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Issue Editor : Dr. Saurabh Mohite

Executive Editor : Dr. J. Ravindranath

Assistant Editor : Dr. R. Sengupta

Editorial BoardDr. Nitin AbhyankarDr. Shrirang PanditDr. Vijay Natarajan

Dr. Jaydeep Date Dr. Dattatraya DhavaleDr. Mahesh Thombare

Dr. Bharat DikshitDr. P. K. Sharma

Board of TrusteesShri. Mukundas M. Lohia PresidentShri. Hasmukhlal A. Shah Vice PresidentShri. Devichand K. Jain Mg. TrusteeShri. Rajkumar H. Chordia Jt.Mg. TrusteeShri. Rasiklal M. Dhariwal TrusteeShri. Chandmal M. Parmar TrusteeShri. Dahyabhai M. Shah TrusteeDr. Chensukhlal J. Munot TrusteeShri. Amichand K. Sanghvi TrusteeShri. Hemraj D. Katariya TrusteeShri. Kiritbhai R. Shah TrusteeShri. Champaklal V. Suratwala TrusteeShri. Mukunddas M. Kasat TrusteeShri. Bhabutmal P. Jain TrusteeShri. Purushottam M. Lohia TrusteeShri. Prakash R. Dhariwal TrusteeShri. Harinarayan J. Rathi TrusteeShri. Nainesh M. Nandu Trustee

* Views expressed by authors are their own and not necessarily those of the editorial board.

* For Private circulation only.* Copyright reserved.* Registration with Register of News Papers of India

No. - MAHBIL/2000/1809

Publisher, Printer & Editor : Mr. Devichand K. Jain, Managing TrusteeOwner of Bulletin : Rajasthani & Gujarati Charitable Foundation

through Poona Hospital & Research Centre, Pune 411 030.

Place of Publication : 27, Sadashiv Peth, Pune - 30.Name of Printing Press : Typographica Press Services 2181, Sadashiv Peth, Tilak Road, Pune 30.

Contents Page

Editorial 2

Breast Conserving Therapy 3Dr. Saurabh Mohite

Breast Reconstruction 6Dr. Abhishek Ghosh

Hospital Update 11

Chemo PORTS 19Dr. Saurabh Mohite

Use of Hydroxyurea with Wheatgrass in 21Thalassaemia Major / IntermediaDr. Vijay Ramanan

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Vol. 15, Issue No. 1 January-April 2014

PHRCBULLETIN

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Dear Readers,

Greetings from PHRC.

This bulletin focuses on Breast conservation therapy and the techniques of Breast Reconstruction.

Breast cancer is one of the most common cancers in our country. Unfortunately, for a majority of our patients, for myriad reasons, a modified radical mastectomy still remains the preferred surgical modality by both doctors and patients alike. This is despite the tremendous psychological trauma and the negative body image associated with losing a breast. Several meta-analyses have proved that the overall survival, cure rates and long term outcomes are the same for well selected conservation surgeries as compared to radical mastectomies.

This bulletin is an attempt to emphasize our conviction that, in this age and time, no woman should lose her breast, unless absolutely indicated.

We hope you enjoy this issue and provide us with inputs and suggestions for the forthcoming ones.

Thank you !

Regards, Dr. Saurabh Mohite Consultant Oncosurgeon Poona Hospital & Research Centre.

EDITORIAL

5*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081.

Breast Conserving TherapyDr. Saurabh Mohite*

Cancer is a leading cause of death around the world. The World Health Organization (WHO) estimates that without intervention about 84 million people will die of cancer between 2005 and 2015.The most prevalent cancer in the world is breast cancer and nearly one in four women with cancer in the world has breast cancer. Half of these are in developing countries.

TREATMENT OF BREAST CANCERFor a complete and optimal therapy for breast cancer, it should be a multidisciplinary approach with input from the patient, the surgeon, the diagnostic radiologist, the pathologist, the general practitioner, the radiation oncologist, the medical oncologist, nurses, and other health professionals.The outcome of patients with breast and other cancers is better if they are treated by a clinician who has access to a full range of treatment options in a multidisciplinary setting.

The primary goal in the treatment of breast cancer is to control the disease with the aim of achieving cure. The other desirable outcomes of treatment include: to improve survival rate, minimize the risk of distant metastases and / or local recurrence, cosmesis, relief of symptoms, and the return to a quality life as close to the life before diagnosis as possible.

The different modalities of treatment include surgery, radiotherapy, systemic therapy (cytotoxic drugs and hormonal manipulation) and treatment targeted at HER2. Surgery remains an important modality of treatment, to eradicate the primary tumor and achieve total disease control.

HISTORY OF SURGICAL MANAGEMENTThe initial surgical treatment of breast cancer was typically wide excision, but was associated with a high rate of local recurrence and poor survival. William Halsted popularized radical mastectomy in 1894. Radical mastectomy (RM) resulted in a significant drop in the local recurrence rate, but the curative potential remained limited.

Attempts with extended radical mastectomy, which included internal mammary node dissection, failed to improve survival. At different times, Modified Radical Mastectomy (MRM), Total (Simple) Mastectomy, and more recently, Skin sparing mastectomy (SSM) and Nipple sparing mastectomy (NSM) were introduced.

