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.

bottling-youth

Sat Jul 30 16:30:57 IST 2022

The Mahabharat tells the story of a king named Yayati who lost his youth because of a curse from sage Sukracharya. On begging for forgiveness, the sage offered a concession to the king—he will regain his youth if he can exchange his old age with one of his sons. His first four sons would decline Yayati’s request; however, his last son, Puru, would agree. In exchange, Yayati announced Puru the inheritor of his kingdom and riches.

The modern-day Yayatis commissioning efforts to solve the secrets of old age are Silicon Valley billionaires like Jeff Bezos and Peter Thiel. Over the past decade, they have invested billions of dollars into life-prolonging and age-reversing research. Ageing is a process that involves many biological changes. Scientists call these changes “hallmarks”. Around nine hallmarks have been identified, including stem cell exhaustion, altered intercellular communication, mitochondrial dysfunction, epigenetic alterations and genome instability. Theoretically, if we can correct these problems, not only will ageing be slowed, but also you can prevent many diseases associated with old age. Venture capitalists and multibillionaires are seeing potential in this theory. And that is why they are betting big on anti-ageing research.

Last September, Bezos invested in Altos Labs, which is pursuing biological “reprogramming”—a process that involves turning mature, specialised cells into pluripotent stem cells. The company became operational in January with $3 billion in funding. Both Bezos and Thiel have invested in Unity Biotechnology, whose anti-ageing research is focused on selectively eliminating or modulating senescent cells—“zombie” older cells that have stopped cell division that gets accumulated and release compounds that speed up ageing. In December 2021, cryptocurrency company Coinbase’s co-founder Brian Armstrong and venture capitalist Blake Byers founded NewLimit—with an initial investment of $105 million—which announced its aim as “extending human health span” by "reprogramming cells to younger states".

Other key players in “longevity therapeutics” include companies like Calico Lifesciences at Google, AgelessRx, Cambrian, bioXcellerator, Betterhumans, Alkahest, and Juvenescence. According to a recent study released by QY Research Medical, a US professional market research publisher, the global longevity and anti-senescence therapy market was valued at $25.1 billion in 2020, and is projected to reach $44.2 billion by 2030, growing at a CAGR of 6.4 per cent from 2021 to 2030. An increase in lifestyle standards and income among the world's population is seen as the primary factor driving the growth of the anti-ageing therapeutics market.

Dr Andrew Steele, a British computational biologist and author of Ageless: The New Science of Getting Older Without Getting Old, recently claimed that scientists are working on a “miracle drug” that can extend lifespan to 200 years. This drug, which works by eliminating senescent cells, gave promising results in a mice trial conducted by Mayo Clinic in 2020. Two decades ago, such a claim would have been seen as an absurd one. But now, considering the kind of exciting research happening, and the kind of money being pumped in, it can no longer be dismissed as a pipe dream.

john-mcenroes-journey-from-brat-to-family-man

Sun Jul 31 12:26:29 IST 2022

John McEnroe’s favourite quote in McEnroe, the bracingly honest documentary that released on July 15, comes from his wife, Patty Smyth: “I married a bad boy who became a really good man.”

“That was really beautiful,” McEnroe, 63, says with a grin via Zoom from his home in New York. Many would agree with Smyth. McEnroe has gone through a striking transformation in the past 40 years, from the “you cannot be serious” tantrums that earned him the nickname “superbrat” to his present status as one of sport’s most cherished elder statesmen. His candid and insightful commentary, delivered in that swaggering drawl, is one of the joys of watching Wimbledon.

McEnroe’s journey is charted with a refreshing lack of sycophancy in the documentary by Barney Douglas, the director who made The Edge, a similarly clear-eyed film about the England cricket team. We see him combine flair, nous and stroppiness to win three Wimbledon singles titles in 1981, 1983 and 1984, becoming the best player in the world. We revisit his demons, his rivalries with Bjorn Borg and Jimmy Connors and his tempestuous, drug-addled first marriage to actress Tatum O’Neal. And we find him now in a state of relative harmony, hanging out with Smyth and his five children, aged between 23 and 36.

A stirring tale of redemption? This being McEnroe, it is not quite that simple. “I didn’t think I was that bad a boy in the first place. People got me all wrong,” he says, looking lean and hip in a black jacket over a white T-shirt. A big reason why he became a bête noire at Wimbledon, he agrees, was because he was such a bad fit with the All England Club, then one of the stuffier corners of the British establishment. “I grew up in Queens in New York, and there were people yelling and screaming all the time,” he says. “It was a loud dinner table. And it seemed normal.” When he first played Wimbledon in 1977 it was his first time overseas. “I was, like, ‘Oh my God, these people are so polite. It’s so quiet here.’”

He accepts, though, that he exacerbated the situation. “You sort of feed into this villain thing, maybe unbeknown to yourself, and then it becomes this out-of-control monster. People started to recognise me—‘Are you that brat guy?’—and it completely changed my life. I was, like, ‘They don’t understand me, I’m a nice guy.’ But of course I wasn’t real nice on the court at times.”

Watching Connors, who cold-shouldered him before one of their early matches, helped him to learn how to be a “prick” to opponents. “Connors isn’t that big a guy, I’m not that big a guy, you have to come at your opponents with an intensity that radiates off your body,” McEnroe says. “That’s what intimidates them.”

He contrasts that with today’s top players, many of whom “seem like unbelievably nice people. Rafael Nadal has claimed he’s never broken a racket in his life.” Yet Nadal and Roger Federer are not representative, he thinks. “Generally, I think people are, as far as tennis goes, more like me and Connors than Borg, who never showed any expression. It’s a very frustrating game that it’s hard not to get emotional about. I’d be, like, ‘I’m gonna go practise and be like Borg for two hours,’ and that would last, like, five minutes. It just wasn’t in my DNA.”

We are speaking before the Australian Nick Kyrgios becomes the talk of Wimbledon after a vitriolic match against Stefanos Tsitsipas of Greece in which Kyrgios verbally abuses a line judge and Tsitsipas hits a ball into the crowd. After the match Tsitsipas calls Kyrgios an “evil bully”.

Surely part of McEnroe would approve. “Grand Slam tennis is not a popularity contest,” he later says in a trailer for the BBC, adding of Kyrgios: “Yes he did go too far. If he’s allowed to get away with it then he gets away with it.” Well, both players were fined, but Kyrgios was ranting away again in the Wimbledon final.

Have his outbursts got so much attention because tennis has become too boring? In his heyday, McEnroe says, “it felt like the inmates were running the asylum—me and Connors and [the temperamental Romanian] Ilie Nastase. And I think in the late 1980s they tried to stifle some of the personality, like that was bad for the game. Which I completely disagree with, by the way. Pete Sampras is one of the all-time great players, but he’s not going to light it up necessarily, personality-wise. In a one-on-one game, you need personality.”

His best match, he says, was the epic Wimbledon final he lost to Borg in 1980, recreated in the film Borg vs McEnroe, while his best performance was beating Connors “one, one and two” (6-1, 6-1, 6-2) in the final in 1984. “It felt like the ball was this big (he holds his hands a foot apart) and I could do anything with it.” There is no false modesty—he talks about “taking the game to another level. I’d sort of mastered what I idolised about Rod Laver (the Australian champion of the 1960s) and I was three or four inches taller. The mistake I made is I sat back and went, ‘Let’s see what they’re going to do,’ instead of, ‘I gotta keep getting better.’”

Borg retired in 1982 at 26. Had he carried on longer, would that have driven McEnroe to more than his three Wimbledons and four US Opens? “Absolutely. It would have been better for me and the game. It was just a huge hole. Novak Djokovic and Nadal have played 59 times now, which is a crazy amount of times. Borg and I only played 14. It was a damn shame.”

Also looming large in the film is McEnroe’s father, John, a former employee of the US Air Force who became a lawyer and his son’s manager. He does not cut a cuddly figure. “When I was born, he was refereeing a basketball game on an army base,” McEnroe says. His mother, Kay, does not sound like a softie either. “I broke my arm when I was eight and she said, ‘Here’s two aspirin, you’re fine.’” McEnroe thinks he overcompensated for that stoicism when he separated from O’Neal. “My kids said, ‘Dad, you gotta stop crying now.’”

His father pushed him hard, which may be why McEnroe did not feel euphoric when he was at the summit of tennis in 1984-1985. “I’m the greatest player that’s ever played at this point,” he says in the film. “Why did that not feel that amazing?” You certainly cannot put all his troubles down to New York abrasiveness. “I’ve had plenty of therapists,” he says. “Some of them court-appointed”— he was ordered to see an anger-management counsellor after his divorce from O’Neal. The film has been “therapeutic in some ways”, helping him to come to terms with the fact that he did not say goodbye properly to his dad before he died in 2017: “That send-off still feels empty to this day.”

Smyth suggests intriguingly in the film that McEnroe could be on the autistic spectrum. His ability to excel in one skill at the exclusion of others fits that theory, as does his irascibility when things do not go to plan. “It’s safe to say that I’m probably somewhere around there,” he says. You could also point to his facility in maths at school and what he sees as his biggest flaw, a lack of empathy. Although I’m not sure the latter is true, given the way he can put himself in others’ shoes when he commentates.

He can also be outspoken as a pundit, having called Boris Becker’s imprisonment a “travesty” and urged America to change its “ridiculous” vaccine laws, which may prevent Djokovic from competing at the US Open. He says he disagrees with Wimbledon’s decision to ban Russian athletes this year: a player such as Daniil Medvedev, the world No 1, is “probably not too happy about what’s going on [in Ukraine]. But if he says anything, his friends or his family could be thrown in prison for 15 years.”

Electronic technology means that today’s players can be more certain whether the ball really was on the line. If McEnroe envies that, it is the opposite with social media. He watches with bemusement as his children chase likes. “Jesus Christ, that’s all they do. It’s worse than being a heroin addict. If I’d been 20 years old and on social media and the press had gone after me, I’d be losing it. I think I might have thrown some things out there that I’d regret.”

Is there anything he would have done differently in his marriage to O’Neal? “Of course. Are you kidding?” They had children too young, he thinks. O’Neal was 22 when she had their first, Kevin, with Sean and Emily following within five years. “It was a little too much to expect.”

Then there were the paparazzi. “You’d be on page six of the New York Post or something.” The film shows him having an altercation with photographers: “I’m taking a shit—you want a picture of that?” His creativity and volatility were suited to the entertainment world, though. His friends include Keith Richards (“If you’re used to working crowds you have something in common,” Richards says in the film) and Chrissie Hynde, on whose debut solo album McEnroe played guitar. He talks in the film about trips to Studio 54 and we see him and his friend, the tennis player Vitas Gerulaitis, being interviewed on MTV while clearly stoned.

Imagine Nadal, Federer or Djokovic doing any of that stuff. Maybe they have the right idea, though, because he happily concedes they are the three best players in history. “Roger is the most beautiful player I’ve ever seen. He’s like an updated version of Rod Laver. I’d never seen anyone that tried harder than Jimmy Connors but Nadal has succeeded in that. Djokovic is like the human dartboard, which I can relate to.” He gives Nadal “the slight edge”, although Djokovic has made the margin even finer by winning Wimbledon after the Spaniard pulled out injured.

McEnroe and O’Neal divorced in 1994 and four years later he was granted sole custody of their children because of her addiction to heroin. How are relations with her now? “We have a difficult time communicating,” he says. “I’m not gonna sit here and pretend it’s great. When I hear people say, ‘We’re divorced and I got remarried and my ex- comes on trips with us and it’s great,’ I’m, like, ‘How’s that even possible?’”

In 1997 he married Smyth, a Grammy-nominated musician not to be confused with Patti Smith. “I was 35, I’d just gone through this horrific divorce, I don’t want any relationships. And then all of a sudden I’m with Patty and I’m, like, ‘Oh my God, I’m getting a second chance. Do not blow this. Don’t be an immature idiot.’”

He hasn’t blown it so far. He and Smyth have two daughters, Anna and Ava. Other than commentary, he is “sort of searching” for something to do. He once considered going into politics as a Democrat, “but I came to my senses, because that is just totally nuts. I’m not cut out for that.” Whatever he ends up doing, the demons have quietened. “I feel proud of the direction I’ve gone in, what I’ve learnt from my successes and failures as a player, as a husband and as a father,” he says. “Ultimately, you have to ask yourself: how comfortable do I feel as a human being? I feel pretty good.”

hurdles-in-the-sky

Sun Jul 31 12:47:51 IST 2022

Adam Harry can fly, but India’s callous rules will not let him.

