link-between-prenatal-maternal-inflammation-and-depressive-symptoms-in-adolescent-offspring

Sat Feb 24 17:16:30 IST 2024

An estimated 280 million people worldwide suffer from depression, a condition influenced by a complex interplay of social, psychological and biological factors. Those who have experienced adversities such as unemployment, loss or trauma are at higher risk. A comprehensive review, from 2001 to 2020, revealed that 34 per cent of adolescents aged between 10 and 19 reported elevated depressive symptoms globally, with the Middle East, Africa and Asia showing the highest prevalence. Notably, female adolescents exhibited a higher prevalence than males.

Depression in adolescents stems from various factors including genetics, environment and social circumstances. A recent study in JAMA Psychiatry delved into a novel link between prenatal maternal inflammation and depressive symptoms in adolescent offspring. The research, examining 674 mother-offspring pairs, focused on those who received obstetric care from June 1959 to September 1966. This study unveiled sex-specific pathways from prenatal maternal inflammation to adolescent depressive symptoms.

Data on pregnancy and blood sera were collected from mothers, with psychiatric symptom data gathered from offspring during childhood (ages 9-11 years) and adolescence (ages 15-17 years). Maternal prenatal inflammatory biomarkers, indicative of inflammation during pregnancy, were assessed during the first and/or second trimesters. These biomarkers, measurable in blood or other bodily fluids, offer insights into the presence and severity of inflammation in the body. Maternal inflammation during pregnancy has previously been linked to adverse neurodevelopmental outcomes in offspring, such as autism spectrum disorder, attention deficit hyperactivity disorder and Tourette syndrome.

The study revealed a significant association between higher levels of interleukin 6 (IL-6), a specific type of inflammation, during the second trimester of pregnancy and increased depressive symptoms in adolescent offspring. Notably, in male offspring, the analysis indicated that childhood externalising symptoms played a significant mediating role in the link between IL-6 levels in the first trimester and adolescent depressive symptoms. Childhood externalising symptoms encompass a range of problematic behaviours directed outwardly towards others or the social environment, including hyperactivity, impulsivity, aggression and rule-breaking. The observation suggested that the impact of maternal inflammation on offspring depressive symptoms is influenced by the child's behaviour during childhood and the timing of maternal inflammation during pregnancy. In female offspring, it was observed that childhood internalising symptoms mediated the link between second-trimester IL-1Ra (natural anti-inflammatory factor) levels and adolescent depressive symptoms. Childhood internalising symptoms encompass various emotional and psychological challenges directed inwardly towards the individual, including anxiety, somatic complaints and withdrawal.

These findings indicate that the influence of maternal inflammation on offspring depressive symptoms is shaped by the child's gender and the timing of maternal inflammation during pregnancy.

ending-period-related-stigma-and-discrimination

Sat Feb 24 17:28:29 IST 2024

I was nearly 12 when I first got my period. My mother had recently relocated to Mohali for work and at the time it was just my father, older brother, grandparents and I in Delhi. I remember seeing bloodstains on the bed sheet and running straight to the bathroom. My father must have seen the stains, too, as a few minutes later my grandmother knocked on the bathroom door and told me to throw my clothes in for washing and take a shower. I do not remember being scared, just uncomfortable. Very uncomfortable. When I came out of the shower, my father handed me a sanitary pad and told me that I would have to use it for a couple of days. He showed me how to open it and where it goes and then I was off to give it a go. The next morning while getting me ready for school, he said, “You might feel eager to tell your friends but please do not tell everyone that you are wearing a pad.” He must have known me pretty well as the first thing I did once I got to school was telling my closest friends that I had gotten my period!

Years later, my mother would tell me what had transpired while I was in the shower. My father rang my mother and told her that I had got my period. She instructed him to go to the pharmacy and get some sanitary pads. In the meantime, he told my grandmother to help me get cleaned up. When my mother came home the next weekend, she made sure I got to spend enough time with her to get all my doubts cleared, including how I thought a sanitary pad was just an adult diaper for women who went to work (and who can blame me, haven’t we all seen the sanitary pad commercials with the blue liquid!).

This has remained a key positive memory of my life. But as I grew older, I realised that not everyone’s memory of how they got their first period was a pleasant one.

Every month, 1.8 billion people across the world menstruate. Millions of these girls, women, transgender men, and non-binary persons are unable to manage their menstrual cycle in a dignified or healthy way. In India, there are more than 35.5 crore menstruating women and girls, and many of them, especially those living in rural areas, face several challenges because of their menstruation, which restricts their autonomy and agency.

Menstrual hygiene remains a pressing issue in India, and a pervasive lack of awareness compounds it. For instance, research has indicated that anywhere between 29 per cent and 71 per cent of girls in India have no prior knowledge of menstruation before experiencing their first period. Cultural taboos and social stigma continue to negatively impact the menstruation experience. A national survey found that 70 per cent of girls in India perceive menstruation as “dirty”, while over 30 per cent experience fear and anxiety because of societal taboos associated with menstruation. Lastly, access to affordable and hygienic menstrual products remains a significant barrier. According to the National Family Health Survey (NFHS-4), only about 58 per cent of women in India aged 15 to 24 use hygienic methods of menstrual protection. Many girls drop out of school and several others are excluded from participating in everyday spheres of life.

It is important to look at menstrual health and hygiene as a basic human right. In fact, there are existing human rights that include obligations related to menstrual health and hygiene. For instance, the right to equality and non-discrimination, gender equality or the right to health, education, water and sanitation. Furthermore, there is a greater emphasis on the interconnectedness of these issues under the umbrella of climate change and sustainable development as outlined by the UN Sustainable Development Goals. We know that women and men experience climate change differently. Based on the findings of the Intergovernmental Panel on Climate Change, it is clear that people who are already among the most vulnerable and marginalised will experience the greatest impacts of climate change.

With that in mind, I undertook a project on menstrual health in Uttarakhand from an intersectional gender and climate justice lens. It was a collaborative effort that was supported by Sheffield Hallam University of the UK; The Sidhast Foundation, a local NGO; Pink Leaf, a sanitary company started by two young men; the Almora chief medical officer's office; and the local panchayat. Participants were local village women and girls, as well as two government self-help groups. The workshop, led by two young female doctors from the local hospital, was aimed at creating awareness about the importance of menstrual and reproductive health and hygiene. After the lunch break, we moved on to the focus groups.

I truly believe something powerful happens when a group of women sits together and shares stories. And that is exactly what happened when we began the focus group. Everyone jogged their memories to remember their first period, which instantly opened a portal to deep and meaningful experience-sharing. The accounts of challenges made me reflect on my own Kumaoni identity and how different my experiences were growing up in a city. Women recalled not receiving proper information about periods, not having access to sanitary products, being denied access to the kitchen, and not sleeping in the same bed as their husbands. However, these were not lamenting narratives and were often balanced with a lot of laughter and giggles. But that was not surprising given the history of resilience shown by pahadi women in fighting the harsh elements of nature, resisting many unsustainable practices of modernisation as well as battling alcoholism among the men. We were lucky to hear narratives of women from across three generations of a family. While the grandmother recalled facing stigma around menstruation, the daughter recalled resisting many such unfounded taboos. Finally, the granddaughter shared how she does not feel restricted during her period and is able to actively engage in all her day-to-day activities. Many women also recalled segregation being common practice during periods and how they want to ensure their daughters and daughters-in-law do not have to go through similar unjust and discriminatory practices. It was interesting how many women shared that their husbands also condemned these ideas.

It was clear that things were slowly changing. Many women were still using cloth pads but were open to switching to reasonably priced, good-quality sanitary products. They were aware of the government-provided sanitary pads through anganwadis but felt that the quality was not good enough to make the switch. As the women and girls of the region are historically known to have sustainable practices, an important conversation about waste management also emerged. The need for biodegradable products and an effective way of disposing them seemed imperative. Another key point was focusing on efforts towards educating boys and men about menstrual health and barriers to gender equality.

The aim of the International Women’s Day 2024 #InspireInclusion campaign is to collectively forge a more inclusive world for women. But this world cannot be forged without support from men, who need to be reminded that they are equal stakeholders in this mission. A gender-equal world benefits all. UN agencies have stressed that if gender quality is not achieved, the implementation of all other goals would be compromised.

On March 8, 2020, Shashi Tharoor, MP, had started a conversation on menstrual health when he tweeted a petition advocating for menstrual leave for women in public and private workplaces. In March last year, Kerala MPs T.N. Prathapan, Benny Behanan and Rajmohan Unnithan posed questions in the Lok Sabha on whether the government had considered making provision for paid menstrual leave mandatory for all workplaces. More recently, Union Minister Smriti Irani came under fire when she made a statement in Parliament on how menstruation is not a handicap, and that the government is not coming up with any policy for mandatory paid period leave.

While all these debates contribute towards a healthy discourse on menstrual health, perhaps the priority needs to be directed towards the grassroots level. For instance, a recent study conducted by the Population Research Centre, Patna University, found that about 40 per cent of rural female adolescents in Bihar use cloth instead of sanitary napkins, and that even among the girls who use the latter, 90 per cent had not received any government-supplied napkins in recent years. And let us not forget this is a state that introduced menstrual leave of two days all the way back in the 1990s. The study also revealed that at least 5 per cent of the girls were not allowed to take bath during their menstruation.

In India, there are various policies and schemes aimed at promoting accessibility to menstrual products and sanitation infrastructure. Among these are the National Menstrual Hygiene Scheme, Menstrual Hygiene Management Guidelines and the Swachh Bharat Mission.

However, more concerted efforts need to be made in educational and awareness-centred campaigns keeping regional complexities in mind. This is not only the responsibility of the Union and state governments, but also every one of us. So, this International Women’s Day, I call to action boys and girls, men and women to be agents of change and promote inclusion by ending period-related stigma and discrimination.

Dr Madhumita Pandey is senior lecturer in criminology and the Gender-Justice Hub lead at the department of law and criminology, Sheffield Hallam University. She works in the area of sexual offence, sex offenders and violence against women, particularly focusing on rape, in the global south.

the-many-benefits-of-repurposing-drugs

Sat Feb 24 13:13:48 IST 2024

Tocilizumab was a drug used to treat rheumatoid arthritis. But, during the Covid-19 pandemic it was used as an injection to treat the symptoms of the coronavirus. The pandemic led to many drugs being repurposed. Examples include hydroxychloroquine, HIV drugs and vitamin C.

The drug developed by Gilead for Ebola received FDA approval for emergency use for Covid-19 patients. Subsequently, India, too, gave approval for emergency use. Favipiravir, a drug used to treat new strains of influenza, received emergency use authorisation from the FDA and in India for mild to moderate Covid-19 patients.

Then, in 2021, the UK's National Health Services started a project called Medicines Repurposing Programme. Its aim is finding alternative use for existing medicines.

But, perhaps the project was not so novel. Experts say that this has been going on for centuries. Many a time, drugs have been repurposed without being labelled so. The oldest example of drug repurposing is aspirin, and it is also the drug that has been repurposed the most.

When German company Bayer discovered the molecule in 1899, it was thought of as an analgesic. Later, it was found that aspirin also helped in decreasing blood clots. As a result, it was approved for use as an antiplatelet drug and millions across the world used low doses of aspirin to prevent heart attacks. This discovery came almost a century after aspirin was discovered and it led to a Nobel Prize. Now, research has it that aspirin may help in the prevention of colon cancer.

Similarly, sildenafil (better known as Viagra), developed by US pharmaceutical company Pfizer in 1989, was a drug to lower blood pressure. But, during trials, people gave feedback that they were getting penile erections. So, it was marketed as a drug to treat erectile dysfunction. Later, as the drug was also helping in dilatation of the blood vessels, it began to be used for a more serious illness called pulmonary artery hypertension.

“This is a much easier and quicker way of getting a new drug into the market rather than spending billions of dollars on discovering a new molecule and going through the testing stages and checking the safety and efficacy,” says Dr Monica Mahajan, director, internal medicine, Max Healthcare.

Over time, a high number of repurposed drugs have been used in the treatment of different pathologies through the strategic redirection of existing molecules or compounds that have already passed safety tests. In fact, AI and machine learning play a huge role in this, say experts. As per a paper published in Nature, titled, 'Drug repurposing: A nexus of innovation, science, and potential', these computational methods allow researchers to sift through vast amounts of data, identify hidden patterns, and generate insights that would be difficult to uncover through traditional means.

Propranolol (brand name Ciplar-LA) was initially meant to be used for managing high blood pressure and is now used for anxiety, palpitation and as a prophylactic for migraines. It is a beta blocker, which means it works by changing the way the body responds to some nerve impulses, including in the heart. It slows down your heart rate and makes it easier for your heart to pump blood around your body. It is worth mentioning that propranolol was also registered in a clinical trial with paediatric patients affected by recurrent respiratory papillomatosis with positive results.

Dr Mohit Sharma, senior consultant, internal medicine, Amrita Hospital, Faridabad, says there are medicines that are more successful in their repurposed avatar. “SGLT2 inhibitors, namely dapagliflozin, empagliflozin and canagliflozin, were initially made to control glucose levels in diabetics by making the person excrete sugar in the urine, but now they have been found to be beneficial in improving morbidity and mortality in patients with heart failure and early chronic kidney disease,” he says. “So, it has found two more uses for which it is used more than for diabetes. It was not that successful as an anti-diabetic medicine. It is a recent drug and for us practising physicians it is a revolutionary medicine. Because research shows that it improves the lifespan and prognosis and reduces mortality rate in patients with heart failure.”

He adds that glipizide is an “emerging repurposed drug”. A diabetes medicine used commonly in the US, it can be effectively repurposed for treatment of some devastating human brain disorders such as Huntington’s disease and other polyQ disorders, according to researchers at Delhi University’s genetics department. In the UK and in India, other salts from the same family, like gliclazide and glimepiride, are more common. And as glipizide is found to have a repurposed role, there might soon be research into other drugs of the same class.

So, what is the process for deciding which medicines can be repurposed and for what? “The repurposing of medicines has been done regularly whenever there is an infection or any kind of disease which is either not responding to other medication or is not identified in detail,” says Dr Abdul Samad Ansari, director, critical care services, Nanavati Max Super Specialty Hospital. “Two things which are simultaneously done are identification of the causation and the mechanism of the illness, whether it is an infectious or non-infectious disease, how the disease progresses.”

He cites the example of psoriasis. “That is one ailment and the other is Covid-19 and the scientist and the physician try to find the similarities between the pathogens, the etymology and then pharmaceutical research collaborates with biological research to understand the type of virus and pathogen, the type of disease, and look at the whole compendium of drugs which fit the bill,” he says. “The point is to look backwards. For example, For Covid-19, the WHO listed hundreds of drugs which had potential. They looked in the past for RNA viruses as Covid-19 was also [caused by] an RNA virus.”

The key step, he says, is to apply the syndromic approach. “That is classifying the disease into syndromes to figure out easily identifiable group of symptoms and signs and most common organisms causing the syndrome,” he says “So, for instance, in polio, upon observing the symptoms, you immediately draw out a parallel with acute flaccid paralytic conditions and then look backwards to see the data in similar conditions to map the disease trajectory and then repurpose the drug for that broad group in which the disease is. This is how hydroxychloroquine, tocilizumab and remdesivir were found and used in the treatment of Covid-19.”

Sharma gives an example of how a drug can treat two interrelated conditions simultaneously. GLP1 receptor agonists were used for glucose control in diabetes, but is now used to cause weight loss in morbidly obese patients. “This way we now have a dual action for diabetic patients who are also overweight,” he says.

Scientist and computational biologist Rituraj Purohit, who works on ayurvedic medicines and contributed to the aforementioned paper in Nature, tells THE WEEK about Himalayan bioactive molecules he works on. He examines how they could be used for treating illnesses other than those they have been traditionally used for. “We repurposed turmeric―two important molecules from turmeric can directly inhibit or demolish viral activity,” he says. “Likewise, we also reported molecules from fennel seeds that could be used against Covid-19.

“Recently, we repurposed molecules from a Himalayan herb called Thalictrum foliolosum for the treatment of cancer and MDR TB. Earlier it was used for anti-bacterial activity. “We started this work two years ago, after the prime minister said we have to find solutions to eliminate TB from India,” he says. “We screened herbs which are used against bedaquiline-resistant TB and that is how we came across the molecule of Thalictrum foliolosum.”

Mahajan of Max Healthcare points out the drug thalidomide. “It became notorious because it was used in women during pregnancy to prevent vomiting, but resulted in babies being born with deformed arms,” she says. “This drug was then banned. Later on, it was found that it was a good drug for the complications of leprosy. And then, it was found that it was also a wonderful drug to fight the cancer multiple myeloma.”

Many older drugs have been repositioned for the treatment of Alzheimer's. “There is a drug called pioglitazone, used to treat type-2 diabetes,” says Mahajan. “But now there is data to suggest that this drug may have a role in the treatment of Alzheimer's. The combination of pioglitazone and insulin, as per research, may have a potentially positive effect on decreasing the risk of developing Alzheimer's.”

Multiple sclerosis, an autoimmune disease which affects the central nervous system, is another area where drugs have been repositioned. An academic paper in the journal Frontiers in Neurology says dimethyl fumarate is an effective treatment option for multiple sclerosis. Dimethyl fumarate was originally used in the treatment of psoriasis, a skin disease.

The recent licensing of anastrozole by the Medicines and Healthcare products Regulatory Agency in the UK, for preventive use marks a milestone. The drug was previously used for breast cancer treatment. Recent trials have shown that it can reduce the incidence of the disease in post-menopausal women at increased risk by almost 50 per cent.

Another example where drugs have been repositioned to treat neglected diseases is the case of leishmaniasis, a parasitic disease classified as a neglected tropical disease. It is caused by leishmania parasites, which are spread by the bite of sandflies. Two repurposed drugs are being used to treat this―amphotericin B, an anti-fungal, and miltefosine, an anti cancer drug.

Repurposed drugs are especially effective in the treatment of rare diseases. In such cases, since the affected population is low, it is not commercially sustainable for pharma companies to create specific treatments. According to a report by the ministry of health and family affairs, aroun 96 million people in India are affected by some kind of rare disease, with limited options for treatment. As per a study by Khujith Rajueni from the department of clinical pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth University, Pune, India’s patent regime prevents the evergreening of drugs and a large generic manufacturing industry provides ample opportunity to explore the potential of repurposed orphan drugs for treating rare diseases.

comprehensive-testing-helps-ensure-good-health-but-it-is-key-to-strike-a-balance-between-clarity

Sat Feb 24 17:18:20 IST 2024

Why so many tests?

How many of us can understand the sheets of paper we receive after a simple blood test? Do we require so many tests, or is it just a money-making tactic? What is the minimum knowledge we must have of pathological methods and testing? How much is too much?

According to one report, profit margins in pathologies are 23 to 25 per cent. The worrying fact is that the diagnostic industry is highly competitive, because of low entry barriers. Organised players cater to only 17 per cent of the market.

For this column, we delve into the why and how of diagnostic testing.

Dr Nilesh Shah’s qualifications include a BSc and PhD in microbiology and a DMLT (diploma in medical laboratory technology). He has 37 years of experience in his field. At 57, he is the president and chief of science and innovation at Metropolis Healthcare Limited.

Why we need to be tested on so many parameters: Comprehensive testing helps ensure good health and well-being, besides providing the clinician a detailed picture for easy decision-making. But it is essential to avoid tests that are beyond the doctor’s prescription and are irrelevant. Renowned laboratories have well-designed test packages that align with best practices. For instance, opting for a lipid profile instead of separate cholesterol and triglyceride tests can provide better value without redundancy, saving both time and money.

What do we do with 40-page reports we cannot make any sense of: Receiving lengthy reports filled with potentially irrelevant data can be overwhelming. The key is to strike a balance between thoroughness and clarity. Reports should be tailored to align with the doctor’s recommendations, focusing on relevant parameters related to the patient’s health concerns. Key findings and actionable insights should be highlighted, presented in a clear, understandable language that is accessible to non-medical professionals. A combination of detailed report and its summary helps doctors and patients understand the findings in the shortest possible time. A trend report in graphical format substantially helps decision-making.

