HEALTHY MIND, HAPPINESS AND HEALTHY SOCIETY

Dr. (COL) PRAHLAD KUMAR SETHI

EMERITUS CONSULTANT AND ADVISOR

DEPT OF NEUROLOGY

SIR GANGARAM HOSPITAL

PRESIDENT--BRAIN CARE FOUNDATION OF INDIA

(www.braincarefoundation.com)

(www.braindiseases.wordpress.com)

• 2 weeks ago, My friend Mr. Memani invited me to speak on health and happiness.

• Many of you who know him well shall agree with me when I say you cannot say no to him!

• I immediately agreed but started thinking what should I speak?

• I was pondering over this when as I lifted my head, I found the ever smiling face of Haider Ali serving me my daily morning cup of cappuccino

at the Siri Fort sports complex.

• Seeing Haider Ali makes me feel happy because he is always smiling and looks contented and happy.

Haider Ali (Barista Siri Fort Sports Complex, New Delhi)

• Now that you all seen the happy always smiling Haider Ali, I ask you all the question--Is he healthy?

• He looks healthy but you will be surprised to know that he can neither speak nor hear. He is deaf and dumb since birth.

• While it is true that physical health is very important for happiness a healthy mind is far more important.

• Haider Ali is one of the happiest person I know of. But he is physically handicapped. Out of the 5 physical senses

(sight, smell, touch, hearing and taste), he doesn’t have 2.

But he is Happy!!!

• When we talk of a healthy mind, question arises “is Brain and Mind same thing?”

• Brain and Mind are not the same.

• So where is the mind located in the brain?

• Difference between brain and mind

Brain: is the hardware, motherboard which is controlling the entire body—arms, legs, heart, liver, spleen. Has two parts

right hemisphere and left hemisphere. Different lobes: frontal temporal, parietal and occipital.

Mind: is the software. Metaphysical. Bhagavad Gita calls it the faculty of the soul. Where the soul/ Atman resides.

• Nobel laureate Eccles in his book “Understanding Brain” commented “How can a brain understand the brain?”

• The brain is the finest computer that can ever be conceived, which God has given us.

• In the past it was not possible to see the living brain.

• Now with advances in neuroimaging such as MRI, CT and PET scans we can not only see the living brain but understand

its functioning as well.

• Strides in neurochemistry have revealed a hot of neurochemicals and neuropeptides which work on different receptors

in the brain.

• Limbic and hippocampal system of the brain is the seat of our emotions, memory and thoughts. This thinking part of the

brain (Mind) makes us differentiate good from bad.

MIND

• Is a philosophical/ metaphysical term which deals with the thinking brain-our ideas, thoughts, concepts, responsibilities to

our families and society.

• Has to be developed and nurtured to be healthy—role of responsible loving parents, teachers, peers at schools,

colleagues at work, friends

• Society too influences our minds and our collective minds influence the society as a whole.

Four possibilities

• Unhealthy brain but healthy mind (eg Professor Stephen Hawkins)

• Healthy brain but unhealthy mind (eg criminals. Role of alcohol and drugs on the mind).

• Unhealthy brain and unhealthy mind (eg people suffering from mental health diseases such as psychosis, schizophrenia)

—How can we make these people healthy in brain and mind?

• Healthy brain and healthy mind

Healthy brain and mind and society

•Mahatma Gandhi said there are 3 types of people

–Those who give everything to society excepting nothing in return

–Those who feel if they give something to society, society should give an equal amount back to them

–Those who believe in taking everything from society and giving nothing back in return

Healthy brain and mind and society

•We each have all the above three tendencies in us ( sattvic, rajasic and tamasic—as the Gita says)

•We need to encourage the good traits, balance the second and curb the third guna).

•The health of the individual and society are interdependent.

•A society where corruption becomes the norm of life, where simplicity is equated with being a simpleton, where honesty is equated with being naïve is an unhealthy society which cannot flourish and shall ultimately self destruct.

•Living in such an unhealthy society shall lead to unhealthy mind and unhealthy brain.

•A healthy mind and brain need a healthy society and vice versa.

Healthy brain and mind and society

•In today’s rapidly changing society with changing norms our duties have increased.

•We each have to decide what is right and what is wrong.

•We each need to be guided by our own moral compass.

•The only answer is to let your inner self (Atma) speak to you.

•Turn inwards, introspection, meditate, do your duty and do not worry about the results (Gita).

•We return back to our index case Haider Ali. He is very happy as he is looking after his family, doing a good job in Barista and contributing to society. In spite of being deaf and dumb he has a healthy mind.

•Society in turn has helped him to be gainfully employed in spite of his handicap.

•So there is happiness all around.

ARTICLE 2

- Every six seconds, regardless of age or gender – someone somewhere will die from stroke.

- This, however, is more than a public health statistic. These are people, who at one time, were someone’s sister, brother, wife, husband, daughter, son,

partner, mother, father… friend. They did exist and were loved. Behind the numbers are real lives. The World Stroke Organization (WSO) is calling for

urgent action to address the silent stroke epidemic by launching the “One in Six” campaign on World Stroke Day, 29 October.

- The objective of the campaign is to put the fight against stroke front and center on the global health agenda.

- The “One in Six” theme was selected by leaders of the WSO to highlight the fact that in today’s world, one in six people worldwide will have a stroke in

their lifetime. Everyone is at risk and the situation could worsen with complacency and inaction.

- The “One in Six” campaign celebrates the fact that not only can stroke be prevented, but that stroke survivors can fully recover and regain their quality of

life with the appropriate long-term care and support. The two-year campaign aims to reduce the burden of stroke by acting on six easy challenges:

- 1. Know your personal risk factors: high blood pressure, diabetes, and high blood cholesterol.
2. Be physically active and exercise regularly.
3. Avoid obesity by keeping to a healthy diet.
4. Limit alcohol consumption.
5. Avoid cigarette smoke. If you smoke, seek help to stop now.
6. Learn to recognize the warning signs of a stroke and how to take action.

- Stroke is the second leading cause of death for people above the age of 60, and the fifth leading cause in people aged 15 to 59. Stroke also attacks

children, including newborns. Each year, nearly six million people die from stroke. In fact, stroke is responsible for more deaths every year than those

attributed to AIDS, tuberculosis and malaria put together – three diseases which have set the benchmark for successful public health advocacy, capturing

the attention of the world’s media and which consequently has provoked world leaders, governments and many sectors of civil society to act.

Stroke-what you need to know about it

Prahlad K. Sethi, MD

Emeritus Consultant and Ex Chairman

Department of Neurology

Sir Ganga Ram Hospital New Delhi

President

Brain Care Foundation of India

http://braincarefoundation.com

http://braindiseases.info

Starting with the basics:

- What is a stroke?

- What is a TIA?

- What are the different types of strokes?

- What are the risk factors for stroke?

- What are the warning signs of stroke?

- How are strokes treated in the hospital setting?

- How can strokes be prevented? Or rather how can I modify my risk factors for stroke?

Stroke/TIA and types of strokes

- A stroke is usually a sudden loss of brain function due to a disturbance in the blood vessels supplying blood to the brain.

- Major cause of death and permanent disability.

- US Data: Third leading cause of death and the leading cause of disability in the United States.

- Indian Data: Good studies are lacking but we know stroke incidence is increasing.

- Disturbance in blood vessel can mean two things: either an occlusion of a blood vessel leading to lack of blood flow (ISCHEMIC STROKE) or a rupture

of a blood vessel (HEMORRHAGIC STROKE)

- TIA (Transient ischemic attack) is caused by the changes in the blood supply to a particular area of the brain resulting in brief brain dysfunction that

persists, by definition, for less than 24 hours; if symptoms persist then it is categorized as a stroke.

Stroke is a disease of blood vessels

Ischemic stroke

Hemorrhagic stroke

Different types of Ischemic stroke:

- Large vessel stroke

- Small vessel stroke

- Embolic stroke

Large vessel stroke

Big vessel supplying blood to the brain gets blocked

http://apps.uwhealth.org/health/adam/graphics/images/en/18009.jpg

Small vessel stroke

Small vessel in the brain gets blocked

Usually small penetrating artery

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9441.jpg

Embolic stroke

Clot can come either from the heart (CARDIOEMBOLIC) or from another blood vessel (ARTERY TO ARTERY EMBOLIC)

http://www.hipusa.com/webmd/images/health_and_medical_reference/brain_and_nervous_system/understanding_stroke_basics_embolic_stroke.jpg

Risk factors for stroke

Factors which cannot be modified (Non modifiable risk factors)

1.Age-strokes are more common in the older age group

2.Sex-different rates in men and women, in women more common after menopause

3.Race-strokes risk vary in Caucasians, blacks, Asians, Indians (hemorrhagic strokes more common in Asians)

4.Genes-your grandfather and father had strokes at a young age, you likely have a higher risk of stroke too

Factors which can be modified (Modifiable risk factors)

1. High blood pressure (hypertension-is the number one risk factor for stroke)

2.High blood sugar (diabetes mellitus)

3.Bad cholesterol (dyslipidemia)

4.Smoking-increases risk of stroke and heart attacks

5.Sedentary life-style (lack of exercise)

6. Factors which make the blood more prone to clotting—hypercoaguable states

Warning signs of stroke

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

Source: American Stroke Association

Stroke management

RECOGNIZE THE WARNING SIGNS OF IMPENDING STROKE.

PRESENT AS SOON AS POSSIBLE TO A WELL EQUIPPED HOSPITAL (as time is brain!!!)

CT scan head done-is it ischemic or is it hemorrhagic?

If ischemic- clot busting drug or anti-platelet drugs like aspirin or anti-coagulants (coumadin)

If hemorrhagic might need surgery to evacuate (remove) blood from the brain.

Rehab plays an equally important role in recovery!!!

Stroke prevention is key!!!

Prevent and control high blood pressure:

1.High blood pressure is easily checked.

2.It can be controlled with lifestyle changes and with medicines when needed.

3.Lifestyle actions such as healthy diet, regular physical activity, not smoking, and healthy weight will also help to keep normal blood pressure levels.

