalassaemia (another blood disorder) causing gene”.

According to the ministry of tribal affairs (MoTA) website, 1 in 86 births in the tribal population has sickle cell disease.

Pilot project in Madhya Pradesh

Madhya Pradesh, with the highest tribal population in the country (1.53 crore in the 2011 census), is considered to have the highest burden of disease.

A May 2015 research paper Sickle cell disease in tribal populations of India in ICMR’s Indian Journal of Medical Research quoted a 2006 study of the National Institute of Research in Tribal Health, Jabalpur, to say that 27 of the then 45 districts of the state fell in the ‘sickle cell belt’. It further cautioned: “About 3,358 newborn babies with sickle cell disease are expected to be added every year and about 13,432 pregnancies are at risk annually.”

Considering that the data was quite old, the state health department decided to undertake fresh screening of the tribals. “In November 2021, a pilot project (in the presence of Prime Minister Narendra Modi) was launched in the tribal-dominated Alirajpur and Jhabua districts with an aim to screen about nine lakh people in the two districts,” said Priyanka Das, mission director of the National Health Mission in Madhya Pradesh.

Of the 9,93,114 persons screened, 18,866 (1.89 per cent) were detected as carriers and 1,506 (0.15 per cent) were found to have SCA, Union Minister of State for Health Bharati Pravin Pawar said in a recent reply in the Lok Sabha.

In Synergy Sansthan's screening in Jhirniya of Khargone district in 2022, it was found that 430 (12 per cent) of 3,601 persons screened were carriers and 24 (0.6 per cent) had SCA.

Das said that the state government has decided to expand the project to all 89 tribal blocks in the state. “The diagnosed people will be given pre-marriage counselling and cards that will have a graphic illustration of their sickle cell status, making it easy for the illiterate to make marital matches,” she said.

Das added that the state has facilities for symptomatic treatment and blood transfusion, and that the screening will help solve the earlier problem of poor detection. The Union budget announcement would help the state get budgetary support and as the Centre has endorsed the Madhya Pradesh project, she said, other states could soon have their own.

Prevention is the solution

“There is basically no cure apart from symptomatic management using folic acid, painkillers and hydroxyurea drug and, in acute cases, blood transfusion is recommended,” said Jhirniya block medical officer Dr Sunil Chouhan. “These facilities are provided free of cost by the government.” Newer interventions like bone-marrow transplants are hardly affordable for a majority of the patients.

Thus, the focus is on prevention. And for this, say experts, it is important to know the sickle cell status of individuals and give them pre-marital counselling.

The availability of sickle cell/genetic status cards, planned through the Centre's SCA mission, will help prevent detrimental matches. The SCI Chhattisgarh has even developed a unique ‘sickle kundli’ in Hindi and English, which advises on whether two persons with specific sickle cell status should marry or not.

Though handing out the cards might be the only way to curb the disease, there are concerns regarding ostracisation that the card-holders might face. “There is little knowledge about the disease and the way it spreads, so the labelling of people might cause big problems for them. The need therefore is to carry out a universal awareness programme on SCA and handle the issue sensitively,” Jat said.

The Chhattisgarh government has also started a drive to check the sickle cell status of all schoolchildren. “The attempt is to identify persons with the genetic condition and counsel them,” Chhattisgarh Health Minister T.S. Singhdeo told THE WEEK. “So, we have started a drive to test all students till class 12, mainly those in the 16 to 18 age group.”

He added that the government is planning to set up an advanced sickle cell research centre and the existing SCIC would be scaled up to the national level. “The chief minister (Bhupesh Baghel) is also keen on this and we are in the process of identifying the land for this,” he said. “The work will start soon. We have also sensitised doctors and paramedical staff to remove the hesitation to use hydroxyurea, which was earlier considered a cancer drug. Studies have shown that it is very useful and reduces the need of blood transfusion to half and, in some cases, to as low as 10 per cent.”

No one probably understands the importance of prevention better than Sunita Badole, an ASHA (accredited social health activist) in Kalikundi, Khargone. A daughter of two carriers, Sunita, 31, and two of her sisters are carriers, too. Their youngest brother Deepak Bhabre, 30, has SCA, and her elder brother, who she now thinks was also a patient, died when he was 14. Two of her cousins also have SCA. Her son, Rohit, 12, is also a carrier and, though normally healthy, is a little prone to illness. Her daughter Neha, 15, and her husband are unaffected.

“Most of our land was sold off because of my brother's illness and the financial condition of my maiden family is still precarious as Deepak requires repeated hospitalisation,” said Sunita. “Earlier, we blamed things on destiny, but after I connected with Synergy Sansthan, I understood the complete implication of sickle cell disease and now I am determined to create as much awareness in my area as possible. We have to ensure that wrong marital matches do not happen and the next generation is spared of the distress.”

john-hopkins-university-endowed-professor-dr-shelby-kutty-interview

Sat Feb 25 15:23:37 IST 2023

Dr Shelby Kutty is an endowed professor at Johns Hopkins University. He directs the Taussig Heart Center and chairs the Cardiovascular Analytic Intelligence Initiative at Johns Hopkins Hospital. Kutty has a Master’s degree in health care management from Harvard University, and is trained in medical artificial intelligence from the Massachusetts Institute of Technology.

With so much expertise, Kutty is a name to reckon with in paediatric cardiology. He leads a team at Johns Hopkins that has developed various clinical programmes in cardiac care and was awarded major grants from the National Institutes of Health to lead data science approaches to manage Covid-19. Kutty, a prolific author who has published over 400 peer-reviewed articles in leading medical journals, says cardiac complications from Covid-19 are rare in children. Excerpts from an interview:

We have been facing high levels of pollution in cities. What is its impact on children?

Air pollution is linked to many adverse health effects in children, affecting a multitude of systems. From a cardiac standpoint, chronic exposure to auto emissions and poor air quality as a child is linked to heart attacks, strokes, and atherosclerotic disease in early adulthood. There are many theories as to the potential cause, with some studies suggesting that increased inflammation from chronic exposure to pollution leads to changes in how we process cholesterol and fat, and it makes our vessels more susceptible to injury. Even among healthy adolescents, there are reports of sudden cardiac arrest and arrhythmias in individuals exposed to poor air quality conditions; many of the affected individuals were healthy, with no pre-existing conditions.

In India, over a lakh children every year are born with congenital heart disease. What factors might be contributing to this?

Congenital heart disease, as it is in the rest of the world, is a major health issue for India. The cause of congenital heart disease in the general population is multifactorial―genetic and environmental. We know that there is a higher risk of CHD in children who have close relatives affected by CHD, as well as certain genetic conditions. Maternal factors during pregnancy, such as diabetes, obesity, and alcohol consumption/smoking, are also well-known risk factors for CHD. Certain medications, taken during pregnancy, are also linked to CHD. Though this is becoming less prevalent with more awareness and education.

What lifestyle changes should parents bring about in children to ensure they are not at risk for heart attacks in adulthood?

Research has shown that risk factors for developing heart disease during adulthood are present during childhood. Some risk factors are genetic and cannot be changed, whereas others are modifiable. The good news is that evidence shows that adopting a healthy lifestyle during childhood reduces the risk of cardiovascular disease in adulthood. These include increased weight or obesity, elevated blood pressure, hyperlipidemia (high cholesterol or triglyceride levels), and smoking. They can develop at an early age, and progress until a child’s risk for heart attack in adulthood becomes substantial. Therefore, interventions to alter these factors should begin as early in childhood as possible.

Regular exercise, in addition to a diet low in sodium and saturated fat, should be a part of a child’s daily routine. Preventative care, with regular visits to the paediatrician, is important to detect modifiable coronary disease risk factors, counsel lifestyle changes and initiate medical therapy.

How often should one monitor blood pressure in children?

Blood pressure should be monitored annually in children over the age of three. Children with risk factors, such as those with kidney or heart disease, need to be monitored more closely at an earlier age. In healthy individuals, high blood pressure, or hypertension, is linked to stroke and heart failure early in adulthood. Poorly controlled hypertension can lead to heart attacks and even seizures.

Can family history of high cholesterol or premature heart disease put children at risk for developing cardiovascular disease?

Yes, very much so. There are certain genetic conditions that affect the way one metabolises cholesterol. Even with a good diet and regular exercise, these individuals are at a greater risk of high cholesterol and triglycerides (or fat in the blood), and require medicines to prevent early heart attacks, strokes, and sudden cardiac death.

Children don’t usually show signs or symptoms of heart disease, but the buildup of fatty deposits in the arteries, known as atherosclerosis, starts in childhood, especially when there is a family history. Obesity, elevated blood sugars, and diabetes also increase the risk of the development of heart disease.

Have you observed geographical disparities in cardiac health of children? How do you rate heart health of children in countries in South America, North America, and Asia?

Cardiovascular disease is the leading cause of death worldwide, but is more prevalent in some locations than in others. Many disparities in cardiac health are linked to lifestyle and diet. In North America, there is a higher incidence of risk factors like obesity, type 2 diabetes, and hypertension at a younger age. This is mainly due to a sedentary lifestyle and consumption of readily available cheap junk food, high in saturated fat and sodium. Diets rich in fat, sugar, and carbohydrates are common in many Asian households, contributing to a higher incidence of cardiac disease in certain South Asian groups. In Japan, however, where the population is physically active and the diet is high in fish and vegetables, there is a lower mortality rate from heart disease.

There are broad geographical disparities in availability of cardiac care services. In less affluent countries, the advanced surgical and medical interventions required for survival in childhood CHD are not available.

Have there been unusual observations among children admitted in the past two to three years?

Cardiac complications from Covid-19 are rare in children, and are often treatable. They can develop a condition called multisystem inflammatory syndrome (MIS-C), which causes inflammation of the heart muscle and coronary arteries after a Covid-19 infection, which can be dangerous. In addition, mental health challenges have increased, with higher rates of depression and anxiety reported in all age groups.

Why do sudden cardiac arrests happen among young children? Is it because of environmental factors, or genetic reasons?

Sudden cardiac death (SCD) is typically caused by structural heart disease, which can have a genetic cause, or can occur just by chance. Hypertrophic cardiomyopathy, which is a thickening of the heart muscle, coronary artery abnormalities, and genetic syndromes associated with arrhythmias are common causes of SCD. Infections that affect the heart, like myocarditis, can also cause a sudden cardiac event. It is rare for environmental and lifestyle factors to cause a sudden cardiac arrest in children, but these can lead to adverse events in early adulthood.

What are the breakthroughs that are helping us in understanding heart disease among young children?

Improving technology has been a key factor in helping cardiologists diagnose and treat children with heart disease earlier, sometimes in foetal life. Imaging modalities have become more precise and accurate, allowing us to pinpoint a problem more effectively. Surgical techniques have advanced, and we are able to treat many common congenital heart conditions less invasively, via transcatheter procedures and devices. Ultimately, our patients are leading longer, more fulfilled lives.

On the horizon, there is great potential to take advantage of major advances in medical information management, artificial intelligence, and machine learning to personalise care for our paediatric cardiac patients. As we combine medical history with cardiac imaging, genetic, metabolic, environmental, and even socio-economic data, there is the deep phenotype, which emerges, upon which fully informed decisions about heart disease management for the individual can be made.

Many Indian hospitals have set up separate departments for paediatric cardiology in recent years. Your views.

While the number of hospitals with paediatric cardiology programmes is increasing in India, many more programmes and providers are needed, particularly to care for CHD in patients who are becoming adults. In the developed world, the number of adults with CHD has exceeded the number of children. Nevertheless, in the US there are approximately 480 adult CHD providers, and close to 3,000 paediatric cardiologists. These numbers are largely mirrored in the rest of the developed world, and in lower income countries the relative shortage of physicians with expertise in adult congenital heart disease is even greater. India faces a great need for more providers and programmes to meet the growing demands for specialised CHD care in children and adults.

advantages-of-medical-video-games

Sat Feb 25 15:15:27 IST 2023

Video games are considered an effective medium for training professionals, especially those working in fields that require high precision, quick reflexes and great hand-eye coordination. In the medical field, video games are generally used to train professionals in surgical techniques, assess patient conditions and diagnose medical conditions. The 1988 game 'Life & Death', in which players had to assume the role of a surgeon and diagnose and treat various medical conditions using a combination of text-based commands and simple graphics, is considered one of the earliest medical video games.But these games were too primitive compared with the medical video games available across platforms now.

Recently, video game maker Level Ex and an educational research company CE Outcomes did a first-of-its-kind study on the effectiveness of educational video games on a rarely-measured demography of doctors. The study assessed doctors who are in the age range of 32 to 57, with an average of 14 years of practice. As part of the study, these doctors played 'Top Derm', a video game developed for dermatologists. The five game modules in 'Top Derm' tested the doctors with focused challenges across a range of dermatologic images and case scenarios. The study evaluated the players' knowledge acquisition during the games and examined their knowledge retention and transfer weeks later. In the follow-up assessment, the doctors were given new patient case scenarios to evaluate their knowledge, but using a format different from the one they had encountered in the game.

About 40 per cent of doctors demonstrated improved knowledge in three specific modules, namely 'Zebra Cases' (unusual skin disorders), 'Visual Skinsations' (hair and scalp disorders), and 'Pesky Pimples' (acne conditions). While presented with patient clinical scenarios, 88 per cent of physicians either maintained or increased their scores.

Notably, clinical competency increased among the older and younger generation alike. It was also observed that 'Top Derm' had a significant impact on physicians' clinical decision-making. For instance, in one scenario, 10 per cent of physicians modified their management of acne during pregnancy after the game session. In another scenario, physicians correctly adjusted topical acne treatments to improve efficacy and decrease resistance based on their game experience.

Medical video games were found to be more enjoyable than traditional continuing medical education (CME). The majority of physician players, regardless of their age or experience, preferred learning through play over CME. Nearly 75 per cent of physicians expressed an affinity for learning through medical video games. It seems the future is here in which high-skilled medical professionals are video game aficionados, too.

the-husband-stitch-vaginal-birth

Sat Jan 28 17:26:11 IST 2023

They take the baby so that they may fix me where they cut. They give me something that makes me sleepy, delivered through a mask pressed gently to my mouth and nose. My husband jokes around with the doctor as he holds my hand.

How much to get that extra stitch, he asks. You offer that, right?Please, I say to him. But it comes out slurred and twisted and possibly no more than a small moan. Neither man turns his head toward me.

The doctor chuckles. You aren’t the first.

The Husband Stitch―Carmen Maria Machado.

Bhanupriya, 23, from Bengaluru, developed pain in the abdomen in the 36th week of pregnancy. “As I wore my gloves to examine if she was going into labour she wept, screamed and refused an internal examination,” said Dr N. Sapna Lulla, lead consultant, obstetrics and gynaecology at Aster CMI Hospital, Bengaluru.

Bhanupriya was married to a sari merchant from Rajasthan. She said to Lulla that obstetricians like her are the reason for her trauma. “It was only then I comprehended what I was dealing with,” said Lulla, who asked Bhanupriya to meet a psychiatrist.

Bhanupriya told the psychiatrist about the husband stitch, which was an additional stitch she was given following a vaginal birth. This was to enhance sexual pleasure for her husband. The tears that ran down Bhanupriya’s cheeks gave Lulla a peek into her emotional trauma. “She refused a normal birth in fear of tightening the vagina to give her husband more pleasure during sex. It took a lot of effort and counselling and assurance to get her to agree to a normal vaginal birth,” the doctor said.

What makes the additional stitch worrisome is that it goes beyond repairing the cut made between the vagina and the anus during childbirth. Though the additional stitch is meant for enhancing the pleasure of the male partner during sex, it often involves tampering with a woman’s body without consent. Ideally, a woman’s consent has to be taken for the husband stitch. “However, on most occasions it is done without the knowledge or consent of the woman,” said Asha Dalal, director, obstetrics and gynaecology, Sir H.N. Reliance Foundation Hospital, Mumbai.

Husband’s stitch is a sexist practice, said Reshma Valliappan from Pune, “Apart from pleasure being a one-sided gender requirement, a woman’s pleasure is not given any value in a patriarchal society.”

The husband stitch can have several side-effects. It may result in discomfort and chronic vaginal pain. “An extra tight vaginal orifice may make the sexual act extremely difficult for the female partner,” said Dr Anagha Chhatrapati, consultant gynaecologist at Global Hospital, Mumbai.

Every time Geetanjali Chetan from Bengaluru thinks of the birthing experience, she is filled with awe. When she gave birth to her child after waiting for nearly 11 hours, the vaginal delivery was facilitated by a "cut" (episiotomy). The cut was immediately closed using dissolvable stitches. Said Chetan, “The stitch was too tight and it made me uncomfortable. It was difficult to maintain hygiene as there was a small pouch like space below the vagina. It gave me an unnatural feel and seemed to have been overdone.” Experts point out that the husband stitch is not medically recommended. “It is sometimes put just for the pleasure of the husband. That is not recommended in any of the medical books. I don’t think it is legal,” said Dr Surabhi Siddhartha, consultant obstetrician and gynaecologist, Motherhood Hospital, Kharghar, Mumbai.So, why is the husband’s stitch still administered? Post delivery, the vaginal wall becomes lax. At the time of suturing an episiotomy, the doctor may put in an extra stitch to make the vaginal opening tighter. However, there is no evidence to prove or disprove the claims about its potential benefits, said Chhatrapati.

