Express Healthcare May, 2013 by Indian Express

In Imaging special Reads that matter

Knowledge Women's healthcare in India Strategy Innovating for good health

GE Healthcare

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LONG-LASTING QUALITY. MINIMISED ERRORS. ELEVATED EFFICIENCY. EXTENDED PATIENT SAFETY. ZEBRA HC100™ DIRECT THERMAL PRINTER — EASY-TO-USE, RELIABLE & HIGHLY COST-EFFICIENT. With Zebra’s new durable, easy-to-scan all-in-one HC100 patient ID solution, now you can enhance critical workflows throughout every department of your government healthcare organisation. Accelerate patient admissions by producing more secure, longer-lasting antimicrobial-coated wristbands on-demand — easily, quickly and conveniently. Enhance productivity and minimise errors in medical record labelling with this reliable and easy-to-use direct thermal printer that automatically detects the wristband size, calibrates — and prints. Ensure your delivery of unrivalled patient safety with Zebra HC100 — the reliable and cost-efficient solution for all your patient ID printing needs. Key Benefits: • Easy-to-use and load for optimum user efficiency • Automatically detects wristband size and calibrates settings for optimal print quality • Lower maintenance costs with longer-lasting wristbands with bar codes and text that remain readable For more information about HC100 printer, please, visit www.zebra.com/hc100 For further enquiries, please email SGMarcom@zebra.com Zebra Technologies India Pvt Ltd Boomerang A202 Near Chandivali Studio Main Chandivali Farm Road Main Andheri E Mumbai 400072 T: 022 67275555 ©2012 ZIH Corp. All rights reserved.

INSIGHT INTO THE BUSINESS OF HEALTHCARE

VOL 7. NO 5, MAY 2013

Chairman of the Board Viveck Goenka Editor

Market

Strategy

Viveka Roychowdhury* Assistant Editor Neelam M Kachhap (Bangalore) Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das Delhi Shalini Gupta

Innovating for good health ................32 Consider hypothetically… a cervical cancer-free India! ............33

MARKETING Deputy General Manager

Knowledge

Harit Mohanty Assistant Manager Kunal Gaurav PRODUCTION General Manager B R Tipnis Production Manager Bhadresh Valia Asst. Manager - Scheduling & Coordination Arvind Mane Photo Editor

Women’s healthcare in India ..............36

Sandeep Patil

Hospital Infra

DESIGN Asst Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka

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Layout Vivek Chitrakar CIRCULATION Circulation Team Mohan Varadkar Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15

IT to be a key driver for change in healthcare................................................16 Cardiac Science, sells diagnostic cardiology product line ..............................17 Hinduja College of Nursing Awarded ‘A’ Grade by NAAC ..............................17 Medtronic's Healthy heart for all' partners with 70 hospitals ..........................18 Key link between obesity and Type 2 diabetes discovered ..............................20 80 per cent of healthy Indians are Vitamin D deficient ..................................24

Global Hospital-Mumbai: The unveiling ....................................94

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In Imaging

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'I wanted to device techniques which required minimal surgery and takes less of patient’s time in hospital' ..........................................................56 Dr Bhavin Jhankaria: Mover and Shaker........................................................57 Gen – X in imaging! ....................................................................................59 Apollo’s pride ..............................................................................................60 Myrian: Multifaceted and multifunctional ......................................................62 MRgFUS: Novel ‘No-touch’ technology ..........................................................64 Rays against cancer ......................................................................................66

Unlocking the secret ..............96

throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is

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Letters ..........................................................................................................................................................10 People...........................................................................................................................................................97 MAY 2013

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Editorial

Another 'accident', another cover up? n April 30, Dr Najma Heptulla, Member of Rajya Sabha (RS), from the Bharatiya Janata Party posed a very relevant query during the RS session. She alleged that several hospitals across the country did not have relevant documents and were operating illegally. She asked the Minister of Health & Family Welfare whether the Ministry was aware of this and whether it has taken/proposes to take any steps to curb such hospitals. The query was no doubt triggered by a tragic incident in her home state of Madhya Pradesh. On April 26, part of the roof of Kasturba Gandhi Hospital in Bhopal, the state capital, caved in claiming two lives and trapping patients for a couple of days. The fact that this hospital was managed by the public sector Bharat Heavy Electricals Limited (BHEL) only reinforces the perception that the infrastructure in such hospitals is suspect and the facilities are mismanaged. It is indeed shocking that some hospitals, supposed to be repositories of life saving equipment, are today themselves turning out to be death traps. To be sure, such 'rotten apples' are found in the private sector as well, and the case that comes to mind is the fire at Kolkata's AMRI Hospital in December 2011, which claimed 89 lives. But despite so many instances of preventable accidents at hospitals, there is still a 'passing the buck' attitude between state and centre which ensures that not much action is taken. Both sides make the usual noises, compensation is paid to the victims/victims' next of kin and the issue is slowly and conveniently buried and forgotten. In reply to Heptulla's query, Minister for Health & Family Welfare Ghulam Nabi Azad predictably made the point that 'health' is a state subject, it is primarily the responsibility of the state governments to regulate and monitor hospitals in the states and no information regarding illegally operation of hospitals is maintained centrally. So while the Centre has enacted the Clinical Establishments (Registration and Regulation) Act, 2010, it has been adopted only by four states (Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim) and all Union Territories with effect from March 2012. Uttar Pradesh, Rajasthan, Bihar and Jharkhand have also subsequently adopted this Act. The Act was brought into force to ensure minimum standards of facilities and services in clinical establishments and also looks to regulate rates of procedures and services charged by such establishments in the states. All the MOH&FW can do is to 'request' other state governments to adopt this Act as well. There has been a lot of opposition to this Act as private healthcare players see this as interference by bureaucrats who may not understand the finer nuances of running a hospital. (See Express Healthcare edit: Return to the inspector raj? http://healthcare.financialexpress.com/200807/ edit01.shtml) Smaller hospitals also expressed concerns that their costs would go up if they had to put in place systems mandated by the Act, like computers for electronic record keeping. Would such systems force smaller hospitals to up their rates, thus defeating the very purpose for the Act, i.e. standardising care at affordable costs? One wonders how certain regulations are enforced with lightening speed while others languish. For instance, the Home Ministry has tightened visa requirements for couples coming to India for surrogacy from last December, apparently with immediate effect. The rules now state that commercial surrogates in India cannot be hired by gay couples, single men and women, non-married couples and couples from countries where surrogacy is illegal. There is confusion on the status of babies to be born out of surrogacies already in progress and industry insiders point out that the Home Ministry should have made this clear as well. But reports point out that the Home Ministry is merely trying to avoid diplomatic tensions with other governments caused due to the differing legal status of surrogacy in different countries. India has seen unexpected complications (See Express Healthcare edit: The Curious Case of Baby Manji http://healthcare.financialexpress.com/201112/editorial01.shtml) and it is only to be expected that the authorities take a firm stance. So does that mean that unless accidents at hospitals impact the nation's standing overseas, Acts like the Clinical Establishment Act will remain toothless and in limbo? That is indeed a scary scenario.

Despite so many instances of preventable 'accidents' at hospitals, there is still a 'passing the buck' attitude between state and centre which ensures that not much action is taken.

Viveka Roychowdhury viveka.r@expressindia.com

EXPRESS HEALTHCARE

www.expresshealthcare.in

MAY 2013

Letters QUOTE UNQUOTE

Synergy for progress Thank you for carrying Narayana Hrudayalaya's offer to operate on wait-listed cases in KEM, Mumbai in the editorial of Express Healthcare. (Ref: Edit, EH April 2013) As you have rightly pointed out, "coupling of the complementary strengths of the private and public sectors" is the way forward. To bridge the massive gap in

INSIGHT INTO THE BUSINESS OF HEALTHCARE

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AK Walia Delhi Health and Family Minister (Addressing a national seminar and workshop on Holistic Health at Maulana Azad Medical College)

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MAY2013

UPFRONT India an ideal market for mHealth services: Frost & Sullivan

hanging disease profiles, increased adoption of smart phones, advancements in mobile technology, and greater focus on health and wellness are laying concrete foundation for mHealth in India. This is according to an analysis by Frost & Sullivan. Currently, there are more than 20 initiatives for mHealth in the country.This number is set to grow as India has a robust mobile technology infrastructure in place and saw the launch of 4G in 2012. New analysis from Frost & Sullivan, Overview of mHealth Market in India, finds that the compound annual growth rates (CAGR) for mobile handset in the rural and urban markets are likely to be 12.4 and 10.6 per cent, respectively, till 2016. mHealth is still a fledgling concept and most of the initiatives undertaken are only a couple of years old. The market has very few successful business models and it will be at least two to five years before a successful model emerges. This is due to the large disparity in mobile infrastructure in rural and urban India. “Mobile connectivity and data transmission is still a challenge in the rural markets,” observed a Frost & Sullivan analyst. “Since people from these market segments use mobile phones mostly for their voice services, the acceptance of value-added services is very low. The primary reason for this is high prevalence of poverty and illiteracy (around 31 per cent) in rural areas.” The urban market, however, continues to witness growth in mobile handset uptake due to the developing replacement market. With quality healthcare being centralised in urban centers, there is a dearth of medical workforce in rural markets. The healthcare industry is hoping that mobile platforms will close the disparity in service provision. With the increasing penetration of mobile services in rural areas, mHealth solutions can strengthen the healthcare delivery system for the rural population.