4. All adults should have their blood pressure checked on a regular basis.

Prevent and control diabetes:

1.People with diabetes have a higher risk of stroke, but they can also work to reduce their risk.

2.All people can take steps to reduce their risk for diabetes.

3.These include weight loss and regular physical activity.

4.Diabetic medications and insulin

No tobacco!!!

1.Smoking can affect a number of things that relate to risk of high blood pressure, heart disease, and stroke.

2. Not smoking is one of the best things a person can do to lower their risk of stroke.

3.Quitting smoking will also help to lower a person's risk of stroke.

4.The risk of stroke decreases a few years after quitting smoking.

Treat atrial fibrillation:

1.Atrial fibrillation is an irregular beating of the heart.

2.It can cause clots that can lead to stroke.

3.A doctor can prescribe medicines to help reduce the chance of clots.

Prevent and control high blood cholesterol:

Eat a diet low in saturated fat and cholesterol and higher in fiber, keeping a healthy weight, and getting regular exercise.

A lipoprotein profile can be done to measure several kinds of cholesterol as well as triglycerides (another kind of fat found in the blood).

All adults should have their cholesterol levels checked once every five years, and more often if it is found to be high.

If it is high, you may need medicines to help lower it.

Moderate alcohol use:

1.Excessive alcohol use can increase the risk of high blood pressure.

2. People who drink should do so in moderation.

Weight and exercise

1.Maintain a healthy weight:

2.Proper diet and regular physical activity can help to maintain a healthy weight.

3.Regular Physical Activity adults should engage in moderate level physical activities for at least 30 minutes on most days of the week.

Diet and nutrition

1.Overall healthy diet can help to lower blood pressure and cholesterol levels.

2.This includes eating lots of fresh fruits and vegetables, lowering or cutting out salt or sodium, and eating less saturated fat and cholesterol.

TAKE HOME POINTS

Strokes are common

Most can be recognized

Seek help early and do not wait—remember when it comes to stroke: TIME IS BRAIN

We now have the means to treat most strokes-medical and surgical options are available in big centers.

Prevention remains the key!!!

Article 3

NO LIFE STYLE CHANGE IS POSSIBLE WITHOUT MIND STYLE CHANGES

Last decade has seen a great shift from communicating disease to non communicating disease. We are increasingly getting focused on heart disease, strokes (Brain attack), demyelinating disease, autoimmune disease etc. Diabetes, hypertension, hypercholesterolemia & obesity – Metabolic syndrome are getting more and more in focus.

Life Style changes are rightly getting emphasis as one of the solutions to help deal with these problems.

Life Style Changes

Exercise every day: Be physically active.
Choose good nutrition – a healthy diet is one of the best weapons to fight metabolic disease - Lower blood pressure.
- High blood cholesterol
AIM for a healthy weight
Manage diabetes
stop smoking - if you smoke quit
reduce stress.

Nobody doubts the value of these life style changes. Question is how many in our society can accomplish it? This question invariable took me back to an incident which my wife narrated to me a few years ago.

My wife was working as child – specialist doctor in Majedhia Hospital those days. She used to drive through GK – II in New Delhi, rather than khandpur, as she felt that this route was less crowded. But when turning near Alaknanda to right, she felt huge difficulty. She used to get very nervous as she found endless cyclists, pedaling down on the main road going from Tughlakabad to chandni chowk on their daily work. One day she grumbled her fear to me. In lighter mood I asked, “Do you ever realise what those cyclist might be thinking?” They probably feel more nervous and terrified seeing a lady driver hesitantly coming from right side getting more scared of getting run over by a car.

Next day while attending a meet on “Life Style Changes” and a healthy life my mind suddenly flashed to this endless cycle drivers.

In a large country like ours, many of my country men, probably lead such a life. Can they afford to change their Life Style?

If you advice them to have a regular exercise to avoid heart attack and strokes, He may turn around and tell you – Doctor I daily do cycling from Tughlakabad to Red fort – a stretch of many Kilometers everyday and I do the same exercise while reaching back to my house. Infact I get so tired exercising that it is a relief to reach home and remove my shoes /chappals. My whole body is paining and tired. Each muscle is tired and aching.

Diet: Next Life Style Change is that of simple diet. The poor guy carries his lunch box with a few chappatis, some onion and simple katori of dal, rare luxury of having some seasonal vegetable, which is possible if he can afford it.

Stress: One can imagine his stress cycling down on such hazardous road, full of cars/ buses/ having trucks & bikes moving in and out. Chances of accidents are so high, that every minute some accident may happen. Daily stress is so exhausting. If you suggest – that he should change such stressful job, he is incredulous. With great difficulty and recommendation he has got this job, he is managing his family on this minor salary.

In other words, major part of people are in low income group, cannot simply afford to change their life style even if they want to.

What about Middle Class?

A Lot of people are moving out of poverty line to middle class, all over the world including India.

Can they afford to change their life style?

They can be made aware the benefits of changes of life style. They may attend classes for life style changes. They may seem as the right group to be concentrated upon for teaching the benefits of lifestyle changes. Surprisingly effect is short lived.

For regular exercise they may feel two rounds of their colony are enough. During this period still they are on mobile talking to clients or contacts discussing scheme to make more money, getting more stressed. Much of their time is spend getting their children to get admitted to the right school. Booking in right schools starts even before the wife delivers the child. When children are grownup, a large part is spent in getting their child into right school or professional college.

In Indian society most of them spend restless nights to get right matches for their children. So no time for regular exercise. Life is full of stress. They don’t have Luxury of Life Style Changes. I know many of my patients have anxiety, sleeplessness & depression because they are constantly worried about their daughters’ not getting married. This stress is always eating them. Unlike in Western society, after high school they leave their children to choose their carriers or matches.

In My long carrier – as a doctor I have seen only one person truly changing his life style. Mr. Vijayan, was CEO of a leading British company in Delhi. He had a very lucrative Job with plenty of perks. One day he consulted me, I found he had stroke with a lot of risk factors – diabetes, hypertension, hypercholesterolemia. He was put on medicine for the same. He even went to Europe, consulted a leading stroke Neurologist. His diabetes, blood pressure and cholesterol were difficult to control. Every time in addition to medicine, I emphasized life style changes. I had known that as a CEO of a large company he was working very hard and passing through a lot of stress. He was lost on follow-up, till one day he suddenly reappeared. He looked very happy and contented and showed me his medical records. His BP was normal, diabetes cholesterol, much controlled with minimal medicine. He said he followed my advice literally and changed his life style completely. One day he chucked his job went back to Kerala, where he had plenty of farms / land & a big house. He lived on his cultivated land, employing a lot of farmers and lived his life without stress, with no competition.

It struck me, he could change life style because he had enough assets to fall back. So life style changes are not possible except for a few.

It is easy to advice, difficulty to follow.

Much more important is mind style change.

For every change to be accepted and executed mind style change is must. Even for blood pressure control, you have to make the patient accept that BP control is a must for his problem and accept regular medicine, so is true for control of diabetes and even regular exercises.

To stop smoking, you have to make up your mind. To reduce weight you need to have right determination and mind to do right diet control.

In short for all life style changes mind set / style change is must.

Let us take some examples - One day while taking ward rounds, I came across this middle aged patient who was a heavy smoker, in addition to high blood pressure and diabetes, he had a stroke involving right side but speech was spared. With medicine his blood pressure and diabetes was getting controlled and he was improving. When I advised him on quitting smoking- he got irritated and replied back that he will not quit smoking, he is not scared of dying but will not quit smoking. All my junior doctors were looking towards me, that how I will handle such a rebelious patient. All my team knew that I was a crusader for anti-smoking.

I quietly replied back that I was happy that my patient was not scared of dying. I told him gently that if he does not quit, the next attack may leave him completely paralyzed and ability to speak or communicate may be affected, the disability may be worse than dying. It is tough to get dependent on others, not able to sit up or speak – is he prepared for that life? and I left saying that one of the movies of our hero - Actor Amitabh Bacchan puts it in Hindi – ‘Laloo, woh jeena bhi koi jeena hai (That Life is not worth living)’. On that sentence I left the room.

Next day, while making daily rounds, I was surprised when my patient said he has now understood and has quit smoking – I was really pleased.

What made it happen? It was his realization and change of mind-set about smoking which changed his life style.

Articles 4

THE TREADMILL OF LIFE

Prahlad K Sethi, MD1and Nitin K Sethi, MD2

1 Department Neurology, Sir Ganga Ram Hospital, New Delhi, India

2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

THE EPISODE

I go to the gym in Siri Fort Complex early morning as a part of my daily exercise routine. The goal is to remainfit and hopefully have a long innings in my life and continue to carryworking in my profession as a physician neurologist.

One day when I was on the treadmill I realized that I was walking rather hurriedly with short quick steps. My goal was to reach my exercise target as fast as I could. Nothing else mattered to me at that moment. I happened to look towards my right and I found a friend of mine also walking on the treadmill. He looked at ease,calm and peaceful taking long steady strides apparently enjoying his workout. On the way back home from the gym, my colleague’s calm peaceful face and long steady strides on the treadmill were itched on my mind. I tried to justify my hurried rushed style on the treadmill…Iam not as tall as him nor do I have his long legs.I felt satisfied that I had met my goal on the treadmill that day.

After a couple of days, I decided to try my friend’s “treadmill style of walking”. I punched in the same distance target on the treadmill, the same speed and incline but instead of taking rushed small steps, I began to walk with slow steady long strides. To my surpriseafter about 5 minutes,I began to feel calm and peaceful. A relaxed feeling enveloped me.

On my drive back home I kept thinking what had justtranspired. How did this small change of walking style create such peace and calmness in my mind?I had walked on the same treadmill the same distance the same incline and the same length of time. I had reached the same targetbut the peace and satisfaction was so much more. Instantly I thought cannot we apply the same analogy to life?

LIFE IS A TREADMILL

Life is like a treadmill; call it the treadmill of life. We allhave to learnto waitpatiently for our turn to get on this usually fast moving treadmill. During the waiting period one has to be patient. We need to remember that opportunities will come our way sooner or later. One needs to set ones goals in life: what you want to achieve, how you plan to achieve it and at what speed you plan to go about accomplishing those goals. These goals, the speed may not be clear to us at the start but the desire to achieve those goals should certainly be there. One needs to be passionate about it. But passionate does not mean desperate. One should enjoy the ride.

