CGP March Month Journal-2022

DEAN, IMA CGP HON.SECRETARY EXECUTIVE EDITOR
Dr. AVINASH BHONDWE Dr. C. ANBARASU Dr. T.N. RAVISANKAR

CO EDITOR ASSOCIATE EDITOR
Dr. L. YESODHA DR. S. REKHA,
DR. SATYAJIT BORAH

MARCH 2022

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Content

Original Article

Dr.J.A.Jayalal M.S., F.R.C.S.,M.B.A.,P.Hd.
Immediate Past President IMA HQs
Professor of Surgery,
K.K.Medical college, Kanyakumari
Page No: 3 to 10

Review Articles

Dr.R.Anburajan , MBBS, DFM (Colombo), FCGP
Page No: 11 to 15

Dr.S.Jamuna M.D.
Professor of Pathology,
Tagore Medical College, Chennai
Page No: 16 to 20

Dr. N.T. RAVI, MD
Retd. Professor of Dermatology
Madras Medical College
Page No: 21 to 25

CGP Editorial Team
Page No: 26

Updates

Dr. M. K. SUDHAKAR, MD (General Medicine)
Page No: 27 to 32

Legal Page

Dr.T.N.Ravisankar MBBS, DFM (Colombo), FCGP, PGDMLE
Page No: 33

IMA CGP Report

Page No: 34 to 41

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Original Article

MESH, A MESSIAH IN SURGERY

Dr.J.A.Jayalal M.S., F.R.C.S.,M.B.A.,P.Hd.
Immediate Past President IMA HQs
Professor of Surgery,
K.K.Medical College, Kanyakumari

ABSTRCT:

Surgical mesh is a loosely woven sheet which is used as both a permanent or temporary
support for organs and other tissues during surgery. Surgical mesh is created from both
inorganic and biological materials and is used in a variety of surgeries. Though hernia repair
surgery is the most common application, having noticed the improvements reported in the
treatment of hernia, in 1970s meshes were introduced for the management of pelvic floor
dysfunctions (PFDs), including pelvic organ prolapse (POP) and stress urinary incontinence (SUI),
with the first Urogynaecological mesh approved by the US Food and Drug Administration (FDA)
only 20 years ago. The ability to provide mechanical support to weak tissues was subsequently
exploited in other clinical fields. For instance, in 2001 meshes were introduced to expand the
size of the reconstructive pocket in breast reconstructive surgery after mastectomy.

The era of Surgery hampered by recurrence and delay are much saved, by the
introduction of mesh and they played a role of messiah in various surgeries.

HISTORY

Surgical mesh implants are generally defined as flexible and thin flat sheets that are commonly
used to provide additional support to a weakened tissue. Theodore Billroth is credited with
envisioning the current practice of prosthesis repair. In 1857, he proposed

“If we could artificially produce tissue of the density and toughness of fascia and tendon, the
secret of the radical cure of the hernia repair would be discovered”.This statement provided
support to pioneers in prosthetic repair”.

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Fig 1: Theoder Billroth

In 1958 Usher published his surgical technique using a polypropylene mesh.30 years
later Lichenstein performed first open inguinal hernioplasty. At present many surgeons affirm
the use of mesh is the preferred way to repair hernias.

Up to now, meshes have been produced mainly using non- absorbable materials,
especially for hernia and PFDs. They have been developed as an alternative to biological
prostheses, aiming to overcome the limitations related to their use, such as the possibility to
develop infections, unpredictable mechanical properties and the high risk associated with tissue
harvesting procedures

Fig:l Different Types of hernia
Irrespective of the site and nature of the hernia the Gold standard of care for hernia

surgery is mesh. When Bassini done anatomical repair of Hernia it is plagued with tension and
recurrence and with Lichenstein tension free Hernioplasty using Mesh, both tension for patient
and doctor is eased. The use of mesh is cost effective and curative. Various special kind of mesh
are used as per need.

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Among the various groups, prosthetic materials falling under this category especially the
polypropylene (PP), polyester (PE), and expanded polytetrafluoroethylene (ePTFE) based
meshes are the one used extensively.

DUAL MESH:

Prosthesis with either an absorbable or a nonabsorbable barrier is used for preventing
bowel adhesions when it placed intraperitoneally. This mesh is engineered in such a way that
barrier on one of their faces to facilitate direct contact with the viscera. Here the barrier
minimize the biological response, provide the limited opportunity for initial adhesion to the
material thereby reducing the activation of imflammatory cytokines and cells, ultimately inhibit
the onset of inflammatory cascade. Selection of an optimum size and its proper fixation are
mandatory. The possible barriers are ePTFE, polyurethane, oxidised regenerated cellulose,
omega-3 fatty acids, collagen, or beta glucan.

COMBINED MESHES:

The main purpose of combined mesh material is to prevent the complications by taking
advantages of the best traits from 2 different meshes. In case of polyester and PTFE combined
meshes, former allows the abdominal wall tissue in-growth whereas later prevent the
occurrence of intestinal adhesion achieved through different pore size of the mesh.

BIOLOGICAL MESHES:

The primary importance for the construction of biological mesh is to overcome the problems of
synthetic meshes and to provide mechanical support, tissue remodelling along the mesh
scaffold in order to create highly organized collagen network thereby to establish new vascular
access to the hernia site.Even though currently available biologic meshes are seemed to have
different origin, these are all common in taking collagen rich tissues from human or animals,
stripping of all cellular contents and stabilizing the resultant extracellular protein structure to
act as a collagen scaffold for the in growth and deposition of fibroblast and collagen
respectively.

APPLICATIONS OF MESH IN PELVIC SURGERY:

Similar to Hernia surgery, synthetic meshes may be used for organ prolapses in the pelvic
region as well. Mesh surgery can be performed in various areas of the pelvic region, such as
cystocele, rectocele, and vaginal vault or uterus. The most commonly used material, as in
hernia surgery, is Polypropylene, which is considered to have acceptable biocompatibility

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within the region. It induces a mild inflammatory response but has a tendency to adhere to the
viscera.

CARDIOTHORACIC AND VASCULAR SURGERY

Chest wall reconstruction following resection of sternal/rib tumours and Hiatal hernia
repairs to reinforce crural closure are based on the use of mesh and Endo vascuslar grafts
e.gfemoropopliteal bypass used in peripheral vascular disorders.

