Transmissible Spongiform Encephalopathy – Prion Protein – Kuru Disease

Transmissible Spongiform Encephalopathy – Prion Protein – Kuru Disease

Introduction: Prions or infectious protein were big news in 1980, when it becomes clear that these proteins cause diseases.

In year 1997, B. Pruisner received the noble prize in medicine for his discovery of prions “An     entirely new genre of disease causing agents.” Even though Prusiner’s work started in 1972, by 2017 we have got only a sort of understanding about prions.

Researchers from case Western Reserve University have synthesized an clear that artificial human prion in June 2018, which is deadly contagious and responsible for causing transmissible spongiform encephalopathy. Their works were published in the journal “Nature Communication” in the first week of June.

Now there may be arousal of a transmissible spongiform encephalopathy?

It is the rare form of brain wasting diseases and the name signifies ‘transmissible’ means infectious in nature, ‘spongiform’ means sponge like and ‘encephalopathy’ signifies disease process in brain or ‘infectious brain disease process where brain become sponge like.’

It is a fatal neurodegenerative conditions in human and animals where the healthy brain tissues are replaced by cluster of tiny liquid filled thin wall cavities and making the brain ‘sponge like’ due to accumulation of misfolded proteins i.e. Prion proteins.

After many years of discovery until now our understanding of prions in the brain has been limited and till now it is a curable, invariably fatal diseases.

History: It is a known for approximately 200 years and is proto-typical prion disease affecting sheep, goats had been known since 18th The crucial break through was achieved in the 1930s by the experimental transmission of Scrapie to goats.

Carleton Gajdusek demonstrated the kuru, a disease affecting the aboriginal people of Papua New Guinea was a TSE. The incubation period of the disease was longer than investigator’s persistence.

William Hadlow suggest that kuru resembled scrapie hence might exhibit a very long incubation period. After influencing by this Gajdusek achieved transmission of Creutz-feldt Jakob Disease(CJD).

History and discovery of prion disease
Pic.1- History and discovery of prion disease

 

Whereas, CJD in human was exceedingly rare. Its incidence is typically  inhabitants / years in Switzerland. However, several aspect of CJD epidemiology continue to be enigmatic and a screen for recognized / hypothetical risk factor for CJD has not exposed any causal factor to death.

 

  • Prion Protein: Prions are the natural human protein, coded by PRNP gene located on the short arm of chromosome no. 20 (between the end of the arm and position 12) known as CD230 (cluster of differentiation).

Expression of the protein is most pre-dominant in the nervous system (cell membranes of neurones), though it found in many other tissue of the body.

  • Structure of the Prion Protein: PrP is highly conserved through mammals consists of a globular domain with 3α-helix and a two strand anti-parallal β-sheet and -NH2 terminal tail and a sort -COOH

The primary sequence of Pr, 253 amino acids converts into mature protein having 208 amino acids long after post-translational modification.

PrP messenger RNA contains a pseudoknot structure (Prion pseudo-knot) which is thought to be involved in regulation of PrP protein translation.

Structure of PrP^c and PrP^sc
Pic.2- Structure of  Pr  and Pr

 

  • Functions of Cellular Form of Prion Protein: All though the exact functions of Pr is unknown and based on structural similarity, it has been proposed that Pr might function as a member of the Bcl-2 family of protein. It might have role in-

 

  • Synapse between neurons that can cause long term memory
  • Uptake of copper into the cell
  • Differentiation neuronal stem cell
  • Neurogenesis
  • Neuritogenesis
  • Neuronal survival via anti-/pro-apoptotic function
  • Red-ox haemostasis
  • Long term renewal of haemopoetic stem cell
  • Activation of T-cell
  • Differentiation and modulation of phagocytosis of leukocytes
  • Altering leukocytes recruitment to site of inflammation

 

  • Difference between Prand Pr:

 

Features   Pr (Normal cellular isoform) Pror Pr  (Scrapie isoform)
1.  Cellular dimorphism 43% α-helical and 3% β-sheet 30% α-helix and 43% β-sheet
2.  Sensitivity to enzyme protease Sensitive  Resistant
3.  Solubility in water Soluble Insoluble
4.  Location Located anchoring to the cell membrane Mainly present in cytoplasmic vacuoles

 

  • Transformation of Prfrom Pr: Prdifferent domains that play different roles in the conversion of PrPr. The first one is stable and ordered ‘core’ domain which contain GPI lipid anchor (Glycosyl Phosphatidyl Inositol) that tethers Pr to the plasma membrane, 3α- helix (helix A, band C) , 2 asparagines amino acid linked oligosaccharides and a protein binding sites capable of lowering the energy barrier for the conversion of Pr to Prwhen Prbinds to protein X (a species specific co-factor necessary for conversion of Prto Pr
Changes after transformation from Pr  to Pr
Pic. 3- Changes after transformation from Pr  to Pr

  

The second domain is a ‘variable’ or disordered domain which interact with Prand changes the Prconformation from unstructured form to the β-sheet of PrDuring conversion, helix A of the core domain of Pr also gets converted into β-sheet.

According to Sanley B. Prusiner’s theory,1997 once infected prion protein (Pr/ Pr) are carried to the neurones, they bind to the normal Pr on the cell surface, as a result, there is release of Pr from the cell surface followed by conversion into Pr/ Pr (as described before), by pot-translational modification by Pr.

When the cells synthesize Pr (new) by repeated cell cycle, a large no. of Pr is formed.

Pr being aggregated forms amyloid like plaques in the brain. As these plaques consist of host proteins, so there is no immune response or inflammation.

Abnormal misfolded proteins are internalized by neurones and get accumulated inside the cytoplasmic vacuoles mostly in the cells of the neurone. Thereby it enhances apoptosis with the help of 14-3-3 protein and large no. of cells are died off and cyst is formed in the brain that causes appearance of sponge form and it degenerates mainly cerebral cortex and cerebellum.

Due to above reasons there is following changes ultimately-

  • Vacuolation of the neurones
  • Formation of amyloid containing plaques and fibrils
  • Proliferation and hypertrophy of astrocytes
  • Fusion of neurones and adjacent glial cell
Coronal section of brain showing the vacuolation in brain due to prion disease
Pic. 4- Coronal section of brain showing the vacuolation in brain due to prion disease

 

  • Disorganisation of Prion Protein: Though it is hypothesized that Pr, the protease resistance forms are responsible for the prion disease, there is a protein sensitive (Pr) but disease associated translational form has also been described.

According to “Protein Only Hypothesis”, we are accepting Pr as the infectious agent, whereas there is “Not Only Protein Hypothesis”, because it is found that 25nm long virus like particle demonstrated in the cell culture with Creutz-feldt Jakob disease and Scrapie. Interestingly, these particles are similar to tubulo-vesicular structure found in all TSE form.

It is generally accepted that prion diseases are prion disease are transmissible, hence the name is transmissible encephalopathy and it is invariably fatal. Though transmissibility may fail in certain disease form associated with amyloidogenesis and there may be a sub-clinical carrier state in different species including human beings.

 

  • Classification of Prion Disease/Transmissible Spongiform Encephalopathy:

No distinct rules/theories can be applied for this classification. TSEs are classified on the basis of their pathogenesis mainly-

  • TSE in Animals:
  • Scrapie Disease: This phenotype of prion disease has been extensively studied. It is commonly found in sheep, goats, mouflons. They are of two types-
  1. Natural Scrapie: It is spreaded by vertical transmission i.e. parent to offspring or rarely by direct contact. After incubation period of 2 years, the affected sheep become irritable and develop intense pruritus, scraping themselves against trees and rocks and hence the name Scrapie . Gradually, emaciation and paralysis occur leading to death.
  2. Experimental Scrapie: The disease can be experimentally transmitted to various animals (research purpose) to several breeds of sheep and other animals by infection of natural tissues of infected sheep. In hamsters and mice, the incubation period is less and facilitated the study of the disease. Different breeds of sheep exihibit marked genetic defects in susceptibility to the infection 0-80% , whereas goats have 100% susceptibility.
  • Transmissible Mink Encephalopathy: Scrapie like disease in mink transmitted by feeding the mink on scrapie infected sheep meat.
  • Bovine Spongiform Encephalopathy / Mad Cow Disease: It commonly occurs in cows, lions, tiger, cheetah, puma, bison and exotic antelopes. It was enzootic in cattle in Great Britain since 1986. The epidemic in 1993 infecting over 1 million cattle with infection spreading to European countries. BSE in transmitted due to practice of feeding the cattle with meat and bone meal contaminated with Scrapie / BSE proteins.
  • Chronic Wasting disease: It occurs in captive and free range cervids of mule deer, elk.

