Vol.75 PagesAugustNo.82022Mumbai60 `135/ISSN E-ISSN0019-61692394-3017ThePractitionerIndian A Monthly Journal Devoted to Medicine, Surgery and Public Health q Successful Lactation in the Modern World: Is it Possible? q Healthcare Workers Satisfaction and Patients’ Satisfaction: An Effort to Find out Linkage q Monkeypox: Transmission, Clinical Features, Diagnosis, Treatment, and Prevention q Exocrine Pancreatic Insufficiency: An Overview q John Connolly’s Seminal Contribution to Psychiatric Practice q We are Moving Forward Towards Providing Access to Affordable and Modern Medical Facilities: Dr. Surekha Kishore, Executive Director, AIIMS, Gorakhpur .... Plus regular features & much more
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5 The Indian Practitioner The Indian Practitioner q Vol.75 No.8 August 2022 STNETNOCEditorial m Successful Lactation in the Modern World: Is it Possible? .. .. 7 Dr. Priya H. Manihar, Dr. Varun J. Wani, Dr. Reena J. Wani Original Article m Healthcare Workers Satisfaction and Patients’ Satisfaction: An Effort to Find out Linkage .. .. 22 – Dr. Dhananjay Mankar, Aditi Choudhary, Dr. Himani Gujar Clinical Practice m Monkeypox: Transmission, Clinical Features, Diagnosis, Treatment, and Prevention .. .. 27 – Dr. Charmi Bhanushali , Vidhi Bhanushali m Exocrine Pancreatic Insufficiency: An Overview .. .. 31 – Dr. Ashni Dharia, Dr. Charmi Bhanushali Column m John Connolly’s Seminal Contribution to Psychiatric Practice .. .. 34 – Dr Ashoka Jahnavi Prasad Interview m We are Moving Forward Towards Providing Access to Affordable and Modern Medical Facilities: Dr. Surekha Kishore, Executive Director, AIIMS, Gorakhpur .. .. 49 August 2022 Medi Matters .. .. 12 Nutraceuticals .. .. 41 Alternative Medicine .. .. 47 News .. .. 52 Events .. .. 54
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Keywords: breastfeeding, mother, infant, newborn, lactation, MBPC, COVID, HIV
Email: varunwani93@gmail.com
Editorial The Indian Practitioner d Vol.75 No.8 August 2022 7
BreastfeedingAbstract is a natural act, but it is also a learned behaviour. This year’s theme for World Breastfeeding Week 2022 is ‘Step up for breastfeeding: Educate and support.’ Organizations like Mumbai Breastfeeding Promotion Committee (MBPC) Mumbai Obstetric & Gynecological Society (MOGS) and Federation of Obstetrics & Gynecologic Societies of India (FOGSI) have been holding activities, webinars and competitions to focus on this important topic. This has been a wonderful way to partner with neonatologists, pediatricians, community medicine and mother support groups. The aim of all these activities is to highlight the physiological importance of breastfeeding, promote exclusive breastfeeding, and make the general population aware about its multiple benefits. This article provides a few key points for practicing physicians to impart knowledge of the evidence-based advantages of breastfeeding to their patients, friends and relatives.
As per NFHS-5, overall 63.7% children under the age of 6 months were exclusively breastfed as op posed to 54.9% reported in NFHS-4. Lakshadweep, Meghalaya, Andhra Pradesh and West Bengal showed the most improvement in early initiation, while Sikkim, Assam, Dadra & Nagar Haveli and Daman & Diu had the worst decline in early initiation of breastfeeding be tween the two surveys.[3, 4] Global Reports [5]
Dr. Priya H. Manihar1, Dr. Varun J. Wani2, Dr. Reena J. Wani3
1 Senior Resident, Dept of Community Medicine, LTMMC and GH, Sion, Mumbai.
“If I have seen further it is by standing on the shoulders of Giants.” - Sir Isaac Newton, 1675.
2 Senior Resident, Dept of Community Medicine, LTMMC and GH, Sion, Mumbai.
Corresponding Author: Dr. Varun J. Wani, Senior Resident, Dept of Community Medicine, LTMMC and GH, Sion, Mumbai.
As per the global reports, breastfeeding rates are too low in developed countries. It is found that only
Azadi ka Amrit Mahotsav: India is celebrating its 75th Independence Day this year and National Surveys are reflecting many surprising changes in early initia tion of breastfeeding as seen in Table 1.[3, 4]
Successful Lactation in the Modern World: Is it Possible?
India: Key Indicators
Breastfeeding is a natural act, but it is also a learned behaviour. Hospitals and health care practitioners should support all mothers to initi ate breastfeeding as soon as possible after birth, with in the first hour after delivery, and provide practical support to enable them to establish breastfeeding and manage common breastfeeding difficulties. Lactation support and management is a multidisciplinary team work of the healthcare providers including physicians, nurses, midwives, registered dieticians, public health professionals, scientists, lactation consultants, peer counsellors, and community health volunteers.[1] There is a dictum: ‘Breast is Best’. Each and everyone of us shares a common commitment of promotion of breast feeding and thus safeguarding the lives of the people.[2]
3 Professor and Head, Dept of Obstetrics & Gynaecology, HBT Medical College & Dr RN Cooper Hospital, Mumbai.
Benefits of Lactation to the Mother[6]
There were many myths and misconceptions espe cially during the first wave of the pandemic. We have all learnt and know that this virus is not transmitted via breastmilk.
2. Wash hands thoroughly with soap and water.
1. Warmer and calmer emotional environment
2. Reduction in postpartum hemorrhage
1 in 25 mothers are exclusively breastfeeding, unlike 1 in 5 in developing nations. Worldwide, 7.6 million babies each year are never breastfed as per UNICEF, 2018. Infants are more likely to be breastfed at least once in low- and middle-income countries. Countries like Bhutan, Madagascar and Peru have the highest nursing rates. Ireland, US and Spain have some of the lowest rates.
Some general instructions were given to the breast feeding mother who had COVID or its symptoms like fever, cough or difficulty in breathing such as:
HIV and Breastfeeding[12]
2. No nurseries, more hospital space
4. Risk reduction of ovarian cancer, breast cancer
3. Cover nose and mouth with a handkerchief.
1. Healthy mother and baby for short term and long term 2. Lesser financial costs as breastfeeding is free
1. Helps in better involution of uterus
Interestingly, in less developed countries, breast feeding duration is longer among the poorer mothers while in developed countries, it is the wealthy moth ers who are more likely to nurse their child for a lon ger duration.
3. Decreased emotional stress caused by illness of the child and mother
4. Use mask and maintain cleanliness.
3. Fewer neonatal infections
It is known that breastfeeding strengthens a child’s immune system, by directly transferring the antibod ies from the mother; it improves survival and provides lifelong health benefits. Hence after initial hesitancy in the first wave, all organizations gave clear guidelines that unless mother or neonate is too sick, breastfeeding should be facilitated with proper infection prevention and control measures.[10, 11]
1. Seek early medical care.
Benefits of Breast Feeding to Families[8]
The Indian Practitioner d Vol.75 No.8 August 2022 Editorial 8
4. Less staff time needed
4. Decreased medical care costs
3. Lactational amenorrhoea as a contraceptive to help in birth spacing
5. Risk reduction of diabetes type 2, hypertension Benefits of Breastfeeding for the Hospital[7]
COVID-19 Pandemic[9]
5. Reduced risk of hospitalization and mortality
5. Continue breastfeeding with precautions to protect yourself and the infant from infections.
2. The evidence on HIV and infant feeding shows that giving Anti-Retroviral Treatment (ART) to moth ers living with HIV, significantly reduces the risk of transmission through breastfeeding and also im Table 1: Changes in the early initiation of breastfeed ing from NFHS 4 (2015-16) to NFHS 5 (2019-20) [3]
1. HIV can pass from a mother to her child during pregnancy, labour or delivery, and also through breast milk.
9The Indian Practitioner qVol.75. No.8. August 2022
3. WHO recommends implementation of the ‘Ten Steps to Successful Breastfeeding’ specified in the Baby-Friendly Hospital Initiative, some being:
• Not giving babies additional food or drink, even water, unless medically necessary.
On the occasion of World Breast Feeding Week (WBW) 2021, Mumbai Breastfeeding Promotion Committee (MBPC) under leadership of President 2019-22 -Dr. Reena Wani, organized “WBW-2021” in augural program on 3rd August 2021 as a hybrid event due to COVID concerns. The theme for WBW 2021 was “Protect breastfeeding- a shared responsibility”. The highlights of the event were Release of Breastfeeding training Module ‘Breastfeeding: A precious Bond’,and prize distribution for street-play and poster competi tions. A copy of this training module was distributed to all colleges along with pen-drive containing powerpoint presentations of the chapters for training of doc tors and healthcare workers.A partnership with oth er state and national organizations in such activities helps to spread awareness, and reinforce positive mes sages for this cause. This year’s theme for WBW 2022 is ‘Step up for breastfeeding: Educate and support.’ This time too, MBPC held various competitions and also added a quiz and slogan competition for breastfeeding. Other organizations like Mumbai Obstetric & Gynecological Society (MOGS) and Federation of Obstetrics & Gynecologic Societies of India (FOGSI) have been part nering with MBPC down the years, and also holding their own activities, webinars and competitions to fo cus on this important topic. This has been a wonder ful way to partner with neonatologists, pediatricians, community medicine and mother support groups.
Editorial The Indian Practitioner d Vol.75 No.8 August 202210 proves their health.
Key Points for Practitioners
2. There are continued benefits from breastfeeding beyond 1 year, and up to 2 years especially in the mother. Hence most organizations now support continued breastfeeding until 2 years or beyond, as mutually desired by mother and child.
• Breastfeeding on demand (that is, as often as the child wants, day and night).
3. WHO now recommends that all people living with HIV, including pregnant women and lactat ing mothers living with HIV, take ART for life from when they first learn their infection status.
• Skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeed ing within the first hour of life.
1. Parents giving birth should be supported to breast feed through early initiation of skin-to-skin contact and frequent breastfeeding, with skilled lactation support readily available in maternity care facili ties.
Figure 1: Prize winning poster (junior category) in MOGS WBW 2022 Competition. (Source: Dr. Sayli Wankhedkar)
‘Let us all take the Pledge to Promote Support Protect Breastfeeding!’
Conclusion Emphasis on starting breastfeeding to the child within an hour of birth, exclusive breastfeeding for first 6 months of life and on completion of 6 months give complementary feeding to the child should be made by education toeach and every mother as well as the family for a brighter tomorrow. One person cannot reach everyone, but every person can reach someone, which may add up together to reach everyone!
• Rooming-in (allowing mothers and infants to re main together 24 hours a day).
WBW & Role of Organizations
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6. Lutter CK, Lutter R. F et al and early childhood undernutrition, mortality, and lifelong health. Science. 2012;337(6101):1495-9.
Ask for FREE sample copy. Digital Version also available.
7. Horta BL, Victora CG. A systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality. World Health Organization. 2013 8. Tiruneh GT, Shiferaw CB, Worku A. Effectiveness and costeffectiveness of home-based postpartum care on neonatal mortality and exclusive breastfeeding practice in low-andmiddle-income countries: a systematic review and metaanalysis. BMC pregnancy and childbirth. 2019;19(1):1-9.
References: 1. Campbell S. Core Curriculum for Interdisciplinary Lactation Care: Jones and Bartlett Learning. 2019:4-6.
Doctors - Keep Abreast of the Latest Medical Advances & Benefit Your Practice
The Indian Practitioner d Vol.75 No.8 August 2022 Editorial 11
3. National Family Health Survey (NFHS-4). 2015-2016. Indian ministry of Health and Family Welfare. International Institute for Population Sciences.
4. National Family Health Survey (NFHS-5). 2015-2016. Indian ministry of Health and Family Welfare. International Institute for Population Sciences
We thank the Presidents and team members of MBPC, MOGS, FOGSI, BPNI and other organizations promotionticipantsworkingtogetherforthisimportantcause,andallparinthevariousactivitiesconductedfortheofbreastfeeding.
5. UNICEF. Breastfeeding: a mother’s gift, for every child. UNICEF; 2018. Accessed on 2022 Aug 11. Available Breastfeeding_A_Mothers_Gift_for_Every_Child.pdfhttps://www.unicef.org/media/48046/file/UNICEF_from:
2. Park K. Textbook of Preventive and Social Medicine. 25th Edition: Banarasidas Bhanot Publishers, 2019:614.
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Acknowledgements
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9. Lubbe W, Botha E, Niela-Vilen H, Reimers P. Breastfeeding during the COVID-19 pandemic–a literature review for clin ical practice. International Breastfeeding Journal. 2020;15(1):19. 10. BPNI. COVID-19 and Breastfeeding Update. 2020 May. Accessed on 2022 Aug 11. Available from ni.org/wp-content/uploads/2020/05/Update-on-COVID-19-https://www.bp and-Breastfeeding.pdf 11. World Health Organization 2020. Breastfeeding and COVID-19: Scientific brief. 2020 June. Accessed on 2022 Aug 11. Available from https://apps.who.int/iris/han dle/10665/332639 12. Yadav P, Wani RJ, Shirodkar S. Impact of Changed HIVTesting Strategy in PPTCT Programme at Tertiary Hospital. Indian Jnl of Applied Research.2021;11(4).DOI : 10.36106/ijar. +
People challenged with chronic back pain have been given hope with a new treatment that fo cuses on retraining how the back and the brain communicate, a ran domised controlled trial run by researchers at UNSW Sydney and Neuroscience Research Australia (NeuRA). The study, funded by the Australian National Health and Medical Research Council (NHMRC), was described in a paper published in the Journal of the American Medical Association.
“People with back pain are often told their back is vulnerable and needs protecting. This changes how we filter and interpret in formation from our back and how we move our back.
Traditional therapies concentrate on fixing some thing in your back, injecting a disc, loosening up the joints or strengthening the muscles. What makes sensorimotor retraining different, according to Prof. McAuley is that it looks at the whole system – what people think about their back, how the back and brain communicate, how the back is moved, as well as the fitness of the back.
In the study, investigators com pared the responses of off sustained alpha (OFFsA) and bSbC ganglion cell types to different visual stim uli, recording the resulting signals that would be sent to the brain.
The study authors discovered the bSbC has a curious mecha nism: The cell has a baseline rate of signalling towards the brain, but increase and decrease in light results in decreased signalling, a one-way signalling pattern. “The signalling can only go down,” Schwartz said.
New insights into retinal neurons
Professor James McAuley from UNSW’s School of Health Sciences, and NeuRA said sensorimotor re training alters how people think about their body in pain, how they process sensory information from their back and how they move their back during activities.
Medi Matters The Indian Practitioner q Vol.75 No.8. August 2022 Medi Matters 12
Further, the investigators test ed the classic view of how these ganglion cells integrate inputs. These cells receive excitatory and inhibitory signals from photorecep tors in the retina, and the prevailing theory dictated that these inputs combine to reach some threshold that causes a change in signalling output.
Over time, the back becomes less fit, and the way the back and brain communicate is disrupted in ways that seem to reinforce the notion that the back is vulnerable and needs protecting. The treatment we devised aims to break this self-sustaining cycle,” he said.
Prof. McAuley said the treat ment is based on research that showed the nervous system of people suffering from chronic back pain behaves in a differ ent way from people who have a recent injury to the lower back.
Effective new treatment for chronic back pain targets the nervous system
Northwestern Medicine in vestigators have identified a new type of retinal ganglion cell, the neurons in the retina that en code the visual environment and transmit information back to the brain; it is published in the jour nal Neuron. The specific features of this cell, which is called a “bursty sup pressed-by-contrast” (bSbC) reti nal ganglion cell (RGC), overturn a decades-old assumption about the relationship between the cells’ inputs from photoreceptors and outputs to the brain, according to Gregory Schwartz, Derrick T. Vail Professor of Ophthalmology, and senior author of the study. “Our findings reveal that these cells have their own intrinsic com putation, which has interesting implications for things like retinal prosthetics,” said Schwartz.
The new treatment challenges traditional treatments for chronic back pain, such as drugs and treatments that focus on the back such as spinal manipulation, in jections, surgery and spinal cord stimulators, by view ing long-standing back pain as a modifiable problem of the nervous system rather than a disc, bone or mus cle problem.
Microglia’s contribution to Alzheimer’s disease
Novel gene therapy could reduce bleeding risk for haemophiliacs
Medi Matters The Indian Practitioner q Vol.75 No.8. August 2022 13
In the study, the researchers wanted to investigate how APOE4 affects interactions between mi croglia and neurons. Recent re search has shown that microglia play an important role in modu lating neuronal activity, includ ing their ability to communicate within neural ensembles. Microglia also scavenges the brain looking for signs of damage or pathogens, and clear out debris. The research ers found that APOE4 disrupts mi croglia’s ability to metabolize lipids and prevents them from removing lipids from their environment. This leads to a build-up of fatty mol ecules, especially cholesterol, in the environment. These fatty molecules bind to a specific type of potassium channel embedded in neuron cell membranes, which suppresses neu ron firing.
One of the hallmarks of Alzheimer’s disease is a re duced firing of some neurons in the brain, which contributes to the cog nitive decline that patient’s experi ence. A new study from MIT shows how a type of cells called microg lia contributes to this slowdown of neuron activity. The study found that microglia that express the APOE4 gene, one of the strongest genetic risk factors for Alzheimer’s disease, cannot metabolize lipids normally. This leads to a build-up of excess lipids that interferes with nearby neurons’ ability to commu nicate with each other. MIT post doc, Matheus Victor is the lead author of the paper, which is pub lished in Cell Stem Cell “APOE4 is a major genetic risk factor, and many people carry it, so the hope is that by studying APOE4, that will also provide a bigger picture of the fundamental pathophysiology of Alzheimer's disease and what fundamental cell processes have to go wrong to re sult in Alzheimer's disease,” says Li-Huei Tsai, director of MIT’s Picower Institute for Learning and Memory and the senior author of the study. The findings suggest that if researchers could find a way to restore normal lipid metabolism in microglia, it might help to treat some of the symptoms of the dis ease
Implantable devices that release insulin into the body hold promise as an alternative way to treat diabe tes without insulin injections or cannula insertions. However, one obstacle that has prevented their use so far is that the immune system attacks them after implantation, forming a thick layer of scar tissue that blocks insulin release. A team of MIT engineers and collaborators have now devised a way to overcome this response. In a study on mice, they showed that when they incorporated mechanical actuation into a soft robotic device, the device remained functional for much longer than a typical drug-delivery implant. The device is repeatedly inflated and deflated for five minutes every 12 hours, and this mechanical de flection prevents immune cells from accumulating around the device, the researchers found. “We’re us ing this type of motion to extend the lifetime and the efficacy of these implanted reservoirs that can deliver drugs like insulin, and we think this platform can be extended beyond this application,” says Ellen Roche, the Latham Family Career Development Associate Professor of Mechanical Engineering and a member of MIT’s Institute for Medical Engineering and Science.
Design prevents build-up of scar tissue around medical implants
Published in the New England Journal of Medicine, experts from UCL, Royal Free Hospital and Biotechnology Company Freeline Therapeutics tri alled and continue to evaluate a new type of AdenoAssociated Virus (AAV) gene therapy candidate, called FLT180a, to treat severe and moderately severe cases of haemophilia.ThePhaseI/II multi-centre clinical trial, called B-AMAZE, and the related long-term follow up study found that one-time treatment with FLT180a led to
When asthmatics’ respiratory tracts are exposed to dust mites, their immune response be comes less effective, which can lead to a weaker immune system. People who suffer from asthma associated with infection may therefore be more susceptible to secondary viral or bacterial infections. According to the researchers, the results suggest that asthmatics should avoid house dust mites and that patients who are also allergic to the mites should consider undergoing so-called hy posensitisation. The study was re cently published in Allergy. In an earlier study, Professor Lena Uller and her research team have shown that house dust mites, when compared to other common allergens, give rise to a more pow erful inflammatory response in the epithelium cells in the lungs of asthmatics. These epithelium cells are a barrier intended to protect the lungs from harmful microbes and particles that we breathe in.
Connection between dust mites and respiratory infections
Lena Uller and Samuel Cerps believe that the results of the study are significant, since they increase understanding of how allergy and our immune system interact in the respiratory tract.
Medi Matters
The Indian Practitioner q Vol.75 No.8. August 202214 sustained production of factor IX (FIX) protein from the liver in nine of ten patients, across four different dose levels, removing the need for regular replacement therapy. Out of 17 male patients aged 18 or over who un derwent screening, ten with severe or moderately se vere haemophilia B took part in the 26-week trial of FLT180a. They are also all enrolled in the long-term follow up study to assess safety and durability of FIX expression for 15 years. Lead author Professor Pratima Chowdary (Royal Free Hospital, UCL Cancer Institute) said, “Removing the need for haemophilia patients to regularly inject themselves with the missing protein is an important step in improving their quality of life. The long term follow up study will monitor the pa tients for durability of expression and surveillance for lateAAVeffects.”gene therapy works by using a packaging from the proteins found in the outer coat of the virus, to deliver a functional copy of a gene directly to patient tissues to compensate for one that is not working prop erly. Newly synthesised proteins are released into the blood and a one-time infusion can achieve long-lasting effects. Patients needed to take immune suppressing drugs over several weeks to several months, to prevent their immune systems from rejecting the therapy, and all reported known side effects. While the treatment was generally well tolerated, all patients experienced some form of adverse events, with an abnormal blood clot in one who received the highest FLT180a dose and had the highest levels of FIX protein.
