HEALTH TRIBUNE Wednesday, November 21, 2001, Chandigarh, India

The endoscopic miracle

Dr Anupam Jindal

n recent years, endoscopic neurosurgery has undergone rapid growth in its applications and indications. recent advances in (CT Scan), Computed Tomography and Magnetic Resonance Imaging (MRI) have revealed lesions which are appropriate for an endoscopic approach. Lesions located in and around ventricles (cavities in the brain which contain cerebrospinal fluid) are particularly important.

Seasons make our moods
Dr Rajeev Gupta
eeraj felt that something had triggered his bizarre euphoria. His mental activity had gone up to new heights. He started liking everything in his environment to one another or to himself. His perceptions were filled with medical vividness. He could point to nothing in his life that had led to present a mental state.

Ayurveda & Total Health
Aromatic healer
Dr R. Vatsyayan, Ayurvedacharya
innamon or Dalchini is a spice which has also been traditionally used as a medicine. It is a native of India and Sri Lanka. Many centuries ago the fame of its alluring aroma attracted traders from distant parts of the globe.

Lose weight  wisely
Radhika Oberoi



The endoscopic miracle
Dr Anupam Jindal

The nervous system

In recent years, endoscopic neurosurgery has undergone rapid growth in its applications and indications. recent advances in (CT Scan), Computed Tomography and Magnetic Resonance Imaging (MRI) have revealed lesions which are appropriate for an endoscopic approach. Lesions located in and around ventricles (cavities in the brain which contain cerebrospinal fluid) are particularly important.

The first endoscopic neurosurgery was performed by Dr Lespinasse who, in 1910, treated two children with hydrocephalus by endoscopic coagulation of choroid plexus (part of the brain which is responsible for the production of most of the cerebrospinal fluid). This was followed by a similar procedure being done by renowned neurosurgeons like Dr Dandy and Dr Mixter.

The quality of surgery done at that time was hampered by the unavailability of a good endoscopic system, a poor light source and magnification problems. The construction of a solid rod lens system by Professor Hopkins revolutionised endoscopic surgery not only for neurosurgery but also for other fields. Neuro endoscope is being used at present with different kinds of ideas.

(1) Endoscopic neurosurgery: in it surgery is performed in a cavity through the channels of the endoscope inserted in the ventricular system or in other cystic structures.

(2) Endoscope-assisted neurosurgery uses the endoscope as an optical device and microsurgical instruments are used to perform the procedure.

Normal instrumentation for endoscopic neurosurgery includes: introducer, Neuro endoscope and working channels, cameras, light source, a display monitor, bipolar cautery and endoscopic instruments like seizures, forceps, catheters and balloon dilators. In general, a small burr hole is made and the endoscope is introduced through a small (6-8 millimeter) dural incision and a ventricle system or cystic cavity is reached. Thereafter, the procedure is carried out depending upon the pathology. With present advances in science and technology, the list of indications is increasing rapidly.

The indications are:
Third ventriculostomy, septostomy, choroid plexus coagulation. (Obstructive asymmetric, multi-compartment hydrocephalus are better treated.

Cystic lesions: arachnoid cysts (located in suprasellar, convexity and cerebellopontine angle); s ependymal cyst; s colloid cyst; s degenerative cyst and paralytic cyst.

Intraventricular tumours: Ventricular catheter placement and removal

Haemorrhage: Intracerebral; chronic subdural and intraventricular haemorrhage

Endoscope-assisted surgery: Aneurysms in anterior circulation; pituitary adenomas (sellar and suprasellar); cerebel opontine angle lesions and carpel tunnel syndrome.

Of all these, hydrocephalus, sellar and suprasellar lesions and intraventricular tumours are the most common indications.

Obstructive hydrocephalus usually requires the placement of ventriculoperitoneal shunt which carries a risk of malfunction and blockage and in about 15% to 30% cases shunts need to be revised a number of times causing significant mordibity and mortality as also the financial burden of repeated surgeries. By using endoscopic third ventriculostomy (ETV) the neurosurgeon makes a new hole at the floor of the third ventricle which provides an alternative route for the CSF to escape through the ventricle system and reach the brain surface from where it can be absorbed. In patients with congenital hydrocephalus, the success rate is about 65-75%. In those with obstructive lesions like tumours or cysts, etc, the success rate is about 75-90%. The advantage of ETCis that it is a one time procedure and if it works, there is usually life-long relief. Complications that can occur during the third ventriculostomy are similar to the shunt procedure, like infection, bleeding while introducing the endoscope, damage to cranial nerves and deeper structures.

