IAP GOA E-Bulletin
BULLETIN November 2018 Activities from July 2018 to November 2018 Issue 5 GOA STATE CHAPTER For Private Circulation
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For private circulation only
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Table Of Contents:
Sr. No Title Page No.
1. President’s Address: Dr. Harivallabh Pai 3 2. From the Editor/ Sub- editors: 4 Dr. Siddhi Nevrekar, Dr. Anagha Dubhashi, Dr. Vinda Arlekar 3. In Conversation with: Dr. Vinay Sawardekar 5-8 Identifying a child with Delayed Development in a Busy Office practice: 4. Dr. Aparna Wadker 9-11 Case Report: Persistent Methotrexate Induced Leukoencephalopathy in a young 12-14 5. child- Dr. Samidha M. Fadte, Dr. Vaishali Joshi, Dr. Lorraine D’sa 6. Hear the female fetus Groan:Dr. Nadia M Fernandes 15-16 7. Retinopathy of Prematurity Guidelines: Dr. Pradnya Kamat 17-19 8. Case Report: Hereditary Sensory Autonomic Neuropathy Type 4 (HSAN): 20 Dr. Anish Bakhale, Dr. Anagha Dubhashi, Dr. Sanat Bhatkar, Dr. Mimi Silveira 9. Multi-Talented Paediatrician: Dr.Poonam Sambhaji 21-23 10. Branch and Other activities 24 - 34 11. Knowing our Member: Dr. Sushma Kirtani 35-38
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
From the Desk of President IAP Goa
- Dr. Harivallabh Pai
Dear Colleagues,
Yet another opportunity to interact with you all through the e- bulletin, perhaps the last one in these last two years.
We have smoothly and successfully sailed through these two years. We have organized many CMEs, Central IAP modules, Community programmes and Health camps, published five – bulletins; and also have a very successful conference – Goa Pedicon Conference 2018. We are indebted to all those have contributed in holding the above programme from time to time.
I would like to thank you all with a deep sense of gratitude for giving me this opportunity to serve the IAP and the community at large through this prestigious organization.
I wish the incoming committee from Margao all the very best in their tenure
Wish you all a very HAPPY And PROSPEROUS NEW YEAR!!!
JAI HIND!!! JAI IAP!!!!
Regards,
Dr. H.P Pai President IAP – Goa State Chapter.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
Editors Write... Greetings to all the readers….
Wishing you all a Happy Winters!!!! The season of Happiness has begun….
As we end our tenure I take this opportunity on Behalf of Dr. Anagha Dubhashi and Dr. Vinda Arlekar to Thank each one of you to have spared some time out of your busy schedule to read the Bulletin and appreciated our efforts.
I also thank our Mentors Dr. Harivallabh Pai, Dr. Kalpana Vaitheeswaran, Dr. Swapnil Usgaonkar to have been there always supporting and guiding us whenever we needed their guidance in time of crisis and otherwise.
Special Thanks to Dr. Purnima Usgaonkar to have taken Time out of her very tight schedule and to have Helped to take the Interviews of our Senior Paediatricians whenever I couldn’t do so in person.
Last but not the least I thank each one of you to have helped me by timely sending the activities and articles and bearing the torment of repeated reminders without grumbling. Special mention of gratitude to Dr. Sushma Kirtani, Dr. Anant Kini, Dr. Nandita D’souza for sending in the reports and helping me out.
I take this opportunity to thank Dr. Vinay Sawardekar and his family to have taken time and shared information for our bulletin and also Dr. Sushma Kirtani to have agreed to be a part of Know our Member. I am thankful to each one of you who have contributed to this e-bulletin.
In this issue we have articles on ROP Guidelines and also on Identifying a child with delayed development in a Busy Office practice: Besides we have Activities done by our members in Private and in Government sector.
We have tried to make the bulletin a memorable one
Hope you like it. Please do send us your feedback. Happy Reading Iapologize if there are mistakes in the issue. If in case there are, they are purely unintentional.
Warm Regards,
Dr. Siddhi Nevrekar, Dr. Vinda Arlekar, Dr. Anagha Dubhashi
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
IN CONVERSATION WITH: Dr. Vinay Sawardekar Dr. Vinay Sawardekar, a well-known name, a Dynamic Personality, our very own Senior Paediatrician and a Founder Member GAP, a definite hard worker has worked his way all through his journey upwards to what he is today with his armour shining high and bright. Fondly called as Gaddoo, Dr. Vinay is the eldest child out of 5, born to Late Mr. Narendra Hirba Sawardekar and Mrs. Ratanbai Sawardekar. 26th July 1952 being his birth year at Old Goa Medical College. Life as a child was sorted with pleasant memories still fresh. Summer holidays being well spent at maternal granny place at Arpora with cousins definitely a cherishable
and Beautiful ‘Pithara’ of Fun filled Happy Moments captured by the Grey matter…. Festivals had a new meaning then wherein all the kiddos in the family got together making a Halla Gulla together and Sir enjoyed Ganesh Chaturthi the best wherein Bappa was welcomed by them with Crackers. I bet must have been fun. Crackers were limited in good old days and hence Chaturthi was a festival kids eagerly wait.
Education lays the brick for growth of all individuals it’s said; Schooling is the first step to it which began at New Ancestral House at Savordem Educational Institute, Curchorem Goa… wherein Sir, has fond memories of his Teachers, Friends and School. He would take part in extracurricular activities especially Sports- Cricket, Table Tennis( esp in College days). The most wonderful memories of school are Gatherings…Sports day….School picnics…. Sir, as I suppose everyone knows is quite humble and down to earth right from his childhood and academically has always been Brilliant, hence after passing from School he went on complete his Higher education from Dhempe College of Arts and Science, Panaji Goa. Later joined Medicine ( Joined on request on Parents). His relative Dr. Sonu Kamat took the initiative and got him the form for admission of the Entrance Exam for Medical Seat at Karnataka to be selected on basis of Merit. In those days 5 seats were reserved for Goans in Karnataka. He passed successful the same and did his 1st year MBBS at Mysore Medical College, but due to the sudden demise of his Father, had to take transfer to Goa Medical College, Goa to complete his remaining studies. Later he went ahead to do his MD Paediatrics from Mumbai. Struggles never let him down be it during MBBS time when he had to transfer to a new college or he had to start a new venture back in his home town in Goa. In 1987, when Dr. Vinay decided to start his practice he says, ‘I couldn’t afford to buy the premises to start the clinic outright, so I had to take a loan by mortgaging our house at Panaji’. It may sound plain and simple now but the uncertainty and dilemma Sir must have faced at that time is understandable.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______It takes a whole lot of courage to start and jump into a new setup by you. And in this journey you need a STRONG SUPPORT. Sir, found this support in form of his wife Mrs. Sunila Sawrdekar whom he says, ‘Tey mahnun hav mago’ – SHE IS MY WHOLE AND SOUL . A guide and a friend Madam has been with him through all his good and bad days. Recently when Sir met with a very horrifying accident she made it sure that she gave him all the comforts with utmost care and to the best possible making him his priority always.