In certain cases they don’t give the cut in the perineum and allow the baby to come out naturally. It could result in the stretching of the vaginal canal.

“If the vaginal opening does not stretch wide enough to allow the baby's head to pass through, it may lead to tear and injuries to the perineum, vagina, vulva, labia, anal canal, and, on rare occasions, even the rectum. Such injuries can cause severe bleeding, sometimes difficult to repair,” said Chhatrapati.

There are better alternatives to husband stitch that women can opt for. Kegel exercises are a great way to tighten the vagina. The tone of the vaginal walls and the perineum are equally important. “Vaginal birth can weaken both. Women can improve this on their own, through regular Kegel exercises,” said Chhatrapati, “In case there is excessive laxity, a surgery can be performed by a gynaecologist later to restore the tone of the vaginal floor.”A plastic surgery performed on the vagina can get it into pre-delivery shape. Dr Sushma Tomar, consultant obstetrician and gynaecologist, Fortis Hospital, Kalyan, however, has a word of caution. “While it is okay to go for such procedures, it is essential to ensure that vaginal stitching is done with care and should only be performed by relevant experts,” she said.

Lulla, meanwhile, ensured Bhanupriya had a vaginal birth. She delivered a 3.46 kilo baby boy, but unfortunately she had a vaginal tear that needed suturing. “I had the husband ranting on about the perineum tightening. I told him I will make a chastity robe for his penis,” smiles Lulla. “Finally, the vaginal tear repair was completed without the stitch. Till date, Bhanupriya’s husband cribs of lack of pleasure at sex.”

Bhanupriya has become Lulla’s best friend.

adhd-factors-manifestations-training-medicines

Sat Jan 28 16:50:46 IST 2023

I was at a friend’s place when I bumped into his child who was restlessly running around. He could hardly wait for his turn. He was constantly in motion as if driven by a motor. I was told that he was disrupting class, interrupting others, and, in general, was unable to focus on things. The child’s behaviour was termed unruly. My friend was at his wits’ end.

I had a long chat with my friend. I asked him if his son had seen a psychiatrist. As expected, there was a hint of surprise on my friend’s face. I had to explain that this could possibly represent an ongoing pattern of inattention or hyperactivity-impulsivity, which was interfering with his son’s functioning and development. This was attention deficit hyperactivity disorder, or ADHD as known in medical parlance.

Clinical manifestations

People with ADHD experience an ongoing pattern of inattention, hyperactivity, and impulsivity, with consequent disruption in the spheres of social, interpersonal and occupational life. The individual will have trouble staying on a task as a result of poor focus and disorganisation. This does not signify defiance or lack of comprehension, but is the result of a complex brain disorder. A hyperactive individual constantly moves about even in situations where it is deemed inappropriate. Alternately, he or she could fidget, tap or talk excessively. An impulsive individual may act without thinking or may have difficulty in exercising self-control. This may manifest as a need for immediate reward or as a difficulty in delayed gratification. An impulsive person interrupts others, or makes major decisions without considering long-term consequences.

People with ADHD may often miss or overlook details. They make seemingly careless mistakes at work, have difficulty in sustaining attention, find it hard to follow through instructions, start tasks but lose focus and get easily side-tracked. They seem distracted when spoken to, avoid tasks that need sustained mental effort, lose things, and, in general, are forgetful about daily chores or keeping appointments. All these are various ways in which a core symptom of ADHD may manifest clinically.

People with hyperactivity-impulsivity may fidget and squirm while being seated, abruptly leave their seats in situations where they are expected to be seated, are unable to engage in hobbies quietly, talk excessively, answer questions fast, finish other people’s sentences, have difficulty waiting for one’s turn, and interrupt others in conversations, games or activities.

ADHD symptoms can appear as early as between the ages three and six years, and can continue through adolescence and adulthood. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12. ADHD symptoms can be mistaken for emotional or disciplinary problems as had happened with my friend’s son. Worse, the diagnosis may be entirely missed in children who primarily have only symptoms reflecting inattention. Adults with undiagnosed ADHD may perform poorly academically, have problems at work, and in interpersonal relationships.

Risk factors

ADHD predominantly affects males, with a male to female ratio of 3-4:1. Multiple lines of evidence point to strong genetic influence in ADHD. Environmental stressors may change the brain structure and function, and can interact with inherent genetic vulnerability to cause differential effects. Low birthweight, prematurity, obstetric complications, utero exposure to maternal stress, tobacco, alcohol, illicit drugs are associated with ADHD, but may not have a causal effect. Maternal smoking during pregnancy remains an important risk factor.

Parent training

These are educational interventions disseminating information on ADHD to carers, and is typically delivered in groups. Parents are educated about strategies to target and monitor problematic behaviours, encouraged to liaise with teachers, use positive reinforcement, and plan ahead to anticipate problems.

Cognitive behavioural therapy

Persons are encouraged to identify dysfunctional patterns of thinking and behaving. They are then equipped with skills to improve self-esteem, and to deal better with emotional and social difficulties.

Cognitive training

This modality targets specific domains such as attention, working memory, inhibitory control, and aims to improve the functionality of these domains. Studies show that although this improves working memory, it has little effect on the core symptoms of ADHD.

Medication

Strong evidence supports the efficacy of drugs for ADHD in reducing the core symptoms over a period of one year. The most common type of medication used is called a ‘stimulant.’ Stimulants increase the brain chemicals, dopamine and norepinephrine, which are thought to be dysfunctional in ADHD, and thereby allow better thinking and focus. Amphetamine and methylphenidate are the most effective stimulant drugs for ADHD with a response rate of 70 per cent. Amphetamine is a controlled substance as a result of the United Nations decree in 1971. Many countries class it alongside drugs like heroin, and thus it needs specialist advice and prescription.

ADHD is a heterogenous condition and can persist well into adulthood. Sixty per cent of affected children have significant ADHD-related impairments as adults. ADHD drugs, especially in the short-term, represent some of the more effective drugs in psychiatry, and, perhaps, in general medicine with a good safety profile. Given these considerations, there should not be any stigma to opt for drug treatment for a condition that can very much be controlled.

―The author is senior consultant psychiatrist at Manas Institute of Mental Health in Hubli, Karnataka.

med-talk-severe-heart-attack

Sat Jan 28 18:05:04 IST 2023

Is it possible to fully recover from a severe heart attack? A recent study by scientists at UT Southwestern Medical Center in Texas, published in Science, suggests that with the help of gene editing, this may soon become reality.

A heart attack happens when blood vessels are blocked and the heart is deprived of oxygen. An estimated 1.9 crore people die because of cardiovascular problems every year.

Recently, the scientific world discovered that much of the damage caused by a heart attack is triggered by the over-activation of a gene named CaMKIIδ (calcium calmodulin-dependent protein kinase IIδ). This gene is a central mediator of several physiological processes in the heart; it has a crucial role in heart cell signalling and function. A part of CaMKIIδ protein is made up of two methionine amino acids. When these two are oxidised―because the heart is stressed―CaMKIIδ gets over-activated.

The USTW team hypothesised that if the methionines could be edited and turned into another amino acid, the oxidation process will not happen, which, in turn, would stop the over-activation of CaMKIIδ. To test this theory, the team edited CaMKIIδ in human heart cells growing in a petri dish using a CRISPR-Cas9 gene-editing system. They then placed both edited and unedited cells in a low-oxygen chamber. As expected, the unedited cells got damaged and died. The edited cells survived.

The researchers then replicated the test in live mice. They induced heart attacks in mice by restricting blood flow to their heart for 45 minutes. They then introduced edited CaMKIIδ components into the heart of a section of the mice. They observed that both gene-edited mice and some from the other batch continued to be alive after 24 hours. However, the condition of the unedited mice worsened over time. Meanwhile, the edited ones steadily improved over the next few weeks. Over time, their cardiac function became nearly the same as before the heart attack.

The CRISPR-Cas9 gene-editing system was discovered a decade ago. But until now, it has been used by scientists to correct genetic mutations responsible for the disease. The USTW researchers proved that it can be employed in a new way―by modifying a normal gene, rather than targeting a genetic mutation, to avoid a fatal situation.

The study published by the USTW researchers says that their findings could lead to a new strategy for protecting patients with heart issues. If the hypothesis holds true, we might soon be able to edit out our heart troubles.

juvenile-dermatomyositis-children-samantha-myositis

Sat Jan 28 16:41:34 IST 2023

Fans were shocked when actor Samantha Ruth Prabhu revealed in October that she had been diagnosed with myositis―an autoimmune condition that causes inflammation of the muscles. “Some days, getting up from bed is difficult,” she said. “It is draining and tiring. I've always been a fighter and I will fight.”

As 'get well soon' wishes poured in from around the world, people also started looking up the relatively unknown disease. The internet was awash with articles on the 'ifs' and 'buts' of the affliction and how one can deal with it.

What most people still don't know, however, is that myositis is not exclusive to adults. When it occurs in children, the condition is called juvenile dermatomyositis (JDM). And though it is usually cured by timely diagnosis and treatment, the former is absent in many cases.

In 2015, Gayatri Ravi, 12, went to Kochi's Amrita Hospital. Extensive calcium deposits had affected her knee joints and she was unable to stand upright. She had been diagnosed with JDM when she was four, but her family did not seek proper treatment. After seven years of subpar treatment and then a stint with ayurveda, Gayatri's condition got worse. Only then did she go to Amrita.

“It has been a real battle to manage Gayatri's condition,” said Dr Suma Balan, paediatric rheumatologist at Amrita Hospital. “We wanted to treat her aggressively, but her bone structure was poor. Physiotherapy was done, but we wanted to do surgery to at least improve her present situation. But her parents were too apprehensive to consent. If the acute phase is not treated properly, there will be deposits of calcium under the skin (calcinosis). This leaves swelling throughout the body, which can develop into lesions and even leak―it is a very traumatic condition.”

In a similar case, Anjali, 13, was diagnosed last year with alopecia areata, an autoimmune disorder that causes patchy hair loss. In certain cases, say doctors, this could be one of the symptoms of myositis. Later, she got fever and muscle aches as well. It was only about eight months later that JDM was detected. A week after treatment started, Anjali's pancreas was affected, which complicated her path to recovery.

Gayatri would not have been crippled and Anjali could have recovered completely if the right diagnosis had been made and the correct treatment given.

JDM can be detected by muscle enzyme testing, myositis antibody test and MRI. Treatment is decided based on the severity of the illness. “We use steroid-based medicines that vary between mild, moderate and severe,” said Dr Sujata Sawhney, paediatric rheumatologist with Sir Ganga Ram Hospital, Delhi. “Methotrexate is also commonly used moderately. We design the protocol for each patient based on his or her condition.”

The underlying causes of JDM are varied. Primary pathology, say experts, suggests that it is caused because of inflammation of the vessels that supply blood to the muscles. “It is not clear and we do not have a definite answer. Many viral diseases also trigger myositis,” said Sawhney. “Autoimmune diseases mostly occur in those who are predisposed genetically; some environmental factors also trigger this. Most of the cases are due to multi-factorial reasons. There is no particular gene or single trigger that causes these diseases. More than 50 per cent children get monophasic (only one episode of inflammation in the nervous system) illnesses. If the child is treated from the age of five, recovery can be successful. Only a very small proportion develops into malignancy in adulthood.”

Treatment might cost Rs1,000 a month for mild cases, but that might go up to lakhs of rupees in case of complicated cases with hospital admission.

Symptoms can vary from child to child―skin rashes, muscle weakness, hair loss and multi-organ involvement are reported in many cases. Due to the nature of the symptoms, the seriousness of the condition goes unnoticed in most cases.

If JDM affects other organs, it can even be fatal. Severe muscle weakness can affect respiratory muscles, restricting the swallowing capacity. Some aggressive methods of treatment can also lead to secondary infections.

“Awareness about this disease is extremely poor,” said Balan. “We get new cases every year. Around 50 patients are being treated here at present. It is more treatable in children. In adults, more cases have been observed around the age of 40.”

There are some important differences between the disease in children and in adults. “In adults, we always look for an underlying malignancy or tumour, which is rare in children,” said Sawhney. “Second, antibodies detected during blood tests may indicate different conditions in adults and in children. A particular myositis antibody in a child would indicate that she would have a serious skin disease, while the same antibody could suggest a higher incidence of an underlying malignancy in an adult.”

The study on the disease is limited in India. “We do not seem to have registries to record these kinds of diseases,” said Dr Joe Thomas, rheumatologist, Aster Medcity, Kochi. “A specialist rheumatologist should be approached for treatment. Other specialists such as paediatricians and neurologists may not be aware of the complete treatment protocol. Also, by switching to alternative medicines, the initial phase of treatment itself becomes improper, which can lead to long-lasting complications.”

The disease is sometimes found in toddlers, too. And it is difficult to diagnose as they may not complain of any symptoms. In such cases, diagnosis is done by observing their activities.

“In most cases, skin rashes are the only visible symptom,” said Balan. “With the use of mild steroids the symptoms will subside; but that is the hidden danger. The net result would be a delay in diagnosis. In extreme cases, the disease can affect other organs. Last year, we lost a child whose pancreas had been severely affected. Now we have an 18-month-old on ventilator with severe muscle weakness.”

In cases where skin issues and muscle weakness occur simultaneously, it gets easier to diagnose. However, if the muscle weakness predates the rashes, the disease becomes harder to identify. “The reasons for muscle weakness can be many,” said Sawhney. “The disease being too rare, even experienced paediatricians may go wrong in diagnosis. This, in turn, causes delay in commencing the correct treatment.”

Sometimes, children can also present with rapid lung inflammation, making diagnosis even tougher. Abdominal complaints and convulsions are possible, too. Unusual presentations such as these also delay the diagnosis.

The most important part of any disease management, say experts, is diagnosis. “I had a 16-year-old who overcame the condition with the right treatment at an early stage,” said Thomas. “She was diagnosed in the initial phase of the illness, probably in the first three weeks. Now she is off her medication.”

Perhaps one can take solace in the fact that the disease is rare. One in a lakh children gets it, said Sawhney. “Having said that, our unit has followed up with 80 to 100 children with this condition over the past 20 years,” she said. “Over the years, paediatric rheumatologist centres have been set up across India, and more and more children are getting diagnosed correctly.”

chef-jose-varkey-cgh-earth-prakriti-shakti

Sat Jan 28 18:00:59 IST 2023

The Amazon rainforest has been a keeper of secrets for centuries, holding within its many folds yet-to-be-discovered flora and fauna. A new species is discovered every three days. But it was faeces of the human kind that intrigued Maria Gloria Dominguez-Bello of NYU School of Medicine and a team of researchers when they travelled to the Amazon more than a decade ago. The team visited the village of the Yanomami―a semi-nomadic indigenous tribe that had never been in contact with westerners till then―with the specific purpose of finding poo.

What make the Yanomami poop precious are the secrets it holds about the human microbiome―a brimming community of microbes that thrives in our bodies and determines, among other things, how our immune system reacts to pathogens. That link between the microbiome and immune system probably developed in the gut as it is their favourite hangout. The study published by Dominguez-Bello and Co in 2015 said the Yanomami have the most diverse microbiomes. Microbiome diversity depends on genetics, geography and culture but also on diet. There is little we can do about genetics, geography or culture, so diet is key for a diverse microbiome. And, when she was asked about what food could help the gut microbiome at the Gala Dinner in support of The Microbiota Vault in Singapore, held in June 2022, Dominguez-Bello just had three words. “Fibre, fibre, fibre, she said,” recalls Jose Varkey, corporate mentor chef, CGH Earth. Varkey was the guest chef for the dinner and also a speaker at the event. “We need to constantly feed the gut bacteria,” he said. “But we don’t really feed them. What they need is fibre. But all the processing has removed the fibre from our food.”

They say we are what we eat. But most of what we eat is, as Varkey calls it, “dead food” or “food that bites us back”. What we need is “living food”, like fibre, he says. “Today, food is made according to the convenience of the person who makes it and not really the biological need of the person who eats it,” he says. “Whether it is at home, roadside joint or a five-star hotel, the primary concern is how do we make food that is tasty, and not the nutrition element.”

Varkey cites the example of packaged tomato puree. “What nature put into the tomato is never reaching the gut of the person because what is more important is shelf life, convenience and meeting the acquired taste of today's customer,” he says.

So, at CGH Earth, Varkey came up with conscious cuisine. “There are some 60-odd definitive steps that we follow,” he says. “Jose Dominic (cofounder, CGH Group of Hotels, Resorts and Wellness Centers) said integrity dividend is the only thing that we want, especially with food. Give what is gourmet, healthy and responsible, he said. By gourmet, he meant food that is of the highest quality and by responsible he meant that the food shouldn’t travel much, there should be less carbon footprint; it should be local. It should be beneficial to the community, it should be environment friendly, sustainable. And as much as possible, it should support the local farmers.”