The 23-year-old, who holds a private pilot’s licence from South Africa, had become India’s first transgender trainee pilot in 2019, when he enrolled at the Rajiv Gandhi Academy for Aviation Technology, Thiruvananthapuram. The following year, though, he was grounded by a regulatory barrier. The Directorate General of Civil Aviation (DGCA) declared him “unfit to fly”, saying he had “gender dysphoria”—the sense of unease transgender persons may have because of the mismatch between their biological sex and gender identity.

Harry hails from Kerala’s Thrissur district. He was in his early teens when he began dissociating from his female identity. For the past four years, he has been undergoing hormone replacement therapy, which he says led to the DGCA’s decision to declare him unfit. On July 27, 2020, Group Captain Y.S. Dahiya of the DGCA’s medical services department wrote to him that he would not be classified as “fit to fly” as long as he was on therapy.

“My identity is that [of a man], and I want to express my identity on my body,” says Harry. “That is why I went through the transition. I did that because I am loving myself and that I want to live as myself.”

Harry's dream of becoming a pilot started around the same time he began transitioning. “By the time I reached high school, I was familiar with the term transgender,” he says. “Initially, I thought this feeling [of being trapped in a body belonging to the opposite sex] was something happening only to me. Then I saw articles about transgenders, and the landmark NALSA judgment of 2014 [in which the Supreme Court affirmed that transgenders have full recognition in the eyes of law]. Those gave me more insights.”

Initially, there was no one to support him in his difficult journey—not even his dear ones. “I didn’t have to tell my family—they knew from my behaviour and clothing,” he says. “Everyone would curse and shame me.”

He got the courage to come out socially after he completed class 12 and went to Johannesburg to train as a pilot. “I got in touch with the LGBTQ community there, and came out socially,” he says. “My family soon asked me to come back to India; they have not accepted it yet.”

Family and financial issues forced him to return to Kerala. He left home in 2018, moved to Kochi and began doing odd jobs to support himself. At 19, he took a decisive step in his transition—to start hormone therapy. “In the first stage, we have to consult a psychiatrist,” said Harry. “Because we have to understand what all changes would happen, and be able to adapt to all changes and the complexities involved in those changes. We have to do this before any surgery or treatment. Then comes the endocrinologist, who will administer hormone therapy after first checking the hormone levels.”

Hormone therapy is a prerequisite for sex-change surgery. But people can opt for just the therapy. A lot of transmen go for “top surgery”—the removal of breast tissue—without opting for the bottom one. Some opt for metoidioplasty, a surgical creation of a penis using one’s existing genital tissue. Then there is phalloplasty surgery, which gives transmen a phallic structure with sensation, and urethral reconstruction, which would connect the urinary system to the new structure so that urine can pass through it. Transmen who wish to have penetrative sex can opt for prosthesis implant surgery as well. Hysterectomy—the removal of the uterus—is another surgical process involved in becoming a transman.

Harry says there is no one-size-fits-all approach to the gender affirmation process. “The decision to undergo surgery or continue with a standalone hormone therapy will vary from person to person,” he says.

It was in January 2020 that Harry applied for an initial medical examination by DGCA. But he was deemed “temporarily unfit” for flying. The reason cited: he was on cross-sex hormone treatment.

Harry was forced to stop the therapy to pursue his dream, but his endocrinologist advised that the therapy should be lifelong. He was in a quandary—he had to choose between his career and his transition.

Harry says the DGCA wrongly assumed that he had gender dysphoria. “Some initial challenges were there when I started the therapy,” says Harry. “For example, there was the cracking associated with my voice change. But I did not face any mental health issues. I have only enjoyed each hormone shot and the changes they brought.”

In July this year, media reports and the CPI(M)’s Rajya Sabha member A.A. Rahim brought Harry’s troubles to the notice of the Union ministry of social justice and empowerment. The ministry wrote to the DGCA that it needed to frame fair and separate guidelines and standards to test transgender candidates. The DGCA has now told Harry to reapply for a medical fitness examination.

“Use of hormonal replacement therapy is not disqualifying if the applicant has no adverse symptoms or reactions,” it said. “However, flying duties are not permitted while the dose of hormonal treatment is being stabilised, or until an adequate physiological response has been achieved.”

Harry says he has won a battle, but the war remains. “Earlier they wanted me to stop hormone treatment; the fact is that for many [transgender] people, hormone therapy will be a lifelong process,” he says.

Now that the DGCA has become sensitive to the issues involved, what are Harry’s plans? “I will reappear for the DGCA’s medical test,” says Harry. “But I will be going to South Africa to obtain my commercial pilot licence. I have been offered admission from Vulcan Aviation, an academy in Johannesburg. But I will come back. I am not going anywhere permanently.”

early-childhood-stimulation-is-crucial-in-childs-intellectual-development

Sun Jul 31 12:49:13 IST 2022

Gianna Fernandes from Bengaluru loves curling up on the sofa with a pop-up book of fluffy puppies. The 18-month-old loves to touch and pet the puppies. “Gianna can easily identify a dog’s breed,” says Albert Fernandes, her dad.

A hands-on parent, Fernandes creates opportunities for his daughter to explore, learn and be heard, instead of letting her watch television all day. Gianna loves animals. Fernandes and his wife, Felicia, show her pictures and create puzzles for her. “She can pull out animal figures and put them back. Each one of those figures makes a particular sound. Gianna can tell what each animal sounds like,’’ says Fernandes. During the day, Felicia and Fernandes make her do brainstorming activities. “In the evening, we make her run and do physical activities so that she gets exhausted and sleeps well at night,” he says.

While most parents know that right nutrition is the key to early brain development, many of them overlook the importance of early stimulation. A growing body of research suggests that early childhood stimulation plays a significant role in a child’s intellectual development. Activation of the senses of vision, hearing, touch, taste and smell is vital to the development of sensory pathways in the brain, which, in turn, promotes cognitive development. “The lovely sting of dad’s one-day-old stubble gives the same secure feeling to a child as the softness of mom’s cuddle,” says Manjusha Sandeep, counselling psychologist and centre head, T.I.M.E Kids preschool, Kochi.

Cognitive development refers to the development of a child’s ability for attending, retrieving, thinking and problem-solving as well as linguistic abilities, says Dr Rajakumari P. Reddy of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Research confirms the role of an enriched environment in cognitive development. An ongoing animal study conducted by NIMHANS shows that visual and auditory stimulation and group housing can make mice smarter and more intelligent. “We created an environment that resembles Disney Land. It was found that mice that were given toys and ladders to play with had higher levels of cognitive development than the ones reared in a deprived environment. Enriched mice could even undo the effects of stress,” says Dr Laxmi Rao, professor of neurophysiology at NIMHANS. The mice were also fed on a diet enriched with protein and vitamins. The study shows that stimulation in the environment leads to positive physiological changes in the prefrontal cortex and hippocampus, parts of the brain involved in learning and memory.

As a parent, Dianne Sunny from California made sure her sons, Neil and Noah, had plenty of outdoor play opportunities every day. “Unless they were sick or the weather was bad, we went out to the park, library or the beach,” she says. “Play is the primary form of learning in kids. It helps develop a well-rounded personality,” says the 39-year-old who worked as an elementary school counsellor for a while.

Early sensory stimulation improves a baby’s memory and attention span and the ability to learn new things, says Dr Sagar Mundada, consultant psychiatrist at Healthspring, Mumbai. “The multi-sensory experiences also help calm the child.” Mundada’s 10-month-old son, Agastya, loves playing with multi-coloured blocks, each side of which produces a different sound.

Researchers emphasise the role of play in cognitive development. Play should be least governed by rules. The crux of play is creativity and fun. It should lead to joy and a sense of wellbeing. That is what matters more than the material being used, says M. Thomas Kishore, additional professor and consultant clinical psychologist at NIMHANS.

Sunny would agree. Even mundane things can be used to boost baby brain development, she says. “Our family is heavily into music. When I cook, I would let my kids bang on pots and pans, listen to music or watch dance,” she says. Her 11-year-old elder son Neil, who was tested “gifted”, has written a book which he self-published.

Fret not if your children do not have access to sophisticated gadgets, imported books or boxed material. Let them spend time with nature. Playing with mud and sand provides natural building blocks for brain development.

Look around and be innovative. Any natural material such as twigs, stones, pebbles, empty cans, shells, flowers, bird nests, feathers and bells can be used as tools for brain development. Ordinary materials used in houses can be used as toys. “Make sure the material is non-toxic, safe and appropriate to the developmental age of the child,” says Kishore.

Babies below the age of six months like toys hanging from above that they can look at. They like to play with objects they can grab. Play involves vision and hearing, with the baby adjusting its position to hold the object and examine it. All these activities promote integration of the senses. Muti-sensory information helps form new neuronal connections leading to cognitive development. A seemingly simple play or sensory stimulus can activate the brain in multiple ways. “We use play as a medium to help mothers bond with their babies better. Play helps the child develop communication skills and motor coordination,’’ says Kishore. “Children above six months will look at their caregivers for approval. Depending on their response, they will repeat the task or explore new things. Play instils inquisitiveness in children. It helps them to be independent and socially responsive.” Depending on the need, play activities can vary. Parents should ensure that there are no gender stereotypes playing out, says Kishore. Boys can play with kitchen sets just as girls can operate automobiles.

Play can give a good indication of the intellectual development of the child, the quality of her thinking and reasoning, creativity and emotional maturity. The quality and nature of play can sometimes help clinicians understand whether the child has any development disorder, says Kishore.

Children experience the world through senses and motor ability, initially. For instance, a child may be curious to smell flowers, taste food, listen to sounds and talk to strangers. The curiosity leads to exploration by physical activity such as moving, sitting, standing, walking and running, says Reddy. “Physical mobility leads to increased cell connections within the brain to enhance cognitive ability.” Researchers say that social interaction and language are the main factors in cognitive development. Caregivers and parents looking at children and talking to them can help their brains develop.

The pandemic has added to parenting woes. According to a study conducted by the National Commission for Protection of Child Rights, 23.8 per cent children use smart phones while in bed before going to sleep. How much screen time is too much? “Screen cannot be a play medium,” says Kishore. “That said, don’t dismiss technology. Gadgets improve hand-eye coordination and finger dexterity to a certain extent. But make sure the gaming and screen time do not substitute everything else.”

The American Academy of Child & Adolescent Psychiatry (AACAP) suggests screen time should be minimal for children up to one and a half years. It may be limited to video calls with a family member who is away. “Some parents take pride in the fact that their toddler can browse internet on a laptop or a smart phone and play music or games on their own. It won’t boost brain development. Too much screen time could impact their socio-emotional processing skills,” says Kishore. Children aged 18 months up to two years may be allowed limited screen time with a caregiver. Children aged between two and five years should limit non-educational screen time to one hour per week day and not more than two to three hours per day on weekends.

If your child is a prodigy, parents should nurture the kid's talent. “An average parent might think I’ll give my child an encyclopedia. The child will be exhausted,” warns Kishore.

The most essential aspect of the work with the little child is the inner attitude of the educator, who provides the example for the child’s imitation, says Hetal Shah, teacher at Advaya Shaale School in Bengaluru. “The development of each individual child and of humanity depends on experiences in the first seven years of life,” she says. “An atmosphere of warmth and guidance that promotes joy, wonder and reverence supports such healthy development.”

why-the-who-needs-to-get-woke-and-fast

Mon Jun 27 10:31:28 IST 2022

On June 14, WHO Director General Tedros Adhanom Ghebreyesus announced that the organisation will give a new name to monkeypox. The decision was made in light of the stigma and racism associated with the name. Recently, a group of 30 doctors wrote a letter to WHO asking for a “non-discriminatory and non-stigmatising” name for the viral disease.

The name monkeypox was coined after the discovery of the virus in monkeys in a Danish lab in 1958. The disease is caused by a virus which belongs to the orthopoxvirus genus of the poxviridae family. The first human case reported was a child from Congo in 1970.

The disease begins with symptoms such as fever, headache, muscle pain and swollen lymph nodes. The incubation period is usually seven to 14 days. Within one to three days after the onset of fever, the patient develops rashes, which become filled with fluid, and eventually scab over and fall off. One in 10 people who get the disease die.

