‘If you have a healthy immune system but administer a trigger too soon after the first infection, your immune system will not respond as effectively as it should. Delaying it too long, on the other hand, may result in re-infection, which could be fatal. As a result, it’s best to get vaccinated three months following the initial infection, because an infection during this time isn’t deemed dangerous’, Dr Rajesh Malhotra explains when asked about the optimal time for vaccination of Covidrecovered patients.

Following are a few snippets from the discussion with the AIIMS Trauma Centre Chief:

What is the co-relation between Covid Immunity and the vaccination?

Dr. Rajesh Malhotra: The level of immunity is different in each individual and the robustness of the response may vary across ages, comorbidities, sex, etc. Natural infection mounts immunity and vaccination but the immune response mounted by vaccine is much more robust because the infection manipulates immune system in order to thrive in the body, as per a study conducted by a University in London. 

People who developed immune response after getting infected by Sars in 2003 carried circulating Antibodies in their bodies in 2020. Therefore, some people may carry the immunity against coronavirus for a lifetime whereas some may get reinfected due to their weak immune system. Another cause for recurrence is the variant, which goes unidentified by the body. Third reason could be if a person’s immune system is fully compromised and has got the persistent infection for months together, the virus inside his body may mutate and come out as a variant which can cause a reinfection. Fortunately, these possibilities are rare.

Can someone, who has developed a mutation, spread the infection while in recovery stage?

Dr. Rajesh Malhotra: A healthy person can recover from Covid in 14-17 days but may spread virus which is dead cannot multiply. On the other hand, an immunocompromised person who has virus multiplying in his body can spread live virus. They may also land up with a mutant due to its prolonged stay because it is a known fact that mutations occur during the prolonged stay of a virus.

What should the immunosuppressed person do in such a condition?

Dr. Rajesh Malhotra: They must wear mask at all times as they may shed mutants. Secondly, they must get vaccinated and if they are vaccinated, various agencies have recommended a booster response in order to control the infection. But the most effective way out is early administration of monoclonal antibodies which can mitigate the persistence of the virus and also the emergence of the variants in their bodies. They should also be isolated from their family members and the family should be vaccinated which will cause an important epidemiological intervention.

Is it a right approach to get vaccinated right after the recovery?

Dr Rajesh Malhotra: The right approach is to get vaccinated which reduces the risk of infection by half. The period between two infections is roughly around hundred days which means that the safe time to get vaccinated is within three months of recovering from the first infection.

I would not worry about antibodies in an immunocompetent people. The other fact that people forget that T-Cells are the most important among the four forces that fight the infection (Antibodies, B-Cells, T-Helper Cells and Killer T-Cells), while antibodies are only ammunitions.

Are you saying that a recovered Covid patient need not get an antibody test right away and can wait 90 days before getting vaccinated?

Dr Rajesh Malhotra: There are no such drugs that can counter the virus, just some drugs that reduce replications. If you have a competent immune system and give a trigger too early after the first infection, the response will not be as robust as intended. On the other hand, delaying it too long may cause re-infection that may be fatal. Thus, it is ideal to get vaccinated after 3 months of the first infection because having an infection in this period of time will not be considered harmful.

Question: Everyone is talking about the third wave. What is the status actually, is it still impending or is it already here?

Dr Rajesh Malhotra: Epidemic has not checked off. Secondly, virus has not been conquered. There is always a risk that it could come back in a way that it could escape the immune system and the vaccination. UK and USA are going through fourth wave, Japan is going through the fifth wave while many countries like South Africa and Bangladesh are suffering from third wave. Many states of India, like Kerala are already going through the third wave. Think Globally, Nationally and Locally. Every area and state needs to have its own plan of action but keep a check on what is happening in other nations and learn from their experience. Nobody should feel secure depending on the number if cases in their states and the strategy should be locally relevant.

Is the healthcare infrastructure of India prepared to face the similar number of cases like the second wave?

Dr Rajesh Malhotra: I would agree that each hospital is better prepared because there are very competent healthcare professionals in our country. Every state is making position for ICU care, thrust on pediatric care and augmenting their healthcare infrastructure. 

Herd immunity is being approached, which is why we may not have such a huge a surge. We were caught off guard during the second wave because after the first wave, serosurvey showed high seropositivity. Firstly, since we did not have vaccines at that time, the natural immunity weenedoff gradually. Secondly, the variant emerged causing huge distinction between the first and second waves. 

