Tharang Dhwani Souvenir (IMA National Conference 2023)

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Tharang Dhwani 2023 102 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr Elizabeth K E MD, DCH, Ph D, FIAP FRCPCH Former Prof. & HOD Pediatrics SAT Hospital, Govt. Medical College, Thiruvananthapuram [email protected] Our Kid’s DietAre we on the Right Track? My Reflections Most of our houses have kids of different age groups. Most of them have bizarre and unconventional eating practices. Hence this reflection. The prevalence of stunting, wasting, anemia, overweight and obesity are on the increase, at the expense of the shrinking normal children. 0-6 months old Young Infants The one and the only food for them is MOM, MOM and MOM. MOM is mother’s Own Milk. But what if MOM is not available. The next best choice is PDHM- Pasteurised Donor Human Milk. We are now guilty of not having enough CLMCs- Comprehensive Lactation Management Centres, previously called Breastmilk Banks, that can provide PDHM to the needy babies. What if both are not available- we may be forced to go for alternate feeding using Milk formula or bovine milk, which are not the ideal food for young infants. The biggest challenges while using these are over dilution, malnutrition, overfeeding, future obesity, anemia and allergy/intolerance. Till 6 months of age, young infants have leaky gut and hence chance for sensitization and allergy are high. Breastfeeding mothers should continue to take IFA- Iron Folic Acid and Calcium for 180 days after delivery, followed by weekly iron throughout reproductive age group. 6-24 months old Infants & Toddlers This period is the transition to Complementary feeding and Family pot feeding, in addition to breastfeeding. Here, the question is, ‘are we

Fig. 3. The seven food groups for 6-23-month-old children, along with breastfeeding-Cereals, Pulses and Nuts, Egg, Meat and Fish, coloured Vegetables and Fruits,Milk and Milk products Are our babies getting MMF – Minimum Meal Frequency and MAD- Minimum Acceptable Diet (Fig. 4), compared to the WHO recommendations? The answer is a big ‘No’. Breastfed babies are to be fed 2 to 3 times per day and non-breastfed babies 4 times per day along with two milk feeds per day. These are all denied to them due to lack of awareness and commitment. Fig. 4. MMF – Minimum Meal Frequency and MAD - Minimum Acceptable Diet for 6-23 months old. Toddlers & School Children They need 5 food groups, 5 colors, 5 times per day. Many of them become picky or fuzzy eaters. The reasons for food refusal are very late introduction of food items like egg fish etc leading to likes and dislikes as well as forced feeding, ignoring behaviour during feeding and lack of role models. Children should be encouraged to eat breakfast, as it is brains’ food. Those who skip breakfast are likely to become overweight (Fig. 5). capitalising on the ’Annaprasan’ or Rice giving ceremony, which is deep rooted in our culture? (Fig 1) This opportunity should be the beginning for introducing a balanced diet. In addition, Biweekly IFA, Biannual Vitamin A and deworming are to be optimised along with immunization coverage and growth and developmental surveillance. Fig 1. Rice-giving ceremony at 6 months of age The need for continuation of breastfeeding till 2 years and beyond is based on the fact that substantial nutrients are supplied by breastfeeding even in the second year of life (Fig. 2). Fig. 2. Proportion of nutrients supplied by breastmilk during the second year of life. As per WHO standards, Minimum Dietary Diversity (MDD) is at least 5 food groups including breastfeeding. The seven food groups are as follows (Fig. 3).and any of these food groups can be introduced as per developmental readiness of the baby one by one. But the reality is that the society is still doubtful and reluctant to start these food groups. Hence the high prevalence of stunting and wasting, also anemia and other micronutrient deficiencies among the kids. 103 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Fig. 5. The Difference between those who take breakfast and those who do not take breakfast Children of all age groups should reduce the intake of ‘ JUNCS”. • J- Junk foods- HFSS- high in fat, salt & sugar, low in micronutrients, protein & fibre. SOFASSolid Fat & Added Sugars, Dalda, Bakery items, Frozen dessert • U- Ultra-processed foods NOVA Classification 4- Packaged Processed foods- Refined sugars, Additives (Fig.6). • N- Nutritionally Inappropriate foods- Tea, coffee, health drinks, Sports drinks with creatinine. Health drinks have nearly 50% sugar, 25% fat and only 10% protein • C- Carbonated/ Caffeinated/Colored beverages- Caffeine adverse effects on CNS & CVS • S- Sugar-Sweetened Beverages- sugar content in beverage 6 -20 tsp. Fruit juice – 95- 100% fruit, Nectar- up to 60% fruit, Fruit drink < 25% fruit. Water Requirement as per Age (Holliday & Segar Formula) Up to 10 Kg 100 ml/Kg/day 10 kg X 100 = 1000 ml 10-20 Kg 1000 + 50 ml/each kg above 10 20 Kg - 1000 + 10 X 50 = 1500 ml 20 Kg 1500 + 20 ml/each kg > 20 30 Kg – 1500 + 10 X 20 = 1700 ml 50 Kg & above Weight X 40 ml/day 50kg X 40 = 2000 ml Fig. 6. Nova Classification 4 included as Ultra-processed Foods. ‘EAT SMART, EAT RIGHT - RIGHT FROM START’ School children need balanced diet. The Plate Method is the best to ensure a rainbow food. My Plate ensures all food groups and seven colorsGreen, Yellow, Orange, Red GYOR- Vegetables & Fruits, Brown – Whole grains, Roots/Tubers & Nuts, Purple- Protein rich Food, White – Milk & Milk Products (fig.7). In order to eat smart, let us reverse the order of eating the food groups in ‘My Plate’. Eat the GYOR first to ensure micronutrients, then Purple to satisfy proteins, followed by Brown – for Carbs and WhiteDairy products. Children should consume enough water. Two water drinking bells in the forenoon and afternoon at school and at home during holidays are welcome to ensure this. 104 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Fig. 7. Seven Colours and Food Groups in MY Plate Currently in our diet, 65-70% energy is coming from carbs, which should be cut down to around 50%, protein should be hiked to 15-20% of energy and rest should be healthy fat. Refined sugars and excess fructose are harmful for metabolic health and should be avoided. Solid fats like animal fat, Vanaspathi, that are trans-fat, should be avoided. It is better to keep salt also in moderation. Traditionally, 100 g used to give 100 Cals. is the ideal. Currently in new gen foods, 100 g is giving 6-10 times more energy to the children, who do not have physical activity also (Fig. 8). Fig. 8. Energy Density in Various Traditional and New Gen Foods. It is important to read food labels while choosing food items. Micronutrient supplements like Iron Folic Acid, Vitamin A, Zinc during Diarrhea, Iodised salt are to be universalised. A significant Social Behavioural Change Communication (SBCC), is expected to prevent deficiencies as well as excess. The importance of physical activity and sleep hygiene also to be highlighted. ‘108 Manthra’ for prevention of Non-Communicable Diseases is 1 hour of Exercise, 0 Junk foods and 8 hours of sleep, that has to be ensured at least 5 days a week Are we ready for a Healthy Nutrition Transition Challenge for our Kids and ourselves? 105 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 106 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr Ganga K R Senior Medical Officer Preventive Clinic BR Life SUT Hospital Pattom Thiruvananthapuram Prevention is Better than Cure – The Key to Sustainable Health The age old adage “Prevention is better than Cure” encapsulates a fundamental principle and key to sustainable health. In a world where Modern Medicine has made incredible strides in treating various ailments, the focus on prevention still remains paramount, especially in todays fast paced world. The concept of “Prevention better than Cure”, has been there since the 17th Century according to Oxford and is still a fundamental principle of Modern Health Care, “An ounce of Prevention is worth a pound of Cure” – holds true and can save your life, time and money. This article delves into the purpose, various preventive checkups ,their advantages and some misconcepts regarding “Preventive Clinic” concepts. The primary purpose of this Preventive Clinic concept is early detection of potential health issues rather than dealing with its consequences; secondly early detection of any complication of existing illness before it pops out. Medical examination by a doctor which includes history taking (purpose of visit, past history, personal history, family history, present medications etc) , detailed physical examination (detection of thyroid malignancies in many cases worth mentioning) along with an array of tests and associated consultation with a dietician (since many metabolic diseases are life style dependent) are main highlights of most of the preventive clinics. Host of investigations are available tailoring to individual needs. This is specifically applicable to medical fraternity & their family , as stress levels are high due to increased demands or expectations from the common man to public on top of our sincere commitments towards a patient.

There are some basic health screening tests that everyone should get done regularly. 1. Hemogram. 2. Lipid profile. 3. Liver function test. 4. Renal function test . 5. Thyroid panel. 6. Blood sugar. 7. Routine urine examination. 8. ECG 9. Chest radiograph. 10.Ultrasound Abdomen. 11.Stool occult blood. 12.TMT along with regular physical examination . 13.BP check up / BMI & eye check up. A diabetic panel of tests include FBS/ PPBS/ HbA1C/ Urine microalbumin/ Ophthalmology check up for early detection of Retinopathy / Early Neuropathy detection ( Podiatry) & Arterial Doppler study in addition to basic tests. Various tests are available viz Mammography, Pap smear, PSA along with tests for tumor markers & low dose CT chest – for early screening for malignancy. Some way cardiac risk markers ( Apolipoprotein A1, Apolipoprotein B, HSCRP, Lipoprotein etc) are important for any one above 30 years to detect abnormalities in the functioning of heart. In addition to TMT, 2D Echo, CT calcium scoring are done if indicated. Non ethanolic fatty liver/ cirrhosis cases are on the rise. Periodic USG Abdomen, Fibroscan liver, LFT, BMI follow & diet counselling are advisable. Last but not the least – Periodic dental check once or twice a year. Preventive Paediatrics is a separate wing headed by Paediatrician for immunization, promotion of physical & mental welfare of children. Advantage : Preventive health check up presents notable economic benefits as it prioritises early detection, intervention and thus reducing financial burden of costly advanced treatment. It fosters a healthier population decreasing overall expenditures and creating a stream lined health care system. The concerns and misconcepts like cost, unnecessary visit to hospital, unnecessary tests etc are proved to be unwarranted. NOW SCHEDULE YOUR NEXT PREVENTIVE HEALTH CHECKUP AND EMBARK ON A JOURNEY TOWARDS A HEALTHIER AND HAPPY LIFE. 107 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 108 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr. M.S. Jayasekhar MS. MCh, DNB, FRCS Consultant Plastic & Cosmetic Surgeon Suvarna Aesthetics Plastic Surgery Centre Thiruvananthapuram-10 More to Life Than Medicine! Have you ever thought of living your life’s aspirations and dreams on a broader canvas, outside the realm of medicine? If you haven’t, probably it’s the right time to take the initiative! In my initial professional days, at the start of my career in India, I was totally engrossed in the murky world of clinical medicine .doing ward work, taking night on calls, performing emergency surgeries, attending clinical meets & CMEs, for that’s how the world of a “perfect doctor” was meant to be !!! Only some weekends provided some relief in the form of playing a Sunday afternoon game of cricket with friends and an occasional Saturday night dinner with friends & family!!! I was getting to an “All work and no play makes Jack, a dull boy “stage!!!!