 

  • Human TSE:
  • Familial CJD: It is the second most group of human prion disease. Disease prevalence rate is approx 10-15%. It occurs due to mutation in PRNP gene. Most common mutation occurs at 200th codon where glutamic acid is converted into lysine and as a result the entire potein is misfolded.

 

  • Variant of familial CJD: It runs in families. There are following variants-
  • Fatal familial insomnia: It is due to the germ line mutation in PRNP gene at 178th codon where aspartic acid is converted into asparagines. Therefore, misfolded prion proteins build up mainly in the thalamus, that regulates sleep rather than causing the typical spongiform degeneration in the cortex and cerebellum, occurs in most other types.
  • Gerstman- Straussler- Scheinker Syndrome: It is extremely rare form of neurodegenerative disorder of brain. It is almost always inheritent and is found only in few families around the world. Onset of the disease usually occur between the ages of 35 and 55 years. It slowly progresses and is usually lasting for 2-10 years. There may be polymorphism at codon 129/ codon 219 of PRNP gene and may associate with pro to lew point mutation at codon 102 of the PRNP gene, as found in large new Italian family in 1997.

 

  • Variant CJD: It is caused by eating the meat of animals having prion in the muscle tissues. Prions enter into blood stream after absorbing through intestine. Somehow these proteins crosses blood brain barrier and enters into the neurone by a process called adsorptive endocytosis, where the plasma membrane of the nerve cell folds inward to bring in substance otherwise not able to cross plasma membrane by themselves. As the prion is in the blood stream, this disease can be spread by blood transfusion. As it was occurred in UK, 1980. In Britain,1996, there was raised fears of infection through eating BSE infected beef among younger (below 45 years).

 

 

  • Iatrogenic CJD: It is caused by medical procedures or by equipment used for that procedures like-
  1. Corneal transplant gets contaminated and infects healthy individuals
  2. Electro-encephalogram (EEG) electrode implantation
  3. Duramatter graft implantation (>160 cases have been recorded
  4. Human growth hormone and pituitary gonadotropin therapy (>180 cases have been recorded)
  5. Mostly iCJD occurs in patient between 50-75 years.

 

  • Total cases of iatrogenic CJD world-wide:*
Mode Cases(n) Mean incubation period (years) Clinical
Neurosurgery 4 1.6 Visual/cerebella
Depth electrodes 2 1.5 Dementia
Corneal transplant 3 15.5 Dementia
Dura mater 136 6 Visual/cerebella
Human Growth Hormone 162 12 Cerebellar
Human Gonadotropin 5 13 Cerebellar

*Data courtesy of Dr P. Brown.

 

  • Sporadic CJD: It is the major type of human prion disease (85-90%). There is no clear cause behind it. It mainly occurs due to spontaneous mutation in the 129th codon of the PRNP gene where valine is converted into methionine.

 

Different types of Prions affecting different areas of brain
Pic. 5- Different types of Prions affecting different areas of brain

 

  • Kuru Disease: (‘kuru’ = tumor)

It was identified in 1957. Kuru was a mysterious disease seen only in the fore-tribe inhabitating the eastern highlands of New Guinea. The disease has incubation period of 5-10 years and led to progressive cerebral ataxia and tremors, ending fatally in 3-6 months.

The infection is believed to have been introduced through cannibalism and maintained by the trial custom and eating the dead bodies of relatives after death as a part of ritual. The disease disappears following the abolition of cannibalism in New Guinea. Carlton Gajdusek was awarded Noble prize for medicine in 1976 for his important contribution on Kuru.

 

  • Clinical manifestation of Prion Disease:

Prion disease is a slow virus infection. Incubation period of prion diseases from months to years (longest 30 years) but once the disease sets in, progression is very fast. There are 3 phases –

  • Pro-dermal phase (3-5 months)
  • Disease symptoms
  • Death

The disease symptoms vary depending on the type of prion disease-

  • Sporadic CJD: The symptoms mainly affect the workings of the nervous system (neurological symptoms) and these symptoms rapidly worsen in few months.
  • Variant CJD: Symptoms that affect a person’s behaviour and emotions (psychological symptoms) will usually develop first.
  • Initial neurological symptoms:
  1. difficulty in walking caused by balance and co-ordination problems
  2. ataxia
  3. numbness or pin and needles in different parts of the body
  4. slurred speech
  • Initial psychological symptoms:
  1. Severe depression
  2. Intense feeling of despair
  3. Difficulty in sleeping (insomnia)
  • Advanced neurological symptoms:
  1. Muscle twitches and spasms
  2. Loss of bladder and bowel control
  3. Swallowing difficulty (dysphagia)
  4. Loss of voluntary movements
  5. Extreme muscle weakness that causes inability to walk and stand
  6. Fatal familial insomnia
  7. Myo-clones (quick, jerky movement of the muscle)
  8. Exaggerated startle response
  • Advanced psychological symptoms:
  1. Dementia (no memory, power of decision making an reasoning)
  2. Loss of memory which is often severe
  3. Problems concentrating
  4. Feeling agitated
  5. Aggressive behaviour
  • Final stages: As condition progresses to its final stages, people with all forms of CJD will become totally bedridden. They often become totally unaware of their surroundings and require around the clock care.

Death inevitably follow, usually either as a result of an infection, such as pneumonia (a lung infection) or respiratory failure where the lung stops working and the person becomes unable to breathe.

 

  • Diagnosis: The diagnosis should be considered in any individual presenting with a rapidly progressive dementia. When other common causes have been excluded and there is other early neurological feature (especially cerebellum/visual). There are mainly 3 investigations of particular diagnostic utility – 1) Electroencephalogram (EEG)

2) CSF 14-3-3 protein

3) MRI

Testing the different types of human prion disease are distinguished by the clinical characters and classified according to internationally recognised published criteria, updated in 2010 and retrospectively applied to all referral since January 2010. The surveillance was last updated in January 2017.

 

Diagnostic criteria NCJDRSU for CJD surveillance across the UK: (The National CJD Research and Surveillance Unit is part of the centre for Clinical Brain Science, University of Edinburgh and is a part of the Deanery of Clinical Science in the College of Medicine and Veterinary Medicine)

  • Electroencephalogram: The EEG shows a progressive deteriotion in the normal background rhythms and in around 2/3rd of cases, appearance of Periodic Sharp Wave Complexes (PSWCs). The important points to be noted-
  • The absence of PSWCs does not exclude the diagnosis
  • PSWCs may be in other conditions (for example hepatic encephalopathy drug toxicity and rarely Alzheimer’s disease)
  • If PSWCs are absent on an initial EEG, repeat EEG may show development. (repeat testing should be considered at around weekly intervals)

 

  • CSF 14-3-3 proteins: CSF 14-3-3 proteins is a normal neuronal protein that has no specific connection to CJD, being released into the CSF following neuronal damage. It has specific diagnostic utility in CJD. However, CSF 14-3-3 concentration can be reasonably readily differentiated from sporadic CJD on clinical grounds. A positive CSF 14-3-3 test may therefore strongly supported specificity and sensitivity (both 94%) are valid only in an appropriate clinical context.

 

  • MRI (Magnet Resonance Imaging): Cerebral imaging is a vital part of the exclusion of other diagnosis and normal brain imaging in the face of a rapidly progressive, devastating encephalopathy, may lead to a consideration of sCJD. However, in some cases MRI shows a characteristic signal change in putamen and caudate. Occasionally high signal may be seen in the cerebral cortex, generally focal and reflecting the particular clinical feature at the time imaging. Significant atrophy is usually if imaging is undertaken within 3 months of onset of disease.

 

  • Measurement of Pr: It is measured by conformation dependent immunoassay is the most definitive diagnostic tool for prion disease.

 

  • Neuropathological diagnosis in Brain biopsies: The pathologic hall-marks of prion disease seen under light microscopy, are spongiform degeneration and astrocytic gliosis with lack of inflammatory response.