"A journey of a thousand miles must begin with a single step."—Lao Tzu

“The journey not the arrival matters."—T. S. Eliot

A wise man once said "If you don't know where you are going, any road will lead you there."So as we travel on the adventure called life we should enjoy the journey and the experiences which we encounter along the road.

The lyrics of the song “Wear Sunscreen” by Baz Luhrmann sum it up perfectly and I shall quote:

“Don’t worry about the future. Or worry, but know that worrying is as effective as trying to solve an algebra equation by chewing bubble gum. The real troubles in your life are apt to be things that never crossed your worried mind, the kind that blindside you at 4 pm on some idle Tuesday.

Do one thing every day that scares you.

Sing.

Don’t waste your time on jealousy. Sometimes you’re ahead, sometimes you’re behind. The race is long and, in the end, it’s only with yourself.

Don’t feel guilty if you don’t know what you want to do with your life. The most interesting people I know didn’t know at 22 what they wanted to do with their lives. Some of the most interesting 40-year-olds I know still don’t.

Maybe you’ll marry, maybe you won’t. Maybe you’ll have children, maybe you won’t. Maybe you’ll divorce at 40, maybe you’ll dance the funky chicken on your 75th wedding anniversary. Whatever you do, don’t congratulate yourself too much, or berate yourself either. Your choices are half chance. So are everybody else’s.

Dance, even if you have nowhere to do it but your living room.”

WAITINGFOR YOUR TURN

Sometime when I go to my gym I found all the ten treadmillsoccupied. I have learnt to wait for my turn. There is a card posted on the fall which requests the members to be considerate of others and notto use the treadmill for more than 15 minutes at one stretch. Often I find people ignore that sign. I have learnt to be patient and wait for my turn.

"When I Consider How My Light is Spent" is one of the best known of the sonnets of John Milton. The last three lines are particularly well known, although rarely quoted in context.

“When I consider how my light is spent,
Ere half my days, in this dark world and wide,
And that one Talent which is death to hide
Lodged with me useless, though my Soul more bent
To serve therewith my Maker, and present
My true account, lest he returning chide;
"Doth God exact day-labour, light denied?"
I fondly ask. But patience, to prevent
That murmur, soon replies, "God doth not need
Either man's work or his own gifts; who best
Bear his mild yoke, they serve him best. His state
Is Kingly. Thousands at his bidding speed
And post o'er Land and Ocean without rest:
They also serve who only stand and wait."

Once your time comes and you are on the treadmill, you can choose your style (run versus walk) and your speed. If you choose to run , run only as fast as you need to. Be kind to your needs, you shall need them when you get old!

GETTING ON A MOVING TREADMILL

Once when I entered my gym, I found only one treadmill unoccupied. I ran to occupy it before anyone else could. To my surprise it was still running. In my haste I had jumped on to a running treadmill and nearly fell. This is true for life too. Running to achieve your goals, taking short cuts does not always yield the desired results. Sometimes one falls and falls hard.

SUDDEN STOPPING OF A TREADMILL

In Delhi, power cuts are frequent and unexpected. My gym lacks a back-up generator. Sometimes I will be walking on the treadmill and it will come to a sudden unexpected stop when we suffer a power outage. I have learnt to be aware of this and have avoided a couple of nasty tumbles. Life too sometimes throws lemons at us, curveballs which strike us when we least expect them. A sudden unexpected loss in business or a sudden unexpected health emergency like a heart attack or stroke. Be aware of this, be humble for the higher we rise the harder we fall.

COOLING OFF PERIOD

The cooling off period is a very important part of my treadmill routine. The treadmill slowly decelerates, the incline gradually declines to baseline. After a vigorous work-out the cooling off period is intended to gradually lessen the impact on the muscles and the heart and to return them to their pre-exercise physiological state. One feels relaxed and has a feeling of “that was a great workout”. Similarly in life, one day retirement looms. One should anticipate this and be prepared for it. It is time to mentally and physically step off the treadmill of life but not leave it altogether! We each have to find hobbies and tasks to keep our brains occupied so that we do not slip into the throes of depression. Some among us shall choose to mount the treadmill again and find a new job, others shall dismount from the treadmill completely and choose to spend time with family and friends.

TREADMILL OF LIFE-THE CONCLUSION

The humble treadmill which we encounter in our gyms can teach us many valuable life lessons.

In the words of Frank Sinatra:

“And now, the end is near
And so I face the final curtain
My friend, I'll say it clear
I'll state my case, of which I'm certain
I've lived a life that's full
I traveled each and every highway
And more, much more than this, I did it my way”

(Song: “My Way” by Frank Sinatra)

(Source: http://embercoaching.com/2015/05/avoid-the-treadmill-of-life/)

Articles 5

Brexit and the lesson to be learnt from the historic Indian scripture Ramayana

Sethi Prahlad K, MD, MBBS, FAAN

Emeritus and Ex-Chairman Department of Neurology

Sir Ganga Ram Hospital

New Delhi

Email: sethiprahlad@hotmail.com

David Cameron, the honorable Prime Minister (PM) of the United Kingdom must have got up from the wrong side of the bed that fateful morning. Later in the parliament on that day he announced the holding of a historic referendum to determine whether the citizens of the United Kingdom should stay in the European Union (EU) or Britain should leave the EU. This infamous referendum is now known to all of us as the Brexit. Prime Minister Cameron action shook up a hornet’s nest and he was wise enough to step aside once the results of Brexit came to light. If the honorable PM had read the historic Indian scripture Ramayana it would have served him well. Ramayana is one of the two major Sanskrit epics of ancient India, the other being the Mahābhārata. Along with the Mahābhārata, it forms the Hindu Itihasa. The epic, traditionally ascribed to the Rishi Valmiki, narrates the life of Rama, the legendary prince of the Kosala Kingdom. In Ramayana, Rama returns victorious to the city of Ayodhya with his wife Sita after spending 14 years in exile. The citizens of Ayodhya joyfully celebrate the return of Rama and Sita. Tradition links the festival of Diwali to the day when Rama, Sita, Lakshmana and Hanuman reached Ayodhya after Rama’s army of good defeated the evil demon king Ravana. After returning to Ayodhya, Rama established “Ram Raj” equivalent to what is modern day diplomacy. He ruled with fairness, generosity and honesty. One day it came to Rama’s attention that a “dhobi” (washer man) in his kingdom had turned his wife out of the home because she had spent a night away from home. The “dhobi” was overheard saying that he was not King Rama who accepted his wife Sita back even though she had been kidnapped and held by the evil king Ravana. The story goes that this led to Rama exiling Sita to the forest, while she was five months pregnant and remains a disturbing and incomprehensible event in the Ramayana to this day. The reasons why Rama did this continues to be debated by scholars and common man alike. Referendums are touted to be a more direct form of democracy where voters decide on a topic bypassing the elected leaders. Governments and elected leaders though should think twice before offering them since they at times backfire. When you have been elected to govern, do not ask for a referendum!

Articles 6

Epilepsy with Single Small CT Scan Enhancing Lesion in IndiaDo we Know all the Answers Yet?

So do we know all the answers when it comes to epilepsy with single small CT enhancing lesion (SSCTEL)? The answer is an empathetic no. In 1985, we were the first to draw attention to these lesions in a publication titled “Appearing and disappearing CT abnormalities and seizures”. 1 Our small series of 11 patients aroused c o n s i d e r a b l e i n t e r e s t n a t i o n a l l y and internationally in these lesions. The patient reported were treated with no specific medicines except anticonvulsants and in all these, lesions disappeared spontaneously after a variable periods of 2-3 months. Prior to our publication, due to high incidence of tuberculosis in our population and response of these lesions to anti-tubercular therapy (ATT) it was widely believed that these lesions were tuberculomas. In absence of any biopsy in our series, by a process of exclusion, we thought that these lesions represented some sort of spontaneously resolving infection, peculiar to the Indian subcontinent and referred to it as a “focal encephalitis”. In hind sight the choice of our word was inappropriate and a better term would have been “focal encephalitides”. Following our publication others r e p o r t e d p r e s u m p t i ve d i a g n o s e s of these lesions as tuberculoma, c y s t i c e r c o s i s , s a r c o i d o s i s , l a r va migrans, transient viral encephalitis, microabscess, post ictal enhancement and even vascular lesions. Rajshekhar d o c u m e n t e d s t e r e o t a c t i c b i o p s y findings in 6 such cases. In all cases the biopsy was reported as “non specific chronic inflammatory lesions” or “focal encephalitides”.2 Five of these lesions were followed up with anticonvulsant therapy and in all of them the lesion reportedly disappeared in three months. The authors disagreed with policy regarding starting these patients on ATT preferring to treat only with anti-convulsants as advised by us. A subsequent paper published in 1991 which included stereotactic biopsy in some of the cases, it was concluded that in Indian epileptic patients with SSECTL, cysticercosis is the commonest etiology. A critical analysis of Chandy’s and Rajshekhar’s paper reveals that in a significant number of their patients, the lesion disappeared or turned into calcific dots with no specific therapy. The authors concluded that disappearing lesions are nothing but a manifestation of a “very benign form of neurocysticercosis”.3 While the disappearance or death and calcification of these parasites in the brain is a natural event in the evolution of most types of benign cerebral cysticercosis, the process can take anywhere from 18 months to 10 years from the time of manifestation. The rapid resolution of the granulomas (disappearance in 4 to 6 weeks) in some patients and the long duration of symptoms in others is difficult to explain except by postulating that this is determined by the individual host immune status and the host-parasite reaction. A point to ponder here is that why in cases reported from the Indian subcontinent 60 to 80% of SSECT lesions disappear while in South America, where neurocysticercosis is rampant, disappearing lesions have not been commonly reported. How do we explain this paradox?