Sir, has been in Private practice for almost 37 years, and believes that ‘Doctor being a Noble Profession, people look at you as second to God, You have to fulfill their expectations of Good treatment with utmost devotion and sincerity’. Being a Peadiatrician, he feels the best part of his profession is that to see the Smile of the Mothers face after treating the Sick Babies. He didn’t limit his good work to his clinic. He is an active member of IAP – Goa Chapter- and as a President our State brought laurels to it (BEST BRANCH) under his guidance. He was felicitated by Rotary Club Margao for implementing Child Health Programmes, Medical Camps including Pulse Polio.
At COMHAD-UK 2011 At Goa Pedicon 2011 held at At Belgavi for Rotary District conference in association with Zuri under able guidance of Dr. Confernce IAP Goa Chapter held at Goa Vinay Sawardekar Medical College
Ups and Downs are a part and parcel of everyone’s life and career. Each case teaches you something new. Some cases remain as memory forever. Dr. Vinay narrated one such case , ‘ Once I had admitted a child in Hospital for fever and vomiting. I had started him on IV Fluids. Next day he started complaining of headache and the father requested me to visit him on Sunday. So I examined him and found meningeal signs. Further on explained to the father the need to shift to GMC. I spoke to Dr. Sunita Gaunekar and explained the case. She agreed with me after listening to the history and examination findings and proceeded with further investigations – Lumbar Puncture. The Child recovered well after the treatment was received well in time. The
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation They ______doctors concerned appreciated the timely referral and made a mention that it was the First case of its kind to have been referred on Time and been treatment without any sequelae.” Indeed Dr. Vinay was satisfied with his efforts put in to save the child’s life.
Spending some cozy time with family and his sweet little grand daughters
Work goes on but Dr. Vinay always kept his Family above everything else in his Priority list. He says,” I have loved my family more than anything else. Given my kids the best education, taught them good moral values and preached them to become good Human beings and I am Happy to see them successful in life. Dr. Vinay and his wife are proud to have a like Son Mr. Varun Sawardekar an Engineer and a daughter Miss Veda Sawardekar an advocate by profession. Mr Varun is married to Mrs. Radhika Sawardekar who is a Dentist. They are blessed with 2 cute little baby dolls named Riddhima and Ashika who are 4 and half & 2 and a half years old respectively and both are definitely Grandpa’s pets!! Spending time with family, bonding with them, going on picnics and creating memories is what means a lot…Many such fond memories are still intact in his mind especially the 1st trip when he took his family to Singapore in 1998. Sir, Believes that work and Recreation – such as picnics with Family and Friends are essential for Mind, Body and Soul.
As a part of recreation at home and otherwise too besides Sports (An Active member at Margao Cricket Club and BPS sports Club), he also enjoys watching Movies; the ANGRY YOUNG MAN – Amitabh Bacchan being his Personal Favourite and Mughal- e- Azam fame Pyar Kiya toh Darna Kya Romantic Number being his Favourite song.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______When asked about his take on the new social media Apps like FB, Whatsapp,”In this fast life of communication, Though these Apps have their own benefits, it’s not a good way to bond and is absolutely of no help as we are distancing ourselves from the real world.” Very True!!
Liberal thoughts with a Positive Thinking and His Firm Belief in Almighty God has made him Strong and Sound in what he does today. He believes that ‘Man has made Religion, Religion doesn’t make Man. But having said that I was born a Hindu and I am Proud of It, because it is most Tolerant. Religion can teach you Way of Life. Never try to Hurt or Hate Others, as its said Don’t Try to Change others Change who you are’ “I Complain Because I had No Shoes, Till I saw a Man who Had No Legs”, that’s my favourite quote he says. An inspirational one too. One with deep meaning.’
Message to Younger Generation: “Whatever you do in your Life; You have to do with Sincerity and Dedication . Have faith in Almighty and Succes will be Yours. Being Sincere, Dedicated and Passionate in what you do is important. Try to be Happy!!”
A Real Gentleman…. As we End this Beautiful Rendezvous….I wish Dr. Vinay and His lovely Family A Blessed and Peaceful Life Always!!!!!
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
Identifying A Child With Delayed Development In A Busy
Office Practice Clinic
In a busy pediatric clinic, identifying a child with developmental delay can be a challenging task. Developmental disorders could manifest as developmental delay or developmental deviancy or both. It is essential that the pediatrician or the general practitioner is well versed with the developmental milestones. Milestones are noticeable skill sets seen in the child’s development process. Normal development is the road that the child must naturally traverse; Milestones are merely noticeable hallmarks on the same.
In a busy clinic, the minimum a doctor must enquire are: 1. Standing without support at a year 2. Speaking one or two meaningful words at one year 3. Interacting meaningfully (nonverbally, verbally and with appropriate joint attention) with the mother at One year 4. Walking without support at one and half year 5. Speaking two word meaningful phrases at 2 years and three word short sentences at 3 years of age
Absence of any of the above should prompt a more detailed, extensive and comprehensive battery of evaluations in the following order, to 1) Confirm a Delay; 2) Diagnose the Etiology, if possible and 3) Plan an integrated, comprehensive, Interventional-Stimulation program.
Developmental Delay is considered when the achievement of well recognized schedule of milestones falls behind that of other children of the same chronological age and needs further attention.
