Tharang Dhwani Souvenir (IMA National Conference 2023)

The etymology of this ancient city has all along been closely associated with the Sree Padmanabha Swamy Temple. Sree Padmanabha Swamy was not just the `Sthala Devatha’ (place Deity) of Thiruvananthapuram but was accepted as the supreme Sovereign of the entire State of Travancore from 1750 AD onwards. Even previously this `Mahakshetram’, was claimant to ongoing royal connections. The twelve Alvar saints with their weighty Vaishnavite tradition have hailed one hundred and eight Sree Maha Vishnu temples in the Indian Sub-continent as `Thiruppathies’ or `Divya Deshas’. This Temple ranks as one among them. Nammalvar, the great Alvar saint has ecstatically sung in its praise. As one among the seven seats of salvation described as `Muktisthals’ in `Syanandoorapurana Samuchayam’ authored by an anonymous 12th Century Tulu Brahmin poet and as one among the six seats of Narayana Bhagavan couched as `Narayanasthals’ identified by the 15th century Bengal saint Sree Chaithanya Mahaprabhu this Temple has been acclaimed. It also finds a place among the `Samadhi Kshetras’ of India since the belief holds strong that Sage Agasthya’s Samadhi is located beneath the sacred feet of the main Idol of Sree Padmanabha Swamy. Significant Features When a `Mahakshetram’ is under survey, over and above its own unquestioned sanctity and connected factors, ten additional features of note have to be taken into account. What they are and how they co-relate with this Temple are being briefly examined. 1. Antiquity – From ancient times this Temple has merited mention. 2. Records – With around thirty lakh records, this Temple is in the frontline even in the world scenario. 3. Royal Connections – As the personal, family and dynastic Deity of the various blue-blooded lines ruling the land and finally as the supreme Monarch of the State, Sree Padmanabha Swamy reigns in all glory. 4. Origin in a forest – Anantan Katu (Forest of Anantha the Serpent). 5. Nearness to an Ocean – Arabian Sea (Previously mentioned as `Retnaakara’, a common term for a sea). 6. Historical importance - From the time of recorded history, the fortunes of the Temple and the Throne moved hand in hand. Unusual and important has been the role assumed by it not only as history-maker but as history itself too. 7. Location at an elevation – The Temple rests on a reasonable height. 8. Architectural and artistic splendor - Bhagavan Vishnu is 'Alankarapriya', He who is fond of decoration. The quality sculptures and other art work offering themselves here bear ample testimony to the same. 9. Grandeur of festivals - Standing witness to the majesty of the festivals are the bi-annual ten day 'Alpashi' and 'Painkuni Uthsavas' (festivals) concluding with the 'Palli Vetta' (royal hunt) and 'Aaraat'/ Arat procession which are replete with royal pomp and pageantry, so also the sacred sexennial 'Murajapam' and the fabulous 'Lakshadeepam' which signals its conclusion. 10. Mention in vintage literature - The Temple has invited direct and indirect mention in ancient literary works including in seven of the 'Puranas'. Languages used read as Sanskrit, Tamil, Malayamma, Manipravalam, Malayalam etc. It also has the distinction of being one of the few temples to have its growth and evolution traced from the dim past to the current 21st century through literature. Notable Spiritual Attributes "Sree Padmanabha" ranks as one among the twenty-four concepts of Maha Vishnu. Here He is visualised as the 'Shantaswaroopa Paramaananda Yogamoorthy', who is the embodiment of supreme bliss and peace. He is conceptualised as reclining on the serpent Anantha in conscious cosmic slumber prior to His incarnation as Sree Rama. Since a 'Padmam' (lotus) spirals up from the 'Nabhi' (navel), He is known as "Padmanabha." 1. The 'Moola Vigraham' (main idol) hailed as a marvel of iconography is made of a highly complex 51 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

amalgum termed 'Katusarkara Yogam.' As the process is most complicated and elaborate such idols are rare even in Kerala which claims them as its contribution to crafting of images. The inside of this Idol is lined with twelve thousand and eight 'Salagramas' out of twenty-four-thousand taken from the bed of River Gandaki in the Himalayan kingdom of Nepal and sent here on elephant back by the Nepal king as a submission to the Deity. This event adds weight to the belief that the Nepal royalty was part of the Chera monarchy and that when the numbers increased some of the members broke away from the Cheras. They left behind them the torrid planes of South India, moved northwards and finally established their own kingdom in the snow-kissed Nepalese terrain. 2. The 'Agamās' proclaim that if twelve 'Salagramas' are collectively and ritualistically venerated within one orbit, in course of time, together they gain the potency of a 'Mahakshetram.' In the Sree Padmanabha Swamy Temple, the 'Moola Vigraham' itself contains twelve-thousand and eight 'Salagramas' and has been the recipient of most elaborate rituals which strictly adhere to the prescribed codes of Vaishnava worship. As such it imbibes the lustrous nature and power of a thousand 'Mahakshetras.' This suffices to highlight the depth of sanctity prevailing here. 3. Ananta the serpent is a Nitya Jeevatman which represents 'Anantham' or infinity. His five hoods are symbolic of the 'Panchendriyas' (the five sense organs) or the 'Panchabhootas' (the five basic elements). Its mighty form is thrice coiled pointing to the 'Thrigunas' (the three qualities) which have the capacity of juggling the mind of man and as the Sovereign of the cosmos, "Sree Padmanabha Perumal" reclines on eternity itself symbolised by Ananta. 4. Even during those ages when the face of orthodox religion lamentably got mutilated due to cult clashes between devotees of different disciplines, Malayala Nadu stood free of it. A perfect example is seen in the main 'Sreekovil' (sanctum-sanctorum) with the presence of Siva under the right hand of the reclining Deity along with Brahma rising from His navel. The cosmic secret revolving round the concept of creation, preservation and ultimate merger stands revealed in one confine. 5. It is possible to view the principle Deity only through three 'Natas' (doorways). They indicate mighty time- past, present and future. a temple. 6. It is considered exceptionally auspicious if the three postures of the main deity are located within a temple. All the three, standing, sitting and recumbent are assembled in this Temple within the main sanctum and are recipients of daily worship. The 'Moola Bimbam' (main Idol) is lying straight on the back, while the 'Abhisheka Bimbam' stands and the 'Siveli Bimbam' (Idol used for processions and circumambulations) sits. 7. Other than the Divinities previously mentioned, the thirty-three crore celestial hordes, 'Devies' (Goddesses) Lakshmi and Bhoomi, 'Maharshies' (sages) Bhrigu and Markandeya, the Sun and the Moon Gods, sages and others array within the sanctum. They are all also made of 'Katusarkara.' Among them Lakshmi Devi reflects prosperity while Bhoomi Devi the very earth itself. The Sun and the Moon represent the day and the night. 8. Though 'Rishi Puja' (Ritualistic worship by renunciates) prevails in Kerala temples, the number is in drastic minority. Sree Padmanabha Swamy Temple stands in the front line in this sphere. It is held that these temples wherein 'Puja' is offered by 'Kshetra Sanyasies' (renunciates attached to specific temples) gain enhanced spiritual worth Ananthasayanam and that surrounding areas prosper. In this Tem52 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

ple two 'Nampoothiri' renunciates who have received 'Sanyas' from the Thrissur Madhom and the Munchira Madhom perform daily 'Pushpanjali' (flower worship) in the morning. 9. For centuries the 'Tantram' of this great Temple has remained vested in the 'Illom' (house/family) of the Tarananalloor Nampoothiripads of Irinjalakkuta village (one among the three famous 'Agnihotri' villages of Kerala). Here the Tantries' adhere to the system of Tantra qualified as 'Padhathi Sampradayam' which was passed on to their forefathers by word of mouth by Sree Parasurama (6th Incarnation of nation of Bhagavan Vishnu). There are only ten 'Padhathi' (system) temples and all are situated in Kerala and in seven of them the Tarananalloor Tantries hold the right to 'Tantram'. The Sree Padmanabha Swamy Temple is the biggest and most important among them where the most complicated and elaborate Tantram is operational. 10. Till the fairly recent past the institution of 'Kuta Santhies' was operational in many important temples of Kerala. The 'Kuta Santhies are those chief priests (but not to be confused with the Tantries who stand supreme),whose movements and way of life are severely restricted during their tenure of office. They have to be strictly celibate as well. They are uncompromisingly operational in this Temple and are four in number. 11. Sree Narasimha Swamy situated on the south of the main enclosure is vested with a fierce nature. He is Ugra Narasimha. 12. Consecrations of Sree Veda Vyasa Bhagavan are, by and large rare even in India. From long back and up to the mid 20th century the Sree Padmanabha Swamy Temple was the venue for 'Anna Danam' (free rice feeding) on a massive scale and for 'Vidya Danam' (imparting free education). Offerings made for success in the educational front to this venerable sage have proved most beneficial. The recent years see a significant increase in the number of 'Vidyarambhas' (starting the little ones on their first letters) being conducted before Sree Vyasa Muni. 13. It is said that at times the muted resonance of 'Pranavam' (the primordial sound vibration) can be heard when one places the head on the long, narrow gold covered window representation on the northern side of the main sanctum to which the lotus feet of the great "Perumal" are pointed. Some are of opinion that it is the muted roar of the 'Palaazhi' (Ocean of Milk) on which the Lord rests. Main Consecrations 1. Sree Padmanabha Swamy The 'Anantasayana Salagrama Katusarkara' Idol 53 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

of Sree Padmanabha Swamy who is adored as the 'Paramananda Shanthaswaroopa Yoga Moorthy of supreme bliss and embodiment of tranquility, was the exceedingly beautiful and marvelous creation of the master icon maker Balaranya Kshonideva . The re-consecration was carried out by Tantri Tarananalloor Padmanabharu Parameswararu in the year 1739, when Maharaja Anizhom Thirunal Marthanda Varma sat on the throne of Travancore. It can be understood how complex is the making of Kutusarkara when the processes involved are even superficially examined. 2. Sree Narasimha Swamy After the main consecration, those commanding great importance are the Ugra (fierce) Sree Narasimha Swamy on the southern side and Sree Thiru Ampati Sree Krishna Swamy. Though description exists of how the fire flared up of its own volition during the exact time of installing Sree Narasimha Swamy's idol, the correct time frame remains elusive. Since there is mention about this powerful Deity in ancient literature, His great age stands assured. This consecration was performed around the 8th Century AD by Sree Sureswaracharya, one among the prime disciples of Adi Sree Sankara. 3. Thiru Ampati Sree Krishna Swamy Specific recorded evidence is available regarding the origin of the Thiru Ampati Temple. After Dwaraka was claimed by the ocean, seventy-two 'Vrishnivamsha Kshatriya' families under the leadership of one Krishna Varman imigrated to Gujarat and settled down there. Disquiet dodged their footsteps. One night Krishna Varman had a dream. In it Sree Krishna Bhagavan Himself appeared and directed him to go southwards to 'Ananthasayana Nagari' which would prove to be their refuge. Next morning Krishna Varman conveyed this dream directive to his clan along with his decision to start for that city of the south. His entire clan decided to follow suit. The city was unknown to them but finally, after much travelling they arrived at that place. They had brought with them The sacred Sree Krishna Idol and a 'Salagrama' which they had installed in their village in Gujarat. Ultimately both of them were consecrated in a separate temple within the confines of the Sree Padmanabha Swamy Temple. It also went by its original name 'Thiru Ampati'. This hallowed event took place on the 5th of the first Malayalam year, in the month of 'Chingom', Friday, under the asterism Thiru Onam. These immigrants identified as 'Krishnavamsajar' (those belonging to the family of Sree Krishna) were honored with positions, landed properties, buildings and so on. (Today this community is known as 'Krishnanvakakkar'.) Their Idol which was initially worshipped as 'Goshala Krishna' (Krishna of the cattle shed) later underwent a transformation of concept and is venerated as "Parthasarathy". 4. Other consecrations and Power Centres In places reserved for them are seen Sree RamaLakshmana-Sita, Hanuman close at hand in a mood of servitude, Ganapathy with a Devi on His lap, Vishvaksenan as the Nirmalya Moorthy fashioned out of Katusarkara, Sree Veda Vyasa Bhagavan with Aswatthama in close attendance, Kshetrapalan with a Ganapathy nearby, a rare 'Swayambhoo' Sasta and Agrashala Ganapathy. Much favored by the devotees is the towering figure of Sree Hanuman Swamy finished in granite which stands close to the main ‘Belikkal ( sacred stones on which sanctified food is offered) who is a claimant to many a miracle. Relatively uncommon Ashtanaga Garudan (Garudan with the eight serpents interned all around his body) rises majestically on the other side. In a sacred area of recent origin are placed the idols of personal worship of Maharajs Sree Chithira Thirunal Rama Varma and Sree Uthradam Thirunal Marthanda Varma. The 'Bhadradeepappura' which has witnessed many great religious ceremonies is another power centre. Origin of the Temple - Sthala Puranam It is impossible to pinpoint the exact time when the Temple originated since it retreats to the undated past. As repeated references surface even in Puranic literature, its antiquity stands established. Even though conflicting opinions are available concerning the period of the Sangam era, the Temple is seen mentioned there. The 'Sthala Puranam has the names of the two venerable sages in this connection - Vilvamangalathu Swamiyar of Nampoothiri caste and Divakara Muni of Tulu stock, both believed to be of the 9th century A.D. Yet another opinion circulates that both them were 54 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