Currently in India when it comes to SSCTEL pendulum has swung from tuberculosis to cysticercosis. In-fact SSCTEL lesion has become synonymous with cysticercosis. This is unfortunate since many things remain unexplained. No critical analysis of published case series has been carried out. In many cases biopsies were not done to confirm or refute the diagnosis of NCC. Neither was immunoblot assay for cysticercosis antibodies carried out. ELISA was done which has a poor sensitivity. Should we treat these patients with anticonvulsants alone or anticonvulsants along with albendazole? Which patients should be treated with anti-tubercular therapy (ATT)?

We want to stress that SSCTEL is not synonymous with cysticercosis. It is a mixed bag. Lesions suggestive of NCC on CT, in patient with compatible clinical picture residing in endemic areas are and should usually be diagnosed as NCC. Differentiating NCC from tuberculoma though remains a diagnostic challenge. On CT scan or MRI unless you have a scolex, etiology at best is an educated guess. Ancillary investigations such as ESR, Mantoux test (PPD), lymphadenopathy on X-ray or CT chest may help to identify a small group of patients. Serology is not usually helpful. In SSCTEL with negative initial ancillary investigation for tuberculosis the lesion in 60-80% may disappear with no other treatment except anticonvulsants. Either this is a non-specific infection or a very benign form of cysticercosis. Lesion may persist in 20-30%. In these cases we advise to repeat ancillary investigations. Of note some lesions may disappear further in 3-6 months. Albendazole may be tried. If lesion does not disappear or patient clinically worsens, ATT should be initiated. Prognosis is excellent in the large number of cases in which the lesion spontaneously disappears, needing no specific treatment other than AED and is thus aptly described as the “syndrome of disappearing CT lesions”. Question though remains when to do stereotactic biopsy for definitive diagnosis.

The syndrome of seizure with SSCTEL is mainly confined to the Indian subcontinent, age group affected is mostly children or young adults and type of epilepsy is mostly focal (partial). Severity of epilepsy is benign responding usually to one AED. The diagnosis is retrospective and made when the lesion disappears and etiology is nonspecific infection vs. benign form of cysticercosis. When one encounters a case with seizure and SSCTEL, there is no way to predict whether the lesion will disappear on its own or not. Disappearing lesions do not require any other treatment except AED which can be stopped after 1 to 3 months of disappearance of lesion. There is no role of albendazole in such a lesion. Addition of steroids may theoretically reduce edema but exposes the patient to risk of having flare up of tuberculosis, if it turns out to be tuberculosis. Why some lesions do not disappear and persist is not known. Other questions remain unanswered. Is the etiology of disappearing lesion same as that of persistent lesion? Why some lesions heal clean, why others get calcified? In patients with seizure and calcified lesion how long should we administer AED? Do we operate on these lesions or not?

We conclude that the mystery of epilepsy with SSCTEL is far from s o l v e d , b e i t e t i o p a t h o g e n e s i s , diagnosis, treatment or prognosis. Unfortunately, interest in solving this mystery is already waning. We need large consecutive biopsy studies to answer some of these questions. This a problem unique to our country and one of commonest cause of symptomatic epilepsy in children and young adults. If we do not solve it, no one will. The battle is far from over, in fact it has just begun. We need to have reappearing interest in disappearing lesions.

References

1. Sethi PK, Kumar BR, Madan VS, Mohan V. Appearing and disappearing CT scan abnormalities and seizures. J Neurol

Neurosurg Psychiatry 1985; 48:866-9.

2. Rajshekhar V, Abraham J, Chandy MJ. Avoiding empiric therapy for brain masses in Indian patients using CT-guided stereotaxy.

Br J Neurosurg 1990; 4:391-6.

3. Chandy MJ, Rajshekhar V, Ghosh S, Prakash S, Joseph T, Abraham J, Chandi SM. Single small enhancing CT lesions in Indian patients

with epilepsy: clinical, radiological and pathological considerations. J Neurol Neurosurg Psychiatry 1991; 54:702-5

Articles 7

STROKE: MY VIEWPOINTS

Dr (Col.) P K Sethi, MD, MBBS, FAAN

Professor Emeritus Neurology & President Brain Care Foundation

What are the statistics for stroke in India?

Burden of stroke in India:

There is lack of good epidemiology work of stroke in India. Stroke is one of the leading cause of deaths and disabilities in India. Stroke may be third leading cause of death in India- first being heart attack and second being cancer, but it is first leading cause of disability. Many times, I say, after heart attack if patient survive, after a few weeks he may join his social functions well dressed without anyone knowing that he has had major heart attack, but a stroke patient may be left with severe disability and he may berecognized from a distance that he has bitten by ‘Dracula’.

Even though India is a leading generic drug producer still many people cannot afford the commonly used secondary preventive drugs for stroke.

As a first step the government of India has started the National Program for Prevention and Control of non- communicable diseases (Cancer, Diabetes, Cerebrovascular disease and stroke (NPCDCS)).

The government is focusing on early diagnosis, management, infrastructure, Public awareness and capacity building at different level of health care for all non-communicable diseases including . An organized effort from both the government and private sector is needed to tackle the stroke in India.

The estimated adjusted prevalence rate of stroke range 84 – 261/ 100000 in rural area such a huge range from 84 to 262 (various studies).

In urban area rate of stroke is 334-424/100000 which is much higher.

The incidence rate is 119-145/100000 base on recent population-based studies. There is also a wide variation in case fatality rate with the highest being 42% in Kolkata.

Indian studies have shown that about 10 % to 15% of stroke occurs in people below the age of 40 yrs. It is believed that the average age of patients with stroke in developing countries in 15 years younger than that in developed countries.

There has been more than 100 per cent increase in incidence of stroke in low- and middle-income countries including India from 1970 -1979 to 2000- 2008. Lack of reliable reporting mechanisms, heterogenicity in methodology, study population and small sample size in existing epidemiological studies, make an accurate estimation of stroke burden in India challenging.

There is great need to conduct many more epidemiological studies about stroke in this vast country. It will be delight for an epidemiologist to study this problem in detail.

The environment, the cultural habits, dietary preferences, the lifestyle changes, the various risk factor of stroke, vary from one end of India say Ladakh to Kanyakumari; In west from Rajasthan to Kolkata in east; to Assam and Mizoram in north east habits vary from states to states.

For example, in Punjab people are fond to meats and chicken.In Kashmir living habits including food habit differs. In West Bengal people love to eat fish every day. In Mizoram two decades salt consummation was negligible. It was only when army came to the station salt was introduced. In Haryana people literally drink ghee about a “” every day. In UP and Bihar people chew the tobacco and smoking of bidi’s and Cigrattes are common things. People even clean their teeth with powder containing tobacco called ‘Gul’. Zarda and Khaini is very popular in these states.

In village hookah and “” is very popular in .

Come to think of ‘Hukkah’ has became very popular even in metropolis cities like Delhi. Many young people including girls are seen in ‘Hukkar bars’. There are lot of recreational drugs also being put with tobacco in Hukkah.

Recently Government has banned e-Cigrattes. E-Cigrattes may become more fashionable in young people. In Haryana, the womans in villages are used to smoke bidis.

2. Based on your experience, what are the key risk factors for stroke from the Indian perspective?

Large vessel intracranial atherosclerosis is the commonest cause of Ischemic stroke in India. The common risk factors, these are

Hypertension
Diabetes
Smoking
Dyslipidemia

are quite prevalent andinadequately controlled: mainly because of poor public awareness.

Hypertension, in my opinion is the most important villain, responsible for stroke. Hypertension enters the body very slowly, stealthy like a thief in house, but slowly starts attacking all vessels, increasing atherosclerosis of medium and large vessels and hyalinization of small vessels. Initially for a long time it may not cause any symptoms. It may be incidentally detected on regular annual medical checkup or during a routine visit to your family doctor for any unrelated medical problem .

Unfortunately, in India except for service like Army, police or paramilitary forces annual checks are not common. Executive check up on annual or regular check up should be encouraged. So, that early factors like high blood pressure are diagnosed in early stage.

Fortunately, in some schools also regular medical checkups are done.

In USA stroke rate has come down because of public awareness.

Many malls, public places have machines where when you put hand/finger in you get BP reading and hence early treatment. Now there are Wrist bands (Fitbit) and mobile apps available which read your health activities including BP reading.

I suggest there should be awareness program for regular check whether adults or children. Regular medical check up in schools should be mandatory and health check up medical record books should be part of school curricular.

Attitudes and Cultural believes prevalent in India society:

Even if BP detected in early stage,it is difficult for the individual to accept that he has the BP problem. Mind makes up is not to accept it as a serious problem. They think once they start taking BP medicine, they will be habituated for it.

Further they get upset thinking they have to take the medicine lifelong. Even when a good doctor tries to convince themthat medicine has to betaken regularly they take it for few days and leave it.

Many times, in follow up visit, if they happen to come back, they say that BP medicine was stopped as their BP was normal. In my practice I take lot of pain to explain them that BP is normal due to medicine, but they have to take it regularly

Sometimetheir excuse that they stopped medicine because they are doing YOGA now.

YOGA may give calmness of mind, tranquility which may help some patient with mild hypertension but in majority of cases BP medicine are needed. Some patient surprise you by telling that they don’t take BP medicine regularly but take when they feel heaviness of head or anxiety.

They don’t understand that medicine needs to be take regularly

If you ask them that time, they may tell you they were prescribed BP medicine, but they did not take regularly.

One of my college had depicted in a poster presentation of all Bollywood villains and pointed out the evilest villain is hypertension which was pictorial depicted as ”PRAN”.

Diabetes

Diabetes is another very important risk factor of stroke as it involves blood vessel of heart, peripheral nerve, kidney and eyes.

India is known world capital of diabetes. Blood sugar has to be kept down, irrespective of the number of tablets or injections to be taken. It needs to be tackled on the war footing. The first defense is dietary control and second defense is weight control and regular medical check up so that blood sugar remains in control both fasting and postprandial.

The most difficult thing for many people is to avoid sugar and sugar rich food. If diabetes goes on unchecked it leads to major events like stroke, heart attacks, kidney failure, diabetic neuropathy and last but not least diabetic retinopathy. The common leading cause of peripheral neuropathy in world is now diabetes.