As with most biological variables, there is a spread (range) in the ages at which children attain Developmental milestones and therefore the definition of delay is somewhat arbitrary. For instance, delay is identified when the milestone remains unachieved by a child at an age when greater than 90% of contemporaries have already done so (as in a commonly used developmental Tool - Denver Developmental Screening Test). Thus, Developmental Delay is NOT a Diagnosis or a confirmation of pathology, but at the least, a definite “Call to Action” to rule out a pathology. Equally important is that this needs to be explained to the parents as such.
Developmental Deviancy is a qualitative alteration in the development of skills and functions, away from the expected norms. Deviancy is considered when the development follows a path which is not normal, in terms of the child doing activities which are not a part of the expected developmental progress. For example, with regards to speech development, the child would develop an abnormal pattern of vocalization, like grunting or humming or Echolalia or Neologisms without having any meaningful speech. These are activities which are outside the expected spectrum of normal development and hence considered as Deviancies from normal developmental path.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______Developmental Regression is considered when previously acquired milestones are lost. Thus, a previously, age- appropriately functioning and well - adapted child starts losing function and adaptability. Developmental regression at any stage is a red flag and needs to be investigated thoroughly.
When faced with a child with a Developmental Disorder, it is necessary to establish: 1. Delay, Deviancy or both vs. Developmental Regression
2. Global Delay(more than two domains affected) or Specific Delay (only single domain affected)
3. Domains affected
4. Degree of Impairment
5. Impact on Functionality/Adaptability in home and other environments
The following should be observed in the following domains:
• Language and Communication: To ascertain whether there is a Delay in the following: 1) Non verbal communication which includes observation for meaningful interaction, meaningful gestures like appropriate bye bye, eye contact, body language, reciprocity of communication(back and forth), symbolic play( with appropriate toys), cooperative play(with children), joint attention.
2) Verbal Communication which includes a) Expressive Speech: One meaningful word by 12 months, meaningful two word phrases by 24 months, meaningful three word phrases by 3 years, with appropriate pragmatics (social use of language), grammar (syntax) and pronunciation (phonology).
b) Receptive Speech: Able to perform (in absence of motor limitations) one-step command (“give your teddy to mummy”) at 18months, two-actions command (“pick up the teddy and give to mummy”) at 24 months and three-step commands (“pick up the pen, go outside to mummy and give to mummy”) at 3 years.
To ascertain whether there are any Deviances like: 1) Echolalia: meaningless repetition of words, phrases or string of words 2) Grunting, Humming: characteristic meaningless sounds 3) Neologisms: word-like sounds but without any meaning 4) Dysfluencies: Stuttering, Stammering, Blocks 5) Misarticulations: Impaired Pronunciations
• Personal and Social Behaviour: Following Abnormalities should be noted: 1) Limited or absent meaningful social interaction with others 2) Restricted interests (keen interest only in the wheels of a car rather than playing with the whole car as such) 3) Repetitive behaviours( like hand flapping) 4) Extreme, non purposeful restlessness and hyperactivity. 5) Restricted Interests (keen interest only in the wheels of a car rather than playing with the whole car as such)
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
• Language Delay and Deviancy needs to be correlated with Social Behaviour for a diagnosis: 1) Delayed Verbal (Expressive and Receptive) with normal Non Verbal Communication and Normal Social behaviour and No Deviancies points towards a Hearing Impairment as the cause. 1) Delayed Verbal and Non Verbal Communication with Deviancies and Impaired Social Behaviour with Normal Motor Development is suggestive of Autism Spectrum Disorder. 2) Delayed Verbal and Non Verbal Communication with/without Deviancies, with Impaired Social Behaviour with delayed Motor Development (Global Developmental Delay) is suggestive of Intellectual disability.
• Identification and Intervention to alleviate delays and deviancies in development are a must. • Early identification should lead to further evaluation, diagnosis, and treatment. Early intervention is available for a wide range of developmental disorders; their prompt identification can spur specific and appropriate therapeutic interventions.
- Dr. Aparna Wadker
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______Persistent Methotrexate Induced Leukoencephalopathy in a young child- A Case Report Dr. Samidha M. Fadte, Dr. Vaishali Joshi, Dr. Lorraine D’sa - Department of Pediatrics, Goa Medical College
INTRODUCTION: Antimetabolite used in the treatment of certain neoplastic diseases, severe psoriasis, and adult rheumatoid arthritis Chemically methotrexate is N-[4-[[(2,4-diamino-6-pteridinyl)methyl] methyl-amino benzoyl ] -L- glutamic acid Inhibits dihydrofolic acid reductase Interferes with DNA synthesis, repair, and cellular replication Administration- oral, intravenous, or intrathecal routes Does not penetrate the blood- cerebrospinal fluid barrier in therapeutic amounts when given orally or parenteral High CSF concentrations – Intrathecal administration
Adverse Effects –Gastrointestinal Hematological- Anemia, Pancytopenia, Neutropenia Neurological – Rare- Progressive Leukoencephalopthy- Dementia, dysarthria, dysphagia, ataxia, spasticity, seizure and coma
CASE REPORT: A 3 year old Male child had presented with pyrexia under investigation, after all investigations he was found to be Pre B call Acute Lymphoblastic Leukemia. Patient was started on Induction chemotherapy as per MCP 841 Protocol which included intrathecal methotrexate, along with other drugs. Patient was admitted and evaluated Hb- 9.4, Total counts- <1000, ANC- 250, Platelets were 1.1 lakhs Se Bil- 0.9/0.3,OT/PT- 55/57, ALP-270, BU-12, SC-0.6 Urine routine- Normal In view of febrile neutropenia and suspected meningitis, CSF analysis was done which revealed Nil cells , clear, Sugars-78/120, Proteins-68, Chlorides- 104, CSF and blood culture was sterile. CT scan of brain – Normal, so MRI was done MRI scan revealed diffuse symmetric bilateral hyperintense T2 signal abnormality within the white matter which suggested methotrexate-induced leukoencephalopathy . Patient was treated with Injection Piperacillin and Tazobactam , and Amikacin for 10 days along with GM-CSF for 3 days. Seizures were partially controlled with Phenytoin and Valparin, and was also started on Folinic acid. Subsequently patient was afebrile and counts improved. Patient continued to be aphasic though his sensorium improved gradually. Subsequent Intrathecal doses from maintenance cycles were omitted but Oral Methotraxate was continued. Patient completed his 8 maintenance cycles. He is in remission as far as ALL is concerned. But continues to have intermittent seizurres, speech difficulties and some motor deficits.