Sellar and suprasellar tumours pituitary adenomas, arachnoid cyst and cranio-pharyngiomas can be dealt with endoscopic neurosurgery. Arachnoid cysts can especially be treated in a very effective way as these are cystic structures and the treatment requires only creating communication between the cyst and the ventricle system. Other tumours in this location are more amenable to complete resection when the endoscope-assisted procedure is done. The use of the endoscope makes the procedure safer by providing better visualisation of the anatomic details during surgery. Para and intraventricular tumours can similarly be biopsied and removed using the endoscopic technique. These tumours, when approached by the routine/open neurosurgical technique, carry a significant risk of complications.

Endoscopic neurosurgery thereby has made the treatment of some difficult conditions safer and more effective with a continuing advance in the technology. This has become a promising technique in today's neurosurgical practice.

Dr Anupam Jindal is a consultant neurosurgeon. He has effectively handled challenging cases at the INSCOL Tertiary Care Hospital in Sector 34, Chandigarh. The endoscopic miracle



Seasons make our moods
Dr Rajeev Gupta

Neeraj felt that something had triggered his bizarre euphoria. His mental activity had gone up to new heights. He started liking everything in his environment to one another or to himself. His perceptions were filled with medical vividness. He could point to nothing in his life that had led to present a mental state. His wife noticed that during every summer he became hyperactive, gained confidence and felt as if some dynamo had been started within his body. In winter, he felt low and found that his energy was getting drained. He fell into a state of acute despair. She had noticed these mood fluctuations for the past three years.

Neeraj was referred by his family physician to a psychiatrist who diagnosed him as suffering from Seasonal Affective Disorders (SAD). Now he is maintained on Lithium carbonate.

Reports of a change in mood with the change of seasons were recognised by Esquirol as early as 1845. It is only in the past decade, however, that Seasonal Affective Disorder has become the focus of systematic scientific study. Normon E, Rosenthal, chief of the unit of outpatient services, Clinical Psychology Branch, National Institute of Mental Health, USA, described a form of the condition where fall-winter depression alternated with non-depressed periods in the spring and summer seasons. Recently, he and his colleagues from the same unit and this author have described a variant with an opposite pattern, namely depression in summer and a non-depressed periods in the fall and winter periods, a condition they have called Reverse SAD.

Most of the patients of SAD have been women. The onset of the illness typically occurs in the third decade. in Washington, such depression lasts, on an average, 5.1 months, generally beginning in October or November and subsiding in March or April.

The depression is generally mild to moderate but it may be severe also. The patients have vegetative symptoms like increased eating, carbohydrate craving, weight gain and too much of sleeping. The single outstanding characteristic of this depression is the reactivity to changes in environmental lighting and climate. Those patients who have lived at different altitudes frequently have noted that the further north they have lived, the longer and deeper their winter depression has been. Sometimes, they have been depressed until they have moved north. Most patients, who have travelled to the South during the winter months have reported an improvement in their mood a few days after their arrival and relapse a few days after returning to the North.

In addition, a reduction in environmental light for any reason, for example a spell of cloudy weather in summer or a move from a well-lit to a poorly lit office, has been frequently followed by deterioration in their mood. Over half of the women patients have reported premenstrual mood changes, which have often been worse in the winter months.

