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Insights into barriers for global mental health "Dr. Rajiv Radhakrishnan:

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Insights into barriers for global mental health

Dr. Rajiv Radhakrishnan is a current Yale Psychiatry Resident.

I spent 2 weeks in India working with the MAANASI project, a rural mental health program run by the Departments of Psychiatry and Community Medicine at St. Johns Medical College, Bangalore, India. The project provides mental health care to women in rural areas and currently covers about 187 villages around Bangalore. The aim of my study was to evaluate reasons for poor treatment adherence, and explore barriers to treatment among women with Major Depressive Disorder in the rural population and to assess attitude towards use of technology, such as text-messaging and appointment reminder devices, in improving treatment adherence. I conducted focus-group discussions with women enrolled in the project who were or were not seeking care at the present time. The experience provided me with insights into barriers to care such as lack of transport and the reluctance to adopt new technology for fear that it would intrude into the privacy of their closed family unit.

The factor that was most important in enabling me to contribute to the MAANASI project was the grant support provided by Yale Global Mental Health Program and Yale New Haven Hospital. Additionally, the presence of local mentors was invaluable to the success of this study.

I think students can play a very important role in global mental health by undertaking short-term projects that are of relevance to the local community. Students are also in a position to access funds and garner philanthropic support for projects in resource-poor settings that would otherwise be inaccessible to them. The challenge of establishing a good working relationship with the local community would require structured mentorship and including local mentors in the process would be important. The availability of funding, protected time and institutional support for global mental health activities would go a long way in helping students make substantial contributions.


Dr Anil D'cruz presents his ground breaking study at ASCO 2015

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Anil D'Cruz, MBBS, MS, FRCS

Huge honor for Dr. Anil D' Cruz presenting results of a randomized clinical trial of elective versus therapeutic neck lymph node dissection in newly diagnosed patients with non metastatic oral cancer at the plenary session of the 2015 American Society of Clinical Oncology meeting in Chicago in from of over 30,000 people. His study has defined the practice changing standard of care for these patients.

Congratulations Anil! Proud day for him, St. John's, Tata's and India!

Dr Leo Mascarenhas

Details of the study below

Elective neck dissection performed at the same time patients have surgery for early-stage, node-negative, oral squamous cell cancer significantly improved overall survival and reduced the risk of death and recurrence when compared with a watchful waiting approach, according to findings of a phase III randomized trial.

These findings should be practice changing, said lead study author Anil D’Cruz, MBBS, MS, FRCS, who presented them during a press briefing at the 2015 ASCO Annual Meeting.

“Our study is the first to conclusively prove that more lives can be saved with elective neck dissection,” said D’Cruz, adding that the results resolve a question doctors have been asking for more than five decades.

That debate has centered on whether it is best to remove surrounding lymph nodes when the primary oral cancer surgery is performed or to wait to perform therapeutic neck dissection when the patient relapses. Clinical practice in this setting varies widely.

Oral cancer is global problem affecting more than 300,000 individuals in both developed and developing countries, D’Cruz stressed. “It is seen anywhere where there is an excessive consumption of alcohol and tobacco,” which is responsible for 90% of oral cancer diagnoses, according to ASCO.

D’Cruz is a professor and chief of the Department of Head and Neck Surgery at Tata Memorial Centre in Mumbai where the trial was carried out between 2004 and 2014. The trial recruited 596 patients with stage I/II oral squamous cell carcinoma (SCC) and no lymph node involvement.

The findings reported at ASCO are drawn from an interim analysis involving 500 patients who after excision of their primary tumors were randomly assigned to therapeutic neck dissection (TND; n = 255), also known as “watch and wait,” or elective neck dissection (END; n = 245).

Both trial arms were balanced based on tumor site and stage: 427 of the cases involved the tongue, 68 affected the buccal mucosa, and 5 were tumors at the floor of the mouth; 221 patients had stage I tumors, and 279 were stage II. Overall survival (OS) was the study’s primary endpoint.