MRI Findings
Bilateral fairly symmetrical confluent areas of hyperintensities involving centrum semiovale and periventricular white matter with relative sparing of the subcortical U fibers
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
DISCUSSION Incidence is around 3% occurs mainly with High dose IV methotrexate and in synergistic effects with cranial irradiation Most of the cases reported in literature are seen following IV Methotrexate and most of these were either transient / reversible leukoencephalopathy or were noticed to be progressive. Majority of cases were seen in adults. In the present case, we observed leukoencephalopathy after 8th dose of 10 mg intrathecal methotrexate and there was no progression neither a complete recovery. MTX-related clinical neurotoxicity is transient, and most patients can receive subsequent MTX without recurrence of acute or sub acute symptoms, in our case also patient tolerated oral Methotraxate fairly well except with mild increase in seizure frequency with oral dose.
Recent MRI is still suggestive of leukoencephalopathy along with EEG still showing focal independent epileptiform discharges over bilateral frontocentroparietal and temporal region. The child did not show any progression when administered oral methotrexate during all his maintainence cycles
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
CONCLUSION
Case thus reported emphasizes the need to keep possibility of leucoencephalopathy even in a younger child treated with only intrathecal doses of methotrexate and with any dose in the course of chemotherapy without high dose IV methotrexate or cranial irradiation
Methotrexate induced leucoencephalopathy can mimic several other conditions like stroke meningitis etc. treatment of which may worsen the outcome. These children may tolerate oral low dose methotrexate without progression of symptoms
BIBILIOGRAPHY
1. Pipzo and Poplack, Principles and Practice of Pediatric Oncology, Fourth edition, Chapter 49, late effects of childhood cancer and its treatment, pages 1438-1440 2. Nelson, Text book of Pediatrics, Acute lymphoblastic leukemia , volume 2, 20th edition 3. Methotrexate-induced acute toxic leukoencephalopathy J Cancer Res Ther. 2012 Apr-Jun;8(2):292-10.4103/0973- 1482.98993 https://www.ncbi.nlm.nih.gov/pubmed/22842379
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
Hear the female fetus groan...
Oh dearest mama, what a beautiful morning, Cozily in your womb, this picture I'm dreaming, Happy, full of anticipation, I'm eighteen weeks old today, Mama I feel your heart pounding, what is it you want to say??
'Come quickly', said daddy, in a stern voice to you, 'Hurry up! It's a busy day with many chores to do!' As she followed, her wave of sadness drenched me, I tried kicking her, but her blurry eyes were all I could see...
At Mrs. Gupta, the lawyer's, was our first stop, Huge office with piles of books touching the ceiling top, 'She's the best', they exclaimed, 'none could ever beat her, Property issues would be sorted out, no worries any longer..'
Towards our next agenda we headed, the hospital site, Excited to see myself on TV, in black and white, Passing by the geriatric ward, we saw an old crippled man, Being led by his married daughter, giving him all she can..
And when we stepped in, the cabin of Dr. Pearl, 'Kill the baby', daddy said, ' cause IT’S A GIRL!' My soul ripping, the world being snatched from beneath my feet, My mom shattered, lay helpless, she couldn't move from her seat...
No daddy no! I'm worthy, I want to live, I'll be your old age stick, I need you to believe, So what, if I'm a girl, daddy I love you, Just like any baby boy, I have dreams too..
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______
Think of mother and all the women we just met, The lawyer, the old man's daughter and this doctor here all set, I'll do better than them, competing through life's sieve With Women shinning in all fields, I've so much to achieve..
Bestow on me the love, your kindness is what I ask, Your little girl child, till your death bed, fulfilling every task, Let me live, I plead, give me this chance, A blessing I could be, give me another glance..
Female feticide! An evil, humanity entangled in it's root, Say no to it and witness this beautiful new life bear fruit, While marching ahead, let’s wipe away all tears of sorrow, As we lead every girl child, to build a better tomorrow...
-Dr. Nadia Muriel Fernandes. Senior Resident, Department of Pediatrics, Goa Medical College
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______GUIDELINES FOR ROP SCREENING: - Dr. Pradnya Kamat Consultant Ophthalmologist
Retinopathy of prematurity (ROP) is a vaso-proliferative disorder of the retina occurring principally in newborn preterm infants. With the increase in the survival of preterm babies, ROP has become the leading cause of preventable childhood blindness throughout the world. A premature infant is not born with ROP. The retina is immature, but this is perfectly natural for their age. It is the post-natal developments in the retinal vessels that could lead to ROP. The sequence of events leading to ROP usually takes about 4-5 weeks except in a small subset of premature infants who develop Aggressive Posterior ROP(AP_ROP) within 2-3 weeks of birth(1). A simple screening test done within a few weeks after birth by an ophthalmologist can avoid this preventable blindness. Although screening guidelines and protocols are strictly followed in the developed nations, it lacks in developing countries, which have the highest number of preterm/low birth weight deliveries in the world. Besides the personal loss to the individual/family as well as economic burden to the family/country, there are indefensible legal repercussions should an infant develop ROP and retinal detachment, but had not received eye examination.
A variation in number of cases has been observed in different era and in different countries and this has been termed as ‘Epidemics’ in ROP. India and the other developing countries come under the third epidemic which is characterized by severe ROP in bigger premature babies; the reason being lack of proper neonatal care and improper oxygen administration(2). Hence there is a need for strict guidelines of oxygen administration and monitoring and neonatologist play a major role in this aspect. Although much has been written about the association of oxygen use and ROP, it has been found that oxygen is not the major cause for ROP(3).
Studies done by Dr. Subhadra Jalali et al concluded that in Indian population, severe ROP is seen to occur in a significant number of babies which fall outside the screening criteria of high income countries and advised modifications in the screening protocol(3,4).