 

  • Sequencing the PRNP gene: It is to identify the mutation – this is important in familial forms of prion disease.

 

 

  • Treatment:

There was no disease like prion before. So till now it is not clear which strategy will lead to a treatment or cure. Scientists are investigating a lot of different possible ways of treating these disease.

  1. Small molecules: Within the fields of molecular biology and pharmacology, a small molecule is a low molecular weight organic compounds (<9000 Daltons) that may regulate a biological process, with a size of 1nm. Most drugs are small molecules.
  2. Antibodies: Anti-PrP antibodies have shown to eliminate Pr from the cultured cell but they failed to do so in vivo.
  3. Gene Silencing
  4. Several drugs like quinacrine

 

  • Decontamination: Prions are resistant to most of common sterilization procedures.
  • Autoclaving at 134ᵒc for 1-1.5 hours
  • Treatment with 1(N) NaOH for 1 hour
  • Treatment with 0.5% sodium hypochlorite for 2 hours

If the prions bound to the stainless steel should be treated with an acidic detergent solution prior to autoclaving; rendering them susceptible to inactivation.

  • Conclusion: Though it is a rare form of neurodegenerative disorder, for example 300-350 cases are reported in the USA per year, but it often progresses rapidly and currently it is incurable. So, till now prions are scary ailment.

In this year June 2018, researcher from case Western Reserve University have synthesized an artificial prions, though a new strain of prion sounds terrifying, but this research could be a bold new step in helping to treat prion disease by discovering auxiliary factors and developing therapeutic approaches to block them.

Artificial prion protein
Pic. 6- Artificial prion protein

 

 

  • Reference:
  1. Essential of Medical Microbiology by Apurba Shankar Sastry and Sandhya Bhat k. Page no.- 521-524
  2. Ananthanarayan and Paniker’s text book of microbiology, 10th edition, Page no.- 560-561
  3. Transmissible spongiform encephalopathy from ‘Zoonotic Disease is in Northern Euresia ,2015’. Prion disease- Pawel P. Liberski, James W. Ircnsicle in ‘Neurobiology of Brain Disorder’; Prion disease- Adrano Aquzzi (M.D., PhD, DVM, hc, FRCP, FRC Path), Markus Glatzel (M.D.) in Neurobiology of Disease.
  4. ISRN Infectious Disease, Volume 2013, Article ID 387925, 11Pages
  5. Prion disease: Am J Pathol. 2008 March; 172(3) Page no.- 555-565
  6. Athena Yenko, June7, 2018
  7. GEN News Highlights, June 6, 2011
When I First Met Death as An Intern – THE CIRCLE OF LIFE

When I First Met Death as An Intern – THE CIRCLE OF LIFE

However many doctors you may meet, some incidents are a rite of passage that almost none will forget.

The first day of college, the first dissection, the first delivery, the first surgery, the first post-mortem. Each of them has a variety of emotions and thoughts associated with them. Each person reacting differently.

But one event, that every single doctor remembers, is the first death they witnessed. It is a perverse memory, where a stranger’s death stays a part of you forever.

I first met death as an intern posted in the pediatrics – This was my first posting as an intern and I still was new to handling patients.

Much less, handling a sick 700-gram preterm baby. I was monitoring him through the night, with instructions to inform the PG residents in case of any complications. I had a senior nurse posted with me and I felt a little more secure. The nurse went for a bathroom break and suddenly I watched the baby’s saturation drop. 99%—-94 %—-90%—-87%—–70%—-I watched helplessly, not knowing what to do, whether to yell for the sister or to call my senior. I started basic resuscitation and the nurse returned. We initiated CPR while waiting for my seniors to arrive.

The next few minutes went by in a blur. I was supposed to give chest compressions to the tiny body. There was no improvement in vitals and my senior PG, who had seen this before, asked me to stop resuscitation. The baby was dead.

But I thought he was being cruel. And I continued chest compressions, hoping my force will bring this child back to life and crying for this child’s death. Not even alive fully, I thought of his parents’ sorrow. Until my junior PG, a good friend, intervened kindly, to tell me to compose myself.

That death is still one of the most vivid of my memories. Also, the composure my residents showed, was almost inhuman to my mind at the time. I could not believe that people could take death without being moved to tears.

A few years later, I was a second-year resident in general surgery, A 16-year-old boy, who had a blunt injury to his abdomen three days ago, arrived in shock. He was the only child of a poor, widowed mother, who was crying helplessly. In view of his hemodynamic status and history of blunt injury, we decided to post him for emergency laparotomy.

As we rushed him, I had an enthusiastic intern posted with us, running all the errands. The child arrested twice before surgery but was successfully resuscitated. We shifted him to the ICU and waited for the OT slot to open quickly.

By the time he reached the OT table, it had been about one hour from his entering the hospital. He had also arrested 13 times, only to be revived each time. I was personally hoping that this child would make one of those wonderful stories. We joked he would go the Guinness book of records if he did survive. My intern looked optimistic and was counseling the mother along with us.

We cut open his abdomen and found multiple perforations. It was a miracle he was alive this long, or that he could be resuscitated at all. Just as we were planning damage control, he arrested again twice. My intern who was also scrubbed in, also jumped into the CPR, while we all were in our scrubs. This sixteen-year-old had arrested 15 times, each arrest making hopes of survival and a full life, less and less likely.

We rushed to get him off the OT table and planned to revisit him, After 24 hours, hoping time and antibiotics would help, where we could not.

He arrested one final time, 16 times for each year of his life.

Each member of our team, the consultant, my senior PG, me, the anesthetist, the ICU staff had hoped and worked hard for a different outcome. Each of us was feeling the mother’s pain.

But we also had played with death earlier; where u lose, better to accept defeat gracefully. Better to joke with death than to hold on to its irreversible decisions. Better to focus on the hundred live patients rather than to dwell on this dead patient. Better to protect yourself and not think of the mother’s grief. Or each death will drive you mad.

We moved to the next patient while remarking how sad it was that this wonderful story did not come true, trying to bring humor to a very sad death. And I caught my intern, crying and remarking how thoughtless we all were, unmoved by the death of a sixteen-year-old, her allegations, reminding me of my own.

My mind flashed back to the day I had cried for that little body. I could not remember when I went from feeling that death as much as that of my family member, to a point where I could move on almost seamlessly when a death happened. Was I as inhumane and cruel as I thought my senior PG was? What is right, to feel the pain of each patient or to move on with a clear mind to the next patient?

Is the naïve desire to save every patient the right way or the cynical acceptance that you cannot win all battles the real answer?

I still don’t know the answers to this question.

My intern is now a PG resident, I guess facing her fair share of deaths.

Perhaps life does come full circle, ironically to death.

The Doctors and Patients are All Human Beings

The Doctors and Patients are All Human Beings

‘Hey you intern, go and call the police !’ there is a chance of relatives becoming violent’, screamed one of our professors and me ‘the intern’ ran out of the ICU following his order. The daily ICU morning round was going on & suddenly an unconscious patient was brought by the servant accompanied by a number of relatives. Immediately the patient was attended by residents & informed the professor. The patient was intubated within a minute & all the necessary procedures were done. The mob of relatives was told to clear the ICU but without knowing the seriousness of the place they started to scream & became furious over the doctors present there. The police arrived at once & handled the situation, all of us caught our breath but were left in shock. This whole scenario crossed my mind many a time, & such similar incidences heard & read in the news compelled me to dwell on the subject of the Doctor-Patient relationship.

The doctors are also a part of society, hence all good & bad aspects are applicable to them. But the faith of patient & relatives on doctors plays a crucial role in maintaining balance in society. No doctor will deliberately act as to cause harm to a patient. The opinion of doctors regarding the condition of the patient should be taken positively and acted upon accordingly. Though sometimes if misconduct happens the matter should be sorted in the court of law, as whatever a Doctor does is in good faith. Physical attack on doctors and damaging hospital infrastructure is not a civic way to solve the problem.

In the era of social media trials occurring in all walks of life, the society goes too bias against medical fraternity & no-one has time & patience to think with one’s own mindset. Since, the information available is considered as knowledge so everyone is ready to consider each medical professional as the culprit that makes the situation harder, vulnerable & a majority of Doctors following good moral code of conduct also face the music & land into a problem.

