From the Director’s desk

PGI, Chandigarh, is holding its 24th convocation today. It is a special occasion as this is the first convocation of the new millennium. It is appropriate to begin this contribution by briefly looking backwards and forwards, to what we have achieved, and what we still have to do, to congratulate, but also to recognise that a hill has still to be climbed. Through the columns of this newspaper, I am sharing with the citizens of India some of our achievements and the difficulties we face.

Today, 38 years on, the advances are too numerous to encapsulate in a few words, PGI is not a mere hospital, it has carved a unique place for itself in the medical community both nationally and internationally. The institute has become a major source for the development of medical/paramedical manpower in the country. A full account of the institute history is being published shortly.

It has amply fulfilled the obligation and responsibility assigned to it: “Service to the community, care of the needy and research for the good of all” . I would like to pay my humble tributes to the founders of the institute and other colleagues for their contribution to the growth of the institute.

The hospital is providing tertiary care services in all medical and surgical specialities to patients. Last year nearly one million patients were seen in the OPD and over 40,000 were admitted. The pressure on the emergency is even more pressing, yet we continue to provide much better emergency care to our people. The hospital has intensive care unit for premature babies, coronary care reparatory care and tetanus care units.

The emergency department functions round the clock providing advanced medical and surgical emergency services. The situation in the area which used to present a frequent chaotic scene has somewhat eased with the coming up of new emergency wing.

The new OPD block will be commissioned very soon. The scene of utter congestion in the main hospital will hopefully disappear. The Sarai, night shelter and cloak room facilities are being provided near the Nehru Hospital to accommodate patients and attendants.

There has been a tremendous progress in the diagnostic facilities now available at the institute. A sophisticated equipment centre in the Department of Experimental Medicine and Biotechnology has met many needs of the patients, research & training programme of the institute.

Preventive care: The hospital while remaining busy in providing advanced medical care to the patients has not forgotten the preventive aspects of health care. The antenatal clinic, well baby clinic, immunisation programme, diet clinic and child guidance clinic are some of the activities undertaken routinely in this direction.

Training: We are providing postgraduate qualifications at the postgraduate (MD, MS, MDS) and superspeciality levels (DM, MCh, Ph.D). The postgraduate training programme commenced in 1963, and the superspeciality training programme was introduced in 1969. A number B.Sc and M.Sc courses are conducted in the fields of nursing medical technology, speech and hearing therapy, physiotherapy and others. The institute has so for trained 4959 postgraduate doctors, 1906 nurses, and 1135 paramedical students.

The unique feature of the training is that it is broad-based and the residents rotate through all the specialities of their chosen subjects. The institute offers short-term training programmes for imparting skills to professionals in health fields tailored to meet the specific requirements of organisations sponsoring them. A large number of medical students from USA, Canada, Europe, Australia and other places come to this institute for their elective training.

Research is an essential feature of postgraduate medical education. The institute is actively engaged in advancing the frontiers of research. A large number of projects are sponsored by various agencies — ICMR, WHO, DST, CSIR and other state governments. The research work is carried out in accordance with approved guidelines.

The future: A society or profession is incapable of progress unless it is oriented towards future. The past two decades have witnessed spectacular advances in medicine and dramatic changes in many surgical practices. Biotechnology has revolutionised the diagnosis, treatment and understanding of the pathology of many serious diseases, and techniques for producing monoclonal antibodies have been nearly perfected.

The Ministry of Information and Technology is funding Telemedicine technology for optimising medical resources in India. Five participating institutes include PGI Chandigarh, AIIMS New Delhi, SGPGI Lucknow, CEDT Mohali and CDAL Pune. This project has been operational since February 2000.

Surgical landscape — bold ventures

WE are in the midst of a revolution. Surgical research contributions to the society in the last half of the 20th century include minimally invasive surgery (laparoscopy), urinary lithotripsy, vascular surgery, transplantation, cardiopulmonary bypass, advanced trauma life support, joint replacement, tumour immunobiology, immune therapy for cancer and other developments. Advances in imaging, energy delivery, optical technologies, and genetics promise to render therapy in an even less invasive fashion.

All these have come from brilliant advances of understanding of basic mechanisms of disease and adaptation to technology. The first successful laparoscopic removal of gallbladder was performed just 14th years ago and had become the procedure of choice wiping out the competing approaches. Other applications such as splenectomy, nephrectomy, colectomy, hernia repair, evaluation of abdominal trauma and peritonitis are promising.

