More en Sat May 04 12:39:25 IST 2019 block-development <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Stroke continues to be a leading cause of death and disability in the country. While significant advancement has been made in the treatment of stroke, there is a need for an in-depth study of causative factors to understand its root cause. Fifty per cent of strokes in those below 60 years is caused by an opening in the partition between the two upper chambers of the heart that failed to close fully after birth. This opening is referred to as patent foramen ovale (PFO). There is very little awareness about the treatment options for these patients. Advances in catheter-based therapy have paved a way for treating these patients more effectively and safely as compared to the more potent blood thinners, which were the only option.</p> <p>&nbsp;</p> <p><b>PFO and its cause</b></p> <p>Prior to birth, there is an opening in the heart partition, between the right and left upper chambers. This opening allows blood enriched with oxygen from mother’s placenta to bypass the baby’s lungs that do not function until birth. Once the child is born and the lungs become functional, a tissue flap closes the opening and within a few months is sealed completely. In about 25-30 per cent of babies, the foramen ovale tissue flap does not close completely. When the foramen ovale remains opens, it is called patent foramen ovale. Although PFO is common, in rare cases, it allows a blood clot to pass from the right side of your heart to the left side of your heart bypassing the lung filter, and then travel to the brain where it can block a blood vessel, resulting in a stroke. Therefore, the presence of a PFO is believed to be a factor that could lead to an ischemic stroke in the young.</p> <p>&nbsp;</p> <p><b>How technology is coming to the rescue</b></p> <p>Among the many treatment options available today, there are different kinds of occluders that can be placed in the heart to close the PFO using a minimally invasive catheter procedure. The procedure involves puncturing a vein in the groin and inserting a small catheter to guide the occluder into the heart. This occluder closes the opening in the heart. Once the device is placed across the PFO, the implanting cardiologist carefully studies its position using cardiac imaging tools. Once the cardiologist is satisfied with the position of the occluder, the device is released to remain permanently in the heart and all the catheters are removed to complete the procedure. After the procedure, the patients can return to normal activities in a couple of days.</p> <p>&nbsp;</p> <p>PFO closure with a device has proven to reduce recurrence of strokes significantly in patients with PFO related stroke, especially in the younger population (&lt; 60 years). It can also reduce the risk of bleeding associated with long-term use of blood thinners that have been used conventionally. Most people can take blood thinners for years without a risk. Since blood thinners help prevent blood clots, even tiny cuts or bruises will bleed a lot more when these drugs are consumed daily and therefore will necessitate change in lifestyle, like inability to participate in contact sports or undertake activities that have a potential to cause trauma or injury. The other disadvantage of this group of medicines is their interaction with certain food and with other medicines routinely used for cough, cold and fever. They also require regular blood monitoring. Stroke is becoming a major cause of death in low-income and middle-income countries like India. What we need today is a focus on early diagnosis, public awareness and capacity building at different levels of health care. It is important to live a healthy lifestyle comprising appropriate diet, regular physical activity, avoiding smoking, controlling blood pressure and diabetes, limiting or avoiding alcohol and modifying response to stress.</p> <p>&nbsp;</p> <p><b>The writer is consultant interventional paediatric cardiologist, Madras Medical Mission, Chennai.</b></p> Fri Mar 06 15:55:29 IST 2020 look-carefully <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The estimated number of cancers diagnosed in India in 2018 was 11.5 lakh, of which 8.13 lakh people died. Cancer contributed 8.3 per cent of the total deaths in India in 2016. Breast, cervix, lip/oral cavity, lung and stomach cancers are the top five killers in Indian women. While cancer is scary, most women do not know the common symptoms that will help diagnose it early. Moreover, majority of Indian women live in rural areas, and lack of awareness and negligence often result in ignorance of symptoms until it is late.</p> <p>&nbsp;</p> <p>So it is important to know the warning signs or 'red flags' that are likely to point towards cancer, and see a doctor at the earliest.</p> <p>&nbsp;</p> <p><b>The five important things to look for:</b></p> <p>&nbsp;</p> <p>■ A painless lump in the breast: Every year 1.5 lakh Indian women develop breast cancer, and it kills almost 75,000 a year. In the west, mammography is a normal procedure, which is not done in India. In fact, more than 20 per cent women with breast cancer come to doctors when it has already spread to other organs. A very easy and simple self-breast examination can be done monthly, after your periods. This can bring into notice any abnormal and painless lump. Other signs that could indicate breast cancer include a lump felt in the armpit, blood stained nipple discharge, sudden onset of inverted nipple and orange peel like appearance of breast.</p> <p>&nbsp;</p> <p>Bottomline: any painless lump in the breast needs evaluation to rule out cancer.</p> <p>&nbsp;</p> <p>■ Abnormal vaginal bleeding: Bloody, dark or smelly discharge is usually a sign of infection. But in some cases it is also a warning sign for cervical cancer. Similarly, in older women, after cessation of menses, a new onset of abnormal vaginal bleeding could be a sign of cancer of the uterus.</p> <p>&nbsp;</p> <p>■ Vague and persistent symptoms: Sometimes symptoms can be vague like distension of belly, weight loss, generalised weakness, persistent pain in the pelvic/abdominal area, and recent alteration of bowel habits. Other vague symptoms include losing more than 10 per cent of your weight without much change in diet, persistent indigestion, the urge to urinate all the time and losing fat from your arms and limbs even as the waist expands. Such non-specific, vague symptoms, when persistent, can indicate cancer, especially ovarian cancer.</p> <p>&nbsp;</p> <p>■ Non-healing ulcer in mouth: This is not just because of stress or lack of vitamins. Sometimes a non-healing persistent ulcer on lips/mouth can indicate a cancer. Smoking, liquor consumption and chewing tobacco are the most common risk factors.</p> <p>&nbsp;</p> <p>■ Persistent cough: A cough that persists for more than two weeks needs evaluation. Often, it is not cancer. However, if a cough is associated with blood-tinged sputum, a recent hoarseness of the voice, breathlessness or sharp chest pain that increases with deep breathing and coughing, it could indicate lung cancer. Unfortunately, by the time the patient feels troubled by lung cancer it would have already spread. There is a saying, “The eye sees all, but the mind shows us what we want to see.” So it is important to know what to look for, that could point towards an underlying cancer.</p> <p>&nbsp;</p> <p><b>Kumar is director and head, department of surgical oncology, Fortis Hospital, Shalimar Bagh, Delhi.</b></p> Fri Mar 06 15:52:58 IST 2020 an-unshielded-life <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Last month, Jagannath, a 10-year-old boy in Odisha's Ganjam district, was in the spotlight for his unusual appearance. His skin is covered in thick, grey scales that are patchy, rough and hard. Even the skin around sensitive areas such as the eyes is tight, making it extremely painful for him to keep his eyes open. His skin grows fast, hardens and sheds itself every six weeks, like in the case of reptiles, which is why Jagannath is called a human snake in his village. Jagannath was born with lamellar ichthyosis, a rare genetic skin condition. He must bathe every other hour and keep himself moisturised at all times with oodles of cream or oil in a bid to ease the extremely painful pull of a very dry skin. He is often unable to walk properly, and requires the support of a stick.</p> <p>&nbsp;</p> <p>While Jagannath struggles with the unforgiving nature of the disease on a daily basis, in another continent Jeyza Gary, a model from North Carolina in the United States, flaunts her scaly skin with pride on Instagram. Being comfortable in one's own skin, especially when it looks nothing like the 'normal' one, takes extraordinary courage and self-love. The 21-year-old recently bagged a modelling assignment for a renowned swimwear company. In the post that she shared on Instagram announcing the new assignment, Gary, clad in a yellow bikini with the Californian sun shining brightly on her skin, wrote to her 12,000 followers: “My spicy skin and I went to Cali on a moment's notice and showed out.... Starting the new year off like this!”</p> <p>&nbsp;</p> <p>Lamellar ichthyosis is a genetic skin disorder that affects one in 2,00,000 people. Children are born as collodion babies, which means their bodies are encased in a tight shiny membrane that resembles a plastic wrap. It is the first expression of some form of ichthyosis. It presents itself at birth or within the first year. According to Christine Wassel, community engagement director at the Foundation for Ichthyosis and Related Skin Types (FIRST), 300 babies with moderate to severe ichthyosis are born every year across the world. “The disease is lifelong,”she said. But not all cases come to the fore. “We have severe cases like that of Jagannath's elsewhere in the country, too,” said Dr Prasanna Shirol, cofounder and executive director, Organization for Rare Diseases India (ORDI). “But only certain cases get reported. Some patients of ichthyosis come from very well-to-do families, and they have the wherewithal to get themselves treated and keep their condition away from prying eyes. [As the condition] spreads to the entire body, continuous bandaging is the only solution. It gets very challenging for the patient and the family.”</p> <p>&nbsp;</p> <p>We all shed skin flakes on a daily basis. Only we don't notice it as it is microscopic. But in children with lamellar ichthyosis, the skin shed is higher and in chunks because of the mutation of a particular gene—TGM1 (transglutaminase 1), which is found in cells that form the outermost layer of the skin and is involved in the formation of the cornified cell envelope that surrounds skin cells and helps form a protective barrier between the body and its environment. That is why such children are prone to infections. Also, the skin helps control the body temperature. So, if the skin is not intact, there will be wide fluctuations in temperature. And, since the skin does not produce moisture in children with this condition, they are bathed in water mixed with baking soda to maintain the body's PH levels. “In slightly older children, we use creams that have salicylic acid and urea, which help in softening the skin,”said Dr Shireen Furtado, consultant, medical and cosmetic dermatology, Aster CMI Hospital in Bengaluru, who has seen at least two cases of lamellar ichthyosis in her ten-year career.</p> <p>&nbsp;</p> <p>Typically, mutations are inherited from both father and the mother, but sometimes can occur spontaneously in a foetus, said Dr Ratna Puri, chairman, Institute of Medical Genetics and Genomics, Sir Gangaram Hospital in Delhi. “It is a group of disorders that are inherited in an autosomal recessive [two copies of an abnormal gene must be present for the disease to develop] manner and are congenital—that is the mutations are present at birth, but in some cases symptoms do not become apparent until later in life,” she said. “I have seen a couple of cases in a year and always suggest to parents to go for genetic testing.”</p> Sat Mar 07 11:17:18 IST 2020 prudent-period <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Bhoomika Sheth, 28, started a Facebook page three years ago to advocate the use of the cups. She was introduced to it by a friend in 2016 and purchased one in no time. But, it was only three months later that she “gathered the courage to try it”. After three unsuccessful attempts at insertion, she got the hang of it and has never used a sanitary pad again. “I used to be uncomfortable in sanitary pads anyway and so the cup was a welcome option,” she said. “Of course, the notion of inserting a foreign object into one's vagina was repulsive.” But the benefits are many, she added. “It is not painful and I do not have to worry about the stains sanitary pads could make,” she said. “More than anything else, it just stays there, often making me forget I am on periods. I have no itches or rashes and can travel without changing pads every now and then.”</p> <p>&nbsp;</p> <p>But why move to something that has to be inserted in one's body, when there is a tried-and-tested alternative, asked Radhika Oberoi, 28, from Delhi, who works as a visualiser with a multinational company. Dr Gayatri Deshpande, senior consultant, obstetrics and gyneacology, Nanavati Super Specialty Hospital, Mumbai, said: “Most modern sanitary napkins have a film which is converted into gel particles once the menstrual blood gets absorbed into the napkin. [Also,] to make it look super white, it is actually made up of wood pulp and bleached several times. It is not paper or cloth or cotton at all. Over a period of time, the chemicals used in making these napkins can lead to irritations and infections in the vagina.”</p> <p>&nbsp;</p> <p>The 121 million women who use sanitary pads produce tonnes of waste. But, should environmental concerns be prioritised over a woman's personal comfort? “To protect oneself, one must be in tune with one's surroundings,” said Deshpande. “Also, the menstrual cup is a soft product which does not damage the vagina. It does not have any side effects either. One can insert, remove and sterilise it in boiling water without any fuss and one cup can last for a good five years. It is economically viable at Rs800 for a reputed brand.”</p> <p>&nbsp;</p> <p>The freedom that comes with the cup works in its favour. One could go swimming during periods, and as the blood does not come in contact with the air, there is no bad odour. But, Dr Manjiri Mehta, senior consultant gynaecologist and obstetrician at Hiranandani hospital, Vashi, said one must not get carried away by all the positive conversation about menstrual cups. “The napkin is easier for young girls to use because they are still to get the judgment about their flow. If not emptied on time, the cup can overflow and leak.” She added that the cup is more suitable for women who are sexually active because the vagina is a little dilated and the hymen is gone.</p> Fri Mar 06 14:50:35 IST 2020 plan-tocare <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Many millennials face the real prospect of juggling a career, raising children and taking care of their parents. As their original caregiver passes on the proverbial hat to their children, millennials are confronted with the struggle of prioritising their parents’needs, to give back the same love, care and attention that was once extended to them.</p> <p>&nbsp;</p> <p>The global population is ageing rapidly, and India is no exception. Before we know it, offering the level of care the elderly need will emerge as a huge social challenge and we need to prepare. Many a time our jobs require us to travel or even stay in a different city or country, and the feeling of not being able to take care of them makes us guilty and anxious. This gets further compounded when they suffer from serious medical conditions, which require constant attention and monitoring.</p> <p>&nbsp;</p> <p><b>Caregivers in the family</b></p> <p>Traditionally, every family has one person who becomes the primary caregiver, taking all the key health decisions, attending to the sick or elderly, and coordinating care and support. It could either be one of the spouses in the elderly couple, so long as they are capable and in good health, their children or the children’s spouses. Most often, the caregiver lives full time with the receiver and takes care of their needs based on the condition or ailment. Sometimes, they may require additional support in the form of professional help like a nurse or an attendant.</p> <p>&nbsp;</p> <p>We fail to recognise that it demands the rigours of almost a full-time job and a big responsibility with no material gratification. In many cases, caregivers must sacrifice their personal lives, too. Without a support structure, this is counterproductive and impacts both the caregiver’s and the receiver’s lives. Currently, most caregivers are family members and they lack the technical training and medical qualifications required for proper health management. This can leave the family member mentally overwhelmed and physically exhausted. Thus, elder care and support needs proper planning, preparation and special skills.</p> <p>&nbsp;</p> <p><b>The essential elements of elderly care: planning to care</b></p> <p>It helps to begin by easing things out; sit together as a family and discuss it. Relatives can assign roles, speak about tasks they can take up. The financial responsibilities could be shared among earning members and individual contributions of the time and effort expected from each can be laid out. Allow your elders to have an input, to discuss their comfort and expectations. Do not compromise on going over any area of concern in a sensitive manner. The main caregiver’s health and wellbeing should also be prioritised.</p> <p>&nbsp;</p> <p>Create a senior-friendly environment at home. This is similar to preparing for a baby’s arrival and proofing the house for them:</p> <p>&nbsp;</p> <p>·Plan for possible emergencies, consider how the elders can go about their routine without potential risks such as hurting themselves or compromising their safety. For instance, a fall can result in being indisposed with an injury or a fracture. Reinforcements in the bathroom and toilet such as grips, non-slip floor mats, a bedside railing, provision of a support such as a walker, can help independent mobility. Monitoring and company for an Alzheimer’s patient can avoid unpleasant confrontations if the older person gets confused and steps out of the house when unattended.</p> <p>&nbsp;</p> <p>·Arrange regular health checkups, monitoring and frequent assessment to detect health conditions well in time.</p> <p>&nbsp;</p> <p>·Limited social interactions can be emotionally draining and often overlooked. It is important that family members step in and spend time to give the primary caregiver a break and to keep the spirits of your loved one up as well.</p> <p>&nbsp;</p> <p>·Make use of technology available today like smartphone apps, social media, local group activities, entertainment options so that the elders do not feel isolated and lonely.</p> <p>&nbsp;</p> <p>Speak to others with similar challenges; create a support group with like-minded people and discuss the challenges and solutions. Get the advice of geriatric experts and seek out and learn from others’experiences.</p> <p>&nbsp;</p> <p><b>The right professionals to guide you</b></p> <p>There are service providers that offer home care facilities and have experienced professionals to take care of the elderly, especially those with chronic ailments requiring special attention. They are well-equipped to assist with your elders’ mental and physical needs. Not only do these nurses and caregivers bring effective and professional expertise but they also work with the family to build trust. Many older parents prefer to be in the comfort of their homes and with the help of such trained staff they can manage daily tasks and activities. For elders with advanced health conditions, they even offer the proper medical equipment setup. From intensive care to intermediate and even basic assistance, top-notch care can be welcomed into your home. The presence of qualified and trusted home health care providers can simplify your lifestyle and is the smartest way for children to ensure a level of care best suited for their parents.</p> <p>&nbsp;</p> <p><b>The writer is MD &amp; CEO, Portea Medical.</b></p> Fri Mar 06 14:48:18 IST 2020 doze-daze <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Hypersomnia, also called excessive daytime sleepiness, is known to be rare in children. Early recognition, prompt diagnosis and appropriate treatment are considered vital, as this condition is noted to cause significant issues on the social and academic fronts. The symptoms are often under-recognised by parents, school authorities and health care professionals alike.</p> <p>&nbsp;</p> <p>Children with hypersomnia will often sleep for more than 10 hours at night and may nap for another four to eight hours during the day. It may also be extremely difficult to wake them up. Other symptoms of hypersomnia may include anxiety, irritation, loss of appetite and slow thinking or speech. If these symptoms persist beyond three months, it is ideal to get the child evaluated.</p> <p>&nbsp;</p> <p>There are two types of hypersomnia—primary and secondary. In the primary group, there are no identifiable causes, except excessive fatigue. Secondary hypersomnia may be owing to lack of sleep or because of medical problems like obstructive sleep apnoea (OSA). Some neurological disorders related to the muscles, epilepsy or medications may also contribute to hypersomnia. Lifestyle changes like excessive use of electronic gadgets, faulty sleep pattern and early school timings may also cause hypersomnia.</p> <p>&nbsp;</p> <p>Obstructive sleep apnoea is a serious disorder. The most prominent sign of this disorder is snoring. Apart from that, children with OSA have disturbed sleep at night, frequent awakening, drooling of saliva and excessive daytime sleepiness. Long-term consequences would include failure to thrive, attention deficit disorder, behavioural problems, poor academic performance and cardiopulmonary disease.</p> <p>&nbsp;</p> <p>The most common cause of OSA is adenotonsillar hypertrophy (unusual growth of the adenoid aka pharyngeal tonsil) in children younger than five years. These children may benefit from adenotonsillectomy after appropriate evaluation. Even though many children have no clear symptoms of OSA, it has been found that OSA occurs in children as a result of loss of neuromuscular tone.</p> <p>&nbsp;</p> <p>A team comprising a paediatrician and an ear, nose and throat surgeon usually diagnoses OSA with the help of polysomnography, which is used in studying the sleep cycle in detail. If there is significant evidence of OSA, then a joint decision is taken about the plan of treatment, which includes adenotonsillectomy or CPAP (continuous positive airway pressure).</p> <p>&nbsp;</p> <p>Sleep disordered breathing is a public health concern, given the increasing incidence of obesity and hyperactivity in children. Studies say that these children can be cured more effectively with appropriate recognition and treatment of sleep disordered breathing than with the use of stimulant medication.</p> <p>&nbsp;</p> <p>One of the under-recognised causes of hypersomnia is depression, particularly in adolescents. This needs to be identified early and appropriate intervention should be given as it may result in a significant lack of motivation and behavioural adjustment issues in future. This may also require help from a psychiatrist.</p> <p>&nbsp;</p> <p>Depending on the clinical evaluation, other investigations in children with hypersomnia may include blood profiling like thyroid function tests, sleep-wake diary, overnight pulse oximetry (testing the amount of oxygen in blood), X-ray of the neck to assess the size of the adenoids and tests for possible neuromuscular disorders.</p> <p>&nbsp;</p> <p>Therapeutic interventions for obese children will require appropriate dietary management, exercise and psychological counselling for the child and family.</p> <p>&nbsp;</p> <p>Healthy sleep habits, including no use of cellphones or e-books before bedtime, avoiding caffeinated drinks and alcohol and regular physical exercise are important preventive measures. Rarely, central nervous system stimulants may be required to correct this problem.</p> <p>&nbsp;</p> <p><b>The writer is consultant paediatrician, Gleneagles Global Health City, Chennai.</b></p> Sat Feb 15 18:50:31 IST 2020 a-deformed-system <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Three years ago, Santoshi Kewat, then 28, from Salaunikhurd village, 250km from Raipur, noticed white patches on her arms and legs. Initially, she ignored them as they were painless and numb. But they grew larger and spread all over her body. Soon, she noticed similar lesions—lighter than skin colour and numb to pain, touch and temperature—on her 15-year-old sister Radha's hands and back. The sisters sensed something was wrong, but could not decide whether it merited attention. Within days, the lesions began to show on their six-year-old nephew Nirmal. That did it.</p> <p>&nbsp;</p> <p>They went to Rajni Sahu, the village mitanin (female health volunteer) and a community health worker, who lived about 100m away. Sahu, who had been trained to identify symptomatic diseases, said that all three had kusht rog—leprosy.</p> <p>&nbsp;</p> <p>They were immediately taken to the community health centre and were put on a year-long MDT (multi-drug therapy) to prevent further deformity. The family, “shocked and devastated” decided to keep it quiet. But their woes had only begun.</p> <p>&nbsp;</p> <p>Four days after Santoshi, Radha and Nirmal were taken to the community health centre, Ganesh Devangan, the government appointed non-medical assistant (NMA) at the centre, examined the other members of the family. Eight of them—the parents, Narayan and Mirabai, three sisters of Santoshi and Radha, Sumitra (Nirmal's mother), Madhu and Sahodhra, and their brothers Kashi Ram, Komal and Chhote Lal—were identified with leprosy. The symptoms were skin lesions, formation of nodules on the ears, thickening of the brow ridge and discolouration of skin on their arms, limbs and torso. Sumitra's husband, Santosh, refused to get tested and went to some local jhaadu practitioner, according to Madhu. But, Madhav Deshpande, then state leprosy control programme officer, Chhattisgarh, said that Santosh was infected and that he had supervised medication for him. But NMA Devangan said Santosh had been “off limits”.</p> <p>&nbsp;</p> <p>Two years after they were all put through MDT, with the possible exception of Santosh as per the NMA, leprosy continued to haunt the Kewats. In January 2019, Sahodhra's five-year-old daughter Garima was diagnosed with the disease. Her father Pooran Lal, also afflicted with leprosy, died in February because of illnesses related to alcoholism. And in April, Sahodhra was admitted to the far away government district hospital after developing a high grade reaction after she left her dose incomplete. Garima now lives with the Kewats.</p> <p>&nbsp;</p> <p>“I was shocked to know that she (Garima) too became positive with MB (multibacillary) leprosy,” said Devangan. “The sisters, Radha and Madhu, informed me that they had noticed lesions on her body just as they had on their own. I am assuming that the little girl got the bacteria from her now deceased father Pooran Lal who had taken her with him to Jammu where he worked as a manual labourer.” Garima's diagnosis rattled the officials, right from the community health workers to the state health department, because infection in children is an indicator of active transmission and high prevalence of infection in the community. “It is a clear indicator that the level of transmission is high,” said Deshpande. “We are aware of it and working on it. But given the nature of the disease, it is almost impossible to know of its existence until the first symptoms are seen.”</p> <p>&nbsp;</p> <p>As a precautionary measure, the WHO had approved a 600mg rifampicin tablet in September 2018. It is a potent anti-bacterial drug, to be given to those who are in close contact with recently diagnosed patients, including family members, neighbours, co-workers and, in the case of children, their classmates and teachers. It should not be given to pregnant women and children below the age of two. Although not foolproof, it helps contain transmission. Accordingly, Garima should have been given the prevention dose. “But we missed it,” said Deshpande. “She might have been saved from it otherwise.” Deshpande pops in a rifampicin tablet once in a couple of years, as a precaution. “Who knows when it might strike me unannounced,” he quipped.</p> <p>Garima is currently undergoing treatment. The Kewats are below-poverty-line migrant labourers who also work in brick kilns and grow paddy once a year during the monsoons. Three of the four Kewat daughters studied till class 10. Komal, one of the three male children, has started class 11 at a nearby village. “We had the disease, but now we are cured. We want to lead a normal life,” said Madhu, looking at her siblings and smiling. She is next in line for marriage and wants the “drama around leprosy to end”.</p> <p>&nbsp;</p> <p>An active surveillance drive followed the diagnosis of the Kewats, during which over 23 new and existing cases were detected from the village within a few months. “People from our village began sensing a sort of ostracisation from the neighbouring villages,” said Madhu. “They would not really interact with us anymore. Now after a gap, everything is coming back to normal and we want it to last.” Fortunately for them, none of the Kewats suffer from deformity resulting from undetected long-term leprosy. “We are trying to investigate but it is very difficult to assess the exact reasons why it happened in a single family,” said Sarwat Husain Naqvi, who works with The Leprosy Mission and is also a consultant with the National Leprosy Eradication Programme (NLEP). “There are predisposing factors and determinants which influence the spread of the disease.” Everyone in the family shares the same environment, is exposed to the same levels of sanitation and overcrowding, and their levels of nutrition is also the same as they are all eating the same food and so their immunity level is also alike. Because leprosy is a disease that strikes people with low immunity, the Kewats are more vulnerable because they lack enough nutrition to support higher immunity.</p> <p>&nbsp;</p> <p>From 2016 to 2019, there have been 124 cases of children with leprosy in the district of Bhalodabazaar under which 225 villages, including Salaunikhurd fall. Bhalodabazaar is third in the list of high-endemic districts in Chhattisgarh, after Mahasamund and Rajgarh. The number of cases with grade-2 deformity, too, have been exceedingly high, albeit with a decline from 4.58 per cent in 2016-2017 to 3.29 per cent in 2018-2019. These two factors suggest an active rate of transmission in the area. High prevalence of deformity—clawed hands, anaesthetic toes with ulcers, skin lumps and bumps—also indicate instances of late detection.</p> <p>&nbsp;</p> <p>“We agree that there is late detection to a certain extent but an average of four to six months of late detection is bound to be there in all cases given the nature of the disease. It is a disease which has a high incubation period from six months to 20 years during which a patient might not show any symptoms at all,” said Dr Firat Ram Nirala, block medical officer at Palari, about 100km from Raipur. “And then when they do appear, they begin as anesthetic patches which are painless and numb. Hence, patients do not end up coming for check-ups until they really experience some form of deformity.”</p> <p>&nbsp;</p> <p>This is precisely why the government began active surveillance through the Leprosy Case Detection Campaign under the NLEP in 2016. The designated officials have to visit homes in every district and proactively examine people for symptoms of leprosy. The officials said that surveillance had started post 2016. However, on the ground, the situation is still the same, at least for some.</p> <p>&nbsp;</p> <p>In early 2019, Santosh Khurre, a resident of Salaunikhurd who works in a pencil factory in Jammu, was asked to take a break when he found it difficult to hold things with his fingers. It was only after two fingers developed numbness and stiffness that he realised that he had leprosy and began taking medicines. “Had I been detected earlier, may be I would have been spared of this deformity (numb and clawed fingers) and my fingers would have been normal. I will now look for some other kind of work which I can do with these deformed hands,” said Khurre. He has been advised reconstructive surgery but has not been counselled enough to be able to do it. “I am afraid my hands might become worse than they are,” he said.</p> <p>&nbsp;</p> <p>For most villagers, the nearest option to get themselves checked for the first symptoms of leprosy remains the primary health centre. However, a visit to the nearest centre in Bhatgaon, about 50km from Salaunikhurd, revealed that nobody would attend to patients afflicted by kusht rog. “We don't examine them here. Neither do we have the MDT tablets for them. We send them to the CHC (community health centre),” said the assistant medical officer (AMO) on duty, on the condition of anonymity. For a villager from Salaunikhurd to visit the nearest CHC, which is about 200km in Bhilaigarh block, it would take close to three hours one way. And the state transport buses ply only twice a day. The state, however, remained in denial. “The AMOs cannot deny treatment to a leprosy patient. They are bound by duty,” said Deshpande. Fifteen-year-old Kulbaruk Kunaar was barely able to move his fingers when he was diagnosed with MB leprosy. On June 16, 2019, he underwent a surgery at The Leprosy Mission Hospital, Chandkuri. “It has brought a fifth of the movement back,” he said. "Enough for me to hold light things and eat on my own. But had I known about it earlier, before it struck me, I could have had my normal fingers today.”</p> <p>&nbsp;</p> <p>“There are gaps,” said Devangan. “I am the only one who is looking after these 20 to 30 villages. But I cannot come to the villages every day because I also need to sit in the block for patients who visit me. But when there are campaigns such as the focused leprosy campaign and LCDC, I along with mitanins and rural health officers visit the villagers from time to time to detect cases and help.”</p> <p>&nbsp;</p> <p>From 2016 to 2019, 801 new leprosy cases came to light within the Bhailaigarh block alone in the district of Bhalodabazaar. The current prevalence rate—number of cases per 10,000 people—is 4.91, while in the entire state it is 1.99, which is still way above the national prevalence rate of 0.6. “The numbers are significantly high but that does not mean that leprosy is back,” said Deshpande. “It had never been eliminated in the first place, contrary to what the government maintained way back in 2005.”</p> <p>&nbsp;</p> <p>Said Naqvi: “What they did was put the population of more than 1 billion in the denominator and the number of cases of leprosy in the numerator and the resulting rate will be less than the definition of the high-endemic country.” The so-called elimination of leprosy sent a wrong message among the workers, he said. “The whole system was disowned but the disease did not end,” said Naqvi. “So, post 2005 funding stopped and the staff, especially the NMAs who were efficient in recognising and treating leprosy, became a dying cadre. And the programme itself was combined with the other programmes.” Now, there are AMOs at the PHC who are supposed to look after leprosy patients, but they say that it still is the job of the NMAs, said Naqvi.</p> <p>&nbsp;</p> <p>Kumari, Radha's friend and a leprosy patient who is now cured, complained about the dapzone tablets she had been taking which she said made her feel fatigued all day. “It is a big pain to take those tablets,” she said. “I know of so many in our village who have given up the treatment because they think that the medicine will make them dark and weak.” Devangan, who knows and is friendly with almost all the villagers, said that some of them do not take his advice seriously. “There's only so much I can do,” he said.</p> <p>&nbsp;</p> <p>In an attempt to locate the index or source cases of transmission in the village, the experts pinned it down to a couple of residents. “First we thought it was Nonibai the septuagenarian,” said Devangan. “But just when we thought it was her, we found another one, older than her—the octogenarian man who does not even have fingers. He had gotten it about three decades back, but wrongly claims that he had medicine and was treated. We have put him on medicines again.” It was not easy to identify Nonibai as the other index case, said Devangan. “She does not have classical leprosy features nor any form of deformity and so it is very easy for her to transmit the infection to numerous others within a short time,” he said. “She looks young with a cherry blossom face colour.” These kind of patients have to be brought to the centre and a proper pathological investigation has to be done. “It is when we miss out on detecting patients like Nonibai that the transmission happens quick and the numbers increase,” said Devangan. “They are the time bombs in leprosy. And they will not be captured by the campaign.”