The concept of “Work- Life Balance” hit my head only, after I moved to the UK in the Nineties’. My medical colleagues in the UK would plan their exotic holidays, months in advance, had their fill of social life like doing their pubbing on Friday nights, clubbing on Saturday nights, playing the customary game of Golf on Sunday mornings( weather permitting !!!),followed by the traditional “Pub Lunch “ They would often nudge me to fall in line, as they opinioned the holiday breaks you take can rejuvenate you – in their words could “recharge your batteries”, so that you can bounce back to work, with a renewed vigor .My desire to explore the world was born and my travel dreams took wings. I was bitten by the travel bug, and I jetted off to far-flung destinations. I explored the world, discovered its many existing civilizations, imbibed local customs and cultures, sampled the local culinary delights and street food scenes, climbed mountains, and even did medical volunteering. Travel changed my views of the world, infused in me, a spirit of adventure, broadened my outlook and taught me to embrace the unexpected. Watching the sun rise over the mountainous ruins of Machu Picchu in Peru, after an exhilarating hike, floating atop freely on the calm waters of the Dead sea in Jordan, Flying a micro light glider over Scotland’s Tay Bridge , trekking the long miles of the Great Wall of China on a sultry day, Watching the humongous Blue Wales splashing and jumping in the middle of Atlantic ocean, Witnessing the season of Cherry Blossoms in Japan, watching the magnificent snow clad Mount Everest emerging beneath the rising rays of the sun from Nepal’s Nagarkot, ,scanning the jungles of Kenya in an open top camper van to see the league of “Big Five “and migration of the beasts, to be at the Wagah Border, where the patriotic vitriol lifts you to heady heights, the picturesque scenic views the slow cruise through the Norwegian Fjords offers , combing the galactic otherworldly landscape of the Pinnacles desert of Western Australia, watching blood-curdling bull fights in Madrid, making the steeply inclined cog train journey to Jungfrau in Switzerland, patting a tubby Koala in the Australian open zoo, hugging the giant redwood trees in California, letting a Madagascar Lemur climb over my shoulders, and the breath taking copter ride over the Giant Canyon …….many more of those delightful experiences ! How much more can my senses be stimulated to leave behind such everlasting visual treats and memories !!! The pale and gloom cast by the Covid pandemic put a halt to my expeditions and got me home bound again. Not to be let down, I took to gardening with passion and enthusiasm. When you nurture the nature, nature rewards you manifold. Your garden is a treat for your senses too, all your senses are put to test-“observing” small daily changes in the garden,” listening”, to the calls of soaring birds, the buzzing of bumblebees, “smelling “enjoying the fragrance of the flowers, and of the raw earth,” feeling” the ground under my knees,” tasting “the fruits of my labor, the produces that the garden offers!!! Gardening has consistently proven to be a healthy, mood enhancing activity, as research has proved that working productively in the garden can raise your serotonin levels in the brain and which can get you into a profuse state of happiness. As the pandemic was coming to its end, the little Persian kitten- “Loki “was inducted as the new member to our household. He is fluffy bundle of joy and affection and has bonded with us so very well. He is the perfect pet that gives you companionship, entertainment, fondness, playfulness and offers the tangible benefit of lowering our daily stress levels. The Covid phase too got over and we resumed our jaunts with a vengeance Practice of medicine is an art and is also our means of livelihood, but instead of just following the beaten path, it’s wise to think outside the box too, as it teaches us to adapt more easily to the unexpected situations, life throws at us. Breaking our routines/ daily habits, by doing things differently and learning to multitask are ways to enhance our creativity and adaptability. Life is short, live your dreams and wear your passion!!! So what are you waiting for? Get, set, go…… 109 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 110 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr.R.C.Sreekumar MS, FVS,FRCS (Glasgow) Professor and Consultant Vascular Surgeon Medical College Hospital Thiruvananthapuram Spend One hour per day to walk till our end : Tips to keep our legs healthy We are all concerned with our face. Ready to spend thousands to lakhs of rupees to keep our face clean and beautiful. Beauty parlors are plenty in the community with many options.

Are we doing justice to our legs. Do we amputate head, face, heart or liver Do the legs are so dirty to be removed or neglected? We are living in an era where mobility is the most important boon. How can we take care of our legs – it is very simple and cheap. 1. Exercise Regularly • Engage in regular physical activity to strengthen your leg muscles, improve flexibility, and enhance overall joint health include simple brisk walking to cycling, running or swimming for 30 minutes a day for 5 days a week. • Include a combination of cardiovascular exercises, strength training, and flexibility exercises in your routine for your heart as part of routine exercise. 2. Use Protective Gear • Wear appropriate protective gear when participating in sports or activities that pose a risk of injury to your legs. This may include knee pads, shin guards, or compression sleeves during biking or risky sports. 3. Proper Warm-up and Cool-down • Always warm up before engaging in physical activities to prepare your muscles and joints for movement. • Cool down after exercise to help prevent stiffness and promote recovery. 4. Maintain a Healthy Weight • Being overweight can put extra strain on your legs and joints, increasing the risk of injuries. Maintain a healthy weight through a balanced diet and regular exercise. 5. Wear Supportive Footwear • Choose footwear that provides proper support and cushioning for your feet and legs. Selection of footwear is very important and given below. 6. Practice Good Posture • Maintain proper posture, especially when sitting for extended periods. This helps prevent strain on your lower back and legs. 7. Avoid Prolonged Sitting or Standing • If your job or lifestyle involves long periods of sitting or standing, take breaks to stretch and move around. This helps prevent stiffness and improves circulation. Remember sitting for long is equivalent to smoking and can affect your legs. 8. Stay Hydrated • Proper hydration is essential for overall health and can contribute to the health of your muscles and joints. 9. Be Mindful of Your Surroundings • Pay attention to your environment to avoid tripping hazards or obstacles that may pose a risk to your legs. 10. Listen to Your Body • If you experience pain, discomfort, or signs of injury, listen to your body and give it the rest it needs. Consult with a healthcare professional if necessary. Foot exercises These exercises can be done alone or with the other exercises. Always these are to be done multiple times and to be done for both legs. 1. Toe Tapping: • Sit comfortably and lift one foot off the ground. • Tap your toes on the floor for about 30 seconds. 2. Toe Stretch: • While sitting or standing, spread your toes as wide as possible. • Hold the stretch for 5-10 seconds and then relax. 3. Ankle Alphabet: • Lift one foot off the ground and draw the alphabet in the air with your toes. 4. Towel Scrunch: • Place a small towel on the floor and use your toes to scrunch it toward you. 111 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

5. Marble Pickup: • Place marbles on the floor and use your toes to pick them up and place them in a container. • This helps improve toe dexterity. 6. Calf Raises: • Stand with your feet hip-width apart and slowly rise onto your toes. • Hold the position for a few seconds before lowering your heels back to the ground. 7. Heel Raises: • Stand with your feet hip-width apart and lift your heels off the ground. • Hold the position for a few seconds before lowering your heels. 8. Foot Roll: • Sit or stand and roll a tennis ball or a specialized foot roller under your foot. • Apply gentle pressure and roll it back and forth. • Focus on the arch and heel areas. 9. Arch Strengthening: • Sit with your feet flat on the ground. • Lift your toes while keeping your heels on the ground, creating an arch in your foot. • Hold for a few seconds and then release. 10. Plantar Fascia Stretch: • Sit with one leg crossed over the other. • Pull your toes back toward your shin until you feel a stretch along the bottom of your foot. • Hold for 15-30 seconds and switch to the other foot Protective Gear These gears should be selected directly and online purchase is not advisable. These should be tested properly and walk for some time after having both side gears before buying. 1. Shoes: • Choose shoes appropriate for the activity you are engaging in (running, hiking, work, sports, etc.). • Ensure they provide proper support, cushioning, and stability. • Check that the shoes fit well to prevent blisters and discomfort. 2. Work Boots: • For hazardous work environments, wear boots that meet safety standards (steel toe, punctureresistant, electrical hazard protection, etc.). 3. Steel Toe Boots: • Essential for jobs where there is a risk of heavy objects falling on the feet. 4. Safety Shoes: • Some industries require specific safety shoes to protect against chemicals, electrical hazards, or other workplace risks. 5. Hiking Boots: • Provide ankle support and stability for hiking on uneven terrain. 6. Orthopedic Shoes: • Recommended for individuals with foot conditions or special orthopedic needs. 7. Arch Supports and Insoles: • Inserted into shoes to provide additional arch support and cushioning. 8. Foot Braces or Splints: • Used to support and protect the foot or ankle after an injury. 9. Steel Toe Caps: • Can be worn over regular shoes to add a layer of protection for the toes. 10. Ankle Braces: • Provide extra support and stability for the ankle, especially after an injury. 11. Toe Guards or Toe Caps: • Protect toes from impact or compression. 12. Socks: • Wear moisture-wicking socks to keep feet dry and prevent blisters. 112 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

• In cold environments, use thermal socks for insulation. 13. Gaiters: • Used in outdoor activities to protect the lower legs and feet from water, mud, and debris. 14. Cleats: • For sports activities on grass or turf, cleats provide traction and stability. 15. Foot Pads or Cushions: • Used to alleviate pressure and provide extra cushioning in specific areas of the foot. How to select footwear 1. Purpose of the Shoes: • Identify the primary purpose of the shoes. Are they for running, walking, hiking, work, sports, formal occasions, or casual wear? 2. Shoe Size: • Ensure that the shoes fit properly. Your feet can change size over time, so measure your feet regularly. • Shop for shoes in the afternoon or evening when your feet tend to be slightly larger. • Consider both length and width. Shoes that are too narrow or too wide can cause discomfort. • If you are a diabetic, select the shoe in the evening after a regular activities and walikng. 3. Toe Room: • There should be about a half-inch (1.3 cm) of space between your longest toe (usually the big toe) and the front of the shoe. 4. Arch Type: • Know your arch type (normal, flat, high) to choose shoes that offer the appropriate level of arch support. Specialty stores or a podiatrist can help determine your arch type. 5. Foot Shape: • Consider the shape of your foot. Some shoes are designed for wider or ` narrower feet, so choose accordingly. 6. Activity-Specific Features: • Different activities require specific features. For example: • Running shoes should provide good shock absorption. • Hiking boots need ankle support and traction. • Work boots may need to meet safety standards 7. Try Both Shoes: • Always try on both shoes and walk around the store to ensure comfort and proper fit. • Consider any specific activities or movements you'll be doing while wearing the shoes. 8. Comfort: • Shoes should feel comfortable right away. Don't assume they will "break in" over time. • Check for any pressure points, rubbing, or discomfort. 9. Breathability: • Choose shoes made from breathable materials to keep your feet dry and comfortable. 10. Sole Thickness and Material: • Consider the thickness and material of the sole based on your activities. Thicker soles can provide more cushioning and support. 11. Closure Type: • Choose a closure type that suits your preferences and foot shape, whether it's laces, Velcro, or buckles. 12. Flexibility: • The shoe should bend where your foot naturally bends, usually at the ball of the foot. 13. Quality: • Invest in good-quality shoes. While they may be more expensive, they are often more comfortable and durable. 14. Replace Old Shoes: • Regularly check your shoes for signs of wear and tear. Replace them when they no longer provide adequate support. 113 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