in reality one and the same The Tarananalloor Tantries and the Pushpanjali Swamiyars both belong to the Nampoothiri community all the other priests of this Temple inclusive of the four 'Nambies' attached to the main sanctums are Malayala and Tulu 'Potties' belonging to the 'Ikkara' and 'Akkara Desies, In presenting the "Sthala Puranam', Vilvamangalam Swamiyar's name is being adopted as that it is more popular. One day a little child presented himself at the door of Vilvamangalathu Swamiyar's hermitage. The response derived by him when he enquired of the lad details about himself was, "I have no parents no a home." Vilvamangalam who led a solitary life was entranced by the charm of the little visitor and invited him to make a home in the hermitage. Though the child assented, it was conditional. He would leave the place the moment any kind of displeasure was shown to him. Taking it to be a childish caprice, the Sage agreed to it. Time passed. One day found the little one in an exceedingly naughty mood. He upset the 'Puja' items arranged by the Swamiyar, knocked over the water kept ready for worship and still not satisfied, hid a 'Salagrama' in his own little mouth. The Swamiyar whose patience was sorely tried, lost his temper when he finally discovered the missing 'Salagrama' and pushed his little guest aside with the back of his hand. Displeased by this gesture, that instant the young boy sped out of the hermitage. Vilvamangalam at once realised the divinity of the young child and though he ran behind him crying out to speeding lad to stop, he very soon lost sight of him. The sage followed the sound of the bells on the anklets which soon faded away. All of a sudden the distraught Swamiyar heard an 'Asareeri' "If you want to see Me, come to Anantan Katu". From then onwards he commenced the long journey in search of Anantan Katu and the beloved little one. The innumerable temples consecrated by the Swamiyar or which have become more sacred due to his connections dotting the land from northern Kerala to south bear testimony to his search. One day as dusk was descending the Swamiyar sat down under a tree, both mentally and physically exhausted. Then from a cottage occupied by a Pulaya family a voice raised in ire floated out "If you do not cease crying, I will throw you out into Anantan Katu." A Pulayi was thus scolding her baby who was wailing and refusing to sleep. At once the sage leapt to his fee and rushed across to the hut where the poor woman frightened by his approach was cowering; to enquire of her the whereabouts of Anantan Katu. Without uttering a word she merely pointed a finger at the wood close by. He blessed her with a heart full of joy, raced in to the forest despite the night hours and unfamiliar terrain. In the early hours of the morning around four o'clock a huge 'Iluppa' tree (Indian Butter tree) crashed down in front of him. Instantaneously the mighty form of Sree Padmanabha Swamy reclining on the serpent Ananta as Sree Anantasayee and extending to about eighteen 'Yoganas' (a measurement of distance) materialised before the Swamiyar's wonderstruck eyes. Since he was empty handed and had nothing to offer to this miraculous vision, he quickly plucked a raw mango from a near-by tree and putting it in a dry coconut shell submitted it as his humble offering. That coconut shell now gold covered and gem studded is still in use for special occasions. Since it was impossible to circumambulate a figure of such magnitude the Swamiyar requested that He may shrink to three times the length of the Swamiyar's 'Yoga Dandu' to accommodate his limited mortal vision. This was conceded to by containing Himself to the present size and place. On hearing these tidings the ruler of the land had a Temple constructed at that spot and an idol of the wood of the Indian Butter tree carrying the same characteristics of the Devine vision granted to Vilvamangalam was consecrated by this sage. Keeping alive the memory of the initial 'Pushpanjali' (flower worship) performed by the Swamiyar it was decided that henceforth it would always 55 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

be the prerogative of the renunciates to conduct it. Since this 'Mahakshetram' was known before the 9th century it can be concluded that Vilvamangalam carried out a re-consecration. On the night prior to this most sacred ceremony the head priest saw a dream in which Bhagavan Himself appeared and issued a directive. "The fire to light the first wick in My 'Sreekovil' should be with the fire from the Pulaya hut." This order was obeyed in toto by the concerned authorities. Thereafter that Pulaya woman came to be known as "Theeyedi Pulayi" (Pulayi who took the fire). There is a different legend connecting Bhagavan to this Pulayi through oral tradition. As a Pulaya couple was busy cutting grass, the wail of a baby reached their ears. Guided by it they arrived at a place where they found a baby abandoned. A serpent was stationed nearby as if on guard with its five heads spread out like an umbrella over the infant's head as though to protect him from the sun. The moment it spied the couple it vanished into the thin air. The poor woman took the babe to her hut, gave him milk and cared for him as though he were her very own. A few months went by One day as she was cradling the little one in her arms to rock him to sleep, suddenly he rose up in a flash of light and disappeared in the direction of the Anantan Katu. In the place of the baby she was found holding a log piece. The king gifted a large field to this family. It came to be known as "Putharikkandom” the name continues to date. Structural Details Enclosed within four massive walls and situated on seven acres of land in the heart of the city of Thiruvananthapuram, the Sree Padmanabha Swamy Temple sheds its lustre far and wide. Since it is not easy to do even moderate justice to the special structural features, a description in compromise alone is being attempted. A fusion of the Malayalam and Tamil constructional systems offers itself here. While the eastern 'Raja Gopuram' with its two thousand odd figures and figurines follows the Dravidian style, the other three gateways are double-storied 'Patippuras' mirroring the Malayalam pattern. Because Sree Padmanabha Swamy was deemed as the symbol and Sovereign of the State, this kind of construction would have been adopted respecting the sentiments of a good percent of subjects who spoke the Tamil tongue and the local Malayalees, aiming at achieving emotional amalgamation of both the major linguistic groups. As a pointer to 'Vanchi Nadu' (land of boats), it is possible to spy the representation of a boat atop the 'Gopuram. 'The architect of Travancore' as he was well known, Maharaja Marthanda Varma (1726- 1758) commissioned repairs and restoration of the Sree Padmanabha Swamy Temple wherever it was found necessary but he was most particular that They should be replicas of the old edifices. With this aim in view the Maharaja himself assumed the responsibility of over-seeing such work while the actual construction rested in the able hands of Vishnuthrathan Nampoothiri. The vast and impressive 'Sivelippura' was completed within an incredibly short time span of six months. Ananthapadmanabha Moothassari, the master artisan had ten thousand masons and one hundred elephants working round the clock to accomplish this feat. Sculptures that stand head high, carvings both in granite and wood, the 'Ekasila'/ Ottakkal Mandapam which continues as a masterpiece in granite, various kinds of lamps, bells of uncommon mould, mural paintings that fill the walls, so runs the description. The mural depicting the 'Ananthasayanam' executed by a Brahmin artist named Chalayil Kalahasthi and which is deemed to be the biggest among Kerala temple murals, is present here. As is usual they too adhere to the 'Panchamala' (garland of five principle). Of special note is the 'Aayiramkal Mandapam' (thousand pillared hall) or 'Kulasekhara Mandapam which took form during the reign of Maharaja Karthika Thirunal Rama Varma (Dharma Raja). This exquisite structure hailed as pure poetry in stone is a source of eternal wonder and delight to art lovers. Other than the four groups of musical pillars in dressed granite, there array twenty-four major sculptures exuding vitality and life. Regarding the musical pillars it may be added that such wonderful pillars producing different musical sounds are found only in eleven temples all over India. Miracles Miracles find a place in the Sree Padmanabha Swamy Temple. A selected few are being presented 56 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

here. The seepage of milk from the granite paved floor of the enclosure containing the sanctum, the sound of pattering feet and tinkle of bells on the anklets heard by the sweeper women from near the Thiruampati as they approached it in the early morning hours, the appearance and disappearance of serpents within the 'Sreekovil' and in other areas, the changing of bells and ferocious roar, emitting from the Sree Narasimha Swamy's shrine in the advanced hours of the night etc all find their places among the miracles. During outbreak of fire in this Temple, despite the fact that fire encircled the main Idol of 'Iluppa' and burning logs collapsed on it from the ceiling, it remained free of harm except for minor damages. Likewise it cannot be forgotten that during the fire of 1934 when Maharaja Sree Chithira Thirunal ruled, an 'Asareeri' was heard, followed by the manifestation of Sree Hanuman Swamy near His own towering Idol to successfully check the encroaching flames. The incident when the left foot of the granite Dwarapalaka near the 'Dhwajasthambham' started to elongate was also during this Maharaja's time. When the foes excited an elephant during an 'Arat procession of the Temple with the intention of slaying the Maharaja, the terror-stricken crowd saw a ferocious lion in his place like a super imposition. The maddened elephant also-would have seen it as it fell down on its knees, the tusks boring the ground. It is believed that Sree Narasimha Swamy Himself had appeared there to save His devotee. That Maharaja was none other than Sree Swathi Thirunal. Inscriptions At least twenty-four inscriptions offer themselves for inspection including an uncommon water inscription in the landed Padmateertham. The script is varied and in Vattezhuthu, Kolezhuthu and in languages like Grantha, Sanskrit, old Tamil etc. They are mostly dated unlike those found in other parts of Kerala which are, by and large, undated. Teerthas From the texts it is seen that twenty-two 'Teerthas' (holy water sources), though opinion on the exact number varies came under the Sree Padmanabha Swamy Temple with some located even as far away as Varkala. The most famous one which has been found mentioned even in the 'Srimad Bhagavata Mahapurana is undoubtedly the 'Padmateertham' which is the Temple's own tank. Within its railings stand nine granite 'Mandapas' which had been put into use as platforms for many a performing art and also for conduct of certain rituals. A small but important temple housing a rare ShivaParvathi seated on Nandi the bull too finds its place within these railings. Butting on to them and with their backs turned are located the shrines dedicated to Sree Hanuman Swamy, Sree Ganapathy and the Navagrahas. Festive and Special Days The two Utsavas, 'Alpashi' and 'Painkuni' of ten-day duration each which fall in the Malayalam months 'Thulam' (October-November) and 'Meenom' (March-April) respectively concluding with the spectacular 'Arat procession ushering in the memories of colour and pageantry of a bygone era are red letter events of this Temple. The second festival is also known as the 'Pancha Pandava Utsavam' because the huge fabricated figures of the five Pandava brothers find their places on the sides of the eastern road running up to the Temple. 'Thiru Onam', Sree Padmanabha Perumal's Thiru Nal' (royal birthday) in mid August-mid September accompanied by the centuries old tradition of submission of the 'Ona Villu' (special painted Onam bow on red painted base of wood), complicated and deeply sanctified rituals like 'Kalasam', 'Kalabham', the famed 'Swargavathil Ekadesi' in the Malayalam month 'Dhanu' (mid December-mid January), all claim their share of importance in the calendar of events of the Sree Padmanabha Swamy Temple. However that which stands in the frontline of the great religious festivals of India is the fifty-six day long 'Murajapam' which takes place here once in six years and the spectacular 'Lakshadeepam' which marks its conclusion. A whole assembly of Brahmins with the majority being Nampoothiries, recite the four Vedas' in specified 'Mura' or turn, along with the chanting of 'Vishnu Sahasranamam’ (thousand sacred names of Bhagavan Vishnu). Sree Padmanabha Perumal is venerated and adored through 'Nadabrahmopasana' (with resonance - in this context with prayers) and 'Tejabrahmopasana' (with luminosity or light). This profound ritual continues to be conducted for the prosperity of the land and the well-being of the people. The 57 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

