The document summarizes several stories from a medical magazine: 1. Researchers were able to regenerate brain cells and restore memory in aged animal models by implanting neural stem cells into the hippocampus. The stem cells survived and produced new neurons and glial cells in both young and old brains. 2. A study found that many migraine sufferers have vitamin D, riboflavin, and CoQ10 deficiencies, though more research is needed to determine if supplementation can prevent migraines. 3. Three clinical trials found that a new drug called canakinumab reduced recurrent cardiovascular events in patients with previous heart attacks by 15%. The drug targets inflammation to provide additional protection beyond statin therapy.

1. DOCNDOC
VOL 7 + ISSUE 8 + JULY 2016 + `300
India’s largest selling doctors’ magazine
CHRONIC
OBSTRUCTIVE
PULMONARY
DISORDER
BETTER CARE
REDUCES CEREBRAL
PALSY
STERILIZATION
IN WOMEN
ABDUCTED BY
THE WEEKEND
CASA DE LA LUNA,
ALIBAUG
THEY ARE
DIFFERENTLY-ABLED
SO, IS EVERYBODY
ELSE!
COVER STORY
Dr. Vivek Nangia
Dr. Pradeep Mahajan
Dr. Shivani Sachdev Gour
Dr. Lily Kiswani&
Dr. Samir Dalwai

2. 2DOCNDOC
REACH
EDUCATE
EMPOWER
RECOMMENCING
A TESTAMENT TO
SKILLS
INGENUITY
AND VISION
3DOCNDOC
DOC+
DOC N DOC
Power Lab
Life Lab
Future Lab
Ink Lab
Saviour Awards
Microscope
Social Media
A revived collaboration of medical updates,
lifestyle stories with a sneak peak into different
events named under specific labs. Grab a
microscopic copy exclusively designed for the
subscribers.
Above all, a deeper takeaway value in the form
of various events and conferences, attended
by the most progressive healthcare experts,
sharing lessons and best practices.
Your monthly dose of medical stories with a
state-of-the-art design, straight from the expert
doctors covering your healthcare concerns
for the last six years, and only growing faster.
A powerful update on major luxury and
management events, with a focus on improving
the management of the business.
An update on the Lifestyle plug-in to the CMEs
and other stand alone Lifestyle events happening
side by side.
An update on monthly CME events within the
hospital premises with a focus on debating
latest medical developments and the future of
healthcare.
A mix of latest medical stories and lifestyle
updates in the form of our official blog.
A leading award honouring excellence in
appreciation for the relentless efforts of the
medical fraternity for providing quality service
and leadership.
A supplement with the magazine for the
microscopic attention to your requirements.
Follow us on Twitter, Facebook, and the
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3. 4DOCNDOC
DOC N DOC Volume 7 Issue 8
18
23
27
31
34
38
Burden Of Healthcare Cost
On Patients With Dementia
Better Care Reduces
Cerebral Palsy
Wireless Capsule Endoscopy -
A Fantastic Voyage
Chronic Obstructive
Pulmonary Disorder
46They are differently-abled,
so is everybody else!
Peripheral Arterial Disease
- The Next Big Killer
Sterilization in Women
COVERPHOTOSHOOTCREDITS:HimanshuRohilla
5DOCNDOC
58
66
76
78
80
82
86
Borderline Personality
Disorder
Rights of Adolescents to
Health and Autonomy
Silicon Gel Breast Implants -
Is it Advisable?
Higher-Fat DASH Diet
Chef Rakhee Vaswani
Superfood-Honey
Pride Plaza Hotel
Abducted by the Weekend
Reviews
90
70

4. 6DOCNDOC
ASDA
July 2016
Volume 7 Issue 8
Shanoob Azad
Publisher
Divya Mary Cyriac
Chairperson
Mathew Antony
Director
Deipshikha Dhankhar
Editor-in-Chief
Dimple Bhavsar
Junior Sub-editor
P Vel Kumar
Creative Consultant
Dipesh Bhanushali
Designer
Anu Ommen
Photo Editor
Jeffy John
Operations Manager
Sales & Marketing Team
Vipul Jain
Maneesha Arun
Roshan Namboodiri
Akshay Ghige
404, Makhani Centre, nr. Makhija Arcade, off
Linking Road, Bandra(W), Mumbai-400050
Please contact our editorial team via
the following email addresses:
Reader feedback: feedback@docndoc.com
General editorial enquiries and requests for
contributor’s guidlines: deipshikha@docndoc.com
Press releases to this address only please:
pr@docndoc.com
Views and opinions expressed in the magazine are not necessarily those of ASDA Media & Entertainment Pvt. Ltd., its publishers and/or editors. We at ASDA
Media & Entertainment Pvt Ltd. do our best to verify the information published but do not take any responsibility for the absolute accuracy of the information.
ASDA Media & Entertainment Pvt Ltd. does not accept the responsibility for any loss or damage incurred or suffered by any reader of this magazine for any decision
taken on the basis of information provided herein. No part of this publication can be reproduced in any form without the written permission of the publisher.
ASDA Media & Entertainment Pvt Ltd. reserves the right to use the information published here in any manner whatsoever. Printed by Shanoob Azad Published
by Shanoob Azad on behalf of Shanoob Azad and Printed at Kala Jyothi Process Pvt. Ltd. 1-1-60/5, RTC Cross Roads Musheerabad, Hyderabad - 500 020 India and
published at Thandanaparambil, Karunakaran Nambiar Road, Trichur P.O., Kerala 680020. Editor K Abdul Khader
DOC N DOC :
FROM THE
EDITOR
Deipshikha Dhankhar
Hello my dear readers!
I am sure you are quite drenched in the
smell of ginger tea and the one that levitates
the senses right after it has rained. Petrichor
as it is called, besides chocolate, that’s just
my favourite emotion. I am totally in love with
the monsoon but I also do miss the kids who
used to occupy the streets the minute it strikes 5. I
guess I miss the odd reasoning they come up with. For
instance, just last week I ran into this kid, not older than 4 years,
and had chocolate all over him. “D, (yes that’s how much he had
edited my name), I am having salad”, when I asked him what was
he up to with so much chocolate. “Salad?” I sighed, rolling my eyes
to find a brain back there which could possibly explain to me how
chocolate is any salad.
Unsuccessful as I came to him, ‘how is it salad?’ I finally asked.
He fought a pack of giggles while putting his tiny, chocolaty, palm
over his mouth and said, “Chocolate comes from cocoa, which is
a tree and that makes it a plant. So, chocolate is a salad! Wow, I
exclaimed, ‘It must be taking you some skills to trip over completely
nothing.’ I had a pot full of laughter at that though and the words
just take me down a notch lighter every time I meet any kid.
Amazed. Inspired. Grateful. That’s how they make me feel.
So, I have decided to take these little ones to plant some
saplings in this rainy season as the BMC has finally given us the
permission to save this planet. I feel it is absolutely necessary to
teach these younglings a thing or two about the environment as
not only are we supposed to leave a better planet for our kids, but
also better kids for our planet.
You can’t see it but I am totally doing a happy dance right now,
because even the cover story for this issue is going to give you a
very different perspective on Autism. And yes, I totally believe that
each one of us is differently-abled as each one of us is able to
do something different and valuable if we maximize our potential!
Take a look and enjoy this edition with a cup of ginger tea. In the
meantime, I am also going to request my boss to consider ‘work
from traffic’ as long as the rains remain a totally legitimate thing to
include in working hours.
9DOCNDOC
ASDA

5. 8DOCNDOC
FROM THE
PUBLISHER’S BLOG
Shanoob Azad
Hello Readers,
July 1 is celebrated as Doctor’s day in India- A day to remember the
contributions of doctors to the society.
The idea of this day originated in the US, when Eudora Brown Almond,
wife of Dr. C B Almond, proposed it. The date was chosen to commemorate
the first use of General Anesthesia in Surgery. The date March 30th was
made a holiday by the Bush Administration in 1990.
However, Doctor’s day in India has a different origin. It is the birthday of
Dr. Bidhan Chandra Roy, the second Chief Minister of West Bengal. He was
a physician and freedom fighter and worked hard to bring peace and order
to a partition-torn Bengal. On this day, we celebrate the value of doctors in
our lives. The healthcare scenario in the country has improved considerably
post-independence and it is the relentless effort of the whole generation
of currently retiring doctors. The collective responsibility this community
took up, even with sub-standard infrastructure, lifestyle and practically no
diagnostic facilities, is truly commendable.
This generation commanded respect from people. Ironically today, even
with high quality infrastructure and better income, we are still falling short
of the dream and we still have to keep fighting to make this dream a reality.
There is a need to rekindle the joy of serving people and a need for patients
and doctors to build more trustworthy and responsible relationships. In
today’s ecosystem, individuals and corporates are equally responsible for
bringing this trust. It is truly gratifying to see that a lot of institutions today
have brought back the focus to patient care.
Looking forward, we must remember the words of Dr. B C Roy, “We
have the ability and if, with faith in our future, we exert ourselves with
determination, nothing, I am sure, no obstacles, however formidable or
insurmountable they may appear at present, can stop our progress... (if)
all work unitedly, keeping our vision clear and with a firm grasp of our
problems.”
Those words contain everything we need to do to move ahead, and it is
quite interesting to see that his advice from half a century back is still what
the community and population need to hear.
7DOCNDOC