Although MRM is a less morbid procedure compared to RM, the patient will still suffer loss of the breast. The attempt to preserve the breast without compromising survival brought up the use of Breast Conserving Therapy (BCT). This includes breast conserving surgery and breast radiotherapy. Although BCT and breast conserving surgery (BCS) are used interchangeably, strictly speaking BCT includes both BCS and breast radiotherapy.

BCS is an important part of the breast-conserving therapy, which may be defined as a combination of conservative surgery for resection of the primary tumor with or without surgical staging of the axilla, followed by radiotherapy for the eradication of the residual microscopic disease of the breast, with or without adjuvant systemic therapy.

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BREAST CONSERVING THERAPYThe National Surgical Adjuvant Breast and Bowel Project (NSABP) B 06 compared Total Mastectomy to lumpectomy, with or without radiation therapy, in the treatment of stages I and II breast cancer. After five- and eight-year follow-up periods, the disease-free, distant disease-free and overall survival rates for lumpectomy, with or without radiation therapy, were similar to those observed after TM. However, the incidence of ipsilateral breast cancer recurrence (in-breast recurrence) was higher in the lumpectomy group that did not receive radiation therapy

PATIENT'S SELECTION FOR BCTThe four critical elements in selecting patients for breast conserving therapy are: A history and physical examination, breast imaging, histological assessment of the resected breast, and assessment of the patient's needs and expectations

CONTRAINDICATIONIf an attempt to preserve the breast is likely to be associated with high rates of in-breast recurrence, then BCT is absolutely contraindicated These situations are : Multicentric disease, diffuse malignant-appearing mammographic microcalcifications (suggesting multicentricity), persistent positive resection margin, prior radiotherapy to the breast or chest wall, and pregnancy. The main reason for contraindication in pregnancy is the need for radiotherapy, which will be contraindicated in pregnancy. BCT can therefore be performed in the third trimester, deferring breast radiotherapy until after delivery.

Relative contraindications are connective tissue disease, especially scleroderma & active systemic lupus erythromatosis (SLE) and a large tumor in a small breast.

Factors thought to be associated with the risk of breast cancer recurrence after BCT are now known to be unfounded as long as there is a negative margin on excision. Some of these are: age, positive family history of breast cancer,

skin or nipple retraction (not necessarily sign of locally advanced disease), tumor location, clinical or pathological axillary nodal metastases, histological subtypes and the presence of an extensive intraductal component.

SURGICAL TECHNIQUEThe essence of BCT is not only to preserve the breast, but also to have an a aesthetically acceptable result. The cosmetic appearance after BCT is determined by surgical factors like: size and placement of incision, management of the lumpectomy cavity, and extent of axillary dissection, if necessary. The surgical technique can therefore make a difference. The goal at the end is to have a cosmetically acceptable outcome without compromising local tumor control.

In planning the incision, the surgeon had to take into consideration the location of the lump, type of incision, depth of mass from the skin, and the incision had to be close to the lump to avoid tunneling.

In order to reduce the local failure and to improve the outcome in breast cancer, there is need to emphasize the surgeon's role in improving patient selection and optimizing the procedure.

The incision should be sited in such a way that if mastectomy is eventually required, it can be included in the mastectomy specimen. In the upper part of the breast, incisions should be curvilinear or transverse, while in the lower part, they should be either curvilinear or radial.

An improved adequate surgical margin is crucial and can be achieved without an excessive re-excision rate, with detailed planning, consideration for oncoplastic resection, and intraopertive margin analysis.

What constitutes an adequate margin of a grossly normal breast tissue around the tumor in BCT is uncertain. In one series, resection of 0.5 to 1.0 cm of grossly normal tissue resulted in a histologically negative margin in 95% of 239 patients.

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The surgical technique must ensure adequate excision. Obtaining a tumor-free surgical margin decreases the incidence of a local recurrence (LR) of the primary tumor.

There are various risk factors associated with a positive margin, among them are: the extent of excision, age, large tumor size, multifocality, lobular histological type, and the number of positive lymph nodes.

In 30 of 34 reviewed studies, persistent micro- scopic inadequate (R1) or macroscopic inadequate (R2) surgical margins were highly significant for LR compared to the negative margin (p = 0.0001.Microscopic disease resulting from a positive margin is more problematic because theoretically, cancer in the relatively hypoxic environment of the lumpectomy scar bed will be resistant to radiation therapy. Furthermore, the inability to achieve negative margins may be a marker of an excessive tumor burden in the treated breast.

In order to ascertain a negative margin, intra- operative margin assessment (IOMA) has been found to be useful. This includes : gross inspection in the operating room, with or without frozen section analysis, cytologic touch prep (CTP) analysis, shaved margin (SM), and intraoperative ultrasound (IOUS). Although these assessments are useful, they do not guarantee an absence of microscopic tumor on permanent section.

At the completion of the excision, the surgeon should ensure adequate hemostasis. Drainage of the lumpectomy cavity should be avoided

and it should be allowed to fill with serum and fibrin. This will give the best cosmetic result. As suggested by Morrow et al., reapproximation is best avoided, as it can result in distortion of the breast contour, which may not be apparent with the patient supine on the operating table. In a situation where the lumpectomy cavity is large, latissimus dorsi reconstruction of the defect may be appropriate

The incision should be closed with a subcuticular suture.