Current screening criteria for Indian population include: 1. Birth weight (BW) of 1750 gms or less. ( AAP criteria for high income countries <1500gms) 2. Gestational age(GA) at birth of less than 34-35 weeks. 3. Exposed to oxygen for more than 30 days.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______4. Infants weighing less than 1200 gms at birth and those born at 24-30 weeks gestational age(GA) are at particularly high risk of not only developing ROP, but also AP-ROP (Rush disease).
5. Bigger babies with a GA of 34 to 36 wk or BW between 1750 and 2000 g should also be screened if child has a stormy neonatal course such as respiratory distress syndrome, sepsis, multiple blood transfusions, multiple births, apnoeic episodes, intra-ventricular haemorrhage.
6. Low weight gain proportion, i.e., weight gain less than 50% of the birth weight in the first 6 wk of life is being considered superior to BW and GA alone as predictors for severe ROP(5).
ROP Score is another excellent index of neonatal cumulative risk factors for ROP, which is easy to record and more accurate than just BW and GA to predict any stage ROP or severe ROP in preterm infants(6). It is a promising tool aiming to reduce the excessive number of examinations performed in very low birth weight patients.
It is important to complete one screening session definitely before ‘Day 30’ of the infant’s life (31 week post conceptional age or 3-4 weeks chronological age).
However, infants weighing less than 1200 grams at birth and those born at 24-30 weeks GA should be screened within 2-3 weeks of birth as they are prone to develop AP-ROP(3).
Steps in Screening: • Screening should include anterior segment and dilated retinal examinations. • The examination technique involves two steps namely the dilatation of pupil and indirect ophthalmoscopy with a 28D/ 20D lens with a careful and controlled 360 degrees scleral indentation. • The recommended eye drops are Trropicamide (0.5% - 1%) with Phenylepherine (2.5%). 2-3 instillations,10 minutes apart are usually sufficient to dilate the pupils in 15-20 minutes. Cyclopentolate (0.5% - 1.0%) can also be used safely. Care should be taken to wipe off any excess eye drop that spills onto the cheeks to avoid systemic absorption from the skin of the babies, which may cause increased heart rate. Use of Atropine or 10% Phenylepherine is contra-indicated. Telescreening using Retcam digital camera and wide angle lens is advisable only in places where no ophthalmologist is available for bed side screening, as a recent review showed that digital imaging screening cannot replace indirect ophthalmoscopy(2) . • It is essential to maintain a clear record of the retinal examination findings using universally acceptable graphical representation and standard notations so as to not miss any important information. Also, this has medico-legal implications.
The follow-up examinations depend on the initial ophthalmological findings and can vary from bi-weekly in cases of zone 3immature retina, weekly in zone 1 immature retina to every 3 days in pre-threshold disease. Threshold disease needs treatment within 48-72 hours. It is important to note that ROP-like disease is not exclusive to preterm or low BW infants.
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______Several case reports, mainly from developing countries have shown the occurrence of ROP in heavier BW babies with or without the presence of comorbidities. Furthermore, case reports in the past have described changes similar to ROP in healthy full-term and near full-term infants.
The risk factors for development of such retinopathy changes in term infants appear to be similar to those seen in premature infants with a complex interplay of factors which can potentially cause ROP like changes in term infants(7).
In conclusion, it is a good idea to screen in the first 30 days of life, any baby that goes through a turbulent neonatal course since ROP like retinopathy has occasionally been seen to occur even in full term infants. References: 1. Fulminate retinopathy of prematurity – clinical characteristics and laser outcome .Shah PK, Narendran V, Saravanan VR, Raghuram A, Chattopadhyay A, Kashyap M, Morris RJ, Vijay N, Raghuraman V, Shah V.Indian J Ophthalmol 2005; 53:261-265. 2. Retinopathy of prematurity: Past, present and future. Parag K Shah, Vishma Prabhu, Smita S Karandikar, Ratnesh Ranjan, Venkatapathy Narendran,Narendran Kalpana. World J Clin Pediatr. 2016; 5(1): 35-46. 3. Programme Planning and Screening Strategy in Retinopathy of Prematurity. Subhadra Jalali,Raj Anand,Harsh Kumar, Mangat R Dogra,Rajvardhan,Lingam Gopal.Indian J Ophthalmol. 2003;51:89-99. 4. Modification of screening criteria for retinopathy of prematurity in India and other middle income countries. Jalali S,Matalia J, hussain A,Anand R. Am J Ophthalmol.2006;141:966-68. 5. Weight gain measured as a predictor of severe retinopathy of prematurity: study with 317 very low birth weight babies.Fortes Filho JB,Bunomo PP,Maia M,Procianoy RS.Graefes Arch Clin Exp Ophthalmol.2009;247:831-36. 6. A predictive score of retinopathy of prematurity in very low birth weight infants.Eckert GU, Fortes Filho JB,Maia M,Procianoy RS. Eye. 2012;26:400-406. 7. Retinopathy of prematurity like retinopathy in full-term infants.Dhanashree Ratra,Lala Akhundova, Manmath Kumar Das.Oman J Ophthalmol. 2017;10(3):167-172.
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Multi Talented Paediatrician: Dr. Poonam Sambhaji
The love for Gardening is a Seed once sown that Never Dies….. This saying is something which is very relatable to Dr. Poonam, as a kid this seed was sown but “It was restricted to small indoor plants”. Off late in the past 3 to 5 years with her kids grown up and having keen interest like their Mom in Gardening, Dr Poonam started venturing into Gardening yet again and this time it was outdoor plants. She was well supported by her Father in law who avidly loves gardening too, only difference being – Dr Poonam is into more of Blossoms and Sir being into more of ‘Kitchen gardening. But both the plants share equal space in harmony and Mr. Sambhaji has started enjoy the Beauty of colours and Flowers Blooming every-day.
