PANDORA’S BOX

Global Vistas Around the world in health & medicine…01 Arbor Vitae The Poet behind the Plasmodium…02 Memory Invigoration Let’s tickle the baby!...03 Been There, Done That! Make the right move, decide now…04 EduO…05 THE PARCHMENT The Rendezvous – Dr. Vandana Jain…06 Worst Case Scenario First Aid Management…08 GREETINGS FROM LEXICON! History Revisited It is with great pleasure that I announce that Lexicon is X-Ray: A look inside…09 BACK! After a quarterly hiatus where we dabbled with Cerebro the blogging world, Lexicon has officially re-launched The Vector Sector…10 its eighth edition. With an ever-growing team of Do you know your vectors well?...12 ardent Lexiconians, new and innovative elements, an LexiGyaan by LexiAmma entire section devoted to recognizing mavens in the Natural Mosquito Repellants…14 field of medicine (Med Marvels), a quirky, fun but LexiAmma Busts Dental Myths…14 wise lady – Lexi Amma – who finally accepted our Health Dotes…14 infinite proposal to share her know-how with our dear LexiAmma’s Guide for a Vegan Diet…15 readers, an interview with the eminent Dr. Vandana Jain, Lexicon’s return has surely resounded with a The New Truth bang! Tackling vector borne diseases…16 It’s Raining Men!...17 With the advent of the monsoon, our theme this time The impact of climate change on vector borne diseases…18 is to do with WHO’s venture on vector-borne Advances in the treatment & control of Lieshmaniansis..19 diseases. In line with the World Health Organisation’s Antimicrobial resistance- The role of med school…20 initiative to raise awareness and implement salutary guidelines on their prevention, our team has put Med Marvels together a series of advisory pieces on insidious Dr. Edmond Fernandes…21 transmitters of disease. An exposition on the impact Dr. Shwetha Mangalesh…22 of climate change, genetically modified mosquitoes, Dr. Carl Britto…23 advances in the treatment of leishmaniasis, surveying Dr. Soumyadeep Bhaumik…24 CDC’s surveillance system – ArboNet and many more! Dr. Subrahmanyam Karuturi…25

With this issue, Lexicon aims to elucidate diagnostic as well as therapeutic tools employed in vector- The Sting Operation control, and key prevention strategies. So put on Feelings of the flea…26 Rise of the rodent army…27 protective gear! It’s time for: The mighty mite…28

Tick me not!...29 The Sting Operation Acts of Kindness Tackling Vector-Borne Healthy is Happy- The medical wing of BTL…30 Dr. Siloo Bhagwager…32 Diseases Tech-X “Your breath smells of cancer”…33 sTMS: Goodbye Migraines?...34 Trusha Taneja Known Case Of Director of Edition (DE) Two rare and scientific cases…35 The Boards of Lexicon…38

Global Vistas Around the world in health & medicine

By Dr.Supriya Kumar Lugansk State Medical University, Ukraine

No More Pricks – Say Goodbye to Unnecessary Health Checks June, 2014: An initiative entitled SLIM (Society for Less Investigative Medicine) has been launched by top- ranking cardiologists of the All India Institute of Medical Sciences (AIIMS). Based on several worldwide studies, it has been established that regular health check-ups and diagnostic tests are unnecessary and only add to medical costs and expenses. Prof. Balram Bhargav, an AIIMS cardiologist has spearheaded the SLIM mission and propagates the need to bring in a checklist of symptoms that call for medical tests.

Trending in the World of Genome Editing – CRISPR June, 2014: The 1998 discovery of RNA interference (RNAi) provided scientists with a powerful tool to target and switch off the expression of particular genes to unravel their function. But RNAi can be imprecise, causing unintended “off-target” silencing of genes, and the technique can be time-consuming and cumbersome to employ in experiments. Other methods, such as zinc-finger proteins, have similar limitations. To the rescue come CRISPRs (Clustered Regularly Interspaced Short Palindromic Repeats), a gene-editing system that could revolutionize everything, from disease treatment to plant biology. The technique involves programming an RNA guide molecule to target a section of defective DNA and replace it with “good” DNA.

Defeating the Superbugs: New Inventions to Kill Drug-Resistant Disease June, 2014: The ominous decline of traditional antibiotics, together with the growing knowledge of good bacteria, has inspired a new wave of research into therapies that target and kill only disease-causing bugs. California-based biotech company, AvidBiotics uses genetic engineering techniques to tweak toxic compounds so that they specifically target one dangerous pathogen, like C. difficile or Escherichia coli O157:H7 strain that cause bloody diarrhea and sometimes, fatal kidney failure. James J. Collins et. al., Boston University are engineering a biological circuit into lactobacillus so that it responds to signaling molecules produced by the cholera bug with a toxin that targets and kills the microbe. A company AmpliPhi Biosciences has developed an inhaled phage cocktail for drug-resistant P. aeruginosa, a stubborn bacteria that infects the lungs of people with cystic fibrosis. The mix was successful in mice, and the company plans to launch a trial in humans this year.

The Mosquito Solution June, 2014: Dengue fever infects millions and kills tens of thousands of people around the world each year. But an Australian-led program is showing positive signs of turning this brutal disease into a bite-sized issue. A mosquito infected with wolbachia bacteria has been effectively disarmed. Although it will still bite and probe human skin for blood, it can no longer transmit the dengue virus from human to human. And best of all, these infected mosquitoes pass the neutralising wolbachia bacteria on to future generations of mosquitoes, eventually rendering entire populations harmless.

Measles making life difficult for US Citizens! May, 2014: Cases of measles have hit a 20-year high in the United States, driven largely by the North-Central Ohio outbreak among the Amish. As of May 23, 288 cases had been reported nationwide. The last time the year-to-date tally was higher was in 1994, when there were 764 cases. The importance of vaccination is being imposed on the healthy population as a means to contain the disease.

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ARBOR VITAE

The Poet behind the Plasmodium: Remembering the Legend! By Dr. Anirban Chatterjee KLE Institute of Dental Sciences- Belgaum

“This day relenting God Hath placed within my hand A wondrous thing; and God Be praised. At his command, Seeking his secret deeds With tears and toiling breath, I find thy cunning seeds, O million-murdering Death. I know this little thing A myriad men will save, O Death, where is thy sting? Thy victory, O Grave?”

Although he had no predisposition to medicine, at the age of seventeen, Sir Ronald Ross submitted to his father’s wish to see him enter the Indian Medical Service. And from then on, there was no looking back for this remarkable man, who was also a mathematician, epidemiologist, sanitarian, editor, novelist, dramatist, and a romantic poet.

Born in Almora in 1857, a cantonment town in North India, Sir Ronald Ross was the progeny of an Indian Army General, Sir C. C. G. Ross and his wife Matilda. It was when Sir Ross was eight years old, that he was sent to the United Kingdom to be educated. Much like a boarding school, very similar to a young Peter Parker (of Spiderman fame), he spent most of his childhood with an aunt and uncle on the largest island of England, the Isle of Wight.

An enthusiastic mathematician who had an inclination for puzzling theorems and amusing statistics and one who had never dreamt of becoming a medical practitioner, accidentally researched an arthropod, designed and customized some of the most valuable experiments with sheer instincts and optimism. His own calculated observations and estimates ultimately won him the second ever Nobel Prize in Medicine in the year 1902, having faced a lot of bureaucratic hindrance and encumbrance. Here’s a tribute to the magic man of medicine!

Young Ross: At the age of eight, Sir Ross was sent to England for education. He knew not much back then about malaria; all he witnessed was his father falling prey to this horrendous pathology. Despite being eloquent with numbers and sketches, young Ross joined St. Bartholomew’s Hospital in London in 1875 as suggested by his father. Not very surprisingly, he was never among the ones to be on distinction with scores. For his first shot, he flunked the examinations for the Indian Medical Service, which was when his father threatened to cancel his monthly pocket expenses. He then took up work as a ship’s surgeon voyaging between London and New York. In 1881, on his second attempt for the qualifying examination, he ranked seventeenth out of twenty- two successful candidates. After four months’ training at the Army Medical School, Ronald Ross finally levelled up to his father’s dream by entering the Indian Medical Service in 1881.

Madras and Malaria: SirRoss was appointed for the Madras service out of the three Indian Presidencies. With single-minded devotion, he toiled away in Mysore and Madras and also served in one of the longest running civil wars of Burma and in the Andaman Islands. While in Madras, a major part of his work was concentrated on treating soldiers infected with malaria. In Bangalore, while working for the post of Acting Garrison Surgeon, he noticed that there seemed to be more mosquitoes in his bungalow than in others and that there was a particularly large swarm around a barrel with water that was kept outside the window. Upon observation, the barrel was found to contain numerous squirming worms, which he described as mosquito larvae.

Eventually he did develop some interest in tropical diseases, like all his seniors would have during the period when these were endemic in most parts of India, particularly the ailment malaria that killed innumerable each year. Moreover, he himself falling victim to the ailment probably acted as the icing on the cake. True to his style, the poet composed a verse about his first impressions of malaria that killed millions. To top it all, August 20th continues to be celebrated as World Honors and Awards: He was awarded the Nobel Prize for Medicine “for his work on malaria, by which he has shown how it enters the organism and thereby has laid the foundation for successful research on this disease and methods of combating it”. He received an honorary M.D. degree in Stockholm in 1910 at the centenary celebration of the Karolinska Institute. In addition, he gained further recognition by being knighted in 1911. Mosquito Day in honour of Sir Ross’s discovery in 1897! Sir Ronald Ross sets a canvas of inspiration with a thick hue of qualities like dedication, commitment and passion which young medicos like us can appreciate and instill hereafter. For him, life was a poem; some phrases matched some didn’t. Very less could he predict his own future, mathematics never became his forte nor fiction a benchmark, what did work was his enthusiasm to acknowledge his surroundings. Who else can find life in cloggy stinking mushy swamps! Isn’t that a magician, as my granny use to say, one who makes the best out of the worst.

REFERENCES 1) http://www.malariasite.com/malaria/ross.htm 2) http://stevenlehrer.com/explorers/images/explor1.pdf 3) http://www.cdc.gov/malaria/history/ross.htm 4) http://en.wikipedia.org/wiki/Ronald_Ross

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MEMORY INVIGORATION Let’s tickle the baby! By Dr. Shreya Agarwal Grant Medical College & Sir JJ Group of Hospitals, Mumbai and By Sneha Nandy Seth GS Medical College & KEM Hospital, Mumbai

‘My Very Educated Mother Just Showed Us Ninjas!!!’

What would we have done without this very perfect mnemonic for the eight planets of our solar system? Mnemonics have always helped make those lengthy dreaded tables and charts a little more bearable, haven’t they? Keeping in mind the WHO’s theme for this year ‘vector borne diseases’, here are a few mnemonics to help you know your bugs and insects a little better!

1. ‘TICK’LE THE BABY 2. ROSY CHEEKS, YELLOW DIMPLE!

‘HARD’ AS A ROCK Vector – Aedes

Subject – Transmitted diseases Vector – Hard Tick What if this baby had rosy cheeks, and a Subject – Transmitted diseases yellow dimple? It would be infected with

Aedes! • Tularemia • Rift Valley Fever • Indian Tick Typhus • Chikungunya • Colorado Tick Fever • YELLOW Fever • KyasanurForest Disease Dengue • Lyme disease • Ehrlichiosis • Tick Paralysis • Hemorrhagic Fever • Encephalitis (Russian Spring Summer Encephalitis) • BABEosis ROCKY Mountain Spotted Fever

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BEEN THERE,DONE THAT! Make the Right Move, Decide Now

By Haleema Munir Allama Iqbal Medical College, Pakistan

“Okay, so you’ll be at the registration desk with the rest of the team members from 3rd year; 2nd year students in our team will be working at the reception and I’ll handle the stage,” I summarized some of the eleventh hour revisions in duties as I ushered my junior from 3rd year towards the registration desk for the “Career Guidance Seminar for Medical Students” being organized in our college.

Once students enter medical college, the general perception is that these individuals have reached their career goals, and there’s no major need for further career counselling. However, what the majority fails to realize is that the field of medicine is vast and so is the scope of a career after medical college. As an antidote to the general lack of awareness of medical students regarding post-graduate career opportunities, my friends and colleagues decided that we needed professional guidance to excel in our careers; hence, the initiative for a Career Guidance Seminar.

The most daring part of organizing this seminar was indeed the very first step of presenting the very idea to the faculty members, but to our relief the entire faculty was very receptive of the idea and within no time, we were working on this exciting venture with some of the most amazing professors of our institution. The excitement that engulfed our entire team was magical.

After numerous meetings with the supervising faculty members, in-depth discussions regarding the format of the seminar, and allocation of the oh-so-many managerial duties, which ranged from the distribution of the invitation letters to the handling of the multimedia presentations, “the day” was finally here and as unbelievable as it may have seemed, we were ready! The cloud of hopeful expectations that rose above the audience was almost palpable.

The seminar itself followed a conceptual pattern for career guidance, beginning with career opportunities provided by the basic sciences. The eminent speakers elaborated on the post-graduate opportunities that invite medical students of Pakistan. The main aim was to highlight the national and international study programs that welcome medical students with open arms, and empower these students to give their best back to their nation and to the world at large. An interactive question-and- answer session was also held in which the medical students attending the seminar cleared any ambiguities that they may have had. This seminar truly fulfilled the demands of its motto that went as “Make the Right Move, Decide Now”.

We were overwhelmed by the heaps of positive responses from medical students, teachers and professors from all over the city who not only appreciated our initiative but also went ahead to feature our event in their official blogs and websites. While we, the organizing team, undoubtedly gained immense knowledge from this seminar as far as our orientation regarding our careers was concerned, but equally important was the unexpected bonus we got. The bonus that came in the form of learning of valuable organizational skills, the exponential increase in our social circles and, of course, the amazing adrenaline-filled happy memories that would last a lifetime.

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EduO By Archit Rastogi Vellore Institute of Technology,Vellore

Name of the Event: Medsicon 2014 Recommended for: All medical and paramedical students Brief Description: The 4th Annual Medical Students International Conference is being organized by the students of Vardhman Mahavir Medical College and Safdarjung Hospital. This is an annual conference especially organized to cater to undergraduate medical students and young doctors. It features research presentations by the budding medicos and also has many fun filled events like JAM sessions, debates and medical quiz competitions.

Date: August 8th to 10th, 2014 Venue: Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India Type of Event: Conference

Abstract Submission dates: June30th, 2014. Registration Fees: For Indian Delegates – INR 1500, For Foreign Delegates – USD 60 Website Link: http://www.medsicon.org/

Name of the Event: IASGCON 2014 Recommended for: Gastroenterology specialists and enthusiasts. Brief Description: The 24th National Conference of Indian Association of Surgical Gastroenterology is being organized by the members of the IASG. This is an annual conference especially organized for gastroenterologists. For experienced doctors, it’s a great place to connect and for students, a brilliant learning opportunity.

Date: October 2nd to 5th, 2014 Venue: Gujarat University Exhibition Hall, 132 Ft. Ring road, Helmet circle, Memnagar, Ahmedabad, India Type of Event: Conference

Abstract Submission dates: July15th, 2014. Registration Fees: For Indian Delegates – INR 6000, For Foreign Delegates – USD 150 Website Link: http://www.iasgcon2014.org/

Name of the Event: KSOS Annual Conference 2014 Recommended for: Ophthalmologists, especially ophthalmic surgeons. Brief Description: The annual conference of Kerala Society of Ophthalmic Surgeons is being organized for the 10th time. The annual event boasts of many presentations by eminent industry leaders. This is also a great opportunity to learn of the latest developments in the field as many industry professionals come to showcase their latest equipment.

Date: July 5th to 6th, 2014 Venue: L F Hospital, Angamaly, Ernakulam, Kerala, India Type of Event: Conference

Abstract Submission dates: June25th, 2014. Registration Fees: INR 500 Website Link: http://www.ksos.in/

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Rendezvous

An Interview With The Eminent Dr.

Vandana Jain

Dr. Vandana Jain is an internationally trained Cornea, Cataract and a Refractive surgeon. Besides being a renowned Cornea Surgeon, Dr. Jain has the rare blend of business management training as well.

She has specialized in Cornea and Anterior Segment at L. V. Prasad Eye Institute, Hyderabad and won the Best Fellow award. Dr Jain also did another advanced Cornea and Refractive Surgery fellowship from the MEEI, Harvard medical school, USA. A clinician and academician par excellence, Dr Jain has more than 40 publications in peer reviewed scientific journals.