The diagnosis, staging and treatment of breast cancer is likely to become a truly minimally invasive experience for the patients in view of the widespread adoption of screening mammography and development of a variety of energy sources. Just imagine the near normal picture of a woman after these procedures as compared to the postoperative chest wall of a woman after a radical procedure. The feasibility of optical methods for tumours of esophagus, cervix, urinary bladder and colon has been demonstrated.

Organ transplantation is a reality. The estimated survival at 10 years of kidney transplantation is over 55 per cent, with live donor it is likely to be 5-10 per cent better. The longest UK survival of liver translation is 27 years and the five year survivals are 65 per cent (heart), 41 per cent (heart & lung) and 44 per cent (lung). Future research will find ways to handle the donor shortage.

Surgery has led to inflate expectations. Technological advances will continue to alter the surgical land-scape, and provide new strategies to meet the challenging and changing needs of our patients in the new millennium. The future of surgery continues to be optimistic. — J.D.W.

Advances in blood transfusion

IN this modern era of transfusion medicine, the transfusion practice is becoming more focussed on blood component therapy than the transfusion of whole blood. It enables multiple recipients to benefit from the one (single unit) donor unit thus conserving this precious fluid. In addition, it prevents unnecessary overload of unwanted blood components in the recipient. The component therapy is invaluable in the management of platelet and coagulation factor deficiencies. These were previously managed by fresh blood, which had the disadvantages in the form of lower yield, requirement of multiple transfusions and refractoriness due to alloimmunization.

The modern practice of Apheresis began only in 1963, when Freireich & Judson developed a machine that could harvest white cells in sufficient numbers to treat a neutropenic patient with sepsis. Apheresis can be used for a number of purposes such as collection of various blood components, plasma exchange, plasma perfusion over absorbent columns, therapeutic platelet and granulocyte removal, the collection of lymphocyte for processing and subsequent autotherapy, harvesting peripheral blood stem cells for bone marrow transplantation.

The most exciting progress is the treatment modalities that are being developed using genetically modified peripheral blood mononuclear cells and insertion of chemoprotective gene in patient’s CD+4, selected peripheral blood stem cells, thereby retaining bone marrow regenerative capability following high multidose chemotherapy in leukemic patients. Thus, the support for these innovative developments need to come from transfusion medicine where expertise in cell separation and purification technology, cell component support, development and use of human recombinant growth factors and transplant immunology are all needed to provide the necessary catalytic environment for dramatic future developments. — S.K.A.

Molecular medicine in new millennium

THE dawn of the new millennium has brought one of the most important breakthrough of all time deciphering the human genome; the 100,000 genes encoded by three billion chemical pairs in our DNA. The ability to isolate, identify and manipulate the individual genes will be the basis of new medical care in 21st century. Genetic engineering has the potential to conquer cancer, grow new blood vessels in the heart, create new organs from stem cells and even reset the genetic clock that causes cells to age. In future, the parents may be able to choose their children’s traits, select gender and perhaps tinker with their IQs.

They could clone themselves or a celebrity they admire. Gene therapy and gene based drugs are two ways to replace an old one. The new millennium will see our children being vaccinated with edible plants such as bananas, potatoes and tomatoes. Human cloning could be used to obtain tissues needed to treat disorders such as Parkinson’s diseases and diabetes. The vaccines of tomorrow are likely to be concoctions, made up of DNA from the genome of a virus/bacteria or a parasite which will generate not only marshaling antibodies but also will coax the body into churning out killer T cells smart bombs of immune system.

DNA based diagnostics will help in pre-natal and post-natal diagnosis or and predisposition to genetic diseases, infectious diseases and malignancies. Biotechnology will also improve and rationalize therapeutics and will aid in better drugs designing and drug delivery systems. — S.M. & M.K.

Botulinum toxin in neuro disorders

Botulinum toxin is a potent neuroparalysing agent produced by the bacterium “clostridum botulinum”. This is of great benefit in various neurological disorders where the muscles show excessive activity. The best response is for the common entity known as “facial tics”. The patient has repeated twitching movements saround the eyes only (blepharospasm) or has in addition twitching movements over the mouth (hemifacial spasm). This causes undue social embarrassment. They may be mistaken for focal seizures (epilepsy) and the patient started on antiepileptic drugs. Inj. Botulinum toxin shows significant benefit with 70-90 per cent relief.