15. Consider Special Needs: • If you have specific foot conditions or needs (e.g., wide feet, plantar fasciitis), choose shoes designed to address those concerns. Posture for foot and legs 1. Alignment: • Stand up straight with your feet hip-width apart. Align your ears, shoulders, hips, and ankles in a straight line. 2. Weight Distribution: • Distribute your body weight evenly on both feet. Avoid locking your knees; keep them slightly bent. 3. Core Engagement: • Engage your core muscles to provide stability to your spine and pelvis. 4. Knees: • Keep your knees facing forward, not turned inward or outward. 5. Pelvic Tilt: • Maintain a neutral pelvis by avoiding excessive arching or tucking. Imagine a straight line running from your head through your spine to your tailbone. 6. Shoulders: • Relax your shoulders; avoid hunching or rounding them forward. Keep your shoulder blades pulled slightly back and down. 7. Chin and Head Position: • Keep your head level with your spine. Avoid tilting your head forward or backward. 8. Foot Position: • Point your toes straight ahead. • Avoid excessive inward or outward rotation of the feet. 9. Arch Support: • If you have arch issues, use supportive footwear or orthotics. Sitting Posture: 1. Feet Placement: • Keep your feet flat on the floor or on a footrest. • Maintain a hip-width distance between your feet. 2. Knee Position: • Keep your knees at hip level or slightly below. • Use a cushion if your chair is too high. 3. Chair Support: • Sit back in your chair with your back supported by the backrest. • Use a cushion or lumbar roll for lower back support if needed. 4. Posture Check: • Align your ears, shoulders, and hips vertically. • Avoid slouching or leaning forward. 5. Computer Height: • Position your computer or work surface at eye level to avoid tilting your head. Tips for Standing and Walking: 1. Take Breaks: • If standing for long periods, shift your weight from one foot to the other or take short breaks to walk around. 2. Walking Posture: • Walk with your head up, shoulders back, and a natural arm swing. • Strike the ground with your heel first, then roll through to your toes. 3. Heel-to-Toe Movement: • When walking, your foot should land heel-first and then roll smoothly onto the toes for a natural gait. 4. Comfortable Shoes: • Wear comfortable and supportive shoes that fit well. Our legs are equally or more important than our face or other organs. It is important for regular activities, mobility and our routine work. Remember - leg health is important for your heart health. Half of major amputees may die or loose other limb in next 2 years. So let us spend an hour per week to walk till death. 114 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 116 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR I f I ask the same question in an IMA meeting, how many would have undergone age appropriate adequate cancer screening ?? A doctor serves as a community's lifeline for many families and friends in addition to our numerous patients. In between this of course we forget to cater for ourselves. We all know the incidence of cancer is rising in our population. Awareness and screening are the two main pillars of early detection, So cancer screening is an unavoidable part of self care for all strata in the society. Taking into account every cancer from the head to the toe, a few can be screened for, including those of the mouth, breast, cervix, colon, lung, and prostate. The cervix deserves special attention due to its prolonged premalignant lesion period (12–15 years), during which time it is easily recognised and fully treated. • What is the ideal screening test for cervical cancer? As per latest guidelines including WHO, HPV-DNA screening test is ideal. Recommendations are to start screening from 25 years onwards till 65, at 5 yearly intervals. For low middle income countries like India, screening can be started at 30 years of age and can increase the screening interval to 5-10 years. • Which HPV-DNA test should I choose from the many that are on the market? If we are opting for HPV-DNA testing alone ASCCP guideline people recommend either HPV-DNA test by COBAS or BD Onclarity. If we have options to do only other HPV-DNA tests only then proceed with co-testing( HPV-DNA and PAP smear together) but WHO guidelines give no such recommendations. Dr. Aswathy G Nath Consultant Gynaecological Oncologist 9846610552 [email protected] Have you been screened for cancers?

• If it's an HIV positive patient guidelines recommend to start screening from 25 years onwards at 3-5 yearly intervals. • If screening is positive, the next step is to proceed with colposcopy and guided biopsy and management according to histopathology report. Breast screening should start at as early as 20 years of age with a regular self breast examination and a clinical breast examination along with self breast examination in those above 30 years of age. • Women aged 45 to 55 years are recommended to have an annual screening mammogram, whereas after 55 years a biennial screening mammogram is recommended. The American Cancer Society also mentions that women should not discontinue screening mammography after the age of 75 as long as their general health is good, and their life expectancy is ten years or longer. For colorectal cancer screening, men and women aged 45 years and older should undergo a high sensitivity fecal occult blood test(FIT test for occult blood). Any positive test should be followed up with prompt colonoscopy, which is the gold standard for screening of colorectal cancers. If you have a family history of CRC or a documented advanced adenoma at <60 years in a first degree relative or two first-degree relatives at any age, then recommendation is to undergo colonoscopy every 5 years beginning ten years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. For lung cancer all adults, aged 55 years and above, who are currently smoking or have a 30 pack-year history of smoking and have quit in the last 15 years are recommended to get annual low dose lung computed tomography (LDCT). The recommended test for lung cancer screening is LD CT scan, which is not routinely followed in a low income country like India. The screening for oral cancers are recommended for men and women, especially the ones with habits, with oral visual examination by a clinician. The screening for prostate cancer is recommended for men above the age of 50 years with yearly S.PSA testing. We have reached so far. Are you feeling overwhelmed? Only we will, ultimately be there for our families and ourselves. We are the best people to know about our body, so please pay attention to any warning signals, get properly screened and look after your physical and emotional well being. 117 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 118 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR As doctors we are not very good at looking after our health although we spend our entire professional life taking care of our patient’s health problems. Medical doctors are no different from other people when it comes to health issues and certain stress related mental conditions are more common among doctors compared to the public. Usually medical issues start arising from the ages of late fifties and early Dr George Paul Emeritus Professor Department of Geriatric Medicine Amrita Institute of Medical Sciences Kochi How good are we in looking after our health

sixties. As we get older there is a tendency for new diseases to join the already existing health problems leading to a poor quality of life in elder years and shortening of the life span. I feel that these factors make it a strong case for us all to look at our life style more closely and evaluate where we stand in looking after our own health. Apart from the changes associated with natural aging process there are physiological and psychological developmental issues to deal with as we get older. It may be hard to quantify how much of functional decline is actually due to aging. The Rule of Thirds states that one third of the decline is due to disease, one third is due to disuse and one third due to aging. Changes in Lifestyle and proper health care can minimize functional decline. The ability to respond effectively to insult and injury decreases as we get older. The human health is at its peak in late twenties which is followed by an inexorable decline for the rest of the life. This decline may become reflected, in clinical practice, as unclassified symptoms. Our concept of age is based on two factors which are Chronological age, calculated from the date of birth and Physiological age, determined by our functional abilities. Health, in an older person, is a product of the life experiences of the individual. Unhealthy behaviors such as smoking, excessive consumption of alcohol, exposure to prolonged infections and parasitic diseases, or environmental pollution may leave the person with impaired function and will predictably shorten life expectancy. Adequate nutrition and exercise throughout life is essential for maintaining good health and finally the genetic predisposition, to be either free of or incapacitated by chronic diseases, determines how well and how long we live. There is undoubtedly a significant percentage of doctors among us above the age of 60 yrs who do not give adequate attention to their own health. Chronic diseases start appearing around the age of 60 and above. Due to declining natural immunity, this group is more vulnerable for acute and chronic infections. Incidence of malignancy also increases with aging. Increased life expectancy without good health and mobility in reality is a punishment. The last thing an elder person wants is prolonged dependence on other people for their activities of daily living. Preventive approaches in elder age group 1. Primary Prevention This is to prevent disease occurring in the first place by removing the causes. Examples include immunizations for many communicable diseases. Vaccinations for pneumococcal pneumonia, influenza, shingles and viral hepatitis are available. Stop smoking, stop excessive alcohol consumption, safe sex, healthy diet, using seat belt in cars and helmet for bicycles and motor bike users are all part of primary prevention. 2. Secondary Prevention This is to detect disease in their early asymptomatic stage so that the progress can be curtailed or prevented. Examples include mammography, pap smear, fecal occult blood test and PSA evaluation in male. Screening for hypertension, diabetes, glaucoma and dyslipidemia are also part of secondary prevention. 3. Tertiary Prevention This is the effective treatment of all the apparent diseases intended to prevent further deterioration and reduce the complications. Examples of tertiary prevention include comprehensive management of diabetes and institution of medication after myocardial infarction to prevent re infarction and cardiac failure. Maximizing the quality of life is the main goal in the tertiary preventive strategy. A screening medical checkup inclusive of history, physical examination and laboratory evaluation at least once a year for all above the age of sixty would be an ideal recommendation as part of a healthy life style. It is important for all of us to pay attention and look after our health as best as we can in order to experience and enjoy a happy, healthy and comfortable elder years. After all ‘the sunset is no less beautiful than the sunrise”. 119 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 120 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Can cancers be prevented by human intervention? Very few cancers are truly preventable by active intervention. Among the top preventable cancers are cervical cancer, hepatoma (liver cancer) and colorectal cancer. Dr Rajeev Jayadevan Co-chairman, National IMA COVID Task Force Evidence-based colorectal cancer prevention for doctors: it’s time to change some old paradigms