Take, for instance, CGH’s Prakriti Shakti, nestled in the hills of Panchalimedu in Kerala. This premium clinic of natural medicine boasts a fireless kitchen. All you will get here is raw food, but one that is pleasing to the eye, easy on the tummy and a treat for the taste buds. “At Prakriti Shakti, the natural taste, colour, texture, flavour, consistency is more or less kept intact but presented in a very colourful manner,” says Varkey. He and his team have stayed true to Dominic’s philosophy.

But how does one incorporate that philosophy in one’s life? Varkey pulls a few simple tips out of his toque. “Our diet should be 80 per cent alkaline and 20 per cent acidic, but what we eat is just the opposite,” he says. “Everybody knows that we have to have a plant-based diet, but we don't. Even if you do, because of reheating and overheating, it becomes acidic. So, even good vegetarian food becomes negative food if you heat it beyond a limit.”

Food can turn negative right from its source, say, if it is loaded with chemicals. While we cannot do much about the chemicals that are injected into food these days, Varkey says it is essential that we soak and wash store-bought fruits and vegetables in salt or turmeric water. But the most important thing to do, says Varkey, is minimum cooking. By that, he means cooking the vegetables for a shorter duration and preferably only once. He would like you to have the vegetables raw (he usually does), but you can have them with gravy. The gravy can be refrigerated and reheated when required, but not the vegetables. Here’s Varkey’s way of cooking veggies: cut vegetables, add them to the gravy, cook them a bit and done. That is opposite of the current burnt food culture, which Varkey explains thus: you heat up the oil, fry onions, put masala powder, stir it until you get the aroma of the masala and then you start cooking. “You are already killing the food because you have burnt the spices, the onions and heated the oil that was never meant to be heated,” he says. But that means we need to redefine and rework the way we cook food. What it essentially means is, “we must recondition our taste buds,” says Varkey.

when-billionaires-face-burnout

Sat Dec 24 17:26:28 IST 2022

Pawel Mowlik knows exactly what burnout is. As an international financier working in hedge funds, he was making millions of dollars a month. But by the age of 24, his life was wildly out of control. “Private jets, yachts, parties, going days without sleep... and also constantly working,” he says, reliving his memories with characteristic intensity. “I developed a lot of unhealthy habits: alcohol, cocaine, sedatives.”

For years he had no off button. Then his body and brain found their own. “I developed a kind of depression; there was no satisfaction in my life,” he says. “But how to stop? I knew I couldn’t do it on my own. I just wanted peace.”

Like many of the super-rich, Mowlik learnt that while from the outside life can look like the pinnacle of success, on the inside it can feel like a pressurised nightmare. And the higher you go, the worse the pressure gets and often the greater the crash, imperilling not only individuals but often corporations and dynasties.

The term burnout (taken from New York’s drug-addict argot) was first used by Dr Herbert Freudenberger to describe care workers suffering exhaustion, headaches, stomachaches, insomnia and breathing troubles as a result of overwork. By the eighties, Christina Maslach, a psychology professor at the University of California, Berkeley, had developed a burnout score around three criteria―exhaustion, negativity about work and falling performance―and doctors reported links to strokes, heart attacks and haemorrhages.

By 2014, scientists at the Karolinska Institute in Sweden had reported finding a change in the brain of those suffering from burnout, caused by the enlargement of the amygdala, a region that processes fear, anxiety and aggression. This, Carmine Pariante, professor of biological psychiatry at King’s College London, says is because “the amygdala, which puts you into fight-or-flight mode, becomes hyperactive and keeps telling you you’re in danger. Thus it can become enlarged.”

Medically defined as a process rather than an illness, burnout is often the result of prolonged and relentless stress, during which a person has to stifle their true emotions to keep going, says Dr Rachel Sumner, a psychobiologist at Cardiff Metropolitan University who is conducting a study on 1,700 people’s experience of burnout while working through the pandemic.

“It usually starts with emotional, psychological and physical exhaustion caused by work and life stresses that mean you feel you can’t get through the day,” she says. “This can lead to a sense of inadequacy or inefficacy where no matter how hard you try, you can’t feel that you’re getting enough done, you’re failing. Then comes the chronic cynicism, where people lose hope about life and work, and become suspicious of those around them. This creeps into all aspects of their lives.”

Substance misuse is a common symptom of burnout, Sumner says, particularly among high-flyers “as a coping strategy―to try to escape after all other coping strategies have failed. Clearly it’s maladaptive and harmful. But they distract from stressors that are causing psychological pain, by squashing down feelings or numbing them out entirely.”

One of the most effective ways of dealing with burnout, she says, is “taking a period of time away from their situations, re-evaluating what causes the stresses and how they can better deal with them”. The problem, as Mowlik discovered when he sought help in two traditional rehab clinics in Florida, was finding places with the right treatments. In rehab clinics, he says, “I didn’t have anything in common with the other people. Some were there because courts or probation officers had told them to go.” Which explains the arrival in the past ten years of a number of discreet clinics specifically created to put broken modern titans back on their feet, such as the Paracelsus Recovery clinic, outside Zurich, to which Mowlik turned in 2014.

With its immaculate white walls, its private chefs and maids, its 24-hour live-in personal therapist and clinical nurse, this was a place, Mowlik says, where at last he felt safe. Having planned to stay for only a month, he ended up there for three. Key to helping him change, he says, was the close relationship he developed with his therapist. “We would take lakeside walks and I would share everything with him,” he says.

The clinic was started by Jan Gerber, its chief executive, ten years ago when a family friend sought help for the chief executive of a listed company who was drinking heavily because he was burnt out. “But he knew that the share price of his company would collapse if his treatment became public,” Gerber says. “My dad is a psychiatrist and my mum a clinical nurse specialist, so we had him stay in our living room, and realised that there was a niche clientele here with real needs.”

Today Paracelsus treats up to 40 clients a year. “Burnout is becoming more prevalent as companies grow larger and the world of business becomes ever more complex,” Gerber says. “As people move at ultra-high speed in an increasingly fast-paced world, they become less fulfilled and may reach a tipping point where they’re too exhausted to function. It seems especially common for wealthy high-achievers who may have trouble admitting they’re worn out, or are reluctant to discuss feeling frustrated and hopeless.”

Because Paracelsus treats only one client at a time in a separate residence, no two clients meet. The environment is strictly controlled. “For psychotherapy to work, their stress triggers need to be minimalised,” Gerber says. “They need an environment to which they are habitually accustomed. But we also need to be close to nature; that’s crucial. We couldn’t do this in downtown New York.”

What the clinic isn’t, he insists, is a holiday destination for the tired and wealthy. “Almost everyone comes to us in crisis. The self-narrative of high-achievers is that burnout only happens to other people. But untreated it can lead to self-medication, compulsive behaviours, gambling or sex addictions.”

Although ideally their clients need to take several months off, Gerber says, “for some that would mean losing everything. So sometimes we can allow them to spend hours working while also undergoing therapy. We have had people appear on Bloomberg financial TV from the clinic as though they were working normally.”

At most clinics, the curative model is based around regimes that include psychotherapy, physical exercise, therapeutic surroundings, bespoke dietary supplements and healthy regimes. But not all are clinical nor are all the therapists trained doctors. At Istana bespoke rehabilitation, the thirty-something Agathe Fay looks precisely like how any burnout sufferer wants to feel again: bright-eyed, healthy, energetic, enthused and purposeful.

She leads the teams providing complementary therapies on clinics sited on Ibiza, Bali and Barbados, teaching meditation, yoga and Pilates, as well as hanging out and surfing. In people with burnout, she explains, there’s “an underlying feeling of ‘not-enoughness’and perfectionism, in an environment where there’s a lot of productivity and a lot of noise. It’s really hard to unplug from the cycle that you’re in. Here we help to disconnect and slow down.”

Training people to try new kinds of exercises and learn new ways of enhancing their wellbeing can be viewed by patients with cynicism, she says. “But most recognise they need to invite in other perspectives because their own ones aren’t working for them any longer.” Surfing, for instance, is an ideal way to try to help people disconnect, Fay says. “It’s fun and healing and meditative. Burnout often affects people who feel they need lots of control. You can’t control the waves.”

Ian Ross-Smith, the director of Istana Jiwa and a former heroin addict, has seen exponential growth in burnout patients and says that he never knows what they are going to get until clients arrive. “Some just fall off the plane completely drunk,” he says. “Others are often on Valium and Xanax. But taking out the drug leaves a black hole, so part of the therapy is to get people to rediscover old passions, find new ones and learn to have a laugh again because they probably have been miserable for years.

“We save lives,” he adds. “Most come for just a month, but the transformation―because it’s one-to-one―is extraordinary. We like clients who come with a serious problem and require all of our resources, so that the whole team can flex their muscles and do their work. We love it when clients are fully engaged and willing. It is a privilege to provide a completely customised service and watch the magic happen.”

What happens afterwards is also crucial. Clients usually stay for six to eight weeks at the Kusnacht Practice, Lake Zurich, and before they leave, their post-stay care is meticulously mapped. “Preparing for discharge begins on the client’s first day, so that what happens in here can sustain long-term changes in the real world,” says Dr Laszlo Urogi, Kusnacht’s head of psychiatry, psychotherapy and relapse prevention. When clients return home the continuing-care team goes with them. “In general it’s several months of very intensive aftercare, teaching people how to cope better with stress and have a better life-work balance, to be more compassionate and get in touch with their true self,” he says.

“Initially a live-in companion gets clients to stick to their schedule: waking times, walks, having meaningful conversations, not eating alone and so on. Later the client has to be their own therapist, or be helped to build their own support structures. The aim is not to help someone lifelong.”And if things go wrong, “we don’t panic,” he says. “Sometimes we have to learn to try again.” To help to maintain recovery, Kusnacht can send chefs to teach clients’own staff how to cook specific food and produce only healthy meals. They can also prescribe individualised supplements and even hormone replacement therapy.

At the Balance clinic, which has luxurious private residences in Mallorca, London and Zurich, clients are even offered electrical stimulation of the brain, using approaches called neuromodulation and neurofeedback. Abdullah Boulad, the clinic’s Swiss-Lebanese chief executive, explains that these “support the brain to re-learn and to stop using the damaging pathways of response that it has built through chronic stress and depression”.

Meanwhile, Beran Parry, who styles herself a doctor of natural medicine at the New Life Clinic in Marbella, explains how she analyses clients’ blood, DNA and gut microbiome for deficiencies that may be treated by natural supplements including ayurvedic herbs. She is also investigating psychedelic plants as a way of accelerating recovery.

Few of these approaches are embraced by conventional medicine. Supporters would say they are ahead of the curve; critics would call them placebo at best. However, placebos can be powerful. And research has shown that the more people pay for an inactive placebo pill, the more likely they are to report benefits.

For Mowlik, the relationship with Paracelsus Recovery has grown rather than ended. “The yoga, the acupuncture, it all opened up my brain receptors, making the psychotherapy more effective. Physically they turned my diet around, and mentally I had a lot of time to sit and think through the insights I had gained. My sleeping improved, my anxieties lowered, I did not feel exhausted.”

In fact, he was so impressed with how the clinic turned his life around that he has become a co-owner and managing partner. His job now includes picking up every new client personally. “It’s my way of saying that we care. I understand how crucial it is to give clients a feeling of protection, safety, sanctuary―a home.”

HOW TO KEEP BURNOUT AT BAY

1. CHANGE YOUR THINKING

Adopting a simple mindfulness practice, taking regular pauses to reflect on how you’re feeling, physically and mentally, can make a crucial difference. This cultivates self-awareness so one can catch himself quickly when he is starting on destructively negative thoughts or actions, and remind himself that he is not going down that pattern again.

2. MAKE A FRIEND

It is vital to have close human connection every day. That involves having meaningful conversations with others and making a habit of not eating alone. A Dutch study in The Journal of Psychology in 2016 found that people rate having a close friend among their colleagues as the best burnout-beating morale-raiser of all.

3. EXERCISE DAILY

Medical trials show that taking a 20- to 30-minute walk a day is as efficient as antidepressants in keeping depression at bay," says Dr Antoinette Sarasin Gianduzzo at Kusnacht. “A few focused daily exercise habits or rituals are an efficient way to go forward and rebalance your work, life, mind and body.”

4. BE GENTLY REALISTIC

Keeping physically healthy is a proven burnout preventive, but creating perfect rules for diet and drinking is a recipe for miserable failure. Instead, your changes should be realistically sustainable and fun. Simple things such as never snacking and sticking to drinking only sociably can make a huge difference.

living-with-hypothyroidism

Sat Dec 24 15:28:48 IST 2022

ROHINI, 35, was experiencing weight gain, tiredness, dry skin, hair loss and joint pain. Like so many others, her hectic schedule made her put off her annual health checkup. When her condition started to deteriorate, she went for a checkup and found that her cholesterol levels had increased, and that she had developed hypothyroidism and high blood pressure. Hypothyroidism may lead to a disturbance in the metabolic system resulting in unintentional weight loss/weight gain, fatigue or irregular heartbeat. If not treated on time, it can lead to cardiovascular symptoms like the slowing of heart rate, constriction of blood vessels, increased blood pressure and cholesterol levels, retention of fluid and oedema.

Hypothyroidism is a common condition where the thyroid does not create and release enough T3 (Tri-iodothyronine) and T4 (thyroxine) into the bloodstream. The gland’s hormone production slows down which, in turn, slows your metabolism.

Age affects the likelihood of getting hypothyroidism; more older people have it than youngsters. According to NHANES III (National Health and Nutrition Examination Survey), the overall prevalence of hypothyroidism is 4.6 per cent globally. In India, it is 11 per cent, compared with only 2 per cent in the UK and 4.6 per cent in the US. Compared with coastal cities (Mumbai, Goa, and Chennai), land-locked ones (Kolkata, Delhi, Ahmedabad, Bengaluru and Hyderabad) have a higher prevalence (11.7 per cent vs 9.5 per cent).

When the thyroid produces less hormone, you may experience symptoms like fatigue, loss of energy, weight gain, intolerance to cold, dry skin, hair loss, pain in joints and muscles, depression, emotional stress, mental impairment, impaired memory, inability to concentrate, constipation, disturbed menstrual cycle, sexual dysfunction, nerve entrapment syndromes, blurred vision and fullness in throat.

The diagnosis of hypothyroidism is based on the symptoms and results of blood tests that measure the level of TSH, or the thyroid-stimulating hormone. TSH tests are the most accurate screening method for primary hypothyroidism and are widely available. A low level of thyroxine and high level of TSH indicate an under-active thyroid. That is because the pituitary gland produces more TSH to stimulate the thyroid gland into producing more thyroid hormones. Further tests may also estimate the total thyroxine (T4) or free thyroxine (FT4) in the body.

Hypothyroidism is generally a life-long condition. It is important that patients take their prescribed medication and do regular thyroid tests and follow-up visits with their doctor. Many patients are afraid that taking thyroid medication all their lives may adversely affect their organs, especially the heart and bones. They should be assured that life-long intake of thyroxine in hypothyroid patients is a natural replacement of the deficient hormone. If given in optimum quantities as prescribed by the physician, it does not affect any organ, but rather improves the patient's quality of life. Patients are also concerned about fertility issues; they should know that these medicines do not cause any harm but rather help in the successful pregnancy of those with thyroid disorders.

Along with medication, a few lifestyle measures can improve the way your immune system functions, and can help control the symptoms of hypothyroidism. Regular exercise can relieve stress, reduce symptoms of depression, and help maintain a healthy lifestyle. It releases endorphins―feel-good hormones―that help one feel physically and emotionally better. Meditation can help one attain mental peace.

The longer hypothyroidism is left untreated, the less the body is able to cope. A severe case, along with precipitating factors like cold weather and infections, can cause myxedema. Usually, it takes years for hypothyroidism to deteriorate into myxedema, which is now rare in developed countries.

Iodine is a crucial nutrient for the body, and since thyroid function depends heavily on iodine, those who consume it insufficiently may also experience hypothyroidism. Adequate iodine intake aids in the proper regulation of the thyroid gland. Good sources of iodine include iodised salt, dairy products like milk, yoghurt and cheese, and seafood like fish, shrimp, tuna, and seaweed.

Vitamin-B complex, selenium and other trace elements play a vital role in hormone production and the overall wellness of the body. Cruciferous vegetables and soya-based dietary products should not be consumed in high quantity.

―The writer is senior director and head, department of endocrinology, BLK Max Hospital, Delhi.

indian-company-developing-an-eye-drop-to-replace-reading-glasses

Sat Dec 24 15:26:09 IST 2022

Only a few people are lucky enough to embrace their 40s without reading glasses. Wearing glasses, however funky they are, can be a real hassle. For one, they make you look older when you are constantly googling ways to look younger and cooler. Forget about the spectacle marks that come along the way. More embarrassing are the emotional scars of being mocked for searching for your spectacles while wearing them.