After working as a super specialty Ophthalmologist for a few years, Dr Jain did a full time MBA from Stanford Business School to pursue her entrepreneurial ambitions. Working closely with Stanford School of Bio-Design, she co-founded a medical device company called Clear Ear Inc which is currently a successful start-up in California. Her rare combination of Medical & business expertise was much sought after and she was often invited for various talks and panel discussions.

Dr Jain’s clinical work includes medical and surgical problems related to Cornea and the anterior segment of the eye such as cataract, keratoconus, Corneal Ulcers and infections, Herpetic Keratitis, Ocular Allergies, PUK’s, Fuch’s and other corneal Dystrophies, Contact Lens related problems, corneal abrasions and corneal perforations. She is well trained and proficient in procedures like Phacoemulsification, Cornea Transplantation, DSEK, DALK, Ocular Surface Reconstruction, Amniotic Membrane transplantation, Limbal Stem Cell Transplantation, Collagen Cross Linking, Keratoprosthesis (Artificial Cornea Implantation) LASIK, Epi-LASIK, PRK and all the other refractive procedures related to spectacle correction such as Phakic IOL’s.

She started multispecialty “Advanced Eye Hospital & Institute” in Navi Mumbai in November 2012. According to her vision, AEHI would offer state-of-art facilities, technology, doctors, research, training and teaching and would poise to become the premier eye hospital of western India.

6 What prompted you to pursue MBA post your medical education? Medicine is a unique profession in many ways. We deal with lives but that is what gives us money also. While our medical training trains us in all scientific and treatment issues, it does not really train us in the ancillary aspects viz: practice management, man management, advertising, financial management and health policy among many others. It teaches us nothing about running enterprises and businesses. My career goals entailed making a difference in the running of health affairs in the larger interests of and for the betterment of society. I felt the need to upgrade my skill set to take my dreams forward and hence decided to pursue an MBA.

Looking back at your career path, what has been the most rewarding for you? There were two inflection points in my life- First one was pursuing a Cornea Fellowship from LV Prasad Eye Institute. This experience taught me the true value of discipline, sincerity and hard work. Besides this I became a better clinician and developed a more evolved evidence based approach towards disease management. The second inflection point was going to Stanford business school. This experience provided me with the necessary confidence, networks and the skill sets to take my dreams forward. Besides some of the most important learnings of my life about human behaviours, importance of continuous learning and drive for improvement have come through this.

How did the idea of your start-up, Clear Ear Inc come about? This was a part of a class called Biodesign Innovation. We were posted in San Francisco general hospital for understanding the existing lacunae and the needs for innovation. While observing the current methods of ear cleaning we observed the need for a safer, easier, more effective and a quicker means to clean ear.

Where should the focus be in ophthalmological/medical research at this point, according to you? What is the next big thing in research? I think the next big thing in ophthalmic research will be increased viability of retinal stem cells and artificial retina research thereby making it available for each and everyone around the world at not such a prohibitive cost and better more predictable outcomes. This will give a hope of vision to lot of people with debilitating retinal diseases.

What challenges did you face in setting up Advanced Eye Hospital and Institute? We faced mainly two challenges- • Fund raising – It was challenging due to high initial set-up costs and eye care being a crowded space. • Unprofessional attitude of contractors and vendors – The contractors and people on the ground executing the project had a very casual and callous attitude towards the quality of work. They did not even try to meet the deadlines for project completion. We felt that in general vendors will always overpromise and under-deliver inspite of prior commitments and timely payments. The people in general do not honor their word.

Having studied both in India and the US, what differences did you observe between the two education systems? What can the Indian system learn from the US and vice-versa? US education system is based more on experiential learning. The structure of the programs encourages thinking, creativity, teamwork and collaboration. Indian education is based more on theoretical grounds. I think we definitely need to learn some of these aspects like skill-based education, rewarding creativity, original thinking, innovation etc. Also, we need to stop accepting mediocrity in our education systems! US education system can borrow from India and try to encourage students to take up and excel in Maths and Science.

Tips for fresh medical graduates who are yet to establish their clinical practice or their career. Being a good doctor is half science and half art. So learning about other ancillary aspects of practise is as important as knowing your clinical area well. A good clinician doesn’t necessarily mean a busy practice and a financially rewarding career. Social skills, communication ability, managing finances etc. to name a few are very important to learn. One must take time to garner these skills.

According to you, the next big thing in ophthalmology is _____. I think it will be use of lasers in almost all aspects of treatment. The aim would be to increase precision, safety and lesser dependence on surgeon’s skills. Examples being, use of femtosecond lasers for surgeries like SMILE Lasik for glass removal, for cataract surgeries, for corneal surgeries like DALK, DSEK etc. Sensing this, we have already installed the best possible Laser equipment at Advanced Eye Hospital & Institute.

Do you prefer Delhi or Mumbai? I prefer Mumbai for its culture and professionalism and Delhi for its infrastructure

Your day must include _____? A workout and reading

What is your favourite food? Stir fried vegetables 7

WORST CASE SCENARIO First Aid Management

By Sankhya Saroj PSG Institute of Medical Science & Research, Coimbatore

So often, in a case of an emergency, we just stand in front of the victim clueless. The cluelessness is either because you don’t know what to do or because you are unable to do whatever you know how to do because of your shaking, panicky hand. Simple example: We know that there is something called as ‘fire extinguisher’ that is used during eruption of fire, as the name suggests. But can you honestly tell me how many of us actually know how to use it? So to break that cluelessness, we are going to talk about five major problems in this article and how they can be aided in a case of an emergency.

The five are as follows: • Heart Attack • Burns • Profusely bleeding wound • Choking The first problem we will talk about is Heart Attack. This is one term that we come across frequently, let it be for doctors or the public community. So what do we do when we come across a person withstanding a heart attack?

There is the presence of a tablet called as aspirin by common name commonly available everywhere. This is the first tablet that should be put under the tongue of the patient. This will reduce the severity of the attack thus saving them until higher life support arrives (such as the ambulance). This is the best first aid a layman can possibly give.

The second situation that we will focus on is ‘Burns’. The burns we are referring to can be due to any cause, such as fire in the building, scorching hot water poured over the hand, oil burns due to spurting. There are various degrees of burns but the first aid that anyone can provide for any type of burn is cold water. Immediately immerse the burnt surface in ice-cold water or colder than normal water.

The third situation that we might come across is a profusely bleeding wound. In case there is a Road Traffic Accident (RTA), which is quite common nowadays in the era of fast and speedy cars and their drivers, we are deemed to face profuse bleeding. In that case, stop the bleeding, is the best first aid we can come up with.

Even bare hands can be used to do this. Close or apply maximum pressure on the area where you can visibly see the bleeding. This will prevent the person from bleeding excessively and from going into shock followed by death. The final situation we are going to look at is choking. For this we all should know how to do something called as Heimlich’s Maneuver.

How do we do this? Keep a fisted right hand above the belly button and press the left hand above it. Press inwards and upward, to push the foreign particle out from the airway.

So in this article we’ve looked at all the very commonly occurring emergencies. Emergencies cannot only be dealt by a doctor, as sometimes doctors are not available. At this point, if everyone knew how to do the basic life support systems in order to just sustain the life within a man, we would be contributing tremendously to the society, to the family of the man and make the busy lives of doctors a tiny bit easier.

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HISTORY REVISITED X-RAY: A look inside By Spandita Ghosh KPC Medical College, Kolkata

The discovery of X-Ray in 1895 was accidental, but its application in the field of Medicine, has been phenomenal ever since. It changed Medicine overnight. It allowed doctors to do something which they couldn’t do earlier without dissecting the human body: that is to see inside.

Wilhelm Roentgen, Professor of Physics in Wurzburg, Bavaria, was the first person to discover the possibility of using electromagnetic radiation to create what we now know as the X-ray. Roentgen was working on the path of electrical rays passing from an induction coil through a partially evacuated glass tube. Although the tube was covered in black paper and the room was completely dark, he noticed that a screen covered in fluorescent material was illuminated by the rays. He later realized that a number of objects could be penetrated by these rays, and that the projected image of his own hand showed a contrast between the opaque bones and the translucent flesh. He later used a photographic plate instead of a screen, and an image was captured. In this way an extraordinary discovery had been made.

By 1896, the first radiology department had been set up at the Glasgow Royal Infirmary. The head of the department, Dr. John Macintyre, produced a number of remarkable X-rays: the first X-ray of a kidney stone; an X-ray showing a penny stuck in the throat of a child, and an image of a frog’s legs in motion. Shortly after, an American physiologist used X-rays to trace food making its way through the digestive system. Dr. Hall-Edwards became one of the first people to use an X-ray to make a diagnosis – he discovered a needle embedded in a hand of a woman.In the first twenty years following Roentgen’s discovery, X-rays were mainly used to treat soldiers injured in World War I, finding bone fractures and imbedded bullets.

More than 100 years after Roentgen’s first X-ray experiments, Gerrit Kemerink, a medical physicist at the Maastricht University Medical Center in the Netherlands, discovered an X-ray machine from the 1890’s very similar to Roentgen’s original and used it to X-ray a hand specimen from his hospital. He found that to acquire the image, the hand received a radiation dose 1,500 times greater than today’s dosage— which explains why many people who were subjected to X-rays or who worked with the original machines suffered from radiation burns and loss of hair. There was also a marked difference in the exposure time required: it took Kemerink 90 minutes to image the hand using the 19th century machine, compared to 20 milliseconds using modern X-ray machines. Kemerink comments, “How you could keep still, I don’t know!”

Today, due to improvement in technology, it is now possible to combine thousands of 2D X-ray slices into a 3D format, for detailed accurate imaging, used to exactly find the location of tumors, fractures of bones, and other internal ailments of the human body.Despite their potential for great harm, X-rays and other forms of radiation continue to play a crucial role in diagnosing medical cases and experimental science.

Radiograph of Wilhelm Rontgen wife’s left hand and her wedding ring on the fourth finger. On December 22, 1895, shortly after his discovery of X-rays. Image Source: National Library of Medicine REFERENCES British Library – Roentgen’s discovery of the x-ray

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CEREBRO

THE VECTOR SECTOR: TEST YOUR KNOWLEDGE QUOTIENT By, Chaitalee Ghosalkar SIES Institute of Management Studies, Mumbai

1. Aedes : Dengue fever :: Culex : ______5. Find the odd one out i. Yellow fever i. Lyme disease ii. Malaria ii. Onchocerciasis iii. Japanese encephalitis iii. Borreliosis iv. Chikungunya iv. Tularaemia

2. Which vector borne disease am I? I am caused by a 6. Which of the following is false when it comes to protozoan parasite. I am transmitted through an insect Malaria? vector – the triatomine bug. I am commonly known as i. The Anopheles vectors of malaria bite mainly at American Trypanosomiasis. night i. Chagas disease ii. Simple precautions like bed nets and repellents ii. Bluetongue disease can prove to be effective iii. African horse sickness iii. Premature discontinuation of artemisinin-based iv. West Nile disease oral monotherapy leads to persistence of parasites in the blood 3. Identify this vector. iv. You can avail vaccines before visiting a disease prone area

7. Which of the following is an arboviral (arthropod borne viral) disease? i. Eastern Equine encephalitis This vector has epidemic potential in humans, although it ii. Phelebotomus fever is not pathogenic for ruminants which are the amplifying iii. Rickettsiosis host. The disease which it causes, abbreviated as CCHF is iv. Bilharziasis endemic in all of Africa, the Balkans, the middle-east and in Asia, also the habitat of the vector. 8. The picture shows a bull’s eye rash commonly seen in i.Tick of genus Hyalomma the disease. It is transmitted by ticks. ii.Tick of genus Ixodes iii.Tick of genus Dermacentor iv. Tick of genus Amblyomma

4. Identify this disease. It occurs in three forms: visceral,

cutaneous and mucocutaneous. Its diagnosis includes Vaccine for the same was formerly available but was combining clinical signs with parasitological or taken off the market owing to lack of complete efficacy. serological tests. Common drugs used in its treatment are i. Tick borne encephalitis pentavalent antimonials, amphotericin B and ii. Lyme disease Pentamidine. The disease is iii. Pogosta disease i. Filariasis iv. African tick bite fever ii. Babesiosis iii. Leishmaniasis 10 iv. Heartland virus disease

9. In May 1981, the Interagency Steering Committee for Cooperative Action for the International Drinking Water Supply and Sanitation Decade (1981–1990) proposed the elimination of ______as an indicator of success of the Decade. i. Sandfly fever ii. Malaria iii. Boutonneus fever iv. Dracunculiasis

10. Identify the vector which causes the disease. Vaccination is applicable as a preventive technique for this vector-borne disease, the symptoms of which include fever with prominent backache, shivers, and subsequently, jaundice. However, there are exceptions for certain people; these include:

- People with severe allergies to egg protein - Children aged less than nine months - People with severe immunodeficiency due to symptomatic HIV/AIDS or other causes, or in the presence of a thymus disorder. i. Anopheles mosquito ii. Aedes mosquito iii. Flavivirus iv. Orbivirus

Answers: 1. 3. Aedes and Culex are mosquito species. 2. 1. 3. 1. 4. 3. Leishmaniasis includes a diverse group of protozoan infections transmitted by sandflies. 5. 2. Onchocerciasis is transmitted through black flies while all the other diseases are transmitted by ticks. 6. 4. No vaccines are available as of now for malaria. 7. 5. 8. 6. Caused by spirochaete Borrelia burgdorferi. Infection occurs through bite of infected ticks. 9. 7. Dracunculiasis is an infection caused by drinking water containing water flies (Cyclops species) 10. The disease in question is yellow fever.

11 CEREBRO Do You Know Your Vectors Well? By Deeksha Seth Kasturba Medical College – Mangalore 9. Which of these is NOT caused by West Nile virus? a. West Nile virus encephalitis b. West Nile meningitis 1. Japanese Encephalitis (JE) is caused by the mosquito c. West Nile fever belonging to the following genus: d. West Nile irreversible paralysis a. Anopheles

b. Culex 10. The areas of the brain mentioned below do NOT c. Aedes have the blood brain barrier. Find the odd one out. d. Opifex a. Median eminence

b. Area Postrema 2. Which type of paresis is common in JE? c. Endothelium of Choroid plexus a. Paraparesis d. None b. Monoparesis

c.Quadriparesis 11. Identify the correct options related to the area d. Hemiparesis marked in red.

3. Which neurological problem has been reported in context of the Dengue fever? a. De Morsier’s syndrome b.Coffin Lowry syndrome c.Guillain-Barre syndrome d.Ramsay-Hunt syndrome

4. In which phase of the Dengue fever is headache included in? 1. Broca’s area a. Febrile phase 2. Wernicke’s Area b. Critical phase 3. Supplied by Middle cerebral artery c. Recovery phase 4. Left temporal lobe d. Both a and b 5. Speech production 6. Understanding Speech 5. How can Tick Borne Encephalitis (TBE) be prevented? 7. Area number 44 and 45 a. Only by the use of Drugs b. Only providing supportive care a. All of the above options c. Only by Vaccination b. Options 1, 3, 4, 6 d. All of the above c. Options 1, 3, 5, 7 d. Options 1, 4, 6, 7 6. All are included in the neuroborreliosis stage in Lyme disease except? 12. Which species of Plasmodium causes neuro- a. Paraplegia complications? b. Meningitis a. P. vivax c. Facial Palsy b. P. malariae d. Sleep disturbances c. P. falciparum d. Both b and c 7. Which drug is widely used to treat Cerebral Malaria? a. Chloroquine 13. Identify the disease based on the characteristic b. Artemisinin pathological picture. c. Doxycycline d. Primaquine

8. The side-effects of Yellow fever vaccination is/are ______. a. Neurotropic disease b. Viscerotropic disease c. Both a and b a. Cerebral Malaria d. Only a b. Neurocysticercosis c. Meningitis d. Encephalitis

Answers: 1 b, 2 d, 3 c, 4 a , 5 d, 6 a, 7 b, 8 c, 9 d, 10 d, 11 c, 12 c, 13 a. 12

Wanna know the home remedies of Acne? Wanna know how to impress when you can’t express? The solution to all your problems is finally here!

LexiAmma

The 55 year old new wise lady though born in Madurai and lived in almost all of India (thanks to her ARMY husband) has finally accepted our invitation to share her expertise and vast knowledge of the age old Vedas!

13 Natural Mosquito Repellants LexiAmma says, Vannakam, my beautiful children! After much persuasion, I decided to accept Lexicon’s invitation to impart my panoptic noesis. It is true that I have great knowledge of the Vedas but wait, do not take me to be an old, conservative shrewd who does not know how to change with the times. I am equally fascinated by the modern day eccentricities and if I may say so, endorse quite a few of them myself. So, without further ado, let’s get to it!

