HOW SHOULD YOU CHOOSE YOUR DOCTOR?

STEPS TO BE FOLLOWED WHILE CHOOSING A DOCTOR

Today, we have choices in every field of life. Whether it is eating out in a restaurant, choosing an airline, or buying a home appliance, there are multiple options available. We follow certain steps such as a comparison of the quality, convenience, cost, etc to arrive at the best choice. Various websites offer comparison between different brands of home appliances, and travel portals give us the flight timings, services and costs, helping us to choose an airline. However, there is not much help available to enable us to choose the best doctors. This article looks at all the important questions that crop up in our minds when we think of consulting a doctor.

Should you consult a doctor or try home remedies?

Many minor ailments are self-limiting in nature (they get better on their own); so one can try home remedies for them. These include viral fever, loose motions, cough & cold, minor occasional headaches, occasional sleep disturbance, minor bruises after a fall, etc. However, one should consult a doctor if symptoms are severe or persist beyond usual duration. For ex- if fever persists beyond 3 days, loose stools continue leading to dehydration, headaches are severe, one should seek a doctor's advice. Generally, one should consult a doctor if the symptoms are severe leading to impairment or interference with activitites of daily living or if the symptoms are recurrent in nature.

Should you consult a general practitioner (GP) or a specialist?

It is one of the most important issues to delibrate before choosing a doctor. GP is one who has the basic medical degree (MBBS in India). MBBS training requires four and a half years plus one year of internship (total duration of five and a half years). Certain specialised courses are available for GPs such as Family Medicine, but very few doctors are trained in that speciality in India. A specialist is one who has a postgraduate degree- MD (Doctor of Medicine). MD is offered in medical specialities and the equivalent surgical degree is MS (Master of Surgery). MD or MS can be done only after MBBS and it is of three year duration. For super-specialisation, one can then do DM (Doctorate in Medicine), which is of further three years duration. MCh is the equivalent degree in surgical specialities. Therefore, the highest medical degrees in India are DM (in medical field) and MCh (in surgical field), and it would take a minimum of about 12 years after +2 to get these degrees. Remember that there are entrance exams before MD and DM, and then one has to pass both theory and practical exams to be awarded these degrees. A thesis (research) is also mandatory during MD and DM. A point to note is that certain foreign countries award MD as the basic medical degree. So, an MD of USA, Russia or China is equivalent to MBBS of India.

Medical science is rapidly advancing and several new diagnostic tests & treatment modalities have become available in the past two decades. These include widespread use of MRI in 90s and PET scans (which show the functional activity of an organ) now. Infections and tumors can now be more accurately diagnosed. Similarly, several new treatment options are available- such as thrombolytic therapy in stroke, deep brain stimulation (DBS) surgery in Parkinson's disease, new medications for high BP & sugar, etc. It is not very difficult to believe that a GP would not be aware of these latest diagnostic & treatment modalitues.

On the other hand, when you consult a specialist, there could be some drawbacks. A specialist is likley to order more tests (such as coronary angiogram for a suspected cardiac problem), MRI scans in cases of headaches to exclude brain pathology, etc. In addition, the consultation fees could be more; it may be more difficult to get their appointments; you may not be able to discuss your problem in detail because of their busy schedules. For example, there are only 1500 neurologists (DM in neurology) out of a total of 1.5 million registered doctors in India (0.001%). This also translates to one neurologist for one million population. In addition, you may have to see several doctors if you happen to have multiple problems. For example, if you suffer from high BP, diabetes, thyroid problem and knee pain; you would have to consult a cardiologist, endocrinologist, and orthopedic surgeon. Sometimes, problems in other systems may remain undiagnosed, if you consulted a specialist of one system.

Therefore, it may be better to consult an MBBS or MD doctor in the beginning, if you have minor ailments or if you have multiple problems. However, please consult a specialist if your problem is serious or not getting better with treatment under a GP; having frequent reccurrences or if you wish so. In several countries such as UK or USA, one may not be able to consult a specialist unless referred by their GP; however, in India, you are free to consult any doctor of your choice including a specialist.

Identify the doctor of the correct speciality (as per your problem)

You need to choose the appropriate doctor, specialising in the disease you are suffering from. For ex- for ear discharge/ear pain/decreased hearing, you need to see ENT; for chest pain-cardiology; for knee pain-orthopedics, etc. Sometimes, you may not be aware of what speciality to consult. In this case, the receptionist or the secretary of the doctor can help you. If you happen to consult or know any doctor for any previous ailment, you could ask him to guide you in choosing the correct specialist for the current illness.

Should you go to a doctor in a clinic set-up or a multi-speciality hospital

Both clinics and hospitals have their advantages and disadvantages. Hospitals have multiple doctors in the same speciality, so, if one doctor is on leave, you can always consult another doctor. Also, if any cross-referrals are given (if you are asked to see another specialist), you could see them in the same hospital. Most investigations and medications are also available in the same hospital. Drawbacks of a hospital may include longer distance from home/office; higher costs; and uncomfortable surroundings. In a clinic, you tend to feel more familiar with a particular doctor, and you may find the surroundings more comfortable. Cost of treatment could be lower in a clinic. However, a serious illness usually can not be treated in a clinic. For ex- if you have suffered a heart attack or brain stroke, thrombolytic therapy may not be available in a clinic, and valuable time may be lost whie shifting from clinic to a bigger hospital.