Cervical cancer is preventable by regular pap smears, which detect premalignant changes in the cervical epithelium. Lately, HPV (human papillomavirus) vaccination has gained acceptance. The rationale is that cervical cancer is linked with human papillomavirus infection which can be prevented by vaccination before onset of sexual activity. Hepatoma has several causes, one of which is hepatitis B, for which an effective vaccine is available. In countries such as Taiwan where universal hepatitis B vaccination was successfully carried out early, the incidence of hepatoma related to Hepatitis B has decreased. The third is colorectal cancer for which screening colonoscopy is the standard of care worldwide. Screening colonoscopy can detect polyps and remove them without surgery. Nearly all colorectal cancers start their journey as tiny polyps, hence the value of removing them early. Not all polyps however have cancer potential. Among the above three cancers, only cervical cancer and colorectal cancer can be detected before the lesion turns malignant. This feature sets apart both these cancers as eminently preventable cancers. What is a colonoscopy? The procedure done to diagnose colorectal cancer is called a colonoscopy. It is done as an outpatient procedure, following a complete bowel clean-out. In developed nations, it is done under IV sedation and analgesia which makes it substantially more comfortable. The advantage of colonoscopy is that the gastroenterologist is able to see the inner lining or mucosa of the large intestine on a large screen and detect small growths on the wall, removing them immediately. Most of these are not cancerous. However, if left alone, some of these polyps turn into cancer. Hence the value of removing these polyps ahead of time - so that they will not get a chance to grow into colorectal cancer. In countries where such screening programs have been in place for several decades, the total death rate from cancer has substantially come down. Regarding other cancers like lung, breast or prostate, only early detection is possible - for example through physical examination, x-rays, scans or mammogram. How good is the preventive advice we give out as doctors? When it comes to bowel cancer prevention, we often give out health advice such as “avoid meat, cut out fat and oils in your diet, do exercise, avoid junk food, eat lots of fruits and greens”. Unfortunately, unlike the west, in India, seldom do we hear a substantial piece of advice that actually is evidence-based, which is “Have you had a screening colonoscopy yet?” If we look at the outcome measures of each one of these pieces of advice, measures such as cutting out red meat and oil only produce an infinitesimally small actual difference in outcomes. However, these appear as impressive relative risk reduction percentages in large populations in the author’s conclusion section in published papers, but are of practically very little or no value to the individual. However, doctors often go to great lengths to propagate and implement such measures, without even realising that these are perhaps futile for the purpose intended, especially when commenced later in life. The question the doctors ought to think of when giving out such advice is what realistic difference is that advice going to make for the person sitting in front of the doctor, for the remainder of that person’s lifetime. For instance, asking an 85 year old man to not enjoy his favourite omelette just because his LDL cholesterol is slightly elevated is not going to make him live longer, let alone prevent a cardiovascular event. Chances are the extra nutrition from the omelette will make him live longer by reducing his muscle loss (sarcopenia), thereby preventing a fall and hip fracture. There are exceptions of course, where lifestyle measures are absolutely essential, such as avoiding salt in heart failure, and reducing weight in metabolic syndrome. It is also true that stopping alcohol and tobacco use at any stage in life will reduce the 121 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

risk of numerous diseases. Salads, really? Yet another common health advice that is given out, often mindlessly, is to “eat more salads”. Exactly how nutritious are salads? Rather than parroting often-repeated phrases, the questions we must really be asking instead are, what is the evidence that they reduce cancer, what is the extra cost of grocery shopping for salads, how much is the pesticide residue on the salads and the cancer risk involved. Also worth a consideration is the risk of food poisoning from E. coli and Salmonella being present by fecal contamination on the salads, remembering that they are eaten raw. It is important to look at the big picture and ground reality before giving out such pieces of advice that border on futility. Don’t be fooled by clever statistics and halftruths found in authors conclusions on research articles In statistics, hazard ratios and relative risks can make tiny differences seem really big, and are often used to exaggerate the implication of the findings. The actual difference between intervention groups and placebo are best measured by absolute risk reduction (expressed as differences in percentage rather than as a ratio) or NNT (Number needed to treat), which are unpopular statistical tools for obvious reasons. For example, 3 rupees is “50% more than 2 rupees” but the absolute difference is only one rupee. Applying these principles to dietary interventions, to prevent one case of colorectal cancer by reducing the intake of red meat, it will take 26,100 person-years. (Mullie et al, January 2021, Eur J Public Health) This means that 26,000 people have to reduce their red meat intake over a one year period to prevent just one case of colorectal cancer in Europe. For India, that number could even be larger, which means the impact of such a dietary intervention is even smaller. While this is not an endorsement for unlimited meat intake, such calculations are helpful to see the right perspective. Dietary habits are best taught in childhood, for any diet-related disease to be really prevented. Those who wish to read more about statistical tricks could refer to my article available online “How not to be fooled by research studies”, Dr Rajeev Jayadevan, January 2022. “Doctor, what can I do to reduce my risk?” If a person comes to a doctor and says:”Doctor, how can I protect myself from bowel cancer?” Going by traditional medical school teaching, most doctors would ask for any symptoms such as bleeding, family history and also enquire if they are non-vegetarian. If the patient says no to these, some doctors might say “Don’t worry, you will not get colorectal cancer. Just keep eating those salads”. Nothing can be further from the truth. For starters, 80 to 95% of colorectal cancer is not familial, it is in fact sporadic. Being vegetarian does not stop someone from getting colorectal cancer. In fact, there are large cohort studies showing that red meat eaters and vegetarians have the same incidence of cancer. Although red meat is considered a IARC group 2a carcinogen, numerous other substances are also grouped into this category, which basically means that if taken in extremely large amounts over a prolonged period of time, there is a proven link with Cancer. But this does not mean that everyone who consumes red meat will develop this disease in their lifetime. For instance, diesel exhaust is classified at a higher grade 1, but that obviously doesn’t mean everyone is getting cancer as a result. Hot beverages above 65 degrees Celsius are classified by IARC as group 2a carcinogen, but the actual number of cases of cancer from drinking hot tea is clearly very small. The difference between screening and diagnostic colonoscopy In India, most doctors advise colonoscopy only if the patient develops red flag symptoms such as blood in stool, persistent change in bowel habits, unexplained lower abdominal pain. This is called a diagnostic colonoscopy. Although the procedure is the same, it must be distinguished from screening 122 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

colonoscopy which is done on individuals who are apparently healthy before any such symptoms appear. Screening colonoscopy is standard of care in all developed countries. The age of onset of screening colonoscopy in the United States is 45 years. This is done on individuals who have absolutely no lower GI symptoms. The aim of the procedure is to detect silent polyps if any and remove them ahead of time so that the lifetime risk for cancer can be reduced. When to screen? When not to? When it comes to screening, many people confuse between individual health and public health. For instance, should we be doing CT scans of the brain to check for brain tumours in all people without symptoms? Obviously the answer is no. The reason is that for screening to be done, there are certain criteria to be followed. First, the target disease has to be serious and common, effective treatment should be available, and test procedures should be acceptable, available, safe and relatively inexpensive. All of these criteria are met for colorectal cancer. Unfortunately, screening colonoscopy is not done much in India. There are two categories of screening. One is called organised screening, which is practised in wealthy nations, where everyone is expected to undergo that procedure and payment is made by insurance companies or the government. But for resource-limited countries such as India where not everyone is in the same income bracket, opportunistic screening can be performed. This basically means that if a person is interested in reducing his or her individual colorectal cancer risk and is willing to bear the expense, screening can be performed even in the absence of symptoms, starting in mid 40s. It is practically impossible to perform screening colonoscopy for all individuals in India due to multiple resource concerns. The available screening modalities for colorectal cancer include colonoscopy, sigmoidoscopy, (which examines only the left part of the intestine) and also stool occult blood testing. The presence of hidden blood on occult blood testing can trigger a colonoscopy. However, a false negative result could mean that a potentially curable cancer or pre-cancerous lesion could be missed. Modifications of FOB testing, including fecal immuno testing, fecal DNA test are also practised in different parts of the world. It is estimated that a small polyp which is only a few millimetres in diameter will take 5 to 15 years to grow into full-blown cancer. Therefore, a colonoscopy done at any point during this timeline will not only detect the lesion before it turns into cancer, but also detect cancer at a relatively early stage - which translates to better survival and also lower cost of treatment. In terms of real world effectiveness, screening colonoscopy reduces the incidence of colon cancer by 77% (Winawer et al. NEJM December 1993). There has been a 53% reduction in CRC deaths (National Polyp Study, NEJM February 2012). Similar findings have been reported from European nations such as Germany. Data from India From India’s perspective, the true incidence of colorectal cancer is difficult to estimate due to paucity of data and absence of large centralised databases. There is no organised screening, therefore, data remain scattered and prone to referral bias. As many cancers are silent, some of these individuals might succumb to other diseases such as heart disease and therefore these cancers might not be diagnosed at all. This leads to undercounting of colorectal cancer cases. In other words, not everyone who has cancer in the colon will have the diagnosis entered in a registry. As a result, there is a falsely low perception that colorectal cancer is rare in India compared to western nations. Studies from India have shown that the average age of diagnosis of colorectal cancer in India is 47.5 years. (Shaesta M. et al., December 2017) In Sri Lanka, 26% of colorectal cancer was diagnosed in less than 50-year-olds (Chandrasinghe, October 2017) In a study from Calicut Medical College, most polyps were adenomatous, and left sided polyps were more common than right-sided polyps (V. Thomas, June 2007). A study from Kochi showed that prevalence of adenoma increased after age 40 (R. Jayadevan, May 2016). 123 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Data from India are heterogeneous, partly because of variation in practice patterns, lack of unified protocols about quality parameters such as colonoscopy withdrawal times, bowel preparation, sedation protocols and cecal intubation rates. In the US, adenoma detection rate is considered one of the benchmarks of quality of screening colonoscopy, in addition to adequacy of bowel preparation. Can we afford it? The question whether colonoscopy screening is affordable in India has a clear answer. The cost of screening colonoscopy in India is about 1/50 to 1/500 of that in the United States. In recent years there has been a substantial investment in infrastructure and therefore unlike the 90s, getting these procedures done is within reach to most individuals in India, especially in urban settings. Cost is even lower in the public sector. In fact, considering the number of unwarranted tests being done in the guise of “health checkups”, the cost of a screening colonoscopy is well within reasonable limits. As diagnostic facilities and trained personnel become available and accessible, predictably the incidence of colorectal cancer is rising in India. Unfortunately we are not doing enough for prevention. Lifestyle modifications purportedly for colorectal cancer prevention, but of very little individual benefit, are however practised widely at great cost as discussed above. Why not wait for symptoms? It is obviously unwise to wait for symptoms of colorectal cancer to appear to undergo testing. That is because all cancers do not bleed, and the tumour could be more advanced by the time symptoms appear. In short, symptoms are not a reliable predictor for colorectal cancer. Likewise, it is unscientific to only offer screening colonoscopy to those with a family history, because it is absent in 90% of cases of colorectal cancer. The most effective tool to reduce an individual’s lifetime risk of colorectal cancer is to undergo a screening colonoscopy at least every 10 years. The intervals are customised depending on findings and family history. In India, young onset colorectal cancer is a problem. Thus, screening even at the age of 45 is going to miss a substantial number of these cases. While it is true that organised population screening is not feasible for a large country such as India, opportunistic screening is perfectly feasible and is already being done in centres of excellence with benefits to those who undergo the procedure. 124 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 126 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Medical professionals today face immense stress which can perhaps precipitate or lead to immensely high burnout rates. Doctors among us face high rates of depression, anxiety, and adjustment problems. The suicide rates among doctors are increasing at an alarmingly high pace, unfortunately. What doctors get to mitigate the effects of the aforementioned distress are methods like Zumba dance, meditation, yoga, and powerpoint presentations. What can we do? Doctors are a population who were once thought to represent the cream of the society from an intellectual perspective. But unfortunately, we found that today’s doctors lack many skills in life and living that they ought to have. Doctors are taught how to look after their patients well. But many of them don’t know how to look after themselves. They teach a lot of skills better than any other generation, using audiovisual aids and online platforms. But many of them lack basic skills like attention, judgment, and compassion which they should have for a peaceful life. There comes the importance Dr. S. Krishnan Professor and HOD, Department of Psychiatry, Government Medical College, Thiruvananthapuram Mindfulness for Doctors – A pathway less travelled; A pathway worth travelling