'Lakshadeepam' with its fabulous display of myriad lamps and lights falls on the first of 'Makaram' (14th/15th of January). It was in 1750 that the first 'Lakshadeepam' was conducted by Maharaja Marthanda Varma. The fame of this mega festival has crossed the boundaries of Kerala to reach the national plane . It continues to this day without cessation. Ninety-nine temple arts used to find an arena for display of their expertise inside the Temple and outside. They included traditional art forms, classical and folk, as well as those performed exclusively by the so-called backward communities. The unique piped instrument, short in length 'Kurunkuzhal', other musical instruments and vocal temple music all offer themselves as 'Nadabrahmopasana' to the Supreme Being. Sree Padmanabha Dasas From time immemorial the links the ruling dynasties of this land had with the Sree Padmanabha Swamy Temple were imperishable. Maharaja Anizhom Thirunal Marthanda Varma, architect of modern Travancore surrendered the territories that he had either conquered or acquired along with all royal rights and privileges, his dynasty and himself to Sree Padmanabha Swamy by deed of gift famous in history as 'Thruppati Danam' (gift at the holy steps). The year reads as 1750. Henceforth Sree Padmanabha Perumal became the true monarch of the State with the Travancore rulers administering the domain as the 'Dasas (slaves) of the Supreme Sovereign. The concept of being a slave is highly significant. While a servant has the option to leave, the slave is forever bound to the feet of his master. The title 'Sree Padmanabha Dasa' had been in existence in the ruling house long before 1750 as is seen from the Temple scrolls but to a large extent it might have been more personal and emotional in nature. For example a 16th century record speaks of 'Sree Padmanabha Dasa Boothalaveera Rama Varma'. With the submission of this title became official as well, in the fullest sense of the term. The thirteen successors of Maharaja Anizhom Thirunal Marthanda Varma including three queens, literally followed the grand legacy of devotion handed down by him . And thus Sree Padmanabha Swamy continues to reign supreme. Princesses Gouri Lakshmi Bayi and Gouri Parvathy Bayi with the Editorial board members Dr Pradeep Kidangoor and Dr Arun Mohan at Kowdiar palace. 58 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Photo: Dilip Nair

Gouri Parvathi Bayi Medical Memories Once upon a time when I was a very little girl, if someone got sick he or she was first checked by our 'daily doctor' who worked in our palace clinic. Then, if the situation warranted it, a senior doctor was called in. Our Dr. Nilakanta Iyer told the children stories, played games with us and plied us with rather beautiful looking but nasty tasting mixtures. He was friend, philosopher and guide from the moment I was born until my first child was born - a physician and a well loved member of our family. With a stethoscope hung round his neck and his panchagacham attire, he treated everyone from the Maharaja to the cleaning ladies with the same serious attention. If he needed a second opinion he called Dr. Jacob Thaliath. This venerable physician did the same, top to toe, his rosy cheeks dimpling as he reeled off anecdotes about his experiences in the medical field and bribed us with chocolate if we swallowed some vile concoction without fuss . Needles rated a greater reward like a toy or a 60 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

doctors who formed part of our extended family when I was growing up. So many more are remembered with affection and nostalgia even if unsung in this scribble of mine today. Fast forward to today's medical scenario. There are so many super specialities and specialists that the average bewildered human being does not know where to start. There are tests galore. There are Insurance companies with attractive schemes to let you sail through sickness to health. Then there is the Great Answer to Everything - Google which analyzes your symptoms, makes you terrified about the possibility of diseases you hadn't even heard of and feeds you questions to irritate your doctor with! Progress is inevitable and necessary too. Surgery for instance has become so much less traumatic and recovery times so much quicker. As long as the personal caring of those who look after the sick is not lost by the wayside, all should be well. Our medical personnel are purveyors of hope and healing - may their tribe increase to make our tomorrows better and safer , more wonderful and worthwhile. Thank you doctors and all your colleagues at different levels in the medical world for being there for all of us. We celebrate you and God bless you all. book. Our female staff went into rhapsodies about Dr. Thaliath's complexion. We were advised to eat up all our greens if we wanted the same skin tone! Dr. Sankararaman who came next had a totally different personality. He was extremely thorough and serious, regarding patients at length with a grave expression. My mother always expected the worst during his silent scrutiny until he gave the all clear verdict with a twinkle in his eye. The doctors those days took time to study their patients; to listen attentively to the rambling tales of woe which very often yielded up valuable clues to the cause or nature of their ailments. Dr. Miss Samuel who brought us into the world had endless patience with her patients. Impeccably dressed in silk saris with a jewelled pin holding the pleats together on her left shoulder, she was the universal beloved Missy. Last but not least in this garland of healers came Professor Narayana Pai. This soft spoken and gentle person was not only a gifted doctor, he was a great human being as well. My grandmother always maintained that just seeing Dr. Pai made sick people feel better! His guiding hand helped us to formulate the plans for what is today known as the Sri Chitra Institute of Medical Sciences and Technology. These are only a few names of the 61 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

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Global Vaccine Leader Vaccines manufactured by the Serum Institute of India are accredited by the World Health Organization, Geneva and are being used in around 170 countries across the globe in their national immunization programs, saving millions of lives throughout the world.The Global leader in vaccine manufacture produced and sold globally around 1.5 billion doses which includes Polio vaccine, Diphtheria, Tetanus, Pertussis, Hib, BCG, recombinant Hepatitis B, Measles, Mumps, Rubella as well as Pneumococcal and Covid - 19 vaccines .65% of global child population receive at least one vaccine manufactured by serum institute of India Serum Institute of India is ranked as India's No. 1 biotechnology company, manufacturing highly specialized life saving biologicals like vaccines using cutting edge genetic and cell based technologies, antisera and other medical specialties. Interview 63 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Serum Institute of India was founded in 1966 by Dr. Cyrus Poonawalla with the aim of manufacturing life-saving immuno-biologicals, which were in shortage in the country and imported at high prices. Thereafter, several life-saving biologicals were manufactured at prices affordable to the common man and in abundance, with the result that the country was made self-sufficient for Tetanus Anti-toxin and Anti-snake Venom serum, followed by DTP (Diphtheria, Tetanus and Pertussis) group of Vaccines and then later on MMR (Measles, Mumps and Rubella) group of vaccines. The Philanthropic philosophy of the company still not only exists but has been proliferated to bring down the prices of newer vaccines such as Hepatitis-B vaccine, Combination vaccine etc., so that not only Indian's, but the entire underprivileged children of the world are protected from birth onwards. This shows the social responsibility and commitment of the organisation . Now the world healthcare industry is rely on Serum Institute of India for vaccine and other life saving biologicals We the team editorial of *THARANG DHWANI * the souvenir of 98 th All India medical Conference of Indian Medical Association IMA is very happy to interview Mr Adar C Poonawalla CEO of Serum Institute of India in context of Vaccine production ,distribution and how Serum Institute of India and IMA can hand hold for better and healthy India and World. 1. Serum Institute has been able to provide the best vaccines at low cost not only in the Indian subcontinent but also in the developed Western countries. What is its secret? Our commitment to quality, affordability, and accessibility has been ingrained in the core philosophy of the organization since its inception. The guiding principle of 'Health for all' has steered our endeavors, emphasizing the responsibility to extend the benefits of our capabilities and capacity to a broader population. Our focus is on ensuring that vaccines reach even the most vulnerable and remote corners of the country, all while maintaining affordability. 2. Could you tell us a little bit about the research activities going on at your firm? We have shifted our focus at Serum Institute to resume the development of other vaccines that were temporarily deprioritized during the pandemic. Anticipated for rollout soon is our malaria vaccine, with a specific focus on addressing the significant malaria burden in Africa. Additionally, we are set to introduce the HPV vaccine for preventing cervical cancer in women within the same timeframe. We are also working extensively on vaccines against dengue and five strains of meningitis. 3. Today in India, we see lot of initiatives effectively run with the help of public private model. Is such a PPP model possible in the vaccine production sector. Why is it important and beneficial for people? In India, the successful implementation of numerous initiatives through a public-private partnership (PPP) model is evident. The adoption of a PPP model in the vaccine production sector is not only possible but also holds immense potential for ensuring the timely, efficient, and equitable distribution of vaccines for the benefit of the people. Add to that, it also enhances financial sustainability. By sharing the financial burden between public and private entities, the overall investment required for vaccine development and production can be more effectively managed. This, in turn, helps in maintaining affordability and accessibility for a larger section of the population. 4. What are the CSR activities currently being carried out by Serum Institute? Our commitment goes beyond conventional health initiatives; it seeks to cultivate an environment where individuals can not only thrive but also achieve their aspirations. This commitment finds expression through various initiatives under the Villoo Poonawalla Foundation, which strategically focuses on key areas such as education, healthcare, water, environmental sanitation, and green space creation. It comprises of schools, hospitals, green spaces, water purification plants, and the impactful "Adar Poonawalla Clean City" initiative. The "Villoo Poonawalla Memorial Hospital," in collaboration with the Welfare Medical Foundation, aims to provide quality treatments at affordable rates, particularly for those below the poverty line. The commitment to enhancing overall quality 64 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