Therefore, for a serious illness, you should prefer to consult a doctor in a hospital; and for a minor illness, you could consult a doctor in a clinic. Also, if your illness is undiagnosed, the chances of making an accurate diagnosis is more in a hospital because of availability of all investigations. So, your initial visit (prior to diagnosis) could be to a hospital, and subsequent follow up can be done in a small clinic.

How do you ascertain that a certain doctor is better than others in the same speciality?

Though it is not always easy to identify a better doctor, certain points can help you in this decision.

1. Look where the doctor got trained: If a doctor got trained at AIIMS, PGI Chandigarh, CMC Vellore or some other good colleges, their knowledge & expertise would be better than if they studied in a lesser known college or colleges that give seats after taking money (management quota). Certain magazines like India Today routinely come out with the rankings of top medical colleges and that could be one source for finding the best medical colleges in India.

2. Look at the degrees and qualifications: A doctor with MD (or MS) is better trained than those with MBBS alone, and those with DM (or MCh) are better trained than those with MD (or MS). Certain doctors may also obtain special fellowships in a more specific disease.

3. Number of years of experience: Senior doctors are generally better than the fresh pass-outs, and as the doctor becomes more experienced, he becomes better. This is true for both surgical and medical specialities. For ex- a surgeon who has performed 500 cases of spine surgeries is definitely better than the one who has performed only 20. Similarly, a neuroloigist who has treated 1000 cases of stroke is better than the one who has treated only 50. Every patient has a right to ask his doctor about the number of similar cases treated/operated by his doctor.

4. Any research in the specific field: A doctor with research experience in the field should be preferred over someone without any research experience. Similarly, if a doctor is on the editorial board of a journal or is routinely invited to give talks on a specific disease, he is considered to be an expert and should be preferred. These details can be obtained from different personal and public websites (such as Google scholar and PUBMED).

5. Look for reviews about a doctor or hospital on websites.

6. Knowledge of a specific language: Good communication is the key to a correct diagnosis and better treatment. So, if the doctor knows your language it is an advantage. Many doctors have translators for the benefit of their patients.

I have tried to discuss various issues in this vast topic, and I may have sounded vague at some places. I would welcome any suggestions from your side.

DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS

HYDERABAD, INDIA- 500033

Phone: 0091-40-23607777/60601066

Email: drsudhirkumar@yahoo.com

FACIAL PALSY (BELL'S PALSY)

FACIAL PALSY (BELL'S PALSY)

What is Bell's palsy?

Bell's palsy refers to unilateral (one side) paralysis of muscles of face.

What are the symptoms of facial palsy?

Facial palsy causes weakness of facial muscles. So, patients may face the following problems:

1. Difficulty in closing the eye, so, the eye on affected side may look bigger.

2. Difficulty in frowning, leading to absence of wrinkles over forehead on the affected side.

3. Difficulty in blowing out cheeks (air leaks out on the affected side).

4. Watering of eye on the affected side,

5. Difficulty in chewing food, food may get stuck within the mouth on the affected side

6. Facial asymmetry, face may seem to get pulled to the normal side.

Other symptoms may include:

1. Loss of taste on the affected side,

2. Faint sounds may also seem louder (hyperacusis)

3. Headache, facial pain and neck pain may occur on the affected side. The pain may start a few days prior to the onset of facial paralysis. 

How does facial palsy start?

Symptoms of facial palsy starts suddenly over hours, so, it is very alarming for the patient. At the onset, patient may have pain behind the ear, in the neck, or the head on the side of paralysis. Symptoms are minor in the beginning, so, they often get noticed first by others or may be noticed on looking into a mirror.

What should be done, if one suspects facial palsy?

There is no need to panic, as it is a benign condition, and often improves over time. One should first consult their family physician or GP and subsequently a neurologist. Care should be taken to avoid any dirt entering the eye (as the eye can not be properly closed) to prevent corneal (a part of eye) infection.

What are the causes of facial palsy?

Bell's palsy is idiopathic (no definite cause has been identified). However, research has shown that it is often caused by viral infections such as herpes simplex. Facial palsy is more common in people with diabetes mellitus and in pregnant women. Patients with facial palsy often give a history of exposure to cold prior to the onset of symptoms (such as direct exposure of AC wind, going out at night or early morning, or long road journey with open windows), but their role in causing facial palsy has not been proven.

Other causes of facial palsy may include brain stroke (decreased blood supply to brain), tumors, other infections, trauma, infections of ear, etc.

What investigations would the doctor ask in facial palsy?

• Generally, no investigations are necessary as the diagnosis of facial palsy is obvious on clinical examination.
• However, brain scan (CT or MRI) may be done if one suspects brain stroke or tumors.
• Blood sugar should be checked to exclude diabetes mellitus.
• Nerve conduction studies (NCV/EMG) may be done to estimate the extent and severity of facial nerve involvement and in some cases to predict the outcome of facial palsy.
• In patients with recurrent facial palsy, certain blood tests may be done to look for the presence of disorders like collagen vascular diseases or vasculitis.

How is facial palsy treated?

Medical management of facial palsy may include the following:

1. Anti-viral drugs: Aciclovir tablets (2000 mg per day in divided doses) are given for 7-10 days.

2. Corticosteroids: Prednisolone 50-60 mg per day for 5-10 days are helpful in speeding the recovery. 

3. Vitamins: Mecobalamin (vitamin B12), alpha lipoic acid, etc are given to speed up recovery and regeneration of the facial nerve.

