IMAGE - nov- dec.2008

FROM THE EDITOR’S DESK

AUDACITY OF HOPE ALONE CAN LEAD TO QUANTUM OF SOLACE !

Audacity of Hope coupled with Action – the ‘karma’, alone can lead to Quantum of solace. That is what was achieved thro’ IMA morcha, protesting violence against doctors.
After the successful march, an opinion was voiced about meeting ‘might with might’ ; another senior colleague thought, brain better over brawn – ‘acknowledge, accept mistake – to err is human – and approach Police & Legal system to solve the vexed issues’. I personally acknowledge both the views, combining it form a “MEDICAL LOBBY” working at peacetimes with Police, Press & Politicians & coming handy in Panic times as well. For this an organized strategy has to be in place, something very much akin to Jewish lobby in America. The Jews have managed to look after their interests inspite of being persecuted & victimized for so long ; physically surrounded as a small nation, Israel , by Muslim nations ; arch rivals & foes from historical times. We Indians have taken a cue & only recently started lobbying effectively, looking after our interests. And this networking has to be done from a position of strength – economic, intellectual, military whatever it takes. It definately cannot be done from a position of weakness, as victims which tantamount to almost begging. And this sense of collective empowerment does throw up ‘Charismatic’ leaders who can transcend petty interests to lead the whole society / nation with the audacity of hope of a Gandhi, Mandela & now an Obama. I sincerely wish Raj Thackeray, Uddhav Thackeray, Rahul Gandhi & Mayawati show similar “O” ‘karishma’ to not only ‘Navnirman’ a state but the whole country, transcending language, caste , creed etc. We have remained divided, in the name of “Unity amidst Diversity” for 60 plus years – let us acknowledge we are a divided house – ACCEPTANCE is the first step towards transformation.
That brings me home to our own medical fraternity. Aren’t we a divided lot, looking after our petty interests, even at times at the cost of patient’s interests – undercutting opinions, advise & price ; exaggerating colleague’s mistakes just to boost self image – Ego with that one patient / family alone ; at the cost of our own fraternity & society. All our lobbying will come to a naught if we have daggers hidden in our cloaks (or scalpels in aprons ! ) all the time – hunting as hyenas while appearing to run with hares ! I think we all have to use our individual good will with our patients - families, going beyond petty politics, for common good not only of the society but ourselves as well – they say Charity begins at home !! “Let us be the change we want to see in the world”, to quote Mahatma Gandhi.
While drawing inspiration from Jews (they have established themselves not only in business enterprises but academically also with maximum Noble Prizes to their credit), little did I know that 26 / 11 was waiting to happen…. The terrorists bullets have indeed shook the collective psyche of the nation. The need of the hour is awakening of the country, the SYSTEM before it falls into stupor once again – a 2nd freedom struggle so to speak! The first freedom fight was led by intellectuals, the lawyers, the likes of Gandhi, Nehru, Rajendra Prasad etc. Can WE, Doctors & other professionals & intellectuals rise to the occasion to lead the 2nd freedom struggle; freedom from apathy, complacency, a “chalta hai” mindset which is letting the country sink.
How to reach out to the society to help bring about a transformation ? Remember, we doctors are uniquely placed vis-a- vis other professionals & intellectuals. We by the virtue of our profession are able to interact with a cross section of the society , right from lower socioeconomic class to upper strata. Thus we are in a enviable position to ‘influence’ all sections of the society, to bring about a social change, whether that be, to vote on election day or population control. In true sense we will act as the guardians of the health of the society.
Nothing is so strong as an idea, a thought whose time has come in the human consciousness. Let us use our good will with our patients, our contacts & involve them in this awakening to create a social movement for better governance & a safe society, “where the mind is without fear & the head is held high……into that heaven of freedom, my Father let my country awake”.
Come, let us take the first step in “ MAHAN RASHTRA NAVNIRMAN”.

JAI HIND.
Dr. Hemant Agrawal

PRESIDENT’S MESSAGE

My dear Friends & Colleagues,

At the outset, I sincerely apologize for the delay in bringing out this issue of ‘IMAGE’. The delay occurred due to Technical reasons arising out of change in Editorial Team. We welcome our newly appointed Editor Dr. Hemant Agrawal, a very dynamic personality. With this and the forthcoming issues, you will notice drastic changes in the quality and contents of ‘IMAGE’. We sincerely hope the new Editor rises up to your expectation.

Friends, the year 2008 saw two major calamities:

The economic slowdown due to global recession, and
The ugly face of terrorism.

Even though economic recession originated in the U.S.A., its effects are felt by us, directly or indirectly. The market is tight and there is liquidity crunch. In a way, we are also affected – patients are holding on and adopting a wait-and-watch policy in elective procedures. Emergency work, of course, will remain unaffected. Salaries and payments are expected to slowdown. Still confined to the West, we are not as much affected as they, and we hope to recover soon.

The biggest challenge facing us today is terrorism. Terrorists have tried to hold our city to ransom. Many innocent lives have been lost and extensive damage has been done to properties, including the heritage ones. The aim of the terrorists is to create panic, cripple the economy and divide the people. Even though there is temporary loss of great magnitude, our Government has shown the terrorists that there is no room for negotiation and terrorists will be dealt with firmly. We applaud the role of our brave police force, army, navy and NSG Commandos in the fight against terrorists, a number of whom have sacrificed their lives in the process. We deeply mourn for them.

Friends, we are concerned with the social issue as well apart from medical activities. At this hour of grief and loss, we request you all to contribute generously to the Fund created for the families of the deceased policemen in our Suburbs. Your contribution will be duly acknowledged in our Circulars and the next issue of ‘IMAGE’. Let it be known that by their dastardly act, the terrorists have only united us together instead of dividing us.

Together we stand united in this period of grief and pledge that no act of terrorism can shake our loyalty and faith in our democratic country. We are determined to root out the evils of terrorism.

JAI HIND, JAI MAHARASHTRA
LONG LIVE IMA MULUND

Dr. V. Seetharaman

ONE DAY TOKEN STRIKE & SILENT PROTEST MORCHA ON 10TH OCTOBER 2008

On 7th October 2008, a meeting of all local IMA Branch representatives was convened at Mumbai IMA office at Haji Ali. President Dr. V. Seetharaman and Secretary Dr. Nilesh Pandya represented Mulund IMA. In the meeting it was conveyed that a one-day token strike be undertaken by all local IMA Branches on 10th October 2008, as directed by IMA – Maharashtra State to protest against attacks on Doctors by hooligans. We were also requested to organize peaceful protest ‘Morchas’ to pressurize the Government to pass a Bill making attacks on Doctors a non-bailable offence. Such an act already exists in states like Andhra Pradesh and IMA MAH wanted the State Government to pass an ordinance and sign a bill at the earliest to this effect. It was also decided to launch a mammoth protest ‘Morcha’ from St. George Hospital to the Collector’s office on the same day afternoon to submit a Memorandum to the Government officials.