BREAST SURGERY:

The mechanical support exerted by meshes has also been used by surgeons during
Breast Reconstruction after mastectomy. Biological (acellular dermal matrix) and synthetic
(absorbable and nonabsorbable) meshes are often used in two stage (expander-implant)
reconstruction, and are also used routinely in most single-stage direct-to-implant
reconstructions. It consists in putting a saline or silicone implant under the skin or the muscles
of the chest (subcutaneous and sub- muscular approach respectively) and lately, prepectoral
approach, through which the mesh is sutured to the inferior margin of the major pectoralis
muscle, has become really promising since it allows to create a larger reconstructive fold, thus
making the final implant more stable and comfortable.

Fig: 2: Most common meshes used for breast
reconstruction.

ORTHOPEDICS:

For augmentation of tendon repairs e/g Acute quadriceps tendon rupture and in
arthroplasties to wrap uncemented implants to encourage bone ingrowth, mesh is used
.Equally, to maintain relative positions of engrafted bone tissues as well as bone fragments
from comminuted fractures various kinds of mesh are used

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Fig 3: Porous scaffold mesh

PLASTIC SURGERY:

As a skin substitutes to provide dermal tissues scaffold for epidermal growth
e.gBiobrane is used.BIOBRANE is a temporary biosynthetic wound dressing used for covering
clean partial thickness burn wounds and split thickness donor sites.It is composed of a silicone
membrane bonded to a nylon mesh to which peptides from a porcine dermal collagen source
have been bonded to the nylon membrane to form a flexible and conformable composite
dressing. BIOBRANE has been proven to provide:
 Decreases length of patient stay
 Increased speed of healing
 Decreased Pain
 Increase rate of Epithelialisation
 Increased Mobility

Fig4 : Skin mesh

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NEUROSURGERY:

As Dural substitute in duroplasty are increasingly used and The nanofabricated dura
substitute demonstrated an optimal time course of resorption suited for repair of both large
and small dural defects.

Fig: 5 Duraplasty after suboccipital decompression

Cranioplastiesandvertebroplasties using Titanium Mesh are another major breakthrough
in mesh use.Surgical debridement, bone flap disposal and immediate titanium mesh
cranioplasty may be a suitable option for the treatment of post craniotomy infections. This
treatment strategy facilitates the eradication of infectious sources and obviates the risks and
costs associated with a second surgical procedure.

FIG 6: Cranioplasty using Titanium Mesh

WOUND DRESSINGS:

Meshes in the form of dressings have been widely employed also in the treatment of
wounds. Currently, a significant number of surgical meshes are available on the market. They
are made of different materials and characterized by different levels of inflammatory response,
tissue infiltration, biodegradation rate and stability.

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FUTURE PERSPECTIVES:

MESH NANOELECTRONICS : Seamless integration of electronics with tissues .Eg 3D neural tissue
to be precisely delivered to targeted brain regions in minimally invasive manner.
Nanobioelectronics mesh represents a rapidly developing field with broad-ranging
opportunities in fundamental biological sciences, biotechnology, and medicine

Fig: Syringe-injectable mesh electronics integrate seamlessly with minimal chronic immune
response in the brain

Developing a mesh that could appropriately integrate with the native tissue, promote its
healing and constructive remodelling, is the key aim of ongoing research in the area of surgical
mesh implants. To this end, the adoption of new biomaterials including absorbable and natural
polymers, the use of drugs and advanced manufacturing technologies, such as 3D printing and
electrospinning, are under investigation to address the previously mentioned challenges and
improve the outcomes of future clinical practice.

DRUG-ELUTING SURGICAL MESH IMPLANTS:

Bacteria associated with mesh surgical site infections, like MRSA and E. coli, are both a threat to
patient health and patient wallets. Among one of the riskier surgeries that use a mesh is ventral
hernia repair, which can often result in high rates of infection.

The proliferation of these surgical site infections presented a need to develop a strategy
for a new type of antimicrobial mesh. Now we have a drug-eluting mesh that aims to prevent
implantable surgical devices’ contamination by hitting a targeted area with bacteria-killing
agents.Ions incorporation could be an additional advantage also for meshes intended for
Guided bone regeneration procedures.

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Eg Copper loaded, Zinc loaded and Silver loaded meshes are being used for its activity against
S.aureus

Fig: Next-generation surgical meshes for drug delivery and tissue engineering applications

CONCLUSION:

Before the use of meshes, sutures were the main solution to manage hernia defects and
Pelvic Floor defects. Passive dressings, such as gauzes, were mainly used to treat chronic
wounds.The employment of surgical meshes in clinical practice has revolutionized the way to
approach some specific health conditions.Exploiting the use of 3D bioprinting and MEW, in
order to manufacture multi-material and/or multiarchitectural devices, is a promising approach
to move forward and thus develop future implant with patient-specific and tailorable
properties

Even though the ideal mesh implant has not been developed yet, the promise of the
latest research in the area can certainly be considered an interesting starting point for future
developments in this field. With advancing technology Mesh as Messiah will take new avatars
to help Surgeons and Public.

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Review Article

WATER THAT MATTERS MUCH – Continued…

“Thousands have lived without love, not one without water....”

Dr. R. Anburajan,
MBBS, DFM (Colombo), FCGP

As a General Practitioner we all must know that proper hydration has other benefits for
reversing the aging process ie., maintaining the youth & vitality of ourselves and our patients.
Water will also help them to manage their weight.

When they don’t drink enough clean water they may lose their good looks. I believe that water
is the single best beauty treatment on the planet. It keeps the skin supple, eyes bright and body
spry. When we remove water from plums, we get prunes. Remove water from our skin, we get
wrinkles. In a dehydrated state the skin becomes dry, flaky, and wrinkled. The skin is designed
to hold in moisture, to be elastic. When water is deprived, the skin sags and loses its elasticity.
Not even a jar of wrinkle prevention cream cannot cure that! So proper hydration has other
benefits for reversing the aging process.

We must know that

Skin…
 Is the largest organ of the body and weighs about six pounds.
 Grows faster than any other organ.
 Is tough, flexible, and waterproof.
 Stores water, fat, and vitamin D.
 Protects the body from germs, heat, cold, and sunlight
 Is replaced approximately every thirty days.

When dehydrated, our body temperature drops slightly and causes body to store fat as a way
to help raise or maintain the temperature. When we are dehydrated, the body secretes
aldosterone, a hormone that causes water retention. As we drink more water, the body
releases the water it was storing for “survival mode”.