6. 10DOCNDOC
A
lthough brains
– even adult
brains – are far
more malleable
than we used to think,
they are eventually subject
to age-related illnesses,
like dementia, and loss of
cognitive function.
Someday, though, we
may actually be able to
replace brain cells and
restore memory. Recent
work by Dr. Ashok K. Shetty,
Ph.D., a professor in the
Department of Molecular and
Cellular Medicine, associate
director of the Institute for
Regenerative Medicine, and
research career scientist at
the Central Texas Veterans
Health Care System, and
his team at the Texas A&M
Health Science Center
College of Medicine hints at
this possibility with a new
technique of preparing donor
neural stem cells and grafting
them into an aged brain.
Shetty and his team
took neural stem cells and
implanted them into the
hippocampus – which plays
an important role in making
new memories and connecting
them to emotions – of an
animal model, essentially
enabling them to regenerate
tissue. Findings were
published in the journal Stem
Cells Translational Medicine.
“We chose the
hippocampus because it’s
so important in learning,
memory and mood function,”
Shetty said. “We’re interested
U P D AT E S
in understanding aging in
the brain, especially in the
hippocampus, which seems
particularly vulnerable to age-
related changes.” The volume
of this part of the brain seems
to decrease during the aging
process, and this decrease
may be related to age-related
decline in neurogenesis
(production of new neurons)
and the memory deficits some
people experience as they
grow older.
The aged hippocampus
also exhibits signs of age-
related degenerative changes
in the brain, such chronic
low-grade inflammation and
increased reactive oxygen
species.
“We’re very excited to see
that the aged hippocampus
can accept grafted neural
stem cells as superbly as the
young hippocampus does
and this has implications
for treating age-related
neurodegenerative
disorders,” said Bharathi
Hattiangady, assistant
professor at the Texas A&M
College of Medicine and
co-first author of the study.
“It’s interesting that even
neural stem cell niches
can be formed in the aged
hippocampus.”
Shetty’s previous research
focused on the benefits of
resveratrol (an antioxidant
that is famously found in
red wine and the skin of red
grapes, as well as in peanuts
and some berries) to the
hippocampus. Although the
results indicated great benefit
for preventing memory
loss in aging, his latest
work demonstrates a way
to affect the function of the
hippocampus more directly.
REGENERATING
MEMORY WITH NEURAL
STEM CELLS
11DOCNDOC
For this latest research,
the team found that the
neural stem cells engrafted
well onto the hippocampus
in the young animal models
(which was expected) as well
as the older ones that would
be, in human terms, about 70
years old. Not only did these
implanted cells survive, they
divided several times to make
new cells.
“They had at least
three divisions after
transplantation,” Shetty said.
“So the total yield of graft-
derived neurons and glia (a
type of brain cell that supports
neurons) were much higher
than the number of implanted
cells, and we found that in
both the young and aged
hippocampus, without much
difference between the two.”
“What was really exciting
is that in both old and young
brains, a small percentage
of the grafted cells retained
their ‘stemness’ feature and
continuously produced new
neurons,” Hattiangady said.
This is called creating a new
‘niche’ of neural stem cells,
and these niches seemed to
be functioning well. “They are
still producing new neurons
at least three months after
implantation, and these
neurons are capable of
migrating to different parts of
the brain.”
Past efforts to rejuvenate
brains using fetal neurons
in this way weren’t nearly as
successful. Immature cells,
such as neural stem cells, seem
to do a better job because
they can tolerate the hypoxia
(lack of oxygen) and trauma of
the brain grafting procedure
better than post-mitotic or
relatively mature neurons.
When researchers tried in the
past to implant these partially
differentiated cells into the
aged hippocampus, they didn’t
do nearly as well. “We have a
new technique of preparing
the donor neural stem cells,”
Shetty said. “That’s why this
result has never been seen
before.”
The researchers did this
work using donor cells from
the sub-ventricular zone of
the brain, an area called the
“brain marrow,” because it
is analogous to bone marrow
in that it holds a number
of neural stem cells that
persist throughout life and
continuously produce new
neurons that migrate to the
olfactory system. These stem
cells also respond to injury
signals in conditions such as
stroke and traumatic brain
injury and replace some of the
lost cerebral cortical neurons.
Even a small piece is good
enough to expand in culture,
so the procedure isn’t terribly
invasive, but in the future,
a skin cell might suffice, as
similar neural stem cells can
be obtained in large numbers
from skin. It’s been well
known in medical science that
a number of cells in the body
– including those of the skin –
can be modified in such a way
to create induced pluripotent
stem cells. With these cells,
scientists can do any number
of things, including making
neural stem cells that will
make both more of themselves
and new neurons. “You don’t
have to get the cells from the
brain, you can just take a skin
biopsy and push them into
neural stem cells,” Shetty said.
Although the way the
grafted cells thrived is
promising, there is still a
good deal of work to be done
to determine if the extra grey
matter actually improves
cognition.
“Next, we want to test
what impact, if any, the
implanted cells have on
behavior and determine
if implanting neural stem
cells can actually reverse
age-related learning and
memory deficits,” Shetty said.
“That’s an area that we’d like
to study in the future. I’m
always interested in ways to
rejuvenate the aged brain to
promote successful aging,
which we see when elderly
persons exhibit normal
cognitive function and the
ability to make memories.”
Source: Science Daily
MANY WITH
MIGRAINES HAVE
VITAMIN DEFICIENCIES,
SAYS STUDY
R
esearchers
uncertain whether
supplementation
would help
prevent migraines
A high percentage of
children, teens and young
adults with migraines appear
to have mild deficiencies of
vitamin D, riboflavin, and
coenzyme Q10 -- a vitamin-
like substance found in every
cell of the body that is used
to produce energy for cell

7. 12DOCNDOC
A
ccording to three
large, long-term
clinical trials led
by Northwestern
Medicine, a new drug called
ixekizumab helped completely
or almost completely clear
moderate to severe psoriasis
of 80% patients. The results
of these phase III trials were
compiled in a paper published
in the New England Journal
of Medicine.
Dr. Kenneth Gordon, a
professor of dermatology
at Northwestern University
Feinberg School of Medicine
and first author of the paper
said, “This group of studies
not only shows very high and
consistent levels of safety
and efficacy, but also that
the great majority of the
NEW DRUG CLEARS
PSORIASIS IN CLINICAL
TRIALS
IMPROVEMENT
PERSISTS FOR MORE
THAN A YEAR
growth and maintenance.
These deficiencies may
be involved in patients who
experience migraines, but
that is unclear based on
existing studies.
Dr. Suzanne Hagler, MD,
a Headache Medicine fellow
in the division of Neurology
at Cincinnati Children’s
Hospital Medical Center and
lead author of the study, said
“further studies are needed
to elucidate whether vitamin
supplementation is effective
in migraine patients in
general, and whether patients
with mild deficiency are
more likely to benefit from
supplementation.”
Dr. Hagler and colleagues
at Cincinnati Children’s
conducted the study among
patients at the Cincinnati
Children’s Headache
Center. Dr. Hagler’s study
drew from a database that
included patients with
migraines who, according to
Headache Center practice,
had baseline blood levels
checked for vitamin D,
riboflavin, coenzyme Q10
and folate, all of which were
implicated in migraines, to
some degree, by previous
and sometimes conflicting
studies. Many were put
on preventive migraine
medications and received
vitamin supplementation,
if levels were low. Because
few received vitamins
alone, the researchers were
unable to determine vitamin
effectiveness in preventing
migraines.
Study says girls and
young woman were more
likely to have coenzyme
Q10 deficiencies at baseline
than boys and young men.
Boys and young men were
more likely to have vitamin
D deficiency. It was unclear
whether there were folate
deficiencies. Patients with
chronic migraines were more
likely to have coenzyme Q10
and riboflavin deficiencies
than those with episodic
migraines.
Although earlier studies
indicate the importance
of vitamin and vitamin
deficiencies in migraine
process, studies that used
vitamins to prevent migraines
however yielded conflicting
success.
Source: Science Daily
responses persist at least 60
weeks.”
An immune-mediated
inflammatory disease that
causes itchy, dry and red
skin – Psoriasis affects
about 3 percent of the
world’s population. It is also
associated with an increased
risk for depression, heart
disease and diabetes, among
other conditions. Ixekizumab
works by neutralizing a
pathway in the immune
system known to promote
psoriasis.
To test the drug’s efficacy
over time and to help
clinicians determine whether
its benefits outweigh any risks
-- the three studies enrolled a
total of 3,736 adult patients at
more than 100 study sites in
13DOCNDOC
21 countries. All participants
had moderate to severe
psoriasis, which is defined as
covering 10 % or more of the
body. Patients were randomly
assigned to receive injections
of ixekizumab at various
doses or a placebo over a
period of more than a year.
The investigators assessed
whether the drug reduced
the severity of psoriasis
symptoms compared to the
placebo and evaluated safety
by monitoring adverse events.
By the 12th week, 76.4 to
81.8 percent of patients have
their psoriasis classified
as “clear” or “minimal”
compared to 3.2% of patients
on the placebo. By the 60th
week, 68.7 to 78.3% of
patients had maintained their
improvement.
“Based on these
findings, we expect that
80% of patients will have
an extremely high response
rate to Ixekizumab, and
about 40% will be completely
cleared of psoriasis,” Gordon
said. “Ten years ago, we
thought complete clearance of
this disease was impossible.
It wasn’t something we would
even try to do. Now with
this drug, we’re obtaining
response levels higher than
ever seen before.”
Adverse events associated
with Ixekizumab included
slightly higher rates of
neutropenia (low white blood
cell count), yeast infection and
inflammatory bowel disease
compared to the placebo.
The safety of therapy longer
than 60 weeks will need to be
monitored in the future.
The drug has been
approved by the Food and
Drug Administration since
the trials were completed.
Source: Science Daily
CIVIL SOCIETY CONCLAVE
HIGHLIGHTS THE NEED TO COMBAT
TB AND CO-MORBIDITIES WITH HIV,
DIABETES & TOBACCO USE
New Delhi, June 10,
2016: The partners of Call
to Action for a TB-Free India
organized a meeting in the
capital today for Civil Society
Organizations (CSOs), urging
them to join the fight against
TB. Representatives from the
Ministry of Health and Family
Welfare, medical associations
and societies, medical
colleges, Global Coalition of
TB Activists, USAID and The
Union attended the event and
discussed opportunities to
reduce the TB epidemic in the
country.
In the panel discussions
experts highlighted the
role of CSOs in TB control
with a focus on TB and the
co-morbidities associated
with HIV, tobacco use
and diabetes. 2.2 million
people in India are infected
with TB every year. It is
a curable disease, yet 2
people die every 5 minutes
in the country. While TB
can happen to anyone,
vulnerable populations, those
suffering from HIV-AIDS,
diabetes and tobacco users
are at a higher risk. India
has the highest number of
TB cases and second highest
number of Diabetes cases in
the world. Diabetes triples
the risk of TB. There is a
clear bi-directional link
between under-nutrition
and active TB. The experts
also highlighted the need
for interventions on TB in
vulnerable populations such
as children and women.
WHAT CAN CSOs DO?
◗ Encourage people who
present symptoms of TB
to get sputum examination
done
◗ Collaborate in active case
finding in community
through house to house
visits
◗ Spread awareness of FREE
diagnosis and treatment
available through the
Government
◗ Spread awareness on how
to prevent transmission of
TB to children and family
members
◗ Talk about cough hygiene
and importance of
treatment completion
◗ Inform health workers
(ASHAs, Community
Mumbai, May 5th
, 2016