COMPLICATIONSSeroma formation, arm morbidity (arm swelling, arm pain, arm numbness, arm stiffness, shoulder stiffness, shoulder pain, & nerve injury), phantom breast syndrome, delayed cellulitis and pain syndromes of the chest wall, axilla, and upper extremity are known complications after breast cancer treatment. Some of these complications, especially arm morbidity are less common in BCT as compared to mastectomy, and less frequent with sentinel lymph node biopsy than after axillary lymph node dissection.

CONCLUSIONAlthough getting a microscopic negative margin is still challenging, BCT as a surgical technique has revolutionalized the surgical treatment of early breast cancer. BCT has not only provided an acceptable oncological outcome, but has diminished the psychological burden, offered better cosmetic results, and reduced postoperative complications.

q q q

Neha found her uncle jumping up & down on the terrace with the great vigour.

‘What’s the matter, uncle?’ She asked surprised at the sudden display of energy.

‘The doctor forgot to shake the bottle before he gave me my medicine.’

8*Reconstructive, Cosmetic and Microvascular Surgeon, E-mail : drabhishekghosh@gmail.com ,Cell : 8551067257.

Breast Reconstruction

Dr. Abhishek Ghosh *

Breast reconstruction is now often considered as part of the breast cancer treatment when mastectomy is required. There has been an increase in the number of women undergoing reconstruction after breast cancer surgery due to increased patient awareness and numerous reconstruction options.

Patients are educated at the plastic surgery consultation regarding the need for multiple procedures required to resect the breast cancer, reconstruct the breast mound & create a projecting nipple & areola. This should especially be discussed in the context of immediate reconstruction where avoiding any delay to adjuvant treatment is an important consideration.

Immediate Breast ReconstructionThe previous fears that immediate breast reconstruction might delay recurrent cancer detection or have a negative impact on prognosis of breast cancer, have been largely discarded. There is no evidence that immediate reconstruction increases the rate of local or systemic relapse. Overall, patients benefit from the reduction in psychological trauma experienced after mastectomy by undergoing immediate breast reconstruction. One of the major advantages of immediate breast reconstruction includes a reduction in the number of operations ultimately necessary to create a reconstructed breast mound following excision of the breast. Disadvantages of immediate reconstruction include extended surgical time and potential complications of

the mastectomy, such as skin loss or infection, which may adversely affect the reconstruction. Perhaps the greatest disadvantage of immediate reconstruction is the inability to predict (in many cases) who will need adjuvant radiation.

Delayed Breast ReconstructionDelayed reconstruction may be performed several days to years after mastectomy. Advantages of delayed reconstruction include increased time to allow for adequate skin flap healing, making the tissues more mobile and pliable, as well as increased time to allow for patient recovery. Also the patient is more inclined to accept less than perfect symmetry after she has lived with loss of a breast. Disadvantages include multiple procedures to obtain the same result as with immediate reconstruction .

Chemotherapy and ReconstructionAdjuvant systemic therapy in the form of chemotherapy or hormonal therapy is routinely administered to women under the age of 70 if they are node positive & to the majority of women with tumors > 1 cm. Chemotherapy can be delivered to patients with implants, tissue expanders or flaps as soon as the wound has healed and there are no signs of underlying infection. Most studies have shown that a delay in the initiation of chemotherapy following immediate breast reconstruction happens only 1% of the time.

Radiation and ReconstructionSpecial consideration is given to women who will require adjuvant radiation and women who have

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received chest radiation in the past. Regardless of timing, radiation forever compromises the quality of the skin and underlying muscle, resulting in a higher incidence of complications, unsatisfactory expansion and a poorer aesthetic result. Women with obvious radiation-induced skin changes prior to reconstruction should undergo autogenous tissue reconstruction.

What are the different types of breast reconstruction procedures that are available?The two types of breast reconstruction are implant of a prosthetic device and the use of one's own tissue to reconstruct the breast (autologous reconstruction).

Implant reconstruction : This procedure replaces the patient's tissue with a saline or silicone implant. Depending on the patient's chest wall characteristics, the implant can be placed immediately at the time of the mastectomy. However, in a majority of patients, a temporary implant known as an “expander” is placed into the pocket of empty space of the mastectomy. The expander's role is to keep the pocket for the implant open as the skin heals from the mastectomy. Expansions will be performed to create a breast mound that is generally smaller than the final implant. Patients often find this process helpful as they can progressively decide what size of implant they may want to have. Once the patient is fully expanded the expander is exchanged for an implant.

Autologous reconstruction : This group includes procedures where one's own tissue is used. The options of tissue that can be used include tissue from the following areas : abdomen (TRAM, DIEP, SIEA), back (Latissimus), upper (SGAP) or lower buttock (IGAP), and inside of the thighs (TUG). Another type of reconstruction that has been recently utilized is a series of procedures that utilize the patient's own processed fat to create a breast. This procedure is termed “fat

injection” and is sometimes used in combination with implant-based or autologous reconstruction.

TRAM Flap Breast ReconstructionThe transverse rectus abdominis myocutaneous (TRAM) flap is a popular technique for breast reconstruction using autogeneous tissue from the rectus abdominis muscle and overlying subcutaneous fat and skin.