The doctors on their part should not consider patients as ATM. The treatment options given should be reasonable LOYAL & practically leading to either diagnosis or prognosis. The increase in chair time for counseling the patient & relatives will help to clear the motive of doctors. & consistency in such behavior will help to eradicate the misunderstanding regarding money extortion thought to be done, nowadays.

The doctor-patient relationship is given a higher value as a reward than money. The patient would pay the money but still bend down to touch the feet of the

service provider subject to the fact that there is no feeling of deception. The feel in doctors voice, touch & comforting look is all that they have always been about.

As a caretaker of the spirit, a doctor must preserve a personal relationship with the patients. “To touch another body with healing hands” is our job but to instill hope is to continue the heritage & nobility of the profession.

The doctors & patients are all human beings so are likely to err but try to reduce these issues and both of them should always ask.

Is it fair?

Is it a truth?

Is it fair to build the understanding between doctor & patient?

Will it build up good rapo amongst all?

Capgras is a bizarre delusion – People Are Strange

Capgras is a bizarre delusion – People Are Strange

 

“My 30-year-old son thinks that I am not his father, that I am an impostor. He says the same thing about his mother, that we are not his real parents. We just don’t know what to do or where to go for help.” (Ramachandran)

Such was the bleak despair in the tone of Arthur’s father, who, on one fine afternoon had decided to ring up the laboratory of Dr. V. S. Ramachandran, hapless as he was about his son’s condition. His son Arthur was a thirty-year-old survivor of a car crash, an incident which had left him with a peculiar delusion – he thought his parents were imposters, who were trying to dupe him by presenting themselves as his mother and father.

Dr. Ramachandran’s interest was piqued. He agreed to meet them at his laboratory, and after breaking the ice through the initial conversation, he asked him simply – “Arthur, who brought you to the hospital?”

“That guy in the waiting room,” Arthur replied. “He’s the old gentleman who’s been taking care of me.”

“You mean your father?”

“No, no, doctor. That guy isn’t my father. He just looks like him. But I don’t think he means any harm.”

Such was the case of Arthur – one of those rarest holders of the Capgras Delusion. Named after French psychiatrist Joseph Capgras, the first documented case of the syndrome dates back to 1923, when a quinquagenarian woman presented to Joseph Capgras and Jean Reboul-Lachaux with a particular dilemma. She was under the impression that a conspiracy to steal her inheritance was brewing under her nose, and a few imposters who had replaced her husband, children, and a lot of other people in her life, were the perpetrators of it.

Capgras is a bizarre delusion – one would expect such a condition to arise from a diseased mind, but funnily enough, a huge chunk of the patients present with a history of trauma or some other organic pathology in the brain. The initial Freudian explanation that was used to dismantle and understand the syndrome, has been replaced by a more scientifically sound, albeit less colorful explanation. The limbic system of the brain is concerned with the perception of emotions – it is wired through neural circuitry to receive a signal from the visual regions of the temporal lobe, which reach it after passing through its ‘gateway’ or the amygdala. The limbic system, after thorough analysis, interprets this visual input that it gets. The hypothesis proposed by Ramachandran and Hirstein, says that the dilemma in Capgras arises out of a disconnection between the face-recognition area of the temporal lobe and the limbic system; and thus, despite being able to recognize the person’s face, the patient is unable to fathom the depth of the emotional attachment that he shares with him.

If viewed through the Freudian lens, Capgras could be described by taking cues from the Oedipus complex, which suggests that male children feel a strong sexual attraction to their mothers in the earlier parts of their life, and a strong sense of jealousy towards their fathers, who is considered to be a sexual rival in this equation. These desires which mostly become latent, are unhinged when the patient injures his head. The shame and repulsion that he feels from such thoughts, thus lead him to claim that since he is harbouring such thoughts for his mother, she definitely has to be someone else (or, an imposter!). As intriguing as this might sound, the Freudian perspective has been contradicted by more scientifically sounder ones.

Unfortunately, except for treating the underlying causes of the delusion, specific treatment options for Capgras are limited. As it stands today, validation therapy and reality orientation techniques are used to calm the patient. In case of the former, the patient is made to believe that the illusion is actually true – this alleviates the constant anxiety that is accompanied along with it. The latter, as the name suggests, focusses on spatially and temporally rehabilitating the person to his surroundings. In the absence of more definitive treatment options, therapy helps.

Family is the foundation – it is from where our emotional needs are satiated. When that foundation becomes tremulous, the anguish accompanied with it is overbearing. For a person afflicted with Capgras, the sense of unfulfilment is immense. Arthur, once asked his mother – “Mum, if the real Arthur ever returns, do you promise that you will still treat me as a friend and love me?” The question lingers.

 

Works Cited

  1. Ramachandran, V S. “The Unbearable Likeness of Being.” The Independent, Independent Digital News and Media, 22 Nov. 1998, www.independent.co.uk/arts-entertainment/the-unbearable-likeness-of-being-1186663.html.
  2. Ramachandran, V. S. “Consciousness and Body Image: Lessons from Phantom Limbs, Capgras Syndrome and Pain Asymbolia.” Philosophical Transactions of the Royal Society B: Biological Sciences, vol. 353, no. 1377, 1998, pp. 1851–1859., doi:10.1098/rstb.1998.0337.
  3. “Capgras Syndrome: Causes, Treatment, and Caregiving.” Healthline, Healthline Media, www.healthline.com/health/capgras-syndrome#coping.
Doctors and patients have a most meaningful relationship

Doctors and patients have a most meaningful relationship

To start with we must know what a relationship means, it’s not a coming together of two individuals and doing things together. It’s about sharing and caring for each other.
Patients and doctors have a most meaningful relationship. Doctor treat patients and help them to pursue their life comfortably. And for patients, they are the channel for curing their ailments. A patient shares everything with a doctor which they even don’t tell their spouse or parents or any other beloved to them. Hence a doctor needs not only to try to treat them but he is also supposed to understand them. And most importantly maintain the secrecy. A person comes to a doctor and tells them each and every detail about their life can be related to family issues or sexual life. So it’s a doctor’s duty that he does not share it with anyone unless and until it’s necessary for the wellness of patient and society.
In a relationship trust is utmost important. This trust maintains the relationship. A patient comes with trust to a doctor and similarly doctor too trust its patient about what they say. Both the individuals are responsible for the further consequences.
Sometimes this relationship may go wrong, may be due to patient who lied or doctor who failed to maintain the secrecy. And for consequences, good or bad, they both face them.
A doctor with his total force tries to save the patient and fight for him, with him. A patient needs to help them by giving the correct history and following a given prescription.
If any bad happen including treatment failure or negligence which turns out to be so violent nowadays. Family members are hitting doctors and insulting them. This need to be changed.
Residency Made Me More of a Doctor and Less of a Human

Residency Made Me More of a Doctor and Less of a Human

It was my second night of start of internship rotational posting. Before this, I had been to wards before but just to search for exam cases and “Hear a Murmur” through my novice ears to diagnose a “Cardiac Condition. In final year we all are cardiologist and nephrologist in our own little world. We all very diligently start reading the bible of medicine Harrison which gradually shifts to Indian writers and then to local circulating notes in respective colleges. I also was a plastic surgeon in my own little world. Every murmur I could diagnose or every fact I learned about my body made me think that there was just an exam in between me and my destiny. I was too smart to be anything else but a super specialized doctor. But life has a harsh way to teach you things, it hits you really hard where it hurts the most. One incidence changed the whole perspective of mine at the way I looked at things and I dealt with patients. It was a fine Tuesday evening, the second day of my start of internship rotational posting which fortunately or unfortunately started with general medicine posting. It was my units admission day and I had been working very hard since morning in taking blood samples and fixing intracatheters. I was very sincerely taking all the history by asking all the right questions my quiet clinically premature but loaded with recently crammed up facts brain could form. I thought I was working really hard and really helping my junior academic residents.

