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RNI No. : UPENG /2014 / 59232 A

May 2018




VOL IV, Issue VI, Rs. 100

Dr Ravi Wankhedkar

Nipah Virus

Dr Vinay Aggarwal

Ayushman Bharat The good, bad and worst?



Contents 20 Advisory Board

Dr. A K Agarwal, Professor of Excellence, Ex-President, Delhi Medical Council and Medical Advisor, Apollo Hospital, New Delhi

Dr Vinay Aggarwal. Member, Medical Council of India Dr. S P Yadav, Member, Medical Council of India Dr. J C Passey, Director Professor, Maulana Azad, Medical College, New Delhi Dr. Suneela Garg, Director Professor, Maulana Azad, Medical College, New Delhi Dr. H P Singh, Sr. Child Specialist Raj Kumar Gupta, Managing Director, Balaji Action Hospital & Research Center, New Delhi


Volume IV Issue VI May - 2018

Face thier Challenge ZLWK&RQĆ…GHQFH



Editor & Publisher Amresh K Tiwary Coordinating Editor Sarvesh Tiwari Roaming Editor Dr. Manisha Yadav Editorial Team Abhigyan, Abhinav, Designer Aparna Advertisements & Marketing Gautam Gaurav, Abhinav Kumar All material printed in this publication is the sole property of Double Helical. All printed matter contained in the magazine is based on the information by those featured in it. The views, ideas, comments and opinions expressed are solely of those featured and the Editor and Publisher do not necessarily subscribe to the same. Double Helical is owned, printed and published monthly. It is printed at Polykam offset, Naraina Industrial Area Phase 1, New Delhi-110028, and published from G-1, Antriksh Green, Kaushambi, Ghaziabad-201 010. Tel: 0120-4219575, 9953604965. Contact us : Email: doublehelicaldesign@gmail. com, Website:,



Dr Vinay Aggarwal on Ayushman Bharat The good, bad and worst?


Men’s Health Prostate Cancer


Affecting Your Oral Health


The Looming Threat

May 2018



Outbreak of Nipah virus….. ear readers, Thanks for your continue support and good wishes. We really appreciate your efforts for staying with us and guiding us like a guardian. Like every month this time too we wish to present very good stories pertaining to improving the quality of life. In the May issue, there are a number of innovative report and analysis-based stories in the field of healthcare. Recently Kerala was in news for an outbreak of Nipah virus in Kozhikide district. This is the first time the virus, which has high fatality rate and spreads mainly through bats, pigs and other animals, has been detected in the state. Nipah virus encephalitis is a zoonotic disease that is transmitted from bats, affects domestic animals, primarily pigs. Dogs, cats, horses, goats possibly sheep can also be infected. It was first time identified in 1999 in Malaysia and Singapore. NiV is a highly pathogenic paramyxovirus belonging to genus Henipavirus. It is an enveloped RNA virus. Nipahvirus is classified internationally as a biosecurity level (BSL) 4 agent. NiV has a number of important attributes that makes it a potential agent of bioterrorism. Bats (Pteropus genus), infected bats shed the virus in their excretion and secretions such as saliva, urine, semen and excreta, but they are asymptomatic carriers. The bats are migratory and they migrate within the AsiaPacific Region. Pig is the intermediate host. Dogs, goats, cats, horses, possibly sheep can also be infected. The Union Minister for Health and Family Welfare, J P Nadda is closely monitoring the situation arising out of reported cases and deaths due to Nipah Virus in Kerala. He has urged citizens not to believe in rumours posted on social media and not to spread panic. J P Nadda has reviewed it with health ministry’s team and has directed for all support to be extended to Kerala in its prevention and management. Following directions of the Union Health Minister, a multi-disciplinary Central team from National Centre for Disease Control (NCDC) is presently in Kerala constantly reviewing the situation. The team found many bats housed in the well from where the family was drawing water. Some bats have been caught and have been sent for lab examination to confirm whether they are the cause of the disease or not. 60 different samples have been collected from the spot




and sent for examination. There are two confirmed cases with history of contact with the index case. They were admitted in the Calicut Medical College Hospital and died due to Nipah virus. And breaking coverage of Ayusman Bharat has raised question mark over- whether it is good or bad? The current scheme where a family will be insured for Rs 5 Lac per annum is a huge sum and will cover most of their health issues. Additional pioneering benefit is that all the Primary health centers and the present sub centers are being converted into wellness centers. The current scenario of primary health centers and its sub-centers were a question of talk for a very long time and its functioning is not doing well which can solely be attributed to poor Governance. Lack of better efforts from the government to improve the primary health care infrastructure has reflected in the current status of our Nation’s health. With the availability of around 30,000 primary health centers, vacancies less than 2000 shows the scanty of doctors. Each Primary health center has five sub-centers and the prime idea was that the health workers there will be running the sub-centers and the doctor in-charge from the associated Primary Health Centers will make a monthly or a fortnightly visit to these sub-centers is a curative point and in anguish. And now with the Government’s direction in the current proposed Ayushman Bharat scheme is to convert all the sub-centers into preventive and wellness centers is a very good initiative by the Government. This will have huge impact in the betterment of preventive illnesses and is a good move that needs to be appreciated. Apart from these, this we also cover on the increasing trend of auto-immune disease which is a big challenge for quality life. The Indian Council of Medical Research (ICMR) has undertaken a nationwide study with the aim of addressing the scarcity of information on auto immune disease and the other diseases. The current phase of the study has reported alarming outcomes. Thank you again for your continued patronage of the magazine! Amresh K Tiwary, Editor-in-Chief

Health News

Be]ROg`WaYQ][[c\WQObW]\e]`YaV]^ P Nadda, Union Minister of Health and Family Welfare inaugurated a two-day workshop on ‘Risk Communication during Public Health Emergencies’ at Shimla. During his inaugural address, Nadda urged the public health functionaries for keeping their communication simple and effective during the delivery of healthcare services. Vipin Parmar, Health Minister, Himachal Pradesh, Vineet Chawdhary, Chief Secretary, Himachal Pradesh, Dr. Promila Gupta, DGHS, Dr. Pauline Harvey, Team Lead-NPSP, WHO Country Office and Prabodh Saxena, Principle Secretary (Health), Himachal Pradeshwere also present at the inaugural function. Addressing the participants, Nadda




said that prevention and control of disease outbreaks or spread of Public Health Emergency of International Concern (PHEIC) in the country need multi-sector approach. “It encompasses inter-sectoral cooperation and co-ordination between various ministries. He added that during public health threats miscommunication or mis-interpretation of public messages can have significant negative impact on preventive and control strategies. “It is important to identify and quantify the risk, possible channels spread, Standard Operating Procedures (SOPs) for prevention, control and treatment,� the Health Minister said. Laying stress on preparedness, Nadda said that many diseases have

the risk of spreading from one state to another. “Health Ministry has been regularly interacting with the States for monitoring and reviewing their preparedness to manage vector borne diseases in the country in terms of availability of diagnostic kits, drugs, testing labs, manpower funds and awareness activities,� Nadda added. Nadda assured the participants for implementing the protocols and SOPs emerging from the workshop and also unveiled a ‘Communicable Disease Alert on Scrub Typhus� and a draftof strategic guidance on “Risk Communication during Public Health Emergencies�. Vipin Parmar, Health Minister, Himachal Pradeshdescribed the workshop as an important effort and

said that the findings from the workshop will prove to be beneficial for not only the State but for the entire country. He further expressed his commitment towards strengthening health services in the State. More than 100 people from various government department participated in the two day capacity building workshop which was jointly organized by National Centre for Disease Control (NCDC), Delhi and World Health Organization. The main objectives were to enhance the capacity of key International Health Regulation (2005) and emergency stakeholders in responding effectively to urgent communication during acute public health events through an application of evidence-based principles in the country, to draw attention to the systemic capacities and planning needs to enable effective risk communication during emergencies, using an all-hazard approach and to share experiences of risk communication during recent public health events.

May 2018


Health News

/US\ROT]`QVO\USb]E]`ZR6SOZbV/aaS[PZg fter one year in office, WHO Director-General, Dr Tedros Adhanom Ghebreyesus will open the Seventy-First World Health Assembly in Geneva with an ambitious agenda for change that aims to save 29 million lives by 2023. Ministers of Health and other delegates from WHO’s 194 Member States will meet to discuss a range of issues, including the 13th General Programme of Work, which is WHO’s 5-year strategic plan to help countries meet the health targets of the Sustainable Development Goals (SDGs). Tedros Adhanom Ghebreyesus, said, “This is a pivotal health Assembly. On the occasion of WHO’s 70th anniversary, we are celebrating 7 decades of public health progress that have added 25 years to global life expectancy, saved millions of children’s lives, and made huge inroads into eradicating deadly diseases such as smallpox and, soon, polio. “ “But the latest edition of the World Health Statistics, published yesterday, shows just how far we still have to go. Too many people are still dying of preventable diseases, too many people are being pushed into poverty to pay




for health care out of their own pockets and too many people are unable to get the health services they need. This is unacceptable,� he added. “We are transforming how we work to achieve our vision of a world in which health is a right for all. We are changing the way we do business,� Dr Tedros said. “Other topics that will be covered at this year’s World Health Assembly include WHO’s work in health emergencies, polio, physical activity, vaccines, the global snakebite burden and rheumatic heart disease.� Health Assembly will open against the backdrop of a new outbreak of Ebola in central Africa, a stark reminder that global health risks can erupt at any time and that fragile health systems in any country pose a risk for the rest of the world. The WHO General Programme of Work, designed to address these challenges and accelerate progress towards the SDGs, is the result of 12 months of intensive discussion with countries, experts and partners, and centers on the “triple billion� targets: ‡ 1 billion more people benefitting from universal health coverage ‡ 1 billion more people better


protected from health emergencies 1 billion more people enjoying better health and well-being.

The World Health Statistics 2018, WHO’s annual snapshot of the state of the world’s health, highlights that while remarkable progress towards the SDGs has been made in some areas, in other areas progress has stalled and the gains that have been made could easily be lost. The latest data available shows that: ‡ Less than half the people in the world today get all of the health services they need. ‡ In 2010, almost 100 million people were pushed into extreme poverty because they had to pay for health services out of their own pockets. ‡ 13 million people die every year before the age of 70 from cardiovascular disease, chronic respiratory disease, diabetes and cancer – most in low and middle-income countries. ‡ Every day in 2016, 15 000 children died before reaching their fifth birthday.

practices; and coordinate with animal sector and enhance surveillance for unusual illness and deaths in animals. The Ministry has ensured availability of diagnostic kits, personal protective equipment and risk communication materials. High quality personal protection equipment has been provided to health care personnel. A

8><ORRO `SdWSea<W^OV DW`caQOaSa W\9S`OZO he Union Minister for Health and Family Welfare, J P Nadda is closely monitoring the situation arising out of reported cases and deaths due to Nipah Virus in Kerala. He has urged citizens not to believe in rumours posted on social media and not to spread panic. J P Nadda has reviewed it with Secretary (HFW). Preeti Sudan and DG (ICMR) Dr. Balram Bhargava and has directed for all support to be extended to Kerala in its prevention and management. Following directions of the Union Health Minister, a multidisciplinary Central team from National Centre for Disease Control (NCDC) is presently in Kerala constantly reviewing the situation. The Central team includes Dr. Sujeet K Sing, Director, NCDC; Dr. S K Jain, Head Epidemiology, NCDC; Dr. P Ravindran, Director, Emergency Medical Relief (EMR); Dr Naveen Gupta, Head Zoonosis, NCDC; Dr Ashutosh Biswas, Prof Internal Medicine, AIIMS; Dr. Deepak Bhattacharya, Pulmonologist, Safdarjung Hospital along with two clinicians and one expert from Ministry of Animal Husbandry. The NCDC team visited the house in Perambra from where the initial death was reported. The team found many bats housed in the well from where the family was drawing water. Some bats have been caught and have been sent for lab examination to confirm whether they are the cause of the disease or not. 60 different samples have been collected from the spot and sent for examination. There are two confirmed cases with history of contact with the


index case. They were admitted in the Calicut Medical College Hospital and died due to Nipah virus. The Ministry has mobilized a public health team from NCDC Branch Kozhikode to assess the extent of problem, for risk assessment and risk management. They are assisting the State Level Team already deployed at the epicentre. So far, seven patients have been admitted in Baby Memorial Hospital and in the Govt. Medical College at Kozhikode and at the Amrutha Medical College, Ernakulum. The field team has advised hospitals to follow intracranial pressure (ICP) guidelines, use personal protective equipment (PPE) for healthcare workers and sample collection; assist in enhancing active fever surveillance in the community; strengthen contact tracing in close contacts of cases, relatives, health care workers; ensure isolation facilities, ventilator support and hospital infection control

total of nine individuals are currently under treatment. Isolation wards have been opened in many hospitals in Kozhikode. Hospitals in public and private sector have been provided with personal protective equipment. Appropriate steps to contain this virus have been taken among domestic animals such as pigs. Since all the contacts are under observation and steps to avoid exposure through animal vectors have been taken there is no reason for people to panic. This appears to be a localised occurrence. With early and efficient containment measures undertaken jointly by the Ministry of Health & Family Welfare and Government of Kerala, the outbreak is unlikely to spread. The Virus Research Diagnostic Laboratory at Manipal Hospital and the National Institute of Virology, a premier institute for research in virology, are geared up to meet any diagnostic challenges that may arise.

May 2018


Special Story - NIPAH VIRUS



ipah virus encephalitis is a zoonotic disease that is transmitted from bats, affects domestic animals, primarily pigs. Dogs, cats, horses, goats possibly sheep can also be infected. It was first time identified in 1999 in Malaysia and Singapore. NIPAH: A village in Malaysia where outbreak of respiratory illness and encephalitis among pig farmers occurred. AGENT: NiV is a highly pathogenic


paramyxovirus belonging to genus Henipavirus. It is an enveloped RNA virus. Nipah virus is classified internationally as a biosecurity level (BSL) 4 agent. NiV has a number of important attributes that makes it a potential agent of bioterrorism. NATURAL RESERVOIR: Bats (Pteropus genus), infected bats shed the virus in their excretion and secretions such as saliva, urine, semen and excreta, but they are asymptomatic carriers. The bats are migratory and they migrate within the Asia-Pacific Region. Pig is the intermediate host.