Clinical data has shown that asthma patients with allergies are more frequently prescribed anti biotics, compared to non-allergic asthmatics, according to Samuel Cerps, first author of the study.
Using bronchial brushing, the researchers collected and cultivat ed epithelial cells from asthmatics including those with and without a dust mite allergy. The cells were then exposed to dust mites for 24 hours before being exposed to a virus. Through this method, the re searchers were able to investigate how a viral infection affects the immune system in terms of both viral and bacterial infections. “The results showed that an allergy to dust mites was in itself a factor that diminished asthmatics’ protection against viruses, i.e. the epithelial cells was less effective in producing antiviral interferons. We also saw that direct exposure to dust mites, regardless of the patient’s allergy status, reduced respiratory cells’ production of both antiviral and antibacterial proteins when they contracted viral infections,” Samuel Cerps explains.
“This suggests that allergy is a risk factor in bacterial infections and that got us interested in studying how exposure to house dust mites affects the immune system of asth matics,” says Cerps.
B vitamins can potentially be used to treat advanced NAFLD Scientists at Duke-NUS Medical School in Singapore have uncovered a mechanism that leads to an ad vanced form of fatty liver disease—and it turns out that vitamin B12 and folic acid supplements could re verse this process. The research was published in the Journal of Hepatology. These findings could help people with non-alcoholic fatty liver disease, an umbrella term for a range of liver conditions affecting people who drink little to no alco hol, which affects 25% of all adults globally. “While fat deposition in the liver is reversible in its early stages, its progression to non-alcoholic steatohepatitis (NASH) causes liver dysfunction, cirrhosis and increases the risk for liver cancer,” said Dr Madhulika Tripathi, first author of the study, who is a senior research fellow with the Laboratory of Hormonal Regulation at DukeNUS’ Cardiovascular & Metabolic Programme. Dr Tripathi, study co-author Dr Brijesh Singh and their colleagues in Singapore, India, China and the US confirmed the association of homocysteine with NASH progression in preclinical models and humans. They also found that, as homocysteine levels increased in the liver, the amino acid attached to various liver proteins, changing their structure and impeding their
Insights into genetic and molecular machinery that predisposes individuals to Alzheimer’s disease
Mount Sinai researchers have achieved an unprecedented understanding of the genetic and molecular machinery in human mi croglia—immune cells that reside in the brain—that could provide valu able insights into how they contrib ute to the development and progres sion of Alzheimer’s disease (AD).
The team’s findings were published in Nature Genetics. Working with fresh human brain tissue harvested via biopsy or autopsy from 150 donors, researchers identified 21 candidate risk genes and highlighted one, SPI1, as a potential key regulator of microglia and AD risk.Senior author Panos Roussos, Professor of Psychiatry, and Genetic and Genomic Sciences, at the Icahn School of Medicine at Mount Sinai and Director of the Center for Disease Neurogenomics said, “By bet ter understanding the molecular and genetic mecha nisms involved in microglia function, we’re in a much better position to unravel the regulatory landscape that controls that function and contributes to AD. That knowledge could, in turn, pave the way for novel ther apeutic interventions for a disease that currently has no effective treatments.”
Medi Matters The Indian Practitioner q Vol.75 No.8. August 2022 15
That process—comparing epigen etic, gene expression, and genetic in formation from the samples of both AD and healthy aged patients—al lowed researchers to comprehensive ly describe how microglia functions are genetically regulated in humans. As part of their statistical analysis, they expanded the findings of prior genome-wide association studies to link identified AD-predisposing genetic variants to specific DNA regulatory sequences and genes whose dysregulation is known to directly contribute to the development of the disease. From their investigation emerged new knowledge about the SPI1 gene, already known to scientists, as the main microglial transcription factor regulating a network of other transcription factors and genes that are genetically linked to AD. Data the team is generating could also be important to deciphering the molecular and genetic mysteries behind other neu rodegenerative diseases in which microglia play a role, including Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis. Dr. Roussos concedes that much work remains for his team to fully under stand how the identified genes contribute to the devel opment and progression of Alzheimer’s disease, and how they could be targeted with new therapeutics.
Common viruses may trigger the onset of Alzheimer’s Disease
Alzheimer’s disease can begin almost imperceptibly, often masquerading in the early months or years as forgetfulness that is com mon in older age. What causes the disease remains largely a mystery. Now researchers at Tufts University and the University of Oxford, using a three-dimensional human tissue culture model mimicking the brain, reported in the Journal of Alzheimer’s Disease that Varicella Zoster Virus (VZV), which commonly causes chickenpox and shingles, may acti vate Herpes Simplex Virus (HSV), another common virus, to set in mo tion the early stages of Alzheimer’s disease. Normally HSV-1—one of the main variants of the virus—lies dor mant within the neurons of the brain, but when it is activated, it leads to ac
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The Indian Practitioner q Vol.75 No.8. August 202216 functioning. In particular, when homocysteine at tached to a protein called syntaxin 17, it blocked the protein from performing its role of transporting and digesting fat in fatty acid metabolism, mitochondrial turnover, and inflammation prevention. This induced the development and progression of fatty liver disease to NASH.Importantly, the researchers found that supple menting the diet in the preclinical models with vitamin B12 and folic acid increased the levels of syntaxin 17 in the liver and restored its role in autophagy. It also slowed NASH progression and reversed liver inflam mation and fibrosis. “Our findings are both exciting and important because they suggest that a relatively inexpensive therapy, vitamin B12 and folic acid, could be used to prevent and/or delay the progression of NASH,” said Dr Singh. “Additionally, serum and he patic homocysteine levels could serve as a biomarker for NASH severity.”
“Stroke and atrial fibrillation are two medical conditions tied to atri al cardiopathy [dysfunction of the atrium, or left upper cavity of the heart],” says study author Michelle Johansen, an Assistant Professor of Neurology at the Johns Hopkins University School of Medicine and an attending physician in The Johns Hopkins Hospital’s cerebrovascu lar division. “We looked to see if we could find any association be tween the left atrium and dementia that was mediated by, or as a result of, the development of either one of these conditions”. In the study, Johansen and her colleagues found that the prevalence of atrial car diopathy among participants was 34%. The mean age of the partici pants was 75, and 59% were female adults and 21% were Black adults. Johansen says the team looked at three markers that could be ob tained from routine medical tests to measure the function of the left atri um. These include an echocardio gram, an electrocardiogram and a blood marker that determines how the heart functions. Using these three tests, the team established a definition of atrial cardiopathy and then grouped participants into whether they met this definition. "We found that patients who had atrial cardiopathy as we defined in our study had a higher hazard, or rate, of dementia over time versus those who did not have atrial cardi opathy,” Johansen says.
Link between dementia and atrial cardiopathy
Older adults with atrial cardiop athy may be at increased risk of developing dementia, accord ing to new research led by Johns Hopkins Medicine. The findings were published in the Journal of the American Heart Association. Johns Hopkins Medicine re searchers studied 5,078 older adults living in four U.S. com munities: Washington County, Maryland; Forsyth County, North Carolina; northwestern suburbs of Minneapolis; and Jackson, Mississippi. The participants did not have dementia when the study began. The researchers sought to determine if there was a difference in the number of people who de veloped dementia by comparing a group that had markers of left atrial (one chamber of the heart) dysfunc tion versus those who did not.
cumulation of tau and amyloid beta proteins, and loss of neuronal function—signature features found in pa tients with Alzheimer’s. “Our results suggest one path way to Alzheimer’s disease, caused by a VZV infection which creates inflammatory triggers that awaken HSV in the brain,” said Dana Cairns, a Research Associate in the Tufts Department of Biomedical Engineering. “While we demonstrated a link between VZV and HSV-1 activation, it’s possible that other inflammatory events in the brain could also awaken HSV-1 and lead to Alzheimer’s disease.”
Collagen a key player in breast cancer metastasis
The researchers found that neurons grown in the brain tissue can be infected with VZV, but that alone did not lead to the formation of the signature Alzheimer’s proteins tau and beta-amyloid—the com ponents of the tangled mess of fibers and plaques that form in Alzheimer’s patients’ brains—and that the neurons continued to function normally. However, if the neurons already harbored quiescent HSV-1, the ex posure to VZV led to a reactivation of HSV, and a dra matic increase in tau and beta-amyloid proteins, and the neuronal signals begin to slow down.
Study shows how microglia are prompted to change their state to adapt to different areas of the brain To accomplish feats of athletic or academic excel lence and even everyday actions like walking and talking, the brain must acquire and seamlessly process a ton of information. That requires a whole orchestra of cells to “listen” and move, interact, and coordinate with one another. One of the most enduring, funda mental questions in neuroscience involves precisely how this Scientistshappens.know that this cellular symphony in cludes not only neurons, but cells that normally play
The research also suggests that measuring the level of collagen XII in a patient’s tumour biopsy could potentially be used as an additional screening tool to iden tify aggressive breast cancers with higher rates of metastasis, such as in the triple-negative type of breast cancer. Furthermore, collagen XII might be a possible target for future treatments.
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Collagen type XII plays a key role in regulating the organisation of the tumour matrix, reveals a new study from the Garvan Institute of Medical Research. A team of sci entists led by Associate Professor Thomas Cox, Head of the Matrix and Metastasis lab, also discovered that high levels of collagen XII can trigger breast cancer cells to spread from the tumour to other parts of the body, a process known as me tastasis. The study is published in the journal Nature Communications. The tumour microenvironment is the ecosystem that surrounds a tumour, one component of which is the extracellular matrix. Cancer cells constantly interact with the tu mour microenvironment, which af fects how a tumour grows. Collagen is an important part of this tumour microenvironment, but just how it influences tumours has not been understood.“There’sstill a lot we don’t know about the role of the extracellular matrix in cancer metastasis. Our study shows that collagen XII plays an important role in breast cancer progression and metastasis,” says senior author Associate Professor Thomas Cox. “Imagine cancer cells as seeds, and the tumour microenvironment as the soil. By studying the soil – the extracellular matrix – we can begin to understand what makes some tu mours more aggressive than others, and by extension, begin to develop new ways to treat cancer,” he says.
“We have been working off a lot of established evi dence that HSV has been linked to increased risk of Alzheimer’s disease in patients,” said David Kaplan, Stern Family Professor of Engineering and chair of the Department of Biomedical Engineering at Tufts’ School of Engineering. One of the first to hypothesize a connection between herpes virus and Alzheimer’s disease is Ruth Itzhaki of the University of Oxford, who collaborated with the Kaplan lab on this study. “We know there is a correlation between HSV-1 and Alzheimer’s disease, and some suggested involvement of VZV, but what we didn’t know is the sequence of events that the viruses create to set the disease in mo tion,” Kaplan said. “We think we now have evidence of those events.”
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“You would no longer have to treat, for instance, microglia as one blanket cell type when trying to af fect the brain,” Stogsdill continues. “We can target very specific states, or we can target very specific subtypes of neurons with the ability to change specific states of microglia. It allows us to have high-level granularity.”
The study provides unique insight into how differ ent cell types work together in harmony.
The Indian Practitioner q Vol.75 No.8. August 2022 a role in defending the body against patho gens. One group is tiny immune cells called microglia, which researchers are increas ingly learning play oversized roles in brain function, health, and disease. In a new report in Nature, researchers from the lab of Paola Arlotta, Golub Family Professor of Stem Cell and Regenerative Biology and the Stanley Center for Psychiatric Research at the Broad Institute, move a step closer to answering this question. The paper published shows that microglia cells “listen in” to neighbor ing neurons and change their molecular state to match them.
Genetic mapping of tumors reveals how cancers grow
Researchers from the University of Oxford, KTH Royal Institute of Technology, Science for Life Laboratory, and the Karolinska Institutet, Solna, Sweden, have found that individual prostate tu mours contain a previously un known range of genetic variation. In a new study published in Nature, the researchers used spatial transcriptomics to create a crosssectional map of a whole prostate, including areas of healthy and can cerous cells. By grouping cells ac cording to similar genetic identity, they were surprised to see areas of supposedly healthy tissue that already had many of the genetic characteristics of cancer. This find ing was surprising because of both the genetic variability within the tissue as well as the large number of cells that would be considered healthy, but which contained mu tations usually identified with can cerous cells. Alastair Lamb of Oxford’s Nuffield Department of Surgical Sciences, who jointly led the study, said: 'Prostate tissue is three-di mensional, and like most organs that can develop cancer we still have much to learn about what cel lular changes because cancer and where it starts. One thing we are fairly confident of is that it starts with genetic mutations.
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“We know that microglia can affect the function of the neural circuit, and now we know that neurons can recruit specific types of microglia to their neighbourhood,” stated Paola Arlotta. This discovery could one day open the door for lines of research that can target com munications between microglia and their neuron partners with pinpoint accuracy, of fering insight into disorders such as autism and schizophrenia, which arise when these communications between cells go awry.
Professor Joakim Lundeberg of KTH Royal Institute of Technology, said: "Mapping thousands of tissue regions in a single experiment is an unprecedented approach to decon volute the heterogeneity of tumours and their microenvironment. This high-resolution view impacts our way of addressing complex ecosys tems such as cancer. The possibility to identify early events is particu larly exciting going forward.”
“When they were first discovered, microglia were assumed to be simply scavengers, cleaning up cell de bris and helping to fight off pathogens,” said Jeffrey Stogsdill, who led the study as a postdoctoral research er in the Arlotta lab. “Now we know that microglia can interact with neurons in very sophisticated ways that can affect neuron function.”
Dr Henry Stennett, Research information manager at Cancer Research UK, who funded the re search, said: 'This fascinating re search challenges our understand ing of how cancer develops. Using cutting-edge technology, our sci entists have built an incredibly detailed 3D map of the prostate. Their results show that apparently healthy cells in the body can have the same DNA damage as cancer cells. Working out what stops them from becoming cancerous could help us to detect this disease ear lier.”
However, since the results show that the vaccine was ineffective in adolescents and adults, “boosting immunoprotection is needed for older populations,” Martinez says. “Novel vaccines are urgently needed to supplement BCG vaccination in high-burden settings.”
These findings provide up-to-date assessments on TB vaccine effectiveness, as the majority of previously published studies on this subject were conducted more than 50 years ago, with varying results, and primarily in settings with a relatively low burden of the disease. This new analysis presents data over the past 10 years, from high-burden settings in 17 countries, including South Africa, China, Vietnam, Indonesia, Uganda, The Gambia, and Brazil.
BCG vaccine prevents tuberculosis in young children, but not adults: study
Amidst longstanding debate on the effectiveness of the tuberculosis vaccine, a new study suggests that the vaccine is protective against TB in children under 5, but adolescents and adults in high-burden countries may need additional protection to maintain immunity beyond childhood. Now, a new study led by a School of Public Health researcher provides new insight and clarity on these issues. Published in The Lancet Global Health, the study found that BCG vaccination at birth does provide sig nificant protection against TB disease—but only among children under 5 years old. The vaccine provided no protection among adolescents or adults in this study. These results suggest that protectiveness from the BCG vaccine may begin to wane as children get older and, thus, children over 10 years old and adults should receive a booster BCG vaccine—and eventually a new, supplemental vaccine, as the researchers note that the BCG booster may also have limited efficacy—for im munity against TB beyond childhood. Unfortunately, a BCG booster has limited efficacy, so new vaccines are needed. “Unlike many of the mRNA COVID-19 vaccines, which we know are highly effective, there is wide spread debate on the BCG vaccine’s effectiveness and duration of protection, as well as whether the vaccine only works in selective settings,” says study lead au thor Leonardo Martinez, assistant professor of epi demiology. “Our findings indicate that BCG vaccina tion is effective at preventing tuberculosis in young children. Since tuberculosis in children is a highly de bilitating and severe disease, BCG vaccination should continue to be used.”
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A new study suggests that neurons are not programmed for a single task, but rather are highly dynamic and agile Even during such routine tasks as a daily stroll, our brain sometimes needs to shift gears, switching from navigating the city to jumping out of the way of a bike or to crossing the street to greet a friend. These switches pose a chal lenge: How do the brain’s circuits deal with such dynamic and abrupt changes in behavior? A Weizmann Institute of Science study on bats, published in Nature, suggests an answer that does not fit the classical thinking about brain function.
“Most brain research projects focus on one type of behavior at a time, so little is known about the way the brain handles dynami cally changing behavioral needs,” says Prof. Nachum Ulanovsky of Weizmann’s Brain Sciences Department. In the new study, he and his team designed an experi mental setup that mimicked reallife situations in which animals or humans rapidly switch from one behavior to another – for example, from navigation to avoiding a pred
The myriads of microbes in our gut, collectively termed the mi crobiome, are considered impor tant to our health, but they can also harbor bacteria that contribute to inflammatory bowel disease or oth er disorders. Currently, however, it is impossible to target such dis ease-contributing bacteria without harming the surrounding beneficial microbes. Antibiotics kill friendly microbes along with the harmful ones, and in any event, they tend to trigger bacterial resistance and to have side effects. In a study pub lished in Cell, Weizmann Institute of Science researchers have demon strated the feasibility of a potential therapy for killing inflammationcausing gut bacteria in a targeted manner: by using viruses that infect them.Phages, or bacteriophages, as these viruses are known, are the most abundant organisms on Earth; they are found wherever there are bacteria, including in the human gut. Attempts to enlist these vi ruses in treating infectious disease go back to the early 20th century, right after phages were first discov ered, but this line of research was abandoned soon after the advent of antibiotics. In the new study, the Weizmann researchers recruited phages for eliminating bacteria that don’t just cause infectious disease, but also spur inflammation and gut damage, contributing to inflam matory bowel disease. “There are thousands of different phages, and their big advantage is that each of them specializes in attacking a dif ferent type of bacteria,” explains Prof. Eran Elinav of Weizmann’s Systems Immunology Department, who headed the research team. “This enabled us to harness phages to target only those gut bacteria that contribute to disease. To our knowl edge, this constitutes the first ‘silver bullet’ approach promising a pre cise suppression of disease-causing gut microbes, without harming the surrounding microbiome.” The study, conducted in col laboration with Prof. Rotem Sorek of Weizmann’s Molecular Genetics Department, was led by postdoctor al fellows Drs. Sara Federici, Rafael Valdés Mas and Denise Kviatcovsky from Elinav’s lab, together with Dr. Sharon Kredo-Russo and other re searchers from BiomX Inc., a clini cal-stage microbiome company ad
A surprising precision weapon against Crohn’s and ulcerative colitis
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The Indian Practitioner q Vol.75 No.8. August 202220 ator or a car crash. Graduate stu dents Dr. Ayelet Sarel, Shaked Palgi and Dan Blum led the study, in col laboration with postdoctoral fellow Dr. Johnatan Aljadeff. The study was supervised by Ulanovsky to gether with Associate Staff Scientist Dr. Liora Las. Using miniature wireless re cording devices, the researchers monitored neurons in the brains of pairs of bats that had to avoid colliding with one another while flying toward each other along a 135-meter-long tunnel at the high speed of 7 meters per second. This amounted to a relative speed – that is, the rate at which the distance be tween the bats closed, or the sum of both bats’ speeds – of 14 meters per second, or about 50 kilometers an hour. To check whether in these situations the bats switched their behavioral mode, becoming more attentive, the researchers took ad vantage of bats’ unique ability to sense their environment using so nar, or echolocation. Indeed, when spotting another animal flying rap idly toward them, the bats prompt ly raised their rate of echolocation clicks, signifying elevated attention levels. As their attention increased, a rapid shift occurred in the neural circuits in the bats’ hippocampus, the main brain area responsible for navigation, among other functions. The scientists discovered this shift by recording electrical signals from individual neurons in this area, known as place cells. When the bats were flying solo, their place cells encoded their lo cation in space, but as soon as the animals spotted the other, fastapproaching bat, more than half of the neurons in the hippocam pus – about 55 percent – switched modes. The scientists could tell that the neural switch had taken place because the neurons’ firing pattern changed, indicating that they now encoded not only the bat’s own, absolute location but also a relative measure: the distance to the other bat. The higher the animal’s at tention, the more pronounced the neural switch. To the scientists’ sur prise, this switch occurred extreme ly rapidly, within some 100 milli seconds, or one-tenth of a second. Whether the fast-approaching bat was a regular, familiar partner or a mere “acquaintance” had no ef fect on the neural coding, suggest ing that the switch was intended to avoid a collision and had nothing to do with social behavior. “Our study suggests that we may need to revise some basic assumptions about the brain’s circuits,” Ulanovsky says.
Agooey slice of pizza, a pile of crispy French fries, ice cream dripping down a cone on a hot sum mer day; when you look at any of these foods, a specialized part of your visual cortex lights up, according to a new study from MIT neuroscientists. This newly discovered population of food-responsive neurons is located in the ventral visual stream, alongside populations that respond specifically to faces, bodies, places, and words. The unexpected finding may reflect the special significance of food in human culture, the researchers say.
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Yummy Food = Happy Neurons!
“Food is central to human social interactions and cultural practices. It’s not just sustenance,” says Nancy Kanwisher, the Walter A. Rosenblith Professor of Cognitive Neuroscience and a member of MIT’s McGovern Institute for Brain Research and Center for Brains, Minds, and Machines. “Food is core to so many elements of our cultural identity, religious practice, and social interactions, and many other things that hu mans do.” The findings, based on an analysis of a large public database of human brain responses to a set of 10,000 images, raise many additional questions about how and why this neural population develops. In future studies, the researchers hope to explore how people’s responses to certain foods might differ depending on their likes and dislikes, or their familiarity with cer tain types of food. MIT postdoc Meenakshi Khosla is the lead author of the paper, along with MIT research scientist N. Apurva Ratan Murty. The study appears recently in the journal Current Biology. More than 20 years ago, while studying the ven tral visual stream, the part of the brain that recognizes objects, Kanwisher discovered cortical regions that re spond selectively to faces. Later, she and other scien tists discovered other regions that respond selectively to places, bodies, or words. Most of those areas were discovered when researchers specifically set out to look for them. However, that hypothesis-driven approach can limit what you end up finding, Kanwisher says.