8. 14DOCNDOC
volunteers, AWWs) about
symptoms of TB and its
diagnosis and treatment
◗ Promote screening for HIV
–TB and Diabetes-TB
◗ Talk about MDR – TB,
duration of the treatment
and the importance of
completing the course of
medication
Speaking on the burden
of TB and HIV co-infection,
Dr. R.S. Gupta, Dy.
Director General-CST,
NACO, Ministry of Health
and Family Welfare said,
“Persons with HIV are four
times more likely to contract
TB because of their already
weakened immunity. The
mortality rate in HIV TB
patients is also higher than
in patients with TB alone.
Screening HIV patients for
TB is not yet a policy, but
we need to test HIV patients
who are exhibiting TB
symptoms to facilitate early
diagnosis and treatment,
thereby improving treatment
outcomes. Missed diagnosis
is a serious issue for the
entire community, so we need
CSOs to work closely towards
combating both HIV and TB.
Close coordination between
CSOs at every level can
ensure symptomatic patients
get screened, they complete
their treatment course and
get access to benefits through
social service programs.
“The global End
TB strategy envisages a
strong coalition of civil
society members working
in partnership with
governments and the
community to strengthen
existing efforts for TB control
and develop newer ones
that yield better results,”
said Dr. Jagdish Prasad,
Director General of
Health Services, Ministry
of Health and Family
Welfare. He further added,
“Under the Revised National
Tuberculosis Control
Programme (RNTCP) we
have most recently made
three important changes –
first, we have introduced
rapid diagnostic CBNAAT
machines that will overcome
limitations in the earlier
microscopic examinations
and improve the accuracy
of diagnosis. Second, we
have introduced the daily
treatment regime for TB
patients. This is important
because the immune systems
of TB patients are weak and
majority of them do not
get adequate nutrition so
administering drugs daily
is important. And third, we
have introduced the drug
Bedaquiline for treating drug
resistant TB (MDR-TB). Now,
our next step is to introduce
guidelines on how treatment
for MDR-TB can be reduced
from 2 years to 9 months.”
Dr. Sunil Khaparde,
Deputy Director General-
TB, Central TB Division
highlighted, “A TB Free
India is not possible without
support of civil society
organizations working on
issues of reproductive and
maternal health, child and
adolescent health, nutrition,
anti-tobacco use, diabetes
and HIV-AIDS. TB mortality,
incidence and prevalence
have reduced, yet the burden
of the disease continues to
be very high. The incidence
is lowering at only 2 per
cent per year and that is not
enough to achieve the targets
set by the government.
TB co-morbidities, low
engagement of the private
sector, insufficient nutrition
to TB patients, missed
diagnosis and low treatment
adherence continue to be
major challenges that we
need to overcome. Without
CSO support the government
cannot achieve the goal of a
TB-Free India.”
The event concluded with
CSOs pledging their support
to TB-Free India.
Commenting what CSO
support means for the TB-
Free India initiative, Dr.
Jamie Tonsing, Regional
Director, The Union
said, “With the help of CSO
networks we can create
greater awareness of TB
control efforts and mobilize
communities for early TB
diagnosis to ensure faster and
complete treatment to stop
transmission and prevent
drug resistance.”
JARDIANCE® (EMPAGLIFLOZIN)
SIGNIFICANTLY REDUCED THE RISK
OF PROGRESSIVE KIDNEY DISEASE IN
ADULTS WITH TYPE 2 DIABETES WITH
ESTABLISHED CARDIOVASCULAR DISEASE
N
ew data from the
landmark EMPA-
REG OUTCOME®
clinical trial published in The
New England Journal of
Medicine
Ingelheim, Germany,
and Indianapolis, US,
June 15, 2016 – New
data showed Jardiance®
(empagliflozin) reduced
the risk for new-onset
or worsening kidney
disease by 39% versus
placebo when added to
standard of care in people
with type 2 diabetes with
established cardiovascular
disease. Boehringer
Ingelheim and Eli Lilly and
Company (NYSE: LLY)
announced today that the
findings have been published
in The New England
Journal of Medicine and also
presented at the American
Diabetes Association (ADA)
76th
Scientific Sessions®
in
New Orleans.
“These findings are
clinically important, given
15DOCNDOC
that one in two people with
type 2 diabetes worldwide
will develop kidney disease,
which can lead to kidney
failure and eventually the
need for dialysis.” said Prof.
Christoph Wanner, Chief of
the Division of Nephrology
and Hypertension
at the University
Hospital of Würzburg,
Germany. “Since diabetes
is the number one reason
people require dialysis
treatment, novel treatments
that may have the potential
to help address this crucial
medical need are necessary.”
These findings were part
of a pre-specified exploratory
analysis plan of additional
endpoints of the landmark
EMPA-REG OUTCOME®
trial. New-onset or worsening
kidney disease was a pre-
specified composite endpoint
that included the below clinical
events. Compared with
placebo, Jardiance® led to the
following statistically significant
changes in outcomes:
◗ 55% reduction in the
initiation of kidney
replacement therapy (such
as dialysis)
◗ 44% reduction in doubling
of creatinine (a waste
product usually filtered by
the kidneys) in the blood
◗ 38% reduction in
progression to
macroalbuminuria (very
high levels of a protein
called albumin in the urine)
Jardiance®
also
significantly slowed the decline
in kidney function over time
compared with placebo.
Most patients in this trial
were already taking the
recommended standard
treatment for kidney disease
in type 2 diabetes, renin
angiotensin aldosterone
system blockade; the kidney
effects of Jardiance®
were
apparent on top of these agents.
Consistent risk reductions
in kidney outcomes with
Jardiance®
were seen in people
who had impaired kidney
function, or increased levels
of albumin in the urine, at
baseline and in those who did
not, according to a post hoc sub-
group analysis. Serious adverse
events (AEs) and AEs leading
to treatment discontinuation
for Jardiance®
versus placebo
were comparable for those
with or without impaired
kidney function at baseline.
Death due to kidney disease
was rare and occurred in
three patients treated with
Jardiance®
(0.1 percent) and
none treated with placebo.
“With these new
EMPA-REG OUTCOME
data, Jardiance is the only
SGLT2 inhibitor associated
with evidence of slowing
the progression of kidney
disease in adults with type
2 diabetes and established
cardiovascular disease in
a cardiovascular outcome
study,” said Prof. Hans-
Juergen Woerle, Global
Vice President Medicine,
Boehringer Ingelheim.
About the EMPA-REG
OUTCOME®
Trial
EMPA-REG OUTCOME®
was a long-term, multicentre,
randomised, double-blind,
placebo-controlled trial of
more than 7,000 patients
from 42 countries with type
2 diabetes and established
cardiovascular (CV) disease.
The study assessed the
effect of Jardiance®
(10 mg
or 25 mg once daily) added
to standard of care compared
with placebo added to
standard of care. Standard
of care was comprised of
glucose-lowering agents and
CV drugs (including for blood
pressure and cholesterol).
The primary endpoint was
defined as time to first
occurrence of CV death, non-
fatal heart attack or non-fatal
stroke.
Over a median of 3.1
years, Jardiance®
significantly
reduced the risk of CV death,
non-fatal heart attack or non-
fatal stroke by 14% versus
placebo. Risk of CV death
was reduced by 38%, with no
significant difference in the
risk of non-fatal heart attack
or non-fatal stroke.
The overall safety profile
of Jardiance® in the EMPA-
REG OUTCOME trial was
consistent with that of
previous trials.
About Jardiance®
Jardiance®
(empagliflozin) is an
oral, once daily, highly
selective sodium glucose
co-transporter 2 (SGLT2)
inhibitor approved for use in
Europe, the United States,
India and other markets
around the world for the
treatment of adults with type
2 diabetes.
Jardiance®
works by
blocking the reabsorption of
glucose (blood sugar) by the
kidney, leading to urinary
glucose excretion and
lowering blood glucose
levels in people with type 2
diabetes. SGLT2 inhibition
targets glucose directly and
works independently of β-cell
function and the insulin
pathway.
Jardiance®
is not for
people with type 1 diabetes
or for people with diabetic
ketoacidosis (increased ketones
in the blood or urine).

9. 15DOCNDOC
PremMathur Commercial Pilot of Deccan Airways
16DOCNDOC
S
tempeutics Research,
a group company of
Manipal Education &
Medical Group and a joint
venture with Cipla Group,
announced today that the
Drugs Controller General
(India) has granted limited
approval for manufacturing
& marketing of stem cell
based biological product
Stempeucel® for the
treatment of Buerger’s
Disease. Buerger’s Disease
is a rare and severe disease
affecting the blood vessels of
the legs. It is characterized
by inflammation and
occlusion of the vessels
of extremities resulting
in reduced blood flow to
these areas, thus leading
to severe pain and ulcers
or necrosis, which finally
may require amputation.
Stempeucel® treatment
is designed to enhance the
body’s limited capability
to restore blood flow in
ischemic tissue by reducing
inflammation and improving
neovascularization.
Commenting on the
approval of DCGI,
Mr BN Manohar, CEO
of Stempeutics said,
“Obtaining DCGI approval for
Stempeucel® is an important
and historic milestone for
Stempeutics. We are the
FIRST Company in India to
achieve such approval.
It took almost 9 years to
develop Stempeucel® for
the treatment of Buerger’s
Disease. European Medicinal
Agency has classified
Stempeucel® as an Advanced
Therapeutic Medicinal
Product (ATMP) and
designated it as an Orphan
Drug (ODD) for the treatment
of Buerger’s Disease. Our goal
is to globalize Stempeucel®
for Buerger’s Disease and the
market size is approx. US$
1.5Billion worldwide”.
Mr Chandru Chawla,
Head Cipla New Ventures
said, “Today is not only a
great day for Stempeutics, but
for everyone involved in the
responsible development of
stem cell therapies. Through
Cipla Group’s investment
in Stempeutics, we have
brought the next generation
of biologics to address unmet
medical needs. Physicians
now have an off-the-shelf
stem cell therapy in their
hand to fight Buerger’s
Disease. Much like the
introduction of antibiotics
in the late 1920’s, with stem
cells we have now officially
taken the first step into this
new paradigm of medicine.”
“It is a significant
milestone for Stempeutics
and a satisfying journey
for Manipal Education
and Medical Group”,
commented Dr. H.
Sudarshan Ballal,
Chairman - Manipal
Hospitals
About Buerger’s Disease
Buerger’s Disease is a
recurring progressive
inflammation and clotting of
small and medium arteries
and veins of the feet. It is
strongly associated with
use of tobacco products
primarily from smoking,
but also from smokeless
tobacco. Stempeucel drug
is expected to address the
root cause of the disease
through anti-inflammatory
and immune-modulatory
mechanisms. It is expected
to induce angiogenesis
through release of vascular
endothelial growth factors,
epithelial growth factors,
angiopoietin and improve
the perfusion and help the
repair and regeneration of the
ischemic muscle tissue.
About Stempeutics:
Stempeutics is an advanced
clinical stage Biotech
Company based out
of Bangalore. It was founded
by Manipal Education and
Medical Group (MEMG)
in 2006 and later entered
into a strategic alliance with
Cipla in 2009. Stempeutics
strength lies in developing
innovative stem cell
products by nurturing
cutting edge research and
clinical applications through
dedicated efforts of its highly
qualified team. Its goal is
to develop novel stem cell
drugs addressing major
unmet medical needs with
India’s first global next
approach.
DCGI GRANTS LIMITED APPROVAL TO
MARKET STEMPEUCEL® PRODUCT FOR
TREATING CRITICAL LIMB ISCHEMIA DUE
TO BUERGER’S DISEASE
◗ Buerger’s Disease
(also known as
Thromboangiitis
Obliterans) is a major
unmet medical need
in India and Globally
◗ Prevalence of Buerger’s
Disease is estimated
to be 1,000,000
in India and 2 per 10,000
persons in the European
Community & USA
◗ Stempeucel® becomes
5th off-the-shelf Stem
cell product to be
approved by a Regulatory
body, anywhere in the
world