Dogs, goats, cats, horses, possibly sheep can also be infected. SEASON: December to May (breeding season of bats) CASE FATALITY RATE: 40 - 75% OUTBREAKS: Bangladesh 2001, 2004 onwards INDIA: Siliguri 2001 Mode of Transmission: Direct contact with infected bats, pigs and infected patients. Person to person transmission reported in Bangladesh and in India among family and caregivers (Contact with body fluids). During the outbreak

FKLOGUHQRIÂ&#x2022;PRQWKVÂ&#x2022;PLQ  ,QFUHDVHGKHDUWUDWH $GXOWÂ&#x2022;PLQ FKLOGUHQRIÂ&#x2022;PRQWKVÂ&#x2022;PLQ  &UHSLWDWLRQVLQOXQJDQG+\SHUWHQVLRQ Hypotension NEUROLOGICAL SIGNSOculoparesis, Pupillary abnormality, Facial weakness, Bulbar weakness, Limb weakness, Reduced deep tendon UHIOH[HV3ODQWDUDEVHQWH[WHQVRU Long term sequelae include resistant convulsions and personality changes. Latent infection with subsequent reactivation of NiV and death has been reported months and years after exposure. Nipah cases occur as clusters means two or more suspect cases living within a 30 minute walk of each

other that develop symptoms within 21 days of each other. Samples will be sent to Manipal Centre For Virus Research for confirmation. CASE DEFINITION OF NIPAH ENCEPHALITIS SUSPECTED CASE A person fulfilling both of the following two criteria is defined as a suspected case like features of acute encephalitis as demonstrated by acute onset of fever and Evidence of acute brain dysfunction as manifested by altered mental status or new onset of seizure or any other neurological deficit EPIDEMIOLOGICAL LINKAGE a. Drinking raw date palm sap or

in Siliguri, 33 health workers and hospital visitors became ill after exposure to patients hospitalized with Nipah virus illness, suggesting nosocomial infection. INCUBATION PERIOD: 6-11 days MEDIAN IP â&#x20AC;&#x201C; 7 days SYMPTOMS: Fever, Altered mental status, severe weakness, Headache, Respiratory distress, Cough, Vomiting, Muscle pain, Convulsion and Diarrhea GENERAL SIGNS- Reduced GCS score, Raised temperature, Increased UHVSLUDWRU\ UDWH $GXOW Â&#x2022;PLQ

May 2018 11

Special Story - NIPAH VIRUS

Eating of fruits suspected to be bitten by bats, occurring during Nipah season or patient from Nipah endemic area.

PROBABLE CASE: A person with features of acute encephalitis : During a Nipah outbreak in the area or with history of contact with confirmed Nipah patient In both suspected and probable cases, the patient might present with respiratory features with or without encephalitis. The respiratory features are: Illness more than 7 days duration, acute onset of fever and severe shortness of breath, cough and chest radiograph showing diffuse infiltrates CONFIRMED CASE A suspected or probable case with laboratory confirmation of Nipah virus infection either by IgM ELISA antibody against Nipah virus in serum or cerebrospinal fluid and Nipah virus RNA identified by PCR from respiratory secretions, urine, or cerebrospinal fluid. CLOSE CONTACT: It is defined as the patient or the person who came in contact with a Nipah case (confirmed and probable cases) AND stayed in the room or veranda or vehicle for at least 15 minutes. DIFFERENTIAL DIAGNOSIS Other viral encephalitides e.g. Herpes simplex encephalitis, Japanese B Encephalitis (JBE), Bacterial meningitis and Cerebral Malaria PREVENTION AND CONTROL Avoid consumption of fruits


suspected to be bitten by bats, Avoid exposure to infected pigs and bats, Do not drink raw date palm sap, Avoid bat inhabited areas, Report fever with altered sensorium to the nearest health facility. VACCINES A vaccine is being developed. A recombinant sub-unit vaccine formulation and another ALVAC Canarypox vectored. Nipah F and G vaccine appears to be a promising vaccine for swine and has potential as a vaccine for humans (WHO). 4. PREVENTION AND CONTROL OF NIPAH transmission depends upon controlling these risk factors like ingestion of fruits suspected to be ELWWHQE\EDWVDQGRWKHUELUGVDQLPDOV Person to person transmission of Nipah YLUXVIURPSDWLHQWWRFDUHJLYHUFRQWDFW patient to health care worker, touching objects used by patients or during handling deceased. Strategies for prevention of Nipah virus transmission are Awareness program, Early case detection through different surveillance systems, Case management, Infection control measures, Household, Community and Hospital PREVENTION OF NIPAH TRANSMISSION FROM PERSON-TOPERSON 1. Segregate Nipah patients from other patients in the isolation ZDUGIDFLOLW\ 2. Restrict the number of service providers in the isolation ward. 3. Maintain at least 1 meter (3 feet: one fully stretched armâ&#x20AC;&#x2122;s length) distance between two beds for

5. 6. 7. 8. 9.

Nipah patients. Wash hands thoroughly with soap and water after coming in contact with patient. Sleep in separate bed. Keep personal items of patient separately. Wash used items of patient with soap and water, separately. Minimize contact with patient. Avoid unnecessary hospital visit by public.

PREVENTION OF NIPAH TRANSMISSION AT HOSPITAL SETTING 1. Admit all cases with fever and XQFRQVFLRXVQHVVFRQYXOVLRQ difficulty breathing to the LVRODWLRQ ZDUG IDFLOLW\ LQ WKH hospital. 2. Use mask and gloves during historytaking, physical examination, sample collection and other care-giving to suspected Nipah cases. 3. Avoid unnecessary contact with suspected Nipah cases. 4. Follow standard precautions for infection prevention at hospital






setting. Immediately report admission of a suspected Nipah case to relevant authority.

PRECAUTION FOR ISOLATION WARD/ FACILITY 1. Segregate Nipah patients from other patients in the isolation ZDUGIDFLOLW\ 2. Restrict the number of service providers in the isolation ward. 3. Maintain at least 1 meter (3 feet: one fully stretched armâ&#x20AC;&#x2122;s length) distance between two beds for Nipah patients. 4. Barrier nursing (PPE use, Isolation). 5. Environmental cleaning and decontamination. 6. Safe waste disposal. PERSONAL PROTECTION DURING CARE FOR NIPAH PATIENT 1. Use personal protection equipments: During history taking, physical examination: wear surgical mask, surgical gloves (examine, specimen collection) and gown. During specimen collection and other invasive procedures (such as nasopharyngeal suction, endotracheal intubation) wear N95 mask, surgical gloves and

gown. Maintain hand hygiene: Wash hands in with soap and water at least for 20 seconds, or Clean hand using 1-2 ml alcohol based hand sanitizer (chlorhexidine or 70% alcohol hand sanitizers) after providing any care to patient. 3. Use disposable items: while providing NG tube, oxygen mask, and endotracheal tube, or If disposable items are not available, reuse after sterilization by autoclave or 2% glutaraldehyde. 2.

PREVENTION OF NIPAH TRANSMISSION FROM DECEASED BODY TO PERSON 1. During Handling Deceased At )DPLO\&RPPXQLW\/HYHO 2. Secretion and excretion from a deceased person are considered to be equally infectious like that of a living infected person. Adequate precautionary measures have to be taken during handling such dead body during transportation, washing and burial or cremation. 3. +HDOWK FDUH ZRUNHUPRUWXDU\ staff should wear PPEs (disposable surgical mask, gloves and gown) while handling corpse of Nipah case.

Hand wash with soap and water (or hand sanitizer), should be done immediately after handling the corpse. Used PPE should be disposed using standard protocol for infectious waste disposal. During transportation, deceased persons should be carried in an DLUVHDOHGEDJLIQRWSRVVLEOHE\ covering with clothes. Health care worker will provide PHVVDJH WR IDPLO\ PHPEHUV community people of deceased person (dead by Nipah infection) to follow precaution during transportation and handling of the deceased from hospital to community.

PRECAUTION TO BE FOLLOWED BY FAMILY MEMBERS/COMMUNITY MEMBERS 1. Avoid close contact with deceasedâ&#x20AC;&#x2122;s face, especially respiratory secretion. 2. Cover face with a piece of cloth GXULQJ ZDVKLQJULWXDO EDWK RI deceased body. 3. Wash hands with soap, if possible take bath with soap immediately after performing ritual bath of the dead body. HANDLING REUSABLE ITEMS OF DECEASED 1. Wash reusable items (clothes, XWHQVLOV HWF  ZLWK VRDS detergent. 2. 'U\PDWWUHVVTXLOWFRPIRUWHU pillow, etc. in sunlight for several consecutive days. The main strategy is to prevent NiV in humans. Establishing appropriate surveillance systems will be necessary so that NiV outbreaks can be detected quickly and appropriate control measures initiated. (The author is National President, IMA, New Delhi and well known consultant surgeon and coloproctologist at Sitaram Hospital, Dhule, Maharashtra)

May 2018 13

Special Story - Ayushman Bharat

Ayushman Bharat The good, bad and worst? Ayushman Bharat is a good scheme initiated by the Government of India, particularly when it is covering upto 10 crore families which means almost 40-50 % of the population will be covered….. BY DR VINAY AGGARWAL


he kind of pre-emblem which has been proposed in the scheme is to cover all the people Below Poverty Line (BPL), rural masses and moreover it is over and above the previously introduce scheme - National Health Protection Mission (NHPM), whose primary objective was to cover BPL citizens with capacity of around 30,000. WHAT IS GOOD ABOUT AYUSHMAN BHARAT? The current scheme where a family will be insured for Rs 5 Lac per annum is a huge sum and will cover most of their health issues. Additional pioneering benefit is that all the Primary health centers and the present sub centers are being converted into wellness centers. The current scenario of primary health centers and its subcenters were a question of talk for a very long time and its functioning is not doing well which can solely be attributed to poor Governance. Lack of better efforts from the government to improve the primary health care infrastructure has reflected


in the current status of our Nation’s health. With the availability of around 30,000 primary health centers, vacancies less than 2000 shows the scanty of doctors. Each Primary health center has five sub-centers and the prime idea was that the health workers there will be running the sub-centers and the doctor in-charge from the associated Primary Health Centers will make a monthly or a fortnightly visit to these sub-centers is a curative point and in anguish. And now with the Government’s direction in the current proposed Ayushman Bharat scheme is to convert all the sub-centers into preventive and wellness centers is a very good initiative by the Government. This will have huge impact in the betterment of preventive illnesses and is a good move that needs to be appreciated. THE PROBLEM AT HAND Since independence health sector has suffered due to the fact that less importance was given to health. In comparison to developed countries like US & UK, over 15% of the GDP is allocated for betterment of health;

India only spends around 1-1.3% on an average. Indian health care scenario can only improve when these numbers are increased and health made as a fundamental right to all citizens. Until and unless health is made as a priority sector, the current situation is unbound to change. This scheme has many inbuilt messages which also highlights the Government’s approach and attention towards improving the primary health structure. But with certain modifications in the system or infrastructure of the Primary Health care centres, things can be made better. If the villagers are covered with 5 lakh insurance, then they can get a much better treatment otherwise. Medical education in rural India needs improvement. One medical college should be there in every three district, but according to the current medical education system, about 200 districts have only 450 medical colleges, which is very less. If we take the examples of UT like Puducherry, it has 11 medical colleges If Government makes more medical colleges

particularly in tribal areas, or areas which does not have medical health care or is looking for medical education, then the overall development of that area is bound to happen with opening of such Government medical colleges and better healthcare. The Government should also make changes in policy making to prohibit any further opening of medical colleges in areas that already has such colleges in abundance. Providing permissions to open new medical colleges in districts with no medical colleges or remote areas will help in overall betterment. IS THERE A SCARCITY OF DOCTORS? Government has always been pin pointing upon the dearth of doctors in the country. But imagine, in a country that produces over 90,000 MBBS doctors annually with 67,000 doctors passing out from 489 medical colleges

in India and approximately 20,000 doctors who join as foreign medical graduates are already available to practice medicine in India. But the problem arises with the fact that the available post graduation seats are limited to only 30,000, and the remaining 60,000 doctors may have only 1750 vacancies to join in any of the wellness centers. If the number of seats and number of vacancies are increased, the so called dearth of doctors can easily be tackled. If the system is made robust, these 60,000 doctors can be employed in the sub-centers on regular basis, instead of providing them contractual and adhoc appointments. For instance, if an MBBS graduate from metro city is appointed in some far flung rural area on a contractual basis, they may hesitate to go. But if certain changes are made in the policies, in terms of incentivizing their

appointments on regular basis, healthcare in rural areas is bound to improve. Moreover if the servings in rural areas are incentivized with their marks for PG entrance exam, the number of doctors willing to go to rural areas will increase drastically. BEING AN INSURANCE SCHEME â&#x20AC;&#x201C; WHO WILL REIMBURSE? Being an insurance scheme with cashless transaction, reimbursement to hospitals remains a hidden aspect, whether the reimbursement is to be provided by the Government or the insurance sector. Again the setback remains that if the Government reimburses, then CGHS is already suffering. Payments in CGHS and ESI are not made for months together and the hospitals truthfully are discouraging such patients to admit. A robust system should be developed by taking more and more