Again, regular annual medical check up may help to detect diabetes in an early stage. Diabetes run in families and with if there is history of diabetes in the family, such children should be screened regularly.

Believes and misconceptions about diabetes in Indian scenario:

Once detected with diabetes, people are not willing to have a good lifestyle and have normal dietary habits. If the sugar levels are not controlled with dietary restriction and exercise, patient should be put on medicine.

First defense in such case is oral anti diabetic medicines. These lot of advances and good oral diabetic medicines are available. If sugars are still not controlled then insulin injections are must.

The idea is to keep Blood sugar fasting near about 100 and PPBS near about 140. Monthly check up of sugar should be encouraged in addition to regular.

Along with blood sugar, HbA1c should be monitored monthly.HbA1c is to be kept below 7. Six monthly check up of eye for retinopathy is very desirable. If retina get affected laser therapy is to be given under supervision of eye specialist.

In India there are lot of misconceptions. People think that if start they are started on treatment for diabetes, they will get habitual. One old Punjabi lady told me that whenever she takes sweet thing like Rasgulla, only then she takesmedicine. She was under belief that this is the only way diabetes should be treated. Indians are very difficult to be convinced for treatment with insulin in addition, when oral medicine alonedoesn’t control their sugar.

There has to be a big effort and campaign for early detection and treatment of diabetes. There is no doubt that diabetes is a KILLER.

There are certain families and groups where Intra-Caste marriages are the rule. Diabetes is very common in one such group asKhukhrain in Punjabis.

Smoking & tobacco intake:

Surprisingly in my practice I find this also as a major cause of stroke in India. While in West because of several campaign smoking is not allowed in public places. Hpwever in Indiasmoking is picking up in big way as afashionable affair in young people. Recently the Indian government rightly banned e cigarettes. Tobacco in various forms namely chewing,eating tobacco pans, Gutka, Pan Parag, Tobacco manjan has become the norms.

I see lot of strokes in young who do not have high BP or diabetes, but their stroke is due to tobacco intakes.

Some times I tell them thy are blessed that thy are born in a family who does not have high BP or diabetes. But smoking is a self-inflicted habit that lands them into sever stroke disability or death.

In ward rounds when I see patients of strokes, after ruling out the risk factors like hypertension and diabetes, I asked them: “Do you smoke?” .Prompt comes the answer that “I don’t smoke”. Now I learnt to ask“when did you stop smoking”, the answer comes and surprise me “Yesterday”.

When they deny taking tobacco, I ask whether they are taking gutka, pan parag or tobacco manjan they reply“yes”.

the habits of smoking and tobacco chewing is an addiction and has to be taken care of with lot of sympathy and encouraged for leaving the habit.

Dyslipidemia

Investigation for dyslipidemia is very important part of management of stroke. High cholesterol is known to cause atherosclerosis of blood vessels.

Atherosclerosis tends to close the blood vessels at an earlier age and rupture the blood vessels.

There has been great advances in management of atherosclerosis with Statins. Different variety of statins are available which help to reduce atherosclerosis and hence the stroke.

If well tolerated it should be continued so that future strokes are prevented.

In addition to LDL (a type of bad cholesterol), Triglycerides may also be raised. Sometimes it tends to run in families. Such families may have high risk of heart attack and stroke. There is special medicine for Triglycerides also.

Early signs of stroke are–

Sudden weakness in any limb
Sudden sensory loss of one side of body or limb
Sudden balancing difficulty
Sudden vision loss or blurring of vision
Sudden speech difficulty
Sudden hearing loss

Many times, some of above signs make come suddenly and after some time they disappear. These signs should be taken seriously and with lot of respect. This may be early warning of a major stroke coming on. These are called as Transient Ischemic Attacks (TIA).

Patient should be thoroughly investigated and put on treatment. Sometimes TIA may be occurring as “clots/emboli “coming from heart or from blood vessels of neck and brain.

4. Is there a quick first aid for stroke until help arrives?

It’s a tough question to answer, many a time people call me at night for such patients. I inquire for the possible risk factor like BP, Diabetes and smoking, and if such history is present and if patient does not have severe headache, I advise them to give a tablet of aspirin; and bring them to nearest hospital/center with stroke treatment facility.

5. What is the biggest myth about stroke in India?

A stroke is a kind of heart attack- is one of the myths.

Fact is stroke and heart disease are related but not the same.

Stroke occur when blood supply to portion of the brain is cut off or blood vessel itself rupture resultingin bleeding in the brain.

I think, one of the biggest breakthroughs in Neurology in recent years occurred when Neurologist realized to increase public awareness. This can be achieved only if they speak in simple language calling STROKE as BRAIN ATTACK.

6. What foods are best for brain health?

In literature Mediterranean diet which in rich in fruits, vegetables, dry fruits, milk and curd, fish are described for good mental health.

Fresh fruits are specially emphasized at least four to five helping per day.Of the cooking materials fatty foods are to be avoided. Olive oil as a cooking material is very good.

In short, in India I generally call it diet. Sugar in recent years has come in great disrepute. Less of carbohydrates, more of vegetable and protein are now preferred. Green salad is encouraged. Vegetarian diets are preferred over non vegetarian.

Fish is always recommended if you are a non-vegetarian.

Moderation is the key.

Healthy lifestyle:

Healthy lifestyle with regular physical exercise, a cheerful spirit and a calm mind is to be emphasized.

Articles 8

Trials & Tribulations establishing the first DNB Neurology Program Dr. (Col) P K Sethi, Emeritus Consultant and Ex-Chairman Department of Neurology, Sir Ganga Ram Hospital, New Delhi

Sir Ganga Ram Hospital (SGRH) is unique in that it is run by a charitable trust. The trustees include physicians and non-physicians. The board of management is composed of physicians of different disciplines who among themselves elect a Chairman, Vice Chairman, Secretary and Treasurer. This board oversees the day to day operations of the hospital. SGRH is committed to providing accessible and affordable world class healthcare to patients as well as teaching, training and research activities. When I joined the department of Neurology, SGRH in 1986, a need was felt to add a formal residency program as this would ensure better care of patients and also generate teaching and research opportunities. In the absence of a residency program, junior residents used to work for a few months and then leave to pursue MD or DM degree. In1987/88 I got the opportunity to get the department approved for DNB training in Neurology. Prof. J S Chopra from PGI Chandigarh came for inspection of the department and to determine whether our department was capable of training doctors in neurology. He had a stellar reputation having trained neurology residents at PGI Chandigarh. Dr. Chopra methodically reviewed academic qualifications of all the consultants and our research activities. He visited the library, neurophysiology laboratory (at that time there was only one EEG /EMG machine), radiology (at that time we had one CT scanner and MRI scanner) as also walked through our intensive care units. After walking through the wards where neurology patients were admitted he met the chairman of the hospital (Dr. B K Vohra) and asked very pointed questions. I had opportunity to talk to him separately. I reassured him of the department’s commitment to developing a strong neurology residency program and also admitted to our weakness (we did not have a neuropathologist on staff). Dr. Chopra recommended seven neurology journals to be made available in the library for residents in training. After a month I received the joyous news that he had recommended our hospital for a neurology post graduation program to the DNB board. The next task at hand was to prepare a formal academic program. To my surprise neither AIIMS nor GB Pant hospital had any formally documented teaching programs. So the next few months I visited ICMR and other institutions to gather information. It was clear to me that any good program should have a mission statement, clear cut objectives and detailed course curriculum. After a lot of hard work, I succeeded in my mission (see formal teaching program below). In the initial years of the DNB neurology program we encountered difficulty finding good candidates. The reasons for this were multifactorial. DM neurology was valued more than DNB neurology and was a 2 year program as compared to 3 years for DNB neurology. The low pass rate also deterred promising candidates. Over time the playing field has leveled out and today DNB neurology at SGRH enjoys the same respect as any good DM program in the country. I look back at the trials and tribulations with pride and a sense of achievement for in spite of significant odds we have succeeded in our mission. Many of our program graduates are professors of neurology in different academic institutions in India and abroad.

Brief Outline of our DNB program:

The curriculum of the department aims to make the trainee independent clinicians/consultants. The objective of the training is that trainees should:

1. Be acquainted with current literature on relevant aspects of basic, investigative, and clinical neurosciences.

2. Have acquired performance skills and the ability to interpret relevant clinical investigations.

3. Be able to diagnose, plan investigations and treat common conditions in the specialty by relevant current therapeutic methods.

4. Be acquainted with allied and general clinical disciplines to ensure appropriate and timely referral.

5. Be acquainted with relevant education delivery system

6. Be able to identify, frame and carry out research proposals in their specialty.

7. Be aware of their own limitations.

Emphasis will be ‘on the job’ training rather than didactic lectures. Training imparted will be in the form of departmental seminars, journals clubs, combined neurology and neurosurgical conferences, bedside cases discussion and practical training in clinical neurophysiology techniques and neuroradiological procedures. Neuroanatomy, neurophysiology and relevant clinical aspects shall be taught in the form of departmental seminars.

In the first 6 months, trainees are expected to know neuroanatomy, neurophysiology, clinical localization and basics of EEG, EMG, nerve conduction/evoked response studies and doppler studies. By the end of the first year they are expected to be familiar about various disease process, their pathophysiology, pharmacology, neurochemistry and EEG/EMG changes.

The second year is spent reviewing the important literature published in old and current journals and analyzing it critically.

Neurobiochemistry and Neuroimmunology

Didactic lectures will be held by trained professional to familiarize the trainees with elements and techniques of neurochemistry and neuroimmunology.

Neuropathology

Trainees will get ample opportunity to perform muscle and nerve biopsies and also to study them with the pathologist. For brain cutting session, they will attend neuropathology sessions every Friday in AIIMS under a trained neuropathologist. They will be rotated to the department of Neurology either in PGI, Chandigarh or AIIMS to familiarize them with the techniques of grossing, staining procedures, autopsy methods and tissue processing including frozen sections.

Neurophysiology

Trainees are required to learn the techniques of application to EEG/EMG and evoked potentials under the guidance of technical assistants and consultants. They are also expected to learn interpretation of nerve conduction studies, EMG, evoked response and ultrasound during their first year of training, interpretation of EEG records to report under the guidance of senior colleagues and consultants in the first year and independently in the second year of training.