The TRAM flap can be harvested as either a free or a pedicled flap. In a pedicled TRAM, the entire length (or a large section) of the rectus abdominis muscle along with a transverse section of subcutaneous tissue and skin is tunneled to the location of the mastectomy defect where it is then molded into a breast. The pedicled TRAM flap maintains its native blood supply from the superior epigastric vessels.

In a free TRAM, only part of the rectus muscle is used and the flap (which includes its attached pad of subcutaneous fat and skin) is totally detached from its surrounding tissues &transferred to its new location based on the deep inferior epigastric vessels, termed the pedicle.

The DIEP flap is a perforator based flap in which no rectus muscle is taken which prevents herniation in the donor site. The pedicle of the harvested flap is then anastomosed to recipient vessels in the axilla (thoracodorsal vessels) or chest wall (internal mammary or intercostal vessels).

While it's the most popular autologous breast reconstruction procedure, a TRAM flap isn't for everyone. It's not a good choice for:

• thin women who don't have enough extra belly tissue

• women who smoke• women who already have had multiple

abdominal surgeries• women who plan on getting pregnant

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Fig 1 : Woman after mastectomy, showing (TRAM) and surrounding tissues, in preparation for reconstruction.A - mastectomy siteB - right rectus abdominis muscleC - left rectus abdominal muscleD - segment of abdominal tissues : skin and fat, to be transferred along with muscle to create the new breast.

Patient intraop TRAM reconstruction.A - lines of reconstructed breast incisionsB - right trans rectus abdominis muscleC - left TRAM muscle is swung over to re–create the new breastD - incision circle of re–positioned umbilical in-cisionE - line of abdominal surgery

Free DIEP flap harvestPost operative picture of free Diep flap with nipple

reconstruction(1 year followup)

Tissue Expander Breast ReconstructionWhile many feel that autogenous breast reconstruction offers superior results to alloplastic reconstruction with tissue expansion/implants, many patients choose this method over autogenous options. Tissue expansion offers a faster & less complicated operation, decreased hospitalization, no donor site morbidity and more rapid recovery than autogenous reconstruction.Currently prosthetic reconstruction with expanders is done as a two-stage technique. Stage one is the placement of the tissue expander and stage two is the removal of the tissue expander and exchange with a permanent implant.

Indications for SurgeryIndications for prosthetic breast reconstruction include patients undergoing a modified radical mastectomy or with significant congenital deformities who desire this technique of reconstruction for their breast deformity. It is also indicated for patients who do not qualify for autogenous reconstruction secondary to obesity, scars, lack of available tissue, or co-morbidities. Commonly, if being performed for breast cancer reconstruction, the first stage is completed at the time of the modified radical mastectomy.While not an absolute contraindication, this technique is relatively contraindicated in patients

Continued on Page 17....

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Hospital UpdateCONGRATULATIONS –l Dr. Kiran Lale & Dr. Varun Nivargi for successfully passing DNB General Medicine.

FOUNDATION DAY CELEBRATION -On 8th March 2014, Poona Hospital completed 29th year of existence in the medical service of thecity.Like every year the celebration began a week in advance with a series of Tournaments & Matches.Also an enormously popular Antakshari competition & various fun games were held. A large numberof staff, residents & consultants participated in these activities with great enthusiasm.On the evening of Foundation Day a variety entertainment programme showcased the in-housetalent in singing, dancing and acting skills followed by a Live Orchestra. The hospital staff looksforward to these events throughout the year.Consistent good performance amongst various categories of staff was awarded. The recipients of theseawards were Mrs. Anagha Gandhi, Ms. Jobina Vergis, Ms. Sonali More & Mr. Ashok Jadhav.The most coveted trophy of the best department went to the Cardiac Recovery Department.The hospital congratulates all the above employees & departments once again.

As a part of the same celebration an annual get together of the Donors and Members of the Rajasthani& Gujarati Charitable Foundation was organised on 7th March, 2014 comprising of a MusicalEntertainment Programme followed by dinner.

l Blood Donation Camps -A total of 11 Blood Donation Camps were arranged during the months from November 2013 toFebruary 2014 at various places the response at all these camps was very encouraging, a total of1010 people donated blood during these camps.

CME’S, SEMINAR’S & TRAINING PROGRAMMES –l Dr. Jayashree Todkar arranged an Obesity Patients Meet on 15th December 2013.l Indian Society of Anaesthesiologists, organized a CME on ‘Myths and Facts of Anticogulation’ on

24th December 2013.l Dr. Jayashree Todkar organized An ‘Advanced Laparoscopic Surgery Workshop’ with the theme-

‘Laparoscopic Surgery Simplified for GI and Solid Organs’ on 19th January 2014.l A 3 days Certificate Course of ‘Advanced Cardiovascular Life Support & Basic Life Support’ was

organized in joint collaboration with Symbiosis Institute of Health Sciences, comprising of lectures,presentations & examinations on 27th - 28th February 2014 & 1st March 2014.

l Diabetic Association of India, Pune Branch arranged a lecture on ‘Prevention of Heart Disease’ on02nd March 2014.

l Department of Medicine, Poona Hospital & Research Centre organized the following CME’s on1. ‘Polymerase Chain Reaction’, ‘ELISA’ & ‘Adult Vaccination’ on 22nd January 2014.2. ‘Iron Deficiency Anaemia’, ‘Megaloblastic Anaemia’ & ‘Myelodysplastic Syndrome’ on 11th

February 2014.3. ‘Hemolytic Anaemia’, ‘Polycythemia’ & ‘Aplastic Anaemia’ on 19th March 2014.

