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GLAUCOMA: EXAMINING THE SILENT THIEF OF SIGHT

Dr Gauri Bhushan

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Glaucoma is the leading cause of irreversible blindness around the world and, as per the National Programme for Control of Blindness, the third leading cause of blindness in India. Glaucoma, popularly known as ‘kaala motiya’ is asymptomatic in its early stages and leads insidiously to an irreversible visual impairment. However, early detection can halt the progress of the condition and prevent loss of vision.

WHAT IS GLAUCOMA?

Glaucoma refers to a condition of the eye where an increased pressure (unrelated to blood pressure) leads to the damage of the optic nerve. This damage is irreversible and once lost, vision cannot be restored by medication or surgery.

The real challenge in the diagnosis of this disease is its symptomatology and its slow progression. It is usually asymptomatic in the early stages, although a patient may complain of increased problems with near vision, occasional headache and loss of peripheral vision. In India, where the majority of visual complaints is still managed by the shorter route of getting a fancy new pair of glasses from the nearest optical shop, a thorough eye examination is often missed. The diagnosis of glaucoma, a condition which is usually picked up by an ophthalmologist in a routine eye examination, gets delayed. Asymptomatic glaucoma is thus allowed to follow its relentless course towards severe visual loss before medical attention is sought. A patient may even ignore glaucoma-induced blindness in one eye as long as the other eye remains functional, not realising that the same fate is slowly unfolding for the better eye.

DO I HAVE AN INCREASED RISK OF DEVELOPING GLAUCOMA?

There are various known risk factors for the development of glaucoma, with age being one of them. People over 40 years are at a relatively higher risk of developing glaucoma. With a strong genetic linkage, a positive family history also increases the risk of developing glaucoma by up to ten times. So, if someone has glaucoma, they must get blood relatives tested as well.

Apart from age and genetics, myopia, migraine, diabetes, hypertension, thyroid and trauma to the eye also increase the risk of developing glaucoma.

WHAT SHOULD I DO AFTER THE DOCTOR TELLS ME I HAVE GLAUCOMA?

Remember that damage caused by glaucoma is permanent and irreversible. Once glaucoma is detected, the treating ophthalmologist performs certain tests to quantify the visual impairment and find the subtype of glaucoma. Subsequently, patients are advised medication, laser therapy, surgery in advanced cases, or a combination of these. The treatment given aims to halt the progression of the disease by bringing down the eye pressure, but it cannot reverse the visual loss which has already occurred.

Treating glaucoma successfully requires the team effort of the treating doctor and the patient. It is imperative that the patient does not discontinue medication without consulting the doctor. Compliance with the prescribed medication is extremely important as any spike in eye pressure can have deleterious effects on a glaucomatous eye.

The diagnosis of glaucoma is often shocking for the patient who perhaps went prepared only for being prescribed new glasses. The possibility of having a chronic, potentially blinding disease is difficult for the patient to accept, hence communicating clearly for better understanding and laying out a clear plan of action are important. Even when glaucoma has already delivered a harsh lesson, careful education is still needed to help the patient understand the nature of the disease, the rationale for treatment and the importance of compliance.

For a patient affected by glaucoma, the impact can be profound, which can include difficulty with mobility, driving, employment and depression. A high level of awareness and knowledge of this silent killer of the eye is the need of the hour. For public awareness and patient education, there are various portals and websites by numerous ophthalmological societies across India. A timely diagnosis, initiation of treatment and compliance with treatment lifelong can conquer this potentially blinding disease.

So, the next time you have any symptoms related to your eyes, book an appointment with an ophthalmologist without delay and kick this devil out before it knocks you out.

The writer is Consultant Ophthalmologist, NKS Hospital, Delhi.

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Medically Speaking

DELHI DOCTOR PERFORMED ENDOSCOPIC SURGERY ON A 14-YEAR-OLD BOY

Shalini Bhardwaj

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A team of surgeons at Indraprastha Apollo led by Dr Noor ul din Malik, Senior Consultant, ENT (Surgery), Indraprastha Apollo Hospital, successfully performed an endoscopic surgery on a 14-year-old boy who had developed a rare tumour (Juvenile Angiofibroma-JA) on his nostrils that was protruding on the external side of his nose. This kind of tumour is extremely rare and even the process of its surgical removal can be life threatening considering its location. The child was admitted to Indraprastha Apollo Hospital, with complaints of a progressively growing tumour on the nostril due to which he was unable to breathe properly.