On the contrary, now we have vaccines as a boost. The variant strain will be kept in mind. A lot of people who are vaccinated or immune due the previous infection can develop asymptomatic or minimally symptomatic re-infection and thus become spreaders. Hence, it is being insisted to follow the Covid protocols.

How important it is for children to get vaccinated?

Dr Rajesh Malhotra: We keep on saying that this virus will eventually become an endemic like HIV AIDS. It’s mortality will reduce. In the coming times, children will go for Covidvaccination like any other vaccine. About now, only children with serious comorbidity should be protected. It is now being said that Delta variant is as contagious as chickenpox or measles and as you know children cannot comply with mask in schools or social distancing. They may therefore spread it rapidly among themselves and people as well, which is why we are encouraging vaccination among children. Although, the mortality is very low among them.

A new study has shown that people who walk at least three to four hours per week, or bike at least two to three hours per week, or the equivalent after having a stroke may have a 54 per cent lower risk of death from any cause.

The findings of the research were published in the online issue of the medical journal ‘Neurology’. The study found the most benefit for younger stroke survivors. When people under the age of 75 exercised at least that amount, their risk of death was reduced by 80 per cent.

“A better understanding of the role of physical activity in the health of people who survive stroke is needed to design better exercise therapies and public health campaigns so we can help these individuals live longer,” said study author Raed A. Joundi, MD, DPhil, of the University of Calgary in Canada and a member of the American Academy of Neurology.

“Our results are exciting, because just three to four hours a week of walking was associated with big reductions in mortality, and that may be attainable for many community members with prior stroke,” added Joundi.

“In addition, we found people achieved even greater benefit with walking six to seven hours per week. These results might have implications for guidelines for stroke survivors in the future,” explained Joundi. The study looked at 895 people with an average age of 72 who had a prior stroke and 97,805 people with an average age of 63 who had never had a stroke.

Average weekly physical activity was evaluated from questions about activities such as walking, running, gardening, weight training, bicycling and swimming.

ACL (Anterior cruciate ligament) is one of the main stabiliser ligaments of the knee joint. Injury or tear of the ACL is one of the most common injuries of the knee.

WHEN?

It can occur at any age or in any sport, but generally seen in young people during sports that involve pivoting of the knee like soccer, basketball, hockey and skiing, when sudden stops or changes in direction occur during jumping and landing. It is also a common injury in contact sports such as Kabaddi and Wrestling. The injury can happen to anyone in common activities like jumping across a puddle or if you miss the last step of the stairs in a rush or just simply climbing a stool.

Once torn an ACL can never repair itself. 40% of people can manage their sedentary life with occasional sports without a surgery but if someone wants to run/ jog or play even weekend sports regularly or they experience feeling of giving way (instability) and sense of discomfort then a surgery is recommended to protect the knee from repeated damage and future arthritis.

WHAT HAPPENS?

The ‘pop’ sound of ACL rupture may not be heard in every fresh injury case and we have to look for other common symptoms like:

1- Pain: If you have a minor injury, you may not feel pain. You may feel sore along your knee’s joint line.

2- Swelling: This is most likely to happen in the first 24 hours. You can reduce swelling by putting ice on your knee and elevating (raising) your leg on a stool or 2 pillows.

3- Trouble walking: If you’re not able to put pressure on your hurt knee to walk, climb stairs and walk on uneven ground. Some people find that the knee joint feels loose than it should be.

4- Less range of motion. After you damage your ACL, it’s very likely that you won’t be able to bend your knee like you normally would.

Symptoms in a chronic case: Instability is the most common symptom in an ACL deficient knee in which patient feels that his/her knee will buckle in certain movements/positions of knee especially while playing sports.

WHAT IS IT?

Ligaments are strong bands of tissue that connect one bone to another. The ACL is one of two ligaments inside the knee that cross in the centre and stop undue movement of your thigh bone (femur) on your shin bone (tibia).

WHO IS AT RISK?

1- Being female — possibly due to differences in anatomy, muscle strength and hormonal influences

2- Participating in certain sports, such as soccer, kabbaddi, basketball, gymnastics,

HOW IS IT DIAGNOSED?

-Detailed History: Your doctor will want to hear exactly how you injured your knee. He’ll look at both the knees to see if the sore one looks different.