4. Physiotherapy: includes facial exercises, massage, and electrical stimulation of the facial nerve.

What is the prognosis of facial palsy?

• As earlier mentioned, facial palsy is not a serious condition and most patients recover well. Almost 60-70% patients recover in 3-4 weeks and the remainder in another few months.
• Less than 5% patients either do not recover or recover only partially.
• Facial palsy does not lead to death.
• Facial palsy usually does not recur, and recurrence is seen in only about 2-5% of cases.
• Patients with residual palsy may have facial asymmetry and they may consult cosmetologist/cosmetic surgeon for correction of asymmetry.

Miscellaneous questions about facial palsy

1. Is it contagious?

No, facial palsy does not spread from one patient to another, so, isolation is not required.

2. How common is Bell's palsy?

It is quite common and I see about 5-10 new cases per month.

3. Is Bell's palsy hereditary?

No

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD, INDIA

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/60601066
Facebook: www.facebook.com/bestneurologist

ROLE OF BOTOX IN NEUROLOGICAL DISORDERS

BOTULINUM TOXIN (BOTOX) INJECTIONS IN NEUROLOGY

Botulinum toxin (popularly sold in the brand name Botox by Allergan company) is one of the commonly used treatment methods in cosmetology. Many actors and models take botox therapy to look young and hide away all facial and forehead wrinkles. Very few people know that Botox has wide applications in the field of neurology and patients with several neurological disorders can benefit from botox therapy. In this post, I would list out all the conditions where I give botox injections and would share my experiences in treating them.

1. POST-STROKE SPASTICITY

Stroke is a common disease leading to paralysis of muscles on one side of the body, due to reduced blood flow to the brain. Patients who survive stroke are left with severe disabilities. Spasticity- increased stiffness and tone of weak muscles- is a common cause of disability in stroke survivors. There are several medications (oral tablets) available for reducing the spasticity, but they have limited efficacy and significant side effects such as drowsiness. Botox injection therapy is a very effective method of treating post-stroke spasticity. Botox is injected in the spastic muscles. In the past 10 years, I have treated more than 100 patients with this condition and most of them do well. One of my recent patients was an ex-army person from Baghdad (Iraq), who was wheel-chair bound for five years due to a stroke. I gave him botox treatment, and referred him for physiotherapy. After a week, he came walking to my office. Patient and his wife were so thrilled! Reduction in spasticity also helps in doing better physiotherapy.

2. CHRONIC MIGRAINE

Migraine is the commonest cause of headache, affecting about 10-15% of women and 5-8% of men. In many cases, migraine becomes chronic and leads to frequent headaches. Frequent, severe headaches adversely affects the patients' quality of life, studies, employment and family life. Oral preventive therapies for migraine are available, but are ineffective in some and lead to adverse events in others. In these patients, botox therapy has a great role to play.

Botox is injected in scalp and neck muscles (frontalis, temporalis, occipitalis, cervical, trapezius, etc) using a very thin needle. The procedure can be done in the office, with little discomfort to the patient, and is completed within 15-20 minutes. In the past two years, I have treated about 30 patients with chronic migraine with botox. 29 of them showed good improvement in pain and quality of life. One patient who did not improve had various stressors in personal and professional life, leading to super-added tension headache. One patient, who I distinctly remember was a 35-year-old woman from Dubai, who came to me with 5 year duration of chronic migraine (20 headache days per month). She returned 3 months after botox injection therapy for review, and reported almost complete improvement in pain. However, she requested me for one more botox shot. I was surprised, as she was pain-free. Then she disclosed to me that her husband had started showing more interest in her now that she looked much younger and prettier (after botox shot to frontalis muscles) and she wanted to maintain the youthfulness of her face. I suggested to her that she consult a cosmetologist, but she insisted on me doing it. So, I along with my cosmetologist, gave her the second botox shot!

3. WRITER'S CRAMP

It is a condition, where patients find it difficult to write. They are able to perform all other activities normally, including lifting heavy weights with hands. Handwriting becomes poorer and illegible. Cheques signed by the patients start bouncing, as the signature on the cheque does not match that of bank records. Another feature of the disease is that writing becomes worse in front of others and when tensed.

Botox is very effective for treating writer's cramp. Injection is given in forearm muscles. Most patients improve very well.

4. SPASTICITY OF LIMBS IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy (CP) is a condition affecting children, characterized by developmental delay (delayed motor and speech milestones). Other features may include fits, deafness, squint, learning disability, etc. Cerebral palsy results due to a lack of oxygen or blood supply to the brain during peri-natal period (immediately before, during or immediately after birth). Many children with CP have spasticity of legs and hands. Spasticity of legs hamper in their standing and walking. Botox injections given in adducor and hamstring muscles of thighs reduce the spasticity, and improve walking. Today, I treated a 5-year old child from Bidar (Karnataka) with this condition.

5. Other dystonias- such as hemi-facial spasm, blepharospasm, cervical dystonia- are also very well treated with botox injections.

6. Hyperhidrosis- increased sweating over palms and feet, which can be embarrassing and cumbersome- responds well to botox treatment.

In general, all botox injection therapies are done on an out-patient basis. Patients can come after eating (fasting is not necessary). It is done without any anaesthesia, in the office setting. The entire procedure is completed in less than 30 minutes and patients are free to return home immediately after the procedure. No leave from work is required and they can join work the next day. Depending on the condition, 100 to 200 units (1-2 vials) of botox is required for the procedure, and the approximate cost could be Rs 25, 000- 50, 000 (USD 1000-2000). Botox treatment is safe and I have not seen any complication in more than 250 botox procedures that I have done in the past 10 years.


DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS
HYDERABAD, INDIA.
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

RIGHTS OF A PATIENT IN A DOCTOR-PATIENT RELATIONSHIP

What are the rights of a patient, in a doctor-patient relationship?

The relationship of a patient and doctor is a very special one and is different from any other professional relationship. The patient shares a lot of personal and private details with the doctor, which at many times are not even known to close family members or relatives. The doctor is one of the most important persons in a patients’ life, as the doctor is responsible for the patients’ good health (contributing to an increased productivity at work and greater happiness in family life).

There is a need to maintain a healthy and cordial patient-doctor relationship, keeping in view the importance of this relationship. Both the patient and doctor have certain rights and responsibilities towards the success of patient-doctor relationship. In this blog, I shall focus on the rights of a patient.

1. Right to get listened to by the doctor

It may seem very basic, but several patients are not allowed to tell their complaints to the doctor. Several senior doctors spend hardly 3-4 minutes per patient, and give a prescription containing 7-10 medications to the patient! History (description of illness as given by the patient to doctor) is the most important step towards arriving at a correct diagnosis; and a patient has the right to insist that a proper history be taken. Today, several doctors over-rely on investigations (such as blood tests, X-rays, CT scan, echocardiogram, etc) to make a diagnosis (ignoring history and clinical examination of the patient). Over-reliance on investigations can lead to an error in diagnosis. For ex- epilepsy can be diagnosed only by a good history, as CT scan and EEG may be normal in true cases of epilepsy. On the other hand, 5% of normal people may have abnormal EEG.

2. Right to receive information about the illness:

Patient can ask anything about the illness to the doctor (such as why did it occur, can it spread to other family members, how long will it take to improve, any likely complications of the illness, can it recur, etc). A good doctor has enough time to answer all the illness-related queries.

3. Right to know all the possible treatment options:

A single disease may have more than one treatment options. There may be more than one medication effective for the same illness. For ex- there are several medications effective for epilepsy. The doctor selects the best anti-epileptic medication depending upon the type of epilepsy; age & sex of the patient; expected drug-related adverse events and cost. The patient has a right to understand why one medication was preferred over another. In diseases requiring surgery, patient has the right to understand different surgical options available and why a certain surgical procedure is preferred over another.

4. Right to know possible treatment-related adverse events:

Many medications may cause adverse effects, which can range from simple nausea/vomiting to liver & kidney damage. A patient has a right to know about all the possible harmful effects of the drug from the doctor. A good doctor would patiently explain them to the patient. Similarly, in patients undergoing surgery, all the possible complications of the surgery will be discussed by the surgeon with the patient.

5. Right to refuse any investigation or treatment:

A patient has the right to accept or refuse any investigation or treatment offered by the doctor. A doctor can only advise, and not force a patient to undergo an investigation or procedure. An informed consent from the patient is mandatory prior to an investigation or procedure.

6. Right to take second opinion:

The doctor’s opinion regarding the treatment is not binding on the patient and a patient can opt for a second opinion before accepting the treatment. The patient can take the second opinion from a doctor suggested by the treating doctor or any other doctor of his or her choice.

7. Right for a referral:

If the treating doctor is not competent in handing the disease, the patient has a right to be referred to another doctor who is a specialist in treating the condition. For ex- if the patient has suffered from an ischemic brain stroke (causing paralysis) and the concerned doctor is not competent in thrombolysis (clot-buster therapy), the patient can ask for referral to a stroke neurologist.

8. Right to know about any modifications in lifestyle, diet or job:

Treatment of a disease involves modification in diet, lifestyle and job. For ex- patients with kidney failure or very high blood pressure should take a low salt diet, patients with recent heart attack should avoid oily/fatty food, patients with epilepsy should avoid driving/swimming, etc. Patients have a right to know these details.

9. Right of confidentiality/privacy:

Patients details (personal or medical) can not be disclosed by the doctor to anyone else including close friends or relatives of the patient without patients’ consent.

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com
http://members.tripod.com/sudhirkumar_5/neurologist/

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

MEMORY- THE MOST IMPORTANT BRAIN FUNCTION

Introduction

Memory is, undoubtedly, the most important function of our brain. Our day-to-day functioning depends on good memory. A person with memory impairment is unable to perform even the most basic of the daily activities. This handicap is well seen in people suffering from dementia.


Better memory is also a prerequisite to being a more intelligent person, and all tests for testing I.Q (intelligence quotient) include some form of memory testing. Good memory becomes even more important in traditional teaching systems such as in India, where a student who can memorise more gets more marks, and also more accolades and so on!

Memory in other species

It is not only humans who have memory. Many lower animals too depend on various types of memory for their survival.

• For example, migratory birds fly upto 10,000 km every year to survive harsh winters, across deserts, mountains and seas; with fear of starvation, exhaustion and death. Yet, they accurately reach the same destination without getting lost (remember, they dont have google maps, GPRS, etc). l
• They can store upto 100,000 seeds underground and retrieve most of them later, when they need them (just imagine doing it without pen/paper or computer!) Birds store Acorn seeds (that grow into giant oak trees) in the ground, by covering with dirt. Acorn seeds are very nutritious and birds can’t eat them all for fear of becoming fat and not being able to fly
• Remeber PAUL, THE OCTOPUS, who predicted so accurately during the recent world cup soccer!
• Chimpanzees and gorillas have even better memory.