Market 'BD seeks to address fundamental weaknesses in developing world healthcare systems'

'Consumerism of healthcare is driving semiconductor manufacturers towards medical devices'

Neeraj Raghuvanshi, Director of the King's Health Partners Integrated Cancer Centre (ICC)

Tom O’Dwyer,Director of Technology, Healthcare Group, Analog Devices

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EH News Bureau MAY 2013

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ursing in India is a very strong profession and has already celebrated more than 100 years of its professional existence. Being the pillar of the healthcare sector, it is unimaginable to look at healthcare delivery without thinking about the nurse,” says Phalakshi Manjrekar, Director - Nursing, PD Hinduja Hospital, Mumbai, who feels proud that by choosing nursing as her career, she has dedicated her life in service of the people. Like Manjrekar, there are many ministering angels who in their own small ways have touched the lives of millions. Yet, the profession still hasn’t managed to gain the glory and continues to remain neglected, battling with several obstacles in its path towards success.

‘N

The story so far... Nursing in India can trace its roots to healthcare practiced since ancient times. However, today, it is predominantly woman’s domain but prior to the 20th century in India, Indian nurses were usually young men, and women were majorly midwives who conducted childbirth. The progress of nursing as a profession in those days was obstructed by the low status of women, the caste system, illiteracy and political unrest. However, the beginning of the 20th century, brought in the winds of change for the profession. The discipline of nursing slowly evolved from the traditional roles, apprenticeship and

EXPRESS HEALTHCARE

humanitarian aims as a professional career with the introduction of nursing education. Nevertheless, as the profession began to progress still further, many roadblocks came in its path. The biggest one being no recognition by the government. This drawback began to discourage many who sought to take up nursing as a career; especially those working in the government sector. The healthcare sector noted a decline in the number of skilled nurses.

Nearly 97 per cent of nursing staff are given a lower status by the government. The need of the hour is that the nursing policy must be modified Col Binu Sharma

The turning point After decades of neglect, a respite came when the Government of India recognised the role of nursing as pivotal to the performance of the National Rural Health Mission (NRHM), and consequently a priority policy was issued, during the 9th Five Year Plan, to introduce a new scheme, known as the Development of Nursing Services. As per the policy, nursing education and nursing services have been given high priority in order to bridge the large gap between requirement and availability of nurses and improve the quality of nursing training. Some provisions of the policy are highlighted below: ● Appropriate changes in syllabus, curriculum, teaching methods and assessment system (initiated by Indian Nurses Council) will be made through various professional councils to improve the undergraduate and post-graduate training ● New 3500 nursing educa-

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VP-NURSING SERVICES, COLUMBIA ASIA HOSPITALS

●

tion institutions have been given an approval on high priority in order to bridge the gap between requirement and availability In addition, efforts will be made to meet the increasing demand of specialised and sub-specialised areas for intensive nursing care in the healthcare system.

Current scenario Despite the efforts taken in the 9th Five Year Plan, the number of nursing professionals kept dipping. In accordance with the statistics provided by the National Institute of Mental Health and Neurosciences (Nimhans) in March 2012, 'India is currently facing a scarcity of around 40-50 per cent of nursing professionals'. The World Health Organisation (WHO) reveals that the current nurses to population ratio in India is 1:1205 as against 1:100-150 in Europe. The nurse to patient ratio in private healthcare is around 1:5-10 which is slightly better than that in government where it ranges from 1:35-50 patients in general ward. More so, experts observe that in certain states, shortage of nurses is more severe. Lt Col Saravjeet Kaur, Director- Nursing, Max Healthcare Institute, points out that states of Chhattisgarh, Jharkhand, Meghalaya, Manipur, Mizoram, Tripura, Uttarakhand and Delhi face the maximum shortage of nurses. Rekha Dubey, COO, Aditya Birla Hospital, Pune draws attentions towards the city of Bengaluru which according to her is currently facing a huge shortage of nursing professionals. Alluding to immigration of nurses from India to the Gulf countries, Rajendra Pratap

Research indicates that 35 per cent fewer women would choose nursing as a career in the coming years Mugdha Lad HEAD NURSING, HINDUJA HEALTHCARE SURGICAL

Gupta, Member, World’s Economic Forum’s (WEF) Global Agenda Council; Member, Technical Resource Group (II), Ministry of Health & Family Welfare, Government of India, feels that the southern states of Kerala and Karnataka would have the highest shortage. Recognising the urgency of the situation and in the interest of patient care, the National Health Policy (NHP) last year, emphasised the need for an improvement in the ratio of nurses vis-avis doctors/beds. It also emphasised on improving the skill level of nurses and increasing the ratio of degree-holding nurse’s vis-àvis diploma holding nurses. On the other hand, the National Development Council (NDC), along with the Planning Commission, conducted a meeting in December 2012 to discuss on the severe shortage of doctors and nurses in India. During the discussion, the Planning Commission explained that the doctor to nurse ratio ideally should be at least 1:3 for the team to perform optimally. This ratio is currently 1:1.6 and is expected to improve to only 1:2.4 by end of the 12th plan if no new colleges are started. It further highlighted that if India adopts a goal of 500 health workers per lakh population by the end of 13th plan, we will need an additional 240 medical colleges, 500 general nursing and midwifery colleges and 970 auxiliary nurse midwives training institutes. Further, during the discussion, the NDC released a document that stated if work on these new teaching institutions begin from the 2013-14 and is completed by the end of the 12th plan, the ratio of doctors to nurses will then MAY2013

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rise from 1:1.6 in 2012 to 1:2.8 in 2017 and reach 1:3 in 2022. In line with same, Finance Minister, P Chidambaram, while presenting the Union Budget 2013, called education in health as a priority area for this fiscal year and allocated Rs 1650 crores for setting up six AIIMS-like institutes and Rs 4,727 crores for medical education, research and training. A good move indeed. However, will increasing medical colleges and nursing institutes play a pivotal role in boosting the current state of the nursing sector in India? Is it the only solution that we can find at present? The answer to this is uncertain. A topic, debated and discussed at several industry meets as well as national forums, without arriving at any productive solutions so far. The huge paucity of nurses is not only due to lack of training institutes but caused by many other factors as well.

they gain the clinical experience and learn about hospital functioning, they apply for jobs abroad that pay them nearly eight times more than what they get here, besides added benefits such as housing, food and other perks. “It’s the lure of foreign jobs that bring young nurses to hospitals for experience and then takes them away. Most hospitals are treated as training schools by young nurses,” she adds. Referring to a survey con-

ducted at one of the government hospitals, Lad also revealed that nurses working in the government sector seemed to be more worried about being unable to adjust to working conditions abroad, and therefore are less keen to migrate. “The fact that they enjoy better pay scales, a more relaxed work atmosphere and more facilities may have also played a part here,” she chips in. Professional alternatives:

Both men and women these days are weighing their interests with multiple career choices available to ensure worthy compensation as well as enhanced quality of life. Unfortunately, the nursing sector currently lacks this. “Women who once willingly took up nursing as thier career are now entering law schools, medical schools, and the corporate world in droves. Research indicates that 35 per cent fewer women

would choose nursing as a career in the coming years,” declares Lad. Declining enrollment and educators: Lad also observes that in the past six years, new admissions into nursing schools have dropped dramatically and consistently. She says that nursing colleges and universities deny many qualified applicants due to the shortage of nursing educators. Geographic maldistribution of nurses training

Reasons for shortage Industry experts say that the growing number of aging population, high attrition rate among nurses, drop-outs due to poor working conditions, no proper nursing policy and low professional profiles of nurses at workplace are few factors that have contributed to the shortage. Shedding light on these issues, experts elaborate: Exodus of nurses to greener pastures: “Opportunity to work in various foreign countries like Dubai, Saudi Arabia, the US, the UK, New Zealand, Australia etc., with attractive facilities, free travel, accommodation, leave and a pay scale which is 10 times more than they obtain in India, better facilities for family, a good life style and affordable education for children are some reason why nurses from India migrate abroad,” observes Manjekar. Sharing some statistics on the attrition rate among nurses in India, Mugdha Lad, Head Nursing, Hinduja Healthcare Surgical states that nearly 50 per cent of the nursing staff leave within two years of service, 30 per cent work for about five years and those continuing beyond five years are less than 20 per cent. Most of the nurses, who join are just out of nursing colleges. They look for some experience to make their resume look better. Once MAY2013

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capacity: Increase in the number of nursing institutions has been accompanied by deepening geographical imbalances. “The southern states of Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu have 63 per cent of the general nursing colleges in the country, 95 per cent of which are private, with the others distributed unevenly across the rest of the country. The distribution of nursing institutions that offer higher education (ie, BSc and MSc degrees) is even more disproportionately distributed—78 per cent are located in the four southern states, all of which have higher numbers of nurses and midwifes per 10000 population than the national average (7·4 per 10000 population). “States such as Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh have fewer numbers of nurses per 10000 population than the national average, but account for only nine per cent of nursing schools in the country,” notes Lt Col Kaur. No proper gazette status: Apart from all the other issues that plague the sector, the nursing sector is also apprehensive of the fact that nurses are not involved in making policies that govern their status and practice. “Most of the decisions concerning nursing care and nurses are made by other people, usually physicians without the inputs from nursing professionals. It is possible that this situation is the direct result of lack of appropriate status accorded to the nursing staff. Nearly 97 per cent of nursing staff are given a lower status by the government (Group ‘C’ category). The need of the hour is that the nurse practitioner and our nursing policy must be modified. The job description for the modern nurse needs to be reviewed and revised,” points out Col Binu Sharma, VP-Nursing Services, Columbia Asia Hospitals. Moreover, the current nursing policy focusses only on increasing the number of nursing professionals, but doesn’t seem to have any apropos initiatives to uplift the profession, the industry feels. Well, as the nursing sector in India bends over backwards in order to improve its current state, there is a lot of scope for betterment in the coming years.