After a median follow-up of 39 months, 146 recurrences were reported in the TND arm versus 81 in patients who had END. Three-year OS also was significantly better in the END cohort compared with the TND group: 80.0% vs 67.5%, respectively (HR = 0.63; 95% CI, 0.44-0.89; P = .01).

The study’s secondary endpoint, disease-free survival (DFS), also favored the END arm of the trial, with the procedure reducing the risk of recurrence by about 55%. Three-year DFS was 69.5% in the END cohort versus 45.9% in patients assigned to TND (HR = 0.44; CI 95%, 0.34-0.58; P <.001).

Overall, D’Cruz reported that performing END in patients with early oral SCC reduced mortality by 36%, preventing 1 death in every 8 patients and 1 recurrence in every 4 patients who undergo the procedure.

Study authors acknowledged in an ASCO statement that the only drawback to neck dissection is that the procedure can be linked to shoulder problems, which affect 5% to 40% of patients because the nerve that supplies the large muscles associated with shoulder movement crosses the surgical dissection field. Future research should focus on techniques that could minimize this complication, they said.

Jyoti D. Patel, ASCO spokesperson and moderator of the press briefing where the results were reported, said the findings were particularly important in countries and in populations where there are multiple barriers to healthcare:

“This one and done approach we know now definitively improves survival.”

“Armed with the results of this study,” said D’Cruz, “doctors will be able to confidently counsel patients that adding neck surgery to their initial treatment is worthwhile.”



The Saint John's Australian Chapter Alumni Meet in Adelaide January 2015

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Following report was prepared by Dr Vikram Mhasker.
The Australian chapter of the alumni association had their annual meet at Adelaide this year. The Adelaide team lead by Dr Vasant Rao Kadam(1982) worked very hard to make it a memorable one. Over 32 members(with families) from all over Australia took time off to relive the old times. Dr Vasant and Dr Jyotsna were gracious in hosting a dinner for the out stationed johnites on 24th evening at their lovely home.
The whole evening was spent reminiscing the past and laughing away to glory,making us realise that it is just years that separate us, but we johnites are just the same. The 25th was spent visiting the lovely barossa valley wineries.Wine tasting of authentic Jacob creek and seppetsfild wineries an Lunch at Tanunda was very relaxing. Dr Jacob (1998) was very kind to organise the transport and drive us all over (Jacob we all owe you one). We then met for dinner in the evening at an Indian restaurant(Samarat indain Cusisne) which was attended by johnites and honorary johnites (parents,partners,spouses,kids and friends).
The evening was wonderful with Dr Vasant sharing his experiences on the outreach programme he conducted at adilabad in andhra pradesh. The very creative Dr Jyotsna created a lovely piece of art with everybody's hand print in blue and gold(St Johns emblem colors). Dr Santosh Olakkengil (1987) was instrumental in arranging the place as well as giving us a taste of our beloved old monk. The evening saw one and all bond beautifully and share their experiences of being a johnite.
The meet left a lasting impression on us and we wish this weekend never ended. This would have never been possible without the untiring efforts of Dr Vasant(1982), Dr Jyotsna, Dr Santosh (1987), Dr Jacob Abraham (1998), Dr Dinesh (PG1999), Dr Vinu Xavier (MLT1999) and the whole Adelaide team. Three cheers to the johnite spirit !!!!!

Johnite attendees
Melwyn dmello (1978) and Sandra
Clara (1984), Lancy and Nitish
Sam Calvin (1999) and Vrithi
Vikram Mhaskar (2002) and Parul
Santosh Olakkengil (1987), Mary Kate, Kayle
Jacob Abraham (1998) Lisa. Ethan, Deeya
Dinesh(PG 1999), Kavitha and Pranav
Smitha Jose(1994) Felix,Penamma,Joseph
Vinu Xavier (MLT1999), Merin and Judy
Vishwanath(Pg  Johnite)
Raj Goud (Staff at Johns)
Lekha (Flinders Medical Student)
The pictures of this  the event could be seen at this link... you may need to copy and paste it into your browser


Dr Patrick Kamath receives the Distinguished Educator Award from the AGA

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Washington, DC (May 18, 2015) -- The American Gastroenterological Association (AGA) is pleased to recognize the 2015 Research and Recognition Award winners, who were honored this past weekend at Digestive Disease Week ® (DDW) 2015 in Washington, DC.