of life extends to a strong emphasis on sanitation and cleanliness. Our active engagement in green initiatives further manifests in reducing dependence on fossil fuels. Projects include Wind power generation, Solar Lighting, and Steam generation using carbon-neutral solid fuel like bagasse briquettes. Rigorous environmental and energy data collection informs strategies to compute our carbon footprint, identifying opportunities to reduce carbon dioxide emissions. In tandem with these endeavors, we have also collaborated with Kineer for "Parivartan Ka Teeka," a nationwide free vaccination drive for the transgender community. This initiative seamlessly aligns with our broader commitment to inclusive healthcare initiatives. 5. Indian Medical Association is a socially responsible organization of doctors in India. The Indian Medical Association has a century-long legacy of excellence in disease prevention and public health services as well as treatment. Are there areas where Serum Institute can collaborate with the Indian Medical Association in the field of vaccine research, production, distribution and social awareness? Absolutely, there are several potential areas for collaboration between Serum Institute and the Indian Medical Association (IMA). This could include joint efforts in vaccine research, dispelling misinformation, and partnering on impactful social awareness campaigns to promote vaccination. Such collaboration has the potential to significantly advance disease prevention and public health efforts in India. 6. Serum Institute of India ranks high in the world vaccine manufacturing and distribution sector. What are the latest global initiatives on your end and how will they help India? Our latest initiatives on the global stage are geared towards addressing critical health challenges and contributing to India's well-being. • HPV Vaccine Launch Our recent launch of an HPV vaccine is a significant stride in preventing cervical cancer in women. The focus is on raising awareness about 65 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

the silent threat of HPV and highlighting the crucial role of early vaccination in saving lives. The pledge to prevent initiative aims to foster awareness, dispel misconceptions, and initiate important conversations about HPV preventive measures. • WHO-Recommended Malaria Vaccine The WHO's endorsement of the R21/Matrix-M™ malaria vaccine, developed in collaboration with the University of Oxford, marks a milestone. This recommendation enables the supply of hundreds of millions of doses to countries grappling with a substantial malaria burden, contributing to global efforts to combat this infectious disease. • MenFive® Meningitis Vaccine The WHO's recommendation of MenFive®, the first conjugate vaccine protecting against the five predominant causes of meningococcal meningitis in Africa, is another significant achievement. Developed through a 13-year collaboration between Serum Institute of India and PATH, with vital funding from the UK government, MenFive® is designed to eliminate annual meningitis outbreaks and epidemics in the African meningitis belt. In addition to these initiatives, we have actively engaged with key stakeholders in the health sector. Our focus is on advancing vaccine equity and advocating for the global harmonization of regulatory standards. This harmonization would enable vaccine manufacturers, including Serum Institute, to have a more impactful and real-time contribution to global health challenges. Our ongoing efforts underscore our dedication to advancing healthcare on a global scale. 7. Our target is 100% vaccination but Indian subcontinent often falls far short of that target. What do you think is the main hurdle? What are the solutions? How much can organizations like the Indian Medical Association help the government and private entrepreneurs in this regard? Achieving 100% vaccination in the Indian subcontinent faces hurdles primarily due to logistical challenges, vaccine hesitancy, and uneven healthcare infrastructure. Solutions entail improving accessibility in remote areas, conducting robust awareness campaigns, and fortifying healthcare infrastructure. Organizations like the Indian Medical Association can play a pivotal role by actively participating in vaccination drives, dispelling misinformation. 8. What is your message to health workers and scientists working in the field of vaccine production in India and other foreign countries, based on your experiences from COVID? What do you think are the biggest lessons from the COVID-19 pandemic that India can learn to be better prepared for the next big outbreak? My message is one of gratitude for all the health workers and scientists across the world. The pandemic has underscored the importance of global collaboration, innovation, and swift response. The biggest lesson for India is the need for enhanced preparedness, robust healthcare infrastructure, and a proactive approach to research and development. Together, we can fortify our capabilities to face future challenges with resilience and collective strength. 9. What are the biggest lessons/learning experiences you would like to share from your experience running SII? The journey has imparted valuable lessons. Firstly, commitment to quality and affordability is paramount in the healthcare industry. Second, adaptability and innovation are crucial for navigating evolving global health landscapes. Lastly, meaningful collaborations, both domestically and globally, are indispensable for advancing public health. These lessons underscore the importance of resilience, innovation, and collaborative partnerships in vaccine production. An exclusive Interview with Mr Adar Poonawalla by Dr Arun S Venudhara Panicker Vice President IMA Trivandrum Editor PEPS, IMA KSB Editor, Social Media IMA KSB 66 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

A Doctor's 24 Hours - A Satheesh 68 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

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Mind Yourself Photo: Dilip Nair

Tharang Dhwani 2023 74 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr Arun B Nair Professor of Psychiatry Medical College Thiruvananthapuram Hon Consultant Psychiatrist Sree Chithra Thirunal Institute of Medical Science and Technology Wellness Among Doctors: How to Heal the Healers A recent study in India revealed a startling fact that the average life span of an Indian doctor is over a decade less than the life span of the patients he treat. We have lost a number of doctors to a myriad of life style disorders ranging from myocardial infarction to cancer and from non alcoholic cirrhosis to renal failure.What is most alarming and distressing is that quite a large number of doctors have also ended their life through suicide in the recent years.These include junior residents to senior residents and even senior consultants who were much respected and doing extremely well in their professional sphere.Despite earnest efforts to decipher it’s nuances suicide still continues to be an enigma which the medical world or even the population at large has not fully comprehended. Why doctors are stressed? As each and every one of you may realize medical profession Is one of the most stressful ones anybody could possibly undertake in their life.The challenges of the profession include managing work life balance to ensuring a good night’s sleep to lack of social connectivity and

even keeping oneself updated with the recent advances in the speciality of practice.The stress and strain of medical practice starts well before one becomes enrolled in a medical school. The intense competition for medical entrance coaching is the index point from which the stress and strain starts mounting in the life of a medical seat aspirant. And even after getting the coveted medical seat the stress and strain remains because as we all know undergraduate medical course is one of the most difficult academic courses anybody can pursue in life.Even after becoming a medical graduate the attitude of the society around you doesn’t allow you to rest.The struggle for getting into a postgraduate course of your choice and the unparalleled strain of work during the junior residency days add on to the stress and strain of everyday life. Even after becoming a specialist the journey doesn’t end.Further attempts to get into super speciality and even after that getting into the fellowships which could sharpen your clinical skills which may extend into decades. And once the academic pursuit is complete does life become a bed of roses? Definitely not! The intense competition to establish yourself as a specialist of repute is going to eat into your personal space as well.The biggest tragedy is that in the course of these academic pursuits you lose contact with many of your friends and even your family.The network of support which is expected to help you during times of crisis gets withered away and after so many years of toiling hard to make it big as a clinician, You may realize with a heavy heart that you are probably alone at the top.Your patients consider yourself as a superhuman who is capable of serving them even at midnight after working for 16 hours a day.The fact that every doctor however hard working or competent he needs sufficient rest to rejuvenate his brain and mind so that he can serve the public effectively on the next day or also, Is an information which probably the common man finds very hard to digest. The lack of effective socialisation is another problem that’s taking a toll on the mental state of doctors. Lack of a support group of doctors, who can effectively identify and intervene in case of fellow professionals, is a part of the work culture of many organisations in the west . Unfortunately, even big hospitals in our part of the world, lack such an internal support system which could go and long way in preventing suicides among medical professionals. Most medical professionals refrain from pursuing hobbies or other creative activities as a consequence of the workload. This is definitely something which could adversely affect their mental state in the long run. Lack of effective communication in family is also a common reality in the life of medical professionals, again thanks to the hectic work schedule. WHAT IS THE SOLUTION? Empowering doctors to manage stress, enhance wellness, balance work and personal life, to identify red flag signs of distress and to practice mental health first aid are some of the key suggestions which may work well in this context. Doctors by nature, are poor patients. They may not regularly follow up with another clinician regarding their own health problems. They may not talk openly about their personal problems to anyone else. One feels that the stigma regarding mental illnesses and taking treatment for them is very strongly embedded in the minds of doctors as well, making them hesitant to take timely help for stress related mental health problems. Some suggestions to overcome these problems include 1. Doctors should take responsibility to manage their own stress. Developing healthy friendships, spending time to explore your creative streak, involving in healthy hobbies, regular exercise, practising relaxation exercises, and opening up to a close person in times of distress help a lot. 2. Be aware of changing scenarios in life and clinical practice and try adapting to those. Managing generation gap related issues with children, handling subordinates positively, trying to learn new things nonjudgementally, mentoring young professionals etc. can go a long way in achieving these. 3. Manage your time effectively and take care of yourself. Spending at least seven hours per day for good quality sleep is absolutely necessary in maintaining wellness and managing stress.Give priority to urgent and important things in life. 75 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Avoid wastage of time including spending excessive time on social media and engaging in inconsequential online arguments. 4. Find a purpose in life. Unless you have a long term purpose or philosophy in life, you may find it difficult to adapt to hardships. Be aware of yourself with all your potential and limitations, utilise your potential to the maximum, remember to provide benefits to maximum people in the process there by generating tremendous goodwill in their minds about you, and become aware of each moment in your life. Practice mindfulness so that you can engross yourself in each and every moment of life in a non judgemental way. Be grateful for all the good things you have in life. 5. Understand your limitations and boundaries. Never try to be a superhuman who is simultaneously engaging in a multitude of activities without rest or sleep. Every human has his limitations and it is important to understand and honour yours. 6. Always believe in and practice good team work. No one grows in isolation. It’s always good to grow as a team, and not be isolated at the top. Discuss about major issues at workplace with trustworthy colleagues, take second opinion for tough clinical scenarios and be open in communication. 7. Learn and practice the art of professionalism. This includes reaching workplace on time, keeping appointments promptly, managing interpersonal issues between team members. Try not to vent out anger at workplace, either to colleagues or patients. Try to master the “art of anger control” and develop healthy alternative strategies. 8. Try to develop the art of “smart work” than “hard work”.Structured document keeping, getting the services of an assistant and prioritising work schedule can help a long way in making life less miserable. 9. Be a life long learner. The practice of medicine is a life long learning process and we need to embrace this reality with zero ego. Utilise every opportunity to learn new things, even if it is from your student or child.Keep yourself updated so that you don’t become useless as a clinician in the long run. 10.Develop expertise in niche areas of your speciality, publish research on those areas, train youngsters and become a master of that area. Focus on your area of interest so that you can get professional satisfaction as well as personal fulfilment out of that. 11.Take care of your diet. Healthy diet is an important aspect not only for physical health but for mental health as well. Avoid getting addicted to substances of abuse that pollute the functioning of your brain. 12.Keep your personal relationships important. Spend quality time with spouse and kids every day. Go for holidays and create some memories you would cherish for a long time. 13.Practice “mental health first aid” whenever you come across a colleague in distress. First, approach the person and proactively enquire about what’s troubling him. Then listen non judgmentally to whatever he had to say. Then give correct information to rectify his misconceptions and give reassurance. If still things are not improving, encourage consultation with a mental health professional to solve the issues . Then assure that the person receives adequate social support and does not feel isolated. For, perceived loneliness is an important factor which may prompt a person to end his life. As the largest professional organisation of doctors in India, Indian Medical Association should take up the task of sensitising and empowering it’s members about stress, wellness, supporting each other during crises and the art of human management REFERENCES 1. E W Krail: Ten commandments of physician wellness; Clin Med Res, 2014 Sept ; 12 (1-2) 6-9 2. Arun B Nair; The Short Book on Mindfulness; Kalapoorna publications 2023 3. Arun B Nair, Devika J: The book on healthy living; Kalapoorna publications 2023 3. Arun B Nair; Live learn look bright; Bodh Books; Fifth edition 2023. 4. Arun B Nair, Abey George: The miracle of human bonding: Indulekha Publications 2023. 76 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 78 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr. Tiny Nair Head. Dept of Cardiology PRS Hospital, Thiruvananthapuram The state of Kerala has an excellent track record of good health; with a life expectancy at birth (LEB) of 74.9 years, infant mortality rate (IMR) at an enviable 6/1000 live births; all of these attributed to a high literacy rate, especially among women in this state. In that backdrop, the recent IMA data showing that Kerala doctors die on an average 13 years younger (at average age of 61.7 years) compared to the general population is shocking and an eye opener. It is time that we woke up and take a look at ourselves in the mirror, care for our own health since the society is hardly interested in our welfare. While the patient demands a better healthcare at an affordable cost, the overcrowded Govt sector is bursting at its seams and the corporate sector focus on balance-sheet; the doctor, the icon of healthcare, is stuck in between the devil and the deep sea. This results in enormous mental stress, physician burnout and a fertile field of lifestyle disease for the healer himself. The human heart is a fascinating machine, beating about a million times in just about 10 days. A little care, a regular lifestyle, and avoidance of smoking could ensure that we have a healthy heart that serves us our lifetime. As doctors we are overburdened by work, stressed out by emergency, cut down on sleep, and too busy to spend time on lifestyle change. This article contains practical tips for a good cardiovascular (CV) health for doctors. Understand that most young Indians with ischemic heart disease have a burden of multiple low-grade risk factors which we often label as borderline and don’t take care. Care for what you eat, drink and inhale Avoid junk food, this includes hospital cafeteria. Have breakfast from home, bring a packed lunch to hospital and a frugal ‘home’ dinner. Try Time to look at the mirror