In spite of very short notice, the office bearers of Mulund IMA worked hard to get maximum support for the strike and protest march. Pamphlets announcing the strike were distributed, Protest banners made in many languages, Black Bands distributed , Mass SMS contact made, personal phone calls & visits to colleagues followed ! Police permission was obtained for the protest march & media was informed. All this was done on a public holiday, Dussera with limited man power !

Despite the short notice of one-day, the response to the strike was tremendous, with approximately 200 Doctors ( including many senior ones ) assembling at our Presidents Hospital, wearing black bands and displaying the Banners. The Secretary Dr. Nilesh Pandya briefed the members about the strike and the protest ‘morcha’ followed by President’s address.. The Members were requested to stage a silent protest ‘morcha’ to the Police Station in groups of three. The ‘Morcha’ started from Devidayal Road and moved towards ‘Panch Rasta’ and then along M.G. Road towards the Mulund Police Station. Many Senior Members joined the ‘Morcha’ all along the route. The Members were escorted by the Police who were helpful all throughout. The media and the press kept interviewing the Members all along the route. Neither the traffic was disrupted nor the pedestrians inconvenienced all along the route .

The ‘Morcha’ ended at the Mulund Police Station where a Memorandum, regarding violent attacks on doctors with an appeal for timely action against miscreants was submitted to the Police authorities. The officials were requested to do the needful in the matter eventually paving way for passing a Bill making attacks on Doctors a non-bailable offence.The police officers accepted the Memorandum and offered us full co-operation and assurance to maintain law and order.

The President briefed the members about the meeting with the police officials. The members appreciated the co-operation and support of the police officers towards our cause. Senior members like Dr. Mukhi, Dr.Davda, Dr. Upasani & others shared their views on the issue. The Senior Police officer also addressed the members and offered his departments full co-operation. Members were assured of immediate police action at any time of the day in case of assault by hooligans. The Senior Police Officer’s talk was well received. Thereafter the press and media coverage was given by the office-bearers for the public to know the details about the strike and the protest ‘morcha’.

The morcha ended with the Secretary Dr. Nilesh Pandya offering a vote of thanks. He requested the members to join the main ‘Morcha’ of Maharashtra IMA at Mumbai. Accordingly a group of members led by the President Elect left with protest banners to represent Mulund IMA at the State level. Members were requested to keep their OPD and routine work closed for the day; emergency work was permitted wearing black bands of protest. Overall, the response to the call for the strike and protest ‘Morcha’ was excellent. We sincerely thank the members of the Mulund Branch of IMA for co-operating with us despite a very short notice and making it a grand success.

JAI HIND JAI MAHARASHTRA
LONG LIVE IMA MULUND

SLEEP AND CARDIOVASCULAR DISORDERS

Sleep is essential for life and for physical, mental and emotional well being. Sleep has a close relation to cardiovascular system scientifically and emotionally.
There are several risk factors for hypertension,diabetes,coronary heart disease etc, but Sleep disorders as a risk factor has not been highlighted.

NORMAL SLEEP AND CARDIOVASCULAR CHANGES
In Non Rapid Eye Movement (NREM) sleep there is generalized decrement of mean heart rate and blood pressure with marked autonomic stability with parasympathetic dominance.( Stable blood pressure and overall cardiac homeostasis giving an opportunity for metabolic restoration). However there is a risk for further ischemia in patients who suffer from severe coronary disease.
During transition from NREM to (Rapid eye Movement) REM sleep there is heart rate acceleration
pauses in heart rhythm or even frank asystole and shifts in posture resulting in autonomic activation. With aging these shifts are more frequent.
At the initiation of REM sleep there is increased excitability resulting in profound bursts in sympathetic activity.These bursts trigger intermittent increase in heart rate and blood pressure. Breathing patterns become irregular and can result in oxygen desaturations. REM sleep therefore has the capacity to disturb cardiorespiratory homeostasis. However cardiovascular homeostasis must be maintained in sleep and this is achieved by close co-ordination of respiratory and cardiovascular systems.

ABNORMAL SLEEP AND CARDIOVASCULAR DISORDERS.
Sleep is generally beneficial and protective but not in subjects suffering from respiratory and cardiac disease as it can precipitate cardiac arrythmias, myocardial ischemia, breathing disorders and even death.

SLEEP DISORDERS :
Obstructive sleep apnea (OSA), Central sleep apnea (CSA), Chronic sleep deprivation ( CSD ), Nightmares are some of the sleep disorders with adverse effects on the cardiovascular system. OSA is a common disorder but is usually not recognized in clinical practice. The disorder is characterized by repeated pharyngeal collapse pharynx in sleep resulting in cyclical hypoxemia. Sympathetic stimulation coupled with release of stress hormones and endothelin impose a significant burden on the cardiovascular and metabolic systems. OSA is a risk factor for the development of hypertension, ischemic heart disease, strokes, type 2 diabetes mellitus,dementia and others. Habitual snoring (often loud) and excessive daytime sleepiness are the two prominent symptoms of the disorder. The other nocturnal symptoms witnessed apneas, choking, dyspnea (can be mistaken for dyspnea of cardiac origin) restlessness manifested by frequent change of posture, nocturia due to release of atrial natrureticpeptide gastroesophageal reflux, diaphoresis and drooling. Some subjects may just complain of insomnia (patient unable to continue sleep due to repeated arousals) and may compel a physician to prescribe an hypnotic. Sedatives, hypnotics and antianxiety medicines are often prescribed in cardiology practice. Such drugs increase the hypotonia of pharyngeal muscles and therefore should be avoided in patients of OSA. Alcohol is used as sleeping aid by some patients and it also carries similar risk. It is not uncommon to observe patients have choked themselves in sleep after consuming such medications/ alcohol before retiring to bed. It is also important to note that OSA patients are often REM sleep deprived. Chronic REM sleep deprivation results in anxiety, excessive eating and hypersexuality. Excessive eating promotes obesity which in turn aggravates sleep apnea. It is therefore necessary to treat sleep apnea in obese individuals to achieve optimal body weight.
Daytime symptoms of OSA includes sleepiness, fatigue, morning headaches, poor concentration, decreased attention, depression, decreased dexterity and personality changes. Subjects of OSA often exhibit mood swings behaviour and may seek psychiatrist’s opinion. Although obesity is risk factor for development of OSA it is not uncommon to observe OSA in low and normal body weight subjects due to anatomical factors (narrow upper airway). Polysomnography is the gold standard to diagnose OSA.
The apneic hyponeic episodes of OSA have the capability of disrupting myocardial perfusion even in individuals without cardiac disease. The resultant effects are manifested by nocturnal myocardial ischemia, arrythmias and hypertension. A greater prevalence of cardiovascular complications is seen throughtout the spectrum of sleep disordered breathing which consists of snoring, upper airway resistance syndrome and obstructive sleep apnea.