"AGA is thrilled to announce the 2015 honorees, who are some of the most talented, hard-working and deserving members of our professional community," said John I. Allen, MD, MBA, AGAF, president of the AGA Institute. "We are humbled to be in the company of such innovative GIs, and AGA extends our deepest appreciation to the award recipients for their hard work and commitment to advancing the fields of gastroenterology and hepatology."

Distinguished Educator Awards

The Distinguished Educator Awards acknowledge exemplary educators in the field of gastroenterology. AGA is proud to be awarding this honor to two deserving individuals.

AGA recognizes Patrick S. Kamath, MD, an esteemed educator and gastroenterologist from Mayo Clinic, Rochester, MN, with its first Distinguished Educator Award.Since 1991, Dr. Kamath has mentored more than 100 fellows who have benefited from his intelligent and thoughtful approach to teaching. His educational prowess has been recognized abroad, as Dr. Kamath has been invited to lecture in countries such as Italy, Spain, Austria, United Kingdom and Brazil and several countries in Asia; and at prestigious universities, including Brown University, Virginia Commonwealth University, Indiana University, Stanford University and Columbia University.

About the AGA Institute

The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, the AGA has grown to include 17,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization.


Back to the BASICS .Osteoarthritis of the knees Dr Vivian D'Almeida

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Dr Vivian Roshan D'Almeida

MBBS, MS(Ortho), MRCS(Eng), MRCS(Ire), MRCPS(Glasgow)

May 18, 2015

As we grow older aches and pains are something that we expect. But for some they are rather a burden which has a bad impact on their quality of life. Arthritis affects all ages. There are more than 1000 different types of arthritis. Among these osteoarthritis is the most common. According to the World Health Organization it is one of the 10 most disabling diseases in the world affecting people of countries like India where agriculture is the main occupation. Researchers have predicted that by 2015 arthritis will be the most common problem in the country.

Osteoarthritis or osteoarthrosis also known as degenerative arthritis, is a disease of the weight bearing joints, caused mainly due to an ageing process. People beyond the age of 60 years are most commonly affected by this condition. As per global statistics 18% of women over the age of 60 suffer from this condition compared to 9.6% of men. 

Occasionally, it may occur in younger people as well, due to trauma to the joint. The hip joint, knee joint and the joints of the thumb are most prone to this disease. It is an incapacitating condition which hampers mobility of the patients thus leading to a non productive life.

Osteoarthritis should not be confused with other forms of arthritis like rheumatoid arthritis (VAATA), psoriatic arthritis and gouty arthritis. The latter conditions are caused by inflammation of the joints, unlike osteoarthritis which is a progressive mechanical joint disease associated with old age. This differentiation is very important as the treatment of these conditions is very different.

Osteoarthritis is of two types:

Primary: There is no exact cause for this. It is seen in older age groups and in weight bearing joints like the hip and knee. Usually joints of both sides are affected, one side more than the other. Obesity is a predisposing factor. There is no hereditary preponderance. People involved in heavy labour are mainly affected.

Secondary: Due to a predisposing factor like trauma, fractures or infection of the joint. Usually one joint is involved and it occurs at a relatively younger age, when compared to primary osteoarthritis.

Pathology: Normally all weight bearing joints consist of bones which are covered with articulate cartilage. This cartilage is healthy in younger people and not sensitive to pain. It's basic function is to protect the underlying pain sensitive bones from coming into contact with each other, something like " a cushion between the joints ".

Osteoarthritis is a disease which causes this cartilage (cushion) to wear off, thus exposing the bony surfaces which rub against each other producing pain.