Why do we develop presbyopia―the loss of near-vision―as we age? Dr Virender Sangwan, director, innovation and faculty in cornea at Dr Shroff’s Charity Eye Hospital, New Delhi, explains: “Our ability to read fineprint reduces as we approach the age of 40. Presbyopia occurs when your eye lens, also known as crystalline lens, becomes harder as part of the natural ageing process of the eye.” This results in the eyes losing the ability to focus on nearby objects. The simple solution for presbyopia is to use corrective glasses, he says. “But most people find it difficult to adapt to the change, especially if they are not used to wearing glasses,” says Sangwan.

Now, 40-somethings have a reason to rejoice. PresVu eye drops, being developed by Entod Pharmaceuticals in Mumbai, could offer them freedom from reading glasses. The drops will be commercially available next year. “One drop of PresVu in each eye improves near vision in about 15 to 20 minutes,” Nikkhil K. Masurkar, CEO, Entod Pharmaceuticals, tells THE WEEK. “It can give sharper vision for six to 10 hours.” PresVu is useful for people with mild to moderate presbyopia. “It reduces the size of the pupils,” adds Masurkar. “Manipulating the size of the pupil helps to manage near-vision problems.”

Could using the drops every day mean unwarranted exposure to chemicals? “There are no chemicals in it,” says Masurkar. “The safety of the drops has already been established. It is not a new molecule. The drops have to be used every day,’’ he says. “We have finished development and are in the process of applying to the DCGI (Drug Controller General of India). Safety studies have been done. We are confident that we will get the DCGI approval. The process may take six months.”

Eye drops that can replace reading glasses is a dream come true for Benezer Lhouvum, a 26-year-old master's student in Bengaluru. Lhouvum, who hails from Manipur, is sick of having to remove his spectacles while swimming, playing football or taking a shower. During the pandemic, he had trouble wearing his mask without fogging his glasses. Nonetheless, he wonders how safe these drops are. “I might still go for LASIK (laser surgery which reshapes the inner cornea to correct vision) instead of PresVu,” he says.

Meera Nair, who is in her mid 40s, shares Lhouvum's concerns. She finds the idea of the eye drops exciting, but she would hesitate to use them instead of reading glasses.

Masurkar, however, reiterates there is no cause for concern. “The drops are based on a molecule called pyrocarbon, which has been used in the treatment of sepsis in the US for a long time,” he says. “The only problem with pyrocarbon is that everyday use is not an option. So, we optimised its strength and brought its Ph value close to tears. Our R&D has been working on these drops for four years.”

PresVu does not help farsightedness (hyperopia) or nearsightedness (myopia). According to Dr Rohit Shetty, consultant, cornea and refractive surgery, and vice chairman, Narayana Nethralaya, Bengaluru, the drops work best in people with presbyopia, belonging to the age group of 40-45. Older people would need high-power glasses.

Clinical trials will be waived for PresVu in India as the molecule has already been studied in the west, says Masurkar. “That being said, we will be doing an additional trial,” he adds. “Even post-approval, we want to carry out more studies in India. We are planning a multi-centric study in India which will cover a large number of patients. It will involve private and government hospitals. We are yet to decide on the sample size, but it should be around 3,000 patients. We have completed toxicology and animal studies, and all the required preliminary studies.” Entod plans to manufacture PresVu under the Make in India initiative.

However, it is a matter of concern that not many studies have been done on the effect of the drops on the Indian population. Caucasian and Indian eyes differ in size. “Indian pupils are smaller,” says Shetty. “Average pupil size can range from 1.5mm to 7mm. The average Indian pupil size is between 2.5mm to 3.5mm. People in the west typically have bigger pupils ranging from 6.5mm to 7mm. The study done was on larger pupil size. The effect of the drops on smaller pupils is yet to be studied, considering the drops are going to make our eyes even smaller. As far as I know, it has not been studied.”

He adds that when the drops make the pupils smaller, it could result in increased sensitivity to light and headaches. “Some people may experience difficulty in driving or lose some amount of distance perception,” he says. Taking all these into account, Shetty says the drops should not be sold over the counter. “There are even instances where unsupervised drops led to retinal detachments in patients with preexisting diseases like glaucoma,” he says. “It is important that your ophthalmologist goes through your records. The drops may not be suitable for everybody.”

Masurkar says the raw material to make the drops is not easily available in India, but adds that the cost “should be economical”. “It will be affordable for someone to buy it on a monthly basis,” he says. “It should be cheaper than spectacles, if you take into account the cost of the glass, the frame and having to replace the frame.’’

what-is-the-gender-pain-gap

Sat Dec 24 15:23:24 IST 2022

Australia will set up a National Women’s Health Advisory Council to deal with gender pain gap. Women experience more chronic pain conditions than men, but studies show that their pain is often downplayed or under-treated by health care providers. A gender pain gap report by pharmaceutical brand Nurofen says that one in two women who sought medical help for pain was either ignored or dismissed because of gender.

Health experts say that the bias against women’s expressions of pain negatively affects their health outcome. A 2018 study analysing journals published in western countries since 2001 on sex, gender and pain revealed that terms like ‘sensitive’, ‘malingering’, ‘complaining’ and ‘hysterical’ were applied more frequently to pain reports from women. In the 2001 paper ‘The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain’, Diane Hoffman and Anita Tarzian say that “women report more severe levels of pain, more frequent incidences of pain, and pain of longer duration than men, but are nonetheless treated for pain less aggressively”.

When women are treated in the exam room, stereotypes come into play. A study last year in the Journal of Pain indicated that when caregivers saw videos of patients in chronic pain, they automatically estimated the women’s pain as lower than that of men. The study said that they were more likely to recommend a psychological treatment to women and an analgesic treatment for men. Interestingly, laypeople also underestimated the pain experienced by women when they were subjected to a similar experiment. In a study on laypeople who watched men and women doing identical rehab exercises, “the perceivers rated the women as being in less pain and more likely to benefit from psychotherapy, while men, they said, would need medication”.

Medical experts suggest that gender-based bias could lead to disasters. For instance, a recent study showed that when women face chest pain, they may face longer delays in getting treatment than men. ‘Gender pain gap’ is a global problem; recently, the expression #medicalmisogyny gained more than 4.5 million views on TikTok. Medical misogyny does not mean that doctors are sexist, but that there is a historic gap in knowledge about women’s bodies and their health.

Now, Australia has become the first country to officially identify the existence of such a problem. Ged Kearney, Australia’s assistant minister for health and aged care, will lead the National Women’s Health Advisory Council. The council will examine women’s biological risk factors for major diseases like cancer and heart disease, disorders such as autism, and other overlooked conditions like endometriosis.

limited-awareness-in-india-about-cardio-oncology

Sun Nov 27 11:49:28 IST 2022

Interview/ Dr Satish C. Govind, chief of non-invasive cardiology, Narayana Institute of Cardiac Sciences, Bengaluru

Q. What happens when you tell the patient, "You have won your battle against cancer, now let us talk about preventing heart disease"?

A. There is usually a sense of relief that the big C has been tamed or can be tamed. When it comes to heart disease and cancer, patients react in different ways. Some are dejected that they may have another battle on their hands, some are not bothered since they think heart disease is a smaller problem to face than cancer, while some get depressed about it as they feel it is another obstacle for which they don’t have the energy and spirit. Additionally, the cost factor also comes into play as some cardiac investigations can increase their financial burden, so affordability also leaves an imprint on their fragile psyche and their battle to survive. But the interesting part is irrespective of their disease or financial background, their individual personality and mental toughness play a crucial role in fighting additional setbacks. Cancer plays havoc on their mental status and a likelihood of heart disease makes matters worse.

Q. What are some of the cancer drugs or treatments that can lead to cardiovascular disease?

A. There are many anti-cancer drugs that are commonly known as chemotherapeutic agents used for different types of cancers. Cisplatin, cyclophosphamide, doxorubicin, epirubicin, capecitabine, 5-fluorouracil, trastuzumab, vincristine, paclitaxel are some of the more prominent drugs. They are grouped according to their mechanism of action, like anthracyclines, HER2 inhibitors and VEGF inhibitors. Most of them have some effect on the cardiovascular system in one way or the other. These effects are seen either due to a specific drug or a cumulative dose or when multiple agents are combined or in those with pre-existing heart ailments.

Q. As more and more immunotherapies are being used for cancer treatment, what are some of the specific cardiac side-effects that can occur during treatment with some of these agents?

A. The side-effects may be overt where they may manifest as breathlessness, chest pain, fatigue, palpitations and swelling of legs. Some drugs cause injury to the cardiac muscle while some cause blood pressure fluctuations. Injury to the walls of the arteries and predisposition to clot formation is also seen, which may lead to heart attack or clots in the veins. Heart failure or myocardial dysfunction is a frequently seen complication which can be of prolonged duration in some patients. Fluid collection around the heart known as pericardial effusion, pulmonary hypertension and arrhythmias are also known to happen. The effects can also occur at a cellular level where overt features mentioned above are absent and these abnormalities are detected only by certain specialised tests.

Q. Does accepting the risks of treatment that might lead to cardiovascular disease mean that cancer patients will have limited ability for things like exercise?

A. Limitation of activity comes into picture only when cardio-toxic effects manifest. ECG and echocardiography are quite reliable in uncovering abnormalities of the heart. Normal activity and even increased physical activity should not be discouraged. Constant monitoring of symptoms and specific tests should be done and any detection of abnormal findings or onset of cardiac symptoms should be a red flag to limit activity, especially exercise. Early detection using newer and more sophisticated testing may reduce risk of progression of cardio-toxicity.

Q. What are the warning signs that cancer patients should watch out for and report during and even after treatment?

A. Sudden onset of chest pain, increasing fatigue, a new feeling of shortness of breath, unusual palpitations especially a feeling of irregular heartbeat and swelling of legs or dizziness should be immediately brought to the attention of the doctor.

Q. How aware are people in India about cardio-oncology?

A. There is limited awareness about cardio-oncology. This is not just among the general population, but also among the medical fraternity. Dedicated cancer hospitals are more likely to have such focused approaches, but unlikely to be seen in other hospitals. It is still a nascent field and yet to gain visibility and the importance it deserves. It is only in the past few years that we are seeing a few scientific sessions dedicated to cardio-oncology at medical conferences. But it is still far and few. In Europe and the US, there are dedicated societies which are gaining prominence, but India is yet to reach that level. The professional skills of specialists in managing these niche patients are of very high standards, but a dedicated focus can definitely take patient management to the next level. Decreasing cardiac morbidity, mortality and improving quality of life is the aim of this focused approach. Prevent, detect and treat are the key objectives. With more and more cancer hospitals being opened hopefully this gap will be addressed and in the next decade we probably shall reach a level where such goals will be achieved.

―Priya Menon is host and producer of CureTalks, an international online talk show discussing medical breakthroughs, research and treatments.

cardiovascular-mortality-risk-in-cancer-patients

Sun Nov 27 11:51:10 IST 2022

Ramya was having a particularly good day. After fighting breast cancer with chemotherapy and surgery, she had it under control. She believed she was through the worst. But the reports from the doctor later that week brought up new concerns. Her heart was getting weaker, and it was due to the potentially life-saving drug that she was taking to prevent the cancer from spreading. Her medical team stopped the drug. Presently, Ramya is waiting to see if her heart will get better so that she can resume the drug. This could damage her heart all over again and so she and her family have to decide if they want to take the risk.

Thousands of cancer patients are confronting similar dilemmas because their treatment may also cause heart problems, either immediately or down the road. Women like Ramya face a tough choice: stay on a miracle drug that might damage their heart, or stop the drug and risk having the cancer spread.

Cancer patients have a 2–6 times higher cardiovascular mortality risk than the general population, and cardiovascular mortality is evident throughout the time of cancer care. The number one cause of death in cancer survivors is heart disease and not the recurrence of cancer. This evidence has led to the explosion of a new field of interest―cardio-oncology, in the last decade.

“Cardio-oncology represents the intersection between heart and cancer. We know that both traditional and new therapies of cancer can have adverse effects on the heart. We are seeing that people who live longer with their cancer or in some cases are cured have heart disease because of the effect of the drug or since heart disease is the most common cause of death globally. But we have to recognise there are new issues after the cancer treatment, and that the risk is much greater than in the general population,” says Dr Javid Moslehi, chief, cardio-oncology and immunology section, UCSF (University of California San Francisco).

A small section of the field of cardio-oncology is dedicated to diagnosing and managing primary or secondary tumours of the heart. A majority of the field focuses on cardio-toxicity from radiation therapy, chemotherapy and immunotherapy. While anthracyclines (a class of drugs used in chemotherapy) are frequently associated with heart disease, a myriad of new chemotherapy and immunotherapy drugs have shown diverse cardiovascular effects. Not only can people develop cancer treatment-related cardiac dysfunction (CTRCD)―the decreased ability of the left ventricle to pump blood effectively, which may lead to heart failure―they can also develop any number of other heart problems including hypertension, arrhythmia, inflammation of the pericardium (the sac-like membrane surrounding the heart) or progressive coronary artery disease.

In some cases, the dangerous effects are spotted quickly. But they can take decades to surface, as seen in survivors of some childhood cancers. Paediatric oncologists began sounding the alarm 20 years ago, when they saw heart problems among patients who had beaten cancer as children. Although modern cancer treatments for children, such as chemotherapy and radiotherapy, have improved over time and are now often given in lower but still-effective doses, new and long-term survivors should know about the possibility of what’s called “late effects” of treatment.

In addition to children, women and adults aged 60 and above are considered at higher risk for cardio-toxic side-effects. The following health concerns are associated with the development or worsening of cardiovascular disease in general and may dramatically increase the risk of cardiac injury from cancer therapy:

◆ Smoking

◆ Diabetes

◆ Hypertension

◆ High cholesterol

◆ Obesity

◆ Pre-existing heart problems These cancer therapies are associated with cardio-toxic side-effects:

◆ Anthracyclines (chemotherapy)

◆ Trastuzumab (breast cancer medication)

◆ Checkpoint inhibitors (immunotherapy drugs)

◆ High-dose chest radiation

◆ Some targeted therapies such as tyrosine kinase inhibitors

Catching cardiac problems that arise early is key. Cardio-oncologists can implement strategies to prevent certain cardiac conditions from becoming worse. In some cases, they can even help heal prior damage.

Pratap had Hodgkin’s lymphoma, cancer of the lymph-node system, when he was in his late 20s. He had radiation therapy along with chemotherapy to control his cancer. Thirty years later, doctors found problems with two of his heart valves and he is scheduled for surgery. Pratap’s cardiologist says his heart problems are the result of radiation he received 30 years ago. The radiation caused scar tissue to form, making the heart valves rigid.

As the numbers of survivors grow, so does the number of patients living with late effects of cancer-related cardio-toxicity. For example, among Hodgkin's lymphoma patients who have received radiation, cardiovascular disease is a major cause of death. Many cancer patients are vigilant about getting checked for cancer, but ignore potentially greater risks they face with their heart.

Over the last decade, the awareness that cancer care can directly result in cardiac complications is growing, as is the understanding that patients who have survived cancer have an increased risk of dying from heart failure, coronary heart disease and stroke.

Unfortunately, within cancer centres, allotment of resources towards cardiovascular evaluation and testing may not be seen as a priority. With evidence mounting on the link between cancer survival and cardiovascular disease, it is essential that a priority be placed on incorporating cardio-oncology specialists into the cancer care treatment model.

Some patients beset by cancer and heart issues manage to survive both. Meena, 48, with a history of lymphoma, had received a cardio-toxic drug―doxorubicin (also known as adriamycin)―about 20 years ago for breast cancer. She needed to use this medication a second time in order to cure her lymphoma. Her heart function was already abnormal, likely because of the earlier treatment with doxorubicin. Her oncologist consulted a cardio-oncologist because there was concern that her heart function would worsen with further doxorubicin treatment. She was recommended cardio-protective medications and cardiovascular management during cancer therapy. She was followed closely and was able to safely make it through her lymphoma treatment. Now, five years later, she remains alive and well, with heart function that is mildly abnormal but very stable.

Given oncology’s fast pace of cancer care and changes in treatment paradigm, it is imperative for oncologists to work closely with subspecialists and keep abreast of the most current information, data, potential side-effects and updated screening protocols that may impact patients.

Because of improved cancer screenings, early detection and screening, people are living longer after a cancer diagnosis; and increasing numbers of patients are cured of their cancer. With further improvement in cancer therapy, this number will continue to increase in years to come. Cardio-oncology needs to be a universal subspecialised group of physicians in all health care organisations and medical institutions. The need is growing. The availability of solutions needs to grow at the same pace.

―Priya Menon is host and producer of CureTalks, an international online talk show discussing medical breakthroughs, research and treatments.