to be choosey when you fill your plate at the post conference free meals. Most doctors don’t smoke, but remember the harm of passive smoking too. Follow what you advice your patients, not even one cigarette a day is safe. Wear mask in hospital, COVID is a strong correlate to CV disease. In highly polluted metros, wearing a mask outside is preferable. Don’t drink alcohol excessively. No level of alcohol is safe or beneficial for the heart. Avoid sugary drinks like colas. Regular exercise 30 minutes a day of brisk walk, at least 5 days a week is fine. Invest in a smartwatch and you would understand how little you exercise. A minimum of 10,000 steps is the goal. Regular check-up Fix up a date mentally, say 10th day every 6 months (at least) and mark your calendar. Ask your nurse to draw blood for checkup. Goals are summarized in Table 1. Stick to goal levels. You are a doctor, don’t be afraid to take medications, if and when indicated. Symptoms Don’t speculate that your dyspepsia is GERD, the headache as stress or ascribe palpitation to too much coffee. Asking help from a colleague is not a sign of timidity. We had a doctor who complained of chest heaviness during morning rounds in the ICCU. ECG showed an acute inferior wall myocardial infarction. Angioplasty was done, ECG reverted to normal. He was back for rounds with us a week later. Remember, early disease detection has a better outcome. When you go to see your colleague for an opinion, do that as a patient; don’t force him your opinion. Treatment Understand that like a barber needing a colleague, for a haircut, you need someone else to treat you. Don’t open your cupboard and look for the available free sample to choose an antibiotics. Will you do it for a patient? Sleep All doctors are busy, and hard-pressed for time. To most of us, the only thing that’s negotiable is sleep. We decide to sleep late or wake up early to squeeze out time for more important events. But a proper good quality sleep of at least for 6 hours plus is necessary for good CV health. Shorter sleep increase events like acute MI. If you have to take night calls, share with colleagues. Lack of sleep has emerged as a major risk factor for CV disease among doctors. Stress Understand that peace of mind is far more important than money, fame, patient satisfaction or a publication. Get a job that’s comfortable with you. Develop a hobby; it is a must. Be it reading, writing dancing or cycling. Table 1 Goals LDL cholesterol < 100 mg% FBS < 110 mg%, BP < 130 / 90, HbA1c < 6%, No smoking. Regular Exercise > 10,000 steps. Sleep > 6 hours No Smoking. No / moderated alcohol Low fat low carb diet (no junk food) Screening Tests Age > 40 Echo / TMT test once in 2 years. A little care would ensure that your heart continues to beat million more times without a fuss. Just show that you care too. Do look at the mirror once-in-a-while. For your sake. For your family’s sake. 79 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 80 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Get Your Jabs in Time Dr Sheeja Sugunan Additional Professor SAT, Government Medical College Thiruvananthapuram I mmunisation of adolescent and adults is a less focussed, but important area. The main aims of immunisation of this sub group of age are, to boost the waning immune response to certain vaccines which were given in childhood like Tetanus, pertussis etc., to protect against diseases that have higher morbidity in this age group like Hepatitis A and varicella, to provide protection during travel and study abroad and to provide catch up immunisation to those who missed completing immunisation previously.

Routine vaccines in adolescents and adults Td / Tdap vaccine TT is being phased out and replaced by Td vaccine. Td provides protection against both Tetanus and Diphtheria. Epidemiological shift of Diphtheria to higher age group during outbreaks prompted Government to introduce Td in place of TT in all areas. Tdap provides additional protection against pertussis. Pertussis protection is found to wane during adolescence , hence Tdap vaccine is preferred at 10 years over TT and Td. Protection provided by Tdap starts waning by 3 to 4years after v but nevertheless it’s use is found to be associated with decreased incidence of Pertussis in adolescence and in infants less than 6 months due to its affect on prevalence of disease in community. Routine vaccination 0.5ml IM at Deltoid at 10 and 16 years. Then every 10 years (decennial TT). For 10year tetanus dose, Tdap is preferred after that Td or Tdap may be given. Pregnancy Tdap vaccination is recommended single dose in each pregnancy between 27 to 36 weeks. Here the main aim is to provide optimal protection to both mother and baby against both Tetanus and pertussis. Catch up vaccination Unvaccinated adults should receive 1 dose Tdap followed by 1st dose of Td vaccine 4 weeks later and 2nd dose of Td , 6 month later (Tdap -Td-Td Tdap / Td 10 year, 16 year, every 10 year there after HPV 9 to 45 years PCV (Pneumococcal Above 65 years Conjugate Vaccine) single dose PPV 23 (pneumococcal polysaccharide vaccine) 1 year after PCV Influenza Vaccine Single dose every year Herpes Zoster vaccine Above 50 years of age at 0,1month, 6 month). It should be followed by a booster 1 year later. Post exposure prophylaxis for wound Unimmunised / less than 3 previous doses of TT : For Tetanus prone injury, give Tetglob plus Td three doses at 0,1month, 6 month interval For all others who have received at least 3 doses of TT containing vaccines previously, they do not need Tetglob. Administer - Single dose Td for tetanus prone injury if last dose > 5 years Single dose Td for clean minor wound if last dose more than 10 years. Human Papilloma Virus vaccine (HPV Vaccine) HPV vaccines have been found to have high efficacy for prevention of HPV vaccine type related persistent infection, adenocarcinoma in situ and cervical intra epithelial neoplasia. Bivalent, quadrivalent and nanovalent HPV vaccines are now available. All vaccines have good efficacy, 9 valent compared to 4 valent covers more cancer causing serotypes.Quadrivalent and nanovalent vaccines also have action against anogenital warts. All vaccines contain virus type 16 and 18 which together are responsible for 70% of cervical cancer cases globally. HPV vaccine dose and schedule 9 – 14 years : 2 doses at 6months interval. 15 – 45 years : 3 dose at 0, 1/2month, 6 month The most favourable time to take the vaccine is before sexual debut. Women aged > 26 years who have been sexually active should be counselled regarding reduced efficacy in older age group and the importance of screening. In a two-dose schedule of HPV vaccine, the minimum interval is 5 months between the first and second dose. In a three-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second dose, 12 weeks between the second and third dose, and 5 months between the first and third dose. Since the vaccine produces good antibody 81 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

response even with single and two doses, WHO has updated its recommendation on December 2022: 9 to 20 years : 1 or two dose at 6 month interval >21years : Two doses at 6 month interval. Annual influenza vaccine Influenza viruses undergo antigenic shift and drift. Hence to get protection against Influenza yearly single dose Influenza vaccine should be taken. Currently available vaccines are quadrivalent containg two Influenza A and two Influenza B serotypes. The strains for each hemisphere is decided by the WHO, depending on the prevalent virus strains. In India vaccines for both north and south hemisphere are released. India does not have a uniform Influenza season. In most parts of India, peaks in Influenza cases occur during the monsoon season. Hence preferable to take before monsoon. Always take the vaccine that became available most recently. Efficacy varies depending on how closely the vaccine strain matches with the circulating Influenza strain. Annual Influenza vaccine is recommended for all health care workers, children less than 5 years, patients with comorbidities including those with malignancy on chemotherapy. Administer killed Influenza vaccine to those with asplenia, CSF leak, cochlear implant, immunosuppressed, contacts of severely immunocompromised persons in protected environment. Influenza vaccine is also recommended during pregnancy. Pneumococcal vaccine Healthy adults above 65 years should receive single dose Pneumococcal Conjugate vaccine (PCV) followed by a single dose of pneumococcal polysaccharide vaccine (PPV 23),1 year later. If the patient has received PPSV 23 before, ensure a minimum of 5 years gap between two doses of PPSV 23. Adults aged 19 – 64 years with chronic heart, lung or liver disease , diabetes , cigarette smoking and alcoholism should receive 1 dose PPV 23 Adults > 19 years with immunocompromising condition should receive PCV followed by PPV 23 8 weeks later . PPV 23 should be repeated after 5 years at age 65 years or older. Herpes Zoster vaccine It is a recombinant vaccine. It is recommended for healthy adults above 50 years of age and for those above 18 years with increased risk of Herpes Zoster due to immunosuppression. In the recommended age group, vaccine may be offered irrespective of the history of prior varicella infection. Patients who are currently experiencing zoster should not be given vaccine as it is not a treatment for zoster. Vaccine can be offered any time after recovery from an acute episode of zoster, no specific interval is recommended. Dose: 0.5ml IM. Two doses at 2 to 6 month interval Catch Up vaccination MMR vaccine may be given to those with no evidence of immunity. It is contraindicated in severely immunocompromised individuals. Students and health care personnel with no previous history of vaccination should be offered 2 doses 4 weeks apart (2 doses of MMR are needed for measles and mumps protection while only I dose is needed for rubella protection). MMR vaccine is contraindicated during pregnancy. Single dose should be offered after pregnancy before discharge from hospital if there is no evidence of immunity. Varicella Vaccine Adults with no evidence of immunity should be offered 2 doses of varicella vaccine 4 to 8 weeks apart. Varicella vaccine can be offered after pregnancy as 2 dose series starting before discharge from hospital. If available, zoster vaccine can be offered to adults 50 years or older as 2 dose series at 2 – 6 months interval. VACCINATION FOR TRAVELLERS All individuals should be up to date with routine vaccinations. Some vaccine are specifically recommended because of increased risk. Travellers to US United States immigration law requires visa applicants to have received age appropriate vaccina82 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