Aedes: The most notorious dengue vector I am sure that by now you have realized what a menace the mosquito is! While a ton of chemicals to combat mosquitoes are available, they harm both the environment and you. Luckily, there are many herbs that can be used in place of these repellents: ê Garlic: You have surely heard the folklore surrounding garlic’s potent powers to ward off vampires. While these are just myths, garlic crushed in water and sprayed on skin sure repels another bloodsucker – the mosquito. ê Lavender: Lavender essential oil has a smell that is simply too good for mosquitoes. Bathing with it is both relaxing and will help prevent mosquito bites. ê Neem: Once again, this Indian plant lives up to its reputation of a panacea. Just boil a few leaves in water and spray it around your house. ê Peppermint: Bite into peppermint and avoid being bitten! To save yourself from the mosquito scourge, just chew a couple of leaves, or use it like Neem around your home. ê Marigolds: A garden full of these beautiful flowers is sure to save you from mosquitoes. (By Archit Rastogi ,VIT University, Vellore)

LexiAmma Busts Dental Myths

Dentist: The word instils fear in the hearts of many, irrespective of age. Most people view dentists as people who love to cause pain. Numerous such myths permeate dentistry. I’m going to try and clear a few of them. • Extraction of teeth leads to brain damage: The damage may perhaps have already been done if you believe that. Extraction will just get rid of a bad tooth and prevent infections and pus from occurring. • Cleaning/Scaling causes loosening of teeth: On the contrary, people who get their scaling done once in six months have healthier gums than those who don’t. Recent studies have linked heart attack and stroke to gum disease. A dental cleaning every six months can lessen the risk of heart attack and stroke. • Brushing is bad for bleeding gums: Gums bleed when they are irritated and inflamed, which happens when there is a plaque/calculus buildup. According to the American Dental Association, holding your brush with the bristles at a 45 degree angle to your teeth is the best way to brush your teeth. • Sugar is the prime cause for cavities: The acid produced by bacteria in your mouth causes tooth decay (Source: American Dental Association). These bacteria are triggered to make acid when they come in contact with carbohydrates. Bread, potatoes and rice also provide carbohydrates and are equally likely to give you cavities. (By Yashada Nabar, YMT Dental College, Mumbai)

LexiAmma’s Health Dotes!

• Do stretching exercises when you wake up. It boosts the circulation as well as digestion. Plus it eases back pain. • Break-the-fast – Skipping breakfast causes blood sugar levels to drop thus leading to an insufficient supply of nutrients to the brain. This can rapidly destroy the brain cells. • Eat raw garlic, onions and spring onions. I know what you are thinking – “Is she insane? I have stood for hours at the bathroom sink trying to brush, floss and gargle away the dreaded bad breath!” That is, unfortunately, a downside but they help you fight off infections. • Go for red, go for tomatoes. They have lycopene, an antioxidant which is shown to decrease the risk of cancer. • Stay hydrated. Drink 10-12 glasses of water every day. This will prevent pimples, stomach problems and ulcers. • Don’t eat carbohydrates for at least an hour after exercise. This will force your body to break down body fat, rather than using the food you have ingested. Stick to fruits and fluids. • Laughter is the best medicine. It heals you from allergies and strengthens your immune system. • Start meditating. It heals your body, mind and soul. • To avoid back pain – You should lift a heavy object by bending your knees and it should be brought close to the body, so that the leg muscles bear the maximum pressure and your back is spared. • To avoid neck, shoulder and back muscle strain, position your arm in such a way so that you reach down to use the keyboard (the keyboard trays are there for a reason). (By Deeksha Seth, Kasturba Medical College- Mangalore)

14 LexiAmma’s Guide for a Vegan Convert

Decided to go through the vegan route, but concerned as to how to fulfill your nutritional requirement? Worry not. Here are some examples of foods you can include in your diet, as a substitute to their non-vegetarian counterparts. • Omega-3 fatty acids American heart foundation recommends a daily intake of 500 milligrams of omega-3 fatty acids with a weekly intake of 3500 milligrams (marine sources). Plant based omega-3 is found in nuts (particularly walnuts), linseeds (flaxseeds), canola oil and soybean-based fats and oils. Even microalgae oil can be used as a replacement for fatty fish consumption. • Vitamin B12 Adults require 2.4 mcg of the vitamin on a daily basis. Available vegan options are fewer, but regular intake of certain foodstuffs can make up for the requirement. Here is a list of some foods along with their vitamin B12 content that can be included in the daily consumption. Food Micrograms per serving Cheeseburger, double patty and bun, 1 sandwich 2.1 Breakfast cereals, fortified with 25% of the DV for vitamin B12, 1 serving 1.5 Milk, low-fat, 1 cup 1.2 Yogurt, fruit, low-fat, 8 ounces 1.1 Cheese, Swiss, 1 ounce 0.9

• Calcium Although calcium requirements vary according to age, anywhere between 1000-1300 milligrams on a daily basis is sufficient. Food Amount Calcium (mg) Collard greens, cooked 1 cup 357 Tofu, processed with calcium sulfate* 4 ounces 200-420 Soy or ricemilk, commercial, calcium-fortified, plain 8 ounces 200-300 Commercial soy yogurt, plain 6 ounces 300 Turnip greens, cooked 1 cup 249 Soybeans, cooked 1 cup 175 Okra, cooked 1 cup 135 Bok choy, cooked 1 cup 158 Mustard greens, cooked 1 cup 152 Navy beans, cooked 1 cup 126 Almond butter 2 Tbsp 111 Almonds, whole 1/4th cup 94 Broccoli, cooked 1 cup 62

• Iron The mineral is essential for health and oxygen transport, the dietary allowance of which is 8 mg in adult males, 18 mg in adult females and 27 mg in pregnant ladies. Food Amount Iron (mg) Soybeans, cooked 1 cup 8.8 Lentils, cooked 1 cup 6.6 Spinach, cooked 1 cup 6.4 Tofu 4 ounces 6.4 Bagel, enriched 1 medium 6.4 Chickpeas, cooked 1 cup 4.7 Lima beans, cooked 1 cup 4.5 Black eyed peas, cooked 1 cup 4.3 Potato 1 large 3.2 Peas, cooked 1 cup 2.5

• Protein The Institute of medicine recommends that adults should get a minimum of 0.8 grams of protein per kg body weight each day. One can determine his/her need using this simple calculation: • Your body weight in pounds divided by 2.2 = ______your body weight in kg • Your body weight in kg times 0.8 = ______grams of protein per day Food Amount Protein (g) Almond butter 2 tbsp 5 g Almonds ¼ cup 8 g Black beans, cooked 1 cup 15 g Black-eyed peas, cooked 1 cup 11 g Broccoli, cooked 1 cup 4 g Brown rice, cooked 1 cup 5 g For most people, the word protein is synonymous to meat and other non vegetarian products. It is true that animal foods tend to possess the highest amount of protein. However, there are also many vegan options available. So there you go. Armed with the knowledge of the right foods to be consumed, you can now be relaxed with regards to meeting the body’s nutritional requirements. (By Chaitalee Ghosalkar, SIES College of Management Studies, Mumbai) 15

Tackling Vector Borne Diseases: Combining THE NEW TRUTH

Geology and Veterinary Science with What makes ArboNET different from other surveillance Medicine! systems used throughout the world, and those in India? By Khushboo Gala ArboNET does not target only humans. The surveillance system used in Grant Medical College & Sir JJ Group of Hospitals, Mumbai India focuses on diseases present in patients, and trends occurring in humans. What gets missed out is the disease prevalence and trends in The biggest problem we face today is not in the treatment of vector borne other animals and the actual vectors – which are the forerunners of the diseases, but in keeping track of and preventing them. The old cliché, diseases in humans. Catching an early diseased animal may prevent the ‘Prevention is better than cure’ is infinitesimally true in case of these outbreak of disease in an area. Also, ArboNET is continually updated diseases! and records are kept in order by the U.S. Geological Survey. Hence, on their website, you can find real time geological maps of disease Every disease has three entities responsible for its transmission – the prevalence – not only in humans, but in animals, birds and vectors too! host, or the patient of the disease; the agent of transmission; and the A real time record of the disease is effectively just a button away! environment in which the host and agent exist. This is known as the epidemiological triad of a disease. So how does ArboNET work? Health care providers, veterinarians, and commercial labs report data to In a vector borne disease, the biggest factor controlling the spread of the their state/local health department. State/local health departments disease are the vectors themselves, along with their breeding environment. receive and enter surveillance data into an electronic database, which is This is what should make the surveillance of these diseases different from uploaded to the CDC database at least weekly. The CDC analyzes data, the surveillance of other infectious diseases. Here, mounting surveillance works with the U.S. Geological Survey and disseminates information. on just the victims of these diseases is not enough. The information is in the form of: - Real time disease maps There is a need for creating multidisciplinary teams to study and respond - Weekly updates posted online to vector-borne disease outbreaks. Keeping a watch on patients is one - Monthly and annual reports thing – we need to start keeping a watch on the vectors and their environments too! Another interesting concept on which the ArboNET system is based on is the markers of virulent diseases. Neuro-invasive diseases are taken The true breakthrough in vector borne diseases will be the creation and to be highly virulent, and data of these are used to calculate rates, expansion of integrated information systems to monitor disease project total number of cases and infections based on sero survey data, transmission and risk factors, and the development of comprehensive, and compare trends over time and place. On the other hand, non- testable predictive models based on input from a diversity of scientific neuro-invasive disease reported data is used to identify human disease fields. in areas where no neuro-invasive cases are reported. This is an One such surveillance system is ArboNET. important tool while reporting cases – especially in a country like India ArboNET is a U.S.A. based national arboviral surveillance system managed – to differentiate between the severities of disease, and to decide which by CDC and state health departments. Its control, however, is not just outbreak deserves more attention. limited to these health departments. ArboNET has strong collaborations The efficacy of ArboNET is proven by several studies. between blood services agencies, farming associations and U.S. Geological The further scope of such a system is: Survey too! - Forming a predictive model for arboviral risk factors and trends - Help perform clinical trials or post marketing surveillance for Initially, it was developed in response to a sudden breakout of cases of the arboviral vaccines West Nile Virus in the U.S.A. Most other vector borne diseases, especially - Help detect emergence of new arboviruses those caused by arboviruses were then added to the list of diseases kept under surveillance. It currently has over 12 diseases in its list, including What is the scope of such an integrated surveillance dengue and chikungunya. system in India? I would say, enormous. The surveillance elements of ArboNET are not limited to humans. In There is already a good human surveillance system in place, covering addition, ArboNET maintains data on arboviral infections among most important diseases, as operated by the National Vector Borne presumptive viremic blood donors, veterinary disease cases, mosquitoes, Disease Control Programme. With good geological and veterinary dead birds, and even sentinel animals! support, we could establish a system as sound as ArboNET – and who knows, maybe even halt the progression of deadly diseases such as The primary objectives of ArboNET are: malaria and dengue! - To monitor the epidemiology, incidence, and The vector biology field is at an exciting juncture. With great potential for geographic spread of novel vector management strategies underway and exciting cutting- arboviruses edge research being performed, there is great promise ahead. The - To provide timely challenge is to work together as a group, with open communication information regarding channels, to achieve the promise of the future to improve people’s arboviral diseases to public health. health officials, government REFERENCES leaders, researchers, (1) Lindsey NP, Brown JA, Kightlinger L, Rosenberg L, Fischer M: State health department clinicians, and the public perceived utility of and satisfaction with ArboNET, the U.S. National Arboviral Surveillance - To support prevention System. Public Health Rep. 2012 Jul-Aug; 127(4):383-90. and control efforts, and (2) Centre for Disease Control, U.S.A. (CDC) – http://www.cdc.gov/ (3) U. S. Geological Survey (U.S.G.S) – http://diseasemaps.usgs.gov/ stimulate research on (4) National Vector Borne Disease Control Programme – arboviral diseases. http://www.nvbdcp.gov.in/ 16 It’s Raining Men! By Supreet Khare Armed Forces Medical College (AFMC), Pune

Recent advancement in genetic engineering has shown how ‘just’ the THE NEW TRUTH male mosquitoes are our new truth hope in fighting malaria. It has been more than a century since Sir Ronald Ross discovered mosquitoes to be the vector for malaria. What the world likes to call serendipity, the scientists call ‘observation’. Interestingly, it was in Bangalore that Sir Ross first got interested in mosquitoes. He suggested that life would be much more pleasurable if there were no water containers for mosquitoes to breed in (Sorry Sir Ross but we are still ignoring you!). Ross reached Malarious Valley of Sigur Ghat and collected specimens. By August 1897, Ross was down to his last 2 mosquitoes. He dissected one and found nothing; until he persevered to its stomach. He saw cells with a perfectly circular outline and about 12 microns in diameter. They were nothing like the ordinary stomach cells of mosquitoes. The following day Ross killed his last mosquito and found the same cells. Eureka! He had discovered the vector. With further research and confirmation, 8 years later Sir Ronald Ross was awarded the Nobel Prize for his discovery.

120 years have now passed since this landmark discovery but we are still prey to this deadly disease. It’s not only taking a toll on its country’s health status but also is a huge economic troll. According to WHO World Malaria Report 2013, malaria killed an approx. 500,000 children under five years of age. That is 1300 children every day or one child almost every minute!

So what is it in that tiny mosquito that has been beating us for centuries? Well size doesn’t matter after all. Not only is the causative parasite capable of showing resistance to the drugs, but also its vector to various insecticides. Our beloved household insecticide, DDT has shown the world that even mosquitoes are smart. Chloroquine, once considered the primary treatment for malaria, is now a defeated drug; a moment of silence for it too. Parasite resistance to Chloroquine has been proved in The enzyme known as i-Ppol attaches itself to the X chromosome 10 countries so far and reports of its failure have been reported from an during the sperm-making process and effectively shreds part of the additional 13 countries. Even Artemisin (the current DOC of malaria) has chromosome’s DNA. Not just that, the effect is self-sustaining. That is, now shown parasitic resistance in four countries in South-East Asia – they are inheritable in all the male generations born, creating a vicious Myanmar, Thailand, Cambodia and Vietnam. cycle and resulting in a population wreck.

This time, the answer is “Y”! “You have a short-term benefit because males don’t bite humans [and transmit malaria]. But in the long term you will eventually eradicate or It seems with years of understanding, scientists have finally developed substantially reduce mosquitoes. Theoretically, if you have it on the Y novel methods involving modern genomics and transgenic technology to [chromosome], one single individual could knock out an entire prevent malaria. A team of scientists, headed by Dr. Roberto Galizi from population.” – Prof Andrea Crisanti the Department of Life Sciences at Imperial College, London have now created transgenic mosquitoes, which bear genes encoding a specific endonuclease, which knock out the X chromosome during sperm The X factorthus seems to play a great role not only in humans but also production. Nikolai Windbichler, a lead researcher at Imperial in mosquitoes to continue their race. Field trials have already been College’s Department of Life Sciences and a co-author of the paper, said done, and soon the specific species eradication will be planned. the concept of distorting the sex of a pest’s population is an old one, Although some may argue that the genetic manipulation of the species more than 50 years old, but the technology to make it possible hasn’t is unethical (the writer is one of those, perhaps still under the influence existed until now. This endonuclease was produced using transferring of The Jurassic Park Movie!) and may create imbalance in the gene from a slime mould to Anopheles gambiae. This procedure results in ecosystem, this approach is only directed to those species of only few X chromosomes carrying sperms and creating a chance of 95% mosquitoes which are causative vectors. Further, not being keystone for bearing a male progeny. Over a period of six generations, the species in the ecosystem, this approach is much safer and also cheaper population will dramatically decrease as females disappear, according to than development of drugs and insecticides. I hope the goal to enable the new research, which was published in Nature Communications. people to live freely without the threat of this deadly disease is reached Previous work carried out in 2008 took a similar approach but soon! unintentionally resulted in sterile mosquitoes and therefore the gene’s ability to spread was limited. It took researchers 6 years to make the enzyme.