Another problem of movement disorders is sustained turning of the head to the back side or front. These are various forms of cervical dystonia which respond well to Injection Botulinum toxin. Unfortunately since the muscles involved are large, patients consume one whole vial (cost per vial is around Rs. 15000) and in rare cases may require two vials depending on the severity and duration of disease. Recently cases of stroke (paralysis) which has increased stiffness (spasticity) have also been administered Inj. Botulinum toxin. Most cases require only one injection and with proper physiotherapy.

Other diseases being treated with Inj. Botulinum toxin are “writer’s cramp” where a patient has difficulty only in writing. Patients with abnormal jaw movement have also been given this injection. However, the latter two diseases show mild to moderate benefit. The patients injected with botulinum toxin have had no significant side effects. The injection acts locally in the concerned muscle and hence the other areas of the body are unaffected. — SP, CPD

Glimpses of immunopathology

Immune system depends on the presence of adequate number of functionally competent immune cells. These cells, through the molecules present on their surface or factors released by them and their product interact in a complex manner to recognise foreign agents and keep the body in normal functional state. Aberrations in the normal number and function of cells lead to abnormal reactions (hypersensitivity, allergy) or to deficient state (Immunodeficiency), or their may be hyperactivity where the immune system fails to recognise its own tissues as self (autoimmunity), or the immune cells may become malignant (plasma cell dyscrasis).

To diagnose all these conditions a detailed clinical history, physical examination and an array of laboratory tests are required. No single test can give a definite clue, since most of the biologic tests, now available, have inherent biologic and technical variability and many conditions require investigations from cellular level to molecular level which include their products and genes. Malignancy, being a foreign growth in the body, antibodies are produced by the immune system and secretory products are liberated by tumor cells. These are called markers and can be detected in the serum.

Success of organ transplantation depends on the proper matching of recipient and donor. The immune system recognises the foreign antigens of the donor by genes of an individual called the Major Histocompatibility Complex (MHC) system. Various methods are used for recognition of the antigen type and match for transplantation. Detection of pre-transplantation sensitisation is a must for surgery and forms an essential part of organ transplantation. A vast arry of diagnostic facilities are offered for diagnosis of autoimmune disorders, paraproteinemias and immunodeficiency. — U.D.

LAND

Eye care — new challenges
Improving socio-economic conditions and rapidly urbanising populaion has thrown up new challenges for the ophthalmologists. Trachoma has become rare in many parts of the urban areas. Rural areas are still abound with infectious diseases of the eye particularly corneal ulcers leading to the corneal blindness. Most of these follow trivial injuries. Simple preventive interventions of antibiotics drops can go a long way in decreasing the burden of corneal blind. A large number of diabetics are at risk of developing blinding complications.

Advanced technology in the field of laser, Phacoemulsification, and other microsurgical techniques have facilitated complex procedures on eye for diseases considered incurable in past.

There has been a phenomenal 300 per cent increase in the number of patients who require tertiary care in various subspecialities viz. retina, UV eitis, cornea & contact lens, glaucoma, lens, oculoplastics, strabismus and paediatric ophthalmology.

Retionopathy of prematurity, diabetic retinopathy, posterior segment diseases and corneal disorders are fast-emerging newer causes of blindness in our country. Management of these disorders is a major advance and a thrust area. Refractive surgery (LASIK) for correction of refractive errors (permanent removal of glasses) has gained universal acceptance. — A.G.

Respiratory care — moving with time
Respiratory problems occupy the top slot of the list of causes of global morbidity and mortality. Tuberculosis and tobacco are two such examples inflicting almost all sections of society. The lungs bear the major brunt of their attack. The fight against both, however, is a joint medical and societal effort.

Fiberoptic bronchoscopic examinations has greatly helped us to define the pattern of respiratory diseases in our country. Another major achievement is the development of our own computer software for reporting of pulmonary function tests reports and bronchoscopic data. Unlike the computerised instruments using Western values, we have incorporated our own normograms for prediction of abnormalities on lung function testing. The customised bronchoendoscopy software works excellently for storage, reporting and analysis of data.

The pulmonary and critical care bulletin is available online at www.indmedica.com/pulmon/pindex.cfm.— S.K.J.

Plastic and reconstructive surgery
The word plastic derives from the Greek “plastikos”, meaning to mould or shape. The term plastic surgery was first used by German surgeons in the earlier part of the 19th century, before plastic (bakelite) was invented. Somehow, the two terms got mixed up in people’s minds and even educated persons often ask what and where plastic substance is going to be placed during surgery.