-Clinical Examination: Your doctor may ask you to lie on your back and bend your hips and/or your knees at certain angles. He’ll then place his hands on different parts of your leg and gently shift the leg around. If any of your bones move in a way that isn’t normal that could be a sign that your ACL is damaged.

-X-ray: Soft tissues like the ACL don’t appear on X-rays, but your doctor may want to rule out broken bones.

-MRI: This exam can show both soft tissue and bone. If you have a damaged ACL, it shows up on the scan.

TREATMENT

Treatment depends on how badly you’ve been hurt.

First is first aid: If your injury is minor, you just put ice on your knee, elevate your leg, and stay off your foot for a while. You can reduce swelling by wrapping a crepe bandage around your knee. Crutches/walker can help you to keep weight off your knee.

Medication: Analgesics and anti-inflammatory drugs help to reduce swelling and pain. Rarely for intense pain and swelling, you may have to get the blood aspirated and get an injection into your knee with a steroid.

Knee brace: Some people with a damaged ACL can get by with wearing a brace on their knee when they run or play sports. It provides extra support. Surgery is done when all else fails and is called Arthroscopic ACL reconstruction in which Surgeon will remove the damaged ACL stump through a keyhole and replace it with a graft sometimes made from the core of your hamstring muscle or a fibre tape.

The writer is Orthopedic and Joint Replacement Surgeon, NHS Hospital, Jalandhar

Thinking is one of the primary functions of conscious brain and the process itself is continuous unless we focus on stopping the thoughts from forming. Overthinking on the other hand is complained when an individual is continuously analysing and building scenarios over something. Most people feel they are exhausted because of thinking all the time, analysing and categorising experiences, interpreting and projecting them and re-running the same or alternate projections. This is called obsessive rumination and is particularly prominent in anxious people. The consequences can be from lack of concentration the inability to enjoy the present and is often associated with anxiety and mood disorders. The performance at work thus declines, interpersonal relationships suffer and productivity is reduced.

Therefore, relaxation and mediation practices are recommended to still the mind. But it’s easier said than done. People with this problem are so habituated to it, that in any given scenario, the processes of analysis, interpretation and projection become automatic and often people don’t know if there is any other way. Seeking professional help is thus advisable because changing a patterns takes time and an exhausted mind is also impatient and impulsive.

One needs to first acknowledge the problem and need to consciously decide to change. It’s like promising yourself to change a habit like smoking or drinking. Next step is to draw a plan, like as soon as one realises that one is stuck on a thought or a scenario, one needs to tell oneself to stop. It will take more than one attempt to do that, so patience and consistency are the key. One may take help of a friend or family member also, asking them to distract them or indulge in a creative activity that one enjoys. Physical exercise, dance, music and art help too. At work also, if one feels one is repeatedly thinking of what and how instead of doing it, write down the thoughts once and then keep them aside, telling oneself to get back to the process if a new scenario turns up.

Detaching oneself from the outcomes of a process is age old wisdom of Bhagwat Geeta which serves the essence of this exercise. Focus on works and not rewards, if one is able to do that, reward will automatically come.

The writer is Senior Psychiatrist and Founder & Director of ‘Manasthali

As we come on terms with the relentless onslaught of the war waged against humanity by the most primitive of living things, a virus, we find that for most of our illnesses, only we are to be blamed. Yes, I am talking about the Covid-19 pandemic that has brought the entire world to its knees.

We had only begun to understand the working of the virus and remarkably, we were able to figure out ways and means to prevent and treat the disease caused by the virus. But then there was the malady of self-medication, practicing of unscientific measures, which proved in many ways the inherently unrealistic approach of most humans. I personally know of many people who started their own therapies for Covid management. Alas, we were faced with unheard of conditions like Black Fungus (Mucormycosis) and now Bone Death (Osteonecrosis). The scientific community is not ruling out the incessant usage of life saving steroids for the unexpected rise in both Black Fungus and Bone Death cases.

The single factor that could be blamed for this upsurge in such cases was steroid use. It is an exercise for statisticians to determine whether these drugs were genuinely prescribed by doctors or blatantly self administered by some people. In vulnerable people who have other medical problems like diabetes, injudicious use of some medicines can be catastrophic and lead to disaster as the body’s immunity is severely compromised, allowing unusual conditions to surface.