17 THE The Impact of Climate Change on Vector N Borne Diseases E By Swati Shriyan W SIES College of Management Studies, Mumbai

Any agent that carries and transmits an infectious pathogen into another living organism is called a vector. The T changes in the geographic distribution of such vectors, R which can cause serious diseases like malaria, dengue, chikungunya etc. is majorly influenced by climate change. U The increase in incidence of vector-borne diseases can also be anticipated by many vulnerability assessments. The T reproduction rate, biting behaviour and survival of vectors depends upon the ambient temperature and hence, the H distribution of vectors progresses as the earth warms. Humidity and water availability for breeding determine a vector’s distribution, longevity and behaviour. Vectors carry pathogens whose incubation period is temperature- Black flies, which transmit onchocerciasis, are affected dependent. Also, climate change alters our interaction with by rainfall, temperature, relative humidity and wind vectors and vector-borne diseases. patterns. Increased temperatures increase the number of biting black flies. Deforestation (especially close to A close collaboration and modeling consortium have been rivers) could lead to longer lived and more efficient established between the Cyprus Institute and the Grantham vector species, in addition to an increase in biting flies. Institute for Climate Change at Imperial College, London. However, there is a negative impact on fly populations This collaboration aims to study the impacts of climate with decrease in rainfall and drought. These vector change on vector borne diseases in the Eastern population models are used to determine the Mediterranean and Middle East (EMME) and also address population dynamics of vectors within a region of the key challenges involved. Insect vectors in the European interest and develop reliable vector-borne disease Union (EU) include multiple mosquitoes, sand-flies, and transmission models to predict the intensity and ticks. The ecology of the vectors and hosts are the most distribution of disease in the future under climate important factors affecting vector borne diseases which are change. specific to individual diseases. Literature search and The six major vector borne diseases endemic to India empirical studies over the last 40 years prove that there include malaria, dengue, chikungunya, filariasis, exists a consistent relationship between increased Japanese encephalitis and visceral leishmaniasis. temperature and faster development of Aedes albopictus, Chikungunya has re-emerged since 2005 while the the Asian Tiger mosquito. However, higher temperatures incidence of others, have reduced over the years. The reduced lifespan in adults and temperature extremes led to studies undertaken in India on malaria conclude that increased mortality in all life stages. The vector-borne transmission windows in Punjab, Haryana, Jammu and helminthes, which are responsible for diseases like Kashmir and north-eastern states are likely to extend schistosomiasis, onchocerciasis and lymphatic filariasis are temporally by 2-3 months and in Orissa, Andhra affected by temperature, flood and drought. Increase in Pradesh and Tamil Nadu, it might reduce. PRECIS temperature causes a shift in worm population model for daily temperature and relative humidity composition. reveals that Orissa, West Bengal and southern parts of Assam will remain malarious and transmission The studies undertaken to elucidate the relationship windows will open up in Himachal Pradesh and north- between climate change and vector-borne diseases include eastern states in 2050. Other findings include increase ecological niche modeling to estimate and project the in transmission of dengue fever with 2°C rise in future global burden of Dengue fever. This modeling helps temperature in northern India, re-emergence of kala to develop interactions between environmental variables to azar in northern parts of India and reappearance of determine the probability of dengue occurrence on a chikungunya mainly in southern states of India. The global scale. Regression analysis of West Nile Virus (WNV) threat of climate change on vector-borne diseases can and climatic factors during outbreaks of WNV in Eastern be avoided with better preparedness. Understanding, Europe and Israel depicted that temperature is the most assessing and mitigating the environmental risks are the important factor associated with increase in WNV and key challenges to respond to outbreaks of vector borne hence, higher temperatures are a critical factor in WNV diseases. transmission. Another model to study the impact of climate REFERENCES: change on vector borne diseases includes the vector • Joanna Waldock, Paul E. Parham, Jos Lelieveld and George K. population model. Christophides, Climate and Human Health: The Impact of Climate Change on Vector-Borne Diseases, Paphos, Cyprus (17–19 October 2012), Pathogens and Global Health, VOL. 107, 2013, 387-392. V. Ramana Dhara, Paul J. Schramm & George Luber, Climate change & infectious diseases in India: Implications for health 18

The New Advances in the Treatment and Control of Miltefosine, an alkylphospholipid, which was developed as an oral Truth Leishmaniasis antineoplastic agent for cutaneous cancers is now being extensively used to treat leishmaniasis. Following clinical studies, By Zenia Poladia miltefosine was approved as ImpavidoTM and has now become the first Terna Medical College, Mumbai choice of drug for oral treatment of leishmaniasis in some

countries. Miltefosine was registered and is in use in India since Leishmaniasis is a deadly vector borne disease which is caused by an obligate intramacrophage protozoan, belonging to the genus Leishmania. 2002. However, it has been found to exhibit teratogenicity, and hence The insect vector, the phlebotomine sandfly, is found throughout the world’s should be avoided during pregnancy. Other alkyl phospholipids such as edelfosine, ilmofosine can be used as well. inter-tropical and temperate regions. The female sandfly lays its eggs in the burrows of certain rodents, in the bark of old trees, in ruined buildings, in the Sitamaquine is another promising oral treatment for visceral cracks of house walls, in animal shelters and in household rubbish or in any leishmaniasis in Africa. A study showed that a 28-day course of such environments where the larva can find organic matter (feces, manure, treatment was efficacious and well tolerated in 61 infected Kenyan leaf litter, etc.), heat and humidity which are necessary for their development. patients. However, the adverse effects include abdominal pain,

headache and severe renal events. The effects of sitamaquine on the It is only the female sandfly that transmits the protozoa, infecting itself with kidney need further investigation. the Leishmania parasites present in the blood that it sucks from its human or mammalian host, in order to obtain the protein which is essential to develop Paromomycin is the only aminoglycoside with clinically important anti- its eggs. During a period of 4 to 25 days, the parasite continues its leishmanial activity. Both visceral and cutaneous forms can be treated development exclusively in the gut of the sandfly where it undergoes a major with this antibiotic, but poor oral absorption has led to the development transformation. When the infected female sandfly now feeds on a fresh source of parenteral and topical formulations. The new topical gel formulation of blood, its painful sting inoculates the parasite into a new victim, and thus the transmission cycle is completed. The parasite is then internalized via may represent an alternative topical treatment for cutaneous macrophages in the liver, spleen and bone marrow. leishmaniasis. Cochleates, a novel lipid particle-based delivery system has demonstrated the potential for oral administration of hydrophobic

drugs such as amphotericin B. Symptoms of leishmaniasis can range from mild self-healing cutaneous lesions to fatal visceral cases. Cutaneous Leishmaniasis is the most VECTOR CONTROL: In the absence of any effective vaccine and an common form of the disease; clinical manifestations range from small ideal drug, the best method to tackle any vector borne disease is to cutaneous nodules to gross mucosal tissue destruction. The disease normally reduce the man-vector contact. Vector control is the second pillar of produces skin ulcers on the exposed parts of the body i.e. face, arms and leishmaniasis elimination strategy. The following methods exist at legs. Visceral leishmaniasis, better known as kala azar, is the most present for leishmaniasis control: severe form of the disease in which the parasites migrate to the vital organs. - Active case detection and treatment Phlebotomus argentipes is the proven vector of visceral leishmaniasis in - Elimination of sandflies by spraying the interiors of human dwellings India. Kala azar is characterized by prolonged fever, hepatomegaly, and adjacent buildings with residual insecticides is an effective control splenomegaly, hypergammaglobulinemia and pancytopenia. If left untreated, measure. Spraying around the doors and windows is especially the fatality rate in developing countries can be as high as 100%, that too important. within 2 years. Which brings me to my topic – - Insect repellants such as dimethylphthalate, when applied to exposed skin, protect for a few hours against the bites of Phlebotomus. - Use fine mesh bed nets (45 holes in a square inch) or insecticide- CURRENT TREATMENT AND RECENT ADVANCES impregnated bed nets and curtains. Sodium stibogluconate and megluminantimoniate are the drugs of choice for Apart from the above-mentioned measures, satellite remote sensing for both visceral and cutaneous leishmaniasis in most parts of the world. The early prediction of the disease and synthetic pheromones can be used choice of treatment also depends upon the in future for the control of this disease. causative Leishmania species. Sadly, most of the commonly used drugs are toxic and do not eliminate the parasite completely. This leads to the REMOTE SENSING: Satellite remote sensing in integration with occurrence of resistant parasites. Geographical Information System (GIS) has been used for identifying Fear not, for there is a silver lining to these dark clouds of despair. Anti- and mapping the distribution of Phlebotomus argentipes, in order to leishmanial chemotherapy has markedly improved since the development of favour early prediction of the disease. It can also be used for the lipid formulations of Amphotericin B. In December 2011, WHO signed an distribution and prediction of the sandfly density in endemic and non- agreement with Gilead Sciences for the donation of Liposomal Amphotericin B endemic sites. injections to treat several visceral leishmaniasis cases in the most underprivileged endemic countries during the five-year period 2012– 2017. The unilamellar liposomal formulation (AmBisome®), lipid complex ROLE OF PHEROMONES: Pheromones are chemical substances (Abelcet®), and colloidal dispersion (Amphocil™) have all been evaluated in which help in attracting the insects at a particular site for mating. Studies have started to explore the role of synthetic pheromones as a clinical trials for visceral leishmaniasis and/or mucocutaneous leishmaniasis. potential sandfly control strategy.Health education about the habitat AmBisome® was found to be most successful in reducing the size of lesions and breeding of the sandfly species may go a long way in controlling caused by L. major, and Amphocil™ also showed similar activity, whereas the vector population. The development of drug combinations, new Abelcet® was found to be inactive against these species. pharmaceutical technologies and development of a larvicide for

successful elimination of the vector is still an open area for research. More research on alternative vector control methods are needed to achieve long-lasting results in the fight against leishmaniasis.

References: - World Health Organization- Leishmaniasis - CDC – Leishmaniasis - Mrcindia.org 19

Antimicrobial Resistance: The role of the THE NEW TRUTH Medical School By Pool Kanrad Aguilar Leon, Antenar Orrego Private University, Peru

Since time immemorial, life makes its way through the evolution in their innate search for survival. And this includes from large multicellular organisms to that small isolated bacteria. And it is with this little character that started the discussion of a future global health catastrophe if we do not take the necessary preventive measures. And this involves everyone, especially us, health professionals of tomorrow. Antimicrobial resistance (AMR) occurs when microorganisms, such as bacteria, viruses, fungi or other microbes, develop resistance to the drug that is being used to treat them. This means that the treatment no longer effectively kills or Medical students are no strangers to this and, from our inactivates the microorganism. position of observers and future health professionals in the community; we call on medical schools to: The case of penicillin illustrates the AMR phenomenon well. When penicillin was first introduced in the 1940s, it • Incorporate antibiotic resistance and rational prescription revolutionised medicine and was effective against a wide range of antibiotics into all undergraduate medical of staphylococcal and streptococcal bacteria. It was also able to curricula to ensure that graduates who enter clinical treat infections that had previously been fatal for many people, practice are able to prescribe antibiotics appropriately including throat infections, pneumonia and wound infections. to avoid contributing to antibiotic resistance. However, with increasing use of antibiotics over the decades, • Implement an antibiotic stewardship program in affiliated bacteria began to adapt and develop changes in their DNA teaching hospitals that would monitor local that meant they were resistant to the actions of the once susceptibility patterns and identify appropriate initial powerful antibiotic. therapy to use for common infections (e.g. community-acquired pneumonia, urinary tract AMR is driven by many factors, including overuse of infection, etc.). Such information should be easily antimicrobials for human and animal health and in food accessible by all learners. production, which can allow microbes to adapt to • Develop policy statements regarding antibiotic resistance. antimicrobials they are exposed to. Poor infection-control Collaborate with practitioners and public health measures, which fail to prevent the spread of infections, also officials to educate the public regarding the dangers contribute. As Dr Margaret Chan, director general of WHO, associated with overprescription of antibiotics. said: “much can be done. This includes prescribing antibiotics • Encourage research regarding antibiotic resistance, appropriately and only when needed, following treatment appropriate prescribing guidelines, and the correctly, restricting the use of antibiotics in food production development of new classes of antibiotics, in to therapeutic purposes and tackling the problem of collaboration with other stakeholders. substandard and counterfeit medicines.” • Ensure that infection control (e.g. hand hygiene, contact/droplet/airborne precautions) is taught in undergraduate medical curricula and that infection The last WHO report presents some startling facts on major control protocols are implemented in affiliated infectious diseases worldwide: Resistance to antimalarial teaching hospitals to prevent the spread of antibiotic medicines has been documented for all classes of the drug, resistance. which presents a major threat to malaria control. In 2010, an • estimated 290,000 new multidrug-resistant tuberculosis (TB) We know that the best way to improve health in our cases were detected among the TB cases notified worldwide, community is being prepared. And the preparation is based and about one-third of these patients may die annually. on a good education and this, in turn, in the arrangement of Resistance rates to anti-HIV drug regimens ranging from 10% that medical school who want professional leaders in global to 20% have been reported in Europe and the USA. Estimates public health. from Europe are that there are 25,000 excess deaths each year due to resistant bacterial hospital infections, and I finish these lines with the wise words of Cesar Vallejo, approximately 2.5 million avoidable days in hospital caused by famous Peruvian poet: “Hay, hermanos, mucho por hacer” AMR. In addition, the economic burden from additional (There is, brothers, much to be done). And in these modern patient illness and death is estimated to be at least €1.5 billion times, there is nothing more true. each year in healthcare costs and productivity losses.

20

MED MARVELS DR. EDMOND FERNANDES

Dr. Edmond Fernandes is the Chairperson How was your experience and CEO of ‘Centre for Health and representing India for the Development’ – a registered Health Association of Medical Doctors Organization. He is also a medical journalist of South-Asia? and researcher. Given his broad interest in I was sent from an organization that medicine and society, it comes as no surprise has the UN ECOSOC Consultant that he is also the Director of Collaborative status to represent the Indian Initiatives & India Country Representative to Chapter of the Association. I was the Institute of Language and sent for the relief mission for the Communications, Turkey. He represents typhoons that hit Philippines, having Mangalore to “Issues & Concerns – towards a a primary objective of screening purposeful regimen”. He’s one of the first people for any post-disaster medical students to publish his book titled emergency, like an epidemic that ‘Small things that matter much’. He has could possibly arise. It was an represented India at many national and international level experience from which I had learnt a lot. From the people conclaves such as the Youth Leaders Assembly, USA. He has and the quick measures that they took to house the refugees also delivered lectures on health issues and policy. He is and give quick medical aid. It inspired me and made me currently pursuing his M.D. in Community Medicine from learn a lot of things, which I wouldn’t have had, without Yenepoya University, India. this experience.

Why did you choose to become a doctor? As a medical student, everybody wants to become I happened to believe I would make a good one, therefore I someone one day other than just a simple doctor. am How did you come to such a position of representing the Indian Chapter in an Which was your most memorable event in medical International Organization? school? I had been a part of their medical journal team for three I can’t really pin-point to say that this or that would be the years in consecution. And then eventually due to the most memorable event. There were too many highs and a consistency and work, I came up to this position. To few lows, but all I can say, in the journey, it wouldn’t matter become someone greater than a simple doctor, you have to much. Those were [the] days [that] we could not really plan, develop contacts. Going to conferences all over the world but rather only appreciate in the remembering. will enable you to develop contacts more than you could ever imagine. With growing contacts, comes the advantage Who / what inspires you? of knowing more about the happenings in your field of Self-motivation is my only inspiration and guide, and my interest around the world. That’s how I believe a doctor dictum to leave the world, a bit better than what I inherited can become who he wants to be. [it] as a citizen of the world. But to some extent, Che Guevara, may be a person to emulate. Message to our readers Follow your heart; keep in tune with the world. Don’t let When did you get the idea of developing the Centre the noise of other people’s opinion influence your own for Health and Development? inner voice. Remember, that bullies are the easiest people I was thinking about that for three years. I always wanted to to lick. Stay alarmed from flattery, don’t put too much of be independent and have a banner to work under. I’ve blind faith in people, try them, test them, before you can always wanted to do something for the society. I wanted to believe them. In a constantly changing world of create an organization where there is less bureaucracy and questionable ethics, of half-truths and a mix of genuine more work being done. So I did the same and created this achievement, find your own peace, find your own road, organization independently without much support, except and believe in the instincts so dear to you. Command from my parents’ side. Today there are people contributing respect, don’t demand it. And respect everyone. Grace, to it from everywhere, in contrast to [the] situation back then. Guts, Glory be with you always.