</p> <p>&nbsp;</p> <p>One of the villagers said that Devangan was the only person who visited them regularly—every four to five months. The NMA sits inside a dingy office which is filled with files—data on leprosy in the area under his charge. But his time serving the patients is coming to an end. The designation of NMA will soon be discontinued. He has already got a new set of visiting cards printed. They have his name as the founder of a business, along with his family members. “What to do? I also need to think about myself and my family,” said Devangan. “I cannot keep doing field visits often because it is too far and there is anyway no motivation. The officers are in their own offices and nobody wants to actually come down and visit the patients as often as they should.”</p> Sat Feb 15 19:04:33 IST 2020 the-ghost-behind-grey <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Marie Antoinette, the last queen of France, is best remembered for her reckless extravagance and her tragic death. French revolutionaries executed her with a guillotine in 1793 for treason. Popular belief is that her hair turned grey the night before her death.</p> <p>&nbsp;</p> <p>There are other stories and anecdotes like this which suggest that stressful experiences are correlated with the phenomenon of hair greying. Now, for the first time, Harvard University scientists have found the real mechanism behind it.</p> <p>&nbsp;</p> <p>Published in the journal Nature, the study was initiated with the aim of analysing the effect of stress on various tissues. Hair and skin are the tissues that are visible from outside. So, the researchers started with effects of stress on hair colour.</p> <p>&nbsp;</p> <p>Their initial hypothesis was that stress initiates an immune attack on pigment-producing cells in the hair follicles. However, when they tested it on mouse, they found those lacking immune cells (nude mouse) also exhibited hair greying. Then, their attention turned to a hormone called cortisol. It is responsible for regulating a wide range of processes through the body, including metabolism and the immune response. In response to stress, extra cortisol is released to help the body to respond appropriately. Surprisingly, when the researchers removed the adrenal gland from the mice—to prevent production of cortisol-like hormone aldosterone—and triggered stress, their hair still turned grey.</p> <p>&nbsp;</p> <p>Finally, the researchers tested the sympathetic nerves that branch out to each hair follicle. The sympathetic nerve system is responsible for the body’s fight-or-flight response. They found that in a stressful condition, the sympathetic nerves release a chemical called norepinephrine, which is taken up by certain stem cells in the hair follicle. Stem cells act as a reservoir for pigment-producing cells. During hair regeneration, some of these stem cells are converted into pigment-producing cells to give colour to new hair strands.</p> <p>&nbsp;</p> <p>When these stem cells take norepinephrine, they are activated excessively and all of them get converted into pigment-producing cells. This would prematurely deplete the reservoir for pigment-producing cells. Once all of them are consumed, pigment regeneration would stop, resulting in permanent damage. The fight-or-flight response has been traditionally viewed as beneficial. But now it is proved that it has its own detrimental effects, too.</p> <p>&nbsp;</p> <p>The study established how neurons interact at the cellular and molecular level to link stress with hair greying. The findings are expected to put light on the broader effects of stress on various body parts. The scientists will initiate new studies that seek to modify or block the damaging effects of stress.</p> Mon Feb 10 14:39:50 IST 2020 leave-no-stone-unturned <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>I often meet people with symptoms which have been mistaken for gastric pain—mostly pain or discomfort in the upper abdomen—either around the midline or to the right. Many patients come to me for a second opinion, after a trial of medication for gastritis with no improvement, and may have even undergone examination which did not reveal any significant gastric problem. A number of them were suffering from gallstone disease.</p> <p>&nbsp;</p> <p>Narein Mathur, 36, a Mumbai-based investment banker, would experience splitting pain in the abdomen. The busy professional blamed long working hours, inadequate workout sessions, and fast food, and almost accepted indigestion as the cause of the constant stomach-ache. He googled few remedies and experimented with certain analgesics. But the pain did not subside and started affecting his personal and professional life. His wife arranged for a consultation with me. Narein was diagnosed with gallstones.</p> <p>&nbsp;</p> <p>In cases where the cholesterol-rich stones are only in the gall bladder, surgical removal of the entire gallbladder is possible to avoid gastrointestinal diseases, and a possible organ failure. However, this was a complicated condition as the stones were also stuck in the bile duct, which allows the bile juice to pass from the liver to the gallbladder to help digest food. The blockage in the bile duct made it impossible to break them with the help of conventional procedures such as external sound waves. Thus a minimally invasive procedure, to break the stones stuck in the passage and resume the normal functioning of the bile duct, had to be performed.</p> <p>&nbsp;</p> <p>With advancements in biliary stone management, cholangioscopy, a minimally invasive procedure, allows doctors to remove gallstones, making complex surgeries possible.</p> <p>&nbsp;</p> <p>When gallstones form in the gallbladder and pass into the common bile duct, via the cystic duct, it can cause obstruction in the flow of bile juice. Such a blockage in the duct leads to severe abdominal pain, high fever, and sometimes even organ failure. A patient must not ignore early signs of abdominal pain and consult a specialist at the earliest. Any delay in medical intervention can worsen a patient’s condition leading to gastrointestinal diseases. The good news is caregivers today have access to sophisticated technologies such as slimmer endoscopes, laser therapies and smarter catheters to carry out effective treatment of gallstones.</p> <p>&nbsp;</p> <p>The advances in the field of biliary stone management is allowing caregivers to close the gaps left open by the traditional procedures. Cholangioscopy works on a 3D platform and does not depend on X-Ray guidance, thereby minimising radiation exposure to patients. From incisions in the abdomen and longer hospital stays to minimally invasive procedures and reduced bed rest, cholangioscopy has enhanced clinical efficacy and safety.</p> Fri Jan 24 16:13:30 IST 2020 care-for-health-care-workers <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Innovations in drug formulations have altered the course of treatment for several life-threatening diseases. But with it also comes the threat of consequences of long-term exposure of health care workers while compounding, administering and handling the waste created out of new drugs. The National Institute for Occupational Safety and Health (NIOSH) estimated 5.5 million health care workers face the risk of exposure to hazardous drugs and chemicals. Chronic exposure to antineoplastic drugs (ADs) has been found to result in reproductive, liver, renal, lung and cardiac toxicity. Bone marrow suppression, mucosal ulcers and cancer have also been noticed.</p> <p>&nbsp;</p> <p>Though several anecdotal reports of antibiotic resistance in health care workers have been noticed, not much is documented or scientifically studied. The consequences of exposure to drugs can be prevented to a large extent by safe handling of drugs and limiting exposure as much as possible. It is imperative to explore the need and availability of technology and products along with the evidence-based guidelines for safe administration and handling of drugs and chemicals.</p> <p>&nbsp;</p> <p>Today, we have the technology to not only cure a patient but also to protect our valuable health care workers from harmful risks of exposure to drugs. The development of specific guidelines related to drug exposure by several health care societies has helped workers in the west. In the Indian health care setting, too, there is increased awareness and adherence to use of personal protective equipment and biosafety cabinets for the use of ADs. The advent of closed system drug transfer device (CSTD) is an addition in this regard. The design of CSTD works on the principle of a closed circuit, mechanically prohibiting the transfer of environmental contaminants into a system and the escape of hazardous drug or vapour concentrations outside the system. By using the CSTD, health care workers can prevent the risk of exposure from leakages and accidental discharges during and after administration.</p> <p>&nbsp;</p> <p>According to the guidelines of NIOSH, the dialogue on minimising occupational hazard for nurses has been doing the rounds since 2004. However, nurses and doctors are still prone to drug exposure despite improvements in safety policy. In a study carried out to map the presence of genetic toxicity in the nurses administering anti-cancer drugs, the nurses presented significant DNA damage. More studies are required to understand the effects of exposure to antibiotics and many other potent drugs on the exposed health professionals. Also, we need to weigh the risks and benefits of each technology and adopt them aptly rather than refusing to use them in the name of cost.</p> <p>&nbsp;</p> <p>Let us, therefore, educate health providers on the need to adhere to safe handling practices, and urge organisations to adopt better technology and products to safeguard the health care task force. Every health care professional must pledge to safeguard their patients and themselves by updating their knowledge and following best practices.</p> <p>&nbsp;</p> <p><b>The writer is nursing director at AIMS, Kochi.</b></p> <p>&nbsp;</p> <p><b>HEALTH CARE WORKERS ARE PRONE TO</b></p> <p>● Chronic exposure to antineoplastic drugs (anti-cancer drugs)</p> <p>● Genetic toxicity due to anti-cancer drugs· Exposure to blood-borne pathogens and infectious diseases</p> <p>● Needle-stick and other sharp objects-related injuries</p> <p>● Exposure to contaminated needles</p> Fri Jan 24 16:09:04 IST 2020 mega-fight-at-nano-level <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Antibiotic drugs were one of the greatest discoveries of the 20th century. But today antibiotic resistance is one of the deadliest problems to global health and security. Antibiotic resistance occurs when bacteria change their response to reduce the effectiveness of anti-bacterial drugs. The bacteria that are resistant to antibiotics may infect humans and animals. The infections they cause are harder to treat compared with those caused by non-resistant bacteria.</p> <p>&nbsp;</p> <p>The world is heading towards a post-antibiotic phase, where common bacterial infections could once again result in large number of deaths. The antibiotics that were used to treat infections like pneumonia, tuberculosis, gonorrhea and salmonellosis are becoming less efficient. And, we reached this situation due to the misuse and overuse of these life-saving drugs.</p> <p>&nbsp;</p> <p>Research to find better bacteria-fighting technologies are on. A groundbreaking discovery in this segment came recently, when a team of researchers announced that precision-engineered and nano-sized particles of magneto-responsive, Gallium-based liquid metal can be used to shred bacteria and bacterial biofilm—the protective “house” where bacteria live and multiply.</p> <p>&nbsp;</p> <p>Published in ACS Nano, the research was led by scientists at the Royal Melbourne University of Technology. This is the only team in the world investigating the anti-bacterial powers of magnetic liquid metal nanoparticles. The liquid metal droplets have the ability to change shape and develop sharp edges when exposed to a low-intensity magnetic field.</p> <p>&nbsp;</p> <p>The team found that when placed in contact with a bacterial biofilm, the movement of metal particles under the influence of magnetic field, coupled with the presence of nano-sharp edges, results in the physical rupturing of bacteria cells and the biofilm matrix. The effectiveness of the method was tested in two types (gram-positive and gram-negative) of bacterial biofilms.</p> <p>&nbsp;</p> <p>The laboratory tests showed that 90 minutes exposure to the liquid metal nanoparticles resulted in the destruction of 99 per cent of bacteria. But the droplets did not affect the human cells. Medical experts say that this technology has versatility: it could be used as spray coating to implants, to make it anti-bacterial; there is a possibility that it would also be developed as an injectable treatment that could be used at the site of infection.</p> <p>&nbsp;</p> <p>The pre-clinical animal trials of the technology are in progress. The human trials would happen in the coming years. The team is exploring the scope of using this technology to treat fungal infections and tumours, too.</p> Fri Jan 24 15:28:24 IST 2020 labour-pain <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Renu Raidas was admitted to Umaria district hospital in Madhya Pradesh three days before her child was born. The hospital staff was ill-mannered, she says, and gave her only sleeping pills when she was in pain. Renu wanted a normal delivery, but was advised a c-section instead. She claims that during childbirth, two nurses pushed her stomach vigorously from both sides and when she shouted at them, they refused to give any further care. Her father had to bribe them to resume work, but the child was born stiff. The family had spent Rs5,000 at this hospital and later Rs35,000 at a private hospital in Katni, where she was admitted for three days. But her child was not fully cured, and Renu blames the nurses at the district hospital for the deformity. The family had to borrow Rs40,000 from a moneylender at an interest rate of 5 per cent per month.</p> <p>&nbsp;</p> <p>Renu is among several women from poor, rural families who, a recent survey shows, had to face health issues and were forced into a debt trap during or soon after pregnancy. The Jaccha-Baccha Survey was conducted by prominent economists and social scientists Jean Dreze, Reetika Khera and Anmol Somanchi, with the help of student volunteers in Chhattisgarh, Himachal Pradesh, Jharkhand, Madhya Pradesh, Odisha and Uttar Pradesh. Undertaken in June 2019 and released recently, it showed some shocking results.</p> <p>&nbsp;</p> <p>The survey, which included 342 pregnant women and 364 nursing mothers (baby born within six months before the survey), noted that only about 23 per cent of the eligible nursing mothers received some benefits under the Pradhan Mantri Matru Vandana Yojana, a maternity welfare scheme. The PMMVY covers all women for one childbirth and Rs5,000 is paid through direct benefit transfer in three instalments. Beneficiaries get Rs1,000 on conceiving, Rs2,000 after six months of pregnancy and another Rs2,000 after childbirth and first immunisation of the newborn.</p> <p>&nbsp;</p> <p>However, most of the above-mentioned 23 per cent got only one instalment, while 30 per cent had to borrow or sell assets to meet delivery expenses. Among pregnant women, only 15 per cent got the first instalment.</p> <p>&nbsp;</p> <p>Under the National Food Security Act, 2013, all pregnant women are entitled to maternity benefits of Rs6,000, unless they already receive benefits as formal-sector employees. This was reduced to Rs5,000 during implementation of PMMVY in year 2017. Even these meagre benefits are elusive.</p> <p>&nbsp;</p> <p>The survey also found that, against the expected weight gain of 13 to 18 kg for women with low body mass index, the surveyed women gained an average of just 7kg; the average was 4kg in Uttar Pradesh.</p> <p>&nbsp;</p> <p>Even these figures are likely to be overestimates, as they exclude women who did not know their weight gain. Some women were so light to start with that they weighed less than 40kg at the end of their pregnancy.</p> <p>&nbsp;</p> <p>Few women got adequate rest or nutritious food, many continued to work throughout pregnancy and several faced health complications.</p> <p>&nbsp;</p> <p>“Whenever some report like the Global Hunger Index or the like comes out... the discussion remains centred on schemes like the public distribution system (PDS) and others,” Reetika Khera, social scientist and associate professor at Indian Institute of Management, Ahmedabad, tells THE WEEK. “The real need is to talk about the fact that one of the key reasons for poor improvement in child nutrition and health is [poor] maternal health. One perspective is to look at women's rights. She does the hard work of child bearing and caring and therefore she is entitled to maternity benefits. The second is about child nutrition. If the mother has some money at her disposal, she can use it to buy extra stuff needed for her child and herself post-delivery, or use it for health-related intervention. She can also have adequate rest and exclusively breastfeed the child to ensure its health.”</p> <p>&nbsp;</p> <p>With this in mind, Khera and the others decided to conduct the survey to find out the status of PMMVY on ground and the health conditions of pregnant and nursing women. “The results are for you to see,” she says. “Awareness of the scheme is low, coverage is low mainly because it is limited to one child, the application process is tedious with the mothers expected to make three different applications to get Rs5,000 in three instalments. It is like a hurdle race, with the system hellbent on throwing as many women as possible out of the scheme's ambit.”</p> <p>&nbsp;</p> <p>Khera also says that even the women in the unorganised sector should receive maternity benefits on par with women in the organised sector (six months of paid leave), which means that they should get minimum wages for six months. But the amount under PMMVY was arbitrarily fixed at Rs6,000 and then reduced to Rs5,000 (another Rs1,000 is given under Janani Suraksha Yojana in case of institutional delivery).</p> <p>&nbsp;</p> <p>Activist Sachin Jain, who mainly works in Madhya Pradesh, stresses on the need to expand the scheme to include at least a second childbirth. “In Madhya Pradesh, the women registered as workers with the labour department get maternity benefits for two children,” he says. “There is a need to probably merge the PMMVY with such schemes to expand its ambit, as only then the women in the unorganised sector would properly benefit.”</p> <p>&nbsp;</p> <p>While Himachal Pradesh, Odisha and Chhattisgarh did relatively well in the survey, Uttar Pradesh, Madhya Pradesh and Jharkhand were found lagging. For example, only 46 per cent of eligible women in Uttar Pradesh applied for PMMVY, while 51 per cent had to borrow or sell assets to meet delivery expenses. As high as 64 per cent faced problems during pregnancy because of lack of money. In Himachal Pradesh, on the other hand, 90 per cent women applied, only 13 per cent had to borrow or sell assets for childbirth and only 12 per cent faced problems due to lack of money.</p> <p>&nbsp;</p> <p>Nisha Singh, additional chief secretary of the women and child development department of Himachal Pradesh, says that proper capacity building and adequate respect to the field workers, proper convergence of schemes, strict accountability and accessibility of the officials, and accessibility of the public representatives were some of the important points that helped. “We also worked a lot on the information, education and communication front to raise awareness so that the people themselves seek the benefits,” she says.</p> <p>&nbsp;</p> <p>Devesh Chaturvedi, principal secretary of the medical health and family welfare department of Uttar Pradesh, accepts that there are a lot of challenges, but says things were improving and maternal mortality rate had shown a steep decline in the state following implementation of institutional delivery scheme, the Janani Suraksha scheme and the setting up of sick newborn care units.</p> <p>&nbsp;</p> <p>“We were so low that bringing the figures up to the national average still remains a big task,” says Chaturvedi. “But the trends are positive. The big challenges we face are unavailability of doctors and, therefore, focus is on opening more medical colleges. The second issue is about high anaemia rate among women and we have that in focus.”</p> <p>&nbsp;</p> <p>As for poor implementation of PMMVY, he said there was no problem in rural areas because of high institutional delivery and because ASHA workers, who get incentives, are themselves interested in getting women registered. But in urban areas, women go to private facilities and there is scarcity of ASHA and ANM (auxiliary nurse midwife) workers. “We are trying to fix this,” he says.</p> <p>&nbsp;</p> <p>According to the survey, 21 per cent of nursing women said that no one was available to help with household work during pregnancy. Almost two thirds (63 per cent) said they had been working right until the day of delivery.</p> <p>&nbsp;</p> <p>The survey also found that many women got some basic services (like tetanus injections and iron tablets) at local anganwadi centres, but little beyond that. When there were complications during delivery, the women were often sent to private hospitals. A significant minority also reported rude or brutal treatment in labour rooms.</p> <p>&nbsp;</p> <p>Institutional deliveries are supposed to be available free of cost to all women in public health centres. But the survey found that nursing women had spent close to Rs6,500, on average, on their last delivery. This was more than a month’s wages for a casual labourer in the surveyed areas.</p> Fri Jan 24 15:26:14 IST 2020 the-other-people <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>In the years before Bernie Madoff was jailed for operating the largest Ponzi scheme in world history, numerous individuals had suspicions about him. Renaissance Technologies, a Long Island-based hedge fund that found itself with a stake in one of his funds, thought something was amiss. It concluded after an investigation that “none of it seems to add up”, but rather than selling its stake, just halved it, an executive later telling investigators, “I never, as the manager, entertained the thought that it was truly fraudulent.”</p> <p>&nbsp;</p> <p>Peter Lamore, an investigator at the Securities and Exchange Commission, tackled Madoff in person about why, in defiance of all logic, his returns did not go up and down as stock markets went up and down, and was told he had an infallible “gut feel” for when to get out just before a downturn. Lamore later recalled, “I thought his gut feel was, you know, strange, suspicious.” He took his concerns to his boss, who also had doubts but did not find that Madoff’s claim was “necessarily… ridiculous”.</p> <p>&nbsp;</p> <p>Why were so many evidently smart people incapable of accepting the truth? In his book, Talking to Strangers: What We Should Know About the People We Don’t Know, Malcolm Gladwell, America’s most famous intellectual—whose postulations have changed the way we think and whose observations have altered behaviour—presents a hypothesis: human beings have a default tendency to believe other human beings.</p> <p>&nbsp;</p> <p>It goes against what seems to be happening in politics and social networking, but Gladwell uses research from social scientists to illustrate that our natural operating assumption is that people are honest. It is why, he argues, a spy went undetected at the highest levels of the Pentagon for years, why Chamberlain believed Hitler when the German chancellor insisted he was not going to invade Poland, and why we tend to believe cheating spouses when they deny they are having an affair.</p> <p>It is fascinating. Although, the various lessons of the book (“The harder we work at getting strangers to reveal themselves, the more elusive they become” or “The right way to talk to strangers is with caution and humility”), which like its predecessors (The Tipping Point, Blink, Outliers, What the Dog Saw and David and Goliath) is packed with dazzling facts and cultural insights, also makes for an incredibly self-conscious meeting at the Covent Garden Hotel in London.</p> <p>&nbsp;</p> <p>“You know, if I gave you the choice between interviewing someone and no one else, and being able to interview everyone around someone and not them, which would you choose?” asks the 55-year-old author. “I would always choose interviewing everyone around someone and not them. Biographers who are writing about a dead subject can be far more insightful, I think, than biographers who are writing about a live subject. Chamberlain would have been better off never meeting Hitler at all. He should have stayed home and read Mein Kampf. I was actually stunned by the fact that on the Allied side, the only head of state who had met Hitler was the Canadian prime minister, who, by the way, fell in love with him.”</p> <p>&nbsp;</p> <p>For what it is worth, Gladwell is very much like the man people have suggested. I have been told he is introverted, and he really is. People have also suggested he is pathologically relaxed, and he is, laughing away the Malcolm Gladwell Book Generator that some wag has launched online to mock his work, and embracing criticism.</p> <p>&nbsp;</p> <p>He credits his mother, Joyce Gladwell, a Jamaican psychotherapist, for shaping him as a writer, but his late father, Graham Gladwell, a mathematics professor from Kent, seems to have had more of an influence over his personality. Graham, who died in 2017, is a strong presence in this recent book, featuring in its dedication, as well as being cited in a chapter about transparency—the idea that facial expressions mean different things to different people in different contexts and in different parts of the world. In this chapter, he narrates the incident of Graham responding to a knife-wielding intruder in his holiday home by simply pointing at the assailant and saying, “Get out NOW.” (Incredibly, the intruder, who had a knife at Joyce Gladwell’s throat, did.)</p> <p>&nbsp;</p> <p>“He responded emotionally but there wasn’t a physiological correlate,” said Gladwell. “There are two reasons. One, that he was a reserved Englishman, so he is just not going to have the same palette of emotions as an Italian. If you knew my father, you would have seen him in other stressful situations, and you would have come to understand that the ‘frightened’ face, for whatever reason, was simply not part of his repertoire. In crisis, he turned deadly calm. And the second thing is—this is a funny thing that I am mildly obsessed with—he had a very, low resting heart rate. People do not really talk about this. Our heart rate is a kind of signature of our emotional arousal. I often ask people, ‘What is your resting heart rate?’ It is a really reliable clue to people who have non-stereotypical emotional responses. Runners are like this as a group. They are not going to raise their voice. They just do not do it.”</p> <p>&nbsp;</p> <p>So is Gladwell always as calm as his father was? As well as the genetic inheritance, Gladwell is a runner, being named among Canada’s fastest teens at 1,500m while at high school, running a 4:54 mile at the age of 51, and at 55 his whippet-thin runner’s physique is the most noticeable thing about him, next to his hair. “Yeah, I am not emotionally volatile,” he said. When was the last time he cried? “Oh, I cry quite frequently: what I do not get is angry. I do not raise my voice. I do not get demonstrative.”</p> <p>&nbsp;</p> <p>The other person Gladwell uses an example of the problem with transparency in the book is Amanda Knox, and her initial, false conviction for the murder of Meredith Kercher. “If you believe that the way a stranger looks and acts is a reliable clue to the way they feel… then you are going to make mistakes,” he writes. “Amanda Knox was one of those mistakes.”</p> <p>&nbsp;</p> <p>And the use of examples from current affairs, to demonstrate the many challenges of understanding strangers, marks the book out from its predecessors. One, is the effect alcohol has on behaviour. He uses the example of Brock Turner, the former Stanford University swimmer who was sentenced to six months in jail in 2016 for sexually assaulting an unconscious woman, to argue that alcohol is not “an agent of disinhibition” but “an agent of myopia” in which “short-term considerations loom large, and more cognitively demanding, longer-term considerations fade away”. Another is about how the shame and horror of sexual abuse can produce denial. He talks about how the victims of retired college football coach Jerry Sandusky, who was eventually convicted of rape and child sexual abuse, “acted as if nothing had ever happened. They did not confide in their friends. They did not write anguished accounts in their journals. They dropped by, years later, to show off their babies to the man who raped them.”</p> <p>&nbsp;</p> <p>A change, Gladwell says, that was prompted by the experience of making podcasts, which include Revisionist History, which offers counter narratives to popular events or ideas. Listen to the episode entitled 'The Prime Minister and the Prof' and you will never view Winston Churchill in the same way again. “A podcast is so immediate,” said Gladwell. “They are emotional, and the form invites you to tackle difficult subjects. It gave me a jolt of courage in writing the book.”</p> <p>&nbsp;</p> <p>The key case study, however, which is used to both preface and conclude the book, and is used to demonstrate most intensely “what happens when a society does not know how to talk to strangers”, is the example of Sandra Bland, the 28-year-old African-American woman who was found hanged in a Texas jail in 2015, three days after being arrested during a traffic stop. “I was deeply affected by that wave of cases that happened in 2014, 2015 and 2016 in America involving police officers and African-Americans, but the Sandra Bland case affected me the most, maybe because we have the tape and so were able to hear the encounter,” he said. “The thing with Sandra Bland is there is nothing sinister going on: she is just driving home from a job interview. She is pulled over for the lamest of reasons; she just wants to smoke a cigarette in her car. And it was the sheer banality of it: it is the middle of the day; no crime has been committed; the cop is not a problem cop.”</p> <p>&nbsp;</p> <p>Is some of the anger his own? He has written before about how when he grew his hair he was suddenly being pulled over all the time. “I was profiled in such a mild way, I am almost feel sheepish about lumping what happened to me with… you know,” he said.</p> <p>&nbsp;</p> <p>Does he feel unsafe, as a person of colour, dealing with the police in America nowadays? “I have several advantages. One is that I am pale brown. I am not black. It is funny. I have younger Jamaican cousins—they are in their twenties and are much darker than I am.... To be male and young and black is a powerful combination.”</p> <p>&nbsp;</p> <p>Does he feel that Donald Trump has made things worse? “Well, the thing that our parents told us when we were growing up turns out to be true. Which is that the tone of behaviour in any society is set at the top. When the guy running the country behaves in a profoundly uncivil manner, it gives licence to other people to behave in the same way.”</p> <p>&nbsp;</p> <p>I could tell you how Gladwell dissects the Sandra Bland case. How he shows that the police officer was of the generation of police officers who has been taught, as a result of popular crime theory, to not default to truth: to pursue doubts in every possible situation even when there aren’t any, and hence escalated tensions. How he demonstrates that the officer wrongly believed in transparency—that people’s demeanour is a reliable guide to their emotions and character—and as a result “mismatched” Bland, thinking she was a criminal when she was actually just upset, having recently tried to commit suicide after the loss of a baby and having had ten previous encounters with police over the course of her adult life, including five traffic stops, which had left her with $8,000 in outstanding fines. But you should read the book. Not only will it change the way you see and approach strangers, the precision with which he analyses this incident is one of the most powerful and damning indictments you will read of race relations in American society.</p> <p>&nbsp;</p> <p>I asked him if he lives by his theories and the rules he has helped publicise. So many now have gone mainstream, from the Law of the Few (which states that a select few individuals make ideas and fads popular through their social networks), to the broken windows theory (which posits that if you concentrate on the small things, such as cleaning up graffiti and repairing broken windows, it will create an environment in which people are less likely to commit serious crimes), to thin-slicing (a psychological process in which people read personalities within moments of seeing people). Meanwhile, Gladwell’s case for “academic redshirting”, the increasingly popular practice of delaying kids’ entrance into kindergarten, has, it has been argued, helped lead to between 4 per cent and 9 per cent of nursery schoolchildren being “redshirted” in America annually.</p> <p>&nbsp;</p> <p>“A lot of what I write about does not apply to me,” came the reply. “I write a lot about law enforcement; I am not in law enforcement and rarely the subject of law enforcement. I write a lot about education; I do not have children.” I mention an interview he conducted with a colleague of mine in 2014 where he said, “I am definitely going to have kids one day.” Will he? “Um, I still hope to, yes.” He has a girlfriend? “I have a girlfriend.” There is an awkward pause before he continues, “I mean, in Outliers I wrote about the relative age effect, but in fact, in school, the opposite happened to me: I was pushed ahead and I was the youngest in my class.”</p> <p>&nbsp;</p> <p>I tell him I was surprised to read that he did not do particularly well at college: Gladwell’s grades were not high enough for graduate school. “Yeah. I had mixed results,” he said. “I took courses because I was interested in the topic, but there are certain things, like philosophy, that I turned out to be disastrous at.” After being rejected by a series of advertising agencies, he accepted a journalism position at The American Spectator and spent more than a decade in business journalism. “Writing about business? I really enjoyed it,” he said. “I find the most open-minded audience you will encounter is not in the university, it is in a group of businesspeople.”</p> <p>&nbsp;</p> <p>The fees must help. I read he charges $45,000 (£37,000) a speech. “I have a practice of not commenting on my rates.” Has money changed his life? “Well, I do not worry about it any more, so if you imagine what your life would be like if you stopped worrying about money, that is what my life is like. I am at the lowest rung where you help the family or you give money to charity. But there is this thing that happens to people when they get financially comfortable. They use it as an excuse to remove money from their thoughts, or they do the opposite: the enhanced amount of money enhances the amount of time they spend thinking about it. I am the former, not the latter.”</p> <p>&nbsp;</p> <p>Does he have any indulgences? “I have more than one car. I am very, very serious about cars. I have a 2018 Volkswagen Golf R, a 2002 BMW M5 and a Porsche Boxster.” I used to write about cars too, and, spookily, two of these cars are exactly what I would buy if I had space for them. Not only is Gladwell incapable of uttering an uninteresting sentence, and is more than probably worth his speaking fee, he also has excellent taste.</p> <p>&nbsp;</p> <p>Before we part, I discover he is attempting to buy an old Mercedes 280 from 1982, and he thinks he might have been scammed. “I found an old one which I kind of liked and I paid money up front to this guy who had one, and this was eight months ago,” he said. “I still do not have the car. I am excessively trusting. I do not spend time worrying about the bona fides of people I deal with, so I [might] have been taken in.... It is a better way to be.”</p> <p>&nbsp;</p> <p>Which brings us back to Bernie Madoff and perhaps the most important lesson from Gladwell’s book. There was, as it happens, one person who did not “default to truth” with the fraudster: an independent fraud investigator called Harry Markopolos, who tried to get the authorities to investigate Madoff on numerous occasions. Gladwell describes him as a man with a tendency to tell “awkward jokes”, who grew up watching his immigrant uncles chase customers who had stolen from their business, an obsessive of “the sort to wipe down his keyboard with disinfectant after he opens his computer”. A man who, when he had an opportunity to meet a prosecutor to discuss Madoff, chose instead to leave information anonymously, turning up at a social event wearing a bulky overcoat and clutching a sheaf of documents wrapped inside two plain brown envelopes because he was so paranoid.</p> <p>&nbsp;</p> <p>“If everyone on Wall Street behaved like Harry Markopolos, there would be no fraud on Wall Street,” concludes Gladwell. “But the air would be so thick with suspicion and paranoia that there would also be no Wall Street.” Or, to put it another way, if being duped is the price we occasionally pay for trusting strangers, it is a price worth paying.