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Many nurses in India battle with the fact that they do not get the opportunity to grow Dr Sheelagh Martindale HEAD OF PROFESSIONAL DEVELOPMENT, ROBERT GORDON UNIVERSITY

Nurses should be given prominent positions in the State and Central governments’ Health Ministries and as representatives of UN Phalakshi Manjrekar DIRECTOR - NURSING, PD HINDUJA HOSPITAL, MUMBAI

The government needs to allot a separate fund for nursing sector development Rekha Dubey COO, ADITYA BIRLA HOSPITAL, PUNE

Measures for progress For sustained improvement within the nursing sector, various steps need to be taken in areas such as education and training of nurses, creating safe and hygienic working conditions, developing policy and regulations that will be beneficial to nursing professionals and other auxiliary healthcare workers, as well as elevate the current image of nurses in India. Firstly, the government needs to focus on altering the current nursing policy. “There is a need for a national nursing policy within the framework of national health policy and national health planning,” affirms Col Sharma. Manjrekar recommends that nurses should be given prominent positions in the State and Central governments’ Health Ministries and as representatives of UN to give them a platform to voice opinions and influence decisions related to the development of nursing as a profession in India. Further, Col Sharma points out that the recruitment process in the government sector needs to be made more transparent. Some experts blame the economic reservations within government hospitals for recruiting unskilled nursing and auxiliary staffs. Few nursing professionals opine that these healthcare work-

There is a lot of scope for betterment in the nursing sector in the coming years www.expresshealthcare.in

ers do not have the basic know-how about hygiene and patient safety. Moreover, deserving students do not get the opportunities available at government hospitals. Therefore, a fair and transparent recruitment process for nursing professionals in the government sector is one step that can help generate skilled nursing staff. With a view to improve healthcare delivery within the hinterlands of India, Manjrekar advocates improving infrastructure of hospitals and PHCs so that nurses stationed at these healthcare set ups have proper infrastructure and a better working conditions there. “The rural areas of India are in dire need of nurses and the present facility already comprises multiple roles developed for the nurses to meet this requirement. However, if the rural nurse-patient ratio is bettered and nurses are given adequate facilities and infrastructure to work, the beneficiaries of rural India will benefit,” she points out. Lt Col Kaur is of the opinion that there is a need to develop new roles for nurses in the rural areas of India. She says that nurses can work in positions that link hospital and community practice and provide a combination of acute care, health promotion and prevention services. They can also play roles as nurse practitioners, advisers, resource person, liaison and speciality nurses. This will help them to enhance their skill set. Drawing our attention towards upgrading the image of nursing professionals in India, especially in the

private sector, Gupta suggests, “Nurses must be given the opportunities to upgrade not only in their roles but also the scope of work. They must be given the option to improve their skills, take up senior roles and rise up to become hospital administrators, COO’s etc. Also, for critically ill patients, nurses must be authorised to administer certain medications based on the formulary agreed by the hospital doctors as per emergency treatment protocols . We urgently need chronic care certified registered nurse practitioners who can help manage chronic illnesses”. He continues, “India’s healthcare system is built around a doctor and his treatment; however, if nurses and other healthcare workers are also given a pivotal role in public health, this initiative would perk up the nursing sector in India.” “Many nurses in India battle with the fact that they do not get the opportunity to grow. We think if nurses are involved in the day-to-day management of the hospital, this not only develops a healthy working environment but also adds value to the healthcare delivery provided at the hospital,” expresses Dr Sheelagh Martindale, Head of Professional Development, Robert Gordon University and Vanessa Smith, Critical Care Nursing Lecturer, Robert Gordon University during their visit to India this February. Speaking about her observation during the Critical Care Nursing Conference, conducted by the Holy Spirit Hospital, Mumbai in association with the Robert Gordon University in February 2013,

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Dr Martindale informed that nursing education plays a critical role in promoting the profession. She observed during the conference that Indian nurses are very keen in educating and upgrading themselves in specialised courses. So Indian hospital and teaching institutions need to add specialised nursing courses in various medical sub-specialities to create more avenues for nurses as well as uplift the current nursing education curriculum.” “What the public generally thinks about nursing and how the media portrays nursing shapes the current image of the profession,” adds Lad, talking about the role of media to better the image of nurses in India. She goes on to say, “The public has heard about the stress nurses are experiencing, the shortage of staff, and stories of nursing errors that have injured or killed patients. Needless to say, the images provided by stories such as these do not bolster the desire to enter the profession. Nursing appears as an unstable, unpredictable, and high-risk career option. Two national media campaigns have been launched to refine the image of nursing. ‘Nurses for a Healthier Tomorrow’ is a coalition of 44 healthcare organisations working together to raise interest in nursing careers among high school students. It has often been said that in order to ensure a continuous flow of nursing students, children must be reached at an earlier age. Educators say that students often have their minds made up by the fifth grade about desirable and undesirable careers, thus an early positive image of nursing is imperative. Another market that needs to be pursued is males. Currently, male nurses account for only 5.7 per cent of all nurses. If men were to enter nursing at the same rate as women, shortages would not be a concern. In order to influence men to enter the nursing profession, society and the media must eliminate barriers and stigmas facing men who may choose this career”. “Apart from creating better working conditions and encouraging men to join the nursing profession, which indeed is a good suggestion, renewal of licenses based on credit points of Continuing Nursing Education (CNE) to be applied all over India should also be considered,” MAY2013

urges Lad. “The government should take an effort to recognise nursing education at par with any other university education programme. A nurse who undertakes a General Nursing & Midwifery (GNM) programme has to successfully pass HSc or its equivalent to enroll in this three and half year course. In equivalence to any other educational programme after 12 th, recognition of GNM or converting it into a University

Degree Programme or merging it with BSc Nursing Programme is strongly advised to standardise nursing education for these young nurses,” reckons Manjrekar. Adding few more step toward improving nursing education in India, Dubey lists down her recommendations: ● Allotment of separate fund by government for nursing sector development.

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Permission to open more nursing colleges as well as strengthening the capacity of nursing colleges. Making it mandatory that 150-200 bedded hospitals only can establish nursing colleges. Upgrading professional standards by laying down proper students selection criteria. Strict and regular inspections of nursing colleges. Qualified nursing faculty with adequate clinical

experience

Lastly... Just like a stitch in time saves nine, if all these commendations are acted upon by the government and private sector soon, then the nursing sector in India will rise up from its current state. A healthy partnership between the government and private players is the need of the hour raelene.kambli@expressindia.com

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M|A|R|K|E|T INDUSTRY UPDATE

IT to be a key driver for change in healthcare Apollo Hospitals Group launches ‘Apollo Protect’

pollo Hospitals has launched a large scale nationwide vaccination drive on the occasion of World’s Neighbourhood Day to create awareness and encourage Indians to take precautionary steps and avoid easily preventable diseases. Titled ‘Apollo Protect’, the campaign will focus on encouraging vaccinations for the adolescent and adult population and it will be driven across the group’s integrated healthcare network of 50 hospitals, 1500 pharmacies, 100 clinics, four cradle hospitals, day surgery centres, occupational health centres, telemedicine centres and patient information centres across the country. Speaking about the social initiative, Dr Prathap C Reddy, Chairman, Apollo Hospitals Group said, “India has witnessed substantial strides in creating basic awareness about the importance of vaccinations, yet a lot more needs to be done to ensure that its benefits reach the remotest parts of the country. I would estimate that at least 2,50,000 precious lives can be saved through this structured drive on vaccination preventive diseases (VPD) and help avoid both chronic and acute conditions like cervical cancer, pneumococcal, swine flu and cholera.” Commencing on the World Neighbourhood Day, the campaign will garner support from neighbourhood volunteers, corporates, various school and College Clubs, Rotary and RWAs to drive awareness among general public. “Vaccination in India has primarily been administered to new born babies with parents’ taking ample precaution for their children with timely inoculation. However, a large share of adults and adolescent children are neglected leaving many susceptible to even lifethreatening, yet easily preventable maladies. This initiative will help save lives, improve epidemiological surveillance and also offer a reasonably inexpensive and valuable protection against diseases. Soon, dedicated vaccination bays will be set up across Apollo Hospitals and Apollo Clinics making, vaccinations a part of regular health checkup programmes”, says Preetha Reddy, MD, Apollo Hospitals Group. EH News Bureau

EXPRESS HEALTHCARE

Cisco's customer experience study indicates shift in consumer attitudes in India toward personal data, telemedicine and access to medical information in healthcare will be the key component of change in healthcare,”said Vishal Gupta, VP and General Manager, Global Healthcare Solutions, Cisco, during the release of their latest study conducted on global customer experience and their attitude towards virtual healthcare, especially telemedicine. The findings from the survey conducted globally indicated a growing shift in consumer’s expectations on medical services in India. It also examined perceptions of consumers and healthcare decision makers (HCDMs) on patient experience in healthcare. The report shows that as information, technology, bandwidth, and the integration of the network become the centre of the 'new world', both human and digital aspects are key parts to the overall patient experience. These components lead to more real-time, meaningful patient and doctor interaction. The survey studied the views of consumers and HCDMs on sharing personal health data, participating in in-person medical consulta-

“IT

tion versus remote care and using technology to make recommendations on personal health. Views on these topics sometimes differed widely between the two groups (consumers and HCDMs) and the 10 geographies surveyed. The global report, conducted early this year, includes responses from 1,547 consumers and HCDMs globally, with a consistent sample size of around 200 local respondents in each of the 10 countries surveyed. Additionally, consumers and HCDMs were polled from a wide variety of backgrounds and ages within each country. Gupta informed that the report findings challenged the assumption that face-toface interaction is always the preferred healthcare experience. While consumers still depend heavily on in-person medical treatments, threequarters of patients and citizens are comfortable with the use of technology for the clinician interaction. Moreover, he went on to say that the Indian healthcare industry needs to create intelligent network in order to increase healthcare access.