“And even when we find something, how do we know that that’s actually part of the basic dominant structure of that pathway, and not something we found just because we were looking for “Weit?” wanted to see when we apply a data-driven, hypothesis-free strate gy, what kinds of selectivities pop up, and whether those are consistent with what had been discovered before. A second goal was to see if we could discover novel selectivities that either hasn’t been hy pothesized before, or that have remained hidden due to the lower spatial resolution of fMRI data,” Khosla says.The researchers found four populations that corre sponded to previously identified clusters that respond to faces, places, bodies, and words. “That tells us that this method works, and it tells us that the things that we found before are not just obscure properties of that pathway, but major, dominant properties,” Kanwisher says. “We were first quite puzzled by this because food is not a visually homogenous category,” Khosla says. “Things like apples and corn and pasta all look so un like each other, yet we found a single population that responds similarly to all these diverse food items.” The food-specific population, which the researchers call the ventral food component (VFC), appears to be spread across two clusters of neurons, located on either side of the FFA. The fact that the food-specific populations are spread out between other category-specific popula tions may help explain why they have not been seen before, the researchers say. “We think that food selec tivity had been harder to characterize before because the populations that are selective for food are intermin gled with other nearby populations that have distinct responses to other stimulus attributes. The low spatial resolution of fMRI prevents us from seeing this selec tivity because the responses of different neural popula tion get mixed in a voxel,” Khosla says.
vancing novel phage therapies that target specific pathogenic bacteria, based on Weizmann Institute re search under exclusive license from Yeda Research and Development Company Ltd., Weizmann’s tech nology transfer arm. “Our vision is to eventually de velop personalized therapies for a variety of disorders, in which the disease-causing strains of gut bac teria will be identified in each pa tient and a phage cocktail will be designed to kill only those strains,” Elinav says.
Medi Matters The Indian Practitioner q Vol.75 No.8. August 2022
“There could be other things that we might not think to look for,” she says.
Methods: Descriptive and analytical research designs were used to conduct the study. A stratified random sampling technique was used while selecting the samples. Twenty-five employees were interviewed according to a structured questionnaire. A patient satisfaction level questionnaire was administered to a sample of 50 patients. Descriptive statistics were used to express the categorical variables.
Healthcare Workers Satisfaction and Patients’ Satisfaction: An Effort to Find out Linkage
Keywords: patient satisfaction, patient experience, employee satisfaction, out-patient department
Conflict of Interest: None declared Source of funding: None declared
Patient satisfaction is the real testimony to the efficiency of hospital administration. A patient is the ultimate consumer of the hospital. Therefore, patient satisfaction has become increasingly popular as a critical component in measuring the quality of care. Literature suggests the significant impact of employee satisfaction on patient satisfaction. Thus, the study’s objective is to determine the level of patient satisfaction towards OPD services with reference to Employee MaterialsSatisfaction.and
Background:Abstract
Results: Patient feedback findings bring out positive responses from over 70% of the patients on this aspect. 56% reacted average/unhappy with the overall experience about referring the hospital. Employee satisfaction findings highlight dissatisfaction among hospital employeeson the grounds of exploiting work atmosphere, inadequate training provision, being overloaded, recognition of efforts, and lack of support from a supervisor. Positive feedback was obtained on the grounds of effective communication by the management, knowledge about the job profile, and training and development.
1 Assistant Professor, Mumbai Campus, Centre for Hospital Management, 2 Student, Mumbai campus, Masters of Public Health, Social epidemiology, 3 Student, Mumbai Campus, Masters of Hospital Administration, School of Health System Studies, Tata institute of Social Sciences
Corresponding Author: Aditi Choudhary, Student, Mumbai campus, Masters of Public Health, Social epidemiology, School of Health System Studies, Tata institute of Social Sciences. Email: aditichoudhary287@gmail.com
Introduction Patient satisfaction is a fact that lies between a patient expectation of an ideal nursing home and his perception of the real nursing care that he receives.[1] As the hospital serves all the members of society, the users’ expectations differ from one indi vidual to another because everyone carries a particular set of thoughts, feelings, and needs. Patient satisfaction is thus defined as a patient’s subjective evaluation of their cognitive and emotional reaction as a result of the interaction between their expectation regarding ideal nursing care and their perceptions of actual nursing care.[2] In general, patient satisfaction is defined as a mea sure of patients’ contentedness with the health care they receive from their health care provider. Modern era pa tients are pretty aware and educated about the diseas es, types of treatments, and available healthcare facili ties, causing increased expectations from the healthcare system. The tremendous rise of competition among the health care providers with the rapidly growing health care industry makes it even more important for pro
Original Article The Indian Practitioner d Vol.75 No.8 August 202222
Conclusion: Assessment of patient satisfaction can improve service quality. By viewing employees as ‘internal customers,’ efforts to create higher employee satisfaction can have desirable outcomes on enhanced care quality and increased patient satisfaction.
Dr. Dhananjay Mankar 1, Aditi Choudhary 2, Dr. Himani Gujar 3
Figure 1: The Performance-Perception gap (Adapted from: Mohd A et al. Patient satisfaction with services of the outpatient department. MJAFI. 2014.)
The Indian Practitioner d Vol.75 No.8 August 2022 Original Article 23 viders to focus on excellent outcomes in terms of both treatment and patient satisfaction. McNealy emphasised the importance of the ‘percep tion gap’ or the gap between patients’ perceptions of care and their needs and expectations. If this gap is nonexistent and the performance level is already at satisfac tion or the ‘delight’ levels, patients will be happy and satisfied, as shown in Figure 1. care to others. As suggested by this wealth of findings, positive changes in employee attitudes lead to positive changes in customer satisfaction. A model developed by Yoon, Hyun Seo and Seog Yoon, indicates three an tecedents affecting employee service quality through their effect on employee service effort and perceived job satisfaction,[4] as shown in Figure-2. Out of these three, perceived supervisory support is the most pow erful predictor of job satisfaction and employee service effort. Job satisfaction is a more important predictor of employee service quality than effort. Healthcare employee satisfaction has been found to have several impacts on the quality of care delivered, which ultimately influences the level of patient sat isfaction. Employee’s satisfaction negatively impacts the quality of care and ultimately has an adverse ef fect on patient loyalty and in turn, hospital profitability, healthcare employee moral also demonstrates a strong relation with patient satisfaction.
Study settings: The study was carried out over four weeks in a multispecialty private hospital in Telangana.
Sample Size Calculation: The study population consisted of 50patients. Three types of patients were in volved in the study, viz: cash patients, international pa tients and corporate patients. 25 employees across var ious positions participated in the study. The age group of the employee ranged from 24 to 45 Years. The per sonnel interviewed consisted of 10 assistant officers, 12 junior officers, 2 senior officers, and 1 executive. The sources from which information was derived were sur veys, relevant file studies, registration data, appoint ment system, and referrals.
The study uses employee surveys and customer sur veys. Descriptive and analytical research designs were used to conduct the study. A structured questionnaire was administered to the employees, including patient and employee satisfaction questions. Another question naire was used to identify the patient satisfaction lev el in a sample of 50 patients. The observation was con ducted on patient traffic control and front office staff absenteeism.
Sampling Technique: Stratified random sampling technique was used in selecting the samples.
Materials and Methods
Method of Data Collection: The questionnaire de veloped for data collection contained both open-ended and closed-ended questions regarding the patient’s so cio-demographic history, satisfaction with the doctor, location of the registration desk, adequate seats in the waiting area, behaviour of the staff and reasons for revisiting the hospital. It was pilot tested, and after ap
Figure 2: Hypothesized model of contact-employee supports (Adapted from: Yoon MH et al. Effects of contact employee supports on critical employee responses and customer service evaluation. JSM. 2004)
Addressing this gap through quantitative measure ment of customers’ perceptions of the performance and their needs/expectations can have strategic implica tions, like better marketing and merchandising services to potential customers.
The measurement of patient satisfaction as an essen tial tool for research, administration, and planning was emphasised by WHO in 1984. It is known to be one of the most important quality parameters as it helps deter mine the level of services catered by the medical staff. Patient satisfaction measurement adds important infor mation on system performance, thus contributing orga nization’s total quality management. A satisfied patient is more willing to recommend the hospital to provide
q Personal observation: direct & indirect observation Interview with staff Interview with patients/ relatives/ attendants and other external customers
• Fairly
q
Tool and Techniques used for Data Collection:
Original Article
Results Patient Feedback Findings [Table 1]: 72% of pa tients/respondents were unhappy with the appoint ment systems. The Contact Centre of the hospital was relocated and was inadequate, which resulted in nega tive feedback and disappointments as a majority of the calls were unattended. It failed to create the desired first impression.
q Systemized feedback Data routinely collected by the hospital was utilised in the study. The hospital regularly collected data on em ployee satisfaction and patient satisfaction. Employee satisfaction data were collected by the hospital as part of an annual employee survey. Patient satisfaction data were collected at the time of a patient’s discharge from the hospital. Both data sets were then matched at the de partment level to assess the relationship between em ployee satisfaction and patient satisfaction.
38% of the respondents were extremely satisfied as they rated excellent, and 42% rated good for the front office team behaviour. The majority of the front of fice staff was polite and courteous as per their feed back. Regarding the registration and billing process ex perience, 20% of the respondents were happy, where as 50% rated well. Explanation of treatment and treat ment plan was experienced as extremely satisfying by the majority of the respondents as 70% ratings were ex cellent and 30% were good. 80% of the study popula tion agreed that cleanliness was good. The sitting ar rangement, signage and directions, drinking water and washroom facilities were also found to be good as per stated responses. However, 56% reacted average or un happy with the overall experience as they would think on referring any near and dear ones.
24% of employees showed dissatisfac tion regarding the organisation’s investment on employees, as they wished that the hos pital should help them for higher studies by granting financial support as a loan. 32% of employees’ expressed dissatisfaction about the extension of consent by the management, when possible, to do so. 48% reported negatively about being treated fairly in terms of below aspects: Mutual respect between all employees are treated courteously and equitably rules to
q
Data analysis: Descriptive statistical analysis was used to determine significant factors impacting patient and employee satisfaction.
The Indian Practitioner d Vol.75 No.8 August 202224 propriate amendments, was used to collect data from the patients. Informed and voluntary consent was tak en from the patients after explaining the purpose of the study to them.
Employee survey findings [Table 2]: Employee feedback survey reflected a great deal of dissatisfaction on the grounds of several parameters, making them feel less valued at work. Positive feedback was also captured by the survey on some grounds. The follow ing results were drawn: 56% of the employees, that is, more than half of the total employees, revealed a neg ative feeling about team co-operation. Similarly, more than half of the employees (52%) believed that the hos pital does not recognise contributing the most to the or ganisation. 60% of employees felt that they do not have the freedom to do the work their way, like assisting pa tients out of the way, which is not as per the SOP. Many employees, 68%, believed that the immediate supervi sor is not friendly and reported unavailability during critical times. Upon asking if the place is friendly to work in, 52% of employees reported groupism among employees who do not wish to extend sup port or involve other team-mates. 68% of em ployees felt that they get unfair treatment from their supervisor.
•
• Employees
all • Proper approach • Equality Table 1: Patient Satisfaction Survey results
The Indian Practitioner d Vol.75 No.8 August 2022 Original Article
Discussion The study agreed that measuring patient satisfaction has a bearing on quality improvement of care. As found in the study by Al-Abri et al., [5] patients’ evaluation of care is a practical tool to provide an opportunity for im provement, enhance strategic decision making, reduce cost, meet patients’ expectations, frame strategies for ef fective management, monitor healthcare performance of health plans and provide benchmarking across the healthcare institutions. In another study conducted in AIIMS, Bhubaneshwar agrees that the satisfaction lev el of patients, from the patient’s perspective, facilitates identifying the areas of improvement, and helps gen 25
A study by Tan, Foo and Kwek,[9] also recognizes that the emotions displayed by employees in in-service set tings have implications for customer satisfaction. The way employees feel about their job impacts their work experience, thereby impacting their quality-of-service delivery. However, they are more likely to do so if they are satisfied with their job. Employees were dissatisfied with numerous aspects of job satisfaction, which was reflected in customer feedback. As described by Berry [10], patients will be loyal if the service provider is able to attract, maintain, and enhance customer relationships.
erate ideas towards resolving these prob lems.[6] A recent study carried out in a ter tiary care teaching hospital in South India complies with the finding, that patient sat isfaction surveys may be a good audit tool and should be used to improve the standard of services.[7] Contrary to this study, where 95.5% of patients agreed to recommend the hospital to others, our study showed lesser satisfaction (56%) when asked for a referral. In our study, 72% of patients/respondents were unhappy with the appointment sys tems. Negative feedback and disappoint ments resulted as most calls were unattend ed. However, in the study by Nilakantam et al. in the Mysore tertiary care teaching hos pital, a small proportion of 7.3% of the re spondents faced difficulties in the registra tion process. 80% of the respondents in our study were satisfied with the Front office team behaviour, as compared to 95% in the study by Nilakantam et al.[7] Results as per observation show that the OPD waiting area was not adequate to ca ter to the footfall. A study at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India, showed 93% patient satisfaction with the waiting area. A good response regarding the signage system was found, contrary to the study at AIIMS, Bhubaneshwar, where only 50% of patients uti lise signage for guidance and navigation. Satisfaction was found to be high (80%) in the study group regard ing the cleanliness of OPD services. A similar study was conducted in the outpatient department of Tertiary care hospital, Jabalpur, Madhya Pradesh, India, which indi cated that 70% of patients are satisfied with the cleanli ness of the OPD.[8]
Pauli et al., explains the importance of word of mouth in the health sector emphasising the linkage with em ployee satisfaction, “Patient loyalty is linked to employ ee satisfaction and also influences the recruiting of new Employee Satisfaction Survey Results
Table 2:
Nonetheless, counting on the positive feedback, 80% of the employees understood and knew the job profile. 76% of the employees believed that the management conveys proper communication. 76% of the employees felt that the organisation promotes ongoing learning, and the Learning and Development (L&D) department plays an active role in improving the necessary skills. 64% of employees felt that the supervisor follows ‘opendoor’ policy and is available to entertain any queries. They thought employees are welcomed to clarify issues. Lastly, 52% of the employees believed that the hospital treats them fairly.
References 1. Penchansky R, Thomas JW. The concept of access: defini tion and relationship to consumer satisfaction. Med Care. 1981;19(2):127-140.
10. Abramowitz S, Coté AA, Berry E.Analyzing patient sat isfaction: a multianalytic approach. QRB Qual Rev Bull. 1987;13(4):122-130.
Conclusion Patient satisfaction is significantly a dependent fac tor of the quality of services provided at the outpatient department. It was observed that apart from medical and nursing care, other support facilities provided by the hospital, front office/customer care play a major role in customer satisfaction. Although, patients were found to be satisfied with both the physical and behavioural dimensions of service, and the overall patient satisfac tion was average, they were found to be dissatisfied/un happy about the front office services. Patient satisfac tion is greatly influenced by staff behaviour, which in turn is determined by employee satisfaction and moti vation. Employees were having some internal disputes among each other, as well as with the organisation, which reflected in their work. Employee satisfaction needs to be addressed by the organisation. In addition to what health care workers do, emphasis needs to be placed on how the employees feel about what they do.
Original Article The Indian Practitioner d Vol.75 No.8 August 2022
• For enhancing more cohesive company culture, the hospital should been couraging and training teams to work well together, thus increasing workplace productivity.
• An open-door policy should be adopted by the man agerial staff. It is a communication policy in which the higher authorities leave their office door ‘open’ to encourage openness and transparency with the employees of that company.
Recommendations
patients and new employees”.[11] Satisfied employees have high energy and willingness to give good service: at a very minimum, they can deliver a more positive perception of the service/product provided. Health care is an extremely people-based industry. Because of this, human resource is believed to be the greatest asset of all, and an empowered, motivated, and satisfied workforce can bring indissoluble strength to the organisation.
• A company-wide email acknowledgment, or shoutout in a meeting, can go a long when it comes to rec ognition and appreciation of efforts, creating moti vation.
• Key Performance Indicators as a long-term goal-de fining process should be developed to inculcate bet ter role clarity among employees and accomplish ment of tasks within clear time limits.
3. The present study only estimates, but does not infer the effect of employee satisfaction and customer sat isfaction on tangible business outcomes.
4. As this study was conducted over a limited period of time, we were not able to include post treatment out come and post treatment quality of life.
5. Pradhan SK, Sahu DP, Sahoo DP, Singh AK, Patro BK, Mohanty S. Experience from a COVID-19 screening cen tre of a tertiary care institution: A retrospective hospitalbased study. Journal of Family Medicine and Primary Care. 2021;10(8):2933-2939.
6. Kiran Kumar MV, Jawahar SKP. A study on the level of pa tient satisfaction on OPD services using standard indicators in a tertiary care teaching hospital, AIIMS Bhubaneswar. International Journal of Scientific Research. 2020;9(1):32-35.
8. Sharma A, Kasar, P, Sharma R. Patient satisfaction about hospital services: a study from the outpatient department of tertiary care hospital, Jabalpur, Madhya Pradesh, India. National Journal of Community Medicine. 2014;5(2):199-203.
9. Tan HH, Foo MD, Kwek MH.The effects of customer person ality traits on the display of positive emotions. Academy of Management Journal. 2004;47(2):287-296.
2. Eriksen LR. Patient satisfaction: an indicator of nursing care quality? Nurs Manage.1987;18(7):31-35.
1. Our study comprises people belonging only to a particular part of India living in southern part of the country.
Limitations of the study
11. Pauli G, Martin S,Greiling D. The current state of research of word-of-mouth in the health care sector. Int RevPublic Nonprofit Mark.2022; 8:1-24. + 26
• Hospital waiting room facility is not enough to sat isfy patients as the level of satisfaction is only 70%. Attendants of the patients who are in ICU are also waiting in the OPD waiting area, which crowds the area and there is no separate facility for them. Free space on the first floor can be utilized by the hospital to create waiting area for attendants, thus decrowd ing OPD waiting area.
2. Reluctance of patient to express their true feelings about the care they received, and also the generosity factor acts as intervening factors.
4. Al-Abri R, Al-Balushi A. Patient satisfaction survey as a tool towards quality improvement. Oman Med J. 2014;29(1):3-7.
3. Mahn HY, Jai HS, Tae SY. Effects of contact employee sup ports on critical employee responses and customer ser vice evaluation. Journal of Services Marketing - J Serv Mark. 2004;18(5):395-412.
7. Nilakantam SR, Madhu B, Prasad MC, Dayananda M, Basavanagowdappa H, Bahuguna J, Rao JN. Quality improve ment project to assess patient satisfaction towards outpatient services of a tertiary care teaching hospital, South India- A cross-sectional study. Ann Afr Med. 2021;20(3):198-205.
Author: Dr. Charmi Bhanushali, General Medicine, TNMC & Nair Hospital, Mumbai. Email: charmi.bhan@gmail.com
Monkeypox: Transmission, Clinical Features, Diagnosis, Treatment, and Prevention Charmi Bhanushali 1, Vidhi Bhanushali 2
Keywords: monkeypox virus, smallpox, orthopoxvirus, skin lesions, antiviral medications, ring vaccination
2 Final Year Medical Student, Seth GS Medical College and KEM Hospital, Mumbai
Corresponding
Dr.
a zoonotic disease that is caused by the Monkeypox virus (MPX). MPX is similar to the virus that causes smallpox. It was endemic to central and west regions of Africa but has recently been reported in different parts of the globe. The primary reservoirs of MPX are wild animals particularly primates (Mangabey monkeys), Gambian pouched rats, and squirrels. Most cases of Monkeypox are due to the transmission of the virus from animals to humans. In addition, there have also been instances of human-to-human spread through respiratory droplets, fomites, and sexual contact. Monkeypox has a varied presentation ranging from mild symptoms to severe disabling complications. Real time PCR is used to diag nose orthopoxvirus. Retrospective diagnosis is done using serological tests. Symptomatic management and prevention of secondary infection are the mainstay aim of treatment. Antiviral drugs like cidofovir, brincidofovir, and tecovirimat seem to work against MPX even though there is no specific treatment against the virus. Health education of masses, prophylactic vaccination, quarantining the exposed, appropriate personal protective equipment for health care workers, etc. is some of the preventive measures to curb the disease. The newer-generation smallpox vaccine, JYNNEOS and the older-generation ACAM20, can also be used for prevention of Monkeypox.
