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Foreword

Greetingsandwarmregards,

The conglomeration of all the special senses in the human body translates into speech,behaviour and premeditated action. Likewise the nal enunciation of the belly, mind, heart and vision of a hospital is its own personal newsletter. It gives me great pleasure and pride to write the inaugural foreword of a hospital with which I have been aliated for almost 4 decades and now head the department of medicine. This transformation over the years has seen Bhatia blossom into a healthcare facility to reckon with The new oors, enhanced diagnostic facilities, the retinue of talented and renowned consultants and staff withaccent on concern with care, has catapulted our hospitalintothecompetitivearenawhereittherstchoiceofmany.Thelatestfeatherin the cap is NABH recognition which signies the arrival of methodical quality and supervised eciency. Let’s open the dialogue- ‘of’ the staff(allof them), ‘for’ staffand ‘by’ the staff through this newsletter whichwill henceforth be,an interactive mode of communication I invite articles, case reports, achievements and anything that any of you ( medical or non-medical) may like to script and share, which is relevant to Bhatia . Through this newsletter we will become more cohesive, enlightened and will endeavour totaketheinstitutetogreaterheights.Cheerstotheinceptionofournewsletter!

Warmregards,

Dr. Hemant P. Thacker Director & Head of Department Medicine

About ADEM

Acute disseminated encephalomyelitis (ADEM) is a rapidly progressive, polyfocal, immune mediated, inammatory, monophasic, demylelinating affecting white matter of brain and spinal cord There are no set of diagnostic criteria for diagnosing ADEM. Children of less than 10 yearsof age accountfor 80% of the cases. Adults between age of 18-82 years can be affected. incidence of male: female is 1.3:1. Most commonly associated organisms include cytomegalovirus, Epstein-Barr virus, herpes simplex virus, human herpes-virus-6, inuenza virus, hepatitis A, human immunodeciency

v i r u s , a n d m y c o p l a s m a pneumonia; though, in the

m a j o r i t y o f c a s e s , t h e causative pathogen is not identied associated bacterial infections include Leptospira, beta-hemolytic streptococci,

and Borrelia burgdorferi Before the immunization programs, ADEM was most commonly associated with measles and an increased incidence associated with rubeola, rubella, mumps, varicella, and smallpox. Today, ADEM is more commonly associated with viral infections of the gastrointestinal or respiratory tracts. Pathophysiology is unclear, however 2 primary theories have been proposed 1: Molecular mimicry theory 2: Inammatory response. There are 2 variants of ADEM. 1. Acute Hemorrhagic Leukoencephalitis (AHL) 2.Acute Disseminated Encephalomyelitis with peripheral nervous system involvement. Diagnosis can be made with symptoms of encephalopathy and polyfocal neurological decits including paraparesis and tetraparesis. MRI is the imaging modality of choice. IntravenousGlucocorticoidsstayastherstlineoftreatment.Nonrespondersaregiven IVIG as a second line treatment. Plasma exchange or cyclophosphamide is used in refractorycases.Prognosisofpatientdependswidelyonage,clinicalandMRIndingsof the patient. However 60%- 80% affected patients recover completely within 1-2 months of time. 4% - 30% of cases have residual focal neurologic decits . mortality is less than 2%.

Case Report

Acute disseminated encephalo-

myelitis (ADEM) is a rapidly progressive , polyfocal ,immune

m e d i a t e d , i n a m m a t o r y ,

monophasic , demylelinating affecting white matter of brain and spinal cord. There are no set of diagnostic criteria for diagnosing ADEM. Children of less than 10 years ofageaccountfor80%ofthecases. Adults between age of 18-82 years can be affected incidence of

m a l e : fe m a l e i s 1 . 3 : 1 . M o s t commonly associated organisms include cytomegalovirus, EpsteinBarr virus, herpes simplex virus, human herpes-virus-6, inuenza virus, hepatitis A, human immunodeciency virus, and mycoplasma pneumonia; though, in the majority of cases, the causative pathogen is not identied. associated bacterial infections include Leptospira, betahemolytic streptococci, and Borrelia burgdorferi. Before the immunization programs, ADEM was most commonly associated with measlesandanincreasedincidence associated with rubeola, rubella, mumps, varicella, and smallpox. Today, ADEM is more commonly

associated with viral infections of the gastrointestinal or respiratory tracts. Pathophysiology is unclear, however 2 primary theories have been proposed. 1:Molecular mimicry theory 2: Inammatory response. There are 2 variants of ADEM. 1.Acute Hemorrha

c Leukoencephalitis (AHL) 2 Acute Disseminated Encephalomyelitis with peripheral nervous system involvement Diagnosis can be m a d e w i t h s y m p t o m s o f encephalopathy and polyfocal neurological decits including paraparesis and tetraparesis.MRI is the imaging modality of choice.