Rajendra Pratap Gupta, Chairman, Healthcare Information and Management Systems Society (HIMSS) Asia Pacific India Chapter gave a presentation that indicates the state of IT in healthcare, in the next five years. Speaking to Express Healthcare's Sr Correspondent, Raelene Kambli, he said that government, insurance, healthcare providers, international development, professional developments, CAG and PACs will be the key drivers of growth in the healthcare IT sector. “In the next five years connectivity may not be an issue. Government's web portal on health would be live and running, all states would have initiated state wide telemedicine network and the government will have issued IT-enabled National Health Entitlement Card (NHEC) to citizens. Moreover, Central government will be directly release money to the states through an IT enabled system, therefore IT will act as a key component for government's healthcare funding”, he added. Dr Chhavi Mehra, MD, Diplomate American Board

of Internal Medicine, Chief of Quality at RxDx – a multispeciality hospital who has partnered with Cisco in their telemedicine project conducted in Bangalore and Andhra Pradesh shared her experience working on the telemedicine project. She mentioned that telemedicine has really increased accessibility of healthcare and patients have really responded positively to the new virtual healthcare delivery tool. She sums ups saying, “In a country where on an average, we have one doctor for 1700 citizens while the optimal average should be one doctor for 600 citizens, this report gives us great hope when we see that patients are comfortable about clinical interactions using technology or virtually, instead of in person. As machines become connected and networked, they can play a large role in the overall health care experience.This can help immensely to balance the doctor-citizen inequity we see in India as well as the urban-rural imbalance in terms of resource availability.” EH News Bureau

PARTNERSHIPS

Government of Puducherry partners with Abbott Puducherry to be a model state in care and treatment of non-communicable diseases he Government of Puducherry and Abbott, a healthcare company in India, have signed a three-year agreement to improve awareness of non-communicable diseases (NCDs) like diabetes, hypertension and dyslipidaemia (cholesterol related disorders) and thyroid disorders; and implement initiatives to fight them and record their prevalence in the Union Territory of Puducherry. The partnership programme will reach out to the Union Territory’s citizens and screen/monitor over seven lakh people, which is the general population of Puducherry who are thirty years or above. It will also build the skills of local healthcare providers through continued medical education. This partnership is initiated in India to capture and

assess reliable population level screening/monitoring data. The collected data will help to create health risk maps to forecast the burden of these non-communicable diseases, facilitate early intervention, and ultimately help reduce disease burden in the Union Territory of Puducherry. The Government of Puducherry will provide the infrastructure and the necessary permissions and logistical arrangements in the Union Territory to run the project, while Abbott will provide subsidised diagnostics, educational support to healthcare providers, patient awareness material and will conduct diet guidance camps. Abbott will also provide NCD management kits (including supplies to measure blood pressure, body mass index and blood gluwww.expresshealthcare.in

cose) and 150,000 glucose test strips free of cost to support monitoring of diabetes, as well as access to a unique internationally-recognised, evidence-based disease risk and health assessment tool. The health assessment tool will help the Government of Puducherry’s healthcare providers to assess each individual’s health risks and support the public health ecosystem to create a personalised care plan to drive better health outcomes for patients and increase the focus of preventive care. The assessment of population-level data of diabetes, hypertension, cholesterol and thyroid disorders will project the likely disease pattern over a period of three years, thereby enabling a targeted approach to reduce the Union Territory’s disease burden.

N Rangaswamy, Chief Minister, Puducherry said, “The partnership with Abbott is one of the first in the country for a state or Union Territory to build awareness, provide treatment and better manage chronic diseases for its citizens, using its existing public health infrastructure. This partnership will not only improve patient outcomes, but also help address the growing disease burden and the associated economic burden of Puducherry.” Vivek Mohan, Senior Director, Global Integrated Health, Abbott said, “Partnerships like these with government will help to prevent and manage these diseases effectively, in particular by strengthening the health care systems addressing NCDs.” EH News Bureau MAY2013

Hospi News

M|A|R|K|E|T COMPANY WATCH

Cardiac Science sells diagnostic cardiology product line Hinduja College of Nursing Awarded ‘A’ Grade by NAAC

he Hinduja College of Nursing was awarded with an ‘A’ certificate by National Assessment and Accreditation Council (NAAC) at Jnana Jyothy Auditorium, Central College, Bangalore University. The award was received by Principal, Professor Jaya Kuruvilla. The NAAC is an autonomous organisation that assesses and accredits institutions of higher education in India and is funded by University Grants Commission of Government of India. The college had upgraded itself to College of Nursing under Maharashtra University of Health Sciences, Nashik from the previously existed School of Nursing of 26 years.

The transaction does not include MySense, the wearable, single-patient ECG recorder system and the resuscitation business unit ardiac Science, an Opto Circuits group company, recently signed a definitive agreement to sell its diagnostic cardiology product line to Mortara Instrument for an estimated sum of $21 million. The transaction does not include MySense, the wear-

able, single-patient ECG recorder system and the resuscitation business unit that markets automated external defibrillators (AEDs) worldwide. “Divestiture of the diagnostic cardiology product line will bring more strategic focus

to Cardiac Science. The company will now be able to exclusively focus on innovation and the expansion of market share in its high-margin and high growth resuscitation business,” said Neal Long, CEO, Cardiac Science. “The addition of these

businesses to our organisation represents a marked opportunity to accelerate the introduction of Mortara’s leading ECG technology to new markets,” commented Dr Justin Mortara, CEO, Mortara Instrument. EH News Bureau

Accreditation from NAAC was a three part process consisting of the preparation and submission of a self-study report by the unit of assessment Accreditation from NAAC was a three part process consisting of the preparation and submission of a self-study report by the unit of assessment. Once completed and published an on-site visit of the peer team for validation of the selfstudy report was done with recommendations of the assessment. And the final decision was made by the Executive Committee of the NAAC. The College of Nursing had also recently gained the ISO 9002 Certification. EH News Bureau

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Partnership

INITIATIVE

Medtronic's Healthy heart for all' partners with 70 hospitals Piramal Enterprises and Tata Memorial Centre forge alliance

iramal Enterprises and Tata Memorial Centre will soon collaborate to enable the development of valuable tools to better understand disease biology and predict responses to various treatments for cancer patients. The new alliance between the two organisations will focus on the development of preclinical cancer models to enhance the understanding of disease biology, treatment response/resistance and biomarkers as they relate to diagnosis, prognosis and response to drugs. These modes will be based on tumour tissues from cancer patients and are predicted to have better translational relevance than the currently used human cancer cell line models. Scientists at Tata Memorial and Piramal Imaging hope to gain a better understanding of the mechanisms through which various drugs work on different cancers. This research could lead to new therapies and predict the medicine best suited to treat an individual cancer patient. "Our collaboration with Piramal Enterprises addresses a critical need in cancer care, which is widely accessible and cost effective personalized medicine for cancer patients," said Dr Rajendra Badwe, Director, Tata Memorial Centre. Dr Swati Piramal, Vice Chairperson of Piramal Enterprises, commenting on the development said, "We are excited to begin this collaboration with Tata Memorial Centre, which is India’s leading centre associated with cancer treatment. We hope that the insights we gain from this alliance will ultimately lead to new treatment options for cancer patients." EH News Bureau

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200 cardiac procedures supported through the low-cost finance mode ndia Medtronic has extended its ‘Healthy Heart for All’ (HHFA) programme to more than 70 hospitals in India. An innovative business model based on EMI scheme, HHFA has already financed 200 cardiac procedures. The programme is enabling those in dearth of finances to support their treatment and has benefitted people across 22 cities in India including Delhi, Mumbai, Kolkata, Durgapur, Bangalore, Ahmedabad and Pune among others. The programme address-

es key barriers of affordability, lack of proper diagnostic facilities and lack of awareness in making the right treatment available to the patients. With the help of the EMI system, patients can take loans for buying expensive cardiac devices and pay in installments starting from as low as Rs 1,000 per month. “Healthy Heart for All is an initiative from Medtronic to help patients get access to life saving cardiac treatment they need. Barriers like low awareness, inadequate diag-

nosis, and affordability constraints are the key reasons for the large number of cardiac patients not being able to get the right treatment in time. We, at Healthy Heart for All, are committed to addressing these barriers and making cardiac therapies accessible to all via this innovative approach. The results are very gratifying, especially when we see people move from a state of hopelessness to getting the appropriate treatment and living longer and better lives,” said Milind Shah, Vice-President, South

Asia and Managing Director India Medtronic. HHFA was piloted in 2010 at Durgapur’s Mission Hospital and Ahmedabad's CIMS Hospital. On the back of the early success, the programme has been scaled up across the country. The programme required broad collaboration to develop a care delivery ecosystem that is geographically appropriate for India and invests in patients’ longterm health and future growth. EH News Bureau