Improving Memory:

It is a common knowledge that nothing could be done about memory loss. That is, until experts
discovered hat humans can grow new brain cells. PET (Positron Emission Tomography) and
SPECT ( Single Photon Emission Computed Tomography) scans can map brain activity and

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measure both the destruction and growth of new brain cells. Thanks to these marvellous
advances, today we know that even damaged brains can grow new cells. Then we may be able
to improve memory.

One way to improve the memory is to drink a lot of water.

The brain loves water. The human brain is roughly one-fiftieth of the total body weight, and
brain cells are said to be approximately 85 percent water. The brain is the only part of the
body that is constantly active. So to remain active, it must have water. Without adequate
hydration, these processes can slow down. I believe that long-term dehydration may even
contribute to Alzheimer’s disease. One way to improve your memory is to drink a lot of water.

Revival of Cells:

Cellular dehydration affects how our cells function. The first sign of failing health is a shift of
fluid from the inside of the cell to the outside of the cell. About two-thirds of the body’s fluid is
inside the cells, and the rest is outside the cells. But, cells die when they don’t have enough
energy to maintain the membrane pumps, which maintain the balance of water inside and out.
This is increasingly important as we age, because cells lose water as we age. Believe it or not,
newborn infants are about 80 percent water, whereas older people are usually less than 50
percent water.

So the next time when you are tempted to prescribe the latest expensive skin cream or pop a
pill ask your patients, try drinking enough water if it is not medically disallowed. It will help
keep the skin hydrated, elastic, attractive, and healthy. It will help manage the appetite, and it
will improve the memory. By giving our body the water it needs, we can maintain youth and
smarts longer.

Water is a powerful nutrient to slow the aging process, and to maintain the brain and Memory.
Increase intake of salads, vegetables, and fruits since they all contain a high percentage of water.

“Pure Water is the World's First and Foremost Medicine”

A look on tap Waters

We have to drink healthy amounts of water, but we need to drink the right kind of water. When
there are harmful substances in our water, those substances get into our bodies and may harm
us. Tap water is not as healthy anymore.

It was told we could find pure water right in the ground. A fifty-foot-deep well yielded plenty of
pure water –that is, water free of contaminants, chemicals, and other substances our bodies
consider toxic. But today, even bore wells of two hundred feet deep may not yield pure water.

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They have been contaminated by the amazing increase of manmade chemicals used in industry,
agriculture, and consumer products.

Industrialization and technology have introduced new, complex, and sometimes lethal
pollutants into our nation’s water systems. Most of the chemicals are water soluble, and many
are toxic. It was reported in one study that they have identified more than 2,000 chemicals in
our drinking water. Municipal treatment plants neither detect nor remove most chemicals from
the water supply. Our ability to filter out toxins is lagging woefully behind our ability to create
chemicals.

We have learned that it is impossible to separate our water supplies from the environment we
live in. The resources that feed city water supplies may catch runoff from dump sites, landfills,
etc. The chemicals we pump into the air from automobiles or factories eventually settle onto
the land. Sooner or later, anything we bury, spray, emit, or flush finds its way into our drinking
water.

The other big offender is modern agriculture. Pesticides, herbicides, and fertilizers, used in
massive quantities, run off from farmland and may end up in resources, which feed city or
municipal water supplies.

Believe it or not, pharmaceutical products may end up in drinking water. After consuming a
drug, humans or animals expel it in their waste (or sometimes people flush their medications).
Wastewater treatment plants then recycle the water for use. Antibiotics, hormones, and
painkillers may found in public drinking water. Personal care products like cosmetics, toiletries,
and fragrances are putting chemicals into water supplies, too.

Finally, though cities treat water to kill most bacteria, they usually cannot kill all viruses and
parasites, such as amoeba, giardia and cryptosporidium. It is observed that some outbreaks of
intestinal flu may actually be caused by such microorganisms in tap water.

Cities add chlorine to public drinking water as a public health measure to kill microorganisms.
But chlorine is not entirely safe. It can combine with organic materials to form
trihalomethanes–a cancer-promoting substance. Bladder cancer has been linked to chlorinated
drinking water. More studies are there from Foreign Countries to support this. One study found
that 14 to 16 percent of bladder cancers in Ontario, Canada, can be attributed to drinking water
that contains chlorination by products.

A study of drinking water and pregnancy outcomes in North Carolina reported a 2.8 fold
increased likelihood of miscarriage among women exposed to trihalomethanes in drinking
water. Chlorinated water has also been linked to birth defects and spina bifida. Many European
countries have already abandoned chlorination in favour of oxidation to disinfect their public
water supplies.

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Chlorine, the Anti-Vitamin

Chlorinated water can destroy nutrients your body needs: vitamins A, B, C, and E, and fatty acids.
Chronic akin conditions like acne, psoriasis, and eczema may clear up or improve by simply switching
to unchlorinated drinking water.

Chlorinated tap water can hurt even if you don’t drink it. Those same trihalomethanes can get
into our body when we get shower. They evaporate out of the water, and we inhale them. A
ten-minute hot shower can increase the contaminants absorbed into our bodies’ more than
drinking half a gallon of chlorinated tap water. When you take a shower with chlorinated water,
it can also make your hair brittle and dry out your skin. To avoid this, purchase a shower filter
which will remove 95 percent of chlorine from the water.

Fluoride- Not So Healthy After All

Teach our patients not to
swallow the toothpaste

The Sodium Fluoride that is added to toothpaste is created by aluminium smelting. There are
two types of Fluoride: the sodium fluoride found in toothpaste and the more toxic
hydrofluosilicic acid or sodium silicofluoride are added in the drinking water. The latter is the
most toxic of the two. Fluoride helps to prevent tooth decay, primarily in children, but it also
partially inhibits a hundred different enzymes in the body.

Points to Ponder:

Best not to drink water straight from the tap, because it may contain toxins, heavy
metals, pesticides, residual personal care products, bacteria, and other microbes.
One of the Chemicals added to our tap water is fluoride.

Is Bottled Water Better?

The very worst plastic used in some water bottles and food wraps, polyvinyl Chloride (PVC), is a
known carcinogen that emits pollutants from the moment it is created until long after it is
discarded. Studies clearly show that PVC leaches vinyl chloride and other pollutants, thus
disrupting the hormonal balance, causing fertility problems, and damaging cells, organs, and
tissues.

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Another common ingredient in some plastics, bisphenol A, is used in reusable water bottles. It
has also been linked to obesity.

We should prefer drinking water from glass bottles or from bio-based plastics, which are made of natural
products like starch, cellulose, and raw rubber.