May 2018 15

Special Story - Ayushman Bharat

private sector into confidence, be it a private healthcare organization or leaderships from private sectors and involvement of the Indian Medical Association before implementing this scheme. Such Public Private Partnerships will be able to work shoulder to shoulder and to frame rules and work out efficiently as far as different rates are concerned. WHAT NEEDS TO BE CHANGED IN POLICY MAKING? This is one of the most wonderful schemes ever thought of, but my concern is that it should not become a victim of poor governance; the proper thought process has to go in. The blatant example of this poor governance is the National Rural health mission, which was started 10 -15 years back to improve the primary health structure. But even after investing crores and crores of money, the Government had to abandon the mission due to high corruption rate. As a medical activist we do not want this scheme also to be a victim of poor governance. A lot of thought process is required to go into this scheme as such. INVOLVE MORE PRIVATE PLAYERS So far in this scheme no private organizations like IMA or any other private players have been consulted. The government seems shaky and cloudy as far as the thought process is concerned, and even the methodology of implementation of this scheme seems unclear. With the participation of private sector which is almost 80% will be a


defining moment for this scheme. Being in no hurry, involve more and more private sector, have consultations with them, talk to IMA, and tag to all possible stake holders before launching this scheme. The rates for various medical procedures should be decided in consultation with various stakeholders including IMA. At this many low unaffordable or unmanageable rates will breed corruption and make this scheme unviable. There should be transparent, clear cut directions along with a robust reimbursement system in this scheme to be implemented. Instill MBBS doctors at sub-centers and focus on improving primary healthcare As a personal opinion the sub-centers can be run by MBBS doctors if proper employment is provided to them. Instead of spending lavishly in building super-specialty hospitals, make most of the investments in improving the primary health structure of the country, be it the primary health centers or subcenters. It is a question of concern that why and how some of the states are doing extraordinarily well? States like Kerala has a very robust primary health structure and recently Tamil Nadu and Gujarat has also started doing well by giving a lot of attention to the Primary healthcare infrastructure. SCHEME REQUIRES A FEDERAL STRUCTURE A federal structure is required in this scheme to be successful which implies that some of the states already have their own schemes, and some are over and above this. As inbuilt in the

pre-emblem, that 40% expenses will be provided by the state and 60% by the central should be implemented properly along with better participation of the states. States should be directed or requested to see that it should become one scheme where everybody is at par looking at it. The issue of empanelment of hospitals, as far as services are concerned both in government and private hospitals, not only primary, but secondary and tertiary care hospitals, neighboring nursing home, atleast maternity benefits should be properly given, accident victims should properly get management issues. Pattern of diseases is changing, from communicable to noncommunicable diseases. If we take a look at 25 years back lot of death were attributed to malaria, dengue, small pox, jaundice and other water borne communication diseases but much more lifestyle related and non communicable diseases are upcoming in the trend. So this changing in pattern of illnesses also needs to be taken care of as far as the preventive health is concerned. So the point is some kind of a quality control, along with a streamlined reimbursement process, private sector to be taken in confidence if we do all these, this can be a great success. (The author is Past National President, Indian Medical Association, New Delhi and Founder Chairman, Max Pushpanjali, Superspeciality Hospital, Vaishali (Delhi/NCR)

Concern - Essential Diagnostics List

Essential Diagnostics List


oday, many people are unable to get tested for diseases because they cannot access diagnostic services. Many are incorrectly diagnosed. As a result, they do not receive the treatment they need and, in some cases, may actually receive the wrong treatment. For example, an estimated 46% of adults with Type 2 diabetes worldwide are undiagnosed, risking serious health complications and higher health costs. Late diagnosis of infectious diseases such as HIV and tuberculosis increases the risk of spread and makes them more difficult to treat. To address this gap, the World Health Organization (WHO) recently published its first Essential Diagnostics List, a catalogue of the tests needed to diagnose the most common conditions as well as a number of global priority diseases. “An accurate diagnosis is the first step to getting effective treatment,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “No one should suffer or die because of a lack of diagnostic services, or because the right tests were not available.” The list concentrates on in vitro tests - i.e. tests of human specimens like blood and urine. It contains 113


for acute malaria or glucometers to test diabetes. These tests do not require electricity or trained personnel. Other tests are more sophisticated and therefore intended for larger medical facilities. “Our aim is to provide a tool that can be useful to all countries, to test and treat better, but also to use health funds more efficiently by concentrating on the truly essential tests,” says Mariângela Simão, WHO Assistant Director-General for Access to Medicines, Vaccines and Pharmaceuticals. “Our other goal is to signal to countries and developers that the tests in the list must be of good quality, safe and affordable.”

products: 58 tests are listed for detection and diagnosis of a wide range of common conditions, providing an essential package that can form the basis for screening and management of patients. The remaining 55 tests are designed for the detection, diagnosis and monitoring of “priority” diseases such as HIV, tuberculosis, malaria, hepatitis B and C, human papillomavirus and syphilis. Some of the tests are particularly suitable for primary health care facilities, where laboratory services are often poorly resourced and sometimes non-existent; for example, tests that can rapidly diagnose a child

For each category of test, the Essential Diagnostics List specifies the type of test and intended use, format, and if appropriate for primary health care or for health facilities with laboratories. The list also provides links to WHO Guidelines or

publications and, when available, to prequalified products. Similar to the WHO Essential Medicines List, which has been in use for four decades, the Essential Diagnostics List is intended to serve as a reference for countries to update or develop their own list of essential diagnostics. In order to truly benefit patients, national governments will need to ensure appropriate and quality-assured supplies, training of health care workers and safe use. To that end, WHO will provide support to countries as they adapt the list to the local context. The Essential Diagnostics List was developed following an extensive consultation within WHO and externally. The draft list was then considered for review by WHO’s Strategic Advisory Group of Experts on In-Vitro Diagnostics – a group of 19 experts with global representation. WHO will update the Essential Diagnostics List on a regular basis. In the coming months, WHO will issue a call for applications to add categories to the next edition. The list will expand significantly over the next few years, as it incorporates other important areas including antimicrobial resistance, emerging pathogens, neglected tropical diseases and additional noncommunicable diseases.

May 2018 19

Cover Story - Rheumatology


Face thier Challenge with &RQƅGHQFH Dr Prasan Deep Rath, MD, FACR, FNIMS, GCPR(AUS, Diploma MSK USG (UCAM SPAIN), Associate Director and Head of Department Rheumatology, Max Super Specialty Hospital Saket ,Smart ,Panchsheel, New Delhi is a leading Rheumatologist treating adult as well pediatric Rheuatology. Also has attended various workshops and courses related to rheumatology worldwide and keeps updated to newer upcoming in the field of rheumatology…… BY AMRESH K TIWARY


e is treating major diseases like Ankylosing Spondylitis, Gout, Juvenile Arthritis, Osteoarthritis, Juvenile Arthritis, Psoriatic Arthritis, Reactive Arthritis, Rheumatoid Arthritis, Systemic Lupus Erythematosus, Back pains and nerve root diseases, Osteoporosis. He has vast knowledge and experience build up during his long career. He has achieved outstanding professional and clinical skills resulting in highly successful results in his clinical endeavours.

May 2018 21

Cover Story - Rheumatology

Dr P D Rath is well known as one of the top Rheumatologist in India who has helped thousands of patients handle their Rheumatism and face their challenge with confidence. He is also running Rheumatology and Pain Clinic in Sector 37, Noida.. According to Dr P D Rath, Rheumatic disease refers to any type of arthritis, certain autoimmune diseases, musculoskeletal pain disorders, and osteoporosis. There are over 100 conditions that range from common conditions like osteoarthritis, tendonitis, and gout to complex problems such as rheumatoid arthritis, lupus, vasculitis, and ankylosing spondylitis. Arthritis can affect anyone of any age, including children, though women tend to be affected more than men. Pain can vary from mild to disabling, but all symptoms must be evaluated as they can indicate far more serious underlying problems. Many types of rheumatic diseases are not easily identified in the early stages. Rheumatologists are specially trained


to do the detective work necessary to discover the cause of swelling and pain. It is important to determine a correct diagnosis early so that appropriate treatment can begin. Some musculoskeletal disorders respond best to the treatment in the early stages of the disease. Today, state-of-the-art treatments are available for the majority of the rheumatic conditions. Cutting edge technology has given us new drugs which can block the interaction of certain proteins with cells, dramatically reducing inflammation and swelling. An autoimmune disorder: Risk cause of many Some years ago, an autoimmune disorder was not a term that people in India were largely familiar with. But in recent times, more and more people especially women - are being diagnosed with it. “In the past, autoimmune diseases weren’t given adequate attention mainly for two reasons. First, many thought that, unlike in the West, autoimmune diseases were not a big problem in

India. Second, they were ignored because they were considered to be untreatable,” says, Dr P D Rath It takes a while for the disorder to be identified because patients first visit doctors to treat its symptoms like acute joint pains or skin problems. When a 35 year old Deepti Sharma’s skin disease persisted, her doctor recommended that she consult a rheumatologist. Five years ago, the specialist confirmed that she was suffering from psoriatic arthritis, a disease that not only leaves patches of the skin inflamed but also attacks the joints in the body, making them swollen and stiff. Since then, Deepti has been on medication, which she cannot afford to skip even for a day without risking a flare-up in her condition. Who suffered from a chronic autoimmune disease called systemic lupus erythematosus, or simply lupus. The disease takes root when the body’s immune cells, which are supposed to fight invading germs and toxins, turn against one’s own cells. The disorder, for which there is no cure so

far, spares no organs in the body and more often than not affects more than one organ. While no data exist on how many Indians suffer from autoimmune diseases, a global estimate shows that nearly 700 million people - that is, nearly one-tenth of the global population - suffer from some kind of an autoimmune disease, in stages ranging from mild and moderate to severe. Yet so little is known about it that it almost severely incapacitated Rajiv Deshmukh a 32-year-old manager at a Nagpur based firm, had been suffering from a low back pain for a while. When the rest and medicines prescribed by his doctor actually aggravated his condition, he went for further tests which showed that his back pain was because of an autoimmune condition called ankylosing spondylitis. According to P.D. Rath, his condition could have worsened and he could have suffered a fused disc if he continued with the bed rest. Ankylosing spondylitis requires not bed rest but regular physical activity. Among the hundreds of autoimmune diseases that exist, the two most prevalent types among Indians are rheumatoid (in women) and ankylosing (in men). Limited studies showed that close to one per cent of women suffered from rheumatoid and one per cent of men from ankylosing disorders. The third most common type is lupus. Nine out of 10 lupus patients are women. It’s not known what causes the disease. In many cases, it may be genetic. Since women are mostly affected, scientists think hormones too play a role.While no hard data are available to indicate if the problem is increasing, rheumatologists say that more and more patients are turning up at their clinics. Dr P D Rath sees 50-60 patients every day nowadays, compared with 15-20 patients some 10 years ago. He says, “The rise in numbers could be because of increasing awareness. It could also be because of an increase in the number of rheumatology clinics and

Normal & Arthritic Joints better diagnostic tests available today.” Dr Rath, however, thinks there are reasons to believe the incidence is more prevalent today than before. As the incidence of infectious diseases decreases, at least among some sections of the population, there is a greater chance that autoimmune diseases will go up, he believes. He points to a study in the UK which showed an increase in IBD among Asians in the UK as compared with Indians in India.Though there is no cure for the disease, the problems can be stemmed with medicine. For most patients, conventional drugs - which can cost Rs 300 to Rs 4,000 a month, depending on the medicine and the disorder - can work. One out of five patients, however, requires drugs that can cost a lot more, says Dr Rath. This is when the disease aggravates and patients fail to respond to conventional to treat cancer. Internationally, efforts are on to develop better drugs. But beyond medicines, there is need for awareness. Most patients tire more easily than their healthy counterparts and they need brief spells of rest in their work hours. Even immediate family members think that they would be all right as they are taking medicines regularly. This is a wrong assumption.Unlike in the West, no support groups are available for

those who suffer from autoimmune diseases in India. Perhaps, in the times to come, and as awareness about the disease spreads, people will extend a helping hand to others Arthritis: A chronic pain condition If you are experiencing symptoms like aching joints, difficulty in dressing or combing hair, gripping objects, sitting or bending over, joint being warm to the touch, morning stiffness for less than an hour, pain when walking, and stiffness after resting, swelling of joint and loss of motion in a joint, you must consult a Rheumatologist. You might have arthritis because these are its common symptoms. In common parlance, Arthritis is a condition that affects more than 10% of the adult population. There are more than 100 different types of arthritis. The false notion that all forms of arthritis are alike has led people to try treatments that have little effect on their arthritis symptoms. Since each type of arthritis is different, each type calls for a different approach to treatment. That means an accurate diagnosis is crucial for anyone who has arthritis. There are two major types of arthritis — osteoarthritis, which is the “wear and tear” arthritis, and rheumatoid arthritis, an inflammatory type of arthritis that happens when the body’s

May 2018 23

Cover Story - Rheumatology







M.B.B.S from SCB Medical College (MCI Recognized) Utkal University, Orissa, India MD (Internal Medicine) – Best Post Graduate , SCB Medical College (MCI Recognized), Utkal University, Orissa, India Fellowship in Rheumatology, Dept of Rheumatology Nizam’s Institute of Medical Sciences Punjagutta Hyderabad Graduate Certificate in PAEDIATRIC RHEUMATOLOGY University of Western Australia EULAR certified MSK Ultrasonography (Completed EULAR competency assessment) DIPLOMA IN MSK USG UCAM SPAIN

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AWARDS INFORMATION: ‡ Recipient of the prestigious ”DRA YOUNG INVESTIGATOR AWARD 2005“ for best paper at the Annual Rheumatology Conference in Hyderabad in Dec 2005 ‡ Member Organizing Committee of IRACON Khajurao 2007 ‡ CHIKITSA RATAN AWARD for




excellence in Rheumatology given by IMA South Delhi Branch IRACON 2009 JAIPUR(SPEAKERTOPIC REACTIVE ARTHRITIS) IRACON 2010 BHUBANESHWAR(SPEAKER -TOPIC SPONDYLOARTHRITIS) IRACON 2011 CMC VELLORE(CHAIRPERSON) IRACON 2012 (SPEAKER-TOPIC ULTRASOUND GUIDED INTERVENTIONS) IRACON 2014(CHAIRPERSON) IRACON 2015 (SPEAKER- LTBI SCREENING ) IRACON 2016(FACULTY MSK ULTRASOUND WORKSHOP) Organizing Secretary for DRA Annual conference 2012 On the Editorial board of Journal of Medical Science & Research Reviewer for International Journal of Rheumatic Diseases First Rheumatologist in India to have successfully passed the EULAR Competency Assessment and certification in MSK Ultrasonography Faculty at CMC - Vellore and SGPGI – Lucknow for MSK USG workshop

immune system does not work properly. Gout, which is caused by crystals that collect in the joints, is another common type of arthritis. Psoriatic arthritis, lupus, and septic arthritis are other types. Osteoarthritis is also called degenerative joint disease or degenerative arthritis. It is the most common chronic joint condition. Osteoarthritis results from overuse of joints but most commonly it is an aging phenomenon. It can be the consequence of demanding sports where joints may be injured or obesity, which places increased load on weight bearing joints. Osteoarthritis in the hands is frequently inherited and often happens in middleaged women. Osteoarthritis is most common in joints that bear weight — such as the knees, hips, feet, and spine. It often comes on gradually over months or even years. Except for the pain in the affected joint, you usually do not feel sick, and there is no unusual fatigue or tiredness as there is with some other types of arthritis. With osteoarthritis, the cartilage gradually breaks down. Cartilage is a slippery material that covers the ends of bones and serves as the body’s shock absorber. As more damage occurs, the cartilage starts to wear away, or it doesn’t work as well as it once did to cushion the joint. As an example, the extra stress on knees from being overweight can cause damage to knee cartilage. That, in turn, causes the cartilage to wear out faster than normal. As the cartilage becomes worn, cushioning effect of the joint is lost. The result is pain when the joint is moved. Along with the pain, sometimes you may hear a grating sound when the roughened cartilage on the surface of the bones rubs together. Painful spurs or bumps may appear on the end of the bones, especially on the fingers and feet. While not a major symptom of osteoarthritis, inflammation may occur in the joint lining as a response to the breakdown of cartilage. Rheumatoid arthritis is the most common type of inflammatory arthritis.