Even though Dr. Poonam had started off with Gardening as meagre Hobby, now these plants have become her babies, and she does take care of them with lots of Special attention especially in time of crisis- An incident occurred about 2 years ago when the Adenium she grew developed her rotten root and she was disappointed, she put in all her efforts to revive it and was very very successful in the same…Now after 2 years the plant is Flowering Beautifully in Gratitude as if it wants to convey its Thanks to Dr. Poonam for all her Love and Care…
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She has started channelizing her kids in stepwise manner towards the same. Gardening is supposed to be the most Satisfying Recreation and giving the Child a Healthy start towards life…
On Similar lines she has a Passion for Cooking, which as a matter of fac, even though existed, re – kindled after her kids started demanding Non Healthy Food; hence finding a HEALTHY substitute became necessity of the hour therefore Cooking at Home started with a BANG!!!. Slowly baking was introduced which made her realise that it was a good Stress Buster….Steadily and Boldly she ventured into making Cakes, pastries for kids along with other savories as add-ons…Her recent creation – Her Daughter Ananya’s Birthday cake is Totally Professional- Rapunzel and her Prince…( see pic on the next page) She believes a Happy Tummy and a Smiling face after a Meal is the Best Award you can have but does want to go ahead and participate in something more in case she gets a chance to.
Some delicacies from Chef Poonam’s Kitchen
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She plans to pass on the culinary tactics to her kid’s in order to make them self-sufficient by the age of 18 to 20 years so as to let them cook a Decent meal of themselves.
Recently she stumbled into something very unique on Social Media – Saree Speak – This gives you a chance to wear our Traditional attire at work and Otherwise making it a very exciting stuff rather than just a routine wear.
Adventurous enough Dr. Poonam is fond of hiking trekking, sorts and exercise freak tooo….
So it’s not wrong to say a ‘Multitalented Paediatrician’…..Keep up the same Spirit Always DOC…Good Luck!!!!
STONE-ART in Her Garden
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Activities: 1. IAP GOA CHAPTER ACTIVITIES: • In the month of July, Dr. Shivanand Gauns and Dr. Harshad Kamat were speakers at the Updat on JE and Prevention of Rabies on 8th July2018. As expected house full were a attentive crowd.
Speakers Dr. Shivanand Gauns and Dr.Harshad Kamat, being felicitated for their informative and brilliant lectures, take away messages
And the CME concludes with all smiles…….
• Month of August we had Cardiology Update with a the speaker a very resourceful individual, Dr. Ravindra Pawar, who gave a very informative talk on ‘Cath Lab Interventions in Congenital Heart Diseases’. The CME was at Hotel tree House Neptune, Neptune.
Dr. Ravindra Pawar, while giving his lecture. To the right are the attendees of the CME.
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• In September, under the IAP Action Plan, Healthways Hospitals in association with IAP – Goa Chapter conducted United Airway Module, on 23rd September. We had a very dynamic faculty viz, Dr. Vikram Patra, Dr. Sushma Kirtani, Dr. Jagdish Bhat, Dr. Swapnil Usgaonkar. Topics covered were recurrent respiratory symptoms, Under 5 wheeze, Rational use of antibiotic in RTI, Radiologi in RTI, Paediatric Emergency and Workstations wherein there were demos on Paediatric emergency and Asthma inhalation device handling.
Sneak peak of the Module… Speakers delivering their information (in clockwise direction) Dr. Vikram Patra, Dr. Jagdish Bhat, Dr. Swapnil Usgaonkar and Dr. Sushma Kirtani
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______• In month of October, EPID course was conducted wherein we had excellent speakers viz, Dr. Suhas Prabhu, Dr. Sanjay Ghorade, Dr. Harshad Kamat, Dr. Mahesh Kore, Dr. Babbanna Kukkeri who enlightened us with their knowledgeable lectures.
Speakers (in clockwise direction) Dr. Suhas Prabhu, Dr. Harshad Kamat, Dr. Sanjay Ghorpade, Dr. Babbanna Hukkeri . Below seen are attendees of the CME.
• On 9th December 2018, CME was held at Hotel Fidalgo where in the Speaker Dr. Wilfred D’sa spoke on ‘Help me Doc! My child doesn’t walk’ and Dr. Sameer Dalwai addressed the topic ‘Counselling Parents of children with Neurodevelopmental Disorders’. The topics were well covered. The CME was followed by AGM and Felicitation of our Senior Paediatricians who have played a Pivotal role in making our Team efficient and helping us out during our tenure. The Paediatricians honoured were Dr.Anant Kini, Dr. Sushma Kirtani, Dr. Mimi Silveira and Dr. Harshad Kamat. Also the prizes for Best Essay and Poster for Rational Antibiotic Use was announced and given- won by Dr. Neha Rocha and Dr. Nadia Fernandes 26 | Page
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Dr. Anish Bakhale and Dr. Aishwarya Gurav were awarded prizes for winning Post graduate Quiz conducted by Department of Paediatrics at Goa Medical College. Glimpse of the CME held at Fidalgo. Dr. Dalwai being welcomed.
Dr. D’sa seen addressing the crowd. Dr. Anish receiving award for winning the PG quiz
2. Activities Conducted by DHS members on various Projects
Breast Feeding week was celebrated at Asilo Hospital wherein the OPD as well as IPD patients were educated by our team of doctors and nurses about Breastfeeding and its benefits
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Breastfeeding week was celebrated at SDH Ponda- Poetry recitation competition,Banner
making competition was held.
Dr. Shastry and Dr. Vinda addressing the Mothers at SDH Ponda
POSHAN MELA at SDH Ponda
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Mascot design on Healthy Nutritious Food for Children on Occasion of World Nutrition week 2018
ORS week celebrated at Hospicio – Dr. Kalpana seen addressing the OPD patients regarding the use of ORS
Breast feeding week celebrated at Hospicio. Various forms of stall were
erected to dispense knowledge by demonstrating how to feed and how to wean the baby. Also Hand painting competition was conducted
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Childrens Day at SDH Ponda
3. Activities conducted by other Members:
• Dr. Anant Kini, Dr. Chetna Khemani, Dr. Preity Shetye, Dr. Damodar Narvekar attended camp conducted by Chinmay Mission at Vidhyaprobhodini School. Dr. Sushma Kirtani delivered talk on ORS And Its Benefits, while Dr. Priety Shetye addressed the topic of Hand washing Technique. Dr. Chetna Kemani – dispensed knowledge with the help of ORS Posters. The camp was attended by 130 children.
