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ANNIVERSARY EXCLUSIVES Lexicon: The Origins

By, Dr.Suranjana Basak, MGMMC Navi Mumbai pic

Where do I go if I want to read what Braunwald said? W hich book should I use to excel in clinical skills? What are my options post-MBBS? Whom should I ask? What if all that I gather is not exactly authentic? One night when these questions were haunting my mind, I sat with my Mac just Googling all the questions and trying to gather relevant answers. After an overdose of search results for 3 hours, I did what most college goers these days do- Call up another crazy friend of yours and blabber about all the time you just wasted. But no, this wasn‘t a waste of time. I can definitely say that now. So while I was talking (cribbing) to this friend of mine, he added to it. Turns out he was least bothered because he knew he wouldn‘t find any answers to this. Ha! The point is, someone was thinking about similar issues. A mutual friend of ours joined the conversation and she actually thought, ―Without guidance, medicine is a bizarre course to survive‖. History has taught me one thing more than any other- the ones who think differently, try to change things or start something new, have always been called ‗troublemakers‘.

They then came together as the founders of ―something literary‖.

So from the vague idea of creating ―Something Literary‖, to discussing the potential and the possible legal work, and other hard work that had to be put in, we planted the seeds of the first student driven All India magazine for the medical society. If you ever happened to Google this, you‘d come across many journals, college magazines, newsletters, blogs but not exactly a medical magazine that focuses on both formal and semi formal content, and that is what we wanted to work on- something that didn‘t already exist. We wanted to make that difference to every medical student aka potential doctors and contribute towards the betterment of the masses on the whole. We wanted to do what our motto says the best, ―Words can what Medicine can‘t‖.

Then, from shortlisting different names like Sync and Parchment, came into existence ―Lexicon‖, which literally means concordance or a branch of knowledge. The ―we‖ that I‘ve been talking about for so long is the only thing that brought us all this far. It refers to the other troublemakers and the co- founders of Lexicon- Sakhi Shah and Abhijeet Sharma. Sakhi Shah, a medical student from Mumbai, an enthusiast, behind the camera person, and foodie, is the Director of Finance while Abhijeet Sharma, a medical student from Manipal, the man in suit, the hire-r and the fire-r, is the Executive Director of Lexicon. Like every loving father who pampers his daughters much and cares for their dreams more than their own, mine was no different. While discussing the idea of creating this medical magazine, my father patronized Lexicon and made the very fierce task of registering a magazine a cake walk. Lexicon is thus, an initiative of SRB Educational Trust yet an entirely independent entity.

Soon after the proposal was passed by the board of directors and trustees at SRB Educational Trust, the troublemakers started doing what they were best at! We opened applications within a close circuit to build a core team that would work towards the big picture. Luckily, people like Spandita Ghosh, Raviteja Innamuri, Haymanti Saha, Caren Otadoh (our friend from Nairobi), Nikita Agarwal, Zenia Poladia and Geeta Sundar walk in the virtual world of Lexicon. Hours of phone calls, conference calls, Skype meetings, emails, drafts and more drafts later, did we finally come up with ‗The Codex‘-our book of bylaws and regulations aka the ultimate reference at Lexicon. So while the team was busy gearing up for the first edition ‗The Cancerous Valentine‘, the administrative heads were hunting for the man who‘d define us best on the web. After 3 months of the pursuit, we found our gem - Kaustubh Barde, an engineering student from Mumbai. That moment onwards, our excitement knew no bounds. Starting from engaging in random conversations to building an editorial of our own, it was another feeling altogether. With each passing day, as the team continued to add words to their thoughts and codes to our vision, we found our identity in a logo by a fresh fine arts graduate, Trupti Pendharkar.

17th {Oct}:- JUST KIDDING

THE TRANSPLACENTAL VOODOO R. Siddharth II MBBS. Grant medical college and Sir J.J. group of hospitals, Mumbai

Chapter one

Central Hospital, New York, March 1973.

The clock showed four in the morning. Attending to patients in pathetic conditions in the emergency ward relentlessly for the past 36 hours had left Dr. Owen drained, both physically and emotionally. The old table creaked, as Dr. Owen rested his head on it, hoping to get a few minutes‟ sleep. “The emergency ward itself is in a state of emergency”, he grumbled, while trying to adjust himself and the table in a state of equilibrium. Dr. Owen was semi-asleep when he heard a distant siren and instinctively knew that it was for him. “There goes my last existing hope for a nap”, he thought sullenly. Sure enough, a minute later, the paramedics rushed in a stretcher with a woman barely breathing. With all the grogginess vaporizing into thin air, Dr. Owen rushed to the patient. One glance at her, and he sighed, “Another one.” Her mouth was laced with froth, and he could spot myoclonic jerks in her hands. She was just out of a convulsion. Dr. Owen examined her. He noted pinpoint pupils and a blood pressure of 96/76. “I was right,” He thought to himself, “Opioid toxicity.” He then swiftly inserted a cannula into the dorsum of her hand and injected a good dose of Naloxone.

Dr. Owen watched grimly as the drug slowly took its effect. She was the third case of opioid poisoning in Central Hospital that night. With the Disco trend setting in, New York had seen an unprecedented surge in the number of drug addicts and alcoholics. He pondered over this malignant issue, he always did, when such cases arrived. Narcotics had wreaked havoc in the lives of the younger generation in the city. Families were being torn apart, the number of depression cases was rising by the day. Barbiturate and alcohol abuse was rampant. The hospital was teeming with delirious drug addicts and depressed alcoholics. Half of them were unwed mothers. Dr. Owen‟s mood turned more sombre with each passing minute.

Chapter two

Gloominess was still lingering in Dr. Owen‟s mind the next day as he prepared for his rounds. Little did he know that this gloomy chain of thoughts would soon lead him to the turning point of his life. He saw from a distance a nurse scurrying towards him. He quickened his steps. “Sir… the… the baby just won‟t stop crying, she‟s inconsolable… please help us”, the nurse said, gasping for breath. “I‟ll be there in just a moment”, Dr. Owen answered, puzzled. He half jogged his way to the maternity ward. As he took a turn to reach the ward, he could hear the baby‟s wails, almost as if screaming out of pain. “Strange, babies‟ cries do not reach this far”, he thought as he entered the ward. The neonate‟s wails were abnormally high pitched. All the nurses in the ward tried to console the baby, but in vain. He turned to the baby‟s mother to ask her whether she had breastfed her daughter or not. “I ain‟t got no time for that, young fella… tell that goddamn monster to stop crying… she don‟t stop crying since she born” she said in a heavy Caribbean accent. Dr. Owen felt a deep sense of resentment towards heroin addicts. She was a known case. Angrily, he left her bedside and took the baby in his arms. He could feel his anger making way for pity. He rocked the baby gently, while asking the Head Nurse for any other abnormalities. “A lone episode of epileptic seizures 24 hours after birth, Doctor. Plus, she has passed loose stools five times and vomited once since this morning.” Dr. Owen nodded absently, his mind still on the baby, who now seemed to have taken a moment off from her incessant crying. “What could be troubling her”, Dr. Owen wondered. He thought of all possible conditions right from an uncomfortable nicker to congenital heart diseases. The very thought of the child‟s mother made his heart ache. Hate for the drug had turned into anger. The baby‟s helplessness had scarred Dr. Owen‟s usually tough mind. “I‟ve seen similar kids… Probably worse, but none affected me as much as this… Oh wait, similar kids?” Dr. Owen‟s mind started racing, so did his heart. This was not the first time he had seen something like this. He recalled his days as a novice, still fresh in his mind, when the very sight of blood used to scare the daylights out of him. … A perplexed Owen watched wide eyed as his professor, Dr. Gordon held a month old infant in his arms. The baby was odd, with a small head, and an ear shattering screech called cry. “She’s born pre term, Owen. I want you to read out her mother’s history loud.” Said Dr. Gordon. Owen flipped through the file, “Ummm… Chronic alcoholic? Nothing else is significant.” Dr. Gordon smiled, “Do you see any relation, Owen?” He thought for a second, “Ethanol is small enough to cross the transplacental barrier. Is it really a teratogen?” Dr. Gordon smiled a bit more, “The baby also gets drunk, and when she doesn’t get a peg after she’s born, she develops withdrawal symptoms, just like any adult. Neonatal abstinence syndrome, as it is called, when a baby is congenitally addicted to a substance.”… Dr. Owen smiled for the first time in days.

Chapter three Dr. Owen wanted to be sure of his hunch. He went back to the ward, with renewed enthusiasm and made a list of the symptoms he observed.  Seizures  Excessive high pitched crying  Sleep disturbances  Diarrhea  Vomiting  Fever  Increased muscle tone  Tremors  Poor feeding  Slow weight gain

He was certain that the poor baby was facing the repercussions of heroin withdrawal, but he was still not satisfied. “Is that all? Or is there anything else?” he thought. There was only one way to find out.

Chapter four

Over the next one year, Dr. Owen observed with eagle like eyes, every baby born to substance abusers. Every tiny detail would be penned down. He toiled hard to maintain comprehensive records. A very important observation in his studies turned out to be the difference in the symptoms of the babies born to mothers addicted to different substances. Babies born to alcoholic mothers had a smaller cranial circumference as compared to babies born to heroin addicts. Dr. Owen was not sure whether he was supposed to feel happy with his survey, the fruit of his labor, but it sure was revolutionary. Dr. Owen‟s study was far from complete. Lucy, the baby who was the trigger to awaken the giant within Dr. Owen last year, had died. The news left Dr. Owen shattered. Lucy was definitely not the first infant death he had seen, but she was close to his heart. Dr. Owen‟s heart used to melt every time he held her in his arms to console her. She had died suddenly. It pained Dr. Owen to write SIDS in his list. He felt a lump in his throat remembering consoling her just the previous day. He vowed to find a cure for Neonatal Abstinence Syndrome. He focused all his sadness into his work to take his study to the next level.

Chapter five

Central Hospital, New York, March 1977.

The next couple of years were really tough for Dr. Owen. He observed the development of every child he had studied. There was one thing in common amongst all the affected children. All of them had mental retardation and behavioral problems, albeit of varying levels. The next important observation was the direct relation between the degree of substance abuse during pregnancy and the degree of retardation of the child. Most of the children were weaned off without any hassle, just requiring a quiet, dark environment and regular consoling. Then there were serious cases like Noah who weren‟t responding to supportive therapy. They were the ones with higher exposure to drugs in their intra-uterine life. No amount of consoling would pacify them in the post natal period. Developmental defects were very common, Dr. Owen had seen Noah and a few others in the cardiology department with patent ductusarteosus and valvular defects. Behavioral problems and mental defects were the hallmark of these cases. Many of them met the same fate as Lucy. SIDS was directly proportional to the severity of the syndrome. This was like a thorn in Dr. Owen‟s flesh. “I wanted no one else to see the same end as Lucy. I have failed my mission… I‟ve failed Lucy.” He thought, wiping a tear off his eye, as he sipped his coffee in the hospital cafeteria. “Supportive care was a no-brainer. My aim was to find a cure. I‟ve lost the war.” He cradled the cup in his hands. “What‟s the point of all the toiling, the sleepless nights, all the analysis…? I could have very well stayed in my department and out of this mess. All the bureaucracy, administrative hurdles and my own department‟s workload never deterred me. But was it worth it?” Dr. Owen‟s morale hit a rock bottom. He raised his cup to take a sip. It was empty. As a coffee addict, he had cut down to three cups a day and planned to reduce his intake further, but he wanted one more cup at the moment. Allowing himself an indulgence he refilled his cup for the fourth time. “I wish I had nipped this in the bud.” He thought, as he raised his cup. His hands froze midair. A wave of euphoria entered through his head and left through his toes. He wanted to run all around the hospital screaming, but only managed to whisper “Eureka!”

Chapter six

A part of Dr. Owen‟s frustration was due to the lack of Naloxone tolerance in Noah like cases, where adverse drug effects overshadowed the benefits of the drug. But a bizarre idea, gave Dr. Owen a spring in his step. He entered the ward with a swagger, and the nurses watched in silent bewilderment as Dr. Owen aspirated a microscopic dose of Tramadol. “Fighting fire with fire!” he explained to a horrified nurse. “He‟s craving for feeling high so early in his life. His request cannot be ignored.” He smiled, as the nurses questioned his sanity. A microscopic dose was all little Noah needed to instantly stop wailing and peacefully drift off to sleep. Dr. Owen smiled triumphantly as he completed the first step successfully. He turned around to address the small mob of nurses gathered around him to witness the unimaginable. “The baby is suffering from withdrawal symptoms of heroin. Now, effective doses of Naloxone would be toxic for him. I injected a very tiny dose of Tramadol, an opioid analgesic, which would have the same effect as heroin. The baby will sleep peacefully, so will you.The dose will be reduced progressively till a stage when the plasma levels of the opioid will be low enough to let Noah tolerate Naloxone well.” The nurses looked at him wide eyed, any doubts of insanity vanished into thin air. “It‟s good to nip the addiction in the bud, isn‟t it?” Dr. Owen Smiled.

Epilogue

Doctors‟ quarters, Central Hospital, New York, March 1981.

Dr. Owen sat in his balcony, sipping his second and last cup of coffee. His seemingly unrealistic idea had worked wonders for kids once having no hope. All of them responded well. Anomalies were minimized to a very great extent, and the kids were leading a normal life. He smiled to himself as he recollected the past eight years. A lot of ups and downs, but worth it in the end. He was awarded the Best Doctor of New York in 1979 and Ambassador of Humanity Award in 1980. He gave numerous interviews on the importance of aggressive treatment and innovative medicine. Life was happy. However, he regretted his inability to save Lucy in the winter of ‟73 throughout. “I wish I could have done something.” He thought for the millionth time. He dedicated all his success to Lucy. She was his inspiration throughout. “The battle is won,” he thought. ”But the war is yet to be won. One of the effects is conquered, but the cause is still at large.” He thought philosophically, and put his cup in the sink, resisting the urge for a third cup.

The Prodigal Parent, and General Conundrums of Conscience and Character.

Bianca S. Honnekeri MBBS Student Grant medical college and Sir J.J. group of hospitals, Mumbai

credit: www.indiatoday.in

"I will drive the blue VW Polo car that my father gifted me two years back, after I won silver at the 2014 Commonwealth Games in Glasgow. I will gift it (BMW) to my dad. He has sacrificed a lot for me," said Sakshi Malik, Bronze-winning champion at the Rio Olympics (insert #hashtags wherever you like, dear Reader), upon receiving the luxury car as a gift for her achievements. At this same fortuitous event, PV Sindhu won hearts world over for a second time in the same hour as her valiant all- guns-blazing bout for glory, when she picked up Marin‟s fallen racket and put it away. Those hallowed incubators of outrage and impulsive proclamation alike, monitors of public diffraction and political discourse, keepers of the cool yet angst-ridden battlers of the calm, swift-typing cynics combatting unfounded extra-mural criticism (Oh hey, Piers Morgan!), smartphone-wielding warriors with armchair launch-pads of intercontinental 140-character ballistic missiles- also known as the Indian Twitterati- promptly trumpeted that these prodigious India‟s betis had a prodigious set of nuanced Indian values; alien to blundering Indian politicians, babus, film stars, Shobha De, KRK etc. So what are these enigmatic „Indian values‟, and why must they beg for a geographical distinction from other value systems; and is the distinction really only geographical? Abhishek Bachchan by way of witty repartee on The Oprah Winfrey Show (at a time when the honor of #trending did not exist), expressed his shock at this idea, sir ji: Oprah: “The both of you are living with your parents. How does that work?” Abhishek Bachchan: “Do you live with your family?” (Oprah: No) “How does THAT work?” In India today, the power of choice is celebrated. Many choose to move out of their homes for work or education; many choose to live with their families for the comfort and homeliness. From personal experience, the latter is also an economically wiser choice! As Indians, even in our rebellious teenage years, we don‟t look at our parents as Us vs. Them. The Generation Gap exists, causes healthy friction, leads to fights/tears/yelling/silent treatment etc., but is also necessary; as anyone in their 20s armed with healthy amounts of hindsight and gratitude, and overwhelmed (largely by procrastination) by the life still ahead of them, will reveal to their directionless teenaged selves. Parents who empower you to make your choices, who celebrate but take no credit for your successes, who don‟t condemn your failures because they are yours to learn from, who believe your mistakes- and not your parents- will be your biggest teachers in life, who are happy to see you do well at things you care about but also know it is important for you to struggle, underperform, have bad days, and shoulder the responsibility on your own; these are the kind of parents more concerned about who you become, rather than what it is you do; and that is the model of parenting we must advocate in society today. Parents who believe that everything has a price and also a moral boundary, and empower you to decide where you draw the line and which prices are too heavy to be paid.

When I was conflicted by certain decisions with gray fringes, my parents laid down Sachin Tendulkar‟s example for me. He was dismissed for a duck, yes, many times; some say he doesn‟t perform to his usual potential when under tremendous pressure, yes; but he was never ever implicated in any wrongdoing; and was ultimately bestowed the honor of carrying our flag around the stadium when India won the 2011 World Cup, despite scoring „only‟ 18 runs. We all have bad days, sometimes even long phases of hopelessness, but it‟s about how you want to eventually go out. Whenever I‟ve been faced with dilemmas, I‟ve had friends and family around me to help guide my floundering compass. This is what family and friends are for- becoming the magnetic field around you that guides your decision-making compass, yet never themselves becoming the pointer for you. We all have had that over-achieving student‟s cosseting, helicopter mom come up to us and say, “Oh hi, actually na, our exams start just next week!” blissfully ensconced in the delusion that the exam is as much a rite of passage for the parent as it is for the child. My parents never took away my cell phone or shut down my TV (a bone of contention I still pick with them when I‟m in having a hey-you-need-to-be-strict-with-me moment!), but they always told me that if I wanted, I could keep it in their drawers. In 23 years, I never have. And the ensuing consequences, good or bad, were always mine to face. Is this the model of parenting I would adopt with my children some day? I don‟t know. (My brother insists I will be a tyrant!) I do believe I would want to raise my daughter (yes, shocker, I‟m an Indian who wants a daughter!) to never need me in her life, but hopefully always want me there. I hope I have enough of a self- identity to never use my child‟s achievements or lack thereof as a yardstick for my own worth. I hope I have enough of a sense of purpose in life to not find myself living through my children or imposing my decisions on their life. Will I succeed? Is there anything like good parenting vs. bad parenting? Is it always trial and error, conflicts and resolutions, arguments and counter- arguments, roles being established and stepped out of, rules or lack thereof, I‟m-your-best-friend and I‟m-not- your-friend-I‟m-your-mom? Is there a right way to raise a child or build a family? And can the right way also have a wrong outcome, or vice versa? I don‟t know. I have seen far too little of life to have the remotest semblance of an ideal here. But, I promise never to subject my children to the horror ofme sitting safely in my bedroom, yet somehow believing I‟m writing the same examination or playing the same football match as them. UK‟s „Child Genius 2016‟participants found themselves subjected to as much pity as their intelligence was celebrated, after the „pushiness‟ of their parents breached infamy. The eventual winner, Rhea, all of 10, was filmed being told by her parents that she could only go to Oxford or Cambridge. While we raise ambitious daughters today, poster-girl of female achievement and CEO of PepsiCo, Indra Nooyi, once said “You really can’t have it all.” When this kind of realization does strike, it plunders, rocks the boat right into the swell of a storm that was once a seamless water-line on a white sandy beach; and it isn‟t the Oxford or Cambridge degree that reinforces balance, it is your family and the values they impart and stand for. Nooyi‟s mother said to her "let me explain something to you. You might be president of PepsiCo. You might be on the board of directors. But when you enter this house, you're the wife, you're the daughter, you're the daughter-in-law, you're the mother. You're all of that. Nobody else can take that place. So leave that damned crown in the garage. And don't bring it into the house. You know I've never seen that crown." Nooyi realized then that she would have to consciously reinforce support systems and coping mechanisms because “How can you do justice to all? You can't.”

At times such as these, when prioritizing seems hard, delegating responsibility is as arduous a taskas trusting others with it, when so much is going on yet so little is actually happening, when you‟re at sea and need to dock at multiple shores at the same time; Nooyi says, after a timely chastisement by her mother, “We co-opted our families to help us.” When you‟re low, when you‟re falling or failing, when you‟re in trouble, the only light at the end of that tunnel is your family, illuminating your path, guiding you out of darkness, and being the beacon of hope for a brighter time still to come. When you find yourself alone in that tunnel, it is the character that your family has helped mould you into, that eventually helps you stand up, and make the right decisions, even when they may be the harder or less profitable ones. Baumrind, in her research „Baumrind‟s Parenting Typology‟, considers four elements that shape parenting outcomes- responsiveness vs. unresponsiveness and demanding vs. undemanding. This lead to Maccoby and Martin's Four Parenting Styles, (for brevity of time, quoted and condensed from Wikipedia at https://en.wikipedia.org/wiki/Parenting_styles) as follows:

1. Authoritative Parenting: Demanding and Responsive. A child-centered approach that holds high expectations of maturity and self-reliance, yet parents are usually forgiving of shortcomings. Authoritative parents encourage independence, but within limits. Verbal give- and-take is seen and children make decisions from their own reasoning patterns. Punishments for misbehavior are consistent, and not violent. Often the consequences of the child's actions are discussed andmotive for punishment is explained, making this style of parenting fair and reasonable, with the best outcomes.

2. Authoritarian parenting: Demanding but Unresponsive. It is a restrictive, punishment-heavy parenting style in which parents make their children follow their directions with little to no explanation or feedback, and focus on the child's and family's perception and status.Corporal punishment, such as spanking, and shouting are forms of discipline frequently preferred by authoritarian parents. Advocates of this style believe that the shock of aggression from someone from the outside world will be less for a child accustomed to enduring both acute and chronic stress imposed by parents.

The child appears to excel in the short term, but developmental shortcomings are increasingly revealed as supervision and opportunities for direct parental control decline. Children who are resentful of or angry about being raised in an authoritarian environment but have managed to develop high behavioral self-confidence often rebel later on in life.'Strict parents' or authoritarian parents more than doubled their teen‟s risk of heavy drinking. Children retreat into escapist behaviors, including but not limited to substance abuse, and are at heightened risk forsuicide.

3. Indulgent parenting: Responsive but Undemanding.

Parents are very involved with their children but place few demands or controls on them.Parents are nurturing and accepting, but do not require children to regulate themselves or behave appropriately.The children will grow into adulthood not accustomed to aggression in others. Permissive parents try to be "friends" with their child, and do not play a parental role. Permissive parents also tend to give their children whatever they want and hope that they are appreciated for their accommodating style. So- called 'indulgent' parents, those low on accountability and high on warmth, nearly tripled the risk of their teen participating in heavy drinking. Baumrindfound that such children were immature, lacked impulsive control and were irresponsible. In better cases they are emotionally secure, independent and are willing to learn and accept defeat.

4. Neglectful parenting: Undemanding and Unresponsive. The parents are low in warmth and control, are generally not involved in their child's life, are disengaged, undemanding, low in responsiveness, and do not set limits. Neglectful parenting can also mean dismissing the children's emotions and opinions. Parents are emotionally unsupportive of their children, but will still provide their basic needs.Children whose parents are neglectful develop the sense that other aspects of the parents‟ lives are more important than they are. The parent and the child will never come to an agreement because the child will be resentful and the parent will show a demanding, with great authority side. This disturbed attachment also impacts relationships later on in life. In adolescence, they may show patterns of truancy and delinquency.

A study by Maccoby and Martin (1983) analyzed adolescents aged 14–18 in four areas: psychosocial development, school achievement, internalized distress, and problem behavior, and found that those with neglectful parents scored the lowest on these tests, while those with authoritative parents scored the highest. In Kota, Rajasthan, a US$ 400million industry for exam preparation has fawned. Close to 200,000 students flock there to study in a highly competitive environment. More than 75 of them have committed suicide in the past 5 years. Students in Kota have hanged themselves, set themselves ablaze and jumped from buildings. Most often, they cite being unable to cope with the intense academic pressure and the guilt of disappointing their families. Is a non-medical/ non-engineering career really such a bad prospect that children today give up on life itself before it has even begun? Do all doctors and engineers find success and happiness? Do people in all other fields only languish in the throes of dereliction and squalor?

credit: Hindustan Times (article dated: 19 October 2015)

Yes, an education is one‟s ticket to opportunity, a beguiling passport to a better life, especially for the middle class. But education is not only an IIT or an AIIMS degree. Education is as much about building character and instilling values, as it is about the coursework, classroom and out-of-classroom experiences. Exploring various passions, indulging in arts, sports and creativity in equal measure as problem-solving and logical reasoning, cultivating perspectives and opinions and having beliefs and unshakeable values- these are equally if not more important than grades and scores. PV Sindhu‟s father has this to say to other parents, "We have been encouraging her right from her childhood - right from dropping her to the training center in the early hours of the day to giving emotional support. My daughter has completed her graduation and is now pursuing a postgraduate degree. At the same time, she is performing well in sports. Every child has the inborn talent.” Explore your talents, indulge your passions, and most importantly, enjoy the journey; because there never really is a final destination.

Neither life nor education ends at school or college, the struggle towards continuous self-betterment and self- fulfillment is lifelong. Every time a school or college exam appears to be the most important thing looming large at the horizon, another one will be quick to follow. By the 10th grade itself you will have lost count of how many tests you have written in your life! Life does not end at your 10th or 12th grade exam. It hasn‟t even begun then! A mark-sheet is a reflection of your performance in one particular construct at one particular point in time and space. It does not define you, it is a small part in the mille feuille that is your life, and in no way an indicator of your whole lifeto come. Parents must realize that withholding their imprimatur in favour of „Sharma jika beta‟ can be irreparably damaging to a child‟s self-esteem.

Books have been written about drop-outs reaching the pinnacle of professional success, engineers becoming theatre artistes, and actors going to medical school half- way into their film careers. Indra Nooyi herself is neither doctor nor engineer, she holds a Bachelor‟s degree in Science. Your life has very little to do with what you study, and much more to do with the person you become. Stress, even from self-imposed expectations, is normal in today‟s demanding world. As long as it is a source of motivation towards achievement and excellence, it has a positive role to play. A proclivity for negative coping mechanisms such as substance abuse and unhealthy relationships will only worsen your long term ability to control such situations. If you find yourself embattled by expectations and sinking under pressure, please immediately seek professional help. And always remember, that too shall pass. The night is darkest before dawn. “In three words I can sum up everything I've learned about life: It goes on.” – Robert Frost.

WORD PORN

All play & No study makes a Jack a Dull Boy ! (*Seems like a reminder note to a second MBBS student ) Saniya Sahasrabudhe II MBBS Grant medical college and Sir J.J. group of hospitals, Mumbai

CREDITS: MEGHA CHOPRA We know that good or bad is relative , that “a relative” decides what is good and bad for us, nonetheless we have to accept that it is all „relative‟ at the end of the day! One of my relative said it is best to play with colony friends and not go outside, the other said it is better to play on playgrounds yet another suggested that it would be good if I would play with my friends in school itself cause my school embodied “of academics and sports” as its name suggested. Me being original I decided to follow none , I dedicated myself for the noble cause of “Say No to Games, be a dull person instead”. I, then, liked to assume that I pursued my passions Without knowing what „passion‟ was and without „pressure‟ to „pursue‟ them. My mom says those were the better times when TV was the only distraction, then came the Xbox. Now we have Smart phone (enough to make us dumb) all in one source of mass distraction. Making it extremely difficult for parents to keep a check and maintain a curfew.

I understand with so many modalities of recreation and fruitful entertainment, pokemon Go addict twitterati current generation of parents is ought to have a buzzfeed search about „ Top 10 reasons :-How Play-stores overrule Play-grounds‟.

First let me take a selfie, Second let me tell you the benefits of 1 hour playground (some empty place in the car-park) routine.  It changes brain.  Animal experiments have proven that play improves memory and stimulates growth of cerebral cortex.  It develops social skills.  Especially for those parents who don‟t want their kids to be antisocial and rant endlessly on twitter.  It keeps you active.  (Helps you save on the fit-bit.)  It improves your academic performance  Helps in Math & reading:- helps in efficient executive function, both needed if you want your kids to pursue engineering followed by an MBA.  It improves focus.  Kids wont have difficulty meditating using 5 minutes meditation apps.  It reduces stress .  It improves sleep  It improves ADHD related behavior.  (* I am no psychiatrist to tell this.)  Reduces aggression .  It fosters creativity and problem sloving .  Good riddance from pinintrest DIY‟s .  It makes you happy. (Free & easy access to the guru gita ,Eat Pray Love !)  [Added benefit your kid will learn swear words for free no special parent training required.]

Now lets talk about video games and super hot virtual reality:-  They are producing better surgeons  Da vinci is bae !  They may help people overcome Dyslexia.  They could improve your vision.  You might give a career boost  ( Only if you have a boss like Frank Underwood! I am pretty sure you don‟t want such a ruthless pragmatic boss .If only you were naïve and suicidal ? )  Players can become fascinated with history..  ( I totally understand, Salman Rushdie and Ramchandra Guha are too boring .)  They may slow the aging process  They might help ease pain.  They help improve balance in MS sufferes  (I bet physiotherapists were taught videogames and programming in their curriculum.)  You will make faster decisions.  Acquired reflexes bro!  Might burst cravings.  (Chocolate is an idiot & fattening)  Gamers might be less likely to bully.  They may help address autism  A study has proven that sharing space with multiple players can also lead to increased social interaction.

“ (Happen what may, if you read the list closely the video games might as well help you learn the proper usage of the words ‘may’ & ‘might’.)”

I conclude that play-store, Hamleys or building with playground are all expensive in the city of Mumbai… I would rather suggest that teach your kids  How to use google search productively . o Will definitely help them write good articles in the future.  Imbibe a fitness decorum o include them in your YOGA day celebrations  Healthy food habits o Say no to the drone delivery of the dominos cheese burst pizza !  Make sure they learn any one thing from the following list so that they feel cool in their college life o (one foreign language , classical or modern dance or some music instrument.)  Heavens sake please sex educate your kids and talk about social media security. o Or else Dr. Mahindra Wastsa‟s column is going to be their afternoon read and pedophiles are gonna be their god fathers!

What If It Was Your Own Child? Vaisli Shanmu, Final MBBS, Madha Medical College, Chennai

29th August 2016, Sivakasi, Tamilnadu

Dear diary, I am turning 14 today. Should I be happy or sad? I won‟t be recognised as a child labour anymore when I complete 14, according to the law. I guess that makes me just “labour” instead of “child labour”. Did I mention how spectacular I look today? Let me explain my appearance since you can‟t see me. Now I am looking at my feet: dark skinned, my finger clefts filled with gunpowder, some cracks here and there on my sole, and my toe nails are indescribable. Oh I forgot, no slippers. I think it‟s been 4 years since I wore any slippers. Anyway I don‟t see the need for them. My hands: again silvery, greyish, blackish chemical powder all over up to my elbow. The backside of my right hand got red and started peeling off skin last week…someone told me it‟s called a scald. Don‟t know why that‟s happening. I am wearing my loose khaki coloured trousers with the last shirt my father bought me when he was alive. Yes, My father. He was alive. Until that fire accident at the factory took away his life in 2012. It not only took away his life, but my life too. My life was my school. Meeting friends, playing with them, carrying a tiffin box, reading my favourite subjects like English, maths, and standing outside the class, the ringing of school bell, and I miss everything about my school days. I wish I could join school again. But if I join school, how can mom and I afford food? That‟s why I work. No work, no money. No money, no food. So I work. Eight hours a day with a half hour lunch break in between. Initially when I started working, my back started hurting because I had to sit for eight hours but now I am used to it. Basically my work is to fill in the gunpowder inside the firecracker and roll it. That‟s what I do the whole day. During Diwali season, the working hours may extend up to 10 or 12 hours. But the one thing I don‟t understand is that, even though mom and I both earn money, we don‟t save any of them. May be we are being paid very less but I can‟t find any other job in this town of fireworks industries. And you know, I no more work in the factory. I work at home. They told they had some inspections and sent us children to work at home itself. Writing on you is the only happiness I get nowadays. I wish I had a different life, the one where I get to go to school, where I get to have my father alive, where I get to become a scientist, where I get to live happily ever after, where I get to live just like other kids around the world. But now, I am off to work. Goodbye.