About 75% of those affected are women. In fact, between 1% and 3% of women are likely to develop rheumatoid arthritis in their lifetime. Rheumatoid arthritis is an autoimmune disease. That means that the immune system attacks parts of the body. The joints are the main areas affected by this malfunction in the immune system. Over time, chronic inflammation can lead to severe joint damage and deformities. About one out of every five people who have rheumatoid arthritis develop lumps on their skin called rheumatoid nodules. These often develop over joint areas that receive pressure, such as over knuckles, elbows, or heels. Symptoms of rheumatoid arthritis can come on gradually or start suddenly. Unlike osteoarthritis, symptoms of rheumatoid arthritis are often more severe, causing pain, fatigue, loss of appetite, stiffness. With rheumatoid arthritis, you may feel pain and stiffness and experience swelling in your hands, wrists, elbows, shoulders, knees, ankles, feet, jaw, and neck. Sometimes the pain occurs in one body part. But more commonly, rheumatoid arthritis pain occurs in combinations of several joints such as in the hands, knees, and feet. With rheumatoid arthritis, the joints tend to be involved in a symmetrical pattern. That is, if the knuckles on the left hand are inflamed, the knuckles on the right hand will also be inflamed. After a period of time, more of your joints may gradually become involved with pain and swelling and may feel warm to the touch. The joint swelling is persistent and interferes with activities. For example, it can interfere with opening a jar, driving, working, and walking — the very activities that allow us to function in our daily lives. Arthritis is a chronic pain condition. Pain relief is the goal of treatment and

disease management strategies. The treatment is aimed at controlling symptoms and slowing progression of the disease. In other words, medication and other arthritis treatments may have analgesic (pain-relieving) effects, anti-inflammatory effects, and diseasemodifying effects. The goal is to feel better, maintain a good quality of life, and slow down and even stop joint destruction. People with certain types of arthritis, such as rheumatoid arthritis may achieve remission with treatment. Researchers are continually developing new and better treatments for arthritis. Take an interest in learning more about what is in the pipeline. You can discuss potential new treatments with your doctor, as you decide together whether a new treatment will be an appropriate option for you or if it would be better to stay the course with your current treatment. Among the most popular supplements used by people with osteoarthritis are glucosamine and chondroitin. In those with moderate to severe knee pain from osteoarthritis, the combination of glucosamine and chondroitin sulfate may be effective in providing are helpful in everyone. Potent anti-inflammatory agents like Visco supplements can be injected to reduce pain and inflammation. The stem cell/Platelet Rich Plasma (PRP) therapyinvolves injecting platelets from the patient’s own blood

to rebuild a damaged tendon or cartilage. It has been successful in not only relieving the pain, but also in jumpstarting the healing process. The patient’s blood is drawn and placed in a centrifuge for 15 minutes to separate out the platelets. The platelet-rich plasma is then injected into the damaged portion of the tendon or cartilage. The surgery procedures are used as a last resort. Like all other surgeries, these surgeries have their own issues like associated risks and high hospitalization and recovery times. However, the success rate for surgeries is limited to 60-70 percent. The symptoms and effects of RA may come and go. A period of high disease activity (increases in inflammation and other symptoms) is called a flare. A flare can last for days or months. Ongoing high levels of inflammation can cause problems throughout the body. Small lumps under the skin over bony areas. Inflammation and scarring can result in shortness of breath in lungs and inflammation of blood vessels that can lead to damage in the nerves, skin and other organs.

May 2018 25

Mens Health - Prostate Cancer

Prostate Cancer Prostate Cancer is the most common noncutaneous cancer in men. Although prostate cancer can be a slow-growing cancer, thousands of men die of the disease each year. In men with high-risk prostate cancer managed with long-term ADT, including radiotherapy as part of initial treatment improved outcomes in a recent randomized study. BY PROF (DR) RAJEEV SOOD


rostrate Cancer is the second most common cause of cancer death in males. Marked variation in rates of prostate cancer among populations in different parts of the world suggests the involvement of genetic factors. Familial predisposition also occurs. Environmental factors, notably diet, are also important. Education about the risks and benefits is important to help men make informed decisions regarding screening and, in those diagnosed with prostate cancer, the various treatment options. Internationally, the incidence of prostate cancer is highest in North America, Australia, and northern and central Europe and the lowest in southeastern and south-central Asia. The prevalence in men of Asian origin is lower than in whites. Mortality rates in African-American men remain more than twice as high as in any other racial group. Hispanic men and African-American men present with more advanced disease.


Most prostate cancers (95%) are adenocarcinomas. Most prostate cancers are multifocal, with synchronous involvement of multiple zones of the prostate, which may be due to clonal and nonclonal tumors. Penetration through the prostatic capsule and along the perineural or vascular spaces occurs relatively late. The mechanism for distant metastasis is poorly understood. The cancer spreads to bone early, often without significant lymphadenopathy. Genetic studies suggest that a strong familial predisposition may be responsible for as many as 5-10% of prostate cancer cases. Studies in different populations have identified several variants in the 8q24 region on chromosome 8 that are associated with increased risk of prostate cancer. Gene alterations on chromosome 1, chromosome 17, and the X chromosome with a family history of prostate cancer. The HPC1 gene

May 2018 27

Mens Health - Prostate Cancer

and the PCAP gene are on chromosome 1, while the human prostate cancer gene is on the X chromosome. BRCA-2 mutations increase the risk for prostate cancer that is more aggressive and develops at a younger age. Epidemiologic studies have suggested a variety of dietary factors , particularly fat intake and obesity. In addition, as indirect evidence of hormonal causes, eunuchs do not develop adenocarcinoma of the prostate. When PSA testing was first developed, the upper limit of normal for PSA was thought to be 4 ng/mL. However, subsequent studies have shown that no PSA level guarantees the absence of prostate cancer. As the PSA level increases, so does the risk of this disease. When the PSA is 1 ng/mL, cancer can be detected in about 8% of men if a biopsy is performed. With a PSA level of 4-10 ng/mL, the likelihood of finding prostate cancer is about 25%; with a level above 10 ng/mL, the likelihood is much higher. A variety of approaches have been proposed for improving the accuracy of PSA for detecting prostate cancer. These include assessment of the velocity of PSA level increase and the percentage of free PSA, PSA velocity, density, isoforms of PSA, prostatic health index, PCA 3 & others. Defining the best candidates for radiologic assessment depends on a clear understanding of the accuracy of the proposed study and on the expected prevalence of the anticipated finding in the population at risk.MRI and CT scanning have equivalent accuracy for N staging. Neither is worthwhile unless the risk of nodal metastases is at least 15% or higher. The presence of PSA levels of greater than 10 ng/mL, high-grade histology *OHDVRQVFRUHÂ&#x2022; RUSK\VLFDOILQGLQJV that suggest stage T3 disease may warrant some imaging studies for staging. The Gleason grading system is used to help determine prognosis in prostate cancer. It is based on histologic evaluation of tumor biopsy specimens. The American Cancer Society (ACS) recommends that men decide whether


to be screened for prostate cancer based on a discussion with their health care provider about the uncertainties, risks, and potential benefits of screening. The recommended age for starting screening is as follows: Â&#x2021; 50 years of age for men at average risk who have at least a 10-year life expectancy Â&#x2021; 40 or 45 years of age for African Americans and men who have had a first-degree relative diagnosed with prostate cancer before age 65 years Â&#x2021; 40 years of age for men with several first-degree relatives who had prostate cancer at an early age Standard treatments for clinically localized prostate cancer include the following: Radical prostatectomy, Radiation therapy,Active surveillance & Androgen deprivation therapy (ADT). Management of Metastatic prostate cancer typically involves the following:

Therapy directed at relief of particular symptoms (eg, palliation of pain) & Attempts to slow further progression of disease. For locally advanced prostate cancer, radiation therapy along with androgen ablation is generally recommended, although radical prostatectomy may be an appropriate alternative to radiation therapy in some cases. A combination of external radiation, brachytherapy, and hormone therapy is also being used, but it is unclear whether it offers advantages over hormone therapy and external radiation alone, and it does increase complications. Metastatic prostate cancer is rarely curable. Management of these cases typically involves therapy directed at relief of particular symptoms (eg, palliation of pain) and attempts to slow further progression of disease. Comparisons between treatments for prostate cancer are complicated by the stage-migration and lead-time bias associated with the adoption of

prostate-specific antigen (PSA)â&#x20AC;&#x201C;based screening and the resultant increase in the detection of small, clinically localized cancers. In addition, treatment selection has become more complicated as options have increased. Surgical treatment currently includes nerve-sparing techniques, laparoscopic procedures, robotically-assisted procedures, and the classic retropubic prostatectomy and perineal prostatectomy. Multiple forms of radiation therapy are currently available. These include the following: Conventional radiation therapy, 3-D conformal radiation therapy, Intensity-modulated radiation therapy, Temporary and permanent brachytherapy, Proton-beam radiation, & Stereotactically guided radiation Hormone therapy for prostate cancer is also known as androgen deprivation therapy (ADT). It may consist of surgical castration (orchiectomy) or medical castration. Agents used for medical castration include luteinizing hormoneâ&#x20AC;&#x201C; releasing hormone (LHRH) analogues or antagonists, ant androgens, and

other androgen suppressants. When imaging studies provide clear evidence of nonâ&#x20AC;&#x201C;organ-confined disease (eg, seminal vesicle or periprostatic involvement), the treatments offered may vary. Typically, some combination of modalities is involved. Survival of men with locally advanced prostate cancer (T3-4N0M0) is improved by combining external radiation with androgen ablation for 6 months. If brachytherapy is used, it is often combined with EBRT and ADT, although studies demonstrating an improved outcome with combined radiation are also lacking. Because of the aggressive nature of these tumors, active surveillance is an option only in highly selected patients with life expectancies of less than 5 years. Reports from the Memorial SloanKettering Cancer Center suggest that ORQJWHUPVXUYLYDOUDWHV LHÂ&#x2022;\ DUH essentially zero in the setting of synchronous nodal involvement at diagnosis. In this group of patients, hormone blockade with or without

EBRT is used. Patients in whom nonâ&#x20AC;&#x201C; organ-confined disease is suspected or confirmed but metastases are absent typically receive radiation therapy with hormone manipulation (LHRH agonist or antagonist treatment). The effect of chemotherapy in this setting has not been well studied. Several phase 3, randomized clinical trials have assessed the value of total androgen blockade in the treatment of patients with nonâ&#x20AC;&#x201C;organ-confined disease. In each of these trials, patients exhibited longer disease-free intervals and PSA control of disease when total androgen suppression is used either during or after radiation therapy treatment. Few data suggest that the improved biochemical control of disease translates to improved survival, however. In men with high-risk prostate cancer managed with long-term ADT, including radiotherapy as part of initial treatment improved outcomes in a recent randomized study. 7KH1&&1JXLGHOLQHDQGWKH (XURSHDQ$VVRFLDWLRQRI8URORJ\ ($8  JXLGHOLQH  SURYLGH recommendations for treating patients with advanced prostate cancer in whom local therapy has failed. Therapeutic options include the following: LHRH agonists, LHRH antagonist ,Complete androgen blockade - LHRH agonist or antagonist with an oral antiandrogen, Nonsteroidal antiandrogen monotherapy, orchiectomy. A balance between disease control and minimization of the toxicity and intolerance of the treatment is difficult to maintain. Androgen blockade, while able to limit disease progression and reduce urinary outlet obstruction, produces a number of adverse effects. Intermittent hormone therapy, which has been studied in men with nonmetastatic disease, does enable some men to minimize their adverse effects without affecting overall survival, even though prostate cancer mortality is slightly higher. An indication for immediate bilateral orchiectomy is spinal cord compression,

May 2018 29

Mens Health - Prostate Cancer

because it avoids the potential flare response that can occur during the first 3 weeks of treatment with an LHRH agonist. Eventually, almost all patients with metastatic disease become resistant to androgen ablation. The general consensus among specialists is that the treatment should continue. The reasoning is that tumor cells are still hormone sensitive and may grow faster if the testosterone is permitted to rise. Therapeutic options for patients with castrateresistant prostate cancer have changed significantly in the past 7 years, beginning with the approval of docetaxel & then cabazitaxel chemotherapy. Use of a bone-protective therapy is an important aspect of managing men with metastatic disease. Two agents are now approved for this indication: zoledronic acid, a bisphosphonate, and denosumab, an antibody that inhibits osteoclastic activity in bone. Both drugs delay the risk of skeletally related events by relieving bone pain, preventing fractures, decreasing the need for