Monkeypox (no new name has been announced as of June 16) was considered endemic to central and western African countries. However, in the current multi-country outbreak, the majority of cases (1,112 or 87 per cent) are in Europe, as of June 8. Cases were also reported from the Americas (153), Eastern Mediterranean Region (14) and Western Pacific Region (6). According to WHO, “most reported cases in the newly affected countries have presented through sexual health or other health services in primary or secondary health care facilities with travel history to countries in Europe and North America rather than to countries where the virus is known to be present”.

But most European and American media outlets—and even outlets in India—used stock images of African or dark/black people during their coverage of the zoonotic disease. The Foreign Press Association, Africa, had, in May, condemned the stereotyping. “Shouldn’t it be logical that if you are talking about the outbreak of monkeypox in Europe or the Americas, you use images from hospitals across Europe or the Americas?” it asked, adding that the stereotype assigns calamity to the African race and privilege or immunity to other races.

There are mainly two variants of monkeypox: the West African clade and the Congo Basin clade. These names are also criticised for inflicting stigma.

There is also criticism that the global media coverage of the current outbreak is rooted in homophobia. On May 25, the WHO had issued an advisory for “gay, bisexual and other men who have sex with men”. It was in the wake of the findings that people from these communities face a high risk of getting affected. The advisory had added that “stigmatising people because of a disease is never ok. Anyone can get or pass on monkeypox, regardless of their sexuality”. But the stigmatising happened, and it once again proves that marginalised sections bear the brunt of health crises.

what-if-we-could-genetically-dial-back-our-skin

Fri Jun 24 18:00:41 IST 2022

When was your complexion at its very best? Perhaps in your late teens, after the curse of spots had finally passed? Or a decade on, when elegance had supplanted callow youth and the wrinkles were yet to appear? So advanced is the aesthetic industry that most of Hollywood is already on this quest, with Brad Pitt, Demi Moore and the like, you name them, looking far more youthful than their near 60 years. But, what if one day we could do more than have facials and tweakments to keep us looking younger? What if we could genetically dial back our skin? That is the ultimate promise raised by British researchers who revealed that they had turned the clock back on ageing human skin cells by 30 years. Just imagine: three decades of sunbathing, stress, late nights and the odd bottle of booze, all wiped from the millimetre.

The news comes amid a wave of renewed interest in the field of regenerative medicine—the idea that we can rejuvenate ageing cells so that our bodies and brains can start afresh, bouncingly free of disease and full of youth’s resilient energy. In the latest advance, researchers from the Babraham Institute, a research institution partnered with the University of Cambridge, took skin cells from a 53-year-old woman and “rejuvenated” them to act as though they were 30 years younger.

When the cells were applied to a simulated wound in a laboratory, their healing response was as sprightly as if they had come from a 23-year-old, the scientists said. The team adapted a Nobel prize-winning technique that uses proteins involved in birth development to get adult human cells to revert back to embryo stem cells. This approach takes the cells’ age right back to zero. Stem cells hold great medical promise as “precursor cells” that can be turned into any new kind of human cell to replace damaged or diseased ones. But that potential has mostly remained unrealised for decades—not least because medically implanted stem cells can be lethal.

Stem cells were discovered in the early 1960s. Then, in the late 1990s, scientists managed to isolate them from human embryos and grow them in the lab. I remember when I was a wrinkle-free young reporter how this news prompted a gush of experts to predict that the novel technology would revolutionise health care within a decade, curing our most serious ills, such as cancer, Alzheimer’s and heart disease. Then stem cells’ potential for danger rapidly began to emerge.Little anarchists they are, lab-derived stem cells. With all that potential to become anything, it was discovered that they can do precisely that. And “anything” includes tumour cells or whatever else they fancy. “If you grow stem cells into pancreas cells in the hope that they will produce new insulin in people with type 2 diabetes, they can instead decide to make all the hormones that a pancreas could possibly produce, which isn’t helpful,” said Dr Diljeet Gill, 27, one of the authors of the new skin study.

The technique that Gill’s experiment used to rejuvenate human flesh was crucially different. Instead of reprogramming the 53-year-old woman’s skin cells back to being age-zero stem cells, it stopped the age-reversal process before they got that young. Thus the cells had dual identity—youthful enough to fizz with vitality, but old enough to know their job as skin cells. The altered cells matched the profiles of cells 30 years younger. Once rejuvenated, they produced far more skin-pillowing collagen than the unmodified cells.Professor Wolf Reik, the German molecular biologist and group leader at the Babraham Institute, co-authored the study. He said, “It looks like you may be able to select the age to which you turn back the cells, at least by the decade, so you could find the general sweet spot.”

The approach marks a potential breakthrough for the field of regenerative medicine. Investors are salivating at the prospect, which helps to explain why analysts are predicting that the scientific industry will be worth $50 billion in five years’ time.Scientific institutions are already developing stem cell-based technologies to regenerate our most frequently worn-out organs. In the UK more than 40 per cent of people over 50 have hearing loss. Now investigators at Frequency Therapeutics, a spin-off company of Massachusetts Institute of Technology, are pioneering a new type of regenerative therapy to reverse it.

A significant cause of hearing problems is the loss of minute cochlear hair cells in the inner ear. These are the sensory cells of the auditory system. Over time they die, and don’t regenerate. In March researchers at Frequency Therapeutics explained how they are developing a drug that programs the descendants of stem cells in patients’ inner ears, called progenitor cells, to awaken and recreate cochlear hair cells.

Eyes are another age-old problem. An Indian biotechnology company called Pandorum Technologies is developing a gel that can carry corneal stem cells into the eye to regenerate people’s corneas.

And where old bones are concerned, researchers from Texas A&M University reported how they had developed new ways of delivering rejuvenating stem cells into damaged and worn limbs using nanotechnology, strengthening hopes that we can keep our skeletons straight and sturdy well into old age.As for being able to completely refresh our midlife flesh, sadly we will have to wait a while. As Gill said, “We think the prime opportunity here is for ex-vivo rejuvenation, in which we take diseased or damaged skin cells out of the patient, rejuvenate them and then return them to the damaged area of the patient’s skin so that it vigorously regrows and heals.”

Because the scientists would effectively be giving patients a transplant of their own skin, only decades younger, there is no danger of their bodies rejecting the tissue as foreign. “With this we could treat severe flesh wounds such as cuts, burns, lacerations and ulcers—situations where aged cells have real difficulty healing,” said Gill.

His next priority involves testing skin-cell rejuvenation further, to be sure that it won’t cause cancer, before trialling it in humans. From there, the research is set to swerve into another age-related disease: dementia. Reik believes the technique may reverse age-related decline in our immune systems, too.

The pandemic highlighted how, as we get older, our defences steadily weaken. “I’m hopeful that the technique can make a vital difference here,” he said.Ilaria Bellantuono, a professor of musculoskeletal ageing and co-director of the Healthy Lifespan Institute at the University of Sheffield, is erring on the side of caution, “It is very early days. The new experiment is only in a laboratory petri dish. We don’t know whether the cells will perform their jobs properly in a living human. We don’t know yet how the changes made will affect the skin cells’ most important functions in humans, such as making collagen and dividing.”

Nevertheless, Bellantuono remains optimistic that in decades to come the new Cambridge technology could put scientifically effective age-reversing therapies on our chemist’s shelves. “I think where the new research goes many years from now is the development of drugs that reverse ageing with cells in the organism directly,” she said. “You may be able to take a pill that partially reverses your age so that it may properly rejuvenate your skin and other organs. If you want to do something about your cellular clocks right now, you need to work on your fitness and general health. Looking after ourselves is the best thing we can currently do to slow the ageing process and protect our skin and other vital tissues.” Oh well, back to the treadmill.

why-we-need-to-publish-more-books-in-braille

Mon Jun 27 12:36:18 IST 2022

Benode Behari Mukherjee, one of the greats of modern art in Bengal, lost his eyesight in 1957, when he was 53. But he never lost his vision. Undeterred by darkness, Mukherjee reinvented himself by relying on touch and memory to produce paper-cuts, sculptures and drawings. “Painting is a blind man’s profession,” Picasso said once, perhaps implying how colours and the visible light spectrum are subjective things. So when the Kolkata Centre for Creativity (KCC) released The Art of Benode Behari Mukherjee—the first in a series of Braille books on art—at the recently concluded India Art Fair, it seemed like a long overdue effort.

Published in collaboration with the NGO Access For All, the book serves as an introduction to the art and life of Mukherjee, enlivened through five paintings that have been converted into tactile artworks (with permission from Mrinalini Mukherjee Foundation, named after his daughter), and an accompanying essay in Braille by K.G. Subramanyan, his student, friend and fellow modernist.

“Art books, most of which are exhibition catalogues, are more often than not written and consumed by the anglophone. As a result, we do not even have art books in regional languages to bridge the divide between the privileged anglophone and the rest, let alone enough books in Braille that discuss art and culture,” says Richa Agarwal, chairperson at KCC. “Realising this need, we have committed to creating at least one Braille book each year on an artist who can inspire people to engage with the arts, if not convince them to pursue it.”

Agarwal plans to honour another master from Bengal in the next Braille book to be published by KCC. The Art of Benode Behari Mukherjee has English text as well, printed in large font for the partiality blind.

It is indeed hard to produce an art book in Braille that truly appeals to, and benefits, a visually impaired adult. Verbo-visual prompts are never enough to fully convey the transformational power of a work of art. Arctic Circle: A Tactile Graphic Novel For Blind Readers (2016) has the artist Ilan Manouach construct an entirely new language as part of his “conceptual” comic book about a pair of climatologists in the North Pole. “To make comic books accessible to the blind, Manouach devised an entire new language composed of sculptural, touchable symbols and patterns, which are pieced together to tell a story….” writes a reviewer in the online arts magazine Hyperallergic. “The result is Shapereader, a system of tactile ideograms, or ‘tactigrams’—haptic equivalents for objects, actions, feelings, characters and other features of any story. They are raised shapes on wooden board, and have more in common with Chinese pictograms than with Braille letters or the Roman alphabet, in that they are textural depictions of what they represent.”

In India, we are yet to see innovative art books that are so thoughtfully produced for the blind or the partially impaired. “While a number of blind schools and Braille presses are active, making visual arts and artists accessible to the visually impaired has remained low priority,” says Agarwal. “KCC’s Braille Books on Art series attempts to bridge this gap by converting two-dimensional artworks into tactile artworks that could be felt and experienced physically.”

Siddhant Shah, founder of Access for All, has been at the forefront of improving the “experiential culture” of public spaces. From museums and lit-fests to art fairs and heritage institutions, Access for All has worked on altering access for people inhabiting a spectrum of development disabilities. From creating a physical Braille copy of The Far Field by Madhuri Vijay, winner of the 2019 JCB Prize for Literature, to making the first Braille handbook for the State Bank of Pakistan’s Museum and Art Gallery in Karachi to coming up with Braille copies on menstrual hygiene, banking and lifeskills, Access for All is perhaps the first point of call in India to produce tactile books that improve readership beyond textbooks for the visually impaired. Shah’s own vision of what constitutes a Braille book has evolved after receiving feedback in the last seven years when Access For All was first established.

“Once we had a very interesting observation from a colleague of a visually impaired person. She said that when this person is reading the book, we become visually impaired because we don’t know Braille. So for us, the information is not accessible,” says Shah, 31. “And that really startled us. We began thinking of ways to bring things together in such a way that everyone can use it. Rather than segregating people under the name of accessibility, we thought of having more of an integrated model.”

Access For All’s three-member team, with an in-house workshop, painstakingly works in an in-house workshop with a veritable library of texture and materials, and patterns and permutations of lines and dots overlaid on images to offer a more fulsome experience. His own inspiration is his mother, who has only partial eyesight. Shah’s next big project: roping in artists with disabilities in India and the UK for a one-of-a kind arts festival.

dostarlimab-might-not-be-a-magic-bullet-for-all-cancers

Sun Jun 26 18:05:38 IST 2022

Earlier this month, a very small trial of rectal cancer patients led to an unheard-of outcome—remission in all participants. The findings of the trial in which patients took dostarlimab, an immunotherapy medicine that spurs patients' immune systems to attack their cancers, were published in The New England Journal of Medicine. The drug was taken by each patient every three weeks for six months and all 12 participants had similar mutations in what is called mismatch repair-deficient colorectal cancer, which occurs in 5 to 10 per cent of colorectal cancers.