Some facts about human brain

Human brain is only 2% of body weight, but it receives 15% of cardiac output (blood pumped out by the heart), 20% of total body oxygen consumption and 25% of total body glucose utilization. Brain metabolism is very active, and brain continues to work even during sleep (during rapid eye movement- REM- phase of sleep, brain metabolism is 30% higher!)

At what age does learning in humans begin?

Human learning begins even before birth. All those who have read Mahabharatha know that! Abhimanyu (son of Subhadra and Arjun) learnt how to penetrate several layers of defence of Chakravyuha, while he was still in his mother's womb (while Arjuna was narrating that to Subhadra). The epic says that Subhadra fell asleep halfway, and so Arjun did not tell her the technique of coming out of Chakravyuha, and Abhimanyu could not learn that either (and later on during the war, he remembered how to enter the charavyuha, got trapped inside and got killed).

Recently, several research studies prove the above point. Ultrasound studies show that fetuses respond in a specific manner (by moving hands or legs) to a specific sound at 30 weeks of gestation. The response of fetuses were replicated at 34 weeks, indicating that they could remember the sound even after four weeks! Also, mothers know that newborn babies respond to their voice even on the first few days after birth. This is because these babies have heard their mothers' voices so many times before birth that they are very familiar with that.

One of my colleagues told me that when his wife was pregnant, world cup soccer was going on, and they would watch all the matches and discuss them in detail. This experience was handy for their yet-to-born son, who showed keen interest in soccer from very young age, and at 10, he was in the school team! So, all prospective parents, please discuss only good things because your yet to be born child is listening to every conversation!!

Brain growth is maximum during the first two years of life, and hence are very important for memory and learning. Any infection or insult to brain during this stage can adversely impact memory functions.

Between 6 months and 12 months of age, babies can recognize familiar places or people (this explains the fussiness on being brought to doctors cabin or smile on seeing grandma).

Long-term memory retention does not start until age 3, and hence most people dont have any memories of events that happened during the first three years of life.

Does memory decline with advancing age?

•  lBrain volume is maximum at age 20 and starts to shrink after age 40!
• lThough certain aspects of memory & cognition may change with age, most older people can function normally (indicating an insignificant memory loss)
• lSo, memory loss causing disability in daily life of an older person is pathological,
• lNew-learning ability and ability to form long-term memory is spared into old age. 
• Different types of memories decline differently.
• Episodic (what did I have for breakfast), source (where did I learn the new car) and falsh bulb (where was I on Sep 1 2001) memory decline fast
• Semantic (words, phrases, facts) and procedural (driving a car) memory decline the least.
• Amount of storage capacity is not an issue; however, retrieval of stored information may become slower with aging.
• Memory lapses start in 20s, but they remain unnoticed till 50s.
• In a recent study, psychologists asked about 2,000 participants to solve puzzles, identify patterns and remember words and details from stories, among other memory tests.
• The top performers were 22-yr-old; researchers saw a notable decline in the ability to make rapid comparisons, remember unrelated information and detect relationships by age 27.
• A weakening memory can usually be detected by around age 37, according to the study.
• The good news was that people's vocabulary and general knowledge increase until at least age 60.

Memory problems in ageing- What is abnormal?

• Forgetting things much more than you used to
• Forgetting how to do things you've done many times before
• Trouble learning new things
• Repeating phrases or stories in the same conversation
• Trouble making choices or handling money
• Not being able to keep track of what happens each day

Whose memory is better- MEN or WOMEN?

Ever wondered why wives always manage to remember the wedding anniversary (and put you in a tight spot)! This is because verbal episodic memory (words, objects, everyday events) is better in women; however visuo-spatial memory is better in men (so women please watch, if you get stuck in dense forests of Amazon, its the men who will take you out of jungle to safety)! Women are also better at remembering faces!

"Husbands never remember marital spats, whereas wives never forget". This is because women have better emotional memory. This could also explain the higher rates of depression among women.

How to improve memory?

l1.Regular physical exercise- increases cerebral blood flow

l2. Regular brain exercises- solving puzzles, sudoku, learning a new language, or playing a new musical instrument, etc in old age can delay the onset of dementia

l3. Avoiding stress/tension; good social interaction

l
5. Good control of risk factors such as high BP, sugars or cholesterol.
6.Ensuring proper sleep and good nutrition

l

Are there any memory enhancing foods?

 

l1. Grape juice- antioxidant & anti-inflammatory properties (Br J Nutrition, 2010)

l2. Strawberries, blueberries, walnuts- (J Nutrition 2009)

l3. Choline rich foods- chicken liver, eggs (J Am Coll Nutrition 2004)

l4. Chewing gum- (Appetite 2004)

l5. Apples, apricots, broccoli, cabbage, cauliflower, cherries, eggplant, fish, onions, plums, beet root, spinach, green tea, soy, olive oil,

l6. Turmeric (a compound called cucurmin) may protect against Alzheimer’s disease- this explains the lower prevalence of AD in India)!

Are there any medicines/drugs to enahnce memory?