1 General Medicine, TNMC & Nair Hospital, Mumbai
Clinical Practice The Indian Practitioner d Vol.75 No.8 August 2022 27
Introduction
MonkeypoxAbstractis
Monkeypox (MPX) is a zoonotic disease caused by a double-helix DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family.[1] It was first reported in the Democratic Republic of Congo in 1970 and is closely related to the virus that causes smallpox.[2] In the past, there have been sporadic outbreaks in Africa, particularly in the Central and West regions where it is endemic. However, the recent surfacing of MPX in several nonendemic areas outside Africa has caused great concern. This could be due to the waning of population immu nity after the discontinuation of smallpox vaccination in 1980.[3] Other plausible causes are the worldwide growth of trade, travel, cultural and diplomatic rela tions.[4] Climate change is another possible factor as de forestation and flooding have driven animals, which are reservoirs of MPX into human populations. On June 23, 2022, the World Health Organization declared Monkeypox as an “evolving threat of moderate public health concern” after more than 3000 cases was identi fied in more than 50 countries since May 2022.[2] Transmission Most cases of Monkeypox are due to the transmis sion of the virus from animals to humans.[5] The pri mary reservoirs of MPX are wild animals particular ly primates (Mangabey monkeys), Gambian pouched rats, and squirrels.[6] Infection occurs by bites of infect ed fauna and through direct contact with blood, body fluids, and MPX lesions of diseased animals. Eating un dercooked infected animals can also spread the virus.[7] Since the eradication of smallpox, there has been a re duction in the population immunity to Orthopoxvirus, leading to instances of human-to-human spread. This can occur through respiratory droplets, direct contact with skin lesions of infected individuals, and possibly
The clinical presentation of Monkeypox overlaps with that of many other rash causing viruses like vari cella and HSV, therefore it is important to differentiate them using laboratory methods. Testing should be do ne on any individual that meets the criteria laid down by WHO 2022.[12] The specimen is mostly collected from skin lesions in the form of vesicular lesions, exudate, or crusts. Vigorous swabbing is done from the surface, floor, cor ners, and exudate of the lesion for obtaining an ade quate amount of viral DNA.[13] Nasopharyngeal swab is collected for viral culture. Two swabs from skin lesions are collected using a sterile, dry, polyester or Dacron swab. The sample is laid down in a sterile and dry container or in a viral transport medium and transported at the temperature of 4°C. One swab is used for screening and another for additional testing.[14,15]
Screening is done using nucleic acid amplification testing (NAAT) - real-time polymerase chain reaction (PCR) that detects viral DNA. The advantage of this test is that it is highly sensitive and provides quick results. [16] Once the test comes positive for Orthopoxvirus, it is sent further to test specifically for Monkeypox virus. Several MPX generic PCR based tests have been de veloped having high specificity for Monkeypox virus to differentiate it from other Orthopoxviruses. In ad dition, there are also tests available that can differenti ate between strains of MPV like Congo Basin and West African strain. [17,18]
The course of infection by Monkeypox virus is mostly self-limiting and resolves on its own. There is as such no specific treatment for the Monkeypox vi rus. Symptomatic treatment is the prime focus in man agement along with the prevention of secondary bac terial infection by early diagnosis and prompt treat
Electron microscopy (round-to-oval inclusions with sausage-shaped structures) and immunohistochemis try was carried out earlier but are no longer in use as they are not specific and cannot distinguish between Orthopoxviruses.Retrospective diagnosis is done using serologi cal tests. Anti-Orthopoxvirus IgG tests for the pres ence of Orthopoxvirus antibodies but is not specific due to cross-reactivity among Orthopoxviruses. There is also a chance of getting false positive results in peo ple who are vaccinated against smallpox.[14,15] Instead, Orthopoxvirus immunoglobulin M (IgM) can be used to determine the infectious agent in a recently retro spective infection or one with previous history of vacci nation against smallpox.[19] Treatment
The Indian Practitioner d Vol.75 No.8 August 2022 Clinical Practice 28 through contaminated fomites. The recent outburst has exceedingly affected men who have sex with men. This points out to the transmission of the virus through sex ual contact. The mother can also spread the virus to the fetus via the placenta.[6]
can present with se vere symptoms. The case fatality rate of Monkeypoxis about 1%–10%.[5] There can be secondary infection of the lungs leading to bronchopneumonia and respirato ry distress. There have been instances of the virus caus ing diarrhea, resulting in dehydration.[8] In extreme cas es, it can cause encephalitis and septicemia. [10] Corneal scarring and permanent vision loss may occur due to the virus attacking the eye or due to secondary bacteri al infections.[11] Other serious complications that can oc cur due to MPX are- epiglottitis, myocarditis, and acute kidney injury. Diagnosis
The incubation period of MPX is 4–21 days.[3] MPX causes mild symptoms in immunocompetent individ uals. However, immunocompromised individuals like children, the elderly, pregnant women, and individu als with co-morbidities such as HIV/AIDS and diabetes, can present with severe disease.[3] Human Monkeypox shares many clinical features with smallpox. The pres ence of lymphadenopathy classically differentiates Monkeypox from smallpox. Monkeypox has a varied presentation. It can pres ent with a prodrome of fever, fatigue, myalgia, and headaches. This is followed by the appearance of a rash which may be accompanied by lymphadenopathy. An individual can have cervical, maxillary, or ingui nal lymphadenopathy. On examination, the enlarged lymph nodes are firm and tender.[8] The rash that fol lows the prodrome begins on the face and spreads on the body in a centrifugal manner. The rash progress es through the following stages- macular, papular, ve sicular, and then pustular. The lesions may be present in the mouth and can interfere with eating and drink ing.[9,10] Fever subsides on or within 3 days of rash on set. The skin lesions can also become secondarily infect ed with Anotherbacteria.presentation is the occurrence of skin le sions due to MPX in the following anatomical regions in the order of decreasing frequency- the anogenital ar ea (73%); the trunk, arms, or legs (55%); the face (25%); and the palms and soles (10%). The involvement of the anogenital region can present with pain, proctitis, te nesmus, and/or Immunocompromiseddiarrhea.[2]patients
Clinical features
5. Qizan G, Changle W, Xia C, Sandra C. Monkeypox virus: a re-emergent threat to humans. VirologicaSinica. 2022;S1995820X(22)00120. Available from- Monkeypox virus: a re-emer gent threat to humans - PubMed (nih.gov)
Clinical Practice
The Indian Practitioner d Vol.75 No.8 August 2022 29 ment using appropriate antibiotics.[20] Usage of antivi ral medications may be necessitated in immunocom promised people, pregnant or breastfeeding wom en, and children. One of the antiviral medications is Tecovirimat which acts by inhibiting the envelope pro tein of Orthopoxvirus.[21] Other medications include Cidofovir and brincidofovir which prevent the action of viral DNA polymerase thus blocking viral replication. [22] Tecovirimat was found to be more efficient and was associated with fewer adverse effects than brincidofo vir.[23]
2. John T, Sapha, Sharon T, Juergen R, Andrea A, Luke H, Romain P, Achyuta N, Iain R, Maximillian H, Vanessa A, Christoph B.Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022. The New England Journal of Medicine. 2022. Available from- Monkeypox Virus Infection in Humans across 16 Countries — April–June 2022 | NEJM
To overcome these disadvantages, the newer vac cine JYNNEOS is used. It is administered in two dos es and confers immunity 14 days after the second dose. [24] It is used as post-exposure prophylaxis in immuno compromised patients and in whom ACAM2000 is con traindicated.Usageof vaccine immunoglobulin is still under re search. Prevention Prevention includes preventing contact with ro dents and primates and consumption of inappropri ately cooked meals. Health education about the virus, its transmission, and means of control should be made known to the masses.
In case of an outbreak, infected animals need to be identified and those who came in contact with them should be traced. These individuals are quarantined for around 6 weeks and given a prophylactic vaccine. Isolation of the diseased and proper transport or care of secretions using gloves, protective clothing, and surgi cal masks is imperative to prevent accidental exposure to the virus. The patient should be kept in a negative air pressure isolation room. Standard, contact, and droplet precautions should be taken.[1]
Vaccine Protection
7. C.K. Ellis, D.S. Carroll, R.R. Lash, A.T. Peterson, I.K. Damon, J. Malekani and P. Formenty. Ecology and geography of hu man Monkeypox case occurrences across Africa. J. Wildl. Dis. 2021;48:335-347. Available from- Ecology And Geography Of Human Monkeypox Case Occurrences Across Africa | Journal of Wildlife Diseases (allenpress.com)
3. Alakunle, E.F., Okeke, M.I. Monkeypox virus: a neglect ed zoonotic pathogen spreads globally. Nat Rev Microbiol. 2022;20:507–508. Available from-Monkeypox virus: a neglect ed zoonotic pathogen spreads globally | Nature Reviews Microbiology.
4. Okyay RA, Bayrak E, Kaya E, Şahin AR, Koçyiğit BF, Taşdoğan AM, Avcı A, Sümbül HE. Another Epidemic in the Shadow of Covid 19 Pandemic: A Review of Monkeypox. Eurasian J. Med. Oncol. 2022;7:10. Available from- Another Epidemic in the Shadow of Covid 19 Pandemic A Review of Monkeypox-2022.pdf (ejmo.org)
The concept of ring vaccination is used to confer pro tection against both smallpox and Monkeypox using ACAM2000.[20] It is administered in a single dose and its protective effect starts after 4 weeks. The disadvantage of this vaccine is that it cannot be used in immunocom promised as it is a live virus vaccine. Moreover, vacci nation leads to the formation of skin lesions that can spread the virus to those that come in contact with it.[26]
Acknowledgments: familiesforWewouldliketoexpressourappreciationtoDr.Shahhisguidanceandsupportthroughouttheprocessofwritingthisarticle.Wewouldalsoliketothankourfortheircontinuedsupport.
8. Andrea M. McCollum, Inger K. Damon. Human Monkeypox. Clinical Infectious Diseases. 2014;58(2):260–267. Available fromHuman Monkeypox | Clinical Infectious Diseases | Oxford
6. Brown K, Leggat PA. Human Monkeypox: current state of knowledge and implications for the future. Tropical med icine and infectious disease. 2016;1(1):8. Available fromTropicalMed |Free Full-Text | Human Monkeypox: Current State of Knowledge and Implications for the Future|HTML (mdpi.com)
All people exposed to Monkeypox or likely to get exposed in the future are vaccinated. These include all the people who have been identified to have been in contact with a person having Monkeypox by a public health officer, those who have multiple sexual partners in Monkeypox endemic areas or got notified that one of their sexual partners was diagnosed with Monkeypox in past 2 weeks.[24] It is also given to service providers that may come in contact with these patients like re searchers, health care workers, field investigators, an imal control personnel, andveterinarians. Prophylactic use of the vaccine either aborts the infection or signif icantly decreases the severity of the clinical course.[25]
References 1. Petersen E, Kantele A, Koopmans M, Asogun D, YinkaOgunleye A, Ihekweazu C, Zumla A. Human Monkeypox: epidemiologic and clinical characteristics, diagnosis, and prevention. Infectious Disease Clinics. 2019;33(4):1027-43. Available from- Human Monkeypox - Infectious Disease Clinics (theclinics.com)
9. Di Giulio DB, Eckburg PB. Human Monkeypox: an emerging zoonosis. The Lancet infectious diseases. 2004;4(1):15-25.Human Monkeypox: an emerging zoonosis - The Lancet Infectious Diseases
12. Surveillance, case investigation and contact tracing for Monkeypox: interim guidance, 22 May 2022]. Geneva: World Health Organization; 2022 (https://apps.who.int/iris/han dle/10665/354486/).
18. V.A. Olson, T. Laue, M.T. Laker, I.V. Babkin, C. Drosten, S.N. Shchelkunov, M. Niedrig, I.K. Damon, H. Meyer a. Real-time PCR system for detection of orthopoxviruses and simul taneous identification of smallpox virus. J. Clin. Microbiol. 2004;42:1940-1946. Available from Real-time PCR system for detection of orthopoxviruses and simultaneous identification of smallpox virus - PubMed (nih.gov)
19. Karem KL, ReynoldsM, BradenZ, et al. Characterization of acute-phase humoral immunity to Monkeypox: use of immunoglobulin M enzyme-linked immunosorbent as say for detection of Monkeypox infection during the 2003 North American outbreak. ClinDiagn Lab Immunol. 2005;12. Available from- characterization of acute-phase humoral im munity to Monkeypox: use of immunoglobulin M enzymelinked immunosorbent assay for detection of Monkeypox in fection during the 2003 North American outbreak - PubMed (nih.gov)
15. Ranganath N, Tosh PK, O’Horo J, Sampathkumar P, Binnicker MJ, Shah AS. Monkeypox 2022: Gearing Up for Another Potential Public Health Crisis. InMayo Clinic Proceedings 2022 Available from https://pubmed.ncbi.nlm.nih.gov/35985857/
23. H. Adler, S. Gould, P. Hine, et al. Clinical features and man agement of human Monkeypox: a retrospective observa tional study in the UK. Lancet Infect Dis.2022;22(7):e177. Available from-Clinical features and management of human Monkeypox: a retrospective observational study in the UKThe Lancet Infectious Diseases
10. Ježek Z, Szczeniowski M, Paluku KM, Mutombo M. Human Monkeypox: clinical features of 282 patients. Journal of in fectious diseases. 1987;156(2):293-8. Available from- Human Monkeypox: Clinical Features of 282 Patients | The Journal of Infectious Diseases | Oxford Academic (oup.com)
21. D.W. Grosenbach, K. Honeychurch, E.A. Rose, et al.Oral tecovirimat for the treatment of smallpox. N Engl J Med. 2018;379 (1): 44-53. Available from-Grosenbach: Oral tecovir imat for the treatment of smallpox - Google Scholar. 22. C.L. Hutson, A.V. Kondas, M.R. Mauldin, et al Pharmacokinetics and efficacy of a potential smallpox ther apeutic, brincidofovir, in a lethal Monkeypox virus animal model.m Sphere. 2021;6(1):e00927-e01020.Available fromPharmacokinetics and Efficacy of a Potential Smallpox Therapeutic, Brincidofovir, in a Lethal Monkeypox Virus Animal Model | mSphere (asm.org)
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11. Learned LA, Reynolds MG, Wassa DW, Li Y, Olson VA, Karem K, Stempora LL, Braden ZH, Kline R, Likos A, Libama F. Extended interhuman transmission of Monkeypox in a hospital community in the Republic of the Congo, 2003. The American journal of tropical medicine and hygiene. 2005;73(2):42834. Available Of_Monk20211028-10917-go1cb6-with-cover-page-v2.pdffrom-Extended_Interhuman_Transmission_ (d1wqtxts1xzle7.cloudfront.net)
13. World Health Organization (WHO). Laboratory testing for the Monkeypox virus: Interim guidance. Geneva: WHO; 2022 Available from: https://www.who.int/publications/i/item/ WHO-MPX-laboratory-2022.1
25. Adalja A, Inglesby T. A novel international Monkeypox out break. Annals of Internal Medicine. 2022;175(8):1175-1176. Available from- A Novel International Monkeypox Outbreak - PubMed (nih.gov)
20. G.D. Huhn, A.M. Bauer, K. Yorita, et al.Clinical characteris tics of human Monkeypox, and risk factors for severe dis ease. Clin Infect Dis. 2005;41(12):742-1751. Available fromClinical characteristics of human Monkeypox, and risk fac tors for severe disease - PubMed (nih.gov)
24. Centers for Disease Control and Prevention. Clinical Recognition. 19 May 2022. Available fromvirus/Monkeypox/clinicians/clinical-recognition.html.www.cdc.gov/pox
26. B.W. Petersen, T.J. Harms, M.G. Reynolds, L.H. Harrison. Use of vaccinia virus smallpox vaccine in laboratory and health care personnel at risk for occupational exposure to Orthopoxviruses—recommendations of the Advisory Committee on Immunization Practices (ACIP). 2015; 65:257-262. Available from- Use of Vaccinia Virus Smallpox Vaccine in Laboratory and Health Care Personnel at Risk for Occupational Exposure to Orthopoxviruses — Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2015 on JSTOR. + 30
16. Li Y, Zhao H, Wilkins K, Hughes C, Damon IK. Real-time PCR assays for the specific detection of Monkeypox virus West African and Congo Basin strain DNA. J Virol Methods. 2010;169(1):223-7. Available from- Real-time PCR assays for the specific detection of Monkeypox virus West African and Congo Basin strain DNA - PubMed (nih.gov)
17. Y. Li, V.A. Olson, T. Laue, M.T. Laker, I.K. Damon.Detection of Monkeypox virus with real-time PCR assays. J. Clin. Virol. 2006;36:194-203. Available from-Real-time PCR assays for the specific detection of Monkeypox virus West African and Congo Basin strain DNA - PubMed (nih.gov)
14. A. Nalca, A.W. Rimoin, S. Bavari, C.A. Whitehouse. Reemergence of Monkeypox: prevalence, diagnostics, and countermeasures. Clin Infect Dis. 2005; 4 (12):17651771. Available cle/41/12/1765/2033760#111799177from-https://academic.oup.com/cid/arti
Chronic pancreatitis is the most common pancreat ic disease associated with EPI.[7] It is reported in 60-90 percent patients 10-15 years after diagnosis.[8] It occurs as a result of progressive inflammatory changes result ing in permanent damage of the acinar cell function. EPI is seen in >75 percent of newborns born with cys tic fibrosis; an autosomal recessive disorder caused by a mutation of the gene that encodes for Cystic Fibrosis
Physiologic digestive process requires pancreat
1,2 General Medicine, TNMC & Nair Hospital, Mumbai
ExocrineAbstractPancreatic
Prevalence
Dr. Ashni Dharia 1, Dr. Charmi Bhanushali 2
Introduction Exocrine pancreatic insufficiency (EPI) is identi fied by the insufficiency of exocrine pancreatic enzymes.[1, 2] Inadequate digestion occurs when intra-duodenal levels of lipase fall below 5–10% of nor mal enzyme output, which is the threshold required for normal digestion.[3] EPI presents with non-specific symptoms similar to other gastrointestinal diseases and can lead to clinical presentations and biochemi cal modifications, which can result in life-threatening conditions and decrease the quality of life. Abdominal distress, loose bulky stools, and malnutrition form a part of the clinical presentations of EPI. The biochemi cal modifications are related to impaired breakdown and absorption of fats and fat-soluble micronutrients. In simple terms, EPI leads to maldigestion and mal absorption.[1,2] Malnutrition, which occurs because of malabsorption, leads to weight loss and contributes to future cardiovascular events. In addition, malnutrition can cause alterations in the bone density.[5] EPI is also an independent risk factor for death in patients with chronic pancreatitis.[4] Mild EPI may have no clinical manifestations but can significantly affect the nutri tional condition of patients.[6] Therefore, it is important that symptoms like flatulence, abdominal cramps, and nutritional deficiencies are identified in patients at-risk of EPI and are diagnosed and treated appropriately.
Pathophysiology
Keywords: chronic pancreatitis, malabsorption, fecal elastase, pancreatic enzyme replacement therapy
Clinical Practice The Indian Practitioner d Vol.75 No.8 August 2022 31
Corresponding Author: Dr. Charmi Bhanushali, General Medicine, TNMC & Nair Hospital, Mumbai. Email:charmi.bhan@gmail.com
Transmembrane conductance Regulator (CFTR).[9] The mutation results in the production of inspissated pan creatic secretions that cause blockade of tubules which results in progressive pancreatic damage. EPI is also seen with acute pancreatitis, autoimmune pancreati tis, pancreatic adenocarcinoma, and resective pancreat ic surgery.Among extra-pancreatic causes, EPI is commonly seen in patients with Diabetes Mellitus Type 1 & 2. It is caused by various factors such as lack of the trophic ac tion of acinar cells, autoimmune damage of islet cells, decreased exocrine pancreatic secretion as a complica tion of diabetic neuropathy, and microvascular dam age induced pancreatic fibrosis.[10] It is also seen with inflammatory bowel disease, celiac disease, gastric re section, Sjogren syndrome, and heart failure patients.[1]
The prevalence of exocrine pancreatic insufficiency in the population is unknown.[1] The causes can be di vided into pancreatic and extra-pancreatic origin.
Exocrine Pancreatic Insufficiency: An Overview
Insufficiency (EPI) is identified by the insufficiency of exocrine pancreatic enzymes resulting in malabsorption. Patients with mild EPI maybe asymptomatic or have mild abdominal discomfort and bloating while advanced EPI results in steatorrhea and weight loss. The causes can be divided into pancreatic and extra-pancreatic origin. Pancreatic causes include chronic pancreatitis, cystic fibrosis, pancreatic tumors, and pancreatic resection. Extra-pancreatic causes include diabetes, IBD, celiac disease, etc.There are various direct and indirect tests available to diagnose EPI, with indirect ones such as the concentration of fecal elastase beingmost commonly used. However, the gold standard test for diagnosis is a72-hour fecal fat test.Treatment for pancreatic exocrine insufficiency includes lifestyle modifications, dietary consultation, and a structured assessment of nutritional status. The mainstay remains pancreatic enzyme replacement therapy, which is administered in the form of enteric-coated minimicrospheres during meals.