Requirements

To be eligible for the final examinations, candidates are required to have:

1. properly indexed log book indicating the work done, rotations and internal assessments.

2. one paper, a peer review of available clinical material and laboratory oriented project written in the form of an article of Neurology (India)

Evaluation

Teachers entrusted with the training of candidates both inside and outside the parent department evaluate them independently. A standardized marking system is followed and the results entered in a log book. The course Director averages these independent evaluations and enters the final evaluation.

Teaching Schedule

Departmental Seminar Once a week

Combined conference with neurosurgeons Once in Two weeks

Journal Club Once in two weeks

Neuroradiology conference Once a week

Conference with the Department of Psychiatry Once a month

Interdepartmental conference Once a month

Neuro-otology case conference Once a month

Neuro-ophthalmology Once a month

Academic Program

Time: 8:30 am-9:30 am, Tuesday and Friday Time table including topics, presenter moderators are prepared in advance for 5 months.

Ward Round

Time: 12 noon- 1p.m, Tuesday and Friday

Postings

The DNB students would be rotated in the following departments.

Neurology 1 years 6 months

Neuropathology 4 weeks

Visit to other institutes 6 weeks

Elective (any field of candidate’s choice) 6 weeks

Electrophysiology laboratory 3 months

A list of our current and former graduates:

Post graduates of Neurology Department PG Name/current position Date of Joining

Dr. Prem Choudhary currently in USA.

Dr. Anjali Sharma currently at SMS, Jaipur

Dr. Muzzafar currently in the UK.

Dr. Kiran Bala currently Prof. of Neurology, Rohtak 1993-95

Dr. Raj Shekhar Reddy currently consultant Max hospital, New Delhi

Dr. Neeta currently in Buffalo, USA.

Dr. Debashish Chakraborty currently in Kolkata Dr. Malti Kulsrestha*

Dr. Sanjay Saxena 1995-97

Dr. Jyoti Garg currently at RML hospital, New Delhi

Dr. Rajeev Ranjan, currently consultant SGRH, New Delhi 2002

Dr. Reena Thukur 2005

Dr. Anuradha Batra 2005

Dr. Aparna Gupta currently at the Indian spinal center 2006

Dr. Laxmi Khanna 08-March-08

Dr. Rajeev Goyal 08-March-08

Abhimanyu Subhash Gupta 11-Apr-10

Sheikh Hilal Ahmad 12-Apr-10

Correla Pamela Wilkie Michael 07-Jan-11

Manish Mahajan 07-Jan-11

Post graduates of Neurology

Department PG Name/current position Date of Joining

Upasana Patel 03-Feb-12

Rajat Kumar Agarwal 05-May-15

Pooja Gupta 05-Mar-13

Samir Patel 03-Feb-14

Davinder Singh Rana 04-Feb-14

Nikhil Dave 11-Mar-15

Virti Dhiren Shah 23-Feb-16 S

agvekar Yatin Chandrakant 24-Feb-16

Neha Pandita 27-Mar-17

Rahul Sharma 27-Mar-17

Rajeswari Rajan 02-Apr-18

Shah Dhrumil Jatinbhai 02-Apr-18

Mohan Lal Sharma 23-Oct-19

Nirja Pandey 26-Aug-19

Ranjan Kumar 11-Sep-19

Bharat Rastogi 18-Sep-20

*stayed for 1 year

Dr. Dinesh Khandelwal is currently professor of Neurology in SMS Hospital

Dr. B K Mishra is senior consultant and HOD of Neurology, In Bhubaneswar,

They opted to spent one year without department as senior resident to have field of practical neurology in practice.

Articles 9

Helping the Helpers to provide better help for Dementia patients

Dr (Col.) P. K. Sethi

President, Alzheimer Association of India

President, Brain Care Foundation of India

'Alzheimer's can be an epidemic by 2030'

1. In India, around three per cent of the rural population and almost five per cent of urban population above 65 years, suffer from Alzheimer's disease, which is characterized by progressive memory degeneration, medical experts pointed out on the occasion of the World Alzheimer's Day (September 21) that by 2030 there may be “epidemic” proportion of Alzheimer’s.

2. A recent survey indicates that with a 42-crore strong Alzheimer's patients, India is poised to overtake US within a year in this category

Indian Scenario vs West

1. Unlike in west there are hardly any organized center/hospitals/caregivers to deal a such large population

2. Unlike west most of the Indian population does not have insurance and patient and patient caregivers have to pay money from own pockets

Indian Scenario vs West

1. Unlike West, In India There is no Nursing Home or Day Care Centre looking after such Patients

2. No such Govt. Aided or Govt. helped care Centre

3. In majority these Patients are looked after by relatives at home

Patient vs Caregiver

1. Some recent articles suggest that patient with Alzheimer may not be suffering that much as they loose insight

2. Indeed the articles suggested that caregiver suffers much more for looking after there near and dear ones

3. The caregivers may even break down both physically and mentally as it is 36 hour job to look after such patients

“36 Hours a day”

1. Looking after some of these patients may not be 24 hours job but “36 Hours” tiring out even to most dedicated caregivers

Small towns vs Big cities

1. Mercifully in many places joint family system still available

2. Large families may still manage these patients looking after their day to day needs by division of labour.

3. Infact many of them take it as part of tradition to look after elderlies, calling them “BUDDHA- SETHAYA/BHATRAH GAYA”

Small towns vs Big cities

1. As Family Size are ‘ shrinking’ , the major burden falls on the spouse

2. Many a time in spite of desire the spouse may not be able to shoulder this burden 24*7

3. In Addition, in many cases, this spouse has to work outside home to support the family income including medical bills

Caregivers desperately looking for Helpers

1. Nine years ago when I went on house visit for one of my patient suffering from Parkinson’s with dementia his wife an old lady took me aside & told me, in tears that a health young man whom she had employed was threatening her to leave, unless she keeps giving him every 2 hours tea & snacks

2. She felt if he leaves how she will manage to lift her husband to bathroom and other chores,

Story of Kamla

1. I had met kamla when she was looking after one of my patient who was disabled and bed ridden with Neurological problem

2. I was stuck with her dedication & devotion

3. When that patient died, Kamla came to me for a job

4. One of Senior colleague brought his mother in law from England, suffering from dementia, I recommended Kamla to them

5. His wife Elizebth was ever grateful for help & devotion

6. Kamla became so devoted and attached to this old English lady

7. After death of patient Kamla also died one month later.

“SUCH HELPERS ARE DIFFICULT TO GET”

Need for trained Helpers

1. Hence Urgent need for reliable “certified” trained persons to help the caregiver

2. This help may supplement the caregiver to look after their near and dear

3. This domestic help may be on daily basis or once a week basis to give some relief to the caregiver otherwise he or she will BREAK

Corporate social contribution

1. An Organization or pharmaceutical Company who can take step in this direction will be doing a very noble well desired need of society and Patient with neurological Diseases. This will be their Corporate-Social Contribution which will be appreciated by whole country

2. Question is to make it also economically Viable and sustainable effort ?

An innovative plan-Indian Jugad

1. Manpower Recruitment

2. Every year a Sizeable Number of Trained Army Persons or Para Military Services from Army Medical Corps retires at relative young age of 38 or 40 yrs. In AMC, there are two Categories:

Nursing Assistant and Ambulance Assistant:

An innovative plan

1. Most of this talent goes waste , some of them may get absorbed in hospitals, majority are looking Opportunity to get Suitable employment

2. This vast pool of trained , disciplined man can be taken on discharge from service and May be given 3-6 months training to look after these Patients in Civil Society and Given a Certification after their training as “ Care-Givers Aids”

An innovative plan

1. There is already great demand for this “ Trained” “Certified” people all over Country

2. It is to be emphasize that these retired army people are recruited from all over india, they will be very happy to get a job near their hometown

An innovative plan

1. Amount initially spent to recruit such persons and train for responsibility, will be Self sustaining economically. It may indeed bring more revenue, if employees of this service Pays back to the Organization, so that Organization may do further Social Venture such as Opening day Care Centre, where the Caregiver can bring the patient for day care in morning and take back him or her home in Evening.

Conclusion

1. This innovative plan will be great contribution by Industrialist, Pharmaceutical companies to able to discharge their social corporate duties

1.That will be great help to caregivers for looking after dementia patients

2.Giving re-employment to ex-service people for serving in Armed Forces

Articles 10

Can a Stroke Kill You? Padma-Winning Neurophysiologist Shares All You Need To Know

“If a patient survives a heart attack, they may join their social roles within a few weeks without anyone knowing, but a stroke patient may be left with severe disability for life. From a distance, it may look like they have been bitten by ‘Dracula’,” says Dr Sethi.

Health Heroes – This article is part of a series to celebrate some of India’s most amazing doctors and to understand the incredible work they are doing.

One in six of us will have a stroke in our lifetime. This Padma Shri doctor tells us how to cut the chances!

Keep your heart healthy, and it will take care of your body. Check out these diabetic-friendly foods here.

Sudden numbness of the face, arm or leg on one side of the body, abrupt onset of confusion with trouble speaking, hearing, understanding–these are the most common signs of a stroke.

The brain equivalent of a heart attack, stroke affects 15 million people worldwide every year. Of these, five million die and another five million are left disabled for life.

2002 Padma Shri awardee, Dr Col Prahlad Kumar Sethi is the man behind the Department of Neurology at Sir Ganga Ram Hospital in Delhi, where he currently serves as the chairman. He is also the founder of the Brain Care Foundation.

Dr Col Sethi began his medical career with an outstanding undergraduate at the All India Institute for Medical Sciences, followed by postgraduate training in the USA. He volunteered in the Army Medical Corps during the Indo-China conflict and also served during the Indo-Pak war, for which he was awarded the Vishist Seva Medal in 1965.

With over 80 publications to his credit, this exemplar neurophysiologist tells us everything about stroke.