They also treat ground water with aluminum to remove organic material. The aluminum
coagulates organic material into clumps. It’s impossible to remove all the aluminum that has
been added, and traces of aluminum remain in the drinking water. Aluminum may be worse for
you than fluoride or chlorine. It has even been associated with Alzheimer’s disease.
People ask us, if boiling water gets rid of the chemicals. The answer is no. harmful bacteria may
be killed, but the chemicals remain. They don’t “boil out.”

Point to continue…

If you have lead pipes, do not drink hot water from the faucet. Hot water increases lead concentration. Flush
the pipes first by running cool water before using it.

At last you have to keep in mind always that, your body needs water, but tap water may not be

the best source. Using any one filtration system as per the affordability and need will be of
much useful. Tap water is good for watering lawns, washing clothes, and flushing toilets, but
not for drinking.

“So what kind of water we can drink?”…

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Review Article

Role of Primary care physician in Fine needle aspiration cytology – An old
technique with new perspectives

Dr. S. Jamuna, M.D.

Professor of Pathology,
Tagore Medical College, Chennai

Introduction:

Fine needle aspiration cytology (FNAC) is a simple, noninvasive and an easy to
perform technique for diagnosis of palpable lesions in the body. FNAC is most
commonly performed in thyroid, breast, salivary glands, lymph nodes and palpable soft
tissue tumors of the periphery. The diagnostic accuracy of the technique in
differentiating benign from malignant lesions is as high as 99% in breast lesions, nearly
97% in thyroid lesions and 85% in salivary gland lesions.

The aim of this review is to highlight the role of FNAC in detecting palpable
lesions, against the background of its diminutive importance compared to core needle
biopsies. There are enough research evidences to state that FNAC along with clinical
examination and mammography (Triple assessment) are concordant in breast lesions,
final treatment can be ensued without an open biopsy [1]. With emerging
standardization on Immunocytochemistry (ICC) which can be performed in FNAC
materials, hormonal status of the tumors is also possible.

Evolution of FNAC Practice:

The technique of FNAC dates back to 11th century even before the syringes were
discovered as quoted in Arabic texts [2]. However, the technique gained momentum in
the 18thand 19thcentury and the current practice of using fine needles of size 22 to 27
gauge compared to 18 gauge emerged in 1980s. Now FNAC is a standard practice across
the world and with increasing prevalence of malignancies, FNAC can be used as a simple
outpatient based procedure even in a resource limited settings.

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Technique of FNAC:

FNAC though a minimally invasive, bed side procedure definitely needs a written
informed consent form explaining the procedure, risks involved and the limitations.

The diagnostic accuracy of FNAC depends on obtaining sample that is representative
and adequate with correct smearing and fixation procedures. Good palpation skills
complemented with radiological imaging guidance will help to obtain representative
samples. The choice of the needle, decision on aspiration or non-aspiration technique
and orientation of the needle towards the target tissue are vital in getting adequate
samples. In deep seated lesions, radiologically guided FNACs can be performed which
gives better image guidance.

 Check whether the informed consent form is filled completely
 Arrange the pre labeled, clean glass slides in the side table
 Check whether the coplin jar is filled with fixatives up to 2/3 of its capacity
 Ask the patient to lie in the aspiration table in a position comfortable to expose the

aspiration site.
 Clean the aspiration site with antiseptic swab
 Introduce the needle into the lesion by gently moving to and fro. Allow multiple

passes by moving the needle tangentially. If material is collected in the hub, gently
remove the needle. If not, create negative pressure by withdrawing the piston of the
syringe.
 Now remove the needle and expel the contents into the corner of slide using air in
the syringe
 If there are samples still attached to the hub of the needle, the sample can be
aspirated from hub using another needle.
 With the help of another glass slide kept perpendicular to the specimen slide where
the sample is expelled, make a uniform smear with well balanced pressure.
 As per the instruction of the pathologist, keep some smears air dried and some of
them to be preserved in coplin jars with fixatives
 Secure hemostasis in the aspiration site by applying pressure

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Diagnostic accuracy of FNAC:

FNAC is most commonly used in lesions of thyroid, breast, salivary glands, and
palpable lymph nodes in the cervical region, axilla, and groin and in palpable cutaneous
swellings of the extremities. The diagnostic accuracy in thyroid lesions is as high as 97%
[3], in breast it is 98% [4] and in lymph nodes especially in pediatric patients, it is 98.6%
[5].

Advantages of FNAC:

The most important advantage is that FNAC is a simple outpatient based
technique which provides rapid diagnosis with high diagnostic accuracy. It is economical
and can be performed in a resource limited setting. Samples from multiple sites can be
done in the same sitting. Advanced techniques such as flow cytometry, polymerase
chain reaction, immunocytochemistry and cytogenetics are possible from FNAC
material.

Limitations of FNAC:

The most common limitation is failure to obtain representative samples. The
reasons could be a hemorrhagic aspirate where the cells are enmeshed in fibrin clot. To
avoid this, it is preferable to do a non aspiration technique. Other reasons could be
needle missing the target, needle in central cystic areas which are devoid of cells, needle
in the dominant benign mass missing small foci of adjacent malignancy. The reporting of
FNAC requires a cytopathologist with adequate training and reporting skills

From the pathologist’s purview, FNAC cannot distinguish ductal carcinoma in situ
(DCIS) and invasive ductal carcinoma (IDC) of breast. Similarly in thyroid, follicular
adenoma and carcinoma cannot be distinguished by FNAC. The absence of malignant
cells in a hypo cellular smear does not rule out malignancy. These limitations should be
borne in mind in interpreting a FNAC report.

Checklists for performing FNAC:

 Informed consent form

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 Skin disinfectants
 Needles of desired size and 10ml syringes
 Clean wiped glass slides
 Slide marking pencils
 Fixatives in coplin jars
 Sterile cotton swabs and adhesive tapes

Some useful tips for performing FNAC:

 Always get a written informed consent from the patient or from the legally accepted
representatives in case of minors/ in patients who are unable to decide due to health
conditions

 Palpate the lesion and decide the area of aspiration. If the lesion is mobile, fix it with
the thumb and index finger of the left hand.

 Always keep narrating the procedure when you perform. This will reduce patient’s
anxiety

 Use a finer needle 27 to 22 gauge (0.4 – 0.7mm) with long shaft measuring 30–50
mm. The conventional intramuscular needles are 24 gauge and 25mm which can be
used as reference.