The basic tests we require at different stages of life: Human bodies change and evolve throughout life, requiring different health checkups at different stages. While some basic tests―such as complete blood count (CBC), blood sugar, lipid, liver and kidney function tests―hold value across the board, specific needs arise at various ages and conditions.

For infants and children, regular check-ups with a paediatrician ensure healthy growth and development. Key tests include monitoring vaccination status, growth metrics, developmental milestones, and basic blood-work like CBC and anaemia screening. As children grow, tests may expand to include allergy, vision and hearing checks, and dental exams.

Healthy adults generally benefit from routine checkups every one or two years, with adjustments based on individual risk factors and family history. Blood pressure monitoring, cholesterol screening, and cervical cancer screening (for women) become crucial. Depending on age and risk factors, tests for vitamin deficiencies, bone density (DEXA scan) and diabetes may be added.

During pregnancy, prenatal care involves a series of crucial tests and checkups throughout pregnancy. Screening tests such as the dual marker test (11 to 13.6 weeks), quadruple marker test (14 to 17 weeks), and non-invasive prenatal testing 10 weeks onwards) should be conducted in all pregnant females based on gestational age. Regular monitoring ensures both mother and baby’s health.

As people age, annual checkups become even more important. Colon cancer screening, glaucoma tests and cognitive assessments may be added to the routine. Managing chronic conditions often requires more frequent monitoring with specific tests relevant to the condition.

The gender differential of testing: While many essential health tests apply to everyone, regardless of gender, there are certain gender-specific considerations when optimising health checks, as they ensure a more comprehensive picture, addressing unique vulnerabilities and concerns. For men, these tests are: prostate-specific antigen (PSA) test to detect prostate cancer, and testicular exam to detect abnormalities. Semen analysis assesses fertility potential.

Women require PAP smear, which guards against cervical cancer, while mammograms screen for breast cancer. Pelvic exams evaluate reproductive organs and overall pelvic health.

There are five essential tests for all―complete blood count (CBC), cholesterol levels, creatinine levels, serum glutamic pyruvic transaminase (SGPT) levels and glucose levels. These tests offer valuable insights into various aspects of overall health, including blood cell counts, lipid profile, kidney function, liver health and blood sugar levels. By regularly monitoring these parameters, individuals can proactively manage their health and detect potential issues early on.

Are the ‘normal levels’ in various tests attuned to Indian genetics/conditions: No, our reference ranges have yet to be adjusted for the Indian population. Thus clinical involvement remains indispensable for interpreting reports effectively, especially when considering the patient’s history and symptoms. This underscores the vital role of health care professionals in contextualising the findings within the specific health context of each individual. By incorporating clinical expertise, we ensure accurate diagnosis and personalised treatment plans, ultimately optimising patient care and outcomes.

With age, there are some changes that are inevitable (example: higher lipid levels); so are tests in such cases just fear-mongering: Ageing brings about various physiological changes. For instance, lipid levels tend to increase with age, reflecting changes in metabolism and lifestyle factors. However, it is important to approach these changes with a balanced perspective and avoid unnecessary concerns. While age-related alterations in health parameters are natural, they do not necessarily indicate pathology or looming health risks. Instead, they should be viewed within the broader context of an individual’s overall health and well-being.

Different tests may exhibit different patterns of change with age. For example, while white blood cell (WBC) count typically decreases with age, levels of follicle-stimulating hormone (FSH) in women tend to increase. Understanding these nuances is essential for better understanding.

Important issues about pathological tests that a layman should understand: There are two fundamental points. Selecting the right tests is vital to prevent over-testing, which can be as harmful as under-testing. Targeted tests for specific health concerns minimise unnecessary procedures, reduce costs and lower the risk of false positives or unnecessary interventions. Second, consulting a qualified health care professional is essential for interpreting test results accurately. Their expertise contextualises results within the patient’s medical history and symptoms, guiding personalised treatment plans or preventive measures. Collaboration between patients and health care professionals optimises the value of diagnostic tests, enhancing health outcomes and informed decision-making.

The question of trust and confidence: Evidence-based medicine is a widely accepted norm in the recent era. As a result, undergoing diagnostic tests should also be embraced. Patients should place their trust in the clinician’s experience with diagnostic centres, in addition to considering laboratory accreditations and the overall brand image.

Regarding doctors, the initial screening should involve assessing accreditation, test menu, technology adoption, team credentials, proficiency test performance, service levels and published NPS (net promoter score). A personal visit to the laboratory and meeting the key team members is a crucial step in building confidence.

A primer on technologies: New-age technologies can be categorised into two distinct realms, emphasising that their applications differ significantly though the underlying technologies may be the same. The first category encompasses technologies related to equipment and machinery, while the second category focuses on pure IT solutions.

Multiplexing: A technique employed in various fields, including molecular diagnostics and immunoassays. Multiplexing enables the retrieval of multiple answers from a single test, exemplified by immunoassay multiplexing tests that can assess numerous allergies simultaneously. Additionally, this molecular method facilitates the evaluation of infections in one comprehensive analysis.

Microarray: Microarrays, resembling small chips, feature coatings of multiple substances. These arrays serve diverse purposes, such as assessing food intolerances. With up to 210 different particles or components on a single chip, microarrays efficiently deliver comprehensive test results.

Next-generation sequencing: NGS, despite being over a decade old, has evolved significantly in terms of applications, automation and customisation for diagnostic purposes. It now finds utility in cancer workup, infection diseases, gut microflora analysis and tuberculosis diagnostics, among others.

Mass spectrophotometry: Although a technology in use for 20 to 25 years, mass spectrophotometry has recently gained traction in clinical applications. Tandem mass spectrometry enables the identification of bacteria and organisms at the gene level.

In the semi-IT domain, IT is integrated with equipment to enhance functionality:

Haematology: In this field, digitised pathology has achieved remarkable precision. Scanners analyse slides, and doctors perform image analysis, leading to a 99 per cent accuracy rate. Immunofluorescence employs similar technology for positive/negative identification and pattern recognition.

Cytology: IT-assisted analysis identifies positive and negative areas, aiding doctors in their assessment.

Histology: Image analysis software enables scoring of slides, streamlining the diagnostic process.

Urine Analysis: Automation has optimised urine microscopy, allowing for fully automated analysis.

Within the middle IT sector, technologies with a history of 10 to 15 years are gaining renewed acceptance, particularly in reputable organisations:

Auto validation: Automation plays a crucial role in assessing calibrations and controls, determining if they adhere to norms and should be accepted.

Moving averages: Moving averages provide ongoing system monitoring by calculating the mean of results. Any deviations trigger system alerts, significantly enhancing quality control compared to previous methods.

why-are-so-many-young-indians-at-cardiovascular-disease-risk

Sat Jan 27 15:04:20 IST 2024

Cardiac arrest and heart attack are the same….Cardiovascular diseases (CVDs) run in my family, so there is nothing I can do to stop it…. CVDs generally affect men more than women…. Heart attacks among younger people are only because of excessive exercise or stress. These are some of the misconceptions among people, resulting in delayed diagnosis and ultimately poor health outcomes.

Although we see that there is a growing awareness about the increasing prevalence of CVDs in India, people are not aware of the onset, the exact signs and symptoms, and the right approach to seek medical aid. In just three decades, India has witnessed a 2.3-fold surge in the prevalence of ischemic heart disease (IHD) and stroke. There is an alarming rise in the burden of heart failure (HF) and acute myocardial infarction (AMI) as well. This can be attributed to six fundamental transitions―epidemiological, demographic, nutritional, environmental, social-cultural, and economic factors.

CVDs in India have escalated from 25.7 million cases in 1990 to 64 million in 2023. In fact, Indians are more likely to develop CVD risk factors at a comparatively younger age, experiencing more severe manifestations of the disease when compared to other ethnic groups.

According to the World Health Organization, India accounts for one-fifth of CVD deaths worldwide, especially in the younger population. The results of Global Burden of Disease study state an age-standardised CVD death rate of 272 per one lakh population in India, which is much higher than the global average of 235.

CVDs reveal a multifaceted reality in India, with implications across various dimensions. Epidemiological studies have consistently linked sedentary lifestyle with increased mortality, particularly from CVDs. For instance, individuals reporting prolonged sitting or extensive television viewing have shown higher mortality risks. Around 50 per cent of respondents of a survey believe that sedentary behaviour has an equivalent detrimental effect on heart health as smoking.

Another important factor highlighted by the study was the existence of co-morbidities among younger Indians, leading to a rise in cardiac events. The presence of conditions like diabetes or hypertension in younger individuals adds a layer of complexity to their vigilance in disease management. Unfortunately, most people with co-morbidities such as diabetes do not opt for, or, are not advised for cardiac risk assessment as part of their disease management programme. The study revealed that 75 per cent of the respondents have not undergone cardiac risk assessment following a diabetes diagnosis.

Another aspect is the genetic risk factor. While a family history of CVDs and excessive stress is a pivotal determinant of CVD risk, identifying one's genetic predisposition to heart ailments can aid in early diagnosis and risk mitigation.

Today, people are much aware about the growing prevalence of CVDs in India, but the knowledge about the disease itself is limited. Most people do not know the difference between the various CVDs. The study mentioned above indicated that more than 60 per cent of the respondents did not know the difference between cardiac arrest, heart attack and a heart failure.

A heart attack is when one of the coronary arteries becomes blocked. The heart muscle is robbed of its vital blood supply and, if left untreated, will begin to die because it is not getting enough oxygen. A cardiac arrest is when a person's heart stops pumping blood around the body and one stops breathing normally. A heart failure, on the other hand, is when the heart doesn’t pump normally, causing the hormone and the nervous systems to compensate for the lack of blood. The body may raise the blood pressure, making the heart beat faster and causing it to hold on to salt and water. If this retained fluid builds up, the condition is called congestive heart failure.

Around 77 per cent of people find annual blood pressure checks ideal for heart health, indicating a clear lack of understanding on preventive and proactive measures.

To mitigate the impact of CVDs on India's population, it is important to spread knowledge about proactive cardiovascular health screening and management. In a nation undergoing rapid epidemiological transitions, it is vital to implement a population-based disease management programme that focuses on access and availability of diagnostics tools, medical treatment and educational guidance to patients and caregivers. This will result in early and right intervention towards disease management while reducing health care costs.

Dr Chandra is the chairman of interventional cardiology at Medanta Medicity.

ss-innovations-founder-chairman-and-ceo-dr-sudhir-prem-srivastava-interview

Sat Jan 27 15:00:49 IST 2024

Interview/ Dr Sudhir Prem Srivastava, founder-chairman and CEO of SS Innovations

Dr Sudhir Prem Srivastava got his medical degree from J.L.N. Medical College in Ajmer before completing his residency in cardiothoracic surgery at the University of British Columbia in Vancouver. In 2003, with 10 physicians, he founded Alliance Hospital, a center of excellence in cardiovascular disease in West Texas. While there, he performed the world’s first single-vessel TECAB (totally endoscopic coronary artery bypass) on a beating heart. After returning to India, he has introduced a made-in-India brand of medical robotics surgery equipment. In an interview, he speaks about the development of the indigenous system.

What was the market analysis that went into understanding and defining the product?

Since the time the world was introduced to robotic surgeries, they have been considered only for the elite class because of the high cost of procurement of a surgical robotic system by a hospital. This explains the low penetration levels in India.

When I first returned to India, there was only one brand of surgical robots which was selling in the country. The high capital cost of the surgical robot was dictated by the monopolistic advantage the manufacturer enjoyed. High cost of the system translates to high procedural cost. This propelled my mission, in 2012, to develop a system that will not only be different, but also loaded with better features, more applications and yet be cost-effective. This took me on a journey to change the direction of surgery by creating a surgical robotic system that will be affordable not only in India, but also in many other economies.

The SSi Mantra is India’s first and only indigenously developed surgical robotic system. It is loaded with unique features for the price at which it is pegged.

When did the research phase begin and how long did it take?

The journey to create the SSi Mantra began in 2014, and after an extensive five-and-a-half-year endeavour, the system was successfully introduced to the commercial market. However, given the continuous evolution in the surgical field, our research and development remain ongoing to incorporate the latest of technologies to help surgeons perform the most complex surgeries with ease and achieve improved clinical outcomes. We are committed to continuous technological improvement, constantly exploring avenues, especially in relation to integrating AI, and devising strategies to make it even more advanced and user-friendly.

What percentage of the components are Indian? What are the possibilities?

Some 85-90 per cent of the components are Indian.

SSi Mantra has been installed at the Aster Hospital, Dubai, and now at the prestigious Johns Hopkins University’s campus in Baltimore, in the US. Under the terms of the agreement with Johns Hopkins University, we installed one system at the MISTIC (Minimally Invasive Surgical Training and Innovation Center). SS Innovations and the MISTIC team will share the benefits of these combined research activities.

This is just the beginning. There is a world of opportunities waiting out there, among like-minded health care professionals who mirror SS Innovations’ vision of taking qualitative surgical health care to the underserved population and putting it within reach of the common man.

Talk us through the roadblocks you hit during the research and development.

The development of the surgical robotic system was not easy. The first system that I developed was entirely funded by me from my personal savings. I reached a point where I had to sell off everything, even my furniture, to fund the development of the system as funding was not coming through. A team of 150 professionals have put in their effort to bring SSi Mantra to life. It is a prime illustration of India’s technical leadership in the medical device industry.

How does a layman best understand the product and its benefits?

It is said ‘seeing is believing’. Across the length and breadth of the country, stories of laymen who have been benefitted by surgeries conducted using the SSi Mantra are numerous. A case in point is from Moradabad. A patient named Jameeluddin had been suffering for more than 10 years and was not even able to digest a glass of water. The only solution was to dissect a particular layer of a muscle of the oesophagus. In view of the level of precision required, robotic surgery using SSi Mantra was suggested to him. The procedure was conducted flawlessly. The patient received excellent results and was up on his feet within a few days.

ssi-mantra-surgical-robotic-system

Sat Jan 27 14:56:39 IST 2024

In the ancient Sanskrit text, Sushruta Samhita―a treatise on medicine and surgery―the author, Sushruta, lists the qualities of a great surgeon. These include courage and presence of mind, a hand free from perspiration, and a tremor-less grip of sharp and good instruments. But what if the grip of the surgeon was replaced by the firmer hold of robotic arms? And what if your robotic surgeon was made in India?

SSi Mantra is the first robotic surgical system to be made in India. It is unlike any other system in the world for the broad spectrum of surgical procedures for which it can be used (from throat to gynaecological surgeries) and its cost effectiveness.

Named after its founder, Sudhir Prem Srivastava, among the world’s best known robotic cardiac surgery experts, SS Innovations International Inc fulfilled its first international order for the SSi Mantra in August 2023. The unit was delivered to Aster Hospital, Dubai.

Dr Somashekhar S.P., chairman, medical advisory board, Aster DM Healthcare, and director, Aster International Institute of Oncology, said that the first installation of the system outside India marked a major medical milestone for the country. “This robotic system, which has world-class technology and was developed by some of the best physician leaders in the industry, offers affordable cutting-edge medical technology to all those who are in need of complex surgical care, regardless of income,” he said.

The use of robotics in surgery, in theory, goes back to 1967. However, the first fully functional multipurpose surgical robot was developed by the US department of defence, in conjunction with innovative startups and established research agencies, only 30 years ago. It was this system, named after Leonardo da Vinci, that was first installed in 2006 at the All India Institute of Medical Sciences, New Delhi. Its cost then was around Rs9 crore; now it is closer to Rs15 crore.

There is much in favour of robotic surgery. It makes it easier to cater to high volumes of patients and bolsters medical tourism. India has earned around $7.4 billion from medical tourism over the last decade.

While the use of the da Vinci system has grown steadily since its introduction, its cost is a deterrent to deeper market penetration in India. At Rs4-5 crore, Mantra costs roughly one third of the da Vinci.

Mantra has been granted regulatory approval by the Indian Central Drugs Standard Control (CDSCO). It has been clinically validated in India through use hundreds of times in more than 40 surgical procedures, including those for cancer, head, spinal and heart surgeries. CDSCO approval is accepted in 56 countries. The company has begun the process of filing for FDA (the US) and CE (European) approval. It hopes to receive these in 2024 and 2025, respectively.

In October 2023, Mantra scripted medical history by successfully performing an ultra-low anterior resection for rectal cancer at Aster DM Healthcare, Bengaluru. It is a surgical procedure involving the removal of part of the left side of the colon including the entire rectum. This also involves removing the supportive tissue to the bowel including the draining lymph nodes to that section. With robotic surgery, the entire procedure was done with minimal invasion, thereby ensuring reduced blood loss, less postoperative pain, shorter hospital stay and faster recovery. It is estimated that recovery from a robotic rectal resection generally takes two to three weeks compared to four to six weeks for conventional open surgery.

Mantra has user-friendly features for the surgical team, which will make training much easier. India currently has no standardised curriculum for the training and credentialing of robotic surgery. Government-funded hospitals remain the mainstay for formal training. SS Innovations is offering on- and off-site training to use the system.

Besides its broad-range surgical capabilities, Mantra has modular, 3D vision, open-console design and superior ergonomics, and engages machine learning to improve safety and efficiency during procedures.

“This is just the beginning,” said Srivastava. “Mantra shall remain a work in progress with constant improvements.”

And some day, it might be the most recognised surgeon in India.

how-social-media-is-facilitating-easy-transaction-and-transportation-of-illicit-drugs

Sat Jan 27 14:28:04 IST 2024

On November 20, 2023, Anne Milgram, head of the US Drug Enforcement Agency (DEA), said at a press conference: “Fentanyl poses the greatest threat to Americans today, devastating families and becoming the leading cause of death for those aged 18 to 45.” The statement followed the successful ‘Operation Blue Brothers’, aimed at dismantling an international drug supply chain. The operation, initiated following the death of 20-year-old Diamond Lynch, exposed a supply chain originating in China, involving drug precursors, progressing to clandestine labs controlled by the Sinaloa drug cartel in Mexico, then reaching wholesale distributors in Los Angeles and retail distributors in Washington, DC.

Fentanyl, a potent synthetic opioid approved by the US FDA for severe pain, gained prominence in the US black market in 2014. Over the past decade, fentanyl and related substances have significantly contributed to the surge in drug overdose deaths in the country. People both knowingly and unknowingly consume fentanyl and synthetic opioids, as they are often mixed or sold as other drugs like heroin, cocaine or counterfeit pills.

Interestingly, while briefing about ‘Operation Blue Brothers’ that led to the arrest of 25 people, Milgram emphasised that the defendants in the case employed Instagram to discover their sources of supply, explore distribution channels, specify pill details like colour, quantity and pricing, and coordinate shipments and payments. “This fentanyl distribution conspiracy―which started with pills sourced in Mexico and spanned across the United States―would not have been possible without Instagram,” she said, while adding that “lawful access” to Instagram messages led to the arrests and dismantling of the conspiracy. But then, Milgram also warned against Meta, the company that owns Instagram, implementing “warrant-proof” end-to-end encryption. “This kind of work to protect the public will become increasingly difficult―if not impossible―if social media companies implement ‘warrant-proof’ end-to-end encryption, that simply turns the lights off and looks the other way while criminals use these platforms to spread poison in our communities,” she said.

Milgram's concern represents a widespread challenge confronted by law enforcement globally. It is a matter of concern for Indian agencies as well. In early December, Meta began implementing default end-to-end encryption settings for all personal chats and calls on its platforms. Shortly thereafter, Maharashtra Deputy Chief Minister Devendra Fadnavis remarked, “Drugs are being marketed on Instagram.”