Another misconception is that plastic surgery is synonymous with cosmetic surgery or “beauty surgery” and is solely concerned with improving the patient’s appearance. In actuality, the work-load of the plastic surgery department mainly comprises of emergencies like burns, facial fractures, hand injuries and loss of skin.

The majority of operations involve reconstruction of deformities which may be congenital or acquired: facial asymmetry, cleft lip and palate, deformities of the eyes, ears, nose and jaws; excision and reconstruction of oral ad skin cancers; skin and muscle reconstruction for major losses in the limbs and trunk; hypospadias, reconstruction of the vagina and penis and other deformities of the genitalia; restoration of function to paralysed limbs and face.

Microvascular surgery has now become a routine procedure and enables the repair of blood vessels of the diameter of a hair, and nerves that are not visible to the naked eye. This has also facilitated the successful transfer of large blocks of skin and the underlying muscle and bone from one region of the body to another.

Craniofacial surgery has made rapid strides in the last two decades. It is possible to extensively mobilise and devascularise the craniofacial skeleton without the risk of it getting necrosed. It is now possible to treat complex deformities like craniostenosis, frontonasal malformations and hyper telorism. — P.S.C.

Pain relief
Medical management using drugs has a very limited role to play in chronic pain. Interventional pain management by the anaesthesiologist becomes crucial when drugs have failed and where surgical therapy can be associated with unacceptable side-effects. Pain relief can be provided in the vast majority of patients if the patients are carefully selected and the proper technique is utilised. Common types of chronic pain encountered in clinical practice include low back ache, cervical (neck) pain, pain following Herpes zoster, trigeminal neuralgia, cancer pain, myofascial pain, traumatic neuropathy, etc.

The commonest procedure is injecting various drugs like local anaesthetics, steroids, or neurolytic agents in the spinal/epidural space. In some patients where pain is felt in the area of distribution of a nerve, the concerned nerve can be blocked by local anaesthetics or neurolytics. The advantage of this technique is that a localised area can be blocked without causing physical impairment. In cases where pain is localized in a specific area drugs can be injected into the target area to alleviate pain.

When pain is due to hyperalgesia (increased sensitivity to pain) or allodynia (pain on light touch) blocking of the sympathetic chain causes dramatic relief. Newer modalities of management like subcutaneous implantable pumps (which release a fixed quantity of drug), electrostimulation of spinal cord or deep brain stimulation are being practised to treat refractory pain.

In cases of terminal cancer pain where a cure is not possible, intreventional pain management will ensure a good quality of the remaining life. — Y.K.B.

Changing face of orthopaedics
Joint replacement procedure — hip and total knee replacement — is a boon for patients with increasing pain & deformity in these joints. The replacement procedure has brought about immeasurable relief and rapid increase in mobility. Research has reached an advanced stage leading to development of a new prosthesis for use without cement.

A better understanding of the biological response to bone repair has brought about reconstruction of bone defects after trauma, infection, and in severe injuries where bone transport and distraction techniques have helped in the healing of fractures and reconstruction of the soft tissues. Distraction osteogenesis is used in reconstructive procedures. Bone transport methods can be employed in reconstructive surgery. In the presence of fresh fractures, they can be combined with interlocking nail techniques and allow better soft tissue healing.

Trauma is regaining a position of greater importance in the provision of orthopaedic services. Newer methods of managing complex cases with percutaneous methods as well as external fixators have been evolved and perfected.

The spine has metastases in two third of cancer victims. Rigid spinal fixation by the pedicle screw and other devices has now been supplemented by extensive techniques in vertebrectomy. The results in metastatic surgery are improving and can given pain relief and neurological recovery. It allows many patients in their last period of life to be independent and pain free. This is a difficult field of surgery.

Advanced technology for percutaneous spinal surgery has added new dimensions in disc surgery. Complex congenital problems in children like scoliosis congenital deficiencies of skeleton and infection of the growing skeleton are being managed successfully. The deformed spine is managed with complicated procedures on the vertebral column and the spine becomes straight. — ONN

Facial trauma — a challenge
Maxillofacial trauma is emerging as one of the major thrust areas needing comprehensive management with the ever increasing fast moving vehicular traffic in India and changing attitudes of people leading to violence and the existing risk of accidents at home and outside. Presence of teeth in the mandible and maxilla makes management of fractures of jaws unique. Reduction of these fractures has to be perfect even to a fraction of a millimetre, otherwise because of a malalignment of teeth, facial disfigurement and malfunction may occur. This is demanding on the part of treating surgeon. These fractures have been usually managed by wiring the jaws together for 4-6 weeks. This causes problems in feeding and maintaining oral hygiene. With the advent of modern methods using mini plates and screws for management of these fractures, these problems are avoided.