Intravenous Glucocorticoids stay as the rst line of treatment. Non responders are given IVIG as a second line treatment Plasma exchange or cyclophosphamide is used in refractory cases. Prognosis of patient depends widely on age, clinical and MRI ndings of the patient. However 60%- 80% a f fe c t e d p a t i e n t s r e c o v e r completely within 1-2 months of time. 4% - 30% of cases have residual focal neurologic decits . mortalityislessthan2%.

What is Metabolic Health?

Metabolic health refers to the optimal functioning of metabolic processes within the body, including how eciently it regulates energy production, storage, and expenditure. When someone is metabolically healthy, their body effectively manages glucose levels, lipid metabolism, insulin sensitivity, and other metabolic parameters.

KEY INDICATORS OF METABOLIC HEALTH INCLUDE:

1

Normal blood glucose levels:

Maintaining stable blood sugar levels within a healthy range is crucial for metabolic health. High blood sugar levels can indicate insulin resistance or diabetes.

3

Healthy weight and waist circumference:

Maintaining a healthy body weight, particularly avoiding excess visceral fat around the abdomen, is essential for metabolic health.

Obesity, especially central obesity, is strongly associated with metabolic dysfunction

2

Healthy lipid prole:

This includes appropriate levels of cholesterol (including LDL, HDL, and total cholesterol) and triglycerides. Dyslipidemia, or abnormal lipid levels, can contribute to cardiovascular disease risk.

4

Normal blood pressure:

Keeping blood pressure within a healthy range helps to reduce the risk of cardiovascular disease and indicates good metabolic health.

5

Normal insulin sensitivity:

Insulin is a hormone that regulates glucose uptake by cells. Insulin resistance, where cells become less responsive to insulin, is a key feature of metabolic dysfunction and can lead to elevated blood sugar levels.

Why should we be concerned about our Metabolic Health?

We should be concerned about our metabolic health because it plays a crucial role in our overall well-beingandlongevity Hereareseveralreasonswhymetabolichealthisimportant:

Chronic disease prevention: Poor metabolic health is closely linked to an increased risk of developing chronic diseases such as type 2 diabetes, cardiovascular disease, andmetabolicsyndrome

Quality of life: Metabolic health inuences various aspects of our daily life, including energy levels, mood stability, and cognitive function. By optimizing our metabolic health, we can enhance our overall quality of life and enjoy greater vitality and wellbeing.

Long-term health outcomes: Good metabolic health is associated with a lower risk of premature mortality and improved long-term health outcomes. By prioritizing metabolic health,wecanpotentiallyextendourlifespanandreducetheburdenofchronicdiseases asweage

Physical performance: Metabolic health directly impacts our ability to engage in physical activities and maintain a healthy weight. By optimizing metabolic function, we can enhance our endurance, strength, and overall physical performance, enabling ustoleadanactiveandfulllinglifestyle

Mental health: Research suggests that there is a bidirectional relationship between metabolic health and mental well-being. Poor metabolic health, characterized by conditions such as insulin resistance and obesity, has been linked to an increased risk ofdepression,anxiety,andcognitivedecline.

How can we achieve good Metabolic Health?

Achieving and maintaining good metabolic health involves adopting healthy lifestyle habits and making positive changes in diet, physical activity, sleep, stress management, and other areas. Here are some key strategies to promote metabolic health:

Balanced diet: Focus on consuming a balanced diet rich in whole, unprocessed foods such as fruits, vegetables, whole grains, lean proteins, and healthy fats Limit intake of rened carbohydrates, sugars,andunhealthyfats.