International counter-narcotic agencies have already flagged India as the largest source of illicit synthetic opioid tramadol. Many western experts believe that India could evolve into a source for both precursors and finished products of various illicit opioids, including variants of Fentanyl, although China remains the primary source for the precursors. And, social media platforms, facilitating the easy transactions and transportation of illicit drugs across the world, clearly remain the elephant in the room.

tips-to-take-care-of-eyes

Sat Jan 27 14:19:29 IST 2024

India is the ‘blind capital of the world’ due to a high prevalence of avoidable blindness. Besides loss of vision we also have high rates of moderate to severe vision impairment. Dr Bela Kamboj, our expert for this column attributes a lot of this to ‘pseudo literacy’ about eye health and our penchant for doctor shopping till we find one who is willing to tell us what we want to hear. Regular eye check-ups must figure on our list of health checks, and we must accept changes that come with age and hormones. She also tackles some of the most popular myths and marketing gimmicks about eye care.

Allow the eyes time to self-heal: Not every redness/irritation of the eye is indicative of an infection. Towards the end of last year, many people self-medicated or took drugs on the prescription of chemists to treat ‘eye-flu’. A flu virus always comes back with some genetic modification. This time, it required no treatment and healed within two to three days. But with medication, it took one week to two months. Also, self-medication by antibiotics or steroids caused loss of vision for many. Continued, unsupervised use of such drugs lowers the immunity, could make you more prone to infections and lower your body’s response to the medicine when you really need it.

Eye make-up: Ideally kajal should not be applied at the rim of the eyes. Apply it outside. Eyelids have glands and their openings are on the margins of the eyelids. When the glands are clogged (because of the particles in kajal), they are unable to make/drain tears and can also cause stye. The best way to clean eye make-up is using just water. Look upward and pull the lower eyelid down, swab a cotton bud with water and gently remove the make-up. Sometimes, when a patient is listed for LASIK, we instruct her not to use kajal for a week to 10 days because that is how much time it takes for the eyelid to clear up completely.

The importance of tears: Every time we blink, a thin layer of tears (tear film) is formed across the cornea. Tears provide oxygen and nutrition to the eyes, contain good bacteria and have naturally produced antibiotics. There are three layers of tears―an oily outer layer which keeps the cornea smooth, a watery middle layer which nourishes the eye, and an inner layer of mucus which helps the tear stick to the eye. If you have tears coming out of the corners of your eyes, these are not excess tears but symptomatic of some other problem. You might be touching your eyes too often, or these could be brought on by the excess use of chemicals (in make-up) or be indicative of dry eyes.

Dry eyes: This is a condition when your eyes do not produce the required amount of tears or there is something impacting a layer of the tear film. The most common symptoms are a feeling of grittiness, and the need to rub eyes or to splash them with water. Dry eyes can happen at any age but they become more common with women as they age and the production of oestrogen falls. The most common treatment is to use an eye lubricant. Splashing one’s eyes with water is the worst thing that can be done, as it just wipes off the naturally produced tears.

The myth of clean eyes: Splashing your eyes with water is not recommended. The blinking action is a natural eye cleaning mechanism as tears are produced and wiped off constantly. Think of it as your eyes being mopped naturally. Avoid putting in random things like rose water or eye drops.

Can one be too young to get spectacles? No. Parents often argue that a young child cannot manage spectacles. The counter is that if a child can see better with spectacles she will manage it, too. Also, do not get expensive glasses if management is a worry. The sooner a problem is identified and the sooner it is addressed, the surer we can be of nipping further problems.

Almost everyone over the age of 40 will require spectacles: We must make peace with the fact of ageing, though there shall always be exceptions. After 40, one should get one’s first eye checkup if never done earlier. Subsequently, this should be done every 3-5 years. As we age, the lens in the eyes becomes less flexible and is unable to focus light correctly on the retina. To patients who are resistant to glasses, there are options like contact lenses. To those who refuse to accept ageing, I tell them if they choose not to use glasses and strain their eyes, they will develop deeper lines/wrinkles near their eyes and appear even older.

The benefits of eye checkups: The eye is the only organ that when examined can detect other problems as well. For instance, if there are deposits on the blood vessels in the eyes, it is likely that the person has high levels of cholesterol. Similarly, if the retina’s blood vessels are leaking, it is an indication of diabetes. Certain cancers also show changes first in the eyes.

We will all develop cataract: With age there will be the development of a cloudy area in the lens of the eye. However, while everyone will get cataract, not everyone will require surgery for it. For example, if your work requires use of near vision (goldsmiths, tailors), you will require surgery quickly. Or suppose you drive during the night and the glare becomes unbearable, then you would require surgery. However, if you have enough clarity of vision to carry on normal activities, surgery is not required. Earlier, surgery would be delayed till the cataract was fully mature. However, now we do it as early as required so that the incision is small and healing is faster.

Glaucoma: This is a group of eye diseases that damage the nerve connecting the eye to the brain because of fluid build-up which in turn exerts pressure on the eye. The two most common forms are open angle, which has no symptom except gradual vision loss, and angle closure, which has more marked symptoms like nausea, severe eye pain and sudden blurry vision. If left untreated glaucoma will lead to blindness.

Too much screen time is ruining our eyes: No. We only need to look away from the screen for 20 seconds every 20 minutes. It is a marketing gimmick that blue ray glasses are helpful. All they do is soothe the eye as the screen does not look as bright. The same impact can be achieved by reducing the brightness of our screens. I am yet to come across a patient who has shown marked difference because of the use of such glasses. In fact, such glasses can impact the contrast sensitivity of some patients. We need to think and blink during screen time.

The loss of the blackboard: More and more schools now use white boards. Children not sitting directly in front of such boards can struggle with light refection and glare and thus are unable to clearly see what is written on the board. Such boards also develop scratches with time.

What kinds of glasses are must: Night vision glasses (the ones with a yellow coating) should be used while night driving. The level of UV protection that we need from glasses varies. Most of us are not even up during sunrise (when UV rays are most harmful). These become more important when in the hills. While a pair of glasses that cost Rs100 will definitely not have UV protection, it does not mean that branded is better. Branded glasses will have better scratch resistance, look better but will in no way give you new eyes―that is more a function of marking the glasses precisely so that the lenses can be placed in the frame properly. Those who work on construction sites, those who use their helmets without visors and those who play sports such as squash, tennis, badminton or lawn tennis, and those who swim or cycle should also wear glasses.

Vision versus power: How much you can see is vision. What you use to see better is power. Thus, our spectacles have power; while near sightedness and far-sightedness are forms of vision.

genomic-testing-is-reshaping-the-way-we-find-and-treat-cancer

Sat Jan 27 14:14:37 IST 2024

In cancer, diagnoses are done largely by looking through the microscope at the appearance of cancer cells and, often, the organ the cancer comes from offers the most important way of making the diagnosis. But, over the past couple of decades, doctors and researchers have realised that a much better way to diagnose cancer is by the molecular abnormalities that distinguish cancer cells from normal ones; these abnormalities are often changes in the DNA sequence in the genome of the cancer cells.

Cancer is a disease of the genome. Each cell within our body contains all of the genetic code required for human life and development. This genetic code is composed of over three billion DNA molecules, joined together into 46 long strings known as chromosomes. Collectively, the DNA that makes up all 46 chromosomes is known as the genome.

Every time a cell divides, it makes two copies of its DNA that are passed on to its daughter cells. But, occasionally, errors are made while copying the DNA, resulting in mutations in the daughter cells. The great majority of mutations are harmless, but some can develop into a tumour.

Cancer genomics is the study of these mutations. For example, 12 years ago lung cancer was classified as either small cell or non-small cell. Today, it is identified by nearly 30 genomic mutations or changes. Identifying specific mutations in patients marks a radical shift from a one-size-fits-all treatment towards more personalised therapy.

Precision medicine

Precision medicine’s central principle centres on the ability to identify personal gene characteristics and match them to specific treatment options. It is an emerging approach in cancer treatment and prevention.

DNA changes, or patterns of changes, can now be used to predict which drugs might be effective, as well as to decide in which patients to use more aggressive therapy. The genomic information can also be now used to predict which patients may have a toxic response to some drugs. Furthermore, it has become clear that some cancers arising in different organs (for example, breast or prostate) can have the same kinds of genomic changes, meaning the same kind of therapy can be equally effective for these patients. This is important as it means there are existing drugs used for patients with breast cancer that could also be used for patients with prostate cancer.

“Fundamentally, I am alive because of genomic testing,” says Dr Sharon Stanley, a cancer patient and an osteopathic physician. “I had uterine cancer, an advanced stage, very aggressive type of sarcoma. I went through a chemotherapeutic regimen, but I did not go into a full remission. Because I had mutations [associated with lung cancer], it didn’t matter if I had uterine cancer; I could get on to Keytruda (a drug), which was approved for lung cancer, and to which I responded very well. If this hadn’t happened, the likelihood of me being alive was under 10 per cent. But now, I’m headed into what appears to be a full remission and even better news is that it is an opportunity for individual treatments based on these markers as opposed to the classic treatment of tumours based on tissue type.

Genomic testing

All patients with a diagnosis of cancer should at some point in their clinical journey go for testing to identify some of the genomic molecular changes that contribute to their disease. Deep understanding of these molecular changes have led to a transformation in cancer care. The testing can be done on tissue after a biopsy of the patient’s tumour or other samples that may have tumour DNA as well, such as in the blood or sometimes in the urine. Detecting these changes are likely to play a critical role in helping the physician choose between several treatment options.

Another unique story is that of Prof William Burhans, a senior cancer scientist at Roswell Park Cancer Institute in New York. Dr Burhans was diagnosed in 2013 with an aggressive prostate adenocarcinoma and went through the usual treatment. But because of the aggressive nature of the tumour, the benefits of the treatment lasted only a short time. He had a family history of cancer and was tested for germ line (sex cells) mutation. The results determined that he had a mutation in the BRCA2 gene, which is associated more frequently with ovarian and breast cancer, and with prostate cancer in some cases. He began treatment with a drug called olaparib, which was approved for patients with ovarian cancer who also had these mutations. “I was told at the beginning of my treatment that I probably had no more than a few months left,” said Burhans. “But here I am now, healthier than otherwise.”

How affordable is genetic and genomic sequencing?

The human genome is made of more than six billion letters, and each person has a unique configuration of As, Cs, Gs, and Ts―the molecular building blocks that make up DNA. Determining the sequence of all those letters used to take vast amounts of money, time and effort. The Human Genome Project took 13 years and thousands of researchers. The final cost: $2.7 billion.

Sequencing has led to genetically targeted drugs, blood tests that can detect cancer early, and diagnoses for people with rare diseases. In research labs, the technology has become essential, but it is still not ubiquitous in medicine. That is in part because of the price. While it costs around $600 for scientists to perform sequencing, clinical interpretation and genetic counselling can drive the price to a few thousand dollars for patients, and insurance doesn’t always cover it. However, the market is competitive with companies vying to launch testing with reduced prices. In the past decade, the cost of genomic testing has come down from about $100/Gigabase (unit of measurement used to help designate the length of DNA) to $10/GigaBase, and are further set to reduce to below $5/GigaBase in the near future.

In India, genomic testing has grown from very little in 2015 to the order of a hundred thousand clinical tests today. The project to bring affordable personal gene mapping to India’s 1.4 billion people will potentially create a treasure trove of biological data that can aid drug development and disease prevention.

Preventive wellness

A decade or so ago, genomic testing got attention when Hollywood star Angelina Jolie went on to describe how her doctors estimated that she had an 87 per cent risk of breast cancer and a 50 per cent risk of ovarian cancer on account of a genomic variant in a gene called BRCA1. She underwent preventive surgery, as a result of which her risk reduced to that of the average woman of her age.

The dramatic cost reduction has fuelled the increasing adoption of these tests for preventive wellness. A recent study published by Mayo Clinic Proceedings indicates that nearly one in eight people who underwent predictive genomic testing found that they had a genetic risk for a health condition and may be able to manage it better with preventive care. Rising adoption of healthier lifestyles and increasing awareness of genomics are expected to drive demand for predictive genomic testing.

The number of people getting DNA reports has been doubling, roughly, every year since 2010. The DNA repositories are now so big that they are enabling surprising new applications.

Even then, some think we are spending too much time searching under the lamplight shed by genetic tools. As Pulitzer Prize-winning cancer doctor Siddhartha Mukherjee wrote: “Perhaps we had been seduced by the technology of gene sequencing―by the sheer wizardry of being able to look at a cancer’s genetic core.”

Priya Menon produces and hosts CureTalks, an internet talk show on health care. She works as vice president, TrialX, a clinical trial solutions company headquartered in New York.

alcohol-industry-s-involvement-in-cardiovascular-disease-research-funding

Sat Dec 30 11:26:48 IST 2023

Alcohol’s effect on cardiovascular disease (CVD) has been a controversial subject in the scientific world. There have been concerns about the alcohol industry’s involvement in research funding, and the bias it creates in scientific reviews.

There has been evidence of corporations from the tobacco industry, food industry and pharmaceutical industry sponsoring and reshaping science in a way that suits their business. In recent years, it has been established that the alcohol industry, too, has sponsored studies in the alcohol and CVD literature. A 2016 study led by UK-based researcher Jim McCambridge had shown that “key industry actors have used evidence of purported health benefits in largely successful efforts to influence public policy globally, in particular by suggesting that alcohol is different from tobacco because of claimed health benefits”.

Studies have shown that the most common sources of funding are not the companies themselves but organisations created and funded by alcohol companies. The now disbanded Alcoholic Beverage Medical Research Foundation is one such example. In 2018, a $100 million clinical trial on how ‘moderate’ alcohol use affects health was cancelled in the US after it was found to be biased in producing findings, which suggested that small amounts of alcohol have health benefits. The alcohol industry and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) had funded the trial. It was found that NIAAA leaders have had extensive contacts with alcohol companies.

In December, another study led by McCambridge―Alcohol, cardiovascular disease and industry funding: A co-authorship network analysis of epidemiological studies―was published in ScienceDirect, which attempted to analyse the extent of the alcohol industry funding. The study analysed 713 unique primary studies with 2,832 authors, published between 1969 and 2019 and located within 229 co-authorship subnetworks. A co-authorship subnetwork is a group of authors who have collaborated on multiple papers and are connected through co-authorship.

The study found that there was industry funding across subnetworks and approximately 8 per cent of all papers declared industry funding. “The largest subnetwork dominated, comprising 43 per cent of all authors, with sparse evidence of substantial industry funding,” said the study. The study, however, found that the second largest subnetwork contained approximately 4 per cent of all authors, with largely different industry funders involved. The study also found that authors affiliated with Harvard, who collaborated with industry-funded authors at the review level, were found to be part of the largest epidemiological subnetwork at the primary study level. Also, it had been observed that a few influential authors in the field had declared significant involvement with the alcohol industry. However, the study authors noted that the declared industry funding should very much be regarded as identifying the tip of the iceberg.

Nevertheless, the study concluded without establishing a straightforward relationship between co-authorship network formation and alcohol industry funding of epidemiological studies on alcohol and CVD. However, it demanded a more fine-grained attention to patterns of alcohol industry funding and to key nodes (here, authors and organisations). “It may shed further light on how far industry funding may be responsible for conflicting findings on alcohol and CVD,” noted the study authors.

rabit-robotic-surgery-procedure-for-thyroid

Fri Dec 29 17:35:15 IST 2023

Cancers are rare among children, and thyroid cancer is more so. The management of thyroid cancer in children presents unique challenges owing to their delicate anatomy, ongoing growth and increased susceptibility to surgical complications.

In recent years, a groundbreaking development has emerged in India in the form of a robotic thyroidectomy technique called RABIT (robotic assisted breast-axillo insufflated thyroidectomy) and neck lymph node removal technique called RIA-MIND (robotic infraclavicular approach for minimally invasive neck dissection). These techniques do not require special equipment (other than the robot), thus reducing the cost. This minimally invasive surgical approach is gradually gaining traction for its numerous advantages, including smaller incisions, reduced pain and quicker recovery. My team has performed more than 150 cases of RABIT and RIA-MIND on adults. The adoption of robotic thyroidectomy and neck dissection for children in India has been limited, primarily because of unavailability of the technique, technology and training.

A FIRST IN INDIA

In 2023, India marked a significant milestone in the management of thyroid cancer in children. My team from Fortis Hospital, Bannerghatta Road, Bengaluru, performed the nation’s first robotic thyroidectomy and neck dissection in a child, employing the RABIT technique. The patient was a seven-year-old girl diagnosed with papillary thyroid carcinoma, the commonest form of thyroid cancer. The groundbreaking surgery was a success, resulting in a recovery with no complications. This achievement serves as a testament to the safety and efficacy of the technique for children and is poised to catalyse further progress in the field. This was not only India’s first but also one of the first few robotic thyroid surgeries on a child of this age in the world.

Challenges of robotic thyroidectomy and neck dissection in children

First and foremost, children’s smaller and delicate anatomy can make the surgical procedure inherently more complex. Precision is paramount, and the robotic system’s capability to provide a magnified view of the surgical field becomes invaluable. Second, the fact that children are still in the midst of their growth and development raises concerns about the impact of surgery on their physiological and psychological wellbeing. An open surgery leaves a scar of 15-20cm, which may look very bad in front of the neck of the child. We can never predict how this scar will look as the child grows. Third, children's heightened vulnerability to surgical complications, such as infection and bleeding, necessitates utmost caution and expertise. Children do not tolerate blood loss as well as adults, as their overall blood volume is low.

HOW THE TECHNIQUES WORK

The RABIT technique involves making small incisions in the armpit to access the thyroid gland and associated structures. It offers significant advantages over conventional open surgery. The incisions made are notably smaller, leading to reduced postoperative pain, minimal scarring and enhanced cosmetic outcomes. The minimised surgical trauma allows for quicker recovery time and less discomfort. The RABIT technique exemplifies the potential for precise, minimally invasive procedures even in paediatric cases.

In tandem with the RABIT approach, the RIA-MIND technique builds on the concept of minimally invasive surgery by employing robotic technology in the best way possible. By accessing the neck lymph nodes without conventional incisions, it further mitigates the visual impact of surgery. The open surgery for neck lymph node removal is associated with wound-related problems, which can be avoided by using RIA-MIND. It demonstrates the commitment to minimising the psychological burden for children who often contend with self-esteem issues arising from surgical scars. Additionally, it significantly reduces the risk of complications associated with open neck dissection procedures.

ADVANTAGES

Apart from faster recovery and less pain and minimal scarring owing to smaller incisions, the RABIT and RIA-MIND techniques allow for more precise dissection during surgery. This precision enhances the preservation of critical nerves and blood vessels, further improving the surgical outcomes. One of the most important structures that must be preserved during thyroidectomy is the parathyroid gland, which is responsible for calcium in the blood. With the magnification and special technique developed by me, it is now possible to save this gland with better precision. The cost-effectiveness of the two techniques is a key feature, ensuring that these advancements are accessible to patients in developing countries such as India. This paves the way for more equitable health care and improved treatment outcomes for a broader population.

FUTURE IN INDIA

The successful completion of India's first robotic thyroidectomy and neck dissection in a child marks the start of a new era in paediatric thyroid surgery. This landmark procedure underscores the feasibility and safety of robotic thyroidectomy and neck dissection in children and serves as a beacon of hope for countless young patients and their families. With the growing recognition of the advantages offered by the RABIT and RIA-MIND techniques, the trajectory of thyroid cancer treatment in India is set to evolve drastically.

Presently, RABIT is being practised in over 10 medical centres across India by surgeons trained by me. Remarkably, this technique received the K.S. International Innovation Award in 2023. It is worth noting that RABIT is a homegrown innovation.

As more surgeons in India and around the world adopt these innovative techniques, it is highly likely that robotic thyroidectomy and neck dissection will emerge as the standard of care for patients with thyroid cancer.

The writer is senior director of surgical oncology, robotic and laparoscopic surgery, Fortis Hospitals, Bengaluru.

ladakhs-first-female-surgeon-padma-deskit-talks-about-her-experiences-amid-hazards

Fri Dec 29 17:13:40 IST 2023

Padma Deskit, Ladakh's first female surgeon, wanted to be a fellow of the Royal College of Surgeons of England, but her hopes were dashed after her father was diagnosed with cancer. As the eldest child, Deskit prioritised family and returned to Ladakh.