Experts from the Memorial Sloan Kettering Cancer Center say immunotherapy revs up the immune system so that it sees the cancer and gets rid of it. Dostarlimab is an antibody that targets a protein called programmed cell death 1, or PD-1 which exists on the surface of T-cells produced by the human body's immune system and helps the body recognise and destroy cancer cells. Cancer cells, in turn, can produce molecules that block PD-1 and evade detection by the immune system. Dostarlimab works by preventing this evasion, allowing the immune system to detect and kill cancer cells. On completion of treatment and six months of follow up, not a single patient was detected with cancer cells or significant side effects.

Mitesh Patel, senior research technician at MSK Cancer Center, works with leading oncologist Dr Luis Diaz Jr, who authored the study. Patel specialises in the study of cancer genomics and its applications towards developing early diagnosis and monitoring the disease by assessing DNA in tumour and liquid biopsies. Excerpts from an interview:

What is the most exciting part of the trial?

The most exciting part is the unprecedented response rate observed in the trial. Immunotherapy has been around for a while, and many cancer types have shown promising results, including lung cancer and melanoma. However, we have not seen such a dramatic response rate in cancer treatment. The standard of care treatment in locally advanced rectal cancer, such as chemotherapy, radiation, or surgery, may have resulted in higher grade toxicity, whereas we observed minimal toxicity with immunotherapy.

What led you to the trial with Dostarlimab?

Dostarlimab is a monoclonal antibody against PD-1 and belongs to a class of drugs called immune-checkpoint blockade. Usually, our immune system should be able to recognise and kill the cancer cells if they look foreign enough to immune cells. However, cancer cells overexpress the protein called PD-L1 to escape the immune system. Anti-PD-1 antibodies help T cells to release the breaks (figuratively speaking) and efficiently detect and kill the cancer cells. Others published promising results of immune checkpoint blockades in cancer types, including metastatic colorectal cancer. However, this is the first study where immunotherapy was given as frontline treatment for locally advanced rectal cancer.

Immunotherapy has been going on for quite a while and has shown impressive results. What was that one point of difference that led to success in complete remission in your trials?

It is a crucial question; what makes the tumours in this study special to be able to respond to immunotherapy and go into complete remission. Careful and thorough molecular profiling would help us answer that question in the future. There might be other tumour-intrinsic factors as well. One explanation is that the microbiome may have played a significant role. Gastrointestinal tract tumours have been shown to benefit from a particular type of gut bacteria by augmenting immune checkpoint blockade treatment.

So, at least in the case of rectal cancer, dostarlimab is the magical drug we have been pining for?

Our trial enrolled rectal cancer patients with a genetic defect called mismatch repair deficiency. About 5 per cent of rectal cancer patients have this defect. The patient with this defect loses one or more proteins crucial for repairing the DNA defects. As a result, after checkpoint blockade treatment such as dostarlimab, our body's immune system can recognise the tumour as foreign and be able to destroy them. So, it may be inaccurate to say it is a magic bullet for all rectal cancer.

What will the next phase of trial look like? How positive are you about the success of dostarlimab in new trials?

Although the study results were outstanding and they presented compelling evidence, we must recognise the small number of patients in the trial. Longer follow up of these patients would also be required to assess the response duration conclusively. However, we are hopeful that these results will change how locally advanced rectal cancer with mismatch repair deficiency is currently treated.

What is the patient profile you will consider in the next phases of the trial?

As I mentioned, this is an exciting study. However, we have to exercise some caution and not generalise and assume that it will be a magic bullet to cure cancer. Our team and collaborators are dedicated to investigating molecular profiles that made these tumours highly susceptible to the treatment. Meanwhile, we are focused on accruing target enrolment for the trial and having a longer follow-up to ensure the durability of the response.

Have there been instances when cancer recurred even after long gaps?

I am not a clinician, so I cannot speak from firsthand experience. Sometimes completely remitted tumour comes back in weeks, months, or even years after treatment. The recurrence rate can be varied based on various factors such as cancer type, stage, treatment, genetic factors. For example, for colorectal cancer, roughly 15 per cent of cancers come back after curative surgery, whereas almost 90 per cent glioblastoma reoccurs after treatment.

What is the cost of dostarlimab? How many doses are required?

I can only speak of the dosing schedule in our trial. We administered the dostarlimab every three weeks for six months.

Why is immunotherapy not working as effectively for other cancers?

Scientists at MSK, and across the globe, are investigating the biology behind the different response rates in various cancer types. Studies have shown the benefit of immunotherapy in cancers with a higher mutation burden. There are molecular mechanisms that we do not yet understand. The interaction between the immune system and cancer cells is so dynamic, multifaceted, and complex that it is naive to think one treatment would show similar results across all other cancers. Immunotherapy is one of the essential treatment modalities of precision medicine where clinicians are looking beyond the “one-size-fit-all” approach of conventional chemotherapy. There are fascinating studies taking place investigating combination treatments, such as combining multiple immune checkpoint blockade agents or combining with chemotherapy.

why-heart-diseases-are-on-the-rise-among-young-indians

Fri Jun 24 17:05:59 IST 2022

Every 39 mg/dL reduction in serum LDL (low density lipoprotein, popularly known as bad cholesterol), sustained over a period of five years, reduces the risk of death from cardiovascular diseases by 20 per cent.

The Lipid Association of India, a team of doctors in the field of cardiovascular medicine, internal medicine and pharmacology, recommends that the screening for high cholesterol levels should begin at the time of leaving school. If Arpan Shah from Mumbai knew this, his life would have been different. The 36-year-old, who works in a diamond shop at Mumbai's Bandra Kurla Complex, consulted a general practitioner last year as he experienced chest pain. He was detected to have a heart attack. “One of my arteries was completely blocked,’’ he said.

To stent or not to stent is a dilemma cardiologists often face. “Since the patient was young, we did not want to put a stent. Instead, we decided to treat him with blood thinning medicines and injections and repeat his angiography after 5-7 days,” said Dr Ruchit Shah, consultant cardiologist at Masina Hospital, Mumbai. “The second angiography showed that there were still some subtle blocks remaining. Then we did a fractional flow reserve procedure to see whether the blocks were significant or not and whether the patient needed angioplasty and stenting. The blocks had dissolved to a great extent and the patient did not require angioplasty.” Shah has been advised to lower his total cholesterol and LDL levels with high dose statins, daily exercises and diet control.

Heart diseases seem to be on the rise among young Indians. “We develop coronary artery disease 10 years earlier than other ethnic groups. What is even worse is that approximately 40 per cent of Indians with coronary artery disease are under 40, and 25 per cent of our cardiovascular deaths, too, are below the age of 40,’’ said Dr C.K. Ponde, consultant cardiologist at Hinduja Hospital, Mumbai.

Elevated levels of LDL is a common culprit behind cardiovascular problems. LDL is responsible for the deposition of cholesterol and plaque inside the arteries in the entire body. “Cholesterol travels through blood on proteins called lipoproteins. Among the various lipoproteins, LDL is the villain that can stick on the inside of the arterial walls and create blocks to cause heart attacks and strokes,’’ said Dr Vivek Jawali, chief cardiothoracic and vascular surgeon and chairman, Fortis Hospitals.

According to Dr Rishi Gupta, chairman, cardiac sciences, Accord Superspeciality Hospital, Faridabad, acceptable levels of LDL are below 100. “In patients who already have the disease, the expected level is below 70.’’ Lowering the LDL level can reduce the risk of cardiovascular problems significantly. Statins are the primary drugs used for controlling LDL, aimed at reducing the risk of heart problems and stroke. However, some patients do not respond to statins. “Despite high doses, 40 to 50 per cent of patients do not achieve the target level of LDL, therefore additional drugs are required. Also, a high dose of statins can cause severe muscle pain,’’ said Gupta.

Bempedoic acid drugs offer hope to patients whose LDL levels cannot be managed with statins alone or those who cannot tolerate statins. “It has been conclusively ascertained that the drug can be safely used in such patients,” said Dr S. Venkatesh, lead consultant, interventional cardiology, Aster RV Bengaluru. Zydus Lifesciences recently launched its bempedoic drug in India under the Bemdac brand.

However, bempedoic acid drugs are not an alternative for statins, said Dr Praveen Chandra, cardiologist and chairman of interventional cardiology at Medanta-The Medicity, Gurugram. “These are not as strong or effective as statins and are only to be given when statins are not effective. For instance, some patients have elevated levels of LDL even after taking 20mg of statins. For them, bempedoic acid drugs may be given in addition to statins,’’ he said.

Statins lower LDL by inhibiting HMG-CoA reductase, an enzyme that produces cholesterol. Bempedoic acid drugs slow down a different enzyme in the cholesterol production pathway known as ATP citrate lyase–but only in the liver. “Unlike statins, bempedoic acid only works in the liver so it is much less likely to cause side-effects affecting the muscles, one of the main reasons some people cannot take statins.”

There are numerous studies on the bidirectional link between LDL and Covid-19 infections. “It is a myth that low LDL causes severe symptoms of Covid infection,” said Dr Siddhant Jain, director, cardiac sciences, and chief interventional cardiologist, Shalby Hospitals, Indore. “It is actually the other way round. The severity of Covid brings down LDL levels and thus low LDL is found in these cases. It is not a causative relationship but a correlation. People often misinterpret this and stop taking their cholesterol medicines."

The LDL levels in blood are predominantly determined by the genes and not by diet, said Dr Ranjan Shetty, head of the department and consultant, interventional cardiology, Manipal Hospital, Old Airport Road, Bengaluru.

Albert Fernandes from Bengaluru would agree. The 34-year-old did a blood test a few months ago as he was suffering from allergic rhinitis. To his dismay, he found that his cholesterol levels were above normal. His total cholesterol was 203 mg/dL and his LDL level was 122 mg/dL. Fernandes was advised to make changes to his lifestyle and diet. “I was told to avoid red meat and shellfish and to do cardio exercises regularly,” he said. He followed the doctor’s advice and repeated the tests three months later. “My cholesterol levels were even higher. Sometimes my chest feels heavy,” said Fernandes, who has now been advised to take statins.

Genetic mutations can also affect cholesterol levels. “A reading of 190 mg/dL is considered high. For diabetic patients, even a value of 70 mg/dL is considered high. People who are already dealing with heart diseases should control their LDL level to a value less than 55 mg/dL,’’ said Shetty.

A low LDL level is critical for everyone, including men and women of all ages, with or without heart disease. “It is critical to get a comprehensive lipoprotein profile if you are feeling any discomfort,” said Dr Amit Pendharkar, director, cardiology, Aakash Healthcare, Dwarka. “If your cholesterol levels are not where they should be, see a dietitian right away and start living a heart-healthy lifestyle. Furthermore, people should avoid fatty and junk food at all cost. Eat more fibre-rich food and live a healthy lifestyle,’’ he said.

Researchers believe that there is a link between stress and LDL. Stress results in elevated levels of cortisol, the stress hormone which, in turn, leads to high LDL. Stress also brings down the good cholesterol.

Music can help maintain better cholesterol levels. Ancient Greeks used music to soothe pain and reduce stress. Singing was part of the healing rituals of native Americans and Africans. Participants in some of the recent scientific studies reported experiencing significantly less anxiety and pain when they listened to music for 30 minutes.

Listening to your favourite songs is one of the easiest ways to bring down LDL levels. Dr Sparsha S. Vasisht, a final-year resident at the department of anaesthesiology at SDM Medical University, Dharwad, listens to music in her operation theatre. “Our OTs have inbuilt speakers,” she said.

But it can be a different story for performing musicians. It is well documented that professional musicians and music students regularly encounter musculoskeletal and mental health problems, said Jain. “Performing music can lead to increased heart rates and blood pressure. Musicians may be dealing with major stress in creating music. Performing in concerts in high temperatures with a large crowd can generate stress.”

Low HDL and high triglyceride levels along with high LDL levels contribute to atherosclerotic coronary artery disease, said Dr Lal Daga, senior interventional cardiologist, Apollo Hospitals, Ahmedabad. He said high carbohydrate levels in the diet must be contributing to the high triglyceride levels.

Harsh Yadav from Indore had a mild increase in LDL with low HDL which made him susceptible to heart problems. The 33-year-old had a terrible lifestyle that included tobacco use, sedentary work and excessive stress and he did not bother to seek medical help even after facing extreme perspiration and chest discomfort.