Maintain a healthy weight: Achieve and maintain a healthy body weight through a combination of balanced diet and regular physicalactivity.

Regularphysicalactivity:Engageinregularexercisetoimproveinsulinsensitivity, promote weight management, and enhance cardiovascular health. Aim for at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorousintensity activity per week, along with muscle-strengthening activities on two or moredaysperweek.

Stay hydrated: Drink plenty of water throughout the day to support metabolic processesandmaintainoptimalhydrationlevels.

Get adequate sleep: Prioritize good sleep hygiene and aim for 7-9 hours of quality sleep per night. Poor sleep quality and inadequate sleep duration have been linked tometabolicdisturbances,includinginsulinresistanceandweightgain

Manage stress: Practice stress-reduction techniques such as mindfulness meditation, deep breathing exercises, yoga, or spending time in nature Chronic stress can disrupt metabolic function and contribute to the development of metabolicdisorders.

Limit sedentary behavior: Minimize prolonged periods of sitting or inactivity by incorporatingregularmovementbreaksthroughouttheday.

Monitormetabolicparameters:Regularlymonitorkeymetabolicparameterssuch as blood pressure, blood glucose levels, lipid prole, and waist circumference Consult with healthcare professionals for routine health check-ups and screeningstoidentifyanymetabolicabnormalitiesearlyon.

Avoid smoking: Quit smoking and avoid exposure to secondhand smoke, as smokingisassociatedwithmetabolicdysfunctionandanincreasedriskofchronic diseases such as cardiovascular disease and type 2 diabetes. professionals for routine health check-ups and screenings to identify any metabolic abnormalities earlyon

image required

Dr Abhishekh Subhash Consultant Internal Medicine

Achievements

th NABH 5 Accreditation

Our organisation started working towards thisgoalsincetheyear2023.Weappliedon st June 1 2023 and the nal assessment was th th st conducted on 19 , 20 and 21 Jan 2024. NABHgrantedustheaccreditationonApril th st 4 2024 and it is valid from March 21 2024 th toMarch20 2028.

Nursing excellence certicate

This certicate was granted to us on April th th 25 2023 and is valid until April 24 2025.This initiative was undertaken to reshape nursing professionals in improving clinical outcomes and patient safety

Laqshya-Manyata certication –FOGSI initiative

We were granted with Laqshya-Manyata certicate on 19th April for compliance withFOGSIqualitystandardsensuringsafe delivery

th10 Edition AHPI Award for Excellence in Infection control activity

Association of healthcare providers(AHPI) recognizes and celebrates excellence achieved by healthcare organisations and various elds every year, this year our hospital was recognized and awarded with excellenceininfectioncontrolcategory.

CAHO - ACE Certication

Our hospital was granted with ACE certicate under the medium healthcare organisation categor y with 92% compliance.

A 38 year old female

was referred from Uttar Pradesh with urinary leakage in December2023.

She had undergone a total abdominal hysterectomy with bilateral salpingooopherectomy,6monthsago(June2023)for?Endometriosis.Howevershehadnointraoperative notes / post operative care records. Following the symptoms of urinary leakage, she underwent a cystoscopy which ruled out the possibility of a vesico-vaginal stula. Though uncommon it is one of the most dreaded complications post hysterectomy for benign diseases. The incidence of post-hysterectomy vesico-vaginal stulae (VVF) is around 1 in 788 and is higher after hysterectomy for cervical cancer. A concomitanturetero-vaginalstulaisfoundinupto15%ofcases.Typicalpresentationis usually after 4-6 weeks post operatively, which reduces the suspicion of a stula 6 months postsurgery. When she came to us in December2023, she was moderately built, para 3, living 3, all being full term vaginal deliveries. On examination her abdomen was soft and vaginal vault was healthy. There was no obvious leak of urine noted. She was advised an ultrasound abdomen and pelvis, with a full bladder, as well as CT intravenous urography (CT IVU). There was no evidence of vesico-vaginal / uretero-vaginal stula on the CT IVU, hence with negative clinical ndings and negative imaging, suspicion for any kindofstulawaslowandshewastreatedformenopausalsymptomsconservatively. She returned in January 2024 with upper backache and low grade abdominal pain. She now complained of recurrent watery discharge from the vagina and on examination, watery discharge from the vaginal vault was noted A 3 Swab Pyridium test was then carriedout.ShewasgivenoralPyridium,whichwouldbeexcretedintheurine,stainingit orangeincolour Onexaminationajetoforangecoloureduidwasseencomingoutfrom theapexofthevaginalvault,suggestiveofurinaryleakfromthevault,pointingtowardsa stula. In the era of minimal access surgery, laparoscopic repair of VVF is the preferred, more commonly opted route of surgery by most surgeons. However, what is forgotten is thatvaginalsurgeryremainsthemost‘minimallyinvasive’route.Vaginalsurgerybeingan art in itself, was successfully revisited by a collaborative approach with a multidisciplinary team. The department of Urology, Dr Malav Modi and department of Gynaecology, Dr Pranay Shah & Dr Sarita Bhalerao came together and planned for examination under anesthesia along with cystoscopy. The surgical plan was for vaginal repair of the stulous track in February 2024. Patientdid well post surgery, catheter was removed after 3 weeks and a micturating cysto-urethrography conrmed a watertight repair Sheisnowcontinent,successfullyvoidingwithgoodbladderfunction Thissetsa good example of the strength of a multidisciplinary approach, specially in cases that have an atypical presentation, negative imaging; making an accurate clinical diagnosis andskilfulsurgicaltechniquetheclincherforsuccess.