Bone death is not something novel. It is the necrosis or death of certain areas of bone, especially the upper part of the thigh bone and a few other bones which results in crippling arthritis and disability. While this condition was known by names such as Osteonecrosis and Avascular Necrosis during the normal times, the pandemic has given it a new name, i.e., Bone Death. A significant percentage of Bone Death patients are found to have a history of alcohol abuse and steroid use, which clearly indicates that Covid-19 by itself is highly unlikely to cause the condition. It is more likely to target patients who are on steroids.

As of today, there are just a handful of patients in India who have had post-Covid Bone Death but it is something that needs a high degree of attention and the awareness on part of healthcare workers as well as patients themselves. There is no sure shot way of preventing its occurrence but there are definitely measures that can be taken for its early recognition and identifying the group of patients who are at greater risk.

In medicine, we always say prevention is better than cure and it’s true here as well. Osteonecrosis, once established, usually requires surgery and sometimes joint replacement too. Doctors are a part of the society who are just a bit more informed and aware of the health issues and it takes a very long time to become an efficient doctor. It is in the best interest of patients to trust doctors and try not to indulge in self-harming medication. Adversity is the best teacher and this pandemic has proven the adage quite well.

We will get benefitted as more data is collated regarding all the manifestations of this viral infection and what it does to the various organs. This is no time to be scared but it is also not a time to be unduly belligerent. Bone Death is not trivial and it is paramount that it is recognized and treated. General rule – post Covid, having hip pain that is not getting better with time – go and see your Orthopaedician and follow his advice. Wishing good health to all.

The writer Senior Orthopaedician, Deep Hospital, Ludhiana.

Scientists have developed a way of using infra-red technology to rapidly test which patients are most at risk of becoming severely unwell from Covid-19.

It’s hoped the test — which performed with 85 per cent accuracy in a small pilot study of Covid-19 patients in India — could in future be used to triage patients in areas with large outbreaks of the disease.

The study was led by QIMR Berghofer Medical Research Institute and the Indian Institute of Technology in Mumbai. It has been published in the journal Analytical Chemistry. The head of QIMR Berghofer’s Precision and Systems Biomedicine Research Group, Associate Professor Michelle Hill, said the test was developed through an international collaboration between academia and industry using blood samples from 128 Covid-19 patients in Mumbai, India.

“We established a method to safely handle potentially infectious blood samples. We then passed this to our collaborators in India, who used it to measure 128 blood samples with an infra-red spectrometer on loan from Agilent Technologies,” Associate Professor Hill said Infra-red spectra measure the levels of different chemical groups in a sample.

The head of QIMR Berghofer’s Statistics Unit, Dr Gunter Hartel, then used artificial intelligence to develop an algorithm to work out which chemical groups, or ‘signatures’, were correlated with patients who became severely unwell.

“We found there were measurable differences in the infra-red spectra in the patients who became severely unwell. In particular, there were differences in two infra-red regions that correspond to sugar and phosphate chemical groups, as well as primary amines, which occur in specific types of proteins,” Associate Professor Hill said.

“We also found that having diabetes was a predictor of becoming severely unwell in this group of patients, so we fed this information into the algorithm.

“We then tested the algorithm on blood samples from a separate group of 30 patients from Mumbai and found it was 85 per cent accurate in predicting which patients would become severely ill.

“However, it did result in more ‘false positives’ than predictions that were based solely on the clinical risk factors of age, sex, hypertension and diabetes. We hope that with more testing we can reduce these false positives.”

The head of the Proteomics Facility at the Indian Institute of Technology, Professor Sanjeeva Srivastava, said the finding that there were chemical differences in more severe Covid-19 cases was consistent with published studies conducted in other countries.

“From our study, we can say that there is a correlation between blood chemical signature and becoming severely unwell with Covid-19,” Professor Srivastava said. “However, we can’t conclude that slight differences in these chemical groups cause patients to become more unwell. We can only conclude that there is an association.”

The study’s lead author and Indian Institute of Technology PhD candidate Arghya Banerjee said further validation was now needed. “We now need to test the method in additional patient groups to confirm whether the findings of this study can be applied to other populations,” he said.

Associate Professor Hill said if the infra-red test proved successful in further trials, the teams hoped it could be used in hospitals facing high volumes of Covid-19 patients.

The study was primarily funded by India’s Science and Engineering Research Board, the Government of India, a grant from the Indian Institute of Technology, and QIMR Berghofer Medical Research Institute. The project was performed with clinical collaboration from the head of the Microbiology Department at Kasturba Hospital in Mumbai, Dr Jayanthi Shastri.