PROF. (DR.) RAJEEV SOOD ‡ Dean, PGI MER & Dr RML Hospital, Delhi ‡ Professor, Consultant and Head, Urology& Renal Transplant, Dr RML Hospital & PGI MER, Delhi ‡ Urologist, President of India and Upper & Lower House of Parliament ‡ President, Urological Society of India (USI) (2016-2017) – Golden Jubilee Year ‡ President, North Zone Chapter of Urological Society of India (NZC USI) (2011-2012) ‡ Hony. Secretary, North Zone Chapter of Urological Society of India (NZC USI) (2008-2010) ‡ Treasurer, North Zone Chapter of Urological Society of India (NZC USI) (2004-2006) ‡ Chairman, Indian School of Urology (ISU- USI) ‡ President, Men’s Health Society of India (MHSI) ‡ President, Delhi Urology Society (DUS) ‡ President, Genito Urinary Cancer Society of India (GUCSI) ‡ Sr. Vice President, Delhi Medical Association (DMA) ‡ Member, Medical Council of India (MCI) ‡ First ‘DUSCON Urology Gold Medal’-NZC-USI (Urological Society of India) ‡ Dr P N Kataria Oration -2016 by North Zone Chapter of Urological Society of India ‡ Urological Society of India (USI) Award for contribution in establishing ‘Central Head-Quarter USI’ ‡ Gold Medal (Research and Organization) – Association of Surgeon of India (ASI) and Urological Society of India- NZ (USINZ) ‡ VishistyaRatan Award – DMA (2016)


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Medachievers Award from IMA – 2014 Medical Teaching Excellence Award – 2014 (International) IEBF Excellence Awards at House of Lords, Westminster, London, UK’ (2014) - European Union Global Award Shield of ExcellenceAward - 2015 Dr BL Kapoor Memorial Oration, Citation & Prize -DMA Presidential Annual Award – 2015 Annual Distinguished Services Awards - DMA (2017, 2016, 2015, 2014, 2013) Conferred with Life Time Achievement Award on the Occasion of 103rd Foundation Day of Delhi Medical Association (DMA) for association and contribution to the field of Medicine. For his exemplary work in the field of Medicine he has been awarded with Double Helical National Health Award 2017 by Indian Medical Association (IMA). Awarded Distinguished Maulanian Award by Maulana Azad Medical College Old Student’s Association (MAMCOS) during the MAMCON MIDCON – 2017, on 9th April 2017 Awarded Best Employee of the Year 2016-2017 by PGI MER, Dr RML Hospital, Govt. of India, Ministry of Health & Family Welfare, New Delhi Chairman, Service Doctor Cell, DMA (Thrice) Chairman, Joint Action Council of Service Doctor Organizations (JACSDO) representing 10 service doctor organizations Editor, Delhi Medical Journal, DMA (2014-2017) Current Member, Central Working Committee, IMA (2014-2017) Convener, Service Doctor Cell, IMA

surgery and radiation to the bones, and lowering the risk of spinal cord compression. Vitamin D and calcium should be taken as supplements with this therapy. In addition, patients should be monitored regularly for hypocalcemia. Despite the availability of new therapies, most men with metastatic prostate cancer will eventually experience progression of disease. For these patients, palliative care is important, and early consultation with hospice may provide for a smoother transition. Possible preventive measures for prostate cancer include lifestyle modification and chemoprevention with 5-alpha-reductase inhibitors (5-ARIs). Use of 5-ARIs, however, has proved

problematic. Lifestyle measures such as weight loss in obese patients and physical activity can be recommended unequivocally because of their multiple benefits. Diets associated with a reduced risk of prostate cancer in epidemiologic studies are composed mainly of vegetables, fruits, grains, and fish. Tomatoes (because of their lycopene content), broccoli, green tea, and soy have all been hypothesized to be beneficial. Increased risk has been shown with high-fat diets, excessive intake of estrogens and phytoestrogens, and the consumption of burned or charred foods. Obesity appears to be the diet-related factor most strongly associated with prostate cancer, so overall energy intake is important.

Because a high-fat diet is linked with a higher incidence of prostate cancer, a low-fat diet may be beneficial for men at high risk of developing prostate cancer .Physical activity appears to lower prostate cancer risk. Improving diet and increasing physical activity to reduce prostate cancer risk will also reduce cardiovascular risk. This is a significant benefit, as cardiovascular disease is the cause of death in many men with prostate cancer. Current prostate cancer treatments, including radical prostatectomy and radiation therapy, result in permanent side effects in many men. The most common ones are erectile dysfunction and urinary incontinence. Prostate cancer is the second most common cause of cancer death in males, after lung cancer. The American Cancer Society estimates that 29,430 men will die from the disease in 2018. However, in contrast with lung cancer, which accounts for 14% of new cases but 26% of cancer deaths in men, prostate cancer accounts for 19% of new cases but only 9% of deaths. Death rates from prostate cancer rose steadily from 1975 to 1991, remained level from 1991 to 1994, and decreased subsequently, but rates appear to have stabilized from 2013 to 2015. Although the decrease has been dismissed as an artifact of lead-time bias, earlier diagnosis of progressive disease and improvements in the treatment of advanced disease are the most likely driving force behind the mortality reduction. (The author is President, MHSI and Dean, PGI MER & Dr Ram Manohar Lohia Hospital, New Delhi)

May 2018 31

Mens Health - Men’s Health

Men’s Health Besides pressure from modern lifestyle, women play a big role in reducing men’s life span. From a young age, males are under tremendous pleasure to do well to meet the high threshold set by society. This could lead to a severe reduction in the male population. BY PROF (DR) RAJEEV SOOD



he idea that men are in decline and may face extinction would have seemed preposterous even a few years ago. Now more and more people are taking it seriously. Men are going extinct and scientists have now put them on the “endangered species” list. SRY gene is at least 130 million years old (Might be as much as 300 million years old) & has reduced its size by one third and lost about 97% genes. It is not over to say that Y chromosome might, in another 100 million years, disappear completely & future male characteristics may only be a special attribute found in women. At the core is male Y chromosome: Genetically and biologically brittle to start with Males are burdened with natural genetic deficits. While the “spare” X chromosomes allow women’s bodies to compensate when faced with damage in ways that men’s cells cannot. In addition, mutations are three to six times more likely in a Y chromosome than an X chromosome. Cells protected by a slightly better variation of a gene on the second X chromosome in women & men don’t have this luxury and don’t get this choice. Some variants of the Y chromosome may make men more prone to heart disease. Physiologically a new born girl is stronger and equivalent to a 4-6 week new born boy As hormones released are different between males and females, & so are the effects of hormones and hormone responses to environment during development and in the adult. Women outliving men by more than a decade in some countries. Cross-regulation of steroid hormone and nutrient-sensing signalling pathways is a promising process in understanding the biological basis for the gender gap. Ageing responds to natural selection on traits that arise as a consequence of sexuality and sexes can respond differently to dietary restriction and altered activity of nutrient-sensing pathways, with females showing a greater plasticity for life extension. Even with boost at conception, male foetuses don’t make it out of the uterus as often as females with death differential estimated to be 111-160 males

May 2018 33

Mens Health - Men’s Health

per hundred females and miscarriages are mostly male. Men had shorter life expectancy and higher mortality rates compared to women. Recent research findings show that women are living several years longer than men: why women are getting extra years over men? Men use health services less frequently than women, Visit Doctor later in the course of condition, has poorer health outcomes. Men Die, on average, 4.9 years earlier than women (Global Average) beside Suicide, and Homicide are four times as often as women. Die accidently about twice as often as women. Men die of acquired immune deficiency syndrome (AIDS) at three times the rate of women. Engage in more high-risk behaviors & work at more dangerous occupations. Certainly things like family conflict, job stress, and the state of the economy can cause any of us, including men, to become irritable, but there is more going on than meets the eye. Men Felt constrained by Social Taboos & embarrassment to discuss health related issues. Besides pressure from modern lifestyle, women play a big role in reducing men’s life span. From a young age, males are under tremendous pleasure to do well to meet the high threshold set by society. We have seen in earlier that men are killing themselves through suicide, through homicide and wars. This could lead to a severe reduction in the male population. Finally, males could continue losing significant roles in the society and might become psychologically extinct, if not physically so. Males are more prone to developmental defects like Reading delays, deafness, autism, ADHD, Blindness, seizure disorders, hyperactivity, clumsiness, stammering, and Tourette’s syndrome, Asperger’s syndrome etc. Men have a 14.9 per cent risk of dying of cancer before the age of 75 - for women the risk is 9.1 per cent (143.1 per 100,000 men die from cancer each year compared to


87.2 per 100,000 women). 410,000 men in developed countries die each year from lung cancer, compared to 188,000 women. Men are having increasing difficulty fathering children and males are actually in decline. Now it looks like something is wrong with baby boys. Fewer boys are being born today than three decades ago, and more of them have undescended testes and effects in their penis. More young men are getting testicular cancer than as recently as the early 1990s, and they are developing it at younger ages. Some trendy magazines have even suggested that male health is an oxymoron. For long , men’s health was synonym with male sexual health as he moves move from the optimistic invulnerability of their 20s to the growing awareness of advancing age around 40.By the time they are in their sixth decade, these unhealthy behavioural patterns are beginning to take their toll: obesity, diabetes, hypertension and erectile dysfunction (ED) are common. Another decade on, cardiovascular and cerebrovascular diseases, as well as cancer, limit the average life-expectancy of men to 5 years on average less than women. During this ‘life journey’, the first symptom that might persuade them to

request a medical check is a urological one, i.e. either urinary frequency, urgency or flow problems, or anxieties about ED. ED may be a marker of silent vascular disease.ED may also indicate the presence of hypogonadism, insulin resistance and metabolic syndrome. Such knowledge may prevent further vascular and endothelial deterioration. Endothelial dysfunction may be manifested initially by ED, which is considered as an earlywarning sign for the development of atherosclerosis and cardiovascular and cerebral disease. Erectile dysfunction and heart disease are related & is a risk factor for CHD that is age-dependent.CV health needs to be considered in men with ED & Interventions may help both ED and CHD. “...erectile function is a predictor of cardiovascular morbidity and mortality. These results remained after adjustment for possible confounders. Thus ED represents an early symptom of endothelial dysfunction and atherosclerosis and patients with ED are at particularly high cardiovascular risk. The identification of these patients with ED offers an opportunity for early risk-adjusted treatment with the goal of further reducing cardiovascular events” . An evaluation, if conducted, often reveals not only underlying

prostate disease but also diabetes and/or hypertension, as well as dyslipidaemia. Women interact more with people, on average, than men .Social connections linked to longer life like more verbal and talk more with friends & Men often discouraged from sharing the deeper stuff women tend to do fairly easily. They tend to open up less to physicians as well . Historically men have been the ‘risk takers’ .Associated with their current attitudes to their health, men have tended to do more dangerous jobs while women are still the gatekeepers. Above that, men disregard symptoms and present later – possibly connected to risk-taking behaviour. Men have a higher calorie burn rate which means they “burn through” their stem cells faster . Frequent injuries or surgeries from a high-risk sport or lifestyle use up a man’s reserves even faster. Larger (size) individuals (within a species) tend on average to have shorter lives. Higher Iron content may translate into aging of the cell. Men seem to invest more resources in getting bigger and stronger early on. Women are geared for endurance in life. They are typically shorter and smaller. Men older than 50 or 60 are no longer useful but women still have a role as

grandmothers, helping to bring up and protect the young. Differential or more intensified pathways leading from depression in men & Suicide with increased mortality in depressed men compared to women. Men have naturally low levels of protective HDL cholesterol & 70 - 89 % sudden cardiac events occur in men. Men die three times more frequently of coronary artery disease than women. Financial stress may increase the risks of incident CVD and all-cause mortality, especially among men. Risks are likely to be greater in men living in single households. Men’s are 60 per cent more likely to die from cancer with 14.9% risk of dying of cancer before the age of 75, for women the risk is 9.1 % .410,000 men in developed countries die each year from lung cancer, compared to 188,000 women. Men were their own worst enemies when it came to generating awareness and funding for male-specific cancers. IT IS WELL SAID THAT : “There Are Millions Of Animal Species, But Men Are The Only Animal Capable Of Destroying Himself ”. Men’s Health Society Of India (MHSI) is dedicated exclusively to Men’s Health, established in 2010 with aim of integrating specialists with interest in Men’s health. MHSI has Conducted over 15 conferences with international Collaborations. VISION OF MHSI: ‡ Identify current issues concerning men’s health in India ‡ Collect data and promote research in the field on Men’s Health ‡ Integrate and encourage medical and paramedical professionals interested in Men’s Health ‡ Promote awareness and train personnel to further the cause of Men ‡ Identify and sensitize health care establishments

Strengthen international collaboration ‡ Formulate guidelines on Men’s Health ‡ Establish a sustainable Health Program for Men. ‘Integrated Men’s Health (IMH) National Program’ ad ‘Male GUD Program’ is actively involved in National Health Program/s, registry of diseases amongst men especially male genito-urinary disease with aim to uplift health of men emphasizing Gender, Genome, Geriatrics, GUDs & Geomedics. For progress to be made, I believe that global health organizations and national governments should, as part of a comprehensive approach to gender and health, address the health and well–being needs of men and boys in all relevant policies (eg, on obesity, cardiovascular disease and cancer) and through the introduction of specific men’s health policies. Educational programs in schools and male–targeted health information can be used to encourage and support boys and men to take better care of their own health. Health practitioners must inform themselves about the psychosocial aspects of men’s health, as well as male–specific clinical issues, and medical training programs should cover gender and other social determinants of health. Workplaces have a key role, in terms of not only reducing exposure to hazards but also providing a setting for health promotion. It is essential for work with men to focus on those groups with the worst health, such as economically disadvantaged men, gay and bisexual men, men who are homeless, migrants or offenders, and men from specific racial and ethnic groups. It is important to recognize that most men want to enjoy good health and well– being and that their strengths and the “positive” aspects of masculinity. ‡

(The author is President, MHSI and Dean, PGI MER & Dr Ram Manohar Lohia Hospital, New Delhi)

May 2018 35

Concern - Oral Health

$ƄHFWLQJ Your Oral Health Many medications can cause bothersome oral side effects, such as dry mouth/xerostomia, altered metallic taste affecting the taste buds, swollen and tender gums leading to periodontitis or gingivitis, mouth ulcers/sores. Learn how to cope…….. BY DR DEEPTI SHARMA


any medications for curing general health conditions and medical diseases can affect your oral health. In addition to prescribed and over-the-counter drugs, vitamins, minerals, and herbal supplements can also cause oral health issues that range from dry mouth to inflamed gums to taste


alterations and bone loss.