INVESTMENT

Canbank Venture Capital Fund invests in GNRC Guawahati The Rs 20 crore investment will be used to set up a 1,000-bed super-speciality hospital at Amingaon in north Guwahati anbank Venture Capital Fund , Bangalore, a wholly-owned subsidiary of Canara Bank, is investing Rs 20 crore in the GNRC hospital group. The investment is being raised as venture finance from Emerging India Growth Fund and it will be used to part-finance the setting up of a 1,000-bed super-speciality hospital at Amingaon in north Guwahati. “The funds will be used to part-finance our upcoming project in the first phase. The project cost, which includes modernisation and expansion in subsequent phases, is currently estimated to be nearly Rs 92 crore. In the first phase, a 300-bed facility is being planned. We plan to increase the capacity to 500

beds in the second phase and months,” he said. “As of now, to 1,000 in the long run,” an we have not set any completion date for the project.” official source said. The medical facility at The hospital is coming up on an 80-bigha plot in the north Guwahati will cater to patients residing in the northAmingaon-Gauripur area. “At present, we only have ern part of the city and those f r o m an outpaDarrang, tients’ clinic Goalpara, on the premThe hospital is Barpeta, ises, which Nalbari started funccoming up on an and rural tioning in Kamrup as October last 80-bigha plot in the well. year. The con“ T h e struction of Amingaon-Gauripur very objecthe clinic tive of this began in May area hospital is last year. to mainAround 10 doctors from various depart- tain quality (in healthcare ments treat 40-50 patients services) and bring down everyday at the clinic. An cost with a subsequent inpatient department will be increase in footfall,” GNRC set up in the next two-three Hospitals Chairman and MD,

Nomal Chandra Borah said. The hospital is expected to have technologies such as PET scan, MRI, cath lab and CT scan, among others. “We are designing the facility as a green building and all steps have been taken to make it environment friendly. It has also been designed so that it consumes minimum energy for its operations. There is no dormitory. Each patient will be provided with a small cubicle, along with a cot for an attendant. That is in addition to the private wards. Locally available material such as bamboo will be extensively used for heat insulation, sound-proofing and adding aesthetics to the architecture,” Borah said. EH News Bureau

HOSPI NEWS

Kokilaben Dhirubhai Hospital, Mumbai to set up Centre for Liver Transplantation The Centre is an initiative to counter the lack of such facilities in western India n a bid to counter the inadequacy of liver transplant services in Western India, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute in Mumbai is setting up a comprehensive Centre for

Liver Transplant with a team of specialists in various fields such as transplant surgery, haepatology, anesthesiology and intensivists. With an estimated requirement of around 4,000www.expresshealthcare.in

5,000 in Mumbai, only 43 kidneys and 18 livers were recovered from brain dead donors in 2012. Moreover, patients from Mumbai have to travel to other parts of the country for getting a liver transplant

done. There was a dire need to overcome such shortages in western India. This centre is expected to alleviate the problem to a certain extent. EH News Bureau MAY2013

New hospital

Sankara Nethralaya at Sri City SEZ

ri City, an integrated business city in South India consisting of a special economic zone, domestic tariff zone and free trade warehousing zone, inaugurated Sri City —Sankara Nethralaya, an eye hospital, a unit of medical research foundation, Chennai. The eye hospital aims to offer affordable and high quality eye care services for the poor and needy. It was inaugurated by Dr MYS Prasad, Scientist & Director, Satish Dhawan Space Centre, SHAR in the presence of Professor PS Manisundaram, First Principal of R E C /N I T., Trichy and First Vice Chancellor of Bharathidasan University, Dr SS Badrinath, Chairman Emeritus, Medical Research Foundation and Ravindra Sannareddy, MD, Sri City. Commenting on the inauguration, Sannareddy said, “We would like to extend our warmest welcome to Sankara Nethralaya to Sri City. Our aim is to provide medical care at an affordable cost to the people of the region and the employees of the industries in Sri City.” This hospital will have tele-ophthalmology and mobile refraction van that takes quality eye care to the doorsteps of people living in this region. He further added, “One of the challenges of any developed economy rests in its ability to provide world-class healthcare, we at Sri City believe Sankara Nethralaya will strive hard to provide the best healthcare to the people of this region”. Sri City—Sankara Nethralaya began offering its services from April 15, 2013. They will move to their world class hospital and research facility once it is ready, the new facility will be spread across 10 acres in Sri City. EH News Bureau

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M|A|R|K|E|T STUDY

Key link between obesity and Type 2 diabetes discovered Reportedly, T-bet, a protein which regulates the differentiation and function of immune cells, could be in the treatment of Type 2 diabetes ew research published in the journal Cell Metabolism has identified a key mechanism in the immune system involved in the development of obesitylinked Type 2 diabetes. The findings open up new possibilities for treatment and prevention of this condition. The study is by Dr Jane Howard and Professor Graham Lord, King’s College London, and colleagues, and is funded by the UK Medical Research Council. The association between obesity and diabetes has long been recognised but the molecules responsible for this association are unclear. Dr Howard, lead author in this research and colleagues from

King’s, studied mice genetically engineered to lack Tbet, a protein which regulates the differentiation and function of immune cells. They found that the mice had improved insulin sensitivity despite being obese. ‘When T-bet was absent this altered the relationship between fat and insulin resistance; the mice had more intra-abdominal fat, but were actually more sensitive to the glucose lowering effects of insulin,’ said Dr Howard. ‘As fat accumulation in the abdomen is typically associated with worsening insulin resistance and other features of the metabolic syndrome, the findings seen were both unusual and unexpected.’

It turned out that the intra-abdominal fat of these mice contained fewer immune cells and was less inflamed than that of normal mice. The researchers then went on to discover that by transferring immune cells lacking T-bet to young, lean mice they were able to improve insulin sensitivity. ‘It appears that T-bet expression in the adaptive immune system is able to influence metabolic physiology,’ added Professor Lord. “Our data suggests that obesity can be uncoupled from insulin resistance, through the absence of Tbet,” said Dr Howard. Several of the main drugs currently used to treat Type 2 diabetes

work by improving insulin sensitivity. Further studies are needed to identify other molecules in the pathway of action of T-bet which could pave the way for future drug development in the treatment of Type 2 diabetes. The administration of specific immune cells as immunotherapy to improve insulin resistance may also one day become a therapeutic possibility. “The idea that the immune system can impact on metabolism is very exciting, but more research needs to be done before we can bring this work from the bench to the bedside for the benefit of patients,” said Dr Howard.. EH News Bureau

PARTNERSHIP

HCG and GE Healthcare collaborate The collaboration is to advance cancer care in India ealthcare Global Enterprises (HCG) and GE Healthcare have signed a partnership agreement to work together and elevate cancer care infrastructure in India. An initial pilot project setting up a cancer care centre in Bangalore will be the first step in this direction and GE will be the technology partner in this endeavour. This new partnership adds to the existing collaboration between GE and HCG on cancer bio-markers for improved cancer management.

“At GE, we envision a day when cancer is no longer a deadly disease. Scaling up of Cancer care at affordable costs requires disruptive solutions and willing partners. Our renewed partnership with Healthcare Global Enterprises, our long standing partner and expert in the fight against Cancer, we hope to propel one of the most critical needs in cancer care in India —access to early detection and treatment technologies, education and building awareness,” said John Dineen,

President & CEO, GE Healthcare. Dr BS Ajaikumar, Chairman, HCG Enterprise said, “The fight against cancer requires more willing partners. This partnership is not limited to GE and HCG alone. We hope to attract healthcare providers and investors join us in this journey” The pilot project in Bangalore is expected to provide insights into methods of cost effective and quality cancer care. With insights from this project and by part-

nering with like-minded investors/ healthcare providers, GE and HCG hope to scale up and spread the cancer detection and treatment facilities to Tier II and III towns, through a proposed hub and spoke business model. GE and HCG also propose to address the challenges of shortage of skilled manpower through education facilities and enhance disease awareness among general practitioners and patients. EH News Bureau

HOSPI NEWS

Fortis launches its flagship hospital - FMRI The hospital aims to bridge the gap between expert talent, trans-disciplinary and quaternary care The Fortis Memorial Research Institute (FMRI), located in Gurgaon, brings the next-generation of superspecialisation in Oncology, Trauma and Paediatric care with embedded centres of excellence at the hospital in Neurosciences, Minimal Access Surgery, Cardiac Sciences and Orthopaedics. With a potential capacity for 1,000 beds (450 beds in Phase I), FMRI aims to

explore new frontiers in healthcare using a multi-disciplinary approach to clinical diagnosis, interventions and treatment outcomes. A harmonic blend of the art and science of healthcare is evident in thisfacility. Dr Ashok Seth, Chairman, Fortis Escorts Heart Institute, while explaining the importance of FMRI in filling a vital need gap, said, “The hospital is an www.expresshealthcare.in

amalgamation of some of the world’s finest specialists and enabling medical technologies. Together, they aim to take healthcare delivery to its next level. Our intent is to create the same equity for FMRI in multi-disciplinary care as the Fortis Escorts Heart Institute has in cardiac care.” Further, Dr Dilpreet Brar, Regional Director, FMRI, said, “This hospital is a momentous step in the fur-

therance of quality healthcare. We are offering clinical and allied services at the cutting-edge of science and technology, to treat patients across the spectrum of superspecialities. I am confident that the Fortis Memorial Research Institute will become a distinguishing landmark for medical care in Asia and beyond.” ” EH News Bureau MAY2013