Yadav ended up paying a huge price for ignoring the body’s plea for help. One day he collapsed in his office and was taken to Shalby Hospitals by his coworkers. It turned out that he had suffered a massive heart attack. “He was taken for angioplasty right away and his blocked arteries were opened, saving his life. Now he will have to be on medications for the rest of his life with a weakened heart,” said Jain.

Taking into account the increasing prevalence of cardiovascular problems among India’s youth, Dr Sudheer Koganti, consultant interventional cardiologist at Citizens Specialty Hospital, Hyderabad, said India needed to develop a mechanism to screen adults under 30, especially those with a family history of cardiovascular diseases. “A simple blood test can help you check and monitor cholesterol levels, particularly triglycerides and LDL cholesterol,” said Koganti. “The test can be performed more often if you have heart disease, diabetes or high cholesterol running in your family.”

infection-that-troubled-justin-bieber-is-in-india-too

Sun Jun 26 18:08:20 IST 2022

Surya Teja is not a huge fan of pop songs. He has never listened to Justin Bieber’s 'Peaches' or 'Yummy'. However, the 33-year-old from Andhra Pradesh can relate to the pop icon. Like Bieber, Teja suffered from Ramsay Hunt Syndrome. The viral disease caused half his face to be temporarily paralysed.

“A sore throat was the first sign of the infection,” recalled Teja, a nursing officer at the casualty department in the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Two days later, he had pain in the left ear and difficulty in swallowing. He popped a pill and went about his daily activities. But when his left ear turned red and dry, he realised something was amiss.

Teja's ENT misdiagnosed the symptoms and gave him medicines for an ear infection. Though Teja followed the doctor’s instructions, his symptoms persisted and he also started having severe headache and was unable to close his left eye. His mouth was also deviating to the right side. A worried Teja consulted doctors at NIMHANS. He was diagnosed with left-sided facial muscle weakness and fluid eruption over the left ear. He also had ear ache and blisters over the left ear canal.

Teja was put on an antiviral drug and a short course of steroids. He also underwent physiotherapy for the facial muscle. “His earache and blisters subsided over the next few days and with continued rehabilitation for the facial muscles, he recovered completely in the next few weeks,” said Dr K. Raghavendra, who was part of the team at NIMHANS that treated Teja.

Ramsay Hunt Syndrome is named after American neurologist Dr James Ramsay Hunt, who first described the disorder in 1907. It is characterised by paralysis of one side of the face and fluid-filled eruptions on the ear and face. Usually the seventh cranial nerve (the facial nerve) is affected. People suffering from this infection lose facial expression temporarily. They may not be able to blink or smile.

Bieber's Instagram posts did a lot to spread awareness regarding the condition. “As you can see, this eye is not blinking,” the 28-year-old told his fans in an Instagram video. “I can't smile on this side of my face. This nostril will not move. So, there's full paralysis on this side. This is pretty serious, as you can see.’’

Sometimes, the patient may have giddiness, hearing loss and a buzzing sound in the ear. “There could be swelling near the ear lobes or the auditory canal inside and the patient may have dry eyes and pain,” said Dr Rohit Shetty, vice chairman, Narayana Nethralaya, Bengaluru. The patient may also have change in taste perception or loss of taste. Ramsay Hunt Syndrome itself is not contagious, but the blister fluid, which contains the virus, can infect those not vaccinated for chickenpox. “So, they can get chickenpox,’’ added Shetty. Teja got chickenpox when he was seven.

The syndrome can cause scarring and severe and disabling pain over the face. “It is a late complication of a viral infection,” says Dr Sushila Kataria, internal medicine specialist at Medanta Hospital, Gurugram. “It is caused by the same virus that causes chickenpox and shingles.”

“After recovering from chickenpox, the virus clears from the body, but sometimes, there could be residue,” explains Dr Shivaram Rao K., consultant neurophysician, Yashoda Hospitals, Hyderabad. “After many years, when there is suppression of the immune system, it can cause reactivation of the virus. If this reactivation occurs in facial nerve distribution, we call it Ramsay Hunt Syndrome.” Infections like Covid-19, and stress could also act as triggers.

Dr H.K. Susheen Dutt, senior consultant-ENT specialist, Fortis Hospital, Bannerghatta Road, Bengaluru says: “People with diabetes and cancer are at risk of Ramsay Hunt Syndrome. Those who have undergone chemotherapy are also at increased risk.”

Girija Seth (name changed), 50, from Andhra Pradesh, was undergoing chemotherapy when she got an ear ache followed by rashes over the ear pinna. She had symptoms of Ramsay Hunt Syndrome, including deviation of the mouth and the inability to close one eyelid (the left). She was referred to Dr Kailas Mirche, consultant neurologist, Citizens Specialty Hospital, Hyderabad, and was treated with an antiviral agent and steroids, apart from physiotherapy. Mirche said she recovered in four weeks.

Dr Srinivasa R., lead consultant (neurology), Aster CMI Hospital, Bengaluru, said that Ramsay Hunt Syndrome is not common in India. “The incidence rate is five cases per lakh every year.” Routine vaccination against chickenpox can help prevent Ramsay Hunt Syndrome. People above 50 should get the shingles vaccine.

john-naish-on-how-to-bolster-your-brain

Sun May 29 12:02:36 IST 2022

If you worry about suffering senior moments in midlife, new research suggests that you can forget about it for now. Our brains are so resilient that they may maintain their full youthful spritz into our sixties, German scientists say. Their study of 1.2 million people, aged between 10 and 80, claims to dispel the belief that our brainpower peaks at 20, after which it’s all downhill into a treacle-headed world of forgotten names, misplaced door keys and anecdotes everyone’s heard 50 times.

The report in the journal Nature Human Behaviour studied the participants’ speed at answering online tests. It found that average levels in mental speed seem to be quite stable until the age of 60. Furthermore, it adds that if midlifers’ brains may sometimes appear a little ponderous, it’s because they have shed the impetuosity of youth and instead cautiously consider their options before acting. The results suggest that people in their twenties are quicker on the draw not because of more efficient brain processes, but because they are more likely to prioritise speed over accuracy.

Does that mean our brains are so resilient that we can ditch the brain-saving exercise regimens, stop trying to learn new skills and instead order up a squadron of junk food-laden mopeds? Despite the good cognitive-ageing news, the flat answer is no.

Indeed, a different study published this week shows that people who are physically fit in middle and older age can cut their risk of developing Alzheimer’s by up to a third. You may only need to walk briskly for two and a half hours a week to maintain sufficient fitness, says information released by the American Academy of Neurology.

One reason that we should all work to protect our neurons is that not all brains age the same, says Dr Mischa von Krause, the psychologist at Heidelberg University who co-authored the German study. The results, he adds, found “great variability in mental speed within all age groups. There were young, middle-aged, but also old people that showed high levels in mental speed.”

Healthy lifestyles may well be helping here, he says, but his study didn’t examine possible links. “We do not want to imply that exercise, diet, education etc do not matter,” he emphasises.

Von Krause would not be drawn on whether his research showed that age brings wisdom. “Rather than ‘wise’ we prefer the term ‘cautious’,” he says. “We do not want to judge whether collecting more information before making a choice is a ‘better’ strategy. It probably greatly depends on content and context which decision style suits best.”

Nevertheless, international research in the same journal last year suggests that, in fact, wisdom does come with age. The study of more than 700 participants between the ages of 58 and 98 found that while mental alertness declines, our key cognitive abilities to focus on new information and one’s situation actually get stronger.

Although that’s good news, emerging evidence shows that such positives may be imperilled by Covid.

First there’s the virus’s direct impact: an Imperial College London study of 81,000 infected people found that those who had suffered even mild symptoms showed impaired memory, attention, problem-solving and emotional processing. The brains of those who had been put on ventilators had aged more than a decade on average, reports the Lancet journal eClinicalMedicine.

There may also be a more widespread effect, warns Dr Alastair Noyce, the clinical senior lecturer in preventive neurology at Queen Mary University of London, and a consultant neurology registrar at Barts Health NHS Trust. This is because the pandemic lastingly changed our lifestyles, he says.

“A lot of the risk factors for poor brain health will have increased over the past two years, such as lack of exercise, social isolation and stress. We must work to reduce the effect that this has had.”

Fully reviving our networks post-lockdown seems particularly important. Numerous studies have shown how feeling isolated socially can accelerate age-related cognitive decline. But it’s not just about being lonely: a study last August, in the journal JAMA Network Open, showed that being sociable actually has brain-protecting benefits.

It found that in people aged 40-plus, simply having someone available whom you can count on to listen is associated with greater cognitive resilience—which is a measure of your brain’s ability to function better than would be expected for its physical age.

Indeed, the study of more than 2,000 people found that those in their forties and fifties with low “listener availability” had a cognitive age four years older than those with sympathetic ears around.

Joel Salinas, the professor of neurology at New York University who led the study, says it “adds to growing evidence that people can take steps, either for themselves or the people they care about most, to increase the odds they’ll slow down cognitive ageing”.

Meanwhile, Noyce adds that improvements in cardiovascular health, particularly through exercise as well as weight control and not smoking, seem already to be helping to keep our brains young. “We have seen evidence from epidemiological studies that there has been a reduction overall in the incidence of dementia, once age is taken out. The most likely candidate for causing this improvement is work done to improve the population’s cardiovascular health,” he says.

Dag Aarsland, the professor of old age psychiatry at King’s College London, agrees. “Everything that is good for your heart is good for your brain,” he says. “Keeping your blood pressure and cholesterol levels under control has benefits inside the brain as well as outside it.”

While we might feel bombarded by exhortations to maintain an extensive list of brain-healthy habits, Aarsland maintains that exercise is the most important of all. “The best research we have, which covers more than 50 countries, shows that to make the most difference you have to do several things: eat healthily, exercise, stimulate your brain, control your blood pressure and cholesterol, and have social interactions. But if you only focus on one thing, it should be exercise, not least because it encourages all the other things,” he says.

As this week’s study from the American Academy of Neurology shows, you don’t have to do much, Aarsland adds: “The biggest beneficial difference we see is between those who do nothing and those who do something once or twice a week, which may only be brisk walking. However, both aerobic exercise—getting your heart beating faster—and strength training are now shown to have significant benefits as we grow through midlife into older age.”

A recent report in Neurology Today explored how researchers have identified a key brain-protecting benefit that we can all get from exercise: physical exertion releases cognitively beneficial proteins and hormones. One chemical, in particular, is exciting interest: clusterin. The protein is high in the blood of lab mice that do lots of exercise. It is low in sedentary mice, which also have faster-ageing brains.

When researchers at Stanford University, California, took blood serum high in clusterin from exercising mice and gave it to the lazy mice, their brains showed significant benefits, in particular a significant reduction in brain inflammation associated with the development of Alzheimer’s. But if the researchers removed clusterin from the exercising mice’s blood serum before giving it to the lazy mice, their brain-inflammation levels remained high.

Dr Ashok Jansari, the senior lecturer in cognitive neuropsychology at Goldsmiths, University of London, is another big fan of exercise—but more importantly of playing a fast-moving physical game. “One of the best to play is table tennis. It is really good for the brain to get numerous areas involved and networking on a task,” he explains. “The game, obviously, requires plenty of exertion, but also coordination and fast movement, which stimulates numerous regions across the brain: areas at the back are involved in the physical stuff, the front brain makes rapid decisions, and the parietal areas—left and right at the rear—process actions. Then there’s the motor-control area, which is like an Alice band on your brain. You also have to use social areas of the brain to guess what your opponent’s about to do next.”

But it’s not all about rushing about competitively. Jansari also recommends mindfulness meditation. “It exercises the brain’s frontal decision-making areas and also the limbic system. When the limbic system is underactive it lets negative thoughts spiral around—there’s a loss of emotional control.
Research shows that mindfulness strengthens this control,” he says.

“If you compare long-term meditators with people of the same age, IQ and socioeconomic status, you find that they have better developed areas of the brain that are associated with the perception and control of emotions, so they are more resilient to life’s challenges and keep their moods buoyant,” he says. “This is important in later life, when there are strong associations between depression and dementia.”