Deskit completed her MBBS from Lady Hardinge Medical College in Delhi and her postgraduation in surgery from Jammu Medical College. After giving up hopes about the coveted fellowship, she served as general surgeon in the Jammu and Kashmir health department, stationed at a hospital near Siachen in Nubra. While serving there, she found out about the stark shortage in specialists and equipment in Ladakh, leading to frequent patient referrals to hospitals elsewhere.

In 2016, a young soldier from the Ladakh Scouts regiment of the Army, arrived at the hospital with subdural haematoma, a severe head injury. Initial treatment did not help and his condition worsened, and an emergency surgery was the only option. Drawing from her neurosurgical experience in Jammu, Deskit conducted a groundbreaking surgery under challenging conditions, marking a turning point in her career and the medical history of Ladakh. Since then, she has dedicated herself to saving lives in Ladakh, where harsh climate, tough terrain and poor health care facilities often lead to tragic outcomes for patients.

Recalling the case of the young soldier, Deskit said he was just 20, and surgery was his only hope. Initially, she wrestled with the decision to operate as she felt nervous about the outcome. Then she reached out to a neurosurgeon in Delhi, who told her that the soldier's fate was in her hands. "Ultimately, I proceeded with the operation as the final recourse," she said.

After a taxing four-hour surgery at the Army hospital, the soldier was shifted to intensive care. Morning arrived with a glimmer of hope as there were signs of recovery. As Deskit returned to check on her patient, she saw him smiling at her. "I was overwhelmed. As tears welled up, I felt an immense sense of relief," she said. A few days later, the soldier was transferred to Sonam Norbu Memorial (SNM) Hospital, the main health care facility in Leh, for further observation. He made a full recovery eventually. That development spurred Deskit to handle more such challenging cases, including one of acute subdural haematoma in a Nepali labourer. Despite being put on a ventilator for ten days and going through all possible complications, he survived.

Deskit's timely intervention also saved the life of a tehsildar, who had slipped into coma caused by diabetes while he was on election duty. He was lying in his room for two days where someone found him unconscious. "We went to the Army hospital and brought an ambulance and revived him after surgery," she said.

She also rescued a prominent politician who had sustained a serious head injury after his vehicle skidded on snow. Heavy snowfall hindered his evacuation out of Leh. "As his condition worsened, we were in a predicament about the future course of action. Given his political status and because many people came to visit him, I opted to perform the surgery here," said Deskit. The procedure was a success, and it involved the removal of a fraction of his skull. "We later inserted a titanium implant to fully cover the affected area, leading to his complete recovery," she said.

In 2017, Deskit was awarded a scholarship by the Royal College of Surgeons of England for a programme called Surgical Training for Austere Environments. Although the course was for doctors working in conflict-ridden regions such as Syria, Yemen, and Afghanistan, she received an invitation after she published a paper detailing the surgeries performed in the resource-limited settings of Ladakh. The opportunity exposed her to advanced surgical procedures, significantly enhancing her skills in managing critical cases, such as damaged arteries, severe burns, amputations, head injuries and blast-related trauma.

During the Covid-19 pandemic, Deskit came across a migrant worker who was admitted to the SNM hospital with a burst artery in his foot. He suffered the injury while trying to carry two heavy sacks of flour at his village. Transporting him from his village to the hospital during the lockdown proved a big challenge. Deskit, with the help of her colleagues, managed to get him to the hospital in an ambulance. He was referred to a Srinagar hospital for treatment, but he declined, allowing Deskit to perform the surgery. She applied the skills acquired during the course in London and the surgery turned out to be a big success.

While serving in the remote corners of Ladakh, Deskit came across multiple cases of skin cancer caused by the exposure to intense ultraviolet rays. Local people believe it to be punishment for past sins, leading to their isolation, especially because of the stench from the infected wounds. Deskit once found a woman who was kept segregated because of the odour from the cancer on her face. It prompted her to launch an initiative to offer reconstructive treatment for such patients by collaborating with doctors from AIIMS, Delhi. After this, she organised medical camps in Leh to treat skin cancer patients with the support of doctors from AIIMS and Safdarjung Hospital in Delhi. "Assisting a specialist in reconstructive surgery from Delhi during one such camp was particularly beneficial," she said. She is now all set to travel to Miami on a scholarship to learn advanced procedures in reconstructive surgery.

Deskit attributes her success to the unwavering support from her husband, a scientist at the Defence Research and Development Organisation, and her mother who steps in to help during her busiest days, to care for her children and to manage her home. "My husband is incredibly supportive," she said. "He understands the demands of my profession and the time I must dedicate for it, even if it means being away from our family."

Deskit, however, says that not everyone was supportive. In pursuing her ambition to become a surgeon, she faced resistance from friends and relatives, especially because of social norms that confined women within certain roles in medicine. "I often heard discouraging remarks about the unlikelihood of a female surgeon getting married as she will have to treat male patients for conditions like hernia," she said. "I made a deliberate choice to challenge such stereotypes. Now, no one dares to question me," she asserted. "I carry out my duties without bothering about social expectations."

Deskit said that during her MBBS days in Delhi, she was troubled by derogatory comments from both students and teachers aimed at those belonging to reserved categories. “Despite securing admission under the Scheduled Tribe category, I did well academically. I never felt that belonging to a specific category made my journey any easier.”

She stressed the importance of understanding the background of reserved category students. "Many people fail to recognise the challenges these students face. They lack access to quality education and other facilities," she said. "When I applied for postgraduation in Jammu, I deliberately competed in the open merit category to dispel the misconception that reserved category students lack competence and merit," she said. "My selection for postgraduation, based solely on merit, gave me immense satisfaction."

Despite going above and beyond the call of duty to provide medical care in Ladakh, Deskit says she is worried about legal challenges that doctors face. Often, the lack of proper infrastructure and other facilities result in undesirable outcomes and doctors bear the brunt of litigation. She said it was a bigger hurdle than scaling the hills near Siachen just to secure internet connectivity for sending patient reports to doctors outside Leh.

But the satisfaction of helping the needy trumps everything else. "This summer, we performed surgery on a patient and successfully removed an ovarian tumour that weighed 3.5kg. The patient was from Turtuk near the Line of Control," she said. "We also operated on patients in the early stages of cancer, striving relentlessly to save lives.”

how-sudden-heart-attack-occurs-and-ways-to-prevent-it

Fri Dec 29 17:08:49 IST 2023

The human heart beats approximately 72 times a minute, which is more than a hundred thousand times in a day. With each heart beat it pumps around 70ml of oxygen-rich blood into the body, and an equal amount of oxygen-poor blood into the lung. The muscles of the heart are designed to push the blood into the body with enough force to deliver the vital elixir of life to all parts of the body, including the brain―overcoming gravity and the resistance offered by the often hardened blood vessels. It is almost a miracle that this bag of muscle―the heart―performs the function for the entire life, while consuming only seven per cent of all the energy utilised by the body.

Controlling this amazing organ is the heart’s own nervous system―a specialised network of cells that have similarity to the brain cells (neurons). The specialised tissue in the heart is organised into nodes and conducts tracts that generate electrical signals for the muscle cells of the heart. The muscle pump function requires all the muscle cells to act at nearly the same time to generate the pumping force with great efficiency.

The heart’s conduction system can activate all heart muscle cells in less than 100 milliseconds (one-tenth of a second), and it controls how fast or slow the heart beats. As you can imagine, abnormalities in the conduction system―a heart rhythm disorder―can affect the blood flow to vital organs and cause various symptoms or even sudden death.

Sometimes there is abnormal neural control of the heart. A specialist will suspect this when an elderly person has a sudden loss of consciousness. After the checks, we would slightly massage his carotid arteries in the neck while monitoring his ECG and we would be able to detect a sudden pause in his heart activity. This is an abnormal neural reaction. It happens because a regulating centre located on the walls of the carotid artery has become very sensitive to pressure. When pressed, or stretched, it relays impulses to the heart to stop beating. The result is loss of blood flow to the brain causing loss of consciousness and injuries. Fortunately, this abnormal reaction is rare, though it is often unrecognised―and is easily treated by implanting a pacemaker. Sudden and transient loss of consciousness, called syncope, is a dangerous symptom. Sometimes the underlying cause is easily identified. Without proper evaluation it may be misdiagnosed as seizures. The greatest risk of misdiagnosis is that syncope could be a warning sign of sudden death.

The last two decades have seen tremendous progress in our understanding of how sudden death happens and in ways and means to prevent it. In nearly all cases, this involves helping the heart to maintain its normal rhythm, and devices to rapidly convert a dangerous heart rhythm before the malfunction results in irreversible damage to the brain or other vital organs as a result of loss of blood supply.

Take, for instance, a recently recognised genetic disease―Brugada syndrome. The signs of the disease can be identified in the usual ECG. The most interesting patient with Brugada syndrome I have seen is a professor in English who was referred for recurrent falls with loss of consciousness. A cardiologist had seen him. He suspected Brugada syndrome and advised further evaluation. But the patient failed to get evaluated for risk of sudden death. In due course he had a prolonged episode of dangerous ventricular fibrillation; luckily he was revived by a relative and brought to a good hospital. The professor survived, but the duration of cardiac arrest was enough to cause some permanent damage to his forebrain. He underwent implantation of a defibrillator―now we can be sure that another prolonged arrest will not happen. The device will detect the dangerous rhythm and ‘shock’ him out of it. He slowly returned to his profession but he was never the same perceptive and nuanced teacher he once was. He would need another intervention a year or so later. This time he came with complaints of multiple ‘shocks’ from the implanted device. The ‘shocks’ were not painful but it was distressing enough to get repeatedly jolted by the device for his dangerous rhythms. We had to find ways to stop these dangerous rhythms from coming. When the drugs failed, we did a percutaneous procedure. We mapped the surface of his ventricle using catheters, looking for abnormal currents called ‘late currents’ which set up ventricular fibrillation. We eliminated these ‘late currents’ using radio-frequency energy and got rid of the dangerous rhythms.

A slow heart rate or sudden pauses between heart beats is a frequent problem in the aged, rarely in the young. It may lead to permanent damage or death and usually causes dizziness, loss of balance and short episodes of loss of consciousness. A sudden fall may result in significant trauma to the skull or fractures in major bones. Less commonly, the heart beats regularly but conduction of current to the major pumping chamber of the heart is blocked. The consequent delayed activation of the ventricle (the chamber that generates the pressure to pump blood) can lead to a lazy and weakened function. Over months or years, this can lead to heart failure―a dangerous condition where the heart cannot pump enough blood to vital organs. Now, a cardiologist can tackle this problem with a special type of pacemaker where an extra wire is used to stimulate the lazy chamber from both sides and make the contraction early and synchronous. One of the early cases where we implanted the device is in a 50-year old businessman who had two previous admissions with breathlessness. Evaluation showed his weakened heart muscle function was the result of a block in the conducting channel that was to supply current to the left ventricle. The patient was on multiple drugs to drain extra fluids from his body. After implantation of the special pacemaker, his heart muscle function improved dramatically within months. We call such improvements as a super response, and this is not unusual. The patient was completely ‘cured’ of his problems and in due course we eliminated all but one medicine.

Today, the specialist uses various tests including MRIs and genetic tests to identify abnormal genes and structural heart disease which increases the risk of dangerous rhythm abnormalities. The purpose of treating these rhythm abnormalities varies, from curing a patient of palpitations (fast heart beats), preventing loss of consciousness and strokes, preventing sudden death and treating heart failure.

Without an understanding of what regulates the normal human heart rhythm many would be suffering from life-changing symptoms. We would have lost many lives unexpectedly and prematurely.

Dr Thajudeen is consultant, cardiology and electrophysiology, KIMS Health Hospital, Thiruvananthapuram.

air-pollution-associated-health-risks-and-ways-to-minimize-impact

Fri Dec 29 17:03:08 IST 2023

Air pollution affects all of India’s 1.4 billion people, according to a World Bank report of 2023. It is not just a silent killer, it also strangulates the economy. In 2019, India lost 3.6 per cent of its GDP to air pollution because workers fell sick, productivity was hampered and greater expenses on health care were incurred.

One recent study by Pristyn Health Care (The Great Indian ENT Survey, 2023) found that three in five residents of Delhi and Mumbai would consider relocating because of poor air quality. The study found that 90 per cent of all respondents had common AQI (Air Quality Index) symptoms such as coughing, breathlessness, wheezing, sore throat and irritated eyes.

The AQI is a yardstick that runs from 0 to 500. At 301, it becomes hazardous.

The five major pollutants are ground-level ozone; particle pollution; carbon monoxide; sulphur dioxide and nitrogen dioxide. Particulate matter is a mixture of solid particles and liquid droplets found in the air. Some particles, such as dust, dirt, soot or smoke are large enough to be seen by the naked eye. When the measure of these particulate matters is 2.5 micrometres or less in diameter, they are invisible to the naked eye and can travel deep into the respiratory tract, getting to the lungs and causing short term problems such as coughing, sneezing and a runny nose, while long term health challenges include greater risk for asthma, heart diseases and low-birth weight. Hence the dreaded mentions of PM 2.5.

Dr Randeep Guleria, chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine, and Director, Medical Education, Medanta, Gurugram, takes us through the issue. He says that in the west, it is held that chronic exposure to high levels of air pollution poses as significant a risk for heart disease as smoking or high cholesterol.

Two aspects of air pollution: The size of particles and whether they are water-soluble are to be considered. Gases like sulphur dioxide, nitrogen oxides and some other oxides are somewhat water-soluble, leading to irritation and airway narrowing, resulting in breathing difficulties, cough, nasal congestion, and occasional chest wheezing.

Additionally, there is particulate matter, particularly PM 2.5, comprising small particles that may carry toxic substances. Even smaller particles, referred to as ultra-fine particulate matter, penetrate deep into the lungs, causing inflammation. Continuous inhalation can allow these particles to enter the bloodstream, leading to inflammation in lung-associated vessels and systemic diseases, including cardiac and neurological conditions. Prolonged exposure increases the risk of chronic obstructive pulmonary disease (COPD), raises the likelihood of lower respiratory tract infections in high-risk groups, and, according to some data, may even elevate the risk of lung cancer over years.

Size matters: Particles larger than 10 microns are typically filtered out by our nasal passages and throat, and do not usually reach the lungs, so they are less concerning. However, PM 2.5 can enter the lungs and cause damage, including inflammation and swelling. This inflammation can exacerbate underlying lung conditions, causing symptoms like chest tightness and constriction. Even individuals without pre-existing lung issues can experience chest tightness, breathing difficulties and wheezing when pollution levels are high. This is because gases like sulphur dioxide, nitrogen dioxide, ozone and particulate matter can damage the lining of the airways and bronchial walls, leading to congestion and spasms, which can mimic asthma-like symptoms.

The reach of particulate matter: These fine particulate matter particles do not just impact the lungs; they can enter our bloodstream, causing systemic effects. This can increase the risk of heart diseases, worsen heart failure, lead to arrhythmias (irregular heartbeat). Emerging data suggesting a connection to stroke, dementia and other organ problems.

The extreme of lung scarring: This essentially indicates damage to the lungs, which tends to contribute more to COPD rather than actual scarring associated with interstitial lung disease (ILD- an umbrella term for a large group of diseases that cause lung scarring). In cases where the exposure decreases, especially in studies involving children and young people, there is evidence suggesting potential improvement in lung function. Studies on children indicate that as AQI improves, their lung function tends to show improvement. However, in older individuals with significant lung damage, particularly those with COPD caused by prolonged exposure to air pollution, the rate of scarring progression may slow down.

A hellish winter for north India: We need to consider a few key factors. First, we are situated in the Indo-Gangetic plain, which is a landlocked region. During the winter months, when there is minimal wind velocity, all the locally generated pollution settles in this area, making it difficult to disperse. To address this issue, we must focus on containing the sources of pollution, which includes addressing vehicular traffic, construction activities, crop burning, and even local use of diesel generators.

Being outdoors: Go outdoors when the sun is shining and ground-level pollutants have somewhat subsided. If you can engage in indoor exercises, either at a gym or at home, that would be a preferable alternative.

Impact on different populations: When considering long-term impacts, we are looking at effects on both the lungs and the entire system. In terms of the lungs, prolonged exposure to high pollution levels can lead to chronic bronchitis, increase the risk of lung cancer (comparable to high cholesterol or smoking) and elevate the likelihood of stroke. Studies also suggest a potential link between air pollution and conditions such as dementia and diabetes. For the elderly, constant exposure may result in breathing difficulties, coughing, a higher likelihood of hospitalisation and an increased chance of requiring ICU care, especially if oxygen saturation levels fall.

The question of exercise: I would advise against performing outdoor exercises in areas with high pollution levels. When you exercise, your respiratory rate increases, causing you to inhale more pollutants than usual. Activities like jogging and fast-paced walking should be avoided, especially for individuals at a high risk of chronic respiratory and heart diseases. If you choose to exercise, it's safer to do so indoors or during times when the sun is out, and ground-level pollution is reduced. Breathing exercises, such as deep breathing, as well as upper and lower limb exercises to enhance cardiopulmonary capacity, are beneficial for improving lung health. Yoga and pranayama may offer some benefits in this regard as well.

Covid and irreversible lung damage: In some individuals, Covid has resulted in lung damage and lung fibrosis, but it typically is not extensive. Many people who exhibited lung changes on CT scans due to Covid have, over time, experienced significant recovery with minimal scarring. While concerns were initially raised about a potentially large number of cases with significant lung damage, most patients have ultimately healed and recuperated. So, post-Covid lung fibrosis does occur, but in terms of the overall number of Covid cases, it is not that widespread.

The self-healing capacity of the lungs: If exposure to pollution is reduced, it can to some extent slow the decline in lung health and stabilise it. This has been well-demonstrated in individuals whose lungs were damaged due to smoking. When lung capacity starts deteriorating rapidly from smoking and the individual quits smoking, it doesn't return to normal, but the rate of decline in lung capacity decreases and stabilises. There may also be symptomatic improvement. If we extrapolate this to the effects of pollution, it is reasonable to assume that if exposure to pollution is reduced, the changes in the lungs may become less severe, leading to a reduction in the decline in lung capacity. However, some changes may persist and may not completely reverse.

The impact of co-morbidities: Co-morbidities that can greatly affect lung health include chronic lung diseases like COPD and asthma, as well as chronic heart disease. Having underlying chronic conditions such as diabetes predisposes individuals to a higher risk of deteriorating lung function and increased susceptibility to respiratory infections. Additionally, individuals at the extremes of age, such as the elderly and young children, are more vulnerable to the severe effects of pollution on lung health.

The effectiveness of air purifiers: Air purifiers have limited utility, primarily due to the persistently high levels of pollution. Furthermore, as most houses in India are not entirely airtight, outdoor air can still seep in even when windows and doors are closed. While air purifiers may offer some benefits, they are not a comprehensive, long-term solution to address the challenges posed by air pollution.

Masking up: Wearing a mask when going outdoors in areas with high levels of pollution can provide some degree of protection. While it may not be an ideal solution, something is better than nothing. As a daily practice, individuals can consider avoiding outdoor activities when pollution levels are very high. If they must go outside, wearing a mask can help reduce the particulate matter they inhale. It is also advisable to refrain from strenuous exercise in such conditions.

The uniqueness of respiratory ailments in India: The spectrum of respiratory ailments in India is diverse due to the country's transition from primarily communicable diseases to an increasing burden of non-communicable diseases. While the burden of communicable diseases, such as tuberculosis of the lung, persists, there are specific factors unique to India. These include the use of cigarette smoke, biomass burning and indoor air pollution stemming from the combustion of fossil fuels, cow dung and other materials. These factors contribute significantly to respiratory problems, especially in rural areas where traditional cooking methods like the ‘chula’ are still prevalent. Moreover, the issue of outdoor and indoor air pollution also stands out, leading to a higher prevalence of lung diseases in the country.

mitraclip-procedure-in-india

Sat Nov 25 15:06:02 IST 2023

Till October last year, Deewan Singh Dardi, 87, was managing a call centre with 5,000 employees. And then, he was not up to it anymore.