Doctors at Vidhyaprabhodini School
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______• Adolescent Camp conducted at Vidhyaprabhodini School for girls of Standard IXth and Xth. Total 150 girls were examined. Problems encountered were Studt stress, Acne, Mentrual related discomforts, Visual complains, Headaches, Poor appetite, Failure to put on weight, difficulty in memorising, diifficulty in concentrating on studies and classwork, Neck pain- Probably due to carrying Heavy School bags. Dr. Anant Kini, Dr. Sushma Kirtani, Dr. Priety Shetye, Dr Chetna Khemani and Dr. Damodar Narvekar paticipated in the camp. Dr. Sushma spoke on the topic Stress related Problem in Adolescence and Brief management.
Adolesence Camp at Vidhyaprabhodini
• MEGAMEDICAL CAMP was conducted at RAMNATHI TEMPLE. 186 patients were examined. 40 children were examined. Paediatric pateints were examined by Dr. Anant Kini and Dr. Surendra Juwarkar. Special services- Blood sugar, Lipid profile, PFTs, free Spectacles and Free medicines were dispensed.
Seen in the pictures are Dr. Pradeep Naik, Dean – Goa Medical College, during inauguration function at MegaMedical Camp held at Ramnathi Temple. Also seen are Dr. Kini and Dr. Juwarkar
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• School Health Camp conducted at People’s School Camurlim. Cases encountered – Dental caries, Pyoderma, Scabies, Acne and PCM. Camp was conducted by Dr. Anant Kini and Dr. A O Nazareth.
Camp held at People’s School Camurlim. Seen in the picture are Dr. Anant Kini and Dr. Nazareth examining the Students
. Dr. Purnima Usgoankar conducted her regular camps at Matruchaya ( inmates and other patients from the vicinity including the Dangarwadi) on every Wednesday and at Sneha Mandir – Mobile Clinic on Tuesday at various places
Activities At Matruchaya
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4. Activities conducted at Goa Medical College by our Members • UG quiz was conducted by Department of Paediatrics, Goa Medical College on 17th August 2018. Quiz Master- Dr. Rataboli. Winners- Aditya Kamat and Karthika George.
Seen in the pictures are quiz being conducted and beaming faces of Winners with Dr. Mimi and Dr. Lorraine
• PG Quiz was conducted on 22nd August 2018, with Dr. Anish Bakhale and Dr. Aishwarya Gurav were the Winners.
5. Activities conducted at Sethu Monsoons are a time when it is raining trainings at Sethu. With its strong belief in collaboration and sharing of knowledge, capacity building is a strength of Sethu's work. Gold Medal in IAP Fellowship in Developmental Pediatrics 2017-18: We are delighted to announce that Sethu's first ever IAP Fellow in Developmental Pediatrics Dr. Aparna Wadkar obtained the highest marks at the final examination at CMC Vellore and was awarded the gold medal for 2017-18 at the National Conference of Developmental Pediatrics in Hyderabad in September 2018 . Her hard work and outstanding performance has earned her many kudos. She has returned to the Pediatric Neurorehabilitation Centre at Goa Medical College where she is strengthening the service for children with disabilities. Dr. Vibha Parsekar from Asilo Hospital, Mapuca, has joined Sethu as an IAP Fellow for 2018-19.
Workshops and training programs: On 15th July 2018, Dr. Nandita de Souza conducted a workshop on Childhood Sexuality at Catholic Club, Bangalore. It was attended by 18 parents and teachers. Sethu staff have been focusing on spreading awareness about ADHD and 2 workshops were conducted for teachers at Regina Mundi HS, Vasco on 28th July and at Mapuca Super School Complex on 31st July. Dr. Vikram Dua, a child and adolescent
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______psychiatrist from Toronto, Canada visited Sethu from 6th to 8th August and did teaching sessions for the staff, as well as conducted case discussions at Goa Medical College, with the collaboration of the departments of Psychiatry and Pediatrics. He focused on the clinical approach to helping children with severe disabilities and challenging behaviors. A 2-day workshop on Narrative Therapy in collaboration with Ummeed Child Development Centre, Mumbai was help on 24th and 25th August in Panaji. It was attended by 25 psychologists, counselors and teachers. On 6th October, Dr. Nandita delivered a lecture on Learning Disabilities at Lemecon 2018, the National Conference organized by the Association of Physiologists of Tamilnadu at Sri Karpaga Vinayaga Institute of Medical Sciences (KIMS), Chennai Children First in New Delhi, organized their conference Imagine 2018, which was attended by mental health professionals across India. Dr. Nandita participated in a panel discussion and spoke on how professionals can be agents of positive change for children. On 24th November, Dr. Nandita presented a session on Inclusive Education at the workshop organized at Chowgule College Margao, with Antarman and the Goa Psychiatric Association. Over 60 psychologists, teachers and parents discussed various ways in which schools can Become more inclusive.
AATISH (Autism Advocacy, Training, Intervention, Support and Hope) Centre at Sethu: With the large numbers of children with autism being referred to Sethu, a New Centre with additional space and staff has been inaugurated on 3rd November 2018 within the premises of Divya Sadan of Caritas, in Sucorro. This will allow better facilities to diagnose, train and support children with autism and their families. Learning Disabilities Camp: On 4th and 5th July, Team Sethu travelled to St. Sebastian HS in Canacona to conduct an assessment camp for children with learning difficulties. Around 20 children from middle and high school were assessed and recommendations for remediation were made. The teachers were also educated about teaching diverse learners. Programs: In association with Rotary Club, Porvorim, Sethu celebrated an inclusive Children's Day on 14th November at Panchayat Ghar, Bastora. Close to 100 children and their families had fun together and participated in a range of activities including fancy dress, face painting, art and craft. There were dance performances put up by the children too. The show ended with a flash mob dance by the Sethu Team to the tune of 'Happy', which the children and parents joined in. It has been a year filled with many blessings and challenges for Sethu. It looks forward to further growth during 2019 and is grateful to all the encouragement from the community of pediatricians in Goa.