10-ways-to-boost-hormone-health

Sun Nov 27 12:02:13 IST 2022

Dr Nicky Keay is on a quest to get us better acquainted with our hormones. We need to nourish and nurture them, exercise to enhance them and limit the kind of “extreme lifestyle habits”―by that she means too much drinking, too little activity and too many faddy diet practices―that hamper our hormonal health. “We each have hormones working magic inside us,” she says of the body’s chemical messengers. “And they have these powerful and far-reaching effects on every single system in the body―the brain, the reproductive system, muscles and bone―yet most people have little idea how to harness their hormones to benefit well-being.”

A prolific author of dozens of published clinical papers, Keay offers advice that is grounded in sound science. It was after studying medicine at Cambridge 30 years ago that she became interested in exercise endocrinology, which looks at the hormonal response to exercise, and started working with elite athletes and professional dancers at St Thomas’ Hospital in London, where her research was supported by the International Olympic Committee. She studied how intense training coupled with often restrictive diets affected hormone balance and impacted susceptibility to injury and illness.

Now an honorary clinical lecturer at University College London’s school of medicine, she contributes regularly to the British Journal of Sports Medicine and has written a book, Hormones, Health and Human Potential, which she hopes will empower all of us to achieve better hormonal health. “Your hormones will do their utmost to maintain balance within your body, but if you are challenging them with too many extreme or detrimental lifestyle habits, their job becomes impossible,” she says. “Making even one small lifestyle change could be the tipping point to improved health and longevity. My message is to do the best you can for your hormones.”

Exercise at the best time

Working out is generally good for you whenever you do it, Keay says. “Physical activity increases the sensitivity of body tissues to key hormones that help us deal with stress. It also harnesses hormones that improve metabolic, skeletal and muscle health.”

However, certain times of the day are more hormonally suited to rigorous workouts than others. “In theory, the morning release of the stress hormone cortisol might be expected to help with exercise,” she says. “Intense exercise later in the evening has been shown to disrupt sleep patterns, which has a negative effect on hormone secretion patterns at night.”

In studies on athletes, their best performances tend to be in the early evening, “a time that matches the most favourable hormonal milieu”, although Keay says there might also be subtle differences in hormonal responses to exercise for men and women. “In one recent study that looked at the effects of exercise timing it seemed that, for women, exercising in the morning helped to prevent the dumping of fat in the abdominal area, the worst place for it to settle, while early evening exercise was more beneficial for improvements in muscular strength.”

Do resistance exercise three times a week from your forties

From middle-age onwards muscle mass starts to decline, a process known as sarcopenia. “It happens because of a gradual drop in sex steroid hormones and growth hormones,” Keay says. “The good news is that even as we get older muscle remains responsive to mechanical stimulus in the form of resistance exercise, so we can slow these losses.”

To compensate for lower hormone levels from your mid-forties you will need to be diligent with resistance training and do it three times a week. “You can lift weights if you want to, but Pilates and resistance bands are an option, as are exercises that involve using your own body weight, such as push-ups and squats,” Keay says.

Our bodies respond to any type of resistance training by producing more anabolic or “body-building” hormones such as IGF-1 and testosterone, a powerful anabolic steroid. “It is when higher levels of these hormones circulate that greater beneficial adaptations occur such as improved muscle and bone strength,” says Keay. “Because it recruits so many muscle fibres, resistance exercise also helps to increase our metabolic rate, which stays raised even after stopping a workout.” The result is greater fat-blasting and more calories burnt.

Avoid alternate-day fasting

Hormones rely on regularity of meals to remain in equilibrium. And Keay says that alternate-day fasting or the 5:2 approach has the potential to cause hormonal disarray. “Any kind of stop-start diet or extremes of eating really confuse the hormones and their biological clocks,” Keay says. “Fasting on some days but eating normally on others causes circadian misalignment, which is just very bad for our hormones as they struggle to adapt and maintain some sort of balance.”

We are naturally designed to have one overnight fast and extending that so that you don’t eat late in the evening―such as the 16:8 approach―won’t cause disruption provided that you stick to it. But, eating regular meals is important. “Our hormones need feeding and the message is that eating in a consistent manner will help to maintain optimally functioning hormonal networks,” Keay says.

Men: extreme endurance exercise is unhealthy for your hormones

While a sedentary lifestyle is bad news for hormone health, extreme exercise habits―lots of lengthy cycles, swims or runs without adequate recovery and refuelling―will take their toll on male hormones. “In men who obsessively maintain a high training load that is not balanced by sufficient sleep and good nutrition there can be suppression of the control centre of the male hormone network,” Keay says. “In an attempt to save energy, the body shuts down processes that are less essential, including reproduction and fertility.” Sleep and recovery are an important part of an exercise routine.

Eat apples, leafy greens and lentils

Our gut microbiome plays an important role in hormonal health. “Food and the gut microbiome influence hormones such as insulin, which regulates metabolism and weight control,” Keay says. “The so-called gut-brain axis helps with the regulation of immune and inflammatory responses that determine cardiometabolic health and are also factors in kidney and musculoskeletal health.”

The first step to prepare the gut for prime hormonal health is to eat prebiotic fibrous food. Dark-green leafy vegetables and fermentable fibre found in fruit and vegetables―garlic, onion, leeks, chickpeas, beans, lentils, artichoke and asparagus―are important. “The cellulose found in the cell walls of many of these plants can’t be fermented but does help to keep the gut moving and prevent ‘unfriendly’ gut microbiota from proliferating,” Keay says.

Inulin, found in wheat, onion and bananas, is also particularly effective as a prebiotic. “Once you’ve been eating these prebiotic foods for a few weeks, it’s time to ‘fertilise’ your gut bacteria with probiotics found in fermented foods such as sourdough bread, yoghurt, kefir, sauerkraut, kimchi and kombucha,” Keay says. “The greater variety of these foods the better the outcome for hormonal health.”

Dance and run for strong bones

Bone is an active tissue―about 10 per cent of the skeleton is replaced every year―and its strength is dependent on a nurturing cocktail of hormones. “A lot of hormones, including calcitonin, that are produced in endocrine glands a long way from bone tissue play a part in bone health,” Keay says. “Even gut hormones play a role in calcium absorption and bone turnover.”

Oestradiol, the most active type of oestrogen, is another hormone essential for the bone health of men and women. In men, testosterone is converted to its sister hormone, oestradiol. And the effect exercise has on strengthening the bones is reinforced by growth hormones that flood through the body when we are active. “When it comes to bone-boosting, the ideal exercise is one that involves both changes in direction and some resistance effort,” Keay says. “Dance is great, as are sports like tennis, rugby and football, while running is good for strengthening leg and hip bones and rowing for strengthening the legs and spine.”

Swimming does not load the skeleton in the same way but involves the whole body with muscle pulling on the bone to help with bone strength. “It is not the best for bone health, but neither is it the worst,” Keay says. “As with cycling―another activity that is not the best at bone-building―it is strongly recommended that you add resistance training to your weekly regimen if these are your main forms of exercise.” Too much of any exercise is not good for the hormones that support bone health. “There is a paradoxical effect of exercise on bone,” Keay says. “More is not better.”

Have a banana milkshake after an intense workout

Refuelling after resistance or strength training or any intense or prolonged workout is important. “Combining some protein with complex carbohydrate is a good strategy to replenish glycogen stores and provide some of the nutritional building blocks for hormone-driven muscle repair and synthesis,” Keay says. “A banana milkshake or smoothie is a great way of combining the elements you need.”

For young women, intense exercise and fasting, or failing to refuel after a workout, is a particularly risky cocktail. “It disrupts female hormone network timing and can have adverse effects on female hormone production,” Keay says. “If you exercise hard or long, you need to promptly refuel with carbs and protein afterwards to support healthy hormone networks.”

Drink a glass of milk before bed

Growth hormones produced when you sleep are important for muscle and bone repair as well as metabolism. Provided that you have been active and have eaten well during the day, you can literally get fitter while you are asleep, and you can further support this hormone-driven repair process by taking in some protein before bed.

“A glass of milk is ideal because it contains casein, a protein for providing the building blocks of the hormone-driven process of muscle repair, and tryptophan, a precursor molecule for making the sleep hormone melatonin,” Keay says. “From middle-age onwards, I would recommend taking a small amount of milk or yoghurt every evening.”

Go to bed before midnight

“If you were to push me on the single most important thing you can do for hormonal health, I would have to say it is sleep well,” Keay says. “It’s when you are sleeping that your hormones work their magic of supporting health.

“Studies have shown that going to bed after midnight increases the risk of cardiovascular disease. You also risk missing out on the benefits of the nocturnal secretion of growth hormone, which strengthens muscle and bone.”

Additionally, sleep is one of the key stimuli for the release of luteinising hormone (LH), which increases overnight to support the production of the sex steroids oestradiol and testosterone. “There’s also an increase in leptin, the satiety hormone, during sleep, which prevents you from waking up ravenously hungry.”

Consistency is key, and that means going to bed at the same time each night, waking up at the same time each morning and trying to get at least seven hours if you can. “When we go to sleep impacts the timing of sleep stages such as rapid eye movement (REM) and non-REM sleep. And these stages, in turn, determine when certain hormones are released in the body.”

Keep your bedroom as dark and quiet as possible. “Disrupted sleep interferes with the timed hormonal control of energy balance,” Keay says. “If you have interrupted sleep it can reverse the timing of peak cortisol production from the morning to the evening, which can mean you are more wide awake and the struggle to sleep continues.”

Avoid screens for at least an hour before bed

Dropping light levels at dusk are detected by the body’s central circadian clock, the suprachiasmic nucleus (SCN), which is located in the hypothalamus part of the brain. “When this happens, the SCN prompts the pineal gland located deep in the brain to release the hormone melatonin, which prepares us for sleep by lowering body temperature and blood pressure,” Keay says. “Looking at the screens of any electronic devices late in the evening, but particularly just before bed, sends false signals to the SCN to delay melatonin release, which is why so many people find it difficult to fall asleep after reading their phone or tablet in bed.”

kangaroo-care-asap

Fri Nov 25 19:13:16 IST 2022

An estimated 1.5 crore babies are born prematurely (less than 37 weeks of gestation) each year. This is more than a tenth of all births worldwide. Around 45 per cent of all children who die before the age of five are newborns, and more than 60 per cent of these are preterm and/or low-birthweight infants (under 2.5kg).

A lot depends on where these preterm babies are born. Studies show that most babies born at or after 28 weeks in high-income countries go on to survive, whereas, in poorer countries, survival rates can be as low as 10 per cent. Based on 203 studies from low-, middle- and high-income countries, the World Health Organisation introduced new guidelines on November 15 to improve survival and health outcomes for preterm and low-birthweight infants.

These new guidelines include 25 recommendations and one good practice statement. Among them, 11 are new and 14 are updated. One of the most crucial recommendations is that 'Kangaroo Mother Care (KMC)' for preterm or low-birthweight infants should be started immediately after birth. KMC involves infants being carried, usually by the mother, with skin-to-skin contact.

It is observed that a lot of preterm babies have problems regulating their body temperature when they are born. This is because they lack body fat, and they require medical assistance to breathe. The previous recommendation was that there should be an initial period of separation from the mother (of around three to seven days), with the baby first being stabilised in an incubator or warmer. However, based on a study published last year in the New England Journal of Medicine, WHO now recommends that KMC should start immediately after birth, as it would improve survival rate, reduce infections and hypothermia (dangerously low body temperature) and improve feeding. The study found that starting KMC immediately after birth can save up to 1.5 lakh more lives each year. The recommendation is particularly important in poorer regions that might not have high-tech equipment or reliable electricity supply.

While releasing the new guidelines, Dr Karen Edmond, Medical Officer for Newborn Health at WHO, said that during the Covid-19 pandemic, many women were unnecessarily separated from their babies, which might have been catastrophic for the health of babies born early or small. “These new guidelines stress the need to provide care for families and preterm babies together as a unit, and ensure parents get the best possible support through what is often a uniquely stressful and anxious time,” she said.

heart-attacks-increase-in-young-people

Fri Oct 28 17:38:00 IST 2022

Recently, comedian Raju Srivastav, 58, died due to complications post a heart attack. In the recent times, playback singer Krishnakumar Kunnath (KK), 53, died of heart attack after a music concert. Last year, Kannada superstar Puneeth Rajkumar, 46, suffered a heart attack during a workout. The same year, television heartthrob Sidharth Shukla, 40, suffered a cardiac arrest and passed away. All of them were young, seemingly fit, flaunting their abs and broad chests. Yet, they died.

According to the World Health Organization, India accounts for at least one-fifth of the 17.9 million cardiovascular disease-related deaths globally.

In an interview, Dr Devi Shetty, cardiac surgeon, and chairman and founder of Narayana Health, explains the why and how of heart attacks among the young in India. Excerpts:

Do you agree there is a rise in the number of heart attacks among young people in comparison to the pre-Covid days?

We saw an increase in the number of patients who were coming in with blood clots in coronary arteries. It has definitely increased during the Covid period, but we do not have documentary evidence to show that Covid is responsible for a significant increase in the number of heart attacks. There is definitely a marginal increase because of the acute phase of the pandemic. We also saw young people, post Covid, develop heart irregularities, heart-related irritability and weakness. But the good thing is that most of them recovered.

How do you assess an individual's fitness?

I remember a 65-year-old man sitting in front of me with a completely damaged heart, gasping for breath, and proudly saying he never saw a doctor in his life, as if it is a badge of honour. I wanted to tell him that he is in the mess today because he did not see a doctor. There is a common misconception that educated people have―that if one is feeling fit, he or she is fit. But, the reality is how fit you feel has nothing to do with how fit you are. You can stand in front of me and say that I climbed Mount Everest three times in a month. But that does not mean you are fit.

As Indians are we more prone to developing heart disease?

We undertook the study of coronary arteries in close to 30,000 Indians and found that 1.5 per cent of Indians have coronary artery anomaly. They have no blockages, but have a coronary artery that comes from the wrong side and runs between the two major arteries, the aorta and the pulmonary artery. At the time of extreme sports, these can get compressed and the person suddenly drops dead. A tiny percentage of young Indians also have a tendency to develop coronary artery disease. It may not be very significant, but if a 35-year-old man has a five per cent blockage, which is not causing any problem, then he will have to quit smoking, control diet and exercise. If these things are done, progression of the coronary artery disease can be slowed down.

What are the chief cardiac complaints among children?

It is mainly shortness of breath and the bluish discolouration of the fingers. It is primarily a part of congenital heart disease. These are cyanotic heart diseases with heart defects at birth that reduce the amount of oxygen delivered to the body, thereby leading to the bluish discolouration. But there has not been a rise in these cases. Just that it continues to be seen.

Women usually attribute chest pain to high acidity. But is that the beginning of a heart attack?

If any adult Indian―man or woman―complains of unexplained hyperacidity, it should be taken as a problem of the heart unless proven otherwise. Also, always approach the cardiologist before approaching the gastroenterologist. It is the first indication of a serious cardiac problem that can result in fatality. In case of any nagging pain that happens above the belt, one must consider approaching the cardiologist.

At 69, how do you keep yourself going? How often do you get health check-ups?

I am into yoga now. When I was young I was into bodybuilding and martial arts. I enjoy my life and my work. I am a very happy person. I have no stress in life. Like most Indians, I never wanted to get a cardiac CT or any other test done. But my wife told me that she would not let me enter the house without the test reports and I had no choice but to get myself tested. That was a decade ago. One needs to do a CT scan only once in a lifetime. So at my age, if heart disease isn't there, it won't happen. It is very unlikely that heart disease will hit me even after the next ten years. I do the other health check-ups on a regular basis.

dogs-smell-stress-in-human-beings

Fri Oct 28 17:34:01 IST 2022

The human-dog relationship started long ago. Archaeological evidence suggests that dogs were the first animals domesticated by humans more than 30,000 years ago. Now, a recent study published in PLOS states that dogs can detect the physiological processes associated with psychological stress in humans with an accuracy of 93.75 per cent.

Dogs have a remarkable sense of smell. As part of the study, researchers analysed whether dogs could sense the chemical signals associated with a person's psychological state. Samples of breath and sweat from non-smokers who had not eaten or had water recently were used for the study. The samples were collected before and after a stress-inducing arithmetic activity. The study participants were asked to report their stress levels, and physiological measures like heart rate and blood pressure were also collected. The samples from 36 participants who experienced increased stress levels and had reported an increase in heart rate and BP were then shown to trained dogs within three hours of being collected.

As part of the study, researchers trained four dogs of different breeds and breed mixes using a clicker and kibble (a training technique that tells the dog which behaviours are rewarding) to match different odours in a discrimination task. The dogs were then asked to identify the stress sample of participants from a group of samples that contained the same person’s relaxed sample, too. The dogs could detect and show alert behaviour on stress samples in 675 of 720 trials. The study gave proof that dogs can identify an odour associated with the change in volatile organic compounds produced by the human body during stressful situations.