 26 gauge 1.5 inch needles are advised for thyroid, vascular tissues and in children.
 Non aspiration technique is preferred in most of the superficial lesions. Though the

aspirate is less, it will be very cellular and cellular details can be better preserved
 In case of necrotic nodes, it is advisable to aspirate from the periphery of the node to

get viable cells
 Clean the glass slides with dry cotton to remove any dirt or grease sticking on the

slides
 Make a uniform smear with well balanced pressure
 Always check the FNAC site for hemostasis before sending the patient
 Last but not the least, always consult your pathologist before the procedure on the

methods of fixation – the choice of fixative used, number of dry smears needed and
ancillary tests if required

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Conclusion:

FNAC is a highly useful and informative procedure with high diagnostic accuracy.
With practice, good quality smears can be made in the outpatient department thereby
avoiding time delays in diagnosis. Surgeries can be avoided in medically treatable
conditions such as Tuberculosis node. Hence FNAC can be utilized by primary care
physicians for early and prompt diagnosis.

References:

1. Kocjan G, Bourgain C, Fassina A, Hagmar B, Herbert A, Kapila K, Kardum‐Skelin I,
Kloboves‐Prevodnik V, Krishnamurthy S, Koutselini H, Majak B. The role of breast FNAC
in diagnosis and clinical management: a survey of current practice. Cytopathology. 2008
Oct;19(5):271-8.
2. Diamantis A, Magiorkinis E, Koutselini H. Fine-needle aspiration (FNA) biopsy:
historical aspects. Folia Histochemica et Cytobiologica. 2009;47(2):191-7.

3. Tan H, Li Z, Li N, Qian J, Fan F, Zhong H, Feng J, Xu H, Li Z. Thyroid imaging reporting
and data system combined with Bethesda classification in qualitative thyroid nodule
diagnosis. Medicine. 2019 Dec;98(50).

4. Ogbuanya AU, Anyanwu SN, Iyare EF, Nwigwe CG. The role of fine needle aspiration
cytology in triple assessment of patients with malignant breast lumps. Nigerian journal
of surgery. 2020; 26(1):35-41.

5. Ronchi A, Caputo A, Pagliuca F, Montella M, Marino FZ, Zeppa P, Franco R, Cozzolino I.
Lymph node fine needle aspiration cytology (FNAC) in paediatric patients: Why not?
Diagnostic accuracy of FNAC in a series of heterogeneous paediatric
lymphadenopathies. Pathology-Research and Practice. 2021 Jan 1;217:153294.

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DRUG RASH EOSINOPHILIA SYSTEMIC SYMPTOMS (DRESS SYNDROME)
(OR)

ANTICONVULSANT HYPERSENSITIVITY SYNDROME

Dr. N.T. RAVI, MD

Retd. Professor of Dermatology
Madras Medical College

It is a life threatening condition frequently misdiagnosed as infection.

A latency period of 1-2 months after the drug is started is common.

Presentation is variable. Course may be protracted with same patients progressing to liver
failure.

Mortality is 10%.

Triad of fever, skin rash and systemic symptoms.

Estimated incidence ranges from 1:1000 to 1:10000

Fever and morbilli form eruptions are the most common symptoms in > 80% of the cases
Face, upper trunk and upper extremities are the usual sites of involvements.

Sterile pustules, purpuric rashes are also seen. Sometimes Exfoliative dermatitis and
erythroderma ensues.

Distinctive diagnostic feature is facial odema mimicking angioedema oral mucosa is also
involved in the form of cheilitis erosions or erythema.

Liver is the most commonly involved organ, with a fulminant hepatitis being the major
cause of death, Myocarditis, interstitial pneumonitis, interstitial nephritis, Thyroiditis and
eosinophilic infiltration of the brain are reported.

Blood dyscriasias are seen in from of Eosinophilia (30-40%) and atypical lymphocytes.

DIAGNOSTIC CRITERIA FOR DRESS

Extent of rash > 50% of BSA – 1 point

Rash Suggestive of DHS - 1 point

21

Systemic involvement - Maximum 6 points
Lymphadenopathy
Eosinophilia
Atypical lymphocytes
Organ involvement
(Liver, Kidney, Cardiac)

Relevant negative serological tests for - 1 point
HRP A,B,C or Chlamydia or Rickettsia’s or HIV
Interpretation

 < 2 Points – No case

 2-3 Points - Possible

 4-5 Points - Probable

 >5 Points – Definitely case

PATHOGENESIS

Genetic Predisposition
Imbalance in bio activation and detoxification
HHV6 Coinfection

MANAGEMENT

Prompt recognisation of the symptoms
Offending drug to be stopped immediately
Steroids are the first line of management.

POINTS TO REMEMBER

Cross reactivity among the aromatic groups
Offending drug should never be administered again
Lamotrigene does not cross react with other aromatic anticonvulsants but can produce
fatal DRESS.

COMMON OFFENDERS

Phenytoin
Carbamazepine
Phenobarbitone
Primidone
Lamotrigene

RELATIVELY SAFE GROUP

22

Sodium valproate Zonisamide
Benzodiazepines Vigabatrin
Non aromatic anticonvulsant Topiramate

Adverse drug reactions are quite common especially in hospital practice. The skin is the
most commonly affected organ in adverse drug reaction. Basically any class of drug can
cause them but NSAIDS, Antibiotics and Anticonvulsant drugs are more commonly
involved.

Cutaneous eruptions occur in 3% individuals who use anticonvulsants. These reactions are
fortunately mild in nature in majority. But severe cutaneous adverse reactions (SCARS)
also seen though rarely but carry significant morbidity and mortality.

Exanthematous rashes and urticarial are the commonest mild side effects seen with
anticonvulsants.

But Life threatening disorders like STEVENS JOHNSON SYNDROME, TOXIC EPIDERMAL
NECROLYSIS and DRUG HYPERSENSTIVITY Syndrome are also seen.

Most commonly implicated drugs are Carbamazepine, Phenytoxn, Primidone, Pheno
barbital, lamotrigine Levetiracetans Lower incidence of side effects are seen with
CLOBAZAM, GABAPENTIN, VALORIATE ZONISAMIDE, BENZODIAZEPINE and non
aromatic Anticonvulsants.

There is a significant cross reactivity (40-80%) among aromatic anticonvulsant almost all
aromatic anticonvulsants can cause SCARS.

MORBILLIFORM ERUPTION

 Wide spread or generalized pink or erythematous maculo popular rash
 Itching
 May progress to exfoliative dermatitis or erythroderma
 Usually resolves rapidly on withdraw of the drug

URTICARIA

 Transient weal’s with pale centers and red borders
 Anaphylaxis may be concurrent or may occur with subsequent exposure.