Other common injury involving the teeth is avulsion of tooth from the socket. Upper central incisor teeth are most frequently avulsed, especially in children in the age group 7-12 years. The projecting teeth are prone to risk of being hit because of their protrusion. It is possible to replant a tooth following avulsion and these replanted teeth may function for many years. Most important factor for success of replanted tooth is extra-oral time. More the extra-oral time, poorer the chances of success. If an avulsion of tooth occurs, tooth should be washed in cold milk (preferably) or tap water and should be immediately placed back into the socket and report to a dentist as early as possible.— H.S.C.

LOOK

Fight against cervical cancer
Cancer of the uterine cervix is the leading cancer in women in most countries. Approximately one-sixth of all cervical cancers of the world occur in India. Altough the etiological factors are not precisely known, it is now established that it is a sexually transmitted disease. The known risk factors are early age at marriage (below the age of 17 years), multiparty (women with 4 or more children), multiple sexual partners or with sexually transmitted diseases and its association with human papilloma virus infection (HPV)

The brighter side of the picture is that amongst all known cancers of the body, this is the only cancer, which has become preventable through regular cancer screening programmes. This involves proper public education about the risk factors involved and the preventive measures to be taken.

Visual inspection of the cervix under magnification for clinical staging of the cancer; use of cytological scrapings from cervix called :Pap smear test” for detection of precancerous lesions; and management and follow-up guidelines are some of the preventive strategies. Because of the cytological screening by the “Pap smear test”, this is the only cancer where the pre-cancerous stages of the lesion have become clearly defined, a stage at whic the disease, if detected, is 100 per cent curable.

In Western countries where a “Pap test” was introduced as an essential health check-up measure in the national health programmes nearly 40 years ago, a dramatic decrease in the incidence of cervical cancer has been achieved. In India, essential cervical cancer screening at the national-level on the same footing as for the preventive programmes for vaccination/communicable diseases has yet to receive attention. — SKG

New-born as a surgical patient
New-born babies vary in their birth weight and maturity. Risks of surgery are considerable in this age group. Neonatal surgery is one of the vigorously growing fields and management of congenital malformations has been perfected. Babies born with major congenital malformations that threaten life are safely treated surgical. Even babies born with two or more major birth defects can be corrected simultaneously.

Over the years it has been possible to save babies born with absent food pipes, absent biliary tract, blocked intestines, and multiple birth defects. Some serious disabilities like neural tube defects. Some serious disabilities like neural tube defects and extrophy (a disorder where the urinary bladder is lying open in a new born) are managed with greater success. New areas like antenatal diagnosis and fetal (yet to be born) surgery have changed the diagnosis and treatment of diseases.

Babies with severe disabling congenital anomalies can be terminated. Other babies can be treated in utero to reduce the disability. Fetal scarring is considerably less than in older children. Understanding fetal healing can help us in treating diseases.

Antenatal therapy is likely to change the incidence diseases. The new millennium promises to throw hopes for the tiny tots ushered into this world. — K.L.N.

Comprehensive cancer care
Cancer is becoming an increasingly important challenge to health services of developing countries. This is because, not only is the population increasing, but it is also aging. Today, with an improvement in treatment modalities, patients are living longer with cancer than ever before.

Cancer is not a single disease but a group of diseases. Different cancers have different characteristic features and natural history of progression. The treatment of cancer also requires a multi modality approach. Since the real answer to a simple and successful cancer treatment still eludes us, the treatment modalities continue to evolve. Chemotherapy has established its role as a major modality, but its true efficacy is seen only in certain types of cancers. Radiotherapy, on the other and has found a definite and predominant place for itself in the management of almost all cancers.

In addition to conventional teletherapy treatment, advances have been made in the field of Brachtherapy (radiation is delivered close to the target area) and accurate radiation dose delivery using CT simulator and three dimensional computerised treatment planning systems.