Tumours also produce volatile organic compounds, which are seen in the patient’s urine, sweat or breath. These compounds are thought to have a distinct odour, especially in the early stages of cancer. In the last decade, there have been multiple studies suggesting that dogs could be trained to detect these compounds. Experiments conducted by institutions like the University of Pennsylvania Veterinary School’s Working Dog Center and Medical Detection Dogs in the United Kingdom have shown that dogs can detect breast and lung cancer by sniffing the breath of patients; bladder and prostate cancer by sniffing the urine; colorectal cancer by sniffing the patient’s exhaled breathing and stool samples; ovarian tumours by sniffing the patient’s tumour and blood samples; and cervical cancer by sniffing the patient’s biopsy samples.

A lot of research is happening to develop and perfect sensors and nanotechnology that mimic dogs’ superior sense of smell to detect odorant changes in the cells of cancer patients. For instance, the Israel Institute of Technology’s two types of NA-NOSEs―nano artificial noses to validate the efficacy of devices to detect specific odorants in the breath of cancer patients―are under clinical trial. Similarly, MIT’s Centre for Bits and Atoms is working with Medical Detection Dogs to develop ways to train artificial intelligence to detect odours associated with prostate cancer.

the-kids-arent-all-right

Fri Oct 28 17:30:00 IST 2022

Last month, four-year-old Aditya, from Thrissur in Kerala, did not go to school for 20 days. Persistent cold, acute throat infection and intermittent fever kept the boy at home, making him irritable and restless, says his mother, Sreedevi Menon, a teacher. In Mumbai, Arjun, a 10-year-old student of EuroSchool in Airoli, has been visiting the doctor “every other day” for the past three months, says his mother, Namrata Sharma. He had to skip school for a week because of fever, ear pain and infection. The mother also observed fatigue, reduced focus on studies and exhaustion in her first-born. In Delhi, Tanmay, 11, was hospitalised two months ago because of “aggressive pneumonia,” says his mother, Ritu Khurana. She adds that most of the children in her Paharganj colony have missed out on studies and playtime because of illness.

Numerous cases of hand, foot and mouth disease (HFM, also called tomato flu) in children under six were reported in the past two months in Mumbai, prompting many parents to ask for online classes to limit the spread. A mild yet highly contagious viral infection common in young children, HFM causes sores on the mouth and rashes on the hands and feet. It is accompanied by fever, a sore throat, a runny nose, mouth ulcers and a loss of appetite. In a particular class of the Arya Vidya Mandir school in Mumbai's Bandra Kurla Complex, 20 kindergartners recently were down with HFM at one go, says a parent.

Ever since schools reopened earlier this year, children have been grappling with viral infections, mental and physical fatigue, lack of attention and contagious diseases. “In the past five months, we have observed a surge in infectious diseases among children aged five and six,” says Dr Tushar Parikh, consultant neonatologist and paediatrician at Motherhood Hospital in Pune. “HFM has been the most common, and has more than doubled in Mumbai and Pune compared with 2019.”

Mild infections have increased “significantly” among children, say doctors, adding that the symptoms are showing in “tangible and visible forms on the body”. “There has also been a severe surge in H1N1 or swine flu infections,” says Parikh. “Most children are testing negative for Covid-19, but positive for swine flu. Of 10 children who get admitted in the ICU for high-grade fever accompanied by fits, hardly one tests positive for Covid-19. In a day, I am now consulting 15 to 20 children who show flu-like symptoms and even dengue and malaria. So, 30 per cent of children come with HFM, 30 per cent show flu-like illness, 20 per cent are diagnosed with dengue and the rest with loose motions.”

Khushboo Mehta, a chartered accountant and mother to eight-year-old Anaisha, recalls how her daughter “took months” to return to full health after a bout of Covid-19. “In pre-pandemic times, she hardly fell ill and, whenever she did get a cough or a cold, my home remedies would work like magic,” says Mehta. “But, after Covid, she developed an allergy that refused to go until we gave her antibiotics.”

Doctors are also seeing puberty-related issues, more so among girls. Dr Sudha Rao, head of the paediatrics department at Mumbai's Bai Jerbai Wadia Hospital for Children, says that, post the pandemic, they are seeing breast development―the first stage of puberty―in girls as young as six and seven. “If that happens early, menses also starts early,” says Rao. “Often, parents are unaware of breast development as the first stage. They start panicking only when menses starts. Ideally, it should start around 12. But we are observing these changes very early. We are seeing an absolute increase in numbers, almost two to three times in comparison with 2019.”

She attributes this to children sitting at home during lockdown and putting on weight, thereby leading to early pubertal changes. “It is a known fact, especially in the west where food rich in carbohydrates comes cheaper than food rich in proteins,” says Rao. “Children there are obese and obese girls hit puberty as early as six. That is exactly what is happening here as well. I believe parents must bathe their children often so as to be aware of their physical development.”

The problem with early puberty is that the hormonal changes lead to faster growth and fusion of bones, which in turn hampers the vertical growth of a child. “Bone maturation happens faster, and though children might look tall when they are in their pubertal stage, once they cross menses, the height does not increase much,” says Rao. “They grow only 4cm to 5cm more.”

Obesity is the number one negative outcome of Covid-19 on children, says Dr Shashank Joshi, consultant diabetologist at Mumbai's Lilavati Hospital. “The age group for obesity is mostly adolescence, but now it is also being seen in younger children. In every OPD we have three or four new cases of obesity [every day].”

According to The Hidden Impact of Covid-19 on Children: A Global Research Series published by Save the Children carried out in 2020, the pandemic had a “significant impact on the psycho-social wellbeing of children”. More than eight in 10 children reported an increase in negative feelings and one-third of households had a child or caregiver reporting violence in the home. And now, with things changing suddenly, children are grappling with a mixed bag of emotions coupled with confusion and anxiety to perform well at home, in school and on the playground, say experts. Almost all the parents THE WEEK spoke to seemed to agree that fatigue remains a major post-Covid problem among their children. This has been backed by research, too. In a study published in Frontiers in Paediatrics, fatigue continues to be the most “frequent symptom of post-Covid condition in children and adolescents with percentages varying between 10.8 and 20.1”. Although this is not an India-specific study, experts say that the percentage is “significantly high” here, too. “I can see such a glaring change in my son,” says Namrata. “Earlier, he used to be quite playful but now he is more exhausted than ever. Maybe it has to do with an overwhelming change in routine with school, classes, play, etc, but I don't think this exhaustion is normal.”

Says Neha Kare Kanabar, mother to Vyom and Ved, aged 16: “My twins have become more forgetful and are having problems focusing on tasks. They both take frequent breaks from studies, which was not the case earlier.” Founder of UNIMO (Universe of Moms), a community with more than five lakh mothers on Facebook and WhatsApp, Kanabar says the forums are filled with messages from mothers complaining of frequent headaches and infections in their children.

Shortness of breath and bluish discoloration of fingers among infants is also being seen, say Dr Devi Shetty, founder of Narayana Health, and Dr Supratim Sen, a paediatric cardiologist. But the cases haven't gotten worse post-Covid, they add. “It is the post-Covid inflammatory syndrome that we are more concerned about at the moment,” says Dr Sen. He has published a research paper on the presence of multi-system inflammatory syndrome (MIS-C) among Covid-positive children between eight and 14 from the Mumbai metropolitan area. “This is the new thing we are seeing in a small percentage of children who were exposed to Covid and these children become quite sick. They do recover if treated in time, but Covid does get to them in the form of inflammation of the body leading to skin rashes and high fever and, at times, can also dilate their coronary arteries.”

A cardiologist at AIIMS, who did not want to be named, says he also saw some extremely rare cases, like blood clots in the kidneys of children with Covid. “We had the most unusual cases among children as a result of Covid-19,” he says. “Fortunately, all is well now. We are only witnessing a high incidence in the number of congenital heart defects among infants and that continues to remain an area of concern.”

A large number of pulmonary, behavioural and neurological issues in children top the areas of concern at Kochi's Amrita Institute of Medical Sciences, says paediatrician and medical director Dr Sanjeev Singh. “There are chronic obstructive and restrictive lung diseases that we are observing in high numbers at the moment,” he says. “The second is behavioural changes. Having been cooped up inside the house with limited social interaction, children are facing attention deficit disorder and the urge for companionship is diminishing. Group work has taken a hit.” The third aspect he points out is neurological issues and uncontrolled rise in glucose levels as a result of post-Covid impact or arising out of steroids administered to children as part of self-medication. “Many children are coming to us with antimicrobial resistance,” he says. “Cases have definitely increased lately, post Covid. Because these children were given antibiotic pills for any and every viral infection. Now they are reporting lower respiratory tract infections for which first line antibiotics do not work.”

He talks about two boys he saw recently. “One is nine and the other, six,” he says. “They were going to school and got into a fight. This kind of belligerent behaviour was absent in both during pre-Covid times. But, of late, the issue became hugely concerning because the boys were underperforming at school and their behaviour necessitated therapy.”

Agrees Dr Avinash Desousa, a Mumbai-based psychiatrist. He has seen children who are finding it difficult to adjust to school even when an entire semester is now almost over. “I'm seeing a lot of hyperactivity, academic difficulties and the inability to perform in offline examinations. It is a straight result of the lockdowns.”

He also says that the consumption of pornography among teens has gone up. “I have seen children on their gadgets for over five hours a day,” he says. “They are addicted to video games and play well into the night. It is a very sad state of affairs at the moment.”

Doctors and counsellors are advising parents to spend more time with their children to help them cope with physical, emotional and psychological pressures that accompany a changing world. Says Dr M.R. Lokeshwar, a paediatrician from Mumbai: “Just ensuring that they maintain a healthy diet and an active lifestyle can help alleviate a lot of stress. Besides, it is important that children receive the influenza vaccine and annual flu shots.”

cutting-through-the-noise

Fri Oct 28 17:22:28 IST 2022

‘CARBS are bad’; ‘Not all carbs are bad’

‘Intermittent fasting could lower risk of Alzheimer’s’; ‘Intermittent fasting is not for everyone’

That’s not news you can use; it’s news that will confuse. In the post-truth age, there is no black or white; it’s all grey. So, how do you swipe right on fact amid the doomscrolling?

Rajiv Ambat, CEO and founder of health tech startup NuvoVivo Center for Obesity, Lifestyle Disorders and Research, decided to tackle the (mis)information overload in his book―The Midriff Crisis: A Sustainable & Scientific ‘Medical Fitness’ Approach to ‘Reverse Your Age’. His own fitness journey began when he was at one of his lowest points in life―his edtech startup had failed and he had slipped into depression. He started working out, and at the same time, the bookworm in him also took to reading up on nutrition science, human anatomy and more. The Midriff Crisis brings in his experience and research together to scientifically explain the concept of medical fitness and what it entails. One would expect it to be full of jargon, but Ambat has tried to keep it simple.

The book begins by dissecting oft-used terms like health, fitness and wellbeing. It may seem like one and the same thing, but as Ambat explains they are connected, not similar or interchangeable. What makes this book relevant is the variety of issues it deals with, and in detail―from our obsession with calorie counts and weight loss to fad diets and clean eating. It also has sections dedicated to women’s health, children, Covid-19 and even cooking oil. It also busts a few myths like women should not lift weights and that green tea helps with weight loss. “The only way green tea can help you lose weight is perhaps if you climb the hill to pick up the leaves by yourself,” he writes.

But, as the author writes, the book does not offer solutions to all your lifestyle problems. There are no shortcuts or quick-fixes here. What it does give is direction to figure out what suits your health and fitness journey.

THE MIDRIFF CRISIS: A Sustainable & Scientific ‘Medical Fitness’ Approach to ‘Reverse Your Age’

Author: Rajiv Ambat

Publisher: Notion Press

Pages: 315

Price: 1450

how-a-virtual-reality-game-is-helping-neuro-divergent

Sun Sep 25 15:08:16 IST 2022

Devesh S. often makes exaggerated and abrupt moves while trying to walk. The seven-year-old has athetoid cerebral palsy, a condition caused by abnormal brain development or damage when it is being formed. Devesh has trouble talking, understanding, learning and even walking straight. When he is in the VHAB (virtual habilitation) “game”, though, the boy forgets these struggles. Created by TCS Rapid Labs, VHAB is a digital-assistive tool that combines virtual reality with gesture analysis.

A typical school day for Devesh starts with a physiotherapist-assisted session in front of VHAB. His eyes fixed on a screen—which puts him as an avatar in a virtual world—Devesh does some “simple” moves to pass the initial levels of the games. As he advances, he will face challenges like “kicking coloured balls”, “touching the flares”, “moving with a cart and collecting flowers”, “walking on a line” and “stepping on to a dance floor”.

“Devesh started VHAB games just three months ago, but the change that happened in him is amazing,” says Ambili Francis, a physiotherapist at the Adarsh Rehabilitation Centre (ARC) in Kochi, where Devesh studies. “The frequency of his falls decreased. He has become confident enough to complete complex operations that require good hand-leg coordination. He was impatient in the initial days; he used to be upset over small delays between two levels of the game. But he is more patient now; he pays attention to the instructions.”

Cerebral palsy is the most common motor disability among children. In India, three out of 1,000 children have it. Another neuro-developmental issue that hinders children's learning is autism spectrum disorder. “To retain a degree of independence and control, children with autism and cerebral palsy require regular physiotherapy sessions,” says Robin Tommy, who heads TCS Rapid Labs. “When a neurodivergent child is undergoing physiotherapy, he has to go through a lot of pain. Your brain would always try to reject pain. So, these children often do not want to come to therapy; they just want to be in bed. But the problem is that the more they are in bed, the stiffer their muscles get. So, therapy is a must. We as innovators thought about what we can do to change how physiotherapy is delivered to children. The result was VHAB.”

Francis notes more enthusiasm from children for therapy sessions using VHAB. “Now they keep asking us when their turn will come,” she says. “Once they started VHAB sessions, their cognitive skills also improved. Many of them became more attentive in classroom sessions.”

Tommy, a movie buff, says the idea for VHAB came from James Cameron's Avatar. “In the physical world, the child may be facing a lot of constraints. But, just like in the movie, he feels more power in the virtual world,” he says. “For the child, it is a game with points and levels. But, by moving his body parts, he is undergoing a therapy session.”

Tommy says the aim is also to retrain the brain of neurodivergent children. “The neurogenesis (forming of new neurons) and neuro-plasticity (a process by which the brain rewires to perform new functions) of their brain are enabled so that they will be able to do things they earlier could not. Also, the system knows to what extent a person can [stretch himself]. It is based on this that the system loads the games for each person.”

Adarsh, which began in 1998 as a day care for seven differently-abled children, now trains and rehabilitates more than 500 children with special needs. It provides a range of developmental solutions, including speech therapy, vocational training and several therapeutic activities. Durga, who was a premature baby and had cerebral palsy, was one of the earlier admissions.

Her mother, Radha Mohan, says that Durga, 28, developed the confidence to climb stairs and try backwards motion after training on VHAB. “Earlier, if she had to turn around from a position, we had to help her,” she says. “But, if she had to earn points in the games, she had to turn around by herself. During the games, she started slowly moving her legs backwards. She uses crutches even now, but she has become more stable.” Durga is now part of the Adarsh Centre of Empowerment, a vocational training school and rehab centre for those above 18.

ARC principal Ashwini Kumar Satyan says the school started implementing IT-integrated solutions in 2006. “We were always open to new technologies for children's rehabilitation,” he says.

It was in 2017 that ARC first used VHAB, for six students. Nirmal Krishnan, now 24, was part of that batch. “Earlier, my son required my support for everything,” says Manju S., his mother. “I had to be available for him even at school. He required my support even to stand up. But, after starting VHAB sessions, he developed confidence. He stands without support in front of the VHAB screen. In that therapy room, he is empowered. He understands his powers.”

Nirmal, who has cerebral palsy, has movement troubles and impaired hand-eye coordination. “He could not even feed himself because of tremors; his mother used to feed him at school,” says Tommy. “She wanted him to be independent and self-sufficient. Parents of special children worry about a future where they won't be available to help. VHAB and our other assistive technologies are aimed at making neurodivergent individuals independent. Once VHAB was introduced, the children became more confident and independent, and the parents—especially mothers—could go to work.”

Tommy is currently mentoring a Kerala-based startup called Punarjeeva Technology Solutions, which is researching game therapy for physical rehabilitation. Two of their tools—Hasth, a gamified system based on hand-tracking that improves fine motor movements; and Samatved, a gamified environment that offers balancing exercises—have shown promise in several cases, including in Nirmal's.

Dr Sasikumar Panicker, founder of Kumar Centre for Stroke and Neuro Rehabilitation, Kochi, uses both Hasth and Samatved at his clinic to help a wide range of patients, including those who had a stroke or have multiple sclerosis, cerebral palsy or brain injuries. “Depending on the areas affected in the brain because of a stroke, the kind of weakness that occurs may differ,” says Panicker. “For instance, if the stroke is in the pons region or the cerebellum, it will impact balance. So, these patients need Samatved-based therapy. As it is like a game, people are interested. Samatved has a platform—a balancing board—with a pivot. When a patient stands on the platform, it becomes mobile. Each vibration and movement happening at the foot level is captured by a sensor, and the data goes to the computer and is fed into a game. The most common is a football game, which has different levels of difficulty. As for Hasth, there is a sensor to capture the hand movements of a patient. The collected data is transferred to a ball-catching game. The game creates a movement for the patient’s hands. It may not work for a completely paralysed patient, but is effective for those who have some level of movement.”