Suddenly a fiftyish man walks through the doors of the ward with a really cachexic looking girl in her twenties on a roll on the mobile stretcher. She was breathless and could barely speak. By taking the history I came to know that she was an antitubercular treatment defaulter who had taken treatment for two months and stopped and now the disease had mutated and grown into multi-drug resistant type which was like cancer(again forgive my then novice mind) and untreatable. My third-year resident who was in a hurry to go was furious at the way the girl has been “playing” with her life and her frustration and tiredness came out too harsh on both the girl and her father. My senior went on for about five minutes on how she would die in a few hours given her condition and there was nothing that could be done. I was ordered to wear double gloves double mask before going near one meter of her vicinity. Once my senior was done blabbering ( of course then it felt that way but now as I myself am dealing with frustration and constant tiredness of residency, I cannot blame her ) she ordered the treatment and went. Once that part was over there came the nurse part about how she could not be placed in the general ward and should be kept isolated as much as possible so she was given a bed next to the public bathroom as far as possible from the normal patients.

I stood there the whole time looking at the chaos but then my clinically untrained and inexperienced eyes could not see the defaulter in the girl. All I could see was her eyes and count each labored breath she took and how much effort it took to take that single breath. I could see the helplessness in the father’s eyes, to see his own child this way and to hear that she may pass in a few hours.

A new issue had risen in the ward and I could hear the heated conversation between the father and the ward nurse. There has been the issue of attendants and the father was the only available relative and there was no female relative available and he didn’t have enough money to pay for the personal attendant. Left helpless he had to leave her daughter in hands of god and leave with teary eyes. I stood there till he collected his meager belongings and as he started to leave the folded his hands in front of me and said nothing but rather just stared at me for thirty long seconds. That stare has somehow stayed with me until now.

I made a silent promise to him and to myself to not let that girl die alone that night. When everything got settled and there was no chance of getting scolded by the nurse for going near the girl I went to her. I stood at a distance of 1 meter from her (the facts loaded mind knew that there was no treatment for multi-drug resistant tuberculosis) and I asked her how she was feeling and did she need anything. Through labored breathing, she told me that she had not slept for three nights and she was too tired to even breath. Suddenly sole aim of a “future plastic surgeon” was focused on how to get this girl some sleep. I was too afraid to call my on-duty resident and too egoistic to ask an on-duty nurse for advice. Before this drugs to me were just a name in KD Tripathy with the mechanism of action and adverse reactions. I didn’t have the courage to give some hypnotic to her on my own.

Gradually I gave in my ego and asked the on-duty nurse for some drug which could be given to her. She promptly replied alprazolam as the drug of choice and how she herself had self-medicated and so many doctors were regularly taking it putting a stamp of safety on it. I googled the drug and carefully studied it as a ten mark nonoptional question. At last, I came to the conclusion that the drug was safe in all aspects except that it may cause respiratory depression. And given the girl’s condition, it seemed a very big risk to me.

I nebulized her twice and pumped her with all the bronchodilators possible(as adviced by my senior). Still, there was no significant change in her breathing pattern. She again asked me if she could get something for the sleep and I mustered the courage and gave her one tablet of alprazolam(0.25). I waited for the magic to happen as soon as she gulped the drug and see her peacefully go to sleep but nothing happened. I told her that I would come back and went to roam around in the ward. It was 2 AM in the morning and I had been working for straight 18 hours now but I didn’t feel tired at all. All I wanted was to give that girl a last peaceful sleep before she died.

Roaming around the ward a sat on the bench in the doctor’s area and dozed off without realising. Suddenly I sat up with a jolt and the clock showed 3:25 AM! I was angry with my self and ran to the girl and saw her still sitting in tripod posture counting each breath she took. Still no sleep. My senior came on the rounds to see the patients and asked why I was still roaming in the wards. This was my chance and I told her all about my mission to give this girl one peaceful night. She had nothing new to suggest and she advised second tablet of alprazolam. I was silently shocked in my mind and thought what if she goes in respiratory depression?!. I told her that I would give her second tablet but I didn’t.

I told her to lie down and try to sleep but it was impossible for her to even lie down. I sat there whole night silently guarding daughter of a man whose eyes had asked for something and I silently had agreed. The girl didn’t sleep neither did her breathing improved but my shift ended. Surprisingly nobody had a solution for her problem, not even the consulting physician who came on morning rounds.

I wrapped my scut work and all the pending files and before going to my room met her once again. As she sat there leaned forward, with not a single layer between her skin and bones, sunken eyes with dark circles around. She weighed not more than 30 kilograms. This was the first time I saw her in sunlight and with such clarity. I bade her goodbye and went to my room

I came for the evening rounds and found that she had died in afternoon 1 hour afterwards I had left. My cointern was not interested to talk about her as she was already “ declared” dead when she came and she was a lost cause.

Till this date I can not forget her hollow sunken empty eyes and how they begged for one last paecful sleep. It has been 4 years to this incident and since two years three months I have been in touch with more patients and lesser books. I have become more clinically trained and emotionally untrained. There has been a huge difference in the way I now see patients and how I treat them.

Probably residency and my experience in medicine has made me more of a doctor and lesss of a human. But I still regret that could give that girl her dying wish. What if I would have given her the second tablet.. what if..

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What is Liver Cirrhosis?

Cirrhosis is a type of chronic disease (slow processing) that’s relative to the liver. Cirrhosis is identified when the cells of the liver are getting replaced by fibrosis (i.e. fibrous thickening of tissue) or the replacement of normal tissue with scar tissue. Basically, cirrhosis leads to damage to our liver and their functions. The liver plays a significant role in metabolism, detoxifying harmful substances, purify the blood and also including bile production and excretion too. Mostly, cirrhosis caused in alcoholic person and also more chances in a patient of viral hepatitis (B and C).

By examing and performing various experiments the medical science finds out a way to limit the further effects of cirrhosis but still cannot be able to cure. The ultimate way to rescue from cirrhosis is liver transplantation.

Globally, At present, there are more than 1 million cases of liver cirrhosis are.

 

Symptoms of Liver Cirrhosis

  • Joint pain
  • Fever
  • Fatigue
  • Vomiting
  • Abnormal personality
  • Neurologically deprived
  • Hepatic encephalopathy
  • Peripheral neuropathy
  • Asterixis
  • Integumentary
  • Jaundice (icterus)
  • Spider angiomas
  • Palmar erythema
  • Purpura
  • Caput medusa
  • Itchy skin
  • Gastrointestinal
  • Dull abdomen pain
  • Dyspepsia
  • Fetor hepaticus
  • Flatulence
  • Varices
  • Gastritis
  • Gynecomastia’ testicular atrophy
  • Hematemesis
  • Feel like overeating
  • Hemorrhoidal varices
  • Digestion problem
  • Increase size of liver
  • Loss of appetite
  • Hematologic
  • Anemia
  • Thrombocytopenia
  • Leukopenia
  • Coagulation disorders
  • Splenomegaly
  • Metabolic
  • Hypokalemia
  • Hyponatremia
  • Hypoalbuminemia
  • Fluid retention
  • Peripheral edema
  • Ascites

 

Causes of Liver Cirrhosis

  • Hepatitis B
  • Hepatitis C
  • Biliary atresia
  • Wilson’s disease
  • Fat accumulated in the liver
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Infection (schistosomiasis, peritonitis)
  • Enlargement of the spleen (splenomegaly)
  • Portal hypertension
  • Esophageal varices
  • Malnutrition
  • Bone disease
  • Gallstones
  • Heart failure
  • Obstructed blood flow
  • Hormonal imbalance
  • Production of toxins
  • Prevent the functions of protein and drugs too
  • Non- alcoholic fatty liver disease (NAFLD)
  • Non- alcoholic steatohepatitis (NASH)
  • Greater chance of Liver cancer

 

Prevention of Liver Cirrhosis

  • Stop or reduce intake of alcohol
  • Focus on the balanced diet
  • Less intake of salt
  • Less intake of sugar too
  • Prevent from taking of non-veg and spices.

Tests to be Performed for Liver Cirrhosis

  • Blood test
  • Liver function test ( ALT, AST, ALP)
  • Creatinine
  • Hepatitis B And C
  • Imaging test (CT, MRI, ultrasound, MRE)
  • Biopsy
  • TREATMENT
  • Endoscopy
  • Medication
  • vaccination
  • Rehabilitation
  • Consume diet with low sodium content
  • Avoiding nonsteroidal anti-inflammatory drugs
  • Hemochromatosis (reduce the levels of iron)
  • By the excretion of copper in urine
  • Liver transplant

 

Conclusion

The liver is the most workable organ within our body, performs various functions relating to circulation too. The liver performs both functions like production and excretion too.