Sleep apnea and hypertension
OSA is an established risk factor for hypertension. In fact it is one of the common and important causes for reversible hypertension.
The chronic usage of continuous positive airway pressure (CPAP) in patients with hypertension and obstructive sleep apnea results in reduction of hypertension both while awake and during sleep..
Sleep disordered breathing in pregnancy may have adverse effects both on the mother and foetus( pregnancy induced hypertension and small for gestational age birth). It is interesting to note that approximately 28% of children born in India are of low birth weight and low birth weight is associated with elevated levels of glucocorticoid in later life. A story from womb to the tomb.
Cardiac medications and Sleep
Lipophilic beta-blockers pinidolol, propanolol and metoprolol increases the number of awakenings and period of wakefulness as compared to placebo and non-lipophilic betablockers like atenolol. Betablockers in general do cause daytime lethargy possibly due to sleep disruption. Melatonin is also depleted by beta-blockers. Beta-blockers and calcium channel blockers may provoke nightmares.

SLEEP DEPRIVATION AND CARDIOVASCULAR EVENTS

Chronic sleep deprivation (CSD) is associated with cardiovascular events by more than one mechanism.viz (1) Sleep deprivation induces or aggravates snoring by increasing muscular hypotonia and delaying contraction of the dilator muscles of pharynx. (2) By causing an autonomic imbalance. (3) CSD in young healthy volunteers has been reported to increase levels of proinflammatory cytokines decrease parasympathetic and increase sympathetic tone, increase blood pressure, increases cortisol levels as well as elevate insulin and blood glucose levels.
Coronary Artery Disease ( CAD ) and sleep apnea.
Several studies have suggested that there is a greater risk of CAD in sleep related breathing disorders. There is 20 fold risk of developing myocardial infarction in untreated OSA. It is therefore important to screen all patients of coronary artery disease for sleep apnea. Treatment of sleep apnea is rewarding in multiple ways viz good quality of sleep, daytime alertness ,normal physical activity which helps in reducing body weight, good cardiovascular function and better glycemic control. Continuous positive airway pressure( CPAP) is the widely accepted mode of treatment of OSA.
Diabetes is a cardiovascular disease There is a close association between OSA and insulin resistance. The nocturnal events in OSA ultimately culminate in cyclical hypoxia, cylclical hypertension release of catecholamines & stress hormones , insulin resistance and diabetes Recently we have reported favourable results in glycemic control in 4 patients of type 2 diabetes who had associated obstructive sleep apnea with regular usage of CPAP. The beneficial metabolic effects of CPAP has been discussed recently and has been documented. There is a close association between diabetes, hypertension, ischemic heart disease, sleep disorders particularly sleep apnea.
Sleep Apnea and atrial fibrillation
Sleep apnea and atrial fibrillation frequently coexist. OSA has been implicated in the recurrence of atrial fibrillation..
OSA and Congestive Heart Failure (CHF)
Central Sleep apnea (CSA) is frequently observed in patients with congestive heart failure (CHF). The condition affects cardiovascular function adversely by causing tissue hypoxia , arousals from sleep and activation of the sympathetic nervous system. It also independently increases the risk of death.Studies have demonstrated beneficial effects of CPAP in CHF. Polysomnography is mandatory in all subjects of CHF.
In conclusion sleep disorders are common in clinical practice. It is time that we took cognizance of this in various cardiovascular disorders since patients usually do not attach much importance to sleep while narrating the history. Society in general has held the view that snoring is a sign of sound sleep. In literal terms sound sleep needs to be differentiated from healthy sleep. A close association exists between anatomical factors in the face, life style, sleep deprivation, sleep disorders, eating, obesity, hypertension, coronary heart disease, metabolic syndrome, cardiovascular morbidity and mortality. It is important to record sleep history in all patients suffering from hypertension, metabolic syndrome and coronary heart disease . Premature death in OSA patients is most often due to cardiovascular disorders. It is now accepted that treatment of OSA by CPAP is rewarding since it can prevent or improve hypertension, reduce abnormal elevations of inflammatory cytokines and adhesion molecules, reduce excessive sympathetic tone, avoid increased vascular oxidative stress, reverse coagulation abnormalities and reduce leptin levels. It is often argued sleep studies may not be economically feasible but given the benefits and properly placed before the patient in question would definitely improve compliance for the test.

Dr.S.Ramnathan Iyer, M.D.(Med) Dr.Revati.R.Iyer, M.S.( OBGY)
(9820143970) (9819598570)

MIGRAINE

A migraine headache is the most common primary headache syndrome. The term migraine is derived from the ancient Greek word hemikranios which means "half head". Attacks are often recurrent and tend to become less severe as the migraine sufferer ages.
Migraine headaches are more common in females usually before the age of 40 years.
Majority of Migraine cases are without aura, only one third of cases being with aura. Less common types include, Ocular migraine, Menstrual migraine etc.
The cause of migraine is unknown. There is often a family history, in 90 % of cases.
Triggers : Commonly identified migraine triggers include the following:
Alcohol , Foods that contain caffeine (e.g., coffee, chocolate), monosodium glutamate (MSG; found in Chinese food), and nitrates (e.g., processed foods)
Environmental factors (e.g., weather, altitude,) ; Glare, contrasting patterns
Hunger, Lack of sleep , Exertion & Stress ; Hormonal changes in women
Medications (over-the-counter and prescription) ; Perfume
MIGRAINE PHASES :
1. Prodrome: Consist of alterations in mood or energy level, excessive yawning, or food cravings.
2. Aura: It is experienced 10 to 30 minutes before the headache. Most auras are visual (scintillating scotomas, zigzag lines or castles- fortification spectra) in nature.
3. Headache: Migraine headache is often described as throbbing or pulsating pain that is intensified by routine physical activity, coughing, straining, or lowering the head.
There may be accompanying symptoms such as nausea, vomiting, sensitivity to light, sound or strong smells.
4. Postdrome: Left feeling tired and weak once the headache has passed.
Diagnosis : Diagnosis is mainly based on symptoms with a near normal neurologic examination.
CT/ MRI, CSF Examination, EEG may be performed to rule out other neurological conditions, including meningitis, intracranial bleeds, vascular malformations etc.
TREATMENT : The goals of treatment are to prevent or reduce the number of migraine attacks (prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine attack (abortive treatment).
A. Abortive Treatment : Mild, infrequent migraines may be relieved using over-the-counter medication. During a migraine headache, people often prefer to rest or sleep alone in a dark, quiet room.
1. Analgesics, e.g., aspirin, ibuprofen should be taken at the first sign of a migraine.
2. Ergots ,e.g., Ergotamine maleate (MIGRANIL) along with anti emetics. Not effective if the headache has moved into the throbbing stage.
3. Triptans: Sumitriptan, Ritzatriptan are fast-acting, usually well- tolerated medications commonly used to treat migraines. They are available in oral, injectable (subcutaneous Suminat) and nasal spray forms and can be taken any time during the headache.
4. Steroids: Used in those with severe, refractory or frequent headaches.