So there you have it, the new recipe for nurturing your naturally resilient midlife brain: just bolster it with brief, brisk bits of exercise and some sociable fun and games. You even get to sit down and do almost nothing.

dr-alok-kulkarni-on-factors-causing-borderline-personality-disorder

Sun May 29 12:03:12 IST 2022

RAMONA, 36, visited me at the peak of the pandemic with anger outbursts, frequent threats of self-harm, problems with her spouse, family members and friends, and intense crying spells lasting hours. Her attempts at ‘deliberate self-harm’ were a frequent occurrence following a tiff with her spouse. Ramona would lock herself in a room, and violently bang on the door threatening suicide.

During my session that followed, it was evident that Ramona’s worldview fit into the classical “all good’’ or “all bad’’ phenomenon. Some people were perfect, according to her, while a few others were extremely bad. At times, she worshipped the same people who she otherwise criticised.

Ramona had a string of failed relationships, and she feared being cut off from people she loved. Her values and ideas about people changed dramatically and quickly. After a comprehensive and holistic clinical assessment, it was deemed that Ramona could possibly have borderline personality disorder.

What is borderline personality disorder?

It is characterised by an ongoing pattern of varying moods, unstable self-image and rapidly changing behaviour. Impulsive actions are at the core of the disorder. People experience intense episodes of anger, depression and anxiety, which can last from a few hours to days. They make frantic efforts to avoid real or imagined abandonment, which may take the form of rapid initiation of intimate (either physical or emotional) relationships or blocking communication with someone in anticipation of being abandoned. Impulsive behaviour—such as spending sprees, unsafe sex, substance abuse, binge eating and reckless driving—may be seen in such people.

A person having this disorder may also have chronic feelings of emptiness. They may experience a deep sense of mistrust, which is termed as “paranoia’’. This may be accompanied by an irrational fear regarding other people’s intentions.

Ongoing research in neuroscience suggests the role of a number of factors behind borderline personality disorder. A positive family history, brain factors, environmental, social and cultural factors modulate the risks associated in developing the disorder. Most people report having experienced painful events, traumatic childhood, abuse, abandonment or other adversities.

I conducted a comprehensive clinical interview that involved many sessions with Ramona and her family. Following this, a thorough physical examination was performed and a few laboratory tests were run to rule out other possible organic causes. Special attention was paid to Ramona’s use of alcohol and nicotine.

Ramona was advised in-patient care for 12 weeks, to which she agreed to after a bit of convincing. During this period, a special form of counselling called ‘dialectical behavioural therapy’ was initiated. Ramona was empowered with skills to tolerate her distressing situations without indulging in self-harm behaviour. The cycle of cutting herself off during periods of imminent crises was finally broken through skills transferred during counselling sessions. Ramona started having a low dose of an anti-depressant to tide over her symptoms. She was told that the medications were safe, effective and devoid of side-effects.

After a year of treatment with an anti-depressant and intensive counselling sessions, Ramona was finally back on track and went on to establish new business ventures. Not just that, she even formed a support group for people with borderline personality disorder.

It is stories like these that inspire mental health professionals to give their best to every patient.

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

how-support-groups-help-people-with-parkinsons

Fri May 27 15:33:41 IST 2022

Brigadier G.R.C. Rajan served in the Army for over three decades before retiring in 1998. He was in the best of health till he was diagnosed with Parkinson's disease (PD) six years ago. Now, the 78-year-old has tremors in his limbs, jaw and face; he moves slow and has poor balance and coordination. He has difficulty performing simple day-to-day tasks and is embarrassed by his condition, leading to him limiting social interactions.

A chronic and progressive nervous system disorder, PD inhibits bodily movement. Tremors are one of its most noticeable and early features. As the disease progresses, typically because of the loss of dopamine in the brain, patients also tend to experience depression, sleep problems and trouble chewing, swallowing or speaking. Though commonly considered a geriatric disorder, PD has been diagnosed even among the 18-to-40 age group; this is known as YOPD—young onset Parkinson’s disease. PD is estimated to have affected close to 10 million people till date, but a cure remains elusive.

Therefore, it is crucial to alleviate symptoms via medication, physiotherapy and other treatments to maintain quality of life for patients. This is where support groups come in. They provide mental and emotional support to patients and families. Rajan said that when he was diagnosed, the prospect of being bedridden and immobile was too much to handle. “My family and I had no idea what this disorder meant and it was as if our lives had come to a halt,” he said. But, luckily, he came to know of Parivarthan for Parkinson's Foundation, a community support group that organises events and activities for PD patients and caregivers. Rajan said that Parivarthan transformed his life. “The negativity went away and I realised that I could carry on,” said Rajan.

He now attends online sessions held by the foundation and receives instructional video clips on WhatsApp. These include interactions with renowned doctors from India and abroad, speech therapy sessions, yoga sessions, art classes and more. He has been contemplating taking up singing as a hobby, too. With the help of his physiotherapy sessions, which take place thrice a week at home for an hour-and-a-half, he is able to go on his morning walks, shave, brush and exercise on his own. He also finds the time to exchange notes on PD with others members of the NGO. Pointing out the benefit of the interactive sessions, he said that recently a question by a member on severe constipation, which is among the most common symptoms of PD, was of interest to him and the replies answered some of his queries on the subject.

Vidhya Krishnan, 60, was diagnosed when she was 40. She was a school teacher and had two young children. Joining Parivarthan offered her reassurance that she was not alone. She said the yoga and therapy sessions were helpful and that there was a lot of encouragement from other members. “In the prime of my youth, I was facing difficulties lifting my left hand,” said Vidhya. “Wearing a sari and driving became difficult. I was not able to cook... even scraping a carrot became so challenging, as if I was a three-year-old.” Now, she keeps herself busy with Parivarthan's numerous programmes. She also conducts tuition classes at home.

Parivarthan was started by Sudha Meiyappan in 2014. She left her job as an international trade analyst in the US to set up the NGO, which is based in Chennai, but now has over 250 members across Tamil Nadu. Meiyappan said that Parivarthan was a platform for patients as well as their families to share information and experiences and foster a positive environment.

According to a 2005 research paper titled 'Online support groups for Parkinson's patients: A pilot study of effectiveness', 40 per cent to 60 per cent of patients suffer from clinically significant depression. They also become increasingly disabled and frequently less mobile with problems that include sleep disturbances, difficulty with swallowing, bladder and bowel disturbances and sexual dysfunction. To address the impact of these issues, many patients turn to support groups, the study concluded.

Another study published in 2021 in Global Public Health, an international journal, said that in high income countries, the benefits of support groups have been well-established. The groups filled gaps in information and services, while acting as an important source of care and support for patients and caregivers.

A study published in the journal Dementia and Neuropsychologia, of 20 PD patients who were part of support groups and 20 patients who were not, concluded that participation in support groups was associated fewer symptoms of depression, anxiety and social phobia.

Hospitals too, have support groups for their people with Parkinson's (PwPs). Dr Pavan Pai, a neurologist at Wockhardt Hospital, Mira Road, Mumbai, ensures that he attends support group meetings at least once every six months. “I think it adds immensely to the morale of a person affected with Parkinson's and that is the kind of emotional support which cannot come from medication,” he said. “These groups are very significant and supplement the treatment.” He added that there was a lack of awareness regarding PD. “People ignore signs like tremors and slowness, attributing them to old age, stress or depression,” he said.

Dr Sudheer Ambekar, a neurologist with Jaslok Hospital, Mumbai, which has a patient support group for PD and stroke patients, said that with the help of support groups, patients will be able to deal with mental, emotional and physical changes. The support group at Jaslok meets once every month.

Apollo Hospitals recently organised an awareness meeting on PD and formed a support group that will, the hospital said in a statement, have a “multi-disciplinary team with patients, caregivers, physicians, surgeons and neuroscientists”.

Most of the patients who spoke to THE WEEK lamented the limited awareness of PD in society, resulting in insensitivity. “Please know a few things: the blank face of a person with PD does not indicate a blank mind,” said Bharatnath Mothiye. “Drooling or spitting while talking is not something we enjoy doing. It is beyond our control.” He said that the only request from PD patients would be that people be more sensitive to their predicament and have patience. “We would also like for many more support groups to mushroom so that [more PD patients can get support],” said Mothiye, who, in his late 60s is “still trying to come to terms with the PwP label”.

dr-mathew-r-john-on-the-roots-of-fury

Fri May 27 15:26:26 IST 2022

Anger is only a letter away from danger, wrote Eleanor Roosevelt. But the truth is that we know very little about the science of anger. And we hardly care.

Anger was in the limelight once again at this year’s Oscars. In fact, it seemed to grab all the limelight. Almost two thousand years ago, the Roman Stoic philosopher Seneca wrote a book on anger titled De Ira. He thought of anger as utterly useless and greatly harmful, whereas Greek philosopher Aristotle had a slightly different take on it, considering it a difficult but useful skill. The inimitable Socrates, in his typical style, is said to have spoken this when he felt great anger towards another man—‘I would have hit you were I not angry’. Well, worth pondering.

Charles Darwin noticed emotional expressions in animals and Walter Cannon discovered the fight or flight response as a universal response to myriad stressors. In simple terms, this is the brain’s decision to run or fight when you encounter a threat. Anger was thought to be a part of the fight response.

Then came the psychologists followed by the neurologists. Psychologist Albert Ellis wrote of the rigid and distorted beliefs that led to anger and, quite naughtily, coined the term—‘musturbation’ in reference to the unrealistic ‘musts and shoulds’ that angry folks impose on and expect from others.

Bob Abelson, psychologist, wrote of hot cognition—decision making under the influence of emotion as being different from the usual cold cognition or thinking. The parts of the brain involved in hot cognition are also different, which might explain the strange decisions we all tend to make when angry.

Daniel Goleman, author and psychologist, proposed the phenomenon of ‘Amygdalar Hijack’. This refers to a part of the brain called the ‘Amygdala’ (a vital orchestrator of the stress response) hijacking a logical and calculated response and launching an emotional assault.

Anger does not seem to be everybody’s problem. But, for some, it can be a lasting behavioural attribute. In psychiatric terms, anger can be a part of many mental health conditions. It can be associated with something as universal as chronic stress. It may be associated with certain personality disorders.

In a minority of cases, it can be associated with severe mental illnesses like bipolar disorder and schizophrenia.

There is also an interesting entity called ‘Intermittent Explosive Disorder’ wherein the patient predominantly complains of intermittent episodes of explosive anger. The standard treatment approach to an anger problem involves a comprehensive mental health evaluation followed by psychotherapy or drug treatment or a combination of both.

Why do we react suddenly when somebody swears at us in public? Why do we react explosively when somebody abuses us taking the name of our father or mother? We still do not know the exact mechanisms of these deceptively simple questions but evolution seems to shine some light on these. Factors like loss of social status and insult to kin have been proposed to be evolutionary triggers for activating the anger response.

What Seneca wrote seems still very relevant today—‘Time is the greatest remedy to anger.’ Delaying a response is the mainstay of the Tucker Turtle strategy wherein the angry person retreats into his shell like a tortoise when angry, and comes up with a good response when cool.

The author is a consultant psychiatrist.

here-is-why-buying-a-pug-is-a-cruel-act

Fri May 27 15:18:23 IST 2022

Pugs are considered one of the “cutest” canine breeds. But a new study from Royal Veterinary College of the United Kingdom says that pugs can no longer be considered a “typical dog from a health perspective” and their breeding leads to a “lifetime of suffering”.

The study—that analysed the records of 16,218 pugs and 8,89,326 non-pug breeds—found that pugs were at higher risk for 23 out of 40 common disorders. The study points out that pugs are more likely to be obese; one in six pugs are obese compared to one in 15 for other dogs. Pugs are also 11 times more likely to have a skin-fold dermatitis. The study was published in the journal Canine Medicine and Genetics.

The “brachycephalic” features—variably shortened muzzle and a rounded, often massive, head—of pugs did not evolve naturally. Those were the results of genetic manipulation by selective breeding. The Lo-Sze dogs of ancient China are considered the predecessors of modern-day pugs. Historians suggest that pugs existed even in the 4th century BCE, and were developed as pets for the Chinese elite. Pugs came to Europe in the 16th century.

The flat-faced look with characteristic squashed nose appearance makes pugs “cute-looking”. However, this facial structure is responsible for a range of health issues faced by the breed. In April, another study from the RVC—that assessed 30,563 dogs from 18 breeds— revealed that short flat-faced breeds like pugs (7.7 years), English Bulldogs (7.4 years) and French Bulldogs (4.5 years) have a short life span.