Pancreatic Enzyme Replacement Therapy (PERT)is the cornerstone of the treatment. It is administered as enteric-coated minimicrospheres in patients with EPI to compensate for the lack of enzyme secretion required for the physiological digestion process and prevent malabsorption. The pancreatic enzyme preparations are extracts prepared from the porcine pancreas.[1] They are consumed along with meals and mixed in the stom ach with the chyme but are protected from acid degra dation by an enteric coating. They are then released in to the duodenum where the acid-resistant coating dis solves in the duodenum’s alkaline environment, releas ing the enzymes at the optimum point for digestion and absorption. The optimal pH for enzyme activation in the duodenum is <6, hence some may require a tri al of acid-suppressing agents in patients who contin ue to experience symptoms of EPI despite high doses of PERT.[19] The APC-recommended PERT starting dose for adults is 25,000-40,000 units of lipase. If there is an insufficient response to the initial dose, it should be ti trated up to a maximum of 75,000-80,000 units of lipase per meal.It is essential to check gastrointestinal symp toms and nutritional parameters such as anthropome try, body weight, and Vit A, D, E, K, B12, and iron levels
The most used indirect test for exocrine pancreat ic function analyses is fecal elastase-1 levels. Pancreatic elastase-1 is a highly stable enzyme and is not degraded in the intestines.[13] Hence, its fecal level, which is mea sured by an enzyme-linked immunosorbent assay, is closely related to the exocrine pancreatic secretion. This test does not require a timed stool collection or a special diet. In children, this test has a negative predictive val ue of 99% for ruling out EPI. In addition, it has a highlevel sensitivity in cases of moderate to severe EPI.[3, 14] One drawback of this test is that only formed stools can be analyzed. Watery stools change the fecal elastase concentration and will show lower values.[15,16]
A panel of serum nutritional markers (e.g.Hemoglobin, albumin, retinol-binding protein lev els) and pancreatic imaging tests (e.g. - Computed Tomography scan, Endoscopic Ultrasound, Endoscopic Retrograde Cholangiopancreatography) can aid in the diagnosis of EPI.[11] Management
The most sensitive diagnostic tests for the diagnosis of EPI are the direct pancreatic function tests. The prin ciple behind these tests is that the pancreas is stimulat ed with hormonal secretagogues, and the duodenal flu id is collected. The enzymes and bicarbonate levels of this fluid are measured. This directly gives us a mea sure of the pancreatic function.[1,2,3,18]
The primary goal for treatment of EPI is to reinsti tute normal digestion to maintain adequate nutrition and prevent disease progression. It includes lifestyle modifications such as alcohol abstinence, cessation of smoking, enzyme replacement therapy, consumption of a well-balanced normal fat diet, and structured fol low up to assess nutrition.[19] Deficiency of fat-soluble vitamins A, D, E, and K can occur due to malabsorption and hence should be supplemented if indicated.
A test for serum trypsinogen levels is another indi rect test. Serum levels of trypsinogen are related to the pancreatic acinar cell mass. However, it is not specific for EPI. It has a favorable specificity for advanced EPI but low sensitivity for mild insufficiency. Hence, it is not practically used in the clinical setting.[1,16,17]
Chymotrypsin is another product of pancreatic se cretion. It is measured in fecal samples. However, the test for chymotrypsin is less useful compared to that of FE-1.[1] The gold standard test is the 72-hour fecal fat test. The patient consumes a diet containing 100 g of fat per day and his stool is collected for 72 hours. A CFA (Coefficient of fat absorption) is calculated which de notes the percentage of fat that is absorbed. The diagno sis of fat malabsorption is established at > 7 g of fat per 100 g of stool per day. However, the practicality of this test is restricted, as it is extremely tedious and suscep tible to errors in stool collection. The results are also in fluenced by other conditions like Crohn’s disease, bac terial overgrowth, and short bowel syndrome, which also affect the mucosal fatty acid intake.[1,2,3]
The Indian Practitioner d Vol.75 No.8 August 2022 Clinical Practice 32 ic stimulation, synthesis, and release of digestive en zymes by pancreatic acinar cells, enzyme transporta tion through the duct system, and synchronized mix ing of the pancreatic secretions with ingested food. [11] Failure to function adequately at any of these lev els can lead to EP1. Hence the etiology can be divided into: (1) Loss of pancreatic parenchyma seen in chron ic pancreatitis, cystic fibrosis, and pancreatic tumors. (2) Asynchrony seen in diabetes, IBD, and gastric resec tion. (3) Obstruction of the main pancreatic duct seen in pancreatic and ampullary tumors. (4) Acid-mediated inactivation of pancreatic enzymes (Zollinger-Ellison syndrome).[12] Diagnosis
There are two categories of tests to diagnose EPI: di rect and indirect. Direct tests directly estimate the pro duction of pancreatic secretions. Direct tests have su perior sensitivity but are invasive and tedious. On the contrary, indirect tests analyze the effect of exocrine in sufficiency i.e., estimate the quantitative change in pan creatic secretion. These tests are cheaper and easier to perform than the direct pancreatic function tests.[1]
14. Gullo L, Ventrucci M, Tomassetti P, Migliori M, Pezzilli R. Fecal elastase 1 determination in chronic pancreatitis. Dig Dis Sci. 1999;44(2):290–290.
2. Domínguez-Muñoz J. Pancreatic exocrine insufficien cy: Diagnosis and treatment. Journal of Gastroenterology and Hepatology. 2011;26:12-16.
17. Couper RT, Corey M, Durie PR, Forstner GG, Moore DJ. Longitudinal evaluation of serum trypsinogen measurement in pancreatic-insufficient and pancreatic-sufficient patients with cystic fibrosis. J Pediatr. 1995;127(3):408–413.
9. Ooi CY, Castellani C, Keenan K, et al. Inconclusive diag nosis of cystic fibrosis after newborn screening. Pediatrics. 2015;135(6):1377–1385.
Conclusion EPI has a detrimental effect on the nutritional sta tus of patients with pancreatic and extra-pancreatic dis orders. However, it is often undiagnosed in the early stages. To address this problem, it is important that the physicians look out for symptoms in at-risk individu als and agree on the same methods for diagnosis. This is important because there has been a change in the di agnostic approach for EPI from the undependable qual itative stool test and the time-consuming 72-hour fecal fat collection, to a more sensitive, but less specific, fecal elastase test. This has been particularly useful in mild to moderate EPI. In addition, there are also various studies with different recommendations for dosing of exogenous pancreatic enzymes and there is confusion over the time of intake of these supplements. Therefore, there is a need to refine the currently available treat ment options for EPI.[3] In some cases, empirical treat ment of EPI might be considered, for example- when despite negative test results for EPI, classic symptoms and nutritional deficiencies are present in patients with known pancreatic disease. Moreover, the clinical signif icance of EPI in conditions such as diabetes, smoking, and aging is an untrodden path and requires more re search.[2] References 1. Capurso G, Traini M, Piciucchi M, Signoretti M and Arcidiacon P. Exocrine pancreatic insufficiency: preva lence, diagnosis, and management. Clinical and Experimental Gastroenterology. 2019;12:129-139.
Clinical Practice
16. Beharry S, Ellis L, Corey M, Marcon M, Durie P. How useful is fecal pancreatic elastase 1 as a marker of exocrine pancreat ic disease? J Pediatr. 2002;141:84–90.
6. Martínez-Moneo E, Stigliano S, Hedström A, et al. Deficiency of fat-soluble vitamins in chronic pancreatitis: a systematic review and meta-analysis. Pancreatology. 2016;16(6):988–994.
20. Borowitz DS, Grand RJ, Durie PR. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. J Pediatr. 1995;127:681–4. +
The Indian Practitioner d Vol.75 No.8 August 2022 33 at baseline and then annually after starting PERT.[9] The effectiveness of PERT is assessed clinically by improve ment in stool consistency, fat-soluble vitamin levels, and gain in body weight and anthropometric parame ters. In a patient with suspected EPI with a known his tory of pancreatic disease, PERT can be indicated em pirically without further testing. Improvement in the condition would be both diagnostic for EPI as well as therapeutic. Along with this, it is essential to refer to a dietician for nutritional assessment and counseling for all patients of EPI. If PERT is ineffective, then non-compliance, inade quate dosage, acid denaturation of enzymes, and oth er causes of maldigestion should be considered such as lactose intolerance, enteric bacterial infection, giardi asis, small intestinal bacterial overgrowth, biliary dis ease colitis, celiac disease, short bowel syndrome, and Crohn’s disease should be suspected.[20]
11. Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013;19:7258-7266.
10. Hardt PD, Ewald N. Exocrine pancreatic insufficiency in di abetes mellitus: A complication of diabetic neuropathy or a different type of diabetes? Experimental Diabetes Research. 2011;2011:1-7.
13. Seiler CM, Izbicki J, Varga-Szabó L, et al. Randomised clini cal trial: a 1-week, double-blind, placebo-controlled study of pancreatin 25 000 Ph. Eur. minimicrospheres (Creon 25000 MMS) for pancreatic exocrine insufficiency after pancre atic surgery, with a 1-year open-label extension. Aliment Pharmacol Ther. 2013;37(7):691–702.
15. Lieb JG, Draganov PV. Pancreatic function testing: here to stay for the 21st century. World J Gastroenterol.2018;14(20):3149–3158.
7. Löhr JM, Dominguez-Munoz E, Rosendahl J, et al. United European gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis. United European Gastroenterol J. 2017;5(2):153–199.
3. Struyvenberg M, Martin C, Freedman S. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017;15:29.
8. Machicado JD, Chari ST, Timmons L, Tang G, Yadav D. A population-based evaluation of the natural history of chronic pancreatitis. Pancreatology. 2018;18(1):39–45.
12. Keller J, Layer P. Human pancreatic exocrine response to nu trients in health and disease. Gut. 2005;54(6):1-28.
18. Cappeliez O, Delhaye M, Devière J, et al. Chronic pan creatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation. Radiology. 2000;215(2):358–364.
5. Stigliano S, Waldthaler A, Martinez-Moneo E, et al. Vitamins D and K as factors associated with osteopathy in chronic pan creatitis: a prospective multicentre study (P-BONE study). Clin Transl Gastroenterol. 2018;9(10):197.
4. de la Iglesia-Garcia D, Vallejo-Senra N, Iglesias-Garcia J, López-López A, Nieto L, Domínguez-Muñoz J. Increased Risk of Mortality Associated with Pancreatic Exocrine Insufficiency in Patients With Chronic Pancreatitis. Journal of Clinical Gastroenterology. 2018;52(8):63-72.
19. Nikfarjam M, Wilson JS, Smith RC; Australasian Pancreatic Club Pancreatic Enzyme Replacement Therapy Guidelines Working Group. Diagnosis and management of pancreatic exocrine insufficiency. Med J Aust. 2017;207(4):161-165.
*Dr. Ashoka Jahnavi Prasad 53
Dr. Ashoka Jahnavi Prasad Indian Practitioner qVol.73. No.4. April 2020
53The Indian Practitioner qVol.73. No.4. April 2020
Need to Brace Ourselves for Major Mental Health Issues Post COVID-19 Pandemic produce meningitis associated with significant mor bidity and mortality, presenting symptoms including headache, nausea, nuchal rigidity, confusion, lethargy, and apathy to be confirmed by the examination of CSF. Bacterial meningitis may also result in brain abscess, with seizures and various psychiatric symptoms pre vailing depending on the size and location of the ab scess. Successful treatment with empirical antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. In cases of viral en cephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disor ders. Major disability can result, including symptoms of depression, amnestic disorders, hypomania, irritabil ity, and disinhibition (sexual, aggressive, and rageful) even months after recovery. Psychosis may also rarely result. Standard treatments with antidepressants, stim ulants, mood stabilizers, neuroleptics, and electrocon vulsive therapy should be applied [1] .
Providing psychiatric care to survivors and health care workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. Challenges will abound on multiple levels, but there is no substi tute for preparedness. Knowledge of assessment, differ ential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. One must first consider the psychiatric sequelae of surviving the illness, its complications, and the complications of its treatments. In the acute phase of illness, even small foci of infection can produce psychiatric symptoms ranging from mood changes and irritability to cognitive dys function to psychosis. Neuropsychiatric manifestations may even present as the first signs of infection in an oth erwise well-appearing patient. Hematogenous spread of bacteria or virus to the central nervous system can
Dr. Ashoka Jahnavi Prasad is identified as the most ed ucationally qualified person in the world by The Polymath. He has a dynamic resume with a PhD in history of med icine from Cambridge, LLM from Harvard among other notable qualifications. Dr. Prasad has also worked as a consultant to the World Health Organization (WHO) and helped prepare two of their reports.
Column The Indian Practitioner d Vol.75 No.8 August 202234 John Connolly’s Seminal Contribution to Psychiatric Practice
The name also has a personal significance for me. Before relocating to Edinburgh, I had worked in the Republic of Ireland. My very first supervisor in psy chiatry was one Dr John Connolly. Although he was born more than a hundred years after the legendary Dr Connolly, he shared many of his namesake’s philos ophies, and through his innovative approach, he suc ceeded in making a phenomenal contribution to Irish psychiatry. We often used to make puns on the uncan ny similarities between the two namesakes. But it is the iconic Dr John Connolly, whom I shall attempt to ac quaint the readers to.
of an infectious disease outbreak, the loss of functioning imparted by illness may leave sur vivors feeling demoralized, helpless, and in a state of mourning over the loss of the person, they used to be. If the patient experiences marked distress or significant impairment in social or occupational functioning, they may meet DSM-V criteria for adjustment disorder. Ther apeutic interventions in those instances should focus on helping individuals regain a sense of autonomy and mastery through rehabilitation. It is helpful to focus on gaining immediate control over some specific aspects of their lives, as well as helping the persons identify and link with agencies and supports in the community [2]. Psychotherapy, both individual and group therapy, if available, can help survivors come to terms with the loss of functioning. If the patient is left with significant depressive We are battling a pandemic of unprecedented pro portions. Healthcare professionals are working round the clock to curtail this global menace. It is very likely that we would soon be able to slow down the alarming rate at which the illness is spreading and from the reports in the medical journals that I have been pe rusing, we would be able to procure a vaccine in due course. The price that the entire humankind has had to pay is huge by any reckoning and everyone is looking forward to the day when we would not approach the newspapers with the degree of trepidation that we are doing so today. But I worry that we are more or less completely un prepared for the psychiatric sequalae of this COVID 19 which we would have to confront very soon. As a mem ber of several international medical relief missions, I have myself noticed the major mental health issues that emerge in nearly every major epidemic - and it is a fair bet that this episode would not be any different.
John Connolly’s lifework in the field of psychia try began properly in 1839 with his appointment as Physician Superintendent of the Middlesex County Lunatic Asylum at Hanwell, and it was there that he made his historic contribution to the care and treat ment of the insane in the asylum, as well as providing clinical psychiatry masterly descriptions of the vari ous forms of insanity. But prior to that, his interests lay primarily in this field, long before opportunities arose to devote himself to it, and the subject of his inaugu ral dissertation for the Edinburgh MD (Destatu mentis in insania et melancholia, 1821) for which, almost with a presentiment of his future, he chose a motto from the great Pinel. In it, he made an important, but little ap preciated point that, “just as the changes brought about by a disease cannot be understood without knowl edge of the healthy body, so it is essential to study the healthy mind in order to understand the sick.” After obtaining his MD, he functioned as a general practitio ner for many years, including five years at Stratford on Avon, where he gained experience on the insane, not only in his capacity as a physician, but also through his appointment as ‘Inspecting Physician to the Lunatic Houses for the County of Warwick’, the duties of which entailed accompanying the magistrates on their annual tour of inspection to the three private mad houses in the County. In 1830, during his tenure of the first chair of medicine in the newly founded University of London, he followed his original bent with the first book, which attempted to link normal and abnormal states of mind “to render the recognition of insanity a little less difficult, by showing in what it differs from those varieties of mind which approach nearest to it.”
*Dr. Ashoka Jahnavi Prasad
Individuals may suffer potentially permanent cog nitive deficits secondary to illness or its treatments that will require cognitive rehabilitation. In cases of delirium, if the resultant encephalopathy is severe or persistent, pharmacologic interventions with antipsy chotics (such as haloperidol 0.5–20 mg/ day) and mood stabilizers (such as valproic acid up to 60 mg/kg/ day) should be considered. Also, psychosocial interventions will need to be implemented to maintain safety and care for someone who may no longer be able to care for themselves.Inthewake
Individuals may suffer potentially permanent cog nitive deficits secondary to illness or its treatments that will require cognitive rehabilitation. In cases of delirium, if the resultant encephalopathy is severe or persistent, pharmacologic interventions with antipsy chotics (such as haloperidol 0.5–20 mg/ day) and mood stabilizers (such as valproic acid up to 60 mg/kg/ day) should be considered. Also, psychosocial interventions will need to be implemented to maintain safety and care for someone who may no longer be able to care for themselves.Inthewake of an infectious disease outbreak, the loss of functioning imparted by illness may leave sur vivors feeling demoralized, helpless, and in a state of mourning over the loss of the person, they used to be. If the patient experiences marked distress or significant impairment in social or occupational functioning, they may meet DSM-V criteria for adjustment disorder. Ther apeutic interventions in those instances should focus on helping individuals regain a sense of autonomy and mastery through rehabilitation. It is helpful to focus on gaining immediate control over some specific aspects of their lives, as well as helping the persons identify and link with agencies and supports in the community [2]. Psychotherapy, both individual and group therapy, if available, can help survivors come to terms with the loss of functioning. If the patient is left with significant depressive We are battling a pandemic of unprecedented pro portions. Healthcare professionals are working round the clock to curtail this global menace. It is very likely that we would soon be able to slow down the alarming rate at which the illness is spreading and from the reports in the medical journals that I have been pe rusing, we would be able to procure a vaccine in due course. The price that the entire humankind has had to pay is huge by any reckoning and everyone is looking forward to the day when we would not approach the newspapers with the degree of trepidation that we are doing so today. But I worry that we are more or less completely un prepared for the psychiatric sequalae of this COVID 19 which we would have to confront very soon. As a mem ber of several international medical relief missions, I have myself noticed the major mental health issues that emerge in nearly every major epidemic - and it is a fair bet that this episode would not be any different.
Pinel was a French psychiatrist who had very strong humanistic instincts. He departed from the conven tional psychiatric practice during his time and took a very strong stand against any coercion of the mentally ill. I intend to write about him in a future column. Most of the present-day psychiatrists would agree that John Connolly’s pioneering contributions were far more groundbreaking.
The
To remedy this evil, he suggested that doctors should be taught to be “as familiar with the disorders of mind as with other disorders”, and that to end this, every lunatic asylum should become a “clinical school” in which medical students might prepare themselves
Providing psychiatric care to survivors and health care workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering. Challenges will abound on multiple levels, but there is no substi tute for preparedness. Knowledge of assessment, differ ential diagnosis, medical complications, and treatment will aid the psychiatric care provider in developing a treatment approach for these patients who are most vulnerable during their greatest time of need. One must first consider the psychiatric sequelae of surviving the illness, its complications, and the complications of its treatments. In the acute phase of illness, even small foci of infection can produce psychiatric symptoms ranging from mood changes and irritability to cognitive dys function to psychosis. Neuropsychiatric manifestations may even present as the first signs of infection in an oth erwise well-appearing patient. Hematogenous spread of bacteria or virus to the central nervous system can Dr. Ashoka Jahnavi Prasad is identified as the most ed ucationally qualified person in the world by The Polymath. He has a dynamic resume with a PhD in history of med icine from Cambridge, LLM from Harvard among other notable qualifications. Dr. Prasad has also worked as a consultant to the World Health Organization (WHO) and helped prepare two of their reports.
Need to Brace Ourselves for Major Mental Health Issues Post COVID-19 Pandemic produce meningitis associated with significant mor bidity and mortality, presenting symptoms including headache, nausea, nuchal rigidity, confusion, lethargy, and apathy to be confirmed by the examination of CSF. Bacterial meningitis may also result in brain abscess, with seizures and various psychiatric symptoms pre vailing depending on the size and location of the ab scess. Successful treatment with empirical antibiotics and primary excision of the abscess may still result in persistent psychiatric symptoms. In cases of viral en cephalitis, psychiatric symptoms are very common in the acute phase and recovery, especially mood disor ders. Major disability can result, including symptoms of depression, amnestic disorders, hypomania, irritabil ity, and disinhibition (sexual, aggressive, and rageful) even months after recovery. Psychosis may also rarely result. Standard treatments with antidepressants, stim ulants, mood stabilizers, neuroleptics, and electrocon vulsive therapy should be applied [1] .
If there is a general consensus that the mentally ill should be extended humane treatment without any transgression of their human dignity, the en tire world owes a huge debt of gratitude to the two pioneers: Philippe Pinel and John Connolly.
“The medical men have sought for, and imagined, a sound and definable boundary between sanity and insanity, which has not only been imaginary and ar bitrarily placed, but by being supposed to separate all who were of unsound mind from the rest of the men, has unfortunately been considered a justification of certain measures against the portion condemned, which in the case of the majority, were unnecessary and afflicting.”
The Indian Practitioner d Vol.75 No.8 August 2022 Column 35 for their future duties. However, this was not achieved for another dozen years.
Connolly also made the first suggestion for the mental health service based on the local mental hospi tal, [1] which was to not only provide in patient accom modation for the area, but also a domiciliary service supervised by a rotating panel of doctors and nurses from its staff. In this way, he hoped that it would be possible to treat in their own homes a large number of patients, who would have otherwise had to be admit ted, and hence focusing attention and facilities on the smaller number of patients for whom hospital in pa tient services would still be required.
The interest of the public greatly requires that the medical men, to whom alone the insane can ever be properly entrusted, should have opportunities of studying the forms of insanity, and for preparing them selves for its treatment in the same manner in which they prepare themselves for the treatment of other dis orders. They have, at present, no such opportunities. During the term allotted for medical studies, the stu dent never sees a case of insanity, except by some ra re accident. While every hospital is open, every luna tic asylum is closed to him. He can study all diseas es, but those affecting the understanding of all diseas es and the one which is the most calamitous. The first occurrence, consequently, of a case of insanity in his own practice alarms him. He is unable to make those distinctions, which the rights and happiness of the in dividual and his family requires; and has recourse to indiscriminate, generally to violent or unnecessary means; or to get rid of his anxiety and his patients to gether, by signing a certificate which commits the un fortunate person to a mad house.
