padmini-janaki-ceo-of-mind-and-mom-promises-to-be-with-women-on-their-fertility-journeys

Sat Aug 31 13:50:41 IST 2024

What can poverty teach someone? “A lot,” says Padmini Janaki, 33, founder and CEO of Mind & Mom, a health tech firm that has helped over three lakh women on their fertility journeys since its inception in 2021. Growing up as the daughter of a single mother who worked multiple jobs―from selling flowers on the streets to being a salesgirl in garment shops―Padmini credits Janaki with instilling in her the fundamentals of entrepreneurship.

“My mother had to figure out so much just to pay my school fees and [to meet household needs],” she recalls. “We had to find solutions for everything, which fostered an entrepreneurial mindset. For instance, during festivals, we would think about where to put our stalls to sell flowers. My mother always found ways to make things work. This taught me invaluable entrepreneurial skills. My friends in school also were not wealthy, but they were incredibly street-smart and resourceful.”

Padmini says she has always been passionate about technology and helping women. Through her initiative Frozen Tomato, which she founded in 2012, she has helped poor single mothers get jobs. She founded Mind & Mom after a six-year stint with PayPal. “I come from a tech background, and solving problems with technology, especially AI, fascinated me,” she says. “Helping women in their careers―particularly those transitioning back after a career break―became a personal mission. I was doing it constantly. So, I took a step back and analysed my passions. I realised that two things came naturally to me: being part of women’s journeys and working with technology. Combining these passions led to the creation of Mind & Mom.”

The core concept of the company initially raised several eyebrows, given that India is already the most populous country. “For many women in India, having a baby is a natural choice. But sometimes it does not happen, whether due to PCOD (Polycystic Ovarian Disease), male partner issues, or other reasons,” she says. “These women often try multiple options, spending significant amounts of money.”

Padmini notes that some people question why, in a country with such a large population, people don’t just adopt or get a dog instead. “But when you are the one facing the problem, it is not that simple,” she says.

Mind & Mom leverages artificial intelligence, data science and behavioural science to offer personalised guidance, support and education to clients. Women begin with the startup’s virtual fertility coach, which tells them natural pregnancy methods tailored to their age and lifestyle. The company reports that about 10 per cent of users conceive within 60 days. For those who don’t, a 90-day fertility boot camp is available, focusing on mental, physical, and nutritional health with expert guidance. If necessary, clinical intervention is suggested, including free checkups and tests, with doctors at M&M-powered fertility clinics guiding them.

“I wanted to support women in whatever choices they make, whether it is deciding not to have a baby in their 30s, exploring egg-freezing options, managing PCOD or considering alternatives to IVF,” says Padmini. “As a virtual partner, we have helped women across India, offering a non-judgmental space for them to explore their options. But I realised that seeing a doctor in person is a completely different experience. That is why we expanded into the clinic space as well.” This new brand of physical clinics―currently only in the southern states―was named LIVF, and became a subsidiary.

Nafeeza (name changed), 32, had been trying to conceive for over two years when she first visited a LIVF centre after attending an educational event on PCOS (Polycystic Ovarian Syndrome). At the centre, she underwent a comprehensive assessment, and her personalised treatment plan included lifestyle modifications as well as medication to induce regular ovulation and to manage other symptoms. Mind & Mom provided regular monitoring and adjustments to optimise her treatment, along with emotional support for Nafeeza and her husband. After several months, her menstrual cycles became more regular, her hormonal imbalances associated with PCOS improved, and she successfully conceived.

Notably, the first version of the Mind & Mom app was a period-tracking tool, initially focusing on users in Tamil Nadu. Padmini used her resourcefulness to give the app its initial boost. “In 2021, when we started, we did not have much funding to spend on Google or Facebook ads. In south India, especially Tamil Nadu, it is common for people trying to conceive to offer a Krishna thottil (a cradle) at temples. So, our first campaign involved being present at these places with placards featuring our app’s QR code, reaching out to those making the offering. So, it was a campaign with zero investment.”

Next, Padmini’s team began visiting fertility hospitals and clinics, and encouraging patients to download the free app. “We did this for almost six months, but it was not sustainable,” she recalls. “What worked for us was leveraging corporate connections. As I come from PayPal and had a strong LinkedIn following, I offered free talks on women’s health at various companies, even bringing in a doctor for the sessions. The only thing we asked was for employees to download our app and use our free services. This approach helped us gain our initial downloads.”

Padmini also notes that from the start, Mind & Mom has focused on scalability and sustainability. “That is why we began as a digital-first health company―because it is virtual. Even with our in-person clinics, we aim to keep them as asset-light as possible. Nearly 70 per cent of our hospitals and assets are underutilised. With so many existing hospitals and medical colleges, we are not planning to build anything new or reinvent the wheel.”

As Mind & Mom is not investing a lot in physical infrastructure, she says, it helps reduce costs by around 50 per cent when it comes to fertility treatment.“And the patients are also happy,” says the entrepreneur, adding that she is fast expanding the service to various parts of India.

sports-mastery-involves-training-the-brain

Sat Aug 31 13:16:32 IST 2024

To triumph over competition, athletes must be the fastest, strongest and the nimblest contenders. Record-breakers must push even further, surpassing the limits of human capability.

But besides their physical prowess, athletes harness a unique set of mental skills that allows them to succeed in their respective disciplines. Numerous studies have shown that athletes' brains differ from non-athletes' brains.

Visual cue processing

The ability to quickly soak up visual information and make decisions accordingly is a crucial skill for athletes, especially those who play team sports. A 2013 study in the journal Scientific Reports revealed that professional ice hockey, soccer and rugby players are better visual learners than people with lower-level abilities in the same sports.

The pros were compared with 'elite amateurs'― in this case, US college athletes and players from a European Olympic sport-training centre. They were also compared with non-athlete university students. Compared with both groups, professional athletes performed better, and improved faster, on a task that tested their ability to focus on and track objects moving across a screen. In other words, their brains are more skilled at processing “dynamic visual scenes”, or the world moving around them, the study authors found. The elite amateurs were also better at this than the non-athletes.

This knowledge could be used to enhance an athlete's training and determine the best time for them to return to their sport following an injury, said Jocelyn Faubert, author of the 2013 Scientific Reports study and a professor at the University of Montreal School of Optometry. For example, assessing how efficiently an athlete can process visual information and not make judgment errors could prevent them from coming back too early and putting themselves in danger, he said.

Muscle memory

Acrobatic athletes, such as divers and gymnasts, need to be exceptionally good at performing sequences of movements without consciously thinking about it― a phenomenon colloquially known as 'muscle memory'.

A 2023 study in The Journal of Neuroscience revealed that the brain plans and coordinates repetitive movements like those performed by athletes and trained musicians by quickly “zipping” and “unzipping” crucial information about them. At first, the sequence and timing of the steps are programmed separately in the brain, but with training, these individual elements become seamlessly integrated into one burst of coordinated brain activity. This process involves a network of neurons in the cortex―the outer layer of the brain―that regulate movement.

Predictions

In baseball, a batter must make quick and accurate predictions about the fate of each ball the pitcher throws. For example, will it enter the strike zone, and how fast will it come at them?

It turns out that, depending on what the batter predicts, their brain activity changes. Specifically, neurons within a region of the brain called the left ventral extrastriate cortex vary in these scenarios, according to a 2022 study in the journal Cerebral Cortex. This is likely because of batters' unique ability to relate visual cues about a pitcher's movements to the potential path of the ball, the authors said.

Structurally speaking, research has also shown that professional divers, for example, have a thicker superior temporal sulcus (STS) than novices. The STS is a region of the brain that plays an important role in the perception of movement of other living things and it also helps decipher the intentions behind those movements. This makes sense in the context of diving, as these athletes often learn by watching other divers' performances, the authors said. And, of course, this is true of many sports.

Balance

Acrobatic athletes, such as gymnasts, have remarkable proprioceptive skills, or the ability to sense where their bodies are in space. An intricate network of neurons in the cerebellum, a region at the base of the brain, enables these athletes to rapidly course-correct in the air or keep their balance on an apparatus when a trick doesn't go according to plan.

If this safety net malfunctions―as famously happened to US gymnast Simone Biles when she got the “twisties” during the 2020 Tokyo Olympics―it can cause these athletes to lose control of their bodies in midair, with potentially deadly consequences.

Focus and attention

Athletes must be able to appropriately divide their attention and dynamically switch between different ways of thinking. For example, during a match, a soccer player who is dribbling the ball one way may need to quickly switch direction if approached by a player from the opposing team.

The cognitive skills needed to switch your attention also extend to tasks in daily life, such as listening to a podcast while cleaning the house. A 2022 study in the International Journal of Sport and Exercise Psychology provided evidence that athletes are much better at this than nonathletes are.

Notably, athletes trained in team sports that require aerobic or high-intensity interval training had particularly enhanced skills in this area. They stood out for their cognitive flexibility and their ability to appropriately allocate attention, researchers found.

At this point, it is unknown why athletic training influences cognition this way, said Art Kramer, co-author of the International Journal of Sport and Exercise Psychology study and director of the Center for Cognitive and Brain Health at Northeastern University in Boston. To find out, you would need to do a long-term study or a randomised controlled trial in which some kids are put into athletic training while others are not and then monitor them over time. But such a study would be unethical because some kids would be completely denied access to sports, he said.

Resistance to ageing in the brain

The cognitive benefits of athletic training may also extend throughout life. Perhaps no one exemplified this better than the late Canadian track-and-field athlete Olga Kotelko, who held more than 30 world records.

Before she died in 2014 at age 95, Kramer and colleagues studied her brain in the lab.

As we age, the 'white matter'―the connections between neurons in different regions of the brain―deteriorates. However, the team found that Olga―despite being in her mid-90s at the time―had strikingly intact white matter, comparable to that of less-active women who were more than three decades younger.

Olga was also quicker at responding to cognitive tasks than other nonagenarians who were tested in a separate, independent study, and she had better memory than them, the team found.

Of course, general conclusions cannot be drawn from one athlete. However, as the team said, there is “only one Olga”. For this reason, she afforded scientists a unique glimpse into the long-term impacts of athletic training on the brain.

It is important to note though that not every elite-level sport is associated with people surviving into old age, or staying sharp into their 90s like Olga did. Scientists are still figuring out which sports bring about such benefits and which don't.

Training of the next generation

Looking forward, encouraging brain training in athletes from an early age may lead to even more sporting gains.

“We're at a point with training athletes, in particular, where the human body can't really go much further, but there's so much more we can actually do with cognition,” said Kylie Steel, a sports scientist at Western Sydney University in Australia.

In an article in The Conversation, Steel and colleagues argued that coaches should focus more on training athletes' cognitive abilities, such as their memory and decision-making skills. This is especially important during the earlier years of life, when the brain is more malleable, they posited.

In a ball sport like soccer, this training could involve asking players to use their nondominant foot to kick the ball. “If we can try and encourage a lot more training associated with that [cognitive enhancement]―particularly in the junior years―by the time they get to those later years, tactically, they'll be more skilled,” Steel proposed.

dental-health-tips-routine-oral-hygiene-tooth-care-myths

Sat Aug 31 13:11:27 IST 2024

Understanding oral health: This is a state of wellbeing of teeth, gums and other structures within our oral cavity or mouth that help in proper eating, speaking and aesthetics. While dental health just denotes healthy teeth and gums, overall state of oral health encompasses maintenance of oral cavity, its structures, their functions and also facial features and aesthetics. So good oral health is when all the components of the oral cavity like teeth, gums, periodontium (tissues that support and surround the teeth) are functioning properly and in harmony with each other, supporting not just eating but also helping in digestion and maintaining proper alignment of facial features.

Proper brushing: Brush for two minutes with adequate (not excessive) pressure; just enough to remove the plaque build-up. Rigorous brushing harms teeth in the long run. Hold the brush at a 45 degree angle, move it in small circular motions and cover all surfaces. Wait for 30-40 minutes after brushing before eating or drinking anything. Some people tend to brush after every meal but do that only if you have had garlic/onion or anything that gives you bad breath. Else brushing twice a day is fine.

Manual or electronic brushes? Both are fine as long as brushing technique and pressure are proper.

What about mouthwash? It is not a necessity. It does complement your brushing, but, if your oral hygiene is good, skip it unless advised by your dentist.

The neglect of flossing: Dental health overall is neglected in India. It is not just about flossing. People find it a waste of time that there should be an added step to their oral hygiene routine. But it is highly recommended as a brush cannot reach between teeth and cleaning that area is important too. Flossing is technique dependent, so one needs to learn to do it correctly.

White is not best: Normal teeth colour ranges from off-white to light yellowish. Sparkly, absolutely white teeth are not necessarily a sign of health. You can have healthy teeth even when your teeth appear a little yellow. Teeth colour tends to darken with age and habits.

Charcoal, bleach and other teeth ‘whiteners’: People tend to run after shiny, bright things. Charcoal is an added abrasive that harms the teeth in the long run. Similarly, DIY bleach can lead to severe sensitivity in teeth when done without supervision and without your dentist’s advice. If you want bleaching, go to your dentist.

Traditional cleaners like ‘neem’ twigs: They are still popular in many regions. Though neem offers many benefits, for oral hygiene, it is imperative to use a proper brush as neem twigs can lead to abrasion of the top layer of teeth which leads to sensitivity. Moreover, these do not provide complete cleaning of the dental structures.

Pay attention to the gums: Maintaining proper oral hygiene, use of a brush with soft bristles, massaging the gums with your fingers after brushing, getting professional cleaning and a visit to your dentist will maintain good gum health.

Clean that tongue too: People often neglect tongue cleaning. Bacteria and food particles stuck over the tongue cause inflammation and bad breath. Prolonged negligence causes glossitis (inflamed and swollen tongue). Avoid vigorous cleaning of tongue especially with metal tongue cleaners, which may damage the taste buds present over the surface of the tongue. Use a soft tongue cleaner or brushes which have a cleaning surface on the back of their heads. Clean the extra deposit over the tongue with mild pressure.

Most common teeth problems: Dental caries is decay in tooth structures because of prolonged exposure to bacteria. Over time, the hard structures of your teeth (enamel and dentin) are damaged, gradually exposing pulp or nerve of teeth. Gingivitis is the swelling of gums. Periodontal disease comprises of inflammation and infection of tooth, gums and the surrounding structure.

What you drink and eat matters: Daily intake of tea, coffee, cold drinks and acidic beverages―over time all tend to erode the top layer of the teeth leading to sensitivity. GERD (acid reflux from stomach) too leads to erosion of teeth. It is also a myth that only sugar is the enemy. Sticky food substances like mayonnaise (and acidic substances) also harm the teeth. Even breathing through the mouth impacts oral health.

Self-examining your teeth: Thorough examination needs a dentist but one can look for deposition, any discolouration, caries, any pain or unnatural growth, bad breath, cracked tooth, mal-alignment and jaw pain. If you observe any of these, get examined at once.

Common among Indians: Periodontitis is highly prevalent in the Indian population. Oral cancer, because of growing use of tobacco is one of the leading cancers in our country. Dental caries is rising among young adults, primarily because of poor eating habits. They also exhibit last molar eruption pain. Children display early childhood caries. They also display mal-aligned teeth and retained primary teeth. Adults and senior citizens show prevalence of gum problems, cavities along with mobile and missing teeth.

Common visible mis-aligned teeth problems: Forwardly placed upper front teeth (proclined anteriors); labially/buccally erupted maxillary (eg. canine buried in your jawbone towards the side of your lip or cheek); anterior deep bites/closed bites (overlap of upper and lower teeth); posterior cross bites (back teeth not touching when one bites down); irregular arrangements of upper and lower front teeth; gummy smile and spacing in between front teeth. All these can be fixed by orthodontic treatment, including metallic/ceramic braces or clear aligners.

Ban the myths: Hard brushing is good for teeth. Scaling weakens the teeth. Tooth extraction leads to loss of eyesight. Only sugar causes caries. Milk teeth are not important.

Simple tips: Brush twice daily for two minutes with adequate light pressure. Visit your dentist regularly, and at once if you notice anything unusual. Be vigilant to any changes in your oral cavity. Have the sweets you love as long as you follow a proper brushing routine.

Not just the teeth: Oral examination can diagnose multiple systemic diseases like diabetes, vitamin deficiencies and adenoid hypertrophy (chronic mouth breathing) among others. Oral health not just impacts teeth but also our jaw and its musculature, our digestion and aesthetics as well. Diabetes causes weakened periodontal health and delayed wound healing and it also causes ketone (metallic) breath.

Not all of us will all lose our teeth: Many aged people have a full set of healthy teeth. You just need to take proper care of your teeth always and see your dentist. Yes, normal wear and tear happens like it does for all body parts.

More on the link with diet: Diet is an important factor as whatever we consume first needs to go through our mouth and teeth. So if you are having sugary, acidic food regularly, it not just leads to various health problems but also, over time, weakens the dental structures. It works vice versa, too. If you have weak/decayed/missing/mal-aligned teeth you can't chew or eat properly and that affects the quality of the food you intake and your overall health.

What’s new in the field? Use of Invisalign (clear aligners) to correct maligned teeth. Use of lasers for root canal treatment and gingival surgeries, TMJ pain (temporomandibular: the joint that connects the lower jaw to the skull), and for dental bleaching. Cone beam computed tomography (CBCT―a kind of medical imaging technique) to explore for any abnormality in jaw, bones and teeth. Use of Digital DC X-ray which emit far less radiation and of intraoral scanners to scan hard and soft tissues of the oral cavity.

mpox-causes-symptoms-treatment

Sun Sep 08 20:45:22 IST 2024

Interview/ Dr Anup R. Warrier, senior consultant (infectious disease), Aster Medcity, Kochi

The surge in mpox cases following the outbreak in Africa is unprecedented: 18,000 cases and more than 600 deaths have been reported this year. The World Health Organization has declared it a public health emergency of international concern (PHEIC).

The new virus strain, Clade Ib, is more virulent and infectious than the earlier ones. This mutated strain is causing severe illnesses and an increase in deaths. Outside Africa, cases have been reported in Sweden and Pakistan too. As the world is yet to fully recover from the Covid pandemic, Dr Anup R. Warrier, senior consultant (infectious disease), Aster Medcity, Kochi, explains whether mpox poses a threat. Excerpts from an interview:

What exactly is mpox disease and how did it originate?

The monkeypox virus was discovered in 1958, and the first human case reported in 1970. It is endemic to west Africa, where the consumption of bush-meat, including that from rodents and monkeys, contributed to its rise. However, human-to-human transmission was limited at that time. The virus primarily spread in close quarters, including through sexual contact, and had a mortality rate of only 1 per cent.

So what has changed now?

The Clade II virus that previously caused illness was less severe, but had led to a global outbreak in 2022-23, with mpox cases reported outside of Africa, including in India. Over time, the virus mutated into a more serious strain―Clade Ib―with a higher rate of human-to-human transmission. Recent research has discovered that this strain spreads through the respiratory route, with over 70 per cent of infections occurring in children. The new strain has also caused more deaths; the mortality rate has increased to 10 per cent. Another worrying factor is that this will likely lead to another mutation in the virus.

The WHO has declared the outbreak a PHEIC. What does this mean?

By declaring mpox a public emergency, the WHO has called on countries to take proactive measures, prepare to handle potential cases. Governments should plan for isolation facilities, enhance laboratory capacity, ensure preparedness of healthcare workers, raise community awareness, establish hospital SOPs, and develop a vaccination strategy. At this stage, encouraging public alignment with vaccination efforts is also crucial.

What are the health complications caused by the disease?

Mpox severely affects vulnerable and immunocompromised people. In severe cases, it can lead to secondary bacterial infections, encephalitis, pneumonia and keratitis (which causes blindness). All these can lead to deaths.