- Child labour. The International Labour Organisation (ILO) defines it as: work that deprives children of their childhood, their potential and their dignity, and that is harmful to physical and mental development. Many of us think that these things like Child labour don‟t exist in today‟s society. But taking a look around, we will see them right in front everywhere. In laundry shops where we give clothes, in the mechanic sheds, in the beach selling sundal, on the road selling books and stickers, every morning distributing newspapers, in the hotel cleaning tables where we just ate, even in our office giving out tea, coffee, in our house sweeping and washing vessels. They are everywhere. The physical, mental and social hazards of child labour are innumerable. From asthma, tuberculosis and upper respiratory tract infections in fireworks industry to other occupation related hazards, overall the growth of the child is totally destroyed. Also the verbal abuse they encounter will leave a permanent mark in their brains. According to the International Labour Organization (ILO), if child labour will be banned and all children get proper education, world‟s total income would be raised by nearly 22% over 20 years. It will boost up the economy of our country. In India we make laws, only to showcase them, not to follow them.The Factories Act of 1948, The Mines Act of 1952, The Child and Adolescent Labour Act of 1986, The Juvenile Justice of Children act 2000, The Right of Children to Compulsory and Free Education Act of 2009. These all appear only to be acts but not actions. If they had been into implementation, child labour would have eliminated in India. Of course, there are strict rules in factories in some places and under child labour act the companies are made to pay huge compensations to fund for the child‟s education. But that is not where the whole lot of child labour exist, they also exist domestically. We need more actions to stop domestic child labour. There is something we, as humans, as literates, could do for these pitiful vulnerable children. We could contact child labour helpline: 1098 or any other nearest NGO or police station to save the life of one child.

Because remember , “Children are not things to be moulded but people to be unfolded.”

16th {July}:- Emergency medicines’ frontline Countertransference Dr.Justin James, DO Resident Physician- PGY 3 Staten Island University Hospital- Northwell Health System Department of Psychiatry and Human Behavior

I am very fortunate to have been given the opportunity to present an aspect of psychiatry that I find fascinating. However, this is not a topic that is unique to only psychiatry. It is in fact prevalent to many others fields of medicine as well. In the following article, I will discuss the concept of “Countertransference”, and how it can be used as a tool to facilitate effective patient care. Have you ever wondered why you feel one way about a patient and different toward another? Mental health professionals refer to the feelings we have toward the patient as “countertransference.” Originally described by Sigmund Freud in 1910, countertransference is “a result of the patient's influence on [the physician's] unconscious feelings” [The Freud/Jung Letters (1974) p. 231]. A patient may make us feel happy and excited, or alternatively annoyed and angry, which can even lead us to disliking them. Physicians are human, and we are not immune to having emotional reactions. Without being consciously aware, the patient may instill a feeling inside us. Recognizing this is vital. Before exploring the importance of being mindful of our feelings, we need to understand the types of countertransference that exist. We classify countertransference in two categories: Complementary and Concordant. Complementary Countertransference is when our own unconscious emotional memories get activated. For example, our past personal experiences influence the way we feel about our patient. This can include parents, friends, ex boyfriends/girlfriends, children, teachers, etc. Concordant Countertransference, conversely, is what is intrinsic to the patient. This is not from the physician‟s own personal experience, and the countertransference is typically generalized to all providers working with the patient. Below are descriptions of two different patients. Think about what feelings you may develop toward patient A, patient B, and why? Patient A: 20-year-old Caucasian female, unemployed, supported by her parents who are lawyers, presented to the ER by herself, saying “I want to cut myself” after her boyfriend of 1 week broke up with her today. Patient B: 88-year-old Hispanic male, Spanish speaking, undocumented immigrant, lives with son and son’s wife, was brought to ER by family who have noticed increased confusion, decreased food intake, and inability to care for himself for the past 4 months. The delay in medical attention is due to patient not having any medical insurance. Factors such as age, race, gender, socioeconomic status, employment, and presenting complaint can influence our perspective of a patient prior to even meeting them. However, I would argue that allowing oneself to experience countertransference can be used as a tool to better understand a patient, and consequently provide a more accurate treatment plan. The following example is a personal anecdote of mine where countertransference was used successfully for treatment in an outpatient setting. Details about the case are altered to protect the identity of the patient. A 35-year-old woman requested treatment for her severe anxiety. She was diagnosed two years ago with Multiple Sclerosis, remitting-progressive type, which caused difficulty with ambulation, inability to drive, and social isolation. She was prescribed steroids by her outpatient providers and after developing palpitations, tremors and nervousness, her doctor prescribed lorazepam for steroid-induced anxiety. She initially presented to me as someone very polite and appropriate. After a thorough evaluation, I diagnosed her with panic disorder with comorbid steroid induced anxiety, and recommended to continue the lorazepam, start an SSRI as the first line treatment for panic disorder, and biweekly psychotherapy. She immediately declined starting a new medication, stating: “I‟m just here for therapy, and I was told that I could get my lorazepam from you”. I validated her concern, apologizing for the miscommunication from a third party, and explained the benefits, the risks, and the alternatives to my treatment recommendation. She maintained that she didn‟t have another anxiety disorder, disagreeing with my initial diagnosis, and the lorazepam is to help with the side effect from the steroids prescribed by her other doctor. I explained that taking lorazepam as monotherapy for an anxiety disorder was not safe, and if the indication is treating a side effect from a medication, the provider prescribing that medication should manage it. The patient started belittling me, questioning how I arrived at that diagnosis after only speaking with me for 45 minutes, and then proceeded to express doubts over my credentials and position. It was then that I first experienced a negative countertransference toward her. I, understandably so, became frustrated and angry with her opposition, and found her behavior to be rude and inappropriate, which yielded thoughts of not wanting to continue her treatment. Her defenses of devaluation and projective identification were prevalent, but I was able to recognize my countertransference and use it as a tool to understand her as a person. It became evident that my feelings developed secondary to her maladaptive defense mechanisms and personality pathology. Being aware of my concordant countertransference empowered me to recall the narrative of her life, and to better understand why she may have reacted this way. I quickly remembered the account of her recent break up with a narcissistic male 5 months ago who stole her money and emotionally abandoned her. Not only was she suffering from the chronically debilitating illness of Multiple Sclerosis, but she also suffered from an emotional loss. I empathized with her fear and panic, which was portrayed by her verbally insulting and devaluing me. I speculated she was subconsciously seeing me as a threat because I was someone who would take away the one thing that provides her with relief: lorazepam. She was motivated to get treatment to help cope with her stressors, but rigid in how to go about the process. A person with healthy adaptive behaviors is able to control and regulate emotions during moments of contention. Her maladaptive behaviors, however, prevented her from doing so. I effectively monitored my tone of voice, staying mindful of the frustration I was feeling, while simultaneously deescalating her irritability through validation and empathy. I understood her as someone who has low frustration tolerance and limited coping skills, which requires a strong alliance before trusting another. If I would have continued my “battle” with her, she would have not returned for a second session, and unlikely would have pursued another mental health professional. We agreed to continue the lorazepam and readdress my initial recommendations in the future. This agreement laid the foundation of a strong therapeutic alliance, which will ultimately lead to a safe and successful recovery. Physicians are human, and in the field of psychiatry, it is both normal and resourceful to empathize with your patients. One cannot perfectly treat a patient unless they understand them, and allowing oneself to experience a degree of countertransference is necessary. You will be fond of some patients, indifferent toward some, and feel hatred toward others. If we are honest with ourselves and accept the emotions that emanate, then we are effectively providing sufficient treatment and service to our patients. ‘Be mindful. Be empathetic. Be great’

********** “Doctor, it is an EMERGENCY!”

Dr.Nikhil Tambe, M.B.B.S., ECFMG (USA) Emergency Medicine Resident Kokilaben Dhirubhai Ambani Hosital, Mumbai.

Working in challenging fast paced emergency department has been extremely rewarding! You never know who will enter through the door- a patient with dog bite, a trauma victim, a VIP with couple episode of loose stools, a talkative lady with headache, a malingering patient, a patient with stroke, a patient in respiratory or cardiac arrest or a brought dead patient. We need to be ready for any kind of emergency.

Who decides what an emergency is? Well, we do! Patients have this false belief that Emergency is a place for „emergent‟ doctor consultation. A fast track method for seeing a doctor! I am sharing few memorable patient encounters that I had in the short span of my residency period.

Dr. Google

It was a night shift; a couple arrived in the emergency with their 4 year old child. She was severely tachypneic with audible wheeze. Her oxygen saturation was in low 90s. Immediate nebulisation was started with supplemental oxygen. The saturation improved a bit, but wheeze continued to persist. She was not asthmatic, had an episode of fever couple days back for which the parents continued to give syrup paracetamol. Her respiratory rate had started to increase since a day, it was only when she had retractions of the chest wall, they googled the symptoms and arrived in emergency. Their small bundle of joy was getting tired, breathing heavily. The parents were primed about intubation, which was a setback for them. She had become drowsy and final decision of intubation was taken. She became better in 4 days with antibiotics and ICU stay and went home with a thank you note to the paediatrician.

Children are very prone to sudden deterioration. They have good compensatory mechanisms, but once they reach a threshold, all the vital parameters crash suddenly. It is always advisable to see a doctor and get the child evaluated at the earliest. We see many anxious parents of paediatric age group who come to emergency with minor complaints ranging from their child not sleeping, to one episode of fever and then there are few who consult Dr. Google. It is advisable to consult a real doctor than Doctor Google for emergency!

The ambulance patient

Being a quaternary care center, we receive many patients from different parts of the country that come for further evaluation and management. Most of the times, we receive a call of these “expected patients”, but we are not always informed about the patient‟s condition. These patients usually arrive at 2am- 3am; due to no road traffic, I guess. The patient is accompanied by an ambulance doctor, who is briefed in short about the patient history. The patient is invariably on one or two pressors. He is stable or unstable, who knows? There is a huge burden of transferring the patient “Alive” to the higher center. The ambulance doctor titrates the ionotropes and keeps the BP stable. As the patient is taken on our bed and monitors attached, vitals taken, it takes only few minutes to decompensate. The relatives get anxious and furious at the same time, “He was fine in the ambulance, what happened to him so suddenly that he needs to be put on a ventilator?” We understand the relative‟s concern! The sad state of our health system is transferring of unstable patients who many a times happen to be in a peri-arrest condition. Was the patient stable enough to be transferred? Was he stable to make a 3-4 hour journey in the back of an ambulance? There could be many reasons for this transfer; ranging from adamant relatives to administrative and legal hassles. The ambulance doctors are also working with minimum resources and insufficient experience. They try their best to keep the patient alive and take him to the higher center at the earliest „uneventfully‟. It is important for any transfer that there is effective communication between the prior doctor taking care of the patient and the receiving emergency physician.

Building an effective EMS system, with well trained ambulance doctors is the need of hour. Generally the post of an ambulance doctor is filled up by an AYUSH specialist (Homeopathic, Unani and Ayurvedic doctors). These doctors must be trained and given experience to handle any kind of emergency during transportation. Instead of shunning the physicians for their degree of BHMS, BUMS and BAMS; an effective government led training program can empower them to be excellent Emergency Medical Technicians with adequate knowledge of the allopathic drugs.

The “to knowledgeable” relative

We occasionally come across relatives that act over smart. The reason being they are either „over educated‟ or simply „sceptical‟. Another reason being, the media that has created a „false image‟ of doctors which has hampered the doctor-patient relationship. Movies are no less in showing doctors in a poor light. We received an elderly lady who presented with complaints of chest discomfort since 1 hour, ECG suggestive of inferior wall myocardial infarction. Time is muscle. Inferior wall myocardial infarction is the deadliest of all the types of heart attacks, with very high fatality.

We explained it to the patient‟s son, who was in a denial. He was laughing it off, thinking it to be a scheme for earning money by doing angioplasty. We gave the option of thrombolysis, but in vain. The outcome with early PCI is better as compared to thrombolysis in inferior wall myocardial infarction. He took his own time to take a decision, during which we had given her anti- platelets, reduced her pain, started intravenous fluids and attached her to a defibrillator. Fingers crossed!

One hour passed, he comes up and says, “I would like to first consult a cardiologist”. Now, our patience was being tested, we had to document the delay, else we may get sued. We got in touch with cardiologist, who made him understand the importance of time; actually, he repeated the same thing that we said. Somehow, he gave us a green signal for thrombolysis. The patient was thrombolysed in ED and shifted to ICU, with ongoing ionotropes for her hypotension. She underwent percutaneous coronary intervention (PCI) the next morning and was discharged home 10 days later. She had 90% right coronary artery occlusion. The son came and apologised for his actions the day after PCI. We were thankful that she went home better.

Documentation is of utmost importance in the emergency. All the documents are of legal significance. From the time of arrival of the patient till the disposition, everything needs to be documented, for doctor‟s safety, patient‟s safety and the institute‟s safety. All the discussions with the patients as well as consultants needs to be documented along with time, date and signature for smooth functioning. It is better to be safe than sorry.

Emergency is a dynamic field, where one has to be a jack of all trades. It not just involves knowing the medical and surgical management, but also extensive patient interaction from explaining the management to breaking bad news. I am glad that I chose this field, where I can be part of a team that makes a difference, by actually saving lives.

**********

MOCKTALE: WELCOME TO THE ER

Amogh Nadkarni II MBBS Grant Medical College & Sir JJ Group Of Hospitals, Mumbai. Welcome to India, the fabled land of milk and honey. Currently, the land of beef bans and 4-nights 3-days packages to Agra. Where the Domino‟s pizza reaches in 30 minutes but the ambulance takes an hour. Where the meaning of screaming, “Call 112!” (India‟s recently adopted helpline) is the equivalent of screaming “Help-Help” in a Bollywood B-Grade while a group of villains approach menacingly.

Cholesterol and food are synonymous for Indians. It may be easier to measure the blood in cholesterol rather than doing the opposite. Unsurprisingly, we lead in the incidence of MI, in reel as well as real life, with serial actors complaining of chest pain at the drop of a hat. Well, who do you think they‟d ring up?

Emergency medicine, the Swiss knife of the medical fraternity, is a highly specialized yet immensely over-worked field. High adrenaline situations are a severe strain on the nerves, and combined with patients who‟ve developed acting skills from the best Bollywood has to offer, you‟ve got a potent combination. At a high profile press conference at the Jantar - Mantar, emergency medical residents broke down. “The screaming. The swearing. Constantly begging for free drugs. The refusal to take medications. Not keeping his arm with the IV straight. It became too much,” a 20 something male was quoted saying. With these working conditions in mind, The Society for Emergency Medicine set forth a list of the most notorious patients likely to be encountered in the Indian ER and ways to deal with them.

1) The Googler: Google and Indians go way back, with approximately 12% of Indians employed at various posts. Why should healthcare be different? Pain in the chest? Collapsed on the ground? Just ask Google. Antidote: Change the WiFi password STAT.

2) The Horoscope guy: Suitable life partners are increasingly difficult to find, with worried parents thinking of innovative ways to find a suitable groom/bride. This kind of patient will wheel into the Emergency room, complain of chest pain, and try to set you up with his daughter. Antidote: Introduce the gentleman to the wonders of matrimonial sites.

3) “Do you have the same in Ayurvedic?”: Back off Baba Ramdev. You may have significantly eaten into Maggi‟s profits, but when the patient‟s relatives ask for Ayurvedic equivalents of Metoprolol, you know the health industry is in serious trouble. Antidote: A consult to the psych ward is a must.

4) The Businessman: Visual analogue scale, possibly one of the most frustrating instruments of data collection, designed to frustrate the doctor and convince the patient he has a life threatening condition. Equating the 1-10 scale with percentages, fractions and proportions is sure to fail, but equate the same figure to 100 rupees and watch the patient answer accurately to the nearest paisa. Antidote: A round figure hospital bill.

5) “Can I get someone older?”: 20-something and ambitious, you stride purposefully into the ER, wearing a white coat and a tie. But in the mind of the patient, you might as well be a toddler playing with a toy stethoscope. Antidote: “If I look too young to be a doctor, you look to old to be a patient. Sign this DNR and let’s continue with our lives.”

6) Mr Clueless: Complains of pain in the chest. When asked to point it out, points to the groin. Antidote: Dora the Explorer may be the only cure.

Author‟s note: Dark humour may be unwise. To the patient, we may sound indifferent, to the society, cruel. The danger arises when stereotypes dehumanize the patient, marring our sense of empathy. To laugh at the patient is to laugh at our helplessness, our fears and apprehensions. We laugh in the face of our fear of failure. To this outcome, dark humour allows us to remain fully human professionals, treating and caring for our patients with care and empathy.

**********

15th {Apr} :- BEING WOMEN POWER OF XX

The voice in my head, and its dramatic overtures. By Dr. Bianca Honnekeri, Grant Govt. Medical College and Sir J.J. Group of Hospitals, Mumbai, India.

Scene 1. Woke up at 5am. Dang, forgot to buy the coffee yesterday. No caffeine = “hey what year is going on?”. No caffeine = no water into my system = “Hello there, afternoon dehydration headache”. No idea of time/place/person + headache = Boss on fire.

Finally, the algebra I learnt in 7th grade comes to some use. Thank you Mr. Pythagoras. Wait, wasn‟t he the geometry guy? Anyhow, he was Greek. You know what else is Greek? Greek yogurt. And since I don‟t have time for breakfast, that would be lovely right now. But who will get me some of that? OMG NOBODY LOVES ME.

Bianca, FOCUS. You have to be at work. Alive. If possible, awake too.

Scrambled over to work. It‟s 7am. Urgh! Must car horns be SO shrill at the crack of dawn? It‟s practically still yesterday, keep a boot on your toot, BuddyBoy, or I‟ll show you some of what I can do. * cue Mean Face * Clearly I ain‟t a morning person today, ya feeeeeel?

Darned elevator is parked on the 25th floor, and my meeting…. Started 15 minutes ago. * remembers joke from 2 months ago and half-smiles * Gosh, that Macallister thinks I‟m smiling at him! Creep! I-HATE-MY-LIFE.

Meeting ends. Or at least I think it does. Not that it matters. Even if it didn‟t, I‟d still have walked out right about now. Not that anyone would notice. Or care. OMG NOBODY CARES ABOUT ME. And darn, there starts off Mr. Heh Dake.

Disclaimer: This pathology has been assigned the male gender by Bianca‟s Brain Voice because it presently is convinced (and has been so since it was 5 years old) that boys have cooties. Its contempt is worsened manifold by the ugly realization brought on by global-enemy-of-womankind, Age; that boys are not visited by the Monthly Monster.

Work is done. (At least to sufficient extent that procrastination doesn‟t herald a suicide attempt tomorrow). Would‟ve loved to drive back home, but I don‟t have enough fuel. I guess I didn‟t look at the dashboard indicator in the morning, because my morning was punctuated by enough unsavoury, unparliamentary “F”s by Bianca‟s Brain Voice already.

Customary overhead avifauna with poor bowel motion. Great, I used up all my tissues last week when I was on my period. No way to wipe this crap. Oh wait, I had Monthly Monster just last week?

DAMN GIRL, YOU MEAN THIS AIN‟T PMS?

Scene 2. On Photoshop.

Step 1: Remove zits and spots. “There, now all I have to do is digitally alter my teeth, nose, mouth, eyes, eyebrows; and then paste on Angelina Jolie‟s cheekbones”

Step 2: Alter complexion as per ideals of the vestige of society this photo will cater to. “Well, I am sure my traffic violations are ONLY because my driving license photo looks like Shrek. Since this photo is for Facebook, let‟s try the Snow White look.”

* Mentally starts counting „Likes‟ while brandishing the paintbrush icon furiously * Twenty-five shade of pallor later….. Nationwide Anemia Alert. Or a modelling contract for Fair and Lovely. “Oh wait, but I guess I have to also be lovely for that…. Never mind.”

Step 3: Appear 20 pounds lighter. Suck in tummy till it pops out from your back. Cock the chin upward to elongate the neck (or at least make it appear). Suck in cheeks to the point of asphyxiation. Arms away from the body, to pretend that a waistline exists. When all the above fails (signs- aneurysmal rupture, sudden voidance of flatus or feces, conjunctival hemorrhage, aortic dissection etc.), just paste on Deepika Padukone‟s Kingfisher calendar image.

There, looks just like me.

It‟s amazing what ovulation can do. Clearly makes a woman so much more attractive for 4 days of the month!

12 hours later. Everything changes, Facebook Likes clearly below industry standards. Social status under threat. Girl- competing-with-me-for-his-attention is strutting around at work, probably masterminding her coup in time for the weekend party.

“I want to throw something. My laptop. With FB open. At Mark Zuckerberg. It‟s all his fault. WHY AM I SO UGLY. I want to cry. But if I cry my make-up will be ruined. And then I will look even more ugly! Gosh, why is my life always so complicated! Can‟t even throw a laptop at a billionaire without feeling like crap. How does one attempt catharsis in this irrational, unfair era? Indeed, kalyug is upon us. Hey, here‟s not-a-joke. GUESS WHAT‟S UGLY, STUPID, AND FAILS AT LIFE? YOU.”

* cue Twitter rant about how PMS alters self-perception* * While begging Suhel Seth and Rishi Kapoor for re-tweets, have an epiphany on how pathetic you really are. Cry, again. *

72 hours later. P-Tracker App: I notification- “Fertile period over now.”

DAMN GIRL, YOU MEAN THIS AINT PMS?

Scene 3. Part 1. 10th Feb, 2100 hours.

Me: It‟s over. I need to move on. He: Please think over it for a week. You‟re not thinking straight right now.

My girl best friend: Urgh, I never liked him anyway. Good for you, let‟s go out tonight! My guy best friend: I‟m sorry it turned out like this, but I think it‟s for the best. I hope you both move on. Call me whenever, bruh.

His guy best friend: Dude, she‟s totally PMSing man, she‟ll change her mind next week when them hormones go swishy-swishy again. His girl best friend: Maybe she wants extra attention. Try shopping. Oooh, I crave carbs when I PMS. Just like, go for ice cream or something?

Part 2. 11th Feb, 0900 hours. Me: It has been 3 weeks, and your Customer Service hasn‟t resolved my issue. Indian Customer Care Dude (faking accent of no decipherable ethnicity): Sorry madam, we are trying our best. Me: Yes, but 15 days at your best has yielded zilch. Please just take this back and give me a refund. ICCD: Sorry madam, we are trying our best. Me: You know what? Just keep your damn product, I don‟t even want a refund. Just take it back, please. ICCD: Sorry madam, we are trying our best. Me: I WILL PAY YOU TO PLEASE TAKE BACK YOUR PRODUCT. ICCD: Sorry madam, we are trying our best.

* I hang Up *

ICCD to chai-buddy: Gosh, women become alligators when they PMS, man! Just 2 weeks ago she was so polite, now she‟s possessed by a demon!

Part 3. 11th Feb, 1630 hours. Review Committee Personnel Appraisal Meeting

Hot woman in business suit 1: You brought in considerably fewer clients this past week. Hot woman in business suit 2: It a 24.475% decline over last week, which is a projected revenue loss of Rs. 10. Care to explain, or do you want to be bayed by shareholders instead? Hot man in business suit: I‟m sure she has a valid explanation…..

Me: Errm yeah, it‟s holiday season, how many people buy school stationery on vacation?!

Hot woman in business suit 2: Your job is to sell. I don‟t care to whom. If people don‟t buy, then go brandish our brochure at zoo baboons for all I care. JUST GET ME THE NUMBERS. Hot woman in business suit 1: One more week you fall behind target, and I don‟t care whether its Hanukkah or Hanuman Jayanti- you‟re on probation. Hot man in business suit: What we mean is, you have one more chance to prove yourself.

Me: Thank you, and I‟m sorry but I just don‟t see how vacation sales can match school term sales. It‟s STATIONERY, not toothpaste!

Hot woman in business suit 1: Well then, maybe you should work for a toothpaste company instead. Hot woman in business suit 2: Work on your strategies, or else I‟ll have to work on your severance package.

Hot man in business suit (swings by my cabin an hour later): Wanna discuss those strategies over coffee this evening? And don‟t mind Linda and Stacey, I‟m sure it‟s just PMS.

Part 4. 12th Feb, 0700 hours. The next morning.

P-Tracker App on my phone: 1 notification- “Fertile period about to begin.” P-Tracker App on Linda‟s phone: 1 notification- “Fertile period ends tomorrow.” P-Tracker App on Stacey‟s phone: 1 notification- “Safe for intimacy.”

Author‟s Note- No, it‟s not PMS. Yes, it can be PMS, but commonly, it is not. In none of the above cases was it PMS.

A bad day, being sleep-deprived or caffeine dependent, not having breakfast, not eating all day, work stress, relationship problems- they‟re all parts of life, and can happen anytime, sometimes even altogether, and at any point of your menstrual cycle.

Branding it as PMS is neither appropriate, nor a solution. You not only shroud your ineptitude to cope under the guise of physiology, but also trivialize something that can be very crippling to real sufferers. You‟re letting yourself off the hook too easily, excusing yourself, instead of working on yourself.

I don‟t need to harp on what PMS is. The emotional upheavals, carb cravings, feeling bloated, flatulence, water retention etc. just before your period. Yes, that‟s all PMS. Studies show that sometimes these symptoms may persist even after your period.

But hey, if every 3 weeks you let yourself get knocked down by life, you‟re looking at FOUR HUNDRED AND SIXTY WEEKS of your life ruined, because you let PMS get the better of you.

To those whom it genuinely is crippling for- Please try to plan your weeks around it, and do seek professional help if it‟s unbearable. Water retention, gas, and carb cravings can be managed by nutritionists; emotional instability requires support systems, never be afraid to ask for professional help. Try not to take major life or work decisions when you know you‟re on shaky ground. Use the previous weekend well, to help ease the work load of the week to come. Symptomatic drug treatment may be recommended to you by your physician.

To everyone out there who refuses to take a girl seriously because “It must be PMS”- Standing up for something, voicing an opinion, or offering an opposing view point isn‟t PMS, it‟s a thinking individual‟s right to speech. Women are suppressed and marginalized enough in most backward societies, but this behavior pervades even into workplaces and social interactions amongst „empowered‟ women. It‟s easy to discard the worth of some one‟s words or actions as being PMS; but hey, maybe they actually have a genuine problem, maybe you‟re at fault, or maybe they put up with your crap for far too long and have finally decided to speak their minds.

Women do this to other women too. Maybe she‟s not dumb, reactive, weird, bitchy, unstable, opinionated or „hormonal‟; maybe she genuinely has a problem, a perspective or a point to make. The fact is, we neither sympathize nor empathize. We just feign pity, and dismiss other people. If you feel someone is genuinely a victim of PMS- you should help them, not slight them or shame them.

The tragedy of society as we know it, is that women who genuinely need medical attention during their period cannot seek it because it is „weakness.‟ They already face a losing battle against patriarchy and chauvinism which is inherent at work places today. When menstrual pain has been rated as severe as myocardial infarction (heart attack) for some, is it something that one should bear with for 35 years because social structure is flawed?

We trivialize it in popular culture, we joke about it, we reference it on social media. But do we ever reach out to people who may need some extra care? Whether it‟s menstruation, or PMS; staining clothes or crippling pain, emotional disturbances or physical symptoms- the more liberated ones amongst us sure do talk a lot, but we all do very little.

Let‟s truly respect women, beyond FB Likes and change.org petitions. Talk to your domestic help, your cook, the woman selling you vegetables, your tailor, your child‟s babysitter, your college juniors, your office colleagues and staff. Help provide sanitary pads for those less fortunate. Educate girls about contraception and menstrual hygiene. Be there for women around you when they have bad days.

William Congreve once said “Hell hath no fury like a woman scorned.”

It wasn‟t PMS.

Pic credits- 1. Caffeine loves me: https://in.pinterest.com/pin/248120260698303381/ 2. Fuel indicator: http://www.dhgate.com/product/motorcycle-fuel-gauge-12v-fuel- level-gauge/193194244.html 3. Bird poop: http://m.inmagine.com/image-ptg00760502-Bird-Poop-on- Windshield.html 4. Photoshop: http://www.filmykeeday.com/worst-indian-photoshop-fails/ 5. Call center: http://www.level5.com/call-centers-are-changing/ 6. Business meeting: http://www.careeraddict.com/prepare-a-business-meeting- agenda 7. Feminist symbol: http://smartgirlsgroup.com/current-affairs/2014/03/feminism- defined/ 8. Human rights quote: https://www.charities.org/news/what%E2%80%99s-next- women%E2%80%99s-rights-have-your-say 9. Malala: http://salve.libguides.com/c.php?g=434938&p=2964726

Does a Dick Entitle a Human Being to a Higher Paycheck? -Archit Rastogi, PhD Scholar, University of Massachusetts, Amherst, US

In 2015, the famous Hollywood actress Jennifer Lawrence became the world‟s highest paid actress by earning a cool 52 million dollars. Think that‟s incredible? Well, think again! As it turns out, she earned a whopping 28 million dollars less than the world‟s highest paid actor, Robert Downey Jr. Sure, when you talk about such large salaries, the amount does not seem to matter. After all, it‟s not like Jennifer Lawrence will be hurting for cash at any point. However, the example does serve as a very powerful reminder of the lack of pay parity between the two genders. Often times, people in developed countries tend to forget that women still face oppression. It is very easy to point fingers at the Arab countries and criticize them for oppressing their women. They forget though, that oppression takes on many forms. The lack of pay parity is a poignant reminder that despite the great strides made in the field of women‟s rights in recent years, much work still needs to be done. The lack of pay parity is but one example. Women often find themselves in situations where they are not considered equal to men. A large number of people still consider women to be the weaker sex. There is still a population of supposedly educated people that believe that a woman‟s place is only in the kitchen. People still find it hard to reconcile themselves with female auto – rickshaw drivers. They doubt the capability of a female doctor owing only to her gender. In smaller rural areas, even in developed first world countries, people truly believe that women would be happiest being mothers. They encourage them to stay at home and learn home – making skills. An extremely interesting fact – studies carried out by the United Nations have clearly demonstrated that countries where women‟s rights are not respected and enforced often suffer from major social and economic problems. This makes a lot of sense. A young woman who is forced to forego her education and become a mother will, through no fault of her own, be unable to be a responsible caregiver to her children. This creates a vicious cycle which is extremely hard to break free from. Nonetheless, for the world to develop in a sustainable manner, it is imperative that women‟s rights be made a top priority. We can actually see a scary live example of what happens when women are not respected in ISIS. Though it sounds a bit extreme, it is a sad fact. Women often prove to be a voice of reason in the midst of the aggression of war. A very scary thing is that the lack of pay parity between the genders is likely to take 118 years to overcome at the current pace. Yes, you read right, more than one full century! This scary statistic comes from respected economist Klaus Schwab, the founder and executive chairman of the World Economic Forum in a study reported in The Guardian. In the same report, he shares that the average working woman makes around 11,000 dollars a year whereas a man makes practically double taking home 20,500 dollars each year. This is the 10th annual report published by the World Economic Forum on Gender Parity. It reveals the scary fact that women are now making what men were making in 2006. Women are exactly a decade behind in terms of the pay gap. And this gap is only widening with time. A very interesting fact is that right after graduating college, men and women usually start at the same salary, but over time, men tend to be picked over women for various benefits widening the pay gap. Women are also often guilted by their employers into putting in longer hours. Employers find it easy to target women due to the family responsibilities women usually have to shoulder. Men are automatically exempt from this. Keeping all these things in mind, the theme of this International Women‟s Day was declared to be “Pledge for Parity”. International Women‟s Day is celebrated around the world on the 8th of March as way to shed light on burning issues related to women‟s rights. This year, the Pledge for Parity theme calls on everyone in the world to help create more flexible and inclusive cultures that promote gender balanced leadership. The idea is to remove all gender bias, be it conscious or unconscious, helping women around the world achieve their ambitions. This will, hopefully, create a society that values men‟s and women‟s contributions equally and rewards them the same. Together, women and men can help society develop. So make a pledge today, a pledge for women‟s rights, a pledge for parity.