23

ERYTHEMA
MULTIFORMA

 Target (iris) shaped lesions
 May involve mucous membrane
 Self limiting
 Resolves without sequlae

Stevens – Johnson Syndrome/
Toxic Epidermal necrolysis

Sudden onset within the first week of exposure to drugs
Severe mucosal involvement
Severe skin tenderness,
Blisters with skin detachment (peeling)
<10% BSA in SJS
> 30% in TEN

COMMON CUTANEOUS REACTIONS

CARBAMAZEPINE

Common

 Diffuse erythema
 Mileary exantheus
 Maculo papular
 Urticaria
 Purpura

Less Common

 Eczema
 Photo Sensitivity
 Lichenoid reactions
 Fixed drug eruption (FDE)

SERIOUS

 SJS
 TEN
 DRESS (DHR)

24

 Exfoliative dermatitis
 Erythroderma

PHENYTOIN

 Gingival hyperplasia
 Pseudo lymphoma syndrome
 Hypertrictiosis
 FDE
 Foetal hydantoin syndrome

GABAPENTIN

 Rarely
 Leucocytoclastic vasculitis

LAMOTRIGENE

 5-10%
 Mostly mild reactions
 No Cross reaction with other aromatic anticonvulsants
 But can Produce SCARS Especially with over rapid titration and concomitant use of

sodium valproate

SODIUM VALPROATE

 Transient rashes
 Hair loss
 Leucocyto clastic vasculitis
 Teratogenic

TRIMETHADONE

 Serious side effects
 EMF, ED, Urticaria

VIGABATRIN

 Rarely vasculitis

ZONISAMIDE
 Well tolerated
 Rare - TEN

25

SYMPTOM ANALYSIS

IMA CGP Editorial Team

Face is the most important Organ.

The beauty and emotion of a person is exhibited by the face. Hence any alteration or symptoms in the
face are given the most important attention by any person.

SYMPTOM COMMON OCCATIONAL RARE

FACIAL  Mumps (Viral Parotitis)  Bacterial parotitis  Parotid tumor
SWELLING
 Angioneurotic Oedema  Cellulites / Orbital  Maxillary or mandibular

(allergy) cellulites sarcoma

 Dental Abscess  Dental cyst  Cushing’s syndrome-steroid

 Trauma (especially  Myxoedema induced

fractured Zygoma)  Nasopharyngeal carcinoma

 Salivary gland stone  Burkitt’s lymphoma

 Maxillary /frontal sinusitis  Cluster headache  Multiple sclerosis

 Trigeminal neuralgia (TN) (Periodic migraines  Nasopharyngeal and lingual

 Dental Abscess neuralgia) carcinoma

FACIAL  Temporomandibular joint  Temporal arteritis  Posterior fossa tumors
PAIN
(TM)  Parotid - mumps, abscess  Glaucoma and iritis

 Dysfunction and duct obstruction

 Herpes Zoster (stone/tumor)

 Cellulitis

 Seborrhoeic eczema  Sycosis barbae  Stevens-Johnson syndrome
 Acne
 Rosacca  Drug side effect-  SLE

especially photo toxicity  Mitral flush

 Impetigo  Simplex, Cellulitis,  Lupus vulgaris
 Perioral dermatitis
FACIAL Chickenpox, slapped Dermatomyositis
RASH
cheek

 Allergic eczema

 Pityriasis alba

 Other generalized skin

disease,

e.g. Psoriasis, vitilligo

FACIAL  Impetigo  Squamous cell  Dermatitis artifact
ULCERS  Herpes simplex virus (HSV) carcinoma(SCC)  Pemphigus
 Herpes Zoster
AND  Basal Cell carcinoma (BCC)  Ulcerating malignant  Actinomycosis
BLISTERS
melanoma Cancrum oris

 Drugs allergy (e.g.

barbiturates)

They take immediate medical care and the family physician must be aware of some the common

symptoms and signs on the face which can be useful in arriving at a diagnosis.

26

Updates
FAQS ON PNEUMOCOCCAL VACCINES
Dr. M. K. SUDHAKAR MD (General Medicine)

Founder President, Indian Medical Association, Porur Branch
Adjunct Professor of General Medicine, TN MGR Medical University, Guindy, Chennai
Q. How does pneumococcal disease spread?

 Direct contact with respiratory secretions, like saliva or mucus.
 Nasal carriers especially children
Q. What diseases can pneumococci bacteria cause?
 Respiratory – URI & LRI, Pneumonia
 Extrapulmonary – Endocarditis, Meningitis, Arthritis

27

Q. How serious is pneumococcal disease in adults with underlying chronic diseases?

 Invasive pneumococcal disease is a life-threatening condition with fatality rates as high
as 10 percent

 The annual U.S. case estimate for invasive pneumococcal disease (bacteraemia and/or
meningitis) is 40,000 and 4,250 deaths.

Q. In the era of good antibiotics, how difficult is it manage a case of pneumococcal
pneumonia or invasive pneumococcal infection in adults?

 Anti-microbial resistance
 Comorbidities

Q. What are the comorbidities which predispose to pneumococcal infections?
A - Alcoholics
B – Bronchopulmonary diseases
C – Chronic Heart / Liver / Kidney, diseases / Cigarette smokers
D – Diabetes Mellitus
E – End Stage Organ Disease
F – Fistula CSF
G – Generalized Malignancies
H – HIV / Hemoglobinopathies / Hodgkin disease
I – Immunodeficiency – Congenital or Acquired / Immunosuppression
Q. Can a person get pneumococcal disease more than once?
Yes. There are more than 90 known subtypes of S. pneumoniae, An infection with one type
does not confer immunity against other types.
Q. When is the ideal time to vaccinate your patients against pneumococcal disease?

 Adolescents and Adults with chronic medical diseases
 Adults 65 years or older

28

Q. What are the recommendations for Pneumococcal vaccination?
A. Individuals who have not previously received any pneumococcal vaccine, CDC recommends

1 dose of PCV13 followed by a dose of PPSV23 at least one year later. The minimum
interval is 8 weeks and can be considered in adults with an immunocompromising condition,
cochlear implant, or cerebrospinal fluid leak.
B. Individuals who have only received PPSV23, CDC recommends

1 dose of PCV13 at least one year after the most recent PPSV23 vaccination.
C. Individuals who have received PCV13 with or without PPSV23, CDC recommends PPSV23 as
previously recommended

29

Q. Can we administer Pneumococcal vaccines along with Influenza vaccine at the same
visit?

CHILDREN
PCV13 or PPSV23 can be administered at the same time as most other routine childhood
vaccinations, with one exception a meningococcal conjugate vaccine.