</p> <p>&nbsp;</p> <p><b>Talking to Strangers: What We Should Know About the People We Don’t Know</b></p> <p>Author: Malcolm Gladwell</p> <p>Publisher: Allen Lane</p> <p>Price: Rs799</p> <p>Pages: 400</p> Sat Jan 11 17:52:22 IST 2020 connect-disconnect <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>On November 1, 2019, Lena Dunham, American actor, writer and producer whose hit show Girls won her a legion of fans, took to Instagram to announce that she had Ehlers-Danlos syndrome (EDS)—a group of disorders affecting the joints and skin. “I could lie and say it was an early Halloween look…. But the truth is just: this is what life is like when I am struggling most with a chronic illness. An Ehlers-Danlos syndrome flare means that I need support from more than just my friends… so thank you, sweet cane,” she posted in response to a paparazzi photo that captured her walking with a cane. Before Dunham, two more public figures had shared on social media about living with EDS. In October 2019, Australian singer-songwriter Sia Furler, who often wears a dramatic wig to obscure her face and protect her privacy, tweeted, “I am suffering with chronic pain, a neurological disease, Ehlers Danlos and I just wanted to say to those of you suffering from pain, whether physical or emotional, I love you, keep going. Life is f**king hard. Pain is demoralizing, and you're not alone.” In June 2019, The Good Place actor and body positivity campaigner Jameela Jamil posted on Instagram about her experience with EDS. “Every time I cut, I scar,” she wrote.</p> <p>&nbsp;</p> <p>EDS weakens the connective tissues of the body, making the joints loose and the skin thin, stretchy and vulnerable to bruises. Depending on the level of severity, it can also weaken blood vessels and organs. Although there is no cure for it as yet, experts believe that the symptoms can often be treated and managed well.</p> <p>&nbsp;</p> <p>“This is an inherited connective tissue disorder, which is either passed on from generation to generation or caused by the abnormal mutation of a gene,” says Dr Paresh Pai, vascular surgeon, Bhatia Hospital, Mumbai. “Connective tissue is found everywhere in the body, including in the nervous system as it is the one which connects every other tissue and organ of the body.” The most common form of connective tissue, he says, is collagen and any weakness in the collagen results in hypermobile (extremely flexible) joints, which means there is a high tendency of damage to joints. “This can happen in any organ of the body,” says Pai. “Take, for example, the heart. When there is no support of the connective tissue, there is a tendency of the artery to damage and rupture. Likewise the uterus, too, can rupture towards the third trimester as the baby grows and the skin stretches.” To further explain it, he cites the example of his 18-year-old patient. “He was playing volleyball and that was enough to cause the rupture of his brachial artery, which is the major blood vessel of the upper arm,” says Pai. “He was immediately hospitalised for the reparation of the artery. The patient will always be prone to it. It can recur. These patients must be extra careful to keep themselves safe at all times.”</p> <p>&nbsp;</p> <p>According to the National Organization for Rare Disorders, which further classifies the disease into thirteen sub-divisions, symptoms of EDS may become apparent in childhood. However, depending upon the form and severity, the age of diagnosis varies widely. Reported estimates of the incidence of all EDS types range from 1 per 2,500 to 1 per 5,000 births.</p> <p>&nbsp;</p> <p>Mumbai resident Radhika Sharma, a mother of two children aged 10 and 15, has been living with EDS for five years now. Every morning, she must take her daily dose of Pantacid 40 to beat acidity or she feels “dizzy, nauseous and giddy”. In addition, she experiences extreme hair fall, dry eyes and a dry mouth. Her knees give her trouble, hips ache every now and then, and she suffers from vertigo, severe constipation and intestinal issues. “EDS symptoms in my case are more internal than external,” she says. “I do not look like a patient. In fact, until my second delivery, I had no medical issues at all. And then they all came together.” Sharma used to be an active girl in school and college. “I did have loose joints and I did dislocate my right hand a few times while playing, but it did not seem to be a cause for concern at the time,” says the homemaker who got married at 25 and delivered her second child at 31. She suffers from severely low blood pressure (her normal range is 70/95, far lower than the normal level—90/120). Sharma is now on medication (Gabapentin 400) for tackling the incessant twitching on the left side of her face. It works as a muscle relaxer. “My neurologist told me that this is common among those suffering from EDS as our nervous system is weak,” she says.</p> <p>&nbsp;</p> <p>Sharma suffers from EDS Type 3 or Hypermobile EDS, which means that in a yoga class she would stand out for above par flexibility. But it also means that she is prone to joint pains, dislocations and sprains. She doesn't have stretchy skin, but her skin itches very badly when, for instance, she is carrying a plastic bag. Giving up on wheat, dairy and sugar on her doctor's advice has helped her immensely. “My intestinal and bowel issues came down considerably,” says Sharma. “Life is not easy when one has to contend with so many restrictions and be cautious at all times. But since there is no real cure for it, managing it is the only way to go.”</p> <p>&nbsp;</p> <p>While EDS affected Sharma internally, in Jamil’s case she has “such severe eczema all over that my legs are covered in huge patches of pigment loss from scratching. I have a ton of stretch marks.”</p> <p>&nbsp;</p> <p>For Bengaluru-based Shanti Satish, it is a joy to see her 13-year-old daughter Malvika walk the short distance from her school gate to her class in the company of her friends, like any other child her age. There was a time when she needed to be escorted at all times and Satish would always be by her side ensuring that she was safe and comfortable. “She suffered from acute back pain, her essential vitamin levels were really low, and her playtime was reduced considerably given that even a little twist here and there would end up as a fracture. Till date, she has had fourteen fractures,” says Satish. The family got to know about EDS when Malvika was all of four. “We have come a long way now,” says Satish, who quit her flourishing corporate career to take care of her daughter and now runs an NGO advocating schools to be sensitive towards differently abled children. “Malvika is now quite understanding and also knows how to take care of herself. She is a bright and cheerful student and an inspiration to many. Yet, every single day I have this anxiety that something might just happen to her.” Malvika is now working on a book about her experiences with EDS.</p> <p>&nbsp;</p> <p>Dr Chethana Dharmapalaiah, consultant, rheumatology, Aster CMI hospital, Bengaluru, says that the treatment for EDS is essentially supportive in nature. “It is mainly physiotherapy to strengthen their joints and muscles so that the tendons become stronger, and frequent dislocations are prevented. Also, occupational therapists offer braces to support the joints. But these patients show a lot of inner strength and positivity and, in the end, faith helps them to overcome the pain.”</p> <p>&nbsp;</p> <p>As Dunham, who dons her glamour nighty one moment for a visit to the doctor and then an hour later is back in “a meeting look”, puts it, “For years, I resisted doing anything that would make my physical situation easier. But it is so much less weird to actually be able to participate than to stay in bed all day. We still rock our dreams and goals and passions (and fashions) and we live many lives in one day.”</p> Fri Jan 10 15:21:25 IST 2020 the-new-route <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Back in 1882, when German microbiologist Robert Koch discovered the microbial causes of tuberculosis, researchers thought that the disease could be defeated with vaccines and drugs. But in the mid-1980s, a tuberculosis epidemic rampaged across the world, killing millions. Soon it got the tag of a global pandemic. As per the WHO Global Tuberculosis Report 2019, India has the highest number of patients suffering from tuberculosis in the world. Though the Ministry of Health and Family Welfare’s National Strategic Plan (NSP) for tuberculosis elimination is aimed at wiping off the epidemic by 2025, researchers say that five years is a short period to accomplish this. The question of whether it is possible for a vaccine to give complete protection against the TB or prevent its development has perplexed researchers for over 20 years now.</p> <p>&nbsp;</p> <p>Currently, the only licensed vaccine against TB is a live but crippled strain of a pathogen (Mycobacterium bovis) which is similar to the bacterium that causes TB (Mycobacterium tuberculosis). The strain, bacilli Calmette-Guérin (BCG), which is given at birth or early in life, has been around for about 100 years. It is definitely effective when it comes to preventing certain types of TB in children but in the case of adolescents and adults, the pathogen often resists the immune responses elicited by vaccination. Surprisingly, most people who die from TB were administered BCG as a child. But the problem is not with the strain used in the vaccination, rather the way it is administered. According to a recent study by Robert Seder and his team at the National Institute of Allergy and Infectious diseases in Maryland, a near-complete protection from TB infection can be had using the century-old vaccine by changing its route of administration. Usually, the vaccine is intradermal—injected into the skin. But it turns out to be super effective when it is delivered directly to a vein.</p> <p>&nbsp;</p> <p>The studies done on monkeys showed that delivering the vaccine via veins rather than the skin can dramatically increase its potency. Robert had earlier discovered that delivering a malaria vaccine directly into the bloodstream, through a vein, was much more effective that delivery through skin or muscle. This raised the question whether a similar route of delivery of BCG vaccine would work for TB. The study was done on monkeys wherein one group (10 monkeys) was vaccinated with BCG by injecting the vaccine under the skin (the usual route) and the other was administered the vaccine intravenously. Months later, the monkeys were exposed to M. tuberculosis. Only two out of the ten monkeys that received the vaccine into the skin were protected from the infection whereas nine out of ten monkeys that had the vaccine intravenously were protected. Monkeys given the vaccine via veins also showed much higher levels of T-cells in the lungs—a key part of the immune system’s protection against TB. The T-cells which can recognise and kill the bacteria, increased 100-fold in the lungs. The lungs of the monkeys in the second group were free of any form of infection. The success of BCG IV will bring hope to millions across the globe who are battling TB. Although the tests in humans can be around 18 months off, the vision for 2025—elimination of TB—could still be a possibility.</p> Fri Jan 10 14:38:07 IST 2020 spine-not-fine <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Vikas Sharma lives in Pune with wife, Alka. Now happy in their marriage, this was not always the case. Vikas had been suffering from ankylosing spondylitis (AS) for more than 10 years before getting married to Alka. However, Alka was completely unaware of her husband’s chronic back pain, till after they got married. She says Vikas could have hid his condition from her out of fear of rejection.</p> <p>&nbsp;</p> <p>Prevalent among 1 in 100 of the adult population, AS is an irreversible, inflammatory, autoimmune disease, which more commonly affects young men, especially in their teens and between their early twenties and thirties. In AS, an overgrowth in the spine’s bones causes them to fuse together to form a rigid spine. A key symptom of AS is pain in the back early in the mornings, especially 30-45 minutes after waking up. If the pain lasts for 30-45 minutes every morning for 90 days or more despite taking painkillers, one could be suffering from AS. While many people living with AS have a gene called HLA-B27, which can be detected by a blood test, it may not be the absolute cause of the condition, nor does it mean that the person with the gene would definitely be affected by AS.</p> <p>&nbsp;</p> <p>If left undiagnosed or untreated, the condition can severely disrupt mobility and cause damage to posture, which can bend the spine and neck to an extent that it may become impossible for one to lift their head high enough to see forward. This is known as ‘structural damage progression’. In some cases, patients can even become wheelchair-bound.</p> <p>&nbsp;</p> <p>As time passed by, Vikas’s condition became worse and hindered his mobility. “I have seen him holding on to the walls and doors of our house to help him walk up until the time when he almost became wheelchair-bound,” recalls Alka. As a result, Vikas lost his job. When Alka's family came to know about it, they asked her to move out. And, Alka did. But after a few months of living apart, she came back to him and took it upon herself to help Vikas. Today, she accompanies him for all his regular visits to the rheumatologist.</p> <p>&nbsp;</p> <p>Dr Danveer Bhadu, assistant professor, department of rheumatology, AIIMS, New Delhi, says that adopting biologic therapy can significantly slow down structural damage progression and improve functional status in AS patients. “Most patients tend to adopt other line of treatments that don’t show long-term results,” he says. “Fear of adverse drug effects that comes with allopathy and greater belief in unconventional medicine such as homeopathy, ayurveda and unani are still prevalent in India. Relying on alternative medicines may increase the risk of fusion of spinal bones, which could further make the patient wheelchair-bound.”</p> <p>&nbsp;</p> <p>Like Vikas, Madhur is also an AS patient. What started as acute pain in his chest progressed to his lower back. It became so unbearable that he consulted a general practitioner who was unable to diagnose his condition as the result did not show up in scans and X-rays. Madhur continued to suffer, even as his family and colleagues taunted him for being lazy and not being able to carry out day-to-day tasks. The fact that he was overweight meant that he also had to endure bullying by peers.</p> <p>&nbsp;</p> <p>“I reached a stage in my life when it became unbearable to listen to loved ones and peers constantly criticising me for my weight and calling me lazy,” recalls Madhur. “Nobody could really understand the hell I was going through and the constant physical pain that made the most basic tasks extremely challenging. I began to feel extremely low and alone.”</p> <p>&nbsp;</p> <p>Due to the continuing pain and frustration, Madhur had no choice but to leave his job. His family eventually found out about a rheumatologist, and his condition was confirmed as ankylosing spondylitis. He was advised biologics, and within a few months of treatment his condition improved significantly. Today, Madhur is happy in his new job and has strong support from his family members.</p> <p>&nbsp;</p> <p>Timely diagnosis is important in AS to curb further progression of the disease and for better management and treatment. Generally, AS is diagnosed through physical examination, X-Ray, MRI and a series of blood tests. In the initial phase, due to low awareness of this condition, patients tend to consult their family physicians, who may prescribe painkillers, anti-inflammatory drugs and disease modifying drugs to help reduce pain and inflammation—the key symptoms of the disease. While commonly used painkillers may provide relief, this is limited to the short-term. Advanced treatment options such as biologics are recommended by medical experts to slow down structural damage progression.</p> <p>&nbsp;</p> <p>In addition to medical treatment, it is advisable that people living with AS consult with medical experts for regular physiotherapy exercise that is also considered important for management of the condition.</p> Fri Dec 06 16:18:29 IST 2019 giving-wings-to-angels <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Jasmine is the heroine and the singer in the film being shot. She does it with the ease of a professional. If you ask her her age, she would say she is six. But if you ask her father, he would tell you she is 25. People say she is mentally handicapped. But Jasmine prefers to be called an artiste, and she blushes when you call her a star.</p> <p>&nbsp;</p> <p>Jasmine is one of the artistes at the Different Art Centre (DAC) at Magic Planet, a magic theme park in Thiruvananthapuram that attracts huge crowds every day. The park is run by magician Gopinath Muthukad's Magic Academy. "Jasmine was coughing in the morning and we wanted to take her to the doctor. But she refused and insisted on coming to Magic Academy," said Salim E., her father. "She is so happy here, and we are so happy seeing her smile."</p> <p>&nbsp;</p> <p>Jasmine and 99 others are now part of the DAC, launched in November. Differently abled persons from all over Kerala are given special training here, as per their tastes and talents. There are sessions for dance and music, with an arts corner and musical instruments.</p> <p>&nbsp;</p> <p>"All of them love to dance... and seeing them dance on stage without missing a step makes us forget the pressures of training them," said Divya, chief coordinator of DAC.</p> <p>&nbsp;</p> <p>Take the example of Vishnu Amarnath, who suffers from Down syndrome. When he is on stage, you will only see a well-trained Bharatanatyam dancer, impeccable with mudras and adavus. He can do classical dances as well as jive to songs like Ed Sheeran's Shape Of You like a pro. "I have always loved dancing. Here, I get to perform on stage every day and that has boosted my confidence. When I hear people applaud, I feel like a star," said Vishnu after the performance.</p> <p>&nbsp;</p> <p>All the kids may not dance like Vishnu but they are all equally eager to get on stage. It was something they never got an opportunity to do. "I did not know that my girl could dance before coming here," said Bindu, mother of Siby, 22. Tears had welled up in her eyes. "Even if I knew [she could dance], who would have given a stage to kids like ours?" she added.</p> <p>&nbsp;</p> <p>One parent, Mini, said her daughter was more settled and peaceful since coming to DAC. Most parents would agree. Prameela, a native of Thrissur, has come all the way with her son, Yuvaraj, 15. "All the recognition that these kids get here has certainly changed them. The changes are so visible. Now I feel that all the difficulties in shifting to Thiruvananthapuram to put my son in the DAC is worth it," she said.</p> <p>&nbsp;</p> <p>Akhil, who hails from Kasargod, the northern-most district of Kerala, has multiple disabilities, says his father Vijayan. But when he sings on stage, few would realise that. "He has become very confident after coming here. And this gives us hopes about his future," said Vijayan, who relocated to the state capital for his son.</p> <p>&nbsp;</p> <p>But things did not sail as smoothly in the early stages of the organisation. Many of the students were aggressive and uneasy. Most of them had not seen much of the outside world. "I was once asked to leave a wedding as I had taken my autistic daughter along. These kids are [considered] a nuisance for others," said a mother who requested anonymity. After that, she rarely took her daughter to public events. The stories of others are similar. "To make them sociable and listen to us was the biggest task," said Divya. "The initial days were very tough. But now as the days passed, we can see their self-esteem grow every day."</p> <p>&nbsp;</p> <p>As of now, there are 100 children enrolled in the DAC at Magic Academy. They do daily shows for the visitors. Some dance, some sing, some play instruments and some paint.</p> <p>&nbsp;</p> <p>For most visitors, this is a novel experience. "I have never seen a differently abled kid perform. I never knew they were this talented," said Priya Sethunath, a teacher who visited on a school tour. Some were seeing differently abled people for the first time, and it served as an eye-opener for them. That was the motive behind opening the DAC, said Muthukad, one of the most sought-after magicians in south India. "We wanted to mainstream them; to tell the public that they also have a special space amid us," he said.</p> <p>&nbsp;</p> <p>It was Muthukad's experience with 10 differently abled kids that he trained to become magicians that gave him the confidence to start this centre. "When those kids came to me a few years ago, they could not even make eye contact. They just stared at the floor. But once they started learning magic, they changed forever," he said with pride.</p> <p>&nbsp;</p> <p>That first lot of kids—some autistic, some with Down syndrome—are part of the Mpower show at the academy now. "They have completed more than 1,000 stage performances and have not made a single mistake. You should see the confidence in their eyes," he added. Those children are about fly to the Middle East to do programmes there.</p> <p>&nbsp;</p> <p>All parents vouch for the importance of mainstreaming special kids. Abdul Khadar whose son, Arafaz, is in the DAC, shared his tale. "My elder daughter is intellectually disabled as is my son. While she needs help for everything, my son has become more independent because of the exposure he received from places like this. All parents of special kids must bring them out of their shells," he said.</p> <p>&nbsp;</p> <p>Muthukad had got doctors to assess the impact on the kids after training. The results of the evaluation carried out at the Kerala government's Child Development Centre were stunning. "We found out that there were significant changes in their personalities. They had become more confident and independent," said Dr Leena Sumaraj, who was on the team that carried out the study. Some kids, who were even reluctant to step out of their homes, now come to Magic Academy by taking the train on their own. "The changes that we observed in them were a revelation for even researchers like us," she added.</p> <p>&nbsp;</p> <p>Muthukad attributes the success of the programme to the state government and to the Malayala Manorama group. "The support I got from the state government is enormous," said Muthukad, who is also a much sought-after motivational speaker. He said he became interested in the issues of special kids after attending a programme organised by Manorama. "I became a motivational speaker for the first time at ArdraKeralam, a programme organised by Manorama's daily for special kids," he said.</p> <p>&nbsp;</p> <p>When THE WEEK caught up with Muthukad at the sprawling campus of Magic Academy, he was busy arranging a chartered bus and uniforms for the kids. "Most of the kids are from poor backgrounds and they spend a lot on travel. If we arrange a bus, that would be of great help to them," he said. Seeing Muthukad, the kids come running towards us. Some wanted to shake his hand and some even wanted to kiss him.</p> <p>&nbsp;</p> <p>"Many of them have started offering us water and seats when we go to the mess," said Rehanas, a facilitator there. "Some have even started saying sorry when they realise they have made a mistake." All these are huge leaps for them. "The most important thing is to understand them. Once we understand them, they also start understanding us," said Divya.</p> <p>&nbsp;</p> <p>Just then, Jijo, who is differently abled, walked up to us and enquired about Divya's three-year-old daughter, who often accompanies her. They had celebrated her birthday together a few days before. When Divya replied that she was in school, Jijo opened his bag with great difficulty and pulled out a packet of biscuits. "I brought this for her," he said, handing it over. Divya's eyes welled up. As did everybody else's.</p> Sat Dec 07 16:57:19 IST 2019 key-to-longevity <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The Adi Parva of Mahabharat has the story of a father who exchanged his old age with the youth of his son. King Yayati, the father, loses his youth and becomes a decrepit old man because of a curse by sage Sukracharya. But the sage gives Yayati a concession: he could regain his youth if he finds somebody to exchange his old age with. Filled with insatiable thirst for sensual pleasures, Yayati demands his son Puru to offer his youthfulness.</p> <p>&nbsp;</p> <p>The mythical story from the epic exemplifies that combating ageing and mortality has always been a concern of humankind. There is plenty of research going on in this field today, though some ethicists say these would result in a denial of the natural limits of human existence. Recently, a significant milestone in this field was achieved by scientists from the RIKEN Centre for Integrative Medical Science and Keio University of Medicine, Japan. They found that super-centenarians—people over the age of 110—have an excess of a type of immune cells called cytotoxic CD4 T cells. The finding could be a breakthrough in exploring the key to longevity.</p> <p>&nbsp;</p> <p>Super-centenarians are a rare group. In 2015, Japan had more than 61,000 people over 100, but just 146 over the age of 110. Studies have shown that most super-centenarians spend their entire life without any major ailment, which implies their immune system always remained active against all sorts of infections and tumours. However, medical science is yet to explore more about their immunological condition.</p> <p>&nbsp;</p> <p>The Japanese researchers studied circulating immune cells from a group of super-centenarians (41,208 cells) and young controls (19,994 cells), respectively, as part of their study. They found that the number of T cells was approximately the same in both groups and the number of a subset of T cells had an increase in the super-centenarians. T-cells have a unique ability to acquire cytotoxic activity and directly kill cancer cells, cells that are virus-infected or cells that are damaged in other ways.</p> <p>&nbsp;</p> <p>Normally T-cells with markers known as CD8 are the ones to show cytotoxic capabilities. Those with CD4 markers (known as helper cells) generally perform regulation of immune responses, and not cytotoxic functions. However, researchers found that CD4 cells in super-centenarians had acquired a cytotoxic status. Interestingly, the blood of young donors had relatively few cytotoxic CD4 cells. It suggests that increased and cytotoxic nature of CD4 is unique to super-centenarians. To understand how these special cells were produced, the researchers examined the blood cells of two super-centenarians in detail. They found that they had arisen from clonal expansion—a process in which many of the cells were the progeny of a single ancestor cell.</p> <p>&nbsp;</p> <p>The research published in Proceedings of the National Academy of Sciences makes the conclusion that cytotoxic CD4 cells which are relatively uncommon in most individuals could be useful to fight established tumours, and also for immune-surveillance. Seems like the Mahabharat story is getting reversed: the super-centenarians may soon help the younger generations to stay healthy.</p> Fri Dec 06 15:50:56 IST 2019 protein-packed-preschools <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Smiles lit up the faces of young Ramsakhi Saur and her son Sagar, four, when they heard that the local anganwadi might serve eggs. “He loves eggs and, of course, we would like him to have it,” the young tribal mother, living in Pajanpura Majra of Niwari district in Madhya Pradesh, said emphatically. Sagar's smile became wider.</p> <p>&nbsp;</p> <p>“Why should we have any problem with eggs being served at the anganwadi, we relish it,” Ramsakhi's neighbour Hariram Saur said, adding that his daughter Madhu, three, laps it up happily.</p> <p>&nbsp;</p> <p>Some 1.14 lakh people from 17 districts in Madhya Pradesh have already signed a petition for inclusion of eggs in anganwadi menus and for other steps to ensure food security under an initiative of the state unit of the Right to Food Campaign, an informal network of organisations and individuals.</p> <p>&nbsp;</p> <p>“The petitions will now be submitted to the office of the chief minister (Kamal Nath),” Sachin Jain of the Right to Food Campaign told THE WEEK.</p> <p>&nbsp;</p> <p>The support comes at the right time for the Congress government, which the opposition BJP has criticised for its plan to distribute eggs to children in anganwadis in 89 tribal-dominated blocks of the state from the next financial year (April 2020). The state government had mooted the idea a few weeks ago, and the BJP accused the government of trying to “tarnish Indian culture by forcing children to consume non-vegetarian food” and warned that it would strongly oppose the move.</p> <p>&nbsp;</p> <p>Former chief minister Shivraj Singh Chouhan had nixed a similar proposal in 2015, saying that eggs would never be distributed through anganwadis as long as he was the chief minister. BJP national general secretary Kailash Vijayvargiya said that the BJP would strongly oppose the move. Leader of opposition Gopal Bhargava went a step further, claiming that feeding eggs to children might turn them into cannibals as adults.</p> <p>&nbsp;</p> <p>A few months ago, similar opposition had arisen in Chhattisgarh, but the Congress government there went ahead with the move. About a dozen states have eggs in their nutrition and food programmes and some of these states, such as Jharkhand, Karnataka and Bihar, have BJP or BJP-supported governments.</p> <p>&nbsp;</p> <p>“Why should we bother about what the BJP is saying? If something is healthy for our children, if something rids them of malnutrition, we give it to them,” Madhya Pradesh Women and Child Development Minister Imarti Devi told THE WEEK. “And we are not forcing anyone. We will give eggs only to children who eat them; for others, we will have other options. Like when we cook non-vegetarian food at our home and if someone does not eat it, don't we cook mattar-paneer for them? We want our children to be healthy and grow to be healthy adults.”</p> <p>&nbsp;</p> <p>Anupam Rajan, principal secretary of the department of women and child development, told THE WEEK that the matter was discussed before Kamal Nath during a recent review meeting and it was agreed that steps should be taken to introduce eggs in the 89 tribal blocks. “The efficacy of eggs in combating malnutrition is well known and the malnutrition rate in our tribal areas is higher than average,” said Rajan. “Tribal families also consume eggs and it makes sense to offer the food as an option. The proposal has been given administrative sanction and is being sent to the finance department. It would then come up before the cabinet for formal approval. It should cost us about Rs113 crore annually to give eggs thrice a week in the 89 blocks.”</p> <p>&nbsp;</p> <p>Rajan said that including eggs in anganwadi menus would generate livelihood options for local people who could rear poultry and supply the eggs locally. He also said that eggs should be included in midday meals at schools, especially for adolescent girls.</p> <p>&nbsp;</p> <p>Notably, the government move has the strong backing not only of nutritionists, but also the people, as shown by the signature campaign. “The tribals and many other rural people are happy at the prospect of getting eggs through anganwadis as they consider it a delicacy,” said Mastram Ghosh, an activist in Niwari district.</p> <p>&nbsp;</p> <p>Dr Veena Shatrugna, former deputy director of the National Institute of Nutrition, Hyderabad, said that those who oppose giving eggs to marginalised children did not have any right to occupy chairs of authority. “Eggs are the best food for children,” she said. “[It is] culturally appropriate, children love it, [it is] easy to be dispensed, and can be counted. Eggs are also regular food among 85 per cent of the population, are the best protein source, and have all nutrients except vitamin C (which you get through most fruits). We are insulting our children by keeping them starved. There is nothing negative I can say about eggs. Only thing is—don't give them to children below six months. But do our dominant caste people care about the poor? Their aggressive behaviour has even made scientists buckle in some instances, like in Karnataka. But the point is that eggs are absolutely necessary for children and there are no equivalent vegetarian options.”</p> <p>&nbsp;</p> <p>According to the National Family Health Survey (NHFS-4), 42 per cent of the children in Madhya Pradesh are stunted and 42.8 per cent are underweight. The malnutrition rate is particularly higher among scheduled tribe (48.2 per cent stunted and 51.5 per cent underweight) and scheduled caste (47.6 per cent and 45.9 per cent, respectively) children, said Sachin Jain. He had written to Kamal Nath this September, asking for inclusion of eggs in anganwadis as well as in midday meals in schools.</p> <p>&nbsp;</p> <p>In his letter, Jain mentions that, according to the National Egg Co-ordination Committee, eggs are one of nature's most perfectly balanced food items and are considered a complete protein because they contain all nine essential amino acids, or the building blocks of protein.</p> <p>&nbsp;</p> <p>Suggested substitutes such as almonds are quite expensive, and while one egg gives around 6gm of protein, a child would have to eat 25 almonds to get the similar amount, Jain's letter to Kamal Nath says.</p> <p>&nbsp;</p> <p>While other suggested measures such as giving milk can be a logistical nightmare, supplying as well as cooking eggs is easier. They do not require cold storage; they can just be boiled and given to children. Also, they have a lower chance of contamination compared with milk.</p> <p>&nbsp;</p> <p>Jain's letter also mentions that, as eggs can easily be monitored, compared with '150ml of milk' or '20gm of almonds', even a child can tell if they are being delivered properly. However, the most advantageous thing, Jain told THE WEEK, is that almost 100 per cent of an egg is absorbed by the body and it is easy digestible, unlike other high-protein sources like soybean or groundnuts.</p> <p>&nbsp;</p> <p>“There should not be any dilemma about giving eggs to the children who eat it, especially in a state like Madhya Pradesh that has been battling malnutrition for long,” said Jain. “Usually, the opposition to distribution of eggs is fired from the shoulders of the community. So we have decided to let the community have its say in the matter, through the signature campaign. Let it be clear that the community demands and wants eggs for its children.”</p> <p>&nbsp;</p> <p><b>NUTRITIONAL VALUE</b></p> <p>Per 100gm</p> <p>Protein: 13.3gm</p> <p>Fats: 13.3 gm</p> <p>Carbohydrates: 0</p> <p>Calories: 173</p> <p>Calcium: 60mg</p> <p>Iron: 2.1mg</p> <p>Vitamin A: 420mg</p> <p>An average egg weighs 55gm</p> <p>&nbsp;</p> <p>Values according to Nutritive Value of Indian Foods report of NIN, Hyderabad.</p> Fri Dec 06 15:47:37 IST 2019 fear-in-the-air <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>The first day of November was meant to be a happy one for Vikram and Meera Goswami. It was their daughter Vinisha's first birthday, and the family had planned elaborate celebrations. Instead, the Goswamis found themselves watching over their sick baby in a hospital, and using pink balloons to make whatever little they could of the special day. “We had planned on inviting a few relatives for the celebrations, too. But all that changed a couple of days before the birthday when she fell sick. Her grandparents were especially disappointed,” says Vikram, a resident of Rohini in Delhi.</p> <p>&nbsp;</p> <p>The ordeal had begun when the couple stepped out for a walk on Diwali evening with their daughter, hoping to cheer up a cranky baby. Next day, the infant had high fever and cough and she kept sneezing. “Two days later, when the fever did not come down, we took her to Max Hospital at Shalimar Bagh where doctors told us that the baby had pneumonia, triggered by air pollution,” he says.</p> <p>&nbsp;</p> <p>Pneumonia is defined as an inflammatory disease affecting the lungs, caused predominantly by bacteria, viruses and fungi. The disease is caused by accumulation of fluid in the alveolus, leading to obstruction of normal breathing. According to the UNICEF, the risk of developing pneumonia in children is doubled following exposure to air pollution, and accounts for more than 9,20,000 deaths globally.</p> <p>&nbsp;</p> <p>Pollutants compromise the host’s immune response against invading pathogens in the respiratory tract, says a study in the journal Environmental Science and Pollution Research International. High levels of air pollution can lead to a compromise in the sterilisation and filtration mechanism of the respiratory tract, .thereby increasing the risk of developing acute lower respiratory infections, authors of the study say.</p> <p>&nbsp;</p> <p>In Vinisha's case, this “compromise” led to a six-day hospital stay and nebulisation every few hours, even after she was discharged from the hospital. “We are now keeping her indoors, with the doors and windows shut. I also try to rotate the air purifier within the house, so that even when she's out of the room, she's somewhat protected,” says Vikram.