Generally no drugs can boost memory in normal people. Memory is genetically determined and it can't be boosted. However, in people with vitamin and nutrient deficiencies, appropriate supplementation can be useful. Multivitamins are safe (containing B12, thiamine, alpha lipoic acid and folic acid). Omega 3 unsaturated fatty acids are used. Chinese herb Ginkgo biloba is also in common use. Please consult your doctor before you consume any of the medications, as even vitamins can have adverse effects!

Dr Sudhir Kumar MD (Medicine), DM (Neurology)

Consultant Neurologist

Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com 

NORMAL SLEEP

What, When, Why and How Much of sleep?

Introduction

Sleep is one of the most important activities that we enjoy a lot. On an average, we spend about one-third of our lives sleeping (assuming one sleeps about 8 hours a day). So, if one's job/profession is important (which also occupies about 8 hours per day), sleep is equally important, if not more!

What is the normal sleep duration?

Normal sleep ranges from 5 to 9 hours per day. Those who sleep less than 5 hours or more than 9 hours per day, have a higher incidence of heart attack, brain stroke, cancer and death.

When is the best time to sleep?

Night is the time meant for normal sleep. This is because the sleep-inducing hormone, melatonin, is secreted only during nights. The secretion of melatonin is inhibited by light, hence, darkness in the bedroom is essential for sound sleep.

Based on the sleep-pattern, there are two types:

1. "Owl" type: Person sleeps late (11 PM-12 midnight) and wakes up late (7AM-8 AM)
2. "Lark" type: Person sleeps early (8 PM-9 PM) and wakes up early (4 AM-5 AM)

These patterns are genetically determined and hence, it is difficult to change them.

Are daytime naps good?

Most of us feel sleepy in the afternoon, especially after a good lunch. However, it is not a good habit to sleep in the afternoon. Between the ages 10 and 60, sleep is monophasic, which means, sleeping only once (at night) is enough. Infants and small children have polyphasic sleep, which means, they wake up and sleep several times in 24 hours. Preschool children and elderly have biphasic sleep, and they require an afternoon nap in addition to night sleep. For others, afternoon nap is not necessary. However, a very short snooze (20 min or so) can be very energizing, especially in those who have to work very hard in the post-lunch session. Sleeping more than 30 minutes in the afternoon may make one very groggy and difficult to concentrate in work.

Why do we need to sleep?

 Sleep serves may important functions, some of them are:

1. Makes us feel fresh, and restores the energy.
2. Consolidation of memory happens during sleep. Brain decides what is important and that gets stored in long-term memory. Whatever is un-importnat is deleted from brain storage. So, lack of night sleep can lead to poor memory functions.
3. Growth hormone secretion occurs at night, so, sleep is important for proper growth.
4. Dreams occur during sleep, which is important for normal human functioning. We shall discuss more about dreams separately.
5. Normal night sleep decreases the risk of cancer. This is because melatonin secreted during sleep is an antioxidant and has anti-cancer properties.

Sleep is therefore one of the most important funcitons of human brain, and those with a good sleep are truly blessed!

Dr Sudhir Kumar MD DM
Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
drsudhirkumar@yahoo.com

POST-PARTUM CEREBRAL VENOUS THROMBOSIS (CVT)

POST-PARTUM CVT (CLOTTING OF BLOOD IN BRAIN VEINS)

Introduction

Pregnancy and delivery are normal physiological processes, which are experienced by more than 95% of women. Delivery and arrival of a newborn is a cause of joy and celebration all across the world. However, due to the normal physiological changes (and certain other factors), mothers in the post-natal period are prone to develop certain diseases. Cerebral venous thrombosis is one such major illness.

What happens in cerebral venous thrombosis?

Brain has two kinds of blood vessels- arteries that transport blood to the brain from the heart, and veins that drain the blood out of brain towards the lungs for purification. In CVT, blood in the brain veins clot (get thrombosed), which impedes the blood flow.

What are the clinical features of CVT?

• Headache
• Vomiting
• Blurred vision, double vision, dimness of vision
• Fits or convulsions
• Weakness of hands or legs especially on one half of the body

Who are the women prone to develop cerebral venous thrombosis?

• Women with severe blood loss during delivery- such as after caesarian section, etc.
• Those who already had low hemoglobin (less than 10 gm%) before delivery
• Women who are dehydrated- such as after prolonged labor, those who can't eat or drink properly after delivery, extreme weather conditions, etc. (In India, in certain cultures, women after delivery are kept isolated in a room, and they fast, which makes them dehydrated too)
• Those with post-partum infections
• Those with deficiency of anti-clotting factors (which increases the clotting tendencies)

How can CVT be diagnosed?

If any woman in post-natal period develops features suggestive of CVT (such as headache, drowsiness, seizures, weakness, visual problems, etc), they should immediately contact the neurologist.

CT scan or MRI scan with venography can be done within a few minutes and the diagnosis of CVT can be confidently made.

Further tests (blood tests) may be done to detect the reasons for blood clotting in the brain.

How is CVT treated?

1. Patients are started on hepain injections, which are anticoagulants, as early as possible. After a period of 5-7 days, they are changed over to oral anticoagulants (warfarin, etc), which may be required for 3-6 months.
2. Anti-epileptic drugs are used for those with fits.
3. Certain medicines (steroids, mannitol) are given to reduce the brain swelling.
4. Glucose and saline infusions are given to maintain hydration.
5. Anemia is corrected (blood transfusion may be required in more severe cases)
6. Any co-existing infections are treated.

What is the outcome of CVT after treatment?