LIVER CIRRHOSIS is the most advanced form of liver disease that’s related to generally drinking alcohol and viral hepatitis B and C. Liver cirrhosis occurs when the liver cells are killed or injured, and after that when the inflammation occurs, the injured want to repair itself by forming scar tissue that consequences in forming new liver cells in clusters form that leads to regeneration of nodules of liver within the scar tissue.

The disease is a part of the progression. It may start with the fatty liver disease, then progress to alcoholic hepatitis, and then to liver cirrhosis.

Liver cirrhosis main identified by jaundice, loss of appetite and fatigue. There are various types of complications occur in liver cirrhosis including liver cancer.

Diagnosis of liver cirrhosis can be started firstly with examing patient history, family history also, the vital signs (physical examination), blood test, and we can also perform complete diagnosis by confirming liver cirrhosis by performing the liver biopsy.

Treatment of liver cirrhosis prevents further damage to the liver, liver cancer, other complications related to liver cirrhosis and other adjacent organs from any damage. By suppressing the immune system by prescribed medications like prednisone and azathioprine to prevent further inflammation related to the liver in such as autoimmune hepatitis.

We can’t cure liver cirrhosis, but we can provide treatment to the patient as medication and further types of test like endoscopy. The best recommendation for the liver cirrhosis patient is to liver transplant surgery, still, the medical science working on the curing of liver cirrhosis by medications and some other remedies.

 

Gandhi had a vision towards health promotion of the society

Gandhi had a vision towards health promotion of the society

Introduction

When we think about Gandhi, what are all the things which come to our mind? Father of the nation, fought for independence, non-violence movement, his adherence to truth, etc. we never realized the immense knowledge on health he had. Yes, he had a vision towards health promotion of the society. Though initially, he hated modern medicine, at the end he himself stressed the need for an evidence-based medicine

My life experiences on Gandhi:

My first experience is with our ENT department. In our college ENT department, there will be a quote told by Gandhi. He says, “It is not our patient who is dependent on us, but we who are dependent on him. By serving him, we are not obliging him; rather, by giving us the privilege to serve him, he is obliging us “. The need for a patient-centered healthcare facility is insisted on by him long ago. This quote is also inscribed in the OP suite at AIIMS, New Delhi.

My second experience was in Velammal Medical College, Madurai in a neurology quiz. There was a question called what are Gandhi neurons. I didn’t expect that question. I was like, there is a neuron named after him? They told those mirror neurons, appears to underlie feelings of empathy was named so by Indian born American neuroscientist Ramachandran on 2008

Keys to health:

Gandhi’s book on “keys to health” is one of his most famous writings. He believed in the 5 element concept of human body earth, water, vacancy, air, light.

  • Air: he insisted on breathing exercises, cleaning the nostrils and the importance of sleeping under the open sky.
  • Water: he insisted that everyone have the right to get pure water and proper drainage facility. It is the duty of government to provide that. He also believed in hydrotherapy
  • Earth: he believed that mud has the potential to cure scorpion sting, constipation, boils, etc.
  • Light: he had faith in yoga and sunbath.
  • Vacancy: it is also called Aakash or ether. Gandhi believed that brahmacharya led to a healthy life.

He insists that we should not abuse the body we have. He says” everything in the world can be used and abused and it applies to our body too. We abuse it when we use it for selfish purposes, in order to harm our body. It is put to right use if we exercise self-restraint and dedicate ourselves to the service of the whole world ”.He wrote about his experiences in his publication, ’Indian option’ under the title ‘guide to health’ and some articles on nature cure and five elements and their effects. Those articles were published in Aga Khan Palace in 1942.

His approach towards diet:

Nowadays people are very concerned about their diet. Now we have paleo diet, Atkins diet, etc. Gandhi during his period stressed the importance of dietary habits in the health of a person. He divides people into vegetarian, flesh and mixed and considered vegetarian diet the best. He insisted on the importance of adequate nutritional proportion in food. Regarding sweets, he supported jiggery, yes the only sweet which contains lots of iron content. He insisted to avoid fried food. Gandhi says,” Food should be taken as a matter of duty even as a medicine to sustain the body, never for the satisfaction of palate. There should be self-control as such habits of elders influence children to some extent”.

His approach towards smoking and drinking alcohol:

Gandhi states that ” Drugs and drink are the two arms of the devil with which he strikes his helpless slaves into stupefaction and intoxication ” .At that time people were drinking to get attention from British, social availability etc. police training schools made it compulsory to drink wine and eat meat. This makes the individual health and the community health in question. He starts that prohibition should start from not selling in shops, etc. he asks the women to actively participate against alcoholism.

He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says,” He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says, “if every smoker stopped the dirty habit of making his mouth a chimney to foul breath by making a present of his savings to some national cause, he would benefit both himself and the nation “.

Hygiene and health, the universal principles:

Gandhi made committees in Africa and Ahmadabad to conduct surveillance on open defecating areas and to promote sanitation there. Today around Tanjore we can see lots of villages with signboards promoting construction of latrines in the home and to avoid open-air defecation. Still, we cannot make people avoid open-air defecation and we cannot expect Gandhi to successfully establish that long ago. But we should never forget his ceaseless effort for health promotion.

Though he had a strong belief in God, he hated the untidy pilgrimage practices in India. He incorporated health education and hygiene in his 18 points constructive programmes

His initial disappointment over Western Medicine:

He suffered from digestive complaints while practicing law in South Africa. He took some medicine but they were ineffective. One of his friends gave him a book “Return to Nature” by Adolf. The book told about dietary reforms, mud application over the abdomen, use of wet compresses, etc. he got relief from these. He insisted that such drugless therapy is needed in countries like India where people don’t have access to the healthcare facility. But in this view, I bet to differ from Gandhi. We need to establish evidence-based medicine all over the country. In Tamil Nadu lots of quarks have arisen to provide the cure for jaundice, AIDS, etc. recently a person calling himself healer Baskar promoted the state to practice domiciliary delivery and as a result, a woman from Thiruppur lost her life. He also claims that sambhar vada is the cure for gallstones. We should never promote such evidence less medicine

His later positive attitude towards modern medicine:

In his 50s he suffered from hemorrhoids he first went seeking a solution from naturopathy. Then he went to Dr.Dalai and he underwent surgery and got cured of the illness. He even suggested others suffering from hemorrhoids to go for surgery. In January 1924, in Yerwada jail, he suffered from appendicitis and was operated by British surgeon Maddock. This life-saving surgery promoted his mind the need for modern medicine.

Gandhi against ancient medicine:

While opening an ayurvedic pharmacy in Chennai, he spoke that Ayurvedic physicians are just living by the glory of their past. The system is less evidence-based than the western system. He wanted the Ayurvedic practitioners to practice research and give evidence for modern medicine practitioners.

The next month he wrote to an ayurvedic physician,” I have faith in the Ayurvedic drugs, but very little in the diagnosis of physicians. I therefore never feel sure about a patient under an Ayurvedic physician if his diagnosis is not checked by a trustworthy practitioner under the Western system “.

My Gandhian views regarding independence for doctors:

As a third-year Medical student, I ‘ve been traveling to lots of colleges for intercollegiate conferences. I’ve seen lots of interesting research papers and case presentation from various Medical Colleges. But when I discuss with them and ask about their ambition most of them would like to join PG in central University in India like AIIMS JIPMER etc or to clear international exams to pursue their career abroad.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

I didn’t say such aims are wrong. But I question why a young medic with great rank which would allow him/her to choose their favorite PG course in their own state, where they tend to interact with their patients in their own language, to choose a college where they must learn a new language, culture, epidemiology difference, climatic variations etc.

And when all the competent Doctors our state for a place with better job security, job satisfaction, pay grade, respect then Tamil Nadu will be left with lack of manpower and will go through a medical crisis with lack of manpower.

Let’s see the PG stipend across the country

Sino. state Stipend for MD/MS 1st yr Stipend for DM/Mch 1st yr
1 Tamilnadu 27,100 32,800
2 Central government 86,335 89,634
3 Kerala 43k 47k
4 Maharashtra 53,360 48,413
5 Madhya Pradesh 45k 50k
6 Rajasthan 47k 54k
7 Uttar Pradesh 55,830 62,633
8 Bihar 50k 90,411
9 Goa 60k 71,238

Of course, after a lot of struggle, the stipend was increased to 40k 45k for PG and superspeciality respectively. Still, this is very low when compared around the country.