B. Prophylactic Treatment : indicated for Frequent headaches (more than 1/ WEEK) or uncommon migraine conditions .
Start with monotherapy), but a combination of medicines may be necessary.
1. Beta blockers (e.g., Propranolol , atenolol) are the preferred medications. To be avoided in asthmatics.
2. Calcium-Channel Blockers prevent spasm of arteries by inhibiting contraction of smooth muscle. Flunarizine ( [FLUNARIN, SIBELIUM] is the most commonly used.
3. Tricyclic antidepressants (TCAs; e.g., Amytriptyline [TRYPTOMER], nortriptyline are also useful for migraine prophylaxis especially in those with associated tension type headaches.
4. Anti Epileptic drugs (AEDs): Valproic acid , Topiramate, Gabapentin.
There are other prophylactic agents to be used selectively like Cyproheptadine in children.
Prevention : There is no cure for migraine but avoiding triggers, managing stress, and taking prophylactic medications can help prevent migraine headaches. Keeping a migraine journal can help identify triggers and gauge the effectiveness of preventive measures.
Stress management techniques (e.g., biofeedback, hypnosis) and stress-reducing activities (e.g., meditation, yoga, and exercise) may help prevent migraines.

Dr Rajesh Benny
Consultant Neurologist (DM)

GUIDED TOUR KOKILABEN DHIRUBHAI AMBANI HOSPITAL

DATE: 16/11/2008 (SUNDAY)As per the planned program, Members of Mulund IMA started assembling at Shree Ram Eye Care Centre at 10.30 a.m. Tea was served to Members present. Sixty Three Members who approached in time were accommodated in two Buses which started at 11.00 a.m. We reached our Destination at 12.30 p.m., where every Member was given a rousing Welcome with Flower Bouquet. We were then escorted to Food court and served Welcome Drink. In order to manage the Event properly, two Batches were formed. The Hospital has four Gates. The Emergency Trauma Centre has one attached O.T. to take care of Urgent Cases for Surgery. Special provision is made for transfer of Blood Samples, Drugs and Records. Thus, whatever we want to transfer have to be inserted in specially designed Capsules which will travel through Duct till Destination. All the beds in the Hospital have attached Suction, Oxygen, Bells, irrespective of Class. The Seven Hundred Bedded Hospital is housed in 16-storied Building serving Vegetarian Food only. Each Floor has attached Hotel Room for relatives. It has Five Hundred Seating Capacity Hall for Conference. At the end of the program, all the Delegates were given attractive Gifts. Lunch was served to all. We were dropped back again at Mulund. We thank Mr. Vaishnav Pravin C., Relationship Manager, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, for arranging the Tour meticulously.

Dr. Nilesh Pandya

Secretary, I.M.A. Mulund

On a Lighter Note…….

• An American , on his first visit to Ireland is advised to be careful about getting into any argument about Catholic & Protestant beliefs of Christainity (something similar to Shia & Sunni sects of Islam – again divisions of mind & belief systems, divisions & divisions alone… any way … For the readers information , Northern Ireland & Mainland U.K. has also gone thro’ lot of trauma of terror of IRA – Irish Republican Army , again settled thro’ dialogue with the guns falling silent ).
  As the American is roaming thro’ the streets of Dublin, Capital of Northern Ireland, he to his horror feels the barrel of a gun into his back, with the voice booming behind, “ Tell me are you a Catholic or a Protestant ?” The American thinks , remembering the advice given to him, “ If I say Catholic & the terrorist is a Protestant, or the other way around, I am dead meat any way !” Doing some quick thinking on feet, he says, “I am a Jew !” The voice behind squeals with delight, “ O Allah, Never I thought an Arab will get a Jew to kill, in Ireland” and boom goes the gun.
  Such are the chasms of human mind , Jews – Arabs, Shia –Sunni Muslims, Hindu –Muslims, Dalits - Upper Caste ! No other Species has been “intelligent” enough to do this to themselves !!!
  
  
• An Israeli doctor says "Medicine in my country is so advanced that we can take a kidney out of one man, put it in another, and have him looking for work in six weeks." A German doctor says "That is nothing; we can take a lung out of one person, put it in another, and have him looking for work in four weeks. A Russian doctor says "In my country, medicine is so advanced that we can take half a heart out of one person, put it in another, and have them both looking for work in two weeks." The American, a Texas doctor, not to be outdone, says "You guys are way behind, we recently took a man with no brains out of Texas, put him in the White House for eight years, and now half the country is looking for work."

‘MANDUKYA’ UPANISHAD ON SLEEP & STAGES OF HUMAN AWARENESS

Sleep remains one of the most unsolved of mysteries of human life & living. And why humans – sleep is one activity universal to all living entities, including plants.
Mandukya Upanishad expounds beautifully on the four stages of human existence, including sleep.
For the reader’s easy understanding, I have tried to summarize the four stages of human existence in the most scientific manner, as I understood it.

FIRST STAGE : WAKEFUL STATE ( जाग्रत अवस्था )
The body & mind are fully active.And even though body might be passive, Mind is always active – full of thoughts, because one is always reacting to the world around.

SECOND STAGE : DREAM STATE ( स्वप्न अवस्था)
Body being gross, gets tired easily ; loses its momentum & falls ‘dead’ – asleep. Mind continues, being subtle with its momentum & plays out the ‘real’ life dramas, perceived as dreams.

THIRD STAGE : DEEP SLEEP STATE ( सुशुप्त अवस्था )
Ultimately MIND also loses its momentum & ‘falls’ asleep- leading to the refreshing Deep state of sleep.

And the DRAMA once again begins after so called waking up as if in a reflex conditioned manner, taking up from where we left night before , apparently life after life which we obviously do not remember.
BUT if YOU have decided enough is enough, “ STOP THE WHEEL , I WANT TO GET OFF IT “ , the fourth stage begins.

FOURTH STAGE : TURIYA ( तुरीय )
Body & Mind stop running in a reflex conditioned manner – they are at ease all the time, in all the circumstances with an Awareness , said to be in Yoga. Thus never getting ‘exhausted’ the Yogi “ACTS” in life (not “REACTS” all the time ), really awake for the first time in ( so called ) wakeful , working state & never asleep in the ( so called ) Dream & Deep Sleep states. Turiya (meaning fourth) stage – You have truly Arrived in Life ! - Editor.

IMAGE 2009 - PLANS , ASPIRATIONS , DREAMS.