The use of phototherapy in SAD: There have been several trials in patients of SAD. Phototherapy has been seen to be as effective as drug treatment. In a study on NIM group in the USA phototherapy helped 30% of the patients with depression. The light sources most frequently used have been full spectrum fluorescent light increased into a rectangular metal box, two by four feet with some reflected surface behind them, and a plastic diffusing screen in front. Patients are asked to place the box level either horizontally on a desk or a table, or vertically on the floor, to sit approximately three feet away from the light and to stare for at least a few seconds every minute. The intensity of the light measured at three feet from the source of 2500 lux (the amount of light to which one is to be exposed by looking out of the window on a spring day). This is five to ten times brighter than the ordinary room lighting. The effect or phototherapy is mediated through the eyes and not through the skin. The mechanism of action of phototherapy in SAD: Various postulations have been made to explain the mechanism of the anti-depressant effect of the bright light. One of the suggestions is that bright light exerts its antidepressant effect by the suppressions of melatonin secretion. It can also do so by means of its circadian shifting properties. It is presumed that certain individuals have a biochemical vulnerability (perhaps genetically determined) which, in the absence of adequate environmental light exposure, produces the behaviour and emotional changes as seen in SAD. Bright light, probably acting via the eyes and presumably via retino-hypothalamic projections, appears capable of reversing this biochemical abnormality if the light is of a high-enough intensity and is used regularly and for a sufficient duration. Bright light has been shown to be capable of producing changes in the P 300 component of the visual potential.

Public health implications: Most SAD patients complain of day-time drowziness,fatigue and diminished concentration. Key symptoms like day-time fatigue, and somelence are important not only for job performance but also for public safety.

Recently, a study from the USA reported that in industrial workers a higher incidence of multiple work accidents was found among workers complaining of excessive day-time sleepiness as compared with normal workers with only night-time sleep disturbances. In another study from Norway it has been found that more than 23 per cent of the people suffer from day-time sleepiness and diminished work capacity during mid-winter, a condition reversible with bright sunlight.

While psychotropic medicines continue to be the mainstay in the treatment of mood disorders, they have certain problems and limitations. SADpoints towards deeper connections of man and the universe. The evolution of life on this planet needs to be understood and studied in total gestalt with nature around us.

The author is a consultant psychiatrist and de-addiction specialist at MANAS Psychology De-addiction Centre, Tagore Nagar, Ludhiana. (Phones 472822 and 472899)



Ayurveda & Total Health
Aromatic healer
Dr R. Vatsyayan, Ayurvedacharya

Cinnamon or Dalchini is a spice which has also been traditionally used as a medicine. It is a native of India and Sri Lanka. Many centuries ago the fame of its alluring aroma attracted traders from distant parts of the globe.

As the bark and skin of the plant is used for medicinal purpose, cinnamon is aptly known as twak in Sanskrit. Scientifically called Cinnamomum zylenicum, its utility is immense. It is pungent, bitter and sweet in taste and hot, light, sharp and dry in effect. It pacifies vata and kapha but aggravates pitta.

Ayurvedic texts describe cinnamon as an expectorant, a carminative, a stimulant and a tonic for the cardiovascular and nervous systems. Its main action is anti-kapha on the respiratory system. It also has digestive, liver-protective and diuretic properties. An analysis of cinnamon shows that it consist of moisture, fat, protein and a few minerals. It also contains an essential oil which is known as cinnamon oil.

Curative properties: Cinnamon is an effective remedy in a number of problems. Here are a few indications:

Cough and bronchitis: Mix 20 gm each of cinnamon, ginger, long pepper, turmeric, cardamom and talispatra. Add 100 gm of raw sugar and grind them all together to make a fine powder. Take half to one teaspoonful of this powder mixed with a little honey twice a day.

Common cold: Coarsely powdered and boiled in a cup of water with a pinch of powdered black pepper, cinnamon is beneficial in common cold occurring due to exposure to cold in the winter season. A small quantity of honey can also be added to this decoction. The paste of fine cinnamon powder can be applied on the forehead to mitigate a headache also.

Digestive disorders: Cinnamon stimulates digestion and is helpful in controlling nausea, vomiting, diarrhoea and flatulance. Adecoction made by boiling half teaspoonful of it in a cup of water and taken after meals helps relieve the distension of the abdomen.

Cinnamon is used in many tooth powders and for allaying bad breath. A small piece of it can be put into the mouth or chewed.