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New launch

STUDY

80 per cent of healthy Indians are Vitamin D deficient

BD launches BD UltraSafe PLUS Passive Needle Guard

D Medical, a segment of Becton, Dickinson and Company (BD) has commercially launched a new passive needle guard technology, BD UltraSafe PLUS. The BD UltraSafe PLUS Passive Needle Guard has received 510(k) clearance as an antineedlestick safety device. This product, in addition to offering needlestick safety in an easy-to-use one-handed device, reportedly has enhanced ergonomic features designed to facilitate comfort and support for healthcare providers and patients. In addition, this safety device is designed to meet increasingly complex biotechnology drug requirements, including higher viscosity. "We are pleased to offer the new BD UltraSafe PLUS Passive Needle Guard which nicely complements our current safety portfolio," said Claude Dartiguelongue, President, BD Medical— Pharmaceutical Systems. "We now have an ergonomic safety device solution for those customers seeking to offer patients the ability to manually control their injection." The BD UltraSafe PLUS Passive Needle Guard provides many advanced features including a robust plunger rod to help support injection of viscous drugs, a larger drug inspection window to improve drug visibility, extended built-in finger flanges and an enhanced plunger head for improved injection support and stability. These ergonomic improvements provide support for all users, including patients with diminished manual dexterity. BD recently conducted a clinical focus group with patients who had reduced dexterity and also suffered from rheumatoid arthritis and multiple sclerosis. Subjects reported that the BD UltraSafe PLUS Passive Needle Guard provided ease of use with 100 per cent of injections executed successfully. “The new BD UltraSafe PLUS Passive Needle Guard is designed to enable easy integration into existing safety device assembly lines and is compatible with ISO standard prefilled syringes,” added Peter Nolan, Vice President, BD Medical – Pharmaceutical Systems, Safety. EH News Bureau

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Irrespective of urban or rural areas, Vitamin D levels are significantly low across India, finds Diabetes Foundation of India t is estimated that around 80 per cent of the Indian population has Vitamin D levels less than normal. However, the bigger concern is that the population at large is not even aware of Vitamin D deficiency and its consequences. Dr Banshi Saboo, Founder of Diabetes Foundation of India, said, “In the past decade research has established the strong association of Vitamin D deficiency in diabetes, immunity, asthma, TB, high blood pressure, neuro-muscular function, etc. Dr Saboo further added, “Low level of Vitamin D is associated with higher incidence of type 2 diabetes and correcting Vitamin D deficiency improves insulin sen-

sitivity and helps in better management of hyperglycaemia. Also Vitamin D deficiency has been associated with high incidence of type 1 diabetes.” As the mother is the sole source of vitamin D substrate for her developing foetus, vitamin D status is very important during pregnancy. Maternal deficiency of vitamin D is linked with abnormal foetal growth and gestational diabetes. Sunscreen lotions, staying indoors, clothing habits, pollution and minimal exposure to direct sun light (during the period of 10 am to 3 pm) are the major reasons of such widespread deficiency in the Indian population. Dr Manoj

Chadha said that Vitamin D deficiency has no defined signs or symptoms. “People who complain of back pains, unexplained muscle pains, general fatigue are the most likely to be Vitamin D deficient. Vitamin D deficiency can be easily corrected by Vitamin D supplementation or some lifestyle changes. In a Vitamin D deficient person, oral 60,000 I.U per week for 8 weeks followed by maintenance dose of 60,000 I.U per month is a reasonably safe method to correct the deficiency.” Although there are few major studies carried out in India to determine the optimum (sufficient) levels of serum Vitamin D 25(OH) D

to be maintained to prevent chronic ailments, globally there is a consensus that Vitamin D deficiency is defined as serum 25(OH) D levels less than 20 ng/ml and insufficiency as serum 25(OH) D less than 30 ng/ml. Whereas serum 25(OH) D levels above 30 ng/ml is found to be sufficient. Given the fact that Vitamin D receptors are present in various organs and tissues of the human body, maintaining Vitamin D levels in blood above 30 ng/ml may ensure normal functioning of the body organs and protect many from the suffering from chronic ailments. EH News Bureau

STUDY

Drug-eluting stent use in peripheral artery disease shows promising results Drug-eluting stent releases drugs to the vessel wall to prevent inflammation and proliferation of cells, thus improving treatment outcomes here is a controversy over whether the drug-eluting stent or the bare metal stent has superior clinical benefit. Numerous studies, however, are indicating successful trials of procedures using the drug-eluting stent to keep vessels in the leg open. The authors of an article published in the current issue of the Journal of Endovascular Therapy compare the use of bare metal stents with drug-eluting stents in the treatment of infrapopliteal occlusive disease. The article is a metaanalysis of the results of six

studies—four randomised trials and two observational studies—that included 544 patients. Peripheral artery disease affects a significant portion of the population. Reconstruction of the arteries through surgery is the primary treatment, but drugeluting stents could offer a less invasive option. The drug-eluting stent releases drugs to the vessel wall to prevent inflammation and proliferation of cells, thus improving treatment outcomes. At the one-year point, the results of these

studies are promising. Patency of the vessel to allow free flow of blood and clinical improvements have increased, and revascularisation of the target lesion due to reclosure is low. What these studies are not able to tell at this point is whether longer-term effects will be as encouraging. Parameters such as saving of limbs and healing of wounds have yet to be assessed. The authors of a commentary article discuss the pros and cons of meta-analyses. They compare megatrials—which offer to defini-

tively settle an issue by studying large numbers of subjects—to a Big Mac, while they describe systematic reviews and meta-analyses, which pool results of smaller studies, as a bowl of Cheerios. The authors praise the careful analysis of drug-eluting stents presented in this issue of the journal but caution that not all types of drug-eluting stents are equal and that these study findings should not be generalised to all types. EH News Bureau

TRAINING

Fellowship programme in clinical genetics Genzyme and SIAMG tie-up to offer this three month programme for Indian doctors enzyme has entered into a tie-up with the Society for Indian Academy of Medical Genetics (SIAMG) for a joint fellowship programme for Indian medical professionals.

This programme of three months duration will be organised at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow and the first batch is set to begin from July this year. www.expresshealthcare.in

Under the terms of the agreement, Genzyme India will provide support to IAMG to help spread awareness about medical genetics in the country. The three-month fellowship programme will be

supported by Continuous Medical Education (CME) and medical workshops at the local as well as national level. EH News Bureau MAY2013

M|A|R|K|E|T INTERVIEW

'BD seeks to address fundamental weaknesses in developing world healthcare systems' Neeraj Raghuvanshi BUSINESS DIRECTOR, BD DIAGNOSTICS - PREANALYTICAL SYSTEMS

ecently, Becton, Dickinson and Company (BD) organised a seminar to help pathologists and lab diagnostic experts, improve specimen quality and subsequently patient care. M Neelam Kachhap spoke to Neeraj Raghuvanshi, Business Director, BD Diagnostics Preanalytical Systems to find out more about their efforts.

What can you tell us about laboratory errors? Why should laboratories pay attention to pre-analytical systems? There have been multiple publications analysing incidence and causes of errors in clinical laboratories. All of these indicate that pre-analytical phase contributes towards maximum number of errors.The human role in sample collection makes complete elimination of errors unrealistic. The analytical stage and post analytical stages depend primarily on the quality and integrity of the specimen received.

Can these errors be minimised and what percentages of laboratory errors can be avoided by pre-analytical systems? Studies have indicated that nearly 68 per cent of all errors in laboratory testing are associated with the preanalytical phase – phlebotomy (blood collection) being a major component of this phase. The major pre-analytical errors associated with phlebotomy include haemolysis, patient identification, insufficient sample volume, incorrect additive, and improper clotting, training phlebotomists on best practices has shown to help in reducing pre-analytical errors.

What are the economical impact of such errors? Error costs as a percentage of total hospital costs ? The cost of laboratory services represent about five per cent of the total healthcare costs, the results generated in the laboratories are responsible for about 70 per cent of medical decisions MAY 2013

Good practices and compliance in blood collection can significantly reduce preanalytical errors and laboratory costs made in the hospitals (Advance Lab Magazine, July 2005; Forsman Rodney S. The Value of the Laboratory Professional in the Continuum of Care. Clinical leadership and management review, 370-373 Nov/Dec, 2002). The devices used in blood collection contribute about five per cent of the total laboratory costs. Good practices and compliance in blood collection can significantly reduce pre-analytical errors and laboratory costs. Pre-analytical errors can contribute to costs by impacting: ● Quality of patient care –erroneous medical diagnosis, and delayed medical intervention ● Safety—needle stick injuries to patients or staff and hence raising risk of transmitting blood borne pathogens ● Time— increased turnaround time and repeat sample collection ● Resources and Budget – reduced staff and equipment efficiency ● Reputation of the facility in overall healthcare delivery

What is the effect on patient outcome? It is estimated that 70-85 per cent of clinical decisions are based upon information derived from laboratory test results (Foubister, Vida. Cap Today Bench press: The Technologist/technician shortfall is putting the squeeze on laboratories nationwide; September 2000; Datta, P Resolving Discordant Samples. Advance for the Administrators of the Laboratories; July 2005: p www.expresshealthcare.in

60), so ensuring optimal sample quality is crucial to the patient, clinician and the efficiency of the hospital. Comprehensive quality control program, along with pre-analytical awareness and training can prove to be valuable tools to improve specimen quality and, subsequently, patient care.

What is the scene of pre-analytical systems in Indian laboratories? There are no defined guidelines for specimen collection in India. Since accreditation of laboratories is voluntary (rather than mandatory), only a small percentage of laboratories are accredited. The accredited laboratories give high importance to preanalytical phase. Such clinical laboratories, like other parts of our healthcare system, are striving to provide high-quality services in the face of evershrinking resources and increasing regulatory demands. Lab directors and managers are viewing the preanalytical phase of laboratory testing as a critical area for improvement that can drive not only better patient care and satisfaction, but also productivity gains and cost savings.