We plan to come out with four regular quarterly editions of Image in the year 2009. It is also my burning desire to come out with a special edition of image, a collector’s delight containing the best of articles on matters of man, mind, medicine ; nature & nurture ; science & art of living. This desire is fuelled by a stray comment of a colleague, that, “ the Image remains for a week on the desk & then ends up in the dustbin !” Indeed this aspiration will not be fulfilled without your active support. Let us use our in-house magazine as an instrument of social change, starting with ourselves. The 2009 , first quarter edition , I would like to dedicate to the subject ,

“SOCIAL AWAKENING & TRANSFORMATION IN THESE VIOLENT TIMES”
MAHAN RASHTRA NAVNIRMAN !

HOW MEDICAL COMMUNITY CAN PLAY A PRO ACTIVE ROLE?

The subject assumes added significance in the wake of increasing violence against ‘soft’ targets - linguistic group, religious minority ,our own medical community & repeated terror attacks against the country as a whole !
With the elections around the corner – a possible turning point in a mature democracy (Americans once again have shown the way by electing a Black president!), Can WE Doctors lead from the front? How do we go about achieving our objective?
Please SHARE your thoughts, opinions with rest of the medical community thro’ IMAGE & formulate a strategy for National transformation in these times of crisis. We are part of the society (well hospitals are even under attack by terrorists!). If WE are not going to be part of the solution, then WE are the problem.
I appeal to all of you, let us play our due role as intellectuals & guardians of the overall health of society ; otherwise our children may not forgive us.

P.S.: All this can be done in a non-partisan, apolitical manner ( politics at present in our society is a dirty word & world. Yet somebody has to do the cleaning up ).

AN APPEAL FROM EDITOR

The Bulletin of IMA , Mulund has been aptly named “IMAGE”. If we want to have quality IMA magazine , the Image of Mulund IMA, then we must contribute regularly,

· Feedback, Suggestions and Opinions on matters relevant to the medical fraternity & society.
· Summary report of CME’s being conducted for the benefit of one & all
· Interesting case reports / studies
· Reader’s recommendations on books - medical & otherwise.
· Travel experiences with interesting photographs.
· And share Special interests – like one colleague amazed me with his in-depth knowledge of music systems & speakers. It helped me no end !

I personally feel articles in Hindi, Marathi & Gujrati should also be welcome, since all of us are not most comfortable in English. And as someone has put it nicely, Hindi is mother & English is Wife – it is possible to love both equally ! “ Bahu bhi kabhi Saas ho sakti hai – Ekta Kapoor stuff.” In this age of SMS opinions, please voice your opinion to 9821131883 with, “ Language : Yes or No “ with your name please.
I also appeal to you to come forward to join Editorial Team to help produce quality IMA magazine & to form a core group to network with Police, Press, Politicians etc . I would like to form two teams one from each Mulund East & West.

CABG – WHAT’S NEW ?

Since the first Coronary Artery Bypass Grafting (CABG) performed in the 1960's, the operation has evolved to make surgical treatment of coronary artery disease safer and more durable. I have briefly outlined the three major aspects of CABG which have contributed to excellent results of CABG.

1. "Off-Pump CABG". The advances in CABG were mainly due to the heart-lung machine (cardio-pulmonary bypass) which made it possible to perform surgery on a still (arrested) heart. Despite the availability of latest heart lung machines, this "on-pump" technique is still associated with few morbidities like stroke, renal failure, bleeding and atrial fibrillation. To minimize these morbidities, we have adopted the "off-pump" or "beating heart" CABG. Off-pump CABG (OPCABG) has the following advantages: Decreased incidence of stroke / renal dysfunction / bleeding / atrial fibrillation; Overall length of ICU and hospital stay is reduced; Decreased cost. There is no significant difference in mortality with either technique. The off-pump technique is technically demanding with a steep learning curve and hence not available at all centers.
2. Total Arterial revascularization: Upto the mid 1980's the conduit of choice for bypassing diseased coronary arteries was the saphenous vein. The saphenous vein was easy to harvest, easy to handle with minimal complications to donor site. However, followup studies showed that patency was only about 50% at 10 years. Hence there was a shift to using arterial grafts for CABG. The left Internal mammary artery was proven to be the ideal conduit for grafting with patency exceeding 90% at 10 years. For multivessel grafting, both right and left internal mammary arteries; as well as additional arterial conduits like the radial artery can be used. With experience, the mammary arteries and radial arteries are easy to harvest and handle with excellent long term patency. Arterial grafts have Superior Graft Patency ; Reduced incidence of Myocardial Infarction and Reintervention and Improved Long-term Survival
3. Minimally invasive surgery. CABG can be performed through small incisions in certain patients with good anatomy. The access could be through a small or hemi-sternotomy; or sometimes via a small lateral thoracotomy incision. These approaches have shown to benefit patients in terms of reduced postoperative pain and also quicker discharge. Robotic cardiac surgery is in evolution and we can expect it to be available to our patients in the next few years. Endoscopic approaches have been used to harvest conduits (Saphenous vein and Radial artery). "Hybrid" procedures combining Minimally invasive CABG with angioplasty have been used for enhanced patient satisfaction.
Dr. Jayesh Dhareshwar,

M.Ch (CVTS, AIIMS)
Consultant Cardiac Surgeon

THE REMINISCENT

Editor’s Note : It was a pleasure listening to the history of Mulund, from a senior doctor. He has very interesting tales to tell. Read for yourself.

I started my practice in the year 1950, when Mulund was a village of Thane district and a sizable land was under cultivation. The then population was about fifteen thousand only. Most of them were average middle-class farmers and fishermen, Gujrathis, Kutchchis and Sindhis. Most of them migrated from Karachi.
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There were very few doctors in Mulund. Most of the patients were depending on home remedies . Paying capacity of the patients was also meager. As there was no facility of pathology and X-ray I used to depend on my clinical examination and treat the patients accordingly. I used to charge the patient eight annas (50 paise) to a rupee. In time of need, I used to refer the patient to the nearest KEM Hospital, Parel.

I was performing various minor surgeries, which included ENT and tooth extraction. At times, I had to manage stab injuries. This was possible due to my surgical training at the Podar Hospital and Haji Bachu Ali Hospital, Parel.
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I used to make home visit even at dead of night, some times tracking through paddy fields and occasionally encountering snakes. Day visit charges were three rupees. I was in Home Guards as a medical officer for twenty five years and rendered my services during Indo-Chinese war 1962, and Indo-Pakistan wars 1965 and 1971, conducting Civil - Defence first aid classes and night patrolling. .
During my time the family doctor was considered as a family member and relations were cordial. Quite a few criminals were externed to Mulund. However, the externees (Tadi-Par) respected the doctors, when they and their families came for treatment.
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The development of Mulund actually started after the Brihan Mumbai Municipal corporation (BMC) extended the limits in eastern suburbs upto Mulund and in western suburbs upto Dahisar in the year 1956. When Mulund was merged in BMC the development of roads started. Gradually the tar roads were made. Some of them were renamed from Cown road to Mahatma Gandhi road and from Carter road to Netaji Subhash road. Tap water was made available. Quite a few gardens were developed in the west and east Mulund. A prestigious cultural & sports complex, Kalidas was developed in the west for public use. .
I and my wife, late Dr. MALINI started our hospital on Dassera day in the year 1956. We could provide facilities for major Gynaec. and General surgeries. For normal deliveries, the charges were Rs. 60/- which included stay with food for ten days.
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At present due to change of time and advent of consumer protection act, the medical fraternity as a whole, has to be very alert to avoid ugly situations and litigations. In my opinion, if group practice is adopted, much of the stress could be relieved ; at the same time updating knowledge should be considered most important.
Dr. Mohan N. Parmar