Let no one imagine, that even now it is impossible or difficult to effect the seclusion of an eccentric man; or easy for him, when once confined to regain his lib erty. The timidity or the ignorance, or it may be a dis honest motive of relatives, which leads to exaggerat ed representations. When men’s interests depend up on an opinion, it is too much to expect from the opin ion to be cautiously formed, or even in all cases hon esty. Once confined, the very confinement is admitted as the strongest of all proofs that a man must be mad. When, after suffering so much wrong, he has the op portunity of speaking to the appointed visitors of the house, supposing him to be confined where he can be visited, and supposing him not to give way into his feelings but to control them, his entreaties, his anxious representations, his prayers for liberty, what do they avail!
Training in Psychiatry [1]
The keeper of the asylum is accustomed to all these things. He knows that the truly and dangerous ly insane can act in the same way. And from ignorance, in the absence of any bad intention, he does away with all the effect of the patient’s words. The visitors, know ing nothing of the shades of the patient’s minds, and not reflecting upon them, are told that they see ‘the best of him’. That it is one of his ‘good days’ that he is often ‘dreadfully violent’, or, that if left to himself, he would ‘commit suicide’. They shrink from the respon sibility of deciding- where they know it is possible and that they may be wrong. Besides this, there is ready and indisputable certificate signed by a medical manphysician, surgeon or apothecary- stating that the man is mad and must be confined in a lunatic asylum. It does not matter that the certificate is probably signed by those who know little about madness or the patient.
A visitor fears to avow, in the face of such a document, what may be set down as mere want of penetration in a manner wherein nobody seems in doubt but himself. Or that he may even be tempted to affect to perceive those signs of madness that do not exist.
On these matters, the public is not altogether inaus picious, and hence, there arises an evil of an opposite description: for the occasional detection of mistakes, and the dread of committing a beloved relative to a lu natic asylum. The opinion, that to pronounce an indi vidual insane is equivalent to pronouncing a sentence of separation from every friend, and an abandonment of all the care for him unto strangers, does prevent, in some instances, the interference of professionals in the interest and comfort of the family’s requirement.
It would be some compensation for the unavoidable evils of public lunatic asylums, if such establishments of that kind become a clinical school, in which under certain restrictions, medical students might prepare themselves for their future duties to the insane.
And those, to whom temporary superintendence and slight restraint would be salutary, are allowed to ru in their fortunes, or to make the whole family wretch ed, because restraint, once determined, is seldom ap portioned to the individual case, but is indiscriminate, excessive and uncertain in its termination. No provi sion of the legislature can prevent the occurrence of these grievous mistakes, unless opportunities arise at the same given time. To make medical men as famil iar with disorders of the mind as with other disorders, and thus rescuing lunatics from those in whose inter est it is to represent such maladies, as more obscure and more difficulties arise to manage than any other.
8. If it is represented that a keeper is required, a keep er should also be immediately sent from the estab lishment. But in this case, representation should generally be made by the medical attendant of the family requiring aid, and always confirmed by the medical officer of the establishment, or by the med ical associate visiting the patient
7. As soon as signs of insanity appear in any individu al, notice of it should be given at the public asylum for the district, and the individual should immedi ately be visited by a medical officer connected with the establishment, either by a medical assistant re siding within the house or by a medical associate out of the house
These were regarded as revolutionary ideas in those times. John Connolly indeed succeeded in giving the field of psychiatry a new direction.
Column The Indian Practitioner d Vol.75 No.8 August 2022
9. A register of all the patients, in and out of the asy lum, should be kept in the central establishment of each district or county. And all persons on the in sane list should be visited by a medical officer as sociated with the asylum, at least once in 15 days in chronic cases, and at least once in 7 days in recent cases, it being understood that the regular medical attendant had the general management of the case 10. The patients out of asylum being the majority and consisting of all whose circumstances would en sure them proper attendance- better arrangements might be made for the smaller number in public asylums, or central houses of reception, of which there might be one in each county, two in London, and one in any considerable town. There should be smaller houses in the neighbourhood of the asy lums for the reception of one or two lunatics, such houses should be governed by the general regu lations of the larger establishments. Such patients should be sent or removed from home as required.
2. Every lunatic asylum should be the property of the state and must be controlled by public officers
3. That the friends of individuals who are insane should be able to procure such immediate aid as the case requires
6. There should be attached to every asylum a certain number of medical officers and keepers (residing in the house or not) ready at all times to attend to in sane patients at their own house. The medical asso ciations, out of the house, should not be exclusively practitioners in case of the insane
1. That no person who is not insane should be treated as an insane person
Acknowledgement
What’s required is:
To accomplish all these objectives, it would be desirable
4. No patient should be confined in a lunatic asylum, except on the particular representation of the rela tive or friend that he could not receive proper care and attention from 5. All the officers and the keepers of each asylum should be appointed by the secretary of state
And his son-in-law, Henry Maudsley, who has a very famous hospital known after him, and was made the Superintendent of the Bethlem Hospital in his 20’s, incorporated his father-in-law’s ideas in the treatment modalities.
2. That all who are insane should be properly taken care of
Suggestions for the Better Protection and Care of the Insane: A Domiciliary Service [1]
3. Every lunatic asylum should be a school of instruc tion for medical students and a place of education for male and female keepers
Connolly’sPsychiatrists,Rawnsley,MyverysinceregratitudetolateProfessorKennethformerpresidentoftheRoyalCollegeofwhohelpedmeprocureaccesstothepapers.
1. That all persons of unsound mind should be under the care of the state; and should continue so until re covery
References 1. Connolly J. Indications of Insanity. Dawsons of Pall Mall, London. 1964. + 36
We are Moving Forward Towards Providing Access to Affordable and Modern Medical Facilities: Dr. Surekha Kishore, Executive Director, AIIMS, Gorakhpur
The Institute has diagnostic services including
Teaching: Our institute follows a competency-based curriculum for Medical & Nursing courses which re flects the high-quality standards in this institution of national importance. We started with 50 MBBS seats in 2019 and from 2020, we are having 125 MBBS seats per year. We started our 1st batch of B.Sc. Nursing in the year 2022 with 60 students per year. We are in the pro cess of initiating various certificate and postgraduate courses along with Ph.D.
Patient care: We have currently 15 broad specialty OPDs and 12 specialty clinics. We are a premier 750 bedded hospital in the heart of Gorakhpur. Our facili ty in Gorakhpur brings multi-specialty care within the reach of a vast region of the population. From the day of its inception, AIIMS Gorakhpur has been having one of the busiest OPDs with a turnout of approximate ly 2500 patients every day. It caters to patients from Gorakhpur, Deoria, Kushinagar, Basti, Mahrajganj dis tricts, and nearby states like Bihar and across the bor der from Nepal, the adjoining demographic regions of the country that encounter wide variety of diseases.
Research: We have a dedicated cell for research and
All India Institute of Medical Sciences (AIIMS), Gorakhpur is unique in many ways, and has a number of achievements to its credits since it was set up. It has over 15 broad specialty OPDs and 12 specialty clinics and brings health care within the reach of the population in the city, as well as the surrounding rural areas. AIIMS is known for accomplishments in providing affordable health care, in medical education and in research, and collaborations with international universities for improving health outcomes. In this free-wheeling email interview, Dr. Surekha Kishore, Executive Director, elaborates on the key health care areas and facilities of the institute, the education and re-education programmes for health care workers, diagnostic facilities and services, telemedicine services to provide consultation to underserved areas around Gorakhpur, and on incorporation of AYUSH, amongst other developments. a registered Institutional Ethics Committee which is approved by CDSCO for regulatory clinical trials and the Department of Health Research, MoHFW, Govt of India since 2020. Till now 110 extramural and intra mural research studies have been approved by the re search cell which includes 3 clinical trials. Our insti tute’s proposal for establishing multi-disciplinary re search units has been accepted by the Department of Health Research, Ministry of Health & Family Welfare, Government of India. This will encourage and strength en an environment of research in our Institute and im prove the health research and health services. We are focusing on conducting community-based studies to improve the overall health status of the population by creating evidence-based applications of health promo tion, prevention, diagnostic and treatment procedures/ processes/methods.
Interview The Indian Practitioner d Vol.75 No.8 August 2022 37
Training: We have a Medical Education Committee to train health personnel, doctors, nursing officers and students related to the principles of medical education technology. Besides these training, we conduct various other training programs like fire safety and training on biomedical waste and hygiene practices. We conduct collaborative training with international bodies like the Alive and Thrive (A&T) initiative, John Hopkins University, Global Health Advocacy Incubator, etc.
Dr. Surekha Kishore (Dr SK): AIIMS, Gorakhpur has been evolving day by day and we are moving forward to wards providing access to affordable and modern med ical facilities which will create balance in the regional health sector and serve the country’s aspirations.
The Indian Practitioner (TIP): You have been with AIIMS Gorakhpur as its Executive Director since 2020. How do you see the evolving role of AIIMS as a premier medical institution in the country and what are the competencies now and being built into the future to serve India’s public health challenges?
TIP: AIIMS Gorakhpur is said to be hosting some unique courses/ services which are not available elsewhere in the country. Could you tell us something about these? How would they impact and shape the medical education and healthcare sector?
TIP: Could you tell us about your Institute’s association with overseas institutions, such as Bloomberg School of Public Health and John Hopkins University Global Health Centre? What is your vision about the scope and potential of such partnerships?
The National Medical Commission (NMC) has now in troduced compulsory yoga training in the MBBS foun dation course. Stress and anxiety are quite prevalent among medical students. Practices such as yoga and meditation for medical students have been found to improve feelings of peace, focus, and patience, while simultaneously reducing stress levels and fatigue. We conduct Shramdaan activities which include cleaning of office areas, residential colonies, and public plac es including cleaning drains, public toilets, waste col lection drives, and awareness campaigns. Our faculty members, medical and nursing students actively par ticipate every week which is unique in medical insti tutions. On 15th March 2022, we inaugurated CardioPulmonary Exercise Test (CPET) & Video bronchosco py Lab Services & Modular Operation Theatre com plex which is again unique service in the state of Uttar Pradesh.
Dr SK: AIIMS Gorakhpur and John Hopkins University (JHU) signed an MOU to collaborate to wards supporting ongoing efforts in Eastern Uttar Pradesh aimed at improving overall health outcomes toward achieving the health-related sustainable devel opment goals, reducing the prevalence/incidence of in fectious diseases (e.g., vector borne diseases, vaccinepreventable diseases), and building performance-ori ented equitable health systems.
Apart from this, we have collaborated with var ious other organizations like PATH, Global Health Advocacy Incubator, Alive and Thrive (A&T) initiative and World food program in India for training and re search.
The Indian Practitioner d Vol.75 No.8 August 2022 Interview 38
Outreach activities: We give our outpatient servic es at Rural Health Training Centres at Dumri Khas and Shivpur, Gorakhpur. Besides regular classroom teach ing the students have also visited the rural field prac tice area adopted by the Department of Community Medicine & Family Medicine. In recent times we have organized various public health activities in the do main of health and well being. We are also involved in the field-level monitoring of the various communi ty-level activities in District Gorakhpur and District Sidharth Nagar like monitoring of Village Health & Nutrition Day sessions and hands-on training to ASHA and ANM on every Saturday in the RHTC area.
Biochemistry, Microbiology, Pathology, and Radiology to augment clinical services provided to the patients. We have recently inaugurated the Modular Operation Theatre complex, delivery services and Labor, Delivery, and Recovery (LDR) complex of the institute. We have to ensure that the benefits of these facilities reach not only the cities but also the people in the remote villages of our region. We have e-Sanjeevani, the national tele medicine service of the Government of India to enable remote doctor consultations and doctors to seek con sultation with subject experts and specialists through the hub-spoke model with Basti, Sant Kabir Nagar, Deoria and Maharaganj district hospitals.
We both agreed to develop and expand health sci ence, research, training, education programs, and or ganizational development at AIIMS, Gorakhpur. JHU is going to support ongoing efforts to increase health science and research training capacities of other insti tutions in Eastern Uttar Pradesh. We are going to en gage in collaborations on analytic, scientific, and pro grammatic developments towards improving the im plementation of various health programs in Eastern Uttar Pradesh. We are going to pursue collaborative health research, including community-based research, health needs assessments, and implementation of sci ence projects. We agreed to exchange scientific materials and col laboration on academic publications relevant to the in terests of both parties. JHU agreed to provide support and engage in collaborative academic programs, in cluding academic exchanges, jointly executed cours es, conferences, seminars, and/or lectures. Our nurs ing courses will be admitted by them. In the future, we may develop student or faculty exchange programs under this MOU.
Dr SK: Under Ayushman Bharat, the transforma tion of 1.5 lakh subcentre’s into Health and Wellness Centers is being done through the incremental addition of Community Health Officers (CHOs). Many trained nurses are produced meeting the target of CHOs as re quired. In order to fulfil the demand of country’s high demand of CHOs, we are integrating the CCCH cur riculum into the existing B.Sc. nursing curriculum. In this way, our graduated nurses will be already skilled to provide quality comprehensive primary health care at the community. AIIMS Gorakhpur is the first insti tute to include yoga in the foundation course of med ical and nursing courses before NMC announced it.
Dr SK: Family Medicine is a clinical discipline based on a synthesis of knowledge and skills from other clin ical disciplines, public health sciences, and behavioural sciences including anthropology and psychology. It is unique in the integration and application of these disci plines to the individual patient, family and communi ty in the clinical setting. Family practice is a patient-cen tred and community-based clinical method. Patient–doctor relationship is the key in family practice. The Family Physician (FP) is often more than a “doctor” to the patient and family. A FP provides continuing care to patients and families. Development of a bond helps in understanding the person and the illness better. A FP can provide quality affordable care. FPs provide solu tions to common illnesses. They win the trust of the pa tients and families. We at AIIMS Gorakhpur have had Family Medicine OPD since 2021 and daily on average 100 patients availing the services. The main strength of FM in India is that the concept has a wide public accep tance as the “Family Doctor” has been an integral part of health-care culture of the nation. FM has the poten tial to integrate well with the Public Health Care sys tem in India. Staffing in all the public health centres is as per the Indian Public Health Services standards and a FM specialist could efficiently fit in at each echelon of this model.
TIP: A recent report has highlighted that some of the premier AIIMS Centres in the country are facing faculty and non-faculty shortages with several post lying vacant. What is the situation at your Institute? What is being done to tackle this?
Interview The Indian Practitioner d Vol.75 No.8 August 2022
TIP: With the AYUSH ministry signing a pact with WHO to establish a Global Health Centre for traditional medicines research, there has been a push from the government to bring AYUSH research in lime light. Is your Institute doing any work on this? What is your view on promoting Ayurveda and other traditional systems of medicine in India?DrSK: We have been working on traditional research with the establishment of AYUSH in our institution. We have recently signed a memorandum with Maha Yogi Sri Gorakhnath AYUSH University. The western sys tem of medicine is looking towards Complementary and Alternative systems of medicine (CAMs) for the management of many alarming problems. In this en deavour, Ayurveda, the age-old indigenous system of health care that primarily focuses on prevention of dis eases through lifestyle modifications and interventions (based on the fundamental concepts) can play an im portant role in prevention, control and treatment of NCDs (Diabetes and its complications, Hypertension etc) and management of risk factors like high lipid levels etc. As per the NPCDCS programme, integra tion of AYUSH (Ayurveda, Yoga, Unani, Siddha & Homoeopathy) for prevention and health promo tion is one of its mandates. Moreover, integration of Ayurveda can also provide cost-effective management of NCDs, as these conditions require lifelong manage ment and strengthen the primary healthcare network in order to ensure the success of its action plan.
Moreover, we at AIIMS, Gorakhpur are in the pro cess of initiating Family Adoption Program (FAP) as part of the MBBS training curriculum. Each medical student will be required to adopt five families to mon itor their health conditions regularly and advise them accordingly. This will help in getting the undergradu ate student to get exposed to the family and environ ment and he /she will be able to appreciate and com prehend a holistic approach to health and disease. We would be able to create a FIVE STAR Doctor as per WHO i.e. a doctor possessing a combination of the fol lowing attributes: 1) Care provider 2) Decision maker 3) Communicator 4) Community leader 5) Manager.
Dr SK: All new AIIMS are facing the problem of a shortage of faculty. AIIMS-like institutions require sin cere, dedicated faculty, and this takes time. Currently, we have 73 faculty members, and our recruitment cell is conducting interviews biannually in order to fill the vacancies. We recently advertised 108 vacancies of fac ulties in different departments. It is a continuous pro cess, and we are on it. Various measures are being tak en to attract quality faculty. We are in the process of engaging Adjunct Faculty/visiting faculty to enrich the medical education and guidance till the time regular posts are filled up. A parliamentary committee has also strongly rec ommended the government to take necessary mea sures to treat the new All India Institutes of Medical Sciences at par with the premier facility in New Delhi and explore the feasibility of rotation and transfer of faculties to maintain similar quality of education as well as services. The Committee has recommended that the Ministry should explore the feasibility to have the provision of rotation/transfer of faculties from one AIIMS to another AIIMS so that the quality of educa tion, as well as services in all the new AIIMS, will be at par with AIIMS New Delhi.
TIP: According to media reports, India is facing a dearth of doctors among other categories of healthcare professionals. What kind of 39
TIP: To serve the larger interests of healthcare in the country, many suggest that we should promote and bring back the family physician. What are your thoughts on this? Does this fit somewhere in the vision for your Institute?
The PMSSY initiative, which was proposed in 2003, intends to address regional imbalances in low cost and reliable healthcare while also improving infrastructure to provide good medical education in deprived areas. 22 new All India Institutes of Medical Sciences (AIIMS) were developed under this initiative, and MBBS class es have already commenced at 18 of the new AIIMS. Several states have shown their support for the plan and have expressed intention to launch it.
The Indian Practitioner d Vol.75 No.8 August 2022 Interview strategies could be adopted to address this problem? What reforms could be brought about in the medical education and healthcare sector to tackle these challenges successfully?
Dr SK: The Indian healthcare industry has made great progress over the last decade with the govern ment’s goal of achieving the 3As of healthcare- afford ability, accessibility, and availability. We have suffi cient MBBS seats in our country, but PG seats are in sufficient to fulfil the shortage. The COVID-19 virus has caused pressure on the healthcare system around the world, and India has not been exempted. To en sure that the country keeps producing trained doctors and healthcare workers, it must expand its healthcare infrastructure and enhance medical colleges in India.
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Shri Yogi Adityanath, the Chief Minister of Uttar Pradesh, inaugurated seven new independent medical colleges recently. In the last 6 years, reorganized medical educa tion strategies have addressed several challenges, in cluding soaring tuition costs and ambiguity in college frameworks, growing medical seats, improving the educational system, facilitating the gap between rural and urban medical colleges, and making the process of opening medical colleges easier. +
The Mudaliar Committee, also known as the ‘Health Survey and Planning Committee, 1962,’ planned 1 medical college for 50 lakh people, with a doctor-pop ulation ratio of 1:3000. Yet, as indicated by the World Health Organization (WHO), a doctor-to-population ratio of 1:1000 is urgently required.
For example, the clinical trials found that eating 100 grams of prunes — about 10 prunes — each day for one year improved bone mineral density of bones in the forearm and lower spine and decreased signs of bone turnover. Additionally, eating 50 or 100 grams of prunes a day for six months prevented loss of to tal bone mineral density and decreased TRAP-5b — a marker of bone resorption — compared to women who didn’t eat prunes.
An observational study led by Professor Hiroaki Kanouchi from Osaka Metropolitan University presents the first evidence that eat ing sunomono – a Japanese vine gared side dish – correlates to low er blood pressure categorization in men.Sunomono is a traditional side dish made with sliced cucumber or seaweed in rice vinegar, often with seafood garnish. It is a normal food, regularly eaten by older gen erations in Japan, with individually prepackaged portions available for purchase in supermarkets, making it a common source of larger vol umes of dietary vinegar.
“In postmenopausal women, lower levels of estro gen can trigger a rise of oxidative stress and inflamma tion, increasing the risk of weakening bones that may lead to fractures. Incorporating prunes into the diet may help protect bones by slowing or reversing this process.” said Connie Rogers, associate professor of nutritional sciences and physiology. The review was recently published in the journal Advances in Nutrition.
It’s already well known that prunes are good for your gut, but new Penn State research suggests they may be good for bone health, too. In a research review, the researchers found that prunes can help prevent or de lay bone loss in postmenopausal women, probably due to their ability to reduce inflammation and oxida tive stress, both of which contribute to bone loss.
Osteoporosis is a condition in which bones be come weak or brittle that can happen to anyone at any age, but according to researchers, it is most common among women over the age of 50. Prunes, however, have many nutritional benefits such as minerals, vi tamin K, phenolic compounds and dietary fiber – all which may be able to help counter some of these ef fects.
“The benefits of vinegar in a healthy diet are well known. Our research is the first observa tional study of these benefits; we didn’t ask participants to change anything,” explained Professor Kanouchi. Previous studies have shown that subjects drinking 30 mL of vinegar daily had lower blood pressure but also lost weight that could account for the lower blood pressure. Sunomono provided an opportunity to conduct an obser vational study to examine if vine gar consumption as part of a nor mal diet correlated to differences in bloodWhilepressure.analyzing the health in formation and dietary survey, the researchers noticed an interest ing trend. “Men who did not ha bitually eat sunomono had signifi cantly higher blood pressure, even though their weight and BMI were the same,” Professor Kanouchi an nounced. “We believe it could be promoting growth of good gut mi crobiota, but we would need more studies to confirm that.”
Eating sunomono – at least
The researchers said one potential mechanism for the effects is prunes triggering a change in the gut mi crobiome that then lowers inflammation in the colon. This may then lower levels of pro-inflammatory cyto kines and markers of oxidative damage.