127 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR of mindfulness and mindfulness-based interventions (MBIs) Mindfulness refers to the awareness that can be cultivated by paying attention, on purpose, to the unfolding of moment-to-moment awareness, with openness, curiosity, and compassionate judgment. Mindfulness rooted in ancient contemplative traditions has been proven to be a powerful antidote to the stressors of modern medical practice. By cultivating awareness of the present moment without judgment, doctors can develop resilience, develop immunity, reduce stress, and prevent burnout. MBIs can also be of use to doctors as a treatment for mild to moderate depression and anxiety. The nature of medical practice demands Unwavering attention to detail, critical thinking, and effective decision-making. Mindfulness exercises train the mind to stay focused in the present, enhancing cognitive abilities crucial for optimal patient care. Attention deficit has been suggested as a reason for diagnostic errors (a product of prolonged stress and burnout) and a high list of prescription medicines in many prescriptions. Studies have indicated that regular mindfulness practice can improve attention span, working memory, and overall cognitive function. By incorporating mindfulness into their routines, doctors can sharpen their mental acuity, leading to more accurate diagnoses and effective treatment plans. Dealing with complexities of patient care, especially in high-state situations, can evoke a range of emotions for health care professionals. Mindfulness equips doctors with tools to navigate their promotional landscape with greater peace. By cultivating emotional intelligence and self-awareness, physicians can respond to challenges with a measured and compassionate demeanor. This not only fosters healthier doctor-patient relationships but also contributes to a more supportive and collaborative healthcare environment. Many peer-reviewed studies have suggested that MBIs can help employees better deal with stress, develop the ability to observe negative emotions and automatic thought patterns and behaviours, and remain calm, present, self-aware, and alert, rather than succumbing to the slippery slope of negative emotions. In the face of demanding schedules and increasing patient loss, doctors may find it challenging to maintain a deep sense of empathy and compassion. Mindfulness practices have been linked to the development of empathetic qualities, allowing healthcare professionals to connect more authentically with their patients. Mindful listening and presence can strengthen the doctor-patient relationships, promoting trust and enhancing the overall quality of health care delivery. Integrating mindfulness into medical education can equip future generations of physicians with valuable tools for self-care and patient interaction. By introducing mindfulness training early in medical training aspiring doctors can develop Brazilians and coping mechanisms that will serve them throughout their careers. Mindfulness education can instill a patient-centered approach, emphasizing the importance of holistic care and recognizing the interconnectedness of physical and mental well-being. Beyond personal well-being, doctors practicing mindfulness can also extend these principles to patient care. Mindfulness-based interventions, such as Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy, have demonstrated efficacy in managing various medical conditions, including chronic pain, anxiety, depression, and extreme levels of stress. Physicians who are familiar with mindfulness techniques can incorporate these approaches into their treatment plans, offering patients additional tools for managing their health and well-being. The impact of mindfulness in medicine extends beyond individual practitioners to broaden the healthcare system. Organizations that prioritize the well-being of their staff, including the cultivation of mindfulness practices, foster a positive and supportive workplace culture. This, in turn, can contribute to improved job satisfaction, reduced turnover rates, and enhanced patient outcomes. Mindfulness is a skill. Doctors can learn mindfulness through workshops by repeated practices. Doctors can learn the skill over a period of 10 weeks by attending workshops. Department of Psychiatry of Government Medical College, Trivandrum conducts workshops on Saturdays from 01.00 to 03.00 PM to train people in mindfulness skills. The program of Mindfulness Unified Cognitive Behaviour Therapy (MUCBT) is the only program developed in India based on the concept of mindfulness and cognitive behaviour therapy. Training in the same can be availed free of cost from the Department of Psychiatry, Government Medical College, Thiruvananthapuram.

Tharang Dhwani 2023 128 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR I ndian doctors are highly acclaimed for their professional skills and patient orientation. Quality of care provided across the nation and even in reputed Health Care Organizations’ (HCOs) across the globe by our own doctors has received high decibel accolades. We are proud of our doctors who rise up to any challenge including sporadic pandemics and come out with flying colours providing succour to the affected. While this aspect of ‘care giving’ is highly commendable, can we be equally appreciative of the ability and orientation of our ‘Care Givers’ in looking after themselves? Without going into data to be evidence-based, a casual look around our ecosystem will indicate that our ‘care givers’ need to indulge in more ‘Self Care’ just as they devote time to care for their patients. The situation being well known, with a pronounced deficit in self care, what is it that needs to be done and can be done? At the individual level there is a profound need for all doctors to be highly conscious of their life styles and make amends where applicable to suitably alter their life styles to make it healthier and less ‘punishing’. A brief exercise régime with ‘an early to bed and early to rise’ sort of daily routine scheduling should be immensely helpful. A well regulated life style should be the first ‘Self Help’ step that needs to be taken by doctors to help themselves remain fit, disease free and active. The next area of concern and application should be that of the diet. A balanced diet without much of fancy stuff and junk food is preferable, as known to all doctors more than anybody else. However when it comes down to adherence to dietary principles and habits may be there is a slip between the cup and the lip which could be best avoided to retain a healthy and sustainable Life Style. Most doctors also do not seem to have regulated timings for food. In the interest of well being of the patients, own comfort and preferences of doctors take a back seat which Col Rajeev Mannali Chief Executive Officer BR LIFE: A Healthcare Initiative of BRS Ventures Ltd. Pattom Palace P.O Kerala Who will care for our ‘Care Providers’?

129 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR is understandable. Though fixed timings for food may not always be possible it may be preferable to have meals and tea breaks to reduce the monotony of work as also help follow a more regularized life style. Sleep deprivation is another major problem that physicians have to contend with especially when ‘On Call’ requirements are not predictable. An effort to adhere to the practice of getting adequate sleep when not otherwise committed, may be of immense help in remaining disease free and healthy. Retiring to bed early might be of help to give doctors adequate time to relax and recoup. Adherence to a minimum of six hours of sleep would be immensely helpful to maintain a healthy life style. ‘Work-life balance’ is an oft-repeated aspect which sounds good but not adequately attended to by doctors. Physicians must find time to spend with their families and must earmark days when it is purely family time which should be spent with the family. The comfort zone which family provides is invaluable and must be looked forward to, as being with the family will certainly help rejuvenation and recreation. Normally, doctors forget to get a preventive health check up done for themselves while they always will recommend one for their patients. An annual or six monthly preventive health checkup will go a long way in ensuring longevity and delay in onset of diseases, if at all. Life style diseases can be kept at bay and controlled, if already affected through regular, periodic health check up. Six monthly or annual vacations is something that doctors must avail of to rejuvenate and recoup from the monotony of daily routine and give adequate time and opportunity to oneself to remain active and fit. Vacations have a way of getting the family relax together and definitely has a therapeutic value. On the whole, ‘Care Giver’s’ health is as important as that of those cared for and there must be a deliberate effort to take healthy breaks, workout and indulge in activities that are likely to improve the quality of life and enhance life span of the care givers. Let us hope that our ‘care givers’ are as well cared for , as their ‘Cared Ones’ and they in turn help keep the society healthy, fit and disease free.

Tharang Dhwani 2023 130 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR The concept of screening is that detection of early disease may permit treatment at a more tractable stage and thus improve prospects for survival and prevention of death from the disease. In technical terms, it is the periodical routine examination of the general population or large subgroups of it for early asymptomatic disease by application of dedicated screening tests. IRIA , Indian Radiological and Imaging Association (IRIA) has taken an initiative at national level that focuses on expanding the integration of clinical radiological services with preventive medicine for early identification, prognostication, and intervention for clinical priorities in India. The program is conceived and founded by Dr Rijo Mathew Choorakuttil, who is the national coordinator for this initiative and was initiated during the president ship of Prof. Dr. C. Amarnath with the wholehearted support of IRIA. In this article, the most relevant scope in preventive radiology is discussed briefly. Cardiovascular Imaging for the Primary Prevention of Atherosclerotic Cardiovascular Disease When it comes to cardiovascular disease, decades of research have shown that there is a wide range of lifestyle and pharmacologic therapies that can have a significant impact on lowering the risk of cardiovascular events. Hence the identification of coronary atherosclerosis can lead to enhanced risk assessment and more appropriate allocation of preventive therapies. The challenge is the need to make cardiovascular imaging more scalable by making it more widely available and simpler to use. The approaches emphasized include coronary artery calcium Dr Arun Mohan M. Senior Consultant , Dept of Radiodiagnosis, BR Life SUT Hospital Thiruvananthapuram Preventive Radiology

(CAC) scoring and carotid ultrasound that allow for the direct visualization and quantification of subclinical atherosclerosis . Coronary artery calcium scanning is a rapid, non-contrast computed tomography (CT) of the heart used to identify calcification, defined as an area of ≥3 adjacent pixels (or 1 mm2 ) of at least 130 Hounsfield units—within epicardial coronary arteries. It is simple, can be performed in any patient with a single breath-hold and at very low-radiation exposure (≤1 mSv), comparable to radiation exposure associated with screening mammography. Coronary artery calcification is most commonly quantified using the Agatston method and is a highly reproducible method. In addition to absolute scores, coronary atherosclerosis severity, as measured by CAC scoring, can be compared to asymptomatic subjects of the same age, gender, and ethnicity using established databases (e.g., MESA), resulting in calculation of an individual CAC percentile score, with both absolute and percentile scores used for cardiovascular risk refinement and medical decision-making. Carotid Intima-Media Thickness and Plaque Screening Ultrasonography for the measurement of carotid artery intima media thickness (CIMT) and carotid plaque in asymptomatic screening populations is another approach. Compared to CAC, the use of ultrasonography has the advantages as there is no ionizing radiation, is highly reproducible, and can typically be done in an office setting with appropriately trained personnel. It is important to note when considering the evidence base that there is significant heterogeneity across studies with regards to the site of CIMT and plaque assessments and hence requires further development of a proper guideline for the practitioners to follow. Low-Dose CT Screening for Lung Cancer Lung cancer has been the greatest cause of cancer mortality for decades, and this trend is expected to continue. Data and observations from screening trials have improved our understanding of the CT manifestations of early lung cancer and have provided information important to the development of guidelines for managing indeterminate lung nodules. The randomized controlled U.S. National Lung Screening Trial (NLST), conducted by the National Cancer Institute from 2002 to 2009, is acclaimed as a major breakthrough in lung cancer screening. After median follow-up of 6.5 years, there were 20% fewer deaths from lung cancer among those randomly assigned to the CT arm (P = .004), with one lung cancer death prevented for every 320 screened with CT. Current United States Preventive Services Task Force (USPSTF) eligibility guidelines reflect those used in the NLST, including a minimum age of 55 years, minimum smoking history of 30 pack-years, and quit time of less than 15 years. However, considering the lifestyle and ethnic differences, we need a more specific guidelines to be applied in our country regarding the definition of high-risk population. In addition, other risk factors associated with lung cancer including second-hand smoking, exposure to solid fuel smoke or outdoor particulate matter, occupational exposures and family history to be taken into consideration. Current guidelines of the ACR and American Association of Physicists in Medicine recommend use of CT scanners with 16 or more detector rows and slice thickness of 2.5 mm or less, with 1-mm thickness preferred. These guidelines and CMS requirements limit the CTDIvol to 3.0 mGy for a standard size patient of 5'7” (170 cm) and 155 lbs (70 kg), with appropriate reductions expected for smaller patients and increases for larger patients. Standardized methods for lung nodule management in CT screening, required by CMS, include the ACR Lung CT Screening Reporting and Data System (Lung-RADS) version. Automated methods for pulmonary nodule detection, size measurement, and tissue characterization have been developed and continue to be refined. With further development and study, these methods may assume an increasing role in future clinical practice. Early breast cancer detection In 2021, breast cancer has overtaken lung cancer to be the world's most commonly diagnosed 131 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