Dardi had a chequered medical history: bypass surgeries and operations on the gall bladder and prostrate, and one for hernia plus morbid obesity. His latest health concern was massive water retention that had started from his legs. In a decade, it had moved through his body and even affected his face and eyes. Everyday activities were a challenge and even his speech was slurred.

After consulting two doctors, Dardi’s daughter Priya Monga took him to Dr Praveen Chandra, chairman, interventional and structural heart cardiology, Heart Institute, Medanta Gurugram. Chandra and his team (including Dr Manish Bansal and Dr Nagendra Chauhan) suspected that the swelling was a result of congestive heart failure. An echocardiogram (an ultrasound test that checks the structure and function of the heart) revealed that two of his valves were leaking.

But first, some understanding of the heart’s valves.

There are four types of heart valves―tricuspid valve (located between the right atrium and the right ventricle), pulmonary valve (located between the right ventricle and the pulmonary artery), mitral valve (located between the left atrium and the left ventricle) and aortic valve (the final one encountered by the oxygenated blood as it leaves the heart).

In Dardi’s case, the mitral and tricuspid valves were leaking, which means that blood was not flowing in one direction as it should. Blood flow in our system goes from the heart to the lungs, gets oxygenated, then goes back to the heart from where it is distributed throughout the body via the arteries. In this case, the blood was moving in two ways―forward, towards the lungs, and backwards, towards the body from where it had just come. This was a very dangerous situation. When blood bombards the heart from different directions, the heart grows larger to accommodate this and its efficiency plummets. The patient begins to exhibit the first signs of heart failure. This pressure on the heart causes breathing problems, discomfort, weakness, fatigue, lethargy and swelling in the body.

The medical term for the condition is ‘massive tricuspid regurgitation’.

MitraClip treatments, wherein MitraClips (that look like large staples) are used to clip defective valves, are standard procedures for high-risk patients of mitral regurgitation with suitable anatomy. US-based Abbott Laboratories holds the patent for MitraClip.

But Dardi’s was a different case―the same MitraClip was to be used to treat both the mitral and the tricuspid valve leaks, simply because the dedicated tricuspid valve clip was not available in India. The procedure was a first not just in India, but also in southeast Asia.

Tricuspid regurgitation along with mitral regurgitation can cause congestive cardiac failure with symptoms of both left- and right-sided heart failure. If not treated in time, it can be life threatening.

“The primary reason this happens is because of age,” said Chandra. “As people get older, their heart valves wear out naturally. Additionally, this patient had undergone two bypass surgeries, in 1987 and 2001. That also contributed to the valves getting damaged.”

The doctor’s first suggestion was medication to manage heart failure. However, drugs are effective in only 25 to 30 per cent of patients. They experience improvement in terms of decrease in the leakage and require no additional treatment. “But in this case, that did not happen. The patient was put on medicines for six months but did not get better,” said Chandra.

The team then initiated an extensive consultation with a wider network of colleagues and a New York-based specialist. Across conference calls and video information sharing, a plan was devised. A seemingly simple solution that required clipping the abnormal part of the valves with the same kind of clip; closing them tightly enough so that the rest of the valves would function as intended.

Clipping itself is relatively risk free as it eliminates the need for open-heart surgery. It is minimally invasive and a non-surgical treatment option for symptomatic patients who are at high risk for surgery and do not respond to just medicines. It involves no traditional surgery, chest incisions, stitches or cuts.

“We use a small device inserted through the legs,” said Chandra. “This device is introduced via an injection, and it contains a catheter. We perform the entire procedure remotely using this catheter, which is controlled from a distance. We don't go deep into the heart; we work through the leg, guided by ultrasound and X-rays, so we need to be really precise.”

Chandra could try the approach because he had, for years, attended specialist meetings and live case demonstrations. “These are vital aspects of advanced medical conferences,” he said. “These events allow us to discuss various treatment options for complex diseases. I had seen such a live surgery in New York.”

While the doctor makes it sound simple, there were complexities. “One major concern was the possibility that the valve might not fit properly, in which case we would need the surgeons to open the chest,” Chandra said. “To address this, we had a surgical team on standby in the second operating theatre. We were fortunate to have a hybrid cath (where there is equipment for both catheterisation and surgery) lab in our hospital, a rare facility in India, which was essential for this procedure. The success of such complex operations relies heavily on teamwork. During this procedure, we had a team of approximately 25 individuals ready to address any further steps that might have been required.”

The challenge of the unavailable clip had to be tackled with extreme precision.

“By itself, the clip is a simple tool we place there to make sure both leaflets are fixed in the right position,” said Chandra. “Once we do this, there is no gap left, and there is no more leaking. We used a similar clip for the tricuspid valve, which is a bit different. It is like using a special tool because the tricuspid valve is in a different spot. The important thing is to put the clip exactly where the problem is.”

The tricuspid valve is a larger valve and requires use of specifically designed clips to address the problem effectively. The number of clips used varies from patient to patient. In Dardi’s case, four MitraClips were used―three in the tricuspid valve.

Tricuspid clips are still not manufactured in India; the bulk are imported from the US. “It wasn't a standard practice for this equipment to be developed or introduced in the country at that time,” said Chandra. “This is why we felt the need to initiate this programme. The necessary skills and expertise had not been developed locally. I conducted the necessary research and preparation so that in case a patient with such specific needs came in, we would be equipped to provide the appropriate treatment.”

Monga said the family’s faith in Chandra came from the “comprehensive and unique understanding of the procedure he and his team” provided. “He explained the process in a way that no other doctor had suggested before,” she said. “While other doctors suggested opting for longer and more complicated processes, Dr Chandra recommended the clipping method because the valve was quite damaged. I had not received a recommendation for the clipping process from anyone else, but he was confident and assured us that it was the right approach.... I had initially thought it would be a one-hour surgery, but it took him around four hours to complete.”

Dardi was in hospital for three days.

Now, three months later, the improvements are gradual but marked. His dosage of diuretics (medicines to reduce water retention) is down, the swelling on his face and eyes has significantly decreased, and his speech is clearer. The only medication he is on is to maintain sugar levels. “The recovery process was quite normal, but it definitely didn't happen overnight due to his age,” said Monga. “It has been three months, and I can confidently say that he has made remarkable progress. He is now going out, meeting friends, taking walks and attending his club meetings.”

In addition to reading and consulting with relatives and friends, the Dardi family’s choice was helped by the fact that they were never pressurised into making an immediate decision. “The MitraClip procedure is not widely known, and awareness needs to be raised about it,” said Monga. “It is not typically covered by insurance in India. We believe the government should recognise such procedures and work to reduce costs, making high-quality operations more accessible to people. MitraClip, despite its high cost, offers better recovery and lower risks, making it a valuable option for patients.”

Chandra said he could see this becoming standard procedure soon. “Even younger patients can be considered, especially when traditional surgery is not a viable option due to various reasons,” he said. “It primarily depends on the presence of comorbidities and previous surgeries.”

As for Dardi, his optimism is rising. “He will regain more energy and feel even better,” said Monga.

What more could one ask for from a simple clip?

patients-have-nothing-to-lose-but-their-ignorance-by-asking-doctors-questions

Sat Nov 25 14:58:44 IST 2023

So, you have lined your kitchen with organic food and whole grains; you’re hooked to yoga; your persistent new year resolution is to walk more and drink less; and you turn to the internet for every little health niggle that comes your way. But, how medically literate are you?

Scientifically: dismal.

According to a 2018 paper in the Indian Journal of Community Medicine, while studies on medical awareness are many and diverse, poor medical mindfulness cuts across regions and classes, thus keeping the lifespan of Indians shorter than what it could be.

One such study in Karnataka, for instance, found out that only a third of mothers, across two generations, had knowledge about breast feeding. Another concluded that while more than four in five respondents in Kerala knew about oral cancer, fewer than three could pinpoint the exact cause. Yet another one, which covered Chandigarh, Tamil Nadu, Jharkhand and Maharashtra, revealed that less than half of the sample population knew anything about diabetes.

What makes us so poorly informed? While inadequate access to health care, deficient manpower and the cost of quality health care are reasons beyond us, a huge role in this knowledge lag also results from our dithering in questioning doctors, our surrendered acceptance of what they tell us.

Look around, someone you know might have been pushed into surgery that a second opinion concluded was not needed. Someone might be on medication prescribed years ago by a doctor, unaware that age, hormones, changing lifestyles, comorbidities and the like require a change in medication or dosage. A third someone might only consult the neighbourhood chemist for ailments.

We are, more often than not, in awe of our doctors. Yes, they have very special skill sets. And yes, we place our wellbeing in their hands. But then, we also place our lives in the hands of pilots when on a flight. At the end of it, both are service providers. And neither is a demigod.

As with other professionals, good communication is vital to healthy doctor-patient relationships. Dr Sushila Kataria, senior director of internal medicine at Medanta, Gurugram, lists a host of challenges that keep patients from conversing with their doctors adequately.

“Patients might lack awareness about their condition, leaving them unsure of what questions to ask,” she says. “They might fear that their questions could come across as trivial, leading to potential embarrassment. They may worry that asking too many questions could annoy the doctor and potentially affect the quality of their treatment.” Especially when it comes to surgical procedures, this handicaps patients with little understanding of the procedure, its potential complications and alternative treatment options.

Another point she underscores is the exercise of caution when gathering information from the internet and uncertified sources. “Excessive and unverified information can lead to confusion,” she says. “In some cases, patients may unnecessarily delay procedures due to excessive scepticism about the medical system. Striking a balance between seeking knowledge and relying on trusted sources is crucial.”

Remember, the internet works around codes, not around consideration for us.

Dr Pradip Tiwari, a plastic surgeon who recently retired as senior consultant at the Burn and Plastic Surgery Unit at the Dr Shyama Prasad Mukherjee Hospital, Lucknow, started his career in the state’s Provincial Medical Services in a neighboruing district of Lucknow. Despite the fact that Tiwari holds an MCH, the highest degree in surgical science, he was reduced to being a general practitioner for the first eight years of his professional life. “When a doctor’s skills are not optimally utilised, his level of interest in patients may go down,” says Tiwari. His observation is significant for the government health care system. Less than a third of India's population relies on it, but the private system cannot match its reach.

When Tiwari was posted in Lucknow, most of his patients were those with congenital deformities or post-traumatic problems (such as scars from a burn injury or accident). As a result, Tiwari’s cosmetic surgery skills were barely used for most of his career. For a brief period that he tried private practice, he bought what was perhaps Lucknow’s first liposuction machine, but was clear about pegging patient hopes pragmatically.

“It is very important for a patient to ask about realistic results and a doctor to not build unnecessary expectations,” he says. “Liposuction, for instance, is not a cure for obesity as the number of fat cells remains constant throughout life. We should tell patients what surgery can achieve and then encourage them to think and ponder before opting for it.”

He also emphasises the need for patients to be completely honest with their doctors. There are patients who can get stuck on one question; for example, will my scar completely disappear? (No, it won’t, though a surgery will give you a smaller, cleaner scar). For such patients, Tiwari suggests a psychiatric evaluation. “If a patient is persistent to the point of being unreasonable, a doctor should list the complications and generally say no. Some patients only want a doctor to say what they want to hear,” he says.

Dr Joy D. Desai, director of neurology at Jaslok Hospital and Research Centre in Mumbai, adds taboo to the list of reasons patients do not open up. In his speciality, for instance, epilepsy and seizures come with social stigmas, a popular one being that a person thus afflicted is seized by evil spirits. “A patient might allow the caregiver to do most of the talking and that builds a barrier between the doctor and the patient,” he says.

Desai also touches upon the issue of our deep respect for doctors. “We have been taught that respect is inherent in the position one occupies,” he says. This is not an ideal relationship between doctors and patients.

Among the questions that Desai lists as must-asks for patients are: the implications of their symptoms, the nature of the disease, and the nuances that determine treatment outcome. “When investigations are asked for, the absolute validity vis a vis the potential expense likely to be incurred should also be discussed,” he says. “For chronic and neurodegenerative disorders, counselling on future trajectory of the illness is also mandatory. An introduction to potential caregiver burden is a necessary component of this communication.”

Desai also speaks of the need for better bedside manners for doctors. It could come perhaps from some background in humanities, he says, but then that would extend the duration of a doctor’s training. Social/softer skills could be a part of the continuous skill/knowledge upgrade that doctors put themselves through conferences, seminars and the like.

We also need to stop banishing some specialities to realms of vanity or magic. Ruby Sachdev, aesthetic physician and founder of Skinnfit Medspa at Gleneagles Global Hospital, Bengaluru, says that we cannot disregard the fact that looks play a part in enhancing self-confidence and thereby ensuring mental wellbeing. “Someone might aspire to become a CEO and looks might play a role in the image that position must project,” she says. “As doctors we should be non-judgmental, but realistic. In our profession, we primarily focus on prevention, enhancement or restoration. It is important to note that while certain features can be enhanced, they cannot be replaced.”

Sachdev does not hesitate to recommend a pause to clients who seem to get addicted to procedures. “I always emphasise that procedures in cosmetology are not emergencies,” she says. “I advise clients to take their time, sleep on it, not rush into decisions, read about the procedure, think about it, and then return with any questions they might have.” One of the most important of these questions is the downtime required after a treatment. One cannot, for instance, trot out into the sun right after a skin-resurfacing session.

Dr Shrikant Srivastava, professor, department of geriatric mental health at King George’s Medical University in Lucknow, is a specialist for a relatively less known branch of medicine. Being medically literate would thus include an awareness of new specialities and medical technologies that can improve the quality of our lives.

Mental illnesses of the old is at such an infant stage (KGMU introduced the country’s first department just 20 years ago) that only five super specialists in it are produced in the country every year. Srivastava stresses the supreme importance of a patient’s choice in treatment. “We can only offer advice for a management plan. It is up to the patient to accept or reject it,” he says.

In a speciality where there are no prescribed, objective tests to measure illness, and where ‘normal’ and ‘abnormal’ lie in a continuum, it is of paramount importance for the doctor to make a patient open up. “If your patient is comfortable, the information will automatically come. In a consultation session of at least 30 minutes, I will spend 10 minutes explaining to the patient what I am prescribing and why, and their role in the management plan. Every doctor wants his treatment plan to work. A plan which is explained to a patient, in a language s/he understands, has greater likelihood of compliance,” he says.

The doctor draws attention to the opposite ends of mental health seeking behaviour―the west where three days of a dip in mood would send one to a psychiatrist, and India, where symptoms are only noticed when they become too prominent to ignore. The balance lies somewhere in between.

As for the need for soft skill training, Srivastava believes that the only expertise required are those in everyday use. “The patient should be treated as an equal,” he says. “Both parties should speak in a conversational, not confrontational/didactic manner. You must follow the same principles you would in everyday interactions. Give each other space, respect one’s privacy, ask questions about the topic under discussion and listen, not just hear.”

So ask away, readers. You have nothing to lose but your ignorance. And it will get you no reds in the report card of life.

does-marijuana-help-with-endometriosis-pain

Sat Nov 25 14:47:40 IST 2023

Medical marijuana is a subject that ignites strong emotions among doctors, scientists, researchers, policymakers and the public. Many think that promoting medical marijuana is merely a ruse to support the legalisation of marijuana. Nevertheless, there is no doubt that medical science is yet to realise the full potential of the therapeutic properties of marijuana, which is often called the ‘wonder plant’.

Recently, a group of researchers from Australia and New Zealand published a study in the Journal of Clinical Medicine, which says that marijuana shows promise in pain management for those suffering from endometriosis. Approximately 10 per cent (190 million) of women and girls in their reproductive age worldwide are affected by endometriosis. This chronic condition is linked to intense, life-disrupting pain during menstruation, sexual intercourse, bowel movements and urination. Other symptoms include chronic pelvic pain, abdominal bloating, nausea, fatigue, and sometimes depression, anxiety and infertility. Currently, there is no known cure for endometriosis, and treatment primarily focuses on managing symptoms. Unfortunately, access to early diagnosis and effective treatment is restricted in various settings, particularly in low- and middle-income groups.

As part of their study, researchers explored existing literature (more than 140

scientific papers) on the use of cannabis as a self-management approach for treating pain associated with endometriosis. They also explored the interactions between gut microbes and the endocannabinoid system (ECS), which regulates and controls many critical bodily functions such as learning and memory, emotional processing, sleep, temperature control, pain control, inflammatory and immune responses, and eating.

The ECS is formed by a complex network of chemical signals and cellular receptors distributed extensively throughout our body. To activate these receptors, our bodies naturally produce molecules called endocannabinoids, which bear a structural resemblance to molecules found in the cannabis plant. The new study reveals that endocannabinoids derived from cannabis offer a protective influence on the gut, reducing inflammation and enhancing permeability. This alleviates bloating, a prevalent symptom of endometriosis. Additionally, cannabinoids inherently inhibit pain receptors, acting as a natural pain-relieving agent. The study concluded that both the ECS and the gut microbiota have the potential to become primary targets for therapeutic interventions for endometriosis. However, clinical studies are required to determine the effectiveness. Currently, there is only one trial on medicinal cannabis for endometriosis in which the different psychoactive cannabinoids extracted from the cannabis are compared for their effectiveness.

huge-demand-supply-gap-for-corneal-tissue-poses-major-challenge

Sat Oct 28 17:08:21 IST 2023

Five-year-old Pranav was born with poor vision in both eyes. After many visits to different hospitals, he was diagnosed with bilateral congenital corneal blindness. One of the leading causes of blindness in India, especially among children, corneal blindness is caused by the cornea losing its transparency to a birth defect, infection or injury.

In Pranav’s case, doctors suggested corneal transplantation. His father, a driver, was initially hesitant, but agreed for the surgery after much persuasion. Today, Pranav is not dependent on anyone for his daily routine, and he attends school. He was lucky that he got a donor, as the parents of an accident victim donated their son’s eyes.

Not many people, though, are as fortunate as Pranav. Doctors say there is a long wait-list of patients awaiting corneal transplants. Dr J.S. Titiyal, head of Rajendra Prasad Eye Centre (AIIMS), Delhi, said there was no definite data on the exact number of patients suffering from corneal blindness in India and patients in need of keratoplasty (corneal transplantation). However, a 2015-2019 survey by the Union ministry of heath revealed that corneal opacity was the second biggest cause for blindness among people aged 50 and above and the biggest cause for blindness among people below 50.

“An ICMR-funded project to survey the disease burden and the cornea requirement will be completed by the end of this year,” said said Dr Titiyal. “The idea is to carry out registration of every patient and allot a unique identity number to avoid multiple registrations of the same patient at different centres. The next step is to allot a unique number to the corneal tissue that is retrieved (removed) from the donor and prioritising the corneal transplantation based on the central registry as not every corneal blindness patient needs a transplant.”

There is a huge disparity in tissue availability across India. While some states like Andhra Pradesh and Telangana have no wait list owing to the effective Hospital Cornea Retrieval Programme (HCRP), there is a huge demand-supply gap in the northern states.

“We have a wait list of 750 patients at AIIMS and it is not decreasing,” said said Dr Titiyal. “The requirement is 1,000 transplants a year. The challenge is not finding eye surgeons or the transplant centres but finding the corneal tissue. In 2022, only 45,000 corneal transplantations were performed though we needed to carry out at least one lakh surgeries to clear the backlog. Also, the utilisation of cornea is 50 per cent and the collection last year was 60,000. The annual retrievals should be around two lakh to avoid the backlog.”

Data collected by Sankara Eye Hospital in Bengaluru says at least 60 per cent of the recipients of the corneal transplants are children and people up to the age of 40. The hospital has a waiting list of 40 patients. “Greater awareness about eye donation can help us overcome the cornea shortage and significantly reduce blindness in the population,” said Dr Pallavi Joshi, consultant, cornea, ocular surface and refractive surgery, at Sankara. “Unlike other transplants, blood typing and tissue matching are not necessary. But we prioritise younger donors for better long term results.”