“This is a rare tumour found only in young boys as it occurs only in adolescent males; male hormones can be attributed to the development of the tumor. In earlier years, external approaches were used for its removal but now endoscopy is the standard treatment. In this case, the endoscopic approach was difficult owing to the location of the tumor as there was no space and the tumour was protruding out of the external nares. We took the challenge and went ahead with an endoscopic approach using a technique called segmentalisation of tumour through which we were able to remove it completely without any external scar and without a preoperative embolisation. The procedure was a success and the patient was discharged within 3 days of the surgery on 28 January 2021.” said Dr Noor ul din Malik.

Majorly reported in young adolescent males, juvenile angiofibroma (JA) is a rare benign, locally aggressive vascular tumour of the nose. The management of this tumour is challenging because any surgical intervention can cause excessive blood loss as this tumour is located at the complex anatomy of the nose base. Out of all head and neck cancers, 0.05% account for angiofibroma.

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EQUITABLE ACCESS TO VACCINES WILL HELP CONTAIN PANDEMIC: UNICEF REPRESENTATIVE

Shalini Bhardwaj

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Dr Yasmin Ali Haque, the UNICEF representative in India, was at Serum Institute of India (SII), Pune, when the shipment containing 600,000 doses of Covid vaccines left for Ghana. A second shipment of 504,000 doses, sent from Mumbai, landed in Ivory Coast, West Africa, this week. In a candid conversation, she talks about the COVAX Facility, the initiative to provide equitable access to Covid vaccine, and how it will help the world end the pandemic. Excerpts:

Dr Yasmin Ali Haque

Q: How did you feel as the first batch of vaccines left for its destination from the Serum Institute of India (SII) under the COVAX Facility?

A: It was a historic moment as the first batch of 600,000 doses of Covid vaccine left for Ghana from the SII in India. It is for the first time that so many partners have come together to ensure that the vaccines that have the potential to save billions of lives reach people all over the world equitably. It is a major step in the global effort to beat this pandemic and a landmark achievement towards global equitable access to these life-saving vaccines.

Q: How many vaccine doses will be provided under this facility and to whom?

A: The first batch of 600,000 doses have already reached Ghana. The COVAX Facility, co-led by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO, together with UNICEF, aims to dispatch 80 million doses by March and provide at least 2 billion doses of approved Covid-19 vaccines by the end of 2021.

As part of the COVAX Facility, UNICEF is leading efforts, in collaboration with the PAHO Revolving Fund to procure and supply doses of Covid-19 vaccines for the 92 low and lower middle-income countries on behalf of the COVAX Facility to enable them to protect their frontline healthcare and social workers, as well as other high-risk and vulnerable groups. Of these, PAHO will be procuring and supplying doses to 10 countries in Latin America which are: Bolivia, Dominica, El Salvador, Grenada, Guyana, Haiti, Honduras, Nicaragua, St Lucia, St Vincent and the Grenadines. The COVAX Facility has put in a system of determining the destinations and recipient countries and number of doses.

Q: How many of these doses will be provided by India?

A: Of the 2 billion, majority will come from SII, Pune, which has a licence agreement with AstraZeneca and Novavax. India’s manufacturing base is playing a critical role in closing the gap between rich and poor countries. UNICEF from India will ship the vaccines to 82 low and middle-income countries participating in the COVAX Facility.

Q: Why are these vaccines being procured only from SII in India?

A: COVAX Facility provides WHO-certified vaccines. AstraZeneca vaccine got WHO-certification on 15 February 2021. As more vaccines get the certification from WHO, based on their price and affordability, other suppliers are being added to the pool.

Q: What is the role of UNICEF in COVAX?

A: UNICEF is a proud and privileged partner of the COVAX Facility. Its role starts with the signing of the agreements for the procurement of the vaccine. We work with countries to see that they have put in place the protocols being advocated by the WHO Strategic Advisory group of experts and also to see that all the systems are in place for safe storage, transportation and administration of the vaccine.

UNICEF ensures safe, timely and efficient transportation of these vaccines from countries where they are produced to the countries where they are to be received. It works with governments and partners to make sure that vaccines reach those who need them the most.