Bookshelf

Essence: THE PSYCHOLOGY OF ESOTERIC by OSHO

“Unconscious evolution ends with man. Man is the last product of unconscious evolution. With man, conscious evolution begins (only in those who choose to begin).” “Only in aloneness, enlightenment can be attained.”
Only a Master like Osho can utter such words. It requires courage to be alone. Meditation means living non-linguistically. It’s pointed out that mind has an automatic ability to verbalize anything & everything. And the first requirement towards a meditative mind is to be aware about it and to be able to stop verbalizing every experience. Consciousness and existence are beyond the language.

“Spiritual learning can not come from words but from the gaps.” Osho’s teaching is to help us see the gaps to understand that ‘life energy’ is one, it is neutral. It can be sexual. It can be spiritual. Then it makes profound sense for us in not creating a dichotomy for or against sex and sees it as simply biological energy force. Time and again, Osho’s emphasis is on transcending it and not in suppressing it. In order to do that, one has to move into it with awareness, witness it…and witnessing liberates!

Explaining “Kundalini”, he states that ordinarily, energy moves from centre towards periphery, where as in Kundalini it moves from the periphery towards the centre. Ordinarily, sex is the only non-verbal natural experience we are aware of. Osho guides us into another- Meditation. Becoming aware, practicing mindfulness, using breathing as the door to the mind instead of using thought opens newer dimensions.

In his commentary on the “Dreams”, he de-mystifies one of the greatest esoteric realms known to man. While explaining the intricacies of seven types of dreams and seven types of realities- kind of penetrating one another, he invites man to feel the body from within as the first step in the journey of transcendence. Fighting with desire creates ‘desire’ against desires. Osho’s emphasis is on meditation and not on knowledge as he believes that ‘the knowing mind’ is a hindrance. A stuffed mind is bound to remain ignorant. Truth is revealed the moment knowledge ceases. The essence is that life is always from the unknown towards the unknown.

“Sat-Chit-Anand” or “Existence-Consciousness-Bliss” is the pointer towards the boundary beyond which there is only divine silence. Experiencing of the divine is explained through the 3 windows of “truth”, “goodness”, and “beauty” he elaborates upon the 3 dimensions belonging to the human mind- the intellectual (truth), the emotional (beauty) and action (goodness or karma)- the eternal wisdom of “Satyam-Shivam-Sundram”. The master puts lot of importance into the process of “Right questioning” and asks not to ask certain questions- the theoretical, philosophical & metaphysical questions- come into the said category as they solve less and confuse more.

You can not grow unless you grow totally seems to be the master’s message to his disciples on the path of journey.
Dr. Amit Ghatalia
( 9869453148 )

ACTIVITIES OF MULUND BRANCH OF IMA

29/06/08
*CME at Jupiter Hospital Auditorium, Thane
Minimally Invasive Yet Maximally Effective Surgery – Dr. Pinky Thapper
CABG–What is New? – Dr. Jayesh Dhareshwar
Myths and Facts of Primary Angioplasty – Dr. Bhaskar Shah
End Stage Kidney Disease…But Not the End of Life – Dr. Mukesh Shete
*Felicitation of Dr. D. G. Thakker, Senior Family Physician from Mulund (W)

01/07/08
*Doctors’ Day Program
*Tree Plantation Drive with Rotary Club of Mulund Hills

15/07/08
*Special General Body Meeting to discuss Assault on Doctors at Hira Mongi Hospital Auditorium
Guest Speakers:
Doctors Risk Medico Legal Services Group
DCP Zone VII

26/07/08
*Elections of IMA Maharashtra State for President’s Post and 3 Vice-Presidents’ Post at Kalidas Cafeteria at
Kalidas Cafeteria, Mulund (W)
*CME at Kalidas Cafeteria, Mulund (W)
Management of Chest Pain & Myths & Realities in Cardiology - Dr. B. C. Kalmath Zynova Heart Hospital
Brain Teasers & Management of Brain Tumours - Dr. S. N. Shenoy Zynova Heart Hospital
Sleep Patterns in Cardiac Conditions - Dr. Ramnath Iyer Zynova Heart Hospital
Antioxidants in Cardiac Conditions - Dietician from Zynova Heart Hospital
*Felicitation of Dr. (Mrs.) S. D. Rao, Senior General Practitioner from Mulund

10/08/08
*Monsoon Picnic of IMA Mulund at Royal Garden Resort and Fashion Show by Professional Models

15/08/08
*Flag Hoisting Ceremony at B P S Plaza, Mulund (W)

30/08/08
*CME in Urology at Hira Mongi Hospital Auditorium, Mulund (West)
Holmium Laser Enculeation of Prostate (HoLEP) – Technology here to Stay - Dr. Hiren Soda
Holmium Laser – The Platinum Standard - Dr. Hemendra Shah
Availability of All Modalities Assuring Results in Urinary Stone Management - Dr. Manish Bansal
*Felicitation of Dr. B. R. Thacker, Senior Family Physician from Mulund

20/09/08
*CME on Infertility at Hira Mongi Hospital Auditorium, Mulund (West)
Lecture on Infertility - From the Very Basic to the Latest - Dr. Sanjeev S. Khot Consultant Infertility Expert, Reliance Life Sciences
*Felicitation of Dr. A. B. Vora, Senior Physician From Mulund

10/10/08
*One-Day Token Strike and Peaceful Protest ‘Morcha’ against Assault on Doctors in support of Strike & Protest call by MAH IMA

22/10/08
*CME on Lasik by Dr. Nitin S. Deshpande
*Special General Body Meeting to Pass the Accounts for the Financial Year Ended 31st March 2008 at Hira
Mongi Hospital Auditorium, Mulund (West)
*Felicitation of Dr. K. D. Tolani & Dr. Pushpa Tolani, Senior Family Physicians from Mulund

29/11/08
*CME on MDR/XDR Tuberculosis by Dr. Ravindra U. Rupwate, Chest Physician at Hira
Mongi Hospital Auditorium, Mulund (West)