cancer, accounting for the severe burden globally, especially among women.Screening for breast cancer is an effective measure to detect early-stage disease and improve the survival rate of cancer patients. The USPSTF recommended mammographic screening for average-risk women aged 40–74 years. 50–69 years were regarded as the optimal age group for screening due to the steep increase of breast cancer beginning around age 50. Mammography was recommended as the primary screening modality for average-risk women suggesting biennial mammographic screening High risk factors of breast cancer identified in the guidelines mainly fell within five categories which could be broadly summarized as the personal history of pre-cancerous lesions and/or breast cancer; the family history of breast cancer; the known genetic predisposition of breast cancer; the history of mantle or chest radiation therapy; and dense breasts. For women at higher risk, there was a consensus among most guidelines that annual mammography screening or annual MRI screening should be given and the starting age should be earlier than the average-risk group. Also required is adequate training of the preventive radiologists in reporting the mammography and universally accepted reporting system like BIRADS so that the study is reproducible and accurate. Prevention of NASH and NAFLD Non-alcoholic fatty liver disease (NAFLD) is the most common diffuse liver disease, with a worldwide prevalence of 20% to 45%. NAFLD can be subdivided into simple steatosis and nonalcoholic steatohepatitis. Most cases of simple steatosis are non-progressive, whereas nonalcoholic steatohepatitis may result in chronic liver injury and progressive fibrosis in a significant minority. Effective risk stratification and management of NAFLD requires evaluation of hepatic parenchymal fat, fibrosis, and inflammation. Liver biopsy remains the current gold standard; however, non-invasive imaging methods are rapidly evolving and may replace biopsy in some circumstances. These methods include well-established techniques, such as conventional ultrasonography, computed tomography, and magnetic resonance imaging and newer imaging technologies, such as ultrasound elastography, quantitative ultrasound techniques, magnetic resonance elastography, and magnetic resonancebased fat quantification techniques. Conventional US is often the first imaging modality used to evaluate fatty liver clinically, especially for screening of suspected NAFLD, due to its lack of invasiveness, wide availability, and relatively low cost. There are several limitations of conventional US for NAFLD evaluation: It is qualitative and therefore subjective. Sensitivity is limited when there are few steatotic hepatocytes. The sensitivity and specificity of B mode sonography decreases as BMI increases. Conventional sonography cannot differentiate steatosis and steatohepatitis or stage fibrosis. Ultrasound elastography (USE) quantitatively evaluates liver stiffness to make noninvasive evaluation of liver fibrosis and NASH clinically possible. Estimated tissue stiffness provides information on the presence and degree of fibrosis. Whole-body MRI for preventive health screening Whole-body magnetic resonance imaging (WBMRI) screening has become an appealing concept since it promises noninvasive and radiation-free detection of diseases in an early stage. WB-MRI is currently an established screening tool for children and adults at high risk of developing malignancy, with the strongest supporting evidence in patients with Li-Fraumeni syndrome. The diagnostic performance of WB-MRI screening has been documented by several studies showing that the method could identify a wide range of clinically relevant diseases such as aneurysms, tumors, and pulmonary infections. Furthermore, MRI image quality is so advanced that it has the ability to clearly define structures and lesions within the body in far greater detail than other modalities. Using the latest technology in MR, physicians can now create 3D reconstructions of targeted areas in the body, allowing them to determine if a lesion is benign or if it requires further investigation. 132 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

However everybody doesn’t require a routine whole body MRI screening. Clinicians are to recommend the study for high-risk patients which includes, patient with history of neurological problems or family history of aneurysm, family history of stroke or cancer, joint or extremity problems or unexplained pain, unexplained weight loss, malaise, fatigue etc. Despite the increased scope for a whole body MRI, an international consensus list of critical findings is needed for standardization. Furthermore, it remains to be investigated which whole‐body MRI protocol achieves the best sensitivity and specificity. To summarize, preventive radiology is a very important area to be given attention to in the present scenario. And so important is the necessity of published clinical practice guidelines to facilitate clinical decision making and to improve health outcomes and health service efficiency. Radiological imaging techniques always pose some risk of adverse health effects to patients or – in the case of screening and preventive diagnosis – asymptomatic persons. Therefore, this issue has to be thoroughly evaluated before conducting interventions to promote radiological screening for persons with an increased risk for specific diseases or even the introduction of regular screening programs. 133 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 134 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Not a single day goes by without a beautiful smile; and your smile is defined by your dentition. A good, tasty meal is impossible to enjoy without good dental health. A healthy set of teeth improves the quality of life in so many ways and we don’t even realize it. While there is a general misconception that dentistry and dental procedures are very taxing, painful and expensive, lack of dental awareness is the actual problem. Dentistry becomes easy if we can identify a problem early on and take immediate action to fix it. Dr Anirudhmaadhav P A Paediatric Dentist - Kumars Dental Clinic KIMS Health Maintaining your Dentition

A dental checkup should ideally be done at the age of 6 months. This is the time when deciduous or milk teeth begin to erupt in a child. Even prior to that when children are still in their pre dentition stage, their gum pads should be cleaned. Getting a pediatric dental check up from a pediatric dentist at regular intervals helps to prevent a lot developing undiagnosed conditions. For eg ankyloglossia or tongue tie if not corrected can hinder the speech development of the child and also can affect the development of the facial structures. Similar is the case with natal and neonatal teeth. There is always a risk of aspiration or formation of ulcers on the ventral surface of the tongue – Riga Fede disease. Once the child is 3 years old, for the next 3 years there will not be any eruption / exfoliation of teeth and maintaining this primary dentition is extremely crucial. The anterior teeth are important for speech development and to build up the confidence of the child. Badly decayed anterior teeth can result in root canals as a final attempt to save the tooth or ultimately extraction. Children tend to lose their confidence on losing their front teeth and in many instances, they refuse to smile. Lack of anterior teeth can also result developing a tongue thrusting habit which is a whole different issue altogether. Now coming to the posterior primary teeth, they are necessary for proper mastication of food and for maintaining the space in the dental arch for the successor permanent teeth to erupt. Early loss of posteriors can result in malalignment as the space for the erupting teeth will be lost by the time they erupt into the dental arch. This is where preventive orthodontics play a major role wherein following premature loss of primary teeth, with the help of certain appliances, we can maintain the space in the dental arch, preventing future malalignment. The ages from 6 – 12 is the mixed dentition period and this according to me is the most important phase. Children may have developed habits such as digit sucking, tongue thrusting or mouth breathing, and the effects caused by these habits will get reflected in the facial growth and in the alignment of the erupting teeth. The dentition may be crowded due to lack of space for erupting teeth, the maxilla can get constricted which in turn results in protruding teeth, facial muscles can show hyperactivity and so on. If identified and corrected at their growing phase itself, by the time children become teenagers, their facial growth pattern and permanent dentition alignment would be almost corrected - close to perfect. This kind of management is what is referred to as Growth Modification or Interceptive Orthodontics. However, there is always Corrective orthodontics for the final correction and orthognathic surgery to correct the more complicated cases. Dental caries management is important at all stages of dentition as the pain that is caused by dental infection / abscess is excruciating. A good endodontic therapy is the ideal treatment option. If preventive orthodontics, interceptive orthodontics and dental caries management with good follow ups are done correctly, by the time a child hits adolescence he/she would be free of almost all dental issues. Early detection of caries during regular checkups can be restored with a wide range of materials. In case of a nerve exposure root canal treatment can be done, the latest being microscopic endodontics, followed by a crown. Gum disease is a chronic inflammatory disease, primarily of the adults, that damages the tissues supporting the teeth eventually leading to tooth loss. Poor oral hygiene, the high prevalence of diabetes, hormone imbalances, nutritional deficiencies, stress, smoking and genetic factors have led to an explosion of gum diseases in our community. The first stage of gum disease is known as gingivitis. It is a mild form of the disease, in which an individual will have red, swollen gums that bleeds easily. However, there is no serious discomfort at this stage. If left untreated, gingivitis progress to periodontitis and in this stage bone loss happens and the teeth will loosen up ultimately leading to exfoliation. Treatment for gingivitis is professional tooth cleaning and polishing and the condition is totally reversible. But if gingivitis has progressed to periodontitis ,complex treatment procedures like flap surgeries and bone grafting may be required, that has to be done by a gum specialist. The best way to prevent gum disease is to get into the habit of taking good care of your mouth and teeth. See your dentist regularly for tooth 135 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

cleanings, usually every 6 months especially if you have risk factors. If you notice any of the symptoms , schedule an appointment with your dentist as soon as possible. The sooner you get care, the better your chances of reversing damage from gum disease and thus preventing tooth loss. Many researchers have established the link between gum diseases and certain systemic diseases like cardiovascular disease, stroke, metabolic syndrome, poor glycaemic control, Alzheimer’s, pregnancy complications etc . Hence gum health is required for overall health. All of us believe in the concept of Prevention is better than Cure; but how many of us actually practice it? This is a question that we all ought to ask ourselves. It is recommended to get a dental check-up done once in 6 months. Problems can be identified as soon as they begin and can be cured then and there. As we get older the periodontal health should be given more priority and an oral prophylaxis once in 6 months or 1 year can be done to maintain gum health. All deep caries will require some form of pulp therapy to preserve them without extraction. In case of tooth loss, prosthetic rehabilitation can be done. Dentistry has evolved into a speciality based practice. Consulting the right specialist would help you get the exact diagnosis and the correct treatment plan that is required. 136 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