The cornea collection happens through voluntary donations and hospital retrievals. “The HCRP helped bridge the demand-supply gap,” said Dr Titiyal. “The quality of the tissue collected through HCRP is also superior as the donors are usually young. Any delay in retrieval and lapses in storage, the age of the donor, delayed consent of donor family, and medico-legal cases affect the quality of the tissue.”

Eye banks have a vital role to play in bridging this gap. To overcome the severe shortage of transplantable corneas, the LV Prasad Eye Institute in Coimbatore established the Ramayamma International Eye Bank (RIEB) in 1989. It is now the largest eye bank in Asia. It has implemented a hospital-based cornea retrieval programme (HCRP) and built a network of 300 hospitals in Andhra Pradesh, Telangana and Odisha. “We collected more than 10,000 corneas each year and suppled close to 7,500 corneas for surgeries to a vast network of surgeons across the country,” said Dr Prashant Garg, executive chair of LVPEI.

“In 1991, we set up a lab to manufacture cornea storage medium in collaboration with IFETB, in the US. The medium allows storage of excised corneal tissues for 96 hours. We produced and distributed 25,000 vials of this medium to various eye banks in and outside our country last year. We led efforts to establish the Eye Bank Association of India as a resource centre to support India’s eye donation movement and also played a key role in drafting medical standards for eye banking in India,” he said.

In India, corneal blindness occurs mostly because of infections, followed by injury and heredity. Earlier, trachoma (contagious bacterial infection of eye) and Vitamin A deficiency were the common factors causing blindness, but they are now negligible. Doctors say immunocompromised patients, diabetics, people who suffer from physical or chemical injuries and trauma, and those who take wrong medication often end up with cornea opacity.

“Not every patient needs a corneal transplantation,” said Dr Titiyal. “A child with bilateral corneal blindness gets priority over an adult, while a patient with progressive disease (fast deterioration) is preferred over an adult with one good eye. Some patients can do well with optical devices and need no transplants. The longevity and the quality of life determine the priority.”

After a corneal transplant, post-operative care is essential for a successful outcome. Dr Joshi said that patients were often prescribed topical medications like eye drops, steroids and antibiotics. In many cases, lamellar transplants that do not require stitches are performed, but patients still need to attend regular follow-up appointments. For children, receiving corrected glasses can be crucial for their visual development, especially in the early years.

the-relationship-between-housing-and-ageing

Sat Oct 28 16:55:30 IST 2023

Ageing is universal, but scientists are exploring ways to slow it down. Internal and external factors, including damage to our cells, affect how our bodies age.

A recent study by researchers from the University of Adelaide and the University of Essex looked at how housing can impact how quickly you age. If you rent a house instead of owning one, your body may age faster.

As a person ages, methyl tags accumulate on certain genes, which can cause those genes to become less active. This can lead to changes in how our cells function and contribute to the ageing process. As part of the study, the researchers studied this DNA methylation process as well as the epigenetic information and social survey data of 1,420 adults in Britain. The study considered various aspects related to housing, including housing tenure (whether individuals rent or own houses), the type of building, government financial assistance provided to renters, the presence of central heating as an indicator of sufficient warmth, and whether the residence was in an urban or rural area.

The study revealed that living in a privately rented place is associated with a faster ageing process, which has a more significant impact than being unemployed or being a former smoker. When historical housing situations were considered, the analysis also linked repeated housing payment issues and exposure to pollution or environmental problems to accelerated ageing.

The researchers concluded that the insecurity and unaffordability of rented homes likely contribute to the connection between renting and accelerated ageing. Notably, the Knight Frank Affordability Index for India, released in August, showed that Indian households, on average, need to allocate 40 per cent of their income to housing loan EMIs, with variations based on property rates in different cities. Ahmedabad, Kolkata and Pune were identified as more affordable housing markets, whereas Mumbai was the most expensive. In Ahmedabad, families, on average, are spending 23 per cent of their monthly income on EMIs, whereas in Mumbai, the EMI to income rate is 55 per cent. As housing is less affordable, Mumbai is highly likely to have a population with a faster biological ageing rate.

What is intriguing is that the researchers who studied the relationship between housing and ageing suggest that the epigenetic effects of renting could potentially be reversed. Therefore, they propose that when shaping housing policies, governments should take into account the potential health impact of housing choices.

how-to-deal-with-climate-anxiety

Sat Oct 28 16:50:30 IST 2023

Remember those rainy days we wore raincoats, opened our umbrellas and gave a gleeful chuckle? Akshada Singh, 17, worries what the rain might do to the crops, and how it might impact farmers. The Delhi-based climate activist, who is also the founder of Vivid Petals, which is an organisation to create awareness on concerns of humanity and environment, said, “Climate anxiety is real. Climate change is scary. We have borrowed this earth and people are worried about its future. There is concern for the future generation. People have anxiety about the future. I feel it, too.”

Climate anxiety, or eco-anxiety, is a fairly new term. A 2021 Lancet global survey found people across ten major countries apprehensive about climate change. The survey included young people and children from Australia, Brazil, Finland, India, Nigeria, the Philippines, Portugal, the UK, and the US. In a 2020 report by the UK's Royal College of Psychiatrists, over 57 per cent psychiatrists were seeing young people distressed about climate crisis.

Climate anxiety is a state of feeling anxious, fearful, or even sad, while thinking of the climate crisis and the collective failure of governments and large companies.

Delhi-based psychotherapist Agrima Chatterjee said, “Eco-anxiety has had a huge impact on our wellbeing. We tend to be worried about the wellbeing of generations to come―thoughts such as will the next generation have a sustainable planet arise.” Chatterjee has worked with There is No Earth B, which is on a mission to save earth and bring about change at the ground level. “The climate change warriors in the organisation left because of burnout. So I was asked to come and understand as to why that happened. We identified about 20 people who were feeling a sense of despair. No matter how consistent they were, it felt as though recovery was difficult, which led to a feeling of hopelessness [in them]. They were directed to [undergo] therapy,” Chatterjee said.

She said creating a boundary between what is in your control and what isn't is the key to prevent the scales from being tipped over. “Keep making changes that can help mitigate climate change. At the same time, find a support group. Talk to your peers and that will help you realise that you aren't alone. It will prevent you from feeling isolated. Try looking at the bigger picture and understand that this isn't on you―corporations are more responsible; remember that change is happening, even if it is on a small level,” she said.

Activist Anmol Ohri, 25, from Jammu, said, “I certainly have climate anxiety. I have it as I am talking to you. I am sweating copiously. It is because people we left in charge of society didn't do anything about it. We are trying to do a lot, but aren't able to do enough.” When I asked Ohri what aspect of climate change scares him the most, he replied, “The issue on the whole scares me. The whole system is messed-up and everything is interconnected. The idea of development that was taught to us is an antithesis to our survival as a species. Modern education is opposite to what people like us believe. People keep saying save the earth, it is about us―not the earth. The earth will survive, we won't.”

Sonika Bhasin, 42, from Mumbai, also has climate anxiety. “I have even taken therapy. I have felt depressed and helpless and broken down several times,” she said. Bhasin, who practices green habits like composting and buying package-free grocery and homecare products, recalls a time she was moved to tears. “It was after I saw a video titled, 'Granddaughter's eyes'. In it you view the world through your granddaughter's eyes. After watching it, I started crying. I started getting worried about what would happen to my son! I started to wonder what I could do to cope with it, what I could do to save the planet,” she said.

Bhasin is educating her four-year-old son about climate change. She taught him simple things like carrying a cloth bag, spoon and fork to avoid producing waste. She is also educating her family on ways to save the planet. “This is a common topic at our dinner table,” she said.

Darsh Vatsa, 16, director of the ResistTwo Foundation, said, “I have climate anxiety, but I haven't taken help for it as yet. Instead, I try to redirect my worry towards taking decisions, planning what to do, so on and so forth.” ResistTwo is a youth collective working to generate awareness on issues ranging from plastic pollution to the lack of queer representation in the climate space.

maharashtra-s-public-health-care-is-breaking-down

Sat Oct 28 16:15:40 IST 2023

More than 100 patients, including infants and newborns, died across government and civic hospitals in four districts in Maharashtra in under a week. Never before has the state seen patient deaths on this scale.

In Thane―Chief Minister Eknath Shinde's constituency―at least 25 people died in 24 hours. In Nanded, which is former chief minister Ashok Chavan's turf, 35 patients, including 16 infants, died in under 30 hours. In Aurangabad, which is represented by MP Imtiaz Jaleel, the Government Medical College, Chhatrapati Sambhajinagar, saw 14 deaths in 24 hours. Nagpur, home turf of Deputy Chief Minister Devendra Fadnavis and the Lok Sabha constituency of Union Minister Nitin Gadkari, reported at least 25 deaths in 24 hours at the government-run Mayo Hospital.

The dean and the paediatrician at the Nanded hospital have been booked for culpable homicide not amounting to murder. But, the root of the problem, not just at Nanded, but at all the public hospitals across the state is that there is not enough money, says.

Swati Rane, health activist, Jan Swasthya Abhiyaan, and visiting faculty at the Tata Institute of Social Sciences. “Every year, since 2019, there have been deaths inside NICUs (neonatal intensive care units) of state-run facilities,” she says. “In the NICU at the Nanded hospital, where the infant deaths occurred, the sanctioned bed capacity is only five, but at present there are 60 to 70 babies there. At any given time, on an average, there is just one staff to cater to 30 to 45 patients.”

Rane says such facilities do not even have drinking water and, given that Maharashtra does not have a Clinical Establishment Act, there is no regulation. “This is neglected in this state,” she says. “There is lacuna in every department across hospitals, from the lack of qualified personnel to infrastructure, medicines and permanent doctors.”

In 2014, associate professor Aswar Nandkeshav, medical officer Rewatkar Mangesh, and postgraduate student Akanksha Jain, all from the preventive and social medicine department at Dr Shankarrao Chavan Government Medical College and Hospital in Nanded, where the tragedy has now occurred, published a paper concluding that each patient waited 75.5 minutes to avail of outpatient services. According to the report, factors contributing to the delay included: registration clerk not coming to work on time; doctors coming late; doctors and pharmacists talking on their phones; difficulty in locating rooms; rush and VIP patients jumping the queue.

Experts question the state government's approach to public health saying that the area does not feature in its priorities. The budget allocation for public health and medical education in the state for 2023-2024 dropped by 7 per cent, year on year. This means it was less than 4 per cent of the overall budget, despite the inadequacies in the public health system highlighted by Covid-19.

In a research paper titled Health Infrastructure in Maharashtra, Prof P.S. Kamble of the department of economics at Shivaji University, Kolhapur, studied the facilities in rural Maharashtra. According to the study, “beds in government hospitals are often unavailable, not only in rural areas, but also in urban areas”.

Another problem is the number of vacancies in the state health department―around 18,000. “Of 42 posts for directors in various departments, 32 are vacant,” says Dr Abhay Bang, activist and community health researcher working in Gadchiroli district. He says 1,600 doctors' posts and 16,000 other key positions are vacant. “With such huge vacancies and overload, it is no wonder that the system is breaking down,” he says.

In Mumbai, which is reputed to have a far better public health care system compared with rural areas, there is a 27 per cent shortage of medical staff in five Brihanmumbai Municipal Corporation-run hospitals―439 out of 1,606 positions are vacant. The lack of assistant professors, who play a crucial role in academic work and patient care, is particularly high.

In August, the KEM Hospital had 180 vacancies. The Lokmanya Tilak hospital, Sion, and the BYL Nair Hospital, Mumbai Central, had 142 and 88 vacancies, respectively. And, doctors on contract had carried out a protest to highlight the shortage. Records at the Nanded hospital reportedly indicate that 42 per cent of medical positions across departments, including paediatrics and general medicine, remain vacant. Also, more than 60 per cent of the positions for senior resident doctors are vacant at the medical college.

The hospital serves patients from across the district and from neighbouring states like Telangana and has an annual footfall of 6.21 lakh. This leads to contractual hiring and that in turn means there are no timely promotions. Moreover, recruitment also takes a back seat. “We desperately need to recruit permanent staff,” says Bang. “Everyone is on contract.”

However, Bang also adds a word of caution with regard to the outrage sparked by the deaths, saying that we need to be sure that the number of deaths are excessive. “Not justifying the deaths, [but, at] any tertiary care hospital, where only serious patients are referred, there is a proportion of deaths which is unavoidable,” he says. “[So,] 24 deaths in a day is an accidental possibility in medicine. If this is perpetually the case, then it is problematic.”

Yet, what is stark and abnormal is the proportion of newborn deaths―out of the first 24 deaths at the Nanded hospital, 12 were of newborns. Sudden newborn deaths have been reported in public hospitals in Maharashtra earlier, too. In 2017, for example, 55 infants died in the NICU of the Nasik Civil Hospital. “One reason is that the tertiary care hospitals cater to the cases referred from the surrounding five to six districts and because the peripheral institutions are not well developed and mismanaged, everyone passes the buck by referring serious patients to district hospitals and further on to the medical college,” says Bang. “Usually, in NICUs there is one nurse for three to four sick neonates. But the situation is such that even for five times more neonates, there is just one nurse. So, there is overloading at these apex hospitals.” The government recently announced the creation of 2,800 temporary posts in the health department. But this is too less and too late, say experts.

Bang says the Centre's Janani Suraksha Yojana, launched in 2006, in which women are incentivised to come to hospitals for delivery, is an issue. In the scheme, women who give birth and the ASHA worker who brings her to the hospital are both paid an incentive. The percentage of institutional deliveries in India has gradually increased from 40 per cent to 90 per cent. “This means that nearly 1.5 crore more women have started delivering in hospitals,” says Bang. “The government has brought this load on to tertiary hospitals, and, [incentivises] it. If 90 per cent of women in nearby villages deliver in hospitals, it is natural that their newborns are admitted, thereby overloading the NICUs. Newborn care is breaking down because of this perverse incentive. It is important for the state government to develop the capacities of peripheral institutions, sub centres, PHCs and CHCs.”

Moreover, there is no nursing directorate in the state's healthy ministry, which means there is nobody to regulate the nursing staff. The Maharashtra Nursing Council was dissolved a few months back, for the fourth time in around 10 years, because of the irregularities in appointments and the functioning of the autonomous body. “The state is only catering to private sector interests,” says Rane. “In 2001-2002, there was Rs31 crore of foreign investment in the hospitals sector in the state. Now, that has grown to more than Rs4,000 crore. This shows the government is only interested in privatising health care.”

The breakdown that begins right at the primary health centres have a massive impact on the state's tribal population. Back in 2000, eminent medical scientist and Padma Shri awardee Prof S.L. Kate had highlighted the issue of sickle cell anaemia (SCA) among children; “in every village, there are at least one or two suffering from sickle cell disease”. He found the prevalence to be high among the Bhil and Pawara tribes from the Nandurbar district and Madia, Pardhan, Otkar and Gond from Gadchiroli. He estimated that there were more than 10,000 sickle cell patients in Nandurbar and an equal number in Gadchiroli. The information has not led to an improvement in the situation. Even today, Nandurbar, which has a predominantly tribal population, has the most number of SCA patients in the state.

The situation on the ground has remain unchanged even in the case of malnutrition and anaemia. Sapna Rokade, a researcher from the department of social work at the Tata Institute of Social Sciences, studied the nutritional status among 4,000 tribal women in Maharashtra and found that more than half, especially in the northwest districts, were anaemic. Severe anaemia was found in almost all districts in western Maharashtra. The study was published in Clinical Epidemiology and Global Health.

Dr Amol Annadate, a paediatrician and activist based in Aurangabad, says the recent deaths are a result of administrative failure, not medical failure. “This issue has been a long standing one and there is no guarantee that this will not repeat,” he says. “It is not the fault of health workers. They are extremely overburdened. There are only five to six doctors for every 100 patients there, which is shocking, to say the least. Health is a state subject and the joint responsibility of the medical education department and the health department and, unfortunately, both are corrupt.” He adds that “so much corruption” was on top of meagre budget allocations.

“What we need is an audit of the number of deaths occurring daily at these hospitals, the magnitude of human errors and infrastructure shortage and more,” says Annadate. “There is an absence of accountability and any system of audits at these hospitals.”

Meanwhile, the state government is announcing new hospitals in a bid to improve health care infrastructure and address the shortage of doctors. It has approved the establishment of new government medical colleges in nine districts at a budget of Rs4,366 crore. “What is the point?” asks Rane. “They should focus on providing doctors in the existing facilities instead of constructing more buildings.”

Padma Shri awardee Dr Himmatrao Bawaskar says: “The most crucial aspect which is often ignored is that medical officers must carry out regular OPDs and one medical officer must be available 24x7 in periphery care centers and PHC/CHCs, especially at night, when most urgencies happen and patients are sent to higher institutions.” This may seem a minor thing, he says, but it will bring significant change.

how-to-prevent-heart-attack-in-young-adults

Sat Sep 23 15:52:19 IST 2023

Imagine a bustling metropolis, filled with the vibrant energy and aspirations of its young inhabitants. Now, picture this same city being plagued by an alarming increase in heart attacks among its youth. Unfortunately, this scenario is becoming all too common in India.

Heart attacks were once considered a condition predominantly affecting older individuals. However, recent years have witnessed a worrisome rise in cardiovascular diseases among young Indians. This perplexing trend demands our attention and prompts us to explore the crucial role preventive health plays in effectively managing life-threatening conditions. Studies and clinical observations have revealed an alarming trend of increasing cardiac deaths among young Indians, even in their 30s and 40s. This change in the age pattern of heart disease affects individuals and families and imposes a significant burden on society.

Indians, due to their ethnicity, are prone to develop coronary artery disease approximately 10 years earlier than their western counterparts. Most people in the west develop coronary artery disease after 65-70 years of age, while Indians develop them at 50-60 years of age. But the last decade has seen an increase in coronary artery disease in much younger individuals. Among these risk factors, smoking emerges as the primary cause of heart attacks in young individuals. Smokers in their early 20s and 30s develop heart attacks, which lead to heart damage that cripples them for life. Nicotine, a key component of cigarettes, predisposes individuals to blood clotting, increasing the likelihood of arterial blockages. Smoking also accelerates the development of atherosclerosis, damages blood vessels, and significantly contributes to the burden of heart disease.

Lack of exercise and sedentary behaviour amplify the risk, as regular physical activity plays a crucial role in maintaining cardiovascular wellbeing. Irregular sleep patterns and an unhealthy diet, characterised by the consumption of processed foods and excessive intake of unhealthy fats, sugars, and salt, also contribute significantly to the increasing incidence of heart attacks in younger age groups. Transitioning of the economy from labour-oriented jobs to blue collared jobs adds to the sedentary lifestyle.

Elevated lipid levels, particularly high cholesterol, play a substantial role in the development of heart attacks. Poor dietary choices, sedentary lifestyles, and genetic predispositions contribute to dyslipidemia, increasing the risk of arterial blockages. Another often overlooked factor contributing to heart attacks is the combination of cold weather and air pollution. Cold weather induces vasoconstriction, which places additional strain on the heart. Air pollution, particularly fine particulate matter, can penetrate deep into the lungs, triggering systemic inflammation and oxidative stress, thereby promoting the development of cardiovascular events.

Preventing and managing risk factors is essential in the prevention of heart attacks. Here are some key measures to consider:

• Know your numbers: It is crucial to be aware of your numbers, such as lipid levels, fasting blood sugar, blood pressure, and BMI (body mass index). Regular monitoring of these values enables early detection of any abnormalities and allows for appropriate interventions. Detection of abnormal levels should serve as an impetus to carry out lifestyle changes and pharmacological intervention when needed.

• Embrace a healthy lifestyle: Adopting a well-balanced diet is important for maintaining heart health. Include plenty of fruits, vegetables, whole grains, and lean proteins while limiting the intake of saturated fats, trans fats, salt and added sugars. Additionally, prioritise regular and adequate sleep of a minimum eight hours, as it plays a vital role in overall wellbeing. Engage in regular aerobic exercise to improve cardiovascular fitness.