SIKKHISM : EK ONKAR-GOD IS ONE

Editor’s Note : With tricentenary celebrations of Khalsa Panth this year, Dr.M.S.Reehal enlightens us on Sikh religion & philosophy.
Sikhism; Punjabi: sikkhī,founded on the teachings of SHRI GURU NANAK DEV JI and nine successive GURUS in fifteenth century Northern India, is the fifth-largest organized religion in the world.This system of religious philosophy and expression has been traditionally known as the Gurmat (literally the counsel of the gurus) or the Sikh Dharma. Sikhism originated from the word Sikh, which in turn comes from the Sanskrit root śiṣya meaning "disciple" or "learner", or śikṣa meaning "instruction."
The principal belief of Sikhism is faith in Vāhigurū—represented using the sacred symbol of ēk ōaṅkār, the Universal God. Sikhism advocates the pursuit of salvation through disciplined, personal meditation on the name and message of God. A key distinctive feature of Sikhism is a non-anthropomorphic concept of God, to the extent that one can interpret God as the Universe itself. The followers of Sikhism are ordained to follow the teachings of the ten Sikh gurus, or enlightened leaders, as well as the holy scripture entitled the Gurū Granth Sāhib, which, along with the writings of the six of the ten Sikh Gurus, includes selected works of many devotees from diverse socio-economic and religious backgrounds. The text was decreed by SHRI GURU GOBIND SINGH JI, the tenth guru, as the final guru of the “Khalsa Panth”.
PHILOSOPHY AND TEACHINGS - The Harimandir Sahib, known popularly as the Golden Temple, is a sacred shrine for Sikhs.
Te origins of Sikhism lie in the teachings of SHRI GURU NANAK DEV JI and his successors. He disapproved of many religious beliefs and practices of his time. The essence of Sikh teaching is summed up by him in these words: "Realisation of Truth is higher than all else. Higher still is truthful living".Sikhism believes in equality of all humans and rejects discrimination on the basis of caste, creed and gender. Sikhism also does not attach any importance to asceticism as a means to attain salvation, but stresses on the need of leading life as a householder. For Sikhs, initiation into the ‘Khalsa’ strengthens their identity and also signifies the Sikh teaching of equality.
According to Sikhism, the goal of life for a person is to progress on a spiritual scale from Manmukh, or "self-centered", to Gurmukh, or "God-centered". Gurmukh implies the qualities of humility, selfless service, adhering to the teachings of and not being a recluse.
GOD - Sikhism is a monotheistic religion. In Sikhism, God—termed Vāhigurū—is formless, eternal, and unobserved: niraṅkār, akāl, and alakh. The beginning of the first composition of Sikh scripture is the figure "1"—signifying the universality of God. It states that God is omnipresent and infinite, and is signified by the term ēk ōaṅkār. Sikhs believe that prior to creation, all that existed was God and his hukam (will or order).When God willed, the entire cosmos was created. From these beginnings, God nurtured "enticement and attachment" to māyā, or the human perception of reality.
While a full understanding of God is beyond human beings, SHRI GURU NANAK DEV JI described God as not wholly unknowable. God is omnipresent (sarav viāpak) in all creation and visible everywhere to the spiritually awakened. Nanak stressed that God must be seen from "the inward eye", or the "heart", of a human being ; devotees must meditate to progress towards enlightenment. SHRI GURU NANAK DEV JI emphasized the revelation through meditation, as its rigorous application permits the existence of communication between God and human beings.God has no gender in Sikhism, though translations may incorrectly present a masculine God. In addition, he wrote that there are many worlds on which God has created life. His teachings are founded not on a final destination of heaven or hell, but on a spiritual union with God which results in salvation.The chief obstacles to the attainment of salvation are social conflicts and an attachment to worldly pursuits, which commit men and women to an endless cycle of birth — a concept known as reincarnation.
In Sikhism, the influences of ego, anger, greed, attachment and lust—known as the Five Evils—are believed to be particularly pernicious. The fate of people vulnerable to the Five Evils is separation from God, and the situation may be remedied only after intensive and relentless devotion.
Guru Nanak Dev Ji described God's revelation—the path to salvation—with terms such as nām (the divine Name) and śabad (the divine Word) to emphasise the totality of the revelation. Nanak designated the word guru (meaning teacher) as the voice of God and the source and guide for knowledge and salvation. Salvation can be reached only through rigorous and disciplined devotion to God.
A key practice to be pursued is nām simraṇ: remembrance of the divine Name. The verbal repetition of the name of God or a sacred syllable is an established practice in religious traditions in India, but his interpretation emphasised inward, personal observance. His ideal is the total exposure of one's being to the divine Name and a total conforming to Dharma or the "Divine Order". He described the result of the disciplined application of nām simraṇ as a "growing towards and into God" through a gradual process of five stages. The last of these is sach khaṇḍ (The Realm of Truth)—the final union of the spirit with God.
Nanak stressed kirat karō: that a Sikh should balance work, worship, and charity, and should defend the rights of all creatures, and in particular, fellow human beings. They are encouraged to have a chaṛdī kalā, or optimistic, view of life. Sikh teachings also stress the concept of sharing—nd chakkō—through the distribution of free food at Sikh gurdwaras (laṅgar), giving charitable donations, and working for the good of the community and others (sēvā).
Dr. M.S. Reehal, ( 9869071271 )

CHRONIC COUGH: IS IT PERPLEXING ?

Chronic cough is a common diagnostic and therapeutic problem. The exact prevalence has proved difficult to estimate and recurrent cough is reported by 3–40% of the population.
Chronic cough is clearly a very common symptom which, although associated with considerable morbidity, goes largely unheeded.
The reasons why patients seek advice regarding chronic cough are not fully understood, but may be related to worry about the cough. Often, cough related morbidity—in terms of sleep disturbance (either of the patient or their relatives), urinary incontinence in women, or syncope—drives the patient to consult. Indeed, chronic cough has been shown to be associated with a marked deterioration in quality of life which returns to normal on successful treatment.
In population surveys, men have reported cough more frequently. However, most
patients referred to specialist cough clinics are women. This paradox may be explained by differences in smoking habit, but women also appear to have an intrinsically heightened cough response.
Classically, cough lasting less than 3 weeks has been considered as acute and that of more than 3 weeks duration has been defined as chronic. In recent years there has been a tendency to redefine chronic cough as cough lasting more than 8 weeks and, for further clarification, the term ‘‘subacute cough’’ was proposed to describe cough lasting 3–8 weeks. While these definitions remain arbitrary, the concept of chronic cough remains clinically important.
Here we highlight 2 cases of chronic cough which on proper history taking and clinical examination and appropriate investigations threw light on the exact etiology.