What is the motive behind creating this You may reach him at [email protected] organization? What do you hope to achieve through this? [To] create an impact on the understanding of non- communicable diseases and make health policies on the same. This organization will set a platform to conduct health programmes on non-communicable diseases. This organization was started to majorly work on non- 21

MED MARVELS DR. SHWETHA MANGALESH

Dr. Shwetha Mangalesh is the Managing What is your take on medical education Editor and co-founder of SYNAPSE in India? (www.drsynapse.co.in). She’s the national Medical education in India is in desperate advisor of India Medical Asssociation – need of evolution. The system needs Students’ Wing. She’s also been the editor of urgent attention. Problem based learning International Medical Journal for Students’ is the need of the hour and the sooner the Research. She is an avid researcher and has system incorporates this, the better the many publications in her repertoire. She has patient care would be. The problem with been recognized for her publications and our system is that it does not encourage us oration skills at various conferences. She’s to brain storm and question WHY! We currently working at Narayana Nethralaya rely on simple ways out through the Postgraduate Institute of Ophthalmology, curriculum and further, the entry into post Bangalore. graduation is a mere memory based testing. This has to change to improve quality of education. What inspired you to take up active medical research and who guided you? I studied in a rural medical college in India and I had ample time apart from studies during the initial years, so I took up How did you go about Synapse? What started it? research as a means of constructive time biding but it turned Synapse just happened over a phone call with 2 other out, I developed a keen interest in the field and eventually, I friends. We decided to write articles online and deliver decided to head my career in the field. information with a little twist to it to make it more interesting. We then added some crosswords and other Inspiration – as such there wasn’t a single source. It’s like I engaging articles to make it more interesting for our readers. said, I just found out that my talents and more importantly, So basically we just tried to get the medicine through in a my interests lie in the field of research. As for guidance, I give different style. credit to my seniors and colleagues who have been helpful throughout. How did you build the contacts and gather the funds? I attended a conference in 2009 in Coimbatore and I found You have been actively involved in researches related to a few like-minded people there so that’s where the idea for retinopathy. Why this subject in particular? IMSA started and initially, it was a non profit organisation Retina as a whole interests me but I wouldn’t want to limit but recently we have started charging students for myself to it yet. One of my researches is on retinopathy of membership in order to gather funds for provision of books prematurity which has a prevalence of 5-8% on an average and and other articles. the fact that there are only 35 ROP specialists in the country ignited an interest in the subject. The research about Diabetic Where do you see yourself in the next 10 years? retinopathy is basically community-based and gene-related, By 2020, WHO, maybe! addressing the question of why some patients respond to anti- VEGF treatment and others don’t and customising the How do you relate to Lexicon? treatment protocol based on individual genetic fingerprints. Lexicon, well, actually I went through your website and I So yes, retina is currently the subject of [my] interest but I am found it quite impressive. I mean I fell in love with it. I was still exploring. quite impressed that you all are working on similar lines as Synapse, with a little more life and much more colour to it. What was your most memorable incident in medical school? The website, the articles, they are extremely well drafted. I Medical school is an amazing journey in itself. There is more think Lexicon is doing a wonderful job. than one incident which can be fondly recounted. The most memorable time would be [my] internship where just being in the hospital 24/7 was exciting in itself. Also, the first Mantra in life independent surgery, delivery, intubation are all treasured Be passionate about what you want to do and be even if that memories. makes you an Outlier.

Message to the readers Follow your dreams!

22

MED MARVELS DR. CARL DENIS BRITTO

Dr. Carl Britto is a passionate medical student Tell us about your interest. After my final [year] MBBS, I took a month to with very humble inclination towards rural health tour various rural health settings. One of my development. He has worked very closely at the objectives was to study rural health models and ground level where over 70% of the Indian devise sustainable health care options. There is population resides in absolute dearth of medical a dearth of epidemiological data and hence, and routine facilities. His research aptitude assessing specific issues in underperforming mainly focuses on infectious diseases. He has areas is not always possible. And, being a received quite a few honorary scholarships believer in Evidence Based Medicine lead me to because of his fine combination of academics consider a career in epidemiology and use available resources for and sports. He is currently interning at St. John’s Medical College, customized interventions specific to each underserved region in Bangalore. India. I am therefore, in the process of collaborating with professionals from non-medical backgrounds like Management Why did you choose to become a doctor? and Innovative technology through the Health Concern Foundation The vocation of medicine is that place where many are called but NGO in order to reach the above said goals because I believe that few are chosen. Growing up, I used to visit an orphanage for rural health care is everyone’s responsibility and not just [of] the children with special needs. It was there that I had a firsthand medicos. experience of how much of a difference a doctor makes in the lives of children. Mantra in life Work smart and find that joy in using your abilities for the benefit What was your most memorable incident in medical school? of the lesser fortunate. Pursue all your God given talents and lead by example. During my final year pediatric posting I came across a child in the

ITU who was limp and it was progressively increasing. This 7-year- What are your research interests with respect to Rural old boy was given a poor prognosis and began to require oxygen India? I have been interested in clinical research from my early support. My Pediatrics professor however, never gave up on that days as a medical student. My passion lies in Preventive child and worked double time with the rest of the unit. A week later, Paediatrics. During my tour of rural health settings I found that I met the child down the corridor; he was being helped to walk and the current Indian Infant Mortality Rate (IMR) of 44 is far from was making progress. After some intelligent investigations, a [a] representative of the current situation. Policies implemented diagnosis of inflammatory myopathy was made and appropriate are not uniformly productive. From the various villages I visited, treatment started. My take home message from this incident was the IMR ranges from 126 in Chhatarpur, Madhya Pradesh to 26 to never give up on a child no matter what the expected outcome. in Goa. The significant etiologic factors vary widely across regions and are not geographically confined which defeats the Who / what inspires you? purpose of nationwide implementation of healthcare policy. I The plight of children born to an underprivileged family. believe that the end result of any research project in the community should be a shift in policy or support existing policies. What is your take on medical education in India? In the rural side, I hope to use my passion of Paediatrics and the The courses and methodology of training is good but the methods weapon of epidemiology to ultimately bring down the IMR by of assessing medical knowledge of a budding doctor is far from shifting policies and strengthening advocacy. desirable. There is too much subjectivity in the scoring system in mainstream exams and too much of factual rather than application- Message to the readers A career in the rural health care setting can be rewarding in more based questioning for entrances. ways than one and every health care professional should consider

playing a role in the delivery of health care in underserved Where do you want to go from here? 23

MED MARVELS DR. SOUMYADEEP BHAUMIK

Dr. Soumyadeep Bhaumik is a Biomedical Genomics Please comment the same on your study Fellow (NIBG,India). He was a Senior Research related to adverse drug reaction in OPD Scientist for South Asian Cochrane Network and Medicine. This was an interesting study indeed Centre for Prof. BV Moses Centre for CMC, Vellore. He which I conducted during my MBBS again, in the year has also worked as a medical sub-editor at the 2008. It was styled on [the] lines of the national Journal of Indian Medical Association. He is very pharmacovigilance initiative, with modifications tailored passionate about medical research and has over 72 to suit patient pool specific approach and aimed to of his works published in various national and establish that differing drug reaction was observed for international indexed journals. He is currently working the same medicine in different patients with similar on 4 research projects. His literary skills have shone diseases. in The Statesman and Times of India (Durgapur- Assansol). His works have won him many awards at conferences and fame, being one of the youngest in A very interesting initiative from your end the world to achieve as many publications. was your involvement with the Journal of Pakistan Medical Students (JPMS). Can you Numerous awards, accolades and elucidate more on you involvement with publications. So much work and effort in so that initiative? This was more sort of a less time. What motivated you to become collaborative initiative to bring about a common unconventional? Basically, I was pursuing my ground of extensive inter-relations between medical MBBS at a college where the entire patient pool was a great scope for professionals as well as students from across the country. I was already further studies. Getting introduced to a huge pool of data, while studying part of some journals, and this seemed a very interesting way to have a MBBS at Bankura Medical College, and the different cases that they platform of discussion, where we could share our views and deepen our represented, kind of made me go further with transforming my urge to knowledge base. JPMS continues to be such an effort even today. research into action. Going unconventional in clinical issues was stemmed by condition-specific cases and related case studies, instead of resorting to contextualised approach to treatment. There are textbook treatments, Your journey has been exemplary and it will continue to and there are unconventional approaches. The latter insinuated me more. inspire so many out there. Going that extra mile; according to you, why do some take it and some don’t? You see, it all comes upon that realisation what you really want to do and don’t. What Currently you are leading four projects which have very interests you and what doesn’t. To realise is important above all, more different implications on the social sphere. Please say sort of a self-awareness. Being in research and continuing to do so is something about why and how any issue attracts you. I was difficult, and finding your own way with some amount of self-introspection always aiming to undertake people-centric approaches during treatment. involved is crucial to keep going that extra mile. I would suggest everyone Systematically understanding and tapping respective treatment to keep on asking yourself, “what do I want to do?” Keep introspecting. procedures, I got to know that we are always left with choices of Career aspirations are different for people, some are bent on academic treatment options. Social issues like affordability of treatment and pursuits and some want to focus more on flourishing through other ways medicine is thus, what I chose to focus upon. Like diazepam is a cheaper and means. So to summarise, research isn’t for everyone and only for the alternative to most epilepsy treatment drugs and thus, the research on most interested and enthused doctors who wish to go that way. But if Diazepam monotherapy for treatment of epilepsy. Occupational safety is indeed that’s what really inspires you and you can tag along? I would another aspect. This can be more clearly explained by the pesticide suggest each one of them to go for it. exposure and its prevention studies of farmers in middle and lower income group countries. That’s how I directed my interest towards more substantial and ‘contributable’ issues; something that might help people Any advice for the upcoming generation of doctors? better. I started off as a naïve student with evolving interests and curiosities related to what really happened around me, especially during my MBBS Your past research project was on nosocomial infections, years at Bankura. That’s kept on pushing me to do what I was doing. And which have high incidences in our surgical wards and ICUs to be honest, medical students don’t go for research generally, but for (keeping the Indian scenario in mind). What were your me the issues attracted me to pursue them through researching. And I observations during this study, and what were its had found it as a rather great journey to explore! So yes, it’s all about outcomes? I conducted this study as an MBBS student, and conducted being honest to yourself, your patients, and trying to do something it in my home college where I was studying to get my degree. And, I took different; why keep investigating the same old thing when we can involve into consideration the surgical wards there, and about two units were ourselves to find out answers to unanswered questions? Contributing to taken up for the same. To delve into the prevalence structures and human knowledge is the best way we can serve. And that’s who we are, pathogenic strains involved popularly in the acquirement of nosocomial aren’t we? Entitled to serve mankind in the best possible way. infections was the main objective where it was found that around 10-20% of entire infection strata was afflicted with hospital-borne infections; with the most prevalent infection being the urinary tract infection and the most common pathogenic source being E.Coli. 24

MED MARVELS DR. SUBRAHMANYAM KARUTURI

Dr. Subrahmanyam Karuturi, a name synonymous with a dream Tell us about Doctors Hangout and Patient.co.in that went right has shown the world that his Doctors using tools like DoctorsHangout.com can story of success is something that anyone can communicate, share and learn medical knowledge by duplicate. “Survival of the fittest” said Charles interacting with doctors on the other side of the world. Darwin to justify the survival of an individual in DoctorsHangout.com is an exclusive next generation this world. History is beset with the examples of social networking service for medical students, revolutionaries who inspired their followers by a residents and doctors. At DoctorsHangout.com, well thought out vision and vigor. He is no less Doctors exchange clinical experiences, review their as far as stirring people and advancing the cases and share clinical knowledge. You can immensely engine called “DoctorsHangout.com” and benefit from the collective knowledge of “Patient.co.in”. Dr. Karuturi provides a role to DoctorsHangout.com members. each of his comrades-in-arms and in turn they When I realized that the information a patient had accomplish it to the satisfaction of their leader, built up from his experience could help similar such accomplishments have gone into making patients, I started Patient.co.in: to help as many DoctorsHangout.com what it is today. Upon patients as I possibly could and share the information pursing medicine at Guntur Medical College; other similar patients learned with them. But I knew Dr. Karuturi with his immeasurable understanding and proficiency there were tons of patients around the world who had gone through in the Internet and its associated realms, has successfully launched their own journeys and had extremely valuable health information to and made DoctorsHangout.com a leader. Backed by a practiced share them. And by sharing it, they could help similar patients. psyche, this high-flying doctor, a workaholic by nature and an Patient.co.in makes it possible for patients around the world to share entrepreneur by intuition have ventured to create and learn from one another. Patient.co.in is an ambitious project with DoctorsHangout.com to connect Doctors across the six continents. only one goal: to build a patient-centered health information sharing network for people with similar health problems. I visualize a world in Why did you choose to become a doctor? which every patient can instantly tap into the health knowledge and I was fascinated with medicine and life. The human being is one of disease experiences of every other, so that every patient can learn how the most complex machines in existence. I have always been in awe well treatments have worked for others, whether they are allopathy, of how so many different parts can work together synergistically to alternative, experimental, or prescription. sustain life. My main reason for pursuing medicine is the desire to help others, the intellectual challenge, the motivational challenge, Mantra in life the autonomy and having a feeling at the end of the day that I’ve There are many ways I think. I suppose I am a thinker. I have always done some good in people’s lives. I love learning and helping been one. The excitement in thinking the unthinkable excites me. I am people. I also never want to stop learning, so the continuing in love with new ideas and don’t dither in discovering the ‘truth’. I education part of it has me stoked. I love to be constantly accept as true that perfection is something I will strive for. I wish this challenged. world could be made a better place. I believe I have a purpose. The purpose of my life is to have a purpose. My purpose is to make this What was your most memorable incident in medical school? world a better place than when I came into it. Education and When I received the Gold Medal. entertainment absorb me and in my scheme of things, I am driven by the urge to make a meaningful contribution to these fields. An Who / what inspires you? incurable optimist I am, who believes in the greatness of humanity. I Eugene Braunwald hate nursing grudges but continue to learn from failures.

Your take on medical education in India Where do you want to go from here? Many intellectuals have questioned the validity of medical student We are very much lucky to witness the revolution [the] Internet has selection on the basis of tests consisting of multiple-choice brought to medicine. It is changing the way we live, the way we questions. The universities are just degree-selling shops. Medical communicate, the way we collaborate and the way we think. It is schools should make radical changes in the curriculum, adopt creating an air of excitement and curiosity among us. Internet is the innovative pedagogical strategies for enhancing students’ learning, biggest and greatest innovation of mankind. Medicine is described improve the methods used to assess students’ performances, and both as an art and science. In future, medicine will be described as a focus on the professional development of faculty as teachers and combination of art, science and technology. Web 2.0 will be educators. We follow a rote method of learning, so the clinical inseparable from medicine in the coming decades. We are going to bedside knowledge is far below the requirement. How is this going witness new technology innovations in [the] coming future which will to make us reliable doctors? While preparing for PG exams to study change the foundations of healthcare industry. abroad, one realizes the importance of adequate clinical skills. The system must emphasize more on this than on distinctions. Message to the readers A hundred years from now, it will not matter what kind of car I drove, what kind of house I lived in, how much money I had in the bank, but the world may be a better place because I made a difference in the life of a student. I advice every doctor to teach the medical skills they acquire to [become] young budding doctors and make this world better than ever. 25 Feelings of the Flea! By Raviteja Innamuri THE STING OPERATION Christian Medical College (CMC) – Vellore

In the quest to find the deepest secrets of the ‘BLACK DEATH’, Lexicon digs deep to bring to you – the ‘Feelings of the Flea’. Somewhere deep down in the burrows

Dear Homo sapiens, I understand that you do not like me. I see no reason you should. I am closely linked to 3 great pandemics in the known history of mankind, responsible for killing nearly 100 million people in Egypt and Byzantium in the 6th century; one quarter of Europe’s population in the 14th and 15th centuries and tens of millions in India, Myanmar and China in the beginning of the 20th century. Why would you like me? But seeing this poster, I thought I needed to make a few things clear between us. By the time Lexicon publishes this in its new tri-monthly magazine, I would be long gone for I live only an average of 90 days. Isn’t it quite a paradox? We live off wild rodents usually. I know they aren’t the best of creatures but what other choice do we have? You humans use way too many stinky sprays. You see, Sir, I have to bite for my day’s meal. Nature has it that way. I read in my history books that sometimes these rodents begin to die in large numbers, almost the same time when my brothers and sisters begin to complain of choking and are no longer able to obtain a complete meal. While many of us completely choke and die of starvation, some of us make frantic efforts to bite and suck blood over and over again from everyone around. This is when humans begin to die as well and print ‘BLACK DEATH’ in big bold letters in their newspapers, my (great)6942 grandfather wrote. It seems to me that this was just an accident. We were just trying to survive, you see.