• Medication adherence for cardiac patients: If you have been diagnosed with a heart condition, it is important to take prescribed medications regularly. Adhering to the prescribed treatment plan can help manage the condition and reduce the risk of future cardiac events. Being aware of one’s symptoms and taking timely medical help is the key to reducing cardiovascular mortality. Also, aerobic exercise is needed to improve functional capacity even in cardiac patients.

To increase the overall health of the citizens, public health policies are instrumental in ensuring the wellbeing of the population and addressing health care challenges at a broader level.

In conclusion, addressing the rising incidence of heart attacks among younger individuals requires a comprehensive understanding of the associated risk factors. Preventing heart attacks requires a proactive approach to managing risk factors. By staying informed about your health numbers, adopting a healthy lifestyle, managing body weight, maintaining an active lifestyle, and adhering to prescribed medications for cardiac patients, you can significantly reduce the risk of a heart attack. Remember, it is always advisable to consult a health care professional for personalised guidance and recommendations based on your specific health needs.

The author is a consultant cardiologist and cardiac electrophysiologist, P.D. Hinduja Hospital & MRC, Mahim.

cleveland-clinic-department-of-hematology-and-medical-oncology-chairman-dr-jame-abraham-interview

Sat Sep 23 15:30:21 IST 2023

There are theories about why Hippocrates, the father of medicine, named a cluster of abnormal cells karkinos (Greek for crab). Was it because the tumour felt hard as a rock, reminding him of the crab’s shell? Or, was it because of the stubborn nature of the disease, quite like how a crab doesn’t let go of you easily when it bites? Cancer continues to baffle and fascinate us, much like the origin of the word. But we surely have come a long way in understanding and treating it. Now, with artificial intelligence, there is new hope, says Dr Jame Abraham of Cleveland Clinic. As someone heading the department of hematology and medical oncology, he has seen both the human and clinical side of fighting cancer. In an interview with THE WEEK, Abraham, whose latest book―Cleveland Notes―traces his journey as a cancer physician, talks about how new therapies are changing cancer care.

Q CAR T-cell therapy has revolutionised cancer care. Most drugs today work on activating the immune system to attack cancer cells. How big a difference has the therapy made in treating different kinds of cancer?

A Training our immune system to attack cancer cells without causing damage to normal cells is one of the most important advances in cancer therapy in the past 10 years. Various immunotherapy approaches including monoclonal antibodies, such as pembrolizumab, and CAR T-cell therapy are currently saving patients’lives. Immunotherapy has improved survival in advanced melanoma and lung cancer―two of the most lethal cancer diagnosis. In August 2015, former US president Jimmy Carter was diagnosed with metastatic melanoma that had spread to his brain. He was treated with pembrolizumab (immunotherapy) and has been in remission for the past eight years, which is a remarkable achievement. Similarly, CAR T-cell therapy is offering long-term remission in advanced myeloma and lymphoma diagnosis.

Q How is AI helping with cancer diagnosis and treatment?

A The impact of artificial intelligence (AI) on our daily lives, medicine or cancer care will be more far-reaching than the internet’s or computer’s. Many specialties in medicine use pattern recognition to make diagnosis, such as pathologists or radiologists. A pathologist when she/he looks under the microscope is looking for patterns of normal versus abnormal cells to make a diagnosis of cancer. Similarly, a radiologist looks at the MRI of the brain or CAT scan of the lung for abnormal patterns to make a diagnosis of a brain tumour or lung cancer.

If we train AI, it can pick up abnormal from normal much faster than a pathologist or a radiologist. Scientists have developed deep learning tools and algorithms that can detect cancer better than the human brain. Another area where AI can help will be sorting through the large amount of genomic data to help clinicians diagnose and select treatment. In addition, AI will play a major role in drug discovery and development.

Q Covid-19 slowed down cancer diagnosis and treatment. Have we been able to catch up? How has Covid-19 changed cancer care?

A Covid-19 has caused significant delay in cancer screening and diagnosis in many cancers, such as breast cancer, colon cancer and lung cancer. In addition, Covid-19 has exposed the innate vulnerabilities and inequities that exist within health care systems across the world. We are still working to sort that out. Another impact of Covid-19 is on workforce. High burnout among health care providers has caused many of them to leave patient care completely. Hospitals in the west, especially the US, are still trying to cope with workforce shortage due to this great resignation. But many things have changed since Covid-19. Telemedicine programme has gained acceptance in mainstream. Scientific breakthroughs such as mRNA vaccine technologies, which were used in Covid vaccine, are already being used in developing new treatments for cancer. This can potentially be a game-changer.

Q Immunotherapy, precision oncology, DNA sequencing and such technologies are already changing how we look at and treat cancer. What is going to be the next big thing in cancer care?

A Due to economic development, the life expectancy in India and around the world will continue to improve. As we age, as a society and individuals, we will be dealing with cancer, heart disease, neurodegenerative diseases (like Alzheimer’s) and metabolic disorders (like diabetes). Health care systems around the world should be preparing to deal with the tsunami of these four diagnoses.

Some of the technological advances in the future that will help us deal with cancer are

* Cancer interception approaches: Individualised risk-based screening, incorporating personal behaviour (smoking/alcohol), family history (history of breast cancer), genomic information and ctDNA (circulating tumour DNA) may allow us to detect cancers before it really happens in an individual. There are a number of studies looking at this.

* Every patient and patient encounter are filled with thousands of data points―when we add genomic information from the patient and the tumour, it can increase exponentially. But all these data points can give us valuable information to provide highly personalised care for that person. Emerging AI tools will help doctors to filter these data points and tailor treatment.

* Evolution of novel approaches such as mRNA-based vaccines, CRISPR technologies for gene editing, cellular therapies, bispecific antibodies, oncolytic viral therapies and novel antibody drug conjugates will continue to transform cancer treatments. They will offer novel options for cancer prevention and prolonged cure.

* Novel technologies such as holograms, virtual reality and AI may further revolutionise telemedicine globally, allowing patients to see a doctor anywhere in the world.

Q In your latest book, Cleveland Notes, you poignantly bring out what it means to fight cancer through your patients' experience. Could you share your experience about putting that on paper?

A There are three main reasons for me to write this book.

First, I would like to tell the story of my journey. It is a story of luck, chances, God’s grace, failures, disappointments, eternal optimism, hard work and perseverance. I am very grateful to the free public education I received, which gave me a passport for social upward mobility. I hope my journey from a small village with limited means to a leadership position at one of the best hospitals in the world will inspire another young girl or boy to dream big.

Second, taking care of patients with cancer on a daily basis is truly inspiring. You will have the privilege of witnessing the strength of human spirit when they are facing the worst crisis in their life. It is amazing to watch ordinary people rising up to the occasion and living with hope, kindness and compassion for themselves and others.

Third, as a cancer doctor, I experience many moments of joy and gratitude. But that cannot diminish the impact of dealing with pain and suffering on a daily basis. Writing is therapeutic for me and it allows me to express my feelings on paper. This work is a compilation of articles over the past many years.

Q You have also written about how doctors do cry, perhaps not in front of patients. Over the years, has dealing with loss changed?

A I chose oncology because I deeply care about patients with cancer and because of my passion to find a better treatment for cancer. That hasn’t changed. I hope I will not develop compassion fatigue, and the day I do, I shall stop seeing patients. As an oncologist, I learned to celebrate small and large victories and milestones. It has given me a strong sense of perspective and purpose. But as any caring individual or a doctor, each loss or suffering takes a bite out of your heart. It will hurt you deeply. As I mentioned in the book, “the size of the cemetery we carry in our heart will continue to expand.”

I will never forget the words by Amber, one of my patients: “I know that I always said that you have the worst job in the world! But I am thankful to you. You were my doctor and my friend. When you get to heaven, I along with so many others will be there to greet you and welcome you to paradise. You are truly amazing and I cannot thank you enough for all you have done.” Three months after Amber died, her husband handed over this letter to me. These words will continue to inspire me to work even harder.

Q You have traced your journey as a cancer doctor in your book. How do you think it will help readers, including patients and medical students who aspire to be where you are?

A Three takeaways from this book:

* Never take yourself too seriously and never forget your roots. That is why I explored my journey from a small village to Delhi, New York, Washington, DC and Cleveland and my identity crisis in a funny manner. Dream big and work hard, but at the same time be prepared to pay the price for big dreams. You will fail and fall down. But your journey will be defined by your courage to persevere.

* Patient stories in my book are filled with hope and resilience. All of us need to practise compassion in our daily lives. As a cancer doctor, I am reminded of the momentariness of life on a daily basis. Those patient stories will inspire anyone, not just someone in the medical field.

* Finding a purpose in your life is important. My purpose is to lessen the pain and suffering from cancer. That is a tough task. As a cancer doctor and researcher with the privilege to work at some of the best research centres and hospitals in the world, my journey is still a work in progress. Whatever your purpose in life, with intense focus and hard work, you will be able to do that, too.

patients-are-at-the-heart-of-magsaysay-awardee-ravi-kannan-s-medical-philosophy

Sat Sep 23 15:16:24 IST 2023

On the list of many inspiring women who illuminated R. Ravi Kannan’s life path, stands the wife of a patient from Tripura. Her husband needed medicines worth Rs5,000, and she requested the doctors to go ahead with the treatment while she arranged the money. When she returned to the Cachar Cancer Hospital and Research Centre (CCHRC) in Silchar with the cash, the doctors told her that he would have to stay on for a few more days for additional treatment. She started crying, begging for his discharge. Kannan, the director of the centre in Assam, tried to understand the reason behind her resistance and discovered that she had pledged her son to a landlord in the village to raise money.

The memory gives Kannan goosebumps. It became a turning point in how the centre approached patients. “We had quoted a cost that she could not afford. Since then we have become extra sensitive and ask patients where the money will come from. We tell them not to pledge their fixed assets. I am sure we continue to make mistakes that cause distress to our patients,” says Kannan.

The renowned surgical oncologist is a recipient of the 65th Ramon Magsaysay Awards. The citation describes him as a ‘Hero for Holistic Healthcare, Providing hope and healing in cancer care’.

This is just one more award in a long list of recognitions including the Padma Shri, but the doctor says he received them just as the ‘face’ of a large team that works with him to provide cancer care. “I will be an idiot to think that all this was achieved just by me,” he says.

Before the CCHRC was set up in 1996 in the Barak valley through public philanthropy, the only option was to travel to Guwahati, 300km away, for treatment. In fact, that was no option as most patients were daily wage earners at tea plantations and agricultural labourers with limited means. And if somehow the means could be met, travel itself was treacherous what with frequent landslides and fierce rains.

Kannan almost did not choose surgery as an option for his masters at the Maulana Azad Medical College in Delhi. He does not though remember a time when he did not want to become a doctor. “I had no other idea since I can recall,” he says. His mother, Indumati Rangaswamy, now 83, had wanted to become one herself. Financial limitations held her back. So deep was the imprint that she made on her son’s mind that by the time he reached class 12, there was no other idea that he would entertain, not even the example of his much-feted Air Force officer father, R. Rangaswamy. His younger sister, Sukanya, who he describes as ‘more independent minded’ chose a career in biochemistry.

MBBS done from the Kilpauk Medical College in Chennai, Kannan fretted over his choice of specialisation in his masters. He was sure that it would not be surgery. Fate intervened. In the form of yet another lady.

On one of his father’s work trips, Kannan went along to Srinagar, where they were invited for dinner to a wing commander’s home. The lady of the house, Uma, a surgeon in the Air Force, was not present for the meal as an emergency at the hospital had popped up. She came in only after the dinner and requested the guests to stay for coffee. She asked Kannan to join her as she made the coffee and update her on his studies.

Kannan paints a strong picture of the memory―how she explained to him what a surgeon’s work entailed. That evening she had been delayed by a patient who had chest trauma, an intracranial haematoma (collection of blood in the skull) and an abdominal emergency. “I was mesmerised as she talked about why she chose the order she did in which to tackle all three. I can still see her small gold earrings go swoosh, swoosh as I listened. I was so taken up by the explanation,” he says.

Back in Ambala, where his father was then posted, Kannan wrote surgery in all the five columns where different choices had to be listed.

His choice of going to the surgical oncology department was also brought on by instinct. “It was believed that anyone who went to the department would actually not get to perform any surgeries,” he recalls. So off he went to that department where he met inspirational teachers who taught him why only a sound physician could make a good surgeon.

“A craftsman who blames his tools is not a good one,” one of his teachers said. Another mentor told him that his duties as a doctor would range from performing complicated surgical procedures to providing a bed pan to a patient who wanted to pee. A third told him that if a patient did not have resources for treatment, it was the job of the physician to get those. A textbook of medicine had a story that stayed with him―that of a doctor who let go of a momentous occasion because he received news that one of his patients had passed away. The doctor chose to be with the patient’s family instead of delivering a prominent presidential address.

And thus was shaped Kannan’s medical philosophy. “A medical practitioner should be entirely focused on the patient to make sure the only interest that matters is that of the patient. All the other interests―that of the physician, the caregiver, the hospital, should be eliminated,” he says.

Kannan was leading the surgical oncology department at the Adyar Cancer Institute (often called the nursery of oncologists) in Chennai when Chinmoy Choudhury, director of CCHRC visited. Though the CCHRC had been set up, it had very few doctors, and Choudhury would visit various cancer institutes and hospitals to understand how to better manage the fledgling centre.

Choudhary was persistent that Kannan visit the centre and take charge of it―regularly calling and writing. Kannan’s colleagues though were convinced that his wife, Seetha, would be unwilling to give up her job at the United States-India Educational Foundation (USIEF) in Chennai and move to Silchar.

However, when the couple and their daughter, Andolika, visited Silchar, Seetha at once decided that it needed Kannan’s skills. The principal of the local Kendriya Vidyalaya turned out to be an old classmate who assured admission to Andolika in class 5. The catch was that the child, who till then had never taken an exam, would have to get through an entrance test. She wept, fearing failure, and wept more, fearing the loss of friends.

Back home, both his mother and mother-in-law opposed the idea. His father, who was suffering from respiratory failure, and his father-in-law, who had prostate cancer, supported and enabled the move.

In 2007 that move was made. Both sets of parents also followed.

Andolika, after a few days of despair at not understanding a word of what her Hindi/Bangla- or Assamese-speaking classmates were saying, struck up some great friendships. Many of which she continues to nurture as she completes her surgical residency.

Seetha started volunteering at the centre. Till a kitchen was set up, food would go from the couple’s home for caregivers. Once again, the women around him had empowered Kannan.

The biggest challenge that the centre faced was a very low compliance rate. Only about 28 per cent of the patients completed treatment. Today, that number stands between 70-75 per cent. “It is not a good figure. We should be able to treat at least 90 per cent patients,” says Kannan.

The CCHRC’s vision is to ensure that ‘no individual develops a cancer that can be prevented, that no patient is denied appropriate cancer treatment for want of resources, that no patient dies in agony and indignity, and that no family suffers treatment-induced poverty and grief’. About 75 per cent of the patients at CCHRC are treated free or at subsidised charges.

“Health care is an infinite story,” says Kannan. “We cannot really be sure of what will happen next. But each one of us has to be a party to it in our lives and transmit these values to the next generation”.

In scripting CCHRC’s bit in that story, many experiments were made. Health camps were organised in the initial years, till it was realised that it was an undue pressure to expect daily wagers to free up a whole day for the camp. Then accredited social health activists (ASHAs) were trained to examine for oral abnormalities while they were doing the government-mandated checkups for hypertension and diabetes. Any abnormalities detected would further be examined by a trained nurse or doctor.

ASHAs also went to houses to do examinations. Mobile clinics were also part of the mix. One-person satellite centres were set up as hospitals were too expensive a proposition. Next, training was offered for home-based care to families, and the ensuing onlookers educated about cancer prevention, health seeking behaviour and about government and non-government help available for cancer treatment. A one-time fee of Rs100 was introduced to ensure free repeat procedures if required so that financial burden would not do away the good achieved by the initial treatment.

Some experiments did not work at all. For instance, the centre once set up tailoring and paper making units so that caregivers could find employment while their loved ones were being treated. “We quickly realized that most caregivers were unskilled and abandoned the units,” says Kannan. The centre then moved to giving them jobs as assistants to the cook, gardener, electrician, and other staff employed at the centre on a salary of Rs300 a day.

Kannan has great faith in the power of the government machinery. “The government has the muscle to achieve what private or not-for-profit players cannot,” he says. “We must work together. All people must demand their right to healthcare. It is not charity that a doctor is doing, s/he is being paid for the job”.

He speaks of the many hesitations that keep people away from hospitals and treatments. “A hospital with marble floors, paintings and fountains scares off the poor,” he says. Another is delayed diagnosis, which is more fatal than the disease itself.

Kannan supports the idea that the young should go out of the country to work and build connections. “But they must return to see the transformative impact of their work,” he says. Unlike many who criticise the younger generation of being materialistic, his take is that it is the preceding generation’s fault. “Why were we not able to provide role models for them?” he asks.

He also sees great power in the good that people can do when they come together, and puts the onus on medical practitioners to give patients the confidence that they are pro-poor and people-centric.

CCHRC is creating a next generation of medical practitioners who will share its vision. To impart academic skills, it offers a DNB (Diplomate of National Board) in cerebral oncology among other specialties. “It is an ongoing process which cannot happen overnight. But if we keep doing our bit and teaching the next generation to prepare the generation after it, we will keep moving,” says Kannan.

As for the mother who imbibed in her son the idea of becoming a doctor, she she is now tech-savvier than the son. His father and father-in-law passed away in 2011.

In the slices of free time that Kannan can steal, he enjoys Carnatic and Hindustani music, reading and travelling.

And there are no regrets. “If I had the opportunity to do it again, I would do it exactly the same way, enabled by the people around me,” he says.

the-impact-of-parental-strains-on-the-childs-mental-health

Sat Aug 26 16:05:40 IST 2023

PARENTAL stress affects countless families worldwide. In today's fast-paced and demanding world, parents often find themselves overwhelmed by the pressures and responsibilities they face. Juggling work, finances, household chores, and raising children, can create a high-stress environment that takes a toll on parents' emotional and physical well-being. Research has shown that children of stressed parents are more likely to experience mental health issues, such as anxiety and depression.

The negative emotions and strained relationships resulting from parental stress can create an unstable and tense atmosphere at home, affecting the child’s emotional development and psychological resilience.

Emotional contagion: Children are remarkably perceptive and attuned to the emotions of their parents. When parents experience high levels of stress, their emotional state can be easily transmitted to their children. This phenomenon, known as emotional contagion, can have adverse effects on the child's mental health. Constant exposure to parental stress can create an environment of tension and anxiety, which can lead to heightened levels of stress and emotional distress in children.

Modelling behaviour: Parents serve as primary role models for children, and they often imitate their behaviour and coping mechanisms. If children witness their parents struggling to manage stress effectively, they may adopt similar maladaptive strategies. Unhealthy coping mechanisms such as avoidance, aggression, or substance abuse can manifest in children.

Disrupted parent-child relationship: Prolonged parental stress can strain the parent-child relationship. When parents are overwhelmed by stress, they may have less emotional availability and limited energy to engage with their children. This can result in reduced communication, decreased bonding, and lack of emotional support. A disrupted parent-child relationship can contribute to feelings of insecurity, low self-esteem, and increased risk of mental health issues in children.

Impact on cognitive functioning: Parental stress can also impair children's cognitive functioning and academic performance. The toxic effects of chronic stress can interfere with a child's ability to concentrate, learn, and retain information. Additionally, children experiencing parental stress may struggle with problem-solving skills and exhibit difficulties in decision-making.

Long-term health consequences: The impact of parental stress on the child's mental health can extend well into adulthood, with potential long-term health consequences. Research suggests that individuals who experienced childhood stress due to parental distress are more likely to develop chronic health conditions, such as cardiovascular disease, obesity, and immune system dysregulation, later in life.