Case 1: RS - 15 year old Girl studying in 10th standard, premorbid history normal, came with chief complaints of predomintly dry cough more in the nights for the last 15 days, frequent sneezing and rhinitis all throughout the year. No breathlessness. No other symptoms. On examination, vitals stable, chest clear. WBC Count revealed 10 % eosinophils, Absolute Eosinophil Count of 700. Serum IgE was done by another referral practitioner—350 IU.
Patient was started on Tablet Hetrazan and Asthalin MDI. Chest X Ray done at the beginning of the illness was normal. Patient was continued on same medications, however started developing increased cough in the nights and low grade fever. Then patient was referred to me. Fresh Chest X-Ray revealed Right lower zone paracardiac consolidation. Patient was admitted and started on IV Amoxicillin Clavulanic Acid. Sputum SCABS and AFB three samples were sent in view of chronic cough.
before the treatment

Sputum SCABS revealed Staphylococcus Aureus and AFB was negative for all samples.
Patient improved dramatically on antibiotics and subsequent Chest X- Ray showed complete clearance of shadows.

After treatment

Case 2: SM - 34 year old Female, premorbid history normal, came with chief complaints of cough predominantly dry for the last 3 months. She also gave history of frequent rhinitis, cold and also allergy to dust, fumes and history of getting rashes and wheals on and off. Patient was treated by local

family practitioner with anti histaminics. However

Three months before the patient had no relief and was referred to a

specialist. However again was given cough syrup,

inhalers and CXR and PFT done which was normal. Then the patient was referred to me for unremitting cough.
Earlier CXR on review showed left lower zone

on presentation reticular opacities and the follow up fresh CXR showed bilateral lower zones interstitial opacities. Her PFT on review also showed Mild restriction suggestive of a restrictive disorder like Interstitial Lung disease. HRCT was suggestive of bilateral ground glassing with right middle lobe consolidation and Fibreoptic Bronchoscopy was done where biopsy revealed Interstitial Lung disease. Patient was started on steroids and showed dramatic improvement in cough.
Thus, chronic cough on proper history taking, clinical examination and appropriate investigations is curable. Further cases on chronic unremitting cough will be in the next editions.

- Dr. Subramanian Natarajan M.D (ChestMed.) 9870566767

Gitanjali

Where the mind is without fear and the head is held high ;
Where knowledge is free;
Where the world has not been broken up into fragments
by narrow domestic walls;
Where words come out from the depth of truth;
Where tireless striving stretches its arms
Towards perfection;
Where the clear stream of reason has not lost its way
Into the dreary desert sand of dead habit;
Where the mind is led forward by thee into ever – widening
Thought and action –
Into that heaven of freedom, my Father,
Let my country awake.

- Gurudev Rabindranath Tagore

A FATHER COMING TO TERMS WITH LIFE WITH A ‘SPECIAL’ CHILD

Editor’s Note : How a ‘special’ child can be a life turning event, hear it in the words of our colleague. And how his spouse makes it a life’s cause is to be seen to be believed.

I, Dr. Shailesh Khakhar & my wife, Manisha were really glad when approached by Dr. Hemant Agrawal to give an article In Image about life with our special child Deep.
Deep was born to Manisha 18 years back (1991) , the day on which Mumbai was submerged with a continuous downpour. It was otherwise a FTND ; only that she did not feel fetal movements , had fallen from a scooter in 2nd month of pregnancy but with no untoward clinical or USG findings.
Deep was born with hypotonia, unable to hold head; poor cry & mild peripheral cyanosis, making us feel something amiss with our new born. On that fateful day we were unable to get a Paediatrician even because of water logging in the city.
Later our friend & Paediatrician Dr. Manoj Sangoi took us to Dr. Vrajesh Udani at Hinduja where my child was diagnosed with M.R. (Mental Retardation). Our world fell apart on hearing the diagnosis; we were shattered & numb; went into denial mode, unable to accept. I was full of negativity & felt alienated to the surroundings, not ready to accept – “how it could have happened to us?” Our next few months went into counselling (psychological) & investigations on Deep including MRI, hearing test like BERA, genetic test karyotype which all turned out normal. Even samples were sent to USA for certain Aminoacid tests to rule out metabolic disorders – no exact cause could be pinpointed for Deep’s CNS affection.
Deep’s milestones were delayed ; we started with physiotherapy thrice a week at Hinduja Hospital.
I was jealous of my friends & relative’s children growing normally & going to normal school ; where as my child was to be taken for therapies & IQ assessment & when I realized that he would not be able to go to normal school , it was difficult for me to accept !
It took me few years before I could come to terms & take control of reality, “Yes I have to live with it & I cannot ruin my & others life around by being ignorant.” I used to avoid taking DEEP to social gatherings previously, but slowly charm of his innocence & cuteness, positive atmosphere in family (& friends) & positive attitude of my wife - all helped a lot to come back to the society in which I felt , “Yes I am part of it.”
Considering his condition of moderate to severe mental retardation we were advised to go for a second issue for which I felt that , “No , I am not ready for any more uncertainties in my life”; even my wife had lost courage in that matter.
Since then our life went ahead with Deep. He has become an indispensable part of our life & our identity has been more prominent, it seems because of him. We have taken him on tours to different parts of India even with all adversities & difficulties. Manisha & Deep have participated in Standard Chartered Marathon held every year with fancy dress , with Deep in wheel chair.
We manage Deep’s daily routine like giving bath, brushing & cleaning him (& soiled diapers), toilet training or feeding & dressing him up for school ; WE divide these duties or share it together; at times we get frustrated , but his selfless love , innocence , gestures makes us forget all our worries of tomorrow.
And as we are seeing today that parents of normal children have same worries & insecurities about their children like we have for Deep, so life is same everywhere.
- Dr. Shailesh Khakhar

( How a Mother dedicates her life to a cause , read in the next edition. Friends, Mrs. Manisha Khakhar is a real life ‘hero’ amongst us. The visit to Skills & Ability school for special children was an overwhelming, humbling experience for me. I implore IMA Mulund to adopt the school – dedicate ourselves to a social cause. – Editor)

For brickbats & bouquets on phone or sms

PRESIDENT : Dr.V.Seetharaman ( 9322517364 )
SECRETARY : Dr. Nilesh Pandya ( 9820421389 )
TREASURER : Dr. Mahesh Mandot ( 9821048907 )

EDITOR : Dr. Hemant Agrawal ( 9821131883 )

LAST BUT NOT THE LEAST !

I must thank our President Dr. V. Seetharaman & IMA Managing Committee for entrusting “ Image” of Mulund IMA to me.

Heartfelt thanks to all of you who responded to my appeal & contributed articles – a last minute job in producing an already delayed edition of ‘Image’.

Besides every man is a woman – in my case it is my wife Rashmi who helped me out tremendously, with time available at a premium. Kindly note, I have not used the term “successful man” – whether I / WE have been successful or not will depend on your feedback, response for the future editions of Image. Till then Good Bye & Best Wishes for a healthy dose of Work, Wealth & Wisdom. See you in New Year with renewed enthusiasm for life & purposeful living.
Dr. Hemant Agrawal
M.S.Orth., F.R.C.S., M.Ch. Orth (Eng)