We liked Galenic medicine better. At least, they didn’t blame us directly. They called it an imbalance of humours and said that the breakouts were because they all breathe the same air and drink the same water. Somewhere around 1546, we began to get our hopes high when your scientists began exploring ‘contagious disease’, ‘seeds of disease’ and ‘spontaneous generation’. We thought 1711, would make a mark in disease theory when scientists using Leeuwenhoek’s discovery of microorganism and several other developments began to claim that tiny creatures caused diseases, irrelevant to the internal state of the body, equating pathogenic organisms to arrows that strike humans, irrespective of age. No offence but things really got funny when Leeuwenhoek showed not much interest in animal contagion and one of his friends began to drown himself in tobacco smoke to kill off the tiny invisible wormlets that carried the Plague. Astronomy didn’t have to wait a hundred and fifty years for such an elementary discovery after they had the telescope but Medicine did after the microscope, until came Lister and Pasteur in the 19th century.

Lucky for us, Pasteur’s works began to lay model for a younger generation of scientists such as Yersin who, in 1894, carrying his laboratory in a small suitcase declared to the world that Plague was a disease of rats as well as humans. For the first time, somebody treated us like victims and it felt like jumping to 7 inches, really! Unfortunately, the story doesn’t end here, instead, only gives us new beginnings. Yersinia is popular not just with its Bubonic Plague but also with its pneumonic and septicemic forms. It soon turned into a celebrity owing to its ability to avoid destruction by the immune system and proliferate in the lymph nodes (buboes)! Finally, the boon of the mid-20th century with Streptomycin, Chloramphenicol, Tetracycline and Fluoroquinolones gave the traditional first line treatment for Yersinia pestis. Anyway, got to jump now. Too much of my life time is wasting. You must know that Yersinia pestis is the culprit here. It just gets into you when I’m trying to make my bite easier and regurgitate. So, do watch out for dead rats, report to the WHO immediately, get a prophylactic vaccine if an outbreak is suspected and get treated immediately. Remember, they’re still out there, somewhere! Be well. Be happy. So long, Mr. Flea 26

Rise of the Rodent Army Is India’s Public Health Situation Losing THE STING OPERATION the Rat Race…To Rats Themselves? By Bianca Honnekeri Prevention Grant Medical College & Sir JJ Group of In high-risk areas, Doxycyline can be administered once a week Hospitals, Mumbai prophylactically. Human vaccines are available in only a few countries, like China and Cuba. The most important measures include proper rodent

population control, and avoiding urine-contaminated water sources. “I only hope that we don’t lose sight of one thing – that it was all Treatment started by a mouse,” said Walt Disney, of the beloved Mickey Mouse. The penicillin group of antibiotics is effective in treating Leptospirosis, as is How true that rings even today, when certain rodent-borne diseases Doxycycline. Severe cases may require cefotaxime or ceftriaxone. amble into context and leave epidemics in their wake! Supportive therapy includes infusion of i.v. fluids, dialysis in serious cases, Rodents include rats, mice, squirrels, guinea pigs and hamsters. In and taking appropriate measures to maintain electrolyte balance. Serum India, the exploding rat population remains a pressing public health potassium and phosphorus levels must be monitored. Corticosteroids (e.g. hazard. Rat urine is responsible for spreading Leptospirosis, the Prednisolone) may be administered in severe cases, for a duration of 7 to incidence of which escalates in the monsoons. It also transmits a viral 10 days. Organ-specific interventions are required if there is kidney, liver, infection resulting in Lymphocytic Choriomeningitis. Rat bites and heart or brain involvement. scratches can cause Rat-Bite Fever (interestingly, first described in SALMONELLOSIS India itself, over 2000 years ago)! Also spread by ingestion of food or water contaminated by the urine or Rats are responsible for diseases spread by the fleas they harbour, like faeces of an infected animal, most people present with fever and Plague and Typhus, and for festering bacterial infections like gastrointestinal (G.I.) symptoms like diarrhoea, vomiting and abdominal Salmonellosis and Tularaemia. Less commonly encountered diseases cramps. As with other G.I. infections, the they spread include Hantavirus treatment is most often supportive (maintaining Pulmonary Syndrome, Eosinophilic hydration). Rat nests in the kitchen are often Meningitis, Lassa Fever and ominous harbingers of this disease. Haemorrhagic Fever. Oh Rats! Most worryingly, a single fertile pair of In an intriguing dichotomy of sorts, the globally rats can breed to over 200 rats annually, renowned Karni Mata Rat Temple in Bikaner is and these skyrocketing numbers further home to over 20,000 rats, which are considered compound the menace! sacred and worshipped here! Conversely, these LEPTOSPIROSIS furry (and some may argue, ‘cute’) little animals The monsoon brings with it an ominous however exhibit an entirely different nature in collapse of infrastructure, heralding unsanitary environs like those of our cities, waterlogging and flooding in various cities, with Mumbai being an already exploding at the seams and severely lacking in supportive infamous poster boy for this debacle. With a welcoming increase in infrastructure. water levels of Lake Tulsi and Lake Vaitarna, there is also a troubling The BMC in Mumbai has a team of trained personnel called Night Rat rise in the incidence of Leptospirosis in the city. Killers, who find themselves waging a losing war against the burgeoning In the year 2013, with approximately 200 reported cases, the outbreak rodent population in the megapolis. This situation is echoed elsewhere too, of Leptospirosis in Mumbai reached a 4-year peak, and claimed 3 lives. including Chennai, Bangalore and New Delhi. Mumbai also has the uniquely In the year 2010, out of 135 reported cases, 18 people succumbed to dubious distinction of having exported rats to Doha, courtesy the rat this disease. infestation at the International Airport! Cause If only all we needed was a pied piper! Leptospirosis is caused by a bacterial spirochaete species Leptospira GET SOME HELP (L. interrogans), infectious to animals like rats, dogs, sheep, cows, On spotting tell-tale signs of an infestation, namely bite marks, smears, rat rabbits, and mice. Humans are infected upon contact with water, food droppings, nests or burrows, chewed surfaces or fabrics, or, more or soil contaminated by the urine of infected animals; however, human- obviously, actually seeing the rat in all its whiskered glory, (once you are to-human transmission is extremely rare. done seeking refuge on the nearest couch!) these are some registered Clinical Features agencies you may contact for professional rodent-control interventions: It is a biphasic disease beginning with flu-like symptoms (fever, chills, myalgia), which are mild and resolve into a briefly asymptomatic phase. • Pest Control Association of India http://www.pcai-india.org/ Severe leptospirosis follows in about 10% patients, and involves • Indian Pest Control Association http://www.ipca.org.in/ damage to the heart, lungs, kidneys, liver, brain etc. • Rentokil India http://www.rentokil.in/index.html The mild type is self-limiting, consists of two stages (septicaemia and It is imperative, however, that rat infestations are not shrugged off as immune) and is called anicteric leptospirosis. Weil’s Syndrome is the seemingly inconsequential side-effects of unhygienic surroundings in a severe, potentially fatal icteric leptospirosis. nation plagued by myriad other public health concerns, but are recognized Signs and Symptoms for the many dangerous and potentially fatal diseases they harbour, and Patients may present with high fever, severe headache, chills, muscle combated effectively. The advent of monsoons further underscores the aches, and vomiting. They could also have jaundice, red eyes, urgency to collectively take action in this regard. abdominal pain, diarrhoea, and rash; or symptoms that resemble “By gnawing through a dyke, even a rat may drown a nation,” pneumonia. More severe cases present with symptoms of organ - Edmund Burke damage, like kidney and liver failure, heart problems and/or meningitis. It is time for us to be responsible citizens, promote civic sense and public Diagnosis hygiene, and never allow the metaphor to extend to India’s public health Serological methods of diagnosis are preferred over culture, ELISA and situation. PCR are confirmatory tests, and MAT (Microscopic Agglutination Test) is considered the gold standard. 27 The Mighty Mite! By Ashwini Ronghe Grant Medical College & Sir JJ Group of Hospitals, THE STING OPERATION Mumbai

I am sorry to disappoint all the history enthusiasts reading this, for I am not talking about the tactical truck that was built in the 1960s for the US Marine Corps. I am talking about the medically significant insects, the disgusting creepy-crawlies, and the miniscule 0.25-0.3 mm small bugs, one of the major inducers of allergies causing us doctors to reach out for an antihistamine drug every time you stumble into the hospital with rashes and itches or even asthma for that matter.

Mites, a distant relative of the spider are among the most diverse and successful of all the invertebrate groups .You may say you have never seen them except in your biology class under a dissecting microscope. The reason is that these creatures have an in-built Cloak of Invisibility i.e. they have translucent bodies making them barely visible to the naked eye. Research on mites began in 1880 with the USDA employee N. Banks, who published several papers on spider mites of the family Tetranychidae, predator mites from the families Stigmaeidae and Cunaxidae, and plant associates from the family Tarsonemidae. Since then the tiny mite has come a long way indeed! They may live either freely in the soil or water or as parasites on plants and animals. It is estimated that 48,200 species of mites have been describedso far. As doctors, the ones, which concern us, are those that can colonize humans directly or act as vectors for disease transmission, and contribute to allergenic diseases.

Mites Medically Important to Humans: 1) Chigger: Chiggers are known primarily for their itchy bite, but they can also spread diseases such as scrub typhus. They do not actually “bite” but instead form a hole in the skin called a stylostome and chew up parts of the inner skin, thus causing severe irritation and swelling. Chigger bites are a complex combination of enzymatic and mechanical damage coupled with allergy and immune response which may lead to possible secondary bacterial infection. Thus treatment is necessary. Application of topical steroids and calamine location may help alleviate the itching. Antibiotics may be required if an infection develops in the stylostome. In the case of scrub typhus, diagnosis is in the form of a characteristic black eschar is seen on the skin due to the bite of the chigger. Here too, antibiotics form the mainstay of the treatment.

But as they say “prevention is better than cure”. Simple measures like hot showers after travelling in chigger-prone areas will prevent them from latching onto your skin. Chiggers hang out in high vegetation, waiting for a passing host. When your leg brushes against the vegetation, the chigger transfers to your body. Hence, choose tightly woven fabrics for working or walking in these areas. An insect repellent on both skin and clothing is highly effective.

2) Itch mite: The itch mite is Sarcoptes scabiei. Scabies, a skin infection by this mite isalso known as the seven-year itch (much like the state of your current relationship) and causes irritating and contagious skin complaints that are hard to get rid of. It is the third most common skin disorder in children which isusually transmitted by skin-to-skin contact with carriers.The mite burrows under the host’s skin depositing the eggs there causing intense allergic itching. The scratching leads to severe damage to the skin in particular by the introduction of infective bacteria, which may lead to impetigo or eczema.The burrow tracks are often linear, to the point that a neat line of three or more closely placed bites is almost diagnostic of the disease.

It can be prevented by avoiding direct contact with an infected person or with items such as clothing or bedding used by that person. Scabies treatment usually is by permethrin which is convenient and easy to use where just a single topical application is sufficient. It is recommended for members of the same household as that of the infected person to prevent possible re-exposure and re-infestation. Bedding and clothing worn anytime during the 3 days before treatment should be machine-washed and dry-cleaned. Ivermectin is an oral medication which may be used in combination with a topical agent in case of persistent scabies.

3) Dust mites: The house dust mite is a cosmopolitan guest in human habitation. They don’t burrow under the skin, like scabies mites. They survive in mattresses, carpets, furniture and bedding. The concern about dust mites is that people are allergic to them. Symptoms associated with dust mite allergies include sneezing, itchy, watery eyes, nasal stuffiness, runny nose, respiratory problems, eczema and asthma.

Treatment is in the form antihistamines, corticosteroids and salbutamol. They depend on moisture to survive; hence, measures such as, air-conditioning can be used to maintain the humidity at a lower level. Furry or feathered pets contribute to dander in the dust and increase food source for mites. If you are a pet lover, locate their sleeping quarters as far away from yours as possible. Vacuuming and dusting are equally important in reducing the exposure to the allergens in sensitive people.

Then there are some non-specific cutaneous conditions: 1) Grocer’s itch which is a condition characterized by dermatitis that occurs upon contact with food such as figs, dates, grain or cheese that has mites in it. Who would want to eat that?! Lucky are those who are lactose intolerant! 2) Baker’s itch is a reaction caused by bite of Acarus siro, the flour mite while baking cakes, pastries etc. That piece of cake doesn’t look so tasty now, does it? 3) Cheyletiellosis is a mild dermatitis caused by mites of the genus Cheyletiella. It is also known as walking dandruff due to skin scales being carried by the mites.

Mites do not just cause diseases. In fact, most species of mites are beneficial decomposers breaking down organic matter, allowing nutrients to be used by plant again. Predatory mites are popular amongst greenhouse growers as they are used for pest mite control. What fascinating little creatures! 28 Tick Me Not By Nikhil Tambe Hahnmann University Hospital, Philadelphia THE STING OPERATION

The first day of my morning report with Dr. Boselli, also known as “Dr. House” or “The Walking Encyclopedia”, was a much anticipated one! I was excited, thrilled and scared to face him as we were going through series of differentials on his iconic blackboard. The case was a 34 year old female who came with complaints of paralysis of one side of the face which started few weeks ago, associated with fever, chills, fatigue and rash. The differential ranged from infections to vasculitis. As we progressed with the case, we realized that the patient came from Connecticut, Ohio an endemic area for Lyme disease. Our doubt was corroborated when we did an immunological assay to determine IgM antibodies against Borellia Burgdorferi, the causative organism for Lyme disease.

Lyme disease is common in the northeastern and north-central parts of the United States, namely, New Jersey, Connecticut, Wisconsin, Denver and parts of Pennsylvania. It is caused by the vector Ixodes scapularis or deer tick, also called black legged or bear tick. Ticks that are brown and approximately the size of a poppy seed or pencil point are deer ticks. Many a times, the bite goes unnoticed and the patient presents with symptoms like the above in a week. The deer tick goes through four stages of its life cycle – larva, nymph, adult male or female and engorged tick. The nymph stage is the most likely stage for transmission of disease in humans in the months of May through July.

Ticks transmit infection only after they have attached and then taken a blood meal and have fed for >36 hours before transmission of the spirochete. The organism lies dormant in the inner portion of the tick’s mid-gut and activates only after exposure to the warm blood meal entering the tick’s gut. Once active, the organism enters the tick’s salivary glands. As it feeds, it salivates the organisms into the wound, thereby passing the infection to the host.

Tick bite prevention strategies are widely implemented and taught in the endemic areas of the United States. The proper technique for removal of ticks is by using tweezers held as close to the skin as possible; care should be taken not to smoulder the tick using match sticks or liquid soaps as it may irritate the tick and lead to a tick bite.

The best way of preventing Lyme disease is by avoiding tick contact. Stay clear of grassy areas and leafy litter. Tick repellents like DEET and Permethrin should be used. Bathe and shower after you arrive indoors within 2 hours and pull off any ticks if you notice them. Examine pets as they can carry ticks along with them. Tumble clothes and dry them with hot air to kill remaining ticks. One should carry out full body checks for ticks in children especially under the arms, in and around the ears, in the belly button, behind the knees, between the legs, around the waist, and especially in the hair.

Lyme disease is classified into three stages – early localized, early disseminated and late or chronic stage. Early localized has clinical features like erythema migrans, fatigue/lethargy, malaise, mild headaches and neck stiffness lasting from few days to a month after tick bite. Early disseminated disease involves organ system. The stage lasts for a few weeks to months after the bite. It presents with carditis (AV block, cardiomyopathy), neuropathy (unilateral or bilateral cranial nerve defects, meningitis and encephalitis), migratory arthralgia, conjunctivitis, multiple erythema migrans, regional or generalized lymphadenopathy. Late manifestations that may present months or years after tick bite include arthritis, encephalomyelitis and peripheral neuropathy.

Erythema migrans in an endemic area is sufficient for diagnosis of Lyme disease. Serology can be negative in acute disease, though one must get serology done in early disseminated and chronic disease. Oral doxycyclin for 28 days is the drug of choice for Lyme disease that should be started promptly. Amoxicillin should be administered to children less than 8 years of age and pregnant females as doxycyclin is contra-indicated. Ceftriaxone intravenously should be supplemented in patients with neurological manifestations, meningitis and third degree heart blocks.

The Lyme disease may manifest as simple fever with rash to as severe as meningitis or encephalomyelitis. Early recognition and treatment is the key to successful cure. But above all, taking appropriate preventive measures to avoid tick bite can drastically reduce the prevalence of Lyme disease.

Prevention is better than cure! – is the absolute mode for vector control.

References: www.uptodate.com 29

Acts of Kindness

Healthy Is Happy – The medical wing of Bigger Than Life By Yashada Nabar Yerala Medical Trust’s Dental College & Hospital, Mumbai

“So I say to you, Ask and it will be given to you; search, and you will find; knock, and the door will be opened for you.” – Jesus Christ These words spoken by Christ have a deeper meaning in today’s age as well. As the disparity between the rich and the poor increases, kindness is also dispensed in smaller doses. The poor and the underprivileged need messiahs to help them and look over them. In this generation, NGOs play that crucial role. In a way, NGOs like Bigger Than Life are the modern day messiahs.