When life-prolonging treatment is no longer possible, palliative treatment, pain relief and psychosocial support are integral component of comprehensive cancer care. Various voluntary organisations and NGOs provide psychosocial and financial assistance to needy patients. The Sahayta Cancer Sahyog provides help and support to the cancer patients.— S.C.S.

Day hospitalisation for mental illness
Treatment of mental illness has been gradually shifting from a hospital-based model to a community-based one since the 1960s. The fundamental principle has been to release chronically institutionalised patients by providing community care. Community-based services such as day care or day hospitals offer a viable alternative to long-term institutionalisation. Day hospitals are hospitals where patients do not stay overnight. Instead they stay at home and attend the day hospital from around 9.00 a.m. to 5.00 p.m. on the weekdays. The hospital is usually located in a central place, which is easily accessible. People with serious mental illnesses form the bulk of these patients, but people with minor mental conditions are also included. The staff consists of psychiatrists, psychologists, psychiatric nurses, social workers and occupational therapist. Medical modes of treatment such as drugs are used, but there is an equal emphasis on psychosocial treatments, rehabilitation and helping family members of the mentally ill.

Day hospitalisation has several advantages. Patients feel less stigmatised while having to attend suh a facility. The deleterious effects of long-term hospitalisation are avoided. The patient is not separated from his/her family and can rely on their support. The process of attending boosts the patients’ sense of independence, increase social interactions and preserves his/her sense of self-worth.

In developing countries like India almost all mentally ill patients live with their families. There has, always been an emphasis on involving the family in care of the patient, and treating patients in the community. The situation demands that more professional help be provided to patients and their relatives. — S.C.

Viral diarrhoea
Every year 5 million children under age 2 die in developing countries as a consequence of acute diarrhoea. The viral agents causing acute gastroenteritis are a group of non-enveloped viruses from diverse families. They cause acute gastroenteritis into two epidemiologically distinct forms.

One form of viral gastroenteritis occurs mostly in infants and children which is usually sporadic, although it may reach epidemic proportions. Most important causative agent under this group is Rotavirus. Major human pathogen belongs to Rotavirus group A. After a 2-day incubation period, the symptomatic infant experiences vomitting and watery diarrhoea with fever and abdominal pain which may require hospitalisation.

Rotavirus illness is characterised by significantly more vomitting with resultant dehydration. Treatment of rotavirus infection is supporative as there is no effective antiviral medication available. The major approach to rotavirus disease is through its prevention by vaccination. As yet a fully effective vaccine is not available.

The second epidemiologically distinct form of viral gastroenteritis occurs year round in a variety of settings including schools, hospitals, cruise etc. among older children and adults. Epidemiological study has revealed association with ingestion of contaminated food particularly raw or poorly cooked shellfish, stored cooked foods, salads and sandwiches.

Contaminated ice & water have also been implicated. Transmission is primarily through fecal oral route. The incubation period is of 24 to 48 hours followed by nausea, vomitting, non bloody diarrhoea, abdominal cramps, low grade fever and myalgia. — A.K.S., K.S.

Advances in neurosurgery
Rapid technical advances have been a boon for those dealing with the diseases of brain and the spinal cord. These advances have made early and precise diagnosis of brain and spinal cord pathology easy and have also greatly contributed in their neurosurgical correction yielding good quality results.

This is evident by the fact that it is not uncommon for a simple rustic to walk into the neurosurgical OPD with a CT scan or an MRI packet in hand. CT and MRI have made tumour diagnosis not only easy but also precise and harmless. Better diagnosis supported with advances in the form of operating microscope, ultrasonic aspirator, better ICU facilities, high quality patient monitoring etc have made neurosurgery easy and safe.

“Brain attack” (brain haemorrhage; sub arachnoid haemorrhage) is a common emergency situation. Sudden, severe headache with or without loss of consciousness are the hallmarks of a brain attack which is easily diagnosed on a simple CT scan and confirmed by angiogram. Timely microneurosurgery gives excellent life time cure. The availability of sophisticated neurosurgical equipment has completely changed the face of the modern neurosurgery.

“Neural protection” is an emerging concept with the basic idea of protecting the functioning of the cells of brain and the spinal cord. Though the newer techniques and drugs are being evolved for protection of brain and spinal cord, the commonest mode of insult to these structures is by way of injury/road traffic accident. Neural trauma needs specialised set up and to this extent the PGI will set up an Advanced Trauma Centre to provide high quality care for neural trauma, and injuries to other parts of the body. — V.K.K.