Across the world, Indian doctors are paid less. Across the country, TN doctors are being paid less. This is one of the reasons which implant the dream of studying abroad in young minds.

People may argue “Doctors should not work for money, they should do well to the society,” I ask WHY? Does anyone tell the society to provide all services to doctors free of cost for “betterment of the society”? OR ask the banks to give away money to all doctors for the same cause. No!

I would tell you an anecdote of myself. I finished my schooling in my hometown which is Mannargudi. I’ve chosen to study at Tanjore MC because it was the best College near my home. I didn’t think of studying in central University or in big cities. I really saw and I really wanted my future here. I didn’t have any calculation to join here; I got an emotional bonding which made me choose here.

I really wanted to join MD pediatry here in our college after I finish my MBBS. But when I came to know about the stipend paid across the country and the situation of TN, my dreams shattered. As a student from the middle class, I would rather sacrifice the comfort of living in my dream College over an increased stipend to support my family economical

So should I choose to join AIIMS or JIPMER? The answer is a big NO. We know the status of TN medical postgraduates in central Universities. Every month we are seeing at least one death news regarding PG death in AIIMS who is from Tamil Nadu. I had a senior friend who joined MD pathology in KEM Mumbai, whose bike was shattered just because it got a number plate TN. We have such a welcome from North Indian states. After all hard work, I don’t want to die in a central University.

The assault on doctors is not restricted to TN doctors alone. These past few years in India have witnessed growing instances of assault on doctors. Many newspaper columns have been devoted to the issue. Recently a doctor in Maharashtra’s Dhulia lost his eye after being assaulted by the relatives of a patient. Assault on doctors by angry patients and their kin is only a reflection of the issues troubling the healthcare system.

Let’s continue my story, where should I pursue my post graduation now? This pushes me to think that I should try writing USMLE. Let’s jump to my statement in the beginning of my essay.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

Do I see a future here? NO. Do I want a future here? NO. But this is my new ambition. This is what I should answer when a stranger asks me what you are going to do after finishing MBBS. I’ve been pushed like the majority of students in TN.

We must accept that corruption has found its way in the health sector too. However, I will be unfair in not adding that majority of the doctors remain committed to the ethics of the profession.

Let’s see another scenario; young Indian doctors are making the country proud through their work in developed countries such as Canada, the US, and many European countries. These doctors are working in a better medical ecosystem unlike doctors in India, who are forced to continuously fight unheeding authorities both for the rights of unaware citizens and overworked doctors.

Only 1.3 percent of the GDP is directed towards healthcare. As per the Universal Health Coverage NHP (National Health Policy) in 2017, four percent of GDP should be allocated for health. This data doesn’t reflect that health is a priority for the country.

India has only 10 lakh doctors working in government and private sectors. According to the World Health Organization, the doctor to patient ratio should be 1:1000. Which means India cannot afford the migration of young minds abroad.

We must find a way to prevent this migration. I didn’t mean preventing the true ambition of students who really know and want a career abroad. I want to stop the migration of students like me who are pushed out due to insecurity.

Recently the NMC Bill was tabled in Parliament and sent to the parliamentary standing committee. The panel has advocated “bridge courses” for indigenous and alternative medicine practitioners such as Ayurveda, and Homeopathy. If bridge courses could have been a real solution then I want a bridge course for local panchayat leaders to fix the shortage of judges in the country.

Thus we are facing a major crisis in TN of loosing young talented doctors to central Universities and abroad. We need to increase the stipend and salary of doctors here and we must provide a safe environment for the doctors. For this, we need a strong political will and planning to prevent such migration.

The basic concept is – rather than counting on what others can do for you, make your life count

Conclusion:

It is better to die on your feet rather live on your knees. Gandhi is an iconic man the world has ever seen. The time when people believed that war was the only solution, there stood a man against violence and proved to the world that humanity, love, and non-violence can win too. He stood up to his lines “Be the change that you wish to see in the world. “ His life itself was a message. In this essay, I have dealt my best to explain my life experiences and my Gandhian principles and Gandhi’s contribution to medicine.

References:

Gandhi M. K., “An Autobiography or the Story of My Experiments with Truth”, Navajivan Publisihng House, Ahmedabad, India, 1927.

Gandhi M. K., “Keys to Health”, Navjivan Publishing House, Ahmadabad, India, 1948.

Gandhi M. K., “Social Service, Work and Reform” (Vol-1), Navjivan Publishing House, Ahmadabad, India, 1976.

Gandhi M. K., “Diet and Diet Reform”, Navjivan Publishing House, Ahmadabad, India, 1949.

Keywords: Gandhi Health, Health promotion by Gandhi

 

Innovation in Medicine – A better solution for the translation issues

Innovation in Medicine – A better solution for the translation issues

Introduction:

Translation is a key process in any medical student’s life. As a third year medico I have faced a lot of situations where I thought that maybe we need a better solution for the translation issues. In this essay, I have dealt with the translation problems faced during my MBBS course and newer ideas as a solution.

My first research and Google translate:

During my 2nd year, me and 5 of my friends did a cross-sectional study on,” diarrheal diseases in relation to possible risk factors in Thanjavur. First, we created the protocol and we started framing research questions. Framing the research questions was absolutely easy as we got a nice internet source. But translating the questionnaire to Tamil was really tough. For that 6 of us divided the 6-page questionnaire (each 1 page) and started translating. 2 of us, including me, used Google translate and the others just translated themselves with few references from the internet. In the end, when we compiled we found that lots of sentences seemed senseless in the pages translated by Google. Google translate is an effective model for translation, but it has its limitations. Afterward, we finished those 2 pages by ourselves and compiled the questionnaire. Machine translation cannot know which definition the source material pertains to as a single word may contain more than one meaning.

Other ways for translating questionnaires:

  • Google translate made a recent update to increase the precision of translation. Also, we can download any language and use it offline. We could translate either way when we have 2 languages.
  • Microsoft translator allows a faster way of translation. We can just type in our regional language words in English letters (as we do during whats app chats) and the translator automatically converts it to English or the regional language letters as we wish. This was popularly being used in whats app chat where we could use the G symbol to access this option.
  • Photo translation is also provided in the recent version of Google translate and this makes translation even easier. We simply need to scan the page we need to translate and instantly the page will be translated to the language we want.
  • SmartMATE machine translation provides a secure translation platform. This service is provided by CAPITA. This service could be used when we have a really large questionnaire or if there is the need for translation into multiple languages.

Dengue outbreak in our area and the stumbled survey due to translation issues:

In the winter of 2016, we had a dengue outbreak in Tanjore. At that time our students along with our PSM department started doing surveys regarding the risk factors of dengue house by house. We had a very good questionnaire in Tamil and the survey was going well without any interviewer bias. At that time a super specialty block was under construction on our campus. Most of the workers in that work were from North India and Andra Pradesh. They couldn’t understand our questions and we couldn’t understand them too. Luckily we got some batch mates from North India and also some knowing Telugu. Thus we have managed to tackle the issue and conducted our survey without any difficulty. This event insists on the need for a real-time translation which would prevent such language barriers.

Real-time translation devices:

  • WT2 real-time translator device by Timekettle is a real-time translation device which brings translation to the next level. It is basically 2 wireless earphones and one phone with an application (hence called 1+2 translation system). We need to charge and plug one on the examiner’s ear and other on public’s ear. It translates face to face. The translation application is meant for use only in i.o.s, as on now. They need just Bluetooth pairing headphones. There are different modes like ask mode, speak mode, chat mode(master) and chat mode(slave)
  • Handheld mobile applications and devices are also available where interviewers like to pass and talk. But all of these are error prone and difficult to use. Yet these are cheap and could be considered in unavoidable situations and there of a lot of such devices and applications available in the market.
  • Google pixel buds are more convenient as the examiner alone needs earphones and the other person hears translated version played through the phone. This cost similar to the WT2.
  • BPC 2+2 type of translation devices are available but not suitable for real-world scenario as it requires both the examiner and the other person to have mobile with the application and also earphones.
  • The pilot system by Waverly labs is an application that allows translation between languages in two ways: speaking or texting. The source language and the target language must be selected and if both are available then real-time translation. This now needs data but future versions could be offline.