Punarjeeva's other platforms include Trana, which primarily improves gross motor abilities of the limbs; Sahay, which provides speech and cognitive training, and helps with limb movement; and Parigyan, which imparts IT skills to the specially abled. All these rely on brain plasticity. “We use only a small section of our brain,” says Panicker. “A lot of neurons are dormant. In the case of a stroke or cerebral palsy, a section of neurons is damaged. But when we stimulate [neurons] with constant practise, it creates new engrams (memory trace) in the brain, which leads to new neural pathways. Through these new pathways, a patient will gain more ability and more strength. So, the idea is to awaken the dormant neurons via stimulation.”

Tommy says that his team's creations have already helped more than 5,000 neurodivergent Indians. “More than 12,000 others are also beneficiaries of the help that these individuals are receiving,” he says. “These are the parents, guardians and siblings of these beautiful human beings. When a person with cerebral palsy or autism or Down syndrome is empowered, a family is empowered. We are also developing applications to make neurodivergent individuals employable. A lot of them have qualities desirable to employers, such as intelligence, attention to detail and high level of commitment. But still, they are not employed because our workplaces are not inclusive. So we started a not-for-profit organisation, Inclusys, to recruit, train and upskill neurodivergent individuals with IT skills like data annotation and data entry. We are also launching a startup as part of Inclusys that will employ 75 neurodivergent individuals soon. Nirmal will be one of them.”

closer-to-the-cure

Sun Sep 25 15:10:03 IST 2022

An HIV infection and AIDS are no longer the death sentence they used to be in the 1980s and 1990s. Nowadays, the majority of HIV-infected people take one or two antiretroviral pills a day and, in many cases, live a normal life. This situation, however, is far from ideal. First, the anti-HIV drugs are not devoid of side effects, and not all viruses are sensitive to them. Second, these medicines are expensive, and create an extraordinary financial burden on health care systems. Finally, and perhaps most important, antiretrovirals must be taken for life, because if one interrupts treatment, the virus starts rapidly replicating again. For these reasons, it would be useful to develop treatment methods that can cure the infection.

But why is it so difficult to find a cure? The main reason is that the virus is very good at hiding inside certain cells that are commonly referred to as “virus reservoirs”. In these reservoir cells, the virus is not produced, but is silently inserted in the genome of the host cell, where it cannot be targeted by antiretroviral drugs. In other words, the currently available therapy is very good at limiting the spread and replication of HIV, but is not able to do anything against the reservoir virus. Unfortunately, the cellular and molecular mechanisms that enable the virus to hide so efficiently (and therefore are responsible for its long-term persistence in the reservoirs) are complex and not fully understood. In recent years, a lot of attention has been given to compounds that can “wake up” the virus from its latent reservoir, therefore making it vulnerable to antiretroviral drugs as well as the host's immune response.

Innovative approaches to curing the infection are currently being tested in many experimental models and systems, ranging from test tubes to animal models such as mice and macaques, with the ultimate goal of transferring this knowledge to humans. The “HIV Cure” team at Emory University, Atlanta, which includes scientists such as Ray Schinazi, Paul Johnson, Mirko Paiardini, Ann Chahroudi, and myself, is active in testing novel HIV “cure” interventions in monkeys. A special role is played by Professor Rama Amara, who is known worldwide for his promising candidate vaccines for HIV/AIDS, but is also interested in using his vaccines to unleash the immune system against the reservoir virus. While HIV infection remains a global scourge, the efforts of the scientific community to find both a cure and a vaccine raise realistic hopes of the possibility of ending AIDS in the near future.

—Silvestri is a Georgia Research Alliance Eminent Scholar in comparative pathology, professor and vice-chair for research, department of pathology and laboratory medicine, Emory University School of Medicine, and chief, division of microbiology and immunology, Yerkes National Primate Research Center.

indian-researcher-in-us-breaking-new-ground-in-pursuit-of-hiv-vaccine

Sun Sep 25 15:11:40 IST 2022

As the aroma of freshly brewed coffee seeps into his cubicle, Prof Rama Rao Amara remembers that he has not had his lunch. Amara, 52, from Kavali in Nellore district of Andhra Pradesh, says that he has become forgetful of late. “At times, I leave my daughter's school bag behind while dropping her off at school,” he says with a smile as he makes me a cup of coffee. The self-confessed movie buff and cricket fan is now completely immersed in his work—an HIV vaccine project.

A Charles Howard Candler professor of microbiology and immunology at the Yerkes National Primate Research Center, Emory University in Atlanta, Amara has made much headway with his research. The laboratory he works with is developing prophylactic (preventive) vaccines to block HIV infection, and immunotherapy to treat people infected with HIV. The improved versions of HIV vaccine candidates developed by Amara can prevent infections with 70 per cent success in rhesus monkeys. In his study, the animals were exposed to the virus six times. The monkeys that were not vaccinated were all infected after the third exposure and 70 per cent of vaccinated animals were unaffected after the sixth exposure.

These improved vaccines are known as adjuvanted DNA/MVA vaccines. Adjuvant is an agent used to create a stronger immune response. MVA—modified vaccinia virus ankara—is a modified smallpox viral vector that holds many advantages as a vehicle for delivery of HIV antigens. Plans were underway to start the phase-1 human trials when Covid-19 struck and pushed things behind schedule. (Amara's laboratory quickly used the same platform to develop a Covid-19 vaccine that showed great promise in primate studies.)

The human trials of earlier versions of DNA/MVA vaccines that Amara co-developed with his postdoctoral mentor Prof Harriet Robinson offer much hope for people with HIV. A study conducted by Geovax, a biotechnology company working with HIV Vaccine Trials Network—a US government funded body that conducts HIV vaccine trials—found that DNA/MVA vaccines are safe and that they generate the desired immune responses in human beings. Emory University has licensed the technology to Geovax and the company is now working to begin efficacy trials.

Amara's laboratory, in an alternate approach to treat HIV-infected individuals, alsoshowed that giving vaccine to animals after they are infected and treated with anti-HIV drugs can control the virus even after discontinuation of the drugs.

So does this mean HIV infection can be cured? “A complete cure means there is no virus in the person's body,” says Amara. “I don't think that is feasible right now. What we offer is a functional cure, which enables a person with HIV to lead a normal life. There could be a low level of virus in their body. But they do not transmit the virus, and they do not have to be on drugs. That is possible. We are trying to reprogramme their immune cells in such a way that they can actually fight the infection.”

According to the India HIV Estimation 2015 report released by the National AIDS Control Organization, India has about 21.17 lakh people living with HIV. Two-fifths (40.5 per cent) of them are women and children below 15 constitute 6.54 per cent.

“A vaccine for HIV is the need of the hour,” says Dr Diwakar Tejaswi, an HIV specialist and member of the governing body of the Bihar State AIDS Control Society. “There have been a few HIV vaccine trials in the past, including the much-hyped RV 144, but no major breakthrough yet. However, we are optimistic.”

Like Amara, the subjects used in his animal trials also have an Indian connection. “[The rhesus monkeys] were brought from India long ago,” says Amara. “We breed them at our Primate Research Center field station in Lawrenceville, which is about 25 miles from the main centre of Yerkes. They live in colonies. We take good care of them.”

The monkeys are used in such studies because HIV does not infect mice or other small animals. “So, for studies on HIV, primates, especially the Indian rhesus monkeys, are the ideal animal model,” says Amara. The pathogenesis differs depending on the primate used. “For instance, sooty mangabey monkeys also get infected with HIV, but they don't develop AIDS,” he says. In Indian rhesus monkeys, SIV—Simian Immunodeficiency Virus—duplicates the symptoms and the disease as in humans. Amara adds that disease progression in Indian rhesus monkeys is also faster because the virus grows to 10 times the levels that is normally seen in humans.

Vaccines are considered the best tool for controlling HIV. “The development of a vaccine is the only way you can prevent HIV transmission efficiently,” says Amara. Though people can do “pre-exposure prophylaxis”, such as taking anti-HIV drugs before having sex, they have to remember to do it, he says. “When you have a vaccine, you ideally do not have to take any precautions,” he adds. “That is the kind of vaccine we are talking about. And then it is cheap. So, typically you just have to take three or four shots.”

The DNA/MVA vaccines being developed by Amara are based on the concept of immunological memory. “[Some] cells can remember what they saw before,” says Amara. “Our vaccine centre director and colleague, Prof Rafi Ahmed, is a world leader in this area and has done great work on how these memory cells are formed. They can respond rapidly and clear the infection fast.”

The vaccines contain “pieces of HIV”, which trick the body into generating an immune response to the HIV infection. When you get infected, the white blood cells in your body start to divide and replicate themselves. So there are more soldiers to fight. Under normal conditions, the number of white blood cells in your body that can fight against one particular infection could be about one out of 10,000 or 1,00,000. “If you do not have enough soldiers to counter the attack, then the virus wins,” says Amara. “But if you have more soldiers, the host wins. You just prepare yourself for a future attack, have more numbers ready for you who can act very fast, and when the virus comes, you kill it.”

Phase-2A trials of the vaccines are complete, but Amara knows that phase-2B studies that involve efficacy trials in humans could be more difficult. Researchers typically vaccinate human subjects and then expose them to the virus. But since there is no cure for the disease, such trials are all the more challenging when it comes to the HIV vaccine. As a solution to this research obstacle, clinical trials are done in areas where the transmission rate is high. Researchers randomly vaccinate thousands of people. Another group in the same locality will receive placebos.

“And then you watch over three years what happens to transmissions,” says Amara. “In the vaccine group, we should see a dramatic reduction in transmission. These experiments need a large number of people and are expensive.” Amara adds that for phase-3 studies he is planning to go outside the US to pockets where the transmission rate is as high as 25 per cent. Another hurdle that HIV researchers face is that the vaccine has to be widely effective as the virus is “genetically variable and different” all over the world. “They have different properties. So we need to overcome that diversity and deal with those different variants,” says Cynthia Ann Derdeyn, professor, laboratory medicine and pathology, University of Washington.

The vaccine can be a boon for HIV's unsuspecting victims. In India, there have been numerous instances where blood transfusions caused HIV infection. There is a risk of transmitting the virus through blood transfusion if the donor is in the “window period” when screening tests on donated blood may not detect the presence of HIV.

Maya (name changed), from Alappuzha, Kerala, contracted HIV allegedly after getting a transfusion at the Regional Cancer Centre in Thiruvananthapuram. The nine-year-old who was being treated for leukaemia passed away due to pneumonia. RCC had apparently complied with all the guidelines for safe blood transfusion stipulated by the National AIDS Control Society and the World Health Organization.

A report of the Kerala State AIDS Control Society revealed that the girl had received blood from 48 people, of whom one was HIV positive. He was in the window period at the time of blood transfusion. Maya's father Shiji C. says the hospital officials concealed that his daughter contracted HIV from a blood donor. “There is enough evidence to believe that there was a lack of transparency on the part of the hospital officials,” says the daily-wager. “They would have thought my daughter might not live long and that we would give up. And one cannot help but wonder why they took so long to confirm her HIV status.”

Gyan Ranjan from Patna contracted HIV through a blood transfusion, at a clinic, following an accident. He went into depression and locked himself in a room for two weeks after he tested positive for HIV. Ranjan got Covid-19 and died in 2021 in his mid forties, but he was excited at the very prospect of an HIV vaccine and believed that it would save the lives of many people who shared his fate.

Dr V.D. Ramanathan, who was a director-grade scientist at the Indian Council of Medical Research, says that Amara's “pioneering work” is of great relevance to India in the context of the focus on HIV prevention. Ramanathan, who was principal investigator for two phase-1 HIV vaccine trials in India and was also involved in evaluating newer anti-TB vaccines in animal models, adds that Amara's work on immunotherapy for those infected by HIV will also be of immense value as it will arrest the disease.

Dr Sunil K. Arora, a professor of immunology and head of the department of translational and regenerative medicine at the Postgraduate Institute of Medical Education and Research, Chandigarh, says the vaccine approach looks promising. “But, we may have to wait for the human trials to show their efficacy,” he adds.

For Amara, the vaccine is a tribute to his late father, who wanted him to take up medicine. “He would always say it is a noble profession that can save lives,” recalls Amara, who lost his dad when he was 17. Amara narrowly missed out on admission for medicine and ended up opting for biotechnology. He loved biology and was fascinated by how our immune system fights infections. For his PhD, Amara worked on tuberculosis, vaccines and immunotherapy. He used to go to TB sanatoria in India, where he saw many HIV patients who developed TB, which he calls “one of the most opportunistic infections among HIV infected people.” He developed an interest in vaccines and joined Emory.

In his immunotherapy study, anti-HIV medicines are combined with an antibody to PD-1—programmed cell death protein 1. PD-1, the discovery of which won the Nobel Prize in 2018, is a protein which regulates the immune system's response. While this prevents autoimmune diseases, it can also prevent the immune system from killing harmful cells and tumours. Therefore, an antibody to PD-1 can make the immune system more 'aggressive' and thereby help reduce the viral load faster—40 days as compared with 150 days for treatment with anti-HIV drugs only. PD-1 antibody is also used in cancer treatment.

According to Amara, only one in 500 sexual exposures results in HIV infection—the process is so inefficient through a mucosal transmission. But the odds of contracting HIV through a needle prick and consequent exposure to infected blood is 100 per cent. A majority of the HIV infections though do occur through sexual intercourse.

Now, HIV is a chronic manageable disorder and has better and cheaper treatments that are being used all over the world, says Dr Ishwar Gilada, president, AIDS Society of India and governing council member, International AIDS Society. “Almost 82 per cent of HIV positive people globally are using anti-retroviral treatment, using medicines made in India at 1 per cent to 5 per cent of the international cost,” he says. “It is very effective HIV treatment that makes the infected person undetectable within three to six months—as a principle, undetectable is untransmittable.”

However, experts say that the prevalence of HIV is still increasing among some populations. “The prevalence is pretty wide from 0.1 per cent to around 20 per cent in some areas,” says Derdeyn. “Some areas have more access to antiretroviral therapies that can impact transmission, some do not. So it is a really heterogeneous mix.”

The pandemic led to a lull in vaccine research. However, learnings from Covid vaccine research have changed the course of HIV vaccine research across the world. The success of mRNA technique in Covid vaccines offers much hope to HIV vaccine researchers. In fact, the Moderna-International AIDS Vaccine Initiative phase-1 study, is now in progress at the George Washington University, Washington, DC.

“The previous shortcomings of HIV vaccine trials are likely to be corrected with the novel approach of mRNA; the results of animal trials using mRNA technique are quite encouraging,’’ says HIV specialist Tejaswi. He is hopeful that HIV vaccines using mRNA techniques will be a reality in the future.

Though no vaccine has yet been licensed by the WHO, efforts have been on for decades. The first candidate vaccine was developed in 1987 and tested in 1989 in a phase-1 trial by Dr Jonas Salk, the inventor of the polio vaccine. Since then, 70 candidates have been developed. “But, only two of them went to phase-3 trial,” says Gilada. “Maybe six or seven went to phase-2.”

The six-year-long RV 144 clinical trial conducted in Thailand, involving more than 16,000 HIV negative volunteers, generated a lot of buzz after its efficacy findings came out in 2009. Volunteers who were vaccinated had a 31 per cent lower rate of HIV infection. Nonetheless, it fell short of expectations as it could protect people from HIV only to a limited extent. Will the DNA/MVA vaccines turn to be another damp squib? “It is too early to comment,” says Dr Prakash Kothari, a sexologist in Mumbai. “But I'm very positive. Anything that increases or improves immunity will be the thing that helps HIV positive patients.”

The vaccines being developed by Emory are based on stronger immune responses and are much better than RV144 vaccine in animal models, says Amara. “My lab has added adjuvants that would actually give us better protection. So we are very hopeful that we will have a better outcome,” he says.

Amara does not fear failure. A firm believer in karma, he is just focused on putting his best foot forward.

whats-retinitis-pigmentosa-a-rare-genetic-condition-that-causes-blindness-over-time

Sun Sep 25 15:13:25 IST 2022

CNN Travel recently published a heartwarming story about a unique world tour by Canadian couple Edith Lemay and Sebastian Pelletier and their four children. The couple wishes to give incredible moments that would enrich “visual memories” of their children before it is too late. Three of their children—Mia, Colin and Laurent—are affected by a rare genetic condition named retinitis pigmentosa—which causes blindness over time. It is a condition that does not have a cure so far, and Lemay and Pelletier’s aim is to help their children have better coping mechanisms that would prepare them for their future.

What is retinitis pigmentosa?