Patients do very well and recover fast. Most women recover fully, without any neurological deficits. A minority may have seizures or mild weakness or other neuro deficits.

If you require any further information, please send me an email at drsudhirkumar@yahoo.com

DR. SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone- 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

VITAMIN B12 DEFICIENCY AND NEUROLOGICAL DISORDERS

Neurological Disorders due to Vitamin B12 Deficiency

Vitamin B12 is an important vitamin required for proper functioning of nervous system. Deficiency of vitamin B12 leads to anemia (low hemoglobin) causing generalised weakness, tiredness and fatigue. In addition, it is an important cause of various neurological disorders.

Common manifestations of vitamin B12 deficiency:

1. Tingling or numbness of feet and hands (due to involvement of peripheral nerves)
2. Imbalance while walking (due to spinal cord involvement)
3. Memory impairment
4. Dementia (due to brain involvement)
5. Psychiatric disturbances
6. Uncommonly, fits, tremors, parkinsonism, etc have also been reported.

Who are prone to get vitamin B12 deficiency?

1. Pure vegetarians- Vegetarian diet is a poor source of vitamin B12, hence, symptoms of vitamin B12 deficiency are more common in veg people.

2. Those with gastro-intestinal disorders such as malabsorption (where food is not properly absorbed after eating, manifested by diarrhea), after certain gastric surgeries, etc.

3. Those with other autoimmune diseases such as hypothyroidism (lack of thyroid hormone), vitiligo (white patches on skin), myasthenia gravis (manifested by muscular weakness and fatigue). This is because presence of auto-antibodies may inhibit the absorption of vitamin B12 in the gut.

How to prevent vitamin B12 deficiency?

1. Eating diet rich in vitamin B12 can prevent vitamin B12 deficiency. All animal sources are excellent sources of vitamin B12, such as meat, chicken, fish, shrimps, eggs, etc. Since, vitamin B12 can be stored in the body for long, 1-2 servings per week may suffice in normal people. No plant source is a good and reliable source of vitamin B12.

2. Regular check ups- If you notice any of the symptoms of vitamin B12 deficiency (as listed above), consult your family physician/neurologist so that it can be diagnosed and treated early.

How to diagnose vitamin B12 deficiency?

1. Vitamin B12 level can be estimated in blood. It is a simple investigation available in most labs.

2. Further tests may be required to see the effects of vitamin B12 deficiency on nervous system or to ascertain the cause of vitamin B 12 deficiency.

How is vitamin B12 deficiency treated?

Once vitamin B12 deficiency is establilshed (after clinical exam and blood tests), patients are started on vitamin B12 supplements. Initially, injections are given, so as to prevent the problem of less absorption. Then, maintenance treatment is given with oral tablets of vitamin B12.

What is the outcome of treatment?

Most patients who are diagnosed and treated early show a good recovery, which, however, may be prolonged over weeks to months.


Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

SHARING NEGATIVE MEDICAL NEWS WITH CHILDREN

SHOULD WE DISCUSS "BAD NEWS" WITH CHILDREN-
a real life experience

We often come across younger patients especially children who are diagnosed to have illnesses with relatively poor outcomes. These may include a child diagnosed to have cancer of blood (leukemia) or cancerous tumor of brain (glioma), etc, which could prove fatal in some cases. In our normal medical practice, we discuss in detail about the disease with the patients and immediate family members. Areas of discussion involve the nature and likely progression of disease, the likely causes of the disease, the different modes of treatment (including cost of medicines or surgery, as the case may be) and the expected outcomes of disease & treatment.

In case of children, parents often tell us not to share any medical details with the child, fearing the child would get depressed or anxious or they won't be able to handle the "bad news" and many other excuses. Sometimes, we are asked to tell a lie to the child- for example, in stage IV glioma of brain, the expected survival could be 6 months to 12 months. In this scenario, parents usually ask us to tell the child that "he does not have tumor" and that "there is no risk to his life because of the illness".

Are we justified in not sharing medical details (bad news) or distorting the facts to child patients?

I want to share an experience that I recently had.

An 8-year-old child Arjun was referred to me by the oncologist for control of convulsions (fits). Arjun was diagnosed to have grade IV (late stage cancer) glioma of brain and was receiving chemotherapy after having undergone a brain operation. In my OPD, Arjun's parents met me first and requested me not to disclose anything about the illness to him, including the diagnosis and likely outcome, and lie to him that "he will be well soon". They told me that Arjun does not know anything about his illness or its outcome. I told them I would do what they expected of me.

When parents brought the child in, he looked very calm and composed. He was on a wheel-chair as he could not walk due to weakness of legs (nerves in brain that send signals to legs were damaged by the brain tumor). He had a beautiful smile on his face. While interacting with him, I found him to be very intelligent and smart. I asked his parents if I could privately talk to Arjun and they agreed. As soon as his parents left the room, Arjun told me he knows everything about the illness. He had read the doctors' medical notes and then browsed the internet to find out more about his illness. He told me that he has grade IV glioma and that at the best, he would survive for six months. He told me not to disclose to his parents that he already knows everything about his illness; otherwise they would feel "hurt".

Next I sent Arjun out and told his parents about the interaction I had with the child. They stood speechless and expressionless. They were shocked! Here, we had a family living in denial....that the other party does not know anything!.