SOURCES: [1] http://www.theguardian.com/lifeandstyle/2015/nov/18/women-will-get-equal-pay-in- 118-years-wef-gender-parity [2] http://www.internationalwomensday.com/Theme

The Dwindling Sex Story (Radhika Ramesh)

14th {Jan}:- THE PARALLAX

INSIDE OUT- THE SCALPEL

Megha Chopra Second year MBBS Mahatma Gandhi Mission College, Navi Mumbai

W-w-w-what...where am I? Has the Galactic Empire taken over? What is this place, what‘s happening? Oh no, am I inside out... Oh my gosh... are those doctors? WAIT; IS THAT ME THEY‘RE POKING SCALPELS INTO?! Imagine being told by your doctor that you have a strange sounding spinal arthritis- ankylosing spondylitis (Anakin Skywalker itis what??), that you're going to have to undergo a knee joint replacement surgery (Wait, knees can be replaced?) and furthermore, the surgery is going to be recorded and handed to you in a nice DVD box once it‘s over (Did anyone else just feel a massive shift in the Force, or was that just me). I know, a lot to take in right. his is so surreal, I‘m watching myself being performed a surgery on. It feels like I‘m watching a sci-fi-thriller-action all rolled into one; look at that doctor go! He looks no less than a superhero. It all looks astonishing, too bad I have absolutely no idea what‘s going on. When Greg Grindley, a retired military veteran underwent deep brain stimulation (DBS) surgery to combat tremors as a result of his Parkinson‘s disease, he was understandably nervous. However, as his surgery proceeded, he became calmer. His surgery was video recorded and aired on national television by National Geographic. When faced with the question of having their surgeries recorded and given to them, most people are initially appalled at the fact that they‘ll be seeing blood and guts galore, but then start liking the idea. Contrary to having a sense of Big Brother watching them, they feel a camera in the operation theatre would make the DOCTORS more responsible and accountable. In a study conducted by Indiana University in 2010, 7 colonoscopies were video recorded and it was found that the overall quality of mucosal inspection technique improved by 31% after awareness of video recording.ii Moreover, the patients and relatives with a strong stomach wouldn‘t mind seeing the procedure, essentially because they can‘t comprehend what the doctor is doing. Video recording is a great tool for surgeons and students alike to learn and teach from, a tool that should be used with the highest amount of fastidiousness and respect. It therefore follows that video recording should be done only after taking proper consent of the patient; all ethical guidelines should be met. This recording could help so many people learn something new; despite the surgery being a standardised procedure, everyone‘s body is different, so the technique would naturally differ. I‘m ecstatic I get to indirectly teach so many students. All in all, I feel most patients wouldn‘t feel like video recording would be too invasive; the doctor is already cutting them up and poking around their insides, how much more invasive can it really get. But the opinions of doctors about video recording surgeries- be it for education or even a malpractice lawsuit, now that‘s a whole other story. NOSOCOMIAL INFECTIONS: DOCTOR’S NOT SO GOOD RETURN

GIFT TO THE PATIENT Susmita Reddy Karri Final year MBBS student Topiwala Medical College and Nair Hospital, Mumbai A 20 year old man,a victim of a hit and run case, was brought to the hospital with a severed limb. The limb was successfully reattached and the patient was doing well. After 2 weeks, when his wound was opened up for dressing, it was found to be gaping. Despite immediate care, the patient dies after a week.

But wait! Not everyone gets it! How is that possible? The factors causing are the same that affect any other disease. Yes, the infamous epidemiological triad that we study in community medicine- 1. AGENT: This includes the pathogenicity and the virulence of the invading organisms. 2. HOST: Here, the patient immunity is already low due to some pre-existing disease process. 3. ENVIRONMENT: The most important factor when we talk about HAI‘s, include the general cleanliness of the hospital, the ventilation, house keeping facilities and most importantly the physician.

Can HAI‘s be eradicated?? .....NO Can they be controlled??...... YES

The most important way of preventing HAIs is the PHYSICIANS, by: * Practicing good hygiene practices. * Notifying cases to the relevant authorities. * Giving advice on good hygiene practices to the patient and their families. Also role of hospital management, nursing and other paramedical staff and the house keeping staff, is extremely important to control these HAI‘s. Hence, control measures and programs should be designed keeping them in mind too. Having said all these, coming to the most important point, how can we prevent them? The first and the foremost is a Good Hand Wash before examine every patient using an effective sterilient. Yes!! Such a simple

WELCOME TO THE HOSPITAL ACQUIRED INFECTIONS. Are they unavoidable? How are they caused? Can‘t we reduce their incidence? Before answering these questions,let us have a look at what is hospital acquired infections... ―These are infections acquired during hospital care which are not present or incubating at the time of admission.‖ Generally, infections occurring after 48 hours of admission are included in this category. The most common HAI are UTI‘s, followed by pneumonia, surgical wound infections, septicemia and others. Mostly, the organisms, which cause them, are the multidrug resistant ones like Clostridium deficile, Methicillin resistant Staphylococcus aureus and Vancomycin resistant enterrococci. The incidence of HAI‘s range from less than 1%in the developed countries to more than 40%in some hospitals of the developing nations.

WORLD OF and cost effective measure is known to eliminate more than 50% of HAI‘s. The other measures include mantaining environmental hygiene.

WHO moments for hand washing: In a developing country, where providing such a hygienic environment is extremely difficult, what can we as doctors do? The least we can and should be doing is to keep the patient and his relatives informed.Gain their confidence. Gain their trust. HAI‘s are something that the can be definitely prevented if not eliminated. It is essential not only for the patient‘s health; but its reduction will also help to strengthen the faith that a patient and his relatives have in their doctor. The ultimate aim of controlling them can be achieved by shifting our narrow individual patient based approach to a wider approach targeting the microbial environment.

IT’S TIME TO LET GO

Dr Nikita Agarwal, MBBS Intern, Raipur. Still no permission, huh?‖ said the tired attending to his intern. ―No, sir‖, he replied. It was the 200th day today since Mrs Singh went into deep coma after the post-partum pyrexia which may have been due to the complicated labour she sustained. The intern, still a soft hearted human, didn‘t feel it right that the attending was insisting on him to convince the family to

let go of the new mother, although she never really could do her role as a mother. Today he decided to talk to the attending regarding it. ―Sir, why do you want the lady to be put off ventilator support since there‘s a chance that she‘ll come out of it and maybe support her new child?‖ he said with rage encaged within him. ―Son, what are the chances that she‘ll be able to take care of an infant when she comes out of her coma? The chances are meagre. I see the soft feelings you have for your patients and that‘s a good quality as a person. But it shouldn‘t blur your judgement as a physician. Hope is one face and reality the other on the coin of medical practice. You see the MI patient who lost his life due to late medical attention? It‘s partly because of the amenities that are hogged by chronically bed-ridden patients. You send the LFT and RFT tests of this lady every day and if you notice, they haven‘t changed from day one. Let‘s say you get a paracetamol poisoning case tomorrow and you send out the tests but you cannot get the results because the reagents are consumed after the terminally ill patients. She is persistently neutropenic; her urine production has gone downhill to about 300 ml now. Her fever breaks only with high dose diclofenac and her BP maintains at the feeble 90/60 mmHg while on dopamine and dobutamine. What‘s the point of artificially holding up her heart when all she is an amalgamation of flesh and bones that needs a ventilator to be alive? What‘s the point of the ET tube down her throat that requires two hourly and definitely not comfortable suctioning? You and I both know that the moment the tubes are out of her body, she will not live. Let‘s not forget the incomparable pain she must be in if only her brain hasn‘t gone completely insensible. I know I seem heartless to you, but believe me, it‘s wiser to work after someone you can actually do something about. This isn‘t a Bollywood Movie where miraculously the mother is revived after hearing her daughter say ‗ma‘ for the first time. This is practical life. ―If you were in other countries, the government doesn‘t allow such patients to consume our time and service. They‘ll be required to be shifted to a care service in forms of nursing homes. Sure, if they suffer anything urgent they will be looked after but once stable they have to be shifted back.‖ Sighing, he added, ―It is going to be your job from now on to understand and to make others comprehend that maybe waiting on a miracle will not savour the life that actually could be.‖ The intern took the article handed over to him by his senior and marked the following. ―As death nears, many people feel a lessening of their desire to live longer. This is different from depression or thoughts of suicide. Instead, they sense it is time to let go.‖ ―The worst part about being chronically sick isn‘t the physical pain, it‘s the emotional pain that goes along with it. You reach a point where you can‘t hold back the tears any longer and suddenly you‘re breaking down in the middle of a doctor‘s office.‖ ―My first three years of college were hell. My grades rose and fell—my ability to focus was rapidly decreasing, and I found immense difficulty in completing assignments that at one point would have been easy for me. I grew more and more anxious in social situations, and struggled maintaining any sort of relationships‖. Perpetually, he kept the article down and ran to resuscitate the new cardiac patient still on the gurney. Mrs Singh‘s family looked distressed seeing the young doctor struggle trying to save a life while their ‗new mother‘s‘ IV was still unfinished. He sighed and said to the tearful ‗new father‘, ―Maybe, it‘s time to let go.‖

WHICH DOCTOR? WITCH

DOCTOR? Dr Raviteja Innamuri PG Registrar, Psychiatry Christian Medical College- Vellore

"The world looks yellow to a jaundiced eye." Privatization of health care in India has grown by leaps and bounds far exceeding the expectations of the then Republic India. This privatization, essentially focused around urban areas have put tremendous pressure for generation of Specialists and super- specialists who are now expected to clear their final exam answering to a single question that carries a hundred marks, meaning to declare that they know everything that can be known in that specialty. However, unlike the UK‘s NHS where a general physician has to be consulted, who alone can refer to a specialist; in India, owing to the out-of-the pocket health care system, most of the now educated India access Google first and decide their specialist doctor next! Let‘s have a look at the already complicated scenario filled with pre- mature diagnosis and treatment demands made by the patients even prior to their consult. Let‘s take a look at the myriad of most commonly presented symptoms to the clinics such as headache, abdominal pain, chest pain, fever, loose stools, vomiting etcetera etcetera and pull out one amongst them. Say, chest pain, shall we? Chest and pain are known entities to all. Chest for a medical doctor will include all the anatomical structures it carries. Pain again categorized according to different criteria, say quality- dull, sharp, tearing, twisting, burning, pleuritic, twisting ectcetera. Based on these and other characteristics such as mode of onset (acute, chronic), duration, location and associated predisposing, precipitating and perpetuating factors, the doctor can then be expected to act on an emergency or refer to a specialist for further management, if required. However, if the same chest pain were directly presented to a Cardiologist, inevitably owing to the several cases that he sees, Angina pectoris would be the first on his mind. Heart burn would be the first on a Gastroenterologist‘s. Cervical disc disease on an Orthopedician‘s and Neurologist. Panic attacks or other supratentorial lesions on a Psychiatrist‘s mind. Owing to this confusion, a lot of unnecessary investigations follow that further add to the burden of the already tedious health care system. Therefore, a much needed holistic is possible only with the mutual cooperation of both the patient and the doctor. Otherwise, each of us contributes to the so-called deteriorating health care losing human touch with each day. Let which doctor not turn into witch doctor, please.

13th {Oct} :- Madness THE ART AND SCIENCE OF PSYCHIATRY -Dr Rishikesh V Behere Associate Professor Kasturba Medical College, Manipal

During the period of MBBS training, psychiatry is an enigma due to limited exposure to the branch. Students can have different perceptions about the nature of psychiatry as a discipline, especially when it comes to making a career choice. In a survey on attitudes towards psychiatry in MBBS students in our college we found that though 88% of students felt treating psychiatric disorders was the most challenging in medicine, however 69% felt that psychiatry was too inexact and lacked a scientific basis. This perception is probably due to lack of investigative procedures in diagnosis of psychiatric disorders. This may be a boon or a bane; as modern medicine moves towards embracing technology, psychiatry is one of the few branches of medicine where the art of eliciting signs and symptoms is still crucial to the scientific clinical methods. As William Osler has famously said “Medicine is a science of uncertainty and art of probability.”

Psychiatry Literally the term psychiatry means treating (iatry) the soul (psyche – greek word for butterfly which represents the human soul). Professor Johann Christian Reil of University of Halle in Germany is credited with introducing the term „psychiatry‟ in 1808 and said that only the very best physicians would have the skills to become psychiatrists. For the purpose of studying psychiatry as a branch of medicine; mind can be understood as an integrative response of the brain to all internal and external stimuli in the form of awareness (consciousness), thoughts (cognition), emotions (affect) and motor response (behavior). This triad of cognition, affect and behavior forms the core basis of evaluation and diagnosis in psychiatry. For example consider a student who is waiting for the result to be announced. He is probably thinking “what if I fail?” [Cognition], he is feeling anxious [affect] and probably fidgeting and pacing around the room [behavior]. The Art: How are approaches and techniques in psychiatry different from that in medicine? Probably the most important difference in psychiatry is the lack of any test to quantitatively measure signs and symptoms. For eg. Delusions and hallucinations are subjective experiences of a patient and cannot be measured. They can only be told by the patient and understood by the psychiatrist and to understand these experiences the psychiatrist must learn the „art of empathic listening‟. Empathy is the art of understanding the subjective experience of another individual by precise, insightful, persistent and knowledgeable questioning. The Science: Diagnosis and treatment in psychiatry is as much a scientific process as it is in other disciplines of medicine. The signs and symptoms elicited may be either qualitative or quantitative aberrations from normal mental functions. Let‟s take an example of student who has failed in her exams. It would be expected that she is emotionally upset about it. But however if this student experiences a sad mood throughout the day, has lost interest in all activities, feels a lack of energy continuously for 2 weeks this would be a quantitative variation qualifying for a diagnosis of depression. In addition if the student is experiencing suicidal thoughts this would be a qualitative aberration. An additional criterion for diagnosis would be if the student has not been attending her classes, not interacting with friends. This is termed as dysfunction and is an essential criterion for diagnosis and which is why the term „disorder‟ is used to describe psychiatric conditions. Using an analogy of diabetes a fasting sugar greater than 126mg/dl would be quantitative variation qualifying for diagnosis of diabetes. In addition presence of diabetic neuropathy would be a qualitative variation. A study by Kendell in (1971) showed US & UK psychiatrists had gross differences in diagnosing schizophrenia. This introduced an important scientific method in psychiatry which was the use of classificatory systems such as DSM and ICD to maintain uniformity of diagnosis across clinicians, and ease of research. The etiology of disease in psychiatry is understood by the concept of biopsychosocial model. Disorders result from interaction of biological, psychological and social factors and this is the essence of all psychiatric evaluation, diagnosis and management. Another important scientific method is the use of structured rating scales which is an objective way to quantify symptom severity and response to treatment.

Psychiatry is probably one branch of medicine that still retains the fine balance of art and science in medicine making it an enriching experience. In the words of Dr Nancy Andreasen, former editor of American journal of psychiatry and pioneer of neuroimaging research in psychiatry: • “We chose psychiatry because we want to understand the human mind and spirit as well as the human brain.”

• “Every person whom we encounter is a new adventure, a new voyage of discovery, a new life story, a new person”

• “This is what makes psychiatry challenging, intellectually rich, complex, and even enjoyable”

Redefining life- Uncovering Madness

-Reshma Valliappan Mental Health Advocate

The story of madness is not something new to mankind and neither are the many experiences of it. However the consumerist bird of demand and supply has purely dominated the limitations in how madness is allowed to exist. A large part of my existence as a youth has been bought by this word called „Schizophrenia‟. A word that has been coined by one person when broken down literally means „split-mind‟. This word found it‟s way into the DSM after one man by the name of Paul Eugen Bleuler who decided to differentiate and categorize experiences of autism, schizophrenia, bipolar and other such labels. To me, he seems to be highly deluded to have taken the role of God. Then again, the rest of the world must have been really deluded to believe what one man said in the 1900 and to even go ahead and build on it.

There are many reasons for my rejection and critique of the ideas or theories around mental illnesses based on Western philosophy and principles. I am not a medical doctor but I am someone with lived experiences of what medical science calls a „miracle‟. In my recently published book Fallen, Standing; My Life As A Schizophrenist– I have gone to the extent of not just owning the word but terming a new one all together as a political statement in itself. This obviously has got to do with sentence formation in Schizophrenia, which is otherwise called word salads. But my book is not really an in depth looks into my experience with schizophrenia but it is just the first part of my story. My publisher had sent me several questions to act as a guideline to help me pen down my journey. The first question was „What do you think caused your schizophrenia?‟ In my attempt to answer her one question, I ended up writing an entire book.

Fallen, Standing; My Life As A Schizophrenist

I traced back every experience I have ever had since I was born, to look at what would have caused my Schizophrenia. At one and half years of age, I had Reye‟s syndrome- a fatal brain disease that only has 500 known survivors in the world. I was supposed to be dead according to medical science and IF I ever lived I should have been a vegetable on life support. Apparently, an aghor tantric also worked on bringing me back from the dead. At age four, I had a habit of wandering away. At five, I began self-harming. At eight to ten, I went through a series of bullying. At twelve, I began becoming rebellious. At fourteen, I ran away from home after I followed through with a voice and was gang raped at the place I hid. When I returned a Psychiatrist diagnosed me as a transvestite. Then this got me thrown into all sorts of camps. I was involved in vandalism, bunking school, substances and a range of things. In few camps, I was given a dosage of disciplining sold as tough love where it involved behavioral methods of breaking troubled damaged teenagers like me. At sixteen, I was forced to come to a new country. At eighteen, I began drinking more. Drugs came in shortly. I was treated for anger issues and addiction. By twenty-two, I was diagnosed with Schizophrenia. I stopped my medications. There was an additional mood disorder that showed up at twenty- six. I stopped my medications. I had a brain tumor removed at thirty- one. Then I had series of severe dissociations and scar epilepsy along with night terrors. I stopped my medications. This is just a summary of my life experiences with many more in between.

The question is, which of these experiences could have caused my schizophrenia? All, none or some of them? But is it necessary to know what caused it in order to prove it exists?

Have we embraced the same colonial mindset of redefining madness in the very language that has defined it? As an Asian Indian Hindu brought up in the mish mash of East West social economical culture– I am still going to talk to this man with an elephant head and big belly when I feel lost. For every human being who undergoes moments of trauma, there is an inner cord attached to faith…something that gives us hope and faith that is mostly given and understood through our religious and spiritual identities. Embracing the voice of God according to my faith is not madness. Believing He is talking to me when I am at my worst is not a symptom of Schizophrenia. Believing that the Goddess Kali has blessed me and therefore I can be angry is not a symptom of aggression but a response to the oppression society has placed on a girl like me. And just because these beliefs can sometimes be acted upon are not symptoms of psychosis but an action, an expression of the inner turmoil that has a language of its own, because ENGLISH is a very new language and it is foolish to assume or expect that every human will be able to communicate themselves through words made up by a group of other people.

This redefining of words, of expressions, of language, of experiences is what drives my inspiration for the work done under „The Red Door‟. To simply enable every human being make meaning out of their madness aka their life experiences and discover their purpose. We can‟t treat human experiences. We need time to heal from them. And even if we don‟t heal it should be okay because wanting to heal is a choice in itself. In the world as we know of it‟s people– be it mad or unmad, many don‟t even know that they can have a choice to heal from their experiences. This is why the so-called madness cannot be called an illness. They are simply waking up. Waking up to the fact that “We are spiritual beings having human experiences”, as Pierre Teilhard de Chardin said. And it will be these so called „mad‟ who will be reminding the rest to wake up.

12th {Jun}:- Game of Hormones

My Research Notes on Multiple Endocrine Neoplasias Shinjini Chakraborty, MSc in Immunology, Kings College London.

I didn’t really understand the challenges of clinical research, exactly when I signed up for my doctoral studies. I was only fascinated with how the world of scientific research could coerce with that of medicine, to influence treatment protocols and identify drug targets. My guide had quipped the first day, “It is going to be a challenging job Ms. Raman… I am sorry I didn’t catch your name?”

“It’s Amodini... you can call me Amu.”

“So we are doing a collaborative study with researchers and clinicians from Netherlands, Sweden, and America… Louisiana State University and also some from Germany, Australia and Scotland. We are trying to pool all patient data available for MEN1 and MEN2 patients. We have clinicians, surgeons, and also mathematicians and bioinformaticians who are doing all the fancy systems networking stuff in the computers…. You would mainly be responsible for all the wet lab procedures, from testing samples, running gene arrays from the biopsy lysates, and also testing out sample synthetics and/or mimetic compounds that be regulate the signaling pathway in these tissues.” I knew my job well. I had struggled to land up with this PhD at Marseilles after a 245 applications to all around the world except the USA. I was enthusiastic anyway, as I would be working in a collaboration that was trying to roll out a first of a kind ‘personalized medicine’ systems database and treatment repository. Yet, I had no idea that soon I would also be entrusted with interacting with patients to help them sign consents and also schedule follow ups. They were also carrying out a concomitant clinical trial with a newly synthesized compound. I had to get organized sooner than I knew, and soon I was not just practically involved with them; it made me question our research ethics, ideologies and a lot more. It was my journey in the most unbecoming way, that I soon took comfort in.

NAME: PATIENTNO1243 AGE: 22 DATE OF BIRTH: 30/10/1990 LAST MENSES: 2nd-5th March, 2013 DATE OF SURGERY: 4/05/2013 PATIENT NOTES: Had been diagnosed with leiomyoma, and hyperparathyroidism, coupled with insulinoma (indicated by hypoglycaemia). This indicated gastro-entero-pancreatic involvement. Currently present with diarrhoea and hypokalemia. Tested for MENS1 gene during former biopsy (of the parathyroid tumor). Total resection parathyroid scheduled, followed by hysterectomy of the uterus.

“You must be Ms. Lafayette? Hello! I am Amu.”

She was heaving. At 21, she had first reported to Dr. Howard, our consultant General Practitioner (GP) with oligomenorrhea (irregular periods) and hypercalcemia. The diagnosis had been fairly quick. Maybe because we were focusing on MENs so much so that we knew what the exact signs were. It is always easier when we know what to look for. Following the first round of blood tests, as she would frequently complain of lethargy, vomiting and dehydration, she showed clear signs of MENS1. She was a County level Lacrosse player too.

“Hey… there. I…. am Emily. Call me Em. Are…. you the Scientist?” “Not really. I am still in the making! Have you got your tests with you?”

She smiled feebly, while bringing out the Thick black file. “Dad is still with Dr. Howard. I reckon he has a few more. The Ultrasound scans… Ah bollocks! My tummy…. Hurts….”

“Do you want me to call…?”

“Nah. This is regular. I just hope Nathan reaches here on time. He said he wouldn’t miss this.”

“Your boyfriend?” She smiled. Her eyes had the glint of any 20 year old. Just that her weak arms made me wonder how she shook her Lacrosse stick in the field. “I need to sign you here and here. We would be taking in your tumor samples for further testing. And if you are willing, we would like to follow you up three months from the surgery to look for remissions or relapses if any…”

She signed them quietly. Still heaving.

“Let me know what you find out! I recently heard a group would be beginning a randomized clinical trial….”

“Sure. All the best for your surgery. Godspeed”.

She smiled as Nurse Stephany assisted her to the operation theatre. I heard the Anaesthetist mulling aloud over the exact dosages with Dr. Fara. I was too used to the Italian accent by now. My Mum often complained how I spoke English like the Italians, pulling and tugging at every other syllable. ……All I hoped was Em’s glint wouldn’t go away and I could mail her back with results from my next gene arrays. Yet, they are confidential. No divulging. That’s not how Science works. It’s hushed. In secrecy.

FOOTNOTES: PATIENTNO1243 stable after surgery. Samples of uterine tumor (non- metastatic; non-cancerous) were collected. Parathyroid tissue has been collected. Samples to be run as lysates and presented in next bi-weekly meeting, with gene array data and RNAseq analyses. It’s been two years since my first patient consent. I didn’t presume we could also report a MEN2 case in India. We were collaborating with Dr. Santhanam Menon. He was a clinician/researcher working at Vellore with his team and had reported a familial case of MEN2A (there are two other subtypes; MEN2B and Familial MTC) with incidence of medullary carcinoma of the thyroid (MTC). I knew I could get back to my comfort zone, my accent and my own skin. Yet, the heat unnerved me beyond expectation. I was taking the bus ride to Vellore Medical College, where Dr. Menon had a lecture scheduled. I would be accompanying him to his surgery next day, but Gangamma and her daughter Parvathy would be seeing us today as well. I had to make them sign the consent too. “You see Amodini, they are too illiterate to understand the significance of your work. I am not sure if you could take a full-consent, assured of what they understand. Besides, they are such staunch Brahmins! I hope they would readily speak to you. You were born here right…?”

“I did my graduation from Pondicherry University, Sir.” “You must be exhausted! Have some cold drink….. I will catch up with you in two hours!”

NAME: PATIENTNO4243, PATIENTNO42444 AGE: 32 years and 16 years respectively DATE OF BIRTH: Unknown; 25/09/1999 respectively. PATIENT NOTES: Mother reported with intense headaches and sudden blackouts. Blood and urine test following full checkup (persistent high blood pressure) revealed high content of adrenaline hormone (pheochromocytoma confirmed upon USG). Upon whole abdomen Ultrasonography (USG), two (one medium sized, and one large on left and right adrenal glands respectively). MTC reported. Mother and Daughter tested for RET gene which was positive (confirming familial transmission). Tumorous spurts observed in the right half of thyroid. Surgery in mother to be coupled with complete removal of lymph nodes in the periphery of the thyroid. Daughter is two months pregnant with first child. “Amma…. I am Amodini…”

Her listless eyes looked in despair.

“My daughter’s first child… I am sure it will be a boy.”

“Seri, Amma. You will let us use your surgery report?”

“Big…. Doctor said it’s this big!”

She motioned her hand into a circle. Her fingers quivered. “…. This long incision they will cut through….”

“No worries, Amma. You will be fit and dancing at your grandson’s birth!” “What will you do with what they will take out?” “We will test it. Why does this disease happen and find a ….. a…. medicine for it.” “Will it be cheap?” I smiled at her. No. Research isn’t cheap. Patents make things legally and monetarily complicated. But that’s what research is for! Do you know how many years does it take to discover one magic bullet? The numerous successful and failed experiments? The endless trials? The inevitable withdrawal of the tests because the effect has been mortifying? Researchers need to be paid. Technological equipment to be paid for. Numerous working hands hired. From technicians to senior lab investigators. I am not supporting the appalling practice of patenting drugs making it inaccessible for those billions in abject poverty yet in need of proper treatment.

I am just gaping at the human mind. It's intricacies. And it's obsession for rules.

“Amma, if I have the medicine with me, I will give it to anyone for free, okay?” “Parvathy will be fine right?” “Yes Amma… after her delivery we can get her for a free surgery too! And we need to test your grandson as well. Then maybe, the free drug will help you all as well?” A faint smile crossed her sullen visage. She did sign the consent. We did get her samples. I had to wait for six more months for Parvathy’s delivery. It was associated with complications but Dr. Menon made sure it was supported adequately. She was blessed with a beautiful daughter, but Gangamma seemed delighted anyway.

We took her blood samples too. I had taken the baby girl in my arms before leaving. Her soft fingers and racing heart was such mellow comfort. I kissed her forehead and hoped god blessed her with a healthy life.

FOOTNOTES: Mother in complete remission. Daughter to be followed up after three months (another trip to sultry Tamil Nadu), Baby girl Kamakshi…. Positive for RET gene mutation. MEN1: Type1 Multiple Endocrine Neoplasia.

Image: Chromosome and genes associated with Multiple Endocrine Neoplasia Type 1 and 2. Source: http://genetics4medics.com/uploads/3/0/8/0/3080157/1636478_orig.png

MEN2: Type 2 Multiple Neuroendocrine Neoplasia

Image: Parathyroid tumor as seen in MENS2. Source: http://www.srithyroidclinic.com/photos/Parathyroid/subtotal-parathyroidectomy- multiple-endocrine-neoplasia-type2-07.jpg

References: 1) Francesca Giusti, Francesca Marini, and Maria Luisa Brandi. Multiple Endocrine Neoplasia Type 1. 2005. GeneReviews. 2) Jessica Moline and Charis Eng. Multiple Endocrine Neoplasia Type 2. 2013. GeneReviews. 3) https://youtu.be/c6js7PJjCZw, https://youtu.be/B6ctQ8TOnd8: Videos of patients and doctors about MEN.

Diabetes Mellitus and Genome Wide Association Studies: In search of a needle in the haystack Dr. Subrat Das

Diabetes Mellitus is a metabolic disease characterized by chronic hyperglycaemia with disturbances of fat, carbohydrate and protein metabolism resulting from defective insulin secretion, action or both. The American Diabetes Association (ADA) has classified Diabetes Mellitus into four major categories depending on its aetiology and clinical presentation with Type 2 Diabetes Mellitus (T2DM) forming the major proportion of all diabetics in the world. DM, especially T2DM is a pandemic with India being the global capital of the disease. The International Diabetes Federation estimates the number of diabetics in India to be around 40 million with the count predicted to rise up to 69 million by 2025. T2DM is characterised by hyperglycaemia, insulin resistance and relative insulin deficiency classically against the backdrop of obesity and sedentary lifestyle. It is often accompanied by other conditions including hypertension, high serum low density lipoprotein (LDL) and increased Waist Hip Ratio (WHR) also known as Metabolic Syndrome or Syndrome X. The pathogenesis of T2DM is a complex one with interplay of genetic and environmental factors each contributing independently and co-dependently. The genetic component of the disease is evident from the fact that there is a strong family history with almost 5-10 times increased lifetime risk of developing T2DM in a first degree relative of patient with T2DM as compared to age and weight matched controls. Moreover monozygotic twin (essentially having the same genetic composition) studies suggest that in twin pairs with one affected twin, approximately 90 percent of unaffected twins eventually develop the disease. This however doesn’t rule out the environmental contribution to the disease, with T2DM pandemic essentially linked with sedentary lifestyle and obesity. This hints towards a complex cause-effect relationship between the genetic and the environmental components at the molecular level.

Medical genetics has gone a long way from the Mendelian inheritance of G6PD deficiency to that of the multiple genes with variable penetrance of common complex diseases such as cancer, cardiovascular diseases and diabetes. With the successful completion of Human Genome Project and major advances in gene sequencing and bioinformatics, it is now possible to do genome studies for such common complex diseases. From karyotyping to look for chromosomal deletions/additions to single gene sequencing to whole exon and genome sequencing, we have an array of tools to study the genetic components of disease. The present techniques of Genome Wide Association Studies (GWAS) using genotyping arrays/ Single Nucleotide Polymorphism chips (SNPs) that can capture up to 1 million SNPs in a single experiment are generally used to detect common gene variants in cohorts of patients and controls for any particular disease. SNPs are single nucleotide changes in a gene that are found commonly in the general population which may or may not be deleterious to health. This is then analysed to find out which genes are involved in a particular disease and its attributability to the disease in the population.