What are the symptoms of the disease that we need to watch out for?

The virus has an incubation period of three days to three weeks, with symptoms appearing within 21 days of infection. Unlike influenza, mpox cases are characterised by lymph node enlargement.

Next is the rash stage and it progresses through several stages: macules (red spots), papules (pimple-like), vesicles (filled with clear fluid), and pustules (containing opaque fluid). Skin rashes and fluid typically persist for two to four weeks.

What helps theinfection spread faster?

Since people are travelling across the world, such diseases can spread at a fast rate. Between 2018 and 2021, eight people were diagnosed with Clade II after travelling from Nigeria to the UK, Singapore, Israel and the US.

During the pre-rash/ symptomatic phase, the spread is relatively faster. Also, it spreads through respiratory route as well as fomites (i.e, utensils, clothes, furniture, environment contamination). However, when you compare with Covid, the spread is less severe as it is not airborne, but the major concern is that we are not sure if another mutation would change its traits.

What are the steps required to prevent an outbreak in India?

In terms of symptoms, checking of the lymph nodes for enlargement is the start. Travel and contact history of the person should be tracked to contain the spread. If anyone is arriving from Africa or has come in contact with an infected person, an isolation period should be mandatory. Rapid testing and further treatment would come in the later stages.

What methods would you advise to keep the virus in check?

There is no specific treatment. Medicines originally developed to treat smallpox are used for mpox treatment as well. There is vaccination. Mpox vaccination comes in two doses. It is about 78 per cent effective for two years. Those who have taken the smallpox vaccine can also prevent the spread of the infection to an extent.

Is there a likelihood of another pandemic?

There is a possibility at this stage. However, it will not be as severe as Covid. Compared to Covid or measles, the transmission rate for mpox is low. In the case of measles and Covid, the transmission rate is 80 per cent, while in mpox it is 20 per cent. The steps we followed during the Covid pandemic will come in handy if such a situation arises in India.

brain-waste-clearance-mechanism-glymphatic-system

Sat Aug 31 13:02:38 IST 2024

Your brain is similar to your room. If you have a cluttered room, it can become a breeding ground for disease, chaos and inefficiency. Similarly, a ‘dirty brain’ can cause trouble. Our brain has an ingenious system to clear out dirt and harmful waste. However, if that system becomes impaired for some reason, it may lead to dirty-brain diseases―such as Alzheimer’s and Parkinson’s. These diseases are characterised by the brain’s inability to effectively clear harmful waste products, primarily due to the decline of the glymphatic system, a waste removal mechanism.

Ageing is an important factor in the development of dirty-brain diseases, as it can affect the waste-clearing process. Now, a new study suggests that it may be possible in the future to reverse this age-related impairment and restore the brain’s waste-clearing mechanism.

The study was done by researchers at the Hajim School of Engineering and Applied Sciences at Rochester, New York, and the University of Rochester’s Medical Center. The researchers focused on the glymphatic system, which utilises cerebrospinal fluid to flush out excess proteins generated by neurons and other brain cells during normal activity. As individuals age, the efficiency of this system diminishes, leading to the accumulation of toxic proteins associated with various neurological disorders.

Once laden with protein waste, cerebrospinal fluid in the skull must travel to the lymphatic system and eventually reach the kidneys for processing. Advanced imaging and particle-tracking techniques have revealed the route by way of the cervical lymph vessels in the neck through which half the dirty cerebrospinal fluid exits the brain. Unlike the cardiovascular system, which has the heart as its sole pump, fluid in the lymphatic system is transported by a network of tiny pumps. These microscopic pumps, called lymphangions, have valves to prevent backflow and are strung together to form lymph vessels.

The researchers observed that in older mice, the frequency of contractions of this system decreased and valves failed, slowing the flow of dirty cerebrospinal fluid out of the brain by 63 per cent compared to younger mice.

The researchers applied prostaglandin F2α, a drug already being used clinically, to the cervical lymph vessels in older mice. It was then observed that the frequency of contractions and the flow of dirty cerebrospinal fluid from the brain both increased, returning to a level of efficiency found in younger mice. Prostaglandin F2α is a hormone-like compound commonly used medically to induce labour and known to aid smooth muscle contraction. This breakthrough offers a potential new treatment strategy for neurodegenerative diseases.

a-new-approach-to-treating-parkinsons-plus-syndrome-a-first-in-india

Sat Jul 27 15:36:58 IST 2024

Mary (name changed), a 65-year-old from Europe, arrived in Bengaluru in a wheelchair, grappling with the debilitating symptoms of Parkinson's Plus Syndrome (PPS). Having endured years of fruitless medical consultations across France, England and Africa, she found herself at Fortis Hospital Bannerghatta Road, where she was diagnosed and given relief through an innovative treatment.

PPS, a variant of Parkinson's disease, presents a unique set of challenges including early-onset dementia, hallucinations and balance issues, making traditional medication ineffective. Mary's case was particularly severe, marked by a loss of bladder control, speech impediment, and a near-complete loss of mobility. Traditional treatment avenues exhausted, the medical team swiftly formulated a novel approach―high cervical spinal cord stimulation.

“While Parkinson's often responds to medication like Levodopa and deep-brain stimulation surgery, PPS presents a more complex scenario,” said Dr Guruprasad Hosurkar, additional director of neurology at the hospital. “Unlike PD, where brain degeneration is localised, PPS affects a broader range of brain functions. PPS patients develop balance issues and gait freezing early on. In PD, a patient may develop similar symptoms 10 to 15 years after the onset of the disease. If tremors are seen in PD patients, the atypical Parkinsonism patients experience difficulty in swallowing, speech and coordination, and clumsiness. They cannot do regular work like eating or standing.”

Conventional DBS surgery could have potentially exacerbated Mary's condition. The doctors went through literature and found that some centres had tried brain stem stimulation and lower spinal cord stimulation.

“We selected the higher cervical cord stimulation, where we put a lead over the surface of the spinal cord for stimulation,” said Hosurkar. “This would modulate the networks in the spinal cord and improve her condition or restore some of the normal functions like speech, bladder control and movement. She improved and started sleeping through the night without disturbance. We put a lead covering 70 per cent of the spinal cord (from C3 to C8 vertebrae) and used an external battery to stimulate the spinal cord. After adjusting the parameters, we saw nearly 40 per cent improvement in her working abilities.”

Dr Raghuram G., additional director, neurosurgery, at the hospital said, “Our approach involved an initial trial surgery utilising an external pacemaker. This step was crucial as it allowed us to closely monitor the patient's response to the stimulation. Following this, we observed promising results, including improved mobility and reduced symptoms. Encouraged by these outcomes, we proceeded with the spinal cord stimulation surgery, which involved precise placement of electrodes along the spinal cord to modulate neural activity and alleviate symptoms. Spinal cord surgeries are different because they involve placement of an electrode on the spinal cord chosen for a particular condition. It is an epidural (space around the spinal nerves) electrode and is not put within the spinal cord. Unlike the deep brain stimulation electrode, which is placed within the brain.”

The procedure, done in a few centres in the US and China, was carried out in India for the first time. The internal battery lasts seven to eight years. The small devices that conduct electricity are placed near the spinal cord.

“The patient who had come in with the assistance of two people for treatment could walk a few steps independently after the treatment. The stiffness in the limbs reduced, speech became clear and she slept peacefully at night after many years. The new procedure has a window of 10 days before which you can remove the lead and the external battery if you don't see some predictive value of improvement. The cost of the lead is around 02 lakh and the battery would cost 015 lakh,” said Dr Hosurkar, adding that the patient was discharged after ten days.

A patient programmer app helps in the follow-up treatment as it sets parameters for stimulation in the device. If the response to the earlier limit of stimulation is lower, they can increase it. Video consultations are held in follow-up sessions.

With the increase in life expectancy, there are more Parkinson's patients―one in every hundred aged 80-plus. And for every 10 cases of Parkinson's, two to three patients have PPS, said doctors.

The spinal cord stimulation can be used to treat Parkinson's, too, as the patient develops similar complications and the gait might not improve even after DBS. However, it is not advisable if the patient is above 70 and has co-morbidities.

“The achievement represents a significant milestone in the field of neurosurgery,” said Akshay Oleti, business head, Fortis Hospital Bengaluru, “and offers hope to individuals battling this challenging condition.”

low-testosterone-is-as-much-a-taboo-for-men-as-menopause-has-been-for-women

Sat Jul 27 15:18:13 IST 2024

Low testosterone, or Testosterone Deficiency (TD), is experienced by two out of 100 men, and while it becomes increasingly common with age, ageing isn’t the only reason. Its impact can be upsetting, leaving men feeling unhappy and unwell. The good news is that it’s an entirely treatable problem. The difficulty can lie in identifying it.

While most people imagine low testosterone to be purely associated with libido and sex, there are actually a whole range of other symptoms that may indicate a testosterone problem, and it’s often spouses and partners who are best placed to spot them.

SYMPTOMS

Men with low testosterone levels may feel excessive tiredness, even after sleep. A lowering of testosterone can produce a range of physical and psychological symptoms in them. Many of these can be easily mistaken for other conditions, or simply the bad temper of age. Knowing what to look out for can help you to get your partner the treatment they need. Dr David Edwards, general practitioner and specialist in men’s and women’s sexual health and contributor to TRTed, shares the key signs and symptoms to be aware of:

1 He’s tired all the time

Whether it’s nodding off on the couch every evening, spending more time at home just relaxing, not wanting to get out of bed in the morning despite a full night’s sleep, or putting off tasks or events that he would usually enjoy, he may have a testosterone imbalance.

2 He’s more irritable or depressed than usual

Testosterone affects emotions and too little can lead to depression. Suppose your partner is snappish or moody for no apparent reason. In the case that he’s not stressed or obviously ill, there are no family or other personal problems—there’s a chance that it might be low testosterone pulling his emotions all over the place.

3 He’s putting on weight

A lot of people gain weight as they age, but if your partner has developed a recent 'spare tyre' around his middle and he’s not noticeably changed his diet or exercise routine, it can be an indication that his testosterone has fallen.

4 His sex drive has dropped off or he’s having trouble maintaining an erection

This is the sign that most people know to look for when it comes to low testosterone, but it can be interpreted in other ways. If your partner isn’t initiating intimacy as often as he once was, it’s easy to imagine that he’s losing interest in you. If he’s failing to maintain an erection, he may laugh it off as too much beer. But if these things are occurring regularly and there are no other reasons—like injury, stress or illness—there could be hormonal issues at play.

5 He’s not as strong as he once was

Testosterone directly impacts the building and maintaining of muscle. When testosterone levels fall, muscle mass falls, too, typically reverting to fat. And this can impact a man’s strength, his ability to lift, carry, and even exercise.

6 He’s finding it hard to concentrate

Testosterone has also been linked to cognitive function, meaning concentration becomes harder when it falls. And this can come into play at work as well as at home. If he’s complaining about not finishing his projects on time, the boss breathing down his neck at work, or he doesn’t seem to be paying attention at home, testosterone could be playing a part.

7 He’s lost his oomph and other symptoms

Although it’s really not an appropriate term, there are a lot of reasons why low testosterone is often jokingly referred to as the 'male menopause'. In some cases, men can experience a range of similar symptoms, including night sweats, hot flushes, sensitive breasts and anaemia. Shrinking testicles can also occur. It’s worth paying attention to how the man is sleeping, feeling, and whether he has any sensitivities.

THE HEALTH EFFECTS

If a man has biochemically low levels of testosterone, he can experience a range of health issues. While some of them are minor, such as tiredness and a loss of energy, others can be more serious, such as depression, diminished bone and muscle strength, as well as low red blood cell count. In fact, research has shown that men with TD have a greater chance of dying younger than men with normal levels.

Testosterone levels and symptoms can improve with testosterone treatment gradually over many months. Interestingly, the first symptoms to improve are often the sexual symptoms such as erections, libido and early morning erections.

Men with type 2 diabetes are more likely to suffer from TD—40 per cent of type 2 diabetics (T2D) have low or borderline testosterone. Those with T2D must ask for a testosterone blood test to be carried out in annual blood tests.

Interestingly, other research has shown that men with TD and T2D can put their diabetes into remission with testosterone treatment. They see an improvement in their diabetic, cholesterol and fat blood levels. Furthermore, their weight goes down, blood pressure reduces and abdominal circumference improves year on year.

But it’s not an overnight fix, so don’t expect miracles straightaway.

How to talk to your partner about low testosterone

Unfortunately, one of the most common symptoms of low testosterone is irritability. And the last thing you probably want to do when you already feel like you’re walking on eggshells is to broach a difficult personal conversation. But the best approach is to offer honesty and sympathy. As soon as your partner realises that there’s a problem, he can start to do something about it.

Start by making a plan.

* Do some research to make sure that low testosterone could be the potential problem, and so that you can make a convincing argument. One that is factual rather than emotional.

* Think about how you’re going to open the conversation—ideally avoiding the "we need to talk" gambit—and what you’re going to cover.

* Choose a time when he’s relaxed, not distracted, has some free time, and is most likely to engage.

* Be open, honest, and sympathetic.

* Give him a chance to speak—and listen to what he has to say. He may have other explanations for his symptoms.

* Have a suggested action plan ready, so if he agrees and wants to seek treatment, you know what to do next.

TREATMENT

“In the first instance, your GP should always be the first point of contact for anyone who thinks they may have low testosterone,” says Dr Edwards. “While online services are available, to gain a true diagnosis, men need to have a medical history, physical examination, and blood work completed. Without this, misdiagnosis and missed diagnosis is common. Once a diagnosis has been made, your GP will be able to suggest the correct treatment or refer your partner to the relevant specialist.”

With the right treatment, men can recover health and their sense of vitality. It’s only when low testosterone is left untreated that wider problems develop.

bone-reconstructive-surgery-3d-bone-graft-printer-osseocraft

Sat Jul 27 15:12:57 IST 2024

In India, professions are often compartmentalised, with doctors and dentists primarily seen as healers. Defying this norm are Dr Adersh G.A., assistant professor at the department of surgery at PMS Dental College in Thiruvananthapuram, and Shivadhath R.P., a house surgeon at the same college. Their passion extends beyond traditional dentistry, to innovating and crafting novel medical solutions. Together, they have pioneered the world’s first clinical 3D bone graft printer, OsseoCraft, which is poised to revolutionise bone reconstructive surgery globally.

“Bone reconstruction for cases of bone loss typically involves the use of material like titanium and certain plastics. But they just provided support for existing bone or tissue, rather than fostering bone regeneration,” says Adersh, who co-founded the startup Pionomed Biogenix with Shivadhath. “Unlike these conventional options, the material we employ possesses unique properties that stimulate bone growth. It is osseo-conductive, which means it attracts bone formation. Consequently, when these particles are implanted in the body, bone forms around them, making this product unique.”

Moreover, this 3D-printed graft significantly reduces operative time compared to traditional methods like bone harvesting from other parts of the body. “For example, in cases of accidents or cancer surgeries resulting in bone loss, traditional approaches necessitate complex microvascular surgeries to transplant bone from elsewhere in the body,” says Adersh.

The duo utilises CT images of the patient to reconstruct the lost bone via 3D printing, directly implanting it into the patient’s body. The 3D printing process resembles that of a robotic system. “As we feed the reconstruction material into the machine, it is melted by an extruder heating to 200 to 300 degrees Celsius, deposited layer by layer according to the design programmed into the system,” says Adersh.

The reconstruction material contains hydroxyapatite molecules, a common component found in natural bone. “When implanted, the material attracts blood, facilitating the absorption of bone-forming factors. Subsequently, bone formation occurs around the implanted material,” he says.

Shivadhath highlights the cost-effectiveness of this printing technology compared to traditional titanium-based bone reconstruction materials. “A titanium graft can cost between Rs3,000 to Rs5,000 per graft, whereas we charge only Rs500 per graft,” he says. “Titanium, while strong, can sometimes weaken surrounding tissues due to its strength surpassing that of natural bone. Our material possesses strength comparable to natural bone, resulting in faster healing and improved surgical outcomes.”

Each graft produced by Pionomed Biogenix is customised to meet the unique requirements of individual patients, eliminating the need for on-table manipulations.

The concept behind the 3D printing-based bone graft was born during a contemplative phase Adersh had when he was an intern. “As a surgeon, I frequently encountered cases necessitating bone grafting or harvesting from alternative sites in the body. This process often extended surgeries by an additional five to six hours, and introduced complications such as donor site morbidity. Reflecting on these challenges, I sought a solution that could effectively substitute natural bone without resorting to metals or plastics. This journey led me to conceptualise a mechanism for producing grafts composed of a material engineered to emulate the properties and functionality of natural bone tissue,” he says.

Adersh’s father is a pioneering dental mechanic in Kerala known for crafting artificial teeth. “My father introduced me to dentistry,” he says. “Growing up in a family that owned a dental lab, I was exposed to various dental procedures from a young age, sparking my interest in the field.” Shivadhath says “fate” brought him to dentistry; he has a longstanding fascination with engineering as well. “In my second year [as undergraduate], I delved into research, eventually securing the first BDS student idea grant from the Kerala Startup Mission in 2022 for a gypsum recycling plant,” he says. “My innovation significantly reduced the cost of gypsum recycling. As I continued with my research, I crossed paths with Adersh, and our collaboration began.”

The award-winning duo’s 3D printer is now in use at PMS for reconstruction surgeries in the head and neck region. Additionally, the team has initiated discussions with several hospital chains and has forged partnerships with institutions like Apollo Hospitals, Hyderabad. Priced at Rs10.5 lakh, their printer offers a cost-effective solution compared to similar models abroad, which often integrate stem cell technology with 3D printing.

“We are aiming to provide an Internet of Things-based printer to hospitals, enabling remote planning and file creation, streamlining their workflow,” says Adersh. “For hospitals unable to invest in the printer, we offer the option to print grafts at PMS and deliver them.”

The entire journey, from conception to regulatory approval, spanned five years for this 3D printer featuring bioactive materials. The project received support from PMS’s engineering team and various other startups. Under Pionomed Biogenix, the duo is spearheading 12 innovative medical technology projects, including robotic exoskeletons, wheelchair-accessible dental chairs, and dental gypsum waste recycling plants. Additionally, they plan to venture into sustainable energy and establish a robotics centre, expanding their innovative endeavours. They are also chasing a world record―3D printing the largest artificial teeth using recycled plastics, leveraging their unique technology.

embrace-early-detection-methods-and-take-charge-of-your-hearts-health

Sat Jul 27 17:20:21 IST 2024

Over the past three to four years, we have witnessed a sudden spike in cardiac events, sometimes fatal. What is concerning is that the patients are getting younger. There has been a spate of healthy-looking people, in their 40s, succumbing to cardiac arrest. Accounting for about 27 per cent of deaths, heart disease has become a silent epidemic in India. Approximately six lakh individuals succumb to sudden cardiac death annually, a significant being under 50.

Atrial fibrillation (AFib), a common heart rhythm disorder, and hypertension contribute significantly to these statistics. AFib, characterised by irregular and rapid heartbeats, poses a heightened risk of complications such as stroke and heart failure. So, early detection and regular monitoring are paramount.

Despite efforts to raise awareness among the public and health care practitioners about hypertension, there remains a significant disparity in the number of people monitoring it. In a recent study from the Indian Council of Medical Research, 30 per cent of Indians aged 18-54 have never had their blood pressure (BP) checked.

Undetected and untreated hypertension elevates AFib risk threefold, and AFib increases stroke risk fivefold. This underlines the importance of monitoring Afib, along with hypertension, and can only be done when one measures ECG along with BP.