Inflammation, mouth sores, or discoloration of the soft tissues in your mouth Enlarged gums Cavities Teeth and gum color changes Bone loss Thrush, or an oral yeast infection

ORAL HEALTH: MEDICATION SIDE EFFECTS Some of the most common side effects from medications that affect oral health include: ‡ Dry mouth/xerostomia ‡ Abnormal bleeding ‡ Altered taste


DRY MOUTH More than 400 medications have the potential to cause dry mouth. Saliva cleans your mouth but if it’s not flowing normally and dry mouth develops, you’ll be more prone to gum infections and tooth decay. The most common types of medications that cause dry mouth include:

May 2018 37

Concern - Oral Health

Antihistamines Decongestants High blood pressure medications (including diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors) ‡ Antidepressants ‡ Sedatives ‡ Pain medications ‡ Parkinson’s disease medications ‡ Antacids ‡ TREATMENT REMEDIES FOR DRY MOUTH: If dry mouth is severe as a result of your medication, you can ask your doctor to switch your medication to something else. If that isn’t recommended, here are some tips to help alleviate dry mouth symptoms: ‡ Ask your doctor or dentist about using an artificial saliva product. ‡ Sip water or any type of sugarless drink throughout the day. ‡ Skip or cut down on caffeinated beverages, alcohol, and tobacco because they contribute to a dry mouth. ‡ Drink water or a sugarless drink while eating to make swallowing and chewing easier. ‡ Suck on sugarless candy or gum to promote saliva production. ‡ Avoid salty and spicy foods, which can cause pain to an already dry mouth. ‡ Use a humidifier at night. ‡ MEDICATIONS THAT CAN CAUSE ABNORMAL BLEEDING Aspirin and anticoagulants, also known as blood thinners, lessen the ability for blood to clot. While they’re helpful in preventing heart attacks and stroke, they can cause your gums to bleed, especially during oral surgery. Tips for abnormal bleeding: Be sure to let your dentist know that you are taking these drugs so that precautions can be taken to minimize bleeding. Also, be sure to use a soft tooth brush and gentle motions when brushing and flossing your teeth to lessen the bleeding. MEDICATIONS THAT CAN ALTER


TASTE Certain drugs can leave a metallic or bitter taste affecting your taste buds in mouth. And some medications may simply change the taste of the things you eat. Such medications include: ‡ Cardiovascular drugs (some beta blockers and calcium channel blockers) ‡ Central nervous system stimulants ‡ Flagyl (metronidazole), an antibiotic drug ‡ Nicotine skin patches for smoking cessation ‡ Some respiratory inhalants ‡ WHAT TO DO ABOUT TASTE CHANGES: If this side effect is intolerable, ask your doctor if your medication can be changed.

MEDICATIONS THAT CAN CAUSE SOFT TISSUE REACTIONS You can develop inflammation, mouth sores/ulcers, or discoloration of the soft tissues in your mouth affecting lips,tongue,floor of the mouth, inner area of cheek when taking the following prescribed drugs: ‡ Blood pressure medications ‡ Immunosuppressive agents ‡ Oral contraceptives ‡ Certain chemotherapy medications ‡ WHAT TO DO ABOUT SOFT TISSUE REACTIONS: Let your dentist know if you are taking any of these medications so he or she can recommend a special dental care regimen to reduce the discomfort.

WHAT TO DO ABOUT OSTEONECROSIS: Be sure to tell your dentist if you are taking a drug for osteoporosis. Your dentist may prescribe an antibiotic or no steroidal anti-inflammatory drug to slow your bone loss. MEDICATIONS THAT CAN CAUSE THRUSH Thrush, also known as an oral yeast infection, is caused by a fungus (Candida) and appears as white lesions on the mouth and tongue. Taking antibiotics, steroids, or chemotherapy can cause thrush. MEDICATIONS THAT CAN CAUSE GUMS TO ENLARGE Enlarged gums, also known as gingival overgrowth, periodontitis, gingivitis, can occur when you take: ‡ Ant seizure medications (such as those for epilepsy) ‡ Immunosuppressant drugs (typically used after organ transplantations) ‡ Calcium channel blockers (for cardiovascular conditions) TIPS ON ENLARGED GUMS: While taking these medications, you’ll need to take extra care when brushing and flossing. Ask your dentist for specific dental care instructions. Medications That Can Increase the Risk of Cavities Many medications, especially those given to children, contain sugar. Sugar is also found in antacid tablets, antifungal agents, cough drops, and many chewable tablets, such as vitamins. Too much sugar can lead to cavities. HOW TO COPE UP WITH SUGAR IN MEDICATIONS: ‡ If possible, take the medication in tablet form. ‡ Take the medications at mealtimes. ‡ Avoid taking the medication right before bed. ‡ Make sure you or your children brush with a fluoride toothpaste or chew sugarless gum after


taking the medication. Seek regular preventive dental care.

MEDICATIONS THAT CAUSE DISCOLORATION OF TEETH AND GUMS Certain drugs can change the color of your teeth or gums. For example, minocycline (which is used to treat acne) can cause an area of black pigmentation on your gums and a black or gray discoloration of your teeth. Chlorhexidine, a mouth rinse used to treat gum disease, can also stain your teeth. HOW TO TAKE CARE OF GUM OR TEETH DISCOLORATION: If a medication has discolored your teeth, ask your dentist about tooth-whitening procedures /bleaching & polishing after scaling that may help. MEDICATIONS THAT CAN CAUSE BONE LOSS Use of corticosteroids, such as prednisone, and antiepileptic drugs, can lead to the loss of bone that supports your teeth. Bisphosphonates, drugs used to treat osteoporosis, can sometimes cause a rare condition called osteonecrosis of the jawbone, which results in destruction of the jawbone. Symptoms include painful, swollen gums or jaw, loose teeth, jaw numbness, a heavy feeling in the jaw, fluid in the gums and jaw, and exposed bone.

WHAT TO DO ABOUT THRUSH: Your dentist may prescribe an antifungal mouthwash or lozenges to treat the infection. If these don’t work, stronger antifungal medications can be prescribed. BEHAVIOUR-ALTERING DRUGS AFFECTING ORAL HEALTH Behaviour-altering drugs, such as psychotropic drugs, can cause lethargy, fatigue, or memory impairment. If you are taking any of these type of medications, take steps to help you remember to brush and floss your teeth regularly — whether that means setting an alarm, leaving yourself a note, or some other reminder method. Never stop taking a psychotropic medication without first consulting your doctor. If a drug is causing bothersome oral health side effects, let your doctor know. In many cases, you may be able to take a different type of medication or make lifestyle changes that minimize the side effects. And, as always, take care of your mouth by regularly brushing and flossing your teeth, getting regular dental checkups, and treating any problems that arise. (The author is Root Canal Specialist, Smile Designer, Implantologist and Owner at Dr, Sharma’s Dental Care,CMPDI Road, Shobhalok Building Jaripatka, Nagpur.)

May 2018 39

Concern - Viral Infections


Attribute of many viral infections Both Airborne and Waterborne diseases are commonly spread by sneezing and coughing, contaminated food, Polluted air, Polluted drinking water making the diseases difďŹ cult to control. Airborne diseases are illnesses spread by tiny pathogens in the air. These can be bacteria, fungi, or viruses, but they are all transmitted through air and water. BY DR V K MONGA


easonality is a longrecognized attribute of many viral infections of humans, but the mechanisms underlying seasonality, particularly for person-toperson communicable diseases, remain poorly understood. Better understanding of drivers of seasonality could provide insights into the relationship between the physical environment and infection risk, which is particularly important in the context of global ecological change in general, and climate change in particular. First we start with air borne disease. Many airborne diseases affect humans. Understanding diseases that spread through the air, and how to prevent and avoid them, is important. There are several treatment options, as well, which people need to know if they catch an airborne disease. Simple measures, such as staying home when sick, reducing contact with people who are sick, and other prevention methods, are also looked.

Airborne diseases are commonly spread by sneezing and coughing, making the diseases difficult to control. Airborne diseases are illnesses spread by tiny pathogens in the air. These can be bacteria, fungi, or viruses, but they are all transmitted through airborne contact. In most cases, an airborne disease is contracted when someone breathes in infected air. And a person also spreads the disease through their breath, particularly by sneezing and coughing, and through phlegm. There are frequent outbreaks of common cold and cough which also need timely attention. Due to intense humidity, skin and scalp infections are common. Often, asthma and arthritis also get aggravated. These illnesses, including colds and flu, are transmitted through the air. Many airborne diseases are common and can have mild or severe symptoms. Prevention tips include good ventilation to swap indoor and outdoor air. Ventilation methods, such

May 2018 41

Concern - Viral Infections

as opening a window or using fans, help to exchange dirty air. Treatment for less serious airborne diseases includes rest and fluids. COMMON AIRBORNE DISEASES Particles that cause airborne diseases are small enough to cling to the air. They hang on dust particles, moisture droplets, or on the breath until they are picked up. They are also acquired by contact with bodily fluids, such as mucus or phlegm. Once the pathogens are inside the body, they multiply until someone has the disease. Common airborne diseases include INFLUENZA: The seasonal â&#x20AC;&#x153;fluâ&#x20AC;? virus spreads easily from person to person. There are many strains of the flu, and it continually changes to adapt to the human immune system. Â&#x2021;7KHFRPPRQFROG7KHFRQGLWLRQ called â&#x20AC;&#x153;a coldâ&#x20AC;? is usually caused by a rhinovirus. There are many rhinoviruses, and the strains change to make it easier to infect humans. Â&#x2021;9DULFHOOD]RVWHU7KLVYLUXVFDXVHV chickenpox and spreads easily among young children. The rash is typically widespread on the body and made up of small red spots that turn into itchy blisters, which scab over in time. Chickenpox is spread for about 48 hours before a rash shows, which is how it infects others so successfully. It is usually spread through the air or by touching the rash. Â&#x2021;0XPSV 7KLV YLUXV DIIHFWV WKH glands just below the ears, causing swelling and, in some cases, loss of KHDULQJ 9DFFLQDWLRQ LV FRQVLGHUHG important to prevent the disease. Â&#x2021;0HDVOHV7KLVLOOQHVVLVFDXVHGE\ contact with a person who has the measles virus, or by inhaling particles IURPWKHLUVQHH]HVRUFRXJK$VZLWK mumps, vaccination is essential for preventing the spread of this disease. Â&#x2021;:KRRSLQJFRXJK SHUWXVVLV 7KLV is a contagious, bacterial illness that causes the airways to swell. The hacking cough that results is persistent and generally treated with antibiotics early on to prevent damage.


infection, but is also caused by an injury or fungal infection. Common symptoms include a persistent headache, fever, and skin rash. The length of an illness caused by a common airborne disease can vary from a few days to weeks, but it is usually dealt with easily. Uncommon airborne diseases may require additional treatment.

UNCOMMON AIRBORNE DISEASES INCLUDE: Â&#x2021;$QWKUD[7KLVLVDEDFWHULDOGLVHDVH that infects the body when a person inhales anthrax spores. It causes nausea and flu symptoms. Inhaled anthrax is difficult to diagnose because it resembles other diseases such as IOX$QWKUD[LVWUHDWHGZLWKDQWLELRWLFV to stop it worsening. Â&#x2021;'LSKWKHULD $ UDUH EDFWHULDO disease, diphtheria damages the respiratory system and attacks the heart, kidneys, and nerves. Its rarity may be due to widespread vaccination. 'LSKWKHULD FDQ EH WUHDWHG ZLWK antibiotics. Â&#x2021;0HQLQJLWLV0HQLQJLWLVVZHOOVWKH membranes around the brain and spinal cord. It is a bacterial or viral

SYMPTOMS 0DQ\ DLUERUQH GLVHDVHV KDYH symptoms similar to the common cold RULQIOXHQ]D7KH\LQFOXGHFRXJKFKLOO muscle and body aches, fatigue, FRQJHVWLRQVQHH]LQJUXQQ\RUVWXII\ nose, sore throat, slight body aches or headaches, sinus pressure, Some people also experience a low fever or general sluggishness with these symptoms. TREATMENT AND OUTLOOK $LUERUQHGLVHDVHVDUHZLSHVSUHDG and easily treatable, in most cases. Complete prevention is difficult, but there are some ways to reduce exposure to the pathogens that cause them. Regular hand-washing and other good sanitary habits will help prevent the spread of airborne diseases. :HDULQJDKRVSLWDOPDVNLQSXEOLFDQG

covering sneezes and coughs with an elbow or tissue, are some of the good habits that are recommended. Regular hand-washing can also help lower the spread of bodily fluids that may contain disease-causing germs. In an unventilated area, pathogens, pollutants, and moisture can build up to unsafe levels. Cleaning the air with a filter is another part of keeping an area as free of pollutants and pathogens as possible. It is important for people to talk to a doctor as soon as they experience symptoms to avoid any complications and to begin treatment. Symptoms of the common cold can be treated, but the illness tends to go away without treatment. The flu runs its course over a few days before someone starts to recover. In the case of chickenpox, the immune system usually deals with the virus on its own. While airborne diseases are common, serious complications are much rarer and normal vaccinations reduce the risk, substantially. WATER BORNE DISEASE According to World