To give a simpler picture, let’s think of a scenario where you are sent to the British Library (which apparently is the biggest library in the world) to find out the book which has the sentence ‘I thrice presented him a kingly crown, which he did thrice refuse’. Now you reach the library but alas the library has been struck by disaster and all the books have been torn into pieces with bits of paper flying around everywhere (that is exactly what happens when you treat a cell’s chromosomes with restriction endonucleases). But adamant a person as you are, you decide to still go on with your task of finding the book which contains that line. Lucky enough the library has ten copies of every book that has ever been written and published (which essentially is akin to amplification of DNA sequence by PCR). So now you start collecting those pieces of paper and start organizing them. You look for overlaps in the bits of paper (remember you have ten copies of each book and not all the copies of a particular book will get shredded in the same pattern) and arrange them to build a book out of scratch literally. So in this process you essentially come across the blessed line ‘I thrice presented him a kingly crown, which he did thrice refuse’. This is what is essentially done in genome studies but the puzzle has just begun. Now the librarian comes by and seeing you do all the mad work of joining pieces of paper, tells you that one of those ten copies reads ‘I thrice presented hem a kingly crown, which he did thrice refuse’ and asks you if you can find out not only the book that has that original line but also the one that reads ‘hem’ for ‘him’ (this essentially represents the defective gene). So summing up the analogy you essentially find out the gene for a certain activity in all that hurricane of DNA and then find out individuals having a defective copy of that gene. The work after that is essentially an epidemiological exercise linking the individual with the defective gene and the disease phenotype. This is the most oversimplified version of GWAS that I could think of and ‘simple’ is the last thing that can be used to describe GWAS. By the way please don’t get your brain scratching over the line. It is from Julius Caesar by William Shakespeare, Act 3 Scene 2, by Mark Antony.

Now that we are equipped with the power given by science to analyze genes to the precision of single nucleotides, we can focus on the problem at hand i.e. finding out the genetic component of T2DM. The search for plausible candidate genes has focused on genes coding for proteins that might be involved in:  pancreatic development  insulin synthesis, secretion or action.

Of the genetic loci associated with T2DM, transcription factor 7-like 2 gene (TCF7L2) has shown promising results. Transcription factors are proteins that bind to specific sites on DNA and promote or inhibit the transcription of a particular gene and its products. TCF7L2 is transcription factor that controls multiple gene expression related to T2DM. Genome Wide Association Studies, initially in a French population and further corroborated in other populations have ascertained TCF7L2 associated with increased risk of T2DM. Meta analysis of various GWAS has also found out new loci associated with pancreatic beta cell growth, development and function. NOTCH2, a cell membrane bound receptor which plays key role in cell growth and development is being studied as a candidate for T2DM pathogenesis. JAZF1, a transcription factor that represses gene expression has also shown promising association with T2DM with its probable role in beta cell growth and development. KCNQ1, a voltage gated potassium channel with its effect on beta cell function and insulin action need further studies. Genes coding for Insulin Receptor Substrate (IRS) are also studied as plausible candidates for T2DM pathogenesis. IRS on activation mediates the insulin signaling pathways in the cell leading to effective cellular metabolism. IRS-2 knockout mouse (i.e. mouse deficient of IRS) models have suggested that IRS-2 signaling may play an important role in improving peripheral insulin sensitivity and regeneration of beta cells. Human GWAS is required to further confirm such hypothesis.

Researchers are also investigating the molecular pathways and the genes linking obesity with T2DM. Initial observations in humans have suggested that mutation in the gene for the beta-3 adrenergic receptor (which regulates lipolysis in fat) is associated with a low metabolic rate, high risk of obesity and early onset of T2DM. A cohort based genomic study might be helpful in ascertaining the initial observation and linking the obesity and T2DM molecular pathways. Adiponectin, an adipocyte derived cytokine and adiponectin receptors have been found to be inversely associated with risk of diabetes in the non-diabetic population. In adiponectin knockout mice plasma and adipocyte, concentrations of TNF-α (a pro-inflammatory cytokine) increased, resulting in severe diet-induced insulin resistance. These findings have further suggested an inflammation mediated pathway for obesity and insulin resistance leading to T2DM warranting further studies on the genes coding for such proteins.

These findings suggest requirement for multiple abnormalities in the expression and interaction of genes controlling insulin secretion and action for the onset of T2DM which may explain the non-Mendelian inheritance and the variable penetrance of the genes. Our understanding of human gene-gene and gene-protein interaction is at its infancy. With improved genotyping techniques and better bioinformatics breakthrough, we might be able to identify all the genes associated with T2DM and their individual and synergistic contributions to the pathogenesis of the disease. Till then, we must keep searching for the needles in the haystack, because someone said, a good researcher is one who manages to find the farmer’s daughter while searching for a needle in the haystack.

References

1. Sullivan PW, Morrato EH, Ghushchyan V, et al. Obesity, inactivity, and the prevalence of diabetes and diabetes-related cardiovascular comorbidities in the U.S., 2000-2002. Diabetes Care 2005; 28:1599. 2. Stumvoll M, Goldstein BJ, van Haeften TW. Type 2 diabetes: principles of pathogenesis and therapy. Lancet 2005; 365:1333. 3. DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care 1991; 14:173. 4. Sladek R, Rocheleau G, Rung J, et al. A genome-wide association study identifies novel risk loci for type 2 diabetes. Nature 2007; 445:881. 5. Scott LJ, Mohlke KL, Bonnycastle LL, et al. A genome-wide association study of type 2 diabetes in Finns detects multiple susceptibility variants. Science 2007; 316:1341. 6. Zeggini E, Scott LJ, Saxena R, et al. Meta-analysis of genome-wide association data and large-scale replication identifies additional susceptibility loci for type 2 diabetes. Nat Genet 2008; 40:638. 7. Grant SF, Thorleifsson G, Reynisdottir I, et al. Variant of transcription factor 7-like 2 (TCF7L2) gene confers risk of type 2 diabetes. Nat Genet 2006; 38:320. 8. Unoki H, Takahashi A, Kawaguchi T, et al. SNPs in KCNQ1 are associated with susceptibility to type 2 diabetes in East Asian and European populations. Nat Genet 2008; 40:1098. 9. Lin X, Taguchi A, Park S, et al. Dysregulation of insulin receptor substrate 2 in beta cells and brain causes obesity and diabetes. J Clin Invest 2004; 114:908. 10. Li S, Shin HJ, Ding EL, van Dam RM. Adiponectin levels and risk of type 2 diabetes: a systematic review and meta-analysis. JAMA 2009; 302:179.

11th {Apr}:- Love Drugs Addiction

WHY DON’T WE TALK ABOUT PORN?

- Dr. Rohin Manipur

Mumbai

It starts with a room lit dimly by yellow light. On a rocking chair of auburn, polished wood, a young brunette, about my age, looks at me tantalizingly. The music is soft, not enough to overwhelm. The lighting illuminates her well, making sure she‟s central as she begins to strip slowly. Shirt off. Gloves off. Saucy lingerie off. All this while she whispers endearments, excited cuss words, and becomes increasingly more breathless, swaying back and forth as her fingers travel into her trousers. She looks right into my eyes and begs me to grab her somewhere unnameable, apparently aroused merely by me looking at her. Unsurprisingly a hand reaches out and grabs her and she yells in an apparent explosion of ecstasy. Now the cuss words and endearments are yelled out in paroxysmal bursts, interspersed with numerous „Oh yeahs‟, „Right theres‟, and „OHMYGOD!s‟ About 30 seconds later, after a prolonged burst of yelling, she exhales one final time, 15 seconds of contented breathing follow and then she asks me to go again. We‟re 4 minutes into an hour and a half long shindig. Evidently there‟s a lot more of this to come.

If you‟re mentally high fiving me for my vigour in bed and the near miraculous powers of my hand, you couldn‟t be more mistaken. If you think I‟ve copy pasted something from Fifty Shades

Of Grey, nope, wrong again. If you‟re disgusted by what you‟ve just read, I should tell you that we‟ve only begun to skim the surface. The first paragraph you just read is a description of one of the „mildest‟ porn videos currently available for free on the Internet to anyone with a phone or a laptop and a decent Internet connection. I Googled porn and this is the first thing that showed up.

How was I in the picture then? Easy. It‟s one of televised porn‟s oldest tricks, also known as breaking the fourth wall. She asks me for my hand, and a hand pops out from behind the camera, apparently connected to me and does what she asks me to do. It obviously isn‟t MY hand, but

I‟m supposed to believe it is, and that I‟m really instructing it to do what it is doing. It‟s all part of an elaborate, overblown charade, the fluttering eyelashes, the loud gasps of pleasure convincing you that you‟re really in charge of someone else‟s orgasm, evidently supposed to make you feel like more of a man, or a woman.

Pornography. Also called porn. Aka porno. And if you were born in the last 40 years, I‟d say you‟ve seen at least a glimpse of some, however unintentionally, at some point in your life unless you‟ve been living in a cave with no Internet. One of the first rules of Internet porn by the way.

“Show me a man who hasn‟t seen it, and I‟ll show you a man who hasn‟t seen the Internet,” as

Julie Ruvolo of Forbes so eloquently puts it. It has been around a while really, even before the

Internet was invented. Nude pictures and sculptures made to sexually arouse and thrill have been around for centuries.

Porn today is easily accessible. From the privacy of your bedroom, you could theoretically see every type of perversion you have ever fleetingly thought about. As a matter of fact, there‟s another rule, the popular Rule 34, which says, “If it exists, there is porn of it. No exceptions.”

Female self stimulation? Child‟s play. Man with woman? Pshaw. Two men with women?Still child‟s play. Three? Get a little more imaginative! Ten men with one woman? Exists, and very popular too according to studies. Girl on girl?Black with Asian? Interracial? Teenager with older women? Taxi driver porn? Nurse fantasy? Cop fantasy? BDSM (Bondage, Dominance, Sadism,

Masochism for the uninitiated)? All there! Get a little darker, dig a little more and the severely illegal stuff like bestiality, coprophagia for apparent sexual stimulation (coprophagia is eating faeces – UGH!), necrophilia (sex with dead bodies), and rape fantasies come to the fore. You name it, it‟s there. Wait a minute you say, does that mean there‟s theoretically even Bugs Bunny and –

Yup. Need I say more? It‟s all there. Which brings us to a very interesting observation. How strange is it that a person you‟ve never met before has thought of the weirdest sex related thing you can think of and ensured there‟s a video of it on the Internet? So much for being unique!

My reason for writing this article however was not merely to get into an imagination discussion with you that sends us both scampering to Google, laughing our butts off as we find even more idiotic things that have had pornographic videos made about them. I slipped in a ghost punch, something you didn‟t catch. Essentially, I just acted like porn, piqued your interest, made you accept something mentally that you‟d never think of on your own, and killed you with humour/satisfaction at the end so that you‟re more accepting of what I said/did. Don‟t believe me? Here we go.

Did you know that people eat their own shit on video and pretend to be turned on by it, all for the benefit of a watching audience who get sexually stimulated by watching people eat their own shit? Disgusting? Hell yes! If I met you and told you this when you were eating, you‟d probably spit the food out and throw a salt shaker at me. But now you‟re just going, „Hang on, I think you mentioned that already just a couple lines ago. It‟s not so disgusting the second time.‟

Porn sort of functions the same way.

Go back to the first time you ever saw nudity or porn on video, a book, and how shocked you were. And then with a bit of repeated exposure, you steadily thought „Oh what the hell. I‟ve seen it before.‟ You probably let it go there, but there are truckloads of people who don‟t stop with just that, steadily going deeper, experiencing forbidden fantasy after forbidden fantasy, and with each they say „Oh what the hell. I‟ve seen it before. It‟s just a step further.‟ Therefore we come to,

Lesson 1: Don‟t pet the dog, it bites.

Er. Down Scooby? ZOINK-!

According to studies, repeated exposure to porn steadily warps one‟s image of sex. It also warps one‟s image of what sex organs look like, what the female body looks like, what the male body looks like, and just exactly how sex happens. Steadily, perverted behaviours spill over from your phone into your bedroom. You find that regular sex just doesn‟t arouse you any more; you need more to stimulate you. You need what you‟re watching to happen to you in real life. That‟s the ghost punch porn slips in when you‟re (not) looking.

The porn stars acting in the movie don‟t necessarily enjoy it either. A damning video surfaced on

YouTube recently, of a porn actress who quit the business, Jessie Rogers, real name Jessica

Mendes, giving a lecture on the harsh realities of porn and what it does for the women acting in it.

She says, “A veteran male performer who was in the industry for over eight years caught syphilis and faked his test, worked knowing that he had syphilis and transmitted it to other performers. I was once hanging out with another veteran male performer off camera who I knew was sadistic but what he did to me, the night that I „woke up‟ was something I was definitely not expecting.

Long story short, he kept beating me, banging my head on his wooden floor to the point where my face and my head were bleeding. He choked me up to the point of me passing out twice, and when he would stick my head into the toilet he would not let me come up for air when I tried. I thought I was going to die that night. Through the course of my porn career, I had to go to the emergency room several times. I had several incidences where I would cry on set coz things had been so painful but none of them like this one.”

Mendes exposes in shocking detail one of the most obvious truths of the porn industry, that women are mistreated, often brutally and often commit suicide rather than face more indignity.

Names like Tori Black, Sasha Grey (ex porn actress), Sunny Leone (ex porn actress), and Jessica

White are perhaps names the frequent porn user thinks of with a flutter in his heart, but few really contemplate the behind the scenes torment they go through.

Why, now you‟re getting mushy, you‟ll think. Or maybe you‟ll say men everywhere are the same, mistreating women! The scoundrels! The perverts! News flash.

Lesson 2: The male pornstars don‟t always enjoy what they do either.

Picture for representational purposes only

WHAT! I mean, what?! From the outside it seems like the perfect life, have sex with decked up, beautiful women to be paid money. The reality is way coarser. I want you to try an exercise in imagination for me, if you‟re a guy. Any time tomorrow you hear the word „happy‟, I want you to try and place yourself in the shoes of a porn actor, and have an erection ready exactly ten seconds after you hear it. Don‟t be sheepish. Just the word happy. That means if you happen to pass by your colleague‟s cubicle, and the dude‟s blasting Pharrell Williams‟ song Happy, wham, need it ready in ten seconds. Because I‟m happy, clap along if you feel like a room without a roof! Sounds crazy? Sounds impossible? Welcome to the world of the male porn actor.

In the instant the director yells „Action!‟ these guys don‟t have to throw some sappy dialogue at the camera. They have to be ready, (Get the damn song out of your head already!) not once but over and over and over again, to perform intercourse in varied positions, sometimes upside down, sometimes same sex, and all as many times as it takes till the shot is perfected. This, in front of quite a large crew. Not pleasant.

In June last year, popular humour site Cracked.com did an interview with porn actor Lance Hart, who spoke about the difficulties of male porn actors. Essentially it boiled down to having to repeat numerous takes, sometimes having erectile injections inserted into the penis, because shooting even a ten minute video took about four hours. I won‟t ruin the article for you and it is easily available if you know how to work Google, but it really shows the trials and tribulations people working in the porn industry have to face. A couple of weeks ago I saw a meme which went something like,

“We are a country that doesn‟t mind having an ex porn star in our films, but hushes up a girl who gets raped for fear of her family‟s honour.” I might be paraphrasing here, but all those death threats Mia Khalifa got sure doesn‟t make her life something to envy. It tells us much about our preconceived notions of porn stars as sex addicts who want to „flaunt and debase our minds and culture.‟

Whether pornography has any serious issues on consumers is a debatable issue. Numerous studies have shown that porn might be a safe release for people and thus prevent them from acting out their fantasies, but an equivalent number of studies have popped up claiming that porn actually increases sexual aggression and leads to more rapes. Your take away?

Lesson 3: Porn really is at least somewhat bad for you.

Superb use of grammar there.

I don‟t want to suddenly go moral police on you after everything I‟ve told you. You can make your own deductions and choices, and so I invite you to, based on what you‟ve read. Sure, porn provides a release to a lot of pent up sexual fantasies in private so you don‟t act them out. It also soothes raging hormones, which is probably a good thing and there are numerous studies which make associations between a boom in the porn industry and decrease in rapes worldwide. But, here‟s the thing. Addiction to porn and self stimulation develops very quickly. It‟s a slippery slope to be on, and soon you find you cannot live without one or the other. While it has no harmful effects on one‟s body, there are the obvious harmful effects on the mind that any addiction might produce. Continued dependence affects professional life as well as interpersonal relationships. Studies report that sufferers have no interest in maintaining longer relationships, choosing instead those relationships which bring instant gratification and are ended easily, just like what they see on video. Decreased concentration is another side effect, affecting studies and work. The aforementioned tolerance and „Oh it‟s nothing‟ phenomenon is one more against the idea of porn, as is the feeling of being used to sexual violence.

Although pornography has been deemed illegal in most countries, including India, it remains easily accessible by anyone. In the time you have gotten through this article, thousands of people have accessed free or paid porn and satisfied their urges. The long term effects of porn viewing on the world at large remain unfathomable. The hope, however, is not that people stop using their Google Chrome‟s incognito mode, which would be impossible, but that they understand what goes into the making of the ten minutes of screen time that the girl on the rocking chair got.

THE INEXPLICABLE REASONING

A TALE OF A SORDID NATION

- Dr. Abhijeet Sharma

Kasturba Medical College ,Manipal

Our story begins exactly like a billion other stories do. A hot, humid, dusty and noisy morning, coupled with a nauseating aroma of a nearby sewer, usually enjoyed with a cup of hot tea and newspaper. The first headline of the news bulletin will almost always pertain to something unfortunate or in some exceptional scenarios, to cricket. Trains will collide, people will be shot dead, a neighbouring nation will be questioned, a scam will be publicised or women will be raped. It‟s like someone puts the “movie of India” on rewind and plays it every morning.

Somewhere in this movie, playing an infinitesimally small role is reasoning and pragmatism.

And the deficiency of such basic human traits is the central figure of this story.

India, home to not only a sixth of the world population, but also a shelter to the most preposterous and disgusting of beliefs. We are the proud inheritors of the most rudimentary and backward pattern of thinking that has given rise to exceptional cesspools of ironical existence.

For a civilization which claims to be the oldest of all, we exhibit very little intelligence and social maturity.

With contradictions piling up in every corner of the country, it‟s not surprising that flowers and sweets are offered to Goddess Durga in the morning and by evening women are raped and mercilessly killed.

It‟s no accident that we claim to be the oldest religious civilization. After all religion is the death of reasoning. And Indians are unmatched in showcasing this paucity.

The social civility of a nation is very poignantly represented, sincerely if not completely, in how it deals with matters relating to the genitals. The manner in which people deal with reproduction and the urge to do it may be a representative sample of their basic understanding of themselves.

It‟s no secret that some populations deal with this concept far more prudently than others.

Unfortunately, it is also the test that our “great nation” fails at badly, very badly. For a nation obsessed with ―fairness‖ of skin, it comes as no great bolt from the blue that we as individuals brand sexual conversations in public as a pathetic and downtrodden thought while engaging in heinous sexual crimes against women simultaneously. That‘s what I like to call, ―mother of all multitasking‖. And let me be clear. My remarks are not limited to the men who rape or assault, but to each and every one of those souls who gets frustrated one fine day hearing a mishap on the news and then stare at a lady‘s cleavage while travelling in the public transport.

A friend of mine, resident of the national capital, who recently finished her medical course, travelled back to her home city. It had been a year since she visited the place and was apprehensive about the journey, the one not between the cities but the journey within. She called me up and asked me to stay on the line while she travelled back from the airport. That‘s just one example of how terrifying it has become to possess ovaries in this country. There are countless others. I am sure the weird and ugly looking, obstreperous moron travelling alongside in the bus or the illiterate auto driver who thinks the world is a urinal or the self obsessed, shabbily dressed, brainless youngster who thinks it‘s ―cool‖ to wink and whistle or the lawyer who tried to defend his clients- men who mercilessly inserted an iron rod up a women‘s vagina eventually damaging her uterus, intestine and other vital organs, with an argument that makes him qualified for ―public castration‖, come to mind.

Male peacocks attract their female partners by showcasing their scintillating feathers and dance during the rains. Lions like to display their might and supremacy by fighting other lions of the clan in order to catch the fancy of the lioness. A male stag uses his antlers as a tool to show his worth as a potential mating partner.

Even the male rats wait for the female to perform the ―mating dance‖ during her ―heat‖, before attempting a sexual act. The logical estimation would be that humans have a more sophisticated and cultured manner to exert a pull on their fellow females. Any logical brain would conclude that given the human‘s extraordinary evolution of grey matter, they‘ll develop some unique and intriguing mechanism to prove their potency as a worthy sexual partner. And indeed we have. We have successfully developed the ―date-rape drug‖. We have successfully managed to make our society filthy enough to blame the females for any and every mishap. We have even attained amazing achievements in the field of forceful copulation of girls even before they achieve sexual maturity. Extrapolating these soul numbing accomplishments we have not failed even a single disgusting expectation when it comes to ill- treating the female human. Sometimes it‘s met with killing one still inside the mother‘s womb; at other instances by stripping her of every basic human right; and still further by burning her alive or killing her after violating every single aspect that makes her a woman. Sickened enough?! I ask because there is no end to these exceptionally filthy tales.

In India, politics is essentially based on the short memory of the populace. The fact that we, as Indians, are exceptionally talented in forgetting even the most unforgettable of events, lead to the production of an interview documentary by the British Broadcasting Corporation (BBC) named ―India‘s Daughter‖. Since the broadcast of the film was banned in India, it really isn‘t possible to make a fully informed comment over it. But what we can comment over is the political turmoil it caused. Whether or not that documentary should have ever been made or if it was justified to ban it, are questions whose answers differ from one individual‘s perspective to another‘s. But here‘s the catch. It took a foreign media corporation to remind us that the convicts of the ―Nirbhaya case‖ are still alive and have not stopped infecting the world with their thoughts. It took a political upheaval in the power corridors of the capital to remind our leaders that such low living forms must be eliminated at the earliest. It took a series of news flashes to remind the people of this rotting society that India‘s daughters are indeed fighting the world every time they travel to work or step outside their homes or travel around with friends. If you ask me, I think the ―British‖ just did us another favour. But alas, it will take more than a rape and murder, to shake the conscience of the Indian people. It took less than a week for the outrage and the anger to die down. And we will happily forget it again. We have perfected the art of forgetting over the past 6 decades.

So yes, while parents all over the world are buying dresses for the ―soon to arrive‖ daughter/son, Indians are illegally trying to find the sex of the unborn child and terminate the pregnancy in the absence of a penis. While governments across the world are trying to eliminate the gender pay gap, Indians are still trying to convince their bright young daughter that the only purpose of her existence is cooking and parturition. While people across the globe are living happily under a female leader/president, Indian males are salivating at the sight of elegantly dressed lady. While women from ―beyond our boundaries‖ are finding cures and treatments for deadly ailments, Indians are still blaming the wives for the birth of a female baby. While the world is witnessing the magnificence and brilliance of Angela Merkel, Janet Yellen, Dilma Rousseff, Christine Lagarde, Mary Barra, Sheryl Sandberg and Virginia Rometty, Indians are still telling women to produce at the least 4 offspring and tagging rape as an innocent boyish mistake which is no big deal.

Natural selection demands inferior traits to be eliminated for the propagation of superior virtues. It is indeed exquisite how we have tricked the law of ―survival of the fittest‖.

Image Source: www.ashytojazzy.com

Image souce: rhrealitycheck.org

Image Source: www.youthconnectmag.com

10th {Jan}:- The Code War

The Girl who won't Can't Cry!! Dr. Supriya Kumar From not being able to set foot in a court to being the champion of the game these Florida sisters have braved many odds. But the one thing they didn't do was, give up on the dream to become no.1 in the world. Be it injuries or sickness they connued to amaze the world with their performance as they set the bar for the game.

From her debut in 1994 to being World no.22 in 1997 with a quick uprise to the top 10 in 1998 and 3 consecuve grand slam tles, Venus Williams has been queen of the game! And then came the dark period of her career where shrouded by a mysterious illness Williams suffered much in terms of stamina. And everybody had an opinion about it. Some thought it was the age showing up while others claimed Williams should have gracefully rered while in her days of glory! 2004-2011 was the darkest hour of Williams' career where she neither had a medical diagnosis nor could she figure out why she had suddenly lost the energy to get through a game. She even aributed her fague as laziness while she toiled to struggle against it.

2011 brought with all the explanaon there was with a final diagnosis of Venus Williams' condion. She was diagnosed with Sjogren's syndrome. 7 years is what it took!

What's worse than your own body switching sides in the game?! How far do you think you'd go when you know your days are numbered? When you are aware that disease will slowly debilitate you to a major degree? Some of us would crumble under the very pressure.

But then there are those who bale it every day and emerge victorious! Pushing their limits and challenging the disease every step of the way.

Sjogren's syndrome is an autoimmune disorder in which the white blood cells of the body aack the exocrine glands of the body, specifically the salivary and lacrimal glands, causing the mouth and eyes to dry up and result in inflammaon. So basically, the protector becomes the aacker. Saliva and tears, we know, are the first line of the defence mechanisms of the body. Damage to these is an open invitaon to a wide variety of bacterial infecons. In Sjogren's the eyes dry up, leading to keratoconjuncvis. Dry, itching and watering red eyes with a persistent griyfeelingwhichcanescalatetocornealperforaonandlossofvision! Adry mouth exposes the mouth to infecons such as candida and dental caries while also posing a substanal risk for dysphagia and fissures in the tongue. Both condions are extremely difficult to cope up with.

But here we talk about the lady who braved it all, the lady who rose to create records despite this disease and the hazards associated with it. In her own words, ―"I'm really disappointed to have to withdraw from this year's U.S. Open. I have recently been diagnosed with Sjögren's syndrome, an autoimmune disease which is an ongoing medical condion that affects my energy level and causes fague and joint pain. I am thankful I finally have a diagnosis and am now focused on geng beer and returning to the court soon." – Venus Williams in USA Today. Thiswas2011andshehasn'tlookedbacksince. .Foranathleteofhercalibre Sjogren's can be a rather liming condion. In a sport where stamina plays a pivotal role, easy faguability and associated arthris are a major challenge. But this lady with an iron spirit did not let it bog her down and rose to set newer records, redefining tennis for the world!

And she prey much DID it!

"As an athlete, you don't make excuses. Either you do it or you don't"

Venus Williams

Friend and Foe Alike

-Dr. Raviteja Innamuri Soul Surgeon CMC, Vellore.

―What happened to my Biju?‖ asked the old man, vehemently following us aer the admission of his 21-year-old grand- son with a diagnosis of Behçet's disease. As we sat down in the counselling room to address his concerns, I could not help but noce the worry, hidden beneath the wrinkles on his forehead. As his frail hands shook, struggling to pull a chair, his silver hair spoke of the youth they had once seen. Biju's parents had passed away in a road traffic accident leaving the weight of their only child's responsibilies on his shoulders, which have grown weary of carrying their own. ―Why should something so strange and ugly befall on his innocent child? Doctor, why is my Biju falling apart?‖ He persisted for answers.

His pensive eyes reminded me of my professor in Medical School who once explained to us, passing to be a doctor isn't answering to a blank sheet of paper in an exam but it is to answer real paents who will confront you 'aer the exam'. The blank sheet was so much easier to write upon. It never quesoned.

He paently waited for me to answer as I filled the air with calmness. How could I explain to him that there are 'none'? Well, we have found some genes to blame but no body really knows why would body fight against itself or against substances that do no harm. To me, it is completely understandable that mankind which otherwise is in conflict with answers from common cold to keeping internaonal peace agreements should be able to answer these quesons but the old man wouldn't take it for an excuse. I had a degree to uphold and I am supposed to know answers that were never taught to me.

I asked the gentleman, ―Sir, are you aware of what the Indian army does?‖ ―Ah? Hmm, yes doctor, it protects us from our enemies?‖ he replied pensively. ―Who are these enemies, Sir?‖ ―Enemies are the ones outside the Indian border. They do not belong here and are trying to harm us,‖ he said eloquently. ―And what would happen if the very same army begins to aack us, Indians?‖ ―Everything would collapse, everything would fall apart,‖ he said, bringing his head down decreasing his tone with each passing word. ―Thank you doctor,‖ he said and shuffled out of the room.

Since birth, we are struggling to establish boundaries that define us, inially from the mother and then the world. Similarly, our immune system also learns to disnguish self from non-self. We define ourselves but don't remain completely to ourselves either. Just as we grow tolerant with the multude of human relaons that we develop over a lifeme, our bodies on the inside too enter a symbioc relaonship with the millions of organisms ('human micro biome') in the oral cavity, intesne etcetera and remain immune tolerant to them (without aacking them).

As we remain suspicious of strangers and keep ourselves on guard both on the inside and the outside, all it takes is just enough confusion in differenang friends from foes who closely resemble each other. In this molecular mimicry, we could end up hurng ourselves if we aacked our friends by mistake (as in Rheumac fever where anbodies to strep aack the valves and joints) or through an exaggerated response to enemies (super angens) that might bring damage to our walls as well. Just as we learn to curtain our weaknesses, we provide immunologic privilege to angens that we fail to develop tolerance for such as the lens and the sperm.

Life teaches us to recognize friends and foes carefully and so with me, we did learn to find these substances that acvate these responses and avoid them. Like all great lessons learnt during crisis, we (Sir Harold Ridley) also learnt during World War 2 that shaered canopies in the eyes of pilots remained inert and began to use PMMA for cataract operaons and other similar substances for various surgeries. The complicaons of these diseases that we call auto- immune are innumerable affecng a single organ to several systems in the body having consequences into the biological and social life of the affected individual- from how his liver would detoxify to how his brain would perceive the world around him. Since we do not know the exact reason for the friendly cross- fire, we suppress their mighty force by disarming them (inhibing effector mechanisms such as cytokine blockade), further decrease their numbers (using steroids) and if necessary, kill them (by hiring an external agency (immunoglobulin). The course of auto immune diseases is embedded with mulple relapses and recurrences and every me we fight back, finding no way to make peace with the traitors.

The queson remains why would our bodies fight themselves or harmless substances under any circumstances? Why do we fight in our homes, with our society, country, world and our own species? Why has the incidence of the auto- immune diseases increased in the recent mes? Is auto- immune an expression of unresolved conflicts both within and outside our bodies?

Perhaps, answers are at sight only if we willing to look for the fire rather than disarming the smoke alarm through immunosuppressants. With technological advancements, humans have adapted to live in a cleaner arficial world of their own (including social networks) missing out on the tender care and dirt of Mother Nature, which would otherwise adopt us to beer survival and acceptance of fellow organisms in the natural world. Are we progressing more rapidly than our minds and bodies are desned for or perhaps in the wrong direcon? Will resoluon of this problem externally bring a peace internally as well? This me, I am willing to wait for an answer. This arcle was wrien on a comparave note between the psychology of man and auto- immune disorders explaining both, at the same me.

The history of the surgery is as old as man's life on the earth, being the surgical procedure of the oldest therapeuc procedures. No medical act is possible without the knowledge of the previous steps -even failed minds that reflected on the problem. Therapy tends to be increasingly less aggressive, non-invasive and, specifically, in the surgery is looking for minimum holes for your realizaon.

The great figures of the surgery of the Arab Middle ages were Abulcasis (Abul Qasim al-Zahrawi, 936-1013), born in Medina Azahara, on the outskirts of Cordoba and Albahad Mamad (939- 1020). The works of Abulcasis (Al-Tasrif) contains all the know the surgical me by way of encyclopedia.

The surgery does not develop unl the twelh and thirteenth centuries. In the thirteenth century, the studies of surgery more important are carried out around Bologna, where it creates a school of surgery. The most important of the surgeons is Lanfranci in Milan, who wrote a surgery magna, which is an encyclopedia of the surgical know unl the thirteenth century.