Besides, UNICEF is also supplying a billion syringes that will be needed to administer the vaccine safely. UNICEF started stockpiling these syringes in 2020 itself to meet this anticipated demand. These 4.5-inch-long syringes, if we put them end-to-end will cover the length of the whole world thrice. UNICEF is also buying 10 million safety boxes by 2021, so that used syringes and needles can be disposed in a safe manner by personnel at health facilities, thus preventing the risk of injuries and blood borne diseases. Every safety box carries 100 syringes.

Q: And how do you think COVAX Facility is going to help in ending the pandemic?

A: The equitable access to vaccines will contribute greatly towards containing the pandemic which has disrupted every aspect of life. Due to the pandemic, children and women have not received some of the essential services they needed. Now that the frontline workers will be vaccinated, these services will resume fast.

With these shipments, we are part of the historic journey to provide equitable vaccine access to lower income and lower middle-income countries to ensure no one is left behind and that every vulnerable person around the world is protected from Covid-19 and its direct and indirect impact.

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Is Patanjali’s Coronil really the first drug for Covid-19?

Immunity boosters have their benefits but Patanjali’s Coronil should not be marketed as a drug against coronavirus, say the country’s top medical experts.

Shalini Bhardwaj

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Patanjali’s Coronil has faced controversy since Baba Ramdev’s company came out with claims of the drug being the “first evidence-based medicine” to treat Covid-19. Debating the issue, top doctors of modern medicine and Ayurveda—Dr J.A. Jayalal, president of the Indian Medical Association, Dr Girish Tyagi, former president of the Delhi Medical Association and registrar of DMC, and Acharya Ram Gopal Dixit, president of Arogya Peeth and a neuropathy expert—countered questions and presented their opinions to The Sunday Guardian.

Q: What is the reason behind the controversy surrounding Coronil?

Dr Dixit: I don’t see any reason behind this controversy because Coronil is a kit that increases immunity which further enables the body to fight diseases. Those creating the controversy should get informed about Ayurveda. When we talk about India, Ayurveda should also be talked about. It has been in the backdrop of our culture till now. No matter which field we are in, we should respect the scientific skills and knowledge of our nation instead of spreading controversies. Corrections and discussions should be welcomed but some things should not be criticised just for the sake of your own profit. 

Q: How ethical is it to promote this medicine?

Dr Dixit: Each one of us must have had kadha during this pandemic. Coronil comprises all those essentials in order to prevent diseases, which includes lung disease. My friends and I caught the coronavirus and were hospitalised. And apart from the medicine given to us by the doctor, we used household remedies to treat the infection. I think the name is the main reason behind the controversy. You cannot call this kit a preventive measure, treatment or post-care kit against Covid-19, because then the vaccine will have no use in the country, but you may call it an immunity booster.

Q: What are your concerns regarding the kit?

Dr Jayalal: We are not against the prestige of a drug. The only concern is the claims of the function with which it was marketed to us. We are well aware of the benefits of immune-boosters but in case of a pandemic with a mortality rate of 1.6 million, if we call Coronil as a preventive, treatment and post-complication care against Covid, we will call it as the monetary benefit of a company. We accept the Ayurvedic drug wholeheartedly, but if someone claims it to be an evidence-based drug of choice for the treatment, it is subjected to question.

When the press asked questions regarding the drug, they showed the evidence proved in the pilot study of a phyto-medical journal. A pilot study is a study that occurs prior to a proper study, and is also called a sample study. They have included only 45 people in the study where every individual was asymptomatic. They say they did it in IL-6 and TNF factor, but how can these biomarkers be raised in an asymptomatic person? To mount on that, the researcher is Patanjali itself. Conflict of interest will always be created if there is no second opinion from other scientists and researchers, but the company itself. If Baba Ramdev claims it as an immune-boosting kit, there is no issue. But they cited it as the first evidence-based drug and claimed to have WHO certification in the presence of the WHO director. This should have been avoided. We respect Ayurveda and Dr Acharya. But we plead the Government of India not to give out a false message to common people.

Q: Trials have been conducted on the false projections of the Coronil kit and a lot of people have shown their concerns about it. What would you say regarding the trials?