Patients, who consistently and accurately monitor their blood pressure fluctuations, can provide comprehensive data to health care providers, leading to better treatment strategies. While we have digital BP monitors available to track BP at home, home ECG monitoring solutions are the newer entrants and add more value. Unlike traditional methods that necessitate time-consuming visits to health care facilities, home ECG monitoring empowers individuals to monitor their heart’s health from the comfort of homes. There are advanced devices available now that enable patients to measure BP and electrocardiogram (ECG) readings and even detect AFib―all in one go, from home. It is important to note that AFib is not detected with just one or two measurements. A home monitoring device is crucial for identifying patterns and providing comprehensive data to health care providers.

These devices are user-friendly and clear to read. They look like standard home blood pressure monitors, with two electrodes on the sides, and can be connected to a smartphone app. Users need to place their thumb and index fingers on these electrodes to take their ECG. They can use the arm cuff for measuring blood pressure. The app not only displays your blood pressure and ECG readings but also tracks them over time. This data can be sent to your doctor in PDF format, providing them better insights into your health status.

The transition from reactive to proactive health care plays a pivotal role in preventing dire consequences linked with undetected heart conditions.

The writer is MD, OMRON Healthcare India.

how-a-teenage-pakistani-girl-found-hope-and-a-new-heart-in-india

Sat Jul 27 16:09:57 IST 2024

It began in 2009. Four-year-old Ayesha Rashan was gasping for air. Her panicked teachers called her mother, Sanober. She took her back home, hoping her daughter's condition would improve with rest. It did not. So, in the evening, Sanober rushed Ayesha to the doctor in her locality in Karachi. The doctor prescribed medication that eased Ayesha’s breathlessness.

Sanober, a single mother, was relieved and convinced herself that the episode was just a temporary health issue and that her little girl would be fine soon. After finishing the medicine's course, Ayesha went back to school. But, before long, she was back in the sick room. Another visit to the doctor followed. Medication provided temporary relief. Ayesha was back in school. And, then, back in the sick room. The relentless cycle repeated.

Slowly, Sanober realised that those grim calls from the school were becoming more frequent. And, she noticed that Ayesha's breathlessness seemed to be getting worse, despite multiple visits to the doctor. But she just did not know what to do to make things better for her daughter.

One day, when she was at the school in response to yet another call from the teachers, the school doctor suggested that she take Ayesha to a cardiologist. And, at long last, there was a proper diagnosis―cardiomyopathy (a disease of the heart muscle that makes it more difficult for the heart to pump blood to the rest of the body). However, according to Sanober, the cardiologist said there would be no treatment available in Pakistan. He prescribed medication for six months, but also warned Sanober that the condition was life threatening.

Sure enough, breathlessness came back to haunt Ayesha again and she had to stop going to school. Tired, and mostly breathless, she would lie on her bed as her two elder sisters shared stories from school. Sanober was already shattered. Her struggles grew as she could not keep up with the medical expenses. She provided for her girls with her earning from a job in a private company.

But despite the challenges and the feeling of powerlessness, Sanober continued her fight. If treatment was not available in Pakistan, she would cross the seven seas to save Ayesha. She scoured the internet for treatment options overseas and frequently visited the cardiologist seeking suggestions on a hospital in the west that could treat her daughter. The cardiologist and her relatives suggested hospitals in the US and the UK. But, they were not affordable. Sanober's search for a hospital lasted years and Ayesha's condition continued to deteriorate.

Finally, one of Sanober's relatives heard of a Pakistani patient who had got a heart transplant in India. It was done by Dr K.R. Balakrishnan, chairman of the Institute of Heart and Lung Transplant and Mechanical Circulatory Support in Chennai. After verifying what she could about Balakrishnan on the internet, Sanober got in touch. It had been 10 years since Ayesha first took ill. The 14-year-old was now fighting for her life, and failing.

Even after finding a doctor, the challenges continued. Getting a medical visa to India took more than six months. By the time Ayesha got to Balakrishnan in 2019, she was critically ill. “Her heart had almost stopped,” said Balakrishnan, who is also the chief of heart transplant at MGM Health Care, Chennai.

Balakrishnan and his team performed CPR and put her on ECMO (extracorporeal membrane oxygenation)―a machine that provides heart and lung support. After a few days, another artificial heart pump―a ventricular assist device―was implanted. Sanober had been unable to afford the device and had told Balakrishnan about her predicament. The doctors pooled money to help her. Ayesha was a candidate for a heart transplant, but once the artificial pump was in place, Sanober went back to Pakistan.

Ayesha took ill again. The right side of the heart became sick and the pump got infected. Ayesha developed a leak in the aortic valve. Before they could return to India, the Covid-19 lockdown was imposed. They did not have access to equipment needed to monitor patients with artificial heart pumps and there was no treatment in Pakistan, said Sanober. And, there was literally no way out. As the weeks stretched to months, Sanober and Ayesha managed the condition solely by following the advice Balakrishnan was giving them from Chennai.

By the time the lockdown passed, Ayesha's treatment options had got complicated. The doctor's decided that a heart transplant was her best bet. Getting a medical visa post-Covid was even more difficult than it was pre-Covid. Sanober's perseverance saw her through and, in June 2023, Ayesha returned to India with hopes of getting a new heart.

Sanober did not have the money for Ayesha's surgery and care. She travelled to India only on the word of Balakrishnan and his team of doctors that the money would not be an issue. “We had to take care of expenses,” said Balakrishnan. “The Aishwaryam Trust (a non-profit organisation) came forward generously to help.” Up next was the unnerving wait for a donor.

The transplant register was overflowing with requests from within India. The list of foreign nationals seeking organs is shared with the Union health ministry's National Organ and Tissue Transplant Organisation (NOTTO). An organ will only be allotted to a foreigner if there are no Indians on the waiting list. Ayesha had been on NOTTO's waiting list since 2019. It was only in January 2024 that the heart of a 69-year-old donor from Delhi was allotted to her.

“Luckily, she got the organ,” said Dr Suresh Rao, co-director at the Institute of Heart and Lung Transplant and Mechanical Circulatory Support. “For international patients, usually it is difficult to get an organ. In Ayesha’s case, there were no takers for a heart that was available in Delhi. We did a lot of logistics, including organising a chartered flight to bring it here on time.”

On January 31, 2024, the heart was airlifted from Delhi to Chennai. Balakrishnan and his team performed the transplant. However, as the donor was much older, the heart was too big for Ayesha. So, her chest was kept open for almost 10 days. She had a slow recovery. “She had to recover completely and the doctors wanted to monitor her health on a regular basis,” said Sanober. The mother and daughter stayed in Chennai and after five months in and out of the hospital, in June, Ayesha chose to go back to Pakistan. This time, she was not worrying about the future, but determined to pursue her dream of becoming a fashion designer.

Balakrishnan had spend his own money and also sourced funds for her recovery. When asked why this case was so close to his heart, he simply said: “She is so young; like my daughter. As a doctor, for me, every life matters.”

“The hospitality we got and the care Ayesha got in Chennai has given me a new life,” said Sanober. “My only request to Indian authorities is to give visas to patients who want to get treated in India. The political or bilateral relationship should never stand in the way.”

In a world divided by borders and beliefs, Ayesha’s heart now beats, somewhere in Karachi, with a resilient spirit.

direct-and-indirect-effects-of-inflammation-on-cognition

Sat Jul 27 15:33:31 IST 2024

If you are not kind to yourself in your 20s, a series of cognitive troubles could affect you in your 40s. Researchers from UC San Francisco found that higher inflammation in young adulthood may lead to reduced cognitive function in midlife. High levels of inflammation are associated with obesity, physical inactivity, stress and smoking. While the link between higher inflammation in adults and dementia is already well-established, this is the first time a connection has been made between inflammation in early adulthood and lower cognitive abilities in one's 40s.

Study author Amber Bahorik, from the UCSF department of psychiatry and behavioural sciences and the Weill Institute for Neurosciences, explained, “Long-term studies indicate that brain changes linked to Alzheimer’s disease and other dementias can evolve over decades. Our aim was to investigate whether health and lifestyle habits during early adulthood could impact cognitive abilities in midlife, potentially affecting the risk of dementia later in life.”

The study tracked 2,364 adults enrolled in the CARDIA study, which investigates factors in young adulthood that contribute to cardiovascular disease decades later. Participants, aged 18 to 30 upon entry, underwent testing four times over an 18-year span to measure the inflammatory marker C-reactive protein (CRP). Cognitive tests were administered five years after the final CRP measurement, when most participants were in their forties and fifties.

About half the participants were female. Among the participants, some 45 per cent had lower stable inflammation, while 16 per cent had moderate or increasing inflammation; 39 per cent had higher levels.

Researchers discovered that among participants, only 10 per cent with low inflammation performed poorly on tests of processing speed and memory, whereas 21 per cent and 19 per cent of those with moderate or higher inflammation levels, respectively, struggled on these tests.

Even after adjusting for factors such as age, physical activity, and total cholesterol, disparities persisted in processing speed. The researchers also observed differences in executive functioning, encompassing working memory, problem-solving, and impulse control.

The researchers discovered both direct and indirect effects of inflammation on cognition. They emphasised that increasing physical activity and quitting smoking are effective ways to reduce inflammation. However, while these steps may sound straightforward, many find them hard to implement.

a-symposium-on-traditional-trees-throws-light-on-india-s-ancient-knowledge

Sat Jun 29 16:04:28 IST 2024

Goa Governor P. S. Sreedharan Pillai inaugurated a day-long symposium on the traditional trees of India, titled 'Vriksha Vygnanika Sadassu', at the Raj Bhavan on April 21. In attendance were experts from various fields who presented papers on traditional trees that have been worshipped over the years in India. “Trees shelter thousands of creatures of all kinds―algae, fungi, insects, squirrels, birds, snakes and other reptiles, animals and humans,” Pillai told THE WEEK. “Every single part of a tree is useful, either as food, medicine, fuel, timber, or as source material for building various things. We must understand and appreciate their indispensable and invaluable existence on the planet.”

In their research paper titled, 'Indian traditional trees and their scientific relevance', researchers Amit Kumar Tiwari, Indrajeet Chaudhary and Alok Kumar Pandey mentioned how bel (Aegle marmelos) and rudraksha (seed of Elaeocarpus) were associated with Shiva, peepal tree with Vishnu, mango (Mangifera indica) with Hanuman and Ashoka tree with Kamadeva.

With the vedic civilisation and the knowledge of ayurveda, they added, society came to worship tulsi (Ocimum tenuiflorum), peepal (Ficus religiosa), banyan (Ficus benghalensis) and neem (Azadirachta indica) for their medical importance.

Dr Pradip Sarmokadam, member secretary, Goa State Biodiversity Board, spoke about the “traditional application of sacred flora of India in yajnas and associated rituals”. The enormous research carried out by vedic scholars and subsequent experts, he said, should be further institutionalised as it has integrated a conservation ethos into lifestyles for the betterment of humanity. “If disregarded and neglected, we would be deprived of a huge knowledge repository that is well documented and has verification methods,” he said.

The knowledge lies scattered and needs to be further strengthened by the integration of knowledge holders, he said. “I suggest we create conservatories of floral diversity of samidha (floral parts used as sacrificial offerings in yagnas) and make them available in its genuine form to establish ground-level successful models to depict floral diversity and its connect with Indian mythology,” he added. “We should create facilities that would provide dignity to the scholars and sustainability to those growing samidha and sacred flora. Livelihood opportunities in this sector should be explored. We should create dedicated libraries and research centres to simplify and ensure availability of vedic literature, plant-related knowledge and we should validate these by using modern scientific methods. People's Biodiversity Registers (PBRs), under the Biological Diversity Act, are under preparation and should capture traditional wisdom-based knowledge systems such as vedic rituals and associated wisdom, along with such knowledge and practices in other religions as an important basis that will lead to conservation of biodiversity.”

N.K. Sundareswaran, professor of Sanskrit at Calicut University, elaborated on the topic of 'Trees in the vedas'. “Here, the metaphor of the nest implies a huge tree, which is seen as a support of the ecosystem,” he said. “One may recall the explicit description of a similar huge tree in the Mahabharat: A huge tree flourishing, many living beings find an abode and habitat in it. When the tree is burnt, those living beings are rendered homeless. Of all the literary expressions of trees and forests in vedic literature, the aranyanisukt (the hymn of the thick woods) of the Rig Veda is the most noteworthy. It is a small hymn, but it carries much value from literary and ecological angles. The frightening solitude of the wild and thick woods is given a beautiful expression.... The deep forest is extolled as the Universal mother, not harming anybody (unless it is afflicted), and providing sweet and healthy food (fruits) in plenty.”

Sundareswaran talked about agriculture and how its practice is extolled in the Rig Veda. “We get references to the foodgrains that are cultivated and are utilised to prepare different food items and sacrificial offerings,” he said. “Grains such as wheat, barley, and rice, cereals and seeds such as mustard and sesame are mentioned as part of rituals.”

Retired professor Janarthanam addressed palm trees and disappearing traditions in south India, while other experts such as Rajendra Kerkar and Dr Sindhu A. spoke about the tradition of sacred trees in Goa, medicinal trees and the ethno-medicinal flora of sacred groves. In the same context, Pillai spoke about his project, 'Vaman Vriksha Kala', a monograph focusing on the specialised subject of bonsai. The name of the book means 'The art of miniature trees'. The prime intention of the book, he said, was to firmly establish the fact that bonsai is originally an Indian art, as against the widely held belief that it belongs to China and Japan. “In the book, I have provided sufficient evidence from ancient Sanskrit texts to establish this claim that the art of bonsai has its roots in India, and why our ancestors reduced trees to potted size,” he said. “After I took charge as governor in July 2021, I had the occasion to visit Partagali Mutt in Canacona taluka. There I saw this 1,000-year banyan tree. It was then that I decided that one day I would return to worship this great tree. About a year later, I began the Saimik Daiz Yatra (journey to learn about heritage trees of Goa) and that is when I learnt about 30 more heritage trees, all of them between 100 and 500 years, spread out across Goa. Some amazing trees I found were shidam, satvin, baobab, and more. These trees constitute an integral part of people's socio-cultural association with nature and environment.” His yatra resulted in the writing and publication of Heritage Trees of Goa, which was released by the West Bengal Governor C.V. Ananda Bose last year.

popular-weight-loss-miracles-that-will-not-work-in-the-long-term

Sat Jun 29 16:01:57 IST 2024

Weight loss miracle cures are everywhere. Every day a new study, product or trend promises a magic bullet that will banish fat and give you a svelte figure with next to no effort.

Fad diets date back to the 19th century, but the advent of Instagram and TikTok has led to a mass proliferation of get-slim-quick techniques from detoxifying teas to volume-eating diets.

“Self-esteem is at an all-time low, and not trusting yourself is a key feature of people who pursue quick-fix solutions,” says Dr Jo Perkins, a chartered psychologist. “You’ve tried it on your own, haven’t succeeded, so you lean on a magic solution.”

This is human nature, says Dr Perkins. “We’re hard-wired to want to expend the least energy on the best result―a hungry monkey reaches for the nearest banana rather than the one at the top of the tree―it’s the same with weight loss,” she says.

The trouble is that “we live in an instant gratification culture where it’s easier to order a weight loss product online than it is to stop and think about it and why we even want it,” adds Dr Perkins. “There’s a perceived credibility that comes with being the first to discover something. It’s a double-whammy inducing us towards fads.”

However, in the long term, these techniques are tricky to stick to. Here are a few popular ‘weight-loss miracles’ and, crucially, why they won’t work in the long term:

DETOX TEAS

Promoted as ‘flat tummy teas’, these products are presented as a natural way to reduce water retention, cleanse the digestive system, and ultimately lose weight. A common denominator in these products is often senna, a natural laxative.

One can get a flatter stomach on a detox tea diet because the laxative effect causes them to excrete food before it is fully digested. They often also contain diuretics which cause drinkers to pass fluid more regularly, resulting in a temporarily flatter stomach. However, consuming laxatives and diuretics can cause stomach cramps and diarrhoea. As soon as a person stops consuming them, any perceived weight loss will be reversed.

BEVERLY HILLS DIET

Created by the author Judy Mazel in 1981, this is an extreme diet that claims to promote weight loss through specific food combinations. The Beverly Hills diet is based on the idea that the order and combinations in which foods are eaten causes weight gain. Mazel claimed that eating foods in the wrong order could stop some foods from being digested, causing fat build-up.

The diet divides foods into four groups: carbohydrates, proteins, fruits, and fats. Fruit, even different types of fruit, must always be eaten alone. If a different type of food is eaten, such as a protein, the dieter must wait until the next day to eat fruit again. Protein and carbohydrates cannot be eaten together.

You won’t be surprised to hear that experts are very sceptical about whether food combining actually works. You will probably lose weight initially because of the low calorie intake, but it’s very complicated to follow and following such a restrictive diet for an extended period of time could result in nutritional deficiencies. Best to confine this one to the history books.

VAGUS NERVE STIMULATION

Currently being trialled by scientists at Moscow State University, this technique involves clipping electrodes to a part of the ear which contains a branch of the vagus nerve, which stimulates appetite. So the thinking is that an electrical current passed through it could tell the brain that the stomach is full, curbing a person’s appetite.

Vagus nerve stimulation has already been heralded as a miracle cure for epilepsy and depression, and animal trials have suggested that it may work for weight loss. Users in the Russian trial will wear the clips on both ears, connected to a battery-powered generator which will provide 10 minutes of stimulation per day.

However, it is not clear whether it will work, let alone its long-term efficacy. “Ultimately, the only way to make weight loss work is if you can shift your habits to move your weight anchor down,” says Dr Andrew Jenkinson, a bariatric surgeon and author of How To Eat (And Still Lose Weight).

CARNIVORE DIET

This involves eating only meat. The idea is that protein has a ‘high thermic effect’, meaning the body has to burn more calories to digest it. Additionally, since protein is used for building muscle, the body quickly increases in muscle size, raising its basal metabolic rate―the calories are burned simply by staying alive.

Weight-loss will happen on this diet because of calorie restriction. The other supposed benefits are questionable, according to experts. “You can’t magically take all of your protein in one meal and turn that excess into muscle,” says the award-winning dietitian Priya Tew. “It will convert it into glucose and your body will either use it or store it.”

CABBAGE SOUP DIET

A popular strategy which sees people eating nothing but cabbage soup for a week, stripping out any other aspect of their diet.

It will work temporarily, because of calorie restrictions. However, like all calorie-restricting diets, it’s “prone to short-term success, long-term failure―as soon as you come off it, your brain will want to get back to its weight set point,” says Dr Jenkinson.

VOLUME EATING

Based on the idea that food loses nutrients when cooked, this diet sees people eating only raw, plant-based foods that are high in water and fibre so you feel full. It is popular on TikTok as the rebranded concept of “volume eating” where dieters eat big helpings of low-calorie foods like spinach to stay full, avoiding carbohydrates.

The diet can help followers avoid the worst excesses of modern junk food. “The western diet is high in ultra-processed foods made with refined sugar and carbohydrates which causes our insulin to become high,” Dr Jenkinson explains. “This blocks your natural weight regulation hormone, leptin. Your brain then thinks you’re running on empty and tells you to keep eating.” In short, by eating raw food and avoiding ultra-processed foods, you will stop overeating.

However, it pays to be careful. A 1999 study by German scientists looking into over 500 people on the diet over three years found that “since many raw food dieters were underweight and exhibited amenorrhea [loss of periods], a very strict raw food diet cannot be recommended on a long-term basis”.

PERSONALISED DIETS

This involves getting analysis of blood or stool samples to create a hyper-personalised diet based on gut bacteria or DNA. The thinking goes that a person can optimise their intake to foods they are best able to digest.