Bigger Than Life is a NGO that was started in the year 2011 with the efforts of one Mr. Avideep Gaikwad, fondly known as Avi bhaiya among the underprivileged children of Khar danda area and Carter road. He is their savior and their guardian angel. The inspiration for BTL came up when he was once taking a walk down Carter road, and saw many of these children begging. Among these children was a girl who came from a broken home and her helplessness and inability to acquire education moved him. Thus was the birth of his brainchild Bigger Than Life, which started off with 7 members and had its first session on 9th April 2011. Currently 6-7 girls from impoverished areas are studying in convent schools through the efforts of BTL.

Healthy is Happy is a division of BTL and was pivotal in organizing the Health Mela Event on 1st June, 2014 at Father Agnel’s Ashram in Bandra which was covered by Lexicon. It began as an initiative by Dr Komal Kanitkar, who met Mr. Avideep in the year 2012 with an agenda to help the masses and HIH was started on 26th May 2012. It received government recognition as a NGO on 19th December 2012. HIH is most active in the first five months of the year. The health camps are conducted in January and follow ups go on till May. Premedical surveys are conducted at slums, and two doctors are sent per family to attain accurate case histories.

The Health Mela Event organized by HIH was a sure shot success. Health and hygiene awareness was communicated to women and children by the means of interactive skits. Women sat in rapt attention as the doctors attempted to clear most of their common myths and doubts. The overall eagerness of the public was very encouraging to the doctors. Through the means of skits, they were provided information regarding the commonly occurring diseases. The patients were offered one on one consultation with the doctors with separate divisions for ophthalmic and dental checkup. Dr Faiz Khan, from KEM college was conducting the ophthalmologic check up and stated that around 50 patients were checked, especially those who needed spectacles. . Many people were ignorant about the government health policies such as Rajeev Gandhi Jeevandayee Arogya Yojana; such patients were made aware of these health policies by an IT team conducting lectures. Dr Riya Bandekar from Nair Hospital who was associated with her first camp for HIH said “Today we are basically screening the patients, their follow up and care will be continued extensively at KEM and Nair Hospital”.

Public satisfaction with the Health Mela was very evident from their positive response. One of the attendees, who was hanging on to every word the doctors said was Mrs. Kusum Koli a mother and a grandmother at 45 years of age. She had gotten her 18 year old daughter and her 6 month old grandson with her. She reminisces about her youth and says “If I knew all these things before, when I had my first child, I would have done things differently”. Other patients were also discussing their health concerns on a one on one basis with the doctors present. Dr Komal adds saying “It’s a two way process. It’s not just beneficial to the patients; their gratitude is very valuable and heartwarming for the doctors”. This gratitude and indebtedness displayed by the patients is what instills a sense of obligation in doctors. Doctors have been given godly status in our society, performing miracles and restoring faith amongst people. Many doctors sponsor the medicines for these camps, and prefer anonymity. Dr Ahuja, the Head of Department of Ophthalmology at KEM College, donates free spectacles and lenses to underprivileged people; He also offers free treatment for minor surgical procedures.These people are the modern messiahs in the true sense. At times people just need someone to listen, to care. BTL has become so much more than just a helping body; they have acquired familial status among the underprivileged. They’ve instilled a sense of purpose in the children and made them believe in themselves.

“There is a difference between treating and healing. Treating is to remove an illness or a bodily infirmity. But healing means restoring a soul back to life” – beautifully worded by Dr Komal Kanitkar, has truly captured the essence of HIH. Such selfless 30 acts by these doctors and organizations like BTL and HIH are not just rare occurrences; they are Acts of Kindness!

31

Acts of Kindness

Dr. Siloo Bhagwager By Rohin Manipur Mahatma Gandhi Mission’s Medical College (MGM), Mumbai

“Men are haunted by the vastness of eternity. And so we ask ourselves: will our actions echo across the centuries? Will strangers hear our names long after we’re gone and wonder who we were, how bravely we fought, how fiercely we loved?” - Odysseus, Troy (2004).

The journey was a long and twisted one along the moisture laden roads of Marine Drive, through to the bylanes of Colaba. The distinct smell of the sea and the partly abrasive screeches of fish mongers drying their catch in the afternoon heat accompanied us as we passed the Radio Club. This was only the second time Lexicon’s active wing had been out on an assignment. The lady we were to meet was well known in these circles for her kindness and her immense contributions to a pressing social cause. The welfare and protection of animals without homes has long been an issue that pervades the streets of Bombay. Who cares for the strays that are run over by errant car drivers? Diseases like leptospirosis, tick fever, tumours abound in animals with no homes, with no one to look after them. Too often a family pet is left discarded or unattended following an accident or incurable disease. These animals are left to die in the streets, in a foreign environment , nursing injuries. If it were not for the actions of some good Samaritans, these animals would have ended up in discomfort, seeing out the rest of their days in agony. Veteran veterinarian and social worker Dr. Siloo Bhagwager is one of those people responsible for alleviating their anguish.

Our rendezvous with Dr. Bhagwager took place in her ground floor apartment in Colaba, which doubles up as her veterinary clinic. She also runs an NGO called PALS, short for Plant and Animal Lovers Society. As we were ushered into her house with a kindly eye, a couple of cats, startled by her new visitors, darted into different corners of the house. Dr. Bhagwager’s house is home to as many as twelve cats and four dogs, and the lady’s connection with her furry friends is one to behold. One can immediately sense her fondness for the animals in her care, a fondness which is voraciously reciprocated. When asked about her motivation to pursue the health and care of animals, Dr. Bhagwager harks back to the days when she would bring injured animals home even as a young girl and care for them. Even though she initially started off with a degree in Microbiology, Dr. Bhagwager switched to veterinary sciences. “In those days, girls doing veterinary sciences were almost unheard of,” she recounts with a chuckle.

Her years of experience as a senior veterinarian serve her well in her objectives. PALS is responsible for the rescue, rehabilitation and treatment of Bombay’s stray animals, which include dogs, cats, birds, and other small creatures like squirrels and reptiles. Dr. Bhagwager works independently, relying on the funding of her private patients and patrons for the costs associated with animals that have no owners. A dog named Elvis has had an accident which has fractured his spine and paralyzed his hind legs. His rehabilitation is an ongoing and expensive process, as he needs intrathecal stem cell injections for the treatment of his spinal cord. PALS also treats animals with parasitic infections, conducts vaccinations, stray animal sterilizations (up to 25 a month), diagnostic blood tests, X rays and amputations. Dr. Bhagwager speaks about the animal amputees with a sense of pride, marvelling at their powers of regeneration and how quickly they bounce back from a debilitating injury, learning to cope with their remaining limbs. As she speaks, Elvis hobbles up to us and nestles his head between my hand and thigh, seeking a friendly pat. Functioning only on his forelegs, the canine is a living testament to Dr. Bhagwager’s assertions.

The fuel of an organization like PALS is Dr. Bhagwager’s strength of will and the help and donations of several well wishers. Her years of back breaking work have been ably complemented by efforts undertaken by the Tatas and the Indian Navy, among several other patrons. The Navy has provided PALS with free land, water and electricity for an animal shelter where rehabilitation and treatment of animals is carried out. In addition, PALS relies on the sale of products like calendars to fund their objectives. One gets the sense that this mammoth mission stems from Dr. Bhagwager’s continuing desire to care for her four legged friends. Watching her in contact with her animals adds to the sense that this not merely an act of kindness, but a bond stronger than hoops of steel. In her own words, “Animals have a lot of character in life; you just have to look for it.” For Your Information: ——————————– PALs is based in Ferena opposite Fariyas Hotel in Colaba. They treat injured and sick animals, and sterilize and neuter stray dogs and cats. Treatment of pets of poor patients is carried out at low cost or for free. You can aid in their mission by adopting a stray dog or kitten and 32 caring for it. You can also donate to their mission by buying their products like calendars.

Tech - X

“Your breath smells of cancer!” New device to detect lung cancer by the analysis of the exhaled air. By Basalathullah Mohd. Gandhi Medical College, Hyderabad

A new medical invention is about to give a completely new meaning to the term ‘bad breath’— a rather ominous one, though. Researchers at the University of Louisville have invented a device that can detect lung cancer by the analysis of exhaled air. The science behind the device is a no-brainer: the metabolism of a cancer cells is quite different when compared to the healthy cells, and the end products of their metabolism are detected by sophisticated techniques that make up this advice. The device can also be used to diagnose Chronic Obstructive Pulmonary Disease (COPD), apart from diagnosing, staging and planning the treatment of lung cancer.

Image Source: http://www.nutripro.net/5-new-breath-tests-that-could-save-your-life/ This means that lung cancer (which causes the highest cancer deaths in the world) can be detected using a simple, portable and a non-invasive test. Presently employed tests like CT and biopsies are invasive and often give false positive results. The nature of the device also makes it an ideal tool for large scale screening purposes in high risk populations. Dubbed the Cancer Breathalyser, this device consists of a tube in which the patient breathes for about five minutes. An array of sophisticated techniques then take place in the device and the results are available on the computer attached to the device.

But what took so long to come up with such a device, one might ask? It is evident that the device looks for a specific ‘signature’ of chemical compounds in the exhaled breath, and detects them. Over the years researches have been doing precisely that: mapping the huge constellation of these compounds. Volatile Organic Compounds (VOCs), mostly predominantly the carbonyls, etc are produced due to the altered expression of cytochromes in tumour cells. When the patient breathes into the device, the overwhelming importance lies with the ‘sensor array’ which is specialised for chemical sensing and identification. These ‘electronic noses’ are made up of several coloured sensors that recognise the specific stereo chemical characteristics of a volatile compound.

Image Source: http://www.gtri.gatech.edu/casestudy/gtri-cancer-breathalyzer-breath-test The patient inhales to total lung capacity, air purified of the atmospheric VOCs to prevent interference with test results, through a disposable mouth piece. A longer tube acts as air reservoir and a smaller one functions as a sorbent trap to capture the VOCs in the breath. A flow meter to measure the amount of air and a timer also form a part of the hand-held portable device. The air in the sorbent traps is analysed by gas chromatography and mass spectrometry, and also by employing sensors based on gold nanoparticles.

The intricacies don’t end here! It is necessary that a sampling system deliver ambient air and the vapour to the sensors in sequence. A reversible electrical change occurs in the sensor array when exposed to the vapours in the air. A wide variety of the sensor materials used ensures that the changes produced in each of them are unique. Finally, a pattern of changes in the sensors is obtained from the array which is called as the ‘smell-print’. The smell pattern is a coloured pattern produced by the computer system which uses complex statistical analysis and algorithms. The smell- print will thus be different for different conditions. And this diversity not only allows the device to detect and stage lung cancer, but also to help decide on the treatment options. The device is also expected to predict the behaviour of tumours.

Several clinical trials have been completed by researches all over the world with specificity of more than 90% to detect lung cancer. In its current state the device is very helpful to detect lung cancer, but is quite evident that in the near future it will revolutionise the field of cancer diagnosis. According to the founder of Metabolomx, a company which has published its clinical trials on this device expects the test to cost around $75. Analogies have been made of this test with the functioning of the nose. It is pertinent to recall that the olfactory sense has been used in medicine since time immemorial: be it the fetor hepaticus or the ‘mousy odour’ in phenylketonuria. It is only natural that with technological development we are able to ‘smell’ the various disease processes. It is indeed the modern day tool and will revolutionise cancer diagnosis.

33

Tech - X

sTMS – Goodbye Migraines? By Utkarsh Mishra Mahatma Gandhi Mission’s Medical College (MGM), Mumbai

Migraine is a primary headache disorder, the second most common cause of headache in the world. It afflicts approximately ninety percent of the people in a lifetime, with 25 percent women and eight percent men getting involved in their prime .

Most commonly migraineurs are said to report something that ‘triggers’ a migraine. Anything like sensitivity to light, sounds or movement and even missing a meal and having stress can lead to a migraine. Symptoms like nausea, vomiting, photophobia, paresthesia, vertigo along with the headache, cause disability in the normal working patterns of an individual. Sixty percent cases have reported pulsating or one-sided headaches, and with a duration of hours to even days (approx. 2-3).

Probable cause of migraine is associated with the dysfunction of the mono-aminergic sensory control systems located in the brainstem and the thalamus. Release of vaso-active neuropeptides like calcitonin gene-related peptide (CGRP) or any inflammatory substances, cause inflammation around the nerves and the vessels of the head.

Source – eNeura eNeura, a privately held medical technology company, has come up with a very non-invasive system as a cure. Use of the portable device called the Spring TMS or sTMS, recently cleared the FDA regulations and is being adapted by the citizens of the United States. As eNeura puts it, “it is the first truly portable, convenient TMS product that will allow migraine patients to administer treatment as needed—at home, in the office or on the go.”

Source – eNeura The machine works on the principle of altering cortical excitability. Transcranial Magnetic Stimulation or TMS works on this principle. It relies on the use of conversion of electromagnetic induction to induce weak currents, which can alter cortical activity. The magnetic field is believed to be approximately half the strenght of a typical MRI. The thalamus, which is the key structure of pathophysiology of the migraine, receives direct cortico-thalamic inputs that modulate its activity, and this could be ideally modulated by a single pulse TMS (a promising novel treatment in migraine with aura).

Early graphs and studies have shown that induction of these currents significantly modulate the trigeminovascular activity, as recorded from the third order neurons and Cortical Spreading Depression (CSD)-induced neuronal firing. This also means that the machine works by interaction with the third order ipsilateral thalamic neurons, through the cortico-thalamic relay.

Source – eNeura The device is fairly easy to use. At the first sign of pain (prodome phase), the patient has to activate the machine and wait for the medication to load on the device. Then, the handles have to be strapped out, and the device has to be adjusted on the base of the skull. By activating a trigger on the handle, a single pulse TMS is induced. Then, the device determines if the dosage was given correctly. The patients do not feel the mild electric current stimulated by the device. 34

KNOWN CASE OF Hemophagocytic lymphohistiocytosis syndrome associated with severe Plasmodium vivax malaria: A case report By Ruchira Dhoke Mahatma Gandhi Mission’s Medical College (MGM), Mumbai

HISTORY Hemophagocytic syndrome has been associated with genetic mutations, Malaria, an ancient disease, has been around since about 2700 BC as mentioned autoimmune diseases, hematological malignancies or infections. There are in Chinese documents, clay tablets from Mesopotamia from 2000 BC, Egyptian reports suggesting hemophagocytic syndrome associated with Plasmodium papyri from 1570 BC and Hindu texts as far back as the sixth century BC.The falciparum monoinfection [12–19], but the reports on the association with P. famous Greek physician Hippocrates described it in detail. In ancient Rome, as in vivax monoinfection are rare. [19–24] other temperate climates, malaria lurked in marshes and swamps. People blamed The case report describes an unusual case of HLH associated with Plasmodium the unhealthiness in these areas on rot and decay that wafted out on the foul air. vivax infection, which was diagnosed and confirmed by using diagnostic Hence, the name is derived from the medieval Italian, “mala aria,” or bad air. In techniques like PCR along with stringent laboratory and biochemical investigations 1880, the French scientist Alphonse Laveran discovered the real cause of to establish the firm association of hemophagocytic syndrome with P. vivax malaria, the single-celled Plasmodium parasite. Almost 20 years later, scientists monoinfection. working in India and Italy discovered that Anopheles mosquitoes are responsible for transmitting malaria. CASE REPORT INTRODUCTION On March 28, 2012, a female child was admitted to the Department of Pediatrics As per UNICEF, malaria is a global burden estimated to kill more than 1 million in a hospital in Rajasthan, India with history of high grade fever with chills, rigors, people annually, the majority of which are young children. It is one of the leading emesis and abdominal pain since the last seven days. She had history of epistaxis causes of death among children under 5 years of age. with noticeable petechiae spots on trunk and other extremities. There was no history of weight loss, bone pain, seizure, frequent infections, previous blood Despite intensive efforts over the last century to understand and control malaria, transfusion and any contact of tuberculosis. it remains one of the primary causes of morbidity and mortality in humans. An estimated 300–500 million people contract malaria every year, resulting in 1.5– Past medical history and family history were found to be unremarkable. On 2.7 million deaths annually. [1] physical examination, there was severe pallor, icterus, petechial spots, palpable cervical lymph nodes and hepatosplenomegaly (spleen 5 cm below the left costal Malaria is caused by intraerythrocytic protozoa of the genus Plasmodium, with margin). Vital signs were 100/60 mm Hg of blood pressure, 108 beats/min pulse humans being infected by one or more of the following species: Plasmodium rate, 36.9°C temperature, and 26 cycles/min respiration rate. Hematological falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and findings 2100/mm3, differential leukocyte count: 41% polymorphs, 53% Plasmodium knowlesi. Plasmodia are primarily transmitted by the bite of an lymphocytes, 3% monocytes, 3% eosinophils, and platelet count: 16,000/mm3, infected female Anopheles mosquito. Infections can also occur through exposure hematocrit 22.6%, peripheral smear showing pancytopenia with all stages of P. to infected blood products and by congenital transmission. [2] vivax (density 8000/mm3) (Fig. 1).