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DEPARTMENT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

MORNING 10 A.M. TO 12.30 P.M.

MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR

SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES

GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. A. SHAH DR. (MS) N. DESAI ----

PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----

ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----

E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----

OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE ---- DR. R. BHANGE DR. (MS) V. RAWAL ---- ----

PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI

DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE DR. H. S. CHOPADE DR. H. S. CHOPADE DR. H. S. CHOPADE ----

CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN

ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----

ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----

11.30 A.M. TO 12.30 P.M.

CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----

CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. SHIV GUPTA * DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only

DR. V. NATARAJAN DR. V. NATARAJAN

NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----

NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----

NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)

URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----

PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----

GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----

GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----

ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----

HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----

AFTERNOON 1 P.M. TO 3.30 P.M.

MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----

SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----

GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----

VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----

OPHTHALMOLOGY ---- ---- ---- ---- ---- DR. (MS) V. RAWAL ----

CARDIOLOGY---- ---- ---- ---- ---- ---- ----

NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----

SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----

ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----

ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----

SPECIALITY CLINICS

HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----

DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----

HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----

PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----

DR. V. KARMARKAR

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MORNING 10 A.M. TO 12.30 P.M.

MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR

SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES

GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. A. SHAH DR. (MS) N. DESAI ----

PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----

ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----

E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----

OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE ---- DR. R. BHANGE DR. (MS) V. RAWAL ---- ----

PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI

DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE DR. H. S. CHOPADE DR. H. S. CHOPADE DR. H. S. CHOPADE ----

CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN

ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----

ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----

11.30 A.M. TO 12.30 P.M.

CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----

CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. SHIV GUPTA * DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only

DR. V. NATARAJAN DR. V. NATARAJAN

NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----

NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----

NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)

URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----

PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----

GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----

GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----

ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----

HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----

AFTERNOON 1 P.M. TO 3.30 P.M.

MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----

SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----

GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----

VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----

OPHTHALMOLOGY ---- ---- ---- ---- ---- DR. (MS) V. RAWAL ----

CARDIOLOGY---- ---- ---- ---- ---- ---- ----

NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----

SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----

ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----

ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----

SPECIALITY CLINICS

HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----

DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----

HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----

PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----

DR. V. KARMARKAR

16

Rajasthani & Gujarati Charitable Foundation’s

POONA HOSPITAL & RESEARCH CENTRE

27, Sadashiv Peth, Pune 411 030.Tel. : 24331706, 66096000, Fax : 24338477

DEPARTMENT OF DENTAL SURGERYTimings Monday Tuesday Wednesday Thursday Friday Saturday

09.30 to Dr. Paresh Dr. Anjali Dr. Shashikant Dr. Charudatta --- Dr. Surendra11.30 a.m. Gandhi Gandhi Bamb Naik Rathi

12.30 to Dr. Mukund Dr. Paresh Dr. Mukund Dr. Paresh Dr. Mukund Dr. Charudatta02.30 p.m. Kothawade Gandhi Kothawale Gandhi Kothawade Naik

03.30 to Dr. Shashikant Dr. Surendra --- Dr. Shashikant Dr. Surendra Dr. Anjali5.30 p.m. Bamb Rathi Bamb Rathi Gandhi

16

CASHLESS FACILITIES

TPAs : The following TPAs (Third Party Administrators) have a tie up with Poona Hospitalfor their members to avail of the treatment facilities provided by the hospital.* Medi Assist India Pvt. Ltd. * Genins India Ltd.* Medicare TPA Services (I) Ltd. * Park Mediclaim.* MD India Health Care Services Pvt. Ltd. * Raksha TPA Services.* Paramount Healthcare Services Ltd. * Dedicated Health Care Services.* Health India (Bhaichand Amoluk Ins.)

INSURANCE COMPANIES : Poona Hospital also provides cashless facilities topolicy holders of the following Insurance Companies* ICICI Prudential, * MAX BUPA Health Insurance* Bajaj Allianz Gen. Insurance Co. Ltd. * Cholamandalam MS Gen. Ins.* Future General Total Insurance Solutions * Religare Insurance Co. Ltd.* Star Health & Allied Insurance Co. Ltd. * Apollo Munich* IFFco Tokio General Insurance * Reliance General Insurance* ICICI Lombard General Insurance (I Health Care),

17

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Continued from Page 8....

who will receive perioperative radiation therapy.

Side view of breast area with unfilled tissue expander in place.A - tissue expander–unfilledB - portC - catheterD - syringeE - ribsF - pectoralis major muscleG - Other muscles of the chest wall.

In general, thesepatients should undergo an autogenous or delayed reconstruction.

Side view of breast area with filled tissue expander in place.A - tissue expander–filledB - portC - catheterD - syringeE - ribsF - pectoralis major muscleG - Other muscles of the chest wall.

Latissimus Flap Breast ReconstructionThe latissimus dorsi musculocutaneous flap was originally described almost a century ago as a method to cover radical mastectomy defects which included a wide skin excision. In recent years, there has been a resurgence of the latissimus flap. Improvements in tissue expansion and implant design, as well as the ability to perform complete

autologous reconstruction in selected patients has, once again, put the latissimus flap in the forefront of breast reconstruction.IndicationsThe latissimus dorsi flap is a good option for women with small - to - medium sized breasts because there's usually not much fat on this part of the back.