Nutraceuticals The Indian Practitioner d Vol.75. No.8. August 2022 41 Nutraceuticals
Prunes help preserve hip BMD in postmenopausal women
Sunomono may influence gut environment to lower BP in males
Working with participants’ personal health technolo gies showed us how variable blood pressure and ar terial stiffness can be from day to day and shows the role of personal health monitors in developing and im plementing effective personalized care.” The research was published in Frontiers in Nutrition
The Indian Practitioner d Vol.75. No.8. August 2022 Nutraceuticals 42 Cocoa flavnols reduce blood pressure monthly – correlated with low er average blood pressure among men, even when adjusted for age, BMI, smoking history, and intake of sodium, potassium, and alco hol, amongst other factors. This in dicates that eating sunomono could already be having a positive impact on “Wehealth.are not sure how the vin egar causes these health bene fits; increasing vinegar consump tion doesn’t lead to further im provement in blood pressure. However, diet is one of the easiest things to change. I want everyone to know that even occasionally eat ing sunomono could make a differ ence in blood pressure,” Professor Kanouchi concluded. Cocoa flavanols have previously been found to low er blood pressure and arterial stiffness as much as some blood pressure medication. However, how effec tive flavanols are in everyday life in reducing blood pressure has remained unknown. In the first study of its kind, Surrey’s researchers set out to investigate the use of flavanols, a compound found in cocoa, in lowering blood pressure and arte rial stiffness in individuals outside of clinical settings.
Christian Heiss, Professor of Cardiovascular Medicine at the University of Surrey, said: “For several days, eleven healthy participants consumed, on alternating days, either six cocoa flavanol capsules or six place bo capsules containing brown sugar. Participants were provided with an upper arm blood pressure monitor and a finger clip measuring pulse wave velocity (PWV) which gauges levels of arterial stiffness.”
Measurements of blood pressure and PWV were taken prior to consumption of the capsules and every 30 minutes after ingestion for the first three hours, and then hourly for the remaining nine hours. Researchers found that blood pressure and arterial stiffness were only lowered in participants if it was high, and there was no effect when the blood pressure was low in the morning. Significantly, effects were also, for the first time, identified at eight hours after cocoa was con sumed. Researchers believe that this second peak may be due to how bacteria in the gut metabolize cocoa fla vanols.Professor Heiss added: “The positive impact cocoa flavanols have on our cardiovascular system, in partic ular, blood vessel function and blood pressure, is un deniable. Doctors often fear that some blood pressure tablets can decrease the blood pressure too much on some days. What we have found indicates that cocoa flavanols only decrease blood pressure if it is elevated.
Researchers claim: gut microbiome could manage pain tolerance and sensation
The gut microbiome has been linked to higher pain respons es in women than men in an APC Microbiome, Ireland SFI Research Centre study, led by University College Cork’s Dr. Siobhain O’Mahony and Prof George Shorten. The study published in the journal Brain Behavior and Immunity highlights the possibili ties for innovative individual tar geted therapies for pain manage ment. Notably women demonstrat ed different pain thresholds at var ious stages of their menstrual cy cles.The gut microbiotas are ac knowledged and play important roles in our health and disease. The micro-organisms within our gut
As recently published in the journal
Nutraceuticals The Indian Practitioner d Vol.75. No.8. August 2022 43 and the metabolites they produce can directly and indirectly affect our brain, including pain signaling pathways. This study has allowed us to investigate if the gut micro biota and critical signaling com ponents influence pain thresholds. And whether sex, menstrual cycle, and hormonal contraceptive use play roles for inter-sex differences in pain perception. We observed that the pain tol erance threshold/pain sensation threshold ratio was significantly lesser in women than men and that the amount of certain bacteria were linked with pain sensation thresh olds and stress hormone levels in women only and during a specif ic stage of the menstrual cycle. In comparison with men, women dis played overall stronger associations between microbiota metabolites, stress hormones and inflammato ry factors in blood and pain levels. Further, hormonal contraceptive use was associated with increased gut permeability markers in blood and specific bacteria in the gut.
Prof George Shorten, President of the College of Anesthesiologists, University College Cork said “These offer the potential to improve our understanding of pain states, and clearly offer new opportunities to develop pain management thera pies. The implication is that main tenance or manipulation of the gut microbiota could positively influ ence pain perception, thereby offer ing new intervention targets. These might include prebiotic or probiotic administration, timing or choice of antibiotics, diet, and fasting proto cols for those undergoing surgery.”
Complementary Therapies in Medicine, Australian researchers assessed the effects of Caralluma fimbriata, on 33 overweight and obese Australian men and women. Study participants took either a placebo or 500 mg of Caralluma fim briata extract twice daily, while having their exer cise and dietary intake controlled and monitored. At the end of 12 weeks, those who received the Caralluma fimbriata supplement had lost an av erage of 2.6 inches from their waists, compared to only 1 inch from the placebo group. Caralluma fimbriata, Kullee moofiyan or kallimudayan (Tamil), KaraIlamu (Telegu), and Ranshabar, Makad Shenguli or Shindalavmakadi (in Marathi), is an edible suc culent plant, native to India. Indian tribal peo ple have used the natural appetite suppressant for many centuries. In times of famine it is a com monly used vegetable. This and other studies show that supplemen tation with Caralluma fimbriata can lead to a clinically meaningful reduction in central adiposity, a key com ponent of metabolic syndrome associated with other risk factors such as elevated blood pressure and car diovascular disease,” said Dr. Paul Clayton, chief sci entific advisor for Gencor, which provided the raw Caralluma fimbriata extract powder for the study. “In conjunction with exercise and a controlled diet, Caralluma fimbriata can improve metabolic risk factors, general health and well-being. The latest research at Carolina State University, which reveals how preg nane glycosides (the actives in Caralluma) inhibit appe tite, validates the clinical results and puts Caralluma at the head of the class of natural weight loss products.” The appetite suppressing properties of Caralluma fimbriata have been attributed to the active component pregnane glycosides. The mechanism of appetite sup pression of pregnane glycosides is unclear; however one hypothesis is that Caralluma fimbriata may downregulate ghrelin synthesis in the stomach and neuro peptide-Y in the hypothalamus, resulting in appetite suppression.
Indian herb to aid in weight loss
“Although the Department of Health has encour aged people to eat high fiber foods since the ear ly 1990s, most people in the UK are still not getting anywhere near enough dietary fiber,” said Dr Burley.
In recent years, a decline in both cardiovascular disease (CVD) and coronary heart disease (CHD) has been seen in some European countries and the United States. However, it still remains a significant issue ac counting for almost half (48%) and a third (34%) of all deaths in Europe and the United States. Many studies have examined the relationship between dietary fiber or fiber-rich foods and CVD risk factors, such as high blood pressure and raised blood cholesterol.
Gut microbiome: A link between red meat and risk of heart disease
Researchers at the University of Leeds have shown that greater dietary fiber intake is associated with a lower risk of both cardiovascular disease and coronary heart disease. Dr. Victoria Burley, from the School of Food Science and Nutrition at the University of Leeds and senior author of the study, said: “It has previously been difficult to demonstrate the long-term influence of diet on heart attacks or strokes. For the first time, our research has shown the long-term benefits, even with quite small increases in fiber intake.”
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This research adds to the growing body of work show ing the health benefits of eating more fiber. Earlier this year, the same research team showed that an increase in fiber intake may lower the risk of a first-time stroke.
The study, published in the jour nal Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB), is the first to investigate the inter-relation ships between animal source foods and the risk of ASCVD events, and the mediation of this risk by gut mi crobiota-generated compounds, as well as by traditional ASCVD risk pathways such as blood cholester ol, blood pressure, and blood sugar. 44
Increased dietary fiber in-take associated with reduced risk of heart disease
Does eating more meat—espe cially red meat and processed meat—raise the risk of cardiovascu lar disease, and if so, why?
The new study was published by the journal BMJ.
Despite intense study, the im pact of animal source foods on Atherosclerotic Cardiovascular Disease (ASCVD) is vigorously de bated, and the mechanisms un derlying the potential effects of animal proteins remain unclear. Understanding the impacts of meat consumption is particularly impor tant in older adults because they are the most vulnerable to heart disease, yet may benefit from the intake of protein to offset age-related loss of muscle mass and strength. Recent evidence suggests that the underly ing culprits may include specialized metabolites created by our gut bac teria when we eat meat.
In the new study, the researchers reviewed litera ture published since 1990 in healthy populations con cerning dietary fiber intake and CVD risk, taking data from six electronic databases in the US, Europe, Japan and Australia. They observed a significantly lower risk of both CVD and CHD with every additional 7g per day of fiber consumed. An additional 7g of fiber can be achieved through one portion of whole grains (found in bread, cereal, rice, pasta) plus two to four servings of fruit and vegetables or a portion of beans or lentils.
“Hopefully our findings will show how even a small change to your diet can greatly improve your health.”
The Indian Practitioner d Vol.75. No.8. August 2022
A new study led by researchers at the Friedman School of Nutrition Science and Policy at Tufts University and Cleveland Clinic Lerner Research Institute quantifies the risk of ASCVD associated with meat intake and identifies under lying biologic pathways that may help explain this risk. The study of almost 4,000 U.S. men and women over age 65 shows that higher meat consumption is linked to a higher risk of ASCVD—22 percent higher risk for about every 1.1 serving per day—and that about 10 percent of this elevated risk is explained by in creased levels of three metabolites, produced by gut bacteria from nu trients abundant in meat. Higher risk and interlinks with gut bacte rial metabolites were found for red meat but not poultry, eggs, or fish.
Regular fruit consumption may lead to enhanced mental wellbeing
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Recent in vitro research further builds on this exist ing evidence, investigating some of the possible mech anisms behind the antiviral activity. A Korean study examined changes in bone marrow-derived dendrit ic cells using RNA sequencing. The study found that cells treated with fucoidan activated the key genes in volved in virus-specific response pathways, including those of corona viruses and influenza. The fucoidantreated cells also increased type 1 interferon response which plays an essential role in combating virus infec tion.
The researchers concluded that the findings may serve as a strong foundation for further research into fucoidan-based strategies for the prevention and treat ment of a range of viruses. The full paper, ‘Gene Set Enrichment Analysis Reveals That Fucoidan Induces Type I IFN Pathways in BMDC’ was published in the journal Nutrients.
Fucoidan promotes antiviral activity, shows research
Over the past two decades, extensive research has explored the ability of high-purity fucoidan ex tracts to inhibit the viral activity.
People who frequently eat fruit are more likely to report greater positive mental wellbeing and are less likely to report symptoms of depression than those who do not, according to new research from the College of Health and Life Sciences, Aston University.
The researchers’ findings sug gest that how often we eat fruit is more important to our psychologi cal health than the total amount we consume during a typical week. The team also found that people who eat savory snacks such as crisps, which are low in nutrients, are more like ly to report greater levels of anxi ety. Published in the British Journal of Nutrition, the study surveyed 428 adults from across the UK and looked at the relationship between their consumption of fruit, vegeta bles, sweet and savory food snacks, and their psychological health. After taking demographic and lifestyle factors such as age, gener al health and exercise into account, the research found that both nutri ent-rich fruit and nutrient-poor sa vory snacks appeared to be linked to psychological health. They also found that there was no direct as sociation between eating vegetables and psychological health. Based on the survey, the more often people ate fruit, the lower they scored for depression and the higher for men tal wellbeing, independent of the overall quantity of fruit intake.
Lead author, PhD student Nicola-Jayne Tuck commented: “Very little is known about how diet may affect mental health and well being, and while we did not direct ly examine causality here, our find ings could suggest that frequently snacking on nutrient-poor savory foods may increase everyday men tal lapses, which in turn reduces psychological health. Both fruit and vegetables are rich in antioxidants, fiber and essential micronutrients which promote optimal brain func tion, but these nutrients can be lost during cooking. As we are more
The Indian Practitioner d Vol.75. No.8. August 2022 45
People who frequently snacked on nutrient-poor savory foods (such as crisps) were more likely to ex perience ‘everyday mental lapses’ (known as subjective cognitive fail ures) and report lower mental well being. A greater number of lapses were associated with higher report ed symptoms of anxiety, stress and depression, and lower mental well being scores. By contrast, there was no link be tween these everyday memory laps es and fruit and vegetable intake or sweet snacks, suggesting a unique relationship between these nutri ent-poor savoury snacks, everyday mental lapses, and psychological health. Examples of these frustrat ing little everyday mental lapses in cluded forgetting where items had been placed, forgetting the purpose of going into certain rooms, and be ing unable to retrieve names of ac quaintances whose name was on the ‘tip of the tongue’.
Alternative and sustainable proteins from plants, microorganisms and fungi
The Indian Practitioner d Vol.75. No.8. August 2022 Nutraceuticals 46 likely to eat fruit raw, this could po tentially explain its stronger influ ence on our psychological health. It is possible that changing what we snack on could be a really simple and easy way to improve our men tal wellbeing. Overall, it’s definitely worth trying to get into the habit of reaching for the fruit bowl.”
In addition to animal-free dairy products, the in dustry and the consumer are also increasingly call ing for more protein from pulses in products such as meat and dairy substitutes, as an alternative to animal proteins. But the taste of pulses is not optimal for this application. You can taste this in dairy substitutes in particular. “The taste is sometimes compared to card board”, says Laurice Pouvreau, Wageningen Food & Bio-based Research.
Laurice Pouvreau and her fellow plant and food scientists are working together on a project to breed pulses (e.g. by cross-pollination and genetic selection), so that they have better taste and other properties for use in food. “We know what causes the cardboard-like taste and through breeding we want to find existing varieties or develop new varieties that have a less un pleasant taste.”
Below listed are few alternative and sustainable pro tein ideas from plants, microorganisms and fungi: Cheese without cows Cow's milk is an important source of protein in the Western diet, but its production has a significant im pact on the climate and animal welfare. Demand for animal-free dairy products is increasing and there are already a lot of vegan products on the market. But vegan cheese is still difficult to make. Dairy products based on plant-based proteins do not have the same taste and structure as cheese from milk. Therefore, Wageningen University & Research (WUR) is investi gating the possibilities to make sustainable, nutritious and flavorful cheese using microorganisms. Vegan milk “Cow milk contains caseins. These proteins form clusters (micelles), and it’s these that create the gellike structure of dairy products”, says Etske Bijl, Food Quality and Design researcher. Bijl and her colleagues intend to use yeasts to produce casein, an animal-free route to produce protein with the same nutritional val ue and properties as protein from cow’s milk. Bijl said, “The vegan cheeses currently available on the mar ket are, for example, made from starch or compressed nuts. These may also be delicious, but they aren’t the same as cheese.”
Improving the taste of pulses
Another example of alternative protein sources are fermented products (with bacteria or fungi) such as tempé and kimchi. The process of fermentation is cen turies old but can be put to better use. For this rea son Jasper Zwinkels, from Food Microbiology, stud ied whether fungal fermentation can improve the nu tritional value of a product. He did this with rice and barley. Zwinkels: “We chose these because these crops are eaten in large quantities, also in low-income coun tries, and it’s precisely in these countries that people need a high-quality protein.”Jasper Zwinkels Followup research is required to study how the fermentation process actually works.
Fermentation helps combat protein shortage
Alternative Medicine The Indian Practitioner q Vol.75 No.8. August 2022 Alternative Medicine 47
Fighting Fibroids with Mahatrik Mudra Fibroids are a common type of growth in the female pelvis. Many women have uterine fibroids some time during their lives. However, many women don’t experience any symptoms from their fibroids and don’t realise its presence. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultra sound.Fibroids range in size--from seedlings, undetectable by the human eye to bulky masses that can distort and enlarge the uterus. A person can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight. The growth patterns of uterine fibroids vary — they may grow slowly or rapidly, or they may remain the same size. Some fibroids go through growth spurts, and some may shrink on their own. Many fibroids that have been present during pregnancy shrink or disap pear after pregnancy, as the uterus goes back to its usualAlthoughsize. researchers continue to study the causes of fibroid tumors, little scientific evidence is available on how to prevent them. But, by making healthy life style choices, such as maintaining a healthy weight and eating fruits and vegetables, you may be able to de crease your fibroid risk. Also, some research suggests that using hormonal contraceptives may be associated with a lower risk of fibroids.In the science of mudras, the little finger denotes the Swadishthan Chakra (water element), while the ring finger denotes Mooladhara Chakra (earth element). While practising the Mahatrik Mudra, one should as sume the moola-bandha and uddiyana-bandha postures seated. Moola-bandha means compression/ squeezing of anus, rectum and urinary muscles upwards. Uddiyanabandha means tightening of the muscles of abdomen, colon and reproductive organs by squeezing them in wards tightly. In doing so, both the earth and water chakras are compressed, thereby affecting all the areas in the sacral region.
Aromatherapy, or essential oil therapy, refers to a range of traditional, alternative or comple mentary therapies that use essential oils and other aromatic plant com pounds.Essential oils have been used for nearly 6,000 years, with the aim of improving a person’s health or mood.The National Association for Holistic Aromatherapy (NAHA) defines aromatherapy as “the thera peutic application or the medicinal use of aromatic substances (essen tial oils) for holistic healing.” In 1997, the International Standards Organization (ISO) de finedTrusted Source an essential oil as a “product obtained from vegetable raw material, either by distillation with water or steam, or from the epicarp of citrus fruits by a mechanical process, or by dry distillation.”A range of essen tial oils have been found to have various degrees of antimicrobial activity and are believed to have antiviral, nematicidal, antifungal, insecticidal, and antioxidant prop erties. Aromatherapy applications include massage, topical applica tions, and However,inhalation.usersshould be aware that “natural” products are also chemicals, and they can be hazard ous if used in the wrong way. It is important to follow the advice of a trained professional when using
Aroma Therapy - What You Need to Know
Siddha walk is a process where you walk in a pattern of number eight or infinity, in a particular direction, and at a required speed. Siddha walk is a process where you walk in a pattern of number 8 or infinity, in a par ticular direction and at required speed, with the right mindset. This technique of yogic and spiritual values is being revived now by a lot of people in order to spread the message of happiness, health and peace to all. Siddha walk has the power to not only accelerate your physical health but it can also elevate your men tal and spiritual development. It is a dynamic system based on a scientific approach, which can drastically transform the human body and mind. In Siddha walk, the shape of 8 or infinity, plays a very important and powerful role. It represents connection and how we transition from one task to the other, apart from dem onstrating how one act or choice that you make today automatically leads to the next set of choices or tasks that we end up performing.
The Indian Practitioner q Vol.75 No.8. August 2022 Alternative Medicine 48
The process of practicing Siddha walk is to trace the figure 8 while you walk from the direction of South to North. The process of walking from the south side to the north, in this shape of 8, must be done for 21 min utes. After having completed the required duration of rounds, you must then reverse the direction and walk from north to south for another 21 minutes.
essential oils.Aromatherapy is nor mally used through inhalation or as a topical
The Siddha walk comes from the ancient scripture of Agastya Nadi. According to him, Maharishi Agastya was one of the learned sages, who adopted this tech nique, researched its benefits and left the legacy of this practice for humankind. Now all of us can adopt it through his manuscript, the Agastya Nadi.
Inhalation:application.theoils evaporate into the air using a diffuser con tainer, spray, or oil droplets, or breathed in, for example, in a steam bath.Apart from providing a pleas ant smell, aromatherapy oils can provide respiratory disinfection, decongestant, and psychological benefits.Inhaling essential oils stim ulates the olfactory system, the part of the brain connected to smell, in cluding the nose and the brain. Molecules that enter the nose or mouth pass to the lungs, and from there, to other parts of the body.As the molecules reach the brain, they affect limbic system, which is linked to the emotions, the heart rate, blood pressure, breathing, memory, stress, and hormone balance. In this way, essential oils can have a subtle, yet holistic effect on the body. Topical applications: massage oils, and bath and skin care prod ucts are absorbed through the skin. Massaging the area where the oil is to be applied can boost circula tion and increase absorption. Some argue that areas that are richer in sweat glands and hair follicles, such as the head or the palms of the hand, may absorb the oils more ef fectively.Essential oils are never applied directly to the skin. They must al ways be diluted with a carrier oil. Usually, a few drops of essential oil to an ounce of carrier oil is the con centration. Most common carrier oils are sweet almond oil or olive oil.
The Siddha walk, known with other synonymous names such as The Eight Walk or The Infinity Walk, was then designed, envisioned and practiced widely. It is also adopted by ancient scholars from the di vine mountains of The Himalayas, namely Bhagwan Vyas, Bhagwan Vashisht, Bhagwan Vishwamitra, Valmiki, Bhagwan Parshuram, Bhagwan Markandeya, Maharishi Agastaya. They all ended up extensively spreading its practices, with a single mission of the well-being and upliftment of humanity.
Siddha Walk: The Benefits of the Ancient Yogic Spiritual Practice
In addition to the immense health benefits, it also provides practitioners with a sense of direction. Siddha actually means someone who is perfect or the accom plished one. Hence, it is a practice to achieve this per fection and Siddha walk should therefore be imple mented in everyday life.
Cures Numbness. Numbness is caused when you lose partial or complete sense of sensation in cer
The Sanskrit word Shunya, which means “void,” “emptiness,” or “spaciousness,” is where the name Shunya mudra originates. Shunya mudra is a tattva mudra (element’s mudra) made to lessen the space element (akasha) effect in the body and is called “Gesture of Emptiness”. Since this mudra focus es on limiting space element, which is expanded throughout the entire body from every cell to muscle, it is very helpful in the treatment of many health Physically,conditions.