LEVONADIFLOXACIN ONE OF THE RECENT ANTIMICROBIALS

It is a uoroquinolone antibiotic. LEVONADIFLOXACIN belongs to the class of 'antibiotics', primarily used to treat bacterial skin and soft tissue infections, including diabetic foot infections and concurrent bacteraemia (presence of viable bacteria in the bloodstream). It also targets Methicillin-resistant Staphylococcus (MRSA), which causesantimicrobialresistance.

MODE OF ACTION

Bactericidal agent that prevents bacterial growth and interrupts bacterial replication Itisalsoabeta-lactamaseinhibitor

LEVONADIFLOXACIN has a broad spectrum activityagainstvariouspathogens,including Methicillin-resistantStaphylococcusaureus (MRSA).

USES OF LEVONADIFLOXACIN

Bacterialskinandsofttissueinfections.

SIDE EFFECTS OF LEVONADIFLOXACIN

Constipation

Vomiting Cough

Pregnant and breastfeeding should use this medicineonlywhenadoctorhasprescribedit.

Avoid driving or operating machinery if you notice any dizziness, headache or visual disorders that may impair your ability to concentrateandreact.

DRUG-DRUG INTERACTION

Do not use LEVONADIFLOXACIN if you are allergic to LEVONADIFLOXACIN or its components. Inform your doctor if you have liver/kidney/heart diseases, diabetes, mentalhealth-related problems, myasthenia gravis, tendon-related diseases or peripheral neuropathy before starting LEVONADIFLOXACIN.

LEVONADIFLOXACIN is not recommended in patientsunder18yearsofage.

LEVONADIFLOXACIN may interact with antacids (sucralfate), multivitamin preparations containing calcium,zincoriron,andHIV/AIDSmedication(didanosine).

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Dr Jyoti Kamat

Consultant Microbiology HIPC

In Charge.

Top of the line Samsung RS85 PRESTIGE 5 PROBES including Hockey stickand2newlydesignedsinglecrystalprobes.IthasthelatestShear wave electrography for liver / breast and fat quantication software/ hardware. New Articial intelligence based S-DETECT software to assist in TIRADS and BIRADS of thyroid and breast lesions, respectively. And for the 1st time in Bhatia Hospital now we have the facility to do contrast enhanced ultrasonography (CEUS), a very useful tool in characterization of liver or renal lesions when serum creatinine is high and also useful for many newer applications. A very sensitive color ow tool called Microvascular ow imaging will help to pick up lowest velocity ow of tumors and gonadal torsion. Probe guides and needle detect tools for better ultrasound guided interventions is also a goodadd-on.

Dr. Asif Momin Designation image required

Prayer Pose (Pranamasana)

Exhale as you return to the prayer position, grounding down through your feet and centering your energy

Raised Arms Pose (Hasta Uttanasana)

Inhale as you sweep your arms out to the sides and then up overhead, coming into a slight backbend if comfortable

Forward Fold (Uttanasana)

Exhale as you fold forward completely, releasing any tension in the neck and shoulders.