Despite all these advances produced in previous centuries, the surgery of the nineteenth century will face several problems: the pain, infecon and hemorrhage, which dodge with three new discoveries: the anesthesia, the ansepsis and hemostasis. The surgery of the tweneth century, once solved the problems, it had a rapid development, which include: the use of anbiocs for prophylaxis and treatment postop, transplantaon and laparoscopic surgery. Laparoscopia surgery is a surgical technique that is pracced through small incisions, using the assistance of an opcal system that allows the medical team see the surgical field within the paent and act in the. Calling these techniques of minimally invasive surgery or minimal- invasive, because avoiding the big cuts of scalpel required by open surgery or convenonal and make it possible, therefore, a postoperave period much more rapid and comfortable applied in a multude of medical speciales because it is a global concept that frames today to almost all the disciplines. In addion, framed amplitude of techniques including endoscopy, or laparoscopic surgery and percutaneous. These therapeuc approaches are very complementary, and increasingly are applying combined for the treatment of individual cases, thus offering a number of advantages over tradional open surgery: Drasc reducon in pain. Accelerated recovery / return to walking and daily acvity. Reducon of the intensive care unit and hospital stay. Improves postoperave pulmonary funcon. Improvement of the quality of life of life. Reducon in the need for inpaent cardiac rehabilitaon. Highly improved aesthec results.

The minimal invasive surgery is considered to be one of the most outstanding scienfic advances of the last 10 years. There are many hospitals in which surgeons operate sing 15 meters from the table that is the sick. Aided by robots, specialists achieve fantasc results. In addion, the use of the navel to make the intervenon or the use of natural orifices (mouth or vagina) to remove the whole organ is revoluonizing surgery.

JANUARY 2015 • lexiconin.com

History

Revisited

Robocs and Minimal Invansive Surgery: One look to the past and future

By Óscar Alberto Castejón Cruz. M.D. Choluteca Regional Hospital. Honduras. Central America.

Introducon

The most significant contribuon of the historical development in understanding rheumatoid arthris was the segregaon of its aeology and pathophysiology. Rheumatoid arthris (RA) is an autoimmune condion in which, the synovial joint is inflamed. Osteoarthris is characterised by way of wear and tear of the joint, while gout is accumulaon of uric acid crystals in the joints. This aeological isolaon was a result of years of research and inquision into the human physiology, and began way back in 1500 BCE. The entwined path of this discovery would fascinate one, when the brief history of autoimmune disorders is looked at.

The likelihood to incidence of this disease was first indicated in the Ebers Papyrus. Egypan mummies were magnificent examples of rheumatoid arthris case studies, and its prevalence was quite an intriguing aspect to suspect a possibility of a newer variety of disease pathology. Hippocrates aempted to describe arthris in the vaguest form around 400BCE, but couldn‘t idealise the disncveness that the various forms were vested with. In India, the Charak Samhita took to describing the cardinal signs of inflammaon with an arthric condion, namely dolor (pain), calor (heat), rubor (redness), and tumor (swelling). However, the fih cardinal sign, funcon laesa, or loss of funcon was an imperave to this condion and not reported. In 129 CE-219 CE, rheumasmus was a nascent introducon to the yet indisnguishable disease and one may find Galen‘s involvement in the same. In the late 15th and early 16th centuries, Paracelsus crudely described accumulaon of substances in joints that couldn‘t make ay through urine.

In Art and Paleopathology: Looking at Rheumatoid Arthris

Source: hp://www.ncbi.nlm.nih.gov/pmc/arcles/PMC3119866/ The Three Graces is an oil painng by Peter Paul Rubens. Interesngly, if one takes a close-up at the hand of the lemost figurine, you may look at the typical deformity that accompanies many RA paents. But, this cannot be considered scienfically significant evidence to the prevalence of RA and its typical phenotypic manifestaon. Skeletal damage as perpetuated by RA was seen in post-mortem studies conducted by Sir Armand Ruffer and Flinders Petrie, on Egypan Mummies. Ruffer conducted these studies of mummies of Macedonian, Egypan and Greek origin, and reported of unique degeneraon of bones, and Petrie confirmed to similar evidences. Yet, what wasn‘t considered was the existence of years of preservaon and/ or effects that might have affected the bones otherwise. Years of went by unl these studies matured. Beauvais and Garrod: Paving way to Modern Descripon of RA

Augusn Jacob Landré-Beauvais took this first aempt in the early 19th century. As a young Physician at 28, he saw paents, especially penurious individuals and the womenfolk and couldn‘t categorize them under the already exisng tenets of gout or rheumasm. He consequently named this unnamed disorder as ―Primary Asthenic Gout‖ or Goue Asthénique Primive, nevertheless, his descripon contained discrepancies.

Alfred Garrod and his son Archibald Garrod, soon followed up this misinterpretaon. Alfred Garrod described the differences between gout and arthric condions and this was related with high blood levels of uric acid in the former and not in the laer. Archibald Garrod carried out extensive work in the same ad documented evidences in a Trease, though, it was opposed with vehemence from an American physician named Charles Short, in the 20th century.

Ancient or Modern? The genesis of RA and Disputes Short pointed out how Archibald Garrod couldn‘t precisely put forward a definive diagnosis to RA. He tried to convince the RA wasn‘t of older origins, but a more modern spurt that afflicted people. This idea is sll under rigorous controversy and counter claims, but remains to be one of the most researched autoimmune disorders. Its aeology has developed into more established descripons, the role of autoanbodies and how the immune system of our body chooses to selecvely target our own self- angens.

9th {Oct} In Hospitium

Curiosity Saves Lives By- Haleema Munir, Allama Iqbal Medical College, Lahore

“I’ve read his admission notes and his symptoms are typical. I know your duty hours are up, but please refer him to the Cardiology Ward before leaving,” the senior doctor instructed Dr. Zaman Khan while pointing towards the young farmer lying in the farthest bed of the ward.

Glancing at his watch, and remembering the promise he made to his three-year-old son to be back home in time to take him shopping for his new school books, Dr. Zaman hurried towards the end of the ward. The half-sleepy patient who was blankly staring out of the window at the steadily darkening skies turned hopefully towards the white coat approaching the foot of his bed. Smiling reassuringly at the patient, Dr. Zaman explained the current situation to him, informing him of his transfer to the cardiology ward. The patient immediately started getting out of the bed, grabbing his belongings and putting on his shoes.

“No, no, wait a bit. The nurses will get you to the cardiology ward in an hour or so as soon as your transfer procedure has been completed,” Khan instructed the patient thinking that the patient must have misunderstood.

“I’m not going to the cardiology ward, doctor, I’m going home!” the patient retorted dejectedly. Stunned by this unexpected response, all the experience from years of interaction with patients and the psychiatric ward training kicked in and soon Dr. Zaman was able to learn that the reason behind patient’s dejected behavior was the fact that since his admission in the hospital, all the doctors had only been asking him questions about his disease and reading his previous lab reports. No one had actually examined the patient clinically since his admission in the ward that morning. Although Dr. Khan knew that the doctors in the Out- Patient Department had examined him before admitting him to this ward, and the lab reports were textbook-obvious as well, for the sake of convincing the patient to stay till the completion of his treatment he assured him that he would examine him.

Dismissing the nagging thoughts of his son waiting for him at home, Dr. Zaman started the examination. Going methodically, Dr. Zaman started from the thin hands of the patient and carried on with the unremarkable examination. To his experienced hands,the fact that the upper left half of the patient’s chest was overtly alive like an electric drill vibrating under the flesh was simply a confirmation of the suspected heart problem. The unreasonably loud gushing of blood under the bell of stethoscope was another textbook sign. Sighing inwardly, Dr. Zaman was about to end the examination and write down the exact same findings that the doctors of the Out-Patient Department had written in the reports. But something was going on at the back of his mind, the wheels running and the metal clanking, and that’s when it clicked, the patient’s heartbeat and breathing patterns weren’t coordinated the way they should have been!

Normally, the heart beats faster when breathing in and slower when breathing out. Abnormal hearts beat even faster when patients breathe in and even slower when breathing out. Or in rare cases, the inspiratory and expiratory heart rates became equal. But this case was neither normal nor abnormal. The patient’s heart was slowing down at inspiration and speeding up when the patient breathed out. The years of medical knowledge began racing through his mind, the pages of medical books flipping mentally but to no avail.

Lost in this medical riddle, Dr. Zaman delayed the transfer of the patient to the cardiology ward for the time being and focused his faculties on the abnormally abnormal heart and breathing combination. He went through the patient’s previous medical records, and then scrutinized the X-rays and scans of the patient from two days ago, where there was nothing to suggest such an unusual observation. None of his medical books were any help, nor were any of the other doctors on- and even off-call. Bewilderingly enough, even the last resort of the online or hard-copy journals had nothing to say on this particular subject. No one had ever reported such an occurrence, at least not in a conscious patient! From all anyone knew this could either be a totally irrelevant finding or it could be a sign that changed the entire diagnosis. But no one knew anything at all.

After almost an entire day of futile attempts to find an answer to this puzzle, the consensus was reached to repeat each and every test, and unconventionally enough, even the scans had to be repeated. And lo and behold, the answer lay in this particular unconventionality: the scans. Later on, the patient revealed that the X-rays and scans that he had claimed to be two days old were actually almost two weeks old. He had been so overwhelmed by the numerous tests and the repeated X-rays when his symptoms first presented almost a month ago that he just gave his two-week-old X-rays to the doctors on admission. The fresh screens showed a massive lung infection, the abscess of which was located behind the heart. This infectious mass compressed against the base of the heart, reflexively increasing the heart rate on expiration, thereby explaining the never-before-reported abnormal correlation between the heartbeat and the breathing. An inquisitive doctor who noticed an abnormality on examination, an abnormality that is not even mentioned anywhere in medical literature, led to a radical change in diagnosis from that of a cardiac disease to a hidden lung infection.

Link to this published case report: http://www.autonomicneuroscience.com/article/S1566- 0702(14)00092-7/abstract

In Hospitium

(7 articles) The Toilet’s Humour, and Other Musings By, Ms. Bianca Honnekeri, Grant Medical College & Sir JJ Group of Hospitals, Mumbai

An autobiographical account of a life well lived, as recollected by a rather rheumy, snarky old (“heritage Baird and Tatlock, if you please, Good Sir”) washbasin, at one of the oldest hospitals in Western India.

Bless my faucets! Yet another batch of twitchy, excitable First-years look upon me with apprehension… Presently stationed in the Physiology Laboratory, it is me (partial credit: BMC Water) who provides them with the instant solace, while they recuperate from the travesty of justice that is the pricking of their own fingers to prepare Blood Smears. But my life wasn’t all about nurturing young, bleeding fingers…

Back in the day (circa 1865), I was often the centre of much frenzied activity. Magical indeed the times were, for physicians back then were a heady mixture of overly dramatic actors, well-meaning experimenters, and base frauds. Science too was more sorcery and trickery than medicine; however that was also the era of colossal ideation. I hear children today laugh over a Shakespearean mention of the Theory of Humours, seldom realising how the modern understanding of diseases like jaundice evolved thenceforth.

The gory practise of blood-letting was often conducted within my roomy catchment; but I’d be wont to deny today’s physicians swabbing away with antiseptic, do owe this attitude of rightful caution to the evolution of science from the centuries past.

Family folklore has it that my great-grandfather Sir Wilbur Cardington I (well-renowned in society as ‘Sir W.C.’) was once victim of a rather unsavoury shock, when his owner, Wheezy Ole’ Archie (plausibly acquainted to you common-folk as Mr Archimedes) sprang out of a (thankfully) well-frothed bathtub screaming “Eureka!”

From a time when mortars and pestles were rubbed clean within my loins, to an era where all sorts of leaf decoctions and bark pastes were poured down my gullet; I have witnessed the sands of time progress, shifting as mighty dunes. From the furious compounding of the Healer trying to find the right ‘balance’ of smoke and rat tail, to the Herbal Doctor toiling away with plant after thorny plant.

While my Stainless Steel modern contemporaries scorn at these supposedly archaic practises; all these years later, I saw a child with chicken pox healing under a cooling shroud of Neem leaves, and realised, possibly not all ancient knowledge needs to be left behind in the ancient times. I suppose there is some truth to the belief that age and experience do teach you more than books ever will...

Indeed, I have also been pivotal in the ‘First, Do No Harm’ ideological revolution in medical practice. Large, blood-thirsty, sword-aping needles washed under me in the 20th century, have been replaced by much less threatening, fine, numbered and coded ones- which are carted off for disposal and never re-used.

Thick metal rods that were shoved down hapless coughing throats, (“rigid bronchoscope,” said someone who couldn’t just call a pipe, a pipe), have been replaced by PVC contraptions that come with soft inflatable cuffs and a promise of being significantly more pliant.

Once, in 1891, when a larger bathroom had to undergo facial reconstruction [M-Seal (or Bathroom Botox) still hadn’t assaulted the plumbing world quite as ferociously back then], the washer-ladies had stationed themselves by my side for an entire month; and when they washed hospital linen, often my intestines were subject to a biochemical fracas that would churn the bowels of even the most stoic, clinical, front-loading Washer-Dryer Machine of today.

When I over-hear Second Year students crib about having to learn about Sterilization and Disinfection, my ulcerated and ageing colon shoots off a silent prayer of thanks to the Autoclave, into whom every item of glass, metal and even cloth is carted off for disinfection these days!

Admittedly, my greatest failing is that I cannot achieve a low enough microbiological count, no matter how hard I try. But I shan’t dwell much on this, for the Engineers of today have deleted it from my job profile anyway.

This next story is about one of the darkest moments of my life. Since I seem to anyway be pouring my entire P-trap out, I might as well part with this closely- guarded secret. At this juncture, I do request the reader to not judge me harshly, as this entire incident was entirely unintentional...

It was the year 1920, and Epidemiology was not as much the evidence-based science it now is. At this point, I had been relocated to the Canteen. However, unbeknownst to me, a pipe supplying my tap had a breach upstream. A week into my service, I heard of a widespread contagion of G.I. illness. Rumour has it that faecal samples were collected from well over 50 hospital employees, to no avail!

A wily Health Inspector who, (in a rare departure from the prevalent laissez-faire attitude towards public health of that time), had recently read about John Snow’s tryst with the Broad Street Pump, decided to swab the Canteen and all its contents (yours truly included).

Vibrio cholerae, my sworn enemy, was festering inside me! I was promptly uprooted en masse, tail piece et al, and sent for a total clean up. Ah, I’d take a modern Spa Treatment over that invasion any day, but alas Non-Human Rights weren’t quite in vogue back then…

It was then that a filter was affixed to me, and ever since, I have been subject routinely to the humiliating exercise of ‘periodic sampling.’ I admit that the improvement in Quality Control bodes well for the public health scenario worldwide, but my ego does take a monthly smarting… I eagerly await the day Quality of Life Indices are made even for us Non-Living denizens of the hospital!

While my uber-chic, suave countenance may portray me as being rather urbane, I have had my tryst with the village scenario in India too. Much to my chagrin, a neonate was given his first wash inside me- and imagine my horror when cow dung from his umbilical stump was cleaned into me! I thank the Lord for the impetus that is now being given to Ante- and Peri-Natal Care, which has put a timely end to such dangerous and unsanitary practices!

Pardon my candour, but Victoria Beckham isn’t the only ‘Posh’ British celebrity around… Recently, the laboratory I am stationed in was upgraded, and now ACs provide my sensitive skin respite from the tropical summer. When the hospital was first being constructed by the British, I was the source of cooling for them! I hate to sound so glib, but this fortuitous twist of fate indeed leaves me with a rather more cushy retirement home! 

As I start to pen my memoirs (on popular demand, of course), I slip into a rather pensive mood, and it strikes me how far healthcare has indeed come. When in my carefree youth I was surrounded by prayer and ritual being practised as treatment modalities, and (much like everyone else in the era of the Black Death) had no cognisance of the importance of sanitation; my Mid-Life Crisis was in the form of a difficult transition phase.

Procedures were finding a basis in science; however, much intervention was done manually and was cumbersome. Technicians would pour over me, shake and stir, and shake and stir, and shake and stir some more. A lot of my 50s, I admit, involved heavy consumption of alcohol. (And it wasn’t even good Single Malt! Bleargh!) Formalin use thankfully picked up at the right time, and my liver was spared any permanent alcohol toxicity.

My retirement has been much less rocky, and far more fulfilling. The zenith of my career was undoubtedly when I was declared a key contributor to the improvement of public health! The practise of proper hand washing has positioned me as quite the game-changer in the prevention of nosocomial infections. 

I am also privy to better intellectual stimulation now... Often clinician-researchers pour over me and think aloud (I like to believe my cool splash calms their frazzled nerves), and I have been a sounding board for everything from genetic mutations discovered by PCR, to colorimeter-revealed aberrations! Despite not having subscribed to an Insurance Policy, I am retiring rather “tension-free.” The wall nearest to me has a regularly serviced fire extinguisher, an AED, and an Emergency Response chart affixed to it; in stark contrast to the moon phases that were once etched in to trace the activity of the Devil. And, as yet another batch of MBBS students pours over me, I hear one of them grumble in innocent naiveté about how ‘backward’ one of their cell phones is; and another is quick to point out that in order to effectively practise medicine, a host of Apps are essential... I smile to myself mildly bemused, for if there is one thing I have learnt in all my years, (as I am sure these doctor-lings too will realise some day), it is that, irrespective of the spectrum of prevalent practise of the time, much can be set right by a little laughter and a lot of love. 

“It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature.” -John Brown.

Women are Sisters while Men are Doctors By, Dr.Suranjana Basak, Mumbai

The society has created an image about every profession. Medicine is no different. We imagine a doctor to be the calm, quiet, peaceful, spectacle adorned, neat haired, iron clothed, patient, smiling, relaxed, intelligent, wise person. I know they’re too many adjectives in one line, but that’s what the society has created. When you walk through the hospital aisle and enter the consultant’s cabin outside of which you were waiting for hours together, anxiously holding your complaints, you expect to see this ideal man! The man who would free you of all your troubles. You would imagine this man while waiting outside. How he looks, what he talks like, will you be able to share your complaints? Will it be cancer? Who will look after your husband/wife/kids? You think that this man has the answers and all the negative thoughts that keep coming into your mind are probably just thoughts. You imagine a man.

Medicine, like most other fields is a profession that has been male dominated for a lot of decades. The rise of female healthcare professionals has been seen only in the last four-five decades. If we were to plot a graph for that, it would be seen that there are more number of women enrolling to become doctors than men. Apart from the reason that medicine is a noble profession and as a child you always say, “My ambition is to become a doctor”, reasons like long years of study, tough competition, exorbitant fees and investment seem to get the better side off people. Invariably, almost 50% of medical graduates if not more are women. The irony is, somehow this isn’t very easily digestible to our society. People still choose a male surgeon over a female (without knowing the competency). People still think that a male otorhinolaryngologist will better handle a bleeding nose and that a female sister can nurse him better. A person could be treated more accurately for his gastroenteritis by a male physician and can be better fed by a female sister. Now everyone has their own preferences and can choose the doctor they want to visit. But what happens in 75% instances is that, a female intern/resident/young consultant is often referred to as a “Sister” in day-to-day OPD, IPD scenarios as opposed to a male brother/technician/phlebotomist being referred to as a “Doctor”.

A 40 year old thin pale bearded man with rugged clothes would come up to you and ask “Sister, where is the doctor?” Whereas, if the same person goes and asks a brother who is titrating the dose of a patient’s drug, he would be like, “Doctor, when do I get operated?”

I mean no offence to the support staff. Just like, behind every successful man is a woman. Similarly, behind every successful doctor is an efficient support staff. But the sexist difference prevails far too much in healthcare. You wouldn’t see many girls signing up for Orthopedics specialty but you would see her cover equal amount of work hours and night calls at the hospital as her male batch mate. The surgeon would happily let a male surgical resident perform a jejunostomy on a 45 yr old female but would probably have the female surgical resident to do her complete pre-op work up and post op care. If at all she manages to get a surgery, it’ll probably be that of a mastectomy or circumcision; where she will probably be mocked. It isn’t always the case, but it is very much the case in most hospitals and healthcare setups of the country. Even high profiled ministers, government officials choose a male physician over a female physician who might be as competent if not more. But when it comes to India’s root cause of all problems – the incessant population growth, you would have a different story to tell. Indian men and women (80% of all population) still wish to have a male child. They’re still of the opinion that the male child will look after them better, even though 78% of men abandon their homes and families for their career and dreams. When they think of conceiving, they don’t mind trying as many as 8-10 times and having as many female children aborted or born and killed for ONE male child. Now you want a male child but you would visit a female obstetrician or a gynecologist. Why? Because she understands better. Why? Because she has the same parts as yours and you would relatively feel little less shy. But then she’s a she and not a he! Why don’t you want to visit a male ob/gyn and have him examine your abdomen and vagina?

It is shameful that we live in a country where there is such lack of awareness and constant prejudice towards men despite the substantial talent that women portray. In a country like India, where life threatening diseases with an ever growing population are so prevalent; issues like antenatal sex determination, female foeticide are only increasing the onus of the doctor-patient ratio of 1:1000 as compared to 1:250 of developed nations. While these issues call for a nationwide awakening, the least that any of us can do is STOP DISCRIMINATING between a male and a female doctor.

A female doctor is as competent as a male doctor. She is as concerned, dedicated and efficient as anyone else. She too goes through the same mandatory training. She too studies as hard and has brains as sharp. She deserves to be respected.

8th {Jun}:- The sting Operation

DIVERGING ROADS To be or not to be: What can you do after 5 and half years? By Shinjini Chakraborty Presidency University, Kolkata You make a mark upon your future with decisions that you take. They say, decisions, be it wrong or right, are our guiding stars. The past five and a half years haven‟t been easy. It wasn‟t meant to be. Not when you have taken the „Hippocratic Oath‟, and you wish to serve mankind. Or maybe, you aren‟t keen with such an idealistic outlook. What do you want? Are you sure? Do you know why you want it in the first place? The late Maya Angelou put it this way: “I've learned that making a 'living' is not the same thing as 'making a life.” By now you are sure what your strength areas or your weaknesses are. You know if your sutures are great or the scalpel doesn‟t suit your grip. You know if the lectures in Microbiology made you snore, or you diligently followed the suit of full-fledged orthopaedics. Are you still unsure? Let‟s see if this article can help you get around and find a way.

AROUND THE BEND: Milestones and Directions Source: Google In line with the healers of the world Images It is imperative for each newbie doctor to know clearly about your post-graduate options before you make a sanguine choice to shift your inclination. Knowing how you can use your MBBS degree is much advised. You may seek a postgraduate degree in medicine, or surgery (MD or MS). And you may follow it with a super-specialisation (a DNB or FNB). Please check for the different set of subjects offered as specialisation or super-specialisation (they may not be the same). Its needless to emphasise that these are tough ones to accomplish. If you wish to see yourself in the Royal College of Surgeons „league‟, you may take up an MRCS. The DNB (The Diplomate of National Board Medical Examinations) presently offers an MRCS (Membership of Royal College of Surgeons) degree to those appearing for and obtaining diploma and basically one lands up with two degrees in hand. Note that the FRCS (fellowship) has been discontinued by the 4 Royal Colleges of London. THE CORPORATE INSIGNIA You may have had a sleepy inclination towards understanding the dynamics of corporate proceedings in hospitals and pharmaceutical industries. However, they do pay generously. Moreover, some amount of glamour, suave intellect and management skills is required to run such firms. The degrees that you may follow up your MBBS with are:  Master‟s in Health Administration (MHA)  Master‟s in Business Administration (MBA)

A number of good to great institutes offer these courses and one may find details of the same just a click away!

THE RESEARCH LABORATORY MBBS may be followed by a post-graduate degree in research application related fields. In the country and abroad, a range of courses (opportunities and variations are still proliferating in India) offer interested candidates with a chance to explore the nooks and corners of unexplained biological and physiological phenomena. If you wish to pursue a PhD in India, you may have to appear for central and specific qualifying tests (e.g. UGC- NET, TIFR entrance exams etc.). If you want to fly away, prepare yourself for a GRE (for American Institutes) or simply apply with your IELTS scores (for European Institutes). Presently, research demands in microbiology, immunology, pharmacology and medical genetics have been incremental. DOING IT DIFFERENTLY: Knowledge Process Outsourcing, Nutrition and Public Health The pay is better, the work is interesting, and needless to say, you can indeed develop your skills as such professionals are in adequately decent demand in most multispecialty clinics. KPO directs you to outsource your knowledge repository as freelancers or professionals. Public Health Services is a brilliant way to channelize your commitment and skills toward the development of the health sector in your own country. Civil services (IAS, IFS) and exams like UPSC may pave your way for the same. Joining the World Health Organisation or United Nations is a far-reaching aim, but not impossible. IN THE FOREIGN LANDS For aspirants who want to completely turn around their career prospects and opportunities, USMLE (United States Medical Licensing Examination) and PLAB (Professional and Linguistic Assessment Board) are ways to do it. Qualifying these two would allow you to practice in USA and Europe respectively. But you should also be aware; the monetary investment is going to be too high in this case. THE JOURNALIST’S VIEW: MEDICAL JOURNALISM It‟s a brilliant way to channelize your knowledge base to interpret clinical trials and represent them in the form interesting bits of information and trivia! Journalism is also a very uncommon, but not impractical option to go with. You may just land up with a job at the prestigious Nature publications or the Lancet and the job is a crux of satisfaction for those who seek it! It is possible to be indecisive. It is possible that this article doesn‟t ideally make you go, “Voila! I know my life‟s purpose!” Admitting with honesty, this was an attempt to inform you and awaken your sanguinity to what is possible. The rest, is your choice; but that should be a deliberate and well-considered choice. But never mind all the pressure! After all, it‟s great to know you are capable of putting your degree to good use as long as you are taking the cues of your innate natural aptitudes.

The Mighty Mite! By Ashwini Ronghe Grant Medical College & Sir JJ Group of Hospitals, 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 described so 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. Image source: Chiggernation.com 2) Itch mite: The itch mite is Sarcoptes scabiei. Scabies, a skin infection by this mite is also 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 is usually 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 Image source: diagnostic of the disease. en.wikipedia.org

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.

Image source: www.easierventilation.co.nz 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! RISE OF THE RODENT ARMY Is India’s Public Health Situation Losing the Rat Race...To Rats Themselves? By Bianca Honnekeri Grant Medical College & Sir JJ Group of Hospitals, Mumbai "I only hope that we don't lose sight of one thing - that it was all started by a mouse," said Walt Disney, of the beloved Mickey Mouse. How true that rings even today, when certain rodent-borne diseases amble into context and leave epidemics in their wake! Rodents include rats, mice, squirrels, guinea pigs and hamsters. In India, the exploding rat population remains a pressing public health hazard. Rat urine is responsible for spreading Leptospirosis, the incidence of which escalates in the monsoons. It also transmits a viral infection resulting in Lymphocytic Choriomeningitis. Rat bites and scratches can cause Rat-Bite Fever (interestingly, first described in India itself, over 2000 years ago)! Rats are responsible for diseases spread by the fleas they harbour, like Plague and Typhus, and for festering bacterial infections like Salmonellosis and Tularaemia. Less commonly encountered diseases they spread include Hantavirus Pulmonary Syndrome, Eosinophilic Meningitis, Lassa Fever and Haemorrhagic Fever. Most worryingly, a single fertile pair of rats can breed to over 200 rats annually, and these skyrocketing numbers further compound the menace! LEPTOSPIROSIS The monsoon brings with it an ominous collapse of infrastructure, heralding waterlogging and flooding in various cities, with Mumbai being an infamous poster boy for this debacle. With a welcoming increase in water levels of Lake Tulsi and Lake Vaitarna, there is also a troubling rise in the incidence of Leptospirosis in the city. In the year 2013, with approximately 200 reported cases, the outbreak of Leptospirosis in Mumbai reached a 4-year peak, and claimed 3 lives. In the year 2010, out of 135 reported cases, 18 people succumbed to this disease. Cause Leptospirosis is caused by a bacterial spirochaete species Leptospira (L. interrogans), infectious to animals like rats, dogs, sheep, cows, rabbits, and mice. Humans are infected upon contact with water, food or soil contaminated by the urine of infected animals; however, human-to-human transmission is extremely rare.

Clinical Features It is a biphasic disease beginning with flu-like symptoms (fever, chills, myalgia), which are mild and resolve into a briefly asymptomatic phase. Severe leptospirosis follows in about 10% patients, and involves damage to the heart, lungs, kidneys, liver, brain etc. The mild type is self-limiting, consists of two stages (septicaemia and immune) and is called anicteric leptospirosis. Weil‟s Syndrome is the severe, potentially fatal icteric leptospirosis.

Signs and Symptoms Patients may present with high fever, severe headache, chills, muscle aches, and vomiting. They could also have jaundice, red eyes, abdominal pain, diarrhoea, and rash; or symptoms that resemble pneumonia. More severe cases present with symptoms of organ damage, like kidney and liver failure, heart problems and/or meningitis. Diagnosis Serological methods of diagnosis are preferred over culture, ELISA and PCR are confirmatory tests, and MAT (Microscopic Agglutination Test) is considered the gold standard. Prevention In high-risk areas, Doxycyline can be administered once a week 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. Treatment The penicillin group of antibiotics is effective in treating Leptospirosis, as is Doxycycline. Severe cases may require cefotaxime or ceftriaxone. Supportive therapy includes infusion of i.v. fluids, dialysis in serious cases, and taking appropriate measures to maintain electrolyte balance. Serum potassium and phosphorus levels must be monitored. Corticosteroids (e.g. Prednisolone) may be administered in severe cases, for a duration of 7 to 10 days. Organ-specific interventions are required if there is kidney, liver, heart or brain involvement. SALMONELLOSIS Also spread by ingestion of food or water contaminated by the urine or faeces of an infected animal, most people present with fever and gastrointestinal (G.I.) symptoms like diarrhoea, vomiting and abdominal cramps. As with other G.I. infections, the treatment is most often supportive (maintaining hydration). Rat nests in the kitchen are often ominous harbingers of this disease. Oh Rats! In an intriguing dichotomy of sorts, the globally renowned Karni Mata Rat Temple in Bikaner is home to over 20,000 rats, which are considered sacred and worshipped here! Conversely, these furry (and some may argue, „cute‟) little animals however exhibit an entirely different nature in unsanitary environs like those of our cities, already exploding at the seams and severely lacking in supportive infrastructure. The BMC in Mumbai has a team of trained personnel called Night Rat Killers, who find themselves waging a losing war against the burgeoning rodent population in the megapolis. This situation is echoed elsewhere too, including Chennai, Bangalore and New Delhi. Mumbai also has the uniquely dubious distinction of having exported rats to Doha, courtesy the rat infestation at the International Airport! If only all we needed was a pied piper! GET SOME HELP On spotting tell-tale signs of an infestation, namely bite marks, smears, rat droppings, nests or burrows, chewed surfaces or fabrics, or, more obviously, actually seeing the rat in all its whiskered glory, (once you are done seeking refuge on the nearest couch!) these are some registered agencies you may contact for professional rodent-control interventions:

1. Pest Control Association of India http://www.pcai-india.org/

2. Indian Pest Control Association http://www.ipca.org.in/

3. Rentokil India http://www.rentokil.in/index.html

It is imperative, however, that rat infestations are not shrugged off as seemingly inconsequential side-effects of unhygienic surroundings in a nation plagued by myriad other public health concerns, but are recognized for the many dangerous and potentially fatal diseases they harbour, and combated effectively. The advent of monsoons further underscores the urgency to collectively take action in this regard. “By gnawing through a dyke, even a rat may drown a nation,” - Edmund Burke It is time for us to be responsible citizens, promote civic sense and public hygiene, and never allow the metaphor to extend to India‟s public health situation.