Today, obtaining information is easy to get. One can get all desired information about a disease with a few clicks on the internet. So, hiding information from a child is not so easy. On the other hand, I feel sharing all details over 2-3 meetings is more appropriate. It is more important in situations where the child has a terminal illness. The child can be allowed to spend a quality time with family and friends and be allowed to fulfil any of his wishes during that period. In my clinical practice, I prefer to tell everything about the illness to my patients- old or young, men or women....unless, of course, they don't want to know (which is very rare).

(Arjun is the changed name to hide identity of the patient)

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Importance of timely treatment in brain stroke (paralysis)

STROKE TREATMENT: Benefits the most within the FIRST 4.5 HOURS

Brain stroke, commonly causing paralysis of one half of the body (called as "lakwa" in Hindi) is among the top 3 causes of death and disability in the world (the other two being heart attack and cancer). Stroke brings about a sudden transformation in the sufferer's life. A completely independent person may become paralysed, making him/her dependent on others for even their basic needs such as bathing, toileting and feeding needs.

Moreover, stroke is a major cause of financial burden for the sufferer. The patient is unable to attend to his job due to disability leading to the loss of income. In addition, the treatment of stroke and caring for the stroke patient adds to the financial burden.

Therefore, it is important to recognize and treat stroke at the earliest. There is only a single approved treatment for brain stroke- thrombolysis (or clot-buster therapy) using a drug called as tissue plasminogen activator (tPA). The point to note is that this medicine should be started within 4 hours and 30 minutes of onset of brain stroke to achieve maximum efficacy and to avoid any complications.

Success of the treatment being linked to time after symptom onset, makes it mandatory to identify the stroke symptoms and transportation to a recognized stroke center at the earliest a priority. In Hyderabad, Apollo Hospital at Jubilee Hills is accredited by Joint Commission International (JCI, USA) for the management of acute stroke since April 2006.

In the best centers for stroke treatment, there is a stroke team comprising of an emergency physician, neurologist, radiologist, physiotherapist, intensivist, dietician, etc. There is a standard protocol for taking care of patients with stroke. The ER is notified beforehand about the expected stroke patient, which in turn alerts the stroke team. As soon as the patient reaches ER, a clinical examination is carried out to ascertain the stroke. CT scan is immediately done (within 20 minutes of arrival to ER). Blood tests are done to ascertain the patients' eligibility for thrombolytic therapy. These reports are obtained and treatment started within 45 minutes of patients' arrival to ER (i. e. door to needle time is less than 45 minutes). Stroke unit and treatment at Apollo Hospitals, Jubilee Hills, Hyderabad, adheres to all the above.

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

EPILEPSY- Is it treatable?

What is epilepsy?

Epilepsy is a neurological disease characterized by repeated abnormal electrical discharges from the brain, resulting in fits or convulsions. Either a part of the body can be involved called as partial or focal epilepsy; or the whole body is affected called as generalized epilepsy. During a generalized epileptic attack, the person can lose complete consciousness resulting in falls or injuries.

 How is epilepsy diagnosed?

Epilepsy is diagnosed on the basis of clinical description of the seizure episode. So, it is important for the eye witness to accurately describe it to the neurologist. Doctor may get brain scans and EEG to confirm the cause and type of seizure.

Is epilepsy treatable?

Epilepsy is very well treatable with medications (anti-epileptic drugs). Neurologist would be able to select the best medication depending on the type of epilepsy and also age & sex of the patient. The medicines are required to be taken for long-term without any discontinuation.

Can women with epilepsy get married?

Women with epilepsy can get married and have normal married lives. They can get pregnant and have babies just like other women. Neurologist would advise on the safe anti-epileptic drugs in pregnancy and some vitamins (folic acid) are also required. Please discuss regarding any concerns with your neurologist.

Can people with epilepsy do normal jobs?

Most jobs are safe for people with epilepsy. However, they should avoid driving, swimming and other hazardous activities, as occurrence of seizures during these activities can be dangerous.

Is epilepsy a result of bad evils/demons?

No, they are only misconceptions.

What are the first aid measures to be adopted when someone has an epileptic attack?

1. Make the person lie down on one side (either left or right)
2. Do not give water or anything else by mouth, as it can get aspirated into lungs (causing pneumonia) in an unconscous person.
3. Try to prevent any injury because of fall or tongue bites.
4. Intra-nasal midazolam may be safely given at that time.
5. There is no point giving any keys or any other metals in person's hands, or making him smell handkerchief or socks.
6. Take him to the nearest clinic/hospital at the earliest.

Dr Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com

Homocysteine in heart and brain disease

IMPORTANCE OF HOMOCYSTEINE

Myocardial infarction (heart attacks) and brain strokes (paralysis) are the two most common causes of death and disability in the world. They occur in all regions of the world, and the prevalence increases with advancing age.

There are a number of known risk factors for causing heart attacks and brain strokes, which include high BP, diabetes, high cholesterol, smoking, positive family history and so on.

Role of homocysteine in heart attacks and brain strokes

• Homocysteine is a normal amino acid in our blood.
• However, elevated levels of homocysteine in the blood is an additional risk factor for causing atherosclerosis (narrowing of blood vessels for heart and brain).
• Elevated levels of homocysteine causes injury to the inside of blood vessel.

Though there are no definite reasons for elevated homocysteine levels, they tend to occur more in smokers and pure vegetarians.

It is easy to identify high homocysteine, by doing a simple blood test in fasting state.

Treatment of elevated homocysteine is also easy. One needs to use certain vitamins (folic acid, and other B group vitamins).
Please consult your neurologist for any further information.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com