Dr Dixit: The Covid pandemic is now under control and we appreciate the vaccine and the achievement of our country in its development and distribution. We are talking about the research on the basis of modern medicine. The Vedic research cannot be conducted for a larger picture. But Ayurveda believes that if all the three Doshas become one, all illnesses will reduce automatically. All the Agnis should be equal and all the seven Dhatus should be equal too. For this, Coronil contains all the essentials.

Q: People are avoiding the diagnosis and treatment of Covid, believing the claims of an immune-booster drug, which is wrong.

Dr Dixit: I would like to say that the number of Covid-positive people being represented to us and the actual number of active cases don’t match at all. Literate people do go to doctors for the treatment of Covid but more than 70% people are treating the disease at home. They don’t tell the medical team about their disease fearing quarantine. Many people who were given HCQ also died, even after being admitted to the ICU.

Dr Tyagi (to Dr Dixit): Can you claim that death won’t be the end result after Coronil?

Dr Dixit: No, I can’t.

Dr Tyagi: Stop claiming that the kit will prevent Covid as it is wrong to do so.

Dr Jayalal: India had a recovery rate of 97%. More than half of the remaining 3% died because they had low immunity and were already suffering from other diseases.

 Q: Some of those who died may have had co-morbidities, but some included young doctors and other young people too.

Dr Jayalal: If you see, 80% of the deaths occurred of the hyper-immune syndrome. This means that immunity is overreacting, which produces more Ferritin, IL6 levels. This is the area which is still not understood. We may say that low immunity is a problem, but other than that, the deaths also occurred due to a cytokine storm, which produces immune cells mismatched to the disease. You can recall the benefits of immune-boosters but how immunity works is still a question. You can claim evidence only on the basis of good research. Otherwise, don’t call it a therapeutic drug. It is very disrespectful for us when Ayurveda claims Coronil as the “first evidence-based drug”. Let us not allow our knowledge to be hijacked on scientific grounds for the profit of a company.

Q: What would you like to say about this, Dr Dixit?

Dr Dixit: I talk about Coronil and not the company. I can only talk about the contents of Coronil and I too am not supportive of the claim that Patanjali makes. Information and claims are two very different things. But I would say that these contents do promote immunity and enable the body to fight any viral or lung diseases.

Q: The kit comprises three components. What are they?

Dr Dixit: One of them is swasari pravahi to normalise breathing. The second one is a nasal spray that clears the nasal passage so that the mucous lining doesn’t clog it. And the Coronil tablet helps to boost immunity.

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NO COVID-19 VACCINATION ON 27-28 FEB; GOVT TO UPDATE CO-WIN

Shalini Bhardwaj

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New Delhi: The Union Ministry of Health and Family Welfare announced that the vaccination drive will be halted for two days, i.e., February 27 and 28, on account of a software change necessary for the second phase of vaccinations. The second phase of the Covid vaccinations will begin from March 1 across the country.

The second phase of the Covid-19 vaccination drive is for people aged 60 years and those above 45 years with co-morbidities. The two-day pause comes at a time when India is being criticized for a slow vaccination process. The vaccination drive in India was started on January 16 and the first jabs have been given to healthcare workers, followed by frontline workers like police personnel, people of the armed forces, municipal workers, teachers, etc.

A high-level meeting was also conducted with States and UTs to inform them about the 2.0 version of the digital platform Co-WIN.

“The States and UTs were explained the basic features of version 2.0 of the digital platform Co-WIN. Private sector hospitals will be involved as Covid vaccination centres to harness their potential to expand the vaccination capacities,” stated the Government of India.

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METALLIC PIN REMOVED SUCCESSFULLY FROM CHILD’S LUNG

Shalini Bhardwaj

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New Delhi: A team of doctors from a Mumbai hospital gave a fresh lease of life to a 10-year-old girl who had accidentally swallowed a large metallic pin with a sharp end two years ago. A team led by ENT doctors Dr Kshitij Shah and Dr Shalaka Dighe, ably supported by paediatric pulmonologist Dr Sagar Warankar and an anaesthesia team led by Dr Pramod Kale, performed a successful surgery at the hospital to remove the pin from the girl’s lung. The patient recovered and was discharged within 48 hours.

Naira Shah (name changed) from Mumbai had accidentally swallowed the metallic pin two years ago. An X-ray of the abdomen had failed to reveal the foreign body and the incident was forgotten about, until Naira started complaining of a dry cough and was taken to Zen Multispeciality Hospital for further investigations.