7th {Feb} The Bitter Sugar

DIABETES EXCLUSIVE Adiponectin an endocrine hormone and its association with Diabetes

By Ruchira Dhoke

Adipose tissue, in recent research is found as not only a major site for energy storage but also as an important endocrine organ that plays a pivotal role in the integration of endocrine, metabolic, and inflammatory signals for the control and maintenance of energy homeostasis. The adipocyte secretes a variety of bioactive proteins into the circulation. These secretory proteins have been collectively named as adipocytokines, which include leptin, tumor necrosis factor (TNF)-α, plasminogen activator inhibitor type 1 (PAI-1) ,adipsin , resistin, and adiponectin.

Adiponectin, the gene product of the adipose most abundant gene transcript 1(apM1), is a novel protein and important member of the adipocytokine family. Adiponectin cDNA was first isolated by large scale random sequencing of the human adipose tissue cDNA library. 1

Adiponectin circulates in plasma as three oligomeric isoforms. High-molecular-weight (HMW) adiponectin is thought to be the most biologically active form of adiponectin in terms of glucose homeostasis. The effects of the medium-molecular-weight (MMW)-subform and the low-molecular weight (LMW)-subform are still unresolved.

Adiponectin when subjected to post-translatory modifications, changes the three- dimensional structure of the molecule. The post-translatory modifications are essential for the formation of different polymeric forms.2 Recent data suggest that it is changes in the ratio of the high-molecular-weight (HMW) subform to total adiponectin rather than changes in total adiponectin that contribute to the improved insulin sensitivity.

Preclinical and clinical studies have revealed that adiponectin possesses anti-inflammatory, antiatherogenic, and cardioprotective properties .3, 4, 5 Low concentrations of adiponectin have been reported in obesity 6, 7, type 2 diabetes 6, 8, and coronary artery disease .8, 9 Maintenance of normal adiponectin levels, or even induction of elevated levels, is considered to be beneficial as high levels have been associated with lower risk of myocardial infarction in healthy men10. However, adiponectin levels are increased in chronic conditions with a clearly increased cardiovascular mortality such as type 1 diabetes (with or without nephropathy)11, chronic heart failure 12, and end-stage renal disease 13.The reason and a possible explanation for an elevated adiponectin level found in these chronic conditions is yet to be found. The molecular distribution of adiponectin remains to be evaluated in these chronic conditions. Association of elevated HMW Adiponectin with Diabetes Type 1

Several studies have shown that type 1 diabetic patients have elevated total levels of the adiponectin. The article establishes the relationship of adiponectin in association with diabetes. To investigate the molecular distribution of adiponectin in patients with elevated total adiponectin levels, a study was carried out to compare type 1 diabetic patients with varying degrees of nephropathy to healthy controls. The Study population included: 207 individuals with 58 type 1 diabetics with normoalbuminuria, 46 with microalbuminuria, 46 with macroalbuminuria and 57 matched controls. The researcher concluded that the Type 1 diabetes is associated with higher adiponectin- levels than healthy subjects. This increase is mainly explained by an elevation in the HMW subform. The elevation is unaffected by gender and diabetic kidney disease.

Adiponectin has been shown to be a predictor of type 2 diabetes. But only a few epidemiological studies have investigated the association of HMW adiponectin with risk of developing type 2 diabetes; some researchers found that HMW adiponectin and the ratio of HMW to total adiponectin were inversely associated with the risk .14,15,16 Moreover, compared with total adiponectin, HMW adiponectin was more strongly related to the development of type 2 diabetes .17

HMW Adiponectin associated with renal insufficiency in type 2 diabetic patients

As the leading cause of kidney failure in the world, type 2 diabetes has been postulated to be a generalized inflammatory condition resulting from obesity-induced dysregulation of Adipocytes, which produce an excess of inflammatory cytokines .18 Scientists have speculated that this persistent inflammatory state further contributes to the development of the extensive vascular disease characteristic of diabetes.

A study was carried out which aimed at determining whether the high-molecular-weight (HMW) complex of adiponectin is associated with renal insufficiency in type 2 diabetic patients. A total of 179 type 2 diabetic patients were selected from among outpatients and divided into four groups according to their albumin-to-creatinine ratio and the serum HMW adiponectin was specifically assayed with a commercially available enzyme-linked immunosorbent assay kit.

The study concluded that the serum HMW adiponectin concentrations were higher in type 2 diabetic patients with nephropathy. Unlike type 1 these levels were found to be associated with renal insufficiency.

Association of elevated levels of serum total and high molecular weight adiponectin with diabetic micoangiopathy

Unlike leptin and many other adipokines, adiponectin’s circulating concentration decreases with increasing adiposity.19 It is believed that adiponectin acts as an anti-inflammatory mediator and thus play a role in the prevention of diabetic microangiopathy. 20,21

In a study carried out to determine the association of elevated levels of serum total and high molecular weight adiponectin with the diabetic micoangiopathy , fasting serum samples of 198 patients with type 2 diabetes mellitus (T2DM) were measured using an enzyme-linked immunosorbent assay (ELISA). The study concluded that serum total adiponectin and HMW adiponectin were found to be positively correlated with the severity of retinopathy and nephropathy but not with neuropathy in T2DM.

Decreased total adiponectin an independent risk factor for type 2 diabetes in Japanese-Americans: is Westernized lifestyle the cause?

Insulin resistance which is induced by a high-fat diet is associated with obesity and is a major risk factor for type 2 diabetes. In a longitudinal study carried out on monkeys, the adiponectin levels decreased before the onset of diabetes in parallel with a decrease in insulin sensitivity .22 Further studies carried out on mice suggest that glucose tolerance is in attenuation with high fat diet as the adiponectin-deficient mice were more susceptible to diet-induced insulin resistance.23-25 Hence, in humans, it is thought that one who has decreased serum adiponectin levels is liable to develop type 2 diabetes on a high-fat diet. Moreover, weight reduction or treatment with the insulin-sensitizing drug known as thiazolidinedione preferentially elevates the HMW adiponectin in comparison with the other two oligomeric complexes .25,26 The aforementioned studies suggest that the oligomeric complex distribution of adiponectin is important for the antidiabetic and antiatherogenic activity of this hormone. Therefore, the influence of HMW adiponectin as a risk for type 2 diabetes is thought to be more important than total adiponectin. A study was carried out on Japanese-Americans subjects enrolled in the Hawaii-Los Angeles- Hiroshima study between 1992 and 2002. The aim of the study was to assess whether decreased total and HMW adiponectin are independent risk factors for the development of type 2 diabetes. Non-diabetic Japanese-Americans; 321 men and 445 women were investigated. Glucose tolerance was evaluated according to 1997 American Diabetes Association criteria and 112 subjects developed type 2 diabetes during the follow-up period. It was found that subjects who developed type 2 diabetes had significantly decreased plasma total and HMW adiponectin compared with those who did not develop the disease .Both decreased total and HMW adiponectin levels seemed to be independent risk factors for the progression to type 2 diabetes after adjusting for sex, age, body mass index, waist-to-hip ratio, homeostasis model assessment, and classification of 75-g glucose tolerance test .

Japanese-Americans who are identical to their Japanese progenitors have lived Westernized lifestyles for decades and consumed high-fat and high simple carbohydrate diets .27,28 It is reported that Japanese-Americans are hyperinsulinemic and insulin resistant compared with native Japanese, and their prevalence of diabetes is two to three times higher than their Japanese counterparts.27 For Japanese-Americans with Westernized lifestyles, the influence of adiponectin on the development of type 2 diabetes is expected to be more apparent than in Japanese. The results also indicated that the association might be more closely related to the development of type 2 diabetes than total adiponectin levels and decreased HMW adiponectin concentrations may be a more useful predictor than total adiponectin for assessing the risk of type 2 diabetes. Reduced Adiponectin Concentration in Women with Gestational Diabetes: A potential factor in progression to type 2 diabetes

In recent years, the adiponectin have been shown to play a role in complications of pregnancy, including gestational diabetes mellitus (GDM) and pre-eclampsia (PE). Since gestational diabetes (GDM) identifies a population of young women at high risk of future T2DM (i.e. representing an early stage in the natural history of the disease) 29, a study was done to determine if decreased HMW adiponectin is a feature of GDM.

HMW and total adiponectin were measured in 121 women at the time of oral glucose tolerance testing (OGTT) in late pregnancy, following an abnormal glucose challenge test. Based on the OGTT, there were 41 women with and 80 without GDM.

According to the hypothesis that hypoadiponectinemia may be associated with GDM the present study investigated the relationship between adiponectin and glucose tolerance in pregnancy. Consistent with the established inverse relationship between plasma adiponectin concentration and insulin resistance, hypoadiponectinemia has been documented in patients with each of these pathologic conditions 30-34 suggesting that hypoadiponectinemia may be an important factor in the development of insulin resistance and the pathophysiology of type 2 diabetes.

The study proved that HMW adiponectin significantly decreases in women with GDM. Deficiency of HMW adiponectin may be an early event in the natural history of T2DM.

CONCLUSION

The view towards Adiponectin as “just another fat cell hormone” is no longer tenable. As a circulating protein synthesized solely in adipose tissue, it appears to play a very important role in carbohydrate and lipid metabolism and vascular biology. It has significant insulin- sensitizing as well as anti-inflammatory properties that include suppression of macrophage phagocytosis and TNF-α secretion and blockage of monocyte adhesion to endothelial cells in vitro.

Adiponectin administration, as well as regulation of the pathways controlling its production, represents a promising target for managing obesity, hyperlipidemia, insulin resistance, type 2 diabetes, and vascular inflammation ,although further studies and investigation are required for the same.

Numerous aspects and other intriguing questions on the metabolic roles of this new adipocyte hormone will undoubtedly provide an additional insight.

REFERENCES 1. Maeda K, Okubo K, Shimomura I, Funahashi T, Matsuzawa Y, Matsubara K:cDNA cloning and expression of a novel adipose specific collagen-like factor,apM1 (adipose most abundant gene transcript 1). Biochem Biophys Res Commun221:286–289, 1996. 2. Richards AA, Stephens T, Charlton HK, Jones A, Macdonald GA, Prins JB,Whitehead JP 2006 Adiponectin multimerization is dependent on conserved lysines in the collagenous domain: evidence for regulation of multimerization by alterations in posttranslational modifications. Mol Endocrinol 20:1673–1687 3. Yamauchi T, Kamon J, Ito Y, Tsuchida A, Yokomizo T, Kita S, Sugiyama T,Miyagishi M, Hara K, Tsunoda M, Murakami K, Ohteki T, Uchida S,Takekawa S, Waki H, Tsuno NH, Shibata Y, Terauchi Y, Froguel P, Tobe K,Koyasu S, Taira K, Kitamura T, Shimizu T, Nagai R, Kadowaki T 2003 Cloning of adiponectin receptors that mediate antidiabetic metabolic effects.Nature 423:762–769 4. 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Arita Y, Kihara S, Ouchi N, Takahashi M, Maeda K, Miyagawa J, Hotta K,Shimomura I, Nakamura T, Miyaoka K, Kuriyama H, Nishida M, Yamashita S, Okubo K, Matsubara K, Muraguchi M, Ohmoto Y, Funahashi T, Matsuzawa Y 1999 Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. Biochem Biophys Res Commun 257:79–83 8. Hotta K, Funahashi T, Arita Y, Takahashi M, Matsuda M, Okamoto Y,Iwahashi H, Kuriyama H, Ouchi N, Maeda K, Nishida M, Kihara S, Sakai N, Nakajima T, Hasegawa K, Muraguchi M, Ohmoto Y, Nakamura T, Yamashita S, Hanafusa T, Matsuzawa Y 2000 Plasma concentrations of a novel, adipose-specific protein, adiponectin, in type 2 diabetic patients. Arterioscler Thromb Vasc Biol 20:1595–1599 9. Ouchi N, Kihara S, Arita Y, Maeda K, Kuriyama H, Okamoto Y, Hotta K, Nishida M, Takahashi M, Nakamura T, Yamashita S, Funahashi T, Matsuzawa Y 1999 Novel modulator for endothelial adhesion molecules: adipocyte-derived plasma protein adiponectin. Circulation 100:2473–2476 10. Pischon T, Girman CJ, Hotamisligil GS, Rifai N, Hu FB, Rimm EB 2004 Plasma adiponectin levels and risk of myocardial infarction in men. JAMA 291:1730–1737 11. Frystyk J, Tarnow L, Hansen TK, Parving HH, Flyvbjerg A 2005 Increased serum adiponectin levels in type 1 diabetic patients with microvascular complications.Diabetologia 48:1911–1918 12. Kistorp C, Faber J, Galatius S, Gustafsson F, Frystyk J, Flyvbjerg A, Hildebrandt P 2005 Plasma adiponectin, body mass index, and mortality in patients with chronic heart failure. Circulation 112:1756–1762 13. Zoccali C, Mallamaci F, Tripepi G, Benedetto FA, Cutrupi S, Parlongo S,Malatino LS, Bonanno G, Seminara G, Rapisarda F, Fatuzzo P, Buemi M, Nicocia G, Tanaka S, Ouchi N, Kihara S, Funahashi T, Matsuzawa Y 2002 Adiponectin, metabolic risk factors, and cardiovascular events among patients with end-stage renal disease. J Am Soc Nephrol 13:134–141. 14. Heidemann C, Sun Q, van Dam RM, Meigs JB, Zhang C, Tworoger SS, Mantzoros CS, Hu FB 2008 Total and high-molecular-weight adiponectin and resistin in relation to the risk for type 2 diabetes in women. Ann Intern Med 149:307–316 16. Oh DK, Ciaraldi T, Henry RR 2007 Adiponectin in health and disease. Diabetes Obes Metab 9:282–289 15. Nakashima R, Kamei N, Yamane K, Nakanishi S, Nakashima A, Kohno N 2006 Decreased total and high molecular weight adiponectin are independent risk factors for the development of type 2 diabetes in Japanese-Americans. J Clin Endocrinol Metab 91:3873– 3877 16. Basu R, Pajvani UB, Rizza RA, Scherer PE 2007 Selective downregulation of the high molecular weight form of adiponectin in hyperinsulinemia and in type 2 diabetes: differential regulation from nondiabetic subjects. Diabetes 56:2174–2177 17. Wang Y, Lam KS, Yau MH, Xu A 2008 Post-translational modifications of adiponectin: mechanisms and functional implications. Biochem J 409:623–633 18. Zinman B, Hanley AJ, Harris SB, Kwan J, Fantus IG: Circulating tumor necrosis factor- alpha concentrations in a native Canadian population with high rates of type 2 diabetes mellitus. J Clin Endocrinol Metab 84:272–278, 1999 19. Sowers JR 2008 Endocrine functions of adipose tissue: focus on adiponectin. Clin Cornerstone 9:32–40 20. Hadjadj S, Aubert R, Fumeron F, et al; SURGENE Study Group; DESIR Study Group. Increased plasma adiponectin concentrations are associated with microangiopathy in type 1 diabetic subjects. Diabetologia 2005;48:1088-92. 21. Brooks NL, Moore KS, Clark RD, Perfetti MT, Trent CM, Combs TP. Do low levels of circulating adiponectin represent a biomarker or just another risk factor for the metabolic syndrome? Diabetes Obes Metab. 2007;9:246-58. 22. Hotta K, Funahashi T, Bodkin NL, Ortmeyer HK, Arita Y, Hansen BC, Matsuzawa Y 2001 Circulating concentrations of the adipocyte protein adiponectin are decreased in parallel with reduced insulin sensitivity during the progression to type 2 diabetes in rhesus monkeys. Diabetes 50:1126 –1133 23. Kubota N, Terauchi Y, Yamauchi T, Kubota T, Moroi M, Matsui J, Eto K,Yamashita T, Kamon J, Satoh H, Yano W, Froguel P, Nagai R, Kimura S, Kadowaki T, Noda T2002 Disruption of adiponectin causes insulin resistance and neointimal formation. J Biol Chem 277:25863–25866 24. Maeda N, Shimomura I, Kishida K, Nishizawa H, Matsuda M, Nagaretani H, Furuyama N, Kondo H, Takahashi M, Arita Y, Komuro R, Ouchi N, Kihara S, Tochino Y, Okutomi K, Horie M, Takeda S, Aoyama T, Funahashi T, Matsuzawa Y 2002 Diet-induced insulin resistance in mice lacking adiponectin/ACRP30. Nat Med 8:731–737 25. Nawrocki AR, Rajala MW, Tomas E, Pajvani UB, Saha AK, Trumbauer ME, Pang Z, Chen AS, Ruderman NB, Chen H, Rossetti L, Scherer PE 2006 Mice lacking adiponectin show decreased hepatic insulin sensitivity and reduced responsiveness to PPAR- agonists. J Biol Chem 281:2654 –2660 M, Combs TP, Rajala MW, Doebber T, Berger JP, Wagner JA, Wu M, Knopps A, Xiang AH, Utzschneider KM, Kahn SE,Olefsky JM, Buchanan TA, Scherer PE 2004 Complex distribution, not absolute amount of adiponectin, correlates with thiazolidinedione-mediated improvement in insulin sensitivity. J Biol Chem 279:12152–12162 26. Hammarstedt A, Sopasakis VR, Gogg S, Jansson PA, Smith U2005 Improved insulin sensitivity and adipose tissue dysregulation after short-term treatment with pioglitazone in non-diabetic, insulin-resistant subjects. Diabetologia 48:96 –104 3876 J Clin Endocrinol Metab, October 2006, 91(10):3873–3877 Nakashima et al. • Adiponectin and Diabetes Risk 27. Hara H, Egusa G, Yamakido M, Kawate R 1994 The high prevalence of diabetes mellitus and hyperinsulinemia among the Japanese-Americans living in Hawaii and Los Angeles. Diabetes Res Clin Pract 24:S37–S42 28. Nakanishi S, Okubo M, Yoneda M, Jitsuiki K, Yamane K, Kohno N 2004 A comparison between Japanese-Americans living in Hawaii and Los Angeles and native Japanese: the impact of lifestyle westernization on diabetes mellitus.Biomed Pharmacother 58:571–577 29. Kjos SL, Buchanan TA: Gestational diabetes mellitus. N Engl J Med 341:1749– 1756, 1999 30. Arita Y, Kihara S, Ouchi N, Takahashi M, Maeda K, Miyagawa J, Hotta K, Shimomura I, Nakamura T, Miyaoka K, Kuriyama H, Nishida M, Yamashita S, Okubo K, Matsubara K, Muraguchi M, Ohmoto Y, Funahashi T, Matsuzawa Y: Paradoxical decrease of an adipose-specific protein, adiponectin, in obesity. Biochem Biophys Res Commun 257:79–93, 1996 31. Weyer C, Funahashi T, Tanaka S, Hotta K, Matsuzawa Y, Pratley RE, Tataranni PA: Hypoadiponectinemia in obesity and type 2 diabetes: close association with insulinresistance and hyperinsulinemia. J Clin Endocrinol Metab 86:1930–1935, 2001 32. Hotta K, Funahashi T, Arita Y, Takahashi M, Matsuda M, Okamoto Y, Iwahashi H, Kuriyama H, Ouchi N, Maeda K, Nishida M, Kihara S, Sakai N, Nakajima T, Hasegawa K, Muraguchi M, Ohmoto Y, Nakamura T, Yamashita S, Hanafusa T, Matsuzawa Y: Plasma concentrations of a novel, adipose-specific protein, adiponectin, in type 2 diabetic patients. ArteriosclerThromb Vasc Biol 20:1595–1599, 2000 33. Ouchi N, Kihara S, Arita Y, Maeda K, Kuriyama H, Okamoto Y, Hotta K, Nishida M, Takahashi M, Nakamura T, Yamashita S, Funahashi T, Matsuzawa Y: Novel modulator for endothelial adhesion molecules: adipocyte- derived plasma protein adiponectin.Circulation 100:2473–2476, 1999 34. Kumada M, Kihara S, Sumitsuji S, Kawamoto T, Matsumoto S, Ouchi N, Arita Y, Okamoto Y, Shimomura I, Hiraoka H, Nakamura T, Funahashi T, Matsuzawa Y: Association of ypoadiponectinemia with coronary artery disease in men. Arterioscler Thromb Vasc Biol 23:85–89, 2003

OPEN LETTER

“PLEASE STOP AND LISTEN” By: Geeta. S From: Your inner self To: The Body Jan 2014 Subject: We are in so much trouble.

Dear fellow, I tried to make this one formal coz you’ve been ignoring all my previous letters. It’s so hard to manage all alone now. You have to understand that we are related. We are a unit together. We function in sync. You can’t keep doing whatever you like without consulting me. All that abuse is getting to me. I am helpless. I am not a junkyard. I send out so many signs, so many signals, and so many protests. But why, oh why don’t you get it? All that nonsense you throw my way, how do you think I am to get around it? I don’t have a magic wand. I am not a wizard like the Harry Potter series you read. You do know somewhere deep down that we are parts of the whole, right? It affects me; my hands are tied, and I can only tell you; you are my only communication, my only helpline. It’s been 2 years since we have been diagnosed with Diabetes type 2. If you had really asked me, given me a chance to explain, I would have told you years ago that we had trouble creeping up. I knew and you knew too that our aunt, our siblings had Diabetes. We knew in unison that our genes had misfortune thrown at them. But you didn’t bother, didn’t care, didn’t even stop and think even for a second whether you had inherited any of those twisted chromosomes. We were young and the impact at that stage was less and we could have managed to come out superior if you controlled it. But you let environment mediate the result. I was in agony then. Screaming sometimes, protesting so much, but you didn’t hear. With the beauty of youth on your mind; why would you listen to me? I let that pass. I thought maybe when you grew mature you would grow a more sensible approach. But you didn’t. You ate everything from the fries, burgers, chips and all that oozed fat. Tiresome of trying so hard to warn you, I let you put on that tummy you hate so much. Maybe I thought that would make you work out and join a gym. But earning money and losing sleep over it was your priority. The doctors advised a stringent control on our blood sugar. They prescribed drugs, asked you to constantly maintain the level in appropriate ranges so that it didn’t affect our kidneys or our eyesight. You didn’t listen to them either. So, obesity was the only way I hoped that you could reciprocate with caution. However, my hoping was way out of direction. You let yourself get morbidly obese. Dyspnea, sleep apnea, hypertension, hyperlipidemia, coronary artery disease…reads the enormous list on the doctor’s chart. Whence, I worry so much about our future. Will we be in kidney failure, requiring dialysis or have a severe retinopathy that we can’t ever see clearly again? The pills go on piling up. Our health is failing. We are straining. We need a plan to remain healthy with the reserve of resources we have. Consider this letter as my final plea to a better lifestyle. A last attempt to correct our outcome. Hoping to see a change… Love, Your buddy.

THE VERSES FROM ATHARVA

By Ruchira Dhoke If type 2 diabetes was an infectious disease, we would have been in the midst of an epidemic. The disease, once known to be adult-onset diabetes, is striking an ever-growing number of adults. What is more alarming is the fact that it is now beginning to show up in teenagers and children as well. It’s time to tweak our brain and assess our lifestyle to decrease the risk. An early detection to prevention or delay type 2 diabetes one can stay at a healthy weight, eat well and be active. With the following steps you can stay healthier longer and lower the risk of acquiring diabetes type 2.

1. Do you have a mother, father, sister or brother with diabetes? If your answer is yes then a family history of diabetes could mean you are genetically vulnerable, putting you at a higher risk.

2. Are you Overweight?

Being overweight raises your risk for type 2 diabetes, heart disease and stroke. It can cause other problems, too, like high blood pressure, unhealthy cholesterol, and high blood glucose (sugar). Losing weight can help you prevent and manage these problems. Even losing 10-15 pounds can make a big difference.

Weight loss can be hard because it means. Losing weight also takes time and can be hard because it means making changes in the way you eat and in your physical activity — and that can be frustrating Get Started

 Cut back on calories and fat.  Be physically active most days of the week.  Eat breakfast every day.  Watch your weight, what you eat and drink, and what form of physical activity you do.  It's much easier to lose weight when you change the way you eat and also increase your activity.

3. Are you eating Healthy?

Eating well to maintain a healthy weight is one of the most important things you can do to lower your risk for type 2 diabetes and heart disease.

Build a Healthier Plate

 Choose more fresh vegetables, fruits, and whole grains while shopping.  Buy leaner meats (such as chicken, turkey and lean cuts of pork or beef such as sirloin or chuck roast) and lower fat dairy products (like low- fat or skim milk and yogurt).  Buy whole grain breads and cereals.  Buy less soda, sweets and chips or other snack foods.  Eat meals with a salad or a broth or tomato- based soup with lots of vegetables. This helps you by filling you up before you get to the higher fat and calorie courses.  In restaurants, ask if meats can be grilled rather than fried, and request sauces and dressings on the side. Save lots of calories, by skipping dessert.

4. What Can Physical Activity do for you?

 Helps keep your blood glucose, blood pressure, HDL cholesterol and triglycerides on target  Lowers your risk for pre-diabetes, type 2 diabetes, heart disease and stroke  Relieves stress  Strengthens your heart, muscles and bones  Improves your blood circulation and tones your muscles  Keeps your body and your joints flexible

A complete physical activity routine includes four kinds of activity:

1. Activity—walking, using the stairs, moving around—throughout the day 2. Aerobic exercise, such as brisk walking, swimming, or dancing 3. Strength training, like lifting light weights 4. Flexibility exercises, such as stretching

5. What is Prediabetes?

Before people develop type 2 diabetes, they almost always have "prediabetes" — blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes.

Doctors sometimes refer to prediabetes as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on what test was used when it was detected. This condition puts you at a higher risk for developing type 2 diabetes and cardiovascular disease. There are no clear symptoms of prediabetes. A prediabetic should show following results on testing:

 An A1C of 5.7% – 6.4%  Fasting blood glucose of 100 – 125 mg/dl  An OGTT 2 hour blood glucose of 140 mg/dl – 199 mg/dl

Preventing Type 2 Diabetes

You will not develop type 2 diabetes automatically if you have prediabetes. For some people with prediabetes, early treatment can actually return blood glucose levels to the normal range.

Research shows that you can lower your risk for type 2 diabetes by 58% by:

 Losing 7% of your body weight (or 15 pounds if you weigh 200 pounds)  Exercising moderately (such as brisk walking) 30 minutes a day, five days a week

Explore you risk

 High Blood Glucose: Managing your blood glucose (sugar) can help you prevent and manage type 2 diabetes.  High Blood pressure: High blood pressure raises your risk for heart disease, stroke, and other problems. Managing blood pressure can help prevent these problems.  Cholesterol: Unhealthy cholesterol levels can raise your risk for type 2 diabetes and heart disease.  Genetics: There are some things that affect your risk that you can't change. Being aware of them can help you take smart steps to lower your risk.  Gestational Diabetes: If you've had gestational diabetes, you’re at higher risk of it in future pregnancies and of type 2 diabetes later in life.  Smoking: Smoking causes a lot of problems in your body and can raise your risk of heart attack or stroke.  Diabetes and Cancer: Type 2 diabetes and certain cancers share many risk factors. Lower your risk for both.

6th {Dec} Human Vitae

Steps to distill ‗Humanae Vitae‘

By, Dr.Raviteja Innamuri, PG Aspirant

―The beauty lies in the cortical areas 43, 16, 17, 18 and 28.‖

Let us consider ‗thought‘ as the as the single quotable unit of measurement

available to us and let me walk you down the street. I cannot help but wonder

at the incredible number of amazing thoughts that have had sex in order to

manifest as the sensual picture that we perceive, every object that we see

being the result of intersection of thoughts of individuals unknown to us over

thousands of years.

Look at the concrete that we tread upon; think of Nobel‘s dynamite that

fragmented that mountain to gravel, that road tar extracted from the Earth

beneath, the highway engineers, the gigantic rollers that have cladded the bare

Earth and the thoughts that have made these ideas and acts possible! Apply

this ideology to the poles that stand, the AV current that sings running through

the wires, steel and plastic that have been molded into every shape possible,

hardware turning into software, you and me. Don‘t you now see thoughts,

which make thoughts, collide with each other in the past, the present and the

future in complete chaos?

We remember many such pioneers in the field of Medicine, Edward Jenner,

"the father of immunology" to Craig Venter who made the first artificial

bacteria! But who is it, I wonder, the father of a spoon that feeds me daily or

for a fact, the inventor of my bread toaster? What makes anything less

important than the contributions of the Fathers of Medicine? Isn‘t the

neighboring toy store spreading happiness as well? What makes these great

things great?

The answer to this incredible or every other question potentially lies in what

Charles Darwin called ‗Evolution‘. The question could be, why men adore large

mammary glands to why our brains get bigger reading Lexicon! The answer is- evolution! Yes, a ‗better you‘ leads to healthier stronger progeny, which results

in the evolution of our race, thereby of the nature. It‘s all right if you don‘t

agree, but we are all subconsciously wired that way! Medicine dominates every

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other branch that has evolved out of Philosophy (even Newton‘s first book was

Latin for "Mathematical Principles of Natural Philosophy") for the single reason

that ‗it saves lives‘ and after all, life is precious, as we have to live first, to

evolve next! An alternate answer was given by a renowned Radiologist recently,

who claimed that inventors invent because they are ‗unhappy‘ with what they

have, which I strongly disagree with but that strangely explains why our saintly

ancestors could have been happy in ancient India- we had nothing but loin

cloth, deep jungles, deeper philosophy and Marijuana!? The life of every great

individual is rooted into the fundamental methods through which they

achieved what they believed in. Mahatma Gandhi‘s ‗The Story Of My

Experiments with Truth‘ reverberates with his determination and his

unshakable belief in Leo Tolstoy‘s ideology of ‗non-resistance to evil by force‘.

Well, if anybody else would ask you to turn the other cheek, wouldn‘t you call

him crazy? This attempt to define these indefinable charismatic characters of

the history would probably be futile but here are ‗Lexicon- handpicked‘

ingredients to embrace their spirit of greatness!

1. Be a freak: Craziness and eccentricity often rhymes well with genius! John

Hunter reportedly inoculated infected pus (in the 18th century when no proper

treatment was available) by puncturing the foreskin and head of his penis to

study characteristics of Gonorrhea and Syphilis (we know the Hunterian

Chancre), which may have caused his death, and so did Barry Marshall

intentionally consume Helicobacter pylori to win the 2005 Nobel prize in

Medicine! Werner Forssmann, in the 1930s drove a catheter through his

forearm vein into his Right atrium and walked down to the radiology

department to confirm its position. His unorthodox methods later won him the

Nobel Prize in Medicine for cardiac catheterization, though he initially lost his

position in the hospital, had to quit Cardiology due to his bad reputation and

join Urology!

After all, the eccentrics get noticed and popularized by the media only because

they are eccentric. Paradoxically, the world preaches mediocrity and yet,

salutes excellence!

2. Be passionate: ―You have to have a lot of passion for what you do, because

if you don't, any rational person would give up", said Steve Jobs. It was Jay

McLean, a second year medical student, a wanna- be surgeon, passionate

about Physiology, who discovered Heparin working with William Henry Howell.

I still wonder whose passion led to the discovery Heparin‘s antagonist

protamine sulphate as an extract from fish sperm!

3. Be observant:/ It was the observation of a young first year medical student

during an autopsy and his curiousness about the nature of ‗sandy diaphragm‘

that led to the discovery of Trichinella spiralis, the nematode parasite that

lives in the muscle. He went on to become Sir James Paget, the famous

pathologist!

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4. Be perseverant: ―If I have done the public any service, it is due to my

patient thought‖, said Sir Issac Newton. Even Mother Teresa had become an

international celebrity after Malcolm Muggeridge‘s 1969 documentary

Something Beautiful for God that was made only after 20 years of her

dedication and service. Dr Eugene Braunwald finished the first Braunwald‘s

Heart Disease text book writing eighteen hours a day, 6 and a half days a week

during the sabbatical that he was eligible for after 7 years! The examples

extend to pages but let‘s not forget to mention the wait of the pharmacologists

who maketh the variety of molecules that answer our patients‘ problems.