RVC researchers point out that pugs lack even “core body functions” expected of a dog breed. They point out that pugs cannot sleep properly as they constantly have to wake up to breathe. They also point out that most pugs cannot sit without snoring and snorting.

The RVC study found that the breed is 54 times more likely to have brachycephalic obstructive airway syndrome (BOAS) and 51 times more likely to have narrow nostrils. Those animals suffering from BOAS may struggle to breathe during exercise and suffer collapse due to lack of air. The breathing difficulties of a BOAS affected pug will amplify in hot conditions.

Pugs have more skin on their face than they require, so they are at higher risk for skin infections. Soreness and itchiness are conditions commonly seen in pugs. Their “beautiful” tail is a “malformed vertebra” which may lead to more slipped discs. The pugs are, however, at less risk for developing conditions like heart murmur and aggression.

Veterinary experts warn that dog lovers should stop buying pugs. They also advise that existing pug owners should carefully watch for symptoms like excessive panting and breathing difficulties. Pugs require special care in hot seasons. They add that weight management is crucial as an “overweight” pug is at a greater risk to develop serious issues.

attention-everyone

Fri May 27 15:12:13 IST 2022

Vivek comes home exhausted from school. Everyone at school calls him naughty, and he hates that. He really does try but is just unable to sit still. His fidget spinner helps, and he is always happy to be asked to run errands by the teacher. Getting up and walking around the classroom helps him focus better. He loves playing with the other boys in class, but lately, he has found that they are ignoring him. The teacher noticed this and asked one of his peers why they were ignoring Vivek. “It’s really hard to play with Vivek,” said Mani. “He keeps playing out of turn and sometimes even leaves the game halfway. The other day, he had the den when we were playing hide and seek, and he just left without telling us. It was 10 minutes before we realised that he had stopped playing and, afterwards, we saw that he was busy running after pigeons in the playground!”

Perhaps one of the most common neurodevelopment disorders that remains a mystery to the population at large is the spectrum of attention deficit disorders. As the term enters popular culture, it is unfortunately also thrown around quite casually as an excuse for when one tunes out of a conversation or forgets to do something they were meant to. While the awareness is welcome, it can also serve to undermine the true nature of difficulties that individuals with attention-deficit/hyperactivity disorder may experience, which is many a time more than just a lapse in attention. Without a thorough understanding of how this experience manifests, it is easy to label children with ADHD as naughty and defiant, resulting in a negative approach by parents and educators alike, with the result of children being misunderstood and losing support.

Contrary to the prevalent notion that children with ADHD are intentionally misbehaving, children genuinely have difficulty focusing and staying on task. This, however, is just one aspect of attention. Rather than being a unitary concept, there are several subtypes of attention. There is selective attention—the ability to selectively attend to some stimuli while filtering out others. While sustained attention is the ability to stay on a task over an extended period of time, divided attention is the ability to divide your attention between two tasks such as listening to the teacher and making notes. And, switching attention is the ability to shift your attention between two or more tasks as required. Children with ADHD may have difficulty with one or multiple types of attention. The condition can also negatively impact higher-level cognitive skills such as planning, organisation, impulse control, decision-making, initiation—a group of skills collectively referred to as executive functioning.

Cognitive limitations are just one part of the story though. Whether it is a lack of understanding from family, peers and educators, a keen awareness of the limitations posed by one’s ADHD or shared neurobiological pathways, children with this condition are more prone to developing a mental illness. Research suggests that a staggering 60 per cent of individuals with ADHD have a co-morbid psychiatric condition. Additionally, children with ADHD and a co-morbid anxiety disorder are reported to have, on average, a ten-fold higher chance of poorer academic performance. Appropriate and timely diagnosis can result in better outcomes for children. Lack of awareness, on the other hand, may compound these deficits.

As with all relatively unknown conditions, building awareness is the first step to assisting these children. Specifically, awareness will help dispel the myth of children with ADHD being intentionally difficult or them just not trying hard enough—negative labelling is likely to only worsen the situation. Positive support from family, peers and educational institutes can go a long way in nurturing a happy child. Interventions are numerous and can range from behavioural to pharmacological.

Behavioural strategies to adopt in the classroom could include seating the child at the front of the class to ensure minimal distractions. Similarly, working in a quiet environment (for example, at a clutter-less desk, in the absence of a TV or radio playing in the background) is likely to result in a more fruitful learning experience for the child. Highlighting or underlining key points in notes would help the individual focus on the important parts, and not get overwhelmed. Allowing children with ADHD to work for brief periods of time—20 minutes at a stretch—followed by a break, would facilitate focus. Expecting them to work for hours on end, however, is merely setting them up for failure. Social skills training and occupational therapy intervention can also assist in improving the child’s functional skills. Team sports or yoga can be other opportunities to build attention span and improve focus on the task at hand. Medication can also serve as an adjunct in improving attention span and reducing hyperactivity. However, consultation with a specialist is recommended before commencing any pharmacological intervention.

Most important though, compassion and a positive attitude are vital for our neurodiverse population to blossom. All of us have strengths and weaknesses and it is important that we not let a diagnosis define an individual, but simply speak to one facet of their personality. With awareness and acceptance, we can strive for a society where neurodiversity is embraced and individuals are supported to make for a healthy, happy new tomorrow.

Bapat is adjunct faculty (psychology) at FLAME University.

our-minds-are-caught-up-in-wandering-between-30-and-47-per-cent-of-our-waking-time

Fri Apr 29 19:47:36 IST 2022

Q/ What is the basic premise of Mindwandering?

A/Mindwandering is the first popular book to explore the multi-faceted phenomenon of the wandering mind. Our mind has different states that are dynamic and that cluster together the many aspects of our mental being: perception, attention, thought, openness and mood. There is a right mind for the right occasion, and our mission is to maximise the match and minimise the friction.

Q/ What happens inside the brain during mindwandering?

A/ Research has revealed that our brains are inherently active. A number of brain regions connected in what is dubbed the default mode network (DMN) are always grinding away, engaged in a number of different involuntary activities that neuroscientists collectively call mindwandering: from daydreaming to the incessant self-chatter and from ruminating about the past to worrying about the future. The brain regions most often identified as being part of the DMN include the medial prefrontal cortex, the posterior cingulate cortex, and the angular gyrus, but there are several more that come and go as part of this massive, large-scale network.

Not only does all this inner commotion tug our attention away from the present moment, but it can also dampen the quality of our experience, lowering our mood and potentially contributing to anxiety and depression. Yet there is a method to this apparent madness. Evolution has clearly taught our minds to wander. According to various studies, they are caught up in mindwandering between 30 and 47 percent of our waking time, gobbling up a great deal of energy. The logic of evolution suggests there must be something beneficial about it, and over the course of the past couple of decades, my neuroscience compatriots and I have identified a core set of its important functions.

Q/ What has been your most fascinating discovery of the brain since you took up neuroscience?

A/ Just like my kids, all my discoveries are dear to my heart (and mind). The highest sense of mission I get is from my findings on how thinking can affect mood, which we are currently using to try to alleviate the suffering of people with depression and anxiety (through science-based games). My work on predictions and mental simulations in mindwandering is another flagship of my laboratory, and it gives me immense pleasure to be able to share it with the general public. My other research ranges from aesthetics and urban design to first impressions and visual perception. One can get a sense of my ADHD from the diversity of my research questions, I guess.

Q/ How have you personally mastered the art of mindwandering and how has it enriched your life?

A/ Mindwandering is a wild beast with a mind of its own, no mortal can master it really. But being aware of this science and ideas can go a long way towards helping us gain some control over our mental lives. Mindwandering is a major activity in the brain. While it is not always welcomed—such as when we really need to accomplish something else or when it sends us ruminating and thus dampens our mood—in the right context it is a precious resource. We should not feel guilty when we catch ourselves wandering; it could be an inventive habit that is worth deliberately allocating time for. Once we do, we should get the most out of it.

Two examples of how we can make use of our wandering thoughts are through learning from simulated experiences and through semi-directed mindwandering.

A great deal of what we have in memory is a result of actual experience, but some of it is also the outcome of imagined experiences and simulated scenarios. My research into the possibility that our brain also stores memories of imagined experiences, although they have never taken place, started a while ago on a flight. I was reviewing a paper, and my mind drifted until it landed on the emergency door, which triggered the following simulation: what if the door suddenly opens while we are in the air? I will need a parachute. I could probably use the airplane blanket on my lap, but I will not be able to hold on to it in the strong wind—it needs holes. I can use my pen for making the holes, and so on. Far-fetched, funny every time, but nevertheless, I now have a script of an imagined experience stored in memory, and it would be helpful should the unlikely event ever take place.

In semi-directed mindwandering, while we cannot really tell our mind where to wander about, we can strive to fill the mental space of possibilities with content that we would have liked to be wandering about. Before I go on a long walk, I ask myself what is on my mind. If it is something like the bills I just paid or an annoying email, I try to replace it with something that I would rather be spending my mindwandering stretch on, such as re-reading a paragraph that caught my interest recently. Or I might revive the idea of an upcoming trip so that I can fine-tune the details as I simulate the future with my mind.

how-to-channel-ones-thoughts-for-a-more-fulfilled-life

Sun May 01 11:39:22 IST 2022

Some time ago, Israeli neuroscientist Moshe Bar caught up with two friends, Daniel Gilbert and Jonathan Schooler, for dinner in Massachusetts. During dinner, Gilbert told him that he was to be awarded the prestigious William James Prize. His three best friends, he said, would be taking him for drinks to celebrate after the ceremony. “I thought that I perceived that he was testing whether I felt like a close enough friend to suggest that I would join them,” writes Bar in his new book, Mindwandering. “I said I would, and he responded that they would love for me to come along.”

However, the next couple of days, Bar found himself tormented with the question of whether Gilbert really wanted him to join them or whether he was just being polite. Had he misread the situation? Had he barged in on their BFF gathering?

Most of us have felt conflicted in a similar way, when we have tried to second-guess someone else’s thoughts to discern what was going through their mind. This is called Theory of Mind—our continuous attempt at deriving others’ intentions, emotions and beliefs. It is one of the activities our minds are constantly engaged in, which is the core premise of Mindwandering. It posits that certain regions of our brain, collectively called the ‘Default Mode Network’, are constantly involved in activities like daydreaming, worrying about the future and self-chatter. When these activities divert our attention from the present, they can cause anxiety and depression. However, in his book, Bar shows us how we can channel this chatter to bring happiness, boost creativity, increase focus and solve problems.

“As I contemplated all our findings about the brain’s default network and mindwandering, I came to what, for me, has been a groundbreaking realisation,” says Bar. “We don’t want to just clamp down on all mindwandering, which is just as well because that is virtually impossible. What we want to do instead is become more aware of when and how our minds are wandering. Then we can become more effective at directing that activity voluntarily as much as possible, so we can buckle down and focus on tasks or, alternatively, let ourselves be truly, deeply immersed in the experience of the moment. At other times, when we want to stimulate our creativity, as well as our mood, we will do best to free our minds to indulge in a good broad-ranging stroll. We want, in short, to work towards bringing the right mind to the right time.”

Bar’s interest in the brain was triggered while studying electrical engineering to fulfil his father’s ambition for his life. “I had quickly learned that I had absolutely no interest in chip design and that the only area of research in the field that captivated me was computer vision,” he says. It was while researching how to make computers mimic the way the human brain recognises images that Bar realised how little we knew about the functioning of the brain. With the zeal of youth, he told his professor how outrageous this was. His professor responded that he would soon come to appreciate how complex the workings of the brain were. He soon did.

“Sadly, it is still largely true that we have no hard knowledge of how the brain recognises images, only some intriguing theories with preliminary support,” he says.

When he was working extensively in the cognitive psychology lab of a pioneer in brain studies, an exciting new development took place in neuroscience, which he began to pursue: the invention of fMRI (functional magnetic resonance imaging). While MRI had been around for a few decades, the functional aspect of it was a breakthrough that neuroscientists had been waiting for. By measuring blood flow, fMRI allowed them to infer where and when brain activity took place.

“This was a moment of extraordinary adventure; we were roaming around inside the pathways of the mind like hikers in the woods at night with flashlights,” says Bar.

Excited by the explosion of research, he went to Harvard Medical School to examine the human brain and mind “in earnest and with insatiable passion”.

Afterwards, he moved back to Israel, where he currently lives with his wife and three children. Until recently, he headed the Gonda Multidisciplinary Brain Research Centre at Bar-Ilan University. Beyond research, teaching and writing, he has also founded a startup to fight depression and anxiety through games.