</p> <p>&nbsp;</p> <p>Even as the country, especially the NCR region, reels under the effect of air pollution and its adverse impact—both short- and long-term—on the health of its residents, its effect on children's health can hardly be overemphasised. According to the 2019 report of the Lancet countdown on health and climate change, that focuses on children’s health, exposure to ambient air pollution, most importantly fine particulate matter (PM 2.5), constitutes the “largest global environmental risk factor for premature mortality”, and results in several million premature deaths from cardiovascular and respiratory diseases every year.</p> <p>&nbsp;</p> <p>World over, studies have pointed out that more than 90 per cent of children are exposed to PM 2.5 concentrations that are above WHO guidelines, which can affect their health throughout their life, with an increased risk of lung damage, impaired lung growth and pneumonia, and a subsequent risk of developing asthma and chronic obstructive pulmonary disease.</p> <p>&nbsp;</p> <p>Experts say that air pollutants affect kids more. Children’s immune systems are weaker and they are more vulnerable to the adverse effects of climate change and air pollution, says Dr Poornima Prabhakaran, one of the authors of the Lancet report. “Children live closer to the ground where some pollutants reach peak concentrations,” says Prabhakaran, additional professor, head, environmental health and deputy director, Centre for Environmental Health, Public Health Foundation of India (PHFI). “Studies have documented effects such as preterm births and low birth weight for children when pregnant mothers are exposed to air pollution. It also affects their cognitive development, their height, and overall development,” she adds. Children also breathe more rapidly than adults and so absorb more pollutants, according to the WHO.</p> <p>&nbsp;</p> <p>“Children's lungs are also smaller, their lung function is only 20 per cent of that of adults. Their exposure to outdoor pollution is also higher, especially in case of school kids, as compared to adults,” says Dr Sonia Mittal, senior paediatrician, Max Super Speciality Hospital, Shalimar Bagh.“Over the last three to four years, we have seen a rise in the number of cases of cough, asthma, pneumonia and allergies in children at this time of the year.”</p> <p>&nbsp;</p> <p>An overwhelming majority of these children, says Mittal, do not even have a family history of respiratory diseases. Ask Garima Gulati Bhutani, 36, whose six-year-old daughter has to suffer persistent cough for days on end at this time of the year. “No one in our family has ever had this respiratory problem. Except for my daughter, whocannot stop coughing for three months in a year,” says Bhutani, an HR professional. “For at least a week, we were giving her medicine through the nebuliser every couple of hours, day or night. Even after that we had to slowly taper off the dose, so that she could breathe comfortably.”</p> <p>&nbsp;</p> <p>Says Mittal: “We have to give steroids to reduce inflammation in the lungs caused by pollutants, and other medication to open up their lungs.” The range of discomfort caused to children by pollution ranges from mild to severe, she says; the mild may mean cough and sneezing, and severe may mean shortness of breath, pneumonia, bronchitis and asthma.</p> <p>&nbsp;</p> <p>“Cases of respiratory issues with children such as persistent coughing, itchy eyes, nasal discharge and breathing trouble have only been rising. Diseases such as pneumonia and chest infections because of viruses are also taking longer to heal because of the effect of pollution,” says Dr Anil Sachdeva, director, paediatric emergency, Sir Ganga Ram Hospital, Delhi. “We have had to step up our dose of medication consistently to provide relief to the children. The situation is alarming, we are seeing children as young as six months being put on nebulisers.” About 3-4 per cent need hospitalisation, while the rest are being treated in OPDs.</p> <p>&nbsp;</p> <p>Experts such as Sachdeva and Mittal also say that while masks and air purifiers can be used, the protective effect of these are still to be proven, and hence, children need to stay indoors until the air quality improves by several notches. “It is also difficult to find a mask that is a perfect fit for a child’s face, and children cannot have it on all the time,” says Bhutani. An environmentalist at heart, Bhutani says she feels using air purifiers and masks add to the problem—for instance, the waste created by filters in the purifiers, and even the appliance itself when it is replaced.</p> <p>&nbsp;</p> <p>This year, however, she made an exception by getting a purifier at home for her daughter. “Even then, the air quality index never went below 60 [considered only moderate air quality, not satisfactory], and the average starting point was never less than 290,” she says. Besides, masks and air purifiers, or even odd-even schemes are at best short-term solutions, adds Singh. “We need to take effective measures so that next year, we do not have a situation such as this where OPDs are full of children and adults with respiratory issues,” he says.</p> <p>&nbsp;</p> <p>Adequate policy measures are in place, but there are gaps in implementation, says Prabhakaran. “Outside of Delhi, especially in tier-II and tier-III cities, we do not even have enough monitoring stations that tell us what the air quality is like,” she says. “In Delhi, at least there are 25 monitoring stations, and so a lot of focus is on this city. But elsewhere, who knows what is even going on.” She adds that the PHFI is currently working on an air quality monitoring project with 50 hospitals to “increase awareness and sensitise people” in cities such as Kochi, Coimbatore, and Guntur.</p> <p>&nbsp;</p> <p>Even as governments refrain from enforcing the implementation of crucial measures to curb air pollution caused by industries, construction work, rising number of vehicles and seasonal farm fires, for parents such as Bhutani and Vikram, the pain of watching their kids suffer is only getting prolonged each year. Watching the children gasp for breath, give up their playtime and remain cooped up in rooms with air purifiers, is not an easy task. “Sometimes, it occurs to us that we should leave the city that we have been living in for so many years,” says Bhutani. “Just a few years ago, who would have thought, that this would be the reason to leave everything.”</p> Mon Jan 06 12:04:58 IST 2020 working-it-out <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Raghav, like many in their 20s, decided to take charge of his health, and was following a nutritious diet and regular exercise plan. He always wanted a well-toned physique and knew that a good mix of weight training and cardio exercises would help him reach his goal. Compound movements like squats, chest press and dead lifts were his favourites, and he was setting personal best marks in each as he progressed over the months. On one 'back day', he was in his last set of dead lifts, when he felt a sharp shooting pain his lower back, towards his right buttock. This pain was so bad, he ended the day's workout session. It worsened over the next few days, hampering his travel and work schedule.</p> <p>&nbsp;</p> <p>When I first saw him in my clinic, a few days after the incident, he was in significant pain and had spasms. All his spinal movements were restricted by pain and he had popped painkillers on a need basis till then. I immediately realised that this was an acute lumbar strain with mild nerve root irritation. He was given a short course of anti-inflammatory medications along with some sessions of pain management modalities at a physiotherapy centre. More than the pain, he was worried about the future of his fitness plan which was going so well. I explained to him that in any exercise programme, there is always a very fine line between intensity and injury and he should not let a setback like this weaken his resolve. Over the next few weeks, he gradually got back his spinal mobility and was put on to a rehab programme that involved strengthening his back and core muscles.</p> <p>&nbsp;</p> <p>It is widely accepted that physical activity can enhance overall health and prevent numerous chronic diseases. No matter what your level of experience or fitness, workout related injuries can happen to anyone. And, this might result in disruption of daily life, loss of income or even temporary or permanent disability. They may be acute in nature or more commonly slow aggravations due to repetitive strain. Rather than getting disheartened by them, one must rest adequately and analyse the situation and formulate ways to ensure they never happen again. The following are a few common injuries I have encountered in my clinical practice.</p> <p>&nbsp;</p> <p><b>Shin splints</b></p> <p>Also called medial tibial stress syndrome. There is sharp pain along the inner leg from knee to the ankle (shins) and is felt when running and jumping. It is more often caused by running on hard surfaces and slopes and with sudden increase in intensity or frequency of training. It usually settles with rest and ice compresses.</p> <p>&nbsp;</p> <p><b>Runner’s knee</b></p> <p>There are vague pains around the knee cap related to poor tracking of the patella (knee cap). There will be creaking and grating sounds when bending or straightening the knee. Compromised posture during heavy training like squats, leg press and lunges causes bad alignment of the knee cap. The inflammation of the patella cartilage and surrounding tendons causes pain. It can be controlled by:</p> <p>&nbsp;</p> <p>■ maintaining proper knee form during ower body training</p> <p>■ hip and knee strengthening exercises balance patella tracking during bending</p> <p>■ glucosamine and vitamin D supplemen tation help quicken recovery</p> <p>&nbsp;</p> <p><b>IT band syndrome</b></p> <p>The Ilio-Tibial (IT) band is a strong ligamentous sheet running from the pelvis to the knee along the outer side of the thigh. It comes under strain and gets inflamed due to repetitive hip and knee movements like in cycling and running, especially on uneven surfaces. In severe cases, this can be very painful, causing a limp while walking. It is best treated with regular icing, IT band stretches and foam rolling. Runners should gradually increase their run intensity and try different routes and terrains to avoid constant strain on one leg. Cyclists must adjust their seat height to optimise hip and knee alignment during each cycling stroke. Gluteal (buttock) exercises like squats, dead lifts and side leg raises help strengthen the IT band.</p> <p>&nbsp;</p> <p><b>Rotator cuff injuries</b></p> <p>The rotator cuff is a group of four muscles that form a hood around the shoulder joint to stabilise this highly mobile and unstable articulation. Any overhead activity like power lifts and throwing or service sports like javelin, badminton and tennis can strain these small muscles. Repeated strains lead to progressive tears and pain in the shoulder called impingement.</p> <p>&nbsp;</p> <p>Regular rotator cuff strengthening exercises and shoulder stretches help keep the rotator cuff healthy and strong. Avoid lifting weights that are difficult to control—machine exercises are safer—and keep to proper exercise form and range.</p> <p>&nbsp;</p> <p><b>Elbow pain</b></p> <p>The commonest cause of elbow pain is the tennis elbow. It is an inflammation of the forearm muscle that originates on the outer side of the elbow joint. It is usually seen in racket sports like tennis and badminton due to backhand power strokes. It also occurs in the gym, when lifting heavy weights causes overstrain on the wrist extensor muscles and produces micro tears at their origin. Try and maintain your wrist in a neutral position even if this means lifting lighter weights. Wrist extension and grip strength exercises help prevent this problem.</p> <p>&nbsp;</p> <p><b>Lower back injuries</b></p> <p>Back injuries can range from muscle strains to disc herniations with nerve compression (sciatica). Keeping a neutral spine during heavy lifts is a protection from these injuries. Core (abdominal) muscle exercises also help stabilise the spinal column when loaded. Only do heavy exercises once you have mastered the proper form and use a lumbar belt for external support. Having a good trainer's guidance is important.</p> <p>&nbsp;</p> <p><b>Prevention</b></p> <p>Here are some golden rules that help prevent exercise related injuries:</p> <p>■ Always warm up prior to any exercise. This would involve general body warm up like 5-7 minutes of cycling or a light run followed by part-specific dynamic stretches</p> <p>■ Gradually increase the intensity of your workouts</p> <p>■ Focus on strength, endurance and flex ibility. This keeps joints supple and muscle strong</p> <p>■ Split your weight training into body parts or movements; like push, pull and legs. This allows muscle groups to ecover and grow to strength</p> <p>■ Rest days once or twice weekly are es sential for your body to recuperate</p> <p>■ A weak body is injury prone. Always fuel your workouts well with food and fluids</p> <p>■ Suitable footwear for cardio and train ing days limits stress on the knees and spine</p> <p>■ Know your trouble areas and avoid ex ercises that hurt</p> <p>■ Take the help of a qualified trainer till you are confident on your own In the eventuality of facing injuries, re member the acronym 'RICE', which has the basic principles of managing them:</p> <p>■ Rest to the injured part. Stop working out</p> <p>■ Ice application to reduce inflammation</p> <p>■ Compression to keep the limb from swelling</p> <p>■ Elevate the part to help in blood flow return and avoid swelling</p> <p>&nbsp;</p> <p>Those who have been working out for long know the difference between the good pain of muscle soreness and the bad pain of injury. When in doubt, do not hesitate to consult a medical specialist to identify the problem and rectify it. Judicious use of investigative modalities like ultrasound and MRI are helpful in diagnosing soft tissue injuries. Be open to a short course of physiotherapy to guide you back on track.</p> Tue Nov 12 15:51:18 IST 2019 matters-of-the-heart <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Heart disease is the leading cause of death in both men and women worldwide. The prevalence of heart disease has increased over time in both men and women. The myth that heart disease is a ‘man’s disease’ needs to be debunked.</p> <p>&nbsp;</p> <p>In coronary artery disease, the coronary arteries become narrowed or blocked by a gradual build-up of fat (cholesterol) and other substances within the artery wall. This build-up is called atherosclerotic plaque. This narrows the arteries, making it harder for blood to flow through. If a plaque erodes and a blood clot forms, it can stop the blood flow. This can cause a heart attack. Heart disease can take many other forms. It can result in heart failure due to weak and damaged or stiff heart muscles, arrhythmia (abnormal rhythm of the heart), and heart valve problems.</p> <p>&nbsp;</p> <p>Women generally have their first presentation of heart disease a decade later than men, commonly after menopause. Women are less likely to call emergency service when experiencing symptoms of a heart attack themselves and are much more likely to die from their first heart attack than men. The most common heart attack symptom is pain, pressure or discomfort in the chest. It may not be always severe or even the most prominent symptom. Symptoms of heart attack in women can be different to men. It is important to understand these differences as they can result in delay in seeking help or treatment and, thus, may lead to more complications. Heart attacks can also be silent. Symptoms unrelated to chest pain may be:</p> <p>&nbsp;</p> <p>¨Shortness of breath</p> <p>¨Neck, jaw, shoulder, upper back or abdominal discomfort</p> <p>¨Pain in one or both arms</p> <p>¨Nausea or vomiting</p> <p>¨Sweating</p> <p>¨Dizziness or light-headedness</p> <p>¨Unusual or extreme fatigue</p> <p>&nbsp;</p> <p>These symptoms can be commonly attributed to indigestion, stress and weight gain. Women can have symptoms of chest discomfort due to blockages not only in their main arteries but also in the smaller arteries that supply blood to the heart, a condition called small vessel heart disease or microvascular disease. There are several factors which increase the risk for developing heart disease, such as high bad cholesterol (LDL and triglycerides) and low good cholesterol (HDL), high blood pressure, obesity, diabetes (women with diabetes are at greater risk than men with diabetes), smoking (greater risk factor in women than in men), and lack of physical activity.</p> <p>&nbsp;</p> <p>Other factors include stress and depression, which make it difficult to maintain a healthy lifestyle and follow recommended treatment. Manage stress levels by finding healthy ways to cope with stress like yoga and meditation or seek medical help. Menopause (because of low levels of oestrogen), certain chemotherapy drugs and radiation therapy for cancer, pregnancy complications and broken heart syndrome (more commonly in post-menopausal women) are also risk factors.</p> <p>&nbsp;</p> <p>Women of all ages should take heart disease seriously and women under the age of 65, especially those with a family history of heart disease, should pay heed to the risk factors. They can make several lifestyle changes to reduce the risk of heart disease such as quitting smoking, and managing diabetes, blood pressure and cholesterol. Staying active is another must. Everybody without a physical disability should do moderate exercise, such as walking at a brisk pace or any aerobic activity, most days of the week. At least 150 minutes of moderate aerobic activity a week or 75 minutes of vigorous aerobic activity a week, or a combination of both is recommended. That is, about 30 minutes a day, five days a week. For more health benefits, aim for 60 minutes a day, five days a week. Also aim to do strength training exercises two or more days a week. If you cannot get all the exercise completed in one session, try breaking up your physical activity into several 10-minute sessions during a day. Also, make other small changes to increase physical activity throughout the day. Try taking the stairs instead of the elevator, walking or riding your bicycle to work or doing situps or pushups while watching television.</p> <p>&nbsp;</p> <p>Losing weight even slightly can help by lowering your blood pressure and reducing your risk of diabetes. What is considered a healthy weight varies from person to person, but having a normal body mass index is helpful. Measuring waist circumference and calculating the waist-hip ratio is a useful tool to measure whether you are overweight.</p> <p>&nbsp;</p> <p>A healthy diet is vital. Include whole grains, a variety of fruits and vegetables, low-fat or fat-free dairy products and lean meats. Avoid saturated or transfat, added sugars and high amounts of salt. Limit alcohol intake to no more than one drink a day. Recent data, however, indicate that even that may be harmful.</p> <p>&nbsp;</p> <p>Treatment in women and in men is similar. It may include medication, angioplasty and stenting, or coronary bypass surgery. However, women who do not have chest pain are less likely to be offered these potentially lifesaving options. It would be prudent to note that hormone therapy, antioxidant vitamin supplements (vitamin E, C and beta carotene), and folic acid, with or without B6 and B12 supplementation, should not be used for the primary or secondary prevention of cardiovascular disease. Routine use of aspirin in healthy women 65 years of age is not recommended to prevent heart disease.</p> <p>&nbsp;</p> <p>All women should work with their health care provider to make a plan for ensuring heart health. No matter what the routine is, a list of all medicines and questions to be asked should be brought along for all the appointments.</p> <p>&nbsp;</p> <p><b>The writer is director, cardiology, Fortis Memorial Research Institute, Gurugram.</b></p> Sat Nov 16 14:33:54 IST 2019 micro-patch-macro-benefits <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It can be hard to watch your baby cry every time it gets vaccinated. The irritability and fever that ensue, though normal, often worry new parents. A newborn gets its first set of vaccinations within 48 hours of birth—Bacillus Calmette-Guerin, oral polio vaccine and hepatitis B. "A child is given at least 16 vaccinations in the first year. Immunisation is definitely a proven tool for controlling and eliminating life-threatening and infectious diseases. But every needle and syringe administration of vaccine can be stressful, both for the baby and the parents,” said Dr Hussain Ali P.V., general physician in the ministry of shipping.</p> <p>&nbsp;</p> <p>In a bid to develop painless, easy-to-use injections, scientists around the world are working on new designs for vaccine delivery. This resulted in adhesive bandage-like patches. These patches, called microneedle or microarray patches (MAPs), consist of thousands of small needles, and when attached to the skin for some time, allow the vaccine to enter the body, and work like the conventional vaccine. In Europe, the first phase of trials has concluded and the technology has been declared "largely safe". Indian researchers are now trying to develop one that is locally sourced, efficient and cost-effective. Scientists at Hilleman Laboratories, a Delhi-based not-for-profit vaccine research organisation, are concluding the final stage of testing the device on animals. Human trials, once initiated, might take up to three years.</p> <p>&nbsp;</p> <p>Hilleman's CEO Dr Davinder Gill says that with the needle and syringe administration of vaccine, which is a 160-year-old practice, only the circumference of the needle and the syringe has changed over time. "As an alternative route to enhance the vaccination efficacy, microneedles have been devised to target the rich network of immunologic antigen-presenting cells in the dermis and epidermis. Studies have revealed that vaccine delivery through micro patches have comparable or higher ability to induce an immune response than conventional vaccines,” he said.</p> <p>&nbsp;</p> <p>The technology’s success would prove beneficial for India’s rural public, as it can be administered by health workers with minimal training, or even self-administered. "The concept of patch vaccines is excellent for mass immunisation," said Dr Jeeson Unni, paediatrician, Aster Medicity, Kochi. "After vaccination, the microneedles dissolve in the skin, and the used patches can be safely discarded as non-sharp waste. The vaccines remained potent in the patches without refrigeration for at least one year, circumventing the issues of cold chain maintenance. The only concern is maintaining records of immunisation. Since patch vaccines will be made available off the counter, there would not be any documentation of the immunisation shots."</p> <p>&nbsp;</p> <p>Reports as per India’s AEFI (Adverse Events Following Immunisation) data state that there was a spike in adverse events in 2017. The database had recorded AEFI cases that caused rashes and related skin reactions and abscess, but the report specified that no deaths were attributed to vaccines alone.</p> <p>&nbsp;</p> <p>Said Dr Mathew Pappachan, fertility specialist and clinical embryologist, Lifeline Hospital, Kerala: "Although adverse events following vaccinations are not very common these days, there have been cases of extreme side effects associated with vaccine administration—mostly attributed to inappropriate handling, contamination, production error or error of medical care. There are a lot of incidents of needle stick injuries. But most cases are not reported or are documented falsely to avoid litigation."</p> <p>&nbsp;</p> <p>Increased thermostability, ease of use and safety are the focus points of the research at Hilleman. The Indian model will be able to administer 0.5ml of vaccine (standard dosage) as against 0.1ml in the western patch. "We have discovered a design which would allow us to administer doses up to 1.5ml at nominal cost. We are working with local component makers to produce the world’s cheapest microarray patch,” said Gill.</p> <p>&nbsp;</p> <p>Does it mean, no more needle and syringe? According to Gill, though not all injectable drugs can be administered with MAPs, it is an option for many major vaccines and drugs. These include the flu, rabies and yellow fever vaccines, injectable polio vaccine, human papilloma virus (HPV) vaccine, tetanus-toxoid and measles-rubella vaccine. The product will also be usable for non-vaccine applications such as anti-retrovirals and as contraceptives.</p> <p>&nbsp;</p> <p>The journey of developing and testing has not been all rosy though. Their initial design failed to deliver the required result. "Both setbacks and failures are part of any research and development project," said Gill. "Our biggest challenge moving forward will be to convince all stakeholders to shift to these innovative modes."</p> <p>&nbsp;</p> <p>Furthermore, researchers in the US and Australia are now working on a nano patch. Vaxxas, an American startup, is testing this. Smaller than a micro patch, a nano patch has thousands of microscopic vaccine-coated projections on it. The patch can be applied using a finger or an applicator. The future of vaccinations is full of surprises and, not to forget, zero pain.</p> Sat Nov 16 14:39:03 IST 2019 fragile-yet-firm <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Sandra Somanath’s troubles began when she was barely eight months old. The toddler had a fracture in her thighbone while playing with her grandmother on her bed. Since then, there have been several such painful instances. “I had one when I was three years old, then at four, seven, 10, 11, 19 and at 20 years of age,” says Sandra, a second-year student of medicine at T.D. Medical College, Alappuzha, counting the number of times she has had a fracture.</p> <p>&nbsp;</p> <p>Each time her bones gave in, the 21-year-old says she was in the middle of a routine activity—walking, playing and, in one instance, merely standing up after finishing a classical music recital at school. While her first fracture was treated simply with traction (the practice of slowly and gently pulling on a fractured or dislocated body part to stabilise and realign it), rest of the times she had to get bone implants to fix the fractures. At 11, she had a spine surgery, too. “In between these fractures, I have also been confined to the bed several times because of the pain in my legs that would come suddenly, or because I had some minor injuries,” she recalls.</p> <p>&nbsp;</p> <p>What ails Sandra is known as osteogenesis imperfecta (OI) or brittle bone disease, a rare genetic disorder that causes bones to break frequently, often from little or no apparent trauma. For many of those suffering from OI, a cough, sneeze, sound or even tapping on a keyboard can cause enough trauma for a bone to snap.</p> <p>&nbsp;</p> <p>“The disease is the result of a random genetic mutation. We now know that there are 12 types of OI,” says Dr Manoj Padman, director, Centre for Paediatric Orthopaedics and Disabilities, New Delhi. “The mutation is present in the collagen gene. Collagen is what binds the bone cells, and its deficiency or inferior quality as in the case of OI patients is what renders the bones brittle and prone to breaking frequently.”</p> <p>&nbsp;</p> <p>Padman says that the severity of the disease varies depending on the type of OI, ranging from intrauterine which is fatal, to ones where patients will have suffered up to 200 fractures until their teens, to milder versions where only certain limbs are affected, as in the case of Sandra where only her thighbone is affected. “Usually the manifestation starts when the baby starts walking, and there is load on the legs, so from the age of one onwards,” says Padman. “Fractures will affect the lower limbs and the spine mostly, but upper limbs may also be affected.”</p> <p>&nbsp;</p> <p>Collagen deficiency also leads to teeth problems (dentinogenesis imperfecta) and blue sclera (blue colour caused by the thinness and transparency of the collagen fibres of the sclera, allowing the veins in the underlying tissue to show through), says Padman. Such patients may also have muscle weakness, loose joints (joint laxity) and skeletal malformations.</p> <p>&nbsp;</p> <p>“The disorder occurs in one in 20,000 children in the world. However, we don’t have the exact numbers for its prevalence in India,” says Dr Neerja Gupta, clinical geneticist, All India Institute of Medical Sciences, New Delhi.</p> <p>&nbsp;</p> <p>OI has no cure, says Padman. Current treatment comprises administering bisphosphonates (class of drugs that prevents the loss of bone density, used to treat osteoporosis and similar diseases). “Cyclical bisphophonate therapy is the gold standard when it comes to treating OI,” says Padman. “This is given until the child’s growth is completed. The other arm of the treatment is surgical straightening, stabilising and putting rods within the bone.” Telescopic intramedullary rods that expand and elongate within the bone as the child grows are used in such cases, he adds. “Sometimes I do get patients whose fractures have been treated as normal fractures. Due to recurrent fractures and not getting the right drugs and implants, bone deformity occurs in such children,” he says.</p> <p>&nbsp;</p> <p>Gupta says that various research groups are working on developing different forms of treatment for OI such as blockade of certain proteins and gene therapy. “Genetic testing helps in establishing the etiology (the cause, set of causes, or manner of causation of a disease) and preventing recurrences in future pregnancy,” she says. “Clinical geneticists and orthopaedic surgeons have a key role in treatment of the disease.”</p> <p>&nbsp;</p> <p>Latha Nair, 64, founder of the Thiruvananthapuram-based NGO Amrithavarshini that works with children and adults suffering from OI, says that the disease is best managed by a group of doctors from genetic, paediatrics, orthopaedics and rehabilitation medicine. “Physical and occupational therapies also help improve their ability to move, to prevent fractures and to increase muscle strength,” she says.</p> <p>&nbsp;</p> <p>Treatment for the fractures is perhaps only half the story. When it comes to OI, coping in a world that is not conducive for the differently abled can be quite a challenge in itself. Nair says that the awareness about the disease remains low, and parents often resist getting treatment for a differently-abled child because of stigma. “The trend is changing now though,” she says. “We do get calls from parents wanting to send their kids to Amrithavarshini to get trained in various skills and in learning to cope.”</p> <p>&nbsp;</p> <p>Her work with OI affected kids began after she learnt about the case of a young boy’s family struggling to manage funds for surgeries to correct the bone malformation in his lower limbs in 2000. It took Nair, a retired state government official, a decade to set up her NGO, which helps bed-ridden kids use their time effectively, provides occupational therapy and also financial support from donations for patients with OI.</p> <p>&nbsp;</p> <p>Nair says that affordability also becomes a major factor when expensive surgeries to fix the bones with implants are required. “Currently, this disease is not recognised under the Persons with Disability Act, 2016. Once that happens, the children can get benefits, especially when it comes to getting the surgeries done,” says Nair.</p> <p>&nbsp;</p> <p>In managing OI, Sandra, who can walk with the support of her elbow crutches, has been tad luckier than others. “My family has been extremely supportive,” she says. Her father and uncle wait outside her college until she finishes her classes, and her friends help her up the stairs in college. Moreover, there is her own grit to make it in the world despite the disadvantages. Individual support systems apart, Sandra says the state and society must support the differently-abled, too. “Simple things like ramps are not available in my college,” she says. “There is no facility for me to attend classes on the ground floor. So, each time, either I have to lift myself up the stairs, or friends and family help out.” Many children suffering from OI are forced to stop studies because of the difficulty in commuting to educational institutions, she adds. “I can now drive an automatic car, but what of others who are more disabled than me and cannot afford this? They end up staying at home,” she says.</p> <p>&nbsp;</p> <p>Both Nair and Sandra foreground the “positivity” in the mindset of OI affected children, and cite examples of those who have gone on to become successful doctors, engineers and have taken up other professions. “Other than their bones that break easily, these are bright, creative and extremely positive kids, who don’t need anyone’s pity, but understanding and acceptance,” says Nair. But it is Sandra, who cleared her first year MBBS as per schedule despite a debilitating fracture just before the exam, who has the last word on the subject. “It is the pain that gives us strength,” she says. “Each day brings fresh challenges, but we learn how to survive and stay happy.”</p> Sat Nov 16 14:43:34 IST 2019 fight-with-light <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>India is fighting numerous deadly diseases. Diabetes is perhaps the biggest villain on the list. According to the 2017 diabetes atlas of International Diabetics Federation, India has the second highest (72.9 million) number of diabetics in the world. IDF projects that soon India will top the list, and by 2045, the country will have 134.3 million people with diabetes.</p> <p>&nbsp;</p> <p>Diabetes occurs when the pancreas does not produce enough insulin hormone or when the body cannot effectively use the insulin it produces to control the blood sugar concentration. According to IDF, around four million people (aged 20 to 79) died from diabetes in 2017. Researchers have been working hard to find cures and better management techniques for diabetes. Recently, an important breakthrough in diabetes research came from Tufts University, Massachusetts.</p> <p>&nbsp;</p> <p>They engineered insulin-producing pancreatic beta cells that are activated by light. The scientists transplanted these cells into diabetic mice and confirmed that these cells can produce more than two to three times the typical level of insulin when exposed to light. These light-switchable cells can compensate for the lower insulin production or reduced insulin response in diabetic cells. The fact that the researchers were successful in controlling the glucose levels without pharmacological intervention could revolutionise the way diabetes is treated.</p> <p>&nbsp;</p> <p>Excessive urination, thirst, constant hunger, weight loss, vision problems and fatigue are common symptoms of diabetes. There are three main types of diabetes—type 1, type 2 and gestational diabetes. Type 1 diabetes develops due to the body's inability to produce enough insulin. Type 2 diabetes arises due to body's inability to use produced insulin effectively. Genetics, unhealthy diet and physical inactivity are main factors for type 2 diabetes.</p> <p>&nbsp;</p> <p>Gestational diabetes is a condition in which a pregnant woman without diabetes develops hyperglycaemia. Women with gestational diabetes and their children are at increased risk of type 2 diabetes in the future. Studies shows that adults with diabetes have increased risk of heart attack, stroke and kidney failure.</p> <p>&nbsp;</p> <p>Current treatments of diabetes include the administration of drugs that enhance insulin production by pancreatic cells or direct injection of insulin into blood to compensate for the reduced natural supply. Regulation of blood sugar is a manual process in both these methods. What Tufts researchers accomplished is a new method which amplifies insulin production without any drugs, while maintaining a real-time link between the release of insulin and glucose concentration in blood. They engineered pancreatic beta cells with a gene that encodes a photo-active adenylate cyclase (PAC) enzyme.</p> <p>&nbsp;</p> <p>When exposed to light, PAC produces a molecule called cyclic adenosine monophosphate which can increase glucose-stimulated production of insulin production in the beta cell. In this method, insulin production increases only when the blood glucose level is high. At low glucose levels, insulin production also remains low. This overcomes a common drawback in the existing diabetes treatment which can overcompensate on insulin exposure and thereby leave a patient in a hypoglycaemic situation.</p> Tue Nov 12 14:34:04 IST 2019 tech-that-saves <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>When Rima Singh, 46, went to her doctor complaining of heart palpitations, she was relieved to be told they were likely the result of too much caffeine and a high blood sugar level. Her relief did not last long. She suffered severe breathing problem with cough in the middle of the night—a sign of acute heart failure—and was rushed to emergency care. Doctors told her that a heart transplant was required for her condition.