As the term ‘benign tertian malaria’ implies, P.vivax malaria is usually an The RDT results, based on the detection of species specific Plasmodium lactate uncomplicated disease that runs a benign course and is rarely fatal. [4] This dehydrogenase (LDH) (OptiMal test; Diamed AG, CressiersurMorat, Switzerland) clinical paradigm has been challenged recently by numerous reports of symptoms and histidine rich protein-2 (HRP-2) (Falcivax test; Zephyr Biomedical Systems, and signs of severe disease, and even deaths due to P. vivax monoinfections. [4– Goa, India), were positive for P. vivax and negative for P. falciparum. The PCR 10] study targeted against the 18S ribosomal RNA gene of the parasite and used 1 genus-specific 5′ primer and 2 species-specific 3′ primers in the same reaction The classic presentation of malaria consists of paroxysms of fever alternating with mixture, confirmed the P. vivax monoinfection. periods of fatigue but otherwise relative wellness. Symptoms associated with febrile paroxysms include high fever, rigors, sweats, and headache, as well as Abnormal liver function tests myalgia, back pain, abdominal pain, nausea, vomiting, diarrhea, pallor, and were as follows: aspartate jaundice. [2] aminotransferase, 104 IU/L (reference: 5–45 IU/L); However, classical presentation is seen in only 50%–70% of the cases with the alanine aminotransferase, 106 rest having atypical manifestations. In endemic regions, malaria can present with IU/L (reference: 5–45 IU/ L); unusual features due to development of immunity, increasing resistance to total bilirubin, 3.3 mg/dl antimalarial drugs, and the indiscriminate use of antimalarial drugs. As a result of (reference: 0.2–1.13 mg/dl); lack of awareness of atypical manifestations, it is not uncommon for malaria to get and alkaline phosphotase, 856 diagnosed late or even remain unrecognized, resulting in severe illness or death. IU/L (reference: 122–378 IU/L). Other investigations, results were as follows: serum ferritin level, 1070 Atypical hematological manifestation of malaria, Hemophagocytic ng/ml (reference: 15–332 ng/ml); fasting triglyceride levels, 297 mg/dl lymphohistiocytosis syndrome (HPS) is potentially fatal hyperinflammatory (reference: 30–160 mg/dl); serum fibrinogen levels, 102 mg/dl (reference: 233– response characterized by a generalized histiocytic proliferation with marked 496 mg/dl); and D-dimer assay, 25.7 µg/ml (reference: <1 µg/ml). Prothrombin hemophagocytosis (Phagocytosis by macrophages of erythrocytes, leukocytes, time, activated partial thrombin time, renal function test, serum electrolytes and platelets, and their precursors) in bone marrow caused by severe glucose-6-phosphate dehydrogenase enzyme levels were in normal range. hypercytokinemia due to a highly stimulated but ineffective immune process. The rare syndrome is characterized by reactive, systemic proliferation of benign Ultrasonography of the abdomen showed enlarged liver and spleen (12 cm). histiocytes throughout the reticuloendothelial system. [11] HLH results from impaired functions of natural killer (NK) and cytotoxic T cells, whereas activities of lymphocytes and histiocytes are augmented, leading to phagocytosis of hematopoietic cells. [11] 35 Immunohistochemistry including natural killer (NK) cells activity, soluble IL-2 and A bone marrow examination in malarial cases with severe or persistent decrease soluble CD25 measurement could not be done due to non-affordability by the in hemoglobin or pancytopenia is highly recommended. However, it could be patient. Repeated culture (BACTEC- ALERT) of blood, urine and stool, and implicated in life-threatening complications due to the infection by Plasmodium relevant serology tests for typhoid, leptospira, rickettsia, hepatitis A/B/C viruses, species, justifying further studies on this syndrome to reduce disease burden. HIV, infectious mononucleosis, dengue infection and fungal infection were all negative. CONCLUSION Malaria is a multisystem disorder which can mimic many diseases. Physicians, especially those in endemic areas, should be aware of the varied manifestations and maintain a high index of suspicion for the disease so that the diagnosis and treatment are timely and morbidity and mortality minimized.

REFERENCES 1. Greenwood B, Mutabingwa T. Malaria in 2002. Nature. 2002;415(6872):670–672. 2. Krause PJ. Malaria (Plasmodium). In: Behrman RE, Kliegman RM,Jenson HB, editors. Nelson Textbook of Pediatrics. 18th ed.Philadelphia,PA: WB Saunders; 2007:1477–1485. 3. Rao A, Kumar MK, Joseph T, Bulusu G. Cerebral malaria: insights from host-parasite protein-protein interactions. Malar J. 2010;9:155. 4. Sharma A, Khanduri U. How benign is benign tertian malaria? J VectorBorne Dis. 2009;46(2):141–144. 5. Islam N, Qamruddin K. Unusual complications in benign tertian malaria. Trop Geogr Med. 1995;47(3):141–143. 6. Makkar RP, Monga SM, Gupta AK. Plasmodium vivax malaria presenting with severe thrombocytopenia. Braz J Infect Dis. 2002;6(5):263–265. Bone marrow was examined due to pancytopenia. Bone marrow aspirate smears 7. Nautiyal A, Singh S, Parameswaran G, DiSalle M. Hepatic dysfunction in a patient with Plasmodium vivax infection. MedGenMed.2005;7(1):8. showed normal cellularity and myeloid/erythroid ratio, adequate numbers of 8. Prakash J, Singh AK, Kumar NS, Saxena RK. Acute renal failure in Plasmodium vivax megakaryocytes/granulocytes/erythroid cells and sufficient hemosiderin particles. malaria.J Assoc Physicians India. 2003;51:265–267. Intracellular parasites were rare but prominent hemophagocytic histiocytes were 9. Beg MA, Khan R, Baig SM, Gulzar Z, Hussain R, Smego RA Jr. Cerebral involvement in seen (Fig. 2). Diagnosis of malaria-associated HPS was made. benign tertian malaria. Am J Trop Med Hyg. 2002;67(3): 230–232. 10. Lomar AV, Vidal JE, Lomar FP, Barbas CV, de Matos GJ, BoulosM.Acute respiratory The child was treated with i.v. artesunate 2.4 mg/kg stat at 12 h, 24 h and then distress syndrome due to vivax malaria: case reportand literature review. Braz J Infect Dis. once daily for 2-days and then with oral artemether and lumefantrine for 3- 2005;9(5):425–430. days.Primaquine was given for 14 days as radical treatment. On Day 3, 11. Rouphael NG, Talati NJ, Vaughan C, Cunningham K, Moreira R, Gould C. Infections associated with haemophagocyticsyndrome.Lancet Infect Dis 2007;7:814-22. hematological findings were: hemoglobin 7.6 g/dl; total leukocyte count 12. Anwar M, Salcem M, Malik A. Severe hemophagocytic syndrome in falciparum malaria. J 7,600/mm3; platelet count 146,000/mm3 and peripheral smear showing Pak Med Assoc1995; 45: 302–3. disappearance of P. vivax. After 14 days of antimalarial medication, the child was 13. Ohno T, Shirasaka A, Sugiyamma T, Furukawa H. Hemophagocyticsyndrome induced by discharged in hemodynamically stable state. Serum ferritin level and fibrinogen Plasmodium falciparum malaria infection.Int J Hemeatol1996; 64: 263–6. level were normalized during follow up. 14. Retormaz F, Seux V, Arnoulet C, Durand JM, SaintyD,Soubeyrand J. Plasmodium falciparum malaria infection complicatedby haemophagocytic syndrome in an old man. ActaHaematol2000; 103: 224–5. DISCUSSION 15. Sermet-Gaudelus I, Abadie V, Stambouli F, Hennequin C, LenoirG, Gendrel D. Haemophagocytic syndrome in Plasmodiumfalciparum malaria. ActaPediatr2000; 89: 368– 9. Pancytopenia in a febrile patient may be the manifestation of bone marrow 16. Abdelkefi A, Othman TB, Torjman L, Ladeb S, Lakhal A, BelhadjS, et al. Plasmodium suppression induced by aplastic anemia, hematologic malignancies, metastatic falciparum causing hemophagocytic syndromeafter allogeneic blood stem cell cancer, infection, and or inflammation. [25] transplantation. HematolJ 2004; 5: 449–50. 17. Saribeyoglu ET, Anak S, Agaoglu L, Boral O, UnuvarA,Devecioglu O. Secondary HPS, a rare cause of pancytopenia and fever, results from impaired functions of hemophagocytic lymphohistiocytosisinduced by malaria infection in a child with Langerhans natural killer and cytotoxic T-cells and augmented activities of lymphocytes and cell histiocytosis.PediatrHematolOncol2004; 21: 267–72. histiocytes induced by overexpressed inflammatory cytokines such as tumor 18. Ohnishi K, Mitsui K, Komiya N, Iwasaki N, AkashuiA,Hamabe Y. Clinical case report: Falciparum malaria withhemophagocytic syndrome. Am J Trop Med Hyg2007; 76:1016–8. necrosis factor-α (TNF-α), interferon-γ (IFN-γ) and macrophage colony 19. Pahwa R, Singh T, Khurana N. Hemophagocytic syndrome inmalaria and kala-azar. stimulating factor (M-CSF), soluble IL-2 receptor, IL-1 and IL-6, resulting in Indian J PatholMicrobiol2004; 47(3):348–50. monocyte activation and leading to phagocytosis of hematopoietic cells. [28] 20. Aouba A, Noguera ME, Clauvel JP, Quint L. Hemophagocyticsyndrome associated with Strikingly high levels of these cytokines have been observed in patients with Plasmodium vivax infection. Br JHaematol2000; 103: 832–3. malaria and could trigger HPS initiation [26–27]. 21. Zvulunov A, Tamary H, Gal N. Pancytopenia resulting fromhemophagocytosis in malaria. Pediatr Infect Dis J 2002; 21:1086–8. The patient presented with fever, hepatosplenomegaly, pancytopenia, 22. Park TS, Oh SH, Choi JC, Kim HH, Chang CL, Son HC, etal.Plasmodium vivax malaria complicated by hemophagocytic syndromein an immunocompetent serviceman. Am J hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia and Hematol2003;74: 127–30. hemophagocytosis in the bone marrow, fulfilled the diagnostic criteria for HPS. 23. Ram Kumar TV, Baghmar S. Plasmodium vivax malaria complicatedby neurological, [26-27] jaundice and haemophagocyticsyndrome.J Nepal PediatrSoc2010; 30(3): 168–70. 24. Bae E, Jang S, Park CJ, Chi HS. Plasmodium vivax malaria-associatedhemophagocytic Severe P. vivax malaria has been recently reported in pediatric age. This case, lymphohistiocytosis in a youngman with pancytopenia and fever.Ann Hematol2011; 90: after extensive research, was found to be first PCR confirmed P. vivax associated 491– HPS in childhood age. The etiological role of P. vivax monoinfection is suggested 25. Young N. Aplastic anemia, myelodysplasia, and related bonemarrow failure syndromes. by the confirmation of species by PCR, ruling out the possibilities of other In: Fausi AS, Braunwald E, KasperDL, Hauser SL, Longo DL, Jameson JL, Lascalzo J, editors.Harrison’s principles of internal medicine, 17th edn. New York:McGraw-Hill Medical concurrent disease by scientific pattern and the total clinical and hematological 2008; p. 663–71. recovery after antimalarial treatment. 26. Rouphael NG, Talati NJ, Vaughan C, Cunningham K, MoreiraR, Gould C. Infections associated with haemophagocyticsyndrome.Lancet Infect Dis 2007; 7: 814–22. HPS is one of the causes of pancytopenia in these infections. Bone marrow 27. Filipovich AH. Hemophagocytic lymphohistiocytosis and otherhemophagocytic examination is not usually undertaken for the purpose of diagnosis of malarial disorders.Immunol Allergy Clin North Am 2008;28: 293–313. infection. Therefore, it is difficult to determine the prevalence of malaria 28. Kochar DK, Tanwar GS, Khatri PC, Kochar SK, Sengar GS,Gupta A, et al. Clinical features complicated by HPS. HPS could play a role in the pathogenesis of cytopenia of children hospitalized withmalaria: A study from Bikaner, northwest India. Am J Trop Med observed during Plasmodia infestation. As its frequency has not been Hyg2010; 83(5): 981–9. systematically studied during malaria, it is difficult to assume its pathophysiological consequences on prognosis. 36

KNOWN CASE OF A Young Case of Fibrocalculous Chronic Pancreatitis Later Presented with Primary Malignancy and Adenomatous Metastases in Liver and Spleen By Dr. Naren Nallapeta JJM Medical College – Davangere

INTRODUCTION DISCUSSION An interesting case presented initially with fibrocalculus chronic pancreatitis later diagnosed with primary pancreatic malignancy and adenomatous metastases in liver and spleen.

HISTORY AND EXAMINATION A 24 year old teetotaler diagnosed with fibrocalculous pancreatitis, IDDM from the past 7 months with malabsorption and peripheral neuropathy on treatment was admitted to the hospital with pain in the abdomen and fever since the past 7 days. On examination, he was found to be malnourished with anemia and palpable left lobe. The rest of the clinical examination was viewed as normal.

INVESTIGATIONS • FBS – 283mg/dl • Total Leucocyte count – 29.35 cells/dl

Differential Count: • Neutrophil – 86 • Lymphocyte – 6 • Eosinophils – 3 Fibrocalculous pancreatitis is a unique form of chronic pancreatitis seen in • Monocyte – 4 developing countries associated with either overt protein calorie malnutrition or • Basophils – 1 more likely with a deficiency of certain micronutrients. Compared to temperate zone pancreatitis, fcp affects younger individuals and has a more aggressive and Liver function tests: accelerated course to reach the end points ofNo diabetes, growth in pancreatic blood culture. calculi and 10.Serum albumin – 2.5 gm exocrine dysfunction. Although a secondary form of diabetes, specific diabetes 11.Serum alkaline phosphatase – 166 U/L related complications do occur in fcpd. There appears to be a high risk of 12.Aspartate transaminase – 35 U/L developing pancreatic carcinoma. Although the etiology of fcpd is still unclear, the 13.Total bilirubin – 0.6 mg/dl role of micronutrient deficiency merits further study. The contribution of genetic 14.Direct bilirubin – 0.2 mg/dl factors and environmental toxins e.g. cyanogenic glycosides still remains unclear. 15.Indirect bilirubin – 0.4 mg/dl 16.Gamma glutamyl transpeptidase – 26 U/L 17.Serum creatinine – 0.8 mg/dl CONCLUSION 18.Serum amylase – Normal

Normal urine routine: Fibrocalculous chronic pancreatitis with diabetes mellitus with malabsorption and 1. Color: Light yellow peripheral neuropathy developed primary pancreatic malignancy with 2. Clarity: Clear adenomatous metastasis in liver and spleen. 3. Specific gravity: 1.009 4. pH: 5.2 REFERENCES 5. Protein: None 6. Glucose: None 7. Ketones: None 1) Complications of fibro-calculous pancreatic diabetes – the Pune and Madras 8. Pus cells: 3 cells /hpf experience. – K.M. Shelgikar, C.S. Yajnik, V. Mohan

USG Abdomen: USG abdomen revealed chronic pancreatitis with multiple calculi with hepatomegaly with multiple ring like echogenicities in left lobe of liver s/o 2) Fibrocalculous pancreatic diabetes (fcpd) in India – V Mohan metastasis with mild splenomegaly.

CT Abdomen: CT abdomen showed chronic calcified pancreatitis with necrotic tissue in head/uncinate process s/o mucinous/serous cystadenocarcinoma head of pancreas with multiple hypodense lesions in liver and spleen s/o multiple hepatic or splenic metastases, with necrotic celiac paraaortic, preaortic lymph nodes.

MRI and biopsy could not be done because of deteriorating patient condition. Patient was treated with insulin, pancreatic enzyme supplements, antibiotics.

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