In the book, there are chapters on connecting with our thoughts, learning from imagined experiences, how to practise immersed living and the benefits of meditation. The last section is a practical one, in which Bar explains how one can implement the research, theories and ideas expounded in the book. For example, he says that if we are aware of our state of mind, it is easier to manipulate it. When we are in a happy mood, it is hard to sit still, and thus it is best to avoid boring chores then. This is also when we tend to take riskier decisions. But this state of mind is best for coming up with a nonconventional solution for a problem. “When I am in a broad and open state of mind, I allow myself to stay upbeat and seek out some exploratory activity to take advantage of that mood, or I let my mind wander in the hope of coming up with some good new ideas to pursue in my work,” says Bar. If you want to explore the treasures hidden in the human brain, it might be a good idea to start with picking Bar’s brain through his book.

Mindwandering: How It Can Improve Your Mood and Boost Your Creativity

By Moshe Bar

Published by Bloomsbury

Price Rs599; pages 253

help-children-cope-with-pandemic-by-setting-predictable-routines-dr-alok-kulkarni

Sun May 01 11:36:50 IST 2022

Rohit was a chirpy 26-year-old software professional who loved hanging out with his buddies on weekends. He would plan an outdoor biking trip to one of the many beaches on the coastline of Karnataka. But things took a drastic turn for the worse with the outbreak of the pandemic; Rohit’s weekend escapades came to a halt, and he could now socialise with his friends only virtually. The warmth and tenderness of a physical meeting was now being missed. Rohit’s youthful restlessness and zest for life had to cope with an unprecedented challenge. It was not long before he slipped into clinical depression, and was referred to have a chat with me.

Covid-19 has thrown a bevy of complex variables before us. Among these, uncertainty, social isolation, and disrupted routines have had an impact on the mental health of children and adolescents alike. Children have understandable worries related to the consequences of Covid-19. Many are wondering if they will ever be able to freely play with their friends as during the pre-Covid times. Parents are not equipped to calm their children’s anxieties as they themselves are battling numerous uncertainties.

At this critical juncture, one can barely hope to plan for the future as everything is on hold. The challenges facing parents may interfere with their usual ability to address their children’s emotional needs. The United Nations Children’s Fund (UNICEF) recently conducted a poll to assess the impact of Covid-19 on the mental health of adolescents and young people in Latin America and the Caribbean. It assessed 8,500 adolescents and young people between the ages of 13 and 29 in nine countries and territories. The report gave an account of the feelings children and adolescents faced in the first months of the response to the pandemic. Among the respondents, 27 per cent reported feeling anxious, and 15 per cent reported feeling depressed in the last seven days before the poll was conducted. Interestingly, for 30 per cent respondents the main reason that influenced their current emotional state was the economic situation. A significant proportion (46 per cent) of the respondents reported a perceptible lack of motivation to do tasks which they previously enjoyed. Their perception of the future has also been negatively affected, particularly in the case of young women.

In India, schools have remained shut for the entire academic year. Classes are being conducted virtually. This has presented a new set of challenges to both the teaching and student community. Teachers have had to adapt to newer technologies, and students have had to adjust to attending classes from home. Online classes have provided children and adolescents an opportunity for increased internet usage. Students tend to remain glued to their screens long after the classes are over. Alarmingly, frequent and unsupervised internet use is associated with self-harm and suicidal behaviour in adolescents with psychological risk factors. I have had ophthalmology colleagues complain that cases of myopia, dry eyes and computer vision syndrome are increasingly coming to their attention.

I ventured to ask my house-help how her children were coping during the pandemic. Her answer disturbed me a great deal. “My elder son does not want to go back to school. He wants to start working. He is barely fifteen. His father and I are doing everything possible to give him an opportunity to educate himself—something that we were denied. This virus has shattered our dreams,” remarked Shobha, who has been with us for the past 12 years.

Disturbingly, many adolescents have had to deal with the demise of a family member. This itself can spark a range of psychopathology in the longer run. Shalini, a 21-year-old medical student, has had to process the demise of her aunt. Her aunt came down with fever followed by breathlessness. She was immediately shifted to the ICU of a well-known hospital. The very next day she was declared dead. “The randomness and acuteness of the situation is what scares me,” said Shalini during one of the counselling sessions.

I have always been a great believer in the fortitude and resilience of people in the face of a crisis. Children and adolescents have shown remarkable maturity in coping with the ongoing crisis. One of the ways in which we can help our children to cope with this randomness is by setting predictable routines. Structuring their day will enable them to cope better with uncertainty. This is also a great time to pick up new hobbies and skills. Reading is one useful pastime that can be incorporated now more than ever before. It is advisable to indulge in reading physical books which will enable us to switch off from online spaces. Children are filled with boundless energy and enthusiasm. We will have to resort to finding creative ways to channelise this youthful energy productively. Combined workout sessions can be organised at home. This will also provide an opportunity for the parents to bond better with their children. Yoga and aerobic exercises have a calming effect on the mind. I have also been encouraging adolescents to dedicate 15 minutes a day doing nothing. In these 15 minutes, I have been asking them to contemplate as to what they would do once this pandemic settles down. I have had adolescents come to me and say that those 15 minutes have renewed their hope that things will eventually fall into place. It is also vital that children and adolescents seek professional mental health support during this crisis. A great deal of stigma is attached to seeking help to mental health in our country, and it is our responsibility to ensure that every individual has access to good quality mental health care.

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

covid-like-tb-may-keep-coming

Sun May 01 11:38:11 IST 2022

DR FAHEEM YOUNUS, chief of infectious diseases at the Maryland University, is on a mission to combat disinformation. In an exclusive interview, Younus expresses his concerns on how the pandemic could widen the gap between the haves and the have-nots. Excerpts:

Tell us about the Covid situation in the US.

I think in 2020 we handled it poorly. In 2021, we handled it better. Now it’s a combination. We are handling it better as well as the virus is receding. So everything is going in our favour, which means we have vaccines, we have all the therapeutics. The government is mailing rapid tests to people at home, which is a huge step forward. As the winter months and holiday season is ending, people are not congregating as much and the Omicron surge has really plummeted about 90 per cent in most states in the country. So we are in a much better shape.

How do you deal with misinformation?

That is the most purposeful work I’ve done in my career—to go out of the frontline, take abuse even where people felt they could not rationally discuss an issue. But I think good information saves lives.

So how I do it? Multiple ways. You’ve to look again. Everybody has his own fears. You’ve to understand where they are coming from. You’ve to start with the position of empathy.

There is a huge history in America of African Americans being marginalised and not treated fairly when it came to medical research. So their distrust is rooted in history. When I talk to the African American communities, I link them with one of the inventors of the Moderna vaccine who is an African American physician. And I make them realise it’s one of their own daughters who is on the front lines of developing this vaccine.

I give them data. Look, this vaccine allergy has no close reactivity with food allergy. So the point I’m making is we can’t broad-brush everyone. Not everyone is a conspiracy theorist. Some people have valid reasons and you engage with them on those valid subjects.

How dangerous is the BA.2 variant?

I don’t think it is wise to say that it is more dangerous than BA.1 or Omicron. Because, as of today, we know that it spreads fast. What we don’t know is whether it’s going to evade vaccine-based-immunity any more than Omicron. I don’t think there is any evidence. And is it going to cause significant number of reinfections in people who have recovered from Delta or Omicron? I don’t think there is any evidence for that either. Rare cases will happen, of course.

So I feel the jury is still out and the numbers are telling me that it is most likely not going to be as different as BA.1 and Omicron.

Have we reached the endemic stage?

Some places, yes. Some place, no. Endemic is not a sign of victory. When we say it’s endemic we are actually saying we’re unable to kill you. So let’s shake hands.

That’s what we are saying. Because ideally small pox or polio are not endemic. They have been eradicated. That’s victory. Endemic is like influenza. We accept it’s going to come every year and kill 20,000-30,000 Americans. I don’t know what that number is in India.

If another variant comes, it can be devastating.

What are your biggest concerns about Covid 19?

Generally I’m an optimistic person. I don’t usually think of fears as much. One of the fears I have is that Covid may keep coming [back] like Tuberculosis (TB). Which means a disease that still kills over a million people every year but it’s largely forgotten because those people are dying in poor countries. And the rich countries continue to gain more control over the virus and more options to keep their economies open. I fear that the world may move on while it is still a huge problem for some .

What lessons did you learn during the pandemic? How did you deal with the virus?

We learnt a lot. I think this pandemic has been a humbling experience. First of all we learnt that none of us can win this war by ourselves. We are all interdependent.

The vaccination would have taken 10-15 years without that massive funding that sped up things. That sort of process cannot be accomplished in a fast amount of time unless regulatory bodies speed up things and give us quick, appropriate and safe approvals, and get rid of bureaucracy.

We cannot project this pandemic just because of basic research or frontline clinicians. We need mathematicians, statisticians and modellers who can project where this pandemic is going in six or twelve months. We cannot decide whether to keep an economy open or shut because now we need economists who can look at the big picture and say what are the risks and benefits—these are the risks of the virus and these are the risks of shutting down an economy and so on and so forth.

How much do we know about long Covid?

Not much. Even though we feel we have hundreds of studies on this subject, we still don’t have a unified definition of long Covid. We don’t have any specific lab tests. Like if this test is positive, you’ve long Covid. It’s all based on history and symptoms. And they vary from one study to another. So it’s very difficult to make comparison. There are about 200 symptoms out there. If you said you have any of those symptoms after weeks of recovering from Covid, then you’ll be considered long Covid. It’s sort of extremely vague. That’s not to say it doesn’t exist. It’s absolutely real. It happens with other viral infections as well. A subset of patients will have long term side effects.

What should we do? People who are currently suffering from it should probably go to a specialised centre. Not everyone can handle those cases. Wherever you’ve a specialised centre, there is more experience and they can get empathetic, timely care. If nothing else, symptom management. But at the same time we need prospective double blind studies with sharp, specific definitions and criteria. And only then we’ll know.

Some people seem immune to Covid. How do you explain this?

It’s hard to say. I don’t think we can say some people never get Covid. We are not doing mass sero testing. We can only say that when everybody was getting tested.

About 30 per cent of people will have no symptoms, remain asymptomatic or have very mild symptoms. So, it is possible that some people are getting milder disease than others.

At the same time, there are genetic determinants. I’ve had HIV patients for 20 years who have had no treatment and they are not getting worse. So it’s known even with other viruses. But I think at this stage we know that there are genetic determinants. But unless we do large sero studies, we’ll never know if some people are truly immune against this virus.

Some experts believe that mRNA vaccines are superior to DNA vaccines. What’s your take?

It is hard to say because I have not seen any head to head trials between the two. The reason we keep talking about mRNA vaccines are: one, they were the first to come out on a mass scale with FDA approval. Two, over a billion people have received them by now. So we know that they are widely used. Three, we have a lot of sub-group analysis published on mRNA which we don’t have on DNA vaccines yet.

We know the mRNA vaccines and their effect on health care providers. We’ve studies on pregnant ladies, we’ve studies on fertility, we’ve studies on lactation, on immunocompromised people. So mRNA vaccines and their sub-group analysis and the published data is so much now. There is a higher comfort level. There is more safety data published.

With DNA vaccines as more and more data gets published, it will be in a better position.

Do vaccines provide better immunity than actual infections?

When I get a natural infection, I may inhale a thousand viral particles or I may inhale a million viral particles. You don’t know. The degree of exposure is not in my control. It’s going to happen randomly, accidentally.

Whether I’m wearing a mask, whether the other person is wearing a mask—all of those are going to determine the amount of virus I’m inhaling. As a result, I may get a different level of immunity. With the vaccine you are getting the exact same dose that has been given to thousands of people in clinical trials that has been measured. So there is a measurable response. The action reaction is more measured. So you can feel like I’ll get reliable protection because it has been tested. So there’s more predictability with that. And then there are follow up studies. You are getting immunity with natural infection but it’s hard to measure. Therefore, I think you are sort of flying blind.

How do you assess India’s response to the pandemic?

I think people living in India are a better judge of that. From the distance I can see that, like the US, India also struggled in the beginning. The first wave hit it really bad. But I’m very pleased to see many nations, including India, ramping up their vaccinations.

Disinformation is going down a little bit. Overall, I think most countries are catching up.