</p> <p>&nbsp;</p> <p>Rima’s medical history revealed multiple co-morbidities, including history of a disorder causing inflammation in blood vessels and chronic inflammatory bowel disease. An MRI scan of her brain showed multiple old infarcts—an area of dead tissue resulting from the failure of blood supply. Considering her medical condition, doctors could not do a heart transplant. After detailed examination and ECG analysis, they suggested a heart failure device implantation—also called cardiac resynchronisation therapy defibrillator (CRT-D)—as a last resort. CRT, particularly CRT-D, has been shown to improve symptomatic status, decrease heart failure episodes and improve longevity in many scientific studies. CRT-D performs three functions: it works as a pacemaker; it improves the pumping capacity of the heart; and in case of serious rhythm problem or cardiac arrest, the device can give automatic electric shock to save the patient.</p> <p>&nbsp;</p> <p><b>What is heart failure?</b></p> <p>Heart failure is a blanket term for the conditions when the heart is unable to provide enough blood to various organs of the body. Heart failure is broadly classified into two categories based on whether the pumping capacity of the heart is preserved or not.</p> <p>&nbsp;</p> <p>Heart damage occurs either because of blockages in the coronary arteries (called coronary artery disease) or chronic disease of the heart muscle (cardiomyopathy and myocarditis). Refractory heart failure is a term which is used for a condition where all kinds of medical therapy, bypass surgery, angioplasty and valve replacement have already been tried.</p> <p>&nbsp;</p> <p>Refractory heart failure has become a massive problem globally. It has been estimated that almost 25 million people in the world have refractory heart failure. To prevent the occurrence of heart failure, we need to apply preventive medicine and control the risk factors for heart diseases. The control measures include quitting smoking, controlling hypertension and diabetes, reducing bad cholesterol and exercising regularly.</p> <p>&nbsp;</p> <p><b>Understanding the technology better</b></p> <p>Suman Kukreja, 60, was taken to the doctor with a history of severe breathlessness and difficulty in walking. She was unable to sleep properly due to coughing. She also developed swelling in the feet and stomach. On examination, it was found that the pumping capacity of her heart had fallen to 25 per cent. Her ECG showed broad QRS complex—the main spike on an ECG line—in the form of left bundle branch block (LBBB). This is a delay or blockage of electrical impulse on the left side of the heart. The doctor immediately recommended CRT-D.</p> <p>&nbsp;</p> <p>Working on the principle of a pacemaker, the therapy can help patients like Suman who have heart failure and LBBB. Depending on the risk assessment for dangerous arrhythmia (a condition in which the heart beats with an irregular or abnormal rhythm) and sudden cardiac death, a patient can be advised a simple CRT with a pacemaker or a CRT with a defibrillator.</p> <p>&nbsp;</p> <p>CRT-D is implanted under local anaesthesia below the left collar bone in the subcutaneous tissue. Three wires from this device go into the heart: one into right upper chamber (atrium), the other two into lower chambers (left and right ventricles). The risk of severe complications during implantation is less than 1 per cent. There is no need of general anaesthesia or open chest surgery for implanting this device. It starts working immediately after implantation and improves the pumping capacity of the heart.</p> <p>&nbsp;</p> <p>Patients with low pumping capacity of the heart are prone to a dangerous heart rhythm problem from lower chambers of the heart. The CRT-D has the capability to diagnose these malignant rhythm problems in practically six to eight seconds and offer apt treatment. Present day devices are MRI compatible and there is no restriction on getting MRI done in the future.</p> <p>&nbsp;</p> <p>The average longevity of the battery of these devices is six to eight years. Lately, there have been further improvements in technology in the form of left ventricular lead with four electrical poles, which gives an option to programme the device. These are more efficient than the older devices with bipolar leads. Also, there is a possibility of stimulating the heart at multiple sites (multipoint pacing) with some of these devices, which gives additional benefits to the patients.</p> <p>&nbsp;</p> <p>These devices can be checked from outside with a programmer via a band kept on the device site or with remote-control methodology. Remote control monitoring devices are small and can send detailed information to the cardiologist practically 24/7.</p> <p>&nbsp;</p> <p>In a nutshell, awareness about heart failure needs to improve among doctors and the people. Primary care physicians should also educate themselves with the knowledge of these modern-day treatments for heart failure patients. In fact, if a patient who is suitable for CRT therapy is not referred in time, it should be considered negligence of duty.</p> <p>&nbsp;</p> <p><b>Kler is chairman, PSRI Heart Institute, New Delhi.</b></p> Fri Nov 01 15:52:17 IST 2019 split-wide-open <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>In the case of high blood pressure, doctors say people ought to “know their number”. In India, though, even a cursory glance at the numbers on hypertension can send anxiety levels soaring.</p> <p>According to the National Family Health Survey-IV, 207 million people in India have high BP. About one-third of urban Indians are hypertensive; less than 15 per cent of those suffering from high BP are able to control it, and the prevalence of the disease, also known as the silent killer, is increasing in India, as compared to other countries.</p> <p>&nbsp;</p> <p>Dr Naveen Bhamri, director, cardiology, Max Super Speciality Hospital, Delhi, said that the “rule of half” best explains the current situation of hypertension in India. “Only half of those who have high BP are aware of it. Of these, only half are receiving treatment. Out of these, only half are getting adequate treatment. So, only 12.5 per cent of those suffering from high BP are actually getting adequate treatment,” he said. Besides, the numbers in India could cause greater distress if they were considered in light of the recently lowered threshold for high BP. While the NFHS data considered 140/90 as the cut-off mark for high BP, in 2017, the guidelines issued by American College of Cardiologists stated that BP was normal only if it was under 120/80, and elevated if it was 120-129/less than 80. The ACC said that a person would be stage I hypertensive if his BP fell between 130-139/80-89.</p> <p>&nbsp;</p> <p>Though the ACC lowered the threshold to less than 130/80, the European guidelines have retained the previous definition of hypertension as higher than 140/90. Both sets of guidelines, however, recommend the same therapeutic goal of BP to be kept under 130/80.</p> <p>&nbsp;</p> <p>Even as doctors debate over whether to follow the Americans or the Europeans, this month the Association of Physicians of India released the latest edition of the Indian Guidelines on Hypertension (the last guidelines came out in 2013). The Indian guidelines, based on work by around 150 experts, are closer to the European guidelines and suggest that hypertension is diagnosed when BP is greater than, or equal to, 140/90.</p> <p>&nbsp;</p> <p>The authors do caution that starting at 115/75 mmHg, cardiovascular disease risk “doubles with each increment of 20/10 mmHg” throughout the BP range. The risk of cardio-vascular death increases “two-fold” if the BP “rises to 135/85”, “four-fold if BP rises to 155/95”, and “eight-fold at 175/105”.</p> <p>&nbsp;</p> <p>“However, the complications show a marked jump after the 140/90 mark. Besides, in India, if the threshold is lowered, we will only end up labelling more people as sick, and spread panic,” said Dr Y.P. Munjal, one of the authors.</p> <p>&nbsp;</p> <p>Authors of the Indian guidelines also said that “all definitions of hypertension issued by various international bodies are arbitrary”. “There is some evidence that the risk of cardiovascular events in Asian Indians is higher at relatively lower levels of BP. Recently, the ACC/AHA guidelines have changed the definition of hypertension to 130/80. However, the European guidelines and many others maintain the earlier definition of 140/90. The Indian guidelines IV will continue with the previous definition,” the authors state. “Each country has its own local variations when it comes to high BP. In India, the difference is that high BP starts at least 15-20 years earlier, fluctuates considerably according to seasons (higher in winter, lower in summers), and salt intake of Indians is significantly higher,” said Munjal.</p> <p>&nbsp;</p> <p>Bhamri, however, said that a large section of cardiologists (about 75 per cent) such as him were following the American guidelines. “Studies have shown that the lower the BP, the better it is,” he said. “More than 25 per cent of our population is hypertensive. So, we consider 130-139/80-89 as stage I hypertension.”</p> <p>&nbsp;</p> <p>Another doctor with a premier hospital, who did not want to be identified, said that the medical fraternity in India was “divided” on the issue of BP threshold and there was “no consensus” on the subject due to “different state and pharma influence” at work.</p> <p>&nbsp;</p> <p>“I don’t think it is prudent to fight on which guidelines are correct,” said Dr H.K. Chopra, senior consultant, cardiology, Moolchand Hospital, Delhi. “Indians need to keep their BP under 130/80. Studies have found that the rate of events (chest pain, stroke, kidney disease) are reduced if the BP is less than that. Most people are diabetic in India, and so, the symptoms are silent for them,” he said. A study done among 600 patients of stroke at Apollo Hospital, Hyderabad, found that 75 per cent of them had uncontrolled hypertension, he added.</p> <p>&nbsp;</p> <p>“Hypertension is a real problem in India, and it is best for us to keep it lower than 130/80,” said Chopra, who is the former president of Cardiological Society of India. The need of the hour with a country of 1.3 billion, and over 25 per cent with high BP, he said, was to reduce the numbers, as concurred by authors of “various Indian guidelines”.</p> <p>&nbsp;</p> <p>Both Chopra and Bhamri said that an ambulatory monitor helps measure BP through the day, and night. At night, BP dips by at least 10 mm of mercury. But some among us are “non-dippers”, for whom BP won't come down at that time, too.</p> <p>&nbsp;</p> <p>Bhamri also points to the fact that hypertension is mostly asymptomatic, and there is a misconception that headaches are a common symptom. He said it is important that BP is monitored as often as possible—once every few months. Doctors also advise that the BP monitoring instrument is calibrated every 3-6 months to ensure an accurate reading.</p> <p>&nbsp;</p> <p>Given India’s precarious situation on hypertension and heart disease, Chopra said that it is time the country had kiosks at public places to measure BP, and people had home BP monitor.</p> <p>&nbsp;</p> <p>At times, patients of hypertension also tend to delay medication in the morning, when BP peaks. “Most heart attacks, strokes occur in early morning because that is when BP shoots up. So patients ought to have their medication first thing after waking up,” said Bhamri. According to Munjal, some low-cost medicines for high BP were as good as the high priced ones, and doctors needn’t go for expensive medication. “Combination of two drugs is better because the dosage can be kept low, and side-effects can be avoided. New diabetic drugs such as SGLT2 inhibitors can also be used to lower BP and sugar levels, and stem kidney disease to some extent, too,” he said.</p> <p>&nbsp;</p> <p>To counter the confusion over which guidelines to follow, Munjal said that the government ought to take the lead by initiating funding for the process of setting guidelines—as was the process in other countries—and bringing together a diverse group of experts such as physicians, cardiologists, nephrologists, and diabetologists to work on building consensus. For a country with mind-boggling numbers of high BP, stroke, and heart disease, that is an initiative waiting to be taken.</p> Fri Nov 01 15:15:41 IST 2019 the-pain-of-laughter <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>For 16-year-old Neerja Naik, who lives in the Navsari district of Gujarat, the recently released Joker was more than a film. It was a depiction of what her mother was going through every day. Though the movie was about the origins of the Batman super-villain, it was the uncontrollable, episodic and heartbreaking laughter of Arthur Fleck, played by Joaquin Phoenix, that haunted moviegoers for days. Fleck, who later transforms into Joker, has a mental illness that makes him laugh involuntarily, mostly at inappropriate moments. The same happens with Vrutti Naik, Neerja's mother, except that the 36-year-old also has episodes of unintentional crying.</p> <p>&nbsp;</p> <p>Just a few days ago, while Neerja and her grandmother were talking casually, Vrutti broke down sobbing. The episode lasted more than five minutes and scarred the college girl. “She was never like this,” says a teary-eyed Neerja. “We had a cheerful and happy mother who was always sure of herself and would go out of her way to care for us. But now, she seems to have lost control. The other day, just as she was drinking water, she broke into laughter and spilled the water. There was no reason for her to laugh, but she could not control it. It was as if her emotions were flowing out without her knowing it.”</p> <p>&nbsp;</p> <p>Experts call the condition the pseudobulbar affect, in which random episodes of pathological laughter and weeping take place, but are completely disconnected from one's actual mood at the time. “It is a case of pseudobulbar palsy (loss of control of facial muscles), which causes the pseudobulbar affect and leads to behavioural disturbances, including involuntary laughter and crying,” says Dr Sudheer Ambekar. The skull-base and endovascular neurosurgeon at Jaslok Hospital in Mumbai has been treating Vrutti for a while now. “In a way, the connection between what the person expresses and what she experiences is lost,” he says.</p> <p>&nbsp;</p> <p>Vrutti first went to Ambekar about ten months ago; she had suffered a stroke due to a blockage in one of the main arteries supplying blood to the brain stem. But there were logistical delays, and by the time the surgery to remove the blockage was done, the brain stem had been damaged. “She had permanent damage in the brain stem because of the stroke. PBA is basically a brain stem phenomenon,” says Ambekar.</p> <p>&nbsp;</p> <p>Dr Rajiv Mehta, a psychiatrist at Sir Ganga Ram Hospital in Delhi, believes that any infection in the prefrontal cortex of the brain—called the “emoting part”—leads to an uninhabited flow of emotions. “Once that area becomes infected, all inhibitions are lost, and the duration, frequency and intensity of emotions increase manifold,” he says. “So, in a way, everything is normal, but in excess.”</p> <p>&nbsp;</p> <p>Traumatic brain injuries or neurological conditions—including stroke, epilepsy, multiple sclerosis and drug abuse—are the primary reasons for PBA, as they can impair the area responsible for controlling emotions.</p> <p>&nbsp;</p> <p>Fortunately, PBA is a rare disorder and affects only one in ten thousand people. “I must have seen hardly three or four PBA patients in my career,” says Mehta. He remembers one of those patients—a 55-year-old—clearly. “It had begun troubling his family because even when the mood around was sombre, he would suddenly start laughing,” says Mehta. “Once, when one of his family members was talking about his daughter's divorce, the man had two extended episodes of loud laughter and crying in a span of 20 minutes, each lasting well over three minutes.”</p> <p>&nbsp;</p> <p>As people often misunderstand the laughter, the patient suffers from isolation, neglect and depression. In the movie, for instance, Fleck carries a card that explains his condition and gives it to people who are offended by his outbursts.</p> <p>&nbsp;</p> <p>Vrutti, on her part, felt angry and helpless on being betrayed by her own emotions and for not being able to do much about it. “Sometimes she acts like a child who goes into this phase of sudden outbursts,” says Neerja. “The doctors have prescribed mood stabilisers and antidepressants, which help calm her down. She has also begun reading books, and keeps herself engaged.”</p> <p>&nbsp;</p> <p>The stroke had left Vrutti, who is obese at 136 kilos, paralysed on the left side and incapable of standing up on her own. And for Anju Desai, Vrutti's sister-in-law, seeing her in such a condition was a rude shock. Just three months earlier, Desai had nursed her husband, who had a stroke, back to health. Interestingly, he did not show signs of PBA. “Not all stroke patients suffer from PBA,” says Dr Pankaj Agarwal, a neurologist at Global Hospitals, Mumbai. “Ninety per cent of the time it happens in cases of repeated ischaemic strokes that affect both sides of the brain and interfere with facial muscles. There are many who go along smoothly as there is no impact on the small part of the brain called the medulla. So, the person is able to speak and swallow well and also remains in control of her emotions, irrespective of an external emotional stimulus. With time, PBA patients do improve, especially with the help of anti-depressants.”</p> Fri Nov 01 15:09:55 IST 2019 halfway-through <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>In February 2017, India launched a massive vaccination campaign against rubella (aka German measles), a contagious viral disease which causes birth defects such as irreversible deafness and blindness in nearly 40,000 children, annually, in the country. With the programme targeting vaccination of 410 million children aged between 9 months and 15 years, it was the largest such effort anywhere in the world. However, a misinformation campaign was launched as well, spreading fear that the vaccine could affect the learning capacity of children. There were also rumours that the vaccine was targeted against a minority community. But the country's health machinery efficiently stopped the smear campaign with the help of the media and positive messaging from influential personalities.</p> <p>&nbsp;</p> <p>Now, as India continues to strengthen its surveillance, the global fight against rubella has crossed a historic milestone. In October, the World Health Organization declared that, for the first time, over 50 per cent of the world's children are safe from rubella.</p> <p>&nbsp;</p> <p>Rubella in Latin means “little red”—the disease is best characterised by its distinctive red rash. It is spread mainly via droplets of fluid from an infected person's mouth, nose or eyes. The main symptoms of rubella include mild fever, headache, red eyes, aching joints and rashes that begin on the face and then quickly spread to other parts of body. Some patients with rubella experience arthritis in the fingers, wrists and knees. If a pregnant woman gets affected by the virus, it can cause serious birth defects or even death to her unborn child. Up to 80 per cent of infants born to mothers who had rubella during the first 12 weeks of pregnancy develop growth retardation, cataract, deafness, congenital heart defects or intellectual disabilities.</p> <p>&nbsp;</p> <p>Rubella was initially considered a variant of measles since the two illnesses have certain similarities. However, the virus causing rubella is different from the one causing measles. It was first described as a separate disease in 1814, in German medical literature, and hence got its common name “German measles”.</p> <p>&nbsp;</p> <p>Rubella virus was first isolated in 1962. Two teams—one led by American physician Paul Parkman and the other by Nobel laureate Thomas Huckle Weller—were simultaneously trying for that. Both the teams succeeded and both published their results in the same volume of the Proceedings of the Society of Experimental Biology and Medicine. Along with Harry Martin Meyer, a paediatric virologist, Parkman later discovered the first widely accepted test for rubella antibodies and the vaccine against rubella. The first rubella vaccines were licensed in 1969. The vaccine is usually given as a combined measles-mumps-rubella inoculation. Children should receive the MMR vaccine between 12 and 15 months of age, and again between four and six years of age.</p> <p>&nbsp;</p> <p>No treatment will shorten the duration of the viral infection. Those who plan on pregnancy should get the MMR vaccination at least 28 days prior to conception. If already pregnant, vaccination is not possible as the vaccine contains a live version of the virus, and it will affect the child.</p> Fri Nov 01 15:05:55 IST 2019 machine-learnings <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Watson for Oncology, IBM’s supercomputer programme that uses artificial intelligence (AI), hasn’t lived up to much of its hype in India.</p> <p>&nbsp;</p> <p>Watson helps in diagnosis and treatment of cancer. Having ingested around 200 medical textbooks, 300 journals and thousands of research papers, it can select the most effective treatment option for a patient in 60 seconds. Despite the promise it holds, most hospitals in India prefer men over machines.</p> <p>&nbsp;</p> <p>Dr Roy Vergis, however, is hopeful that AI will increasingly be used in health care in future. An honorary consultant clinical oncologist at Mount Vernon Cancer Centre in north London, Vergis says AI has a crucial role to play in cancer care. “Oncology is a very emotional and challenging speciality. It is very complex as well,” he says. “There is going to be more and more data coming out in cancer care. You have a lot of evidence and new trials. It is very difficult for oncologists to keep up in such a scenario. Something like AI will support the oncologists in their practice, help them take better decisions and provide personalised care as well.”</p> <p>&nbsp;</p> <p>Technology facilitates improved diagnosis. Leukaemic cells can be easily detected with AI, says Dr Narayanankutty Warrier, medical director, MVR Cancer Centre and Research Institute, Kozhikode. “It makes the pathologist’s job much easier. AI can be used to distinguish between benign and malignant tumours as well,’’ he says.</p> <p>&nbsp;</p> <p>Oncology is in for exciting times. Advances in technology have changed cancer care in unfathomable ways. Be it an image-based technology to detect lung cancer, chest X-rays, CT scans or MRIs, or machines used to support precision support system, patients derive tremendous benefits from technology.</p> <p>&nbsp;</p> <p>Technology has also made cancer treatment more precise and less toxic, says Dr Prasad Narayanan, senior consultant, medical oncology, Cytecare Cancer Hospitals, Bengaluru. “Early diagnosis is the key for cure. Tumour cell detection in blood or saliva or breath are potential areas in this regard,” he says. “Robotic surgeries, nanotechnology in chemotherapy drug delivery and radiotagging of isotopes for diagnostic and therapeutic effect have also made giant leaps in cancer treatment.’’</p> <p>&nbsp;</p> <p>Dr K.V. Sajeevan, consultant medical oncologist at MVRCCRI, feels blessed to be living in such exciting times. “Earlier, we would depend on basic pathology or baseline investigations like CT scans for cancer diagnosis,” he says. “Now, besides the conventional biopsy, a lot of immunohistochemical markers are being used for diagnosis. It means the proteins that are expressed in some types of cancers can be detected in a better way.”</p> <p>&nbsp;</p> <p>Gene therapy and immunotherapy are gaining momentum in cancer treatment, too. “In immunotherapy, the body’s natural defence cells are being utilised to fight cancer. It has made its impact in lung cancer, stomach cancer and breast cancer,’’ says Sajeevan.</p> <p>&nbsp;</p> <p>There are pathbreaking advancements in radiotherapy as well. Precision radiotherapy, where the tumour cells are targeted with image-guided radiotherapy, is increasingly being used. Proton therapy has been a real game changer. It targets the affected cells, minimising damage to surrounding tissues. Each person’s cancer cells are unique, says Sajeevan. Precision medicine offers customised treatment, taking into account the unique defects in one’s cancer cells.</p> <p>&nbsp;</p> <p>Dr Dinesh Makuny, radiation oncologist at MVRCCRI, suggests AI be used for analysing data and improving treatment outcomes. “For instance, when you give radiation to a patient with cancer on the left breast, a lot of radiation goes through the heart,” he says. “AI should be used to analyse the effect of the radiation on the heart and how it is affecting the mortality of the patient in terms of cardiac diseases later.’’ This involves collecting data on mortality rates of patients with left-sided breast cancer and documenting how many of these were cardiac deaths. “With the help of AI, we can find out the optimal dose,” adds Makuny. “We give a lot of expensive drugs to cancer patients. We should have data on their outcome and the amount of survival benefit the patients are getting.”</p> <p>&nbsp;</p> <p>Makuny defines data as intelligence. “What we lack in oncology is data,” he says. “We should have a data of the cancer problem, the kind of population that is getting affected, the common types of cancer, the kind of treatments being given and the outcomes.” With none of it available, we are only aggregating from the western data, says Makuny.</p> <p>&nbsp;</p> <p>AI can also give inputs on managing and treating certain cancers. “For instance, you want to study a rare tumour. AI will tell you whether a particular stream of treatment would be effective for the tumour,” says Makuny. “AI can also look into patterns of tumour regression and guide doctors. They can intelligently analyse and tell whether a patient is going into a treatment response mode.’’ According to Dr Kumara Swamy, senior consultant and head, radiation oncology, Aster CMI Hospital, Bengaluru, AI can more aptly be called augmented intelligence, rather than artificial intelligence.</p> <p>&nbsp;</p> <p>Do doctors fear that machines will make them redundant? “I suspect they do. There is a natural scepticism,” says Vergis. “When AI was being introduced, my wife who is a doctor as well, used to worry that AI would take away all our jobs. Now that I have been involved in AI for more than a year and a half, I can see that it will only help.” That said, he quickly adds that it is good to have some amount of scepticism. “We have to be careful that AI is introduced in a safe and effective manner,” he says.</p> <p>&nbsp;</p> <p>The fact is that technology is here and a lot of exciting work is happening, says Vergis, but it is difficult to say how it is going to develop and how it is going to improve. “It is rapidly evolving. Some really amazing work has happened in proper deep learning,” he says. “This is where machines will learn from what they have already experienced. That will translate into better outcomes, better decision making, better support systems.”</p> <p>&nbsp;</p> <p>It takes a multidisciplinary effort involving researchers, entrepreneurs, clinicians and technical brains to translate technology into meaningful patient outcomes, observes Narayanan. Advancements in technology are largely inaccessible to the masses in India. The costs could go down when the devices and machines become more adaptable and the volumes increase. Experts hope technology will help save resources and bring down the cost of cancer care in the long run.</p> <p>Is AI smarter than human beings? “It is, in some aspects,” says Vergis. “However, humans are necessary and important because we have empathy and compassion, unlike machines. But AI serves a purpose as well. So, it is more of a synergy rather than replacing [humans with AI].’’</p> Fri Oct 04 19:31:48 IST 2019 spread-no-dread <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Anupama Mishra from Mumbai sums up her CANCON experience as “revealing, enlightening and clarifying”.</p> <p>&nbsp;</p> <p>Mishra’s mother has been suffering from metastatic breast cancer. The 43-year-old attended the conference to gain insights on advances in treatment. “It is important to know your enemy, not just in sports, business and workplace, but also while fighting cancer,’’ says Mishra, the lead singer in a music band.</p> <p>&nbsp;</p> <p>CANCON is an annual conference on oncology conducted by MVR Cancer Centre and Research Institute (MVRCCRI), Kozhikode, Kerala. It attracts delegates from across India and countries like the UK and Japan. The conference has been truly transformational for many.</p> <p>&nbsp;</p> <p>The three-day conference—August 30 to September 1—makes one see the cancer cell in a new light—apparently it is the most evolved and smartest organism on the planet. “We need to try to learn from the cancer cell. It is one step ahead of whatever we are doing,’’ says Dr K. Govind Babu, consultant medical oncologist at HCG Hospitals, Bengaluru.</p> <p>&nbsp;</p> <p>This year, CANCON focused on metastatic cancer. Metastasis happens when a tumour spreads to a site or organ distant from its site of origin, says Dr Narayanankutty Warrier, medical director, MVRCCRI. “A tumour needs nutrition to be able to grow beyond 0.5cm. So, it produces its own blood supply. This process is called neovascularisation,’’ he says. Neovascularisation happens through growth of new blood vessels from major blood vessels near the tumour. “Once the tumour gets blood supply, it starts shedding cells into the blood stream,” says Warrier. “The tumour cells thus reach other organs, causing secondaries or metastasis.’’</p> <p>&nbsp;</p> <p>Any tumour bigger than 0.5cm has the potential to metastasise. Normally, our body controls the division of cells, but malignant tumours have the ability to control their own division. They can either spread directly—the tumour will just grow and push into the next organ—or they can go through the blood stream or metastasise via the lymphatic system.</p> <p>&nbsp;</p> <p>There are some tumours that are more likely to metastasise. “The more common tumours that are likely to affect us are the ones more likely to metastasise,” says UK-based Dr Faheez Mohamed, a general surgeon with special interest in peritoneal malignancies or cancers inside the abdomen. “For instance, bowel cancer, colon cancer, rectal cancer, which are increasingly common among the young population, are likely to spread to the lung and the liver.”</p> <p>&nbsp;</p> <p>In the case of breast cancer, some patients have metastasis only to the lymph glands or bone, some will have it in the liver, abdomen, peritoneum and brain. ‘”Prostate cancer that is very common among men in the west also can metastasise. It can spread through the blood stream of the lymphatic system and then it gets to the liver, lung and the bone,’’ says Mohamed.</p> <p>&nbsp;</p> <p>If diagnosed early, the chances of metastatic cancer would be very less, says Warrier. Ruchika Khanna, a metatstatic cancer survivor from Saket, New Delhi, learnt it the hard way. The 42-year-old squash player’s tryst with cancer began in 2015 when she found a small lump in her right breast. On further medical evaluation, she was diagnosed with stage 2 breast cancer. She underwent a surgery, followed by radiation and chemotherapy and was able to get back to her routine.</p> <p>&nbsp;</p> <p>Three years later, when Khanna had pain in her left shoulder, she mistook it for a random sports injury and consulted a physiotherapist. The pain did not subside despite the physiotherapy. Subsequently, it spread from her left shoulder to the arm. “The pain was so bad that I couldn’t sleep for more than three hours,’’ she recalls. Khanna thought it could be a tissue or ligament tear. A visit to an orthopaedic expert, however, revealed a lesion in her left shoulder, and a PET scan showed two more lesions—one in the pelvic area and the other in the tailbone. “The cancer was caused by an underlying hormonal issue and the odds of recurrence of cancer was high. So, I had to have my ovaries removed,’’ she says. Khanna has been put on hormonal therapy and has now got back on court.</p> <p>&nbsp;</p> <p>The general misconception of people is that once cancer spreads, it is not treatable. “But now quite a few of these patients can have a good [chance at] long-term survival and an excellent quality of life with treatment or one of the modalities like surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy or hormone therapy,’’ says Dr Sanket Mehta, consultant surgical oncologist, Saifee Hospital, Mumbai. “There are so many options within the field of oncology that can give good outcomes in stage 4 cancer.”</p> <p>&nbsp;</p> <p>Two decades ago, Warrier treated a 26-year-old patient with cancer in his testes. The cancer had spread to his stomach, lungs and the brain. “His brother who accompanied him to the hospital had almost given up on him,” recalls Warrier. “I insisted he undergo treatment. I was so happy to hear from him recently. He told me he has two grownup children now. His voice brought back memories.”</p> <p>&nbsp;</p> <p>The survival rate in metastatic cancer was less than ten months earlier. Today, patients live up to five years, says Babu. “One of my patients, a farmer, has finished his five-year followup. He is living normally, doing his work,’’ he says.</p> <p>&nbsp;</p> <p>Mohamed says that a combination of chemotherapy, drugs and infusions into the blood stream along with surgery can give good outcomes for a range of cancers like bowel cancer, rectal cancer and for rare cancers such as appendix cancers.</p> <p>&nbsp;</p> <p>But the road to conquering cancer isn't an easy one. Parul Thukral, 27, would know. The Delhi resident suffered from an aggressive, triple negative breast cancer that had spread to nearby lymph glands. The cancer made its presence felt with breast pain and mass. Thukral had severe pain as the tumour cells were multiplying fast. “The line of treatment adopted was chemotherapy first and then surgery followed by radiation, which were done one by one,’’ says Dr Ramesh Sarin of Indraprastha Apollo Hospital, New Delhi. Thukral and her husband decided not to have children as she was diagnosed with cancer. The couple was counselled to reconsider their decision. “It was ensured that chemotherapy did not destroy the ovarian germ cells,’’ recalls Sarin.</p> <p>&nbsp;</p> <p>Every patient need not get chemotherapy, which has its own side effects. However, most patients with metastatic breast cancer are often treated with chemotherapy. “We are initiating a protocol in India as part of a global study to compare chemotherapy with hormonal therapy in premenopausal women with breast cancer, who are usually given chemotherapy,” says Babu. “This may help us to avoid chemo in these women and thus avoid some distressing side-effects.”</p> <p>&nbsp;</p> <p>Oncology has seen exciting advances in recent times. A group of researchers in Israel has come up with a new ultrasound and freezing probe. The probe is inserted into the tumour, injecting it with liquid nitrogen solution and freezing it. “The tumour crystallises and the cells die,’’ says Babu, adding that this could be useful in oligometastasis, where the metastasis is limited to two or three sites.</p> <p>&nbsp;</p> <p>Oncosurgery has evolved, too. In certain cancers, we have come a full circle, from the ultra-radical surgeries to the conservative ones. For instance, breast cancer treatment previously involved very aggressive surgeries like mastectomy. But now, there are breast-conserving surgeries. “However, in certain cancers like the colon cancer, we have gone from very limited surgeries to aggressive surgeries. Even in stage 4 cancers that spread to the peritoneum, liver or the lungs, we do multiple surgeries and achieve long-term survival,’’ says Mehta. Robotic surgery is coming up in a big way in India. “At the last count, I guess there were some 28 robotic installations in India,’’ he says.</p> <p>&nbsp;</p> <p>Insights into which patient has a propensity to develop metastasis or not can be a game changer. “We are trying to see if we can pick up the circulating tumour cells and study them outside the body,” says Babu. “We will do drug testing and gene signature profiling so we can find out if the patient has a propensity to develop metastasis or not. If there is a propensity, we could perhaps have some intervention—use some particular drug to silence those genes to prevent metastasis.”</p> <p>&nbsp;</p> <p>Advances in the treatment of peritoneal malignancies offer much hope to patients. Some peritoneal cancers can now be treated with radical surgery that comprises of completely removing the tumour combined with hot chemotherapy given directly to the peritoneal cavity—hyperthermic intraperitoneal chemotherapy (HIPEC). “Peritoneum is a thin layer that lines the inner side of the abdominal cavity and the organs contained in it like the liver, stomach and intestines,’’ explains Dr Aditi Bhatt, consultant, department of surgical oncology, Zydus Hospital, Ahmedabad. Generally, cancer spread to the peritoneum is considered stage 4 cancer, and the person affected may survive for a few months to a couple of years with chemotherapy.</p> <p>&nbsp;</p> <p>“Cancers arising from the appendix and some cancers of the peritoneum have been treated with HIPEC with great success,” says Bhatt. “Recently, a benefit of HIPEC has been shown for patients with advanced ovarian cancer and those with stomach cancer. This treatment can enable these patients to live a long and normal life.”