10. 18DOCNDOC
BURDEN OF
HEALTHCARE COST
ON PATIENTS WITH
DEMENTIA
D
ementia is a syndrome usually
chronic, characterized by a
progressive, global deterioration
in intellect including memory,
learning, orientation, language,
comprehension and judgement due to disease
of the brain. It mainly affects older people; only
about 2% of cases start before the age of 65 years.
After this, the prevalence doubles every five years.
The common causes like Alzheimer’s disease,
Vascular dementia, Dementia with Lewy bodies
and Frontotemporal dementia accounts for 90%
of all cases of dementia. Some less common
causes like chronic infections, brain tumours,
hypothyroidism, subdural haemorrhage, normal
pressure hydrocephalus, metabolic conditions,
toxins or deficiencies of vitamin B12
and folic acid
are particularly important to detect since some
of these conditions may be treated partially
by timely medical or surgical intervention.
Dementia is one of the major causes of disability
in late-life.
Demographic aging is a global phenomenon;
and India is no exception. Soon, there will be
a sharp increase in the number of older people
in our population. Dementia being a disease of
19DOCNDOC
elderly will also be on the rise. In 2010, there
were 3.7 million Indians with dementia and the
total societal cost towards it was about 14,700
crore. The numbers are expected to double by
2030; the cost would increase three times.
Dementia affects every person in different
ways. Its impact can depend on what the person
was like before the disease; his/her personality,
lifestyle, significant relationships and physical
health. Dementia reduces the lifespan of affected
persons. In the western countries, a person
with dementia can expect to live for roughly
5-7 years after onset/diagnosis (Ganguli et al
2005; Fitzpatrick et al 2005). In low and middle
income countries, diagnosis is often much
delayed, and survival may be much shorter. The
mortality rates could be higher in the absence of
interventions (Dias et al, 2008) and the severity
at the time of identification could also predict
mortality.
Currently, there are no treatments available
that cure or even alter the progressive course
of dementia. Current medications available
for dementia only improve the cognitive,
behavioural and symptomatic aspect of
dementia especially in the early and moderate
stages (Birks and Harvey, 2006; Loy and
Schneider 2006; Birks et al, 2009). The costs
of these drugs in India are much less than
the international prices. Despite this, poorer
sections in India are not likely to be able to buy
them. Non-pharmacological interventions are
an important aspect in dementia. There are
several systematic reviews and meta-analyses
(Brodaty et al 2003; Lee and Cameron, 2004;
Smits et al 2007), which have shown the benefit
of care-giver interventions in preventing or
Contribution of chronic diseases to Years
Lived with Disability
Arthritis 9.66%
Blindness 21.93%
Diabetes 2.55%
Digestive 5.60%
Endocrine 0.85%
Genitourinary 1.86%
Heart disease 5.39%
Mental disorders 9.31%
Respiratory 6.40% Skin 0.59%
Stroke 10.30%
Cancer 2.56%Deafness 10.82%
Dementia 11.9%

11. 20DOCNDOC
delaying hospitalisation or institutionalization.
Although numerous new medical therapies are
being investigated; any new agent is likely to be
very expensive and would pose an ethical and
practical challenge in making such a treatment
widely and equitably available, particularly to
the two-thirds of dementia patients who are
living in low and middle income countries. It
is necessary to formulate ways and means by
which new cost-effective treatments can be
made affordable.
Dementia remains a largely hidden problem
in India, especially in those parts of India where
poverty and illiteracy levels are high. Prevalence
of dementia reported from Indian studies
amongst the elderly range from 0.6% to 10.6%
in rural areas and 0.9% to 7.5% in urban areas.
In India the number of people with dementias
is increasing every year because of the steady
growth in the older population and stable
increment in life expectancy.
it involves tasks that may be unpleasant and
uncomfortable and are psychologically stressful
and physically exhausting.”
‘Formal care’ includes institutionalised
activities related to providing health services,
social /community care, respite and long-term
residential or nursing home care, etc., unlike
‘informal care’ which is the unpaid care by family
members or others. As noted earlier, in countries
like India, a greater part of caregiving is informal
care particularly by the members of the family.
While formal care is relatively easier to cost,
costing informal care poses several challenges.
Apart from difficulty in defining the number of
hours spent for care, there is substantial difficulty
in defining the various components of informal
care, costing lost productivity, etc. (for details see
Jonsson and Wimo, 2009 and Wimo et al, 2007).
Cost of illness studies generally classify,
costs into direct costs, indirect costs and
intangible costs (Kapur, 2007).
16
14
12
10
8
6
4
2
0
Millions
2010 2015 2020 2025 2030 2035 2040 2045 2050
India
UK
USA
The impact of dementia on social-economic-
health of the individual, family and society
is huge. Care for dementia patients has been
considered either as ‘formal’ or ‘informal’ care.
Most of the healthcare in old age is home-
based; outside clinical settings. Such care is
supervised or provided by a co-resident family
member or relative. This is commonly referred to
as informal care. Informal care is a natural social
resource which allows members of a social unit to
offer and take help. All over the world, the family
remains the cornerstone of care for older people
who have lost the capacity for independent
living. Care giving has been defined as “…the
provision of extraordinary care, exceeding the
bounds of what is normative or usual in family
relationships. Care-giving typically involves a
significant expenditure of time, energy, and
money over potentially long periods of time;
21DOCNDOC
Direct costs are those incurred directly
for treatment and care for dementia within
or outside the formal health care system. This
includes cost of providing institutionalised care,
paying care providers including physicians,
long-term care / nursing homes and hospitals,
medication, community-based care, over-
the-counter medications and other out-of-
pocket expenses. Direct costs could be further
divided into direct medical costs (consultation,
investigations, medicines, etc.,) and direct
non-medical costs (long term care /day care,
transportation, assistive devices, etc.).
Indirect costs are those that are related to
the consequence of dementia like reduction
in workforce productivity, absenteeism or
loss of productivity due to informal care (lost
wages, lost profits, ‘resources lost’, etc.,) (CDC,
2010,Alzheimer Europe, 2009).
Worldwide, the annual cost of dementia has
been estimated to be US$ 604 billion for the year
2010 (1.01% of world GDP) (Wimo and Prince,
2010), almost double (92%) of 2005 estimate
(US$ 315.4 billion) (Wimo et al, 2007).). Low
income countries with 14% of dementia patients
contributed to less than 1% of the total cost,
while high income countries with 46%. Much of
the costs have been due to informal care (US$
252 billion, 41.7%) or direct social cost (US$ 256
billion, 42.3%). North America had highest cost
per person (US$48,605) and South Asia region
the lowest (US$903): a difference of nearly 53
times. Reflective of the need for continued and
long term care, direct social costs was 120 times
more in higher income countries. However,
two-thirds of the costs in low income and
lower middle-income countries (58% and 65%,
respectively) is due to informal care as against
one-third (40%) in high income countries
(Wimo and Prince, 2010). This is indicative of
the critical and relatively dominant role of family
care in resource-poor situations. Worldwide
the number of dementia patients is expected to
double by 2030 (65.7 million by 2030) (ADI,
2009); just this increase would push the cost by
85% in 2030 (Wimo et al, 2007.
THE COST OF DEMENTIA:
INDIAN SCENARIO
With an estimated 3.7 million dementia patients
in 2010, the calculated total societal cost of
dementia for India was estimated to be US$
3.415 billion (INR 147 billion). While informal
care is more than half the total cost (56%, INR
88.9 billion), nearly one-thirds (29%) of the total
cost is direct medical cost (INR 46.8 billion).
The total cost per person with Dementia is US$
925 (INR 43,285). Interestingly, the informal
care cost per person in urban area (US$ 257)
was two and half times more than those in the
rural area (US$ 97) (Wimo and Prince, 2010).
Wimo et al (2010) updating costs of dementia
for 2009 from 2005, estimated the total societal
costs of Dementia for India to range between
US$ 9.4 (INR 451) billion to US$ 13.7 (INR 657)
billion, depending on the quantum of Informal
care (1.6 hours per day or 3.7 hours per day
respectively). Direct costs were estimated to
be US$ 6.1 (INR 292) billion. With increase in
quantum of informal care, the costs increased
from 34% to 56%. In an earlier paper, Wimo et
al (2007) observed that the costs per dementia
patient for the year 2005 was INR 96,850 (USD
2,229), INR 141386 (USD 3,254) and INR
263,350 (USD 5,061) with informal care of 1.6
hours per day, 3.7 hours per day and 7.4 hours
per day respectively. The increased quantum of
informal care indicates the increasing severity of
dementia. These estimates included a direct cost
of INR198, 197 (USD 4,561) per person per year.
Direct medical cost
Direct social cost
Informal care cost
1.0, 29%
0.5, 15%
1.9, 56%
CHALLENGES FOR COSTING DEMENTIA
CARE IN INDIA:
The diverse landscape of India precludes
estimating uniform average costs. The huge
urban –rural divide, the ongoing process
of urbanisation and globalisation pose
methodological challenges in cost estimation.
Cultural differences in help seeking, difference
in health and social care systems and other
ecological parameters (changes in awareness,
availability of specific services, promotion of
early diagnosis, and access to benefits linked to
diagnosis) (Wimo and Prince, 2010) influence
cost estimations. Amidst a faster pace of
globalisation and with Indian families shrinking
in size, the joint families which have given way to

12. 22DOCNDOC
Dr. Sushil V. Tandel
Neurologist
Bhatia Hospital
Mumbai
nuclear or two generation families pose peculiar
challenges in care related issues. Healthcare
services, particularly for the geriatric population
is often neglected both by the families and
by the health systems. Like several low and
middle income countries, economic analysis of
a disease/health situation is quite limited in the
Indian subcontinent. Analysis of household costs
for dementia care showed the average minimum
amount needed to manage one dementia patient
would be `42,585 per year. Much (56.5%) of the
cost would be due to informal care (primarily as
money not gained by the care-giver in the family
who could have been otherwise employed and/
or money paid for outside help), while nearly
one third (31.1%) would be due to direct social
cost (transportation, day car, residential care),
about 12.3% would be direct medical costs
(cost of medication, consultation, investigation,
hospitalisation). With the recognition that as
the disease progresses, the costs also increase,
estimates indicate that, during the average
7 years of life for a dementia patient, living in
an urban area, the total cost of care would be
about `9.6 lakh. India is currently spending `15
to `16,000 crores per year for care of dementia
patients. It is predicted that as the number of
patients with dementia would double by 2030
(3.69 million to 7.61 million), the immediate
consequence would be that the cost of care would
also double. Assuming a nominal 5% annual
inflation, the actual cost of care would almost
treble by 2030. Obviously, two-thirds or more
of this huge burden is being met by individual
households. It is worthwhile to note that, the
above costs are nominal and do not include the
huge infrastructure (Prince et al, 2009) costs
needed to set up services for dementia care.
Given the current levels of awareness regarding
dementia care amongst the health service
providers, the costs of appropriately training the
healthhumanresourcesitselfismuchlarger.Care
giving in India, like elsewhere in the developing
world, is associated with substantial economic
disadvantage. The economic vulnerability of
families who care for people with dementia in
India is indeed overwhelming particularly for
the families who live below the poverty line.
Studies from India indicate that 23% of care-
givers (17% primary care-givers and additional
6% of other care-givers) cut back on work and
nearly a quarter of all care-givers suffer economic
losses as they are unable to fulfil their work
responsibilities. While formal health insurance
is predominantly an urban phenomenon, only
few older people in India receive government or
occupational pension and the income security for
those with dementia is marginal.
RECOMMENDATIONS:
Dementia must be made a national health and
social care priority. This must be reflected in
the plans for service development and public
spending. Education of the general public as well
as training health service providers and social
services sector is of utmost importance. Patients
with dementia need improved home care
support packages to retain their independence
and dignity. Care-givers need to be provided
support packages. ✚ ✚ ✚
23DOCNDOC
C
erebralpalsy(CP)isdefinedasan“umbrellatermcovering
a group of non-progressive, but often changing, motor
impairment syndromes secondary to lesions or anomalies of
the brain arising in the early stages of development”. Cerebral
palsy is characterized by motor impairment and can also
present global physical and mental dysfunction. It is the most common
physical disability in childhood, occurring in 2.0 to 2.5 per 1000 live births.
Better Care
Cerebral Palsy
Reduces

13. ETIOLOGY
Congenital brain malformations including
those of cortical development are the most
important known causes for Cerebral Palsy
(CP). Other known antenatal causes are vascular
events and maternal infections during the first
and second trimesters of pregnancy (rubella,
cytomegalovirus, toxoplasmosis). Less common
causes include metabolic disorders, maternal
ingestion of toxins and rare genetic syndromes.
Obstetric emergencies such as obstructed
labour, antepartum haemorrhage or cord
prolapse may compromise the fetus causing
hypoxia (oxygen deprivation to brain). Birth
complications, including asphyxia, are currently
estimated to account for about 6 percent of
patients with congenital cerebral palsy. Neonatal
risk factors include birth after fewer than 32
weeks’ gestation, low birth weight, intrauterine
growth retardation, intracranial haemorrhage,
and trauma, severe hypoglycaemia, and severe
infection.
In about 10 to 20 percent of patients, cerebral
palsy is acquired postnatally, mainly because of
brain damage from bacterial meningitis, viral
encephalitis, hyperbilirubinemia, motor vehicle
collisions etc.
Risk factors before pregnancy
Maternal factors such as delayed onset of
menstruation, irregular menstruation or long
intermenstrual intervals are associated with
an increased risk of CP. Maternal conditions
such as intellectual disability, seizures and
thyroid disease may also predispose to CP in
the offspring. Similarly, paternal factors such
as advanced paternal age may predispose to
athetoid/dystonic cerebral palsy. Motor deficit in
a sibling has also been reported as an association
with CP.
Risk factors during pregnancy
Pre-eclampsia is associated with an increased
risk of CP due to release of catecholamines.
Antepartum haemorrhage is associated with
mortality, CP and white matter damage in
preterm infants. There also appears to be an
association between inflammatory mediators
and markers of autoimmune and coagulation
disorders with CP.
Risk factors during labor
Perinatal asphyxia may be caused due
to prolapsed cord, massive intrapartum
hemorrhage, prolonged or traumatic delivery
due to cephalopelvic disproportion, a large baby
and maternal shock. Additionally, prolonged
second stage of labor, emergency caesarean
section, premature separation of the placenta
and abnormal fetal position may also lead to
distress and CP in the infant. Recent evidence
has emerged that intrauterine exposure to
infection, particularly chorioamnionitis, in the
latter stages of pregnancy and during labor, is
a strong risk factor for CP, particularly in term
infants.
Risk factors at birth and neonatal
period
Low placental weight and APGAR scores are
strongly associated with cerebral palsy.
Neonatal seizures, sepsis, blood transfusions
and respiratory disease have also been described
as risk factors.
CLASSIFICATION
1The topographic classification of CP
is monoplegia, hemiplegia (20-30%),
diplegia (most common: 30-40%) and
quadriplegia (10-15%): Quadriplegia is the
most severe form involving all four limbs. Upper
limbs are more severely involved than the lower
and are commonly caused by acute hypoxic
intrapartum asphyxia.
Hemiplegic type presents as unilateral
spasticity. Upper limbs more severely affected
than the lower limbs. Lower limbs are more
severely affected then the upper limbs in diplegic
type of CP. Nearly all preterm infants with
spastic diplegia exhibit cystic periventricular
leukomalacia on neuroimaging. Periventricular
leukomalacia (PVL) is the most common
ischemic brain injury in premature infants.
2Based on the type of neuromuscular deficit
CP may be classified as spastic, dyskinetic
(inclusive of choreoathetoid and dystonic),
ataxic, hypotonic and mixed types.
Spastic CP is the most common and accounts
for 70-75% of all cases while dyskinetic and
ataxic types occur in 10-15% and 5% of cases
respectively.
3The Gross Motor Function Classification
System (GMFCS): This is a recently
developed system that classifies children with
cerebral palsy by their age-specific gross motor
activity. The GMFCS describes the functional
characteristics in five levels, from I to V, level I
being the mildest in the following age groups: up
to 2, 2–4, 4–6 and 6-12 years.
Spasticity is present in 70-80% of patients
with CP. Affected limbs may demonstrate
increased deep tendon reflexes, tremors,
muscular hypertonicity, weakness, and
a characteristic scissors gait with toe-
walking. The athetoid or dyskinetic type is
characterized by abnormally slow, writhing
movements of the hands, feet, arms, or legs
that are exacerbated during periods of stress
and are absent during sleep. Ataxic cerebral
palsy predominantly impairs balance and
coordination. These patients walk with a
wide-based gait and have intention tremors
that complicate performance of daily activities
requiring fine-motor function. Intellectual
impairment occurs in about two thirds of
patients with CP. About one half of pediatric
patients have seizures. Growth problems are
common, as well as neurologic abnormalities
such as impaired vision or hearing and
abnormal touch and pain perceptions. CP
by definition is non-progressive, therefore,
children who show deterioration with respect
to previously acquired skills and development
should be evaluated for genetic, metabolic,
muscular, or neuronal tumor disorders that
precipitate neurodegenerative conditions.
The brain damage
that causes CP
also affects other
brain functions
that lead to
additional medical
issues, which
could be:
Blindness
Hearing loss
Food aspiration
Gastroesophageal
reflux
Speech problems and
drooling
Tooth decay and
behavioral problems
Sleep disorders
Osteoporosis
Seizures

14. Dr. Pradeep Mahajan
Chairman & MD
StemRx Bioscience Solutions Pvt. Ltd.
DIAGNOSIS
It is not possible to diagnose CP in infants of
less than 6 months except in very severe cases.
Observation of slow motor development,
abnormal muscle tone, and unusual posture are
common initial clues to the diagnosis of cerebral
palsy. Assessment of persistent infantile reflexes
is important. As in all medical conditions, a
systematic approach focusing on maternal,
obstetric and perinatal histories, review of
developmental milestones, and a thorough
neurological examination and observation of the
child is mandatory.
Complete evaluation of a child should
include an assessment of associated deficits
like vision, speech and hearing, sensory profile,
epilepsy and cognitive functioning as well as
orthopedic evaluation.
Brain imaging, particularly magnetic
resonance imaging, can provide evidence about
the timing of adverse events. For example,
cortical dysplasias date from early in pregnancy,
around the 12th
to 20th
week of gestation,
periventricular leukomalacia occurs between
the 28th
and 34th
week, and term infants with
perinatal asphyxia have cortical and subcortical
gliosis and atrophy in the parasagittal areas.
Role of stem cells
Bone marrow and umbilical cords are rich
sources of mesenchymal stem cells (MSC),
which normally produce the tissues of the
skeletal, muscle, and circulatory systems.
Evidence suggests that MSCs can migrate to the
brain and improve function following injury.
MSCs have strong self-renewal, proliferation,
and differentiation potentials. These cells can
be induced to differentiate into neuron-like
cells and glial cells. The mechanism underlying
the function of stem cell transplantation
in neurological conditions may involve cell
replacement function and neurotrophic effect
(through factors such as BDNF and NGF). BDNF
can promote B lymphocytes to increase the free
calcium ion concentrations in cells and thus
improve their immune regulation and resistance.
Furthermore, induction of angiogenesis due to
the release of vascular endothelial growth factors
that is promoted by stem cells, thus improving
blood circulation in the injured regions or
creating a microenvironment that is favorable
for the regeneration. Additional modalities of
physiotherapy, neuromuscular stimulation,
oxygen therapy, yoga, diet modification,
nutraceuticals also play an important and
supportive role in management of cases with
CP. Studies have reported an improvement
Supreme Court
has recently
ordered Jet
Airways to pay
Rs. 10 lakh to the
flyer Jeeja Ghosh
after noticing that
she was not given
‘appropriate,
caring and fair
treatment’ and
was forcibly
offloaded in 2012.
in spasticity, gait as well as cognitive and
behavioral parameters following cellular therapy
and rehabilitation program.
Conventional treatment programs
encompass physical and behavioral therapy,
pharmacologic and surgical treatments,
mechanical aids, and management of
associated medical conditions. Pharmacological
management includes use of Botulinum toxin,
Baclofen etc. Botulinum toxin is a formulation
derived from the bacterium Clostridium
botulinum. The bacterium produces a protein
that blocks the release of acetylcholine and
relaxes muscles. Baclofen has been used for
spastic and dystonic cerebral palsy. However,
there is limited evidence for reduction in
spasticity or other symptoms with the use of
these agents.
CP is a chronic condition with considerable
impact on affected individuals. Overall
prevention of CP has not been successful.
Mesenchymal stem cells are able to travel to
and change the injured environment, increasing
survival of neurons and making up for losses,
thus proving to be a promising approach for
treatment of CP. ✚ ✚ ✚
WIRELESS CAPSULE
ENDOSCOPY - A
FANTASTIC VOYAGE
What is Wireless Capsule
Endoscopy (WCE)?
It is a test to visualise the entire small intestine
using a pill sized wireless camera. This device
when swallowed is capable of transmitting
thousands of colour pictures and real time
video taken from the digestive tract. Capsule
endoscopy is also being used to image the food
pipe (oesophagus) and large intestine (colon).
Rapidly evolving technology has made it
possible to localise the presence of abnormalities
in the intestine like bleeding spots, ulcers or
small growth called polyps using WCE. The new
generation capsules have a wider panoramic
view, higher image resolution and longer battery
life. With over 15 years of clinical experience
backed up by scientific data, WCE is now at the
forefront of scaling one of the final frontiers in
medicine.
Why the need for WCE?
The human digestive tract from mouth to the
rectum is the site of a variety of diseases like
peptic ulcer, inflammatory bowel disease and
cancer. For more than a hundred years the
oesophagus, stomach and duodenum (first part
of small intestine) were accessible via endoscopy.
The advent of flexible videoendoscopes using
fiberoptic technology made evaluation of the
upper part of the digestive tract a routine but
vital part of diagnostics in gastroenterology.
Similarly, the large intestine can also be studied
real time with a long flexible colonoscope.
However, for more than 50 years after the
advent of these endoscopes, the 20ft length
of small intestine in between was a blind area
for clinicians. Diseases in this region were
diagnosed based on findings on X rays or CT
scan which was suboptimal or at surgery which
was invasive. The unmet need for non-invasive
evaluation of the entire small intestine led to
the development of the capsule endoscopy
system in the 1990s. Widespread clinical use
and acceptability of this test started at the turn
of the millennium and the availability of flexible
small intestinal enteroscopes for sampling and
treatment has increased the clinical utility of
WCE as a screening procedure. The inherent
non-invasive nature and ease of performing the
procedure make it an attractive option for both
patients and physicians.
How is the procedure done?
The WCE system consists of a plastic capsule
with an on-board high resolution camera and
transmitter which transmits images, a data
recorder belt which is worn by the patient and
receives the images and a computer workstation
to download, process and store the images
for interpretation. After an overnight fast and
bowel preparation with laxative solution, the
patient is required to swallow the capsule with
water following which the recording starts. Oral
liquids are allowed 2 hours after the ingestion
of capsule and light diet about 2 hours later.
Images are displayed in single or multiple views
at 5-40 frames per second. The new generation
capsules have a battery life of 10-12 hours. They
transmit the images real-time at 5-40 frames
per second and do not require to be recovered
at the end of the procedure. Once the recording
is done, the images and video are replayed at
the dedicated workstation where representative
images can be selected for the report. The
physician studies the examination and gives
a report of the findings. The portability of the
system makes it possible for tele-reporting by
physicians at remote sites.

15. What are the indications and
benefits of capsule endoscopy?
BLEEDING from an obscure source in the
digestive tract is presumed to be of small
intestinal origin and comprises of about 5%
of all newcomers. An important caveat is that
patients with such a condition must have a
normal upper endoscopy and colonoscopy
prior to being subjected to a WCE evaluation.
Capsule is able to pick up bleeding sources
in the small intestine like ulcers, abnormal
blood vessels (Arteriovenous malformations)
and tumours. The common causes for small
intestinal ulcers causing bleeding being used
of pain killer medications called non - steroidal
anti-inflammatory drugs (NSAIDs like aspirin).
UNEXPLAINED IRON DEFICIENCY
ANEMIA is seen in 2-5% of adult men and post
- menopausal women. Chronic blood loss that is
not visible to the naked eye is seen in up to 20%
of these patients and is important indication
for WCE. Conditions such as inflammatory
bowel disease (Crohn’s disease), small intestinal
tumours and tiny bleeding spots called angiomas
can be detected. WCE evaluation is positive in
40-50% and yield increases with increasing age.
CELIAC DISEASE is occasionally associated
with ulceration in the small intestine which can
be picked up by WCE.
SCREENING for precancerous growths called
polyps and small intestinal cancer is important in
people with inherited cancer syndromes. Timely
diagnosis and treatment by endoscopy and/or
surgery can be life saving in this population.
UNDIAGNOSED CHRONIC ABDOMINAL
PAIN may be associated with small intestinal
inflammatory conditions like Crohn’s disease
and WCE is able to detect a possible cause in
up to 20% of individuals. The diagnostic yield
increased by 2-3 folds with good patient selection
(positive blood tests for inflammatory markers
or small intestinal thickening on CT scan.
OESOPHAGEAL DISEASES like acid reflux
(GERD), precancerous conditions like Barrett’s
oesophagus and enlarged veins in chronic
liver disease (oesophageal varices) can now
be diagnosed with reasonable accuracy and
excellent patient preference with a specially
designed oesophageal capsule.
COLONIC POLYPS which can turn into cancer
if untreated are seen commonly in western
countries. Screening for these polyps requires a
colonoscopy. Non-invasive screening with stool
tests are grossly inadequate. WCE is emerging
as a good modality for screening and is able to
pick up polyps of up to 6-9mm in the colon in
60-80% of subjects.
What are the risks of the
procedure?
The main complication of WCE is retention
of the capsule which is seen in 1-2% of
patients. The main reason for retention is
intestinal obstruction. Prolonged retention
is also seen in people with delayed transit
in small intestine. Occasionally anatomical
abnormalities like diverticula or hernia can
cause retention which needs surgical extraction.
Very rare complications include perforation
and interference with pacemakers and other
electronic devices.
When should capsule not be
used?
Suspected or known intestinal obstruction is
an absolute contraindication. Patients with
previous abdominal and/or pelvic surgery are
likely to have adhesions and can cause retention
of capsule. Swallowing disorders, extensive sac
like pouches in intestine called diverticulosis
pregnancy and presence of pacemakers are
relative contraindications.
Wireless capsule
INTRAOPERATIVE EVALUATION OF THE
SMALL INTESTINE WITH REGULAR
ENDOSCOPE COMPARES FAVOURABLY
WITH WCE FOR DETECTION
OF LESIONS. PREOPERATIVE
LOCALISATION CAN BE AIDED BY A
GOOD CT SCAN EXAMINATION. LOCAL
AVAILABILITY AND URGENCY OF
DIAGNOSIS MAKES THIS PROCEDURE
NECESSARY SOMETIMES. THE INVASIVE
NATURE AND HIGH COST PRECLUDE
ROUTINE USE IN DIAGNOSIS.

16. TWO DECADES OF SCIENTIFIC DEVELOPMENT AND
CLINICAL EXPERIENCE HAVE MADE A DEVICE FIT FOR
SCIENCE FICTION MOVIES IN THE PREVIOUS CENTURY,
READY FOR DAY TO DAY USE IN THE REAL WORLD
TODAY. RAPID PROGRESS IN RADIOFREQUENCY AND
NANOTECHNOLOGY ARE LIKELY TO WIDEN THE UTILITY OF
WIRELESS CAPSULE IN THE DIGESTIVE TRACT.
What are the shortcomings and
alternate options?
The cost of a WCE procedure is about 40,000,
which prohibits its use as a screening test.
Compared to this an upper endoscopy and
colonoscopy can be performed at one tenth
of the cost. Added to this is the fact that WCE
can provide only images of the diseased area.
Confirmation sometimes requires a biopsy and
treatment may require a second therapeutic
procedure. This adds to the cost incurred.
Lack of air insufflation may lead to suboptimal
evaluation. Capsules can get retained for more
than 2 weeks in patients with blockage in the
intestine and this complication necessitates
surgery in 1-2% of patients. The development
of a test patency capsule given prior to the VCE
examination has reduced this complication but
has not completely eliminated it.
Some of the disadvantages of the WCE system
can be overcome by advances in endoscopic
technology.Balloonenteroscopyofsmallintestine
is a procedure by which a long endoscope is
passed over an overtube into the small intestine.
This carries the benefit of ability to obtain tissue
for diagnosis and potential therapy like stopping
bleeding and removal of polyps. In trained hands
balloon enteroscopy can achieve similar rates of
lesion detection as WCE. In patients with post-
surgical altered anatomy balloon enteroscopy
scores over WCE. Overall, the invasive nature,
patient discomfort and lower rates of complete
small bowel evaluation makes the balloon
enteroscopy complementary and not a substitute
to WCE in evaluation of small intestine.
Intraoperative evaluation of the small
intestine with regular endoscope compares
favourably with WCE for detection of lesions.
Preoperative localisation can be aided by a
good CT scan examination. Local availability
and urgency of diagnosis makes this procedure
necessary sometimes. The invasive nature and
high cost preclude routine use in diagnosis.
Another shortcoming of the WCE is lack of
manoeuvrability of the capsule once ingested.
Magnetic devices are in development which can
be used to control the device for a more thorough
assessment of intestinal lining in area of interest.
Two decades of scientific development and
clinical experience have made a device fit for
science fiction movies in the previous century,
ready for day-to-day use in the real world
today. Rapid progress in radiofrequency and
nanotechnology are likely to widen the utility of
wireless capsule in the digestive tract. Access to
biliary and pancreatic ductal systems seem to be
the new holy grail in this regard and that will be
a truly fantastic voyage.
Bleeding angioma in small intestine
Polyp
✚ ✚ ✚
Dr. Naresh Bhat
Medical Gastroenterology
Columbia Asia Referral Hospital
Bangalore
COPDCHRONIC OBSTRUCTIVE PULMONARY DISORDER

17. A
mongst the various diseases
causing breathlessness, one of
the most common ones and an
easilypreventableone,isChronic
Obstructive Pulmonary Disease
(COPD). Traditionally, the term COPD refers to
include Chronic Bronchitis and Emphysema. It
is a disease, which causes permanent, irreversible
damage to the airways as well as the lung tissue,
making it hard for an individual to breathe. It
is a leading cause of morbidity and mortality in
adults worldwide and will remain a challenge for
the future.
The burden of COPD is projected to increase
in coming decades due to continued exposure to
COPD risk factors and the aging of the world’s
population. Deaths attributable to COPD have
increased sharply. It is currently the fifth leading
cause of death but the rate at which its prevalence
is increasing; it will soon become the fourth
leading cause of death, globally. Hospitalizations
attributable to COPD are also sharply increasing
and every hospitalization leaves the patient with
some further irreversible damage to the lungs.
In our country, this progressive disease affects
more than 12 million people with a prevalence
of respiratory symptoms in 6%–7% of non-
smokers and up to 14% of smokers.
The disease usually occurs as a result of
an inflammatory response to various noxious
stimuli like tobacco smoke, outdoor and indoor
air pollution, pollution from heating and cooking
with biomass in poorly ventilated dwellings,
organic and inorganic dust and myriad of other
agents like chemicals, dust and fumes. The
biggest risk factor for COPD is tobacco smoke.
Smoking whether it be a bidi, cigarette, pipe,
cigar, sheesha or even second hand smoke
(passive smoking) is equally harmful. Tobacco
smoke contains over 4,000 harmful chemicals,
many of which can damage the lungs. Passive
smoking can be even worse as two-thirds of
the smoke from a cigarette isn’t inhaled by the
smoker, but enters the air around the smoker,
which is then inhaled by the unsuspecting
bystanders. Nearly 90% of COPD patients are
smokers. Genetic factors play a role in non-
smokers, especially.
It is most common in men over 40 years
of age. The common symptoms are cough,
breathlessness, tightness of chest and wheezing.
Wheezing refers to whistling or squeaky sound
when an individual breathes. Mild symptoms
in the initial period could go unnoticed, as the
patients tend to adjust their lifestyle to make
breathing easier. They start to restrict their
physical exertion like they would take the elevator
instead of the stairs, or avoid going for morning
walks. Over time, the symptoms progress. The
severity of the symptoms will depend on the
extent of lung damage. If smoking or the exposure
to noxious elements continues then the damage
will occur faster. As the disease progresses other
symptoms, such as swelling in the ankles, feet or
legs, weight loss and lower muscle endurance,
bluish discoloration of fingers appears.
COPD is linked to various systemic diseases,
such as cardiovascular disease, diabetes,
osteoporosis and possibly peptic ulcer. Studies
suggest that cardiovascular risk should be
monitored and treated with particular care in
any adult with COPD and should be carefully
considered in patients with chronic heart failure.
COPD and lung cancer commonly occur in
the same patient. The presence of moderate or
severe COPD is a significant predictor of lung
cancer in the long term.
A clinical examination and a simple test,
called spirometry can be used to measure
pulmonary or lung function and detect COPD in
anyone with breathing problem.
Even if risk factors were avoided today,
the toll of COPD would continue for several
decades because of the slow development of
the disease. Once developed, COPD and its
comorbidities cannot be cured and must be
treated continuously. The mainstay of therapy
is the use of drugs called bronchodilators
ONCE
DEVELOPED,
COPD AND ITS
COMORBIDITIES
CANNOT BE
CURED AND
MUST BE
TREATED
CONTINUOUSLY.
Trachea cross-section
CHRONIC OBSTRUCTIVE PULMONARY DISORDER
Dr. Vivek Nangia
Director & Head, Lung Centre
Fortis Flt. Lt. Rajan Dhall Hospital
Vasant Kunj, Delhi
and steroids from time to time. While,
bronchodilators relaxes the muscles around the
airways, opening them and making breathing
easier, steroids on the other hand, are used to
control the inflammation. Inhaled steroids with
the bronchodilator are given through inhalers
for a trial period of 6 weeks to 3 months to see
whether the addition of the steroid helps relieve
the breathing problems or not. Inhalers are
preferred over tablets or syrups as the dosage is
in micrograms. The drugs act locally and does
not cause any significant systemic side effects.
Domicilary Oxygen therapy and non invasive
ventilation (NIV) are often given to patients
with advanced disease.
Certain lifestyle changes can help patients
feel better, stay more active, and slow the
progress of the disease. Regular brisk walk,
arm curl and forward arm exercises, calf raising
and deep breathing exercises are strongly
recommended. A low carbohydrate diet with
extra proteins, eating smaller, more frequent
meals, resting before eating, and taking vitamins
or nutritional supplements is also helpful for the
health of the lungs.
People who have COPD are at higher risk
of pneumonia and can develop severe life
threatening complications following a simple
influenza infection. All such patients should take
the influenza and pneumococcal vaccinations
periodically.
Early detection of COPD might change
its course and progress. Also, one should try
to avoid lung irritants that can contribute to
COPD. Examples include secondhand smoke,
air pollution, chemical fumes and dust.
Newer modalities of treatment for COPD
1Using a device called BiPAP at home for
patients suffering with advanced COPD. It
is recommended to patients who develop
retention of carbon dioxide. This improves
their respiratory muscle strength, alertness
levels and reduces respiratory distress.
2Portable Oxygen Concentrators can get the
mobility back to the patients unable to walk
even a few steps because of low oxygen levels
in the body. These are small easily carried
machines to deliver oxygen. Patients, who
earlier would find even the daily chores an
uphill task, can now easily move around and
even travel abroad.
3Newer therapies in the form of once a day
medication and some anti-inflammatory
drugs have evolved which have revolutionized
the treatment of COPD and improved the
outcomes
4For patients with large voluminous lungs,
certain bronchoscopic (endoscopic)
techniques have also been tried with fair bit
of success. As against a surgical technique
these are simpler, less costly and have the
advantage of being carried out under a local
anesthesia.
5Pulmonary rehabilitation is an essential part
of their management. ✚ ✚ ✚

18. PERIPHERAL
ARTERIAL DISEASE -
THE NEXT BIG KILLER
P
eripheral arterial disease
(PAD) is a circulation
disorder that affects blood
vessels outside of the heart
and brain. In PAD, blood
vessels are narrowed which is known
as arteriosclerosis. Arteriosclerosis is a
condition where plaque builds up inside
a vessel. It is also called “hardening of
the arteries.” Plaque decreases the
amount of blood and oxygen supplied to
the arms and legs. As the growth of the
plaque progresses, clots may develop
which further restricts the affected
vessel. Eventually, arteries can become
obstructed.
There are numerous risk factors
for PAD. Some are due to underlying
medical conditions, age, and gender
while others are due to lifestyle choices.
Smoking and Diabetes are 2 of the major
causes of PAD. Other risk factors that
lead to PAD are abnormal lipids (high
cholesterol), high blood pressure, obesity
etc. The prevalence of PAD in the lower
limbs in general population is more in 55
years of age and is between 10% and 25%
which increases with age. People who
have PAD are also at an increased risk for
heart diseases and strokes.
The symptoms of peripheral artery
disease depend upon the location and
extent of the blocked arteries. The
most common symptom of PAD is
“claudication”, meaning leg pain, mostly
in the calf muscles on walking and is
relieved by short rest and can walk
the same distance again. The walking
distance can gradually decrease over
time and progress to pain in the foot
even while resting.
Rest Pain – burning pain in the
distal part of the leg (foot) that is
present even at rest and gets worse on
elevating or placing the foot on the bed
and is relieved by hanging the leg down
over the edge of the bed.
Gangrene/Non-Healing wounds
also can take place when the tissue
dies because of poor supply of blood.
Presence of Rest pain, Gangrene or
wounds is referred to as Critical Limb
Ischemia and signifies a high risk
(50%) of loss of limb or death.
There are two main goals of PAD
treatment. The first is to control the
pain and symptoms which allows you
to remain active. The second is to stop
the disease from progressing. This
will lower your risk of serious and
life-threatening complications. Like
all diseases, whether heart, brain or
legs, the most important is “lifestyle”
modification. The best way to prevent
PAD is to control diabetes, stop
smoking, healthy diet, regular exercise,
correct medications for high cholesterol
and control blood pressure. Quitting

19. to smoke is one of the most
important ways to treat PAD as it
directly causes reduced blood flow in
vessels. An often active treatment for
PAD symptoms is regular physical
activity. Doctors may recommend
a program of supervised exercise
training for you, also known as cardiac
restoration. Simple walking regimens,
leg exercises and treadmill exercise
programs can ease the symptoms.
Significant artery blockages may
require surgery. Patients with above
mentioned symptoms should visit their
physician or a surgeon immediately for
a physical examination. The physician
57 years, male chronic smoker (smoked 5–10 cigarettes
per day) for 20 yrs had pain in the right thigh and leg.
On walking for 50–100 meters, pain was also present
at rest and was so intense that it did not allow him to
sleep well. On examination the pulses in the leg were
very feeble. With these complains the patient underwent
multiple tests and investigations before he was sent to us
for angiography which revealed a block in the artery of
the thigh. The artery was opened with the help of balloon,
and stent showed good blood flow with no residual
block. Post balloon dilatation and stenting, the patients
symptoms were relieved and he was back on his feet. Now
he can do long distance walks as well. He has now quit
smoking and educates and helps others to quit smoking.
stenting, directional atherectomy, etc.
Balloon and stenting have generally
replaced invasive surgery as the first-
line treatment for Peripheral Vascular
Disease where an interventional
radiologist inflates a balloon to open
the blood vessel narrowed or blocked,
and in some cases this is then held open
with a stent. Advances in technology
make it possible to restore circulation
in big and small arteries even as far
as the foot using thin wires, thin
catheters (micro-catheters) and newer
balloons opening an entire new horizon
for treating those cases that had to
have open surgery with long bypass
operations that took 6-8 hours in the
past. It is now also possible to open
up entirely blocked arteries that were
previously not seen on the angiography.
There are also specific drugs to improve
walking distance in patients which have
a very good response. They need drugs
to prevent future complications (like
aspirin, anti-cholesterol drugs etc.)
It is also necessary to alter eating
habits and preferences by paying
more attention to the foods you eat
namely their type, amount and quality.
One should avoid high fat foods; if
diabetic follow the dietary advice of
your doctor, control salt in your diet.
Dr. Vimal Someshwar
Director
Interventional Radiologist
Wockhardt Hospitals, Mumbai✚ ✚ ✚
may prescribe an ultrasound test to
check the blood flow and health of the
artery. He may also recommend an
angiogram, where the health of the
artery is checked with a special X-Ray
machine. There are several surgical
treatments for PAD. If the arteries
that are affected are very small or if
the blockage involves short segments,
one may be able to improve blood
flow without any surgical cuts. The
technique used is called endovascular
surgery and uses various techniques
such as balloon angioplasty using
simple balloons or drug eluting
balloons, balloon angioplasty with
Sugar is the root cause harming human
health but unfortunately, many people
are actually addicted to sugar. This
common phenomenon often is referred
to as an intense desire to consume
simple sugars, or a carbohydrate or
sugar craving. The greener, the better.
Green leafy vegetables also contain
compounds known as thylakoids that
trigger satiety signals in humans to help
people regulate food intake, prevent
weight gain, and promote weight loss.
All you need to do is start implementing
these recommended dietary changes
and you will begin seeing miracles
occur. Simply, do your best!
ASE STUDY

20. STERILIZATION
in Women
S
terilization is a method of permanent birth control,
intended for couples who have completed their
family and who do not wish to ever have another
pregnancy. Although technically, sterilization is surgically
reversible, the re-do surgery is more extensive and the
success rate is low, so it is never recommended to someone who may
desire another child sometime in the future.
Perhaps the memory
of the forcible
sterilizations during
the emergency era has
continued to give a
bad rapport to what is
essentially a very safe,
very effective, very
simple and economical
procedure.

21. According to the most recent government
data, on tools used for family planning, a little
over 37% of married women between the age of
15 and 49 say that they relied on the fact that they
were sterilized to prevent pregnancy. Only 1%
said that their husband or partner’s vasectomy
was their form of birth control.
Remarkably, often it is the women who
oppose the procedure. They worry that it will
cause a man to lose his strength and virility. Or
that sterilization will leave their husbands unable
to earn a living. In India, female sterilization is
more socially acceptable, said a 2012 Human
Rights Watch report. It added that male and
female health workers acknowledged that they
actively sought women for sterilization because
they “found it easier to convince women than
men.”
The data also indicated that among
modern methods of permanent contraception,
male sterilization is significantly less well
understood and known about than its female
equivalent.
There are two common surgical techniques
for female sterilization:
◗Minilaparotomy, which involves making a
small incision in the abdomen. A portion of the
fallopian tube is ligated and incised. Minilap can
be performed postpartum, post abortion or at
any time (interval procedure) after ruling out the
pregnancy. Risk is of minor complications such
as wound infection. The rule is: for postpartum
sterilization, the youngest child should be 5 years
old before tubectomy is recommended, and that
there should be at least 2 children in the family.
This means this method is recommended for a
3rd
child and above. Of course in modern days,
a family may choose to override these concerns,
but it is important to fully comprehend the
irreversible nature of the surgery.
◗ Laparoscopy is another technique which
involves inserting a long thin tube with a
lens (laparoscope) in it, into the abdomen
through a small incision. The laparoscope
enables the doctor to view and occlude the
fallopian tubes with Falope rings. It could be
performed only for interval and after first-
trimester abortion procedures. Risk is of major
complications related to anaesthesia, or to
surgery, such as bowel or vascular injury that
may require an additional surgery. However,
both the methods are equally safe and effective.
IS Sterilization A GOOD BIRTH
CONTROL MEASURE?
Sterilization, where is the procedure of choice
for committed and motivated couples who are
certain about their decision about having no
more pregnancies ever, it also assures permanent
protection against pregnancy, obviates necessity
of continuous use of non-permanent methods
and thus leads to peace of mind. Once the
procedure is successfully completed, there are
no lasting side effects. It does not affect sexual
pleasure; hence technically it should have a
high acceptance rate. But the myth persists
among men, that it leads to a decline in sexual
performance and hence its acceptance among
men is abysmally low. Perhaps the memory of
the forcible sterilizations during the emergency
era has continued to give a bad rapport to what
is essentially a very safe, very effective, very
simple and economical procedure.
STERILIZATION IS
INDICATED FOR
Couples who have
completed their family
If pregnancy would
cause serious health
issues, such as
cardiac conditions
Hereditary illness or
disability such as
autosomal dominant
conditions
Sometimes for
mentally challenged
girls, for safety
reasons
3DOCNDOC

22. In India, female
sterilization is
more socially
acceptable,
said a 2012
Human Rights
Watch report.
It added that
male and female
health workers
acknowledged
that they actively
sought women
for sterilization
because they
“found it easier to
convince women
than men.”
In fact, sterilization does not affect the body’s
natural hormones and does not involve ingestion
of any hormones, so that’s another plus.
STERILIZATION REGRET
Nationally, 5% of sterilized women aged 15–49
reported sterilization regret, with those sterilized
before age 25 more likely to express regret.
Also, those who had only daughters or who had
experienced child loss were more likely to express
feelings of regret. Given the large proportion of
women undergoing sterilization, the potential
numbers experiencing regret are considerable.
If one’s age at sterilization continues to
decline, sterilization regret is likely to increase.
Encouraging couples to delay sterilization and
increasing the availability of highly effective
reversible contraceptives are options that
India may consider to avert sterilization regret.
Health workers vigorously promoted
female sterilization to fulfil their targets and
often misled women about other method
choices. In fact, the dominance of female
sterilization undermined the promotion and
use of other spacing methods and it was often
the only method of contraception in women’s
reproductive lives.
Aninformedchoicesmodelofservicedelivery
was introduced in 1998, emphasizing individual
reproductive and family planning needs and
rights, and offering quality services without any
form of coercion or discrimination. It is seen
that with improved economic status, and higher
literacy level, women chose effective, long term,
reversible methods such as IUCD or injectable
contraceptives over sterilization.
Ethnic status is yet another source of
discrimination for poor women from scheduled
tribes, scheduled castes and other backward
communities. Poor women in Indian states
generally have poor access to education
and health care, and have little choice for
modern temporary methods other than
sterilization. These women usually have little
autonomy within and outside the household and
have little control over their own reproductive
and contraceptive choices. This is particularly
the case among newly married women with
poor education, who lack security and often
surrender to the ideals, norms and expectations
of their husbands and in-laws. For example, son
preference is deeply rooted in the Indian culture
and usually dictated by husbands and in-laws,
especially in joint households, independent of
economic status.
Rural women who represent the majority
are more inclined to choose sterilization
whereas their urban counterparts favor modern
temporary methods. As expected, the southern
region dominates sterilization choices whereas
modern temporary method choices are popular
in the northern and western regions. About
one half of the women in the northeast region
choose traditional methods such as rhythm and
withdrawal, which in contrast is less than one
tenth in the southern region.
Lalit Sharma, a nurse who trains outreach
workers says, “When a new method comes
online, women will almost certainly accept it.
Whatever method it might be,” he said, “if the
government implements it, they blindly trust
it.” It is up to us as providers to ensure that this
trust is never misused.
The technique, timing and setting of the
operation have progressively changed since
the early 1970’s and the advent of minimally
invasive surgery. The most appropriate method
of female sterilisation in a particular family
is often determined by local situations and
constraints. According to Cochrane review, the
decision as to which method to choose should be
a multifactorial one, depending on the setting,
the surgeons experience and the woman’s
preference.
53DOCNDOC

23. Dr. Lily Kiswani
MD - Internal Medicine
Mumbai
Dr. Shivani Sachdev Gour
IVF expert & Gynecologist
Founder & Director
SCI Healthcare & Isis Hospital
New Delhi
“When a new
method comes
online, women
will almost
certainly accept
it. Whatever
method it might
be,” he said, “if
the government
implements it,
they blindly trust
it.” It is up to us
as providers to
ensure that this
trust is never
misused.
WHY IS
STERILISATION
DONE?
Since it’s a
permanent method
of contraception, it
is recommended for
those women who
have completed their
family and don’t desire
to have more children.
Therefore counselling
of the couple is
very important. It is
recommended that
the woman should be
married, be above 22
years and below 49
years of age and the
couple should have
at least one child
before they go for the
procedure.
Summary: A retrospective analysis was carried
out by date et al in 2014 in which findings on
the failure rate of various types of sterilization
techniques done during the period of 10 years from
April 2002 to March 2012 were presented.
Duringtheperiod,140womenhavereportedto
the institution as tubal sterilization-failure making
an average of 14 cases/year. The sterilization
techniques that were covered in the study included
mini laparotomy (minilap), laparoscopic (Lap
TL) and lower segment cesarean section (LSCS)
tubal ligation. These constitute the majority of
sterilization types that are performed in India.
Minilap failure constituted 59% followed by Lap
TL - 38% and LSCS - 3%. The sterilization-failure
interval was <1 year in 22 (15.71%) cases, 1-5 years
in 80 patients (57.14%), 6-10 years in 30 (21.43%)
and>10yearsineightpatients(5.71%).Thelongest
documented sterilization-failure interval was 20
years in the study presented with ruptured ectopic.
A greater proportion of early failures (<1
year) were mainly due to initial non-occlusion of
tube due to improper procedure compared with
late failures where tubal regeneration leading to
spontaneous tubal re-approximation associated
with tubal reanastomosis and recanalization or
formation of tuboperitoneal fistula were likely.
When failure due to improper procedure was
further analyzed, 78% contribution was found
to be from occlusive methods with laparoscopy.
In resectional methods with minilap, failure
was prominently due to spontaneous luminal
regeneration. The authors concluded that female
sterilization-failure is well-known and proven
entity and no age, method and interval is failure
free. Although, it is not completely preventable,
failure due to improper procedure could be
avoided if standard guidelines for tubal ligation
are followed. Proper counseling of the patient
regarding chances of failure and early reporting
if menses are delayed can help in diagnosing
failure in early gestation and to reduce related
morbidities.
Summary: The study compared patient
satisfaction, discomfort, procedure
time, success rate and adverse events of
hysteroscopic (ESSURE, Conceptus Inc, San
Carlos, USA) versus laparoscopic sterilization.
A 2:1 ratio of ESSURE placement to
laparoscopic sterilisation was undertaken.
Laparoscopic sterilisation was carried out under
general anaesthesia in the day surgery unit
whereas all ESSURE procedures were carried
out in a dedicated outpatient facility. All patients
completed a self-assessment diary on days 7
and 90 post-operatively. Patient satisfaction,
tolerance and discomfort were measured
ASE STUDY 1
ASE STUDY 2
Female Sterilization Failure: Review over a decade
and its clinicopathological correlation.
Date SV, Rokade J, Mule V, Dandapannavar S.
FEMALE STERILISATION: A Cohort controlled
comparative study of ESSURE versus laparoscopic
sterilization.
Duffy S, Marsh F, Rogerson L, Hudson H, Cooper K,
Jack S, Hunter D, Philips G.
All women who underwent laparoscopic
sterilisation had the procedure successfully
completed whereas the overall bilateral device
placement rate for ESSURE was 81%. Patient
satisfaction with their decision to undergo either
ESSURE or laparoscopic sterilisation was high
with 94% of the ESSURE group being ‘very’ or
‘somewhat’ satisfied at 90 days post-procedure
versus 80% in the laparoscopic sterilisation group.
At 90 days post-procedure 100% of women in
the ESSURE group were ‘very satisfied’ with their
speed of recovery versus 80% in the laparoscopic
sterilisation group. The procedure time (defined
from the time of insertion of the hysteroscope or
laparoscope to its removal) took significantly
longer for ESSURE than laparoscopic
sterilization. 82% of women in the ESSURE group
described their tolerance of the procedure between
‘good and excellent’ compared with only 41% of
the laparoscopic sterilization group. Only 31% of
the ESSURE group reported moderate or severe
pain following the procedure compared with 63%
of the laparoscopic sterilisation group. Only 11%
of patients had problems immediately post-
operatively in the ESSURE group compared with
27% in the laparoscopy group. Finally, in the more
medium term (three months post-operatively),
patients still had an advantage in terms of post-
procedure adverse events in the ESSURE group
(21% vs 50%).
This study provides evidence that ESSURE
could be performed in the majority of women
and, when successful, is associated with a greater
overall patient satisfaction rate than laparoscopic
sterilization. However, the devices cannot be
bilaterally placed in all cases and some women do
not tolerate the procedure awake. ✚ ✚ ✚

24. 46DOCNDOC
THEY ARE DIFFERENTLY-ABLED
SO, IS EVERYBODY ELSE!
47DOCNDOC
H
e buttoned up his S uperman jacket and
glanced at his wrist watch, which was broken.
With an audible grumble he looked at the
young woman standing next to him, fishing
for a place to sit. I had almost entered the
clinic, and almost immediately caught by the
colorful chairs kept in the lobby. While I made
myself seated at one of the bright orange colored ones, half-
blinded he took a step forward and almost fell over this
other kid who must not be older than 4 years. He stared at
the wooden desk kept next to me, his eyes reading the same
scribbles as last week and all the weeks before that. His social
communications seem to be weak, but not his heart-to-heart
conjunctions. He only knew to smile at everyone; to wave at
everyone and to clap at everyone, as if everyone was a miracle.
But isn’t that true? I thought.
Dr. Dalwai entered the clinic and the smiles at these
toddler-faces became all the more vibrant. He crouched down
in front of this kid to brush his dark brown silky bangs from his
face and revealed his beautiful, wide eyes. The doctor seemed
to have the posture of more like a soldier. Every action that
he took looked precise and full of purpose. As we sat down to
have a chat about the IAP, various monsoon epidemics and
his clinic for Autistic children, from behind came running a
cute, little child wearing yellow, and a smile to light up the
whole town. She giggled at the doctor, waving her arms for
pick-me-up-twirl-me-around she already knew was coming.
She was rose high in the air and she was on the bottom again,
her laughter came down much later.
I think this scene kept coming back to my mind even
during the interview, more like a reminder that people are
actually inherently good and loving. Soon my little trip down
the memory lane was interrupted by the ticking watch.
“Dr. Dalwai, to begin with, would you like to talk about
the monsoon epidemics and what kind of advice do you have
for the GPs when it comes to diagnosing these?”, I was eager
to ask this question as, as a child, I had always suffered severe
stomach pain whenever the monsoons arrived.
He looked concerned and his face turned serious,
washing away the smile he just had while playing with the
little girl. “The biggest monsoon epidemics that we’re getting
in Mumbai because of changed topography and water logging
are obviously dengue and malaria, along with illnesses
spread by mosquitoes breeding in collecting artificial water.
Another is food poisoning and diseases spreading through
faecal route that is, diseases like cholera, dysentery and
diarrhoea.
I think it’s very important for a GP to recognise a very
serious illness from a mild illness, not panic and get blood
test done for everybody and at the same time not miss that
child who is going to end up with a serious complication. So,
again it all depends on the clinical knowledge that we have
been imparted. It’s not just a blood test kind of a thing. And
at IAP we keep taking a lot of CMEs regarding this. Indian
Medical Association (IMA) also does a lot of training. So we
have to realise that the machine doesn’t have a brain. The
doctor has a brain and experience. It’s more important for a
doctor to be able to clinically judge and if not treat, at least
decide if something is manageable. That is very important.”
His face at that point, was a perfect picture of
disappointment. It grew over him for a few seconds but he
remained rooted to the spot. And I was thinking what could
possibly be so bad that he seemed so worried about children.
Maybe that comes with an empathetic nature and being a
doctor, combined together.
“So, what is Autism Spectrum Disorder? You have a
clinic of your own, ‘New Horizons Child Development
Centre’; how is that contributing to make a positive mark
towards Autism?” His eyes glistened and his movements
were unhurried and periodically he would stop to think which
was oddly comforting, exactly like I had not seen with more
doctors. He continued, “What we believe is, labelling children
doesn’t help and very often in neuro developmental problems,
it often starts and ends with just a diagnosis. Unfortunately,
there are no pharmaceutical medicines for it and doctors
don’t really advice more beyond that. What New Horizons
has done is, in the entire field of developmental paediatrics
that is, children with delayed development, children with
intellectual issues, children with academic or learning issues,
behavioural issues, and communication issues; what we have
tried to show is that a huge amount of improvement could
be brought about but by a co-ordinated, inter disciplinary,
and professionally well organised method. And that’s exactly
what we have done here.”