tions against Hepatitis B, Hepatitis A, Influenza, Hib, Measles, Mumps, Rubella, Pneumococcal, Pertussis, Polio, Rotavirus, Tetanus, Diphtheria, Varicella. Students joining universities in US need to show documented evidence of vaccinations specified by the respective universities. Routine Vaccines recommended for travel to US Vaccine Recommended age DPT/ DPaT 2 months to 6 years Polio ( IPV / OPV ) 2 months 17 years Td /Tdap >10 years substitute 1 time dose with Tdap then Td booster every 10 years.* Rotavirus 6 weeks to 8 months Hib 2 through 59 months Hepatitis A 12 through 23 months Meningococcal ACYW 11 – 18 years Pneumococcal PCV 2 – 59 months PCV or PPV 23 for those > 65 years depending on vaccination history. Influenza Above 6 months MMR 12 months to 64 years Varicella >12 months Tdap may be needed for children 7 – 10 years if previously unimmunised. All travellers from countries infected or exporting wild polio virus (Nigeria, Afghanistan, Pakistan) and travellers who have been to these countries in the last 12 months need to show documentation of receipt of OPV or IPV within 12 months of travel. HAJJ PILGRIMAGE The Government of Saudi Arabia requires the following vaccines to be administered before travel to Mecca. Meningococcal Vaccine Travel to countries with hyperendemic meningococcal disease necessitates meningococcal conjugate vaccine single dose ( MCV4). If there is continued risk it needs to be repeated every 5 year . Military recruits and college students above 16 years if not previously vaccinated should also receive single dose . Those with asplenia, HIV or eculizumab should receive 2 doses 8 weeks apart and dose repeated every 5 years. Meningococcal conjugate vaccine is preferred over meningococcal polysaccharide vaccine because of its better immunogenicity. Meningococcal Vaccine All travellers to Mecca must receive Meningococcal quadrivalent vaccine at least 10 days before or at most 3 years before travel. Poliomyelitis All travellers from polio endemic countries and re-established transmission countries namely Afghanistan, Pakistan, Chad, Nigeria should receive 1 dose of oral polio vaccine at least 6 weeks prior to departure to apply for an entry visa for Saudi Arabia. Travellers are also given 1 dose of OPV at border points on arrival in Saudi Arabia. Travellers from India are also required to take OPV as the country is considered recently endemic and at high risk for importation. All visitors less than 15years arriving in Saudi Arabia are administered 1 dose of OPV at border points. Seasonal Influenza Influenza vaccination is recommended for all international and internal pilgrims especially those with increased risk of severe disease like children under 5 years, pregnant ladies, elderly and those with underlying medical condition like asthma, chronic heart disease, chronic lung disease. Yellow Fever vaccine Yellow fever vaccine for those coming from areas at risk of yellow fever transmission. The vaccine should be administered at least 10 days and at most 10 years before travel. Dose 0.5ml subcutaneously single dose above 9 months of age. 83 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

VACCINATION FOR ADOLESCENTS / ADULTS MOVING TO HOSTELS Adolescents and young adults as they move out to hostels are more prone to contract water and food borne diseases and other infectious diseases. Away from home, in a new place, prevention of common infectious diseases becomes a priority. They themselves can fall sick as well as can cause outbreaks in Hostels, colleges or workplace. Ensure they are upto date with Td/Tdap vaccine (16 years Td , then Td every 10years) Varicella vaccine two doses 1 month apart (if not previously received) MMR Vaccine: 2 doses one month apart if not previously received. If Previously received single dose, give one dose now. In case of outbreaks in Hostel an additional dose can be given even if previously 2 doses received. Typhoid Conjugate Vaccine Single dose 0.5ml IM. Typhoid polysaccharide vaccine is also available. Conjugate vaccine is preferred over polysaccharide vaccine because of better immunogenicity. At present Typhoid conjugate vaccine is licensed for use, only upto 45 years of age. Hence above 45 years of age if there is an indication single dose Typhoid polysaccharide vaccine may be given. Polysaccharide vaccines need to be repeated every 3 years as duration of protection is limited. Hepatitis A vaccine two doses 0.5ml IM, 6 months apart. In case of students joining medical school 3 doses of Hepatitis B needs to be taken 0,1month , 6 month if not previously taken. Annual Influenza vaccine single dose 0.5ml IM is desirable especially for those with respiratory illness like Asthma. If animal lover or moving to place where risk of Rabies is high pre exposure prophylaxis with anti Rabies vaccine 0,7,28 can be offered ID or IM. If moving to Polio endemic or outbreak zone, OPV/IPV (IPV preferred as trivalent) single dose . within 4 weeks of departure. If previously unimmunised give three doses 0, 1 month 6 month. If going to hostel in Meningitis belt/ US/UK single dose quadrivalent meningococcal conjugate vaccine, General Guidelines Try to complete immunisation schedule according to the recommended interval. In case of any inadvertent delay, there is no need to restart the whole schedule , just continue from where stopped. Live vaccines like Varicella, MMR , OPV are usually contraindicated in those with immunosuppression. History of anaphylaxis to a previous dose of the vaccine is a contraindication to receive it in future. Avoid vaccination during current acute severe illness. Mild URI, low grade fever, current antibiotic therapy, convalesence from disease etc. are not contraindications for vaccination. Ensure all patients are up to date with immunisation, at discharge from hospital. Do not give vaccines in gluteal region as the risk of vaccine becoming subcutaneous is high in gluteal region. Rabies and HBV vaccine if given in the gluteal region is considered invalid and needs to be repeated. Preferred site for IM injection is Deltoid for all above two years of age. Anterolateral part of mid thigh is also a valid site for IM injections. 84 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

85 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Tharang Dhwani 2023 Dr R Anupama Director & Chief Consultant Pran Fertility & Well Woman Centre Kumarapuram, Thiruvananthapuram Menopause... How Will You Deal It? Menopause is a natural part of aging and marks the end of your reproductive years. Menopause is a point in time when a person has gone 12 consecutive months without a menstrual period. Menopause usually starts between the ages of 40 and 58 years in developed countries. In the United States, the average age is 53 years. Average age at natural menopausal in India varies with region. In Eastern India, it is 47.3 years; 46.2 years in Western India; 45.5 in Northern India; 46.1 years in Southern India; and 47.8 years in the Central parts of India. STAGES OF MENOPAUSE A) Perimenopause or “menopause transition”: Perimenopause can begin eight to 10 years before menopause when your ovaries gradually produce less estrogen. It usually starts when you’re in your 40s. Perimenopause lasts up until menopause, the point when your ovaries stop releasing eggs. In the last one to two years of perimenopause, many people may experience menopause symptoms. But you’re still having menstrual cycles during this time and can get pregnant. B) Menopause: Menopause is the point when you no longer have menstrual periods. At this stage, your ovaries have stopped releasing eggs and stopped producing most of their estrogen. C) Postmenopause: This is the name given to the time after you haven’t had a period for an entire year (or the rest of your life after menopause). During this stage, menopausal symptoms, such as hot flashes, may get better. Also, they are at an increased risk for several health conditions, such as osteoporosis and heart disease.

COMMON QUERIES What are hot flashes and how long will I have them? Hot flashes are one of the most frequent symptoms of menopause. It’s a brief sensation of heat. Aside from the heat, hot flashes can also come with: • A red, flushed face. • Sweating. • A chilled feeling after the heat. The intensity, frequency and duration of hot flashes differ for each individual. Typically, hot flashes are less severe as time goes on. Maximum it will last for 5 yrs. How will you diagnose menopause? • Follicle-stimulating hormone (FSH). This usually goes up as you near menopause. • Estradiol. This level will go down in menopause. Why I am getting wet on coughing or sneezing? A loss of bladder control is called incontinence. You may have a sudden urge to urinate, or urine may leak during exercise, sneezing, or laughing, which is known as stress incontinence. Before reaching wash room, you may pass urine due to lack of proper control, which is known as urge incontinence. All urinary symptoms are related to effects of hypoestrogenism on bladder muscles. Can I have normal sex after menopause? After menopause, the vagina may become drier, which can make sexual intercourse uncomfortable. You could be less interested, decreased libido, pain during sex, vaginal itching, rarely bleeding. Hypoestrogenism leads to thinning and atrophy of vaginal mucosa, lack of proper lubrication can all lead to sexual problems . Couldn’t sleep .. why is it so? Around midlife, some women start having trouble getting a good night’s sleep. Maybe you can’t fall asleep easily, or you wake too early. Night sweats might wake you up. And if you wake up during the night, you might have trouble falling back to sleep. I can’t control my anger .. why? You might feel moodier or more irritable around the time of menopause. It’s possible that stress, family changes such as growing children or aging parents, a history of depression, or feeling tired could be causing these mood changes. My figure changed Your waist could get larger. You could lose muscle and gain fat. Your skin could become thinner. You might have memory problems, and your joints and muscles could feel stiff and achy. Symptoms may include aches and pains, headaches, and heart palpitations. Can I get a cure from these There are lot of hormonal and non-hormonal measures. • over-the-counter gels and other products for vaginal dryness • prescription pills, creams, and rings for vaginal dryness • low-dose hormonal birth control pills for hot flashes, vaginal dryness, and mood changes • low-dose antidepressants for hot flashes, even among people who do not have depression Lifestyle tips Tips for managing the challenges of menopause include: • getting regular exercise • practicing relaxation and deep breathing exercises • having a healthful diet that includes plenty of fresh fruits, vegetables, and whole grains • Quitting smoking and avoiding second hand smoke • limiting the intake of alcohol • seeking counselling for anxiety, mood changes, and relationship concerns • establishing good sleeping habits and getting plenty of rest 86 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Systemic estrogen — which comes in pill, skin patch, ring, gel, cream or spray form — typically contains a higher dose of estrogen that is absorbed throughout the body. Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — minimize the amount of estrogen absorbed by the body. Because of this, low-dose vaginal preparations are usually only used to treat the vaginal and urinary symptoms of menopause. HRT increases the risk of Heart disease, Stroke, Blood clots and Breast cancer. View menopause not so much as the end of the reproductive years but as the beginning or rebirth of a whole new you. Take time for yourself, give yourself encouragement, and find mutual support. Also, be optimistic about the future rather than thinking about how good things used to be. • doing Kegel exercises to strengthen the pelvic floor • talking to friends and family about the experience of menopause • exploring new ways of enjoying intimacy with a partner • joining a club, volunteering, or taking up a new hobby HRT Hormone replacement therapy is medication that contains female hormones to replace the estrogen that your body stops making during menopause. Hormone therapy is most often used to treat common menopausal symptoms, including hot flashes and vaginal discomfort. Hormone therapy has also been proved to prevent bone loss and reduce fracture in postmenopausal women. 87 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

Tharang Dhwani 2023 88 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Dr.Unnikrishnan Ramachandran Consultant Physiatrist (PMR) Thiruvananthapuram Physical well being for Doctors Human body by design is tailored for movement. The multitude of bones, joints, muscles all have evolved to ensure bipedal ambulation and hand dexterity which defines human functioning in daily life. Changing lifestyle, food habits, technological advances and mechanisation of many jobs / domestic chores have made human beings less physically active in recent times. The advent of digital tech has disrupted the already fragile physical activity schedule of most, so that people are becoming more and more sedentary with an alarming rise in life-