Organization, every year more than 3.4 million people die as a result of water-related diseases, Most of the victims are young children. Common symptoms include high fever, nausea and vomiting which can become life threatening if ignored. Monsoon is around the corner. The onset of monsoon brings relief from the scorching heat of summer but it also makes one susceptible to a host of waterborne diseases. The most common waterborne diseases associated with monsoon are Malaria, Jaundice (Hepatitis) and Gastro-intestinal infections such as Typhoid and Cholera. Apart from many biological reasons why these diseases flourish in monsoon, there are some other reasons you should be careful about: overflowing drains, sewage pipe bursts and mix-ups with municipal drinking water lines which contaminate your drinking water. It is rightly said that prevention is better than cure. If one follows preventive measures then such potentially life threatening waterborne diseases can be kept at bay. 1. Avoid wading in rainwater or

going out during a heavy downpour. If you must, remember to wash the area of contact with soap and water as soon as possible. 2. Personal hygiene can be intensified during this period. One thing is to keep skin clean and dry. Washing hands often throughout the day can spell the difference between prevention and disease. 3. Stagnant water is a breeding ground for mosquitoes. Check your living space for any hotspots of contamination eg. air conditioning trays, flowerpots and vases, and choked drains. If thereâ&#x20AC;&#x2122;s a pond near your premises, then breed Gambusia fish as they reduce the chances of mosquito breeding. Alternately, call the municipal authorities for fumigation. 4. Use effective mosquito repellant while going out and cover windows with mosquito nets. 5. Our digestive system becomes weak during this season so one should avoid eating spicy, fried and junk food as these have heated thermal effect on our bodies and make us feel lethargic and sluggish. 6. Keep food covered. Flies look harmless but are carriers of serious waterborne diseases such as Typhoid and Cholera. 7. Drink warm water and strictly avoid untreated water, or water/ice from unknown sources. 8. Make that important decision about investing in a home water purifier for the safety of your loved ones; during the monsoon and every day. Consider a water treatment option based on your water quality. UV technology is an excellent disinfection technology and is ideal for municipal treated and supplied water. When the water is from underground sources such as bore wells and is high in salts/ TDS making it hard and unpalatable, consider RO technology. (The author is well known Family Physician and Honorary Finance Secretary, IMA Headquarter, New Delhi)

May 2018 43



PANACEA FOR AUTOIMMUNE DISORDERS An optimum synergy of various drug-free modalities of the ‘Science’ of evidence based modern medicine with the ‘art’ of officially recognised traditional systems of health comprising management of life-style, organic diet, mental relaxation, ashtanga yoga, physical exercise, panchakarma, acupuncture and hypnosis has shown to CURE even advanced stages of wide spectrum of autoimmune disorders with a very high success rate.... BY DR R K TULI


he efficacy of this therapy is endorsed by eminent medical personality Dr. Shanti Talwar, former Director Professor & Head of Pediatric Surgery at the prestigious Maulana Azad Medical College, New Delhi who has recorded, “I had been diagnosed to suffer from progressive advanced Interstitial Lungs Disease (ILD). After consulting all the doctors here and abroad (U.K. & U.S.A.), many of whom were my former students, I had decided to retire after I was told nothing much could be done. But, after having this drug-free treatment by Dr. Ravinder K. Tuli at the Holistic Medicine department of Apollo Hospital, I’ve tremendous improvement in my health and I really now believe about the theory of LIFE- FORCE which can naturally CURE many conventionally incurable ailments Autoimmune diseases are known to develop when our immune system, designed to defend our body against foreign entities goes out of tune and misidentifies own healthy cells as foreign and attacks them resulting in inflammation in the concerned tissue, leading to pain, dysfunction, damage,

destruction and deformity, leading to prolonged morbidity with eventual mortality. It can affect one or many different body tissues at the same time. There are 81 types of recognised illnesses attributed to autoimmune disturbance. It affects 2-5% of the population in western world. According to this estimate there may be 30 to 60 million people in the world suffering from various autoimmune diseases. Women are found to be 75% of those affected, and it’s the leading causes of death among women in the United States up to 65 years of age. The common disorders comprise Rheumatoid Arthritis, Ankylosing Spondylitis, SLE/ LE, Psoriasis, Leucoderma, Nephritis, Type-1 Diabetes, Multiple Sclerosis, Interstitial Lung Disease, etc. All autoimmune diseases are chronic in nature, fluctuate between periods of remission and exacerbation, and are usually progressive. The allopathic medicine, at best, offers mere disease modification aimed at symptom relief, and does not assure any curative treatment. The disease progresses with ever increasing morbidity and disability, and deterioration in health.

It’s not only due to the disease, but side-effects as well as cumulative toxicity of drugs contribute to, in certain conditions, a miserable and expensive death. However, an all inclusive management comprising balanced organic diet, adequate fluids intake, mental relaxation, ashtanga yoga, regular physical exercise, physiotherapy, panchakarma detoxification, acupuncture and hypnosis have shown, not only to efficiently alleviate the symptoms without use of any drugs, but enable lasting cure in majority of all autoimmune disorders even in very advanced stages with a very high success rate. This all integrative treatment of sickness is termed Holistic Medicine. Disease, Interstitial Lung Disease (ILD), Severe Scleroderma with intolerable Itching all over the body, Hair Loss, Anxiety, Exhaustion, Fatigue, Irritability & Poor Digestion ?IBS, etc., for the last 10- 15 years. The drugs by top specialists in different hospitals only made my condition worse. But, with the support at this Holistic Clinic, I’ve got a new life. I’m now full of energy, my health is improving, I look

May 2018 45


Dr. [Prof.] R. K. Tuli has pioneered optimum synergy of the evidence based ‘science’ of modern medicine with the ‘art’ of various non-conflicting and complementary drug-free modalities of recognised traditional systems of health. He is a 1964 batch alumnus of the prestigious Armed Forces Medical College and a decorated veteran of 1971 Indo-Pak war. He is the founder of Society For Holistic Advancement of Medicine “SOHAM”. He was invited to establish the first of its kind the Department of Holistic Medicine at the state-of-the-art multispecialty tertiary care corporate Indraprastha Apollo Hospitals, New Delhi in year 1996. Currently he works as the Chief Consultant at world famous “SOHAM” The Clinic for Holistic MediCare & Cure. He has developed a very efficient protocol which has consistently proven miraculous success in permanent CURE for his patients suffering from even advanced complications of different autoimmune diseases in a limited time. The success of this all inclusive model of health is well illustrated by following series of case studies involving multiple and even rare autoimmune conditions.


better and feel confident of a healthy future.” WHAT ARE THE DISEASES CURABLE BY HOLISTIC MEDICINE? The holistic approach to medicare works to restore ‘milieu interior’ of the individual to initiate one’s own inherent natural healing ever ready to initiate the process of recovery. It leads to eliminate the root cause of all diseases and help to restore positive health. It’ll, without any conflict, comple- ment medical procedures to improve outcome in all emergency and acute conditions, and enhance efforts to cure all diseases of the person concurrently. The indications may be summarised as below: PAIN: Headache-Migraine, Arthralgia, Neuralgia, Neuropathy, Fibro-Myalgia, Trauma, Phantom, etc. PALLIATIVE CARE: Incurable or Terminal Sickness, Cancer, etc. PARALYSIS: Trauma, Polio, Stroke, Neuropathy, etc. STRESS / PSYCHOSOMATIC DISORDERS: Anxiety, Depression, Insomnia, Chronic Fatigue, Neurosis, Psychosis, etc. AUTOIMMUNE DISTURBANCES: Arthritis, Spondylitis, Nephritis, Thyroiditis, Type-1 Diabetes, ILD, SLE, Scleroderma, Multiple Sclerosis, etc. ALLERGY – ASTHMA - ECZEMA : FOOD SENSITIVITY DEGENERATIVE DISEASES: Arthralgia, Spondylosis, Disc Disease, Dementia, Parkinson’s or Alzheimer’s

disease, etc. ATHEROSCLEROSIS: Hypertension, CAD, Post-PTCA or CABG, PVD, Gangrene, etc. METABOLIC & HORMONAL DISORDERS: Obesity, Dyslipidemia, Gout, Diabetes & All Complications, Menstrual Disturbances-PCOD, Infertility, Menopause & Andropause, SEXUAL HEALTH: PME, ED, Frigidity, etc. SUBSTANCE ABUSE – ADDICTIONS RESISTANT INFECTIONS: PUO, MDRTB , Viral Infections: HIV / AIDS, Hepatitis. NATURAL CHILD BIRTH / FAILED FERTILITY / REGENERATIVE MEDICINE SPORTS MEDICINE & INJURIES: To enhance & sustain performance, faster recovery and early rehabilitation. CONCLUSION In spite of such unparalleled success, Dr. Tuli remains very humble to state that his individual work in such efficient cure of the vast range of ailments may be just a drop, but it’s an EUREKA, in alleviating the ocean of suffering due to the autoimmune diseases. It’s high time that this phenomenon is noticed by health care authorities at the highest level in the country. To enable its benefits become available to the masses, a beginning needs to be initiated through nationwide trials to establish scientific credibility of this model and develop appropriate protocols for its universal adoption.

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Spotlight - Ear Care

Primary but Vital There is acute need for skilled primary ear care workers for delivering essential ear and hearing care services, considering skewed doctor population ratio in the country BY TEAM DOUBLE HELICAL


n India, the estimated significant auditory impairment reaches up to 6.3% prevalence (moderate to severe hearing loss) out of the total population of 1.25 billion. It is important to note that nearly half of causes of hearing loss are preventable. Lack of awareness regarding importance of ear care is a major challenge in the country. People also have poor knowledge about the resources available for ear care. Myths and Misconceptions worsen the situation. Also, there is inadequate manpower in the country for addressing ear and hearing care issues. In India, the


doctor population ratio is skewed with only 0.7 doctor /1000 population as against WHOâ&#x20AC;&#x2122;s recommended ratio of one doctor per 1000 population. When it comes to ENT specialists, the situation worsens with there being only 6 ENT doctors per one million populations. According to Dr A K Aggarwal, Professor of Excellence and well known ENT Specialist, in view of immense disease burden and scarce manpower, the existing ENT manpower is already overburdened. National Programme for Control of Blindness has a provision of Ophthalmic Assistant at the community health

care level who is responsible for screening patients with eye ailments, test vision and prescribe glasses, assist in conducting eye care camps and organizing community education. However, there is no provision for such personnel under National Programme for Prevention & Control of Deafness. Therefore, the role of skill-based primary ear-care worker becomes vital for delivering essential ear and hearing care services. A skilled primary ear care worker can perform certain clinical and administrative duties and thereby play a significant role right from early identification of people with hearing loss to awareness

generation, screening of patients to making adequate referrals. Dr Suneela Garg, HOD, Department of Community Medicine, Maulana Azad Medical College, New Delhi, said, “First the primary ear care worker can obtain and record the history of patient having ear morbidities including history of patient’s past ear diseases, family history of diseases affecting ear, social history including occupation and details of exposure to industrial or occupational hazards and patient’s current and past general health and trauma, including any surgical procedures.” Dr A K Aggarwal, said, “The primary ear care worker would carry out basic examination to screen and recognize patients with common ear diseases (wax, simple foreign body removal, discharging ear etc.) and counsel & refer patients requiring further medical/surgical care. He/she would also be responsible for promotion of ear and hearing health by creating awareness through community-based actions including promoting and teaching healthy ear and hearing habits, creating awareness of avoidable causes of hearing loss and ear disease, identifying the need for and means of early detection of hearing loss, recognizing signs of hearing loss in infants, children and adults, facilitate in providing and maintaining hearing aids, cochlear implants and other listening and signaling devices and offering support services for hearing aids users.” The primary ear care worker would also be responsible for carrying out hearing assessment and counseling of patients which could be done through an audiometer (a machine for testing hearing) or using voice tests. Dr Suneela, Garg, said, “The worker’s responsibility would encompass carrying out public health actions through promotion and implementation of immunization, maternal and perinatal health care and child health care. He/she would also undertake advocacy for appropriate ear and hearing services, including

ontological and audiological services at health centres and hospitals as close to the community as possible. He would also facilitate in training all teachers in the community in aspects of primary ear and hearing care, the impact of hearing loss and provision of an effective learning environment for children with hearing loss.” Regarding the rehabilitative aspect, he/she would be responsible for informing children and adults with hearing loss, family members and the general public of available options for the inclusion and integration of people with hearing loss in the community. He/she would advocate for promoting the use of hearing aids and provide support services explaining the benefits and limitations of these devices. The worker would facilitate in sensitizing families of children with hearing loss understand the local policies relating to the education of such children. He/she would facilitate to educate teachers about the special needs of students with hearing loss, including deaf students. He/she would try and explore educational opportunities for children and students with hearing loss at preprimary, primary, secondary and higher levels of education and availability of non-formal and vocational training opportunities for people with hearing loss. He/she would take initiative for developing

and encouraging training for speech and language development for persons with hearing loss. He/she would try and engage the local deaf community in the implementation of these activities. A teleotology model conducted in certain parts of the country has demonstrated that trained community health workers who are equipped with an ear screening handheld device can be deployed in low income urban communities and rural areas. The customized application enables the health workers to gather patient’s details, complaints and other details including an image of the tympanic membrane which could be transferred to an ENT surgeon. Patients with positive conditions are counseled for further treatment. The skilled primary ear care workers could also be trained to implement the teleotology model. Additionally, his administrative roles and responsibilities would include scheduling appointments, maintaining medical records, recording vital signs and medical histories and preparing patients for further examination and surgeries. To conclude, creation of a cadre of skilled primary ear care workers would go a long way in not only reducing the burden on the existing scare ENT manpower but also address the problem of avoidable hearing loss in the country.