Half Forward Fold (Ardha Uttanasana)

Inhale as you step or walk your feet forward between your hands, coming into the halfway lift position

Prayer Pose (Pranamasana)

Stand at the front of your mat with your feet together, palms pressed together in front of your chest in prayer position. Take a moment to center yourself and set your intention for the practice

Raised Arms Pose (Hasta Uttanasana)

Inhale deeply as you raise your arms overhead, lengthening through the spine and stretching your arms upward. Arch slightly backward if comfortable, keeping the shoulders relaxed

Forward Fold (Uttanasana)

Surya Namaskar

also known as Sun Salutation, is a series of yoga poses performed in a sequence to create a owing movement. It's a dynamic way to warm up the body, stretch various muscle groups, and increase exibility. Surya Namaskar is traditionally practiced at sunrise, facing the sun, hence the name "Sun Salutation."

Here's a basic breakdown of the steps involved in Surya Namaskar:

Downward Facing Dog (Adho Mukha Svanasana)

Exhale as you lift your hips up and back, coming into an inverted V shape with your body. Press your palms into the mat, engage your core, and lengthen through your spine and hamstrings.

Upward Facing Dog (Urdhva Mukha Svanasana)

Inhale as you straighten your arms and lift your chest and gaze upward, pressing the tops of your feet into the mat and keeping your thighs lifted off the ground

Chaturanga Dandasana (Four-Limbed Staff Pose)

Exhale as you fold forward from the hips, bringing your chest toward your thighs and your hands to the oor beside your feet. Keep your knees straight or slightly bent if needed

Half Forward Fold (Ardha Uttanasana)

Lower down with control, keeping your elbows close to your sides as you lower halfway down. Your elbows should be at a 90degree angle, and your body should be in a straight line

Inhale as you lift your torso halfway, extending your spine forward and lengthening through the crown of your head. Your hands can either come to the shins or ngertips to the oor

Plank Pose (Phalakasana)

Exhale as you step or jump back into a high plank position, aligning your shoulders over your wrists and your body forming a straight line from head to heels. Engage your core and keep your neck in line with your spine

That completes one round of Surya Namaskar. You can continue the sequence, alternating which leg steps back rst in steps 5 and 9, to balance the stretch on both sides of the body. Surya Namaskar is often repeated several times to create a full practice, incorporating both physical movement and mindfulness.

Thinnest bone in human body Thinnest bone in human body

The stapes bone, also known as the stirrup bone, is the thinnest bone in the human body It is one of the three tiny bones in the middle ear, collectively called the ossicles, and it plays a crucial role in transmitting sound vibrations from the eardrum to the inner ear.

The stapes bone, despite its small size, plays a crucial role in the auditory system. Here aresomekeyaspectsofitsimportance:

1

Sound Transmission: The stapes bone is part of the ossicular chain in the middle ear. It connects the tympanic membrane (eardrum) to the inner ear (specically the oval window). When sound waves hit the eardrum, they cause vibrations that are transmitted through the ossicular chain. The stapes bone converts these vibrations into mechanical waves in the uid-lled inner ear, where they stimulate sensory receptors for hearing.

2

Amplication of Sound: The shape and orientation of the stapes bone help to amplify sound vibrations as they pass from the middle ear to the inner ear. This amplication is essential for maintaining the sensitivity of the auditory system, especially for detecting low-intensity sounds.

3

Protection of Inner Ear Structures: The stapes bone, along with the other ossicles (malleus and incus), helps to protect delicate structures within the inner ear. These structures include the cochlea, which contains the sensory cells responsible for hearing, and the vestibular system, which contributes to balance and spatial orientation.

4

Maintenance of Hearing Sensitivity: The stapes bone's precise movement and interaction with the inner ear uids are crucial for maintaining the sensitivity and dynamic range of hearing. Any abnormalities or damage to the stapes bone can lead to hearing loss or impairment.

Overall,thestapesbone'sroleintransmittingandamplifyingsoundwavesisessentialfor normal auditory function, highlighting its signicance in the human body's sensory system. Do You KNOW?