89 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR style related diseases worldwide. So it is obligatory that we realise the importance of physical activity for health and its varied effects on general wellbeing, and institute a structured exercise program. Physical activity and being active in daily life is a necessary skill for all, including doctors. As doctors most of us are cognizant of important guidelines including those on physical activity(1). As health care providers, we are expected to be at the forefront of health awareness programs for the public and patients. Studies have shown that Doctors who engage in regular exercise are more likely to advise exercise and physical activity to patients(2). It would therefore seem like sacrilege advising doctors on physical fitness. Or is it? Searching for data on doctors’ fitness and physical activity, many studies (Indian and foreign data) brought to light what we had always dreaded. Doctors, armed with all the knowledge, are in fact very poor when it comes to carrying out regular exercise and fitness related activities(3) (4). The findings were unequivocal -around 50% of doctors don’t engage in regular exercise programs or maintain an active life style. Few casual phone calls to doctors in my contact list also reaffirmed this, many do exercises but in a disorderly and irregular pattern, reducing the optimal benefits expected of exercises. The reasons for this phenomenon may be varied from being too busy at work, job dissatisfaction, and professional burn out. In fact some studies also point to a lower life expectancy for doctors in India(5) This is indicative of the detrimental effect of a vicious circle connecting mental health, sleep, physical activity, obesity, lifestyle diseases, and quality of life. Exercise by definition is a planned physical activity with a defined goal. So here’s what is needed 1. Aerobic exercise 30 minutes of aerobic exercise, minimum of 150 minutes (5 days) of moderate intensity exercise per week. There should not be a gap of more than 2 days of exercise. Any exercise raising the heart rate and breathing rate, where large muscle groups are working and with increased oxygen intake is aerobic. Aerobic is the efficient way of energy (ATP) production in humans. Examples : walking, jogging, running, cycling, swimming, dancing etc.. Exercise intensity should be moderate, which is the intensity which raises your heart rate to 50 % to 70% of the maximal heart rate. This is the recommendation for maintenance of health and control of lifestyle diseases in general. If weight loss is the aim, the aerobic exercise needs to be continued for 45 minutes to one hour along with diet restriction. 2. Strengthening exercise Muscle strength is key to our effective functioning in daily activities, right from self-care to daily chores, work and recreation. The strength of our major muscles of the hips and core muscles determine our ability to remain independent in later years of life. Sarcopenia is a major problem, where we lose muscle mass and hence muscle efficiency. Although age related sarcopenia is common, it can be prevented to a large extent by regular strengthening exercises. Standard guidelines advise strengthening exercises for major muscles, 2 to 3 days per week. This could be done by use of small weights/ dumb bells, elastic exercise bands, or using ones own body weight ( eg.,push ups, squats, lunges) 3. Balance exercises It would be good practice to do atleast a few simple balance training exercises regularly, eventhough we don’t feel any imbalance as such. People who do not exercise regularly are more likely to experience instability and falls than those who engage in regular exercise. This is because many exercises by default may have

a component of balancing. Simple tasks like standing on one leg while trying to lift the other leg or to moving it sideways is a balancing exercise. Many of the yoga postures, tai chi etc all have components of balancing and is proven to prevent falls in the older age. 4. Flexibility or stretching exercises Joint movement should be optimal to ensure good muscle function. Tight muscles function ineffectively. Some muscles like the hip flexors and rotators, hamstrings, quadriceps, back muscles etc are prone to become tight unless they are regularly stretched. Gentle exercises to stretch these muscles would make joints more pliable and flexible. It is a good practice to move all the joints of the body from head to toe regularly, it improves range and proprioception of joints. Many of the natural movements like looking up and looking to either side, spinal rotation, spinal flexion all are gradually getting lesser used by humans. 5. Posture correction exercises As a result of sedentary lifestyle, work related sitting, poor core muscles and weight gain, many have significant postural issues, which may be a reason for chronic musculoskeletal pain. Posture correction exercises (cervico thoracic and lumbosacral) and good ergonomic practices at work and leisure are important. 6. Be active We are all familiar with the new slogan “ sitting is the new smoking”. A number of studies have pointed to a link between hours of remaining sedentary per day to an increase in all-cause mortality(1) . Adding extra physical activity by moving as far as possible during the waking hours can add to the benefits of an exercise program. Taking stairs instead of an elevator, walking to a nearby shop, doing light household activities, gardening all are examples. While choosing a physical reconditioning program, it is important to opt one which is appropriate for age, physical fitness, and one that is easily accessible. One should always start at a level appropriate for their fitness and gradually increase the duration, intensity etc. No specific tests are needed to embark on an exercise program except in people with poorly controlled or advanced medical issues ( eg.,severe asthma, heart disease, Kidney disease, osteoporosis) Regular physical activity ,maintaining appropriate body weight along with good mental health and adequate sleep is the key to good health. References 1. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018. 2. Predictors of physical activity promotion in clinical practice: a cross-sectional study among medical doctors. Silva et al. BMC Medical Education (2022) 22:624 3. Knowledge, Attitude And Practices On Physical Activities Among Health Care Providers Of A Medical College In Haryana. Dr.Kapil Kumar, Dr.Sneh Kumari, Dr.Deepmala Kamboj, Muskan Aggarwal; Journal of Pharmaceutical Negative Results ,Volume 13, Special Issue 8, 2022 4. Doctors’ self-reported physical activity, their counselling practices and their correlates in urban Trivandrum, South India: should a full-service doctor be a physically active doctor? Lipika Patra, G K Mini, Elezebeth Mathews, K R 5. Doctor, heal thyself: Addressing the shorter life expectancy of doctors in India. Suresh K Pandey, Vidushi Sharma, Indian Journal of Ophthalmology; 2019 ,Volume : 67, Issue 7,Page : 1248-1250 90 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

91 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Tharang Dhwani 2023 As doctors, most of us go through a stressful professional and personal life on a daily basis. Some of us spend time to do a BP, sugar and lipid profile check-up at least once in a while. But it is a fact that we seldom care about a vital organ in the chest- our lungs. Who should have periodic lung heath check-up? • Age more than 55 years. • Ever smoked in life. • Working in high-risk areas (those areas with high concentration of environmental pollutants or background radiation) • Anyone with access to screening test facility. The frequency of lung health checks can be tailored to meet individual needs, but for those without specific lung issues, regular checkups every 1-3 years are generally recommended. These check-ups serve as preventive measures, enabling early detection and intervention for potential respiratory concerns. Screening tests The most common pulmonary function test (PFT) is spirometry. Spirometry testing measures the volume of air you inhale and exhale during a breath. It also measures how fast the air moves when you blow out and how much effort it takes. Spirometry testing is done as an outpatient procedure. Those who are already diagnosed with COPD should measure their spirometry at least once a year to assess disease progression. Some other advanced respiratory function tests are: Lung volume Measures how much air you can hold in your lungs and how much It's time to have an annual lung check - up too! Dr. Binu Krishnan Senior Consultant Pulmonologist PRS Hospital, Thiruvananthapuram

air remains after you exhale. This is also called body plethysmography. Diffusing capacity Measures how well oxygen moves from your lungs to your blood. Fractional exhaled nitric oxide Measures amount of nitric oxide exhaled. It serves as a tool for monitoring and assessing treatment response in asthma. Exercise stress test Measures how your lung and heart functions are affected while you exercise, usually on a stationary bike or treadmill. Lung cancer screening with LDCT (Low dose CT scan): Screening is recommended every year, if you: • are between the ages of 50 and 80. • Smoke now or quit smoking within the past 15 years. • Have smoked an average of 1 pack a day for 20 years or what comes out as the same number of cigarettes. The UK is showing just how simple cancer screening can be: High-risk patients are examined within a few minutes, get certainty about the state of their lung health, and don’t even have to go to the hospital. The CT scan needed for the lung check is performed in a converted motorhome, in a supermarket car park – so patients can get screened on their way to the shops. Several studies have already shown that lung cancer screening with low-dose computed tomography (LDCT) scans can prolong life. Back in 2011, the National Lung Screening Trial in the USA showed a reduction in cancer-specific mortality in high-risk patients. The more recently published European NELSON trial came to the same conclusion: A decade after the screening program started, death rates due to lung cancer amongst smokers and former smokers who were examined with an LDCT scan were 24% lower for men and 33% percent lower for women, compared with the control group that was not screened. This Targeted Lung Health Check programme estimates it will diagnose around 6,000 cancers earlier than would otherwise have been within the 23 places it is currently established. This offers the opportunity for more and earlier interventions, including curative surgery. When Should Screening Stop? The CDC Task Force recommends that yearly lung cancer screening stop when the person being screened: • Turns 81 years old, or • Has not smoked in 15 or more years, or • Develops a health problem that makes him or her unwilling or unable to have surgery if lung cancer is found. To Conclude Next time you think about your routine health check-up, try not to miss out your lungs too! 92 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

93 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Tharang Dhwani 2023 Dr Ajoy Samuel Mammen MBBS, DNB, DTCD, MNAMS, FAPSR, FICM, FCCP(USA), DAA (CMC VELLORE) Senior Consultant Pulmonary, Critical Care and Sleep Medicine Cosmopolitan Hospital Thiruvananthapuram Sleep and Doctors – A Strange Relationship Sleep plays a vital role in good health and well-being throughout your life. During sleep, your body is working to support healthy brain function and maintain your physical health. Getting inadequate sleep over time can raise your risk for chronic (long-term) health problems.

Heart and circulatory system When you fall asleep and enter non-REM sleep, your blood pressure and heart rate fall. During sleep, your parasympathetic system controls your body, and your heart does not work as hard as it does when you are awake. During REM sleep and when waking, your sympathetic system is activated, increasing your heart rate and blood pressure to the usual levels when you are awake and relaxed. A sharp increase in blood pressure and heart rate upon waking has been linked to angina, or chest pain, and heart attacks. People who do not sleep enough or wake up often during the night may have a higher risk of: • Coronary heart disease • High blood pressure • Obesity • Stroke Hormones and sleep Your body makes different hormone at different times of day. This may be related to your sleep pattern or your circadian clocks. In the morning, your body releases hormones that promote alertness, such as cortisol, which helps you wake up. Other hormones have 24-hour patterns that vary throughout your life. Respiratory and immune systems During sleep, you breathe less often and less deeply and take in less oxygen. These changes can cause problems in people who have health problems such as asthma or chronic obstructive pulmonary disease (COPD). Asthma symptoms are usually worse during early morning sleep. Sleep also affects different parts of your immune system, which become more active at different times of day. For example, when you sleep, a particular type of immune cell works harder. That is why people who do not sleep enough may be more likely to get colds and other infections. Problems with thinking and memory Sleep helps with learning and the formation of long-term memories. Not getting enough sleep or enough high-quality sleep can lead to problems focusing on tasks and thinking clearly How Much Sleep Is Enough? Experts recommend that adults sleep between 7 and 9 hours a night. Adults who sleep less than 7 hours a night may have more health issues than those who sleep 7 or more hours a night. Sleeping more than 9 hours a night is not necessarily harmful and may be helpful for young adults, people who are recovering from sleep deprivation, and people who are sick. Recommended hours of sleep Below you can find the recommended hours of sleep, including naps, for different ages. • For newborns younger than 4 months, sleep patterns vary widely. • Babies 4 months to 1 year old should sleep 12 to 16 hours per day. • Children 1 to 2 years old should sleep 11 to 14 hours per day. • Children 3 to 5 years old should sleep 10 to 13 hours per day. • Children 6 to 12 years old should sleep 9 to 12 hours per day. • Teens 13 to 18 years old should sleep 8 to 10 hours per day. If you think you are not getting adequate high quality sleep, you will feel heaviness of head, excessive tiredness, lack of concentration the next day. It can be easily picked up by undergoing a sleep study (polysomnography) after consultation with a pulmonologist. So, as fellow colleagues and friends, please take care of your health by getting adequate sleep. However busy you may be, ensure you get adequate sleep because if you fall ill, none of your patients will stand by you except your family. So, our motto to our patients should be “If I am healthy, you will be healthy “ Take care. 94 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

95 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Tharang Dhwani 2023 Food for thought for the health care practitioners To be productive and give the best to patients and treatments, doctors need to make a healthy diet their topmost priority. After all, selfcare is the first step towards good health, which in turn helps doctors treat their patients better. Dr Leena Saju PhD.RD Group ManagerClinical Nutrition KIMS Health, Thiruvananthapuram