“People love the idea that something is just for them, that you’re getting something no one else has understood,” says Dr Jenkinson. “But it’s based on pseudoscience. There’s no evidence that you can tailor a diet to your gut microbiome or that it will have any effect. Eventually all these diets end with advising you to eat normally, but avoid ultra-processed foods, which works but isn’t personal.”

JUICE CLEANSE

Popularised by catwalk models and the Kardashians alike, juice diets were all the rage several years ago. The diet is essentially a simple calorie-restriction―by cutting out normal solid foods, you limit the amount you are eating, putting you into a calorie deficit.

Work has been put into making sure low-calorie meal replacement shakes have the right nutrients and vitamins in them, so a reputable juice cleanse diet is usually nutritionally complete. However, according to Emer Delaney, a spokeswoman for the British Dietetic Association, juice cleanses are inherently unsustainable: “People might be able to follow them for a couple of weeks, but it’s not addressing your behaviour around food. They’re not sustainable. People can’t just go on drinking shakes for the rest of their lives.”

In short, once you come off the diet, the weight will go back on.

THE REAL SECRET TO LASTING WEIGHT-LOSS

Lasting weight-loss happens by altering the brain’s weight anchor. “The brain is in control of your weight, not you,” Dr Jenkinson explains. “It is like saying you can control your breathing by holding your breath; the brain takes back over. It will drag you to the weight it wants you to be. The only way to lose weight sustainably is to understand why your weight anchor is set at such a level.”

Reducing the brain’s weight anchor is a gradual process, about adjusting habits and lifestyle in the long-term. “You can reduce it by changing not just the type of food you’re eating―cutting out those refined carbohydrates and sugars―but also by reducing your stress, and getting better sleep,” says Dr Jenkinson. “Forming healthy habits requires repetition. The more a habit is performed the more the neurological pathway will become ingrained into your brain. That’s when the weight anchor will move.”

how-to-take-care-of-your-skin-explained-by-dr-sunil-sanghi

Sat Jun 29 15:43:34 IST 2024

Dr Sunil Sanghi, 57, senior consultant, dermatology, studied medicine at the Armed Forces Medical College in Pune. A fellow of the American Association of Dermatology, he enjoys playing lawn tennis and table tennis.

BEYOND ‘JUST’ SKIN: The condition of our skin is indicative of overall health. Thus skin which is yellow, blotchy or sallow is indicative of trouble elsewhere. Many diseases like hepatitis first manifest as itching or rashes on the skin. The quest for beauty has shone an even more intense spotlight on it.

THE LOOK OF HEALTH: A healthy skin reflects a healthy body. Such skin is smooth, warm, hydrated and has an even tone. There are five primary skin types: oily, dry, normal, combination and sensitive. Each skin type has its own sets of unique characteristics and needs that can affect the look and feel of your complexion. A balance of oil and moisture leads to blemish-free and smooth skin with fine pores. While genes play a major role in skin type, care routine, sunlight, temperature, stress, hormones, smoking, alcohol and exercise also affect it.

SIGNS THAT ALL IS NOT WELL: Flakes, cracks, rashes or visible hair and nail changes.

NORMAL CHANGE: The skin becomes thinner over time. There is loss of volume, especially in the cheeks, and bags form under the eyes. The effects of aging on the face are inevitable. These changes are normal with time. A newborn has delicate skin, teenagers have acne and the elderly have wrinkles. During pregnancy or rapid weight gain or loss, stretch marks can appear, which, despite the marketing hype, will not go. The marks result from the dermis―the middle layer of the skin―being stretched beyond its capacity and a resultant tear in its fibres.

WHAT IS UNACCEPTABLE: Severe acne leading to scars, rapid wrinkling and loss of volume or early progression of baldness.

INDIAN SKIN: Is much thicker than Caucasian skin, more prone to pigmentation and less prone to melanoma, the most dangerous type of skin cancer. The pigment in the skin is a boon.

MALE SKIN: Is approximately 20 per cent thicker than female skin, with more collagen (protein) and tightness. Men get more infections, but women have more pigmentary disorders, allergic diseases and hair problems. (The scalp is also skin.)

WHERE WE LIVE: Has little impact on our skin, though external factors like low temperature and high altitude cause changes. Low temperature, for instance, makes it harder for the skin to retain moisture, and makes it dry or itchy.

DIET: Which supports overall health also promotes good skin health. Nutritious food like fruits and vegetables, whole grain and healthy fats are good for the skin. Among the biggest misconceptions about diet is the role of food allergens in skin conditions and certain food practices associated with acne (eating sour foods, for example, does not enhance acne).

COMMON INDIAN SKIN PROBLEMS: Acne (clogging of hair follicles under the skin), eczema (inflammation of skin), psoriasis (build-up of cells causing scaly, itchy skin), fungal infections and hair disorders. Increasing pollution and temperature can trigger or worsen skin problems like rashes.

NO CURE FOR SKIN PROBLEMS? This is a misconception. With rapid advances in available therapies, most chronic skin conditions like psoriasis can be treated, ensuring a good quality of life. Both cure and continuous management work in various skin diseases just like in other chronic conditions like diabetes and hypertension.

WHY SO MANY STEROIDS? Dermatologists use steroids when needed. In such cases, benefits outweigh risks. The problem is self-medication, with over-the-counter prescriptions, especially topical steroids, being misused. The current epidemic of fungal infections is caused by the use of OTC medication, which addresses some obvious problem, but aggravates the real cause. For some conditions like anaphylaxis―a life threatening inflammation―steroids can be life-saving. The only skin regime you need: Good cleaning in the morning, followed by a toner (for removal of left-over dirt), moisturiser and sunscreen. In the night, use a cleanser, toner, retinoids and a moisturiser.

UNFAIR FAIRNESS: Allergic reactions are very common with the long-term use of pigmentation creams available over the counter. These lead to untreatable pigmentation and red, sensitive skin which persists lifelong.

EXPENSIVE IS NOT BEST: It is a myth that expensive creams can keep your skin young forever. The skin cream industry is huge, with significant reach on social media. But no skin cream can protect indefinitely against aging. It is better to visit a dermatologist once to understand the correct regimen for your skin, rather than spending money on products which are industry-driven.

SKIN FADS: Such as the recent Korean glass skin trend only promote misinformation for a ‘perceived’ perfect skin. No one should cultivate false hopes as there has been no scientific analysis of ingredients in products which promise the unbelievable.

NATURAL IS NOT ALWAYS SO: Products marketed as ‘natural’ are popular among consumers, but being natural does not mean they are effective or safe. Though comparatively expensive, they offer no additional benefit over cheaper medicated products. Aloe vera, for example, has been used for centuries for its health, beauty and medicinal properties. Though usually safe, it may cause allergic reactions in some people. This is true of all products.

LOOK OUT: For skin products that are healthy and good for the environment. Read and understand labels. Avoid parabens, for instance, which upset the skin's environment. Look for detailed information on the ingredients used. Organic products might not have lab-made substances, but colours and fragrances can also cause allergies. A sunscreen, for instance, is useless if it does not have zinc oxide, and can in fact have harmful ingredients, such as salicylate.

GOING TOO FAR: The influence of social media in promoting the use of expensive, anti-aging products at a young age.

MYTHS: Chocolate and oily food cause acne. Anti-bacterial soaps are good for skin. Natural and organic products are a better choice. All sun exposure is bad for skin. The higher the SPF the better the sunscreen.

SOME RED FLAGS: Fever with rash, painful swelling of skin, change in existing moles, loss of sensation or fluid-filled eruptions.

DO NOT SELF-MEDICATE: Any self-medication should be stopped immediately. Let me give two examples: We are currently going through an epidemic of fungal infections caused by OTC steroids. And self-medication with antibiotics is leading to significant antibiotic resistance.

TRAPS: The quest for ever-youthful skin leading to misuse of anti-aging creams. Hair oils that cure balding. Complete cure of psoriasis, vitiligo and eczema with alternative medicine. Quick-fix botox/bleach/skin peels.

TIPS: Have a balanced diet of adequate fruits, green leafy vegetables and healthy fat in the form of nuts and flax seeds. Follow a skin care regimen with cleanser, moisturiser and sunscreen. Carefully read what ingredients go into these products and use as per skin type, weather and external environment. Avoid stress and smoking, and exercise adequately. Essential oils can have some benefits, but which ones to be used should be individually determined. Such oils in heavy concentration can lead to skin irritation and worse.

flesh-eating-bacterial-infections-in-japan

Sat Jun 29 15:31:23 IST 2024

On June 18, Japan's National Institute of Infectious Diseases (NIID) reported a spike in the number of 'flesh-eating bacterial infections' in the country. As of June 9, the preliminary number of cases of Streptococcal Toxic Shock Syndrome (STSS) since the beginning of this year reached 1,019. A patient infected with Group A Streptococcus (GAS) bacteria could develop STSS, which can lead to flesh-eating bacterial infections, also known as necrotising fasciitis. This year has seen a significant increase in the spread of this rare and severe bacterial infection.

The mortality rate for necrotising fasciitis is 30 per cent. The bacteria can enter the body through surgical wounds, puncture wounds, burns, and minor cuts and scrapes. Early symptoms include redness, swelling, pain, blisters, fever, nausea, and vomiting. The infection progresses rapidly, leading to tissue death and causing severe pain, discolouration and peeling of the skin.

Flesh-eating bacterial infections have been documented for centuries, with some notable cases and outbreaks. Joseph Jones, a Confederate Army surgeon during the American Civil War, is credited with providing one of the first modern descriptions of necrotising fasciitis. He described it as “hospital gangrene”, a condition characterised by rapid and progressive soft tissue infection caused by Group A beta-hemolytic streptococcus, now recognised as necrotising fasciitis.

The term 'flesh-eating bacterial infections' is relatively new, coined and popularised by British tabloids towards the end of the 20th century to describe the necrotising infections caused by Group A Streptococci. Back then, the media suggested that epidemics of streptococcal infection were imminent. Scholars, however, note that such aggrandisement was unfounded. The moniker, though, helped in heightening public awareness of this infectious disease.

Diagnosing necrotising fasciitis involves a combination of physical examination, blood tests, tissue biopsy and imaging tests such as CT scans. Serious complications may lead to sepsis shock, organ failure, amputation and death. The infection can also cause severe scarring and long-term disability. Prompt and aggressive treatment is crucial, as necrotising fasciitis can rapidly progress and become life-threatening.

Treatment protocols include intravenous antibiotics, surgery to remove infected tissue, and other medications to manage complications such as sepsis and shock. Patients with underlying conditions like diabetes, immunosuppression, and chronic alcohol use are at higher risk and may require more aggressive management.

the-new-breed-of-wellness-gurus-from-fitness-experts-to-biohackers

Sat May 25 15:10:37 IST 2024

Wade Warren works as a product manager for a financial technology company. He is 28-years-old, bearded, bespectacled and lives in a small apartment in Brooklyn, New York. Every evening he puts on a special pair of goggles designed to block the short-wavelength, high-energy blue light that is emitted by his smartphone and laptop screens and, in so doing, he enhances his ability to fall asleep later. He sleeps on a more than Rs 2 lakh temperature-controlled mattress, which helps keep his core cool, which in turn stimulates melatonin, and, thus, ensures a better night’s rest. When he wakes, he will flick on the large 800W floodlight he keeps in a corner. By doing this, Warren suppresses his melatonin production and signals to his body that it is time to be awake. It also, he believes, improves his gut microbiome.

He adheres to a diet that is high in protein, low in carbohydrates. He also does a lot of other specific things to improve his “efficiency and effectiveness”. But you get the gist.

Warren had not thought to do any of this until one evening when he stumbled across a podcast hosted by Dr Andrew Huberman, a neuroscientist and professor at Stanford School of Medicine. He was drawn in by Huberman’s ability first to present complex scientific or biochemical concepts in a way that made sense, and then to provide listeners with advice about how to use this information, whether to do with fitness, mental health or behavioural change.

It was, essentially, self-help with science, and this pleased Warren. He became a devotee of Huberman, whose appeal is only enhanced by his incongruous appearance. With his beard, broad chest, meaty hands and piercing dark eyes, the 48-year-old Californian appears more like an Iron Age warlord than a neuroscientist. Today, the Huberman Lab advertises itself as the world’s most popular health podcast. He has more than six million Instagram followers, another five million on YouTube and several million across other platforms. Recent allegations made by a number of former partners that he is guilty of serial infidelity and controlling behaviour, which he denies, are unlikely to dent these numbers much.

Huberman is one of a number of popular online male personalities who are offering us the chance to become healthier, more efficient, better optimised human beings. If one of the dominant trends of the 2010s was “wellness” ― think Gwyneth Paltrow, Goop, crystals, healing energies, vague spiritualism and an endless list of alternative health practices made commodifiable and Instagrammable―then what we are seeing now is the emergence of something quite different. It is, ostensibly, a rationalist alternative―a Wellness 2.0―in which “science bros” offer advice founded, they insist, on research and data.

So there is Dr Cal Newport, a boyish 41-year-old computer science professor who writes popular books about focus and productivity and whose YouTube channel attracts millions of views via videos with titles such as ‘How to Reinvent Your Life in 4 Months and The Productivity System to Win at Anything’. There is Dr Mark Hyman, a 64-year-old silver fox who has developed “peganism” (a hybrid of the paleo and vegan diets), writes bestselling books called things like Young Forever: The Secrets to Living Your Longest, Healthiest Life, and who has three million Instagram followers. Dr Peter Attia, 51, who specialises in the medical science of longevity, counts Elon Musk as a fan and hosts his own podcast, which delves into questions such as the metabolic effects of fructose or the dangers of poor sleep. Dr David Sinclair, a professor of genetics at Harvard Medical School, also operates in the field of longevity. He advocates resveratrol, a natural supplement with antioxidant properties, and claims he has “reclaimed” his 20-year-old brain despite being 54.

These men, and others, all exist in the same online ecosystem. They cross-promote, appearing on each other’s podcasts and YouTube channels. If Wellness 1.0 was fundamentally feminine in tone, then Wellness 2.0 is distinctly masculine. It co-opts the stern, didactic language of the gym or boardroom. Science bros regularly use the word “protocols” rather than “routines” or “exercises” when telling their audiences what to do. Similarly, they will describe certain mindful practices as “tools” as if they were cordless drills or angle grinders. The name of a popular online radio show dedicated to fitness and wellbeing is, simply, ‘Mind Pump’.

Brad Stulberg writes bestselling books about performance and psychology and has a background in public health. He could pass for a science bro―he is trim, shaven-headed and bespectacled―but instead it was he who coined the term “broscience” five years ago, and he regards this world with a thoughtful curiosity as well as scepticism. “This is the more masculine version of the Paltrow self-care crystal stuff,” he says. And there’s no reason why the same psychological triggers that led wellness to become such an all-consuming thing for women can’t also apply to men. “We ultimately have the same human frailties and insecurities as women. Perhaps men were just an untapped market.”

The language of “efficiency” and “performance” permeates so much science bro rhetoric, and listening to these podcasts you’re often left with the sense that the main advantage of sleeping well and feeling energised, etc, is so that you can be a better employee. There is a reason you now see men posting their impressive daily routines on LinkedIn―their gym sessions, their moments of mindfulness, their healthy lunch recipes―and it’s because they believe it shows them to be better professionals.

Like Wade Warren, Michael Fields is another fan of Huberman. He is 27 and, having worked as a technical recruiter, he made the switch to become a fitness coach as well as an online trainer. Fields says that the vast majority of his clients are young professional men and that this simply reflects the kind of people who are most drawn to Wellness 2.0.

“I definitely feel like it’s way more targeted towards young men,” he says. “I think it’s because of that constant striving for status and purpose in life.”

And it is young men stuck in sedentary office jobs, Fields continues, who most often need the tools that science bros are selling. Looking at a screen for hours will make sleeping hard. Sitting down for hours will drain your vitality. What makes it worse is that the very fact of having a career that demands all this of you makes it all the more difficult to do something about it. “They have a hard time figuring out how to incorporate habits into their daily lives while working in a corporate job.” Fields says that his male, corporate clients often insist on knowing precisely why they should, say, take cold showers in the morning. So being able to tell them what someone like Huberman has said on the subject―stuff about dopamine and boosted alertness levels, etc,―is helpful. “He provides the scientific backing.”

Many of the men within this world trade on their scientific or medical qualifications. Others have achieved their profile via a willingness to go to extremes. Dave Asprey is a multimillionaire who made his money in Silicon Valley and as founder of the Bulletproof coffee and nutrition brand. He is 50 but has regularly made the claim that he will live to 180. Today, he says he wishes to revise that claim. “I think I’ve been shockingly conservative,” he says, frowning, before breaking into a bright white smile. “I think 180 is a boring, easily achievable goal.”

Asprey has built his platform as a podcaster and self-help author around claims like these. He believes that with the proper application of cutting-edge science it should be possible for all of us to live much, much longer. I’m 42, I tell him, and in decent health. How long does he think I can expect to live? “There is no reason you shouldn’t be able to live to at least 120 and be healthy the entire time,” he assures me.

Hang on, I say. How come you get to live to at least 180 but I only get 120? He smiles again and says that it’s only because he’s been “actively managing” his age for the past 25 years.

Asprey identifies as a “biohacker”. Having spent much of his twenties overweight, arthritic and struggling with “brain fog”, he has turned his life around via a slew of different treatments and protocols, from intermittent fasting to cryotherapy and various medical interventions. He has had more stem cell injections, he believes, “than anyone out there at this point”. He recently travelled to Mexico to undergo a form of gene therapy not permitted in the US and which “takes nine years off your measured age”. He takes 84 supplements a day and says he has had his “immune system taken out, amplified by thousands of times, and then reinjected to give myself a younger immune system”. He has, he continues, done a lot of neurofeedback therapy, which, in conjunction with taking a smart drug called modafinil, has provided him with what he describes as an “upgraded brain”.

Bryan Johnson is another tech millionaire. The 46-year-old is attempting to drive down his biological age through “Project Blueprint”, which, among many other things not dissimilar to what Asprey does, involves receiving blood transfusions from his teenage son. Johnson sleeps attached to a machine that measures the number of nocturnal erections.

Asprey approaches the question of longevity with a Silicon Valley mindset. “I take control of systems for a living,” he explains in a recent appearance on the Finding Mastery podcast. And human beings are, he continues brightly, simply “meat operating systems”.

There are, however, people within medicine who find this approach more than troubling. Last year, the British cardiologist and video blogger Rohin Francis wrote in the British Medical Journal about “the problem with Silicon Valley medicine”. He points out that the “move fast and break things” mindset that underpins so much of the tech world has the potential to cause much more harm than good. The human body, he writes, cannot be compared to a machine, while the demand for profitability sees claims become ever more spurious. “Waiting for evidence gained from clinical trials is often deemed too slow a process for venture capitalists hoping to see a return on their investments, so therapies are endorsed and sold based on theoretical or mechanistic evidence,” Francis writes. “These ‘breakthroughs’ are enthusiastically promoted at events more similar to the launch of a new Apple product than a medical innovation.”

Although not everybody wants or can afford to go as far as Asprey or Johnson, the desire for control drives so much of the science bros’ present success. “I think the story of wanting to live for ever, wanting to control the controllables and wanting to ‘science’ our way out of mortality is as old as time,” Brad Stulberg says. And many of the podcasts out there today are “preying on people’s desire for control and certainty in an inherently uncontrollable and uncertain world”.