Pre operative patient with LD muscle LD muscle swung anteriorly to reconstruct the breast mound

Post mastectomy defect

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Reconstruction with Pedicled LD muscleflap with nipple/areola graft

Nipple Reconstruction and TattooingThe final stage in breast reconstruction is creation of the nipple-areolar complex (NAC), which carries aesthetic and psychological importance to patients. The current trend is the use of local dermal flaps along with tattooing. These methods have proven to be cost-effective and carry low morbidity.

Indications and TimingA patient undergoing NAR can have nipple creation and tattooing performed simultaneously or as two separate procedures.

It is recommended to delay NAR for approximately

Nipple reconstruction with skate flap

3-6 months after breast reconstruction in order to achieve stable breast volume, overlying skin and contour.

Conclusion : The wide variety of choices in breast reconstruction and increasing expertise has made breast reconstruction a feasible option to offer to our patients. The increase in awareness and patient demands have resulted in an increase in the number of reconstructions. Further awareness is needed to educate the patients so that breast reconstruction becomes a part and parcel of the breast cancer management protocol.

q q q

One afternoon, a man went to his doctor and told him that he hadn’t been keeping well lately. The doctor examined the man, left the room and came back with three different bottles of pills. Then he gave the patient the following instructions: ‘Take the green pill with a big glass of water after you wake up. Take the blue pill with a big glass of water after you eat lunch. Then just before going to bed, take red pill with another big glass of water.’ Startled at being put on so many medicines, the man stammered, ‘My God, Doctor, what exactly is the problem with me?’ The doctor replied solemnly, ‘You’re not drinking enough water.’

21*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081.

Chemo PORTSDr. Saurabh Mohite *

Chemotherapy is now an integral part in the treatment of breast cancer. As a rule, almost all cases of breast cancer, regardless of the stage of disease, benefit from chemotherapy. It is used in the neoadjuvant and adjuvant settings, and with curative and palliative intents.

A major problem in the administration of chemotherapy; and also a cause of significant morbidity, is securing intravenous access. The veins on the operated side cannot be accessed due to risk of thrombosis. Besides, almost all chemotherapeutic agents are cytotoxic &can cause significant thromophlebitis & tissue reactions on extravasation. The veins may not be accessible in the obese or in children. Patients who have undergone bilateral breast surgery obviously cannot be administered chemotherapy through peripheral lines.

A Chemo PORT is strongly recommended in all of the above.

What Is a Port for Chemotherapy ?

A chemotherapy port (also known as a port-a-cath) is a small device that is implanted under the skin to allow easy access to the bloodstream. A port can be used to draw blood, infuse chemotherapy drugs and for transfusion of blood products.

How Is a Port Inserted ?

Usually a day care procedure, PORTs are usually placed at least a week before the start of chemotherapy. They can also be safely placed at the time of primary surgery for the cancer, thereby reducing costs and hospital stay.

During insertion, a small round metal or plastic disc is placed under the skin through an inch-or-two-long incision. This may be located on the upper chest or occasionally the upper arm. This port is then attached to a catheter tube that is threaded into one of the large veins near the neck, such as the subclavian vein or jugular vein.

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After the port is placed, a slight protrusion is noticed over the chamber site. During blood draws or chemotherapy infusions, a needle is inserted into an area called the "septum," a resealing rubber/silicon center on the Port. Since the port is completely under the skin, the patient can bathe and swim without being concerned about getting an infection.

Benefits• Greater comfort – A single needle stick through

the skin is usually all that is needed to access the port. With IV therapy and traditional blood draws, sometimes many needle sticks are needed to find a good vein, especially if the veins have been damaged from repeated blood draws and infusions.

• Avoiding delays and multiple needle pricks in attempts to secure a good peripheral IV access

• Lowering the risk of "extravasation" – When an IV is used, medications are more likely to leak (extravasate) into the tissues surrounding the hand or arm. Since many chemotherapy medications are caustic to tissues, a port can reduce the risk of inflammation related to leakage of these medications.

• Easier bathing and swimming – Since a port is completely under the skin one can usually bathe and even swim without being concerned about the risk of infection.

Possible DrawbacksPossible risks include :

• The risk of the surgical procedure to install the port.

• Rare (less than 1%) complications of insertion can include bleeding (such as if the subclavian vein is punctured) and pneumothorax (collapse of the lung)

• Infection – The risk of infection varies in studies but isn’t uncommon. If a port becomes infected, it will often need to be removed and replaced.

• Thrombosis – A clot may form in the port or catheter, causing it to stop working. Between 12 and 64% of people who have a port placed for chemotherapy will develop a thrombosis (clot) in the catheter (often causing a need for the port to be replaced.)

• Mechanical problems that cause the port to stop working – In some cases mechanical problems, such as movement of the catheter or separation of the port from the skin, can cause a port to stop working.

• Limitations in activity – Though activities such as bathing and swimming are usually okay, the oncologist may recommend holding off on exercises to strengthen the upper body or arms until the port is removed.

• Scarring–Given the gravity of cancer treatment, a scar from the port is a relatively minor drawback. But some people may find a scar on their upper chest disturbing for cosmetic reasons or because it is a symbol that they once went through chemotherapy.

q q q

Having recovered from a serious illness, Nikhil had gone for a final checkup to the doctor.