Pain is the most important symptom. In the early stages pain typically occurs following weight bearing and on walking for a long time. It's more severe while climbing stairs or squatting. It is typically relieved by rest and pain killers.

However in the later and severe stages the pain worsens, thus hampering the movement of the patient. In most severe cases pain is present even at rest.

Pain can also referred to the neighboring joints.
Eg: osteoarthritis of the hip can present as knee pain.

Restriction of mobility: It occurs due to pain and stiffness. Initially the person might not be able to walk long distances, but as severity increases he might not be able to move around, even well within his home. The range of movement of the joint also reduces gradually.

Crepitus: The patient usually complains of "click" like sound on moving the joint which is due to the "loose bodies " formed within the joint due to the disease process.

Swelling and redness: This might occur occasionally. But is not as severe as the swelling that occurs in other forms of inflammatory arthritis.


X rays are the gold standard to diagnose this condition. The X rays are usually taken in the standing position, from the front and sides.

Normal X ray
X ray with osteoarthritis

A. Showing decreased space between the bones showing wear and tear of the joint
C. Loose bodies

MRI might be occasionally required to see the condition of the cartilage.


"Prevention is the best cure" is a common saying and is true to this condition as well. However one must understand that the process of the joints wearing off is a normal age related process and it cannot be completely avoided. However the extent to which the joint wears off can definitely be controlled.

The following measures would help to protect our joints:

1) Weight reduction: Obesity being an important factor contributing to this disease, weight reduction becomes paramount in avoiding this condition. Though conditions like diabetes and binge eating have no direct bearing on this condition, as they predispose to weight gain, they must be controlled.

2) Activity modification: Activities like climbing and getting down stairs, sitting cross legged, squatting should be avoided whenever possible. Western toilets should be preferred. Walking and jogging should be done using soft footwear and on jogging tracks whenever possible. While jogging, Concrete surfaces should be avoided.

3) Exercises: These are prescribed so that the muscles of the limb become strong so as to reduce the workload on the joints. Light exercises like yoga and swimming are preferred.


There are no medications to reverse the damage that has already occurred in the joint. However medications do help in reducing pain and protecting the joint from wearing off further, to a certain extent.

1) Pain killers: These are prescribed in acute painful episodes. They provide immediate pain relief. However their action is temporary and long term continuous usage is discouraged as they can cause kidney damage and acidity problems.

2) Drugs to protect the cartilage: They help to prevent disease progression.
Commonly used drugs that protect the cartilage are diacerin, glucosamine, pro, collagen peptides.

3) Injections into the joint: Hyaluronate injections into the joint are advised in mild to moderate cases, which improve the lubrication within the joint. These injections are given once a week for 3-5 weeks, depending on the severity. There is a yearly injection available as well, which is expensive.

Surgical treatment: In moderate to severe conditions where the patient depends on pain killers on a regular basis to relieve the pain surgery is indicated.

1) Arthroscopy and debridement: This is done in moderate cases. This is a key hole surgery, where very small surgical wounds are made over the knee. Joint is washed thoroughly with surgical fluid. Following surgery, patient has considerable relief from pain. However it provides temporary relief, usually lasting for around 4-6 months.This surgery is relatively inexpensive and minimally invasive.

2) Osteotomy: This is a protective surgery that is done in mild to moderate cases, in order to prevent the condition from progressing. This is a bone surgery in which the bone us straightened and is fixed with a "plate". The patient needs to walk with a crutch without bearing weight on the operated limb, for 6 weeks following surgery.

3) Total knee replacement: This is done in advanced cases. Following this surgery the patient would have significant pain relief and a reasonably good range of joint movement. The patient can walk around independently. However squatting is discouraged following this surgery, as it would damage the implant. The patient requires physiotherapy and exercises for 4-6 weeks following surgery to attain the best possible result.

With the advances in the field of medicine, life expectancy has improved. Hence many people around the world will continue to develop age related arthritis. Preventive measures are well worth taking. A regular check up and early specialized treatment would go a long way in improving ones quality of life.



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