What is BD's investment in pre-analytical systems ? BD’s lab strengthening programme is exceptional in its comprehensive approach to transferring knowledge, technology and expertise to the developing world through a combination of hands-on training workshops, and the provision of equipment. By investing in lab strengthening, BD seeks to address fundamental weaknesses in developing world healthcare systems. In India, BD has designed preanalytical audits (May I Help You) to help laboratories across the country to identify gaps in their practices as compared to international guidelines. Through this tool, laboratories are able to prepare a step by step approach to make improvements in their practices. Further, the content and methodology used in BD phlebotomy training programmes have been endorsed

by Association of Clinical Biochemists of India (ACBI) and is widely accepted by laboratory professionals throughout the country.

How will this space change in the future and how will BD keep pace with this changing environment? For more than 60 years, BD has advanced the science of specimen collection that has helped enable laboratory tests to become the foundation for 70 per cent of all medical decisions.(The Lewin Group (2005). The Value of Diagnostics: Innovation, Adoption, and Diffusion into Health Care, Published for the Advanced Medical Technology Association, pg 1) Today, the gold standard in sample collection is the BD Vacutainer product family, which leading hospitals rely upon to enhance sample quality and protect their nurses, phlebotomists and other caregivers from costly accidental needle-stick injuries. These products, backed by unrivalled customer support and training, help hospitals everyday to enhance lab productivity and work-flow by reducing retests, recollects and instrument downtime. During the last ten years, BD in India has put tremendous efforts towards increasing the awareness of laboratory personnel in better and safer blood collection practices. Every year BD India conducts more than 1000 training programmes for healthcare workers training close to 10000 healthcare workers in a year on best practices in blood collection. BD Laboratory Consulting Services works as a partner in obtaining pre-analytical excellence through sustainable education and training solutions. The customised training programmes deliver the skills and knowledge laboratory staff needs to reduce costly pre-analytical errors and help achieve the critical organisational goals and objectives of enhancing quality and improving productivity and reducing costs. mneelam.kachhap@expressindia.com

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'Consumerism of healthcare is driving semiconductor manufacturers towards medical devices' Tom O’Dwyer DIRECTOR OF TECHNOLOGY, HEALTHCARE GROUP, ANALOG DEVICES

emiconductors have revolutionised the medical device landscape. From a top end hospital CT machine driving for better image quality, to a heart rate monitor talking to a mobile phone, it is semiconductor advances which have enabled the envelope to move forward, and will continue to do so for the foreseeable future. Tom O’Dwyer, Director of Technology, Healthcare Group, Analog Devices explains these concepts to M Neelam Kachhap

Why are semiconductor makers looking at medical devices as the next big opportunity? Traditionally medical devices have been expensive and only sold to clinics and hospitals.The trend today has shifted from healthcare being delivered in hospitals to more home-based care.This is driving the need for smaller and more compact monitoring devices such as vital signs monitors. This migration will drive up unit volumes by several folds and hence justifies IC solutions which are more tailored to the particular application. The phenomenon is also referred to as ‘consumerism of healthcare’. The rise of the mobile phone as a healthcare platform is a key driver. Several medical device companies have released add-on modules to mobile phones which provide functionality similar to hospital equipment but are targeted for the consumer. Although lower in performance, these devices will also drive up volume. Thirdly, the move towards ubiquitous wireless connectivity is driving up volume.The advent of Bluetooth 4.0 SMART standard has been a key enabler to new wrist- or arm-worn monitors which talk to mobile phones in a very energy-efficient manner.

Choosing a chip to design a medical device is a complex process. Kindly comment. The task can certainly be complex, since it depends very much on the function of the medical device, and in particular the grade level under FDA (US) guidelines. Devices which are designed to support life-critical functions require extremely high reliability, and it is important to

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select a product which matches this need. Failure to do so could result in litigation which could cripple the supplier, or result in halted shipments if problems are found. Device longevity is another serious consideration. Medical equipment will often have a useful life of 15 years or more, and in today’s fast-changing process migration following the Moore’s Law curve, this can be a problem of ensuring long term supply of the IC solutions used in the medical equipment. So it is important to work with suppliers who can support these life cycles, like those who service into the industrial and avionics markets, which have similar longevity issues. Size can often be another concern, especially for implanted devices. Very often this drives the medical device designer down the ASIC path, which can be very expensive and takes time. The task is getting easier though as more suppliers develop more targeted healthcare chips, which lower the power and cost for these applications.

What should a designer expect from a semiconductor supplier? These days, before designing any new equipment, it is worth checking around with all the suppliers focused on the medical market to check for their latest offerings. Newer and more tailored designs are coming onstream all the time, such as Analog Device’s ADAS1000, complete single chip ECG measurement system. Many of these devices are complete hospitalquality measurement systems, and considerably ease the burden of system design. The ADAS1000, for example, contains fully integrated detection of pacemaker rules, and can even measure respiration, features which are found in high end hospital equipment. Also with regard to expectations, several suppliers who are focused on the medical market have dedicated applications teams who understand most of the major equipment types to a deep level, and customers can now expect a very high standard of support.

How does advances in precision analog components www.expresshealthcare.in

help medical device manufacturers The components are becoming more sophisticated these days, with higher levels of integration, at least for the standard medical functions, and as a result, overall performance can be greatly improved due to removal of parasitics due to PCB routing, cabling, etc. These new generation of devices considerably ease the problem of the hardware design, and result in lower development costs and time to market. It leaves the equipment designer free to focus on the software and algorithms, which is typically the added value in many cases.

On–chip integration of analog functionality provides many system cost benefits. Kindly comment. The major cost benefits relate to both reduction of development cost and also lower per-unit cost. Typically the devices contain many integrated functions, thus shortening the design time. But in addition, the size, weight and power of the final system design is often smaller, and each of these drive down the per-unit cost. For example, ultrasound systems have been cart-based, and rather clumsy to move around a hospital. Thanks to integration innovations such as Analog Device’s AD9278, ultrasound systems are getting smaller and even handheld versions are now available.

Tell us about ADI’s single chip solutions for integrating front-end A/D functions? Some of the single chip or single package solutions from Analog Devices that integrate the entire signal chain are: ● ADAS1000: Low power , 5-electrode electrocardiogram (ECG) analog front end with respiration measurement and pace detection ● AD8232: Single lead heart rate monitor analog front end ● AD9278/9: Ultrasound AFE ● ADXL345/62 3- Axis digital accelerometee for fall detection and movement detection as an auxiliary to any physiological measurement Many other solutions are currently in development and

will be announced in the next few quarters.

What do you think about Indian medical device manufacturers? Our estimate is MNCs today control 70-80 per cent of the market in terms of revenue and Indian manufacturers the rest. While MNCs control a significant portion of the imaging market, patient monitoring systems have stiff competition with strong Indian players, MNCs and cheaper Chinese imports, while home health is controlled by MNCs again. Few Indian manufacturers are strong contenders internationally and there are several across West and North region doing smaller volumes. Most MNCs now are doing substantial amount of their product development in India. While originally they started redesigning existing equipment to reduce costs for the local market catering to India and other BRIC countries, now they are doing complete designs of their own. We are seeing more and more Indian-designed equipment finding its way into mature markets such as US, Europe and Japan. Design houses in India have emerged strong in the subcontract design space, particularly for vital signs monitoring equipment. They have matured from a software-only model, to full turn-key solutions providers, and several design houses are now established world players doing more and more of the R&D work for global medical electronics companies.

How is ADI helping shape the medical device landscape in India? ADI continues to grow in India through its design centre in Bangalore. This group has worked on some of our new generation components aimed at healthcare markets, and is likely to see an expanding role in the future. We continue to monitor the Indian market closely as it is one of the fastest growing in the world, and we continue to build relationships with the key design companies there, with the help seminars, training and direct support to the designers through our medical electronics system experts. mneelam.kachhap@expressindia.com MAY 2013

M|A|R|K|E|T PREEVENT

2nd Annual India Hospital Expansion Summit, 2013 to be held in New Delhi The event will focus on topics like hospital expansion, trends in hospital designing and investments in healthcare equipment rganised by Noppen Conference & Exhibitions, the 2nd Annual India Hospital Expansion Summit will be held on May 9-10, 2013 at the Hilton Eros Hotel, New Delhi. The event will lay emphasis on the ongoing and upcoming hospital expansion projects, global trends in designing hospitals and the enthusiasm of big hospitals to invest in world class

healthcare equipment. Major issues to be addressed at the 2013 event: ● Exploring funding landscape and how to acquire funds for upcoming projects ● International green hospital practices and development ● Designing world class hospitals ● Insights in important legislative amendments

Speakers like Dr Rahul Kashyap from Mayo Clinic, USA will address on the ‘Implications of Clinical Research and Evidence Based Medicine’ and Dr Jagprag Gujral from Anand Rathi Bank will share his views on means and ways to acquire finances for the construction of new hospitals. Among others, Dr Deoki Nandan who is the Former Director from National Institute of Health &

Family Welfare, Dr Gurbir Singh from Fortis Healthcare and Dr Anil Goyal, Chairman of Delhi Medical Council are the few eminent speakers participating in this conference. Contact Samantha Dasgupta Regional Marketing Manager Tel: +91 80 4333 4012 Email:samantha@blr.noppen.com.cn