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KNOWING OUR MEMBER: Dr. Sushma Kirtani
1. When is your birthday? 17th October 1964…. I am sweet 54 years.
2. What does you name mean? Do you have a Nick Name? What’s it? It means Meditation, SUSHAM is what my Mom’s family calls me. Though Sush as per my Teachers like Dr Nandita and Dr Ira and SUSAMMA by Dr. Gauns
3. Why Paediatrics? Actually, don’t know. My Mom wanted me to be a teacher or work in bank. The medical education was expensive for my parents. I studied on scholarship from Goa Hindu Association. My Moms two elder brothers helped by paying my fees and with books. I topped my MBBS and was a gold medalist and best lady graduate with a Distinction holder in all four subjects of 2nd MBBS. But I loved kids and so was admission in Paediatrics was a smooth sail. I am happy today with my decision. Want to share a small incidence .When I went to sign my form from late Dr H.B.Rao who was HOD and my MD guide , Dir had said “You will never repent for taking Paediatrics . You have your knowledge and your magic Stethoscope, even if you sit on the footpath you will make wonders in the life of those kids”.
4. What do you like most about your profession? If not a doctor, then what would you be? The life, happiness on the face of little angels I would have been a cook or in the hospitality field. I love cooking, learning different recipes and trying them.
5. What would you describe yourself as a child? As a child I was very shy, very obedient. My parents never complained about my behaviour. Though Mom was very strict and disciplined person, dad was my Superhero. Always loved anything I did. I was a target for my Schoolmates due to my mild nature, they would rob my books, pens and stuff like that. Today I feel so funny when I recollect those days. In fact, one child even pulled out my earring and took it forcibly. Though I got reprimanded by My Mom for no fault of mine, my Maternal Grandpa was a rich man, immediately got me the new pair next day.
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6. Your favourite hobby? Reading medical books and journals, attending scientific sessions in conferences and cooking. I do compose poetries.
7. What is your favourite cuisine and eat out place? Chicken Dum Biryani from Delhi Darbar and Hotel Mandovi is my favourite spot
8. Besides Goa if you had been given an option to live somewhere else it, where would it be? Amsterdam
9. Your most treasured memory? The day I received my gold medal in final MBBS
10. Your worst night mare? If I could not treat my patient properly or despite every effort if I am aware I will lose him or her and of course my spouse!!
11. Your 5 most cherished possessions? My daughter Pooja ;love and affection of my teachers ;lovely friends; fond memories of my father in law who loved me like a daughter and looked after my girl so that I excel in my profession. ;fond memories of brownie, my adopted pet who had unconditional love for me.
12. What creatures/ things scare you? Snake and spiders: bats are there in my house and they often scare me more than the other two.
13. What irritates you most? Laziness in my spouse, indecisive behaviour from anybody I deal with
14. Your strongest personality trait? Determination, I will do it and I am not at rest till the work is completed to perfection.
15. What is your Definition of a) Being Famous and b) Being Successful? Famous as a Doctor amongst patients is not important for me. I want to see whether I was successful in my dealing with that particular child and his parents that I could touch their lives. Success does not depend on how many patients you have outside your cabin, it depends on according to me whether I have done justice to the person who wanted my opinion. You can be anything, but I feel at the end of the day you got to be a good human being. 36 | Page
IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______16. What are you most thankful about in your life? Thankful to god, my parents and teachers to make me what I am today.
17. If you were given power to change what would you change in a] World b] India c]Pediatrics? Globaslisation and Westernisation that has a very bad impact on the lives of our kids especially the poor. In India definitely the violation of basic rights of our children and especially poverty and corruption delaying our overall growth. In Pediatrics various programmes for children lauched by our centre has not reached the beneficiary.I would see to that proper guidelines and SOPs are made to implement those programmes.
18. Your best childhood memory? Climbing on the roof tiles(Nalle) of the house and eating Gooseberrys (Indian aavale). The tree would be loaded with them and the branches would rest on the roof. In hot sun, me and my cousin used to regularly do this, especially in the afternoons when elders used to have afternoon siesta! If they come to know later a good beating was Guara.
19. What is your definition of a Perfect Day? All days are perfect provided you have been successful to make someone smile.
20. Who inspires you most, in other words Who is your Idol? My teachers, Dr. Amdekar and Our Hon.CM Mr.Parrikar.
21. What comprises of an ideal Vacation? Driving long distance and watching nature
22. What you prefer: • Messaging/Calling up I call up to talk to my loved ones • Watching a movie or watching Drama in theatre I love watching a movie and a drama • Vacation at a Hill station or Beach or Safari Vacation at a hill station • Read a book/ Watch TV/ Browse net Reading a book, listening to Gazals and Drinking a hot coffee on a rainy Sunday evening is a dream • Facebook/Whats App/Twitter/Snapchat/Instagram I don’t enjoy social media. I would rather speak to some loved one on the phone
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IAP Goa E-Bulletin; E- BULLETIN November 2018 Issue 5; GOA STATE CHAPTER For Private Circulation ______• Travel by car/plane/bus/train/cruise Travel long distance by car and enjoy nature’s beauty. I need to be seating next to the driver to do that as I get motion sick. • Sunrise/Midday/Noon/Twilight/Midnight/Past Midnight Watching sunrise and sunset is my favourite past time
23. If you could go back in time, which year would it be? It would be 1984 when I was in 2nd MBBS. Those were the best days of my life…
24. If a Genie granted you 3 wishes, what would you ask for? • To grant me strength to do something for poor children, money to do that and the position to reach my goal. • Without genie with my willpower and determination I know I can do it. 25. Do you have a Bucket list? What hits the list? No, I never wished for material things. God has been kind to grace me with his blessings. I feel one should achieve all the things he aspires by his hard work. Good karma will fetch good fruits.
26. Do you talk to yourself? YES OFTEN! especially when I am stressed and I find it is a good stress buster. It sometimes help you to take a decision in difficult situations when you are the decision maker in my case this happens often!!
27. How do you recharge yourself? What are your stress busters? I chant often and I am a Iskcon follower just going for a stroll and having a limboo soda recharges me. Talking to Pooja my daughter is always been a big stress reliever for me. I sometimes wonder who the Mother is!!Me or She. The focus and encouragement that she has in her words is enough to stand up even in worst condition.
28. Advice to GenX Pediatricians? Hard work and love for what you do is the key to success. Everyone needs money but beyond that there is satisfaction of doing something which one cherishes FOR THE ENTIRE LIFE.
29. What is your favourite quote? “No matter how big your house is, how recent your car is, or how big your bank account is, our graves will always be the same size. STAY HUMBLE”
30. How do you want People to remember you? For my dedication and simplicity.
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