May 2018 49

Therapy - Pain Relief


Ice therapy for pain and injury Ice decreases the blood flow to an injured area, reducing the pain and inflammation……. BY ABHIGYAN/ABHINAV

May 2018 51

Therapy - Pain Relief


eat and cold are the two most common types of non-invasive and nonaddictive therapy for muscles and joint pain but it depends upon the pain whether it is acute or chronic. Inflammation has four signs: swelling, redness, pain, and heat. When we apply ice to injured part ice initially decreases the blood flow to the injury, then increases blood flow with decrease in inflammation & swelling, to that area. By this process it blocks the inflammatory process. According to Dr Amit Saraswat, an expert in physiotherapy and founder in PhysioVeda India, when we apply ice to

̸͜Î&#x201A;Î Î&#x201A;ĎŹÍąĐ&#x160;Đ&#x160;͞ϹÍşÎ&#x201A;ĎŹĐ&#x160;͹;ͽ͜͝Ď&#x153;͡;Ϗ͞ϹĎŹÎ&#x201A;ύͽ͝Πϭύ͡ÍżÎ&#x201A;͝ύϏĎŹÎ&#x201A;ϯ͡͞ ͝Πʹ͡Ϗϯ͡͡ΠϏͺ͡ύͽ͝Π͹Π͜ÍşÎ&#x201A;ĎŹĐ&#x160;͹;ͽÍśÎ&#x201A;Î Î&#x201A;ĎŹͽ͡͡Đ&#x160;ÍşÎ&#x201A;ĎŹĐ&#x160;͹;ͽ ͸Î&#x201A;Ď&#x153;ÍżÎ&#x201A;Ď&#x153;͡Ϗͺ͹ΠͿ͝ΠϭϏ͡ύÍśÎ&#x201A;Î Î&#x201A;ĎŹϭύ͡ͺ͡͹Ϗ͝͸ύϯ͡͞͞͝Π͚͝ύ Ϗͺ͡Ď&#x153;͡͝Ϗ;͹ΠͿ͹ͽ͡͝Π͸͞͹ͿͿ͹Ϗ͝Î&#x201A;Î ĎŻÎ&#x201A;Ď&#x153;ύ̚͡ÍśĎ&#x153;͹Ϳ͝ϏĎŤÍąĎ&#x153;͹ύϯ͹Ϗ ͹Π͡ϰĐ&#x160;͡Ď&#x153;ĎŹ͝ΠĐ&#x160;ͺϹύ͝Î&#x201A;Ϗͺ͡Ď&#x153;ÍąĐ&#x160;Ďą͹Π͜͸Î&#x201A;ϭΠ͜͡Ď&#x153;͝ΠĐ&#x160;ͺϹύ͝Î&#x201A;ώ͜͡͹ injured area vasoconstriction occurs first to reduce heat & then approx 5 to 10 min, the blood vessels will vasodilate. Ice can be applied in towel as a pack or slightly wet towel dipped in ice and water mixture or containing crushed ice for not more than 5-10 minutes at a time. Any cold treatment should be used for 24-72 hrs after an injury. Cry therapy is useful after replacement operation like TKR & THR to reduce inflammation. When there is an injury or discomfort a good rule to follow for first aid is the â&#x20AC;&#x2DC;PRICEâ&#x20AC;&#x2122;. Here P means Protect the injury part, R for Rest the injury, I for Ice the injury, C for Compress injury and E for Elevate the injury above heart level. Ice pack will also serve as a local anesthetic, numbing the pain, reduce muscular spasm, swelling & heat. Donâ&#x20AC;&#x2122;t apply ice directly to the skin. Role of heat is to open up blood


vessels, which increase blood flow i.e. vasodilatation & supplies oxygen & nutrients to reduce pain in joints, relaxed sore muscles, ligament and tendon. There are two types of heat application: dry heat & wet heat or moist heat. Mostly we use moist heat i.e. heat that has moisture content, it may be applied as hot packs, towel soaked in hot water. Moist heat improves the flexibility of muscle and increases ROM because it penetrates better & goes deeper in the skin. Dry heat does not penetrate through skin so you can get burnt by that. Apply heat if you have joint stiffness, chronic pain. â&#x20AC;&#x153;Do not apply hot pack directly to skin. Use moist towel in between the skin and hot pack. Do not keep hot pack for more than 10 minutes. Do not use heat if swelling is there, it can make inflammation worse. Do not use heat in diabetic neuropathy, circulatory or sensory problem. If possible ask your doctor or physical therapist which heat source would be best for you.

â&#x20AC;&#x153;It is a beneficial immersion of a part of a limb in warm water and immediate immersion of limb in cold water. Role of contrast bath, is that warm water causes vasodilatation (Widening of blood vessels) in the limb or body followed by the cold water which causes vasoconstriction (narrowing of blood vessel). It increases local blood circulation,â&#x20AC;? Dr. Amit Saraswat, said. For contrast bath we take two buckets. One is filled with warm water other is filled with ice water. Immerse the area in warm water for 3 min and then switch immediately to the cold water & soak for one minute. Repeat these 5 times. Always start with warm water and end with ice water. Donâ&#x20AC;&#x2122;t use if you high blood pressure, any circulatory problem, any area of broken or sore skin, reduction sensation in the affected area. Contrast bath are contraindication during the acute inflammation stage, acute inflammation begins at the time of injury and lasts for approximately 72 hours.

Odd-Even scheme - Pollution

The burden of pollution To curb increasing level of pollutionthe Odd-Even Scheme launched by Delhi Government last year in Delhi did not respond well. A holistic approach involving energy, industry and building sectors, together with the transport sector, can only reduce the ambient air pollutionâ&#x20AC;Ś.. BY ABHIGYAN


espite the odd-even campaign by the Delhi Government, the air quality of the capital city is still not improving. Almost all of the patients are still claiming to be suffering from respiratory problems or chest congestion. As per report many families with elderly members ailing from respiratory illnesses have installed oxygen cylinders at home for emergency


purposes because they canâ&#x20AC;&#x2122;t keep running to the hospital for every frequent breathing crisis that arises. The medical practitioners feel that the problem needs the attention of not just a single man, but of an entire system, whose combined effort must be to make whole capital cityâ&#x20AC;&#x2122;s air breathable again. It is important to know how will reducing the number of cars in circulation in a large city reduce ambient air pollution and have a benefit

on health and well-being. Although newer motor vehicles have more efficient engines and are using cleaner fuels, the absolute number of vehicles is still increasing in many cities worldwide, and consequently so are levels of ambient air pollution in many urban regions. For example, in parts of Europe where stricter standards and regulations for vehicles have been enforced, ambient air pollution levels are stable or continue to rise. Per

kilometer of travel, diesel vehicles also typically emit more particulate emissions than gasoline, gas-powered, or electric vehicles of comparable size and age so that increased reliance on diesel vehicles in the vehicle fleet may be a contributing factor to healthharmful air pollution in many cities. Diesel emissions have also been defined by WHO’s International Agency for Research on Cancer as a carcinogen. Building cities around rapid public transport systems, complemented by dedicated walking and cycling networks, is more fuel efficient, in terms of transport. This also tends to facilitate a “virtuous cycle” of more compact cities, more energy efficient housing, fewer private car trips, and thus fewer air pollution emissions overall. This helps minimize the health burden from ambient air pollution – as well as encouraging healthful active transport on safe walking and cycling networks, where people are at less risk of traffic injury. However, it should be kept in mind that transport may be directly responsible for anywhere from 15 to 70% of urban ambient air pollution in urban areas, depending on the city, but a holistic approach involving energy, industry and building sectors, together with the transport sector, is required to reduce the disease burden from ambient air pollution. Around 50 percent of people, almost all in developing countries, rely on coal and biomass in the form of wood, dung and crop residues for domestic energy. These materials are typically burnt in simple stoves with very incomplete combustion. Consequently, women and young children are exposed to high levels of indoor air pollution every day. There is consistent evidence that indoor air pollution increases the risk of chronic obstructive pulmonary disease and of acute respiratory infections in childhood, the most important cause of death among children under 5 years of age in developing countries. Evidence also exists of associations with low birth weight, increased infant and prenatal mortality, pulmonary

Around 50 percent of people, almost all in developing countries, rely on coal and biomass in the form of wood, dung and crop residues for domestic energy tuberculosis, nasopharyngeal and laryngeal cancer, cataract, and, specifically in respect of the use of coal, with lung cancer. Conflicting evidence exists with regard to asthma. Exposure to air pollutants is largely beyond the control of individuals and requires action by public authorities at the national, regional and even international levels. The health sector can play a central role in leading a multi-sectoral approach to the prevention of exposure to air pollution. It can engage and support other relevant sectors (transport, housing, energy production and industry) in the development and implementation of long-term policies to reduce the risks of air pollution to health. Mortality from ischaemic heart disease and stroke are also affected by risk factors such as high blood pressure, unhealthy diet, lack of physical activity, smoking, and household air pollution. Some other risks for childhood pneumonia include suboptimal breastfeeding, underweight, second-hand smoke, and household air pollution. For lung cancer, and chronic

obstructive pulmonary disease, active smoking and second-hand tobacco smoke are also main risk factors. These risk factors may contribute to deaths that are caused by ambient air pollution. Reducing the public health impacts of ambient air pollution requires addressing the main sources of the air pollution, including inefficient fossil fuel combustion from motor vehicle transport, power generation and improving energy efficiency in homes, buildings and manufacturing. Reducing the health effects from ambient air pollution requires action by public authorities at the national, regional and even international levels. Individuals can contribute to improving air quality by choosing cleaner options for transport or energy production. The public health sector can play a leading role in instigating a multispectral approach to prevention of exposure to ambient air pollution by engaging with and supporting the work of other sectors (i.e. transport, housing, energy, industry) to develop and implement long-term policies and programs aimed to reduce air pollution and improve health. Indoor air pollution is a major global public health threat requiring greatly increased efforts in the areas of research and policymaking. Research on its health effects should be strengthened, particularly in relation to tuberculosis and acute lower respiratory infections.

May 2018 55

Spotlight - Air Pollution


orldwide 3.7 million premature deaths were attributable to ambient air pollution in 2012. About 88% of these deaths occurred in low and middle income countries. The regional breakdown (low and middle income countries) is: The Western Pacific: 1,670,000 deaths, South East Asians regions: 936,000 deaths, Eastern Mediterranean region: 236,000 deaths, Europe 203,000 deaths, Africa: 1,


76,000 deaths, Americas: 58,000 deaths. The regional breakdown for high income countries: Europe 279, 000 deaths, Americas 94,000 deaths, Western Pacific: 68,000 deaths, Eastern Mediterranean countries: 14 000 deaths. The WHO maintains a worldwide, public database on urban outdoor air pollution in its Global Health Observatory. The database contains measured outdoor air pollution levels of PM2.5 and PM10 from 1100 cities in

92 countries for the years 2003-2010. These are used for estimating mean annual exposures of the urban population to fine particulate matter. In 2013, the WHO began collaborating with major institutions and agencies worldwide in the development of a global air pollution platform that includes data on air pollution concentrations based on satellite monitoring, chemical transport models and ground measurements, inventories of pollution emissions from key


sources, and models of air pollution drift – permitting estimates of air pollution exposures even in areas where there are no ground level monitoring stations. WHO’s main function is to identify and monitor those air pollutants with the greatest impact on people’s health. This helps the WHO Member States to focus their actions on the most effective way to prevent, or reduce health risks. WHO’s task is to review and analyze the accumulated scientific evidence, and

use expert advice to draw conclusions on how much different air pollutants affect health as well as identify effective measures to reduce the air pollution burden. Governments can identify their main sources of ambient air pollution, and implement policies known to improve air quality, such as: promotion of public transport, walking, and cycling (rather than transport relying on private motor vehicles); promotion of power plants that use clean and renewable fuels (e.g.

not coal), and improvements in the energy efficiency of homes, commercial buildings and manufacturing. Essential accompanying steps include increasing awareness about the high disease burden from ambient air pollution and its main sources, as well as highlighting the importance of taking action now to implement countryspecific interventions. In addition, the use of effective monitoring to evaluate and communicate the impact of interventions is also an important tool

May 2018 57

Spotlight - Air Pollution

in raising awareness. It can help drive policy action that brings benefits for health, climate and the environment. WHO estimates that 12.7% of deaths could be averted by improving air quality worldwide. Lower levels of air pollution will reduce the burden of respiratory and cardiovascular diseaserelated illnesses, health-care costs, and lost worker productivity due to illness, as well as increasing life expectancy among local populations. In addition, actions that reduce ambient air pollution will also cut emissions of short-lived climate pollutants, particularly black carbon which is a major component of soot emissions from diesel vehicles, and other sources, as well as greenhouse gases (CO2) contributing to longer-term climate change impacts. Climate change produces a number of adverse effects on health. This includes those from drought and extreme weather events (e.g. windstorms, floods), such as waterborne and food-borne diseases. It also increases the prevalence of vectorborne diseases like dengue or malaria. Here it is matter of debate over what challenges do countries face, and what


obstacles are preventing assistance in improving ambient air quality? Enough knowledge exists internationally about the health effects of ambient air pollution but what often can limit policy development for the improvement of air quality, is the lack of access to information on levels of air pollutants and their main sources of pollutants. There is also often a lack of awareness about the health burden of ambient air pollution. This can be due to little awareness of the international evidence from both developed and developing countries linking ambient air pollution exposure and health, or due to a gap in information from air quality monitoring, or even due to an under-appreciation of the potential solutions and measures that can be taken to improve air quality. Improving ambient air pollution is an inter-sectoral challenge. Improving air quality should be an important consideration in policy planning across different economic sectors (e.g. transport, energy, industry, urban development) to ensure the greatest benefits for health. In addition, there is significant inequality in the exposure to air pollution and the related health risk:

air pollution combines with other aspects of the social and physical environment, creating disproportional disease burden in populations with limited incomes and with minimal local resources to take action. â&#x20AC;&#x153; Exposure estimates for ambient air pollution are based on a global model using all available surface monitoring data, atmospheric transport models and satellite observations. One of the advantages of this approach is an ability to estimate risks in countries with no, or little, locally collected data. Exposure distributions produced by such models for larger regions agree well with the distributions from surface observations and are more reliable than estimates for smaller ones. All studies are observational and very few have measured exposure directly. As a result, risk estimates are poorly quantified and may be biased. Exposure to indoor air pollution may be responsible for nearly 2 million excess deaths in developing countries and for some four percent of the global burden of disease. (The author is Medical Practitioner, New Delhi)

Double Helical may 2018  

Challenge with Confidence Dr Prasan Deep Rath, MD, FACR, FNIMS, GCPR(AUS, Diploma MSK USG (UCAM SPAIN), Associate Director and Head of Depar...

Double Helical may 2018  

Challenge with Confidence Dr Prasan Deep Rath, MD, FACR, FNIMS, GCPR(AUS, Diploma MSK USG (UCAM SPAIN), Associate Director and Head of Depar...