To manage double shifts and stressful days, a healthy diet is very essential to keep one’s body energized. Skipping meals, irregular meal timings, and lack of wholesome or nutritious food have a negative impact on health. This can lead to fatigue and headaches, but also makes you more prone to infections, weight gain and stress, which can come in the way of your professional responsibility towards patients. Two main cornerstone principles to consider are having a wholesome breakfast which gives the required energy to kick-start a day and never miss out on the lunch breaks even if it is a busy day full of appointments. Here is how you can follow a healthy diet regime despite a hectic schedule. A healthy diet is one that gives your body everything it needs for ensuring good health , this includes macronutrients (carbohydrate, fat and protein), micronutrients (vitamins and minerals), fibre and water. Start the day with a nutritious breakfast packed with carbohydrates, good fats and proteins which can work wonders. Foods that may be added to the meal include the following. • Cereals and muesli (without processed ingredients and added sugar) eg. rice, wheat and millets • A combination of fruits and vegetables • Lean meats like poultry, fish, eggs or plantbased protein like tofu, paneer and legumes/ beans • Yoghurt or milk • Healthy fats, nuts and seeds Incorporate these foods into your breakfast by planning simple combinations so that you can have it on the go. For instance, adding ground flax seeds to your oats-fruit smoothies and sipping on it on the way to the clinic or at your work desk, a chapati or multigrain wrap or sandwich with a mix of sautéed vegetables and cottage cheese while you work or a salad bowl with a good portion of cereals and lean protein along with your veggies. If you can manage a sit-down meal, try to have a balanced meal as mentioned above. Snack on healthier options to boost energy levels The gap between breakfast and lunch hour can be long, especially if you have an urgent appointment or emergency surgeries, and that’s exactly when snacking can be necessary. Be it mid-morning or mid-afternoon, getting an energy boost in between your major meals can be of great help. This is where fiber-rich granola bars, nuts like almonds or walnuts, fresh or dried fruit and yoghurt can be game changers. Though snacks like packaged chips and processed foods are easy to reach for, swap them for bananas or apples for the same instant energy but without the high fat and sodium content. Eat a well-balanced meal loaded with fiber and protein for lunch While breakfast is an important meal to kickstart the day, a well-balanced lunch can help keep the brain and body going strong all through the afternoon. Here is what doctors can consider while planning their lunch menu. • A portion of healthy proteins like lean meat such as chicken or fish, legumes and dals or paneer. • Consume carbohydrates which are low in glycemic index like brown rice, wheat, and millets. Avoid having high-glycemic carbohydrates like processed cereals, white bread, pasta, or potatoes as these may cause an instant spike in blood sugar levels. • Include a bowl of salad as a high fiber option with ingredients like lettuce, bell peppers, carrots, beetroot, tomatoes, kidney beans or chickpeas, quinoa, and sweet potatoes. Remember, a heavy carb-laden lunch can cause lethargy, which can affect overall productivity. Instead, a high-fiber meal keeps the stomach full for a longer period while ensuring the required amount of energy. A healthy packed lunch (salads bowls, wraps or rice bowls with protein) is suggested in terms of convenience. Stay hydrated by drinking a minimum of 2 liters of water Good hydration helps in regulating body temperature, minimizing hunger pangs, reduces fa96 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

tigue and maintains mood. Try to sip on plain water, infused water, or herbal teas which also help to improve the immunity over a glass of processed juice or fizzy drinks. Caution should be practiced against having excessive cups of tea or coffee in a day and also keep a close eye on the amount of sugar included in them. Meal ideas If you’re stuck on how to put the dietary guidelines on your plate, you may want to try these ideas: Breakfast: • Vegetable upma / poha seasoned with lentils and nuts with a glass of milk. Make sure that the proportion of vegetables is considerably good. • Oatmeal with nuts/seeds and cut fruits. For regular use it is ideal to use unsweetened milk or probiotic yoghurt. • Banana smoothie with probiotic yogurt, nuts and seeds. • Whole wheat toast with vegetable / egg omelette/ paneer – vegetable sandwich • Idly with vegetable / dal, sambhar / Moong cheela with curd Mid-day snack • Tawa roasted paneer tikki and coffee • Fruit and probiotic yogurt • Roasted chickpeas • Sprouts chaat Lunch& Dinner • Rice with dal/fish served along with a curd and vegetables • Chapati with grilled chicken curry and vegetable stir fry • Quinoa with stir-fried vegetables and lentils • Chicken breast with roasted vegetables, hummus • Dal Kichdi with curd and vegetables Nutrition needs differ with gender and age A healthy diet for a man is different from a healthy diet for a woman. And what a middle-aged individual needs from his/her food differs from what a younger or older individual needs. It is important to know your nutrition need that is specific for your age, gender and physical activity and to design an eating pattern according to a schedule that suits you. If you combine your food plan with some regular physical activity, you’re on your way to good health. Below 40 years Younger people in this age bracket generally require more energy than their older counterparts, but it is important to eat in moderation, while ensuring a good variety of foods. If you want to change your appearance or performance by building muscle, remember you don’t need to overdo it: most young adults only need about 0.83 to 1 grams of protein per kilogram of body weight per day (ICMR 2023), which is about 60-70 grams a day for an adult weighing 70 kilogram. Approximately 20 grams of protein can be obtained in each meal by including 100gm of fish/ chicken/paneer, 3 eggs and 45gm of soya chunks. While 10gm protein can be obtained from 300ml milk or yoghurt or by including 40gm of lentils and pulses. This can be used as a handy tool while meal planning. The recommended calorie intake for adults is 30- 40 kcal per kg of body weight; however, this figure should be customised based on gender, nutritional status, degree of physical activity. If you’re watching your weight, calorie restriction by limiting high calorie foods such as fried and oily options, highly processed food, soft drinks and alcohol is a good option. 40 to 60 years Around this stage in your life, your nutritional requirements tend to change. As we get older, the key tool is choosing foods that give you a bang for your buck – that is, foods that are nutrientrich, without excessive calories. You’ll also need to watch your ‘extras’ or ‘sometimes foods’ such as commercial burgers, pizza, alcohol, lollies, cakes, biscuits, fried foods and fruit juice– for managing weight and lifestyle disorders. The importance of having a balanced meal with adequate protein and 97 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

ample amount of plant foods does not reduce at this stage and only gains more importance. 60+ years The decline in physical activity and ageing reduces the muscle mass and energy expenditure in sedentary people. It is noticed that people often forget to reduce their energy consumption in a manner that matches the drop in their energy requirements as they age, which results in an increased fat percentage in their bodies. For older adults, a lower energy demand poses a complex nutritional dilemma because their vitamin and mineral requirements tend to remain the same or even rise for several nutrients. The recommended calorie intake for older people is 27- 30 kcal per kg of body weight. However, it should be customised based on gender, nutritional status, degree of physical activity, illness state and tolerance. To achieve carbohydrate needs while also limiting discretionary energy intake, elderly people should eat a range of fiber-rich vegetables, fruits, and whole grains. This will help them to manage blood sugar, cholesterol, and bowel health. For proper laxation in individuals of all ages, 25 gm of fiber per day have been recommended (WHO 2003). As aging progresses, dehydration can have worsening effects, leading to fatigue, confusion, and increased susceptibility to infection. As the sense of thirst may diminish with age, it is crucial for them to consciously consume water. Adhering to a balanced diet and catering to changing nutritional requirements, enhances health, quality of life, and mitigates the risk of chronic diseases. Studies also suggest that a Mediterranean- diet pattern packed with veggies, fruits, and seafood could preserve lean muscle mass and lower the incidence of mental dysfunction and Alzheimer's disease. Several evidences also indicate that a nutritious diet and meticulous monitoring of adequate nourishment could be beneficial for all age-associated medical conditions. Tips for a healthy diet and weight • Mindful eating - Listen to your body and learn your cues for hunger and satiety. • Chew your food thoroughly and eat slowly. • Make water your main drink to help you stay hydrated. • Make healthy choices, and know your serving sizes /portion size 98 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR

99 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR Tharang Dhwani 2023 Spectacles for the Presbyopic Doctor Everyone ages, even doctors! We usually notice the effects of aging around 40 years of age when we lose the ability to see objects at very close distances. We might first notice this when we have difficulty in reading the small print on our medicine bottles or legal documents. As we grow older near vision will slowly become progressively more blurry, but distance vision will not be affected. This inability to see near objects is called presbyopia. Dr Devin Prabhakar MS, FRCS Divya Prabha Eye Hospital, Thiruvananthapuram

We have two types of spectacles to help people with presbyopia see near objects. These are Bifocal and Progressive lens. The major physical difference between the bifocal lens and the progressives lens is the demarcation line between the area used to see far and area used to see near objects. The main functional difference is that bifocal has only two focal points, while progressive has many. Bifocal as the name implies have two areas of focus- the top portion for distance and the bottom circle for near. The reading power can be titrated to the distance that the person requires. For a person who read books in his hand would need the focus to be at 20-30 cm, while if he reads with the paper on a desk while he leans back the focal distance would be 3-40cm. If he requires to see both near and intermediate objects/ print then he has to opt for a progressive lens. The reading segment can be round, D shaped or a flat line as in executive bifocals. Round shape is most comfortable while D shape gives more area for distance. Executive bifocals have large area for near for people who read a lot. Progressive glasses are also known as varifocal, graduated glasses and no-lines bifocals. These lenses have more than one focal point or lens power with different powers at different levels of the lens. At the top of the lens, the power is minimum, which gradually increases in the middle level and finally, the bottom part of the lens has the maximum power. Commercially, progressive glasses are quite popular because of the absence of any line on the lens. The greatest advantage of progressive glasses is the ability to look at objects at varying distances with just a slight tilt of head. As the different levels have different powers, the top part can be used to view objects at a distance, the middle one at the objects at an intermediate distance and the bottom part while working on the nearby objects, like reading a book. They also avoid the discontinuities like image-jumps which occur in the visual fields created by bifocal and trifocal glasses. For a doctor progressive lenses are most apt as they let you see at all distances. You can read the fine print on a medicine bottle as also messages on your mobile phone, articles and images on your computer. They are useful during procedures to visualize images at varying distances like instruments held at arms length and images on TV monitors. Let us look at some practical aspects of choosing a progressive lens. HOW EXPENSIVE ARE PROGRESSIVE LENSES: Good quality Progressive lenses are available from about 2,000 rupees to upwards of 50,000. The price depends on the brand, the type of antireflective coating, ability to darken in sunlight, the refractive index and design. DO OPHTHALMOLOGISTS RECOMMEND ANY PARTICULAR BRAND OF LENS: As you would have seen from your specs prescription Ophthalmologists only recommend if bifocal lens or progressive lens are more suitable for a person. We do not recommend or prescribe any brand. LENS DESIGN: When you buy a more expensive lens you are paying for distortion free vision. Cheaper lenses have a narrow corridor of power and therefore the vision through the sides of the lens will be distorted. This becomes a concern for only higher powers as in lower power lenses distortion is anyway not much. LENS MATERIAL: Higher refractive index lens are more expensive but are thinner than cheaper lens. If you have a high power you benefit a good deal from having a higher index lens. For lower powers the lens will be thin anyway. TAKE HOME MESSAGE: For the ordinary power lens there is hardly much difference between various brands of progressive lens if you just require specs for near work. If you need high power lens for distance then a more expensive progressive lens might give you much more clarity. WAY FORWARD: Currently most of the counseling with regards to which lens to choose is done by the dispensing optician at the optical shop. It would be good in the future to discuss with your Ophthalmologist when you get your prescription done about which lens design, index, coating and tinting to choose. You can then choose any brand that suits your pocket and life style. 100 THARANG DHWANI 2023 - IMA ALL INDIA MEDICAL CONFERENCE SOUVENIR