Please click bellow link for more information

https://www.thebetterindia.com/205704/can-a-stroke-kill-prevention-effects-symptoms-brain-padma-shri-doctor-india/

Articles 11

Emphasise mindset change over lifestyle change for patients: Dr. PK Sethi advises

On World Obesity Day, Dr. PK Sethi, a renowned Neurologist explains how doctors should be focusing on helping patients make mindset changes in order to achieve success in their lifestyle interventions.

Please click bellow link for more information

https://www.m3india.in/contents/editor_pick/89747/emphasise-mindset-change-over-lifestyle-change

Articles 12

Step up efforts to diagnose & manage Alzheimer’s disease: Dr. PK Sethi

On World Alzheimer's Day, Dr. PK Sethi, a renowned Neurologist discusses the rise of Alzheimer's disease incidence in India, patient vulnerability and the need for holistic care of Alzheimer's patients.

Please click bellow link for more information

https://www.m3india.in/contents/editor_pick/88537/step-up-efforts-to-diagnose-manage-alzheimer-s

Articles 13

NO LIFE STYLE CHANGE IS POSSIBLE WITHOUT MIND STYLE CHANGES

Life Style changes are rightly getting emphasis as one of the solutions to help deal with these problems.

Life Style Changes

Exercise every day: Be physically active.
Choose good nutrition – a healthy diet is one of the best weapons to fight metabolic disease - Lower blood pressure and cholesterol.
AIM for a healthy weight
Manage diabetes
stop smoking - if you smoke quit
reduce stress.

My wife was working as child – specialist doctor in Majedhia Hospital those days. She used to drive through GK – II in New Delhi, rather than khandpur, as she felt that this route was less crowded. But when turning near Alaknanda to right, she felt huge difficulty. She used to get very nervous as she found endless cyclists, pedaling down on the main road going from Tughlakabad to chandni chowk on their daily work. One day she grumbled her fear to me. In lighter mood I asked,“Do you ever realisewhat those cyclist might be thinking?” They probably feel more nervous and terrified seeing a lady driver hesitantly coming from right side getting more scared of getting run over by a car.

Next day while attending a meet on “Life Style Changes” and a healthy life my mind suddenly flashed to this endless cycle drivers.

In a large country like ours, many of my country men, probably lead such a life. Can they afford to change their Life Style?

If you advice them to have a regular exercise to avoid heart attack and strokes, He may turn around and tell you – Doctor I daily do cycling from Tughlakabadto Redfort – a stretch of many Kilometers everyday and I do the same exercise while reaching back to my house. Infact I get so tired exercising that it is a relief to reach home and remove my shoes /chappals. My whole body is paining and tired. Each muscle is tired and aching.

In other words, major part of people are in low income group, cannot simply afford to change their life style even if they want to.

What about Middle Class?

A Lot of people are moving out of poverty line to middle class, all over the world including India.

Can they afford to change their life style?

In Indian society most of themspend restless nights to get right matches for their children. So no time for regular exercise.Life is full of stress. They don’t have Luxury of Life Style Changes. I know many of my patients have anxiety, sleeplessness& depression because they are constantly worried about their daughters’ not getting married. This stress is always eating them. Unlike in Western society, after high school they leave their children to choose their carriers or matches.

In My long carrier – as a doctor I have seen only one person truly changing his life style. Mr. Vijayan, was CEO of a leading British company in Delhi. He had a very lucrative Job with plenty of perks. One day he consulted me, I found he had stroke with a lot of risk factors – diabetes, hypertension, hypercholesterolemia. He was put on medicine for the same. He even went to Europe,consulted a leading stroke Neurologist. His diabetes, blood pressure and cholesterol were difficult to control. Every time in addition to medicine, I emphasized life style changes. I had known that as a CEOof a large company he was working very hard and passing through a lot of stress. He was lost on follow-up, till one day he suddenly reappeared. He looked very happy and contented and showed me his medical records. His BP was normal, diabetes cholesterol,much controlled with minimal medicine. He said he followed my advice literally and changed his life style completely. One day he chucked his job went back to Kerala, where he had plenty of farms / land & a big house. He lived on his cultivated land, employing a lot of farmers and lived his life without stress, with no competition.

It struck me, he could change life style because he had enough assets to fall back. So life style changes are not possible except for a few.

It is easy to advice, difficulty to follow.

Much more important is mind style change.

For every change to be accepted and executed mind style change is must.Even for blood pressure control, you have to make the patient accept that BP control is a must for his problem and accept regular medicine, so is true for control of diabetes and even regular exercises.

To stop smoking, you have to make up your mind. To reduce weight you need to have right determination and mind to do right diet control.

In short for all life style changes mind set / style change is must.

Let us take some examples- One day while taking ward rounds, I came across this middle aged patient who was a heavy smoker, in addition to high blood pressure and diabetes, he had a stroke involving right side but speech was spared. With medicine his blood pressure and diabetes was getting controlled and he was improving. When I advised him on quitting smoking- he got irritated and replied back that he will not quit smoking, he is not scared of dying but will not quit smoking. All my junior doctors were looking towards me, that how I will handle such a rebelious patient. All my team knew that I was a crusader for anti-smoking.

I quietly replied back that I was happy that my patient was not scared of dying. I told him gently that if he does not quit, the next attack may leave him completely paralyzed and ability to speak or communicate may be affected, the disability may be worse than dying. It is tough to get dependent on others, not able to sit up or speak – is he prepared for that life? and I left saying that one of the movies of our hero-Actor Amitabh Bacchan puts it in Hindi – ‘Laloo, wohjeenabhi koi jeenahai (That Life is not worth living)’. On that sentence I left the room.

Next day, while making daily rounds, I was surprised when my patient said he has now understood and has quit smoking – I was really pleased.

What made it happen? It was his realization and change of mind-set about smoking which changed his life style.

Articles 14

The neurology of Bharatanatyam

Prahlad K Sethi1, Nitin K Sethi 2

Departments of Neurology Sir Ganga Ram Hospital, New Delhi, India 1

New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, U.S.A 2

Address correspondence to:

Nitin K Sethi, MD

New York-Presbyterian Hospital

Weill Cornell Medical Center

525 East 68th Street

New York, NY 10065, U.S.A.

Email: sethinitinmd@hotmail.com

Tel: + (212) 746 2346

Fax: + (212) 746 8845

It all began with my friend Nagi inviting me to be chief guest at his daughter’s arangetram. Arangetram, the debut on-stage performance of a Bharatanatyam student after successfully completely years of arduous training under her guru is certainly a matter of immense pride and joy not only for the student but also family and friends. Ekanta had worked hard for many years to achieve this milestone and finally was about to graduate. Touched by Nagi’s affection, I readily accepted to preside over the function.

But being the chief guest meant that I would have to give a short speech to the assembled gathering. As a neurologist I knew precious little about Bharatanatyam. Well maybe you can talk about the neurology of Bharatanatyam advised my son Nitin himself a neurologist. I had seen Bharatanatyam performances many a times but had never studied the art form from a neurologist’s point of view. I opened Bradley’s Neurology in Clinical Practice and to my dismay found nothing about the neurology of dancing let alone the neurology of Bharatanatyam. After a Pubmed search was unhelpful, an Internet search via the trusted Googleyielded two interesting articles from Scientific American and the Journal of Aesthetic Education.

Bharatanatyam is a classical dance form from South India dating back to 1000 B.C. It is based on ‘Adavu’ (steps) and ‘Hasthamudra’ (hand gestures). The dancer expresses herself via ‘bhavabhinaya’ (facial expression) and ‘hasthamudra’. The dancer is dressed bright colors and adorned with a garland in her hair and foot trinklets. The music is Carnatic classical music yielded by instruments such as violin, flute, mridangam (South Indian drum) and veena (string plucked instrument). The nattuvanar is the most important member of the Bharatanatyam orchestra and plays a set of cymbals known as talam and sings ‘Vaaythari’ (chanting). In a Bharatnatyam performance the dancer attempt to become the charactershe portrays be it Rama, Krishna or his beloved Radha and mimics all actions of the Supreme as best as she can. During the duration of the programall participants, the artist and the audience alike are elevatedto a spiritual dimension which the Upanishads call ‘ Raso vai sah. Rasam hyevayam labdhvanandi bhavati’ (he the highest self is bliss in itself). Every recital starts by invoking the blessing of Ganesha and Nataraja the cosmic dancer and it ends by seeking their blessings again.

The complexity of the central nervous system is evident even in the simplest of hand movements such as movement of the right index finger. Neurons in the contralateral motor strip are activated as are neurons innervating the corresponding antagonist muscles which need to relax so that movement can take place. Neural impulses travel down from the cortex via the internal capsule, mid brain, brain stem, pyramidal track, cervical spine, peripheral nerve finally reaching their target muscles. The accompanying facial expressions add yet another dimension and convey a story to the spectator.

Let us take the example of ‘Shabdam’ bharatanatyam performance – a scene from the epic Mahabharata where Draupadi is in great peril. The Pandavas have just lost her to the Kauravas in a game of dice and is forcibly brought to the court being dragged by her hair. The evil Duryodhana attempt to disrobe her by pulling her sari. The bharatanatyam artist performs this scene with just her facial expressions. A look of contempt towards her five husbands who wagered her in a game of dice and the next instant pleads with her eyes to Lord Krishna to help protect her modesty which he does so by extending her sari repeatedly. At the same time the artist covers her bosom with her hands to save her modesty, eyes turned down exhibiting shame. Thus a story involving many characters is conveyed by a single artist all with the use of hand and face gestures as well as eye movements. The artist during this complex performance is keeping time and synchronizing her actions to the vocalist who is singing and narrating the complex story.She also needs to keep pace with the music and her feet to the beat of mirdamgam.

It is indeed fascinating how the artist’s brain is able to accomplish all these actions simultaneously: eyes moving in different directions at times independent of each other while the play offacial expressionschanging depending on the scene as narrated by the vocalist.

Behind every bharatanatyamrecital there is intense ‘tapasya’ (practice) of several hundreds of hoursand repetitive rehearsals starting from a very tender age under the watchful eyes of the guru. This extra ordinary coordination of movements of the hands, eyes and facial expressions synchronized to music is indeed a testament to the wonder which is the human brain. It incorporates several neuronal pathways.