What he means is, when you find yourself listening to a podcast that delves into the minutiae of exposing your body to cold water, avoiding particular types of cooking oils or the critical importance of tracking your sleep patterns, it can become easy to convince yourself that these things are all really important. In fact, you want them to be important because these are all things you can do and thus take control of. Thanks to health-tracking smartwatches and continuous glucose monitors, it is now possible to collate and crunch huge amounts of data about our bodies. “But just because something is measurable doesn’t mean it’s important,” Stulberg says. “Like, how did we get from ‘move your body for 30 minutes a day’ to ‘measure your erections for longevity’?”

He’s not saying that all science bros are manipulative or providing misinformation. But the truth is, we already have a pretty good sense of what people need to do to lead healthy, happy lives. “We have decades of good epidemiological data,” he says, and it shows that it’s important to avoid tobacco products, not to drink much alcohol, to exercise regularly, avoid becoming obese, maintain healthy social connections and, ideally, find meaningful work.

Stulberg points out that a lot of the podcasts are sponsored by supplement companies, and one YouTube video I watched, which featured Asprey comparing his deep-breathing techniques with the host’s, featured ads for dietary supplements as well as for a “personal analysis and data-driven wellness guide”. Also, people will always want to see content they perceive as comforting. If there is somebody telling you that if you buy the right medical treatments you can live to 120, then there’s a good chance a lot of us are going to click on it.

“I don’t necessarily think there’s always malintent,” Stulberg says. “Motivated reasoning is a very powerful drug, and we can convince ourselves of anything. If you can make a lot of money from a comforting belief and create a whole business model from it, then you can start to believe it yourself.”

Bryan Johnson, 46

“Don’t die” is this tech mogul’s goal. He made headlines around the world last year when he said he was trying to reverse his biological age to 18. He has had some success―he claims his heart is 37 years old. Johnson made his fortune when he sold his company, Braintree Venmo, to PayPal in 2013. Since then, he has spent more than 016 crore a year on cutting-edge “age-slowing” techniques developed by his team of doctors. His routine includes getting up at 4.30am, taking more than 100 pills, bathing in LED light and sitting on a high-intensity electromagnetic device to strengthen his pelvic floor, before going to bed at 8.30pm. Johnson calls himself “the world’s most measured human”.

Power list

By Georgina Roberts

Prof Valter Longo, 56

He wants to live to 120 and thinks the secret to longevity lies in a diet that tricks your body into thinking it’s fasting. Having spent 30 years researching ageing as professor of gerontology and biological sciences and director of the Longevity Institute at the University of Southern California, he used this experience to create the Fasting Mimicking Diet or FMD. It is a low-protein, plant-based diet that includes periods of fasting, which he says will make our cells regenerate and slow down ageing.

Wim Hof, 64

Once tried to scale Everest topless to demonstrate the health benefits of being extremely cold. The Dutch extreme athlete known as the Iceman has also broken records for climbing Mount Kilimanjaro wearing only shorts, swimming 66 metres beneath ice and running a half marathon above the Arctic Circle. He has built a business empire on his cold-water method and claims that it stimulates the autonomic nervous and immune systems, which strengthens physical and mental health.

Prof Andrew Huberman, 48

Fans of this Stanford academic call themselves “Huberman Husbands” and post videos on TikTok following the elaborate daily routine he recommends. #Huberman has 78.9 million views on the platform. He dishes out this advice on his hit podcast, Huberman Lab, which often ranks as the number one health podcast in the world, and on his Instagram page (6.2 million followers) and YouTube channel (5.2 million subscribers). He is associate professor of neurobiology and ophthalmology at Stanford University, which is said to have hung up an “Authorised Personnel Only” sign to deter fans from searching for his lab.

David Goggins, 49

More than 11 million people follow the endurance athlete and former Navy Seal on Instagram, where he shares fitness and motivational tips alongside shirtless selfies. He has completed more than 70 ultra-distance races and once held the Guinness World Record for the most pull-ups completed in under 24 hours (4,030 in 17 hours). In 2020 he invented the 4x4x48 fitness challenge, where you run four miles every four hours for 48 hours as if training for an ultra-marathon.

Ben Greenfield, 43

A former bodybuilder turned “biohacker”, Greenfield went on to develop an elaborate biohacking regime to strengthen the pelvic floor, ice baths, fasting, infrared light therapy, LSD microdosing and a 034 lakh machine that heals cells, he says. When he was 40, Greenfield said he had a biological age of nine.

Dr Peter Attia, 51

This cancer surgeon turned longevity expert says that in our later years we often live with ill-health and pain, crippled by diabetes, cancer, heart disease and dementia―he calls these the “four horsemen of chronic disease”. To change that, he says we need to focus on our healthspan (the number of years we live in good health) rather than just our lifespan (the number of years we’re alive). Celebrity fans of his 2023 bestselling book, Outlive: The Science & Art of Longevity, include Gwyneth Paltrow, Arnold Schwarzenegger and Oprah Winfrey, and he hosts a podcast about longevity called The Drive.

Tim Ferriss, 46

Ferriss had a nutritional supplement business before he struck it big when he published The 4-Hour Work Week, which presented a working structure that subverted the idea of long hours as a path to success. It was followed by The 4-Hour Body: An Uncommon Guide to Rapid Fat-Loss, Incredible Sex and Becoming Superhuman and then The 4-Hour Chef. He has a long-term chart-topping podcast called The Tim Ferriss Show, for which he interviews leaders in psychology, fitness and business as well as Hollywood stars about their optimisation techniques. Ferriss has invested heavily in research into therapeutic psychedelics at Imperial College London.

Nick Bare, 33

A fitness guru who is often shirtless when he films his intense training regimes for marathons, Ironman triathlons or ultra-marathons and posts them on YouTube for his 1.1 million subscribers to watch. He started building his supplement brand, Bare Performance Nutrition, as a side project while he was serving in the US army. It sells pre and post-workout supplements and protein powders. After he left the army he created a spin-off fitness training app, which costs Rs8,000 a year. On The Nick Bare Podcast he gives tips on longevity, nutrition, fitness and “human optimisation”.

Dr Paul Saladino, 46

Graduated from medical school but lost faith in western medicine and became a “meatfluencer” known as Carnivore MD, eating meat exclusively. He claimed his carnivorous diet, which excluded all dairy, carbohydrates, vegetables or fruit, was the way to achieve “optimal health”. He published The Carnivore Code followed by a cookbook. Then, in a podcast interview last year, he revealed that after five years on the carnivore diet his testosterone levels had decreased, plus he had sleep issues and joint and muscle pain. Now he promotes an “animal-based” diet, which includes fruit, honey and unpasteurised milk.

cerebral-palsy-could-not-stop-sarika-from-achieving-her-dream-of-becoming-a-civil-servant

Sat May 25 13:26:18 IST 2024

There is an innate confidence on Sarika A.K.'s face and a warm smile, too. The 24-year-old from Kerala―who ranked 922 in the UPSC exam―not only went through the rigours of preparing for the tough exam, as lakhs do, but she did so while battling cerebral palsy. “I prefer the IAS, but I am not sure whether I will get it. Whatever service I get into, I will do everything in my capacity for the differently abled community,” she says, sitting on her electric wheelchair.

Cerebral palsy is a group of disorders that affects muscle movement and coordination, with symptoms varying from person to person and ranging from mild to severe. There are four main types. Spastic cerebral palsy―which affects 80 per cent of those with cerebral palsy―is characterised by increased muscle tone, which leads to stiff muscles and awkward movements. Dyskinetic cerebral palsy affects the limbs and involves difficulty in controlling movement, leading to slow or rapid jerky movements. Ataxic cerebral palsy impacts balance and coordination, resulting in unsteady walking and difficulty with precise movements. Mixed cerebral palsy refers to symptoms that are a combination of different types of cerebral palsy.

Diagnosis typically occurs during the first two years of life, with tests to evaluate motor skills and monitor development, growth, muscle tone and more. “In my case, at birth itself, my legs were in a crossed position and doctors performed an immediate surgery,” says Sarika. “Six months later, additional difficulties emerged. I did not achieve the development milestones, prompting my parents to consult a doctor who identified movement and musculoskeletal issues. Further surgeries were recommended. At the age of five, I underwent a hip surgery to address the height discrepancy between my legs. Unfortunately, this procedure was unsuccessful and exacerbated my condition. Since then, I have relied on a wheelchair. Doctors suggested further surgeries, but we were unsure of their success and decided not to pursue it.”

Sarika is the daughter of Sasi, who is a driver in Qatar, and Ragi, a homemaker. She also has a younger sister. Her mother has been Sarika’s biggest support system. “Even now, I require assistance in all my daily routines, and my mother is helping me,” she says. “Throughout these years, she has taken care of me. She has dedicated her life to me.”

While speaking to THE WEEK, Ragi said that her daughter had to endure a lot of pain over the years, including not being able to be like the other kids at school. “A major issue we faced during those growing years was finding a physiotherapist in our locality,” she says. “Now, we have a physiotherapist who visits Sarika thrice weekly at home to ensure that her muscles do not get stiff.”

Accessibility also poses a great challenge for the differently abled, says Sarika. In fact, special arrangements had to be made at the centre for her UPSC mains exam in Thiruvananthapuram.

“During my primary school years, I remained in the same classroom for four years because the school had only one ramp. Although I progressed academically, my classroom remained the same,” she recalls with a smile, noting the invaluable support of her friends and teachers. “She enjoyed going to school; she never preferred sitting idle at home,” says Ragi.

Reading became a habit for Sarika during her upper primary years, and this habit eventually steered her towards the UPSC. “I came across a book, Collector Bro, written by former Kozhikode collector Prashant Nair,” she says. “It served as a great inspiration.”

One of her teachers then sent her information about Project Chitrashalabham (butterfly), a initiative of Absolute IAS Academy that offered scholarships for free civil service coaching for the differently abled. “I applied and was selected for online training,” she says. “I mostly studied during the night, as it was the most suitable time for me. I cannot sit for long hours, so I took breaks. Whenever I had back pain, I would lie in bed for 30 minutes to an hour.”

During her school years and into her late teens, Sarika had a manual wheelchair. Only last year did she get an automatic one, which significantly enhanced her mobility and made her more independent. It also helps that she is not currently on any medication. “However, my physiotherapist helps me with stretching and movement exercises,” she says.

Sarika adds that though she has grown up to see society becoming more inclusive, there is a lot left to be done. “When I was in school, the concept of accessible toilets or classrooms did not exist,” she says. “Transportation posed another significant challenge; public transport was inaccessible for someone like me, so I had to rely on auto-rickshaws, which cost a lot.”

Sarika will now get an official vehicle as a civil servant. But her ultimate dream is to take along as many differently abled people as she can on this journey.

taking-good-care-of-your-bones-will-take-a-big-load-off-your-old-age

Sat May 25 13:22:44 IST 2024

Dr Sandeep Kapoor calls himself a docpreneur. The orthopaedic surgeon specialises in trauma and joint replacement surgery. He did his MS from King George’s Medical University, Lucknow, and is a DNB, and the recipient of many prestigious fellowships. Dr Kapoor worked in the not-for-profit and the corporate sectors before co-founding the Health City Hospital in Lucknow, and is in the process of setting up another 300-bed hospital. An avid listener of podcasts, he is also a golf enthusiast.

Essentials about bone health: The human body is made up of the musculoskeletal system. The skeletal part is the bone, and the surrounding is the musculature. Bone health encompasses bones and muscles; and the point at which two bones join each other―joints. For an infant on mother’s milk, it is a sufficient diet that provides calcium for the growth and nutrition of bones. Adequate diet is important right from childhood. Drinking pasteurised milk (without boiling), using iodised salt are some of the habits we have always followed. It is also important to get adequate sunlight. The other important component is activity. Body movements with pressure stimulate growth.

As we grow: Medicines do not have a large part to play in bone growth and health, but habits, nutrition and lifestyle do. Alcohol will harm you. Red meat eaters could have high uric acid levels, which will in turn lead to joint pain and further harm the joints. Wrong posture can lead to head and neck pain. Till the age of 40, the calcium we intake and the calcium in the bones maintain a kind of equilibrium, but post that, calcium from the bones starts to deplete; and muscles begin to waste.

The start of trouble: Some people will be genetically predisposed to rheumatoid arthritis. This is a long-lasting auto-immune condition in which the body’s defence mechanism attacks its own tissues leading to pain, swelling and stiffness. Other kinds of arthritis might manifest in certain people without warning signs and we cannot prevent them.

Three broad challenges: Calcium (and vitamin D) deficiency in children leads to rickets; in adults to osteomalacia; and when bone mass begins to fall it leads to osteoporosis which changes the strength and structure of bones.

What we can control: Every particular height and body structure is made for certain loading. Excess load will lead to both joint and bone pain. Thus having control over one’s weight is very important.

Calcium supplements: It is a myth that every fracture needs calcium. If a fracture is caused by say an injury, then it does not. Calcium would be more relevant for weak bones. Thus, underlying pathological causes need identification before prescribing any supplement. Ideally, one’s diet should be adequate to provide the body with the essential vitamins and minerals. The challenge is to identify the deficiency points in one’s diet.

Is lactose intolerance a myth? No, it is not, but how many people have been diagnosed as such? On the other hand, take up any (prescribed) diet these days, it will have no milk because milk is calorie dense. We see calcium deficiency more in urban patients because for the rural population which has cattle, milk is still an important part of the diet.

Vitamin D deficiency: This is definitely not because of the lack of sunlight but we have not been able to pin point the reason behind it. Vitamin D is essential for absorption of calcium. How much one requires depends on age and stage (lactating mother versus post-menopausal woman, for instance). When given as a combination with calcium, it is for maintenance. In case of deficiency, it is prescribed separately in pure, heavy quantities according to international standards. But there are various schools of thought among endocrinologists, paediatrics and ortho-physicians about how this is to be given―in low doses every day, alternate days or in weekly doses. Expert advice is essential because vitamin D toxicity is real.

The role of genetics: If a mother has osteoarthritis, offspring will have a predisposition to it, but this is not proven. There are certain genetic bone syndromes that are beyond what we are discussing here.

The gender differential: Menopausal women are at risk for osteoporosis and osteoarthritis―two conditions that are often incorrectly understood. Osteoarthritis, which I have seen almost always in women, is age related arthritis of the weight bearing joints. In the west, this mostly affects the hips; while in India it is the hands and knees that bear the brunt. Osteoporosis is a condition where the bones are weak and prone to breaking and fracturing easily. It is common in post-menopausal women because of falling levels of oestrogen. (According to some studies, women lose 10 per cent of their bone mass in the first five years after menopause). Pregnancy, lactation, menopause all contribute. Recovery in male patients is much faster than female patients, probably because their bones are stronger to start with.

High life expectancy, more fractures: Age-related fractures are like an epidemic with increasing life expectancy. This is not just a health problem but also a socioeconomic one as not everyone in the growing elderly population has an insurance. Expensive implants, keeping these patients in critical care and monitoring them while family members are busy―all of these are challenges.

Understand activity right: What we do in our daily life as part of everyday chores or our jobs does not count as activity as the body is used to it. There are two parts to it―activity for the muscoskeletal system and for lung health; or weight training and cardio. Yoga is very good. For the heart, 45 minutes to an hour of walking is essential. This helps the heart to develop more vessels to pump better. Let us say we get a 40-year-old patient who has difficulty climbing the stairs. His cardiologist and his diabetes doctor have asked him to walk. Arthritis patients have no problems in straight-walking, it is elevation they find difficult. Thus, activity should be in tune with orthopaedic condition. Activity becomes a problem when you disregard your orthopaedic reality. If you are turning 60 and have never jumped in your life, and suddenly decide to do high-jumps, remember your body is not tuned for it. On the other hand, one who has been a marathon runner will be able to run till the age of 90 and beyond.

We hear of so many deaths during/post gym workouts. That is possibly because people are pumping huge amounts of weight but the body is not used to the sudden increase in the musculature of the heart. I am also a strong proponent of activities for mental fitness for while people might have healthy bodies, their minds are not healthy.

Balance is the key: As we age we tend to lose muscle strength and put on fat. There are fads such as intermittent fasting where people are accelerating this muscle loss, while the focus should be on losing fat. If you are doing your mandatory 45-60 minutes of brisk walking but following it up with a fat rich breakfast and partying till late in night, you are undoing all the good. Excess of anything is bad. Pain and fatigue are very important deciding factors for what our bodies are meant for.

Pointers other than pain: Fatigue and lethargy are indicators that something is wrong. Drop in alertness, fall in energy, lack of sleep or too much sleep are also indications that something is wrong. Weak neck muscles, for example, can lead to headaches. So we ask the patient to build neck muscles. Similarly if you were once able to climb steps easily but not anymore, build quad muscles with advice from a trained specialist.

The various stages of problems: Stage one and two might have very mild problems such as occasional pain, which you might notice only if very careful. It will not show up in X ray findings. In the first, mild painkillers will work. In the second these will be supplemented by physiotherapy.

Knee replacement surgery: Come stage three and the symptoms become obvious―walking with a waddle or a duck like gait, having bow legs, knock knees or other deformities. Such patients are in constant pain and might have difficultly even using the washroom. When lifestyle modifications, physiotherapy, medicines, precautions and external support all fail, patients require replacement surgery. Some expensive joint health supplements (collagen peptides, glucosamine, C supplement) are available and might help.

Knee problems are epidemic: Particularly in females (caused by all the factors discussed above and made worse by longer life spans). Replacement surgery is a well-accepted procedure and understood by lay persons. Its success has also been well demonstrated.

The use of AI: In medicine, AI should be used where the human eye cannot see or cannot see very clearly―such as cancer of the prostate sitting behind a bone. For knee and hip there will be selective indications for use of AI. We have been using everything from computer navigation to robots. AI has its limitations in a country like India where people are unable to get a knee replacement even in the most conventional form.

Myth that surgery is very expensive: Not really, but big players have jacked up costs. We need the government’s support to bring these down. Government hospitals are conducting a high volume of knee replacement surgeries. There is also a government fixed ceiling on the cost of implants.

Rehabilitation period: Results and down time depend on timing of surgery. Hospital stay is generally between three to five days. If a patient comes with functional problems, before the bone on bone stage, the muscles have not deteriorated and recovery is faster. Timing is important. Joint surgery should happen ideally just once in a lifetime. Revision surgery is mutilating and results are unpredictable.

Quality of life: While it does come back to normal, you will not become an athlete. You will not be running, but you will easily be able to walk three to five kilometres a day. Remember, this is tied in with the age of the patient.

The next epidemics: Patients who have had a knee replacement surgery and lived on for 20-25 years will need replacement surgeries. Peri prosthetic fractures―those that happen around joint replacements―will also come in. There is nothing patients can do to prevent these.

An ideal patient: One who is in the 60s. If your quality of life is extremely compromised, do not wait till 60. When everything else has failed, such a patient should ideally come to you walking and not in a wheelchair (which indicates poor muscle strength).

Common risks: If a patient has been not walking for long, there might be deep vein thrombosis (DVT) wherein s/he gets blood clots in the limbs from which they can go to any other part of the body and lead to strokes or cardiac arrest. However, prophylaxis are given for these conditions and it rarely comes up as a challenge in surgery. A bigger concern are infections. That is the reason the patient should find out the number of surgeries being done in that centre and if the infrastructure is designed to minimise infections.

punitive-psychiatry-a-tool-of-abuse

Sat May 25 13:17:41 IST 2024

Psychiatry has profound potential to heal human minds. Nonetheless, history serves as a stark reminder that, in the wrong hands, it can become a tool of abuse.