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Kudos to our Artists Dr Unnikrishnan Ramachandran Consultant Physiatrist Sarswathy Hospital, Thiruvananthapuram Joint Organising Secretary Tharang 2023 Dr Juni Menon Consultant Ophthalmologist Arogya Medical Centre, Surat , Gujarat A multitalented personality with excellence in the fields of fine arts, dance and ophthalmology. A. Satheesh Secretary Kerala Cartoon Academy. Member of Advisory Board Kerala Chithrakalaparishat Dr Heera Salsa Consultant Physical Medicine and Rehabilitation KIMS Health, Thiruvananthapuram Dr Sreehari PM Junior Resident Department of Radiodiagnosis Government Medical college Thiruvananthapuram Cartoons Photos Design & Layout Cover Page Modern Art Dilip Nair A freelance photographer based in Thiruvananthapuram, brings moments to life through his lens. Vinayak Jayan J Nair 138 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

REEFS HALL 27.12.2023 REEFS 27.12.2023 Time Topic Speakers 09.00am -10.30 am Surging incidence of Cancer in Kerala . Is there reason for a panic? Dr Satheesan B, Director MCC Tellichery Cancer diagnosis and treatment ; New challenges and opportuniƟes in the current digital era Dr .Boben Thomas , GG Hospital Trivandrum and Caritas Hospital KoƩayam Panel Discussion ConƟnuum of care a�er treatment of Cancer; What a general pracƟƟoner can contribute Moderator : Dr Chandramohan K RCC Trivandrum Dr Chandramohan K RCC Trivandrum Dr.Satheesan B, Tellichery Dr .Boben Thomas Dr Bipin P Gopal ,Trivandrum Dr Ansar PP, SreeGokulam MC Venjarammooudu Dr Madhu Muralee,RCC Trivandrum Dr Elizabeth Mathew Iype, Trivandrum THARANG 2023 Scientific Programme chart 140 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

BAY HALL 27.12.2023 BAY 27.12.2023 Time Topics 8.00-8.15 Reverse Diabetes Dr. Sreejith. N. Kumar, Diabetes Care Centre, Thiruvananthapuram 8.15-8.30 Winter infecƟons and its management – Dr. Shyam Sunder, Dr. Reddy's Laboratories 8.15-8.30 Different cough sounds and its management – Dr. Ketan Mehta, Dr. Reddy's Laboratories. 8.30-8.45 EvaluaƟon of Foetal response to music & sounds using MAPS apparatus and its influence on biophysical assessment Prof. P. M. Venkata Sai, Radiologist, Sri Ramachandra Medical Centre Recommended lifesaving technologies in diabetes for the clinician Dr. Jothydev Kesavadev, Director, Jothydev’s Diabetes & Research Centre Youthful Skin..CosmeceuƟcals and Procedures. Dr.Rema Devi T J MD DNB, Senior Consultant Dermatologist & Cosmetologist, KIMSHEALTH Medical Management of Thyroid DysfuncƟon Dr. Joe George, Senior Consultant Endocrinologist, Endo Diab Care, Kozhikode Telemedical AI ED on Wheels Dr. Ajith Venugopalan, Chief OperaƟng Officer, Sr. Consultant –EM & TC, Caritas Hospital & InsƟtute of Heal th Sciences, KoƩayam. AestheƟc gynaecology- current scenario Dr. Anupama R., Chairman, Pran Hospital, Trivandrum Management of acute ischemic stroke - an update Dr. Shylaja P.N., Professor & Head Neurology, SCTIMST, Trivandrum Surgical management of Parkinson’s disease, Dr. Shejoy P Joshua, Consultant- Neurosurgery, Aster Medcity Hospital, Kochi MulƟple Sclerosis and Spectrum of CNS DemyelinaƟng diseases an update Dr. Syamlal S., Senior Consultant Neurologist, In Charge MulƟple Sclerosis Clinic, KIMSHEALTH, Trivandrum Management of Drug resistant epilepsies Dr. K. Radhakrishnan, Senior Consultant & Head Advanced Comprehensive Epilepsy Centre, KIMSHEALTH Importance of Migraine prophylaxis – Dr. Manoj Dr. Reddy LaboraƟes Management of peripheral Neuropathy Dr. V.G. Pradeep Kumar, Sr. Consultant Neurologist, Baby Memorial Hospital, Kozhikode 8.45-9.00 9.00-9.15 9.15-9.30 9.30-9.45 9.45-10.00 10.00-10.15 10.15-10.30 10.30-10.45 10.45-11.00 11.00-11.15 11.15-11.30 11.30-11.45 Multi Omics of LISA – Dr. Roshith J. Kumar , SK Hospital 141 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

BAY HALL 27.12.2023 11.45.12.00 12.00-12.15 12.15-12.30 12.30-12.45 12.45-01.00 01.00-01.15 01.15-01.30 01.30-01.45 01.45-02.00 02.00-02.15 02.15-02.30 02.30-02.45 02.45-03.00 03.00-03.15 03.15-03.30 03.30-03.45 Childhood Seizures Dr. K.P. Vinayan, Professor & HOD, Paediatric Neurology, Amrita InsƟtute Medical Sciences, Kochi ArƟficial Heart Valves and Beyond Dr. Varghese T. Panicker, Professor Department of Cardiac Surgery, SCTIMST, Tr vi andrum Recent advances in management of Dyslipidemia Dr. Ketan Mehta Imaging and intervenƟon in Heart Failure Dr. Aneez Thajudheen, Sr. Consultant Cardiology and Electrophysiology, KIMSHEALTH Recent advances in Cardiology Dr. Deepak Davidson, Sr. Consultant & IntervenƟonal Cardiologist, Caritas Leadless Pacemakers: Evidence to PracƟce Dr. Sajan Ahmad Z, Sr. Consultant IntervenƟonal Cardiologist, Lifeline Trans fat - in health and disease Dr. Tiny Nair, HOD & Sr. Consultant Dept of Cardiology, PRS Hospital, Trivandrum Current Trends in management of Structural Heart Diseases Dr. Bijulal, Sr. Consultant - Cardiology, KIMSHEALTH A comprehensive faƩy liver diagnosis and control program – insights from a single centre Dr. Manoj, Senior Consultant, Metro Scans, Trivandrum Plugging Leaks, Opening Blocks, Barbecuing and Home Delivery of Drugs - Welcome to IntervenƟonal Radiology Dr Praveen Kesav R, Consultant IntervenƟonal Radiologist, Sree Gokulam Medical College & GG Hospitals Current trends in IntervenƟonal NeuroRadiology Dr. Santhosh Joseph, Sr. Consultant and Clinical Lead-Neuro IntervenƟonal Radiology KIMSHEALTH Current trends in the management of Hepatocellular Carcinoma – Dr. Subhash R, SK Hospital. Advances ni TherapeuƟc ERCP Dr. Madhu Sasidharan, Sr. Consultant Gastroenterology, KIMSHEALTH. APD: diagnosis and management – Dr. Reshmi Mehta, Dr. Reddy's Laboratories. Care of Cirrhosis Dr. Arun Valsan, Clinical Assistant Professor, Gastroenterology and Hepatology, Amrita InsƟtute of Medical Sciences. Novel concepts in MAFLD(Metabolic dysfuncƟon Associated FaƩy Liver Disease Dr. Harikrishnan S, Associate Professor, Gastroenterology, Pushpagiri InsƟtute of Medical Sciences & Research Centre 142 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

BAY HALL 27.12.2023 03.45-04.00 04.00-04.15 04.15-04.30 04.30-04.45 04.45-05.00 05.00-05.15 Assortment - a walk through the GUT Dr Arunkumar ML, Lead Consultant, Surgical Gastroenterology & Liver Transplant, GG Hospitals Small Bowel Transplant Dr. Shiraz, Consultant and Head of MulƟvisceral Transplant, KIMSHEALTH. Bariatric Surgery for weight Loss Dr. Mathews John, Bariatric Surgeon, Lifeline Hospital. Approach to Thyroid Diseases Dr. Mathew John Endocrinologist and Pediatric Endocrinologist, Providence Endocrine and Diabetes Centre, PaƩom Syndromic tesƟng - A new approach for diagnosis of InfecƟous diseases Dr. Karthika Mohan, MD, Consultant Clinical Microbiologist, DDRC Agilus, Ulloor Tvm Beyond Mechanical VenƟlaƟon: ECMO Dr. Naveen Jasmine, HOD & Senior Consultant, Dept of CriƟcal Care Medicine, PRS Hospital, Trivandrum 05.15-05.30 HematopoieƟc stem cell transplant in children an overview, Dr. Kesavan MR, Senior Consultant Paediatric hemato oncologist and BMT Physician, Aster InternaƟonal InsƟtute of Oncology, Aster MIMS Hospital, Calicut 143 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

WAVES HALL 27.12.2023 Waves 27.12.2023 Time Topics 8.00-8.15 From InformaƟon to Intelligence—IntegraƟng Medical Data: Insights from Cardiology - Dr. Shelby KuƩy 8.15-8.30 Genomics and Technology puƫng paƟents in charge – lessons from the world of Diabetes - Dr. Nisha Nigil Haroon 8.30-8.45 Medical issues during air travel - How to tackle? Dr. Ajith Kumar Sivasankaran, Consultant Physician & Travel Medicine, SP Fort Hospital, Trivandrum. 8.45-9.00 Suicide prevenƟon among doctors based on NaƟonal Suicide PrevenƟon Strategy Dr. Sagar. Thevalappuram, Consultant in Psychiatry, Kollam District hospital and Nodal officer DMHP ReproducƟve Health in Autoimmune rheumaƟc diseases Dr. Vishad Viswanath, Senior Consultant Rheumatologist and Medical Director IRIS, Trivandrum & Kollam Rheumatology for physicians, A primer on management. Dr. Neeraj Manikath, Associate Professor, Govt. Medical College, Calicut The expanding world of immunotherapy, drawing from a rheumatologist’s experience - Dr. Nigil Haroon, AKMG Recent Advances in RoboƟcs Surgery Prof. Dr. Somashekhar S P Chairman Medical Advisory Board, Aster DM Healthcare - GCC & India, Global Director - Aster InternaƟonal InsƟtute of Oncology - GCC & India, Lead Consultant - Surgical & Gynaecological Oncology & RoboƟc Surgeon, HIPEC & PIPAC Super-specialist Expanding horizons of RoboƟc surgery Dr. Kishore TA, Senior Consultant-Urology, Aster Medcity Hospital, Kochi. How an IntervenƟonal can help you breathe beƩer Dr. Tinku Joseph, IntervenƟonal Pulmonologist Amrita Hospital AnƟbioƟcs for Respiratory infecƟons- to give or not? Dr P Arjun, Sr Consultant and Group Coordinator, Respiratory, KIMSHEALTH The ageing lung and diseases Dr. A.K. Abdul Khader, INPAAR Chevayur, Calicut InvesƟgaƟons in renal disease - Dr. Beena Unnikrishnan, Trivandrum Nephrology AssociaƟon Approach to glomerular disease - Dr. Jacob George , Trivandrum Nephrology AssociaƟon 9.00-9.15 9.15-9.30 9.30-9.45 9.45-10.00 10.00-10.15 10.15-10.30 10.30-10.45 10.45-11.00 11.00-11.15 11.15-11.30 144 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