Sitopladi Churna: Cinnamon is an ingredient of Sitopladi Churna, the famous classical ayurvedic medicine. It can be easily prepared at home. Take 250 gm of sugar, twasheer (banshlochan) 125 gm, pippali (magh) 60 gm, chhoti elaichi 30 gm and dalchini 15 gm. Crush them together in the kitchen mixer and make a fine powder. Mixed in a little of honey or almond oil, 2 gm of this churna can be taken twice a day by patients other than diabetics as a safe household remedy to treat cough and cold, sinusitis, bronchitis, general weakness and many other ailments.

(Next week: Ashwagandha, the Indian ginseng)
Dr R. Vatsyayan is an ayurvedic consultant based at the Sanjivani Ayurvedic Centre, Ludhiana. (Phones: 423500 and 431500; E-mail- [email protected]).


Lose weight wisely
Radhika Oberoi

Q. I eat very little but I am overweight. Why ?

A. Obesity is the generalised accumulation of excess fat in the body. Except a few who gain weight because of the dysfunction of the thyroid, pituitary or suprarenal glands, obesity is almost always the result of over consumption of calories or decreased expenditure of energy due to lack of physical exercise or both. The basic guiding principal for reducing weight is to provide fewer calories. It is not the quantity but the low-calorie equivalent that produces weight loss ( 100 gm of cucumber provides 16 Kcal but the same quantity of roasted groundnuts gives 600 Kcal).

Q. One of my friends lost 4 kg in a period of 10 days by crash dieting. I am highly motivated but is it right?

A. Drastic measures can be taken for a short period but whenever one reverts to the usual diet, he or she may end up gaining all the weight back - or even more. Also, one may have during this period deprived his or her body of essential nutrition. A gradual weight loss of 2-3 kg per month is recommended.

Q. Why is so much emphasis laid on sugar restriction in a weight loss programme ? Is jaggery a better option?

A. Sugar provides only empty calories to the body. It is one substance that provides no other nutrient except calories. So, even total restriction will not cause any nutritional deficiency in an individual. Jaggery and sugar both provide the same number of calories. So, whether you have sugar, jaggery or honey, it doesn't matter. One teaspoonful of each gives you 20 Kcal.

Q. Does soaking nuts in water wash off its fats and reduce the calorie content?

A. Soaking nuts in water has no effect on its calorie content. All dry fruits and nuts are rich in calories and should , therefore, be avoided.

Q. Why are lots of green salad-vegetables recommended ? Are they calorie-free?

A. Green salads and leafy vegetables are recommended basically because of their low-calorie content and the roughage (fibre) they provide. They give more satiety and encourage bowel evacuation, which cleans out the system. A good serving of salads 30 to 45 minutes before meals is recommended.

Q. Can excessive intake of water lead to weight gain ?

A. No. It is basically a food fad.

Q. Does salt have calories ?

A. Salt has no calorie but the restriction of sodium as salt is helpful in getting weight-reducing diet. Excess sodium in the body predisposes one to the retention of fluid.

Radhika Oberoi is a well-known dietician based at 2285, Ph X, SAS Nagar, Punjab.
(Next week: Eat wisely to keep cancer away by Dr Rajiv Goel.)


Prosperity through right means

A person should develop a drive for the second ambition, prosperity. Because, after life, prosperity is the best ambition. There is no misfortune worse than having a long life without resources. One should endeavour to acquire resources that provide livelihood and affluence. Furthermore, the means of prosperity should be just and not that which is frowned upon by good people. Charaka Samhita


Stress: how to meditate

Meditation is a way to calm your body and mind by focusing your attention on one thing, such as a phrase, an object or your breathing. The most common way of meditating is to pick a word or a phrase that you can say to yourself in coordination with your breathing. If you use a single word, repeat it when exhaling. If you are using a few words, try coordinating some of the words on the in-breath and some on the out-breath. It's ideal to meditate at least 10 to 20 minutes a day Value Circle



How to breathe well

When you are under stress, you often inhale from your chest, which trends to be a more shallow and constricted way of breathing. Breathing deeply, inhaling from your abdomen instead of your chest, provides more oxygen to your bloodstream and can help you control your emotions stay clam. To start, place your hand over your belly and slowly breathe in through your nose. Feel your stomach expand, then slowly exhale. Do this 10 to 20 minutes a day. Novo Nordisk