Smiling brightly the doctor said, ‘Young man, you owe your fine recovery to your wife’s tender care.’

With a twinkle in his eyes Nikhil replied, ‘Thanks doctor. I will make out the cheque to my wife.’

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IntroductionB-thalassaemia is caused by mutations in the β-globin locus resulting in loss of or reduced hemoglobin A (HbA, α2β2) production.

Hydroxyurea, an antimetabolite, is a potent inducer of HbF production.

Mechanisms :1. A cytotoxic effect resulting in stress erythro-

poiesis, with increased HbF levels occurring as a result, is most commonly proposed.

2. More complex effects involving the production of nitric oxide and the soluble guanylyl cyclase and cyclic guanosine monophosphate–dependent protein kinase pathway gene have been proposed as being responsible for this activity.

Hydroxyurea therapy is not associated with considerable or steady effects on erythrocyte deformability in β- thalassemia, which may explain the reduced response to the drug in some patients.

Wheatgrass contains Chlorophyll which makes up >70% of the solid content of wheat grass juice. Both chlorophyll and hemoglobin share a similar atom structure. Hemoglobin consists of iron, while in chlorophyll the metallic atom is magnesium. The believers of alternative system of medicine claim that as chlorophyll and hemoglobin are alike in atom structure, intake of wheat grass juice enhances hemoglobin production.

The treatment of transfusion dependent b-thalassemia imposes a considerable burden on the family and

*Consultant Haematologist, E-mail : mvijayr@gmail.com , Cell : 9325315471.

Use of Hydroxyurea with Wheatgrass inThalassaemia Major / Intermedia

Dr. Vijay Ramanan *

institutional resources. In economically challenged nations, basic management (red cell transfusions, iron chelation) is a distant dream for the majority, who, consequently, endure a poor quality of life.

Aims and Objectives :To study the effect of hydroxyurea and wheatgrass in reducing the frequency of blood transfusion.

Materials and MethodsThe study was carried out between January 2008 and June 2013 on 74 patients diagnosed as Betathalassaemia by HPLC.

Randomly selected 74 patients with transfusion dependent B-thalassemia, were recruited for the study.

Patients were enrolled irrespective of whether they were receiving chelation therapy with defiriperone /desferrioxamine or not.

A medical doctor exclusively on the roll of thalassemia center maintained records of the study subjects.

Exclusion criteria :1. Indiscipline in intake of wheat grass and

hydrxyurea tablets. This included interruption in intake exceeding 3-days/week or more than 7-days month.

2. Hydroxyurea was not administered below 2 years of age.

Methodology• Our index case gave me insight into follow up

in these cases. He had been transfused for over 30 years but first transfusion was after 1 year of age.

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• I realised the real effect of Hydroxyurea +/- Wheatgrass can only be judged by allowing the hemoglobin to fall upto 5 to 6 gm% with pulse rate never crossing 120/min.

• This level allows the inherent hemoglobin synthesis to start i.e HbF synthesis. If a patient doesn’t receive transfusion for over 3 months then it translates into

TRANSFUSION INDEPENDENCE

Patients have better energy levels in general. They don't become unenergetic close to their previous transfusion period.

Patients without palpable spleen, those who underwent splenectomy as well as those who required first transfusion after 1 year of age could become transfusion independent to great extent.

There are 3 children who presented at age of 5 to 7 months, who have received wheatgrass and have not been transfused for 12 to 14 months. Meaning a Thalassaemia Major can probably be converted to Thalassaemia Intermedia with Wheatgrass alone or with Hydroxyurea.bmtpune@gmail.com09923693304 / 09890661341 / 09325315471www.vijayramanan.comDownload - Anemia Diagnosis App

q q q

Sardarji : Doctor, I have a problem. Doctor : What’s your problem?

Sardarji : I keep forgetting things. Doctor : Since when you had this problem?

Sardarji : What problem?

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*Consultant Oncosurgeon, E-mail : saurabhmohite1@gmail.com , Cell : 9220451093, 7387000081.

ñVZm_Ü`o hmoUmè`m JmR>tn¡H$s \$ŠV 10% JmR>r `m H$H©$amoJmÀ`m AgVmV. {ó`m§_Ü`o H$H©$amoJm{df`rÀ`m Om{UdoMr nmViro gm_m{OH$ d Am{W©H$ nmíd©^y_rZwgma Am{U e¡j{UH$ nmÌVoZwgma doJir Agë`mMo bjmV `oVo. ^rVr, bmOo_wio AZoH$ {ó`m hr JmR> KamVë`m AJXr OdiÀ`m ì`ŠVrnmgyZhr bndyZ R>odVmV.

_J S>m°ŠQ>an`ªV H$Yr nmohmoMUma? AZoH$ {ó`m§Zm ñdV:bm OmUrd Agbr Var Hw$Qw>§~mVyZ nm{R>§~m {_iVmoM Ago Zmhr. `m gJù`m AS>MUr ~mOybm R>odyZ {ó`m§Zr Amnë`m Amamo½`mMr H$miOr ñdV:M ¿`m`bm {eH$bo nm{hOo. _{hÝ`mVyZ EH$Xm R>am{dH$ doir hr VnmgUr H$aUo Amdí`H$ Amho.