“To our utter surprise, an X-ray of the chest revealed a metallic foreign body in the lower airway on the left side. A CT scan of the chest was done to precisely locate the foreign body. After an initial attempt at removal of the foreign body by flexible bronchoscopy, a decision was made to perform a rigid bronchoscopy,” said ENT surgeon Dr Kshitij Shah.

“Rigid bronchoscopy is a procedure done to gain access to the patient’s airway using a hollow metallic tube under general anaesthesia. The foreign body was successfully removed without any complications and without an external scar on the body after an hour-long surgery,” informed ENT surgeon Dr Shalaka Dighe, adding, “The child was hale and hearty in a couple of hours after surgery. Failure to remove the foreign body via bronchoscopy would have meant a very morbid open surgery (thoracotomy) to remove it.”

“For over 1.5 years, Naira (name changed) was fine and did not encounter any problems. But suddenly she started coughing. We panicked, feared Covid and took her to Zen Hospital. We are thankful to Zen Hospital for promptly treating our child. We urge other parents like us to keep sharp or metallic objects like pins or coins away from their children,” concluded the patient’s father, Sanjiv Shah (name changed).

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UNRESPONSIVE MOUTH ULCER CAN BE CANCER

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Mouth ulcers are quite common in all age groups and can make regular activities such as eating, drinking, and talking very uncomfortable. However, mouth ulcers can be cured with antimicrobial or painkilling mouthwash, gel or spray. However, if the ulcers persist for several weeks even after treatment, one must not ignore the signs as it may indicate a cancerous growth. There are many signs of mouth cancer but red sores that do not respond to treatment or heal is a telling sign. Lifestyle habits such as drinking alcohol or consuming tobacco—both smoked and smokeless—can cause cancer of the mouth. Besides human papillomavirus (HPV), known to cause sexually-transmitted infections (STI) and cervical cancer, can also cause mouth cancer. HPV-affected mouth cancer is seen in the soft palate, tonsils, base of the tongue, and pharyngeal wall areas.

SYMPTOMS OF MOUTH CANCER

1. Persistent and unexplained lumps in the mouth or the neck

2. Unexplained loose teeth or sockets

3. Unexplained, persistent numbness on the tongue or lips

4. White or red patches on the lining of the mouth or tongue

5. Changes in speech like lisp

The types of mouth cancer are categorised by the type of cell it starts to grow in. Medically it is known as carcinoma. The most common type is squamous cell carcinoma that affects 9 out of 10 cases of mouth cancer.

LESS COMMON TYPES

1. Adenocarcinoma in which cancer develops inside the salivary glands

2. Sarcoma in which cancer develops from the abnormalities in cartilage, bone, muscle, or any other tissue

3. Oral malignant melanoma in which cancer starts in the cells that produce skin pigment (melanocytes). They often bleed and appear as dark, mottled swellings

4. Lymphoma in which cancer grows from cells in lymph glands

Mouth cancer as well as treating it can cause complications and affect the appearance of the mouth. Besides, it can cause dysphagia (problems with speaking and swallowing). Dysphagia can be a serious complication. If a small piece of food enters the airways when you try to swallow and gets lodged in the lungs, dysphagia may lead to aspiration pneumonia (a kind of chest infection).

PREVENTING AND TREATING MOUTH CANCER

Cancer of the oral cavity (lips, tongue, buccal mucosa, tonsils, and palate) can give rise to various complications that include difficulty in eating, speech, alteration in voice, inability to open mouth fully, pain in the ear, and bleeding if not treated in time.

Easy lifestyle changes and preventive measures including but not limited to the following can help in preventing mouth cancer in most people:

1. Quit smoking or consuming smokeless tobacco as well as alcohol

2. Get vaccinated against HPV

3. Using a condom during oral sex to lower the chances of HPV infection

4. Visiting a dentist regularly for screening

5. Consuming a balanced diet of fresh vegetables (especially tomatoes), citrus fruits, olive oil, and fish with omega-3 fatty acids

If diagnosed early, mouth cancer can be completely cured in 9 out of 10 cases using surgery.

The writer is working in Clinical Oncology, Columbia Asia Hospital, Palam Vihar, Gurgaon.

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