5. Be flexible- Arthur Guyton, who intended to be Cardiovascular Surgeon was

unfortunately struck by Polio in his final year of residency training which put

him to his wheel chair making him change his specialty to Physiology, thus

proving to us that, what doesn‘t kill us only makes us stronger except

(ironically) including Polio.

6. Be innovative- Like the great Indian surgeon Sushrutha who sutured with

ant heads by letting them bite at the incision and then cutting their body

leaving the jaws in place.

7. Be an addict: The power of addiction that comes with ‗will over desire‘ can

be as fulfilling as what I call- our addiction to breathe. However, surprisingly, it

was an addiction to Cocaine that turned our shy Freud into a chatterbox laying

foundations for Psychotherapy and it was his colleague Karl Koller, an

ophthalmologist who introduced cocaine as a local anesthetic for eye surgery.

8. Be a good husband- Cocaine addiction reminds me of the famous surgeon

Dr. William Halsted who introduced the first latex gloves to protect the hands

of his scrub nurse Miss Caroline Hampton (later his wife), who developed a

bad case of dermatitis due to repeated disinfection in mercuric chloride.

9. Or a good wife: It was Angelina Fannie Hesse who suggested her husband

microbiologist, an assistant working in Robert Koch's laboratory, the use of

agar as a solidifying agent introducing Agar to Microbiology!

10. Or a good father: Like cholera is to public health. Seriously, cholera is the

father of Public health!

11. And a good human being, after all.

So the recipe of ‗Humane Vitae‘ is simple- 99% inspiration, 1% perspiration,

200mcg LSD and 30ml (an ounce) of craziness. God bless.

RENDEZVOUS DR.DEVI PRASAD

SHETTY

Contribution to Cardiac surgery

First Heart surgeon in India to perform heart surgeries on newborn babies, used Micro chip camera to close holes in the Heart. Pioneered operations for complex problems of the Heart like Pulmonary Endarterectomy, Redo Heart surgery, Valve Repairs in newborn Babies and Aortic Aneurysm surgeries.

Contribution to the field of Medicine

Dr. Shetty and his team have performed over Seventy thousand major heart surgeries out of which Fifteen Thousand operations were on children, many of them new born babies.

First team in the world to coin the term Micro Health Insurance. Helped Karnataka state Government to launch Yeshashwini Micro Health Insurance considered as the largest Micro Health Insurance Programme in the world.

Arogya Raksha Yogana in association with Mrs. Kiran Majumdar Shaw of Biocon.

First team in the world to coin the term “Health City” and in the Process of creating 5000 bed Health cities in every state capital of India Manages worlds largest Telemedicine Programme through Indian Space Research Organization (ISRO).

Manages a chain of Rural Clinics in Karnataka and Uttar Pradesh.

Awards

• Rajyotsava Award – 2002 • Sir M. Visvesvaraya Memorial Award – 2003 • Ernst & Young – Entrepreneur of the Year – 2003 • Padmashree – 2003 • Dr. B C Roy Award – 2004• Citizen Extraordinaire, Rotary – 2004• India Innovation Award – 2004, By NDTV & EMPI (Awarded to Micro Health Insurance Division) • Social Entrepreneurship Award – World Economic Forum – 2005 • “Commendation for driving affordable and quality healthcare for all 2010” - Healthcare Awards Program presented by ICICI Lombard & CNBC TV18 held on 20th Dec 2010 • Indian of the Year 2010 – Awarded by NDTV 15th February, 2011 • The University of Mysore has conferred the “Doctor of Science” (Honoris Causa) on Dr. Devi Prasad Shetty at the 91st Annual Convocation held on Sunday, the 10th April 2011. • The Regents of the University of Minnesota, upon recommendation of the faculties, confer upon you Dr. Devi Prasad Shetty, the degree of “Doctor of Laws” honoris causa conferred on 19th April, 2011. • In recognition of his dedication and commitment to the cardiovascular community world- wide as well as his philanthropic efforts to bring affordable medical care to numerous communities the Minnnesota Chapter awarded “The President‟s Award” is bestowed on Dr. Devi Prasad Shetty on 20th April, 2011. • Winner of “Business Process Award” for Lowering Health Care Costs by Mass Production from-The Economist Magazine. The competition is called as “The Economist Innovation Award‟s 2011” on 21st October, 2011 in London. • Padma Bhushan – 2012 (Third Highest Civilian Award conferred by the Government of India)

It is an unparalleled honour to be interviewing you and to have you featuring in the anniversary edition of Lexicon. As one of India's foremost medical practitioners and a cardiac surgeon par excellence, we feel we might have reached our pinnacle in having you on our pages. It is with this hope then that we seek to interview you for our anniversary edition, whose theme is Humanae Vitae. You have been an exemplary individual and an inspiration to medical students all over India, who will be eagerly awaiting the publishing of the edition.

1. What motivated you to take up this profession? Was it a childhood ambition or did you decide on it much later? When I was in fifth standard Dr. Christian Barnard in Cape Town did the first heart transplant. My teacher announced in the class that somebodyin South Africa removed the heart of a sick man and implanted a heart from somebody braindead and gave a new lease of life to the sick man, I was very fascinated. That was the day I thought I should become a heart surgeon. In fact I decided to become a heart surgeon well before I planned to become a doctor. Also as the young eighth of the nine children when I was growing up my parents were growing old and falling sick. In our life as children doctors were heroes, that definitely helped me.

2. During the course of your studies in medical college, was there a particular incident that profoundly affected your outlook to patients and medicine? Is there an anecdote that describes what galvanized your resolve to reach out to people and heal them?

I studied in Kasturba Medical College, Manipal which was attached to a government hospital. Most of the patients we treated as medical students were poor struggling to find something to eat. A young girl was suffering from mitral stenosis, my teacher told her parents that nothing can be done and she will die. That really made a big impact and resolved to make a big difference to these people.

3. The study term of a medical student is often an introspective experience. An aspiring doctor must not just rely on his own diligence, but also on other external support systems to guide him. Who were your biggest influences and mentors and how did they assist you in reaching your goals?

Your heroes keep changing. In our medical college my teachers, some of the surgeons were my heroes. They taught basic skills of surgery and they made a big impact in my life. I am admiring Dr. Christian Barnard, Denton Coolly, Micheal Bebachee, Mayo brothers who built Mayo Clinic apart from my teacher but the biggest influence among them other than my teachers is Mahatma Gandhi and his ideology.

4. The doctor in India today is often a maligned and misunderstood personality, sometimes through his own misdeeds, and sometimes as a consequence of yellow journalism and smearing. In your opinion, how must a doctor conduct himself so as to be of service to the public and be above snide accusations of ordering 'too many tests' or 'charging too much',when sometimes these tests may be essential, even life saving?

Some doctors, very few of them not following ethical practice. In this process the entire profession is looked upon with suspicion. Every profession has black sheeps so, we can‟t be an exception. However, over a period of time I am sure good will prevail over bad.

5. What is the most vital change that medicine in India needs to undergo? In what areas are we lacking as a medical system and as individual medical practitioners in your opinion and what corrections are needed to remedy them?

The biggest challenge for Indian healthcare is reaching out to the underprivileged. We have to open the medical education and train as many specialists as possible so that every nook and corner of this country has experts to deal with non-communicable diseases. It is important that low cost healthcare becomes a norm for government to make the right policies.

6. As Lexicon happens to be a magazine majorly run by doctors just out of college, we are used to seeing our seniors and colleagues struggle with entrance exams for further studies. In the same vein, just being an 'M.B.B.S.' is now undervalued and difficult to work with, whereas other streams such as engineering and even dentistry offer 'instant gratification' in terms of further studies and financial stability. It is harder to cope with studying modern medicine, given the already long years, the tough struggle and limitation of seats for postgraduates. What are the steps that need to be taken to remedy this?

The difficulty in getting PG seats is totally artificial. We can increase the number of PG seats to three times more than the units just by opening the medical education. This is continuing unabated because civil society is not demanding better services from the medical profession. When we take to streets, believe me, policies will change. Unfortunately, medical profession and medical students are disillusioned and they feel nothing can be done. It is a matter of time before every graduating doctor will get a PG seat and the situation of healthcare and the future of the doctors will improve dramatically.

7. You have been associated with the medical student movement 'Save The Doctor'. Is the solidarity and strength in numbers of medical students likely to influence the 'powers that be' into increasing the number of postgraduate seats across India? The biggest road block in opening up the higher medical education is the policies. Unless the policies change, it won‟t happen. First we should understand the problem of a common man. Look at the maternal mortality, infant mortality and needless death in rural India and right policies. 8. Lexicon's year-end edition theme is Humanae Vitae - Of The Human Life. Nearly all of what we do is to ease the myriad sufferings and ailments of this human life. The first steps of this begin in medical college and internship, in studies and encounters with patients. What advice would you want to give to an aspiring doctor or a medical student finding his steps in the field, to be used as guidance in the years to come?

My single advice to the young medical students and doctors is that never look at rich people. Just take the poor and they will make you a hero and the rich people will automatically chase you. Never chase, it is like a mirage; as you run faster it will run even faster than you. It will come to you even if you don‟t want. Never get carried away when patients call you a God. The day you become a God that is the beginning of fall. Do not get excited with adulation at the same time do not get depressed with criticism. You do what you think is right, but not what people around you feel about it. In the end, our life is precious. We have only one life and we should do what gives happiness and believe me, in the process everyone will be happier.

Dr.O.P .Kapoor

By,Dr.Rohin Manipur, MGMMC

Navi Mumbai

A lean man stepped onto the stage. He was immaculately dressed in a manner that befitted, not a teacher giving a lecture, but a performer who was committed to delivering a performance that would enthral his audience and etch his talent in their minds. We were, as far as medicine was concerned, still infants. Novices, even. Just learning how to deal with a patient, learning how to read a few basic X rays. In a hall packed with what appeared to be senior doctors, we seemed to be woefully out of place. But this was no ordinary classroom, it was an auditorium. And the man about to discourse was no

ordinary teacher either. He seemed to be a veteran of the stage, remarkably at ease in front of a throng of people. It wouldn‟t have seemed shocking had the buzzing of the crowd grown steadily into a chant of „O.P., O.P.‟, akin to the concert of a virtuoso. Then the collar mike squealed to life, and the man on stage said, “It is time to show you the Burkhe wali sign on an X ray.”

Medicine today appears to be a genre for the limited. The doctor was once supposed to be the most intelligent man in the room, well versed not only in his own healing art, but also a connoisseur of many disciplines. Medical students today, however, appear to be beasts of burden struggling against the workload of 11 hour long classes on the weekends, lectures, and postings. There is little left for appreciation of medicine as a subject, let alone the venturing into other disciplines. Few medical students, if any, keep interests outside of their own field, and even these are consumed in the relentless question of „What will happen in the future?‟ It is little wonder then, that the students and younger doctors of the time are perceived as relentless go- getters in a cutthroat competition.

In Birla Matoshree auditorium next to Bombay Hospital, however, the years appeared to roll back. Our entry into the hall was set to the voice of Dr. Kapoor singing over karaoke versions of Mohd. Rafi songs. It was astonishing to see a crowd like this on a Sunday morning. It was our first introduction to Dr. O.P. Kapoor, and it ended up being one we would never forget. Six hours, far longer than the time the average young adult spends at the movie theatre, being spent listening in rapt attention to one of the keenest minds in the profession discourse about a variety of topics. His command over his subject was superlative, however, what was most astonishing was his ability to hold sway over a crowd of people of different ages, from different backgrounds, and make them learn in the process. I might add that Birla Matoshree is a very comfortable, air conditioned auditorium, quite capable of putting a man to sleep over the course of 6 hours. Not so, however, with Dr. Kapoor on stage. The crowd laughed, ooh-ed and aah-ed as if on cue. It was a delight to be away from regular classes and attend this, even on a Sunday morning.

To the uninitiated, Dr. O.P. Kapoor was formerly part of the Grant Medical College. Following his retirement, he became editor of the Bombay Hospital magazine on condition that he be allowed to use the hospital‟s Birla Matoshree hall to conduct lectures. 58 years of lectures later, he has etched his name into history, and has benefited innumerable medical students and general practitioners. Dr. Kapoor‟s lectures are free of charge and open to all medical students and doctors. They are conducted on eight Sundays in the year. He uses a wide variety of tools to aid him in his teaching, from video cameras to demonstrations with his „hathyars‟ (medical instruments) and even brings patients on stage to explain the value of a properly taken history and a meticulous examination. The value of this also lies in the unspoken lesson on how to deal with patients. He is most courteous and gentlemanly with those he brings on stage, and never makes them feel ill at ease.

When it finally came to an end, we had, at least, the comfort of knowing that we would be part of it again on the Sunday to come. We had gotten a thorough grounding in medicine, learned from a teacher blessed with the ability to showcase the flair that this profession has to offer, as opposed to the mundane that we mistakenly assume that we must encounter otherwise. Although he is about eighty years old now, Dr. Kapoor still has ardent disciples about a fourth of his age! As he is undoubtedly one of the finest teachers I have had the pleasure of learning from, I have no doubt that he will have many more by the time he finally decides to stop. A prime example of energy, wit and panache in a field that may sometimes feel bereft of it, a legend, and a teacher.

5th {Oct} Known Case Of

Battle against the Brain By: Ms. Swati Shriyan

Photo courtesy: Google images She kept staring at me with an unhappy, rather disinterested or bored look, as I entered the room. I welcomed her expression with a broad smile as I sat right next to her while she practised her yoga lessons. I very well knew that her indifferent look did not portray her true feelings for it was those frozen facial muscles which were successful at masking her intense emotions of love and glee. As I gently touched her trembling hand, there was a sudden flashback of the past when she used to hug me with joy and kiss my forehead and cheeks, whenever I visited her during my vacations in childhood. She is 62 years old and the person who has inspired and motivated me the most. She is the most senior member in my paternal family. Yes! She is my grandmother. Slowly she managed to place those gentle and caring hands on me as I hugged her. At the age of 45, my grandma‘s left hand began to tremble for no apparent reason. During those days, they suspected the cause was anxiety, weakness or stress and ignored it. As time passed, she became more and more aware that something was definitely wrong. Her left arm would no longer swing when she walked and she began to drag her left foot. It was only after her MRI's and CT scans, that she was diagnosed with Young Onset Parkinson Disease at the age of 46. She had difficulty picking up her feet when she walked and would often stumble. She slurred her speech, and often had blurred or double vision. Soon she learned that Young Onset Parkinson Disease is no joke! Parkinson‘s disease (PD) is a progressive neurodegenerative movement disorder consisting of four cardinal features: bradykinesia, muscular rigidity, resting tremor, and an impairment of postural balance leading to disturbances of gait and falling. The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset, begin between the ages of 20 and 50. The pathological hallmark of PD is a loss of the pigmented, dopaminergic neurons of the substantia nigra pars compacta, with the appearance of intracellular inclusions known as Lewy bodies. As she grew old, there have been instances when she simply could not get up off the bed, or the couch. She frequently found herself frozen in a certain position, unable to move even the tiniest muscle. As she stood upright, she would make her legs remember what walking felt like and would get going again. It was as if someone had pulled a plug, causing her brain to lose its connection with her body. Her energy would dissipate quickly and her ability to socialize and multi-task began to diminish. The stiffness in her body and the pain in her feet from cramping and curling were extremely painful. The trembling of hands became worse when she was tired, sick or stressed. I can never imagine the level of frustration she must have through on not being able to control her own body. What is really inspiring of her, is her constant enthusiasm to not let PD refrain her from doing the little things which give her joy. She always says it‘s a question of mind over matter —mind should be strong enough to control the impact of any disease. Apart from the medications, physiotherapy and yoga have played key role in helping her combat the symptoms of the disease. Physiotherapy enabled her limbs to recognize patterns of movement. These patterns helped her stop, turn and do basic tasks. Whenever I see those trembling hands, I stroke them gently to help her relax and ease the pain, the fear and the stress. As I hug my most favourite person, she says in a low yet sugar-coated voice, ―Your hug prevents my arms from trembling and makes me feel calm and relaxed‖ and those words gratify my soul.

The Joker By: Mr. Utkarsh Mishra

"Don't make us laugh. The green hair. The crazed smile. The maniacal cackle. You know exactly who he is and how far he'd go to put a smile on your face." One of the most compelling comic characters of all time and a villain of the Batman series by DC comics, we know him as the deranged psychotic and the archenemy of the Batman, who would go to lengths to kill the 'bat freak'. The violent sociopath who murders people for his amusement. A vicious, cold, calculating killer, with zero empathy. The Joker has been referred to as the Clown Prince of Crime, the Harlequin of Hate, and the Ace of Knaves. Originally appeared as the 'Red Hood' in the comics, but after an accident which involved him falling into a vat of chemicals at a plant on being pursued by Batman, he emerges with the characteristic look that defines him. Events, like the killing of his wife and unborn child along with a failed plan, induce a massive personality shift that results in the birth of the Joker. There are many versions as to how he becomes the Joker, but all conclude on the same note: He goes insane. The Joker's behaviour is characterized by apparently anomic violence and destructiveness: shooting, setting fires, creating lethal explosions, poisoning people with the 'Joker gas'. He is adjudged as totally unpredictable by his enemies. It has been suggested by many psychiatrists, that he has no personality of his own, and that he may be a happy clown a day and a vicious killer the other, depending on what would benefit him the most. This has been associated with a form of 'super-sanity', a form of ultra-sensory perception. It can also be dubbed as hyper-awareness. He is primarily said to suffer from three conditions: Antisocial Personality Disorder, depression and schizophrenia.

This diagnosis of Antisocial Personality Disorder, depression and schizophrenia can be proved by stating the following points: • He has no regard for social norms and continues to commit crimes that are grounds for arrest, by disrespecting lawful behaviours

• He can easily deceive people. He lies and can very well kill his own comrades for his own personal gain or pleasure. For instance, he tried to impregnate Harley Quinn (his feminine side kick), through artificial insemination, without her consent, just to prolong his era.

• He has no regard for his own safety, let alone that of the others. He has been observed to be reckless in closed out corners: jumping off buildings, being shot in fire fights, being caught in explosions and even developing a resistance to his own poison. • Irritability, aggressiveness, topped off with lack of remorse, as indicated by being indifferent. He has always challenged the Dark Knight, and killed countless citizens. The Martian Man hunter also re-wires his brain to understand his psyche.

• Failure to maintain a consistent behaviour, and impulsivity. Totally unpredictable, never honours his allies.

Throughout the comics, one thing is clearly evident. The mutual obsession of the Batman and the Joker with each other is what makes the other back off at the last minute from killing each other. He has given Batman many a chances to kill him off, but he knows that if he did do it, it would be his victory, and Batman would never want to become like him by doing it. He realises that he too cannot terminate the Batman. 'Batman' is a concept, his complete opposite. In order to exist, he has to spare him. One can dub him as 'conceptual opposite'. With all the crimes that have been witnessed, this makes the mass media dub him as 'psychotic'. Although, someone who is 'psychotic' is said to experience symptoms of psychosis, a mental disorder, which can include auditory hallucinations, such as hearing voices; visual hallucinations, where they see objects that are not truly there. It also includes having delusional thoughts, like being followed by someone, or say, even a satellite. But in the depictions of Joker, it is better to say that he showed symptoms of psychopathy (it is a personality construct, rather than a diagnosis of a mental disorder). He is aware of the way he works, and acts unpredictably, so that the enemy can be caught off guard. Many people are quick to misunderstand the fact that if someone's behaviour is considered crazy or aberrant, then the certain individual does so because of a mental illness. There are a varied number of ways as to how mental disorders can occur, plus the fact that the Joker had gone through a lot of trauma before he turned. He is aware of the way he works, and acts unpredictably, so that the enemy can be caught off guard.

Mending The Cradle By: Ms. Caren Otadoh Ignorance (noun): that vice that retards maternal health across populations It‘s a simple tread, a walk of poise; short gentle steps upon grounds of great me. Her smile was quickly deceived by the surveillance. One day it feels like a runway; furrows that held it in place. She needed another, like a pirate‘s plank- winding directions to town. courses, sinking boulevards, swallowed We walked in uncomfortable silence. As I avenues and unsure trails. I‘m talking about was still debating on whether or not I had the growing up. emotional strength to handle whatever she In many cultures around the world, the issue had to say, if I enquired, she volunteered the of sexuality has been a topic spoken in information. With bursts of fury and hushed tones- a taboo of some sorts. I sentimentality she explained that her teenage completely support the moral reasons behind daughter had been admitted in hospital. I it. However, I suppose it‘s a universal understood her compassion, but the anger thought that, somebody should teach young was slightly confusing. Well, at least until people about sexuality, at the least, against she mentioned the ward number. It was the the backdrop of specialized beliefs. The obstetrics and gynecological ward. The unfortunate fact is that everyone assumes juvenile had been admitted the previous someone is doing it, so, at the end of the day, night due to heavy bleeding, that insinuated people in the formative years end up an abortion. As soon as the lady found out teaching themselves and each other. that I am a student at the Teaching-hospital, As we take the homestretch in the pursuit of she pleaded with me to go visit her daughter the Millennium Development Goals, my th th and talk to her. lime-light goes to the 4 and the 5 : Although I am fully conscious of and Reducing child mortality rates and passionate about my role as a future healthcare worker, on educating the The developing female needs to learn about population on practices that promote health, sexuality, in progressive detail... when all I was a little concerned about whether or concerned ‘teachers’ faithfully stand at every not the lady had fulfilled her role as a milestone; when every single person plays their mother in educating her daughter. Speaking role in this long chain of edification, the gaps … of which, I have a slight concern in regards will be rectified. to the fallacies that parents present to improving maternal health. children about storks delivering babies and One Sunday afternoon, a few months ago, I retails stores where children are bought, decided to take a stroll to town, to buy a few however that is a Pandora‘s Box that I supplies. As I walked past the hospital gates, wouldn‘t wish to open. a shrill voice jolted me from my passing According to Wikipedia, Maternal health is trance. A middle aged lady of a rather the health of women during pregnancy, conspicuous stooped stature, stood before childbirth and the postpartum period, encompassing the health care dimensions of family planning, preconception, prenatal and postnatal care in order to reduce maternal morbidity and mortality. I view its scope as a build on; a relay of some sorts; and an evolution of thought, principle, knowledge, culture, physiological changes and mental development, from the very second the little girl is aware of the uniqueness of her body. When I was younger, my siblings and I used to play a game where we‘d take a pack of cards, fold each one, on a horizontal scale (for stability) and arrange them on a level ground, each, adjacent to the other. This would result in a long train of cards, which we‘d whirl to meet our fancy. Afterwards, we‘d gently knock down the first card and watch it knock down the adjacent, up and till the last card. I later found out that this was a family rendition of the game, dominos; a highlight of how each concerned element of a particular issue is vital for the completion of the ‗chain reaction‘. As we seek to mend the ‗chronically‘ broken cradle, that is, improve maternal health and reduce child mortality, education in all its forms should be at the centre of the web. The developing female needs to learn about sexuality, in progressive detail, from the moment she can say the words ‗I am a girl‘. When all concerned ‗teachers‘ faithfully stand at every milestone; when every single person plays their role in this long chain of edification, the gaps that are currently filled by theories and fallacies will be rectified.

4th {Aug} The hypocritic Oath

Been There, Done That !!!

THE MATADOR OF SMILES!!! By- Dr. Kaustubh Chaudhari

'The matadors are here, let the battle begin!', cheered my co-physician Sharad (name changed) as we began to scramble through the 300 patients brought to our Ambulatory Clinic by the Forest Ranger‟s vans at the Kokrajhar forest in Assam.

After finishing my internship from the highly sophisticated, state-run JJ Hospital in Mumbai, my life was going to change forever as I decided to volunteer for a tribal health mission for the Vanvasi Kalyan Ashram in the monsoon of 2010.

As our jeep pushed through the narrow mud lanes, I could see hutments ravaged by the Brahmaputra floods, homeless running away with their belongings, officials distributing food packets and cattle floating along the banks. The chaos evoked horror and yet a lot was still to come.

Our camp had three cane-walled rooms that harbored 3 doctors, 5 nurses and 7 attendants. It was overwhelming that they were used as the OPD, the ward, the lab, the pharmacy and also the OT and catered to nearly 500 patients per day. Most of my patients were Bodo Adivasis (nomads) oblivious to the world; we may have been the first few doctors they had seen in decades. To some we were saviors; to others just warlocks.

Every challenge here was as inflated as the resources were deflated. Once, we admitted a 3-year old, puffy, severely malnourished girl Arita (name changed) with persistent loose motions. Clinical judgment suggested Kwashiorkor; hence we began treating diarrhea with supplemental nutrition. 6 days on, we realized we‟d missed the target by miles as the bloating worsened on the face, urine ceased and the child went pale in shock. I desperately pulled out the portable ultrasound to examine the kidneys, and to my utter horror they had crumpled to the size of a candy wrapper.

I knew that it was a contracted granular kidney. Umm! Or maybe looking at the abdominal guarding it could even be a ruptured polycystic kidney or in this part of the world even a ruptured renal Hydatid cyst. There was nothing to confirm. 2 days later, Arita succumbed to toxemia and respiratory failure, she died in my arms.

With remorse in my eyes, I unsuccessfully tried to hide my tears as I desperately carried Arita‟s body for 800 kms to Kolkata for a post-mortem; only to discover Meiloidosis Glomerulonephritis, a rare manifestation of Burkholderia pseudomallei infection. Still a student, my heart quivered and mind perplexed over the dilemma of putting an early diagnosis in the resource deprived jungle.

Unfortunately at Kokrajhar we were 800 miles away and centuries behind even from the idea of a renal transplant or even the RIGHT antibiotic. Then, would a diagnosis have helped at all?

The hours of work may not tire you, but the incapacitation and helplessness will. Scarcity often causes conflicts; it makes hope fragile and crushes your wine- coloured dreams. I often wept in frustration over our utter failure to mitigate such ubiquitous human suffering.

Several heads peeping into the Pharmacy window, hundreds of expectant mothers waiting for a single ultrasound machine and the neglected infections often more severe than the textbook photographs made these challenges worth pursuing.

The unshakable spirit and enthusiasm of the Bodo volunteers left me spellbound. Hours after hours they walked barefoot into the deep forests convincing the tribal-folk, cooked food for the homeless and nursed the ill. From 8 in the morning to 7 at dusk they persevered with no signs of exhaustion. Each day ended with patients going home in the same matadors that brought them in, smiling and waving hands.

Torn by utter poverty, deprived of any state support, repeatedly attacked and raped by naxals; to see these innocent faces smile was nothing short of divine.

As I packed up on my last day, I wondered if I had just begun to realize the true altruism that Gandhi once proposed, „No matter what you do it will always be insufficient, do it anyways‟. Walking with the tribes in their desperate moments has only strengthened my intent to continue my battle.

(Disclaimer: This Article was previously published in Lancet Student, UK, by the same Author. Prior permission and consent has been taken from the author before its reproduction.

Further reproduction of this article is subjected to a written permission by the Author. Lexicon India, has not and does not intend to violate the copyrights of this article, which are reserved with the Author and Lancet Student, UK. We acknowledge Lancet Student, UK as the official publisher of this article)

From reverence to revulsion: Is it the oath that is hypocritical?

By- Dr. Rohin Manipur The oath is over two millennia old. For centuries, it has been the beacon that sheds light over the well-trodden paths of luminaries who have walked before us, and in whose footsteps we must now follow. In that time, medicine has undergone vast and numerous changes. It has been a quantum leap from Hippocrates using lead pipes to drain a chest wall abscess and witch doctors carving crosses into the backs of people's skulls to let the demons escape, to the intricacy of a cardiac keyhole surgery. We do not need to appease the gods to keep our ships free of illness before they set out any more. We do not need to 'beat the demons' out of an epileptic to cure him. It is little surprise then, that since medicine has changed, so has the attitude and outlook to its practitioners. Aided and abetted by a few unscrupulous men and the avarice of the media for sensationalism when tales of malpractice come out, medicine today is frowned upon by the common man, as opposed to the respect it once garnered. There was once a time when the healing man of the village had the pick of his gifts irrespective of whether he managed to keep his patients disease free. He was generally well respected, given the status of a demi god and placed on the same footing as the village chief himself. Naturally, it was only a matter of time before such practices were stopped, however, the role of the doctor as a prominent part of society was carried well into the future. Fast forward to the present, where the doctor, far from being the most prominent member of society, is now frowned upon and almost treated with the utmost revulsion. Partly to blame, of course, are a select percentage of unscrupulous individuals part of just about every profession. There are many in this profession too, and dangerous are the crimes they commit. However, they form but a small part of a dynasty that has served with immaculate care all of humankind from times immemorial. Many a long surviving civilization has been steered to that pinnacle by the expert hands of its healthcare professionals. It is still the case today, in the age where we can fight and beat even cancer, the most dastardly of diseases and stand over its banished carcass, but the adulation for the men who make it possible is nowhere to be seen. There are those who cast a slur on the profession they practice, but it is the doctor whose faults are highlighted, pinpointed, and used as a yardstick to judge the entire profession by. It is the doctor who becomes the favorite scapegoat for everything that goes wrong. The evil that they do lives after them and is magnified to span the entire profession; the good is non-existent. A fickle public is partly to blame. So is yellow journalism, targeting the medical profession and some practices beyond its comprehension. But it is hardly the fault of Aamir Khan and his Satyameva Jayate when millions across the nation choose to respond to a programme highlighting the faults of a select percentage and come out in an outrage against the profession in general. It is easy to whip up the emotions of the masses by showing them a few clips of the oppressed and the tears of a few people in the audience, set to the background score of a band playing sad music. With due respect to Mr. Khan, he has never been a man who has done a half-baked job, and we are inclined to believe that at least seventy percent of the accusations he made in that show were backed by solid fact. We are appreciative of this truth based journalism, of this 'satya' that must prevail. But if truth is in the eye of the beholder, then Mr. Aamir Khan makes the folly of catering to some rather myopic eyes.

His fault lies not in the truth of his documentary but in the fickleness of its beholders. And by choosing to play to the emotions of this public and not present both sides of the story, it is almost as if one wanted the programme to serve a certain agenda and not present the truth in its shades of black, white and grey. Therein lies the basis of this folly, that with full knowledge of the nuances of their public, the programme still chose to present their version of the truth in such a way that the disjecta membra taken home by the audience would show the profession in a negative light. But this isn't the only example of journalism trying to subtly alter the views of its public. There are hundreds of cases showcasing thousands of examples of malpractice, all the while blatantly ignoring the millions of lives saved. This profession has no spokespersons, and this isn't a piece trying to do that job. The profession has its fair share of people unskilled at their job, of megalomaniacs who believe themselves second to none, of cheaters and blackmailers who extort every dying drop of their patients. But there is good. Good that is the core of this profession. Good that has always been in the minds of men who want to heal the ailments of their fellow men. And it is this good that every doctor, intern and medical student strives to reach. It is not dictated by how much money one tries to make, or how many years of compulsory rural service that must be thrust upon every doctor since he wants to 'serve the people.' The basis of this good is that every time a patient comes to a doctor, the doctor tries everything in his power, irrespective of how fatal the prognosis, to make the patient feel better. That is the standard we all strive towards, and must all strive towards. The general public might never recognize the work that goes into this, the intricacy of every diagnosis, the years of effort required to perfect a brain surgery, but something is surely amiss if they That is the standard we all strive towards, and must all strive towards. The general public might never recognize the work that goes into this, the intricacy of every diagnosis, the years of effort required to perfect a brain surgery, but something is surely amiss if they

Let Me Rest in Peace -

---By Ms. Zenia Poladia

“When life becomes unbearable, quick death can be the answer.