Retinitis pigmentosa is a condition where the cells in the retina break down slowly over time. The condition would result in vision loss. RP is caused by mutations in certain genes that control the cells that form the retina. These mutated genes are passed down from parents to children.

Symptoms of RP would typically appear in childhood itself. Loss of night vision is the most common early symptom. Children with RP may have issues adjusting to dim light and walking in darkness. The condition would cause loss of peripheral vision, too. Over time, a person with RP will have trouble seeing things out of the corners of the eyes. Eventually, they would lose this tunnel vision, too. Some others may experience loss of central vision, which would hamper their ability to do tasks such as reading or threading a needle.

RP-affected people will exhibit sensitivity to bright light and may also experience loss of colour vision. The type and speed of vision loss associated with RP would vary from person to person. Global estimates say that RP affects about one in 3,000 to one in 4,000 people. In India, the prevalence of RP is high. A study published in 2012 found that the prevalence of retinitis pigmentosa was about 1:1750 in the adult population of rural central India.

How is RP detected?

The most common method for the detection of RP is a comprehensive dilated eye exam. Here the doctor would give the patient some eye drops to widen his pupil and examine for RP. Electroretinography, optical coherence tomography and fundus autofluorescence imaging are other tests that used to detect RP.

Can RP be treated?

There is no cure for most types of RP so far. But low vision aids and rehabilitation programmes may help those with RP to manage their lives. Those with RP are advised to use sunglasses and other means to avoid exposure to too much light. Voretigene neparvovec-ryzl, a gene therapy product, is now being used to treat a specific type of RP—cases in which the disease develops because of mutations in the RP65 genes. Researchers believe that advancements in gene therapy, cell therapy, and medications would bring changes in RP treatment soon.

aquaporin-4-for-a-healthier-brain

Sun Sep 04 15:02:22 IST 2022

A simple bath may help you clean up your outer body. However, cleaning up the toxic waste that gets accumulated in your brain or other internal organs is not that easy. When a toxic protein like amyloid (produced in the bone marrow) gets accumulated in the brain or other organs, it may cause dysfunction of various systems.

Accumulation of beta amyloid in the brain is seen as the first indicator of the development of Alzheimer’s dementia. A 2018 research article published in Proceedings of the National Academy of Sciences of the United States of America had shown that acute sleep deprivation is an important reason that impacts the beta amyloid burden in brain regions. Millions have been poured into the research of finding ways to clear amyloid before the appearance of cognitive symptoms of Alzheimer’s. Immunotherapy targeting beta amyloid is in clinical trials, but they have shown limited success. Now, a group of researchers has found a novel way to increase the clearance of toxic waste by ramping up a tricky process known as readthrough.

When the brain synthesises a protein called Aquaporin 4, it sometimes creates an extra tail at its end. This is because the protein synthesising machinery did not stop at the stop sign. This process of crossing the stop sign during protein synthesis is called readthrough. The researchers thought this quirky mechanism was nothing more than an occasional failure in the protein manufacturing process. However, when they analysed the gene sequence, it had shown a striking pattern in the brain—it was in structures that are important for waste clearance.

The researchers then created tools to analyse whether the long-form Aquaporin 4 behaved differently compared with the regular form. They found the long form in the “end feet” of astrocytes—support cells that help in maintaining a barrier between the brain and the rest of the body. The “end feet” of astrocytes wrap around the blood vessels and regulate blood flow, which means it is the best place to be if a compound’s job is to flush toxic waste out into the bloodstream.

Assuming that increasing the amount of long-form Aquaporin 4 might increase the waste clearance, researchers then screened 2,560 compounds for the ability to increase readthrough. They found two compounds: apigenin, a compound found in onions and other edible plants; and sulphaquinoxaline, a veterinary antibiotic used in the poultry industries. Then, the researchers studied the effect of these compounds in genetically engineered mice with high levels of amyloid in their brains, and they found promising results. Their study was published in the journal Brain. Mice models have shown that reducing the amyloid levels by 20 to 25 per cent will stop its buildup in the brain.

The accidental finding about readthrough could open up a novel way to treat not just Alzheimer’s, but other neurodegenerative diseases that involve protein aggregation in the brain.

a-theatre-project-hopes-to-teach-attappady-tribals-maternity-car

Sun Sep 04 14:18:00 IST 2022

It was a bumpy ride made jerkier by sharp turns and goatherds. The houses en route looked half-finished—some had clay roof tiles, some others concrete, and some were naked on top. The narrow road running parallel to the Siruvani river took us to Kottamala Ooru, a hamlet in the tribal-dominated Attappady region of Kerala. We were there to meet Geethu Dhanush, who had a miscarriage some weeks earlier.

The house on a small hillock had goats, dogs and puppies as guards. Geethu, 21, came out with her 18-month-old daughter, Dhanshika, in her arms. Year 2022 had been cruel to her—she lost her husband, Dhanush, in a bike accident in February, before losing her unborn child.

On June 28, she had gone to the Vivekananda Medical Mission Hospital, a private facility in Agali, for her second-trimester anomaly scan. There was no foetal movement. From there, she went to the government tribal speciality hospital in Kottathara the same day. It was created exclusively for the welfare of the area's tribals, but it is ill-equipped and short-staffed. At around 2:15pm, the assistant surgeon there suggested abortion and referred Geethu to the Government Women and Children Hospital in Palakkad—more than 90km from her home. Geethu and her mother took an ambulance there, but the abortion happened only the following day. The scan report said that Geethu was borderline anaemic (10.4 g/dL; 12-16 g/dL is the normal haemoglobin range for women). She was anaemic when she was carrying Dhanshika, too. The child was born pre-term and weighed just 1.9kg.

The Palakkad hospital authorities told Geethu that the baby had died because the umbilical cord was tied around its neck. She did not ask for a post-mortem, and the aborted foetus was buried in Palakkad.

Geethu’s miscarriage is not a one-off; it has to be seen in the backdrop of the larger infant mortality problem in Attappady. The area has a tribal population of 33,000; Irula, Muduga and Kurumba are the three main communities there. According to the O.R. Kelu Committee report submitted to the Kerala assembly on March 15, 80 per cent of the tribal population is either malnourished or has sickle cell anaemia (a genetic disease).

It was in 2013 that Attapaddy's infant mortality rate first attracted national attention. That year alone, 47 infants died in the block. Thampu, a tribal welfare NGO, had studied and highlighted the issue then, shocking the nation and setting off alarm bells in the corridors of power.

In 2015, Thampu released another study about malnourishment in Attappady. It was based on children (below six) and mothers from 42 hamlets in Attappady. Every child part of the study had stunted growth because of malnourishment. A lot of children had mental disabilities, too.

Post-2013, the Centre and the state spent more than Rs250 crore on tribal welfare in the region. A lot of fancy projects were also announced. However, there have been questions on whether these were only on paper. For instance, in some cases, benefits of the Janani Janma Raksha scheme (2013)—started to help mothers-to-be with money and nutritious food—reached only after the child had died.

Geethu T.K., a 22-year-old from Veettiyoor, lost her three-day-old baby on November 26. Her mother-in-law, Selvi K. (43), said they got the money only after the death became a controversy. “After we lost our child, they came with a sum of Rs11,500,” she said. “What use is it if we do not get the money at the right time? This has happened not just in our case.”

Selvi had snapped at the politicians who visited after her grandchild’s death. “They come with all these empty promises,” she said. “But the adivasis will always have to stand in this graveyard.”

According to official records, 114 child mortality cases were reported in Attappady between 2013 and 2021 (October). Activists from the region say that the real number could be higher. Also, this number does not cover miscarriages, stillbirths or abortions. Twenty abortions were reported in the area in 2020.

Kerala boasts major advancements in health care; at the state level, infant mortality rate is just six (per 1,000 live births), as per the Sample Registration System (SRS) bulletin, 2020. This is comparable to several developed countries in the west. However, Attappady has been left out of this development story. Experts feel that the top-down approach in the implementation projects has failed to produce intended results.

V.K. Suresh Kumar, project officer at the Integrated Tribal Development Project (ITDP) office, said that for the implementation of any project, the beneficiaries also have to cooperate. “[Under the] Janani Janma Raksha scheme, we pay a monthly sum of Rs2,000 from the third month of the pregnancy till the baby turns one,” he said. “However, what happens is that the tribal women will not reveal that they are pregnant for up to even six months because of certain superstitions. Then how can the junior health inspector or junior public health nurse identify the case and report it to us?”

Kumar added that, currently, around 650 women are supported via the JJR scheme. “I agree that sometimes there are delays in getting the funds for the project and in releasing them,” he said. “However, we ensure that there is no delay on our part.”

To spread awareness about government schemes and projects, the ITDP and the state health department have joined hands with tribal welfare NGOs like Thampu.

Activist Rajendra Prasad founded Thampu in the late 1990s, when he had come to Attappady to shoot a 30-minute documentary film. In the past two decades, Thampu has introduced several programmes for the uplift of the tribal community. “Our intention was to create leaders from the tribal community itself,” said Prasad. “Our activists, who are all tribals, toured villages in Attappady with Nammtthu Kanavu, a play in the Irula language supported by UNICEF, to spread awareness and create dialogue about ways to prevent infant mortality.”

Over 39 days, the Thampu team toured 114 villages with their play. The final performance was on Independence Day.

To see the team in action, THE WEEK travelled with Thampu’s theatre group to Bhoothivazhy village. Directed by Kuppuswamy Maruthan, the first Irula with a theatre degree, the play uses motifs and characters from tribal mythology to talk about health care during pregnancy.

Prasad noted that the tribals of Attappady used to have an efficient system to support childbirth. “But now, things have changed,” he said. “We have observed that many pregnant women are not going for consultation in time. That is when we decided to develop this script to talk to our people and make them aware of the issues.”

Attappady has a rich culture of tribal dramas called “koothu”. Maruthan’s play takes inspiration from Harischandran Koothu, a popular play in the region. The lead roles in the play were handled by a couple—Udaya Kumar and Revathy K.—who themselves lost a child in 2014. “In the play, we talk about how to take care of your woman when she is pregnant,” says Kumar. “When Revathy was pregnant the second time, I took good care of her and gave her nutritious food. And, so, we could save our second child.”

Nammtthu Kanavu means “our dream” in the Irula language. “In the play, a komaali (joker) has a recurring dream about a healthy generation of tribals,” said Maruthan. “Initially, no one understands his dream. But the community soon realises the importance of his dream and starts implementing the necessary changes to ensure a healthy future generation.”

The joker's dream, though, is likely to remain a dream if the government continues to dictate terms to adivasis, said Maruthan. “We are really worried for the health of our generation,” he said. “We are wary of the [nutritional] content of the food that we eat. Our food system always depended on millets. But now the tribals do not have land for farming. And, instead of making the tribals self-sufficient, what the government has done is create community kitchens. What is served there is not in tune with our traditional food habits. Plus, tribals have to stand in queue like beggars every day for food. Now, a lot of people have even forgotten how to cook. These sort of ideas from the government are not helping us.”

Dalit activist Sunny M. Kapicadu led a team of researchers, doctors and activists—under the banner of Dalit Samudaya Munnani—to study the recent rise in infant deaths in Attappady. He found that many of the projects did not take into consideration the needs of the tribals. “So, it will either be a big failure or they will have to stop it halfway,” he says. “In the case of community kitchens, we found that the government is not regularly giving money in advance to run these kitchens. The members of Ooru Sabhas (village governing bodies) are getting the provisions at personal risk from shopkeepers as the government will not pay money in advance. The funds are allocated to them only later. Also, the government has allocated just 018-020 a day for each person. Do you think people would get nutritional value from that food?”

K.A. Ramu, a tribal activist part of the Thampu team, said that the ill health in Attappady has a direct link to the destruction of the adivasi culture linked to farming and agriculture. Each village in Attappady has a hierarchical power structure. The Ooru Mooppan is the head of the hamlet. He has two assistants: Karuthala, the minister, and Vandari, the treasurer. There is also a Mannookaaran, who is responsible for agricultural activities. Nowadays, though, there are complaints from the villages that the government is bypassing the traditional hierarchy by communicating only via a Scheduled Tribe promotor while implementing projects. “We were self-sufficient, and we had to rely on the outside world only for salt and dried fish,” said Ramu. “But now that situation has changed. And every issue we face now—social, economic and health-related—arises from alienation.”

In the 1961 census, tribals made up 63 per cent of Attapaddy's population. However, in the next three decades, state-supported migration policies changed that. By 1991, the tribal population plummeted to below 35 per cent. From the 1960s onwards, a lot of fertile land on the banks of the Bhwani River was snatched by settlers for Rs30 to Rs40 an acre. The tribals were unaware of the market system of the outside world, and could be cheated easily. An official ITDP survey released on February 15, 1977, revealed that 10,106.19 acres of adivasi land in Attappady was taken from them.

According to a study (by researchers Elizabeth Edison and Rugmini Devi) published in South Asia Research in 2019, land alienation in Attappady took place in three forms. Tribals were forced to register their lands—given to settlers for agricultural purposes—in the settlers’ names. A lot of tribals gave their land on lease for meagre sums to meet urgent expenses, and those who could not repay the money lost the land. “The tribals rarely fought legal battles in this regard,” said the study. “Finally, alienation also occurred when the implementation of the Forest Conservation Act of 1980 resulted in unattended land becoming property of the forest department.”

The tribals could no longer use the forest for agriculture or to even collect produce. This destroyed traditional food habits and led to over-dependence on the public distribution system, say activists.

Climate change has also affected the tribals. In the 1950s, around 83 per cent of Attappady had forest cover. Now, it is less than 20 per cent. Earlier, the average temperature was around 17 degrees Celsius; it is now above 22 degrees. This has changed the rain patterns and affected agriculture.

“The gravity of these issues cannot be understood by sitting in AC rooms,” said Manikandan A.D., an economist and author who has done extensive research on Attappady. “The government schemes and projects should be implemented by living and interacting with the tribals. Without taking the tribals into confidence, nothing will work here.”

how-to-strengthen-your-bones-in-old-age

Sun Sep 04 12:17:55 IST 2022

A person's structure is maintained by her bones. They play many vital roles in the body, such as protecting organs, maintaining muscles and storing calcium. It is important to build bone health from childhood. Once an individual steps into adulthood, bone health is often neglected and it can lead to major health issues.

Old bones break and new bones replace them. The process of replacement is quick in young people, and it slows with age. The bone mass is at its peak when an individual is around 30. After that, the bone mass one loses is more than the bone mass one gains. Here are a few measures that can be used to increase bone health and maintain overall health in old age.

Plenty of vitamin d

Vitamin D plays a vital role in improving bone health and helps the body absorb calcium. Research shows that adults with low vitamin D levels tend to have lower bone density and are more prone to the risk of bone loss than individuals who get enough vitamin D.

Vitamin D deficiency is quite common. One can get vitamin D through exposure to the sun and food supplements such as cheese, liver and fatty fish. It is recommended that an individual gets at least five to ten minutes of sun exposure two to three days a week on the hands, legs and face. It helps the body absorb the required vitamin D.

Keep the body active

The key to keeping the bones strong is keeping the body active. Walking, jogging, running, and climbing staircases help build strong bones and maintain the body. These exercises help the body resist gravity and stimulate the growth of bone cells. Exercises that are focused on strengthening muscles help increase bone strength. Working out for at least 30 minutes a day can help strengthen bones and prevent most orthopaedic ailments.

Maintain healthy weight and a healthy lifestyle

Maintaining a healthy and stable weight, and lifestyle, is not easy. But having a balanced diet rich in nutritious food, and maintaining a healthy weight can help strengthen bones. One should neither be underweight nor overweight, as both could lead to problems related to bones and joints.

An underweight individual is prone to osteopenia or osteoporosis. And an overweight individual is at a higher risk of fractures due to excess weight. Any kind of drastic weight-loss or weight-gain diet or exercise contributes to losing bone mass.

Balanced diet

Eating food rich in vitamin C, protein and calcium helps maintain bone strength. Vitamin C can stimulate the production of bone-forming cells, and as it is rich in antioxidants, it even protects the bone cells from damage. Protein-rich food and vegetables are very important for bone health. Low protein intake can reduce the absorption of calcium in the bone, which would affect bone formation, and high protein intake will lead to acidity in the blood. The right amount of protein should be consumed, as prescribed by the doctor.

The main mineral required for bone health is calcium. Calcium helps in protecting the bone structure and maintaining strength. It is important to include calcium-rich food in the diet, as it helps in replacing old bone cells with new ones faster.

It is important to motivate oneself, have a healthy diet and exercise regularly, especially in old age. Keeping oneself active and flexible is very important. It is widely seen that after retirement people feel lazy or tired. Yoga, meditation and walk can help relax the mind and keep the body active. Consulting a doctor for a bone density scan is recommended, just to rule out osteoporosis. With the help of this test, doctors can evaluate the risk factors and assess the medications.

Author is senior orthopaedic consultant, Apollo Spectra Hospital, Bengaluru.