Prevents Motion sickness. Motion sickness is caused when our mind cannot distinguish sensory signals over brain signals. It is of ten caused due to inflammation in the inner ear and can result in diz ziness, lightheadedness, nausea, or vertigo. Practising shunya mudra directly affects and stimulates the nerves near inner ear, preventing balance disorders.
Alternative Medicine The Indian Practitioner q Vol.75 No.8. August 2022 49
Shunya Mudra: Benefits
Chiropractic Care for Rheumatoid Arthritis
Do you ever feel sluggish or out of your senses? Are you expe riencing excessive numbing or tin gling in some parts of your body?
shunya mudra can provide relief from most ear ail ments, prevent heart diseases, im prove the sense of balance, and oth er problems which are caused due to an imbalance in ether element. Some common health conditions in which shunya mudra is helpful are; • Ear disorders such as hearing loss or tinnitus • Throat problems, enlarged thy roid • Motion sickness • Numbness in different body parts Shunya mudra is performed with the middle finger and thumb. To form shunya mudra, you need to curl your middle finger for its tip to touch the base of the thumb. The thumb is then placed over the bent finger giving a slight pressure. Keep the rest three fingers straight. Then place the back of the hand (with mudra) on the knees in any sitting posture. Shunya mudra aka Aakash shamak mudra is a therapeutic as well as a spiritual hand mudra. Here are some main benefits of this mudra.
People choose chiropractic care for all kinds of health concerns. If you have problems with your joints, you may be wondering if chiropractic care can help you. The answer may depend on the cause of your pain. Here’s what to consider before you try chi ropractic care.The theory behind chiropractic care is that your nervous system works best when the bones in your spine are aligned correctly, to benefit not just your muscles and joints, but all the systems of the body. Many people use it to address musculoskeletal problems.Chiropractic care is a form of manual therapy, which means practitioners use their hands and special instruments to deliver treatment. They don’t prescribe medication and they don’t do surgery. But they are licensed and may have recommendations on exercise and other therapies.Some types of joint problems may limit what your chiropractor can do. Spinal manipula tion should not be used on joints that are inflamed or infected. It also shouldn’t be done on people with weak bones, as it can cause a fracture. But other techniques chiropractors use, such as joint mobilization and soft-tissue therapies, may be used safely. Damage to a joint can cause a domino effect of tightness and spasms in the surrounding muscles, liga ments, and other tissues. Working on those can relieve yourTalkpain.toyour primary care doctor or arthritis special ist about whether chiropractic care would be a good addition to your treatment plan and what the risks might be. They also might be able to refer you to some one.It’s important to discuss your symptoms and any changes in your overall health at every treatment ses sion. Changes to your condition may mean a specific therapy used in one visit may not be right for another.
Relief from Ear-Related Problems. Since excess space ele ment in the body is mainly respon sible for hearing issues, Shunya mudra (which suppresses space ele ment) can relieve ear-related prob lems such as earache, tinnitus (ring ing or buzzing noise in the ears), and deafness.
Clary sage, Coriander, Patchouli, Basil, Peppermint Essential Oils can also be considered. 50
Mandarin, Orange, Grape fruit, Tangerine, Neroli: Is gentle, calming, anti-depressant, promotes happi ness. It calms nervous tension and restlessness. It is also traditionally used for digestive disorders.
Lemon: Is used for digestive problems, anxiety, an ti-depressant. It promotes a sense of well-being. Its has invigorating, warming, and enhancing aroma. Lemon also promotes clarity of thought and purpose as well as physical energy.
Eating disorder is a serious condition and an early intervention is thought to be one of the most important ways of preventing complications due to anorexia. It’s not an easy disorder to be treated permanently, but to day a wide range of effective treatments are available including; regularly monitored by a doctor, cognitive behavioral therapy, support groups, dietic guidance, acupuncture, guided meditation to reduce stress and anxiety, and therapeutic use of Essential Oils through Aromatherapy to tackle the underlying cause.
Ginger: Is stimulating, used for courage, loss of ap petite and other digestive disorder.
Angelica: Is calming, helps release and let go of negative feelings, trauma or anger, used for loss of ap petite as well.
Spiritual benefits – Makes Able to Hear Anahata Sounds
Jasmine: In addition to its romantic and exotic qual ities, used to support healthy-looking skin.
The Indian Practitioner q Vol.75 No.8. August 2022 Alternative Medicine
. Anahata is the mystic sound and sounds of nature, often heard by yogis at the beginning of their meditation. You might be able to hear these sounds when you do shunya mudra with meditation. This also signifies that the Nadis or astral currents are get ting pure. Helps activate the Heart chakra. The finger formation of shunya mudra promotes a smooth flow of prana towards the heart chakra. It opens up the heart centre.
Aromatherapy Aid to Eating Disorders
Lavender: Is calming, anti-anxiety, and helps with insomnia.
Eating disorder (anorexia and bulimia) is engaging in unusual and persistent behaviors in order to prevent weight gain, by attempting to follow rigid di etary rules, like only consuming very small number of calories of a limited number of food at specific times per day, which puts the body in starvation mode. Per dictionary meaning; “Anorexia, also called Anorexia nervosa, a disorder characterized by fear of becom ing fat and refusal of food leading to debility and even death.” It affects 3 in 100 and not surprisingly, it af fects the teens in industrialized countries the most. In Western world, where size zero models – actors are the role models, young people, especially girls, see them selves not standing up to the cultural expectations of the social norm. Anorexia is often preceded by a trau matic event and other emotional problems.
Inhalation of essential oils may alter emotions that could change the underlying psychology and dis turbed-thinking pattern which supports the self-de structed behavior. Essential oil aroma directly affects the limbic system of the brain. There are several essen tial oils that are calming, anti-depressant, and sooth ing, that are traditionally used for anorexia based on each individual needs, eg: Bergamot: Is uplifting, antidepressant, regulates the appetite.
tain parts of your body. It happens when there is excessive presence of space element in our cells or veins. Shunya mudra will decrease this extra space element and give relief from numbness or tingling. Prevents Heart Disease. Placing the middle finger at the base of the thumb also acts as an acupressure point for Atrium – chamber through which blood enters the heart. Hence, shunya mudra may also relief from a wide range of heart diseases such as Atrial fibrillation (strokes), ASD (Atrial Septal Defect), blood pres sure, and other heart disorders.
To know any element is to know its qualities. Water is cool, stable, heavy, moist, smooth, gross, flow ing, dull, cloudy, and soft. The water element is the antidote to symptoms that have the opposite qualities in the body. It is impor tant to take in the qualities of water when you are feeling too warm, un grounded, emaciated, dehydrated, rough, lacking in self-esteem, ob structed and immobile, irritable with a sharp tongue, transparent and vulnerable, or if your heart has become too hard. The Five Waters of The Body In the human body, water is expressed in five distinct ways, known as the five types of kapha. The water that protects the mouth against the actions of chewing and against the enzyme that begins the breakdown of car bohydrate (salivary amylase) is called bodhaka kapha. Bodhaka kapha is the salivary fluid, and also the mucous membrane secretions of the lips, checks, and phar ynx. The water that protects the mucous membranes of our stomach against the acids that aid digestion is called kledaka kapha. The water that stabilizes the flow of neurological impulses and protects the nerves of the brain is called tarpaka kapha. The water that protects the joints from the friction of motion is called sleshaka ka pha. Sleshaka kapha is found in the synovial fluid that moistens joint surfaces, and in the bursae that allow tendons to glide smoothly over each other. The water that protects the respiratory system from the move ment of breath (a drying process) is called avalambaka kapha. Avalambaka kapha keeps the mucous membranes of the bronchi and lungs healthy and also provides the fluids that support the pleura and pericardium.
Alternative Medicine The Indian Practitioner q Vol.75 No.8. August 2022
The Five Elements: Water in Ayurveda
The kapha dosha contains both water and earth. It is water that is responsible for most of the protective and healing aspects of the kapha dosha. As water is the foun dation for earth in the body (water supports earth’s heavy, stable qualities) an increase in the qualities of water will result in weight gain and sluggishness. 51
Water and the Kapha Dosha:
The tongue is the vehicle through which the rasa tanmatra manifests. The tongue is the sense organ of water. Through the tongue we taste the world around us. It is interest ing to note that the taste buds of the tongue only work when water or saliva is present. No water, no taste. The urethra is the organ of action. Through the male urethra, highly potent reproductive fluid is expelled from the body. Through the male and female urethra, wa ter is expelled in the form of urine. Imbalances of the water element in the body can be observed by moni toring changes in a person’s experi ence of taste as well as through al terations of urine or seminal fluid.
The element water, called “apas” in Sanskrit, is the fourth of the five great elements (pancha mahab hutus). It comes fourth because it evolves from ether, air, and fire; water contains aspects of the oth er three elements within it. Ether provides water the space to exist within. Air provides water with the ability to move and flow. The rela tionship between fire and water is more esoteric. Air creates the fric tion that generates the heat of fire. Fire moves in a fluidic or flowing manner. In each evolution from one element to the next, nature becomes denser. As fire becomes denser it cools and takes greater form. This is the form of water. The element of water represents fluidic matter and the cohesive prin ciple of physics. Water is the protec tor of the body. It provides the body with its most basic nourishment. Water protects against the dissolu tion of the ether element, the rough ness and motion of the air element and the heat of the fire element. The water element sooths all pain and inflammation in the body. The origin of the water element is the tanmatra of taste, rasa. Rasa in this context is the primordial causa tion of the experience of taste. Rasa is the causal energy that provides the potential for the experience of taste to occur. It is not the taste it self. However, since taste depends upon the water element for its man ifestation, disorders of the ability to taste are due to an imbalance of the water element. Water: Sense Organ and Organ of Action
The Qualities of Water
The National Cancer Grid (NCG) has established the Koita Centre for Digital Oncology (KCDO) to promote use of digital technologies and tools to im prove cancer care across India. The Centre has been set up with the contributions received from the Koita Foundation, which will support it for five years. The Tata Memorial Centre and Koita Foundation formal ized the collaboration by signing a MoU at the Tata
Around seventy-four million people suffer from diabetes in the country and this figure is likely to in crease to ninety-three million by 2030. The number of people with diabetes in India is the second highest in the world, after China, as reported by the Economic Times.
SRM hospital gets Autism Centre of Excellence
National Cancer Grid Establishes New Centre for Digital Oncology to improve Cancer Care
Medi News The Indian Practitioner q Vol.75. No.8. August 202252 Medi News
Bayer Launches Kerendia for Chronic Kidney Disease
Strong emphasis is laid on in tegrating them into regular class rooms and enabling them to live in competition with the community. Children with autism can obtain free rehabilitation services from SRM ACE. Through research in the fields of occupational therapy, speech therapy, special education, and clinical psychology, SRM-ACE will also promote innovation in au tismTheintervention.occupational therapy services cover a wide range of therapeutic modalities, counting Sensory Integration through Playbased Intervention, Behavioural Modification, Social Skills Training, Group Therapy, Handwriting Intervention, and ADL training.
Drugmaker Bayer recently said it has introduced a medication for the treatment of chronic kidney disease related with diabetes under the brand name Kerendia. The drug is a non-steroidal, selective min eralocorticoid receptor antagonist designated for pa tients with chronic kidney disease associated with type 2 “Thediabetes.majorfocus of therapy in patients with chron ic kidney disease and diabetes is to prevent end-stage renal disease or kidney failure. Despite therapy, these patients with chronic kidney disease associated with type 2 diabetes. Finerenone (Kerendia) therefore of fers a new treatment approach for these vulnerable patients to slow down the progression of chronic kid ney disease and reduce the risk of kidney failure,” said Bayer Pharma, Managing Director Manoj Saxena.
Autism Centre of Excellence (ACE) was inaugurated by Founder Chancellor, SRM Institute of Science and Technology Dr. T. R. Paarivendhar at SRM Medical College Hospital and Research Centre (SRM MCH & RC), Kattankulathur, Tamil Nadu. This centre offers children with autism all necessary services under one roof. This centre is also first-of-itskind in an Indian medical college hospital.Thecentre has been launched by SRM College of Occupational Therapy. The mission of this centre is to make available all the indis pensable services, such as occu pational therapy, speech therapy, special education, and clinical psy chology at one location with welltrained certified individuals.
KCDO will play an important role in driving digi tal transformation across the cancer care continuum. KCDO will support NCG hospitals in sharing best practices in digital health, adopting digital health tools, and driving many common technology initia tives including EMR adoption, healthcare data in teroperability, reporting and analytics. KCDO will also enable NCG and NCG hospitals pilot and adopt new technologies – including AI, ma chine learning, big data, automation, and cloud, mo bile – which will benefit hospitals, doctors, patients and consumers. Embracing digital tools like telemedicine and remote patient monitoring will help make care more accessible especially in semi-urban and rural areas. AI-assisted clinical decision support tools will help improve doctors’ ability to provide better care, and mobile patient engagement apps will help patients with medication management and better compliance with care guidelines.
News
Medi
Memorial Hospital in Mumbai recently.
Apollo Hospitals, Jubilee Hills, commemorates 34 years of service with a pledge Apollo Hospitals, Jubilee Hills, celebrated its 34th Anniversary recently. Doctors and employees who were part of the hospital since its inception were felicitated and congratulated for their contribu tion. Apollo Hospitals, Jubilee Hills, Hyderabad, has emerged as one of the trusted integrated healthcare service providers in Asia. Speaking on the occasion, Dr Sangita Reddy, Joint Managing Director, Apollo Hospitals Group said that what has been achieved over the last 34 years has been briefly presented as milestones, milestones are the marking of one day’s achievement, but what you really achieved is that you touched the lives and hearts of so many fam ilies. It is that outstanding contribu tion to the society which stands out and sets the way, creates the light, shows the path, inspires others and for that I can only say a very big thank you, a great congratulations and most importantly wish you the strength, the energy, the inspiration and the courage to continue to take forward the legacy, because there is so much more to do. She also added saying that let’s work to protect what is priceless, that’s what you all do every day, you are curing, you are saving and also focusing on prevention. What you do is not limited to India and Indian patients, but for patients from all over the world. Recently I was in Indonesia as a representative of the Indian Government as part of G24 Women and everyone there was well aware of Apollo Hospitals and its work and very appreciative of our extraordinary achievements in the healthcare domain.
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June 2017 Articles, Case Reports, Review Articles and/ or any such paper should conform to the interests of the readership of The Indian Practitioner. The Indian Practitioner reader is primarily the general physician, though now the journal has extended the scope to specialities also due to increasing readership among specialty doctors. The information provided through articles should add additional knowledge and be of interest to the practisingAuthorsdoctor.arerequested to prepare their manuscripts as per these Guidelines.
Generally, the manuscript should be submitted in the following format:
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“Submit online” on the right and upload all of your manuscript files following the instructions given on the screen. All manuscripts must be submitted on-line through the website www.theindianpractitioner.com with cc to tipeditors@gmail.com. First time users will have to register at this site. Registration is free but mandatory. Registered authors can keep track of their articles after logging into the site using their user name and pass word. To expedite an email could be sent to our edito rial office mentioning the online submission. If you ex perience any problems, please contact the editorial of fice by e-mail at editor tipeditors@gmail.com.
2. Review Article – word limit 2500 (excluding the ref erences). References as stated above. It should in clude an abstract of 250 words.
1. Title Page/First Page File/Covering letter
m Acknowledgement: Acknowledgement, if any, should be included in the title page of the manu
57The Indian Practitioner q Vol.75 No.8 August 2022
Opinion/Editorial/Perspective articles on any sig nificant aspect of Indian healthcare, esp. topical issues. Word limit 700-1300 words. Book Review – word limit 700, image of the book cover, ISBN and Publisher details required. Correspondence (Letter to the Editor) – word lim it 600 words. Readers are welcome to send comments, questions, criticisms or clarifications on published ar ticles. Online Submission Electronic submission substantially reduces the ed itorial processing and reviewing times and shortens overall publication times. Please follow the hyperlink
m Authors: Names of all authors/ contributors (with their highest academic degrees, designation and affiliations) and name(s) of department(s) and/ or institution(s) to which the work should be credited should be mentioned. The name, address, e-mail, and telephone number of the corresponding author, who is responsible for communicating with the other authors about revisions and final approv al of the proofs, must be included in the manuscript Author/sitself. brief biodatas should be included.
GUIDELINES TO CONTRIBUTORS
4. Clinical Practice: Word limit upto 2000 words. Articles discussing ailments (esp. their manage ment)/clinical conditions/procedures and tech niques of interest and importance to the general physician in their everyday practice. Apart from ar ticles, algorithms, flowcharts, and figures shall also beConsentconsidered.forpublication must be obtained from the patient/s.
3. Case Report – word limit 1000-2000 (excluding ref erences). Unusual findings or case reports will be appreciated. The journal encourages the submission of unread cases and/or unusual findings of known conditions.
1. Original Article reporting original research – word limit 2500 (excluding references). References to be kept to a minimum, only really relevant and not more than 10 years old. The article should include a structured abstract of 200-300 words.
The title page of the manuscript should include the following: m Manuscript Type: The type of manuscript, (origi nal article, case report, review article, Letter to edi tor, etc) along with the title should be submitted on line in a MS doc files.
Types of Papers
m Source of Support: Source(s) of support, if any, in the form of grants, equipment, drugs, or all of these should be mentioned. All forms of financial support if any for the manuscript preparation/ data/ study etc should be disclosed in the beginning of the man uscript.
m Conflict of Interest: Conflicts of Interest of each au thor/ contributor for an industry/ pharma spon sored article or where manuscripts report on medi cine/ medical products should be mentioned at the beginning of the manuscript.
2. Article file m Main Text: The main text of the article, begin ning from Abstract till References (including tables) should be in this file.
m Abstract: For Original Articles and Case Reports, please provide a structured abstract of 200-300 words. Organize it into background/ purpose of the study, methods, results and conclusion. The struc tured abstract should state the purpose of the study or investigation, basic procedures (study subjects or experimental animals and observational and an alytical methods), main findings (give specific da ta and their statistical significance, if possible), and the principal conclusions For Review Papers please provide a running/unstructured abstract of 250 words. The abstract should not contain any unde fined abbreviations or unspecified references.
The Indian Practitioner q Vol.75 No.8 August 202258
script and not in the main article file. One or more statements should specify: 1) Contributions that need acknowledging but do not justify authorship, such as general support by a departmental chair; 2) Acknowledgments of techni cal help; and 3) Acknowledgments of financial and material support should specify the nature of the support.
A statement that the manuscript has been read and approved by all the authors, that the re-quirements for authorship as stated earlier in this document have been met.
m Peer Review: Manuscripts that are found suitable for publication after preliminary review by our Executive Editor are sent for expert peer review. The initial acceptance/rejection at this stage shall be in formed to the authors within two weeks of submis sion. We follow a double-blind peer review policy. A final decision on the manuscripts shall be reached within 4-6 weeks of submission. The comments and suggestions (acceptance/ rejection/amendments in manuscript) received from peer reviewers are con veyed to the corresponding author and explana tion/clarification may be sought. Where changes/in corporations are suggested from the author/s, they would be requested to revise the article according ly. Once revised article is received it is again sent to peer reviewer and if accepted then to Executive Editor who decides and schedules the article for publishing.Acceptance of manuscripts for publication will be informed to the corresponding author. 9
m Informed Consent: For clinical trials or research ar ticles, participants / patients’ interests and privacy should be protected and informed written consent obtained from patients.
The journal will hold the copyright for all arti cles published and where required jointly with the author/s.
m Protection of Human and Animal Rights: Author/s must attest that their research involving human subjects has been performed in keeping with the Declaration of Helsinki, and approval obtained from the concerned Ethics Committee/ Review Board. The journal reserves the right to reject a submission and/or contact the approving Ethics Committee/ Review Board in case of suspicion of ethical noncompliance, even if approval has been obtained from Ethics Committee/ Review Board. Research/ experiments on animals must comply with institu tional and national guidelines for use and care of laboratory animals, and Ethics Committee approval obtained wherever available.
m Author Consent: A covering letter signed by all the authors stat-ing that the article has not been pub lished else-where or submitted for publication else where at the time of submission should be sent.
m Ethical Issues: Clinical trials registration number along with name of registry and url, ethics commit tee approval should be mentioned.
m Copyright: Authors wishing to include pictures, fig ures, tables, or text passages that have already been published elsewhere or sourced from any website etc are required to obtain permission from the copy right owner(s) for both the print and online format and to include evidence that such permission has been granted when submitting their papers. Any material received without such evidence will be as sumed to originate from the author.
m Keywords: Please provide 4-6 keywords other than what is in the title, which can be used for indexing purposes.
The Editorial Process
A manuscript will be reviewed for possible publica tion with the understanding that it is being submitted to The Indian Practitioner alone at that point in time and has not been published elsewhere, simultaneous ly submitted, or already accepted for publication else where. Manuscripts with insufficient originality, se rious scientific or technical flaws, or lack of a signifi cant message are rejected before proceeding for formal peer-review. Every article will be subjected to plagia rism check before it proceeds for peer reviewing.
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The Indian Practitioner is a medical journal of 75 years standing. Go through issues of The Indian Practitioner now and realise the value of the content. m Each issue of The Indian Practitioner gives you: m Peer reviewed original articles, clinical studies & trials and case reports m Comprehensive news coverage on the happenings in the medical world m Medi Matters - on new treatment and surgical practices m Profiles on doctors in the news and on hospitals m Alternative Medicine - Reports from the Indian & traditional systems of medicine m Diary of major events such as conferences, exhibitions, etc.
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