</p> <p>&nbsp;</p> <p>Namrata Raha’s story is full of unexpected twists and turns. The 37-year-old from Ranchi had a giant cell tumour in her right hand that progressed to bilateral lung metastasis. “Initially, in 2005, it was just a tumour in the middle finger of my right hand that kept reoccurring, and ultimately my finger was amputated,” she says. Raha was fine after her finger was amputated in September 2008. “But we were never told that it could spread to other organs,’’ says Raha. “I wish my doctor back then had advised me to get a chest X-ray so as to keep a tab on the disease's progression.”</p> <p>&nbsp;</p> <p>One rainy night in September 2010, Raha vomited blood. “It was very traumatic as doctors from a leading private hospital took ten days to diagnose my problem and in the process also did a surgery that could have been easily avoided,” she recalls. In the following months, at a different private hospital, Raha had open surgeries on both sides of the lungs and more than 40 tumours were taken out from each side. Fortunately, they were benign. “I think the fact that I met the right doctor in S.M. Shuaib Zaidi [of Indraprastha Apollo Hospital, Delhi] was critical and lifesaving. I would not have lived to marry and have a blissful life, had it not been for him,” she says.</p> <p>&nbsp;</p> <p>Raha lost a bit of her lung mass, and her recovery time was almost six months. Initially, she had to get a scan done every three months; today it has become a once in a two-year ritual. “Mine was not a case of cancer, but yet I think it is very important that you stick to the regime of followup even after recovery and stay in touch with your doctor because cases like these need to be very closely observed for several years,” she says. “Also, I think trying to stay positive is helpful in recovery. It is not always possible but there is not an equally good second option to help yourself.”</p> <p>&nbsp;</p> <p>Delayed diagnosis is one of the major challenges in India’s battle with cancer. “Around 60 per cent of breast cancer patients in India come with cancer that has spread from the breast to the armpit area. Distant spread of the disease is found in 20 per cent of the patients at presentation,’’ says Dr N. Aditya Murali, consultant, medical and haemato-oncology, Aster CMI Hospital, Bengaluru.</p> <p>&nbsp;</p> <p>Late diagnosis increases the mortality associated with metastatic cancer. In western countries, thanks to the screening programmes, breast cancer is detected early, while it is confined to the breast. By the time Lata Janardanan sought treatment, she had a fairly advanced form of breast cancer with a lump in the breast. On further investigations, it was found her cancer had spread to the lymph nodes and also to one of the backbones. The 50-year-old special needs teacher based in Bengaluru had HER2/neu mutation, a gene mutation that causes breast cancer to present at multiple sites at the same time. Around 20 per cent of breast cancer patients have this mutated gene, which can be turned off with medications. Janardanan was treated with chemotherapy, targeted therapy and radiation to the backbone.</p> <p>&nbsp;</p> <p>Cost is a major factor why metastatic patients don’t usually follow up. Once a patient is diagnosed with cancer, insurance companies deny them coverage. Experts say that it makes sense for people who are genetically predisposed to cancer to invest in a health insurance policy. MVRCCRI, in association with the Calicut City Service Cooperative Bank, has come up with the City Care Scheme, in a bid to provide affordable cancer care and treatment for all. Those who deposit Rs10,000 in the bank will get lifelong cancer treatment coverage of up to Rs5 lakh, provided they have not been diagnosed with cancer at the time of joining the scheme. Anyone can join this scheme and avail free treatment up to the age of 70.</p> <p>Khanna had health insurance while she was diagnosed with cancer. However, only half of her treatment expenses were covered by her policy. “Despite having health insurance, only half of my expenses were covered during surgery, radiation and the tests stages. Rest was all paid by me,’’ she says. The entire expense of hormonal therapy was also paid by her.</p> <p>&nbsp;</p> <p>Despite hurdles, Khanna's strong will made the journey of treatment much easier, says Dr Harit Chaturvedi, chairman, Max Institute of Cancer Care, Delhi. Cancer has been a life changing experience for her. “It can be a great motivator that constantly reminds you to do things you love right now than later,”says Khanna. “It makes you realise the fragility of life—that nothing can be taken for granted. Every morning I wake up, I thank God for letting me experience yet another day. That is, in its own way, a beautiful experience. And I am glad that I am able to fight it till now.’’ Cancer also made her realise that no matter how busy our lives are, we must find time to listen to our bodies and prioritise that over everything else. “Always believe you are much bigger and stronger than the disease itself,” she says. “Half your battle is won then.”</p> <p>&nbsp;</p> <p><i><b>Some names have been changed.</b></i></p> Fri Oct 04 19:22:41 IST 2019 ban-is-not-enough <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>There are two central arguments made in favour of the ban on e-cigarettes. The first is that it targets adolescents, and evidence suggest this to be true. E-cigarettes are being sold in various flavours, and being advertised as a safe alternative to smoking tobacco. This is unfortunate as decades of work done in the field of discouraging smoking are bearing fruit, especially in developed nations, and e-cigarettes have the potential to negate all such efforts.</p> <p>&nbsp;</p> <p>A recent study revealed that 9 per cent of eighth graders and 25 per cent of 12th graders in the US had vaped last month (the corresponding prevalence in 2017 was 3.5 and 11 per cent, respectively). Studies have also indicated that a significant proportion of adolescents who vape will eventually switch to smoking tobacco. Vaping thus has the potential of being a gateway drug—the absence of which may have prevented an individual from smoking. Not being confident of enforcing a regulation on the sale of e-cigarettes to minors, the government's ban is a step in the right direction.</p> <p>&nbsp;</p> <p>The second argument revolves around the safety of e-cigarettes. Emerging data suggest that e-cigarettes potentially blunt the defence mechanisms in the lung, cause certain biochemical reactions in lung tissue—that are akin to those caused by cigarettes—and contain volatile organic compounds that could potentially be carcinogenic.</p> <p>&nbsp;</p> <p>There is an epidemic of vaping-associated deaths and ICU admissions that is presently being investigated in the US. However, the initial data suggest that these were caused by street-made and modified products (including those spiked with cannabis), and blaming all e-cigarettes in this instance might be analogous to blaming all alcohol sold for the ill-effects of spurious liquor. While most experts agree that it is premature to endorse the safety of e-cigarettes, none would consider them as dangerous as smoking tobacco. There is a consensus that switching to e-cigarettes is a harm-reduction strategy for individuals addicted to nicotine from cigarettes. Depriving them of such a strategy, while the sale of cigarettes continues unfettered is paradoxical.</p> <p>&nbsp;</p> <p>I run a clinic that helps individuals quit smoking. Most individuals are self-referred, and have had multiple quit attempts before consulting me, highlighting the power that nicotine addiction has over individuals. We now have medicines and strategies that can help individuals quit, but most individuals who smoke do not have access to such services.</p> <p>&nbsp;</p> <p>The move to ban e-cigarettes is welcome, but it needs to be coupled with services that help individuals quit smoking. This is especially true for adults who have successfully quit smoking with the aid of e-cigarettes. Without any support, they will be thrown back into a world where their only access to a substance they are addicted to is through the route of smoking or chewing tobacco.</p> Fri Oct 04 17:09:19 IST 2019 the-worry-over-vaping <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It is an argument that swings between two extremes. According to the Union health ministry, which banned e-cigarettes on September 18, they are not a safe alternative. Citing “available literature”, ministry officials have argued that these may act as “gateway products” among non-smokers, especially youth and adolescents, leading to use of conventional tobacco products. The government has also contended that though the use of electronic cigarettes as cessation aids is being promoted, their safety and efficacy have not yet been established. According to an ICMR white paper on Electronic Nicotine Delivery System published in May in the Indian Journal of Medical Research, e-cigarettes contain “highly addictive” nicotine solution and flavouring agents, and vapourisers, which are “harmful for health”. The authors of the paper also argue that the use of e-cigarettes has documented adverse effects such as “DNA damage, carcinogenesis, cellular, molecular and immunological toxicity, respiratory, cardiovascular and neurological disorders and adverse impact on foetal development and pregnancy”.</p> <p>&nbsp;</p> <p>Vapers, however, say the ban has forced them into a “quit or die” situation. Take the case of South Delhi entrepreneur Kanav Rishi Kumar, 30. He took to smoking at 17. Kumar was able to quit cigarettes in January 2015 with the help of e-cigarettes. “It seems that the government is willing to risk my health and well-being in the name of someone who may or may not take up cigarette smoking after using e-cigarettes,” he says, adding that the ban has left the vaping community “upset” and “panicky”. Kumar, who was smoking a pack a day before quitting, says vaping made him feel much better, cleaner, and helped him to regain lost stamina and lung power. When he bought his first vaping device in December 2014, it cost him 04,000 plus 050 to 0100 per day for the liquid. “For the first month or so, I was using both the vaping device and cigarettes,” he says. “After that I was comfortable with vaping.”</p> <p>&nbsp;</p> <p>Until the recent ban, he had not even considered going back to cigarettes, and had even reduced his nicotine dose in the device (from 18mg/ml to 6mg/ml). “Even as the news of the ban was playing on TV, I rushed to the market and bought as much vaping liquid as I possibly could. I think my stock might last until February,” he says. Others in the vaping community were considering buying from overseas. Those who may not be able to do so will end up switching back to cigarettes, he said. Samrat Chowdhery, founder-director of Council for Harm Reduced Alternatives (CHRA) and Association of Vapers of India, says that while smoking has been declining in the last two decades, the rate of decline has increased by three to four times in countries where vaping is allowed. “The US now has the lowest recorded smoking prevalence,” he says.</p> <p>&nbsp;</p> <p>Before the ban, the vaping industry had also been advocating “harm reduction” and “quitting aid” as advantages of using e-cigarettes. An independent expert on addiction medicine, who did not wish to be identified, told THE WEEK that while there was enough anecdotal evidence on the use of e-cigarettes as a quitting tool, proper studies/clinical trials on the subject had not yet been done. “What has been established scientifically is that these products pose a lower risk than e-cigarettes, and are safer, ” he says. The expert said that the argument of the government and a section of the medical fraternity that all citizens should be free of nicotine addiction is purely moral. He also cited the heavy use of e-cigarettes in hospitals in the UK.</p> <p>&nbsp;</p> <p>Says Chowdhery: “The UK now has the lowest number of smokers in Europe, and going by the decline in smoking, the country is aiming to be smoking-free by 2030.”</p> <p>&nbsp;</p> <p>In the US, there is currently a backlash against vaping because of the rising number of cases of people who have developed severe lung illnesses after using vaping devices filled with tetrahydrocannabinol (the main active ingredient of cannabis) and nicotine. At least 530 cases and nine deaths have been reported in the American press; the cause of the illnesses and deaths have not been officially identified yet. While the state of Massachusetts has introduced a four-month ban, New York has banned most flavours of e-cigarettes barring menthol and tobacco, and California is planning to regulate e-cigarettes with new health warnings, awareness campaigns and weeding out of counterfeit products.</p> <p>&nbsp;</p> <p>The adverse events caused by vaping have more to do with contaminated liquids in the devices, and not the standard e-cigarette concoction, says the medical expert. Those in support of vaping devices invoke the analogy of the device itself as “a glass”, one that could be filled with anything—water, milk, alcohol or as Kumar says, “even poison”—and argue for the need for regulation, rather than a blanket ban. The expert also says that while the government was right in fearing its use among youth and young adults, a complete ban would give grey market sellers an opportunity to push other illegal substances such as cocaine and heroin, too.</p> <p>&nbsp;</p> <p>Kumar agrees, and adds: “The worst hit will be young professionals, typically in their early 20s, who were using vaping devices. Majority of them would not have the time, resources or even access to procure it from other sources. The ban will only push them to smoke cigarettes, and it clearly seems like the government does not care about their lives.”</p> Fri Oct 04 17:06:44 IST 2019 art-of-birth <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>On September 5, Erramatti Mangayamma, 74, and her husband Raja Rao, 80, became the world's oldest parents. Mangayamma had twin girls at the Ahalya Nursing Home in Guntur, Andhra Pradesh, following in-vitro fertilisation (IVF) treatment.</p> <p>&nbsp;</p> <p>While it brought joy to the parents, the news perplexed many medical professionals—they wondered why IVF was administered to such an elderly couple. Many others asked: “What will become of the children in the future?” The Union government is all set to introduce the Assisted Reproduction Technology (Regulation) Bill in the next Parliament session. The bill proposes a 50-year age limit for women seeking IVF to get pregnant.</p> <p>&nbsp;</p> <p>It is estimated that one in six Indian couples is infertile. Factors like low sperm count, infections and erectile dysfunction in males, and damaged fallopian tubes, ovulation disorders, endometriosis (a disorder in which tissue that normally lines the uterus grows outside the uterus) and problems in menstrual cycle in females are the main causes of infertility. Lifestyle changes also adversely affect fertility. In-vitro fertilisation is the most common and effective type of assisted reproductive technology used to treat infertility. IVF is a process in which the ovum (female reproductive cell) is combined with a man's sperm cells outside the body, and the fertilised egg is then implanted in the uterus.</p> <p>&nbsp;</p> <p>The IVF procedure starts with a hormonal treatment to stimulate egg production in the woman. Multiple eggs collected from the ovaries are then mixed with the sperm cells in a culture dish to facilitate fertilisation. The embryos (fertilised eggs) formed are kept in incubators for two days and are transferred back to the ovary for normal growth.</p> <p>&nbsp;</p> <p>More than eight million births have been recorded via IVF process since the world's first in 1978. A recent study by Centre for Reproductive and Genetic Health, London, showed that clinical pregnancy rate declines with maternal age over 35 years—from 51.1 per cent for under-35s to 21.7 for over-40s. The study, which was based on 4,833 IVF cycles between 2009 and 2018, found that pregnancy rate declines with increasing paternal age, too—from 49.9 per cent in the under 35 group to 30.5 per cent in the over 51s. There has been no comprehensive study on the success rate of IVF in India.</p> <p>&nbsp;</p> <p>Louise Brown, born on July 25, 1978, in Oldham, England, is the first baby to be conceived through IVF. English physiologist Robert Edwards and gynaecologist Patrick Steptoe pioneered the conception through IVF. The second ‘test tube’ baby, Durga aka Kanupriya Agarwal, was born in India on October 3, 1978—just 67 days after Louise was born. But her creator Dr Subhash Mukhopadhyay did not get recognition. The government did not allow him to share his achievements with the world. In 1981, he committed suicide in Kolkata. The physician’s work was finally recognised in 2002 by the Indian Council of Medical Research.</p> Fri Oct 04 16:51:13 IST 2019 elephant-in-the-workroom <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Mental health issues affect corporate employees across all levels and age. We may choose to live in denial or ignorance, but an employee’s mental health has a direct impact on office dynamics, inter-personal/client relationships, overall productivity and even innovation and problem-solving.</p> <p>&nbsp;</p> <p>Competition, deadlines and the constant need to perform better result in employees feeling exhausted, anxious and insecure. For those who are already stressed or experiencing burnout, even simple tasks like attending a meeting, scheduling or engaging in a conversation are a challenge. Therefore, they may come across as under-confident or incompetent.</p> <p>&nbsp;</p> <p>A World Health Organization study estimates an approximate global loss of $1 trillion in productivity because a large chunk of the global workforce suffers from depression and anxiety-related disorders.</p> <p>&nbsp;</p> <p>On average, Indians work a 52-hour week, one of the highest in the world. This is directly linked to the fact that 80 per cent of corporate employees in India showed symptoms of anxiety-related disorders and 55 per cent showed signs of depressive disorders. According to Optum, 46 per cent of the Indian workforce is also known to experience stress-related issues like fatigue, weakened immune systems, insomnia and other cognitive issues.</p> <p>&nbsp;</p> <p>The sad reality is that because of the stigma attached with mental illness, employees suffering from depression or anxiety fear discrimination and even job loss. Because of this, most of them single themselves out, which affects team dynamics and work output, and might lead to an uncomfortable or toxic atmosphere at work. Others might see them as unapproachable or irritable. It is important for organisations to institute policies that minimise the rise of mental illnesses and to provide support to those who need help.</p> <p>&nbsp;</p> <p>The cause of anxiety or depression in a workplace can be a single factor or combination of factors like relationship problems with superiors, bureaucratic constraints, work-family conflict, issues with colleagues, performance pressure, poor job prospects or feeling undervalued.</p> <p>&nbsp;</p> <p>According to the Journal of Occupational and Environmental Medicine, apart from a significant economic loss, there are indirect effects of mental health issues in employees, such as “increased short-term disability, safety incidents, absenteeism and presenteeism (working while sick), underperformance, stress imposed on team members, overstaffing to cover sick-day absences, and hiring costs related to recruitment and retention”.</p> <p>&nbsp;</p> <p>There are many initiatives an organisation may take to address the mental well-being of its employees. A study by the WHO estimates that for every $1 you spend on common mental disorders, there is a $4 return in improved health and productivity of your employees.</p> <p>&nbsp;</p> <p>Statistics show that India is one of the most depressed countries in the world. It indicates how we as a country address mental health. The implementation of the Mental Health Care Act 2017 is an active effort to provide treatment for mental illness while ensuring that those impacted are not discriminated against by the government or any other institutions. However, this does not imply that anyone is forced to disclose mental health issues they are facing. It is up to the employer to create a safe space so that anyone can talk about their issues.</p> <p>&nbsp;</p> <p><b>To better address and manage mental health issues, an employer can:</b></p> <p>&nbsp;</p> <p>● Offer flexible hours, which gives the employee the flexibility to manage his or her schedule. This can be a protective factor.</p> <p>● Ensure that the right person performs the right job, to ensure maximum productivity. It helps bridge the gap between the job and what the employee has to offer, thereby maintaining higher levels of productivity.</p> <p>● Address negative workplace dynamics and office politics, which can cause a lowered sense of satisfaction at work, in addition to stress. Lowering these would ensure a more conducive work atmosphere.</p> <p>● Provide supportive and confidential communication with management, which can help people with mental disorders continue to or return to work.</p> <p>● Construct a programme for employees suffering from common mental health disorders, to provide them regular support at the workplace.</p> <p>&nbsp;</p> <p>Give employees an environment where they can talk openly about mental health issues. This can greatly reduce long-term effects. Support from employers and small changes in the workplace environment can support and enable people suffering from mental health issues to take timely help, which results in happier and more productive employees.</p> <p>&nbsp;</p> <p><b>The writer is chairperson, board of trustees, Live Love Laugh Foundation.</b></p> Sat Sep 14 16:56:57 IST 2019 capping-a-scandal <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>We are in big trouble,” [Rajinder] Kumar [director, research &amp; development, 2004-2005, Ranbaxy] said to [Dinesh] Thakur [director and global head of research information and portfolio management] intently as they returned and then motioned for him to be quiet. In his office, Kumar handed Thakur a report from the World Health Organization (WHO). It summarized the results of an inspection that the WHO had conducted at Vimta Labs Ltd., a company that Ranbaxy had hired to administer clinical tests of its AIDS medicine. The WHO had done the inspection on behalf of the South African government, which was buying Ranbaxy’s antiretroviral (ARV) drugs to treat its AIDS-ravaged population.</p> <p>&nbsp;</p> <p>The inspection, conducted by a French inspector named Olivier LeBlaye, had uncovered astonishing fraud. Many of the “patients” Vimta had enrolled in the study did not seem to exist. Much of the data purporting to measure the drugs’ dissolution in the patients’ blood appeared to have been fabricated. The graphs from tests on entirely different patients were identical, as though photocopied. As Thakur read, his jaw dropped. There could be no assurance that the medicine had even been given to actual patients, owing to the lack of documentation. And there was no evidence that Ranbaxy had monitored the work or audited the results, as was required. This level of fraud meant that the drugs—destined for terribly sick AIDS patients—had essentially been untested.</p> <p>&nbsp;</p> <p>With the company’s credibility on the line, Dr. Tempest [CEO and managing diretor, 2004-2005, Ranbaxy] had sent Kumar to reassure South Africa’s drug regulators that the situation at Vimta was isolated. Once there, however, Kumar went further, assuring the South Africans that he would do a full review of the antiretroviral portfolio and redo patient tests if need be.</p> <p>&nbsp;</p> <p>Thakur listened intently as Kumar spoke. On the plane back to India, Kumar’s traveling companion, the director of bioequivalence studies for the company’s entire generic portfolio, told him that the problem was not limited to Vimta or to the ARVs.</p> <p>&nbsp;</p> <p>“What do you mean?” asked Thakur, barely able to grasp Kumar’s point.</p> <p>&nbsp;</p> <p>The problem went deeper, said Kumar. He told Thakur that he wanted him to put aside all his other responsibilities for the foreseeable future, go through the company’s entire portfolio—every market, every product, every production line—and determine what was real, what was fake, and where Ranbaxy’s liabilities lay. Kumar then asked him to check in by day’s end, as they set this plan in motion.</p> <p>&nbsp;</p> <p>Thakur left Kumar’s office stunned. Were more of Ranbaxy’s drugs compromised? If so, how could the company have gotten approvals from the FDA, the world’s toughest drug regulator?</p> <p>&nbsp;</p> <p>As directed, he returned at the end of the day, but Kumar was not in. Thakur waited. Finally, Kumar arrived, looking visibly upset. Without a word, he sat at his desk and worked intently for twenty minutes before finally looking up. “I need a drink,” he said darkly. Kumar explained that he’d spent the day fighting with the corporate office over what to do with the fraudulently tested ARV drugs. Kumar had insisted that there was only one right course: to withdraw the drugs from the market immediately and conduct the biostudies properly.</p> <p>&nbsp;</p> <p>Though the corporate office had initially agreed, it drafted a press release stating only that Ranbaxy would look into the problem. Kumar revised the draft to state that the company was pulling the drugs off the market, effective immediately. But corporate kept returning the initial, vaguely worded press release for his approval. He sent back his revision again. “I am a physician, and I cannot sign off on something knowing full well it will cause harm to patients,” Kumar declared. “I don’t care how much money or face Ranbaxy loses. Either this stuff comes off the market or I am gone.” Thakur did not want to contemplate losing another boss—especially one he liked so much.</p> <p>&nbsp;</p> <p>Thakur later returned home to find his three-year-old son, Ishan, playing on the front lawn. He suddenly recalled an incident from the previous year when the boy had developed a serious ear infection. The pediatrician prescribed Ranbaxy’s version of Amoxyclav, a powerful antibiotic. Despite his son’s taking it for three days, the boy’s 102-degree fever persisted. So the pediatrician changed the prescription to the brand-name antibiotic made by GlaxoSmithKline. Within a day, Ishan’s fever was gone. Thakur took the boy in his arms, resolving not to give his family any more Ranbaxy medicine until he knew the truth.</p> <p>&nbsp;</p> <p>****</p> <p>&nbsp;</p> <p>On October 14, 2004, several months after assigning Thakur to dig up the truth, Kumar stood in the boardroom at Ranbaxy’s corporate headquarters in New Delhi, facing members of the scientific committee of the board of directors. His audience included Brian Tempest; Malvinder Singh, then president of pharmaceuticals; the board chairman, Tejendra Khanna, who had served as the lieutenant governor of New Delhi; Dr. P. S. Joshi, a prominent cardiologist; and several others. The company secretary was asked to leave the room.</p> <p>&nbsp;</p> <p>Kumar showed the men a PowerPoint of twenty-four slides that Thakur had prepared. It was entitled “Risk Management for ANDA Portfolio.” To some extent, it was a work-in-progress, as it still did not contain U.S. market data. But the presentation made clear that in its race for profit, Ranbaxy had lied to regulators, falsified data, and endangered patient safety in almost every country where it sold drugs. “More than 200 products in more than 40 countries [had] elements of data that were fabricated to support business needs,” the PowerPoint stated. “Business needs,” the report showed, was a euphemism for ways in which Ranbaxy could minimize cost, maximize profit, and dupe regulators into approving substandard drugs.</p> <p>&nbsp;</p> <p>No market or type of drug was exempt, including antiretrovirals purchased by the United States and the World Health Organization to fight HIV in Africa. In Europe, the company used ingredients from unapproved sources, invented shelf-life data, tested different formulations of the drug than the ones it sold, and made undocumented changes to the manufacturing process. The PowerPoint also noted that the fallout from the Vimta audit, which had initially taken Kumar to South Africa, was already drawing the attention of regulators and could do further damage to the company’s reputation.</p> <p>&nbsp;</p> <p>In entire markets—including Brazil, Kenya, Ethiopia, Uganda, Egypt, Myanmar, Thailand, Vietnam, Peru, and the Dominican Republic—the company had simply invented all the data. Noting a corporate agreement to manufacture some drugs for brand-name companies, a slide stated, “We have also put our partners (Bayer &amp; Merck in Mexico and in South Africa) at risk by using suspect data in our dossiers.”</p> <p>&nbsp;</p> <p>Kumar proposed a drastic course: pull all compromised drugs off the market; repeat all suspect tests; inform regulators of every case of switched data; and create a process for linking the right data to the right drugs. A slide entitled “Guiding Principles” laid out what Kumar considered to be the company’s obligations: “Patient safety is our first responsibility. Our products have to be proven safe and effective. A short-term loss of revenue is better than a long-term losing proposition for the entire business.”</p> <p>&nbsp;</p> <p>Kumar completed the presentation to a silent boardroom. Only one director, a scientist, expressed any surprise about the findings. The others appeared more astonished by Kumar’s declaration that if he was not given full authority to fix the problems, he would resign.</p> <p>&nbsp;</p> <p>“Can you not bury the data?” one of the board members turned to ask Tempest. No one responded. The silence told Kumar everything he needed to know. Tempest asked for every copy of the PowerPoint to be destroyed and for the laptop on which it was created to be broken down piece by piece. No minutes of the meeting had been created.</p> <p>&nbsp;</p> <p>Kumar had been certain that Ranbaxy would have to do the right thing after seeing incontrovertible proof that it had done the wrong thing for so long. Instead, within two days of the board meeting, Kumar submitted his resignation. He had been at Ranbaxy for less than four months. “Given the serious nature of the issues we discussed,” he wrote to Tempest, his only choice was to withdraw “gracefully but immediately.”</p> <p>&nbsp;</p> <p>But the specter of Kumar’s PowerPoint, one of the most damning internal documents ever created by a company executive, would divide the executives for years to come. Inside the company, it would come to be known as “the SAR” (for Self-Assessment Report). The incriminating document was like a slow-burning fuse, headed straight toward the company’s top executives.</p> <p>&nbsp;</p> <p><b>Extracted with permission from Juggernaut Books.</b></p> Tue Aug 20 11:50:57 IST 2019 in-the-end-the-book-and-truth-won-out <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>Two years ago, the prime minister of India said that doctors should prescribe generic drugs for Indian patients. How do you see the quality affecting patients in India? How is it any different when it comes to US patients?</b></p> <p>&nbsp;</p> <p>My book exposes how a number of generic drug companies routinely alter their manufacturing standards and the quality of their drugs, depending on the vigilance of regulators in the markets to which they are selling. They sell drugs of lower quality in less regulated markets, which includes India.</p> <p>&nbsp;</p> <p>The practice is so widespread that it has a name: dual-track production. This is not just a question of companies following different standards, based on those set by a country’s regulators, but rather flouting standards with impunity in making drugs with lower-quality ingredients and fewer manufacturing steps, or simply fabricating testing data.</p> <p>&nbsp;</p> <p>That is bad news for patients in India, where some companies do not even feel compelled to actually test drugs or submit authentic data for Indian regulators. The result is a drug supply of very uneven quality, where the safety and efficacy of each dose is far from guaranteed.</p> <p>&nbsp;</p> <p><b>When it comes to medical devices, too, questions have been raised on the ways in which FDA assessments might be compromised, endangering the safety of patients. What changes do you think the FDA should bring about to ensure quality?</b></p> <p>&nbsp;</p> <p>The problem now is that the FDA is regulating overseas drug plants largely on an honour system. It is reviewing data submitted by companies, and conducting inspections after giving the manufacturing plants weeks of advanced notice that its investigators will be arriving. That allows the plants to stage inspections and create a façade of compliance. Plants will invent data, fabricate documents, conceal offline equipment and clean up lizard and bird infestations.</p> <p>&nbsp;</p> <p>The FDA’s top officials like to talk about promoting a culture of compliance, in which companies willingly raise their own standards. But that simply doesn’t happen without the threat of regular, unannounced inspections that require compliance 24/7.</p> <p>&nbsp;</p> <p><b>How has the FDA responded to the serious allegations in your book?</b></p> <p>&nbsp;</p> <p>The FDA’s position has long been, and continues to be, that it has an effective inspection and oversight system. However, the US Congress has grown sceptical of these claims, and appears to be gearing up to do some real oversight, which, of course, is its designated role. In June, a month after the release of Bottle of Lies, a Congressional committee sent a letter to the FDA, asking questions about its regulation of overseas drug plants.</p> <p>&nbsp;</p> <p><b>How long did you work on the project? Could you recall a particularly challenging moment during your investigation?</b></p> <p>&nbsp;</p> <p>I reported on the generic drug industry for a decade, with the last five years specifically spent on the book. Along the way, there were numerous challenges. The first came early on, essentially with the premise of the project.</p> <p>&nbsp;</p> <p>My reporting began in 2008, when I was contacted by the co-host of a US radio show, The People’s Pharmacy. He said that patients were contacting him with complaints about side-effects from their generic drugs, and he posed a question to investigate: what is wrong with the drugs? It quickly became apparent to me that just documenting patient concerns would not get me very far in answering that question. I realised the answers most likely lay in the manufacturing plants and boardrooms of the companies making our drugs, which meant in India and China. So that was the first challenge: how was I, an independent journalist without a newsroom, a team of colleagues or other resources at my disposal, going to undertake a project like that? The answer was: with great difficulty.</p> <p>&nbsp;</p> <p>The other challenges along the way stemmed from that initial one. Warned of safety risks in India, I tried to meet sources only in public places. In China, I was followed by government security officials, who, in one instance, commandeered the home screen of my iPhone to send me a message that I was being watched: a picture of a security official seated in my hotel lobby, holding up an English language newspaper. I met a reluctant whistleblower from one company in a bar in Mexico City, and he ultimately gave me important documents. The reporting was like that: global in scope, painstaking, and trying to convince one source at a time to cooperate and share information.</p> <p>&nbsp;</p> <p>In the run-up to publication, the threats were legal ones, from companies who were trying to intimidate me and my American publisher into not including all the information we had. But in the end, I am happy to say, the book and the truth won out.</p> <p>&nbsp;</p> <p><b>The world, including the US, needs more generic drugs that are safe, cheap and accessible. At this point, what do you think are the biggest hindrances in making that possible?</b></p> <p>&nbsp;</p> <p>To some extent, the pathway to affordability is clear. The model, used during the height of the AIDS crisis, is for governments to unite in aggregating purchases, so that low-cost manufacturers can achieve sales in large volume. The problem is really with how we can guarantee quality when companies are willfully undercutting their own products in order to increase profits.</p> <p>&nbsp;</p> <p>The big purchasers—The Global Fund to Fight AIDS, Tuberculosis and Malaria and The President's Emergency Plan For AIDS Relief—must provide stronger incentives for quality, while regulators must increase their vigilance. Regular unannounced inspections at manufacturing plants, coupled with routine surveillance testing of drugs on the market, are required to ensure compliance.</p> <p>&nbsp;</p> <p><b>Besides drugs safety, do you think patents are also a big issue when it comes to developing countries having access to generics?</b></p> <p>&nbsp;</p> <p>Bottle of Lies does not delve into the patent issues so much, but they certainly can be a barrier. History offers one model for how to overcome that problem, in extreme circumstances. During the height of the AIDS crisis, so much public pressure was brought to bear on big pharma companies that they were forced to waive their patents so that generic drugs companies like Cipla could step in to manufacture the AIDS cocktail. As the multinational companies expand into the generic sector, I would like to think that, in the future, patents will serve as less of a barrier.