University examination in Madhya Pradesh Medical University- a novel approach to language hurdles.

On May 30 this year, Madhya Pradesh University has decided to allow medical students to write their exams in English or Hindi or HINGLISH (both languages mixed). This is a very novel approach to allow students to exhibit their full potential without any language hurdles. I am from English medium, but I got friends from Tamil medium too. During 1st year exams, they found it very difficult to exhibit what they know in their papers. Most of them adapted but still, some find it difficult to express their knowledge. Allowing them to write in their comfortable language would provide everyone a fairground in the exams. In the medical profession, we get to interact with our patients only in regional languages. So English is actually a tool for learning (as many medical books are available in English) and also for academic purposes. Other than that having a great English knowledge is not an important thing for a good medical practitioner.

Other language patients entering in our outpatient department:

Effective doctor-patient communication is essential for a good health care system. One day in our ENT OPD we got a north Indian patient who does not speak Tamil or English. We were unable to elicit a history from him. For example, if I need to ask the type of pain from a patient in his own words I should put forth the leading question about how the pain is. I finished my B.A. equivalent degree in Hindi (Praveen Uttarardh) from Dakshin Bharath Hindi Prachar Sabha on 2015. When my professor asked, “Anyone knows Hindi?” I raised my hand and went to take history. But I could only elicit his personal details and his chief complaint as difficulty in breathing. Other than that I was not able to elicit any. Luckily we got an ENT postgraduate from LakshwadeepDr.Shahira who knows Hindi well. She elicited the history and the patient was diagnosed to have an allergic Rhinitis. Such language barriers seem to hinder even when practitioners know the language to some extent. This event proves that we need an effective referral system for such patients.

Health Information in Other Languages

The National Library of Medicine provides access to health information in other languages on general health and special topics. These resources include:

HealthReach — Health Information in Many Languages

MedlinePlus en español — Información de salud para usted

MedlinePlus — Health Information in Multiple Languages (45 languages)

infoSIDA — Información sobre el tratamiento y los ensayos clínicos del VIH/SIDA

ToxMystery (en español) — Una actividad ToxMystery.

ToxTown (en español) — Inquietudes de salud ambiental y sustancias químicas tóxicas en su lugar de residencia, trabajo y diversión.

Across the word technologies now used to overcome language barriers:

There’s an app for relaying basic medical instructions in Fukienese, a group of dialects spoken in southeastern China. Need a way to help bedridden non-English-speaking patients instantly alert a nurse for assistance? Touch-screen software exists that allows patients to click a pained face — perhaps marked “pain” in Russian — to instantly alert a nurse. Both were created by New York City-based Transcendent Endeavors to improve communication between patients and healthcare professionals who speak different languages.

For now, phone-based interpretation services are the best technological substitute for having a trained interpreter in the room. Some hospitals have made it their policy to use phone-based services in emergency rooms because it’s faster to call than to wait for an interpreter to arrive, says Catherine West, the senior research scientist at the George Washington University School of Public Health and Health Services

Federal law regarding language services:

Federal law requires all health care facilities that receive federal funding offer language services to patients who need them. Most hospitals accomplish this by relying on a mix on staff interpreters, bilingual staff, outside interpretation agencies, and phone-based services. Yet many facilities don’t do a good job connecting patients with language services. Less than half of patients who need an interpreter say they usually get such assistance, according to a 2001 survey from the Commonwealth Fund.

Conclusion:

Language barriers are everywhere in the medical field. Starting from a 1st-year student trying to learn concepts of physiology to a senior medical practitioner getting stumbled by other language patient coming to his OP. in this essay I have dealt with the possible solution for language barriers in medicine.

References:

  • The Future of Translation, Technology, and Translation Technology – memoQ https://www.memoq.com › the-future-of-…
  • The Most Important Trends in Translation Technology for 2018 | Slator https://slator.com › sponsored-content › i…
  • The Latest Language Translation Technology – United Language Group
  • daily.unitedlanguagegroup.com › …
  • Modern Technologies in Translation | ZELENKA
  • https://www.zelenka-translations.com › m…
  • Translation Technology: Types and Definitions | …
  • https://www.gala-global.org › language-t…
  • The Effects of Technology on Translation Students in Academic Translation Teaching – ScienceDirect
  • https://www.sciencedirect.com › pii
  • https://www.theatlantic.com/amp/article/430746/
  • https://www.nlm.nih.gov/information-in-other-languages.html

 

Five Years of My MBBS Life

Five Years of My MBBS Life

I had joined the medical college with all the excitement that is humanly possible. Getting merit-based scholarship and not having to pay a single penny as a donation to college, I had made my parents proud. Not that I had always wanted to be a doctor. Being a doctor is the epitome of success academically in our society. The toppers of the country would choose to be a doctor. More than me, my parents were happy that I was studying Medicine. What more could I do than to make my parents proud. Not that I was forced to study medicine. Personally, I was indifferent. I wanted to go through the tough road that elites chose. Deep down inside, I still wanted to explore passion in life. But I was far too lucky (and thinking now maybe unlucky) that I got my name in the successful candidate name list in the MBBS entrance examination.

First year: Crushed euphoria

I was so happy to sign in the admission forms and submit all my certificates. More than that I was happy to see my dad’s smile while I was signing. Getting my hostel room key and filling a small sheet of paper for college identity card filled me with utmost pride.

As classes started, the happiness curve went down. All my expectation of med school became upside down with the reality. As happy I was to get the key to my hostel room, I was more disappointed to open the room of the hostel that was located 3 kilometers away from the hospital right next to the public bus park. Unlike the photos are shown on the website of the college, the hostel was a temporary rented hotel, with zero facilities. The hostel corridor had a leaking terrace and in the monsoon flooded our room if we opened our door for long. The soaked carpet smell mixed with our own sweat smell during the power cuts was in the air. Love definitely wasn’t in the air.

Second year: Exams

Literally, the second year was nothing but the exams. We had monthly big exams, and countless small posting examination. The syllabus was vast and time very limited. On top of that, we would hear about the terror of HODs of departments during practical Viva examinations. Our only aim was to pass every internal examination so that we would not be barred from giving board examination.

Third year: Honeymoon year

We were posted in the hospital. We had our first share of exposure to the patients. Only two subjects whose exam would be there. Taking history and learning physical examination. It was far different kind of learning compared to learning from the cadavers of first-year anatomy class. For the least, all we had to do was to maintain our attendance to 80 percent.

Fourth Year: Minors

We had already spent a year in the hospital wards and OPDs. The place felt familiar and we had been quite familiar with the history taking and physical examination. Watching POP casts and slabs in the Orthopedics OPD was exciting. Learning to use an Otoscope and be able to visualize the perforated eardrum gave all of us some happiness of sorts.

Final Year: The real exams

We were the same as the third year and our posting was the same. But the way our teachers treated was entirely different and that increased the fear. They would constantly remind of us being the ‘exam giving batch’ and that we had to cover each and every topic. Everyone was seriously studying except for the legends who still got time to flaunt the new bike they had bought.

Time passed in a blink of an eye. There was so much to study and so less of time. Nothing except the syllabus mattered. The frequency of mom and dad calling to ask about my whereabouts decreased. Going out for parties were almost nil. Birthday parties got postponed.

Internship: Three Ds

Dressing. Discharge. Daru (alcohol). The dressing of wounds and especially of the burn patients was really difficult and time-consuming. Making discharge sheets of patients who were admitted for delivery of babies was hectic as hell as the number many a time crossed half-century. And a chilled beer once in a while was the answer for releasing the frustration of doing ‘clerk-type’ work every day.

Right now, I am almost halfway through my internship. The days are so varied. Some days, we get all the time in the world to talk about all the things that are shitty in this country. Other days, we are so tired we fall asleep right as we close our eyes. The way we are treated also varies greatly. Some patients treat as if we are magicians wearing white gloves applying elixirs in their wounds and heal them. Other patients treat as if we don’t even exist there.

Final Note:

With all the free ‘no-need-to-read-compulsorily’ time that I have got in the internship, I get plenty of time to introspect. I think about the situation in the country. I talk with the residents and learn about the things I could do during my internship days to make the future a little bit easier when I would be working in a hospital far from cities. And some nights when I am alone in my room and it is raining outside, I wonder with one question on my mind:

Would I be a good doctor?

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