Rohan’s response

Rohan, seven, came from a caring and supportive family. His mother had conceived him at the age of 28―a full term C-section delivery with no prenatal or postnatal complications, or no history of organicity. Lately, his parents were facing several stressors, including financial difficulties and work pressures. These stressors had affected Rohan’s emotional patterns. His behaviour underwent noticeable changes. He became more irritable and easily frustrated, often exhibiting outbursts of anger or tearfulness over minor issues. He experienced a decline in his motivation and engagement in school activities. His concentration and focus were compromised, resulting in decreased productivity and an overall decline in academic achievement. He often displayed signs of anxiety, such as restlessness and trouble sleeping. He also exhibited clinginess or sought excessive reassurance from his parents.

This emphasised the importance of recognising and addressing the effects of parental stress through intervention and support systems. By implementing appropriate strategies and fostering a nurturing environment, parents and professionals could help children like Rohan navigate the challenges associated with parental stress, promote their emotional resilience, and support their healthy development

Zara’s silence at home

Zara, six, experienced selective mutism, a condition where she consistently refrained from speaking in certain social situations despite her ability to communicate in other settings. Her parents' frequent and intense conflicts at home created a distressing and negative environment, leading to Zara's silent response as a coping mechanism in certain situations.

Her parents were engaged in marital conflict due to her mother's mental illness, obsessive-compulsive disorder (OCD), which her father finds difficult to understand. Zara, being a perceptive and sensitive child, absorbed the negativity and developed an aversion to speaking, particularly outside her comfort zone.

She depicted signs of anxiety, such as avoiding eye contact, withdrawing into herself, and clinging to her parents in public settings. Addressing the underlying problem of parental conflict is crucial for Zara’s emotional well-being and future development.

Recognising the potential consequences of parental stress is crucial for parents, caregivers, and society as a whole. To mitigate these effects, it is essential to prioritise the well-being of parents, provide support networks, and promote healthy coping strategies.

Dr Gupta is clinical psychologist at Madhukar Rainbow Hospital, Delhi.

india-needs-a-more-targeted-approach-to-raise-protein-consumption

Sat Aug 26 16:00:50 IST 2023

The statistics are stark, but they are a true reflection of the prevailing situation in the country. Over 53 per cent of young Indians (aged 18-35) find nutrition access challenging, while over 50 per cent feel that they eat a balanced diet, despite failing to identify nutritional food sources correctly. The Nutrition Awareness Index 2023, a state-wise index assessing awareness, affordability and accessibility of nutrition in India as perceived by end-consumers, provides key insights about nutritional access.

Punjab emerged the top state on nutritional access, while Bihar ranked at the bottom. Uttarakhand has the highest recognition of fats as a part of a balanced diet at 70 per cent, while Andhra Pradesh has the lowest recognition of pulses and legumes (29 per cent) as body-building foods. The recognition of protective foods like eggs (28 per cent), vegetables (60 per cent) and fruits (60 per cent) are among the lowest of all states in Rajasthan. Eighty-five per cent of Indians are unaware of vegetarian sources of protein, while more than 50 per cent are unaware of healthy fats.

The Nutrition Awareness Index, developed by YouGov, an internet-based market research and data analytics firm, is part of the Right To Protein campaign. It was prepared after a survey among more than 2,000 adult urban internet users, who can read and understand English. The survey was spread across 20 states with the highest GDP. The index is a dynamic, quantitative ranking model constructed from the average of the scores of all 20 states weighted by the relative share of each state as per population numbers from Census 2011. It presents interesting data points on state-wise awareness of and access to nutrition.

The survey shows that India really has no understanding of a balanced diet. The country is protein deficient and there is a large awareness gap as far as protein and nutrition sources are concerned. As health safety continues to be a major concern, the index was compiled to educate people about a balanced diet and also make them aware of sources of good proteins.

In 2012, Sumathi Swaminathan, a researcher from St. John's Research Institute in Bengaluru, published a report in the British Journal of Nutrition, pointing out that while the proportion of individuals at risk of deficient protein intake was high in rural and tribal adult populations, it happened against the backdrop of a high prevalence of low BMI. “This is a big burden in disadvantaged populations; it is not simply the burden of enhancing the quality of protein intake, but also the quality of the diet in general, and represents a severe challenge that needs to be met. It would also appear that the diet of Indian pregnant women do not meet their increased protein requirement.”

A decade later, nothing has changed. According to Shobha Suri of the Observer Research Foundation, proteins are not only lacking in Indian diet, but are overlooked. India’s protein consumption is much lower than the 48gm per day recommended by the Indian Council of Medical Research. The recommended dietary allowance of protein for an average Indian adult is 0.8gm to 1gm per kilogram of body weight. However, the average intake is only about 0.6gm per kilogram of body weight. “Globally, protein consumption is on the rise, averaging at 68gm per person per day. India has the lowest average protein consumption (at 47gm per person per day),” said Suri.

The Union government has various safety net programmes under the National Food Security Act, like the Integrated Child Development Services (ICDS) and the Mid Day Meal Scheme (MDM) for improving nutrition and food security. As Suri notes, “The ICDS provides 500 kilocalories, with 12-15gm of protein per day to children and up to 25gm of protein for adolescent girls. The school meal scheme provides for 300 kilocalories and 8-12gm of protein per day. Despite this, India is home to the world’s second largest undernourished population and high rates of malnutrition.”

According to experts, with the rise in non-communicable diseases, the inclusion of high-protein foods in diet has been strongly associated with improving insulin response and reducing diabetes. Said Dr Charu Dua, chief clinical nutritionist at Amrita Hospital in Faridabad, “While young Indians are consuming enough proteins, the intake reduces considerably for those in the elderly age bracket. To prevent deficiency, the RDA is 0.8gm per kilogram of body weight for an average sedentary adult. A vegetarian diet is easily able to meet this demand,” she said.

The latest ICMR guidelines, meanwhile, recommend consuming proteins as per EAR (estimated average requirement) and not RDA. As per EAR, the requirement is 0.66gm per kilogram of body weight. "What we need is two bowls of dal a day, lots of vegetables and milk on a daily basis,” said Dua. “A balanced diet with a cereals-pulses combination is crucial. One need not look for a non-vegetarian option to consume enough proteins.”

Deepa Bhatia, general manager, YouGov India, said it was important to work together towards building a healthier and more nourished India. “The Nutrition Awareness Index highlights the perceptions and understandings of nutrition across various states, allowing us to identify crucial areas that require immediate attention and investment,” she said. “Tailoring educational campaigns to state-specific nuances is crucial. Understanding regional variations allows us to design more targeted approaches to increase awareness.”

UNAWARE INDIA

States with the lowest nutrition index scores (% below national average)

Bihar: 10%
Lowest recognition of nuts and oil seeds as energy sources

Andhra Pradesh: 10%
Lowest recognition of pulses and legumes as body-building food

Rajasthan: 8%
Among the lowest recognition of benefits of eggs, vegetables and fruits

Tamil Nadu: 6%
Low acknowledgment of nuts and milk as body-building food

Gujarat: 6%
Particularly low awareness of body-building food like meat

Source: Nutrition Awareness Index 2023

the-future-of-digital-plus

Sat Aug 26 15:25:04 IST 2023

In November 2017, the US Food and Drug Administration approved a groundbreaking “digital” pill. Named Abilify MyCite, it contained aripiprazole, a medication prescribed for schizophrenia and mania, and had an ingestible sensor that would track medicine intake.

The sensor would transmit data to a wearable patch, which would forward it to a mobile application. This convenient setup would help patients monitor their medicine intake; they could also share this data with their caregivers and medical practitioners.

The pill was developed by American firm Proteus Digital Health and Japanese company Otsuka Pharmaceutical. Notably, Proteus, headquartered in California, created both sensor and patch. The company swiftly forged substantial partnerships within the pharmaceutical industry, amassing nearly $500 million in funding and achieving a valuation of around $1.5 billion.

However, Proteus encountered a series of challenges. Abilify had been an FDA-approved antipsychotic medication since 2002, and Abilify MyCite, twice as costly, was introduced as an adjunct to the generic Abilify. Moreover, the concept of an ingestible sensor did not resonate with many at the time. Proteus filed for bankruptcy in mid-2020.

However, the spark it lit, in terms of digital pills, continues to glow. Health care investors are optimistic about this niche domain as digital pills could improve treatment outcomes, increase compliance and reduce hospital stays. A recent market study published by Precision Reports underscores this optimism, projecting a robust compound annual growth rate (CAGR) of +8 per cent for the global digital pills market from 2023 to 2029. In July 2022, a study conducted using various internet databases showed that, by the end of June 2021, close to 250 products in this domain were at different stages of development.

This period also saw an increase in the number of patents related to digital pills, notably those featuring ingestible sensors tailored for mobile clinical monitoring, intelligent drug delivery and endoscopy diagnostics. The patent activity was mostly happening in areas of mental health, cardiovascular disorders, diabetes, gastroenterology, oncology, tuberculosis and transplantology.

Innovators in this field, however, are poised to grapple with hurdles, including pricing. An even more formidable obstacle is the fear surrounding the potential compromise of privacy―in 2018, cardiologist Lisa Rosenbaum had likened the use of digital pills to “swallowing a spy”. So, the establishment of an ethical and legal framework is imperative to ensure principled ownership and utilisation of medicinal data.

Currently, the US, Europe, China, Canada and Australia account for approximately 72 per cent of the global patent landscape. Indian researchers are also active in the field. According to Frontiers in Pharmacology, between 2012 and 2022, 977 research papers related to digital pills were published. Indian researchers, with 46, ranked third in terms of number of papers. Given India's status as a pharmaceutical leader and its ability to provide cost-effective IT resources, it has the potential to become a pivotal force in combining pharma with digital. This potential aligns with the core challenge that companies will inevitably face―that of making these smart pills more accessible and affordable.

indian-psychiatrist-dr-vikram-patel-interview

Sat Aug 26 18:25:02 IST 2023

DR VIKRAM PATEL, the Pershing Square Professor of Global Health in the Blavatnik Institute at Harvard Medical School and a well-known expert in public health, will take charge as the new chair of Global Health and Social Medicine at the prestigious Harvard Medical School on September 1. Patel has served on several World Health Organization advisory committees and has served on multiple Lancet commissions on global mental health. He currently co-leads the Lancet commission on reimagining India’s health care system. In an exclusive interview with THE WEEK, Patel spoke about a range of issues from the barriers in achieving health equity to the problems with our medical curriculum. Excerpts:

Q/ Harvard has partnered with historically black educational institutions to promote equity, social justice, and human rights. How do you envision fostering similar partnerships with institutions in the global south?

A/ First and foremost, it's important to acknowledge that health inequities stem from distinct historical factors in various countries. In the United States, a significant portion of these disparities can be traced back to a history marked by violence, beginning with the mistreatment of indigenous and native American peoples, followed by the atrocities inflicted upon enslaved African populations.

India grapples with a distinct form of structural violence perpetuated through its caste system. Interestingly, both nations share a form of violence that transcends borders, namely the impact of neoliberal systems that have exacerbated wealth disparities on a global scale.

Within these neoliberal economies, there's a pronounced fragmentation of health care, manifesting as a privatised and profit-driven medical system catering to the affluent, while the less privileged are left with an inadequately funded and resource-deprived public health care system. This dynamic isn't confined to India; it's equally applicable to the United States. There's a peculiar similarity between these two countries in terms of the sorts of injustices and inequities.

What Harvard is seeking to do is to participate in a national process of reparation to correct this violent past of America by forming partnerships with historically black universities. Also, in my department, we have a strong commitment to decolonising global health. What does that mean? It's a movement. The global health component of a much larger conversation that's happening in India as well when we talk about decolonising education. When we say decolonising the way we think about the world around us.

This, I think, is an important process. Because colonisation was a brutal experience for three-fourths of the world's people, including everyone in India. It only ended recently for some parts of the world. And I do believe that, in my department, we need to directly address how the practice of global health has been influenced by those colonial inequities.

A prime example is the setting of health research agendas, which has frequently been dominated by entities in the global north―akin to institutions like my own. This bias also becomes evident in the allocation of health research budgets, with an unjust proportion flowing toward institutions like mine. Moreover, historically, research credit has predominantly been attributed to universities in the global north.

My colleagues and I are, however, committed to partnerships with the global south. I co-founded Sangath, an Indian NGO that remains one of my university's leading health research partners in India. Our goal is to ensure, for example, that when we work with Sangath, our colleagues in Sangath set the research agenda. They do this in partnership with local ministries of health and communities that they're trying to serve. And importantly, when we publish our findings, Sangath researchers are given the opportunity to be the lead or senior authors.

Q/ Research universities, like Harvard Medical School, have the potential to effectively address health care delivery issues, especially for vulnerable populations such as the poor. In your opinion, how can research universities contribute to achieving global health equity?

A/ Harvard is an incredibly privileged institution. And I think what our role has to be is to use and deploy our privilege and also, honestly, our authority to actually do public good. And that public good must include explicitly addressing historic injustices in how health care resources are distributed. I think one example is our investment―direct investment through research capacity building in institutions in Africa, South America and, of course, in India.

I'll give you one concrete example. In Rwanda, a significant feat was accomplished through the establishment of the University of Global Health Equity (UGHE), an endeavour spearheaded by my predecessor, the late Paul Farmer, whose legacy I now follow. This university is one of the first medical schools in the world where the entire focus of medical education is addressing health inequities.

This approach is potent and transformative. Contrasting this with the scenario in India, medical education continues to carry vestiges of colonial influence. Scrutinising the curriculum and its historical context, one can discern that it closely resembles its state in 1947. Its foundations were heavily shaped by the notion that we were preparing doctors as if they were bound for England, destined for city hospitals. What was required, however, was a comprehensive curriculum overhaul that mirrored the health inequities prevailing in India during that era. Regrettably, traces of these inequities endure to this day, albeit, hopefully, to a lesser degree.

A pertinent example lies in our failure to emphasise primary health care, equipping doctors to serve both urban and rural underprivileged populations. Our curriculum should have gravitated toward ailments that disproportionately affect our populace, such as infectious and tropical diseases. Instead, we find ourselves entrenched in a medical education paradigm that readies doctors for careers in the NHS or the corporate hospitals in India, or even those in prominent medical centres like Boston, rather than centring on addressing India's public health demands. What UGHE is doing in Rwanda is completely turning that around. It is training doctors primarily in the skills that they need to work with the average person in Africa and indeed in any part of the world, you know, depending on where the students come from.

Q/ What are the elements from different medical education models that Indians must take note of?

A/ Various aspects of different medical education curricula warrant examination. Take the United Kingdom, for instance. Following the completion of MBBS training, individuals are not automatically eligible to practise in any setting, including primary care. Instead, they proceed to undertake speciality training, which includes primary care or family medicine specialisation. This model merits consideration on a global scale, with the aim of elevating primary care and family medicine to specialised status and thus rendering it more appealing. The challenge at hand is to strategise how to entice the brightest medical graduates toward primary care. Rather than overhauling the entire medical curriculum, one approach could involve establishing a specialised MD track in primary care and family medicine.

Another innovative approach is exemplified by certain medical schools, mostly situated in the global south. For instance, in Granada, Zimbabwe, there's a medical school where students engage with families in the community from the onset of their MBBS training. Over the span of four-and-a-half to six years, students establish ongoing relationships with these families, frequently visiting and interacting. This immersive experience fosters a comprehensive understanding of health and health care within its social context, effectively expanding medical education's focus from being hospital-centric to embracing community-centric principles.

Numerous such innovations are evolving within medical education. However, it's paramount that we address a shared concern in both India and the United States: the privatisation of medical education. This matter warrants deep consideration due to its potential repercussions. Graduates burdened by substantial financial debt incurred during their medical education are inevitably compelled to prioritise debt repayment. As fresh medical graduates are not typically high earners, there's a subconscious temptation to gravitate towards lucrative commercial practices rather than patient-oriented care, largely driven by the need to settle the debt. This phenomenon underscores that the commercialisation of medicine poses a significant threat to global health equity. This trajectory is initiated from the very moment a student enrols in a private medical school. So I do believe that the commercialisation of medicine is the single biggest threat to health equity in the world today. And we really do need to, therefore, re-examine the cost of medical education.

Q/ India is considered a global pharmaceutical major. But do you think that we still lack original research? And what can we do to improve the situation?

A/ I think India’s research infrastructure in the health field is extremely weak. We have to take [into consideration] what scientific publications we have and products and patents that have transformed health care. There are only a few, for a country of our size. In large part, it has to do with our health research infrastructure and the funding mechanisms.

Another big challenge is the fact that most health research should be taking place in medical schools. However, medical schools in India do not do any research. Barring a few exceptions, medical schools are largely educational and service centres. This is in contrast to Harvard Medical School, for example, which is one of the world's top medical schools, not only for the medical care that the hospitals deliver, but actually because of the outstanding research that is conducted there. So I do think that the lack of adequate investment in medical schools for research is a big barrier.

Our biotechnology sector is very strong. We have 1.4 billion people. We have diseases of all kinds in the country. We have this enormous network of hospitals. India should be at the forefront of medical research, but we're not. And I think this is a very important challenge that can be fixed.

uterus-fibroids-causes-risk-and-treatment

Sat Jul 29 16:17:43 IST 2023

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

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

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

TYPES OF FIBROIDS

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

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

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

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

CAUSE OF FIBROIDS

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

RISK FACTORS

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

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

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

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

TREATMENT

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

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

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

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

CONCLUSION

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

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

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

Sat Jul 29 15:51:14 IST 2023

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

Excerpts from an exclusive interview:

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

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

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

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

Q/ What is antibody library?

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

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

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

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

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

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

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

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

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

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

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

Q/ How cost-effective are these?

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

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

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

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

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

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

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

thyroid-hormones-effect-on-bone-health

Sat Jul 29 15:48:19 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jul 29 15:43:25 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jul 29 15:23:23 IST 2023

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

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

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

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

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

innovations-in-medical-diagnostics-and-treatment

Sat Jul 01 18:21:58 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jul 01 17:49:56 IST 2023

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

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

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

Prescribed tests for women in their early 20s:

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

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

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

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

The cost ranges from Rs500 to Rs1,400.

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

The average cost is between Rs300 and Rs700.

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

Prescribed tests for women in their 50s:

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

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

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

The test costs around Rs200.

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

The test costs between Rs100 and Rs300.

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

Conclusion

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

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

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

Sat Jul 01 17:46:59 IST 2023

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

What are the advancements in bioeconomy in India?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CUT, PASTE, CURE

Genetic code

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

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

Gene editing

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

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

CRISPR gene editing vs base-pair editing

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

computer-vision-syndrome-symptoms-treatment

Sat Jul 01 17:40:35 IST 2023

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

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

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

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

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

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

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

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

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

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

Sat Jul 01 17:28:48 IST 2023

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

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

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

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

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

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

Fri Jun 02 18:52:37 IST 2023

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

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

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

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

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

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

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

Fri Jun 02 18:50:27 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

―With inputs from Sravani Sarkar

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

Fri Jun 02 18:44:37 IST 2023

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

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

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

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

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

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

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

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

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

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

Fri Jun 02 18:34:58 IST 2023

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

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

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

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

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

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

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

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

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

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

Fri Jun 02 18:31:36 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fri Jun 02 18:27:42 IST 2023

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

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

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

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

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

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

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

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

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

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

Q. How do you report malaria cases and deaths?

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

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

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

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

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

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

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

Fri Apr 28 17:34:27 IST 2023

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

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

Wheezing―a high-pitched sound while breathing.

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

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

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

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

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

Severe asthma can be life-threatening

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

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

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

◆ Lack of speech

◆ Chest tightness

◆ Loss of consciousness

◆ Exhaustion and confusion

◆ Extremely low levels of oxygen in the blood

◆ Death

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

Severe asthma can be managed

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

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

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

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

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

Fri Apr 28 17:31:28 IST 2023

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

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

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

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

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

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

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

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

Fri Apr 28 17:28:51 IST 2023

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

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

The experience

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

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

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

The benefits

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

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

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

The stigma

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

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

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

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

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

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

drug-price-hike-in-india-details

Fri Apr 28 17:02:52 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Mar 25 15:43:40 IST 2023

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

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

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

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

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

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

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

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

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

The writer is former dean, AIIMS Rishikesh.