</p> Tue Aug 20 11:45:30 IST 2019 bitter-battle <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Insulin vials contaminated with “black, metallic particles”, improperly sealed caps of drugs used for chemotherapy, garbage bags full of incriminating reports, and data manipulation to get over the United States Food and Drug Administration's regulatory requirements—journalist Katherine Eban's Bottle of Lies: Ranbaxy and the Dark Side of Indian Pharma lists these and more instances of USFDA violations found inside manufacturing plants of certain generic drug manufacturers in India.</p> <p>&nbsp;</p> <p>Eban focuses on the Ranbaxy case that unfolded a decade ago, triggered by the revelations made by Dinesh Thakur, a senior employee of the company who later turned into a whistleblower for the USFDA.</p> <p>&nbsp;</p> <p>After the scandal broke out, Ranbaxy Laboratories ceased to exist—Daiichi Sankyo sold the company to Sun Pharma. Subsequently, former Ranbaxy CEO Malvinder Singh and his brother Shivinder Singh were caught in a high-strung legal battle with Daiichi Sankyo (the Japanese drugmaker took them to court for allegedly concealing information during the sale of Ranbaxy).</p> <p>&nbsp;</p> <p>Last year, the Singh brothers courted another controversy—they were accused of diverting funds from Fortis Healthcare, also a family-held business, to their personal accounts.</p> <p>&nbsp;</p> <p>The instances mentioned in Eban's book, however, go well beyond Ranbaxy. She cites cases where USFDA inspectors found lapses in the facilities of Wockhardt, Dr Reddy's and RPG Life Sciences. This has rekindled the issue of drug quality and lack of regulations in the generic drug industry, particularly in India and China.</p> <p>&nbsp;</p> <p>India is the largest provider of generic drugs globally. Predictably, the narrative of lack of regulation and poor quality has left the Indian pharma industry frothing at the mouth. According to the Indian Drug Manufacturers Association (IDMA), the industry exports generic medicines worth $19 billion to 200 countries, and supplies 40 per cent of the generic drugs consumed in the US.</p> <p>&nbsp;</p> <p>Pharma lobby groups have dismissed the claims in the book, calling the Ranbaxy case “history”. “You can't take a few instances from the past, and use it to malign the whole industry,” says Sudarshan Jain, secretary general, Indian Pharmaceutical Association (IPA).</p> <p>&nbsp;</p> <p>The IPA is a representative body of 23 research-based national pharmaceutical companies. Its members account for “over 85 per cent of the private sector investment in pharmaceutical research and development”, more than 80 per cent of the country’s exports of drugs and pharmaceuticals, and over 57 per cent of the domestic market. The IPA has termed the instances mentioned in the book as “dated”, “fed on half-truths” and drawing on historic information of select cases. “These are far from the current situation,” insists Jain.</p> <p>&nbsp;</p> <p>According to the IPA, the Indian pharmaceutical industry supplies over 60 per cent of global demand for various vaccines and antiretroviral drug supplies, 30 per cent of the annual supply of the United Nations International Children's Emergency Fund globally and about 60-80 per cent of the UN's purchases of drugs. India also contributes 57 per cent of active pharmaceutical ingredients and 69 per cent of finished pharma products to the pre-qualified list of the WHO. “This shows the trust millions of people have in the high-quality, safe and efficacious drugs manufactured by the Indian pharmaceutical companies,” says Jain. “If we are so bad, why are all these agencies still buying from us?”</p> <p>&nbsp;</p> <p>The generic drugs that Indian companies manufacture undergo rigorous procedures to ensure the same quality standards as those of originator drugs, says Jain, adding that the industry had also taken several steps to enhance quality, including rigorous guidelines that were being followed. “Our industry received 290 final ANDA approvals [Abbreviated New Drug Application contains data submitted to FDA for the review and potential approval of a generic drug product] from the USFDA in 2018,” says Jain. “These approvals were received after due diligence and have contributed to an estimated saving of over $80 billion in 2017 [for the US].”</p> <p>&nbsp;</p> <p>In a statement, the IDMA says that the allegations made in the book are “biased” and that the Indian drug regulator was doing a “commendable job”. “What happened in the Ranbaxy case... such aberrations have been rectified. It is not that things don't happen in the US; many drugs manufactured in the US are on the USFDA's recall list,” said a representative of the pharma industry. “It is our generic industry, the small companies, that provide affordable drugs to remote areas of the country, not the MNCs. Also, our pharmacopoeia is better than that of other nations. How can you discredit the entire industry because of a few examples?”</p> <p>&nbsp;</p> <p>Srividhya Ragavan, professor of law, Texas A&amp;M University School of Law, who works on international trade law and intellectual property issues, says that in the US, the general rhetoric and dialogue seems to be prejudiced against generics by highlighting the issues [with the drugs] while carefully leaving out the economic and therapeutic benefits of these medications.</p> <p>&nbsp;</p> <p>On the issue of USFDA inspections at Indian pharma companies, Ragavan says that its inspections of foreign-based facilities could be construed as an “administrative overreach”, given that there is no international instrument that made US manufacturing practices the global standard. Also, “more than half (55 per cent) of the human drug CGMP (current good manufacturing practice) surveillance inspections were conducted at facilities outside the US,” says Ragavan. The better option, she says, is to have a global agency that uses standard international principles and conducts inspections in all jurisdictions, including the US.</p> Sat Aug 24 15:41:26 IST 2019 medical-advancements-bring-respite-to-patients <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Tobacco is a powerful trigger for bronchial asthma symptoms. Exposure to environmental tobacco smoke, be it active or passive, the advisory “smoking is injurious to health” holds true in all cases.</p> <p>&nbsp;</p> <p>Lokesh, 65, has had bronchial asthma almost all his life. He recalls being 17 when he started smoking. The same year he was hospitalised because of breathlessness and cough. His reports revealed that he had severe bronchial asthma that aggravated owing to tobacco. When medicines did not help, the doctor suggested he opt for bronchial thermoplasty (BT).</p> <p>&nbsp;</p> <p>Bronchial asthma is a chronic inflammatory disease of the airways that causes periodic attacks of wheezing, coughing, chest tightness and shortness of breath. When diagnosed with severe asthma, the patient's condition does not get better with usual medicines, and she needs specialist care and support.</p> <p>&nbsp;</p> <p>According to reports by the World Health Organization, the tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 8 million people a year. Of these, 7 million deaths are owing to direct tobacco use, while around 1.2 million are the result of non-smokers being exposed to secondhand smoke.</p> <p>&nbsp;</p> <p>Tobacco is not healthy in any form. It is estimated that one person dies of tobacco-related disease every six seconds. Tobacco contains more than 200 harmful chemicals, including tar and nicotine that are carcinogenic and cause cancer of the mouth, throat, lung and bladder.</p> <p>&nbsp;</p> <p>While we witness a surge in the number of smokers and thereby the number of severe asthma patients, the development of newer therapies like BT give hope of a better quality of life to patients. BT is a minimally invasive and non-drug procedure used to treat patients, who are 18 years or older, suffering from severe asthma. The procedure can only be carried on patients who are already on oral steroids for asthma exacerbations, ones who use inhalers more than twice a week and who have physical activity limitations because of asthma.</p> <p>&nbsp;</p> <p>BT is carried out in three parts, scheduled three weeks apart. Each session is performed under moderate sedation and takes less than an hour to complete. BT procedure is not for patients who have an active implant device or known sensitivity to medications used in bronchoscopy. A thin catheter is introduced in the patient’s airway through a bronchoscope, and pushed to the end of the airway. It slowly heats up the area and contracts the expanded smooth muscles. This is withdrawn after every ten seconds from the airway. When the airways broaden, it becomes easy for the person to breathe, reducing asthma attacks.</p> <p>&nbsp;</p> <p>Passive smokers get more affected as there is a lack of awareness. Secondhand smoke is one of the leading causes of asthma in non-smokers. Tobacco smoke inside a room stays in the air rather than dispersing, therefore people smoking indoors create a low-lying smoke cloud that is inhaled by others around them. Tobacco smoke contains around 7,000 chemicals, more than 70 of which are known to cause respiratory diseases and cancer. As mentioned by several leading health authorities, secondhand smoke is also a cause of lung cancer.</p> <p>&nbsp;</p> <p>Smoking habit in pregnant ladies directly affects the baby, with the baby having more chances of developing bronchial asthma and smaller size lungs.</p> <p>&nbsp;</p> <p>The need of the hour is to spread awareness among the masses to quit tobacco consumption in any form. A chest specialist can guide you regarding the management of withdrawal. For people who want to quit, chewing gums and skin patches can help decrease the craving to smoke. Oral medicines are available for patients who are unable to quit despite using gums and patches.</p> <p>&nbsp;</p> <p>While exploring different ways to fight asthma, BT has helped bring down the dependence on steroids and multiple hospital visits. The technique does not promise to cure asthma, but has proven to reduce attacks. Despite introduction of improved medical interventions such as BT, quitting smoking remains the prime factor for adequate control.</p> <p>&nbsp;</p> <p><b>Sharma is consultant, pulmonology, Metro Centre for Respiratory Diseases, Metro Hospital.</b></p> Fri Aug 02 17:17:27 IST 2019 smoke-alarm <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Ten lakh people in India die from tobacco-related diseases every year. India, after China, has the second largest population of tobacco consumers in the world—30 crore consume oral tobacco, mainly women in rural areas, often risking head and neck cancers, and another 20 crore, predominantly men, risk lung cancer, coronary artery disease and chronic obstructive pulmonary disease by smoking.</p> <p>&nbsp;</p> <p>Health policy should aim to add years to life and add life to years. As smoking and oral tobacco take so many lives in India, reducing the number of such deaths should be high priority for policy makers and medical professionals. Fortunately, technological advances have made that task easier.</p> <p>&nbsp;</p> <p>In 2004, Chinese pharmacist Hon Lik developed the world’s first commercially viable electronic cigarette. This produces an aerosol that provides nicotine while avoiding the tar and other toxic products of tobacco combustion.</p> <p>&nbsp;</p> <p>British psychologist Michael Russell once observed that in the UK of the 1970s, people smoked for the nicotine but died from the tar. He called for the development of safe forms of nicotine, minus the toxic products of tobacco combustion. A decade and a half ago, Russell’s prayers were answered, through vaping.</p> <p>&nbsp;</p> <p>Vaping mimics many of the characteristics of smoking while providing similar blood concentrations of nicotine, making it easy to switch from combustible cigarettes.</p> <p>&nbsp;</p> <p>In several countries, vaping and other lower-risk methods of consuming nicotine are disrupting the cigarette market at an exponential level. The global vaping industry will soon be worth more than $40 billion.</p> <p>&nbsp;</p> <p>In business circles, the phenomenon of ‘disruptive innovation’ is well recognised. This happens when a major technological advancement, such as smartphones, takes off and destroys older and well-established industries.</p> <p>&nbsp;</p> <p>In the US, for instance, cigarette sales have fallen 11 per cent in the past 12 months. After many years of increasing prices, shares in cigarette companies are now starting to fall. Several major international cigarette companies are racing against time to transition from cigarettes to reduced risk options for dispensing nicotine.</p> <p>&nbsp;</p> <p>For example, in Sweden, a moist, oral form of tobacco known as ‘snus’ has been popular among men for many decades. This is often taken as a teabag-like pouch placed between the gum and the upper lip. The tobacco for snus is pasteurised, which largely destroys nitrosamines, a chemical compound mainly responsible for head and neck cancers in people consuming oral tobacco.</p> <p>&nbsp;</p> <p>Possibly because of this, smoking-related diseases and deaths are much lower among Swedish men than men in all other EU countries. Swedish snus has been well studied and is regarded as proof of the concept of tobacco-harm reduction.</p> <p>&nbsp;</p> <p>India needs to find low-risk forms for nicotine delivery and encourage people to switch to these options.</p> <p>&nbsp;</p> <p>Notably, Australia is the only rich country that has a de facto ban on vaping. Recent smoking rates in Australia have been flat despite aggressive tobacco control policies such as plain packaging, high and still rising cigarette prices and restricted cigarette availability and legal opportunities for smoking. However, the smoking rate has dipped more in countries like the US and the UK, where vaping is a readily available option.</p> <p>&nbsp;</p> <p>Harm reduction aims at reducing the adverse health, social and economic costs of psychoactive drug use rather than aiming only to reduce or eliminate consumption of the drug.</p> <p>&nbsp;</p> <p>In many countries, there is now a debate between supporters of traditional tobacco and those of lower-risk options. The hostile debate resembles the nasty debates that took place in many countries between supporters and opponents of drug-harm reduction as public health attempted to slow the spread of HIV among and from people who injected drugs.</p> <p>&nbsp;</p> <p>Fortunately, evidence and common sense eventually prevailed in that debate. Needle and syringe programmes were allowed, as were methadone and buprenorphine treatment, and HIV was brought under control.</p> <p>&nbsp;</p> <p>Similarly, it was found that in countries where authorities make it easy for smokers to switch to safer options, the decline in the smoking rate has accelerated.</p> <p>&nbsp;</p> <p>However, in India, the opponents of tobacco-harm reduction are well organised and receive ample international funds. Like other forms of harm reduction, tobacco-harm reduction is a ‘bottom-up’ rather than a ‘top-down’ movement. So, decisions made in the streets and villages are more important than decisions made by officials behind closed doors in big cities. The vaping industry began and is still largely a movement of smokers and ex-smokers, but a desperate cigarette industry is now trying to rapidly catch up and has been buying the most successful vaping companies.</p> <p>&nbsp;</p> <p>Doctors in India have a critical role to play in this very important debate. They could transform the debate relying on the strong and increasing evidence for tobacco-harm reduction. In New Zealand, Quebec and Switzerland, the argument over tobacco-harm reduction has ended up in the courts with comprehensive victories for tobacco-harm reduction on each occasion.</p> <p>&nbsp;</p> <p>The stakes are high. Up to two of every three long-term smokers will die from a smoking-related disease. About 70 lakh deaths from smoking-related diseases occur in the world ever year.</p> <p>&nbsp;</p> <p>It is time India reconsidered its approach to controlling the prevalence of oral and smoking tobacco. That will only happen if Indian doctors make it happen.</p> <p>&nbsp;</p> <p><b>The writer is president, Australian Drug Law Reform Foundation.</b></p> Fri Aug 02 17:15:12 IST 2019 sting-down-but-not-out <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It has killed more people world over than wars have. So, when India registered a decline in the number of malaria cases, it became an obvious reason to cheer. The optimism in certain policy quarters and nonprofit organisations working on the disease has been palpable. After all, not too long ago, India was among the top three countries leading in the number of malaria cases. In 2017 though, the country managed to register a 24 per cent decline in new cases (according to the World Malaria Report, 2018). Odisha, which has 40 per cent of the malaria cases in the country, saw a staggering 80 per cent fewer cases. The malaria burden has also declined by over 80 per cent between 2000 and 2018 (from 2.03 million cases to 0.39 million), and malaria deaths by over 90 per cent (from 932 deaths to 85).</p> <p>&nbsp;</p> <p>Even as scientists and public health experts grapple with more confounding disease outbreaks such as those caused by dengue, Zika and Nipah viruses, the malaria front has looked promising. In that context, the government's target to completely fend off the scourge of the deadly single celled malarial parasite by 2030 (zero indigenous cases) also seems achievable. Well, almost.</p> <p>&nbsp;</p> <p>Fiindings from the MalaFA (Malaria Futures for Asia) report released in Bangkok in April suggest that while there is much to celebrate, roadblocks await us, too. The report, commissioned by Novartis Social Business, reflects views of 36 policymakers in India and four south-east Asian countries (Cambodia, Myanmar, Thailand and Vietnam).</p> <p>&nbsp;</p> <p>In India, experts working on malaria felt a “high level of optimism”, especially among state-level functionaries from Odisha and Assam, as opposed to their counterparts in the Union government, in achieving the 2030 malaria target, the report said. This optimism, however, was restricted to eliminating plasmodium falciparum, one of the two more common malarial parasites in the region (the other one is plasmodium vivax). Indian respondents, particularly in Odisha and Assam, also felt that the country had political commitment for malaria elimination, and at least state-level funding was not a problem.</p> <p>&nbsp;</p> <p>However, the report recorded caveats, too. India's malaria success story could get marred by grim ground realities such as a “lack of infrastructure, availability of trained manpower, access to diagnostic kits, treatment failure” and the looming threat of drug resistance.</p> <p>&nbsp;</p> <p>“The study is meant to guide domestic and donor commitments towards malaria elimination in the face of increasing challenges. The findings will help countries such as India, which are fighting the rising burden of non-communicable diseases as well as a disease such as malaria, towards the best use of their resources. We also need to know what are the best practices that can be scaled up, and how best we can engage and educate those on the ground,” said Deborah Gildea, head Novartis Social Business Asia. The nonprofit, which has been working on strengthening primary care in India, is now planning to expand to 40 villages in Odisha and work on malaria awareness among other public health issues, said Gildea.</p> <p>&nbsp;</p> <p>While Odisha has registered success in bringing cases down, it is important that other states, especially high endemic ones, do so, too. “Other states with a high malaria burden also need to exhibit the same level of political will and professional skill,” said Dr K. Srinath Reddy, director, Public Health Foundation of India, and co-chair of the MalaFA report.</p> <p>&nbsp;</p> <p>The big point that the report and experts are making is that given our history of the fight against malaria, we can’t afford to be laidback. “Despite a successful malaria control programme launched in 1953, there was a resurgence of the disease in the 1960s and 1970s. This was the result of technical, financial and operational problems,” said Dr Manju Rahi, senior scientist at the Indian Council of Medical Research. “In the late 1960s malaria cases in urban areas started to multiply, and upsurge of malaria was widespread. Government efforts led to a decline by 1987, but by 1996, there was a surge again. The eradication goal was officially shelved and the programme was changed to National Anti-Malaria Programme in 1997.” The annual case load, though steady around two million cases in the late 1990s, has shown a declining trend since 2002. Malaria control interventions have also been scaled up after the launch of National Framework for Malaria Elimination in February 2016. “But we must not be fooled by the recent decline, because in the past too, we have seen that the cases went down, and then the disease came back,” said Rahi.</p> <p>&nbsp;</p> <p>In April, the ICMR launched the Malaria Elimination Research Alliance India, bringing together several organisations, including funding bodies, working on the disease under one platform to streamline research efforts, develop new solutions and avoid duplication. Such an effort is warranted because in the run-up to India's “malaria-free” status by 2030, the government has its milestones defined—by 2022, 26 states are targeting eliminating malaria; by 2024, all states are to reduce the annual parasite incidence to less than 1 per 1,000 people, and in the next three years, all states should have interrupted indigenous transmission.</p> <p>&nbsp;</p> <p>Though it is known that certain efforts such as preventive techniques, mass screening and better diagnostics have worked, researchers need to introspect what exactly has worked on the ground, said Rahi. “We know that the use of long-lasting insecticide nets (LLINs) has worked. Not only do these nets have direct benefits of protecting people against the malaria mosquito, it also has indirect benefits in that those outside the nets are also protected because it stems the transmission of the parasite,” she said. “But the question is what after these nets—issues such as how to dispose it.”</p> <p>&nbsp;</p> <p>Those interviewed in the report also highlighted the challenges in preventing the disease in remote jungles, hilly terrains, tribal areas, city slums, large cultivated lands and rice paddies, and issues with proper treatment and diagnosis. “The challenge is: do I have a qualified technician with a working microscope at every public centre? Do I have mobile people at the sub centre level who can go from house to house taking samples,” the report quoted an interviewee, highlighting the lack of trained health care workers.</p> <p>&nbsp;</p> <p>Another set of interviewees cited the lack of training among ASHA workers, who, they said, were at times unable to provide proper treatment and ensure the patient stuck to the medication regime.</p> <p>&nbsp;</p> <p>“We need to ensure the availability of expertise, which calls for investments in training, especially in primary health care,” said Reddy. “Rapid diagnostic kits are essential and should be widely available. More than research, surveillance systems need to be strengthened. Our surveillance systems are weak and produce conflicting estimates. District-level malaria maps are essential for guiding and evaluating intensive efforts in programme implementation for elimination.”</p> <p>&nbsp;</p> <p>Rahi said there are other challenges in the fight against malaria— asymptomatic malaria and the threat of drug resistance from across our borders. As countries such as Thailand are already seeing cases of drug resistance, India, though untouched by drug resistance, needs to be alert and prepared. “For us, the northeast is the corridor for the drug-resistant malarial parasite from the Greater Mekong region (Cambodia, China, Laos, Myanmar and Vietnam) to reach us,” said Rahi. Detecting asymptomatic low-density malaria—where the concentration of the parasite is too low—will constitute the next challenge, she said.</p> <p>&nbsp;</p> <p>For a country such as India, the challenge is even greater. A new vaccine against plasmodium falciparum that is being celebrated as the world's first against malaria does not hold much promise for India. “The vaccine has only 40 per cent efficacy and has to be re-administered, too. For a low resource country such as ours, it won’t make sense at all,” said Dr Raman Gangakhedkar, senior scientist, ICMR. Besides, as Gangakhedkar and Rahi contend, developing a vaccine against malaria poses an inherent challenge because the organism is complex, as is the mosquito, of which different varieties survive in different ecosystems.</p> <p>&nbsp;</p> <p>In the face of such challenges, Rahi said we ought to be prepared at all fronts—better diagnostics, surveillance and new drug development, too.</p> <p>&nbsp;</p> <p>But in India, given the absence of drug resistance to artemisinin combination therapy, used to treat malaria caused by p. falciparum, simple strategies are more relevant. As the report defines, we are looking for lessons from Odisha—mass screening, diagnosis for all fevers, treating asymptomatic malaria, and use of LLINs. “Ultimately the answer will lie in strengthening primary health care,” said Gildea.</p> <p>&nbsp;</p> <p>In low endemic states, elimination of malaria is a low hanging fruit, experts say. “By next year, 15 states are targeted to achieve elimination, which is doable. The high endemic states will be challenging. Funding for LLINs from the Global Funding for TB, HIV/AIDS and Malaria has ended, but the government is confident that money won’t be a problem,” said Rahi. “If a highly populous country such as China can do it, our neighbour Sri Lanka can do it, we can’t be left behind.”</p> Sat Aug 03 14:12:22 IST 2019 delivered-with-love <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>When Anamika Gupta was 38 weeks pregnant last year, she went for a scan. Her gynaecologist told her that they would not be able to go ahead with a normal delivery as the umbilical cord was found wrapped around the baby's neck. The doctor suggested a C-section as per a date and time convenient to Gupta but she was unconvinced. Three years earlier, she had undergone a C-section for first born, Kairav, because of the same reason. This time, she was determined to have a VBAC (vaginal birth after Caesarean). In her 40th week, just in the nick of time, she approached another obstetrician at Sitaram Bhartia hospital in Faridabad, who helped her birth her second son, Kaveer, vaginally with a healthy weight of three kilos. "The reason I was not ready to accept a C-section was that the cord was not wrapped tightly around my baby's neck and there seemed to be no emergency," says Gupta. "Yes, my diagnosis of gestational diabetes did pose a threat but I was well aware that I could still have a normal delivery." Her awareness was the result of a number of workshops she attended during her pregnancy, which helped her understand her own physiology better.</p> <p>&nbsp;</p> <p>In the last four years, the process of pregnancy and birthing has undergone a transformation, wherein the mother now wants to lead from the front, says Dr Rajeshwari Pawar, a gynaecologist at Motherhood Hospital, Pune. "She is no longer ready to remain in the backseat and let the doctors dictate terms. Leaving aside the medical expertise, everything else is now in the control of the mother," says Pawar. And, putting her in the driver's seat are a number of service providers—from hospitals and doctors to counsellors, doulas, birth centres that insist on natural birthing and, more important, midwives. "It is the concept that pregnancy is a natural body process that must be accompanied with minimum medical intervention that is at play here. But these can supplement medical expertise at best, not replace it altogether, especially in case of high-risk pregnancies," says Pawar.</p> <p>&nbsp;</p> <p>Vijaya Krishnan, who runs a natural birthing centre called The Sanctum in Hyderabad, agrees. The centre is predominantly led by midwives who emphasise on natural birth (vaginal birth with minimal medical intervention) and provide preconception counselling, antenatal checkups, water birth, VBAC and lactation support. "Women's bodies are tuned to give birth to their babies on their own without unnecessary medical interventions," says Krishnan. "We lay emphasis on birthing outside of hospitals and on the role of the midwife as they can be most effective, outside of obstetric-centric environments. Therefore, autonomous or independent midwives have been most successful in achieving best outcomes in maternal health and in natural births."</p> <p>&nbsp;</p> <p>The government, too, is encouraging the role of midwives. In February, the ministry of health and family welfare announced guidelines on midwifery services at a World Health Organization-led global forum for maternal, newborn and child health in Delhi. "Approximately 85 per cent of pregnancies and births do not require specialised obstetric intervention," said Jagat Prakash Nadda, then minister of health and family welfare, in December 2018. "Midwifery-led care can play a critical role in promoting physiological births and reducing over-medicalisation. Not only can a strong midwifery cadre provide quality childbirth care to our mothers and newborns, it can also ensure care with dignity and compassion."</p> <p>&nbsp;</p> <p>Says Dr Sarla Shah, a family physician in Mumbai: "A midwife essentially helps in carrying out normal deliveries. In hospitals, too, they have midwives in the form of well-trained nurses who are equipped to help carry out a normal, risk-free delivery and also provide pre-and post-pregnancy care. Then, there are also doulas, whom the couple can hire, for a more intimate counselling-based support."</p> <p>&nbsp;</p> <p>Towards her seventh month, Gupta says she felt more in-charge of herself after she began attending workshops by Neha Misra Mutluru, a professional birth doula and a Lamaze-certified childbirth educator. "I was counselled on everything, be it my diet and exercises, or how to keep my hospital bag, making a birth plan, building a mood in the hospital room with the help of music, incense sticks and a prayer altar, and actually breastfeeding my child the very first time," says Gupta. Mutluru was with Gupta in the hospital's labour room, too, providing moral support.</p> <p>&nbsp;</p> <p>Aruna Yellampalli, a software tester with an MNC in Hyderabad, had her first child at 26 via C-section and a natural birth thereafter for her younger one. She believes that the presence of a doula and a midwife during her second delivery made her feel "supported, well cared for and happy". "I realised that the doctor is one part of the story and largely one who is a risk-identifier," says Yellampalli. "But for motherhood being a journey of happiness, it is the women around you who make you feel comforted and cared for, which is most crucial and valuable during pregnancy and childbirth. I would advise more women to opt for a midwife-assisted birth, be it in the hospital or at the birth centre."</p> <p>&nbsp;</p> <p>However, Dr Sonal Kumta, consultant, obstetrics and gynaecology, Fortis hospital in Mumbai, says it will take some time before millennial mothers in urban cities are ready to accept the midwifery-based care model for childbirth. "The number of expecting women with lifestyle disease and complications is only rising by the day. Hence, the role of the doctor is inevitable, except for normal, risk-free deliveries. Also, the problem is that in private practice in India, pregnant mothers still do not accept the midwife delivering the child. And even if they do, we do not have trained midwives," says Kumta.</p> <p>&nbsp;</p> <p>Telangana became the first Indian state to help bring in a new cadre of certified midwives to improve maternal and infant health care. It was a pilot programme in 2017, and in November 2018 the first batch of professionally trained midwives graduated. Vijaylaxmi, a nursing superintendent with a masters in nursing with specialisation in obstetrics and gynaecology, says her hospital, too, provides midwife-based care where necessary. "A midwife today has to be more than her area of expertise, which is delivering babies through normal delivery. With changing times, the earlier qualification of an ANM (auxiliary nurse and midwife) has now been disregarded in many hospitals, which are now demanding domain expertise."</p> <p>&nbsp;</p> <p>Be it in a hospital or a birth centre, it is the continuity of care which is the hallmark of midwifery. Women who have experienced medically-managed childbirth often complain that they met several people during the course of their care. "Having to repeat herself time after time, to a new person involved in her care can take away from the meaningfulness of the birth experience," says Priyanka Idicula, who runs a natural birth centre in Kochi. "A number of studies show that women attended to by midwives need fewer epidurals, and were less likely to have Caesarean births. Also, where midwives are the main providers of care, women are less likely to give birth prematurely."</p> <p>&nbsp;</p> <p>Hospitals are also upping their game by bringing in innovative ways of making the mother-to-be comfortable. At Hiranandani Hospital in Vashi, Mamma Mia is a dedicated centre for expecting mothers. A number of tailor-made treatments such as massages, reflexology and breathing techniques help alleviate physical discomforts such as morning sickness, backaches, water retention and fatigue. Birth preparation classes are held, along with tutoring of fathers-to-be on the many ways they can care for a pregnant wife and thereafter for a new mother.</p> Sat Aug 03 14:11:16 IST 2019 the-next-phase <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Diabetes affects more than 425 million people worldwide. By 2045, it is expected to rise to 625 million. It caused four million deaths across the world in 2018. And, health expenditure wise, it cost $327 billion in 2017.</p> <p>&nbsp;</p> <p>Most people are aware of only two types of diabetes—type 1 and type 2. However, there exists other subtypes. Type 1 diabetes that develops later into adulthood is called latent autoimmune diabetes in adults (LADA); 2 to 12 per cent adults have this condition.</p> <p>&nbsp;</p> <p>Glutamic Acid Decarboxylase (GAD) antibodies belong to a group of diabetes-associated antibodies that instruct the immune system to destroy the insulin-producing cells of the pancreas. Testing for GAD antibodies helps a doctor to diagnose the LADA variant and offer the correct treatment. A person with LADA will require insulin treatment reasonably soon after diagnosis, unlike most people with type 2 diabetes, who can be treated by various other oral drugs and injectables. Unexplained weight loss is a hallmark of type 1, rather than type 2 diabetes. GAD is not routinely tested in India.</p> <p>&nbsp;</p> <p>Maturity onset diabetes of the young (MODY) is caused by a mutation in a single gene. If one of the parents has this gene mutation, there is a 50 per cent chance that their child would inherit the mutated gene. Those children will generally go on to develop MODY before they are 25. Insulin is not necessarily needed for MODY patients. Common type of MODY are HNF-1 alpha, HNF-4 alpha, HNF-1 beta and glucokinase. Testing blood for pancreatic antibodies, and urine or blood for C-peptide, is the method to test for MODY.</p> <p>&nbsp;</p> <p>The US Food and Drug Administration has recently approved Medtronic's insulin delivery device, the MiniMed 670G, that measures glucose level every five minutes and delivers insulin as required. This machine mimics the normal pancreas in sensing glucose fluctuations. Another exciting device is the smart watch by Apple, in association with Dexcom, that can measure blood glucose on a real-time basis.</p> <p>&nbsp;</p> <p>In the past five years, smart devices have created a paradigm shift in the way blood glucose fluctuations are monitored. Wearables like Fitbit can monitor your sugar level and sleep pattern on real time basis, and alert the patient when there is a sugar spike or drop due to lack of sleep or walking. Also there are applications like One Drop that can measure blood glucose via smartphones and alert the doctor about the fluctuating sugar levels of his diabetic patients. A more sophisticated device of Medtronic checks sugars for 72 hours and plots a graph whereby we can detect where the spikes occur. In the pipeline is GLP-1 agonist (semaglutide), an incretin hormone therapy in oral form which can be taken once weekly. It may eventually replace insulin therapy in the next decade. All these developments point to a big change in the way diabetes is going to be managed.</p> <p>&nbsp;</p> <p><b>Joseph is consultant in internal medicine and diabetology, VPS Lakeshore Hospital, Kochi.</b></p> Fri Aug 02 16:39:37 IST 2019 a-woman-worry <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>There are diseases exclusive to women, like breast cancer and cervical cancer. But, it is still heart attacks that are responsible for the maximum number of deaths (among non-communicable diseases). Though hormones like oestrogen provide some protection, women still fare poorly when it comes to heart attacks.