Imagine yourself lying on a hospital bed, hooked up to 20 tubes, your body is being kept alive by means of machines, you are totally unaware of the happenings around you. Doctors and family members come and go, mostly out of habit now, because they know there‟s nothing more they can do. Many of their visits are a blur to you, with their voices and movements becoming unrecognizable. The pain you experience is nothing short of excruciating and your condition exacerbates with each passing day. The hospital has exhausted all of their resources in their attempt to help you. After months of heavy medication and endless efforts to assist your recovery, you‟re left with nothing to show for it other than the exorbitant bills and your family is standing by watching you suffer in your final weeks of life. Luckily, you are not in a situation like this. However, one must wonder what they would want to be done if they ever were in such a situation. Is this something you would wish to prolong? Would you want the hospital to keep searching for answers and cures? Or would you, like many others seem to, prefer ending your personal suffering and inconvenience to family through euthanasia?

Because the Hippocratic Oath instructs physicians not to provide a „deadly drug‟, some have concluded that physicians, by their training and moral commitment, must necessarily reject assistance in hastening death. This is not so. The physician who prolongs his/her patient‟s life, but who then aids in the patient‟s request to die, has not violated the Hippocratic injunction, and in fact has fulfilled the physician‟s duty to heal so far as is reasonable without producing harm. The Hippocratic injunction against the use of deadly drugs was good public relations for the medical guild, and had nothing to do with terminally- ill patients. Those who turn to the oath in an effort to shape or legitimize their ethical viewpoints, must realize that the statement has been embraced over approximately 200 years, far more as a symbol of professional cohesion than for its content. Its pithy sentences cannot be used as all- encompassing maxims to avoid the personal responsibility inherent in the practice of medicine.

ARUNA SHANBAUG has been in a semi- comatose and vegetative state, ever since she was raped by a ward boy at Mumbai’s King Edward Memorial (KEM) Hospital in 1973, where she was once a bright capable nurse. She has not walked or spoken a word in 37 years. The staff of KEM Hospital has nursed her since she was discovered in the basement with an iron chain around her neck, 11 hours after she had been sodomized by a ward boy who she had scolded for stealing food that was meant for stray animals adopted by the hospital. The chain used to strangle her had cut off the supply of oxygen to her brain. The damage was irreversible. On 24th January, 2011, the Supreme Court of India responded to the plea for Euthanasia, filed by Aruna‟s friend, Pinki Virani, by setting up a medical panel to examine her. In February, 2011, the committee submits a report that Aruna Shanbaug “meets all the criteria for being in a permanent vegetative state”. The Supreme Court‟s verdict on her case allows passive euthanasia contingent upon circumstances, and after this verdict, India joins selected nations in legalizing

“passive euthanasia”.

Passive euthanasia is usually defined as withdrawing medical treatment with the deliberate intention of causing the patient‟s death. This form of euthanasia is different from “active” euthanasia, or simply euthanasia, where death is caused by the use of lethal substances.

Ms. Pinky Virani issued this statement after the verdict, “Because of the Aruna Shanbaug case, the Supreme Court of India has permitted passive Euthanasia, which means that Aruna‟s state will worsen with persistent diarrhoea as her body cannot handle much of that being put through the pipe; no catheter to catch body fluids and waste matter which excrete themselves; lengthening response times due to „sinking‟. But, because of this woman who has never received justice, no other person in a similar position will have to suffer for more than three- and- a- half decades”. One can‟t imagine how tough Ms. Shanbaug‟s life is. She is being forced to live her life stripped of basic dignity.

Everyone wants to live their life with dignity and die with dignity. Terminally ill patients, as well as their families have been bringing about the topic of legalizing euthanasia, to put an end to the misery of their loved ones. Are we being human by prolonging one‟s suffering? Death is inevitable and imminent. The pain that precedes death is so unbearable that the only morally appropriate response is to end the life of the person. Cancer surgeon, Dr. P Jagannath says, “As a cancer surgeon, there are some instances when one feels that it is justified to seek euthanasia.” But he feels that the government and the courts should use the opportunity to spell out a clear framework under which euthanasia has been sought. “We have a stringent framework for brain death and subsequent organ donation. Similarly, we should define rules for euthanasia. Denial is not an answer.”

Opponents contend that euthanasia is nothing more than suicide and murder. Euthanasia is killing, but killing in the name of compassion and mercy. It is a caring, merciful and humane act.

ALL MURDER IS WRONG, NOT ALL KILLING IS MUDER

Let them break the fetters from their suffering and misery and, rest peacefully in His arms.

3rd {Jun} Of Knots and Ties

YOU TODAY? By, Zenia Poladia

Medical school is a place in which you will grow as a person and as a professional. Long arduous hours of studying, sleeplessness and the massive amount of knowledge you need to learn in a short period of time makes medical school one of the most challenging professional schools out there. After joining med school in 2011, I have realized that this place can be really tough sometimes, and it is easy to feel completely alone. Hence, it is really important to create a sense of community in med school. No one quite knows the struggle of anatomy and placements and patients as well as we do. So far, I have had the pleasure of interacting with all kinds of people. I have an excellent rapport with my colleagues and trusted advisors. I have also interacted with some brilliant professors. However, no one has touched my heart like the patients I have interacted with, during my clinical placements, my patient-doctor class or any other setting. It is extremely important to establish a good rapport with our patients. I learned that a successful doctor-patient relationship requires mutual trust and respect. If the patient is uncomfortable with his/her doctor‟s demeanor, then the patient would hesitate to disclose private, and sometimes embarrassing information. The effect of withholding the information is detrimental to both, doctor and the patient. It could lead to grave repercussions including misdiagnosis or improper treatment. The doctor-patient relationship forms one of the foundations of contemporary medical ethics. It is important in the doctor-patient relationship that a „neutral, safe space‟ is established which allows a therapeutic alliance to grow. The consultation involves a chat about the problems, medical examination, description of the diagnosis and a feedback from the patient. During the talk, the doctor builds an interpersonal relationship and ensures there is mutual trust. A simple, warm smile of a doctor can go a long way in assuring patients and lighten their mood. A physician‟s “bedside manner” is an essential aspect to a patient‟s treatment. It is essential for doctors to realize that while their clinical skills are indispensable, personality matters too. The body language, vocal tone, openness and concealment of attitude may all affect the bedside manner. Poor bedside manner leaves the patient feeling apprehensive, worried and unsatisfied. TYPES OF DOCTOR-PATIENT RELATIONSHIP: 1) Autocratic Doctor: In this relationship, the doctor has little regard for the opinions of the patient. Any query from the patient regarding the treatment is considered irritating. The doctor believes that the patient is fortunate to have the benefit of expert advice and the patient is being ungrateful if it is not accepted. For such doctors, patients exist for the sake of medicine rather than medicine existing for the sake of patients. 2) Paternalism or “Doctor knows best”: A paternalistic doctor genuinely wants the best for his/her patients, but is also of an opinion that patients often need to be guided firmly through the decision making process as they do not always know what is best for them. However, it is difficult to be sure what is best for a patient. It is difficult to know when one is acting in patient’s interest and not in one’s own. Paternalism is difficult to practice. When it comes to making an important decision considering the long term interest of the patient, the doctor feels justified in overriding the patient’s wishes; at the same time being responsible for these decisions if things go wrong. 3) Doctor as agent : In this relationship, the doctor does not see him or herself being in charge, but considers the patient to be the final arbiter of all important decisions. The degree to which general practitioners consult patients and explain their decisions is related to the personality of the doctor and the patient, their communication skills, the type of problem, and the time available in the consultation. Majority of consultations in general practice are those in which the doctor is acting as an agent or enabler. „VAIDYO NARAYANO HARI‟ (the doctor is next to God) was the concept 30-35 years ago. The doctor-patient interaction then was at a personal level. In the recent past, medical ethics have taken a downturn and the faith and trust that patients once had in doctors has taken a beating. Doctors say that their changing relationship with their patients is only a reflection of the changing time and relationships in the society. “Instead of spending time with the patient in examining in detail, they find it much easier and profitable to subject the patients to various costly investigations. Sometimes the patients themselves demand high tech investigations which result in high cost of medical treatment and very often ruins diagnosis of simple diseases”, Dr.V.N. Jindal, Goa Medical College and Hospital dean. Patients should allow the stipulated time needed for the results of the treatment to show, instead of hopping from one doctor to the other in hope of finding the best doctor. On the other hand, the doctors, too, should prove themselves to be worthy of that trust. Doctors were often devastated at the loss of patients. Orthopaedician and former Indian Journal of Medical Ethics editor, Dr. George Thomas said, “Doctors top the suicide list, world over. In addition, society has itself become violent. People who believe they have not been given adequate care often attack the doctor or the hospital. DOCTORS AREN‟T GOD. In some situations, death occurs, no matter whether you care or not.” Doctors always want the best for their patients. They work towards the welfare of their patients and medical profession. The incidences of conflicts between doctors and patients are on the rise. Hence, students should be taught better ways of handling patients to improve the doctor-patient relationship. Freshers should be taught how to behave well with patients and politely communicate with them. Emphasis should be laid on communication skills such as ways to communicate with patients and their kin, how to respect the rights of patients, how and when to break the news of any major illness or death to the patient‟s family. A doctor- patient relationship is built on trust and empathy and it is important to develop a human approach among the young doctors. In interacting with different patients, I have realized that patients are often our most important teachers. They bring with them wisdom that cannot be acquired from any textbook, medical journal, didactic lectures or an endowed Professor of Medicine. They arguably are the most important part of medical education. The relationship I share with the patients, as a medical student, is the one I share with none other- a relationship filled with respect and compassion and based on faith and trust. FAITH AND KNOWLEDGE LEAN LARGELY UPON EACH OTHER IN THE PRACTICE OF MEDICINE ~ PETER MERE LATHAM

CEREBRO: How well do you bond?

By,Swati Shriyan

Human bonding or your ability to develop interpersonal relationships determines the type of personality you are. Your bonding, be it with your family, your kins, your friends, your colleagues or perhaps with any stranger, moulds your approach towards life. Take this simple quiz to find out how well you handle relationships.

1. You have had a busy day at work and all the travelling made you tedious. After you come home... a. You spend rest of the evening with your parents. Spending time with your family refreshes your mind and mood. b. You complete your pending office work and have dinner with your family before dozing off. c. You are too busy with your phone or laptop. After completing any pending office work, you plan for the next day. You try to have dinner with your family and later go to bed. you plan for the next day. You try to have dinner with your family and later go to bed.

2. Your sibling is... a. Your best friend. You share every little thing with him/her. b. Your saviour. He/she is the first person you think of, when in trouble. His/her guidance and motivation helps you to look through the positive side of a dilemma. c. A sibling-cum-friend.

3. You have a family function coming up this weekend... a. Family function! Wow!! Time to socialize with your folks. b. I don’t mind attending family functions as long as the menu is attractive. c. Weekends are meant for chilling. No family functions for me

4. You are at a cousin’s wedding; your cousins have all gathered after a long time... a. Its gala time people!! b. You have a decent interaction with your kins. c. You are constantly thinking of a topic to socialize.

5. The first thing that comes to your mind when you think of your grandparents... a. There is no substitute for a grandparent’s love and knowledge. b. They need to be constantly taken care of. c. Advice, advice and advice.

6. In your class... a. Apart from your close pals, you know almost all of your classmates because you are the kind of person who loves to mingle with different people.

b. You have a set of close pals and you are also well acquainted with most of your mates because of your helpful nature.

c. Few friends or best friends! That’s it! You hardly interact with the rest of the class.

7. You happen to attend a one day hobby class, where you meet new people... a. Apart from learning new things, you interact quite well with new people, share your email id’s so that you can get in touch later in future for such similar classes.

b. During the class, you won’t mind sharing your varied ideas with new people.

c. You are too engrossed into learning new things that you hardly care to mix.

8.You are travelling by train and the lady next to you has a cute baby... a. You love babies!! You try to play with and entertain the little child.

b. You look and smile at the child’s innocence.

c. Dude! Which is the next station?

9. You have your exams in few days and your best friend is undergoing an emotional crisis... a. You take some time out, call her up and discuss her problems and convince her that all would be fine with time.

b. You call up your best friend and tell her to not think of her problems and try to concentrate on studies for the time being.

c. You send a text message asking her to be strong and utilise her time on studies rather than thinking about her problems.

10. How well do you know your neighbors? a. You know them quite well. You have a short conversation with them whenever you come across them at your building premises or elsewhere.

b. You interact with your neighbours only during festivals or any gatherings.

c. You are not quite sure about who stays next door.

1. One with majority of a’s: You are the kind of person who maintains strong interpersonal relationships. Be it with your own family or a complete stranger, you bond pretty well. You love to socialize and meet people with varied ideas and interests. You have quite a balanced life and your nature attracts people towards you. In brief, you maintain and manage relationships very well!! 2. One with majority of b’s: You are the kind of person who believes in healthy bonding but are not always quite successful at it. You care for the people in your life but may not always show up. Your good deeds fetch up good feedback too. You take an initiative to mingle with your kith and kin. You always aim to have a balanced life. You are quite an amiable personality but you need to work a bit on getting along with your family and society to develop strong bonding. 3. One with majority of c’s: You are the kind of person who would like to stay aloof rather than mingle with people. You are too engrossed into work and tend to use it as an excuse for not socialising. You find it difficult to manage relationships and work. You also seem to be an introvert person. You find it difficult to interact with new people and often tend to avoid social gatherings. You easily get depressed and may not even share your concerns with your close ones. This in turn may lead to negative thinking and you may easily fall prey to failures. It is extremely essential for you to work on building up your interpersonal bonding to help maintain a healthy relationship and a healthy living.

2nd {Apr} The Social Poison HOUSE AND

HOLMES

By, Dr.Rohin Manipur

Image: Debapriya Mondal

To the uninitiated, the title of this piece sounds like an awful advertisement for residences. The addition of the words „Doctor‟ and „Sherlock‟ might just make things clearer. One is one of television‟s most iconic characters; the other is the literary world‟s most famous detective. Both men are unparalleled geniuses in their respective professions and both misanthropes of the first order. Dr. Gregory House and Mr. Sherlock Holmes.

For those who came in late, Dr. House is the head of the department of Diagnostic Medicine at the Princeton- Plainsboro Hospital in the recently concluded series, House MD. He has ruled over the silver screen for eight seasons and actor Hugh Laurie, who plays House, was the highest paid man on television. Sherlock Holmes is the main character in Sir Arthur Conan Doyle‟s stories. In his 130 year old run, the super sleuth has seen numerous personality changes and has been represented in every form of the media. That he is still as fresh and popular now as he was more than a century ago and being cast and recast in new avatars is testament to Doyle‟s character. In truth, Dr. House too is one of the various representations of Holmes, or is, at least, based on him to a formidable extent. Both men seek the answer to the puzzles in their profession and are rarely concerned with their clients. Both men live at 221B. The name „House‟ was picked for the character because it sounded like „homes‟, a play on Sherlock‟s last name. And perhaps most significantly to the theme of this magazine, both men abhor social contact. Had both men actually existed in society today, they would be branded social poisons.

It is a little known fact that Sherlock Holmes himself was based on a doctor. Conan Doyle‟s professor in medical college, Dr. Joseph Bell, always instilled in his students the importance of observation and deduction. Bell always insisted that his students deduce the trade of a man by the way he dressed and by certain tell tale signs. It was his opinion that this would not only train his students in the art of observation and deduction, it would also enable them to reach a diagnosis faster. Doyle learned at the knee of this man, and, when his practice as an ophthalmologist wasn‟t flourishing, created a detective based on his professor. Bell was known to be very pleased when he was told Holmes resembled him. This was also briefly referred to in an episode of House, where House opens a gift from an anonymous sender and it is the book, “A Manual of the was bored of Holmes and killed the character, thousands of young men and women took to the streets of London, wearing black armbands in

Operations of Surgery,” by Dr. Joseph Bell. Both men also have arch nemeses sharing the same name. Holmes‟ antagonist is the well-known Professor Moriarty. House was once shot in an episode by a man bearing the same name.

Holmes‟ antagonist is the well-known Professor Moriarty. House was once shot in an episode by a man bearing the same name. There is also the matter of their only friends, Dr. John Watson and Dr.James Wilson.

That both men are depicted as being at the pinnacle of their profession despite being high functioning sociopaths shows a general affinity towards the anti- hero. Both are characters loved immensely by their respective audiences. When Doyle decided he was bored of Holmes and killed the character, thousands of young men and women took to the streets of London, wearing black armbands in protest. The character was subsequently revived with the explanation that he had fakes his death. House too fakes his death at the end of the last season, riding off into the sunset with Wilson.

While they might not have fit into society, they remain nonetheless two of the foremost characters ever produced in media and literature. Proof perhaps, that just sometimes, one man's poison is another man's antidote

Open Letter The Abnormal Dilemma of the Normal By, Abhijeet Sharma Executive Director-Lexicon

“I used to think the hardest struggle of doctoring is learning the skill. But it is not, although just when you begin to feel confident that you know what you are doing, a failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part of being a doctor, I have found is to know what you have power over and what you don‟t”

--- Better, By Dr. Atul Gawande

Over the past two and a half years of my medical training, I have developed a very keen interest in Medicine and its sister streams. Right in the first year, the human physiology amazed me more than the anatomical intricacies. In one of our lectures, one of our much respected professors of Physiology said, “It is more difficult to understand the “Normal” than the “Abnormal”. To bind a mechanism or phenomenon, be it the function of your Gastro-intestinal tract or your interactions with your surrounding environment, in the spectrum of “Normal” is the hardest. What may be normal for you might be the most absurd argument to me”.

I have come across similar arguments a number of times, during the past few years. With every passing year, I learn and grasp innumerable patho- physiologies, their managements and their prognosis. But those few lines make sense every single time. Over decades, as medicine has evolved, we have stepped into unchartered waters. And this journey has completely changed the definition and understanding of almost every known element of our existence. There was a time when the world of microorganisms was absolutely unknown to us. Today infectious diseases comprise more than half of the disease burden of the world. Once under- nutrition was our big concern. Today over-nutrition is the hot cake of non-communicable diseases.

From the divine theory of infirmity to the germ theory, and now the genetic dimension of diseases, medicine has been waging war against the “abnormal” with the best armories available to it. Now while our swords and armors become better, we realize that we have just begun to scratch the surface. While the battle with the “Abnormal” continues, the vagueness of “Normal” still lingers around.

The other day, our much-esteemed professor of Medicine was delivering his lecture on Portal Hypertension. While explaining to us about the intricacies of as to how the body opens dormant blood channels along the porto-systemic circulation, he conveyed a very poignant argument. Over that 1 hour, he very subtly explained to us that this very known pathology has innumerable dimensions when it comes to its clinical presentation. However its basic definition itself is purely theoretical and provides the physician with very little help, when it comes to its management.

Once again the “no mans” land between “Normal” and “Abnormal” elude us.

And this is just one instance. Over the spectrum of all sorts of Metabolic, Inflammatory, Degenerative, Neoplastic, Infectious and autoimmune pathologies, this zone becomes all the more unclear and vague.

While physicians and researchers continue their expeditions in unknown landscapes, they often overlook one very crucial component; A component that influences both the “normal” and “abnormal”. Everything in this universe is a result of interactions. Anything that is inert or incapable of interacting, remains as it is. This rule applies to, perhaps everything and anything in this universe. A state of equilibrium is practically the cessation of existence. This basic rule underlies every single concept of Medicine. The human body itself is a giant chemical factory where every second, millions of interactions and reactions occur. Some of these interactions define life, while others play a crucial role in senescence.

But what about the interactions among the humans themselves? After all the WHO definition of health incorporates the social component as well. As I understand it, the social dimension of health is a necessary evil. And unlike the other components, here the relationship is extremely subjective.

The saying of “Medicine to one, poison to other” may be the most apt description that can be found to describe it.

I relate back to the very beginning of my article; “the hardest part of being a doctor, I have found is to know what you have power over and what you don‟t”. The social component perhaps provides us with a single major entity where we can control our interactions and reactions with negative elements. And while we discover means and ways to do so, we realize that this entity in itself is extremely dynamic. It alters from one place to another, from one time to another, from one individual to another and from one society to another.

The day when we will master this complex web of human interactions, we might just transform from Homo sapiens sapiens to Homo sapiens futuralis.

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1st {Feb} The Cancerous Valentine

―The Battle was won.. but was it really?‖ Written by: Rohin Manipur Final year MBBS. MGM Institute of Health Sciences, Navi Mumbai. India Image: Dr.Debapriya Mondal MBBS. N.R.S. Medical College, Kolkata. India.

―The window burns to light the way back home A light that warms no matter where they've gone. They're off to find the hero of the day But what if they should fall by someone's wicked way?‖ - Hero Of The Day, Metallica. 29th August 1993. A twenty one year old boy slaloms around an 18.4 km track at Oslo, Norway on a bicycle. He is built heavily for his age. Tooheavy, his coaches have told him often, too much muscle. The roads are slick in the wet weather. Balancing on inch wide tires is difficult. Other cyclists in the race crash around him. The boy does too, twice, but leaps back onto his bike with dogged determination. He waits with infinite patience. He has been told he doesn‘t have patience. Riding around him are ex champions, Tour de France winners and riders far more distinguished than he. Compared to them the boy is a novice. Unheralded. Unsung. Riding in his first World Championship race. On the last lap the lead group pulls into the second last climb. The boy is among them. He grits his teeth and pedals furiously. His bike leaps ahead of the lead group and creates a gap. The boy continues pedalling into a 4 km descent. The road is slippery, the ride is dangerous but the boy manages to hold on while those behind him crash. The finish line is within sniffing distance. The boy crosses it, triumphant, with his arms raised, the youngest world champion ever in the sport. Enter Lance Armstrong. 24th March 2011. He has been called fat. He has been called lazy and unambitious. A play only when I please‘ talent, too erratic to ever be counted on. He almost didn‘t make the World Cup team. And yet, here he was facing Australia, three time world champions, with only one other specialist batsman left at the other end and 72 runs to be scored in 11 overs. The tournament has been good to him. He has been amongst the runs and wickets, many of which have been crucial in the earlier stages of the tournament and one colossal effort, a century against the West Indies in trying conditions, while battling dehydration. Yet none of that would matter if he lost today. His team would be out of the tournament. His captain has fallen, as have the other illustrious members of the team. Aussie spearhead Shaun Tait rushes in to bowl. Yuvraj Singh takes up the guard with his trademark snarl and dispatches the ball over backward point for four. The crowd erupts and the tone is set for the rest of the match. That match was won, as were the two that followed and Yuvraj Singh was adjudged Man Of The Tournament. Two men, in two very different sports were at the peak of their game, poised to take the world by storm. And then it came. A very different storm. The words, ―You have cancer.‖

At the time of writing this, both men are at completely opposite stages in their career. Lance Armstrong, at present, is perhaps the most pilloried man in the world with newsreels, late night shows and Facebook and Twitter messages baying for his blood. He has been found guilty of (and has confessed to) doping and has been subsequently stripped of his seven Tour de France titles. The aftermath of his revelation has turned some of his most seasoned fans against him and there are many who will now scoff at any good word ever written about him after the extent of his most elaborate lie has been discovered. A lie that held strong over 15 years as he bullied team members and opponents alike, destroying numerous lives in the process. And yet, the one part that cannot be refuted is his status as a cancer survivor. Yuvraj Singh is at the other end of the spectrum. He has just returned from fighting his own battle with cancer and, after the departure of Ganguly, Dravid, Laxman and Tendulkar, he is now one of the veterans in the ODI side, widely considered as one of its lynchpins.

You have cancer.

Cancer is one of the leading causes of death in the world. More than 16 percent of all deaths annually are attributed to cancer. The disease is not just a statement, it is a life altering catastrophe that is potent and unique in its ability to strike fear. In his book, It‘s Not About The Bike, Armstrong describes his fear of the disease and how, upon diagnosis, it made all his other fears seem insignificant. When he was 26 and heading into the prime of his career, Armstrong developed testicular cancer. It was a germ cell tumour, embryonal carcinoma to be precise, and it quickly metastasized to his abdomen, lungs and brain. He underwent emergency surgery to remove the testicle and sought treatment from Dr. Lawrence Einhorn at the Indiana University Medical Centre, who pioneered the development of a lifesaving treatment for testicular cancer, increasing survival rates from 10 percent to 95 percent. Not coincidentally, Yuvraj Singh, who also developed a germ cell tumour, although it was extragonadal, sought treatment from the same doctor after reading Armstrong‘s book. The extent of Armstrong‘s cancer is aptly described by a conversation he had with one of his doctors over the phone. ―My prognosis isn‘t good.‖ ―What‘s your HCG level?‖ ―It says a hundred and nine.‖ ―Well that‘s high, but not extraordinary.‖ ―Uh, what‘s this K‘ mean?‖ The doctor was silent for a moment. ―It means a hundred and nine thousand.‖

Lance‘s levels automatically put him in the worst prognosis category and that he survived a cancer that had metastasised to his brain was no small achievement. Yuvraj, on the other hand, developed an extremely rare tumour of the same type. He had an extragonadal germ cell tumour in his mediastinum which was golf ball sized. He credits Armstrong‘s books as a major source of inspiration during his treatment and was vociferous in his support of the cyclist after he had been found guilty of doping. As much as the monumental achievements of the seven Tour de France victories are a lie, Armstrong‘s book provides a gritty, no-punches-pulled approach to his condition and it is a detailed and fascinating perspective from the eyes of the patient who has had a death sentence pronounced on him. Yuvraj‘s course back to the team has been documented several times in the media and it was nothing short of miraculous. Pictures of a bald and somewhat flabby Yuvraj Singh were released training with his IPL team, the Pune Warriors, but he had to wait a span of ten months before he rejoined the national Twenty20 side in a thrilling display against New Zealand. Yuvraj Singh had beaten his demons and had worked hard to get back into the team. Before the match, he said, ―Don‘t know how I will fare in the match, if I will score 1 or 20 but I am happy to be back. When I was sick, I couldn‘t climb the stairs and now I have this chance.‖ It was a chance he utilized well, contributing with the bat and the ball. And although India lost the match by one run, Yuvraj‘s story had already been deemed miraculous, the fans screaming their lungs out every time he stepped up to bowl or when he was at the crease. There are lessons to be learned from both these sports personalities. In the case of Armstrong, it is his struggles with the disease and with the arduous chemotherapy that he has documented in his book. That he doped in the subsequent years en route to winning his seven Tour de France titles was undoubtedly a felony he perpetrated against the world. But the fact that he could survive the disease that had pronounced nothing less than a death sentence on him and then bear to climb onto a bike, doped or not, and ride a race in which one must ride around 200 km on a daily basis in chilly mountains was no small achievement. And if there is one thing Armstrong‘s book can instruct one about, it is how to develop a lack of fear when it comes to facing cancer by understanding the disease. In Yuvraj Singh‘s case, it is his unfaltering dedication and perseverance in clawing his way back to a place in the team. He intends giving a full account of his trials in book that he will pen. He has also set off his cancer foundation YouWeCan which will run in India along the lines of Armstrong‘s LiveStrong. He faced his fears and perhaps a more glorious future lies ahead of him now.

Diverging Roads

―M.P.H. – The Road less trodden‖ Written by:Dr. Arjun Lakshmana Balaji MPH student and Research Associate. Yale Medical College, Connecticut. USA Image: Trupti Pendharkar B.F.A.(Applied Arts)

Everyone joins MBBS with an aim of being a cardiologist or an oncologist or some specialist. They definitely do have an inspiration. I wanted to be like Dr.Naresh Trehan or Dr.Devi Prasad Shetty. As I pursued my career in medicine, I realized the need for preventive medicine along with curative medicine. This line may not strike a chord with a lot of people reading this. Yes, you are reading right. I decided to take up masters in public health before I can jump into residency. This is one of the options available to broaden your understanding of health before taking the plunge into investigative and evidence based medicine. This is a program, which is offered in various universities in the world. Universities in the United States of America need you to enter their programs via a common portal called SOPHAS. Being students of India, we need to complete a World Education Services (WES) evaluation since we are graded with percentages unlike GPA in the US. There are 50 schools, which participate in the SOPHAS. Each school has a different deadline for application process. It also requires the candidate to complete his/her GRE and TOEFL. There is a cost for applying through SOPHAS as well. Evidence based medicine is usually a brainchild of researchers and epidemiologists who are public health professionals. The patient contact may be lesser but at the end of the day, it gives you immense satisfaction in preventing the disease before thinking of the cure. The cost of education like public health may be anywhere between 10 lakhs to 40 lakhs depending on the school of public health, the duration of the program and the availability of scholarships. A degree in public health can lead you into careers with the WHO, UNICEF and World Bank. You can have a career in epidemiology or health policy or work on research methodology or infectious disease prevention. This can also be used as a foundation to understand health from a broader perspective or used as a pathway to residency into the USA. The same masters degree can also be obtained in various other countries including Australia, Singapore and Europe including United Kingdom. Some of the best schools for cancer and cardiology related public health courses are Yale School of Public health‘s Chronic Disease Epidemiology, University of Melbourne, Berkley, London School of Tropical Medicine and Hygiene. Requirements for universities in UK and Australia and Singapore can be got from their respective websites. These courses may not give out a lot of scholarships but there are a good number of them available including TOEFL scholarship, TATA, Australian Development Scholarships and so on. There are various interesting aspects of cardiac and cancer care while doing PhD‘s too. A PhD will be able to narrow your cardiac and cancer care interests better, as you will be working only on a narrow topic with a good base. I suggest cancer epidemiology at Yale and Harvard who work on topics ranging from Nutrition in Cancer to indoor tanning and skin cancer. As Max Learner says, I am neither an optimist nor Pessimist – I am an opportunist. This is the attitude that is required because the opportunities are plenty and the possibilities beyond that are endless.

The Convenient Deception By, Dr. Raviteja Innamuri MBBS Intern. Kasturba Medical College, Manipal. India

Cancerous Valentine. Two words, those involve the deepest matters of the heart, a tyrannical disease, an emotional zodiac sign and an unconcluded conundrum. A very long time ago, it was first recorded that injury to the head resulted in behavioral disturbances. That was perhaps the beginning of establishing the link between thinking to the brain. What fascinates me even more is what lead man to link heart and emotion together. The closest I could come to, perhaps a thumping heart in flight or fright. Heart was always such a mystery except for the cardiothoracic surgeons enjoying their roaring practices! People joke that the symbolic heart as two buttocks approximated together, while in medical school, we were taught that the best representation would be a closed fist to the chest deviated to the left side, something similar to the Levine‘s sign. Recent consciousness- based studies have shown that heart perhaps has it‘s own brain and in turn communicates with the brain accordingly. If such a thing is true, who makes the decisions? Is it the heart or the brain? I always wondered the true nature of difference between a reason and an excuse. The reason being the true foundation of what you want while excuse being the varied circumstances that persuade to take another decision in disguise of reason. It‘s easy when it comes to physical realms. The body easily seems to accept what‘s good for it and sees to it that you are running to the sink/ loo the next minute it isn‘t comfortable with it. So, is it the self-consciousness that we need to listen to? Almost a year ago, I visited the valley of lakes- Nainital to attend a conference on Mind- Body- Medicine. It was there, in the midst of Surgeons, Anesthetists, Physiologists, Psychiatrists, Theologists, Homeopathic doctors and experts on Naturopathy that I realized that the body has the innate ability to heal itself and mind is the key to unleashing and focusing that energy for healing. If an underlying string connects all life and body has a natural capacity to accommodate to the environment, is cancer (new abnormal excessive growth) such an attempt made to satisfy the excessive demands levied upon it just like hypertrophy of a muscle? Sometimes, I wonder what medical progress we have made when we cannot understand the basics of human behavior, things such as sleep that we essentially undertake every single day. Man‘s effort to make his environment accommodative now makes him struggle to just accommodate to what he has created himself. Cancer remains the emperor of all maladies taking its toll every single day. The cures continue to develop for centuries to come or just yet waiting to be discovered? Is it that collective consciousness that we all need to embrace, to evolve, to synch with nature (that we pretend not being a part of anymore), to love, and to unite the brain and heart, before we all fall victim to this cancerous valentine?