30

ADULTS
PCV13 or PPSV23 can be administered during the same visit with influenza vaccination.
Administer each vaccine with a separate syringe and, if feasible, at a different injection site.
Q. How is pneumococcal vaccine to be administered?

The pneumococcal vaccine is given as a single injection in adults. The vaccine is injected
as a liquid solution of 0.5 mL

PCV 13 is administered IM whereas PPSV 23 can administered IM or SC
IM is vastus lateralis of thigh in children and deltoid in adults
Q. For a patient who has taken COVID vaccine or is about to take the COVID
vaccine, when would you recommend the Pneumococcal vaccine?
A COVID-19 vaccine can be administered before, at the same visit, or after other
vaccines without regard to timing (including live, attenuated vaccines).
Multiple vaccines are to be administered at a single visit, administer each injection in a
different injection site. The injection sites should be separated by 1 inch or more or on different
limbs
Q. Can both pneumococcal vaccines be given at the same visit? What is the
importance of sequence of conjugate vaccine followed by polysaccharide vaccine for
pneumococcal vaccination?
ACIP does not recommend the administration of PCV13 and PPSV23 during the same
visit.

31

PPSV 23 PCV 13
Conjugated capsular polysaccharide +
Type Unconjugated capsular protein carrier
Serotypes polysaccharide vaccine
13
23 T Cell Dependent immune response

Immune Response T Cell Independent immune Present
Anamnestic Response response Prefilled Syringe
0.5 ml IM
Absent
80 – 90% Children & 30 – 40% Adults
Preparation Vial Reduce
Dose 0.5 ml SC or IM

Efficacy in Non Invasive PD Nil

Efficacy in Invasive PD 50 – 70 % elderly
Nasopharyngeal Carriage Ineffective

32

LEGAL PAGE
LIFE CERTIFICATE

Dr. T. N. Ravisankar , MBBS, DFM (Colombo),FCGP, PGDMLE

This is a document that a family physician is always encounters is practice.

Life Certificate is issued to prove that an individual is alive.

It is needed annually for all government pensioners to produce during the last quarter of the
calendar year.

It is also needed in private sector and in quasi government sector for all pensioners. This is to
confirm the live status of the individual who is eligible to receive the pension till his death.

Life certificate along with mental status certificate is also need for registration of property in
Register office.

It is a legal document and has to be issued with all verification and a copy must be retained by
the family practitioner.

Features of the Document:

Name, Age, Sex, Address, mobile number and with consent the Adar number will have to be
entered in the letter head of the family physician while writing the LIFE CERTIFICATE.

Two markers of identification will have to be entered.

The recent photograph of the individual must be affixed, with Signature of the person and must
be attested by the family physician after due verification of the individual. One need to get a
copy of the Adar card or any other government identify to authenticate the persons identify
such as Driving License, Passport, Workplace identity card, Ration card and such other
government identity card.

A copy of the Life Certificate can be kept with the family physician with a Signature obtained
from the individual so that there is a proof that you have issued the Life Certificate to the
concern individual.

If you are not sure or you suspect a foul play do not issue Life certificate, as it can impose legal
liability on your professional practice.

33

Indian Medical Association
College of General Practitioners

Head Quarters - Chennai

Activity Report from Jan to March 2022

On Jan 09th -2022

Our IMA CGP Dean Dr.Avinash Bhondwe visit IMA CGP HQs office at Chennai, and
conduct two zoom meets at the day.

1. National CGP Office Bearers Meeting.
2. All State president and Secretary Meeting.

Minutes of National CGP Office Bearers Meeting

1. Clarify of membership and payments to the made for CGP HQs.

2. To get membership data of MBBS graduate to reach them for CGP membership.

3. To appoint persons on part time with target fixed on payment mode for

membership- should be from each state.

4. Regional Conference Suggested

 Dr.Jayant Sharma – North Zone

 Dr.Vinay Ranjan - South Zone

 Dr.Janmejaya Mohapatra – East Zone

 Dr.Avinash Bhondwe – West Zone

5. CGP HQs – CME’S
One Fixed day a month 1 ½ hour once in two months – National level on regional
basis faculty.

6. To appoint a chairman for Academic Council.
7. May 19th National level celebration of Family Doctor’s Day.
8. Website to be upgraded with a new team.

34

9. To appoint an executive editor for website and a team to support him – Pan
India.

10. Family Doctors issue monthly.
11. Public Journal in Regional language.
12. Youtube with 3-5 minutes public awareness in Hindi and regional language –

monthly release on specific days.
13. To plan for continuation for membership to state /local branches.

On 10 Jan -2022

IMA & IMA CGP of Madhya Pradesh state conduct a CME on 10.01.2022

Topic: Current Status, features and recent management Guidelines.

On Feb 02nd 2022

IMA CGP HQs the Family journal Release of first copy, with presence of

 Dr.Sahajanand Prasad Singh – National President

 Dr.Jayesh lele - Hon. Secretary General

 Dr.Anil Goyal - Hon. Finance Secretary

 Dr.Ravi Wankhedkar - Past National President

On Feb 13th 2022

Fellowship in Family Medicine Course started on 13th Feb 2022, by Hybrid Platform by
Faculty Dr.Ramesh & Team. No of candidates joined 26.

And IMA CGP HQs office bearers meet with dean.

On Feb 22nd 2022

Indian Medical Association and IMA College of General Practitioners Presents CME on
“Management of Burns and Recent Advances in Treatment”.

35

Programme : Dr. S. REKHA, Joint Secretary, IMA CGP HQs
: Dr. JAYANT SHARMA, Joint Secretary, IMA CGP
IMA Prayer : Dr. SATYAJIT BORAH, Joint Secretary, IMA CGP
Physician Prayer : Dr. AVINASH VINAYAK BHONDWE, Dean, IMA CGP HQs
IMA Flag Salutation : Dr. C. ANBARASU, Hony. Secretary, IMA CGP HQs.
Welcome Address : Dr. SAHAJANAND PRASAD SINGH, National President, IMA HQs
Secretary Report : Dr. JAYESH LELE, Hony. Secretary General, IMA HQs
Presidential Address : Prof.Dr.J.A.JAYALAL, Imme. Past National President,IMA HQs
HSG Address
Felicitations

Prof. Dr. S. ARULRHAJ, IMA CGP Patron, IMA HQs
Dr. NATWAR SHARDA, Imme. Past Dean, IMA CGP HQs

Topic – “Burns Update for General Practitioners”

Speakers

Dr. R. Raja Shanmuga Krishnan - MBBS, MS, MRCS, DNB(Plastic),Consultant Plastic & Aesthetic
Surgeon, Ganga Hospital, Coimbatore

Dr. S. Raja Sabapathy - MS (Gen), M Ch (Plastic), DNB (Plastic), FRCS (Edin), FAMS, Hon FRCS
(Glasgow), Hon FACS, D Sc (Hon) Director Ganga Hospital and Head Department of Plastic
Surgery, Ganga Hospital, Coimbatore.