</p> <p>&nbsp;</p> <p>This paradox stems from atypical and delayed presentation of heart attacks in women. It has been found that 10 to 40 per cent of female patients commonly have atypical to no symptoms during heart attacks. This leads to misdiagnosis and, as a result, lack of appropriate treatment and delay in delivering the right therapy.</p> <p>&nbsp;</p> <p>While the heart of a man and a woman may look similar, there are significant differences. For example, a woman’s heart is usually smaller, as are some of its interior chambers. The walls that divide some of these chambers are thinner. And while a woman’s heart pumps faster than a man’s, it ejects about 10 per cent less blood with each squeeze. Hence, gender plays a role in the symptoms, treatment and outcomes of coronary disease.</p> <p>&nbsp;</p> <p>When women experience stress, their pulse rate rises and heart ejects more blood. However in the case of men, the arteries constrict, causing a rise in blood pressure.</p> <p>&nbsp;</p> <p>Noticeably, women tend to suffer from heart attacks at older age than men (average age for women is 70 and for men is 66). The protection offered by oestrogen is affected by menopause, when estrogen levels drop.</p> <p>&nbsp;</p> <p>The most common symptoms of a heart attack is a compressive chest pain in the centre of the chest associated with radiation to the arms and neck, with profuse sweating. Awareness campaigns have lead to the faster recognition of these symptoms. Health care professionals are also educated on the options available for diagnosis and treatment, which has led to a vast utilisation of services like angioplasty. Primary angioplasty done within the first hour, called the golden hour, can result in a significantly better outcome both in terms of saving lives and also preserving the functional capacity of the affected heart.</p> <p>&nbsp;</p> <p>For not completely known reasons, the female gender have shown lesser incidence of the typical presentation. They are less likely to have a central compressive chest pain. Often, they only have a vague discomfort, described by a few as fatigue that is of a sudden onset, and lasting from a few hours to days, without chest pain. Patients are fatigued even without exerting themselves. Few have a mild pain, localised to the upper abdomen or back, with nausea and sweating. Also seen are symptoms like a pain that starts in the chest and spreads to the back or pain in the lower left side of the jaw. Compared to men, women are more likely to have symptoms like palpitation, indigestion, weakness, nausea, breathlessness, dizziness, and back and neck pain; all in the absence of chest pain.</p> <p>&nbsp;</p> <p>Most often the patients either do not go to the physicians for these complaints, or they are branded as suffering from acidity or stress-related issues. This significantly delays the suspicion of a possible cardiac etiology, which in turn delays the right treatment. Not only do the patients cross the golden hour, but they also suffer a large degree of heart muscle loss, which leaves them in a more vulnerable state ahead of procedures like angioplasty.</p> <p>&nbsp;</p> <p>Here are a few risk factors that could potentially trigger heart attacks in women:</p> <p>&nbsp;</p> <p>Diabetes: Frequent spiking in blood sugar damages the blood vessels and nerves. Yet the impact tends to be more visible among women than men.</p> <p>&nbsp;</p> <p>Pregnancy complications: Diabetes and high blood pressure during pregnancy can increase the long-term risk of heart disease.</p> <p>&nbsp;</p> <p>Gender-specific diseases: Conditions like polycystic ovary disease, endometriosis may also raise the risk of heart disease in women.</p> <p>&nbsp;</p> <p>Pathophysiologically, the cause of deviation in the symptoms may be the underlying mechanism in which the blockage happens. Atypical ways of blood flow stoppages are more common in women. The most common mechanism is the deposition of a waxy substance inside the vessel leading to physical blockages. Though it is not gender specific, women develop a clot over the minor erosions on the surface of the vessel. This leads to partial obstruction of the vessel and causes the difference in the degree and location of pain. In a few cases, the vessel only goes for a transient spasm, only to re-open spontaneously. This leads to a short duration of symptoms, which keep recurring intermittently.</p> <p>&nbsp;</p> <p>Preventive measures that can help in reducing the risk factors include avoiding tobacco, daily exercise, and a heart-healthy diet—low-fat dairy, lean meats, whole grains and plenty of fruits and vegetables. It is also important to manage stress and maintain healthy blood sugar and cholesterol levels. Devote time towards regular health screenings so that you may catch any anomalies or symptoms early on. Unlike the symptoms, treatment and medication for both men and women are similar. They go through stenting and angioplasty. Doctors recommend cardiac rehabilitation to improve health and aid recovery from heart disease.</p> <p>&nbsp;</p> <p>Owing to the high incidence of atypical presentation in women, both physicians and patients need to have low threshold of suspicion for heart attacks, especially in those with risk factors like diabetes, hypertension, obesity, hypothyroidism, dyslipidemia or a family history of coronary artery disease.</p> <p>&nbsp;</p> <p><b>Venkatraman is consultant interventional cardiologist, BGS Gleneagles Global Hospitals.</b></p> Sat Jul 20 17:58:13 IST 2019 suffering-in-silence <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Hearing loss affects more than 5 per cent of the world’s population. Left untreated, it can affect communication and can lead to social isolation, anxiety, depression and cognitive decline. One in five such people would benefit from hearing aids or implants.</p> <p>&nbsp;</p> <p><b>Hearing loss in senior citizens</b></p> <p>Hearing loss can drastically affect the life of a senior citizen, and the severity of the hearing loss is associated with a reduced quality of life. A day in the life of a hearing-impaired older adult may include struggles with the following:</p> <p>&nbsp;</p> <p>Hearing alarms or telephones; understanding someone while talking on the phone; when several people are talking; when a speaker’s face is unseen; hearing in a car, wind, or traffic; understanding speech on TV; understanding whispers; understanding cashiers or sales clerks; or enjoying “sweet nothings” in a romantic situation.</p> <p>&nbsp;</p> <p>People with normal hearing often assume that simply saying something louder or turning up the volume will help a hard-of-hearing elder. Volume is not necessarily the issue; difficulties with sound and word discrimination may be involved. The need to repeat responses adds to the negative perception of senior citizens being slow.</p> <p>&nbsp;</p> <p><b>Psychological implications</b></p> <p>Inability to hear and discern message and meaning can result in feelings of shame, humiliation and inadequacy. It can be highly embarrassing to be unable to behave according to applicable social rules. The feeling of shame linked to hearing loss stems from elders inadvertently reacting in inappropriate and socially unacceptable ways, such as responding to a misunderstood question in an inaccurate fashion. Older adults may think “How stupid I must look!” “How embarrassing!” or “What will others think?”</p> <p>&nbsp;</p> <p>The desire to hide hearing aids, a visible sign of hearing loss, often arises from the feeling of shame. Society’s value on physical perfection affects everyone, including senior citizens.</p> <p>&nbsp;</p> <p>Inability to understand verbal communication results in feelings of isolation when elders are left out of group conversations. To avoid shame, they sometimes choose isolation.</p> <p>&nbsp;</p> <p>Depression and adjustment disorder can occur as a natural response to hearing loss and its subsequent impact on the quality of life. On the other hand, some people have pre-morbid mental health issues and hearing loss simply compounds the problem.</p> <p>&nbsp;</p> <p>Some elders who are hard of hearing feel isolated or lonely within their own families. They miss the side conversations or easy banter during family outings or conversations.</p> <p>&nbsp;</p> <p><b>Communicating with a hearing-impaired person</b></p> <p>It is important to speak openly and naturally to elders with hearing loss. Take all feelings seriously and show respect. Don’t speak on behalf of an elder with hearing loss, and if you address the elder in the presence of another family member, avoid using that person as an interpreter if the hard-of-hearing elder doesn’t hear the question. Instead, repeat the question clearly or rephrase in another way and allow the individual to answer for himself or herself.</p> <p>&nbsp;</p> <p><b>Mental health in children with severe hearing impairment</b></p> <p>Deafness does not in itself cause emotional, behavioural, cognitive or psychiatric problems. However, children with hearing impairment are at greater risk of developing emotional/behavioural problems and neuro-developmental disorders. The incidence of both seems to be higher in deaf children from 'hearing' families.</p> <p>&nbsp;</p> <p>Lack of effective communication with caregivers, typically in families with hearing parents and deaf children, and consequent lack of or delayed language development is an important environmental causative factors. It may also affect the individual’s cognitive ability and their ability to understand the emotional states of others and develop friendships.</p> <p>&nbsp;</p> <p><b>Language and emotions</b></p> <p>It is clear that deaf children from hearing families where there is not an adequate level of communication, have a higher incidence of mental health problems than their hearing counterparts. This often seems to be related to a lack of language development caused by either a delayed diagnosis of deafness and/or families failing or being unable to learn how to communicate effectively with their deaf child. This language deficit will have an impact on the essential development, understanding and regulation of emotions.</p> <p>&nbsp;</p> <p>In clinical practice, mothers have often stated their preoccupation with their child’s sensory impairment, which could distract them from the child’s non-linguistic cues. Hence, the interaction between a hearing mother and a deaf child is more susceptible to poorer emotional regulation, linked to the mother’s potential growing sense of incompetence at communication and inability to tune in to the child in a ‘deaf-aware’ manner.</p> <p>&nbsp;</p> <p><b>The value of early intervention</b></p> <p>There is evidence that if early diagnosis is accompanied by intervention and support before the baby reaches six months, parental adjustment is better and the child’s language development will improve.</p> <p>&nbsp;</p> <p>Facilitating better interaction between parents and their deaf child minimises the possibility that the child will develop an emotional disorder.</p> <p>&nbsp;</p> <p><b>The writer is MS (ENT), FRCS (Glasgow), has a fellowship in paediatric ENT surgery (Canada), and is head of the ENT and cochlear implant surgery department at Lourdes Hospital, Kochi.</b></p> Sat Jul 20 15:56:24 IST 2019 sleep-apnoea-can-go-undiagnosed-for-many-years <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>How did you connect sleep apnoea to tau accumulation and Alzheimer's disease?</b></p> <p>&nbsp;</p> <p>We asked the bed partners of the participants of the Mayo Clinic Study of Aging—a large population-based cohort of community-dwelling older adults from Olmstead County in Minnesota—whether they had observed stop breathing events (apnoeas) during sleep. We found that those participants who were seen having these episodes had higher levels of tau protein in the entorhinal cortex. Since tau protein accumulation is one of the major hallmarks of Alzheimer’s disease and is associated with cognitive decline, we concluded that it was possible that this association between sleep apnoea and dementia could be in part explained by higher tau accumulation. It is important to note however, that 1) the study did not include sleep studies to confirm whether the participants who had those episodes indeed had the condition called obstructive sleep apnoea, but they were certainly at higher risk of having the condition; 2) this was a cross-sectional analysis so we cannot make any final conclusion on causal-effect relationship as that would require watching these patients over time (longitudinal studies).</p> <p>&nbsp;</p> <p><b>What is the relevance of the study for patients with sleep apnoea?</b></p> <p>&nbsp;</p> <p>First of all, sleep apnoea can go undiagnosed for many years. Many people might have been told they stop breathing during sleep and have not sought medical attention because they did not feel particularly bothered by it. Most patients don’t share their sleep issues with their primary care providers. This study raises the red flag for patients.</p> <p>&nbsp;</p> <p>Often, patients with sleep apnoea try the CPAP mask during sleep and feel uncomfortable with it and simply give up on treatment because they may not be aware of the consequences. With modern masks that are more comfortable and a little more effort to get used to it, these patients could benefit. We don’t know yet whether treatment of sleep apnoea slows down tau accumulation, but this is a possibility. Since we don’t have good treatments to stop or slow down the dementia process in Alzheimer’s disease, it is better to do everything we can to avoid it.</p> <p>&nbsp;</p> <p><b>Do you recommend brain imaging as screening for patients with sleep apnoea?</b></p> <p>&nbsp;</p> <p>No. Sleep apnoea should be diagnosed with sleep studies and be treated. If there is cognitive decline associated with it that does not improve with treatment of the sleep apnoea, then brain imaging with an MRI may be indicated as part of other investigations to check for causes of cognitive decline. The tau PET used for this study is experimental and has not been validated as a diagnostic tool.</p> <p>&nbsp;</p> <p><b>Are you planning a larger prospective study to establish the causality for Alzheimer's disease?</b></p> <p>&nbsp;</p> <p>Yes. We will continue to follow these participants and check not only for tau accumulation, but also conversion to dementia.</p> <p>&nbsp;</p> <p><b>Do you think timely treatment of sleep apnoea can prevent tau accumulation and Alzheimer's disease?</b></p> <p>&nbsp;</p> <p>We don’t know about that yet. However, it is possible that it could slow it down. As tau accumulation occurs even with aging alone, we don’t expect that the treatment will stop it completely.</p> Tue Jun 25 18:28:22 IST 2019 sleep-loss-memory-loss <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Loud snoring is more than just an annoyance to your sleep partner. A new study presented at the American Academy of Neurology's 71st annual meeting suggests that people who snore loudly and have sleep apnoea might have an increased risk for Alzheimer’s disease.</p> <p>&nbsp;</p> <p><b>WHAT IS SLEEP APNOEA?</b></p> <p>Sleep apnoea is a sleep disorder that causes you to stop breathing temporarily and repeatedly during sleep. The breathing pauses can last from a few seconds to several minutes.</p> <p>&nbsp;</p> <p>The most common type is obstructive sleep apnoea. It causes the upper airway to become blocked during sleep, reducing or completely stopping airflow. Central sleep apnoea, another type of the disorder, occurs when the brain fails to send signals to the muscles that control breathing.</p> <p>&nbsp;</p> <p>According to an Indian study published in the Asian Journal of Pharmaceutical and Clinical Research in 2018, 13.7 per cent of the 1,012 Indian participants had the disorder. It was more common among men and those aged between 50 and 59.</p> <p>&nbsp;</p> <p><b>SYMPTOMS</b></p> <p>If you snore and feel extremely tired and sleepy during the day, you may have sleep apnoea. Other symptoms include gasping for air during sleep, insomnia, waking up with a dry mouth, morning headaches, sexual dysfunction, irritability and difficulty in concentrating.</p> <p>&nbsp;</p> <p><b>WHO IS AT RISK?</b></p> <p>Sleep apnoea can affect people of all ages and both sexes, but it is more common in men. Also at risk are people who are overweight, have a family history, are above 50, smoke, drink alcohol, have large tonsils and have a thicker neck circumference. Medical conditions such as endocrine and neuromuscular disorders, heart or kidney failure and certain genetic syndromes can also increase the risk.</p> <p>&nbsp;</p> <p><b>MEDICAL CONCERNS</b></p> <p>People with sleep apnoea are at a higher risk for car crashes and workplace accidents because interrupted sleep can make them drowsy during the day. They also have an increased risk for a number of medical problems including type 2 diabetes, hypertension, glaucoma, metabolic syndrome, heart, kidney and liver problems and cognitive and behavioral disorders.</p> <p>&nbsp;</p> <p>The current study adds Alzheimer’s disease to the list.</p> <p>&nbsp;</p> <p><b>SLEEP APNOEA AND ALZHEIMER’S DISEASE</b></p> <p>The study found that people with sleep apnoea have a higher accumulation of tau, an Alzheimer's disease biomarker, in an area of the brain that is important for memory.</p> <p>&nbsp;</p> <p>Tau is a protein that forms into tangles inside brain cells and disrupts their ability to communicate with other cells. This can induce neuro-degeneration. This toxic protein is found in the brains of people with Alzheimer's disease.</p> <p>&nbsp;</p> <p>“A person normally has fewer than five episodes of apnoea per hour during sleep,” study author Diego Z. Carvalho of the Mayo Clinic explained in an American Academy of Neurology news release. “Bed partners are more likely to notice these episodes when people stop breathing several times per hour during sleep, raising concern for obstructive sleep apnoea. Recent research has linked sleep apnoea to an increased risk of dementia, so our study sought to investigate whether witnessed apnoeas during sleep may be linked to tau protein deposition in the brain.”</p> <p>&nbsp;</p> <p>The study included 288 people, aged 65 and above, without cognitive impairment. The researchers used PET scans of the brain to look for accumulation of tau tangles in the entorhinal cortex, an area of the brain in the temporal lobe that helps manage memory, navigation and perception of time. This area is more likely than other parts of the brain to accumulate tau.</p> <p>&nbsp;</p> <p>The researchers asked the partners of the participants if they had noticed episodes of stopped breathing during sleep. Partners of 43 participants (15 per cent) had witnessed episodes of apnoea.</p> <p>&nbsp;</p> <p>Those who had sleep apnoea had 4.5 per cent more tau in the brain than those who did not have apnoeas, even after accounting for factors that affect tau levels in the brain, such as age, sex, education, cardiovascular risk factors and other sleep complaints.</p> <p>&nbsp;</p> <p>However, according to the researchers, it is not fully clear if sleep apnoea causes the buildup of tau protein tangles, or if higher levels of tau causes sleep apnoea.</p> <p>&nbsp;</p> <p><b>TREATMENT</b></p> <p>Lifestyle changes such as losing weight, quitting smoking and limiting alcohol intake may help address mild cases of sleep apnoea. For moderate to severe cases, breathing devices, such as a CPAP (continuous positive airway pressure) machine, and mouthpieces or oral appliances may be recommended to help maintain an open airway during sleep. If all other options fail, surgery may be required.</p> Tue Jun 25 18:25:03 IST 2019 an-inner-journey <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p><b>BIPASHA BASU</b></p> <p>Bipasha Basu took to yoga aggressively around five years ago, after her marriage to Karan Singh Grover, who she describes as the modern version of a yogi. “He wakes up at sunrise, walks barefoot, stays connected to nature as much as possible and practises yoga with a determination and regularity that only a few can manage,” she says. The couple started attending yoga classes together twice a week. Of late, they are practising at home. “We are essentially into Ashtanga yoga, which is a more rigorous and demanding form of yoga focusing largely on one's breathing,” she says. “In between, problems of “severe acid reflux and knee issues” kept her from doing many asanas, including the Sirsasana and the Halasana—two of her favourites. “I did many things to contain the reflux, including homoeopathy and a change in diet,” she says. “And then when I came back to yoga, I realised how it helped the body gradually heal and bounce back. The deep breathing also helped my system become more alkaline.” For someone known for her high adrenaline freestyle workouts—her 30-minute videos on cardio workouts and aerobic dance have become very popular—yoga became a stabiliser. It helped her find balance and peace last year when she experienced “sudden and clinical numbness in the body”. “It was as if I was working out not just for the body, but also for the mind and the psyche,” she says. “It helped me find relief from stress.”</p> <p>&nbsp;</p> <p><b>TEJASVI SURYA</b></p> <p>“In my life, yoga is as necessary as a meal,” says 28-year-old Tejasvi Surya, MP from Bengaluru South. He starts his day with a 20-minute session of Kapalbhati Pranayama. This is followed by Baddha Konasana, Dhanurasana and Virabhadrasana. They give him the much-needed stretch after a good seven-hour sleep. “I begin by chanting 'omkara' thrice and performing Suryanamaskara 12 times, for about 15 minutes,” he says. “I end the session with Shavasana—my favourite one-minute relaxation time that prepares me to face the day. It is like my cup of coffee in the morning.” Surya was introduced to yoga in school around 15 years ago. After that, his parents helped him stay on course. His mother is a yoga instructor. “Both my parents practise yoga every day without fail and strictly watch their diet. They do asanas better than me even at this age,” he says with a laugh. The lawyer-turned-politician practises under the guidance of Shri Parameshwar Guruji—a popular yoga teacher from his locality.</p> <p>&nbsp;</p> <p><b>SONU NIGAM</b></p> <p>Around 15 years ago, Sonu Nigam was so addicted to yoga that it became imperative for him to take a break from it. “Initially I would practise it for 30 to 45 minutes, but I soon reached a point where I would enjoy it so much that I would spend five to six hours every morning just doing yoga,” he says. But that was not the problem. He admits that Ashtanga yoga made him feel “happier than ever”. But he also sensed the complete surrender to the deeper, emotional self. “I was very young at the time and the intense one and a half years I gave to yoga, during which I also extensively read about it, brought me so close to it that I began to feel as if I had risen above materialism itself,” he says. “I had reached a level where I could actually have an affect on people. Once, I was discussing yoga with a group of people at home and soon, a British girl who was working with me was in tears.” At the time, the feeling was both stimulating and unsettling in equal measure. Today, the playback singer practises on his own at his home gym by mixing different kinds of workout—stretching, yoga, weight training and cardio. “But there is nothing quite like yoga,” he says. “Even today, I believe I can touch people's soul. My attitude to life has changed with regular practice and I have evolved as a person.”</p> <p>&nbsp;</p> <p><b>SHILPA SHETTY KUNDRA</b></p> <p>At the launch of her yoga app ahead of International Yoga Day, pictures of Shilpa Shetty Kundra doing yoga went viral. They attracted a lot of comments on social media from fans who applauded her commitment to the activity. Her YouTube videos on 'Yoga for Beginners', in which she deconstructs complex asanas, have got hundreds of subscribers. “To me, yoga is discipline,” says the 44-year-old actor, who has been practising it for over 10 years now. She has been trying to pass on her love of yoga to husband Raj Kundra. “He has started taking it seriously now,” she says. “He has lost eight kilos and needs to lose more. He is still at the beginner's level while I have reached an advanced stage. So we can't really do it together.” There are, however, still a few asanas like Mayurasana and Vrischikasana that she struggles with. “Practice is the key,” she says. “Sometime back, I had a severe neck injury and found it difficult to practise my asanas. But now, I think I have overcome it. It has to do with the power of my mind and not my body. Your mind negotiates with your body and pushes you to test your limits.”</p> <p>&nbsp;</p> <p><b>ESHA GUPTA</b></p> <p>Esha Gupta was inspired by her parents to do yoga, especially her father, who is a retired army officer. “My family have taken to [yoga] in a serious way,” she says. “Over the years, my body has got accustomed to practising yoga and meditation at least twice a week.” Gupta practises Iyengar yoga, which uses props to do various asanas. “I have always been hyper-flexible or double-jointed, so the chances of me getting injured are high,” she says. “Two years ago I got a bad shoulder injury but Tittibhasana helped in easing the pain.” Other than yoga, she incorporates different workouts during the week, including dance, cardio, kickboxing and weight-training. “If I don't mix them, it gets very monotonous and boring,” she says.</p> Fri Jun 28 17:02:01 IST 2019 the-wheat-puzzle <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>It has been two years since 32-year-old Nishi Khattar stopped including wheat-based chapatis in her meals. She instead has either bajra, jowar or millet chapatis and gets her quota of carbs with rice and oats. Khattar makes sure to stay away from anything that has even a small proportion of wheat in it. The main reason for this is that every time she has it, she feels bloated and irritable. “It happened a few times when I would suddenly have this feeling of inflammation in the gut and I realised that this may be because I was eating wheat chapatis. When I skipped the rotis in my meals for two days, I was feeling just fine. So, I figured that this may have to do with my wheat intolerance,” says Khattar. What she refers to as wheat intolerance is, in scientific parlance, known as gluten intolerance—a range of physical disorders caused by gluten protein in wheat. One of these, celiac disease, affects one in 100 people in north India.</p> <p>&nbsp;</p> <p>Soni, too, has given up on the intake of wheat, but for a different reason. She says it will help her lose weight easily because it is the gluten that has kept her from shedding the excess weight, according to her dietician. “I totally stopped wheat about four months ago and I have noticed the difference in my body after that. I have lost one and a half kilos and I feel much lighter and more energetic,” says Soni. Dr Karishma Chawla, nutritionist, connects the gluten in the wheat to describe what both Khattar and Soni are trying to convey. “There is no doubt that whole wheat is good for one’s overall health. That is precisely what we have all grown up eating. However, the gluten in it is also known to lead to problems of bloating and weight gain. It must be consumed in a very limited way and a complete shift to other protein-rich staples works better for good, lean and energetic health.”</p> <p>&nbsp;</p> <p>Very soon, all those who have so far avoided wheat—the second largest produced staple in India—are going to be able to have it without worrying. That is because, last August, 200 researchers from across the world, including three Indian scientists, and their teams finally managed to crack the wheat code, or sequence the wheat genome. This means that they will now be able to edit the faulty parts in the crop's DNA that cause allergies and intolerance and replace it with good DNA, which provides increased nutritional efficiency and productivity.</p> <p>&nbsp;</p> <p>But doing this was no mean task. The wheat genome is the most complex plant genome—over 40 times more mysterious than the rice genome and has 1,07,891 genes, which is five times than that of a human being's. This is one of the reasons why scientists could sequence the genome of rice, of mice and even that of a human but the wheat somehow always bewildered them. The Human Genome Project (HGP), which ended in 2003, was the world's most significant project and India missed out on participating in it. So, when there came the opportunity to work with scientists around the world on the International Wheat Genome Sequencing Consortium (IWGSC), which was formed in 2005, India's Dr Kuldeep Singh took it upon himself to ensure that India would be a part of it.</p> <p>&nbsp;</p> <p>As the molecular geneticist in the School of Agricultural Biotechnology at Punjab Agricultural University, Ludhiana, he and his institute approached the department of biotechnology with a proposal for India's participation and soon the wheels were set in motion. “Nobody ever thought that wheat genome mapping was possible. Especially because 85 per cent of wheat's genome is replicated, meaning nearly everything looks identical or has identical characteristics. What we had to do was to sequence the genome, which meant break it down into thousands of pieces, identify each piece and put it back together again. So it was quite a task,” says the 57-year-old scientist. In wheat there are three genomes—A, B and D—with seven chromosomes in each. So the consortium had to sequence all 21 chromosomes. But since each is so huge, every country took to sequencing just one and India took the 2A.</p> <p>&nbsp;</p> <p>Helmed by three scientists—Kuldeep Singh, N.K. Singh from ICAR-National Research Institute Plant Biotechnology, New Delhi, and Jitendra P. Khurana from the University of Delhi (South Campus)—a team of 18 scientists got down to work together from their respective campuses. The chromosome 2A that India took was the second largest, while France took to mapping chromosome 3B which is said to be the most complicated and longer than the entire soybean genome.</p> <p>&nbsp;</p> <p>The project was carried out on a budget of Rs35 crore. The teams worked for long hours over eight years to conclude their research. There were moments of frustration, but one which Dr N.K. Singh will never forget was when the international community started questioning if India had the ability to complete the project in the given timeline. They wanted to do everything by themselves, according to him. The problem he says was that the IWGSC was formed in 2005 and most countries had already begun work on their respective chosen genomes. Whereas India joined it in 2010. “The UK was about to snatch it from us. It was after a lot of convincing that they agreed and asked us to make sure we finish it in time, no matter what,” he says.</p> <p>&nbsp;</p> <p>The initial DNA sample that was to come from the Czech Republic to India also got delayed by six months. Then there were infrastructural issues, too, according to Ajay Kumar Mahato, who worked as a research associate on the project along with Dr N.K. Singh. “The wheat genome is based on the next generation sequencing technology so the data that is generated for the sequencing machine is approximately 230GB. So, the problems we faced was the availability of computational resource to assemble all that data. We established new infrastructure and purchased new servers with high computational facilities. It took us about one and a half years and a lot of night shifts in the lab for data generation alone. And then another almost 2.5 years for actually capturing the analysis of the data of the assembled genome of wheat chromosome 2A short arm,” says Mahato.</p> <p>&nbsp;</p> <p>In 2014, IWGSC with 2,400 members across 68 countries published the first draft of the genome sequencing and by 2018, as per an article published in Science, the DNA sequence had been ordered and it represented the highest quality genome sequence generated to date for the bread wheat, covering 94 per cent of the entire wheat genome.</p> <p>&nbsp;</p> <p>Naveen Sharma, who works as a research associate in the department of plant molecular biology under Professor Khurana, managed the bac-n sequencing in the wheat genome project, which means fragmenting the DNA, cloning the genomic fragments and then doing the n-sequencing which finally helps in the assembly of the sequence. “The major problem we faced was with repeat sequencing,” said Sharma. "There was so much pressure to complete the work in the given time frame that it got very exhausting at one point. We used to take one week for sequencing of 3,200 clones which would sap us of all our energy. There was always the risk of failure because everything was so expensive. A 20ml chemical used in sequencing cost us approximately Rs5 lakh to Rs6 lakh. So it had to be perfect the very first time. There was no room for error, wastage and repeat work." Sharma and his researcher friends partied once the research got published in the Science journal.</p> <p>&nbsp;</p> <p>The decoding of the wheat genome will help identify genes controlling complex agronomic traits such as yield, grain quality and resistance to diseases and pests, as well as tolerance to drought, heat, water logging and salinity. According to Minister of Science and Technology Dr Harsh Vardhan, it will also go a long way in developing climate-resilient wheat and help tide over possible impact of climate change on farm output.</p> <p>&nbsp;</p> <p>“The genome map will also help in isolating proteins that cause gluten intolerance so that you will no longer have to give up on consuming it,” says Dr Kuldeep Singh. “We also believe that it will help in increasing the bio-availability of iron in bread wheat. As of now only 5 per cent of the iron content in wheat can be absorbed but once we identify the genes and double the bio-availability, we can increase the nutritional quantity of iron in wheat.”</p> <p>&nbsp;</p> <p>According to a study in the journal PLOS One, it was estimated that the current agricultural output would be insufficient for humans by 2050 and crop yields would need to increase by 1.6 per cent annually to meet the demand. All this, in the face of depleting land and water resources and vagaries of climate change. By cracking the wheat genome, scientists have ensured that wheat remains resilient to most natural calamities and its productivity increases manifold to address the concerns of quality and nutrition. According to well-known wheat researcher Bikram Gill, who is a professor in the department of plant pathology at Kansas State University, scientists in India must be given the freedom to do what they want to. He says that since wheat is an integral part of India's food consumption, it was natural for the country to be part of the history that has been created. He hopes we can now enjoy wheat without worry or panic.</p> Fri Jun 28 17:10:29 IST 2019 doc-bloc <a href=""><img border="0" hspace="10" align="left" style="margin-top:3px;margin-right:5px;" src="" /> <p>Dr Shobhana Lekshmy had long dreamt of building a retirement home for doctors, where they could use their medical skills to help the community around them. As a palliative care specialist at Amrita hospital in Kochi, she had seen hundreds of aged patients leading lonely lives, their children settled elsewhere. Dr Jeeji Palocaren, head of biochemistry at MOSC Medical College in Kolenchery, near Kochi, had observed a similar phenomenon. She saw many of her colleagues retire at 65 and get bored at home, despite the fact that they still had so much to contribute to society. Both doctors were determined not to succumb to the same fate after retirement.</p> <p>&nbsp;</p> <p>They happened to meet each other two years ago, and instantly connected. Thus was born their dream project—a retirement home for doctors. The home, which will be located on the Edappally-Pukkattupady road, will be nestled in one acre of greenery, with high-tech, age-friendly facilities like a canteen, laundry service, movie theatre, swimming pool and gym. Most important, it will include an outpatient clinic, where doctors can treat those who seek their services. “The OP clinic is a win-win,” says Palocaren. “On the one hand, it allows the needy in society to access subsidised medical care. On the other, it helps doctors keep themselves occupied, and contribute positively to society.” Also, the apartment will be only five minutes away from a lively hub of restaurants and shopping centres.</p> <p>&nbsp;</p> <p>The founders are firm about one thing—that the apartments are retirement and not old-age homes. In Kerala, old-age homes are seen as a shelter for the aged who are sick and bed-ridden. “There is a big difference between a retirement home and an old-age home,” says Lekshmy. “Ours will be a luxurious community where doctors will be united by a purpose—to make the most of their post-retirement lives. We want people to move to our retirement community when they are still healthy and able to contribute to it.” The community will have assisted living facilities to help doctors who subsequently become bed-ridden.</p> <p>&nbsp;</p> <p>The project is open to doctors between 50 and 70 years. “We have got enquiries from chartered accountants, engineers, and lawyers as well,” says Lekshmy. “But for now, we are limiting our membership to doctors.” The cost of the apartments range from Rs30 lakh to Rs50 lakh. “For doctors in our community,” says Palocaren, “life will begin at 55, in the company of friends.”</p> Sat Jun 15 19:04:19 IST 2019