WAV E S H ALL 2 7.12.2 0 2 3 11.3 0-11.4 5 11.4 5.12.0 0 12.0 0-12.15 12.15-12.3 0 12.3 0-12.4 5 12.4 5-01.0 0 01.0 0-01.15 01.15-01.3 0 01.3 0-01.4 5 01.4 5-0 2.0 0 0 2.0 0-0 2.15 0 2.15-0 2.3 0 0 2.3 0-0 2.4 5 0 2.4 5-0 3.0 0 0 3.0 0-0 3.15 0 3.15-0 3.3 0 0 3.3 0-0 3.4 5 Approach to acid base balance - Dr. A. Vimala, Trivandrum Nephrolo g y AssociaƟ on Medical management of Urinary stone : Dr. Sajeev K, Trivandrum Nephrolo g y AssociaƟ on Diabetes Emergencies Dr.Tony P Joseph, C onsultant Endocr ni olo gist, Sree G okulam Medical C ollege Thyroid Emergencies Dr. Akhil Krishna, C onsultant Endocrinolo gist, KIMS Trivandrum Approach to calcium emergencies Dr. Thushanth Tho mas, Chief C o ordinator & C onsultant, Endocrinolo g y Diabetes, KIMS Health, Trivandrum Management of Drug resistant epilepsies Dr. K. Radhakrishnan, Senior C onsultant & Head Advanced C o mprehensive Epilepsy Centre KIMSHEALT H Tuberculous MeningiƟs Dr. Tho mas Iype, Former Professor & H O D, Medical C ollege, Thiruvananthapuram Approach to Headache Dr. Fiju Chacko, Professor of Neurolo g y, Jubilee Mission Medical C ollege, Thrissur Balance Bey ond Spins Dr. Sajeesh S.R., Senior C onsultant Neurolo gist, Welcare H ospital, K ochi Epilepsy surgery: IndicaƟ ons, procedures and outco me Dr. Biji Bahuleyan, Head: Dept of Neurosurgery & Neurosciences, Welcare H ospital, V y Ɵlla, K ochi Cracking the C ode of High Blo od Pressure: A Secondary H ypertension R oadmap, Dr. K.G. Sajeeth Kumar, Professor and H O D Dept of Medicine, G o vt. Medical C ollege, Manjeri. O ff Pump Strateg y: Making C A B G Safer Dr. S. Rajag opal, Sr. C onsultant Cardiothoracic & Vascular Surgeon C oronary ReconstrucƟ on in co mplex artery bypass surgery. Dr. Sunil A garwal & Dr. Geevarghese K Mathew, Dr. K M Cherian InsƟtute of Medical Science. Neurodevelopmental problems in children Dr. M K C Nair, Director NIMS Spectrum and former Vice Chancellor, NIMS Medicity. Advance in management of diabeƟc reƟnopathy Dr. Ashad Sivaraman, Sr. C onsultant Vitreo ReƟnal Surgery, Sreenethra Eye H ospital DiabeƟc reƟnopathy for the non- ophthalm olo gist Dr. Asok Natraj, Ophthalmic Surgeon, Precise Speciality Eye Care,Trivandrum. Journey of Ophthalm olo g y in the last century Dr. Anitha Unnikrishnan, Paediatric Ophthalm olo gist, Precise Speciality Eye Care, Trivandrum. 145 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

WAVES HALL 27.12.2023 03.45-04.00 04.00-04.15 04.15-04.30 04.30-04.45 04.45-05.15 Current trends in the management of myopia Dr. Jayaram V.R., Senior Consultant Cornea & RefracƟve Surgery, Precise Speciality Eye Care, Trivandrum. “Glaucoma the silent killer”What u should know? Dr. Kiran Gopalakrishnan, Senior Consultant Glaucoma & Cornea, Precise Speciality Eye Care, Trivandrum. What is a normal ECG? A primer Dr. Abhilash S.P., Professor, Cardiology, SCTMIST Abnormal ECGs: Common and relevant ECG abnormaliƟes Dr. Narayanan Namboodiri, Professor, Cardiology, SCTMIST, TVPM InteracƟve Session : 10 ECGs that every doctor should know Dr. Abhilash S.P, Dr. Narayanan Namboodiri, Dr. Jyothy Vijay 146 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

CASCADE HALL 27.12.2023 CASCADE HALL 27.12.2023 Time Topics 9.00-9.15 9.15-9.30 9.30-9.45 9.45-10.00 10.00-10.15 10.15-10.30 10.30-11.00 11.00-11.15 11.15-11.30 11.30-11.45 11.45.12.00 12.00-12.15 12.15-12.30 12.30-12.45 12.45-01.00 01.00-01.15 PerioperaƟve pain management spearheaded role of Regional blocks Dr. Sajeesh Gopalan, HOD Anaesthesia, Neyyar Medicity KaƩakkada, TVPM Idiopathic Granulomatous MasƟƟs Dr. Sheela Prince, Laparoscopic and Breast Surgeon, NMC Royal Hospital, Sharjah, Dubai InnovaƟve applicaƟon of coblaƟon in head & neck surgery Dr. Sunil J., Chairman KERF, ENT Hospital, Kollam Pre implantaƟon geneƟc tesƟng? Dr. Sreelakshmy R. Nair, FerƟlity Specialist and Consultant Gynecologist, Lifeline. Male InferƟlity Dr. K. Jayakrishnan, Chief Consultant in ReproducƟve Medicine, KJK Hospital Pvt Ltd Contrast induced nephropathy, is it a myth or truth ? All you need to know about contrast imaging in kidney diseases. Dr. Jithu Kurian, Assistant Professor, Nephrology, Pushpagiri InsƟtute of Medical Sciences & Research Centre Moderator – Dr. V. Rajasekharan Nair PPH, Beyond oxytocics - Dr. Lekshmi Ammal Ectopic pregnancy, the spectrum of treatment - Dr. Sreekala Whither hysterectomy- non surgical opƟons in AUB - Dr. Simi Haris When to refer to a Fetal Medicine Specialist? Dr. Anusmitha Andrews, Consultant in Fetal Medicine, Life Line Role of Hysteroscopy in InferƟlity Dr. Indira Vijayakrishnan, Amar Maternity & FerƟlity Centre, Aƫngal Joint PreservaƟon - How we can move forward Dr. Shammas B.M., Consultant Orthopaedic Surgeon, Al Arif Hospital and Travancore Medical College, Kollam Spinal DeformiƟes : Current trends in the management Dr. Suresh S. Pillai, Sr. Consultant Spine Surgeon, Baby Memorial Hospital, Kozhikode Bilateral simultaneous Total Knee Replacement - an analysis – Dr. Kailas Vishwanath, SK Hospital. Surgical Management of Drug Resistant Epilepsy Dr. George C. Vilanilam, Professor (Neurosurgery) SCTIMST, Trivandrum Diagnosis and Management of Trigeminal Neuralgia Dr. Easwer H.V., Professor, Department of Neurosurgery SCTIMST, Trivandrum MulƟmodality Monitoring in TraumaƟc Brain injury Dr. Vishnu P.S., Head, Department of Brain & Spine Surgery, Lifeline. H Pylori treatment- prime Ɵme for a paradigm shi�? Dr. Nandakumar, Senior Consultant, EMS Memorial Co-operaƟve Hospital, Perinthalmanna 147 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

CASCADE HALL 27.12.2023 01.15-01.45 01.45-02.00 02.00-02.15 02.15-02.30 02.30-02.45 02.45-03.00 03.00-03.15 03.15-03.30 03.30-03.45 03.45-04.00 04.15-04.30 04.30-04.15 04.15-04.30 04.30-04.45 04.45-05.00 Hand TransplantaƟon - Dr. Subramanian Iyer, Clinical Professor and Head, PlasƟc and ReconstrucƟve Surgery, Advance Centre of RoboƟc Surgery - Head & Neck Surgery & Dr. Ravi Shankar, Professor & Head, Physical Medicine & RehabilitaƟon, Amrita InsƟtute of Medical Sciences HIPEC – A Ray of Hope in Oncology Dr. Jojo V. Joseph, Sr. Consultant, Surgical Oncology Caritas Cancer InsƟtute, Caritas Hospital & InsƟtute of Health Sciences,KoƩayam, Kerala Oncology year in review - Dr. MV Pillai, AKMG Immunotherapy in Oncology: OpportuniƟes and challenges, Dr. Arun R Warrier, Senior Consultant- Medical Oncology, Aster InternaƟonal InsƟtute of Oncology, Aster Medcity Hospital,Kochi. Current management of axilla in breast cancer, Dr. Jem Kalathil, Senior Consultant - Surgical Oncology, Aster InternaƟonal InsƟtute of Oncology, Aster Medcity Hospital, Kochi. Breast ConservaƟon Surgery in CA breast Dr. Jeevan G.S., Consultant Surgical Oncologist NIMS Hospital EvoluƟon and uƟlity of genomics in cancer . Dr Prashant Ariyannur, Karkinos Healthcare, PRS Karkinos Cancer Centre Trivandrum Cervical cancer screening and HPV vaccinaƟon -recent evidences Dr. Aswathy G Nath, Karkinos Healthcare, PRS Karkinos Cancer Centre Trivandrum. 1500 PaƟents treatment with Cyberknife - Amrita Experience: Dr. Debnarayan DuƩa, Clinical Professor and Head, RadiaƟon Oncology, Amrita InsƟtute of Medical Sciences. Understanding basics of extracorporeal therapies in Nephrology Dr. Satheesh Balan, Trivandrum Nephrology AssociaƟon Deceased donor Renal TransplantaƟon Dr. K.P. Jayakumar, Senior Consultant, Nephrology, Caritas Hospital & InsƟtute of Health Sciences,KoƩayam, Kerala Recent advances in renal transplantaƟon Dr. Bejoy N. Abraham, Senior Consultant, Urology & Renal TransplantaƟon, Caritas Hospital & InsƟtute of Health Sciences,KoƩayam, Kerala. Flexible Ureteroscopy in the management of Renal Calculi - Current trends – Dr. Vinod K.V. SK Hospital Recent trends in the management of Acute Renal failure – Dr. SaƟsh S. SK Hospital CombaƟng InfecƟous Diseases with Next GeneraƟon Sequencing - A Clinician's perspecƟve Dr Shareek PS MD FID Consultant - InfecƟous Diseases, NIMS Medicity 05.00-05.15 VATS - the Nims experience Dr. Asher Ennis Nayagam, Consultant Cardiovascular and Thoracic Surgeon, N MI S Hospital 148 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Dr Pradeep Kidangoor Dr Ajaiyakumar S K Dr Arun Mohan M From the desk of Editorial Board We have tried to make it different. We hope you had a good time and found THARANG DHWANI instructive, motivating and entertaining. Thank you and good bye. 149 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR