August Edition, 2016.of Health Spectrum

www.healthspectrum.org HEALTH STUDY/RESEARCHAugust 2016 Volume I Number 2 Price ` 75Risks ofSaving LivesOver 75% Of Doctors Have Faced Violence At WorkIndia Needs A Culture Of Sanitation Face to face with Dr. Bindeshwar Pathak, Sanitation Man of India who managed toreHlieevaeltmhoSreptehcatnruomne million people forced to earn their living as manual scavengers

2 August 2016 Health Spectrum

August 2016Cover Story Risks of Saving Lives Doctors in our country are at rising risk in the workplaces due to the angst of distressed relatives. Many reports con- cern medical professionals being roughed up, even killed, by patient's disgruntled relatives. There are a numerous cases of violence against healthcare professionals leading to death of some doctors as well as nurses by patient’s relatives. This situation seems to be similar in most of the countries in this 18 region including China, Bangladesh and Pakistan.In The News Case Report  Alternative Medicine l India continues to be Polio-Free 8 l Ballistic trauma : Retrieval of l Yoga : A Novel Integrative Therapy 40l ‘Solar for Healthcare’ Initiative 9 bullet from knee by Athroscopy 22 l How to Treat “SleepApnea” withDiscourse Health Issue Homoeopathy42 India Needs organisedl Better Half of a Breast Cancer 10 trauma systems Healthy Motherhood Health Articles  14 12 l Certain Myths Of Women 48 Health You Need To Knowl Traumatic Brain Injury Health Tipsl Spontaneous Brain Haemorrhage l Tips of Dr. Sunita Godara to: Prevention and Cure 16 Reduce stress 50l Migraine headaches 24 Q&Al Hypertension : The Hidden Dan- l Gamming Addiction 39ger30 l Triggers of Cancer 47l Conjunctivitis: Most Common l Weights Loss 33Eye Problem 43l Don’t ignore the snoring and its Health Studyharmful effects 46 l Contraceptive failure 44Face to Face Alternative Medicine Beatuty Care 26 36 34India Needs A Culture Of Miracle story of Kamal Returning Afresh & Anew :Sanitation : Dr. Pathak Kaur Dr. P. K. TalwarHealth Spectrum August 2016 3

August 2016, Volume 1, Number 2 Dr. Raju Vaishya Dr. (Prof.) Raju Vaishya is President of Arthritis Care Foundation &Editor: Vinod Kumar a Senior Orthopaedic & Joint Replacement Surgeon at IndraprasthaManaging Editor : Sushila Kumari Apollo Hospitals, New Delhi. He is also well known for hisEditorial Head : Aarti Kapoor academic contributions. (Page : 22-23)Editorial Advisors:Dr. Manoranjan Sahay Dr. P. K. TalwarDr. Pallavi Vaishya Dr. P. K. Talwar is a Senior Plastic and Cosmetic Surgeon & DirectorContent Team : of Cosmetic Laser Surgery Centre of India, Greater Kailash - I,New Delhi : Dr. Atul Kumar, Uday Kumar New Delhi. He was also associated with the Indraprastha ApolloManna, Adheesh Vats, Deba Prasad Sahoo Hospitals, New Delhi as a Senior Cosmetic Surgeon. (Page : 34-35)Mumbai : Sama Irani, IPS YadavLucknow : Choudhary Zia Imam Dr. Rahul GuptaRanchi : Aloka Dr. Rahul Gupta is a Senior Neuro and Spine Surgeon at FortisPatna : Arun Kumar Mayank Hospital, Noida. He worked in many government hospitalsSingapore : Deepa Tomar including PGIMS, Rohtak, PGIMER Chandigarh & G B PantKuwait :Vartika Tomar Hospital, New Delhi. (Page : 16-17)Art Director : Kripa ShankarDesign & Graphics : K A Choudhary Dr. Harish KapilaAdmin & Business : Satnam Singh Dr Harish Kapila is a Senior Consultant, General and LaparoscopicWeb & Mobile : Athar Haque Surgery at Max Smart Super Speciality Hospital, Saket, New Delhi.Editorial Office : 21, UNI Apartments, He was associated with Moolchand Khairati Ram Hospital and SitaSector-11, Vasundhara, Ghaziabad – 201012 Ram Bhartiya Hospital as General Surgeon. (Page : 12-13)Tel : +91 120 4320050M: +91 9013074414, +91 9868793203 Dr. Jitendra KumarDelhi Office : 909-910, B-Wing, Naurang Dr. Jitendra Kumar is the Director of Nephrology and TransplantHouse, Opposite : Hindustan Times Medicine at Asian Institute of Medical Sciences (AIMS), Faridabad.Building, Kasturba Gandhi Marg, He is an expert in many procedures such as CRRT, hemoperfusion,New Delhi-110001 CAPD and kidney transplant. (Page : 30-32)Mumbai Office : 37/911, Adarsh Nagar,Worli, Mumbai- 400030 Dr. Sushma P. SinhaLucknow Office : 338, Prince Complex, Dr. Sushma P. Sinha is a Senior Consultant ObstetricianHazaratganj, Lucknow -226001 Gynaecologist, IVF & Infertility Expert & CO-ordinator andSingapore Office : 236, Westwood Avenue, Laparoscopic & Robotic Surgeon of Institute of Obstetrics &5-42 SG 648363, Singapore Gynaecology at Indraprastha Apollo Hospitals, New Delhi. (PageEmail : [email protected] : 48-49 )Website : www. healthspectrum.org Dr. Sonia Lal GuptalPrinted, Published and Owned by Dr. Sonia Lal Gupta is a Neurologist (Headache & Stroke Specialist)Vinod Kumar at Metro Centre for Neurosciences, Noida. She is one of the world`sPrinted at Subhashini Offset Printers, F-10, youngest and most qualified neurologists. She was formerly Asst.Jagdish Nagar, Patel Nagar-III, Ghaziabad Prof. of Neurology at Loyola University, Chicago. (Page : 24-25)(U.P.)Published at 21, UNI Apartments, Sector-11, Dr. Nikhil SethVasundhara, Ghaziabad – 201012 Dr. Nikhil Seth is Senior consultant eye surgeon and Head ofEditor : Vinod Kumar Department, Department of ophthalmology at Asian Institute ofTitle Code : UPENG04171 Medical Science (AIMS), Faridabad. (Page : 43)4 August 2016 Dr. Ananda Balayogi Bhavanani. Dr. Bhavanani is the Deputy Director of Centre for Yoga Therapy, Education and Research (CYTER), MGMC & RI, Pillayarkuppam, Pondicherry. He is a renowned yoga therapist, researcher and author of more than 20 books on Yoga. (Page :40-41) Health Spectrum

Health Spectrum is the Health Spectrum will be a and most trusted magazines in our country.need of time milestone for all - Akanksha Chaudhary I hope that the \"Health Spectrum\" I congratulate and appreciate Writer & Assistantmagazine will create awareness in the Mr.Vinod Kumar for launching “Health Professor (Humanfield of health and sanitation. Your Spectrum” magazine. Health problem, Resources),magazine is the need of time. The more one of the high rise problems, facingthe awareness about health issues is each one in current scenario. I wish Delhi Technical Campus,created among the people, the better it “Health Spectrum” will be a milestone Greater Noida - 201306would be for the society. This would also for all.lead to a healthy society as healthy mind Bridge between Healthis only possible with a healthy body. A Alternative therapies are distinctperson with good health will be able to philosophy and science which strengthens providers and the generalthink rationally and logically. Our Prime the age-old faith in correction of bodilyMinister, Shri Narendra Modi has taken disorder, restoration and maintenance of publicmany initiatives regarding public health health through elements freely availablewhich include Amrit yojana, Health in nature. Our body has inherent curative “Health Spectrum” is a goodCards for poor, Clean India Mission, powers to heal the problems whether initiative. Today a number of peoplepromotion of Yoga on International it’s physical, mental or psychological. seeking help from Google and Facebooklevel and decision to increase the age One can enjoy perfect health by proper for medical problems, it is importantof retirement for doctors. In addition to regulation of eating, drinking, thinking, that we have a credible group ofall this, the government is also working breathing, working and other social professionals who can give unbiasedon plan to open new hospitals across activities on a natural basis. Be Healthy and scientific information to the public.the country. \"Health Spectrum\" should Be Happy. I am confident that this magazinealso create awareness about government would give opportunity to discuss thepolicies and programs in health sector, - Dr.Alka Gupta prevention and management of theseso that the general people can avail the Holistic Health Coach, health problems and its solutions.benefits of these government programs. “Health Spectrum” will full fill the Bangkok (Thailand). objective of disseminating scientifically Shri Arun Singh [email protected] proven health information among the National General general public. This magazine will act as Secretary, Bhartiya Bridging the gap between a bridge between Health providers and the general public. We hope that it will Janta Party the hearsay and the facts become a medium of communication A-57, Parvana between them. Apartments, Mayur It is a tremendous relief that Health Vihar Phase-I Spectrum has come out with its first Dr. Sameer Kalani Delhi-110091 ever amusingly informative issue. It is Senior Psychiatrist,arunsinghbjp@gmail. indeed blissful and a rather colossal add Cosmos Institute of Mentalcom on in terms of serving as a substantial Health and Behavioural source for trustworthy health related Sciences (CIMBS), New DelhiGreat Initiative, especially information. Gobsmacking, in-spite of many health related magazines already Take a hard line againstin a country like India doing the round in the country, this one is different however in terms that malpractices Thank you for sharing the 1st issue it is aimed at bridging the gap betweenof Health Spectrum. I must say, it is a the hearsay and the facts. It collates I am delighted that a much neededgreat initiative, especially in a country excerpts from experts in medicine and health magazine “Health Spectrum” islike India. I have been to India more fitness lines, serving as a perfect treat launched under your watchful eyes. I amthan 30 times. I am also aware of some for those looking for effective ways to confident that this magazine would do aof the health problems of Indians and fight ailments and read about healthy yeoman service for the people of India.their causes. Maybe I will consider lifestyle habits. Apart from that I also hope that not onlysharing some of experiences relating to create health awareness in the society buthealth in the magazine. My best wishes A big applaud to Mr. Vinod Kumar you would also take a hard line againstto the founders of the Health Spectrum and his creative team for taking this shady doctors and those hospitals whichMagazine. up for social good! Even though the are indulging in malpractices. availability of information over internet Dev Rakhah is massive but a trustworthy source of Vivek Shukla Writer, Educationist, genuine information is hard to access Senior Journalist, Previously and remains time consuming. and Social thinker worked with Hindustan London, U.K (Email : Looking forward to \"Health Times Group, New Delhi [email protected] Spectrum\" becoming one of the best, [email protected] Spectrum August 2016 5

Editor Speak A platform for differ-We want to be a ent shades of opinionsam pleased to present to you the second edition of Health Spectrum. The inaugural edition had a great and heartening feedback from different platform to promote health Isections of readers as well as the medical community, and we got some col- awareness and offer an avenue laboration suggestions some of which we accepted with pleasure. for meaningful As a fledgling health magazine in India, we want to be a platform to pro- debates on mote health awareness and offer an avenue for meaningful debates on chal- challenges and lenges and problems in the healthcare sector. We also want to empower our problems in the readers to lead a happy, healthy and disease-free life. It goes without sayinghealthcare sector. that there cannot be any substitute for a robust health, which is a prerequisite for both physical and mental well being. We have an unwavering goal to meet this objective through the magazine, which can be a trusted friend and coun- sellor in all aspects of their lives. This edition puts spotlight on some of the day-to-day health challenges and problems and encourages us to reflect on how we treat the people (health providers) who take care of our health while we are at work. It also explores the causes of increasing incidents of attack on doctors. There are numerous cases of violence against healthcare professionals, and, at times, have resulted in deaths of doctors and nurses by patients’ relatives. A study by the Indian Medical Association (IMA) reveals that more than 75% of doctors across the country have faced at least some form of violence. Nearly 75% of doctors feel that they are unsafe in this country and they fear for their lives. This is a seri- ous problem because as healthcare professionals, doctors should be able to invest their energy into saving lives of people, not their own. In this issue, we also put focus on increasing road accidents and lack of an organised trauma system in India, which has the highest number of road acci- dents in the world. Every minute a life is lost in road accidents in our country but there is no systematic trauma care centre. We have included articles on prevention and treatment of diseases like hypertension, Spontaneous Brain Haemorrhage, migraine, conjunctivitis, sleep apnea and Traumatic Brain Injury. The articles in this issue are all writ- ten by people who are engaged in providing healthcare to the public. They have freely shared their viewpoints with lots of gusto and passion. I encourage you to do the same. However, we want to clarify that Health Spectrum is a platform for different shades of opinions, and many writers may not may not be conducting clinical trials or research. As such, we do not confirm state- ments made by any author. The magazine insists that readers should consult a medical doctor prior to following any opinion or advice or using any product or service published in the magazine. On that note, I invite you to explore this magazine. So please, sit back and dive into this issue’s selection of articles and discussions. We will look forward to your suggestions and feedbacks for improving the magazine. After all, it is your magazine. We will surely publish the worthwhile comments from our readers. With warmest thanks, Vinod Kumar6 August 2016 Health Spectrum

HEALTH STUDY/RESEARCHHealth Spectrum August 2016 7

In The News India continues to be Polio-Freendia continues to be polio free as the country has eradi- cated wild polio virus and the last case was seen on 13thIJanuary, 2011, and it is more than 5 years that no wildpolio virus has been detected. onset in children up to 15 years (which is called Acute Flac- cid Paralysis or AFP) are picked up by the polio surveillance network. Each of these cases is followed up and their stool samples tested for poliovirus in WHO accredited laborato-Last case of Wild Polio Virus Type 2 in country was re- ries. In addition, sewage samples are collected from over 30ported 17 years back in 1999. The detection of vaccine de- sites spread across the country for poliovirus detection atrived polio virus (VPDV) does not change the polio free regular intervals.status. It only indicates the robustness of the surveillance According to Ministry of Health and Family Welfare,system and willingness of the country to detect any kind of Between Jan 2015 and May 2016, a total of 14 sewage sam-polio virus even from the environment(sewage). Vaccine derived poliovirusesare rare strain of the polioviruses thathave genetically mutated from the straincontained in the Oral Polio Vaccine(OPV)According to a report of Ministry ofHealth and Family Welfare , a rapid sur-veillance review of the area revealed thatthe population immunity against poliotype 2 is high as trivalent oral polio vac-cine (tOPV) was in use in the state until24th April, 2016 and two mass vaccina-tion campaign were conducted in Janu-ary and February, 2016. As per recentsample survey in the area, 94% childrenwere found to have received at least 3doses of OPV. Therefore, chances of itstransmission in concerned area is un-likely.According to report, however, as aprecautionary measure against Polio, a special immunization ples collected from different parts of the country testeddrive is being held, covering high-risk areas of Hyderabad positive for VDPVs. All of these have been responded to ur-and Rangareddy districts, starting from 20th June, where an gently and appropriately with polio vaccination campaigns.estimated 300,000 children will be protected against polio None of these VDPVs detected in the sewage infected anyusing Inactivated Polio Vaccine (IPV). The special immuni- children, so far.sation campaign will ensure all vulnerable children living in The response by the health authorities to the VDPV inhigh-risk areas are given protection against polio. Hyderabad is in accordance with World Health Organiza-As part of the special campaign being organised now, tion protocols to mitigate any risk of spreading of the vi-children between the age group of six weeks to three years rus. WHO, UNICEF and Rotary are supporting Ministry ofwill be given an additional dose of the injectable polio vac- Health and Family Welfare in rolling out the polio campaign.cine (IPV). Vaccination booths will be set up in the areas Strong measures have been put in place in India to miti-being covered in these campaigns. However, there will be gate the risk of an importation and spread of poliovirus fromno door-to-door vaccination campaign. Parents of children countries with continued circulation of poliovirus. Countryliving in these areas will be encouraged to ensure that their has done two nationwide polio campaigns this year. Poliochildren get the IPV dose from the nearest vaccination vaccination is being carried out at international borders andbooth which will provide additional protection against all is a must for people travelling to polio affected countries.types of polio. The polio eradication programme in India continues toThe last case due to wild poliovirus in India was detected protect children from the crippling disease by conductingon 13 January 2011 and the country was certified polio-free two nationwide mass polio vaccination campaigns and twoby WHO in March 2014. The polio-free certification per- to three sub-national campaigns each year. Intensive effortstains to the absence of wild poliovirus and thus country re- are also being undertaken in India to improve routine im-mains polio-free. munization coverage that involves administering polio vac-India continues to maintain a highly sensitive surveil- cines, in addition to other vaccines, to infants under thelance system for polio. All cases of paralysis with sudden Universal Immunization Programme (UIP). n8 August 2016 Health Spectrum

In The News‘Solar for Healthcare’ InitiativeT he Indian Council of Medical Research (ICMR) has and children.” signed an MoU with the Council on Energy, Envi- As of 2015, nearly 35 million citizens in rural India rely ronment and Water (CEEW), a policy research in-stitution, to launch a new ‘Initiative on Solar for Healthcare’. on un-electrified PHCs for primary health services. In theThe collaboration will focus on providing effective health absence of electricity, services catered by health institutionscare delivery at the last mile by reducing uncertainty in criti- such as institutional deliveries, paediatric emergencies, andcal infrastructure, particularly electricity supply via cost ef- administering of vaccines get severely affected. Electric-fective solar-based solutions. ity access in health centres is also imperative as a means to facilitate communication services, tele-health applications Dr. Soumya Swaminathan, Director General, ICMR said: and to retain skilled health workers. Dr. Arunabha Ghosh,“The collaboration with CEEW will bring together synergies CEO, CEEW, said, “The collaboration with ICMR supportsbetween the objective of ‘time to care’ as mandated in the the systematic and productive advancement in national pol-National Health Mission (NHM) and clean energy as out- icies, regulations and actions to leverage solar energy for alined under the National Solar Mission (NSM). Under this social purpose: enhancing the quality of healthcare deliverycollaboration, on a pilot basis, we will install solar systems at various levels of governance.”at select PHCs in partnership with three state governmentsand evaluate its impact on healthcare delivery and health The synergy between health and energy are the two spe-outcomes. The aim of the collaboration is to create resilient cific goals of this initiative, and the efforts within this col-health systems in rural India, benefitting primarily women laboration advances on both fronts. n Health Spectrum August 2016 9

DiscourseBetter Half of a Breast Cancer Patient actions, but speaking words brings com- Dr. Rohan Khandelwal western statistics reveal that nearly fort, reassurance and knowledge of your Consultant - Onco-plastic seven out of ten marriages touched inner feelings. She cannot read your mind. by breast cancer do not survive Being there for her is more than physical Breast Surgeon and ultimately lead to divorce. With the or economic security. Words have mean- W-Hospital (Gurgaon) incidence of breast cancer increasing in ing. And the three most important words Head - Medical Affairs at young Indian women, this problem will in the English language at this time, at thisCurofy (Doctors Networking soon be evident here as well. In fact, dur- moment, when together you are facing her ing my tenure in Bangalore, I did come mortality, are: “I love you.” App) across a few patients who were deserted by their families after their diagnosis of Breast Involve her in the decision makingEmail : rohankhandelwal@ Cancer. It is not easy for a lady to deal with the diagnosis of breast cancer. Often it has gmail.com Although there is no magic formula been seen in India that husbands and fam- for a couple to weather this difficult pe- ily members make clinical and personal riod, but some of these points can help decisions on their behalf. Although these husbands support their wives during their ladies appreciate some of the decisions but Breast Cancer treatment. they would love to be part of others, which involve their future. Stand by her during the treatment & A simple example is deciding between tell her that you ‘love’ her a mastectomy & breast conservation sur- gery. Family members err towards the side In a marriage or any intimate relation- of mastectomy but in reality a lot of young ship, silence is not golden. The strong si- patients actually want breast conservation lent type need not apply for the position of surgery. It always helps to consult them in husband, lover, best friend, confidante and private and then take a collective decision. supporter of a woman with breast cancer. Go to Her Appointments Your bride, your wife, needs and wants to It is not what you do when you accom- hear from you. Actions may speak louder pany her to treatment, but rather the act it- than words, and you may take all the right self that speaks volumes to her. It also gives you some sense of empowerment. You are more than a helpless spectator cursing the damned disease. You have to join the battle and be her rock solid foundation. Sometimes humor helps Funny, it does. There’s even a study to prove it, by psychologist Sharon Manne of the Fox Chase Cancer Centre in Phila- delphia. Couples who laughed at cancer coped better with the stress of treatment. We know that the act of laughing is itself healing. It makes us feel better and helps us get better. Continue to enjoy as a couple – she is NOT invalid Treatment can be grueling and tiring, but you both need to live your life as fully as possible. Continue to enjoy what you enjoy individually and as a couple, par- ticularly the latter. Don’t let cancer put an end to your personal and social life. If you follow these simple steps, you can also become a Proud Husband of a Breast Cancer Survivor!!. n10 August 2016 Health Spectrum



Health IssueIndia Needs organisedtrauma systems Dr. Harish Kapila R oad accidents kill approxi- arrival of medical emergency services, Senior Consultant mately 1, 50,000 people per enrooted to the hospital, or in the first General and Laparoscopic Surgery year in India out of a total of hours of care. These immediate deaths Max Smart Super Speciality 500,000 accidents reported every year. are typically the result of massive hem- Every minute a life is lost in road ac- orrhage or severe neurological injury. Hospital cidents in our country. We have an ac- Saket, New Delhi-110017 cident rate of 140 per 10000 vehicles Deaths represent only small part of Email : [email protected] compared to 2per 10000 in west. injury disease burden. The amount of economic and social burden it entails12 August 2016 Injuries rank fourth as a cause of is colossal. Injury accounts for 20% of death for all age groups in this coun- years of potential life lost (YPLL) be- try. It is the leading cause of death fore the age of 65. This is more than among children, adolescents and any other disease like malignant neo- young adults. Injuries account for plasm (15%) and heart disease (12%). more premature deaths than cancer, heart disease or HIV infection. Definitive care for trauma patients is offered by government hospitals, Recent studies suggest a bi modal corporate hospitals and a large num- pattern of trauma deaths with a reduc- ber of clinics across the country. Fa- tion in late deaths. The majority of all cilities that offer treatment for trauma deaths still occur within minutes of patients, at different levels, report 10- the injury, either at the scene prior to 30% of their beds occupied by victims Health Spectrum

Health Issueof road accidents. Most government hospitals offer free care Level II It works in collaboration with level I centre. Itbut the quality of care differs from one centre to another. provides 24hr availability of all essential specialties, person-Most university hospitals provide a reasonable level of care. nel and equipment. It is not required to have a residencyThese hospitals are able to fulfill the role of tertiary care cen- programme.tres but critical care remains a weak link in such settings fora variety of reasons. Private and corporate hospitals, located Level III It does not have full availability of specialists.mainly in big cities, are well equipped, offer good operat- It does have resources for emergency resuscitation, surgerying facilities and intensive care units. But, few run dedicated and Intensive care of most trauma patients. It has transfertrauma services. There are no norms to govern their stand- arrangements with other centres.ards of healthcare delivery. Level – IV – A level – IV center provides the stabiliza-Problems due to lack of tion and treatment of severely injured patients in remoteorganised trauma systems areas where no alternate care is available.l Pre hospital care in most cities is nonexistent. Even if Importance of treatment at trauma centres patients reach the hospital, the golden hour concept is still a distant dream. John Hopkins Bloomberg school of Public health and University of Washington conducted a research survey tol Ambulances services are poorly organised and there study the effectiveness of treatment of a trauma victim at is no centralised agency to monitor the services. The a specialised trauma centre against the treatment at a non training of paramedics in the ambulances is an impor- trauma centre. The research provided convincing evidence tant concern. to suggest the treatment of a trauma victim at a trauma cen- tre reduces the risk of deaths by 25% for the injured patients.l Concept of “Triage” is followed in less than 50% hospi- Review of multiple expert panel studies led to the conclu- tals. Casualty medical officers are the only physicians to sion that care delivered at trauma versus non trauma centre provide resuscitation. may be associated with less inappropriate care, A signifi- cant reduction in preventable deaths in very severely injuredl There are no dedicated trauma surgeons in India. Clin- patients was also noticed. Based on currently available evi- ical decisions are often delayed in the absence of clear dence, the conclusion can be made that the development of perceptions of responsibilities amongst different physi- trauma systems is important and must be supported. cians. Conclusionl Rehabilitation is mainly restricted to physiotherapy. Occupational rehabilitation is generally missing at Currently even the best emergency services and trau- most centres. ma systems are largely ineffective in preventing those deaths that occur at the site of accident. Efforts at pre-l Finally, there is no central trauma registry in any insti- venting the occurrence of injury events or reducing the tute. severity of injuries incurred will be the most effective means of reducing the large number of immediate deaths.What is the way out of this tragic situation? Continued efforts at development of trauma systems that foster rapid and efficient means of triage and transfer to The answer to above problems lie in having dedicated higher levels of care and research in the area of trauma,trauma centres in various cities across the country. A trauma hemorrhage, infection will eventually serve to decreasesystem is an organised approach to acutely injured patients the late and delayed deaths. nin a defined geographical area that provides full and optimalcare and that is integrated with local medical emergency. A trauma ce nter is a hospital equipped to perform asa casualty receiving station for the emergency medical ser-vices by providing the best medical care for the trauma in-juries, 24 hours. In order to qualify as a trauma centre, ahospital must have a number of facilities including a highquality intensive care ward and an operating theatre, wellequipped in terms personnel and equipment.Classification of trauma centres Trauma centres are classified on the basis of resourcesavailable and the number of patients admitted regularly.These are categories that define the national standards fortrauma care in hospitals. Level I A level centre has full range of specialists andequipment available round the clock and admits a mini-mum required annual volume of severely injured patients.It has a programme of research and is a reference centre forother centres.Health Spectrum August 2016 13

Health ArticleTraumatic Brain InjuryT raumatic Brain Injury (TBI) or Head Injury is a major cause of (b) Learning and reasoning (d) Dizziness death and disability worldwide (c) Judgment (e) Difficulty in recognizing objectsespecially in children and young adults. (d) Attention or concentration span (f) Abnormal postureIt is seen that males suffer more fre- (e) Problem solving and decisionquently than females and the causes are It is important for parents to knowmostly vehicular accidents, falls, sports, making capability that small children with moderate toand violence. Preventive measures in- severe head injury may have some ofclude use of helmets, seat belts, and Communication these symptoms, but may not be able todriving safely. The Brain is the CPU of communicate them. Children also showthe body, so we always must protect it. TBI could cause disruption in commu- other signs like persistent crying, refusal nication skills and social problems like: to nurse or eat, and irritability. In adults, Head Injury results mostly from an (a) Difficulty in understanding speech TBI is mostly caused due to Road Acci-accident where the head suffers a hit dents, but in small children, it is mostlyand the force of the hit could be violent or writing accident, falls and child abuse. If any ofenough to cause permanent or tempo- (b) Disorganized thinking the foregoing symptoms are noticed inrary brain damage and could lead to dis- (c) Confusion, awkwardness and slur- children or adults, have them examinedruption of brain and bodily functions. by a doctor immediately. As far as pos- ring of speech. sible, a Head Injury victim must be seen Sometimes, even minor injuries by a Doctor in the golden hour.which are often overlooked, could lead Behavioralto serious after effects and must not be The incidence of TBI is increasingignored. These effects of injury which Behavioral changes as follows may be globally and India is leading the pack.could be cognitive (thinking, under- noticed after a head injury: The largest bracket is in the age groupstanding, learning, reasoning and re- of 15 to 25 and thereafter it is 26 to 45.membering), social, emotional and (a) Lack of self control The age groups at most risk of mortalitybehavioral. Depending on the type and (b) Risky behavior are adults over 70 year age and childrenlevel of injury, and the time elapsed (c) Verbal or physical outbursts between 5 to 9. In a country like Indiafrom time of injury to time of reaching (d) Loss of confidence where there are large tracts of poverty,hospital, the outcome could range from especially in the rural areas, there is acomplete recovery to permanent dis- Emotions tendency to ignore mild or moderateability or even death. cases of Head Injury as the people of- Emotional changes may include: ten do not understand the significance According to the National Institute (a) Depression and anxiety of such injuries. It is important for theof Health (US) and Mayo Clinic, there (b) Mood swings and increase in ir- Government, various informed groupsare six main brain functions that may and NGOs to educate our massesget affected by an accident involving ritability through all methods at our disposalthe headand they all show some form of (c) Changes in self esteem including the PanchayatSystem andsymptoms. (d) Insomnia and other sleep related District Hospitals on how to recognize irregular behavioral patterns in theirNerves problems wards and in case of any doubt, have them examined at a hospital. The earlierWhen an injury occurs to the Nerves in Affects on Senses the better. nand around the skull, the following maybe noticed: (a) Ringing in the ears Ranbir Talwar(a) Facial muscle paralysis or loss of (b) Hand eye coordination Commodore (Retd), VSM (c) Tingling, pain or, itching of the skin Executive Director sensation Indian Head Injury Founda-(b) Double vision tion (IHIF), New Delhi(c) Loss of sense of smell(d) Loss of vision Chitra Sony(e) Problems with swallowing Senior Executive Indian Head InjuryIntellect Foundaion (IHIF) New DelhiDepending on the severity of Injury,there could be changes in normal func-tioning abilities like:(a) Memory14 August 2016 Health Spectrum

Health Spectrum August 2016 15

HEALTH Article Spontaneous Brain Haemorrhage Prevention and Cure Dr. Rahul Gupta S pontaneous brain hemorrhage ac- unconsciousness. Sometimes, headache counts for about 10% of all strokes may be gradually progressive and associ- Senior Neuro & Spine and is fatal in about 50% of the cases. ated with limb weakness or epileptic attack surgeon Its incidence, in contrast to other types of (seizure). strokes, has not declined. According to Fortis hospital Dr. Rahul Gupta, Senior Neuro and Spine Reasons for Spontaneous Brain surgeon at Fortis Hospital, Noida, Hyper- haemorrhage? Noida tension accounts for about half of these Email : rahulguptaneuro@ hemorrhages; the rest are due to tumors, It is usually associated with high blood aneurysms and vascular malformations, pressure (BP). Different types of brain gmail.com inflammatory and degenerative vascu- haemorrhage may have different reasons. lopathies and hematologic and iatrogenic16 August 2016 disorders of coagulation. Different types of brain haemor- rhage? Brain haemorrhage Intracranial haematoma (ICH) is fre- Brain haemorrhage is bleeding into the quently seen in people with uncontrolled brain tissue or its surface due to rupture of high BP. Sometimes, it may be due to de- blood vessel. It can be spontaneous or due fect in vessel wall (like aneurysm, AVM). to head injury. Uncommonly, a brain tumour may also develop an ICH. Another type of haemor- Symptoms of Brain haemorrhage rhage may be Subarachnoid haemorrhage (SAH) which is due to aneurysm sup- Most often presentation is sudden se- ture. Another type is subdural hematoma vere headache, vomiting and transient (SDH) which is due to trauma or con- Health Spectrum

HEALTH Articlesumption of blood thinners. depends on delay in treatment given to the patient. In SAH, if patient conscious before surgery then recovery isDiagnosis of Brain haemorrhage very good. Chronic SDH patients do very well within a week time. CT scan is the investigation of choice. Angiography ofbrain helps to identify cause of bleeding. Sometimes MRI is Bleeding inside Tumoursrequired to look for bleeding inside tumour. Some brain tumours may present with bleeding insideTreatment of ICH them. MRI helps in diagnosis. Removal of tumour along with blood is the treatment. Without any delay, patient A6. Small ICH can be managed with medicines. Surgery should be taken to a hospital equipped with facilities of CTis required if the ICH is large, causing pressure effect on scan, MRI and Angiography.brain and if the patient is unconscious.Treatment of SAH Tips for prevention In 90% cases, SAH is due to aneurysm supture. Angiog- Most important is frequent monitoring and controlraphy is mandatory to identify aneurysm. There are 3 types of blood pressure with medication and lifestyle modifica-of angiography. Digital Subtraction Angiography (DSA) tion. Brain haemorrhages are more frequent in early morn-done in Neurocathlab is the best method. Others are CT or ing especially in winters. Drinking lot of water and timelyMRI based angiographies. After diagnosis, aneurysm needs consumption of medicines is essential. Minor headachesto be secured by clipping or coiling to prevent re-rupture. should not be neglected and a Neurosurgeon/NeurologistVasospasm (shrinkage of blood vessels) is a dreaded com- should be consulted.plication of SAH, which may lead toneurological deficits. It is managed Burden of Brain haemor-with medicines. rhage on the populationCoiling or Clipping of Spontaneous brain haemor-Aneurysm rhage is very common and almost 50% patients expire before they can These are methods to prevent be shifted to a tertiary care hospi-re-rupture of an aneurysm. Coil- tal. Patients who are unconsciousing is done in Neurocathlab, where before surgical treatment takewithout opening the skull, the an- months to recover. Unfortunately,eurysm is packed with coils. It is a there are few centres for rehabilita-relatively new method with excel- tion in India and patient has to belent results. In clipping, the skull is shifted home after definitive treat-opened, aneurysm is exposed and a ment. Hence, role of preventionclip is placed across its neck. This is and timely intervention cannot bea time tested method and provides overemphasised. npermanent cure.Trreatment of SDH Brain haemorrhage is Dr. Rahul Gupta is the man be- bleeding into the brain hind the department of Brain and SDH is usually seen after trauma. tissue or its surface due spine surgeon at Fortis Hospital,Chronic (late) SDH may present to rupture of blood vessel. Noida. He was trained at Nagoyawith subtle symptoms, many weeks It can be spontaneous or Japan, which has made him anoften minor trauma and is com- expert in Endovascular procedures.mon in elderly. It may occur in pa- due to head injury. He worked in many govern-tients consuming blood thinners like ment hospitals including PGIMS,Ecosprin. Reversal of blood thinning Rohtak, PGIMER Chandigarh &effect is essential before surgery. Govind Ballabh Pant institute ofChronic SDH needs two holes in Postgraduate Medical Education &skull and drainage under local an- Research, New Delhi.aesthesia. Dr. Rahul Gupta has performed surgeries on hundreds of patientsPrognosis of brain with head and spine injury. He hashaemorrhage treated numerous complex spine ailments like metastatic tumors, os- In small ICH, patient recov- teoporotic fractures (vertebroplasty),ers well in 3-6 months with minor degenerative diseases and listhesis.deficits. In large ICH, patient needsprolonged hospitalisation and reha-bilitation and chances of recoveryHealth Spectrum August 2016 17

Cover StoryRisks of DOCS AT RISKSaving Lives • Nearly 50% of violenceD - Vinod Kumaroctors in our country countries in this region including reported form ICUsare at rising risk in the China, Bangladesh and Pakistan. or after a patient hasworkplaces due to the undergone surgery, saysangst of distressed rela- According to a recent study by ongoing IMA study the Indian Medical Associationtives. Many reports concern medi- (IMA), over 75 percent of doctors • Kin & attendants ofcal professionals being roughed up, in India have faced some form ofeven killed, by patients' disgruntled violence at work. An another study patients behind 68 % ofrelatives. There are a numerous published in medical journal The such casescases of violence against health- Lancet said that delay in attendingcare professionals leading to death to a patient, request of advance pay- • Visiting and peak hoursof some doctors as well as nurses ments, or withholding a deceasedby patient’s relatives. This situation body until settlement of final billing most prone to violence,seems to be similar in most of the are a few of the reasons why angry besides the tense mo- ments during transfer18 August 2016 of critical patients to hos- pital • Experts say figures would be higher as most doc- tors don’t report such incidents Health Spectrum

Cover Storyrelatives tend to lose their temper and Violent society is detrimental to theattack doctors. practice of humane medicine In view of growing violence many It May Be Asking Too Much Of Doctors To Be So Active, Given Thedoctors feel that medicine has become Present State Of Affairs. We Can Begin Small, By Promoting Ethical Anda 'dangerous' profession, and they Honest Voices From Our Profession. We Can Also Increase Our Credibilityshould be provided 'security'. A report By Condemning Colleagues Who Collude With Criminal Politicians.suggests that almost 70% of doctorswon’t want their own children to go A violent society is detrimental to the practice of humane medicine; itinto the medical profession. negates all the 'achievements' of modern medicine. The medical profession must do more than just condemn such violence; it must reflect on the eth- Increasing commercialization and ics of its own practice. For doctors, this means not perpetrating violencecorruption coupled with unethical through their practice, through the medical system or through collusionpractices by some medical profession- with the perpetrators of violence. It also means practising an active socialals, lack of communication between ethics, being at the forefront of preventing violence and caring for all vic-doctor and the patient, poor image tims of violence, irrespective of their crimes and ideological affiliations.of medical profession, lack of faithin judicial system and the police and -Dr. (Prof.) RAJU VAISHYAinsufficient security for doctors have President, Arthritis Care Foundation &lead to increased violence against the Sr Consultant Orthopaedic & Joint Replacement Surgeonhealthcare professionals which has Indraprastha Apollo Hospitals, New Delhihighlighted the importance of patientssatisfaction and patient safety. Periodic updating of nication to the patient and their the condition of the attendants, relatives should be A number of news reports also patient to the attend- ensured.throw light on the fact that violence in 8. Patients should be involved inhealthcare sector has been increasing at ants is necessary. decision making regarding theiran alarming level throughout the coun- Healthcare profes- treatment giving them adequatetry. Doctors become an easy target for sionals in general information about the possiblethe blame game by sensational media and junior doctors complications.reports. Since a wide gap exists between in particular must 9. Periodic updating of the condi-the patient’s expectations and the real- develop proper com- tion of the patient to the attend-ity, patients who feel they have not been munication skills and ants is necessary. Healthcare pro-looked after properly then take the mat- fessionals in general and juniorters in their own hands. These incidents empathy. doctors in particular must devel-have certainly decreased the self esteem op proper communication skillsof the doctors. “Health Spectrum” has ly examined, investigated and and empathy.speaked to many doctors and health treated. 10. Every healthcare facility mustactivists. According to them, it is high 5. Negligence should not be accept- have a liaison office to deal withtime that authorities in our country ed under any circumstances. the media and respond to theirshould wake up and initiate some effec- 6. Over confidence and too much queries. No media personneltive measures. Some of these could be cautiousness in patient care the electronic media in particu-as under: should also be avoided. lar should be allowed to enter1. Strict accreditation of medi- 7. A realistic appraisal of the pre- the healthcare facilities without vailing situation and commu- permission and they should be cal and dental schools ordering briefed by the liaison officer or closure of all those institutions the hospital spokesman. Media with poor quality and standards. in particular has to show respon- Those institutions which fail to sibility while reporting health get accreditation should be given issues and those covering health some time to improve and make must have some core knowledge up the deficiencies failing which of health issues. they should be closed down. 11. All healthcare facilities must have2. The number of enrollments in each medical and dental school should be based on the number, quality of teachers and other teaching facilities.3. Doctors should never assure 100% cure and avoid negligence.4. Each patient should be adequate-Health Spectrum August 2016 19

Cover StoryNearly 75% of doctors fear for their lives “I solemnly pledge myself to consecrate my life to ing and it’s no wonder human that a few mistakes occur.service of Humanity.” This is the first declaration that we If you overload an individual with work beyond humanmake as a doctor. The day we get our degrees and start capacity, mistakes are bound to occur.practicing, a new life begins for us, a life that was pledged 2) Deplorable condition of government run hos-for humanity. pitals - Thousands of doctors graduate every year in In- dia, out of these only 10% get to do a post graduation. Doctors are considered as ambassadors of wellness What about the 90% who didn’t? They either try to findand health, whom the society can look up to. It’s no won- jobs or set up their own private practice. In a country thatder that more than 50% of our population wants their kids has a skewed patient: doctor ratio, it’s an irony that there isto grow up and become a physician. Yet, doctors are the a dearth of jobs for healthcare professionals. But unfortu-most misunderstood underrepresented and overworked nately, government does not want to increase the numbercommunity in India. of vacancies in government hospital, and a few hospitals that do have vacancies are in deplorable conditions. A resident is supposed to work for 36 hours continu-ously, without making any error. Today, under every cir- Patients who get treated in such institutions are ob-cumstance a doctor is expected to be efficient, congenial viously dissatisfied; they can’t express their anger on theand ever smiling. Any break in this perfect behaviour is government so they blame it on the person nearest todealt with extreme backlash, usually in the form of vio- them, the doctors.lence. 3) Commercialisation of healthcare ecosystem- It’s no secret that private hospitals have led to unethical Violence amongst doctors is not something new, it’s medical practices. They exist to make profit and make nosomething that we read every now n then in the newspa- qualms about it. They justify their pricing by providingper, condemn on social platform and then forget till the world class amenities to patients, but in the process a pro-time another doctor gets beaten up. fession that was considered noble by everyone became a service to be provided. A doctor is still a healthcare pro- Many blame this on the commercialisation of health- fessional who saves life, but a patient becomes a consumercare, which has led to a trust deficit between doctors and who wants a perfect service. In such a scenario, if the doc-patient. But many of the incidents have happened even tor falters in anyway he/she has to face the wrath of thebefore the treatment was started. A resident ophthalmolo- patients.gist was beaten up in Jaipur till his hand was broken, allbecause he asked a patient to get in line for OPD. A dentist Nearly 75% of doctors feel that they are unsafe in thiswas beaten up in Pune because he wanted to step out for country and fear for their lives. As a healthcare profes-lunch after spending hours treating patients, and the pa- sional, they should be able to invest their energy into sav-tients waiting outside thought it was too much to ask for. ing lives of people, not their own. India as a country has grown largely intolerant to-wards doctors. Medicine is a noble profession, so how didwe come to this point where violence against doctors hasbecome an everyday occurrence? 1) Skewed patient: doctor ratio - According to a - Dr Prerna Motwanireport there are only 0.7 doctors per 1000 people in India. Writer with CurofyThis means that every doctor is overloaded with work,sometimes beyond human capacity. The sheer volume ofpatients that a single doctor has to treat is overwhelm- a proper boundary wall with ad- tor should be criticized. 16. Relationship between the Physi- equate security system in place 13. Avoid using words like you have cians and the Pharmaceutical with monitored entry of public. Trade and Industry needs to be Security guards should be posted come late. looked into and Guidelines pre- inside the hospital particular in 14. In desperate situations, the pa- pared by the National Bioethics most sensitive areas like Emer- Committee on the subject should gency, Intensive Care Units, and tient must be given the choice of be implemented which will go a Operation Theaters. calling another doctor for second long way in eliminating unethical12. There is a need to improve the opinion if they so desire. practices. Doctor-Patient relationship. Un- 15. Professional specialty organiza- In short there is an urgent need der no circumstances the previ- tions should play their role and ous hospital or the referring doc- come up with a mechanism of self to make the healthcare facilities a monitoring of their members to safe environment for the healthcare20 August 2016 ensure ethical medical practice. Health Spectrum

Cover Story Hospitals should have Over 75% of doctors have faced better communication violence at work, study finds with the patients Violence against doctors varies from physical assault to threatening behaviour to mere verbal abuse. There is no doubt that violence against doctor is increasing but cannot initially put the NEW DELHI: Those who save lives are themselves at risk. More blame on the violator. Empathy is one thing than 75% of doctors across the country have faced at least some that is missing now a day in medical profession form of violence, initial findings of an ongoing study by the Indian because of lack of trained medical profession- Medical Association (IMA) have revealed. als and increasing work load leading to less time left for communication between doctors Doctors faced maximum violence when providing emergency and patient that is the root cause of these vio- services, with as many as 48.8% of such incidents reported from lent episodes. intensive care units (ICUs) or after a patient had undergone surgery, the study said. Relatives and attendants of patients were often found As a doctor, I myself have been a patient guilty of such actions. According to the findings, data of the past in one of the busiest hospital of Delhi, where five years showed that escorts of patients committed 68.33% of the I could not get to see the doctor who operat- violence. ed on me, before or after the surgery, being a surgeon myself I could understand there busy However, experts said the findings did not reflect the actual schedules and did not react as most of the ma- situation as not all cases were reported. The gravity of the problem jority who react to it, Probably as a doctor, I is much more. \"All cases of violence are not reported. Doctors often know everything is going to be fine, but non understand the situation of relatives who are in distress and do not medicos get anxious very fast, when their close report such cases. Mostly, those cases are reported where the doctor one has a medical aliment which they have no feels serious threat of life or has already faced so,\" IMA secretary clue about, and the cold attitude from the hos- general Dr KK Aggarwal said. pital and staff make them go angry and leading to taking out there frustration on the doctor. Violence against doctors varies from physical assault to threat- It’s neither their fault nor the doctor’s. Its fail- ening behaviour to mere verbal abuse. While most incidents of vio- ure of communication and the warmth touch lence were found to have occurred during visiting hours and peak and assurance they need from medical side, hours, when doctors are busy and visitors are around, the study which lots of hospitals fail to delivery. Hos- found that doctors and paramedical staff also had to face rage while pitals should have special \"patient _medical transporting serious patients to hospital. staff \" purely dedicated to communicate with the patients and their attendant and apprise \"The transport time is very crucial. This is also a kind of emer- them of condition of the patient. gency service and relatives of patients are nervous and under stress. Any delay or even an unintended negligence results in huge rage Dr. Monisha Kapoor. and anger among the patient's escorts,\" the head of emergency ser- J-18, Near SBI Bank, Saket vices in a leading private hospital said. Mehrauli-Badarpur Road New Delhi-110017 While IMA is advocating a stringent law at the Centre to ad- Phone: +91 11 40666307/08 dress the situation, doctors and healthcare experts say there is a Mobile: +91 9811439395 strong need for counselling of relatives and escorts of patients.professionals to work only then they can be ex- Doctors need to keep patients and their relatives in the looppected to work with devotion and dedication. from the very beginning. \"Patients should be told the truth, aboutBreaking News on the Television Channels regard- the adverse effects and also given the choice of alternative treat-ing death of patients due to doctor’s negligence ment,\" Dr Talat Halim, director, trauma and emergency at Fortishas only served to work against the patient’s own Hospital, said. He added that medical practitioners needed to showinterest as now the healthcare professionals are empathy with patients as well as their escorts, who are often in dis-very reluctant to handle serious cases, hence many tress when in hospital.precious lives which could have been saved arebeing lost. n Experts also pointed out the need to streamline processes in hospitals and at other healthcare delivery centres. For instance, a Health Spectrum lot of violence-related cases happen when the patient passes away. While hospitals insist on clearing payments before handing over the body, distressed escorts often get into fights in such situations. Experts said such processes needed to be streamlined and handled by non-medical people. The trend of violence against doctors is also on the rise in Chi- na. In 2006, around 5,500 medical workers were injured by patients or their relatives. However, in 2010, such cases increased to 17,000. Source : Times of India, May 4, 2015 August 2016 21

Case Report Ballistic traumaRetrieval of bullet from knee by Arthroscopy Chief Surgeon : Dr. (Prof) RAJU VAISHYA President, Arthritis Care Foundation & Sr Consultant Orthopaedic & Joint Replacement Surgeon Indraprastha Apollo Hospitals, New Delhi Team Members : Dr. Vipul Vijay, Dr. HarshCase presentation Singh & Dr. Amit Kumar AgarwalA 45-year-old policeman who allegedly misfired a 0.38caliber bullet from his service revolver, presented to ouremergency 12 h after sustaining the injury to his left knee.The knee was in a flexed position while disembarking fromthe van and came in the way of the bullet with the entrywound located just inferior-medial to the knee joint. Thebullet traveled three centimeters in the proximal tibia (Theproximal tibia is the upper portion of the bone where it wid-ens to help form the knee joint)., overthe inferior-medial aspect of left knee,joint before lodging in the inter-condy-lar notch of the knee joint. Initial wounddressing was done at a local center, fol-lowing which patient presented to ouremergency with a locked knee.Investigations bullet. The skin incision was extended The position of the bullet was con- when the bullet was subcutaneous, and the bullet was extracted under arthro-firmed on plain antero-posterior and scopic guidance. The redundant softlateral radiographs. Since the retrieval of tissue and the frayed articular cartilagethe intra-articular bullet was considered were debrided to achieve balanced margins. All the six com-an emergent procedure, no other radio- partments (medial and lateral compartment, supracondylarlogic investigation was done. All other space and inter-condylar notch, medial and lateral gutters)routine blood parameters were within were reinspected for any remaining foreign particles andnormal limits. charred tissue. Adequate joint debridement and lavage wasTreatment done, with an additional extrarticular debridement of the entry wound, before closure and an ankle free static knee The patient underwent arthroscopy-assisted bullet re- immobilizer was applied. The patient was started on thirdtrieval from the knee joint, under general anesthesia and generation cephalosporin and aminoglycoside postoper-tourniquet control. Through the antero-lateral-inferior por- atively iv for 3 days and oral for 3 weeks.tal, a large hematoma was washed out, and a thorough diag- Outcome and follow-upnostic knee examination performed. There was a partial tear The postoperative radiograph revealed a hairline fractureof the anterior cruciate ligament, and the bullet was found of the tibial condyle that was obscured in the initial ra-displaced in the lateral gutter, due to the fluid distention. diographs behind the bullet and was decided to be treatedThe lateral femoral condyle cartilage showed focal damage conservatively. The knee immobilization was continued forand both menisci were found to be intact. The exact loca- another 3 weeks given the undisplaced fracture. The patienttion and ideal direction of the portal on the lateral aspectof the knee was confirmed using a spinal needle. The thirdportal was created directly over the spinal needle with an11 number surgical blade. A fine-toothed artery forceps wasintroduced into the joint from the third portal to hold the22 August 2016 Health Spectrum

Case Reportthen underwent a magnetic resonance imaging (MRI) of the in military ballistic injuries are Clostridia and beta-hemo-knee to delineate better the injury pattern to the soft tissues. lytic streptococci. The most effective antibiotic for theseThe MRI revealed marrow edema in the lateral femoral con- organisms has been penicillin but given the possibility ofdyle and the proximal tibia around the tibial eminence (Fig. penicillin resistance, cephalosporin or erythromycin may7). It also corroborated the intra-operative findings of ar- be added.ticular cartilage injury to the lateral femoral condyle. On the In view of risk of lead induced arthropathy and the bulletbasis of the MRI findings, the patient was advised to con- serving as a nidus for infection, retrieval of bullet shouldtinue knee immobilization for another 2 weeks, and gradual be executed, sooner than later. It is known that a metal ob-physiotherapy and range of motion exercises were started. ject freely floating or lodged in the intra-articular space canThere was no evidence of any infection or significant history cause late erosion of the vital structures inside the knee andof catching in the knee. This case was managed conserva- may even lead to delayed arthritis of the knee. There is antively, and he regained complete range of motion from 08 even higher chance of an early lead toxicity induced by theto 1308 at the end of 3 months. The patient has remained bullet and disseminated in the systemic circulation by theasymptomatic with no effusion or synovitis in the knee till free synovial fluid.the last follow-up of 2 years. The main advantages of an arthroscopic-assisted removalDiscussion of the shell is the minimal operative trauma to the joint,Intra-articular bullet as a foreignbody has been sparingly reported in small skin incision, preservation ofthe literature. Bullet injuries around the blood supply to the joint andthe knee are usually caused by inten- the overlying soft tissue envelope,tion or as part of criminal punish- the possibility of examination of thement. Rarely, this may be caused by joint in detail, and shortened recov-accidental injury. The mechanism of ery and rehabilitation time. In theinjury in this case report is unique as present case, the knee immobiliza-it was caused due to accidental firing tion was, however, continued for aof the bullet from an unlocked gun, longer period because of the associ-which accidentally fell from its hol- ated fracture of the tibial eminence.ster. Also, although late migration of The patient was still able to achievebullets from thigh has been reported, full painless range of motion at theearly arthroscopic retrieval of a bul- end of 3 months.let from the knee has been rarely The ideal placement of the portal forreported in literature. The common extraction of the foreign body is offoreign bodies in the knee that have paramount importance and shouldbeen described are pencil lead, plas- be dictated by its location. Caretic bottle caps, glass and metallic should be taken in avoiding a far lat-debris, etc.1 The main problem with eral portal to decrease the chancesany intra-articular foreign body is of encountering inferiorlateral-as-the risk of bacterial contamination cending geniculate vessels, leadingthat may lead to late onset infective to excessive amount of bleeding. Aarthritis. A retained bullet can fur- precise knowledge of anatomy and ather compound the problem due to the possibility of lead thorough experience in carrying outinduced arthritis. According to Hurst, there are four main arthroscopic procedures around the knee is mandatory be-criteria for achieving ideal results with the removal of for- fore undertaking this procedure.eign bodies. These are early diagnosis, adequate debride- In the present case, an undisplaced fracture would havement and lavage, immobilization as deemed necessary and been picked up accurately if a computerized tomographyrestoration of function.8 Eliciting proper history and trying scan had been undertaken before the procedure. The bul-to understand the mechanism of injury is of prime impor- let, in the preoperative plain radiographs came in way oftance. Keeping a high index of suspicion for the possibility the fracture and obscured delineation of the fracture line.of intra-articular migration of a foreign body may help in An MRI of the knee was performed in the postoperativeearly start of management. The presence of an entry wound follow-up for delineation of the fracture and to assess anyshould always force the examiner to look for the location of more associated intra-articular injuries. Since the fracturethe foreign body. The presence of the foreign body in the was undisplaced and did not carry any significant risk forperi-articular region must prompt a regular follow-up as de- displacement or an intraarticular step-off, it was decided tolayed migration of the bullets has been reported. treat it conservatively with immobilization in a knee brace.The key to prevention of the sub-acute or late septic arthritis This present case report suggests that an early arthroscop-is adequate debridement and thorough lavage of the joint ic removal of bullet along with antibiotic cover can helpand it can be achieved satisfactorily through arthroscopic- achieve a satisfactory result with minimal long-term mor-assisted technique. The most common causative organisms bidity. nHealth Spectrum August 2016 23

Health Article MIGRAINE HEADACHESDr. Sonia Lal Gupta M igraine headaches are one of the most ing for the patient as they affect the day to day common conditions which can affect life, both personal and professional. Hence it is Consultant Neurolo- us. It is more common in women very important to treat migraines before theygist (Headache & Stroke than men. Having a family history of migraines become chronic and debilitating. increases the chances of having them too. Specialist) Migraine headaches can be caused by vari- Migraine headache is a unilateral or bilat- ous triggers which include food triggers like Metro Centre for eral headache which is typically pulsating and red wine, chocolate, Monosodium glutamate Neurosciences, throbbing in nature accompanied by nausea/ (MSG). Other triggers can be lack of sleep, vomiting, light and noise sensitivity. These stress, weather changes, hot weather, bright Noida headaches can last for 4 hours upto 72 hours. lights and dehydration. Some women, have mi- Typically, patients with migraines like to stay in graines around their periods as well. Email : drsonialal@ a dark room and try to sleep, hoping for some relief. It is very important to recognize these trig- gmail.com Migraines can be of 2 types: gers. Once the triggers are known, the treatment can vary and also preventing these triggers can 1. Migraines with aura avoid migraine attack. 2. Migraines without aura Aura’s are neurological symptoms that ap- Migraine diaries can be very useful in docu- pear before the headache pain and occur in menting these triggers and migraine attacks mostly about 40% of the patients. Most com- when patients seek medical help. mon aura`s are visual changes (seeing colored Prior to meeting the doctor, it is very helpful for lights or rainbow colors) but may also include patients to note the following in their migraine speech disturbances or numbness in the arm diaries: lasting for 5- 60 minutes. These aura’s are fol- v Symptoms : Write their migraine symptoms lowed by headache which can last upto 72 hours. and be prepared to provide information about Even after the pain is gone, a lot of patients com- the pain location, character, and associated plain of fatigue which can last upto 24 hours. symptoms (e.g., nausea, vomiting, light sensitiv- If migraine headaches occur for more than ity) 15 days a month- they are known as chronic v Patterns and characteristics: Follow the migraines. Chronic migraines can be debilitat- onset and history of their headache symptoms over time. This will help determine any patterns24 August 2016 Health Spectrum

Health Articleor triggers, such as menstruation, travel, allergies or stress. The goal of the migraine preventive therapy is to:v Medications: Record all medications (both prescription v Reduce frequency, severity, and duration of attacksand over-the-counter) that they are taking and recall past v Improve responsiveness to treatment of acute attackstreatments and their outcome that they take or have taken for v Reduce level of disabilityheadache. Also record other possible triggers that may impact v Maintain cost of care for migraine treatmentsheadache such as caffeine, vitamins, or dietary supplements. v Reduce excessive or overuse of acute medicationsv History: Learn about any possible family history of head- When migraine preventive therapy is started, it may takeache. Migraine often runs in families and this will help con-firm a diagnosis. 2-3 months before the patient may notice the decrease in fre-v Illnesses: Provide the necessary information about other quency of headaches. Hence, it is important to be diligent inmedical conditions that may influence their headaches—such taking the medications as prescribed by the doctor. If thereas depression, sleep irregularities or eating disorders. are any side effects, the doctor should be told right away, so an alternative can be used. By giving all the above information to the doctor, it caneffectively help diagnose the type of headache the patient has Treatment with Botulinum toxin injections is of the onlyand hence effectively treat the headache. approved treatment for chronic migraines. In these, we inject the Botox medication in various muscles along the forehead, Migraines occur due to the release of neuro-chemicals in head and neck muscles, which are frequently involved in thethe brain which causes over-activity or excitation of the brain. migraine attack. The treatment is given every 3 months andThis “over-activity” causes the migraine attacks. Hence it is im-portant to treat these headaches with the right medications, at-least 3 treatments are recommended to see the gradual low-which can help lower the activity and chemicals and hence de- ering in the frequency and intensity of the headaches. This iscrease the headache. a good option for patients who have daily headaches and who have side effects from other preventive therapy as these injec- There are 2 types of treatments which have to be given for tions are localized and hence have very few side effects.migraine control.v Acute treatment of migraine: This means to effectively Non–pharmacological treatments like meditation, Bio-treat the pain and other symptoms of the migraine when they feedback and physical therapy are also effective for decreas-occur. There are multiple medications like paracetamol or ing the migraine frequency and should be done along with theibuprofen which are available over-the-counter which can be above treatments.used for treating the pain. The most important feature to treatthe migraine attack is to treat it early. The longer you take for Migraine headaches can be treated effectively and it istreating the headache, the more difficult it is to get the pain important for patients to go to their physician and let themunder control. know about your headaches. Proper management and treat ment of these headaches can help improve the quality of life There are “migraine-specific” medications called triptans effectively. nwhich the doctor can prescribe for treating the pain. Triptansspecifically work on the chemicals relea sed during an attack Dr. Sonia Lal is one of the world`s youngest and most qualifiedand is very effective in getting the symptoms under control is neurologists. She was formerly Asst. Professor of Neurology at Loyolataken in time. They are not recommended to patients with ahistory of heart disease or stroke. University, Chicago. She is a Diplomate from American Board of Neurology, American Board of Vascular Neurology, United Council Medications for nausea and vomiting can also be used of Neurological Subspecialities - Headache Medicine and Americanalong with the other acute medications to effectively control Society of Neuro Imaging - Transcranial Doppler. Special Interest inthe symptoms.v Migraine prevention : Botox Injection for Migraine. Migraine patients do not want to suffer from an attack, so August 2016 25prevention is important, even if they suffer from only one at-tack a year. Those who suffer from frequent attacks will needmore aggressive prevention strategies that sometimes includemedication. This decision is made by discussing treatment andmanagement options with the doctor.Migraine prevention is indicated if the patient has v Disabling attacks despite appropriate acute treat-ment v Frequent attacks (>1 per week) v Insufficient or no response to acute drug treatment v Poor tolerance or contraindications for specificacute pharmacological treatments v History of long-term, frequent, or excessive use ofpain medications (analgesics) or acute medications that makeheadaches worse (or lead to decreased responsiveness to otherdrug therapies)Health Spectrum

Face to FaceMeet Dr BindeshwarPathak, SanitationMan of IndiaIndia NeedsA Culture OfSanitation - Vinod KumarD r. Bindeshwar Pathak is a great humanist, social reformer and icon of sanitation movement in contemporary India whose pioneering initiatives have made an im- pactful change in the lives of millions of people. In particular, his innovative ideas in the field of sanitation and his crusade against manual scavenging have posi-tioned him as a front-ranking social reformer. Because of his efforts, the erstwhile manualscavengers, who were hated and ostracized, are now being increasingly integrated into themainstream society; they can now dine with their fellow human beings irrespective of theircastes and offer prayers in temples. He has played a significant role in creating a new para-digm of equity and equality and building a new culture which embraces the poor and extolsthe dignity of labour. Inspired by the ideals of Mahatma Gandhi to abolish manual scavenging and leveragingnew age technology, Dr. Pathak founded Sulabh International Social Service Organisationin 1970 and launched a social reform-cum-environmental upgradation movement. His ob-jective was to address the problem of environmental degradation and health hazards causedby the practice of defecation in the open and use of bucket toilets. In search of a solution, Dr. Pathak developed an eco-friendly twin-pit compost pour-flushtoilet technology for the individual households as an alternative to the cost-prohibitive sewer-age or septic tank-based system of excreta disposal. The technology he developed continues tobe relevant in India where over 130 million people are without access to a toilet. Here’s an extract from an interview with Dr. Bindeshwar Pathak, the man behind one ofthe most amazing success stories of social entrepreneurship in India: www.sulabhinternation-al.org. Thanks to Sulabh sanitation, more than one million people have been able to banishthe odious tag of being manual scavengers.26 August 2016 Health Spectrum

Face to Face Q. Sanitation and clean toilets are such study, but All India Institute of to strike roots in our country. Afteressential for public health. How? Hygiene & Public Health (AIIHPH) Mohenjo-daro and the Harappan civi- Ans. Sanitation significantly im-pacts not only our health, but also has done a study to establish the fact lisation, India developed a notoriousour social and economic develop-ment. About 50 diseases, including that sanitation is closely interlinked image of being a country with poordiarrhoea, cholera, typhoid, infectioushepatitis, polio and cryptosporidiosis with health. habits of sanitation.are caused due to lack of sanitationand clean toilets. My own sister’s son In India, there is a predominantdied due to diarrhoea at the age of 6 or7. Poliomyelitis is one of the most dan- Q. Even today people are not aware notion that a particular section of thegerous diseases caused by lack of sani-tation. This disease may cause muscu- of the importance of sanitation and society will clean toilets and sweep thelar weakness resulting in inability tomove. This can occur over a few hours Cleanliness. We can see garbage every- roads. We have to change this culture.to a few days. It is called \"Lakwa\" inthe common parlance. It is a proven where but people do not bother to clean In fact, cleanliness is related to culture;fact that lack of sanitation triggers alot of diseases. their surroundings. How can people be there is an imperative need for devel- It is quite distressing to note that made aware of sanitation as a vital oping a robust culture of sanitation.till recent times in India’s urban ar-eas, more than 85 per cent houses had fact of their lives? During the Konark period, there wasbucket toilets, which were cleaned by“untouchables” of the society. Even Ans. During the Mohenjo-daro a practice that no one would defecatenow, public toilets in several areas ofthe country are hardly used as they and Harappa period, India had a well- near human habitations. They had toare dirty and unhygienic. It has a verynegative effect on our health. developed sanitation system. When the go to a distance and they also covered Q. Has Sulabh done any study to Aryans came, they divided the society waste material with grass and soil. Soestablish how sanitation and healthare co-related? into four varnas - Brahman, Kshatri- the living environment was very hy- Ans. We have not conducted any ya, Vaishya and Shudra. Sanitation gienic. But times have changed now.Health Spectrum work was assigned to the Shudras, People do go to toilets in their home but who were later came to be known as they do not want to clean their toilets ‘untouchables’. So only one section or homes by themselves. They depend of the society did the work of cleanli- on others. This is our main problem. ness. The three other segments in the Varna system — Brahman, Kshatriya Q. Do you think ‘Clean India’ mis- and Vaishya — treated cleaning their sion of Prime Minister Narendra Modi house and toilet as below their dignity. will have the desired im- ThcuIssnuo,otlchIttienhuecedruterylitua.awr,Waercioenlfeualeslshcate.nluadeiAtvraaeeoctniotftinusotcfoaautcliihllllhetyeaduattcnsr,l,eogecaenolnefltyahlsinainosnerncisoteusaalsitdtseiusocr,rtneeail.o.naTntdehodceflretteoahnies pact? Will it be successful in its mission? Ans. Prime Minister Shri Nar- endra Modi has come out with an idea that has made people real- ise that cleanliness is crucial and pivotal for their well being. Now everybody is talking about toilets, cleanliness and sanitation. In my school, teachers and students used to clean toilets. No Prime Minis- ter before Shri Modi had given so much of importance to sanitation and building toilets. His concept and concern are the same as that of Mahatma Gandhi’s. Gandhiji had said, “I want a clean India first and independence later”. The vision and initiative of the Prime Minister will become a reality only when everybody starts clean- August 2016 27

Face to Faceing their toilets and maintaining hy-giene in their households and offices.Only then India will become a cleancountry. The Prime Minister’s motive hasbeen a laudable one. Even while was inthe USA, he talked about the impera-tive need of having hygienic toilets.His ‘Swachh Bharat Abhiyan’ (CleanIndia campaign) has created a hugeawareness about sanitation. Q. The Modi Government has im-posed a 0.5 % cess for ‘Clean India’campaign. Do you justify this? Ans. Your money is Government’smoney. Cess is justified because thegovernment wants to implement newideas and it needs money for that. Thepoint is where from the money willcome? Who will give the money forsuch a huge project?Q. What are the future plans of Su-labh?Ans. We are in full support of thePrime Minister for his “Clean India’movement. We have constructed 1.5million household toilets and 8,500public toilets which are being usedby 20 million people daily. We havetalked to government companies likeONGC and SAIL and also corporateslike Mittal and Bharti. We have to syn-ergise our efforts to provide toilets inboth rural and urban areas. We are de-termined to fulfill our Prime Minister’sdream of a clean India. Not only Su- life to rescue the untouchables. Martin Luther King Junior had said: “I haveWLetoesvrheosGeouovcleddierhtymyba.asoAkdmelylao.oadIuflfesruoyupsolslusoaahvnlboeoeluvteyeloatdouobmt.hehteaetlrerpcrsh,owottohtohregleredrst,s.hawerbi.lelt- a dream to see that the sons of former slaves and the sons of former slave- opposed by my father, owners will be able to sit down together at the table of brotherhood.” brother and father-in-law. I had to I am happy that in my life time I face lots of problems even during my have freed thousands of untouchables from the shackles of untouchabilitylabh, even several other organisations childhood. I had to sell land in my vil- and brought them in the mainstream of society.are joining this lofty mission. lage and ornaments of my wife. I had to Q.What is your message for the sleep on railway platform. Once I even people of India?Q. What Challenges and problems thought of committing suicide. But I Ans. God has made us able to help others. We should make our planetyou had to face? am a man of determination; I have my a better world, a better society. All of us should march together. Love every-Ans. I have faced many challenges goals, missions, ambitions and com- body. If you love others, others will also love you. nin my life – social, economical and eco- mitment. I worked with honesty and Health Spectrumlogical. There was a time when I was integrity. Gandhi Ji wanted one more28 August 2016

HEALTH STUDY/RESEARCHHealth Spectrum August 2016 29

Health ArticleHypertensionthe hidden dangerHypertension is a major contributor to avoidable death and disease in India, with anincreasing impact in the rural areas. Over 140 million people are believed to be sufferingfrom high blood pressure in the country and the number is expected to cross the 214million mark in 2030. Hypertension is a major risk factor for cardio-vascular diseasesthat killed 2.7 million people in 2004 and will result in the death of over 4 million O people by 2030. cury. Whereas when heart relaxes (diastole) ur body needs oxygen and other nu- pressure normally decreases to 80 mm of trients for proper functioning. This mercury and is called diastolic pressure. So is achieved through circulation of a normal BP is expressed as 120/80 (Systolic blood. To achieve this purpose, our heart BP/Diastolic BP). Millimeter of mercury pumps blood through blood vessels to each (Hg) is a method to measure pressure. It and every cell of the body. Because of this means that pressure of blood is enough to pumping activity, blood flows under some lift a mercury column to the said height. pressure. This is similar to the water supply of our How to measure your blood houses. Water flows because of pressure. pressure? Normally the pressure should be just ad-Dr. Jitendra Kumar equate to achieve flow to even distant taps If we put one tube inside the artery of but at the same time it should not be that a patient, through a pressure-measuringSenior Nephrologist high that pipe gets damaged or there is some device, blood pressure can be directly esti- leakage. But some times the balance is dis- mated. This is the method applied in inten-Director of Nephrology and turbed and blood pressure increases from sive care unit where exact measurement is Transplant Medicine a normal acceptable level, this condition is required in presence of various variables. known as hypertension. Asian Institute of A balloon cuff (1) is wrapped aroundMedical Sciences (AIMS) arm. Then through a balloon pump (2) the cuff is inflated to a pressure above theFaridabad During heart contraction (systole) pres- blood pressure. When pressure in the cuff becomes more than that of blood pressure,Email : jitendranephro@ sure inside the blood vessel becomes maxi-gmail.com mum. This pressure is known as systolic pressure and is normally 120 mm of mer-30 August 2016 Health Spectrum

Health Articleblood to forearm ceases to flow. Now In more than ninety percent people and presence or degree of hyperten-seeing the mercury column (3), cuff there is strong family history of hy- sion. So periodic measurement of BPis gradually deflated and blood flow pertension and the cause cannot be is the only solution.is listened through a stethoscope (4). pinpointed. This is called essentialWhen pressure in (3) is similar to hypertension and occurs most com- Other symptoms are- Dizziness,systolic pressure, blood starts flowing monly between the ages of 35 and 55 palpitation, easy fatigue, nasal bleed-and a sound is heard at (4). After some years. In rest of the patients there may ing, blurring of vision, chest pain,time sound disappears and this corre- be a specific cause most important be- breathlessness and fits.sponds to the diastolic pressure. ing diseases of kidney or hormone. Contraction of main abdominal artery If there is underlying kidney dis- Instead of mercury column, pres- and intake of steroid drugs are among ease then there may be swelling of facesure can be measured by a dial ma- other causes. and feet, urinary difficulty in formnometer also. There are some more of frequency, difficult voiding, inad-simple electronic versions for home Every effort should me made to equate voiding or decreased urine out-use. Ambulatory Blood Pressure mon- exclude the presence of underlying put. Presence of obesity, rounding ofitors have been developed to monitor offending condition especially when face, muscle weakness, episodic head-BP continuously for 12 to 24 hours as onset of disease is in extremes of age ache, palpitation and perspiration arepatient is sleeping or performing nor- and there is no family history. Plan of found if there is underlying hormonalmal activity. treatment may be totally different in disease. these patients.Normal and high blood When high BP is detected forpressure High salt intake, excessive weight, the first time lack of exercise, mental stress, alcohol It is very difficult to define nor- intake, crowding are the environmen- First, presence of hypertension ismal blood pressure. When a group of tal factors, which increase blood pres- confirmed by repeated measurements.healthy people will be examined, all of sure. Person should be calm and quiet andthem will have different values. Not should have taken some rest before BPonly this, a same person may have dif- Why one should treat measurement. If presence of hyperten-ferent value at different times. If you hypertension? sion is confirmed, then initial evalua-are angry or tense, blood will flow tion is done tomore rapidly and your blood pressure Treatment of hypertension is sim- v Determine cause of hypertensionwill increase. There is a term called ple. But many people do not take treat- v Determine extent of damage es-white-collar hypertension. Here blood ment because of ignorance. If left un-pressure is high when in a doctor’s treated, hypertension can decrease the pecially on heart, kidneys andclinic but at home blood pressure is life span by 10 to 20 years. So cost of eyesnormal. Similarly when you are calm this ignorance is heavy. v Determine presence of other dis-and quiet, after a good night sleep, ease, which help in deciding bestyour blood pressure will be lower. Hypertension can damage various treatment plan.These are normal fluctuations. So, to organs. Because heart has to pump A competent doctor should makedefine hypertension BP should be per- against pressure, its size gradually a thorogh examination at presenta-sistently high. And it should have been increases. This further leads to heart tion. He should measure BP in bothmeasured at least twice during two attack and cardiac failure. Delicate arms in, sitting and standing position.separate examinations after the initial blood vessels of eyes get damaged due He should make note of all the pulses.screening. to high pressure leading to distur- Following basic tests must be done- bance of vision. In brain, damage of urine examination, kidney function At normal blood pressure, a per- vessels can cause formation of blood test, hemoglobin level, sodium andson should lead a normal life. This BP clots or bleeding causing stroke (pa- potassium level, blood glucose andis less than 120/80. As per the Seventh ralysis). Sudden rise of BP can cause cholesterol level, eye check up for ret-US joint national Committee on Pre- blindness and coma. 10 % of patients ina and ECG. Depending on require-vention, Detection and evaluation of die of kidney failure. Bleeding from ment, the doctor may prescribe, chestHigh Blood Pressure (JNC-7), if BP various sites such as nose, lungs and X-ray, ultrasound abdomen, Doppleris more than 140/90, it is termed as menstruation is also common. study, Nuclear scan, other blood testshypertension. Values in between (120- including assessment of hormonal dis-139/80-89) are pre-hypertension. Do you have hypertension? eases. What are the symptoms? If there is no family history, if onset In children and pregnant women is abrupt or if hypertension has startedblood pressure should be lower. Anger and headache are not reli- before 35 years of age or after 55 years able symptoms. Hypertension may be of age or if BP is difficult to control,Why does one develop found in children and sanyasis also. there is high probability of underly-hypertension? Early morning headache at back of ing disease. In two persons with same the head may be found in severe hy- level of high BP, the hypertension may This occurs due to a combination pertension but normally there is no be twenty times severe if there are un-of genetic and environment factors. direct correlation between headache August 2016 31Health Spectrum

Health Articlederlying risk factors such as-onset in be sufficient. Then a person should Target blood pressureyoung age, male sex, persistent dias- not feel disheartened. Requirementtolic pressure above 115 mm Hg., obe- of medicine is not a sign of failure of Treatment should be started whensity, smoking, alcoholism, diabetes, patient’s effort on lifestyle modifica- BP is more than 140/90. If diastolichigh cholesterol and presence of dam- tion. There are many groups of anti- BP is less than 89 and systolic is moreage to heart, kidney, eyes and brain. hypertensives from which the best than 160 then again treatment shouldThese people need more aggressive can be chosen for a particular patient. be started in patients above 65 years oftreatment. Various groups of medicines with ex- age. Patients who have fluctuating BP amples are as under- and those who are not receiving treat-Lifestyle and dietary v Diuretics- Furosemide, Hydro- ment, should be followed six monthlymanagement so that treatment may be started at chlorothiazide. proper time. Lifestyle has a major bearing on v ACE-inhibitors- Enalapril, Ram-BP management and all patients, even In patients of diabetes and evi-if they are on medicines, must be en- ipril, Lisinopril dence of organ damage, target BPcouraged to follow general non-phar- v Angiotensin receptor blockers. should be 130/85. Lower is better andmacological methods. in some patients especially those with (ARB)- Losartan, telmisartan, kidney diseases, it is advocated to Relief of stress is important. One Irbesartan. achieve a target of 120/75. In patientsmay have to change his job or his at- v Antiadrenergic- Clonidine, me- in whom target is not being achieved,titude towards job and life. Relaxation thyldopa, Doxazocin, Prazocin, there are several possibilities. Pre-techniques and Yoga will be of help. atenolol, propranolol, labetalol. scription might be faulty with inclu- v Vasodilator- Minoxidil. Hydrala- sion of inadequate and inappropriate Smoking and alcohol intake zine drugs. Or patient may not be takingshould be minimized. v Mineralocorticoid receptor an- medicines as prescribed. Excessive tagonist- Spironolactone salt intake makes BP control difficult. Weight reduction of 4.4 kg over 6 v Calcium Channel blocker- Am- Some times BP remains high due tomonths is proven to decrease BP by lodipine, Nifedipine, Diltiazem concomitant use of medicines such as2.5 mm Hg. Caloric reduction is im- Treatment has to be individual- steroids, contraceptive pill or even na-portant. ized. A doctor should start with the sal drops for cough and cold. best possible medicine as per patient Exercise as per physical limitation need. For example, diuretics are better Summaryof a person should be encouraged. for elderly and patients of heart failureIt helps in Bp control directly and but may precipitate gout.. ACE-I and Hypertension is a very commonthrough weight reduction. Exercises ARB are better for patients of diabetes disease. But many people are notlike jogging, swimming are better than and of heart attack but ACEI can cause aware about their disease due to ab-weight lifting and push-ups. dry cough and foetal damage in preg- sence of clear-cut symptoms. This ig- nancy. Drugs like propranolol reduces norance can reduce the life span of a Role of diet has been proven in anxiety but is harmful in asthma. person by up to 20 years and can leadseveral clinical trials. In this regard, Drugs like Prazocin may be beneficial to serious complications such as heartimportant aspects are- calorie, salt, in prostate enlargement. Calcium an- failure, kidney failure and brain hem-potassium, calcium and fat. Calorie tagonist can better control BP but may orrhage. So regular BP measurementshould be restricted to achieve normal cause swelling of feet. Proper choice of even in absence of symptom is desir-weight. Salt restriction is beneficial in medicine along with a change in life able. When hypertension is detected,lowering BP and it also increases the style and diet will be able to achieve one should not jump with BP lower-efficacy of medicines. Some types of target BP. ing drug but a complete evaluationpatient are particularly salt sensitive of patient is mandatory. Lifestyle andsuch as- kidney patient, elderly and dietary management has an importantdiabetics. Up to 5 gram of common role in treatment but along with this,salt per day is desirable. There is no medicines may be required. There areneed and use of completely stopping numerous medicines from varioussalt. Increased intake of potassium groups to choose from. An aware andhas same effect as that of salt restric- motivated patient with the help of ation. Potassium is found in fruits and competent doctor can lead a normalvegetables. But kidney patients should healthy life. nbetter be avoiding potassium. Highcalcium intake has also been found Dr. Jitendra Kumar is the Director ofto be beneficial for BP control. Fat re- Nephrology and Transplant Medicine atstriction helps in reducing weight and Asian Institute of Medical Sciences (AIMS),in limiting damage to blood vessels. Faridabad. He is an expert in many pro- cedures such as CRRT, hemoperfusion,Drugs for high blood pressure CAPD, and kidney transplant. Although lifestyle and diet is defi- Health Spectrumnitely important, they may not alone32 August 2016

Q&A Articles Weight Loss Q. Can someone lose 108 kg in 18 months just by con- Before Weight Loss After Weight Loss trolling diet (low-fat, low sugar, low-carb diet) and ex- ercise (walking, yoga)? breads, pluses with skin, vegetables etc. Q. What are the recommended exercises and is a trainer A. The recommended weight lose is about 3-4 Kg per required? month. To lose 1 Kg of fat one has to lose 7500 calories. Walking at a brisk pace for 30 minutes you can only lose A. High intensity cardio like jogging, swimming, 133 kg. running, cycling should be combined with weight train- ing to get the desired results. Q. So this means that people in obese or super obese cat- egory can lose over 100 kg weight just by controlling diet Losing 3-4 kg of weight per month is the recom- and exercise and there is no need for weight-loss sur- mended weight loss. If one loses a lot of weight very gery, fat-burning capsules, intense exercise or any other quickly, it might be loss of water weight or even lean tis- method? sue as it hard to lose that many fat calories such a short period. A. To achieve a very big goal like 100 kg of weigh lose, involves a complete change in lifestyle, eating hab- A trainer is utmost important. All exercise should be its, exercise, involving intense training and extreme dedi- done under supervision. cation and motivation. It is not impossible, but very-very difficult and hence people do take the help of weight lose Dr. Pallavi Vaishya surgeries, capsules etc. under medical supervision and Nutrition Expert once their goal looks closes reset to diet and exercise for maintenance. Kailash Healthcare, Noida & Q. What diet plan will you chart out for people like Anant Ambani (Son of Mukesh Ambani)? Healing Touch Clinic New Delhi A. Creating a deficit of 1000 calories in the diet of an obese person would lead to a weight loss of about 1 August 2016 33 kg per week. High calorie foods, such as chips, candy bars, soda or sugar filled beverages, fried foods, pizza, burgers, sweats etc. significantly increase the daily calorie consumption. High calorie foods should be replaced with low calo- rie options like fresh fruit and vegetables. Salt should be kept minimum. Drinking water instead of sugar or calo- rie filled beverages boosts weight loss. A small regular meal boots the metabolism. Foods should have a low glycemic index like whole grain,Health Spectrum

Beauty Care Returning Afresh & AnewSCombining a Vacation with a Facelift is the New Idea of a Break pending a week at the seaside; After a procedure with Botox and roaming around aimlessly in Juvederm fillers to erase fine lines and the mountains; retreating to the wrinkles, and fill up her under eye countryside to rejuvenate your body hollows, she flew to Istanbul, a city and mind! These are some ideas that she wanted to visit for a long time. Not lure people to a vacation. However, only is she rejuvenated in mind, she some people today are adding another can’t take off her eyes from the mirror. interesting dimension to their idea of Now, she is raring to return to work. a break: the idea of rejuvenating your Greater exposure to the entertain- appearance with a lavish cosmetic ment industry, greater connectivity procedure. and free flow of information of de- The idea is to return from a break velopments across the world, and in- not just rejuvenated in the mind but crease in purchasing power are some also in body and skin. A vacation also factors that have made Indians more provides enough time to seek an aes- amenable to the medical aesthetics. Dr. P. K. Talwar thetic physician’s advice and decide Over the past decade, there has beenSenior Plastic and Cosmetic Surgeon on what procedure your face needs. a considerable increase in the number It also provides the crucial downtime of people opening up to medical aes- Director needed for some procedures to settle thetics and cosmetic procedures to getCosmetic Laser Surgery Centre of IndiaE-34, Greater Kailash - I, down. better facial features, and a younger At 36, Aditi Rao had spent most looking skin.New Delhi - 110048 of her last decade working day in and However, unlike the west wherePhones: +91-11-29236550, 29236912 day out, with hardly any major vaca- plastic surgery is more acceptable andE-mail - [email protected] tion, other than a few days spent with widely practiced, most Indians are stillWebsite : www.drpktalwar.com family. She was travelling so much for apprehensive about going under the work that travelling for leisure seemed knife. This is why non-invasive cos- a bad idea to her. She felt a desperate metic procedures and injectables are need of a break and decided to take 15 the most popular in India. days off in a planned way. Among the things planned for the fortnight was a Here are some procedures few hours with an aesthetic physician that women and men seek: to help her treat her facial aesthetic Botox: Botox remains one of the concerns and regain the glow of youth. most popular cosmetic procedures in34 August 2016 Health Spectrum

Beauty Care India, acid fillers such as Juvederm can turn peels,and arguably the most popular among around your appearance, giving you micro dermabrasion,men. As we reach our mid 30s, the more pronounced lips and smooth and laser skin resurfacing help exfo-bunch of lines and wrinkles that ap- skin around the mouth. liate the damaged outer layer of skin,pear around our eyes when we laugh reducing scars, pigmentation andor smile, start becoming permanent; Skin rejuvenation proce- dead cells. Quick procedures with Ju-so do the stress lines of the forehead. dures: There is nothing more dis- vederm Refine help skin retrieve itsA Botox shot can prevent the crow’s lost glow.feet and forehead lines by relaxing the couraging than a dull, dry and lack-muscles responsible for them. A quick luster looking skin. The environment Correcting under eye hollows:procedure makes you appear less we live in, the high degree of pollution Dark circles and under eye hol-wrinkly, more relaxed, and younger. and stress, along with unhealthy eating lows are common in young men andOlder women also take recourse to and drinking habits puts a lot of stress women today. With greater exposureBotox to treat the wrinkles and sag- on out skin, leaving it dull, pigment- to digital screens, faulty lifestyles andging appearance of the neck. It is also ed, dry and sheen less. A lot of people lack of nutrition, this problem ag-very effective in achieving an eye brow seek aesthetic solutions for skin reju- gravates. Even as we advice patientslift, or a beautifully arched appearance venation. Procedures such as chemical to correct their sleeping patterns andof the eye brow. eat a healthy diet, we offer quick solu- tions to improve the appearance of the Lip Augmentation: Lip en- eyes. When administered intelligently under the eyes, hyaluronic acid fillershancement is another popular pro- can reduce the hollow appearance andcedure that is sought by women of all give the eyes a healthier look. Laser re-ages. The younger ones come influ- surfacing can help reduce the appear-enced by the in-vogue pouty appear- ance of dark circles.ance with a perfectly created Cupid’sbow that looks luscious and attractive. How a vacation helps:As we age, the facial features includ-ing the cheeks and lips experience a Some of these procedures needloss of volume. This is accompanied more than one session and also re-by appearance of fine lines around quire some time to settle down com-the mouth that do not look quite at- pletely. This is what makes a vacationtractive. A session with hyaluronic visit to an aesthetic physician even more helpful. The new age vacationers travel, meet new people, spend time relaxing and eating, and add to their leisure a visit to an aesthetic physician that helps them return with a new re- juvenated self post their breaks. n Dr. Talwar is one of the leading cosmetic and plastic surgeon in India. Since 1996 he has been running Cosmetic Laser Surgery Centre of India. He was also associated with the Indraprastha Apollo Hospitals, New Delhi (India) as a Senior Consult- ant, Cosmetic Surgeon. His clientele includes Top Models, Film Stars from neighboring countries, Sport Stars and a lot of foreign tourists.Health Spectrum August 2016 35

Alternative MedicineMiracle story of Kamal KaurT he 83-years-old woman, Kamal Kaur from a village in Meerut District has successfully under-gone drug-free Holistic Medicine ther-apy, for intolerable and uncontrollablePain due to Severe Osteoporosis andsuspected Cancer leading to Fracture inD-12 Vertebra of her Spine, at \"SOHAM\"- The Clinic for Holistic MediCARE &CURE that specialises in curing peoplesuffering from various incurable ail-ments with conventional drug based sys-tems or surgery. According to Dr. R. K. Tuli, \"Smt.Kamal Kaur was brought to me on the04th of February 2016, with complaintof severely intolerable Pain (10/10 onPain Assessment Scale) in her middlespine, restricting all her movementsfor the previous two months, withprogressive deterioration in her symp-toms in spite of treatment by reputed36 August 2016 Health Spectrum

specialists at different hospitals. cer, Hiatus Hernia-GERD, Lu- Alternative MedicineAccompanying reports revealed pus-SLE with Sarcoidosis, Kid-that she suffered from Fracture ney Failure, Slip Disc-Sciatica, PROFESSIONALS’D-12 vertebra, Severe Osteopo- Arthritis of Knees needing total OWN EXPERIENCESrosis, Osteoarthritis of Spine & joint replacement, and a rangeKnees and Anemia with just 6.0 of ailments amongst his family “Holistic Medicine is SURELYgms. per deciliter of Haemoglo- members and friends circle. the highest form of Healing.bin; her body weight was 85.0 Dr. Tulis’ team is really aidingKgm. for her height of mere 155 As per his reputation with the Divine Healer and in thecms., putting her at risk of other us, Dr Ravinder K. Tuli assured process motivating their pa-morbidities.\" her that his therapy shall alle- tients in the right direction.” viate her pain and suffering in This reporter met this lady last next few days and here she is in - Dr. (Prof) Kusum Sahgal, Fmr.week having attended the therapy front of everyone proving magi- Principal, Director & Professor Ladyat Dr. Tuli's New Friends Colony cal success of the all inclusive Harding Medical College, New DelhiClinic for the last three months. drug-free system of treatment.She was found to be bursting He stated that he didn't reveal to “I had brought my wife Veena Guptawith boisterous energy in appre- him at that stage that the doctors after I was fed up with allopathic treat-ciation of the therapy that has re- suspected Cancer of the Spine. ments as in spite of the best she contin-lieved her pain, restored her full In retrospect, as the reports and ued to suffer from multiple problems ofmobility, she has lost 10 kgm. of clinical condition reveals that Mental Depression-OCD; Hypothyroid-her body fat; she finds a pink vis- she has been absolutely cured ism; Fibromyalgia; Obesity; Cervicalible on her cheeks as her haemo- of all her visible and non-visible Spondylosis + Vertigo with Osteoarthri-globin has improved to 12.0 gms. ailments and the quality of her tis of Knees & Ankles + Restless LegsShe reported of not only normal health at this stage speaks in her and APD-GERD + Fatty Liver, etc. Afterlife after being severely restricted own words. drug-free Holistic Medicine therapy atfor several years, but states to en- “SOHAM” just over the last two months,joy her health today better than Dr. Tuli explained that Holis- I am THRILLED with the improvementin preceding ten years. tic Medicine is the latest emerg- and shall continue with it till she is in ing speciality in the developed absolute Positive Health. I wish more Shri Jagdish Singh, the son of world and it's a board certified people take advantage of this treatmentSmt. Kamal Kaur, a master's de- speciality in the US for nearly the pioneered by Dr. Tuli. My Good Wishesgree holder from Meerut Univer- last 20 years. It complements the and Blessings.”sity and a garment exporter re- 'science' of evidence based mod-vealed that doctors in several big ern medicine with the 'art' of time - Dr. (Prof.) A. K. Guptahospitals had attributed her ex- honored and highly reproducible Fmr. Dean, Maulana Azad Medical College &cess weight and muscle wasting drug-free modalities of the vari- Technical Expert on World Bank Blindness Project,to have completely damaged her ous officially recognised alternateback bone and knees, restricting or traditional (AYUSH) systems Govt. of India.her to a bed for the last several of health to overcome inherentyears. They advised that she ur- deficiencies of modern system of “I used to feel exhausted and breath-gently needed to go under Can- medicine to improve 'quality of less ‘dyspnoea’ on mild exertion and hadcer surgery and demanded huge life' and 'add life to years' of each been diagnosed to suffer from progres-money for her treatment. But, individual. According to him sive Interstitial Lungs Disease (I.L.D.).when her condition deteriorated this 'synergy' of all the systems of After consulting all the doctors here andto a threatening level, the family medicine, in fact, helps to eradi- abroad (U.K. & U.S.A.), many of whomdecided to seek Holistic Medi- cate the root cause of all kinds were my former students, I had decidedcine treatment with Dr. Tuli. of sickness, initiate healing, effect to retire when I was told nothing much true CURE, and restore positive could be done. But, after having this Jagdish Singh cursed himself health and total wellness in ma- drug-free Holistic Medicine treatmentfor delaying his mother's treat- jority of patients. for about four months, I’ve tremendousment by Dr. Tuli as he recalled improvement in my health and I reallythat his family has patronised Finally, it offers an opportu-Dr. Tuli for over 25 years for his nity to all health practitioners August 2016 37holistic therapy, and it has each to achieve highest professionaltime come to their rescue with satisfaction, and simultaneously100% success rate whether it was restore old glory of the medicalfor cure of Infertility of his wife, profession. nsevere Bronchial Asthma of hisfather, Heart Disease, Oral Can- - Adheesh VatsHealth Spectrum

Alternative Medicinenow BELIEVE about the theory of What is Holistic Medicine?LIFE-FORCE which can CURE manyincurable ailments.” “Holistic Medicine is an optimum synergy of all -Dr. Shanti Talwar the recognised systems Sr. Consultant Paediatric Surgery, Apollo of medicine as it ex- Hospitals and Fmr. Director, Professor & Head tends benefits of all, at Maulana Azad Medical College, New Delhi. the same time overcom- ing deficiencies inher- “I came to Dr. Tuli in a desper- ent in each system in-ate condition with unbearably severe dividually, to extend theLOW BACK PAIN due to Inoperable best in harmless healthAdvanced L-S Degenerative Spondy- care to each individual.losis + DDD & PIVDs L1 to L5, Spi- It’s a board recognisednal Canal Stenosis and Radiculopathy specialty in the U.S. forBLLs causing Anxiety, Sleep Distur- over two decades, andbance & Hypertension. I already had leading medical institu-both Knees as well as a Hip joint re- tions all over the world are seeking to extend its benefits to their patients.”placement. I got very positive vibra-tions and a feeling of reassurance at “Holistic Medicine takes care of the human being as a whole, and therebyhis “SOHAM” Clinic. I felt very re- helps to eradicate all the ailments of an individual concurrently and restorelieved after only a first few treatments. Positive Health and Total Wellness, Body-Mind-Spirit.”At the end of recommended course Iam completely relieved and I’d like to “Holistic Medicine integrates the wisdom of Western, Indian, Chinese &share that I am able to play better Golf New Age evidence based ‘science’ of medicine with the time honored repro-today than I did 10 years ago! Thank ducible ‘art’ of Health: Holistic Medicine = Modern + Traditional + New AgeYou Dr. Tuli & your very polite and Medicine.”efficient team. May God Bless all ofyou.” ery from all the deformities and her vices of Dr. R.K. Tuli, the renowned freedom from heavy toxic medica- Holistic Physician at the stage when - Dr. Kavita Sama tion. It was a medical miracle that specialists at AIIMS gave up on me! Sr. Obst & Gynaecologist, SAMA Nursing stands proven till today! My mother Due to his sincere and vigorous sup- has now crossed the age of ‘80’ years port I’ve fully regained my liver func- Home & Sir Ganga Ram Hospital. and she continues to independently tions. What’s amazing is that the manage her entire household without universally INCURABLE ‘C’ & ‘E’ “I am pleased to share that I had any help at this age!! Long live Holis- Antigens and the entire Virus loadbrought my bed-ridden mother here tic Medicine!!!” have been eliminated from my body.more than 15 years ago as she suf- My health has bounced back to befered from severe Rheumatoid Ar- -Dr. Anand K. Gupta better than in previous ten years, andthritis with multiple crippling de- Senior Family Physician & I’ve resumed my medical practiceformities. She had, also, developed Dermatologist, New Delhi nearly after three years of its closureserious side-effects to drugs includ- due to my morbidity.”ing heavy dose of prednisolone pre- “I’ve been given a SECOND LIFE!scribed to her at AIIMS, New Delhi. I had slipped into Hepatic Coma -Dr. Deepak ChandraI am highly obliged to Dr. Tuli’s team & Total Renal Shut Down follow- Senior Family Physician,and the drug-free holistic method of ing Chronic Progressive Multi-Virus Vishnupura, Kanpur (U.P.)treatment for total cure of my mother Hepatitis. My family sought the ser-from the very cause of disease, recov-Dr. R. K. Tuli “SOHAM”, the Clinic for Holistic MediCARE & CURE is dedicated to Eradication of all Sickness and restore Positive Health and Total Wellness of each individual as a whole, body-mind-spirit, by a ‘synergy’ of the evidence based ‘science’ of modern medicine with the time honoured ‘art’ of natural, drug-free, harmless and highly reproducible modalities of all the officially recognised systems of traditional medi- cine. This ‘synergy’ is termed HOLISTIC MEDICINE as it complements all the systems and specialities of medicine to add life to years of each individual, and improve the final outcome of every sickness. It helps to minimise dependence on medical interventions, manage all the diseases of an individual concurrently, and enable even permanent cure of the vast range of conventionally incurable diseases. Dr. R. K. Tuli and Dr. Poonam Tuli combine to offer over 90 years of their collective expertise to lead a committed team to achieve unique, incomparable, and cost-beneficial healing & “Health For All”. n38 August 2016 Health Spectrum

Q&AGamming Addiction Video gaming stimulates the dopamine neurotransmitter pathways in the brain - thereby making it an addictive activity for some. Instant gratification of pleasure experienced during gaming can lead to poor impulse control in children. Spending too much time on gaming can deeply impact a child's physical health as well as psycho-social well being. Here is Q& A about Gamming Addiction. Dr. Shobhana Mittal Q. How bad gaming addic- propriate limits for their tion can be for young kids? children with regards to the Attending psychiatrist  type of videogames permit- Cosmos Institute of Mental Gaming stimulates the ted and time spent on them. dopamine neurotransmitter Video games at a very young Health and Behavioural pathways in the brain, thereby age should be avoided, so that Sciences making it an addictive activity children can have an opportu- for some. Instant gratification nity to develop other interests New Delhi. of pleasure experienced dur- and hobbies at this age. Chil- ing gaming can lead to poor dren should be encouraged impulse control in children. to participate in alternate fun Spending too much time on activities depending on their gaming can deeply impact a interest, including playing child's physical health as well outdoor sports, music, dance, as psycho-social well being. art or interacting with other Q. How parents can ensure children their age, which their kids are not hooked to would contribute to a child's playing video games? all round development. n Parents need to set ap-Health Spectrum August 2016 39

Alternative MedicineYOGAA NOVELINTEGRATIVETHERAPY Dr. Ananda Balayogi M odern medical advancements Yogic lifestyle can reverse heart disease Bhavanani provide the rationale for the in- says, “Yoga is a system of perfect tools for tegration of various traditional achieving union as well as healing”. Deputy Director healing techniques like Yoga, Naturopathy, Centre for Yoga Ayurveda, Siddha and Music to promote According to Dr B Ramamurthy, emi- Therapy Education healing, health, and longevity. The Govt nent neurosurgeon, Yoga practice re-ori- and Research (CYTER) of India is currently promoting indig- ents the functional hierarchy of the entire enous systems of health in a strong man- nervous system. He has noted that Yoga not MGMC & RI ner through the Ministry of AYUSH. The only benefits the nervous system but also Pillayarkuppam limitations of modern medicine in manag- the cardiovascular, respiratory, digestive, ing stress induced psychosomatic, chronic endocrine systems in addition to bringing Pondicherry illnesses is the strength of these traditional about general biochemistry changes in the Email : yoga@mgmcri. healing systems and hence a holistic inte- yoga practitioners. gration of both systems enables best quality ac.in of patient care. We are today faced with numerous de- bilitating chronic illnesses related to aging,40 August 2016 It is imperative that advances in medi- environment, and hedonistic lifestyle, such cine include the wholistic approach of Yoga as cancer, diabetes, osteoporosis, and car- to face the current challenges in health care. diovascular diseases as well as many incur- The antiquity of Yoga must be united with able diseases such as AIDS. Modern medi- the innovations of modern medicine to im- cal advancements provide the rationale for prove quality of life throughout the world. the integration of various traditional heal- No wonder that Dr. Dean Ornish, the emi- ing techniques including Yoga to promote nent American doctor who has shown that healing, health, and longevity. It is impera- tive that advances in medicine include the Health Spectrum

Alternative Medicinewholistic approach of Yoga to face the are yet to research and understand level increasecurrent challenges in health care. The subtler effects of Yoga. v Weight normalizes, sleep im-antiquity of Yoga must be united withthe innovations of modern medicine Some physiological benefits of proves, immunity increases andto improve quality of life throughout yoga: pain decreasesthe world. While modern medicinehas a lot to offer humankind in its v Yoga induces autonomic nervous Some psychological benefits oftreatment and management of acute system equilibrium with a ten- yogaillness, accidents and communica- dency toward parasympatheticble diseases, Yoga has a lot to offer in dominance rather than stress-in- v Somatic and kinesthetic aware-terms of preventive, promotive and duced sympathetic dominance. ness increaserehabilitative methods in addition to This is of great potential in psy-many management methods to tackle chosomatic stress related illness. v Mood improves and subjectivemodern illnesses. While modern sci- well-being increasesence looks outward for the cause of all v Heart rate and blood pressureills, the Yogi searches the depth of his decrease implying better relaxa- v Self-acceptance and self-actual-own self. This two way search can lead tion, reducing load on the heart. ization increaseus to many answers for the troublesthat plague modern man. v Respiratory rate decreases and v Social adjustment increases respiratory efficiency improves. v Anxiety, depression and hostilityScientific basis of applying The amplitude and smoothnessyoga as a therapy of respiration increases along decreases with all the pulmonary param- v Psychomotor functions such as Numerous studies have been eters like tidal volume, vital ca-done in the past few decades on psy- pacity and breath-holding time. grip strength, balance, dexteritycho-physiological and biochemical and fine motor skills, eye handchanges occurring following practice v EEG - alpha waves increase. coordination and reaction time,of Yoga. A few clinical trials have also Theta, delta, and beta waves also steadiness and depth perception,been done that have shown promise increase during various stages of and the integrated functioning ofdespite Yoga not being ideally suited meditation body parts improvefor the scientific gold standard of ‘dou- v Cognitive functions such as at-ble-blind’ clinical trials. Some of the v Cardiovascular efficiency in- tention, concentration, memory,researched benefits that are quite well creases. and learning efficiency improveproven are given below to facilitate anunderstanding of how Yoga works at v Gastrointestinal function and Some biochemical effects ofleast at the physical level though we endocrine function normalizes. yogaHealth Spectrum v Excretory functions improve The biochemical profile improves, v Musculoskeletal flexibility and indicating an anti-stress and antioxi- dant effect which is important in the joint range of motion increase prevention of degenerative diseases. v Posture improves while strength, v Decreased levels of: blood glu- resiliency endurance and energy cose, total white blood cell count, total cholesterol, triglycer- ides, LDL and VLDL. v Increased levels of: HDL cholesterol, ATPase, hematocrit, hemoglobin, thyroxin, lymphocytes, vi- tamin C and total serum protein. n Yogacharya Dr Ananda Balayogi Bhavanani is a medical doctor, Yoga thera- pist, researcher and author of more than 20 books, DVDS and two hundred articles on YOGA. He is a Yoga Expert on CCRYN and Ministry of AYUSH committees for Inter- national Day of Yoga celebra- tions and currently Deputy Director of the Centre for Yoga Therapy, Education and research in the Sri Balaji Vidyapeeth at Pondicherry. August 2016 41

Alternative Medicine How to Treat “SleepApnea” with Homoeopathy“S leep Apnea” a disease which more prone to get this disease in their Symptoms we do not know that how is life span so they should be more care- it dangerous for your physi- ful and immediately consult Homoeo- 1. Problem in inhalingcal as well as psychological health? pathic 2. Feeling short breatheActually, “Sleep Apnea” is a respiratory 3. Feeling tired whole daydisease related to breathing function of expert but it never confirms that 4. Night time awakeningyour body resulting in day sleepiness, women are far away from this disease 5. Feeling irritatedinability to work physically. If, this dis- so they also should be aware if any 6. Forgetfulnessease increases then it pave way to enter symptom persists with respect to the 7. Feeling tired just by doing aother diseases like diabetes, high blood respiratory problem or difficulty in in-pressure, stroke etc. There are num- haling fresh air. light workber of patients in India and Overseas 8. Snoringwhich is totally under the grip of this But, Homoeopathy acts as a boon 9. Memory Lossdisease and taking regular help of other for treating this disease because it canbranches of medicines. treat both types of Sleep Apnea with- Homoeopathic Remedies out giving any problem to the patients It is basically of two types: Central but all is depend on the remedy that a 1. Arsenicum album is pre-and Obstructive. In central Sleep Ap- Homoeopathic Physician prescribe to scribed for individuals whonea brain fails to send signals to the a particular patient according to one’s have breathing difficulties.breathing muscles and it is known to age and seriousness of disease. It isbe the less common among patients concluded by 2. Sulphur is a commonlyand in obstructive Sleep Apnea air is used homeopathic remedyobstructed from flowing into and out asking different questions regard- especially given in breathingof the nose resulting in reduction of ing his ailment and how is he feel? Let congestions.oxygen level in the us look. 3. Lachesis is a remedy pre- body as a result patient starts snor- Keep faith in Homoeopathy, it scribed for uncontrollableing at night. It basically persists in ly- definitely works in crucial times and conditions which sometimesing position and is highest percentage has ability to cure the diseases from its persist at night.among patients all over globe and there root. nis more percentage of men who are 4. Spongia is also a better op- by Dr. Samiksha Choudhary tion when there is a feeling Health Spectrum R L Jussal Memorial Clinic of blocked chest area. Paschim Vihar, New Delhi 5. Opium is also prescribed for the patients who feel con- fused after sleep disorder. Prevention 1. Stop smoking. 2. Stop the consumption of liquor. 3. Do some respiratory exercis- es in morning hours before sunrise. 4. Eat healthy food especially fibrous eatable items in your diet. August 2016 42

HEALTH ArticleConjunctivitis: Most eyes, sticky eyes and swollen eyelids.”Common Eye Problem But if you want to try to cure yourself Dr Nikhil Seth C onjunctivitis is a common commu- from the contagious eye sore, there’s onlySenior consultant eye surgeon nicable disease and spreads mostly so much you can do. “If a patient is suf- during summer and the rainy sea- fering from conjunctivitis, then at home Head of Department son. It is basically an infection and inflam- they are advised to follow these tips:Department of ophthalmology mation of the conjunctiva — redness and v Wash the eyes with previously boiledAsian Institute of Medical swelling of the thin protective membrane of eye — and can be caused due to any kind water Science (AIMS) of viral or bacterial infection, irritants, v Ice or cold compression thrice a day Faridabad abrasions chemical reaction, dust allergy, v Self-medication should never be at- pollens, contact lens, eye cosmetics etc.\" tempted as it may further harm your Besides washing your hands, the dif- eyes ferent ways you can prevent conjunctivitis, v Person should be isolated; no school, “Conjunctivitis generally spreads through office or public gathering touching or contact. The virus spreads v Keep the eyes clean during monsoon when the weather condi- v Use dark glasses tions are ideal for it. Its incubation period v Never start self-medication is 3-7 days and is highly contagious, as it v Consult an eye specialist as early as gets transmitted by hand-to-eye contact possible; till eye specialist is not avail- and can happen at any age. Here are some able, start with lubricant eye drops of the simple precautionary measures to be v Never use steroid eye drops” followed: With these guidelines and strict precau- tionary measures in place, you can stop the Your eyes may turn red due to dust, lack contagious spread of this conjuntivitis. of sleep; strain on the eyes, allergy cold, If symptoms persists after 3-5 days do so how to differentiate. One is advised to consult your eye specialist as it can be a po- consult a doctor if the following symptoms tential complicated conjunctivitis involv- persist for more than 2-4days: Redness of ing cornea and can lead to various serious eyes, watering, itching, discharge, eye dis- visual problem including corneal ulcer; comfort in bright light, swelling around the dermatitis etc. Ice or cold compression thrice a day, frequent hand wash with soap, avoid itch- ing or touching of eyes, use of preservative free artificial tear drops should be the best self treatment plan. n Do's and Don'ts vDo not touch/hand shake vDo Not rub your eyes; avoid busy common places vAvoid contact with patients having red eye ,common cold or recur- rent sneezing patients vDo not touch taps or door handles vDo not share common towels, pil- lows, beds, toiletries vDo not share common eye cosmet- ics vIf already suffering from eye flu, then do not use contact lenses and say no to swimming for the time being.\" vDo not use steroid eye drops or over the counter drops.43 August 2016 Health Spectrum

Health Study Contraceptive failure Leading Cause For Unwanted Pregnancies Among Young Women by Vartika Tomar C ontraceptive failure is cited as the most the fetus while abortion in the case of rape survi- common cause for unwanted pregnan- vors is negligible, the analysis suggests. cies in the India. Such unplanned preg- nancies very often end up in abortions, Ipas Development Foundation (Ipas India) did according to an analysis done by Ipas Development the analysis for over 3 lakh women who had sought Foundation. This is more significant for young to terminate their pregnancies. women in the age group of 15-24 years. The analysis corroborates another study by Ipas More than 80% abortions in India are a result of India ``How prepared are young, rural women contraceptive failure. While the percentage is 79% in India to address their sexual and reproductive among women below the age of 24, for those more health needs? – A cross-sectional assessment of than this age, the percentage goes up marginally to youth in Jharkhand.’’ The study was done by Sush- 82%. anta K. Banerjee, Kathryn L. Andersen, Janardan Warvadekar, Paramita Aich, Amit Rawat and Bimla Dr Sushanta Banerjee, Senior Director, Research Updahyay which says irrespective of marital status, and Evaluation said that, ``this suggest even those rural young women are ill equipped to deal with young women who have exposure to modern tech- their sexual and reproductive health. This assess- nologies (amenities and thoughts) are not aware of ment of young women’s awareness of SRH matters sexual and reproductive health issues.’’ As pointed and current practices of utilizing healthcare ser- out in another study among young women, more vices for reproductive health issues including abor- than 90% young women do not have any knowledge tion and post-abortion complications suggests a about sex and pregnancy and more than half of the need for a comprehensive, youth-focused behavior young women do not have correct kn owledge on change communication intervention. oral contraceptive pills. Moreover, after four decades of legal abortion Risk to life or grave injury to mother’s men- in India (MTP Act), almost all young women were tal and physical health account for 16% abortions unaware that abortion is legal. among women more than 25 years of age, and 18% for those below 24 years. Only 1% to 2% pregnan- Despite national policies, participants married cies are terminated for congenital abnormalities in young (mean 15.7 years) and bore children early (53 % with first birth by 17 years). Women achieved44 August 2016 Health Spectrum

Health Studylow composite scores on knowledge married and unmarried women re- is not legal in India.around sex and pregnancy, contra- ported family and friends as the Linear regression modeling indi-ception, and abortion knowledge. primary source for all three types ofAround 3 % of married young women information (71% vs 79 %, respec- cated that married women and wom-reported experiencing induced abor- tively). Besides family and friends, en with middle or secondary educa-tion; 92 % of these women used pri- married women were more likely tion were more likely to have accuratevate or illegal providers. Married and to have received information from knowledge in all three knowledgeunmarried women also had limited outreach, whereas unmarried more domains, older women (19–24 years)agency in decision-making, freedom likely to obtain information from had a better understanding of sex andof mobility, self-efficacy, and financial mass media. Receiving any abortion pregnancy and contraception thanresources. Most of the women in the information was low for both groups, younger women, and women withsample received SRH information by with unmarried women being signifi- a high standard of living had betterword of mouth. cantly less likely to receive any abor- knowledge about contraception and tion-related information compared to abortion. Exposure to any SRH infor- A majority of 1381 married and married women. Importantly, a large mation from any source was foundunmarried women participants (52 proportion of women deny having to have strong association with the%) reported seeking SRH treatment knowledge level of all three SRH re-or advice from a private facility orprovider. Thirty-eight percent alsoreported seeking SRH services from atraditional healer or unqualified ruralmedical practitioner. Of the 23 married women report-ing an induced abortion, only 4 %sought treatment from governmentfacilities (where services are virtuallyfree and provided by trained provid-ers). Instead, most (52 %) went to aprivate facility, or to a chemist/ruralpractitioner (43 %); few private facili-ties are approved to provide abortionby the government, and chemists/rural practitioners are not legally al-lowed to provide induced abortion inIndia. Reliance on private sector wasalso observed for the 90 women whoreported an induced abortion. Married women were more likelyto have received information on SRH,contraception and abortion than un-married women. Among those whodid receive any information, bothA majority of 1381 received any information about SRH lated issues.married and unmarried issues (29 %), contraception (19 %) or ``Interventions intended to ad-women participants (52 abortion (93 %), while 94 % of young%) reported seeking SRH women received no information on dress the SRH needs of young pop-treatment or advice from all three topics. ulation must consider the need ofa private facility or pro- highlighting access to youth-friendlyvider. Thirty-eight percent Knowledge about SRH issues was health facility. This approach will notalso reported seeking SRH extremely limited in both groups, al- only raise their awareness but alsoservices from a traditional though married women knew more enable them to translate informationhealer or unqualified rural than unmarried women in all three into practice through improved agen-medical practitioner. knowledge categories. Of note, 55 % cy. At the same time, it is important of young married and 71 % of young to build formal and informal peerHealth Spectrum unmarried women could not cor- networks of young women to ensure rectly respond to any of the questions social support within the same com- about safe abortion. Furthermore, 10 munity,’’ Dr Banerjee suggests. n % erroneously believed that abortion August 2016 45

HEALTH ArticleDON’T IGNORE THE SNORING AND IT'S HARMFUL EFFECTS Good Sleep is one of the three essential pillars of good health apart from exercise and diet. Dr. Prerana Garg What is Snoring? with daytime lethargy and excessive Chief Physician & Director Snoring is the loud hoarse or harsh daytime sleepiness. Men snore more (25%) than women (15%) and older Aviss Health Pvt Ltd sound that occurs when your breath- subjects snore more than the young. Centre for Sleep Disorders ing is partially obstructed in some way Why do we Snore? while you're sleeping. Snoring occurs Gurgaon, Haryana when the flow of air as we breathe Snoring happens when there is ob- Email : director@avis- makes the tissues in the back of our struction of a person’s airways. Many throat vibrate and makes those irritat- factors influence snoring. shealth.com ing sounds. It can occur during any 1. Most often, muscles in the roof of stage of sleep. Snoring is more than a46 August 2016 bedtime nuisance and it shouldn't be the mouth (known as the soft pal- ignored. ate) or the back of the throat relax and partially block the flow of air. Prevalence of Snoring 2. Obesity - Extra tissue in the throat Snoring is a common phenom- can vibrate as you breathe in air in enon in society. Snoring affects 20 your sleep, causing you to snore. percent of the adult population and as People who are overweight, obese much as 60 percent of men above 40 or pregnant often have extra bulky years of age. Snoring can be classified throat tissue. into a) Simple b) Symptomatic. Symp- 3. Genetic factors – which cause tomatic refers to snoring associated Health Spectrum

HEALTH Article Q&A snoring include extra throat tissue is a warning sign that should be taken Triggers of as well as enlarged tonsils, large seriously. adenoids, long soft palate or long Q. When it comes to what triggers uvula. If you or your loved one have any cancer, whom will you blame first --4. Allergies, Congestion and Cer- of the following symptoms along with Bad lifestyle, gene mutation (family tain Nasal Structures- Anything snoring you may have Sleep Apnea history), ageing or a combination of that prevents you from breathing all? through your nose can cause you Excessive daytime sleepiness (to the to snore. This can include conges- extent that people fall asleep behind the It’s a combination of all the tion from a cold or flu, allergies or wheel) above. Lifestyle is a major contribu- deformities of the nose such as a v Choking or gasping while you tor especially obesity as it increases deviated septum. the risk by 30%5. Alcohol, smoking, aging and cer- sleep tain drugs and medications, in- v Pauses in breathing Q. How one can keep cluding muscle relaxants cause v Morning headaches cancer at bay (if not your throat or tongue muscles to v Difficulty concentrating triggered by muta- get relaxed which may cause you v Moodiness, irritability or depres- tions)? to snore. These all raise your risk for Ob- sion Healthy lifestyle,structive Sleep Apnea a condition that v Frequent need to urinate during no tobacco, maintain an optimal weight the night Q. In case if some- When should you visit a sleep clinic/ one is diagnosed with c a n - Sleep Disorders Centre? cer, what next: Embrace the situa- tion and fight it off or let it happen?causes you to temporarily stop breath- Sleep Centre refers to a clinic/ing when you are asleep and the heart Centre dedicated to the diagnosis and Cancer treatment and prognosisand brain isn’t able to get enough oxy- treatment of sleep disorders. Your is directly dependent on the stage ofgen to function properly. family doctor may refer you to a sleep the disease doctor if he / she suspects somethingWhy can’t we afford to Ignore Snor- serious underlying your inability to Stage 1—cure rate >90%ing? sleep well. A Sleep medicine physician Stage 2—cure rate is 60-80% or a Sleep Specialist is trained to treat Stage 3—cure rate – 40% Snoring may be early sign of future Snoring and detect and diagnose sleep Stage 4-- < 10%health risks. Besides being a nuisance apnea using sleep study or polysom-to your bed partner or roommate, nography. Sleep apnea is manageable Q. What woman should know?loud and frequent Snoring is a com- using several approaches including Every woman should be breastmon symptom of sleep apnea, a seri- CPAP (continuous positive airwayous sleep disorder and a risk factor pressure), oral appliance therapy and aware i.e. she needs to know what isfor heart disease, stroke, diabetes and surgery. normal and report any abnormality.many other health problems which in Every woman irrespective of fam-turn can result in further complica- Snoring is generally regarded as a ily history needs to have a mammo-tions. In children snoring is usually cosmetic issue by patients. We're hop- gram done every year after the age ofdue to enlarged tonsils and adenoids. ing to change that thinking so patients 40. Breast cancer is the fastest grow-OSA in children can cause learning can get the early treatment they need, ing disease in women in India, itdisabilities. While not everyone who before more serious public health is- can’t be prevented but if caught earlysnores has this sleep illness, snoring sues arise. n it has lesser chances of causing harm than dengue fever. nHealth Spectrum Dr. Rohan Khandelwal Onco-plastic Breast Sur- geon W-Hospital (Gurgaon) August 2016 47

Healthy Motherhood This may be partly true. Al- though vigorous sexual activity may be dangerous, but a gentle sex during pregnancy is not that harmful. Semen contains some amount of prostaglandins which may provoke miscar- riage in same cases. So using a condom even during pregnancy is always better.Certain Myths Of WomenHealth You Need To Know Dr Sushma P. Sinha Q. Menstrual blood is impure and it has you like. Though one should eat healthySenior Obstetrician, Gynaecolo- to come out. Even if the bleeding is heavy and hygienic food to have a normal bowelgist, IVF & Infertility Expert & it shouldn’t be stopped. activity during menstruation.CO-ordinator, Laparoscopic & Ans- Menstrual blood is actually the Q. One should not take pain killers during Robotic Surgeon, Institute of endometrial lining(lining of the womb) periods. Obstetrics & Gynaecology mixed with blood from the blood vesselsIndraprastha Apollo Hospi- supplying the lining of the womb. Ans-Taking few pills for pain allevia- tals, New Delhi-110076 tion during menses is safe. Not taking a Email : sinha_sushma@hot- Sometimes these blood vessels are pill and being in agony disturbs one’s daily not able to contract (close) completely activities& has a profound psychological mail.com and lead to heavy blood flow which is ul- impact as well. timately the blood from the body blood stream. Flow ofa lot of blood will lead to Q. Having intercourse atcertain times anaemia and weakness. One should rather during the cycle decides the chance of seek a medical help for it. having a male or a female child. Q. Eating sour or spicy foods during men- Ans- Absolutely untrue. There is no struation may lead to heavy bleeding. such science which can support this myth. Ans- There is no proof of changes in Sex of the child is determined by chro- blood loss related to food. Eat whatever mosomes and there is no such mechanism48 August 2016 Health Spectrum

Healthy Motherhoodrelated to any affinity for X or Y chro- adverse effects or pregnancy. This may be partly true.mosome according to the day of the Although vigorous sexualcycle. There is no reason to resort to Q. One should not exercise during activity may be danger-many practices. pregnancy. ous, but a gentle sex dur- ing pregnancy is not thatQ. Oral contraceptive pills lead to Ans- Moderate exercise is advisable harmful. Semen containsweight gain. during pregnancy. Being active and some amount of prosta- working all through the pregnancy is glandins which may pro- Ans- Well this might be partially rather recommended than taking rest. voke miscarriage in sametrue with the older pills used decades However, a sleep of 8hrs at night and cases. So using a condomage, but the very low dose pills avail- 1hr. in day time if possible is preferable even during pregnancy isable at present are quite safe and have during pregnancy. Yoga and breathing always better.almost 99.9% efficacy in preventing exercise also help allay stress.pregnancy if taken properly. They don’tcause any obesity and have minimal Q. Each and every fibroid should beside effects although they should never operated.be used without prescription of a doc-tor as safety differs from person to per- Ans- Just on sight of fibroid on ul-son& detailed information should be trasounography on routine checkupgiven and warning signs need to be dis- women get frightened. It is never advis-cussed together with some general ex- able to operate each and every fibroidamination of the patient are done prior unless there aresymptomslike veryto starting the pills. heavy periods pain infertility.Even be- fore operating other medical methodsQ. Copper T is not advisable for wom- available can be taken into considera-en who had a Caesarean delivery. tion if surgery is not acceptable. Ans- This is not true. Whether a Q. Having sex during pregnancynormal delivery or C-Section Copper may lead to miscarriages.-T is effective for almost all womenwho have delivered a baby before& Ans- This may be partly true.with equal safety & efficacy. Although vigorous sexual activity may be dangerous, but a gentle sexQ. Copper –T interferes with your sea during pregnancy is not that harm-life. ful. Semen contains some amount of prostaglandins which may provoke Ans- The reason one goes for an miscarriage in same cases. So using aoption like Cu- T is to have sex without condom even during pregnancy is al-risk of unwanted pregnancy. Women ways better. nthink that the thread that comes outof vaginal opening is going to be a dis-traction. However, the thread is presentonly in the upper part of vaginal open-ing and rarely come in contact withmale organ during the act.Q. Eating fruits like papaya or pine-apple harm your pregnancy. Ans-There is no evidence thatpapaya or pineapple cause mis-carriage or any kind of harmto the pregnant patient. Toomuch of anything is notgood during pregnancy anddoctors advice to eat a bowlwith variety of fruits. Toomuch of sugary fruits likemango, dates, banana andlitchi regularly may shootup the sugar levels and haveHealth Spectrum August 2016 49

HEALTH TipsTips of Dr. Sunita Godara to Reduce stress1. Get up 15 minutes earlier 46. Keep a journal 92. Recognize the importance of un-2. Prepare for the morning the night 47. Quit trying to fix other people conditional lovebefore 48. Have a support network of people, 93. Remember that stress is an attitude3. Avoid tight fitting clothes places and things 94. Remember God several times a day.4. Avoid relying on chemical aids 49. Read a story curled up in bed 95. Remember you always have op-5. Set appointments ahead 50. Do a brand new thing tions .6. Don't rely on your memory ... write 51. Stop a bad habitit down 52. Buy yourself a flower Dr. Sunita Godara is7. Practice preventive maintenance 53. Take time to smell the flowers an asian marathon8. Make duplicate keys 54. Find support from others9. Learn to say \"no\" to things which 55. Ask someone to be your \"vent- champion & fitness ex-you think not good for us partner\" pert.. She is an eminent10.Set priorities in your life 56. Do it today11. Avoid negative people 57. Work at being cheerful and opti- international athlete12. Use time wisely - Time Manage- mistic marathoner of repute.ment 58. Put safety first She has completed 7613. Simplify meal times 59. Do everything in moderation full marathons (42.2km)14. Always make copies of important 60. Pay attention to your appearance till date and won 25 Golds, 12 Silverspapers 61. Strive for Excellence NOT perfec- & 13 Bronze medals across the globe in15. Anticipate your needs tion 26 countries. She is director of Health16.. Repair anything that doesn't work 62. Stretch your limits a little each day Fitness Trust and President of Healthproperly 63. Look at a work of art17. Ask for help with the jobs you dis- 64. Talk less and listen more Fitness Society.like 65. Maintain your weight Email : [email protected]. Break large tasks into bite size por- 66. Plant a treetions 67. Feed the birds19. Look at problems as challenges 68. Practice grace under pressure20. Look at challenges differently 69. Stand up and stretch21. Un-clutter your life 70. Always have a plan \"B\"22. Smile 71. Learn a new doodle23. Be prepared for rain 72. Memorize a joke24. Tickle a baby 73. Be responsible for your feelings25. Pet a friendly dog/cat 74. Learn to meet your own needs26. Don't know all the answers 75. Become a better listener27. Look for a silver lining 76. Know your limitations and let oth-28. Say something nice to someone ers know them, too29. Teach a kid to fly a kite 77. Tell someone to have a good day in30. Walk in the rain Latin31. Be aware of the decisions you make 78. Throw a paper airplane34. Believe in yourself 79. Exercise every day35. Stop saying negative things to 80. Freely praise other peopleyourself 81. Get to work early36. Visualize yourself winning 82. Clean out one closet37. Develop your sense of humor 83. Play patty cake with a toddler38. Stop thinking tomorrow will be a 84. Go on a picnicbetter today 85. Take a different route to work39. Have goals for yourself 86. Leave work early (with permission)40. Get enough sleep 87. Put air freshener in your car41. Say \"hello\" to a stranger 88.. Eat popcorn42. Ask a friend for a hug 89. Write a note to a far away friend43. Look up at the stars 90. Go to a ball game and scream44. Practice breathing slowly 91. Cook a meal and eat it by candle-45. Practice a monster smile light50 August 2016 Health Spectrum