To hop on one foot—never mind patting your head at the same time—requires calculations relating to spatial awareness, balance, intention and timing, among other things, in the brain’s sensorimotor system. In a simplified version of the story, a region called the posterior parietal cortex (toward the back of the brain) translates visual information into motor commands, sending signals forward to motion-planning areas in the premotor cortex and supplementary motor area.

Several neuronal networks indeed involved. The center and networks appreciating the sound of vocalist, sound of mridangam and sound of taalam (whether there is one center or more) and perceiving it at the highest level of the cortex, performing appropriate hand movements, center for moving the eyeballs, center and networks associated with facial expressions for contempt, networks involving the facial expression and eye movement pleading for help from lord Krishna to prevent herself from disrobing , emotional centers for modesty to cover her bosom. Simultaneously dancing with her feet to keep rhythm with vocalist and all other musical instruments. The whole performance of this unique activity of multiple neuronal circuit of brain brings in cernte of planning and execution. How much frontal and hippocampal and cerebellumpart play a part we do not know.

To be honest at present we don’t have enough knowledge for the whole neuronal network involvement. Unlike singing we are functional MRI have added to our knowledge of singing /music. There are no functioning MRI for dancing. There is one thing is definite the art can be learnt when you are young because there is lot of plasticity of brain.

The nobel lauriest Ecclesin his famous book “UNDERSTANDING THE BRAIN” wrote how can brain understand a Brain.

It still remains the LAST FRONTIER to conquer.

Articles 15

SENSE OF SECURITY FACTOR(SS FACTOR) -- AN HYPOTHESIS

Many a time I am called to see the elderly patient who came with vagure symptoms of heaviness of head or a sensation of tightness of head . They may in addition complain of feeling of buzzing in head or feeling of instabilty or giddiness. A detailed examination does nt reveal any abnormailty to explain these vague symptmsps, Investigations including MRI scan may all be normal . A question asked as to if they are depressed generally elicit explaination in negative.They may add that with God,s grace they have everything . Aggod house to live,. a good amount of money and famliy . But if you tactfully question them there is indeed a sense of insequrity. THis sense of insequrity comes about in all old people . In some more , in others to a lesser extend . This makes me to hypthesis that there is factor secreted in hypthalamus - S S Factir ; This factor is at its maximum at birth and in young adults. When we are young , we are very carefree , we are full of confidece . Ecven if dont have much money or even a bicycle to ride , we are the richest and full of confidece . When we are really old , this factor secretion decreseses , and insecurity sets in . We may a very large house to live , lot of money in bank , a posh car and servants , but one may feel insecure and always worrying as to what will happen to me. , resulting in vague symptoms of heaviness of head etc as described above. Surprising if you ask them- are you scared of death they deny it, but this insecurity of unknown remains.

Articles 16

India News - India State News, Alzheimer's patients are highly vulnerable:

By Premshila Singh
Saturday, September 22, 2007 (17:49:02)
Alzheimer's patients are highly vulnerable
New Delhi:

People from Uttar Pradesh call it 'sathiya gaya hai' (for person who have crossed 60) while from those belonging to Punjab say'bahatariya gaya hai' (Person who have reached 72). Even the Indian medical fraternity until very recently thought such activities of aged people to be signs of senile behaviour. But of late, certain strange behaviours of aged people in our family, society, like forgetfulness, suspicion, over excitement or depression are considered the symptoms of Alzheimer's disease. Alzheimer's is a neurodegenerative disease, or if put in simple words it means, gradual fall of neurons that is responsible for memory, intelligence etc, in human beings. Alzheimer's is a common form of dementia affecting over three million lives in India.

So, what are the symptoms that differentiate a normal aged people and one who is suffering from Alzheimer's? P K Sethi, Head, Department of Neurology, Sir Gangaram Hospital, New Delhi says, Â"Alzheimer's symptoms include forgetfulness, suspicion, over excitement or depression or in other words, its a disease that affects an individuals regular task of life. The diseased person might forget to dress, to swallow food and even fail to recognise their near and dear ones.Â" Citing a case study Sethi says, Â"I have a patient who is 85. His wife is 75. But, she is responsible for everything right from dressing him to feeding, so she has to take help from her servant.Â" Sethi adds that in spite of appreciating her efforts, he suspects his wife is having an affair with the servant.

The burden of the caretaker of such patients is not merely physical, but more importantly, emotional. They struggle every minute not only in taking care of the patient, but also live with the agony that the person for whom they are having sleepless nights is gradually slipping away from them. Earlier, it was said that counterparts of the Western countries are more susceptible to this disease, but with growing life expectancy in India the disease is taking its toll in India too.

Most of the people do not recognise the disease on time, which makes the situation even more grave for the patient, Says Sethi. Â"People in India are still unaware. They take the patient for medication only when some drastic deviation is noticed from their routine affair.Â" he adds. Is the disease curable? Sethi replies, Â"As such there is no cure for the disease but it is curable to an extent, which can make people at least better behaved.Â" Pondering on the big question, Is there any way people can avoid catching up with this disease? Giving a psychological and social perspective to it, Sethi advises that there are at least three ways to beat the disease. One should keep his/her brain occupied in some or the other constructive work, after the so called retired age.

The different ways to keep the mind engaged is to indulge yourself in social activity, play cards, visit temples etc. The second important way is to go for physical activity that includes walks, routine exercise, yoga etc. Last, but not the least is have a good self image, otherwise the person might suffer from depression and isolation. In that context, the role of family members becomes very crucial, says Sethi. It has been estimated that the number of people above 60 would rise to 137 million as against 76 million at present. The disease might assume alarming proportion if the government does not give due attention. As the World Alzheimer's day is celebrated on September 21, its high time that people should be made aware about the disease.

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Articles 17

Doctor in uniform: my experiences in the Indian Army Medical Corp

Col Prahlad K Sethi (VSM), MD, MBBS, FAAN
Email: sethiprahlad@hotmail.com

I often reminisce of my days in the Indian Army Medical Corp (AMC). The India-China skirmishes in the news nowadays bring back fond memories of my time in service. Wikipedia defines the AMC as a specialist corps in the Indian Army which primarily provides medical services to all Army personnel, serving and veterans, along with their families.

During the 1965 war with Pakistan, I was posted as the Regimental Medical Officer (RMO) of the 3rd Dogra and 2nd Sikh. The RMO is usually an army general practitioner with additional training in pre-hospital emergency care and occupational medicine. In one of the fiercest battles fought during that war at the Uri Pooch link for the capture of Haji Pir Pass, our soldiers claimed victory over both the pickets but at a tremendous cost in blood and human lives. We had two hundred casualties at an altitude of 7000 feet above sea level. We earned 8 gallantry awards for our heroism but only Havildar Prem Singh and I were alive to wear those medals.

It was the year 1966 when I was posted to the office of the Directorate General Armed Forces Medical Services (DGAFMS) to work as a Defense Research Pool Officer. My assignment was to coordinate and actively participate in high altitude research in collaboration with Professor of Cardiology Dr. Sujoy Roy at the All India Institute of Medical Sciences (AIIMS), Delhi. I established the first defense research cell in AIIMs housed on the 4th floor teaching block.

We were researching the effects of high-altitude pulmonary edema and acute mountain sickness in jawans when they were suddenly inducted to the high-altitude battlefield of Leh. I recall waking up at 6 am to learn the skills of cardiac catherization. Our team went several times to Leh on an Indian Air Force plane to study the acute effects of high altitude on cardiac and pulmonary metabolism. We used to travel first to Chandigarh and then onwards to Leh on an Indian Air Force AN12; a cargo plane modified to have limited seating capacity. During a flight back from Leh, our plane developed a snag and the pilot informed us that we may have to belly land since the aircraft wheels were stuck. While hovering over Chandigarh, we got the welcome news from air traffic controller that our landing gear was actually down and the problem was a faulty indicator at the pilot’s console. We all thanked God that day feverishly.

During one of these many trips, I recall that both Professor Dr. Sujoy Roy and the Director General of Armed Forces accompanied the research team. Our headquarters was the army hospital at 153 GH. Under the mentorship of Professor of Neurology, Dr. Baldev Singh I did research on reaction times, H-reflex and nerve conduction velocities (NCV) on twenty Dogra Regiment soldiers at sea level (Delhi), immediately after induction to high altitude and after 6 months of acclimatization and compared the results with that of twenty Ladakhi natives born and raised at high altitude. Dr. Baldev Singh was over 70 years of age when he accompanied me on one of these trips. He jokingly told me “Captain, I wish to see whether my old bones can bear the freezing cold!” The local division commander at Leh, General Singh was not pleased with our research since he was of the opinion that it distracted his men. But our orders came straight from Army Headquarters and Defense Ministry and he reluctantly allowed our work to proceed. Dr. Baldev Singh gave an excellent talk titled “Chronic Sensory Deprivation” and suggested practical ways in which soldiers who were residing in these inhospitable conditions away from their families and loved ones could deal with the isolation. Remember this was much before the time of cellphones, Internet, Face Time and WhatsApp. It was only letters which kept a soldier in touch with his family and mail was only delivered once every week.

I shall not indulge on your time here with the results of our hard work under extremely difficult conditions.1-9 It is said “Once a soldier, always a soldier”. I now know that to be true. I took an oath to serve my country as a doctor in uniform and I feel very proud of the work our team did; the results of which continues to serve the men and women of the Indian Army who help protect our country from enemies both domestic and foreign in these high altitudes. To those still in uniform who guard our icy frontiers, I salute you. Jai Hind!

Padma Shri DR (COL) P.K.SETHI

MBBS, MD, FAAN

Emeritus Professor of Neurology(GRIPMER)

Advisor & Ex Chairman Department of Neurology

Sir Ganga Ram Hospital, Delhi

President Brain Care Foundation

President Alzheimer's Association of India

Articles 10

Can a Stroke Kill You? Padma-Winning Neurophysiologist Shares All You Need To Know

Articles 10

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Can a Stroke Kill You? Padma-Winning Neurophysiologist Shares All You Need To Know