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hr VnmgUr nwT>rbà_mUo nm`ar-nm`arZo H$amdr :-

n{hbr nm`ar

1) Amaemg_moa C^o amhÿZ XmoÝhr hmV H$_aoda R>odyZ XmoÝhr ~mOy§Zm ZrQ> {ZarjU H$am. Imbrb Jmoï>r AmT>iVmV H$m Vo nmhm.

l ñVZm§Mo AmH$ma, _mn d a§J Zoh_rà_mUo Amho H$m?l XmoÝhr ñVZm§Mm AmH$ma gmaIm Amho H$m? {H$§dm Hw$R>ë`mhr àH$maMr gyO AWdm

~Xb {XgVmo Amho H$m?l ñVZmÀ`m ËdModa IÈ>m, ómd AWdm EH$m ~mOyMo ñVZmJ« AmV AmoT>bo OmUo VgoM

ñVZmÀ`m Q>moH$mda ^oJm nS>Uo d doXZm hmoUo `mn¡H$s H$mhr bjUo AmhoV H$m?l ñVZmda bmbganUm AWdm OI_ Amho H$m?

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Mm¡Wr nm`ar

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2) AmVm, Amaí`mg_moa C^o amhÿZ XmoÝhr hmV H$mZm§n`ªV da ZodyZ XmoÝhr ñVZm _Ü`o ì`dpñWV {ZarjU Ho$bo AgVm darb à_mUo H$mhr \$aH$ {XgVmo H$m ho nmhUo.

3) Ooìhm Vwåhr Amaí`mg_moa C^o amhÿZ nmhVm Ë`mdoir ho nU {Z[ajU H$am {H$, Vw_À`m EH$m {H§$dm XmoÝhr ñVZm§VyZ ómd ~mhoa `oV Amho H$m? (hm ómd EImÚm doiog nmUrXma, XþYmi, {ndù`m a§JmMm qH$dm aŠV Aem ñdê$nmV Agy eH$Vmo) Xþgar d {Vgar nm`ar

4) Z§Va, {~N>mÝ`mda PmonyZ COì`m hmVmZo S>mdm ñVZ d S>mì`m hmVmZo COdm ñVZ em§VnUo VnmgUo. `mV hmVmMr ~moQ>o gai R>odyZ JmobmH$ma nÜXVrZo ñVZmJ«mnmgyZ gwadmV H$ê$Z ñVZmÀ`m eodQ>n`ªV JmobmH$ma nÜXVrZo hmV {\$adV hmVmMr ~moQ>o EH$Ì d gai AmhoV ømMr ImÌr H$am. gwadmVrbm hbŠ`m hmVmZo Z§Va WmoS>m X~md dmT>dyZ Vnmgm.

øm nÜXVrZo g§nyU© ñVZ danmgyZ Imbrn`ªV VnmgyZ nmhUo. Vy_À`m Jù`m^modVmbÀ`m ImbÀ`m hmS>mnmgyZ (H$m°ba~moZ) nmgyZ Vo nmoQ>mn`ªVMm ^mJ nyU© Vnmgm. AJXr H$mIo_Ü`o gwÜXm gai hmVm§Mr ~moQ>o {\$a{dbr AgVm ~hÿVoH$ JmR>tMo {ZXmZ hmoVo.

Ë`mMà_mUo Xþgè`m nÜXVrZo åhUOo Vwåhr Vw_Mr ~moQ>o Cä`m gai aofoV dê$Z Imbr {\$adUo gwadmVrbm hbŠ`m hmVmZo Vnmgm. Z§Va WmoS>m X~md dmT>dyZ nyU© ñVZmbm Vnmgm. Aem àH$mao WmoS>m A{YH$ X~md åhUOo ñVZ nyU©nUo nmR>r_mJo N>mVrÀ`m qnOè`mMr hmVmbm OmUrd hmoB©b EdT>m X~md dmT>dyZ g§nyU© ñVZ Vnmgm.

5) eodQ>r, Vwåhr C^o amhÿZ qH$dm ~gboë`m pñWVr_Ü`o gwÜXm ñVZ VnmgyZ nmhÿ eH$Vm, ~è`mM {ó`m§Zm ñVZm§Mr hr VnmgUr H$aVmZm ËdMm Amobr Agë`mg gmono dmQ>Vo. A§Kmoi H$aVmZmgwÜXm hr VnmgUr H$ê$ eH$Vm.

nmMdr nm`ar

AemàH$mao Amnë`mbm Á`m nÜXVrZo VnmgUr H$aÊ`mg gmono OmB©b Vr nÜXV AmnU {ZdSy> eH$Vm. ñVZ VnmgUr H$aV AgVmZm Oa JmR> hmVmbm bmJbr Va H$moUVrhr JmR> ~moQ>m§À`m {M_Q>rV Yê$Z Vnmgy Z`o.

g§nyU© ñVZ hmVmV Yê$Z 4 H«$_m§H$mÀ`m nm`ar_Ü`o XmIdë`mà_mUo VnmgUr H$amdr.

gd© d`moJQ>mVrb {ó`m§Zr Aem nÜXVrZo {Z`_rV nUo VnmgUr Ho$ë`mg {ZpíMVM \$m`Xm hmoB©b.

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