Vote of Thanks : Dr. JANMEJAYA MOHAPATRA, Vice Dean, IMA CGP HQs

Program Coordination : Dr. R. ANBURAJAN, Joint Secretary, IMA CGP HQs

On Same day IMA CGP HQs “The Family Doctor” 2nd journal release.
36

On Feb 26th 2022

IMA CGP HQs Dean Installation Ceremony. The ceremony took place on a web based
platform, on 26th February 2022 (Saturday) at 5.00 pm. IMA Nashik (Maharashtra) was
the host Branch for the ceremony.

On March 06th 2022

IMA CGP HQs Dean and Office bearers meeting by virtual.

On March 10th 2022

2nd zoom meeting of south zonal CGP conference planning on 10/03/2022.

On March 13th 2022

Conducted CME program, hosted by our IMA College of General Practitioners HQs - CME on
“Psychiatry for Family Physician” in association with Indian Psychiatric Society Maharashtra
State Branch and SMARTT on 13th March 2022 from 10:00 AM to 5:00 PM. It is only a Virtual
Meeting.

Inauguration

IMA Prayer : Dr. S. Rekha, Joint Secretary, IMA CGP HQs
Physician Prayer : Dr. Satyajit Borah, Joint Secretary, IMA CGP
IMA Flag Salutation : Dr. Sanjay Dattatray Patil, Joint Secretary, IMA CGP
Welcome Address : Dr. Avinash Bhondwe, Dean, IMA CGP HQs
Secretary Report : Dr. C. Anbarasu, Hony. Secretary, IMA CGP HQs
Presidential Address : Dr. Sahajanand Prasad Singh, National President, IMA HQs
HSG Address : Dr. Jayesh Lele, Hony. Secretary General, IMA HQs
Felicitations : Dr. Nitin Dalaya, President, IPS MH State Branch
Dr. Bharat Sarode , President SMARTT
Co-Ordination : Dr.R.Anburajan, Joint Secretary, IMA CGP HQs

37

Chairperson : Dr.Sudhir Bhave (IPS MH State Branch)
Moderator : Dr.Sushil Gawande (IPS MH State Branch)

Topic - Introduction, Classification in Psychiatry

Speaker - Dr. Vihang Vahia, Professor Emeritus of Psychiatry, Consultant Psychiatrist
Breach Candy Hospital, Mumbai

Topic – De-addiction Psychiatry

Speaker - Dr. Shilpa Adarkar, Addl.Professor, Deaddiction Specialist Center of Excellence
KEM Hospital, Mumbai

Topic – Psychotic Spectrum Disorders

Speaker - Dr. Bhalchandra Kalmegh, Consultant Psychiatrist, Hon. State Secretary IPS
MH State Branch, Pune

Topic – Neurotic Spectrum Disorders

Speaker - Dr. Henal Shah, Additional Professor TNMC and Nair Hospital, Mumbai

Topic – Mental Health Care Act, 2017 in a Nutshell

Speaker - Dr. Sanjay Kumawat, Consultant Psychiatrist, Ex Superintended of Mental
Hospital, Ex DDHS Maharashtra, Thane

Topic – Consultation Liaison Psychiatry

Speaker - Dr. Alka Subramanyam, Ass.Professor, Psychiatry, TNMC and Nair Hospital,
Mumbai

Upcoming Programs

IMA CGP South Zone conference proposed at Trivandrum (Kerala) got postponed to
May.

38

IMA CGP HQs Life Membership Details State Wise from Jan 2021 to till date

Sl No States Total Life Members
3
1 Andhra Pradesh
46
2 Assam 5
2
3 Bihar 2
2
4 Delhi 1
1
5 Gujarat
32
6 Haryana 83

7 Jharkhand 9
5
8 Karnataka 2
208
9 Kerala 24
66
10 Maharashtra 491

11 Manipur 39

12 Madhya Pradesh

13 Odisha

14 Tamil Nadu

15 Telangana

16 Uttar Pradesh

Total

IMA COLLEGE OF GENERAL PRACTITIONER HQs-CHENNAI
Life Membership Details As On March - 2022

Sl No States Total Life Members

1 Andhra Pradesh 1601
513
2 Assam 1050
1147
3 Bengal 171

4 Bihar 28
29
5 Chhattisgarh 1094
1727
6 Chandigarh 435

7 Direct Branch 1
10
8 Delhi 589
1206
9 Gujarat 2723
64
10 Haryana

11 Jammu & Kashmir

12 Jharkhand

13 Karnataka

14 Kerala

15 Maharashtra

16 Manipur

40

17 Madhya Pradesh 6579
18 Meghalaya 1
19 Overseas LM
20 Odisha 47
21 Pondicherry 348
22 Punjab
23 Rajasthan 5
24 TamilNadu 177
25 Tripura
26 Telangana 65
27 Uttaranchal 1720
28 Uttar Pradesh
42
Total 152

88
986
22598

41

IMA CGP HQs Office Bearers List – 2021-22

Dr.Avinash Bhondwe Dr.Janmejaya Mohapatra Dr.C.Anbarasu
Dean, IMA CGP HQs
Vice Dean, IMA CGP HQS Hon. Secretary, IMA CGP HQs

Joint Secretaries

Dr.S . Rekha Dr.R.Anburajan Dr. Jayant Sharma
(Tamil Nadu) (Tamil Nadu) (Uttar Pradesh)

Dr.Sanjay Dattatray Patil Dr.Prabhat Kumar Shrivastava Dr.Satyajit Borah
(Chhattisgarh) (Assam)
(Maharashtra)
42

CGP EDITORIAL TEAM

EDITOR IN CHIEF EXECUTIVE EDITOR
Dr. C. ANBARASU Dr. T.N. RAVISANKAR

CO EDITOR
Dr. L. YESODHA

ASSOCIATE EDITORS

DR. S. REKHA DR. SATYAJIT BORAH
43