The term ‘punitive psychiatry’ refers to the abuse of psychiatric practices such as diagnosis, detention and treatment to violate human rights. In April, the International Federation for Human Rights in Mental Health and the Andrei Sakharov Research Centre for Democratic Development at Vytautas Magnus University, Lithuania, released data that showed a surge in psychiatric abuse against civilians who “exhibit anti-war behaviours” in Russia. Their study revealed that, as of March 24, at least 35 individuals were subjected to involuntary “treatment” in psychiatric facilities across Russia. Prominent among them were opposition activist Olga Nedvetskaya, medical student Alexey Korelin and teenage protester Yegor Balazeikin.

Another such case is that of Alexander Gabyshev, who embarked on a cross-country trip to Moscow’s Red Square to perform a shamanic ritual that he said would peacefully oust President Vladimir Putin. Gabyshev, too, was subjected to punitive psychiatric practices. Dissidents like him have reportedly undergone intrusive surveillance, violent threats, humiliation, compulsory medication, physical restraint and other measures that infringe on their rights.

Psychiatric abuses were a prominent tool of repression in the Soviet Union, particularly in the 1970s and the 1980s. It is estimated that approximately one-third of political prisoners in Russia were confined to psychiatric hospitals, leading to a significant rift within the World Psychiatric Association. The Soviets were compelled to withdraw from the association in 1983, and returned conditionally only in 1989.

According to Robert van Voren, a Dutch human rights activist who led the study on punitive psychiatry at the Andrei Sakharov Centre, most countries that were part of the Soviet Union have made strides in developing mental health care services based on ethical norms. But Russia, under Putin, is backsliding.

Punitive psychiatry has been in practice in other totalitarian regimes as well. Last year, a criminal court in Iran ‘diagnosed’ three prominent actresses―Azadeh Samadi, Leila Bolukat and Afsaneh Bayegan―as anti-family, antisocial and mentally ill for not wearing the hijab. Top Iranian psychologists condemned the court’s decision, and denounced the misuse of psychiatry by the judiciary. China, too, has faced accusations of employing punitive psychiatry against the Uyghurs.

Even liberal democracies have had instances of punitive psychiatry. In 2009, Adrian Schoolcraft of the New York Police Department blew the whistle on his superiors who manipulated crime reports. As a response, he was arrested and held for six days in a psychiatric ward at Jamaica Hospital Medical Center. Subsequently, he filed a lawsuit against the police department, alleging intimidation and retaliation. The case was settled in 2015, with Schoolcraft receiving $6,00,000 in compensation.

transitional-care-centres-can-add-a-lot-to-india-s-health-care-system

Sat Apr 27 15:15:25 IST 2024

Some years ago, Hyderabad resident Krishna Mohan was diagnosed with a lung condition that required immediate medical attention. He underwent treatment at a leading hospital and was subsequently discharged. However, the family was instructed to install an oxygen cylinder at home just in case. Soon, he was diagnosed with a failing liver and, once again, got treatment and was discharged. His family was asked to monitor his health closely. They turned one of their rooms into a makeshift nursing ward, hiring nurses and taking turns caring for the patient. This placed a significant strain on both their mental and financial wellbeing.

Today, if faced with the same situation, a family could handle it differently. They could consider transitional care centres, which are slowly becoming a crucial part of the Indian health care system. Transitional care comes into play when patients no longer require acute medical care in hospitals, but still need rehabilitation or ongoing treatment.

Although still relatively scarce, established transitional care centers can be found in cities like Hyderabad, Delhi, Mumbai and Bengaluru. And though awareness of transitional care remains low in India compared with the west, the number of patients and available beds are steadily rising. The patients typically admitted to these centres include those who suffer from cancer, stroke, orthopaedic problems, long Covid and cardiac ailments.

Ucchvas, based in Hyderabad, is one of the leading transitional care providers in the country. Since its establishment in 2018, the organisation has treated more than 2,000 patients and has 65 beds at its two centres. Ucchvas received positive reviews for its work during the pandemic and, with high occupancy rates at both centres, it is planning to expand.

One of the patients at Ucchvas was Masoom Pasha, who had a stroke. After receiving necessary treatment, he was transferred to Ucchvas for rehabilitation, where he received care from a speech specialist and others. After nearly three weeks, his wife, Nusrath, is optimistic about his recovery.

Families often find that the therapy and treatment at transitional care centres make a significant difference and instil confidence in patients. The affordability factor also works in favour of these centers. Said Dr Ambati Rampapa Rao, founder-chairman of Ucchvas Transitional Care: “When I established the centre, I aimed to ensure that patients do not spend more than 25 per cent of what they would at a private hospital. I am pleased that we have kept the costs lower than that.”

Rao, an anaesthetist, conceived the idea after some friends in the medical field found it increasingly challenging to monitor and prevent morbidity and death post-hospitalisation.

Upon a patient's arrival at Ucchvas, a treatment protocol is designed based on their condition, which might require multiple specialists and personalised care. Rao noted that patients typically stay at the centre for weeks, and in some cases, even months.

The centre also employs best practices and innovations to facilitate better patient recovery. For instance, recovery mapping helps develop more effective rehab therapy models using datasets, and plateau stage tapping is applied to predict and prevent progress stagnation. Considering patients' mental health, recreational therapy sessions are also offered.

Brinnova Transitional Care and Rehabilitation Centre is another well-known brand in Hyderabad, founded by doctors M.V. Sumanth Reddy and Pavan Reddy, who previously worked in corporate hospitals. “In some hospital rooms, you do not even see windows,” said Sumanth. “We made sure every room has ventilation so that patients do not feel suffocated. We ensured that there are no steps near bathrooms for patient safety.” Brinnova operates two centres in Hyderabad, with 100 beds, and is beginning to attract patients from various parts of the country.

In a typical transitional care setting, patients have access to multiple specialists, including psychologists, and necessary help to address mental health concerns that cannot be taken care of at home.

Pavan also underscored the role of a family member, who must be with the patient, as they play a crucial role in the recovery process. “Here, the family role is almost 50 per cent,” he said. “For example, in accident cases, we often encounter alcoholics. Having family around helps them cope with withdrawal symptoms.”

The primary challenge faced by transitional care providers is the lack of recognition by insurance companies. In India, those admitted as in-patients typically have to pay out of pocket because insurance companies fail to categorise transitional care as hospitalisation. Another challenge is finding space as increasing real estate prices in cities have pushed back efforts to start more facilities. Industry stakeholders also believe that the government should introduce policies and programmes to boost their services.

Rao said India needed more transitional care centres because of the growing population of elderly adults. According to various research reports, the transitional care management industry is growing at 17 per cent annually worldwide. And though many people in India see it as just another hospital, these centres have a unique identity and purpose.

how-well-drug-regulation-policies-can-be-implemented-in-india

Sat Apr 27 15:13:02 IST 2024

East Delhi resident Gaurav Kumar has entirely shifted to Jan Aushadhi Kendras for medicinal needs. He unequivocally dismisses doubts over the quality of drugs sold at the Centre-run kiosks. “The price difference is also whopping, 50-90 per cent,” he says. Anil Vats, a retired government servant from Ghaziabad, says: “My lung disease tablets cost Rs250 per pack. At Jan Aushadhi, I get it for Rs60.”

To ensure quality, all batches supplied to over 10,000 Jan Aushadhi stores across 750 districts go through double checks. Ravi Dadhich, CEO, pharmaceuticals and medical devices bureau of India, ministry of chemicals and fertilizers, tells THE WEEK: “After procuring medicines from WHO GMP (Good Manufacturing Practices) certified suppliers, each batch is again tested at our laboratories to ensure quality.”

Certainly, these stores are striving to provide affordable generic medicines. This, however, is only a small part of the story. The ecosystem of generic drugs in India is far too wide and cumbersome. Generic or branded medicines have no specific definitions. They, for all purposes, generally “contain the same active ingredient in the same dosage form, intended to be administered by the same administrative route” as the branded drugs.

Dr Preeti Kumar, vice president, public health system support of the Public Health Foundation of India, explains: “There are primarily three types of drugs―generic, branded-generic and patented.” She adds that the generic and patented together constitute around 20 per cent of the market. “The remaining 80 per cent is covered by branded-generics that constitute around 2,800 formulations and unique molecules for various diseases spanning over 55,000 brands,” she says. “If we keep the patented drugs aside (which is only 8-10 per cent), the issue of quality remains with both generic and branded-generics and it is not entirely correct to equate branded-generic with quality.”

Dadhich adds, “The generics sold under a brand become branded-generics.” By numbers, the labyrinth is even more gigantic―India is the biggest exporter of generics to around 200 countries. The top five importers are the US, Belgium, South Africa, the UK and Brazil. More than 60,000 generic drugs are produced in India across 60 therapeutic categories. India's drug and pharmaceutical products exports grew by 125 per cent from Rs90,415 crore in 2013-14 to Rs2.04 lakh crore in 2022-23. “These constitute 5.71 per cent of the total exports and ranks third worldwide by volume,” according to the ministry of health and family welfare.

Domestically, the market reach in India is to the tune of Rs1.5 lakh crore. The enormity of the sector speaks volumes about the inadequacy of all government schemes put together in making medicines affordable, accessible and acceptable to all.

Understandably, therefore, the doctors were up in arms over a government order making it compulsory to write generic names on prescriptions. Although existing rules do exhort physicians to prescribe drugs with generic names, the mention of penalties for non-compliance and potential licence suspension in the August 2023 order took the doctors by surprise. Their vociferous opposition forced the government to put the directions on hold within two weeks. At the heart of the doctors’ opposition was the uncertainty over quality of generic drugs.

“The government is sensitive on the issue and understands,” says Sharad Aggarwal, president of the Indian Medical Association, which led the resistance. “That is the reason they reversed the decision. Spurious drugs is a national issue and all of us will have to show maturity in handling the situation.”

The doctors’ apprehensions are not misplaced. A recent study by the Postgraduate Institute of Medical Education and Research, Chandigarh, attests to the substandard quality. In the study, published in an international journal, subjects given a patented (innovator) drug achieved better therapeutic levels than those administered the generic counterpart.

Dr Rahul Singh, head of critical care unit, Yathartha Hospitals, concurs with the findings of the study. “Certainly, the efficacy and blood levels will differ in case of generic medicines and innovators,” he said. “In case of generic drugs, the standards and optimisation is not validated so the results are compromised.”

This issue acquires additional significance as the WHO says that generic products must satisfy the same standards as innovator products. Legislatively, the rules in India forbid malpractices in manufacturing of drugs. Pharmaceutical companies claim that apart from compliance necessities, the risk to reputation leads brands to meet global standards. “To ensure quality of medicines sold under brands, companies adhere to rigorous quality measures,” says Nikkhil K. Masukar, CEO, Entod Pharmaceuticals. “They conduct thorough testing, follow GMP and comply with regulatory standards to guarantee the safety and efficacy of their products. Brand reputation is often built on a commitment to delivering high-quality medications, and companies invest significantly in maintaining these standards.”

Dr Rajeev Sood, vice chancellor of the Baba Farid University of Health Sciences, Faridkot, Punjab, says that while the guidelines are ideal, the problem lies with the implementation. “There is no set mechanism to monitor the quality of generic medicines,” he says. “Batch by batch, the quality is different.” Dr Girish Mathur, president of the Association of Physicians of India, adds that there is a pressing need to put mechanisms that ensure quality.

Aman Gupta, managing partner, Health Practice Asia Lead, Spag Finn, a Gurugram-based consultancy firm, says common assurance needs to be provided on quality, efficacy and safety. “In recent times, questions have been raised on manufacturing practices and quality standards of Indian drugs (specially generics), not only within India but at the global level,” he says.

Insiders reveal that the quality erodes as a result of manufacturing and market imperfections. “The problem arises when the approval procedures are sometimes compromised because of corruption at multiple levels,” says an employee of a leading pharmaceutical company, who requested anonymity. “The minuscule levels of monitoring of the samples add to the woes and the sub-standard quality reaches the market.” He adds that Indian generic manufacturers start compromising on the quality to sell on lower costs engendering “camouflaged competition”. “The quality is majorly compromised when it comes to the huge domestic market and exports to developing markets such as Africa, West Asia and East Asia,” he says.

The IMA had recently pointed out that less than 0.1 per cent of the drugs manufactured in India are tested for quality. Multiple alerts from the WHO on sub-standard quality of Indian cough syrups in the wake of a number of overseas deaths linked to India-made drugs in countries like the Gambia, Cameroon and Uzbekistan is a case in point. However, that is not the case with exports to developed countries. The stringent regulatory systems and authorities in western and European institutions like the US Food and Drug Administration and European Medicines Agency make it risky for the manufacturers to export inferior quality.

The impediment to ensuring quality, especially for domestic consumption, experts believe, is the ever expanding gulf between demand and the requisite infrastructure, expertise and finance. “Every product should be checked,” says Sood. “But, we do not have the wherewithal to monitor effectively. We do not check where the raw material has been sourced from, there are no proper labs for testing.”

An important factor, according to Kumar, is that India has a federal structure and health is a state subject. “The regulation is also done by state drug control organisations,” she says. “Therefore, it becomes important that states also make adequate budgetary allocations to pick samples and send them to laboratories for testing to ensure quality. Both generic and branded-generic drugs are same in dosage form, chemical strength and quality checks. However, some are directly marketed through prescribers and pharmacies and in some cases the quality of the medicine is associated with the degree of regulation.”

Doctors also blame pharmacies for the bad quality. “It should not only be about controlling doctors but also about controlling the pharmacies,” Sood points out. “Pharmacists manufacture their own medicines and sell them in large numbers. There have also been instances when certificates have been sub-let, thereby exploiting the guidelines.” Aggarwal adds that the move to prescribe generic names gives more power to pharmacists, who may give the medicine which suits their interests and may not align with patients' interest.

There is unanimity on the urgent need to have a “centralised” and a more “proactive” system of testing to make safe and affordable medicines available to all Indians. Says Kumar: “The regulatory investment will have to be commensurate with the quality of the medicines. Best practices at all three levels―procurement, testing and regulation ―will have to be extended to a much wider base to ensure quality medicines reach the market.”

The government’s efforts to strengthen regulations and promote generics are lauded by a few. “Generics have to be the way forward,”says Priyadarshi Mohapatra, founder and CEO of Curebay, promoting e-clinics in rural Odisha. Adds Dr Sujit Chatterjee, CEO, L.H. Hiranandani hospital, Mumbai: “By advocating the use of generic drugs, the government is promoting an environment in health care that respects accessibility and affordability.”

Kumar also agrees that the government is really upping the regulatory mechanisms to ensure only quality drugs come into the market. Aman Gupta praises recent steps by the Drug Controller General of India, including implementation of QR codes and the decision to overhaul drug regulations. He considers work towards framing the Drugs, Medical Devices, and Cosmetics Bill “a crucial step towards upgrading and streamlining the regulatory framework.”

In late December, 2023, the Union health ministry notified its new Good Manufacturing Practices for pharmaceutical products. The new rules facilitate major changes in ensuring quality and categorically hold senior management of the manufacturing companies responsible for quality. The new guidelines are seen as a step in the right direction to elevate the quality of drugs to global standards.

Says Dr Viranchi Shah, national president, Indian Drug Manufacturer Association, “The new rules will of course make a difference in aligning more with the WHO standards and is a welcome step in upgrading the sector.” However, he suggests that a larger window could be given for transitioning, especially to the small industries. “We should engage with small and medium enterprises, handhold them and help them become a part of the envisaged new normal,” he says.

Reiterating the IMA’s stand on introducing “one drug, one quality, one price system”, Aggarwal says, “Why not subsidise the health sector the same way as other sectors are subsidised? The government should do away with this differentiation of generic, branded, non-branded and find a permanent solution to this problem.”

While the government’s intentions to ensure quality is apparent, how much the rules are going to match the monitoring on the ground to make Indian drugs risk-free remains to be seen.

nobel-hygiene-adult-diapers-friends-support-quality-living

Sat Apr 27 15:07:47 IST 2024

When the idea of using an adult diaper was first suggested to Narendra Mishra, now 75, his instant reaction was outright rejection. “Do you want to shame me? Am I so helpless? Is my life a burden?” he remembers asking his son.

Seven years ago, when the suggestion was first made, Mishra had no alarming health concerns. But a persistently low blood pressure made him dizzy if he got up suddenly, and chronic knee pain made walking to the toilet onerous. Nights were particularly challenging.

In a country where social conditioning has led us to believe that a marker of being a grown-up is the ability to control bowel urges, and to clean up after oneself, Mishra’s concern was not misplaced.

Dr Abhishek Shukla, senior geriatric physician who established Uttar Pradesh’s first and only dedicated elderly care facility, Aastha Geriatric Hospital and Hospice in Lucknow, said a number of psychosocial reasons stood in the way of diaper acceptance. “As we age, there is natural functional decline in our five essential organs―heart, lung, liver, kidney and brain. This becomes difficult to accept as our conversations around healthy and graceful ageing are still nascent. There is an urgent need for seminars, awareness building and the like,” Shukla said.

While incontinence, he said, could be age-related (for instance, the outcome of a natural weakening of the bladder and pelvic floor muscles), it could also result from a completely different cause such as hypocalcemia (too little calcium in blood), which when corrected would reverse the incontinence.

Incontinence itself can be either urge- or stress-induced. The first is when a person feels the need to use the toilet immediately; the second is caused by pressure on abdominal muscles. “For persons who are at the end of their life, the use of diapers becomes non-negotiable. For others, whose senses are functioning, acceptance is a great challenge, for they perceive it as an assault on their dignity and self-respect,” said Shukla.

Then there is incontinence that is not age-specific, caused by injuries or illness. As Shukla explained this, a patient walked into his chamber. When asked if he would ever consider using a diaper, the patient said he never would. “It is a psychological sign that I am becoming feeble and helpless. It is better to die than continue like this,” said the patient.

Ujjwala Shanker is the sole caregiver to her 88-year-old father and 76-year-old mother. The former has Alzheimer’s disease while the latter lost a majority of her senses after a brain surgery in 2020. The decision to begin using diapers was not an easy one. Shanker initially tried seating her parents on a commode every couple of hours, but when their physical frailty made this challenging, the shift to diapers was made.

For a couple of years, Shanker herself changed her mother’s diapers, sometimes every two hours at night. (She employed an attendant for her father.) It took a toll on her―she was permanently sleep deprived and unable to focus on the school and enterprise she runs. She became, in her words, a “zombie”. She now has two attendants to look after her parents round the clock, and spends Rs35,000 to Rs40,000 every month to care for her parents.

“I have very rarely had patients who are willing to use diapers, even for the off chance that they might sometimes soil themselves,” said Shrikant Srivastava, professor of geriatric psychiatry at King George’s Medical University, Lucknow. According to him, a major mental block is that people are conditioned to not let poop stick to the skin. “This habit is ingrained, and diapers feel unnatural,” he said. There is also the embarrassment of foul smell, and often lying for long hours in one’s own refuse if help is not readily available.

Research says it takes almost a year and a half for adults to accept diaper use. The various stages in this journey include denial, concealment, rejection and reluctance.

Thus, diaper manufacturers have to look beyond business. Said Kartik Johari, vice president of marketing and commerce at Nobel Hygiene, India’s largest manufacturer of disposable hygiene products: “We are not in the business of just creating quality products. Our goal is to consistently empathise with all our users, listen to them, and create products that may solve key issues they face. Our marketing strategy has been more about educating users, and de-stigmatising adult diapers.”

Nobel Hygiene has named its adult diapers ‘Friends’, underscoring the concept that these are not clunky products to be ashamed of, but ones that support quality living―much like a compassionate companion would.

Nobel launched its adult diapers in 1999, and later the country’s first pants-style adult diaper, and kept churning out innovations that include antibacterial absorbent gel that prevents urinary tract and related infections; odour-lock technology that controls release of foul smells; ultra-slim designs that are not revealing when dressed; and fibre waistbands for better fit and elasticity.

Yet, uptake remains slow.

Mishra, for instance, took more than five years to accept the pants-style diapers he now uses. “I have greater freedom to move about, and even go to the cinema with my grandchildren,” he said. “To be young and in control was wonderful; but now, I accept myself as I am.”

cosmetic-surgery-risks-associated-results-you-can-expect

Sat Apr 27 14:47:24 IST 2024

The Indian surgeon Sushruta (circa. 1000-800 BC) is considered the ‘father of plastic surgery’. The earliest form of such surgery was the use of skin from other parts of the body (arm, cheek, or forehead) to reconstruct amputated noses. The word ‘plastic’ in the term comes from the Greek 'plastike', or the art of modelling or sculpting. While originally used for restoration, it has now expanded to rejuvenation and enhancement. Between eight to 10 lakh cosmetic surgeries happen in India every year, and the country is one of the most popular hubs for such procedures. Surgeries which are considered medically necessary (like those for correcting nasal deformities which hamper breathing) are covered under insurance, while the rest might or might not be.

Dr Amit Gupta, MBBS, MS and DNB, is the founder and chief surgeon at Divine Aesthetics in Delhi. He has treated over 25,000 patients from the US, the UK, the UAE, Canada, Australia and Russia. When not wielding the scalpel, he likes to play the piano.

In layman's terms: Cosmetic surgery is the science of enhancing a person’s natural body aesthetics. It helps individuals attain bodily features that complement their body or face type better.

Difference from plastic surgery: Plastic surgery encompasses a broader scope, including procedures like cancer reconstruction, birth defect correction (like cleft lip), and accident injury reconstruction. It can be divided into two main categories: reconstructive and cosmetic. Cosmetic surgery does not have further subdivisions. It is optional in most cases since it enhances a person's appearance whereas reconstructive surgery is a medical necessity.

An ideal patient: One who understands what is achievable, recognises the importance of the changes, is emotionally stable and socially settled, and has realistic expectations from the procedure.

Post-surgery downtime: This varies depending on the procedure. While minimally invasive procedures like fillers and botox require no downtime, more extensive surgeries like breast implants may require a day while procedures like tummy tucks may require up to six days.

Make me look like a film-star! One of the most common misconceptions about surgery is that you can look like your favourite film star (Katrina Kaif being among the most popular). However, a surgeon cannot achieve a body shape or structure that replicates any other person. Therefore, the patient’s expectations are brought down to reality. What is achievable and what is not is clearly explained. Then it is assessed whether the patient is able to understand what we can create. If they have expectations beyond reality, then they are not ideal candidates for surgery. This is because most of the time these patients are not satisfied with the results, approach surgery in an obsessive way, undergo multiple surgeries and end up with botched looks which eventually bring a bad reputation to cosmetic surgeries.

The vital role of counselling: It helps us assess if the person can understand the results that are possible with surgery. It also helps to determine if a person is obsessed with looks, and is thus not a suitable candidate.

The changing age of patients: While the lower age range has come down to 18 or 19 years, the upper range has increased from 60 to 65. There is a rise in the desire to look more presentable, there is more awareness, and there is also the increased safety of cosmetic procedures. Social media has also played a vital role by making people more inquisitive about available procedures.

What age is ‘too’ old: Generally, a person should be an adult to undergo cosmetic surgery. As for the upper limit, we don’t usually have a cap as long as the person is medically fit for surgery. Even a 70-year-old can undergo cosmetic surgery safely if the body permits.

Essential questions for the doctor to ask: Is the candidate medically fit for such a procedure or do they have contra-indications that could affect the surgery? If they are on blood thinners, for example, they cannot undergo a breast implant surgery immediately because of the risk of excessive bleeding. Does the patient have someone to take care of them after the procedure? Can the patient’s expectations match the results that are possible medically? Is the patient willing to adhere to the doctor’s post-operative advice? Is the patient in the right headspace to understand what is being done?

What you should ask your doctor: What are the results going to look like? What could be the procedure's possible side effects? How much rest is needed post-procedure? Is there any additional procedure that needs to be done? What are the possible complications of the procedure?

When would a doctor say no? Undergoing a procedure for purely cosmetic reasons is not a contra-indication as long as it is medically safe and the person understands the changes that are going to happen. If someone approaches the procedure without knowing or understanding the consequences, then it is a contra-indication for me.

Beware of:

* Medical complications: Undergoing a procedure without a prior medical test for conditions like diabetes, high blood pressure or heart disease that could cause a problem during the procedure.

* Choosing the wrong surgeon: Not every surgeon is qualified to perform all procedures.

* Under-qualified clinics: There are many clinics that are not recognised by the government and operate without adhering to proper guidelines, certifications, and standards.

* The low-cost trap: Many people fall for low-cost procedures which use poor quality consumables like Chinese and Korean breast implants.

* Poor post-surgery care: Many people don’t adhere to the recovery time that is suggested by the surgeon and start indulging in sports and physical activities sooner than they should. This often aggravates the scars and disrupts the healing process, thus impacting the desired results.

A one-time procedure: Every surgery is a one-time procedure, but the process may require management. For example, we can conduct a hair transplant on someone, but with time they are prone to losing more natural hair and would require hair fall treatment. In the case of facelift surgery, the results last for eight to 10 years, but the impacts of sun and pollution are ongoing. So the person might need additional treatment to preserve the quality of skin in order to reduce the signs of ageing.

Fads like the Brazilian butt lift (aka the Kim Kardashian butt): Every surgical procedure is to be approached with utmost caution. BBL is an extremely safe procedure, but has been criticised lately because of the poor technique used by some doctors. There are precautions and correct selections for every plastic surgery procedure. All procedures are completely safe as long as proper techniques are followed.

Procedures most in demand: For men, the most common procedures are hair transplant and gynecomastia treatment (male breast enlargement correction). For women, liposuction, breast implants and botox are the most common.

Top five myths: Plastic surgery makes you look unnatural. Hair transplant can cause migraine. Botox makes you look plastic. Breast reduction is very painful. Unmarried girls should not undergo breast implants.

How far is too far? Approaching cosmetic surgeries in an obsessive manner and doing multiple surgeries on one body part that creates an unnatural look.

Surgery makes one look unnatural: If done with realistic expectations, a skilled surgeon can deliver natural looks using modern cosmetic surgery techniques such as non-invasive procedures and second-generation dermal (skin) fillers. A skilled surgeon can use these tools to ensure you look like yourself, only rejuvenated.

Do breast implants break or tear? Average-sized breast implants used in today’s procedures can withstand up to 300 pounds of pressure before rupturing. It is unlikely that normal contact or force would cause your breast implants to rupture.

Migraines and hair transplants: There is no scientific evidence linking migraines to hair transplant procedures.

Botox equals plastic: The most common misconception is that botox makes one appear frozen or plastic. In reality, the enhancements made with botox injections can look exceptionally natural when performed by an experienced injector.

The pain of breast reduction: Usually, the patient is anaesthetised before the procedure so that they don't feel any pain. However, soreness can persist for two or three days after surgery. That is taken care of by mild painkillers and ice wrapping. Now, surgeons are developing methods to provide day-care surgery for breast reduction that will largely reduce the operation and recovery time.

Breast implants are a no for unmarried women: This notion stems from two concerns: breastfeeding and scars. There is, however, no evidence suggesting problems with breastfeeding after breast implant surgery. Breastfeeding is completely safe and possible after surgery. If done by an experienced cosmetic surgeon, there will be minimal bruising post the procedure, and the scars will vanish in due course. However, some patients who have poor healing and scarring tendencies must inform the same to the surgeon so that surgery can be planned accordingly.

effective-vaccines-developed-against-meningitis-in-african-region

Sat Apr 27 14:42:29 IST 2024

In sub-Saharan Africa, from Senegal in the west to Ethiopia in the east, and encompassing the northern part of Nigeria, there exists a region known as the African Meningitis Belt (AMB). Here, meningitis, a serious infection of the meninges―the membranes covering the brain and spinal cord―is hyper-endemic. The incidence of meningitis varies globally, with the highest rates found in the AMB. The region is particularly susceptible to meningococcal meningitis due to its high temperature, geographical proximity to the desert, and the influence of the dry season on air particulate concentration.  Historically, major epidemics have occurred in the AMB every 5 to 12 years, with the disease proving fatal in 80 per cent of cases if untreated.

Meningitis can be caused by various pathogens, including bacteria, fungi and viruses. Bacterial meningitis―caused by streptococcus pneumoniae, haemophilus influenzae and neisseria meningitidis―is the most common form leading to outbreaks. Experts warn that bacterial meningitis can result in blood poisoning, and can seriously disable or kill those infected within 24 hours. Last year saw a 50 per cent increase in meningitis cases across Africa.

Nigeria is one of the 26 hyper-endemic countries within the AMB. Between October 1, 2023, and March 11, 2024, Nigeria witnessed 153 deaths in seven of its 36 states, with over 1,700 suspected meningitis cases reported during this period. Nigeria now has become the first country in the world to introduce a new vaccine, Men5CV, which protects against five strains of meningococcal bacteria (A, C, W, Y and X), all capable of causing blood poisoning. Previously, vaccines were only effective against the A strain. This new vaccine employs the same technology as the meningitis A conjugate vaccine (MenAfriVac), which successfully eradicated meningococcal A in Nigeria.

Notably, Indian hands and brains had a role in the development of the life-saving vaccine for Africa. The multivalent conjugate vaccine took 13 years, and was made possible with financial support from the UK, as well as through a partnership between the international non-profit global health organisation, PATH, and the Serum Institute of India. Said Adar Poonawalla of Serum Institute of India, “As the first conjugate vaccine to safeguard against the five predominant causes of this deadly disease, Men5CV offers hope for a future free from annual outbreaks and epidemics in the AMB. It is a significant moment as we pave the way towards a healthier Africa, saving countless lives.”

clinical-interventions-have-to-be-aligned-with-the-patients-preference-and-understanding

Sat Mar 30 15:34:24 IST 2024

Medicines can be the lifelines of the health care system as they play a vital role in preventing, treating, and managing various conditions, contributing significantly to the overall health and wellbeing of individuals. While these medications are found in every nook and cranny of the country, we often tend to overlook the efforts that go into ensuring their efficacy and safety. With clinical trials, the journey from lab to patient takes its most crucial turn, revealing the true potential of each medication.

Clinical trials are scientific studies that test the efficacy of the medication in treating or preventing specific diseases. These trials also evaluate the safety of the drugs by understanding the potential adverse effects.

How do patients' insights shape decision-making in clinical trials?

Patients play an active part in the development of the product lifecycle and in shaping the narrative of a clinical trial. From their motivations to their daily lives, each patient's journey through a clinical trial is unique. Their insights provide a real-world perspective including disease burden, treatment complexities, and trial participation barriers along with the potential side effects, and the overall impact on the participant’s quality of life. This paves the way for clinical interventions to be aligned with the patient’s preference and understanding.

Advancements in technology have provided a range of digital tools that empower patients to actively participate in clinical trials. Mobile applications, web-based platforms, and wearable devices have become instrumental in capturing Patient-Reported Outcome Measures (PROMs), monitoring adherence to study protocols, facilitating real-time data collection and enhancing the objectivity and credibility of the trial data.

These tools enable patients to conveniently report their symptoms, side effects, and overall experiences directly to clinical investigators, eliminating the need for cumbersome paper-based methods and ensuring timely data capture.

Traditionally, patients had to visit clinics or research centres for regular assessments and data collection during clinical trials. Remote monitoring not only improves patient comfort and convenience but also reduces the burden on clinic resources and enhances data accuracy.

Tele-health has gained significant traction in recent times, particularly in response to the pandemic. This technology allows patients to have virtual visits with health care providers, eliminating the need for in-person consultations. In the context of clinical trials, tele-health can be leveraged to perform remote study visits, collect patient feedback, and provide support throughout the trial period.

Clinical trial designs are expected to become more complex in the future, generating even greater data volume and diversity. The future of clinical trials is expected to be remote and decentralised, with the use of technology to enhance patient and health care provider involvement.

Patient engagement in clinical trials reflects a future where trials are not just scientific achievements but compassionate journeys, shaped by the unique needs and experiences of every patient involved.

The writer is MD, executive director, medical sciences, Parexel India.

exosomes-superior-drug-delivery-ke-cheng

Sat Mar 30 14:56:55 IST 2024

Exosomes in our bodies function much like your neighbourhood couriers. Just as couriers transport packages containing important information or goods from one location to another, exosomes carry various cargo molecules, including proteins, messenger RNAs and microRNAs, facilitating communication between cells. These tiny spheres transport fats, proteins and genetic material, playing a crucial role in regulating everything from pregnancy and immune responses to heart health and kidney function. A recent study published by Columbia University suggests that these nanobubbles could be utilised in inhalation therapy to treat lung cancer.

Lung cancer is widespread and has one of the lowest survival rates among cancers. Cytokines, such as interleukin-12 (IL-12), show promising potential as potent tumour suppressors. However, their effectiveness is limited by severe adverse effects.

Now, a groundbreaking method developed by Ke Cheng, a biomedical engineering professor, and his research group presents a new avenue. Exosomes, naturally secreted by the body or cultured cells, possess low toxicity and multiple mechanisms for delivering their cargo into cells.

Historically, clinicians have primarily administered IL-12 for cancer treatment through direct injection into tumours or the bloodstream. While scientists have previously used liposomes or lipid nanoparticles to deliver mRNA, these methods face challenges such as insufficient tissue targeting and concerns about long-term toxicity. Over the past 15 years, Cheng’s group focused on developing exosomes as superior drug delivery carriers compared to liposomes and lipid nanoparticles, particularly in specific medical applications.

Cheng's laboratory discovered that administering IL-12 mRNA enclosed in exosomes via inhalation not only localises concentrated IL-12 delivery to the lungs but also enhances cancer-fighting efficacy with minimal side effects. Moreover, inhalation is entirely noninvasive; there is no requirement for a nurse to administer treatment intravenously. It was observed that the inhalation method is more efficient in building higher concentrations of IL-12 right where it is needed than other ways of delivering mRNA.

Inhaling the nanobubbles containing the blueprint for IL-12 can activate lung immune cells and transform them into formidable defenders capable of releasing substances that directly target and eliminate tumour cells. Furthermore, IL-12 aids in training these immune cells to remember the unique characteristics of tumour cells. Consequently, if the tumour attempts a resurgence, these well-prepared immune cells promptly recognise and eradicate it.

Additionally, these empowered immune cells can transmit their acquired knowledge to untrained immune cells throughout the body, forming a defensive army. This implies that even if tumour cells attempt to spread beyond their original site, these primed immune cells can detect and eradicate them, establishing a comprehensive body-wide defence against cancer. Cheng expects a human trial to launch in five years.

the-common-myths-outline-diagnosis-treatment-and-prevention-strategies-about-cancer

Sat Mar 30 14:47:11 IST 2024

According to the Global Burden of Disease study, cancer caused 8.3 per cent of the total deaths in India in 2016, almost double of what it did in 1990. As per the WHO Global Cancer Observatory estimates, 1.32 million new cancer cases and 0.85 million cancer-related deaths occurred in India in 2020.

According to the National Cancer Registry Programme, the most number of women with cancers are found in west India followed by the south. Northeast India reports the lowest numbers. Breast cancer is the most common cancer in urban India, while it is cervical cancer in rural India. The average age for women for these cancers ranges between 45 and 60 years. One in nine people in India is likely to get cancer, with women outnumbering men.

For this column, we delve into the complexities of cancer in Indian women.

Dr Mandeep Singh Malhotra is an oncologist with more than 20 years of clinical experience. Currently working as director, surgical oncology at CK Birla Hospital, Delhi, he completed his senior residency in the speciality at the All India Institute of Medical Sciences (AIIMS), Delhi. He has done stints at Broomfield Hospital, Chelmsford, UK, and the University of Pennsylvania, US. His various awards include the Young Scientist Award in 1992.

In layman terms: Cancer is a complex disease characterised by uncontrolled growth and division of abnormal cells. These cells originate within the body, not from external factors like bacteria, fungi, or viruses. Such growth disrupts normal cellular processes and can lead to the invasion of surrounding tissues and, in some cases, spread to other parts of the body through the bloodstream or the lymphatic system.

The speed of division: The development of cancer often occurs in cells that undergo frequent division, like the lining of the oral cavity, respiratory tract, gut (colon and stomach), and reproductive system (endometrium—the lining of the uterus). Additionally, blood cancers can arise from white blood cells and their precursor cells (cells that mature into functional forms). Frequent cell division increases the likelihood of mutations in the cell’s genetic code or DNA. These mutations can disrupt the normal control mechanisms that regulate cell growth and division, leading to uncontrolled proliferation and the development of cancer.

What causes mutations: Exposure to carcinogens (like tobacco smoke) and alcohol consumption can damage the DNA and increase the risk of mutations in cells lining the mouth, respiratory tract, and other organs.

Hormonal imbalances: long-term exposure to estrogen can contribute to breast and endometrial cancers.

Genetics: In some cases, cancer susceptibility is inherited from parents. However, most cancers are not directly inherited. Other factors are ultraviolet radiation, certain viruses, and chronic inflammation.

Most common cancers in Indian women: Breast cancer ranks as the most common, followed by cervical cancer. Both pose significant health risks, but ovarian cancer carries a notably higher mortality rate primarily due to late-stage diagnosis. Still, breast cancer remains the leading cause of cancer deaths as it accounts for more than a third of women’s cancer. Thus, while cancer-specific mortality (death rate) of ovarian cancer is more than breast cancer, the overall mortality of breast cancer is higher.

The age factor: For breast cancer, unlike in western countries, the average age for women in India is around 45 years, preceding menopause. This earlier age of presentation is a critical concern. Ovarian and endometrial cancers typically manifest after menopause, mostly beyond 50 years. However, younger cases are increasingly observed. Cervical cancer peaks in the 35 to 50 age bracket, particularly affecting women with multiple sexual partners, poor hygiene, and financial limitations. The nationwide HPV vaccination initiative promises a significant decrease in future cases.

The stages of breast cancer: It begins with stage zero which is detectable through screening methods like mammography, ultrasound, or MRI. Early-stage breast cancer is limited to the breast, with no involvement of the underlying chest wall or armpit nodes. Locally advanced breast cancer (stage 3) involves lymph node spread or larger tumour size, potentially with skin or chest wall involvement. Stage 4 breast cancer indicates spread of cancer cells (metastasis) to other organs like bones, lungs, liver, or brain. Treatment depends on hormone receptor status (whether or not cells have proteins that bind to a specific hormone). Hormone-positive cancers respond well to hormone therapy, while aggressive subtypes like HER2-positive (HER2 being a protein that promotes the growth of cancer cells) or triple-negative (which has neither estrogen nor progesterone or HER2, and thus gives doctors fewer treatment options) require targeted therapy or immunotherapy alongside chemotherapy. Treatment response significantly impacts cancer control, with favourable responses leading to better outcomes even in advanced cases.

The march of ovarian cancer: This may also begin as borderline ovarian lesions (damage) before progressing to cancer. Initial stages involve localised ovarian tumours, and then it progresses to adjacent structures like fallopian tubes or uterus, causing symptoms such as pain or urinary/bowel changes. Advanced stages spread throughout the abdominal cavity and potentially to distant organs like the liver or lungs. Treatment strategies involve upfront surgery for early stages and systemic therapy for advanced cases, with chemotherapy, targeted therapy, and immunotherapy showing promising results, especially in responsive patients. CA 125 (a kind of blood test) is a sensitive marker for monitoring response to treatment and detecting cancer recurrence post-surgery. Hyperthermic intraperitoneal chemotherapy (a two-step procedure where cancerous tumours are surgically removed, and then heated chemotherapy drugs applied directly inside the abdomen to eliminate the remaining cancerous cells) is a newer technique enhancing chemo effectiveness. It is particularly beneficial for aggressive cancers or those with good initial treatment response.

What to do before pain strikes: While pain often indicates advanced cancer, proactive measures and lifestyle changes can lead to earlier diagnoses. For breast cancer, Self-Breast Examination (SBE) is a valuable screening tool. Performing monthly SBE is crucial in India due to the younger onset age (45 years). Mammography may not be effective at this age. Additionally, schedule clinical breast exams by a health care professional every six to 12 months and enrol for screening mammography under the supervision of a family gynaecologist or physician. For cervical cancer, the HPV vaccine drastically reduces chances of getting it by 80 to 90 per cent. It also prevents oropharyngeal (head and neck) cancers in both men and women, and penile cancer in men. Women should also go for regular gynaecologist consultations and consider pap smears (that test cells from the cervix) every three to five years or HPV DNA testing. They should watch out for symptoms like post-coital bleeding and unusual discharge. Early symptoms of ovarian cancer are often vague, but watch for bloating, dyspepsia (indigestion), and increased abdominal girth. Advanced symptoms include urinary/bladder/bowel obstruction and pain. If there is a family history of ovarian cancer, consult your doctor for more personalised advice.

The rise of cancer kinds: Over the past few years, a significant shift has occurred. Cervical cancer, which once held the top spot, has been surpassed by breast cancer. Additionally, there has been a rise in both ovarian and endometrial cancers over the same period. However, a promising trend is emerging, with the increased uptake of HPV vaccination, cases of cervical cancer are falling by seven to 10 per cent.

Busting common cancer myths: Bras (underwired or otherwise) and/or deodorants do not cause cancer. Breast cancer risk factors are largely genetic and environmental, not related to clothing or hygiene products. The HPV vaccine might, like all vaccines, cause mild, temporary side effects like fever or soreness, but has no serious side effects. The benefits of the vaccine far outweigh any potential risks. Biopsy does not spread cancer, but is crucial for accurate diagnosis. It is a dangerous generalisation that any female problem requires a hysterectomy (removal of uterus). Treatment options vary depending on the specific condition and severity. Consult a qualified health care professional for an accurate diagnosis and appropriate treatment plan.

Mastectomy is not the answer: Modern surgical techniques allow for breast preservation while achieving excellent cancer control in many cases. It is now proven that women at early stage of breast cancer who survive the cancer with breast tend to live longer compared with those who have undergone complete breast removal (mastectomy). Talk to your doctor about the best option for your situation.

Chemotherapy not so unbearable: Modern chemotherapy has come a long way, with advancements in supportive care significantly reducing side effects. Hair loss and other effects are often temporary and reversible.

Immunotherapy not a replacement for chemotherapy: Immunotherapy plays a vital role in women's cancer treatment, but it typically enhances the effectiveness of chemotherapy, and does not replace it. Each therapy has its unique role and works best in combination with others.

Alternative medicines: While traditional therapies like ayurveda can offer benefits in managing side effects and promoting general well-being, they cannot cure established cancers. Standard treatments like surgery, radiation, and chemotherapy remain the cornerstone of cancer control.

The role of genetics and lifestyle: The dynamic nature of breasts which undergo constant changes from puberty through menopause, increases the likelihood of cellular abnormalities leading to cancer. Lifestyle and environmental factors—early puberty, delayed pregnancies, reduced lactation periods, stress, alcohol consumption, smoking, and exposure to pollutants play a substantial role in this surge. Obesity is associated with higher estrogen levels, which further increases the risk. Understanding the genetic aspect is crucial, as 15 to 20 per cent of breast cancers in India are hereditary.

Genomic alterations: Mutations in BRCA1 and BRCA2 genes (that protect against cancer) contribute significantly to cancer risk. Women with these mutations face a 70 per cent lifetime risk of breast cancer and a 45 per cent risk of ovarian cancer. Genetic counselling becomes imperative for those with a family history of breast, ovarian, prostate, colorectal, or other related cancers.

Prevention strategies: Focus on lifestyle modifications, stress reduction, exercise, a healthy diet, and timely family planning. Encouraging women to consider childbirth before the age of 35, prioritising fitness, and promoting adequate lactation can mitigate risk factors. The advent of assisted reproduction technologies, while aiding conception, introduces new considerations and trends, potentially impacting breast cancer incidence.

Family history: In families with a history of breast or other related cancers, consulting a genetic counsellor is a proactive step. Assessing risk through analysis and pedigree charts allows for personalised interventions, such as intensive screening or risk-reducing procedures like mastectomy, which can remarkably reduce the risk of breast cancer-related mortality by 95 per cent.

The (perceived) loss of looks and confidence: Hair loss is a side effect associated with chemotherapy used for various cancers, including those of the breast, ovary, cervix and endometrium. Counselling reassures patients that hair loss is temporary and hair will grow back. Depending on the patient's mental state and support system, the hospital may involve trained counsellors specialising in post-cancer support.

Because of advancements in oncoplastic breast conservation, 90 per cent of women undergoing breast cancer treatment can save their breasts. Robotic surgery allows for precise procedures with optimal functional breast preservation, including skin, nipple, and sensation. Traditional medicines like ayurveda and nutraceuticals can help reduce the side effects of chemotherapy and radiation. Medications like high-dose IV vitamin C may also be used to manage hair loss and other side effects. Modern chemotherapy regimens are optimised to minimise side effects while maximising effectiveness.

A matter of cost: It is a common misconception that cancer treatment is always expensive and unsuccessful. For cervical cancer, the HPV vaccine is more affordable due to government initiatives. Early detection of uterine cancers often only requires straightforward surgery, making it significantly less expensive than treating advanced stages requiring radiation, chemotherapy, and other interventions.

For hormone-positive breast cancer, the most common type in India, the basis of treatment is surgery and hormone therapy. Risk assessment can even identify patients who don’t require chemotherapy, further reducing costs. Hormone therapy itself is inexpensive. Only a specific type of breast cancer, HER2-positive, requires targeted therapy, which can be more expensive. However, the availability of biosimilars (medicines that are very similar to biologics, or drugs derived from living organisms or natural resources) in India has brought down the cost considerably. Even for triple-negative breast cancer, not every patient necessarily needs immunotherapy. While it can improve response rates, adding it increases the cost significantly. Standard chemotherapy alone delivers a 50 per cent response rate, and immunotherapy only increases that to 64 to 65 per cent. Therefore, most patients can be treated effectively with standard chemotherapy, with immunotherapy offering an additional benefit for those who can afford it. Early-stage cancer treatment promises an 80 to 90 per cent success rate, regardless of cost. The high expenses and disappointments typically arise when treating advanced stages, requiring multiple lines of treatment, expensive diagnostics, and advanced medications.

Family and Friends: Research has highlighted the important role of family and friends in supporting cancer patients. Studies show that patients with a strong support system and positive mindset tend to live longer compared with those lacking social support. Family support acts as a powerful boon in a patient’s fight against cancer. It not only provides emotional comfort, but also practical assistance with daily tasks and treatment adherence. Interestingly, research also suggests a link between stress levels and cancer risk. Patients lacking social support or experiencing loneliness and depression often exhibit higher stress levels. This chronic stress may be a potential factor in increased cancer risk.

Post-treatment life quality: Modern breakthroughs in science and technology have improved the quality of life for women undergoing cancer treatment, particularly breast cancer. Today, the mission is to ensure women remain as they were before treatment, both physically and emotionally. Techniques like oncoplastic surgery and robot-assisted procedures allow women to not just walk out cancer-free, but walk out with their breast shape, sensation, and function preserved, with restored normalcy and confidence. Researchers are working tirelessly to reduce the burden of treatment side effects like hair loss, pain, and skin changes. Innovative medications like targeted therapies and immunotherapies, alongside advancements in chemotherapy, have significantly increased response rates. Even during chemotherapy, doctors take precautions to ensure ovarian function and reproductive potential remain intact. Modern radiation therapy minimises undesirable effects like skin irritation and scarring, further enhancing quality of life. Early detection, coupled with these innovative technologies, ensures not just increased survival rates, but also an improvement in post-treatment quality of life.

Top cancer self-care tips: Embrace happiness. While I cannot say that happiness completely prevents or cures cancer, a positive outlook has a significant impact on your fight and recovery. Stay informed about symptoms and follow the doctor's instructions diligently. Attending all follow-up appointments is important. Recurrent thoughts of cancer can be overwhelming. Seek support and practise stress management techniques to keep anxiety at bay. While research on dietary specifics is ongoing, consider potential triggers and incorporate nutritious elements to support overall health. Consult a registered dietitian for personalised guidance. Shifting the perspective can be empowering. Instead of dwelling on the negative, view the journey as an opportunity for growth and self-discovery.

tb-eradication-in-india-by-2025-genome-sequencing

Sat Mar 30 14:40:36 IST 2024

Rohit Kumar had lost all hope. All anti-tuberculosis drugs had stopped giving results for the 23-year-old from Delhi. As a last resort, his doctor asked him to undergo genome testing. Kumar (name changed) was found to be multi-drug resistant (MDR). Fortunately, he had not reached the extensive drug-resistant stage. He was immediately put on a new drug regime and is now on the road to recovery. Like Kumar, there are several TB patients who are benefiting from genome sequencing, which helps to make the right diagnosis at the right time.

“Genomics is the future of effective tuberculosis diagnosis,” says Gunisha Pasricha, principal scientist, infectious disease expert, MedGenome, a genomics research and drug development organisation. “With advanced techniques like culture-free, whole genome sequencing (WGS), we are gradually progressing towards overcoming the challenges around accurate and timely diagnosis of tuberculosis.” As per a paper titled, ‘WGS of Mycobacterium TB Isolates from India’, published in Frontiers in Microbiology, “WGS of mycobacterium tuberculosis (MtB) has been constructive in understanding its evolution, genetic diversity and the mechanisms involved in drug resistance.” The study highlighted the immense significance of employing WGS in diagnosis as well as treatment.

Numbers, too, merit attention and call for timely interventions to stymie the endemic. As the world celebrated World TB Day on March 24, nearly 10 million people were estimated to have developed tuberculosis globally. In 2022, 1.5 million people died from it. India has the world’s highest TB burden, with an estimated 26 lakh people contracting the disease and approximately 4 lakh people dying from the disease every year, as per the Union government figures. In 2022, India accounted for the highest number of TB cases in the world, representing a whopping 27 per cent of the global burden, revealed the World Health Organization's Global Tuberculosis Report 2023.

A growing body of scholarship underscores that wrong dosage, poor quality of drugs and delay in diagnosis have precipitated India’s MDR TB epidemic. Out of 1.1 lakh cases, 63,801 were diagnosed with the MDR variant. Understandably, therefore, in recent times, experts have advocated the use of molecular diagnostics to treat the contagious disease, especially in the backdrop of MDR emerging as a major concern. The WHO, too, recommends molecular tests. The latest India-TB report, however, shows that the traditional culture-based sputum test continues to be the predominant method across the country.

Vinod Scaria, senior consultant, genome informatics and computational biology, Vishwanath Cancer Care Foundation, told THE WEEK that both diagnosis and treatment need to be kept in mind. “Tuberculosis is an endemic, but when it becomes active infection the problem arises and the big issue is resistance to drugs,” he said. “The culture-based (microscopic) methods are no doubt the gold standard around the world. But, there are limitations in the sense that they may or may not detect infections that are called extra-pulmonary in case of TB.” Scaria, who was part of Indian SARS-CoV2 genomic sequencing (INSACOG) project during his stint with CSIR Institute of Genomics and Integrative Biology, added that the solution to this problem was meta genome sequencing, which can identify and make information available holistically. “When it comes to treatment, in case of TB the conventional ways may miss the drug resistance markers available, delaying the diagnosis and the treatment,” he said. “By sequencing the entire genome, all markers will be covered and the exact causes can be learnt in much less time.”

Pasricha concurs. “The conventional techniques like liquid culture or solid culture will take more time to give results,” she said. “The molecular methods, on the other hand, sequence the whole genome and we have validated the tests within 14 days.” She further explained that culture-based WGS had proven effective in predicting drug resistance and providing insights into the genetic makeup of TB strains. However, culture-based WGS takes 10-12 weeks to determine the drug resistance susceptibility results of the sample. “WGS from direct sputum/clinical samples offers a solution,” she said. “Advancements in genomics have helped us address these issues, and today we have technologies like SPITSEQ, a culture-free WGS method that comes with 100 per cent sensitivity, 98.4 per cent accuracy in resistance variant profiling and 97.7 per cent accuracy with phenotypic drug susceptibility tests for at least six anti-tuberculosis drugs.” She admitted that although culture-based microscopic methods are the gold standard, the world is increasingly recognising the importance of next-generation sequencing. “We get a regular inflow of requests by doctors to perform WGS using new technologies,” she said.

The government also acknowledges the gaps. A senior official in the department of biotechnology, the nodal organisation sequencing more than 30,000 TB strains, told THE WEEK that there are at least two challenges in the current methods of surveillance of drug resistance in MtB. “Existing genetic testing for drug resistance picks only the known genes/mutations and because of the long doubling time of Mtb, traditional drug sensitivity tests are time-consuming,” he said. He added that this necessitates the development of novel technologies for rapid detection of drug resistance and identification of novel mutations. Developments in WGS technologies make it an extremely useful tool to address both these issues.

The government has initiated a slew of measures to combat TB. The campaign got a renewed push with the launch of Pradhan Mantri TB-Mukt Bharat Abhiyan in September 2022 which aims to eradicate TB by 2025. In fact, the reported increase in TB cases the same year were attributed to enhanced surveillance. According to the India TB report 2023, published by central TB division in the ministry of health and family welfare, the year 2022 marked a “milestone year for TB surveillance efforts in India, with a record high notification of 24.2 lakh cases, a 13 per cent increase from 2021”. This means a case notification rate of approximately 172 cases per lakh population. The highest notification was seen in Delhi (546 per lakh population) and the lowest in Kerala (67 per lakh population). Ni-kshay Mitras, Ni-kshay Poshan Yojana, TB Vijetas and TB Champions are some other initiatives of the government focusing on generating awareness on TB prevention.

To provide impetus to molecular testing, there was another initiative called the Indian TB Genomic Surveillance Consortium (InTGS) launched under the government's DARE2ERAD TB (data-driven research to eradicate TB) umbrella in March 2023. It was modelled on the lines of INSACOG, to monitor the genomic variations in MtB through a multi-laboratory network. The partners of this consortium are CSIR and the Indian Council of Medical Research (ICMR). As part of the initiative, the department of biotechnology plans to perform whole genome sequencing of 32,200 clinical strains from active TB patients.

Acknowledging the importance of WGS in TB, Union minister for science and technology Dr Jitendra Singh had said: “In order to fully understand the biological characteristics of MtB and the effect of the mutations on transmission, treatment and disease severity, analysing the genomic data of the organism is essential.” Singh admitted that WGS is increasingly gaining traction as an important molecular tool for TB surveillance. “InTGS is a first pan-India initiative at such scale to fully understand the biological characteristics and could lay the groundwork for use of modern technology such as WGS for TB diagnosis and surveillance in future,” said Singh.

  Dr Rajendra P. Joshi, deputy director general, central TB division, wrote in the 2023 India TB report that under the national tuberculosis elimination programme, 4,960 nucleic acid amplification test machines have been deployed across the country for rapid molecular diagnosis of TB to ensure early and complete case finding.

However, observers feel that the pace at which India is performing WGS on TB strains may not be enough to achieve the TB-mukt target by 2025. The numbers attest to the pessimism. In March 2023, the Union minister declared the commencement of the pilot phase of InTGS with successful completion of whole genome sequencing of 182 strains isolated from TB patients. In nearly a year since then, the sequencing has been completed for only 513 strains, as per the recent data provided to THE WEEK by the department of biotechnology.

“The reason behind the slow progress is the reluctance of the government to rope-in the private sector,” said an expert, on condition of anonymity. “While the government may take years to perform WGS of 32,200 TB strains, the private sector is capable of doing the job within 3-4 months. In case of Covid-19, the government opened up the testing of RT-PCR by the private players. This resulted not only in reduced cost of the test but also in availability of early reports. The molecular tests were extensively used for Covid-19 detection and they can be re-purposed for TB diagnostics to eradicate the disease by 2025. It is surprising why the government is not doing it.” The apprehension of experts is not misplaced. The organisations chosen for the execution of InTGS are all government agencies. Whereas sequencing will be performed together by BRIC-National Institute of Biomedical Genomics, Kalyani, CSIR-Centre for Cellular & Molecular Biology, Hyderabad, and ICMR-National Institute for Research in Tuberculosis, Chennai, a bio-repository for TB strains is being established at International Centre for Genetic Engineering and Biotechnology, New Delhi.

For data analysis and storage, National Institute of Immunology, New Delhi, and Indian Biological Data Centre, Faridabad, have been given the responsibility, respectively.

The chorus is growing for strengthening access to WGS TB services, improving surveillance and drug resistance management besides investing heavily in R&D, as explained in a recent paper titled, ‘Genomic revolution: Transforming TB diagnosis and treatment with the use of WGS’ published in the Indian Journal of Tuberculosis.

For India to be TB-mukt by 2025, it will have to make rapid strides in using whole genome sequencing to its full potential. Said Pasricha: “Public private partnership is very important so that all go hand-in-hand to eradicate TB from India.”

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

Sat Feb 24 17:16:30 IST 2024

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

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

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

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

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

ending-period-related-stigma-and-discrimination

Sat Feb 24 17:28:29 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

the-many-benefits-of-repurposing-drugs

Sat Feb 24 13:13:48 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Feb 24 17:18:20 IST 2024

Why so many tests?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jan 27 15:04:20 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jan 27 15:00:49 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ssi-mantra-surgical-robotic-system

Sat Jan 27 14:56:39 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jan 27 14:28:04 IST 2024

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

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

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

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

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

tips-to-take-care-of-eyes

Sat Jan 27 14:19:29 IST 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sat Jan 27 14:14:37 IST 2024

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

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

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

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

Precision medicine

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

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

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

Genomic testing

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

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

How affordable is genetic and genomic sequencing?

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

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

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

Preventive wellness

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

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

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

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

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

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

Sat Dec 30 11:26:48 IST 2023

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

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

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

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

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

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

rabit-robotic-surgery-procedure-for-thyroid

Fri Dec 29 17:35:15 IST 2023

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

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

A FIRST IN INDIA

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

Challenges of robotic thyroidectomy and neck dissection in children

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

HOW THE TECHNIQUES WORK

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

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

ADVANTAGES

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

FUTURE IN INDIA

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

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

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

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

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

Fri Dec 29 17:13:40 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fri Dec 29 17:08:49 IST 2023

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

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

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

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

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

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

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

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

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

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

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

Fri Dec 29 17:03:08 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

mitraclip-procedure-in-india

Sat Nov 25 15:06:02 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dardi was in hospital for three days.

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

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

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

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

What more could one ask for from a simple clip?

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

Sat Nov 25 14:58:44 IST 2023

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

Scientifically: dismal.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

does-marijuana-help-with-endometriosis-pain

Sat Nov 25 14:47:40 IST 2023

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

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

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

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

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

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

Sat Oct 28 17:08:21 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

the-relationship-between-housing-and-ageing

Sat Oct 28 16:55:30 IST 2023

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

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

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

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

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

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

how-to-deal-with-climate-anxiety

Sat Oct 28 16:50:30 IST 2023

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

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

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

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

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

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

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

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

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

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

Sat Oct 28 16:15:40 IST 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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