POST EVENT

Healthcare IT India Summit kicks off on a high note Highlights advantages of integrating healthcare with information technology ealthcare IT India Summit by Fleming Gulf conferences was recently held in Hyderabad. The objective of the summit was to highlight the advantages of integrating healthcare with information technology to make way for the future of healthcare management system. The opening remarks were delivered by Sid Nair, Dell Services Vice President and Global General ManagerHealthcare & Life Sciences (HCLS). The premise for session one was Efficient Healthcare IT Ecosystems. Andrew W Litt, Dell Healthcare and Life Sciences Chief Medical Officer shared his views on Information Driven Healthcare. This was followed by a talk on the Relevance of Health Informatics Standards in the Indian Scenario by Baljit Singh Bedi, CDAC, TSI, IAMI & Medical Electronics & Telemedicine Div Dept of IT, MCIT, Government of India. The action packed day also witnessed panel discus-

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sion on The Evolution of Pharmacy Management in India. Sanjeev, CEO & MD, Meddiff Technologies; Carlos Royo, GMV Director, eHealth Business Development Director, UK; Sampath Kumar,

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CIO, Sankara Nethralaya; Syam S Adusumilli, UnitedHealth Group – Global Sourcing & Delivery (GSD)Head – Consulting, Products and Solutions were the key speakers for day one. The second day of the

summit had insightful presentations on intriguing subjects like M Health, Informatics in General Operations, Scope for stakeholders in E-health. Aliasgar Bohari, Zulekha Hospitals, Director, Information Technology, Dr Thanga Prabhu GE Healthcare & IAMI were among the expert speakers for the concluding day for the conference. Dell was the Platinum Sponsor and HTC Global Services, UnitedHealth Group and GMV – innovating solutions were the Bronze sponsors along with GE Healthcare, which was the Supporting Partner. Express Healthcare was the official media partner for the summit. EXPRESS HEALTHCARE

M|A|R|K|E|T POST EVENT

ConvaTec organises nurse course on advanced wound management in Bengaluru, India Opens North India regional office in New Delhi onvaTec, a developer of innovative medical technologies, conducted its first nurse course on Vascular Wound Assessment and Advanced Wound Management in its training centre located in Bangalore. Organised under the banner of 2nd Indovasc Symposium, India’s premier vascular and endovascular meeting, the course was conducted in partnership with the Narayana Hrudayalaya Institute of Vascular Sciences, Bangalore. Inaugurating the course, Dr Ramesh Tripathi, Director, Narayana Hrudayalaya Institute of Vascular Sciences and Course Director said, “I am delighted to see this course happening and very happy at ConvaTec’s initiative and commitment to imparting healthcare education. We look forward to more such courses from ConvaTec for the benefit of the nurses and medical fraternity as a whole. I hope that participants get the maximum benefit out of this course and put into practice what they have learnt in their day to day clinical activities.” This course is the first-ofits-kind conducted in India on Advanced Wound Management covering a wide range of topics that included: fundamentals of wound science, skin integrity, wound assessment and etiology, types of wounds, exudate management, infection control, factors affecting wound healing, progression of wound healing and selection of appropriate dressings to promote the healing process. Nurses from different hospitals in Bangalore participated in the course. Course highlights included lectures on Advanced Wound Management by international expert Rachel Mathison from ConvaTec, UK. Nurse registrants participated in a hands-on workshop with practical sessions on simulated vascular and diabetic foot ulcers and the application and usage of ConvaTec’s wound dressings including DuoDERM, AQUACEL and AQUACEL Ag (Silver) dressings. “With the growing incidences of pressure ulcer, diabetic foot and venous ulcers

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Nurses being trained at the ConvaTec Wound Nurses Programme

Rachel Mathison addressing nurses during the ConvaTec Nurses Training Programme in India, ConvaTec is committed to providing quality and professional healthcare education. We will continue to bring in more such courses and initiatives for clinicians and nurses to share the best practices and transform www.expresshealthcare.in

wound treatment practices into advanced wound management solutions,” said Anand Shirur, MD, ConvaTec, India. The course concluded with certification awarded to the nurse participants by Shirur.

ConvaTec previously unveiled plans to establish an advanced wound clinic and limb salvage centre at the Narayana Hrudayalaya Hospital located at NH Health City in Bangalore. The centre is expected to provide world class support and treatment for diabetic foot ulcers, pressure ulcers and venous leg ulcers, and will have state-of-the-art diagnostic capabilities, patient treatment rooms and specialists in wound management. The centre is being touted as the first-of-its-kind in India, bringing together the collective experiences of a leading multinational product manufacturer of advanced wound dressings and one of India’s leading healthcare service providers. ConvaTec also opened a branch office in New Delhi for the North India region. The office was inaugurated by John Lindskog, President, Asia Pacific, B2B, and Continence and Critical Care. “ConvaTec is committed to healthcare excellence across the globe including India and we are very excited by the response we are receiving from the healthcare community and professionals in India to key initiatives such as the advanced wound clinic and nurse training course,” said Lindskog. MAY 2013

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National Conference on Family Medicine and Primary Care More than 400 delegates, including several distinguished faculty as well as delegates from abroad participated in this two day conference he Academy of Family Physicians of India (AFPI), in association with the National Rural Health Mission (NRHM) and National Health Systems Resource Centre (NHSRC), organised the first ever National Conference on Family Medicine and Primary Care (FMPC) 2013 with the theme “Preparing Multiskilled and Competent Primary Care Physicians: Consensus on Family Medicine in India.’’ Held on April 20-21, 2013, at the India International Centre in New Delhi, the conference was inaugurated by Keshav Desiraju, Secretary (H&FW) Ministry of Health & Family Welfare, Government of India in presence of a large number of Indian and international experts in family medicine and primary care including Professor. Michael Kidd President Elect, World Organization of Family Doctor, Professor Srinath Reddy, President, PHFI, Dr Purushottam Lal, Member, Board of Governors, Medical Council of India and Dr T Sundararaman, Executive Director, NHSRC National Rural Health Mission MOHFW GOI. Nation Wide Primary Healthcare Services (NationWide), a chain of primary care clinics, was principal sponsor and preferred partner for this event. The conference was also supported by international partners –the World Organisation of Family Doctors (Wonca ) and The Spice Route, and academic partners—Christian Medical College, Vellore; All India Institute of Medical Sciences, Jodhpur; Calicut Medical College; and the Indian

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Council of Medical Research. In his opening address, Health Secretary, MoHFW, Desiraju, focussed on the tug of war between state and government when it comes to implementing universal healthcare. “There is a lot of discussion in India on UHC, however, there is no consensus that there needs to be a provision of health services universally by the state. Poverty, lack of resources and political barriers to healthcare in states complicate this further.” He also declared that MCI is soon set to approve a curriculum or course in family medicine. This along with the rising number of students acquiring DNB degrees was a good indicator of the expansion of family medicine in India.The opening session saw Dr Sunil Abraham dwell on the role of family physicians in primary healthcare and community healthcare centres and how doctors trained in India are ill equipped to deal with it. He emphasised the role of a generalist specialist at a PHC who can manage 80 per cent of all the medical problems of the community providing acceptable cost effective quality care. This would lead to less crowding and better access while improving the quality of care as one moves to tertiary care facilities. Dr William Wong then enumerated how GPs can intervene and improve health outcomes in marginalised groups who might have more access to such vulnerable populations and can tackle them better. The next session was on how culture plays an important role in the increasing burden of NCDs in the world and how family physicians can help bring

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about required changes. Dr Raman Kumar, Chairperson, Organising Committee FMPC 2013 and President, Academy of Family Physicians of India, said, “India is moving towards Universal Health Coverage (UHC) and National Health Mission (NHM). Multi-skilled and competent primary care providers and their knowledge figure prominently in the evolving schemes, themes and initiatives of our healthcare systems. Family Medicine has received attention in several policy documents of the Government of India, including the National Health Policy 2002. Such a conference is the need of the hour as India is moving towards the goal of all-inclusive health, including the poorest of the poor, who cannot afford multi-speciality and super-specialty hospital care.” Dr Santanu Chattopadhyay, Founder & CEO, NationWide Primary Healthcare Services. and a key note speaker at the conference said, “Current healthcare scenario in India is staring at a crisis, as patients face increasing healthcare expenses due to the skewed emphasis on hospitals and super-speciality care. Much of this expense can be avoided if the primary care provision is strengthened, which can only happen when we have a robust system for training and producing more family physicians.” Dr. Raman Kumar said that more than 400 delegates and experts from India and from neighbouring countries are participating in the conference with the common objective of developing the discipline of Family Medicine in Nursing. Prasanth K S Convener, National Consultation on Family Medicine Program and Senior Consultant (Public Health Administration) of National Health Systems Resource Centre said, “The conference is also hosting a national consultation convened by National Health System Resource Centre (NHSR), National Rural Health Mission (NRHM), Ministry of Health and Family

Welfare Government of India. During the conference a number of Indian and international experts in family medicine and primary care have been deliberating on the scope of expanding family medicine programmes in India—especially on the critical skills to be ensured at a Community Health centre level.” According to Dr Raman Kumar, a rainbow session is also going to be organised— where International family physicians of Indian origin is participating. Young delegates from India, Nepal, Pakistan and Sri Lanka is participating in huge number. There is a special session called Youth Leadership Summit for Primary Health Care (YLS- PHC), where selected students and young healthcare professionals will present their concept notes on how to strengthen primary healthcare in India. The conference brought together Indian and international experts in family medicine and primary care with a common objective to define family medicine in India. The event will also host a National Consultation convened by NRHM, NHSRC and MOHFW Government of India, on development of Family Medicine Programme to ensure availability of skilled doctors at Community Health Centre (CHC) level. Apart from CME and scientific seminars sessions, family medicine practitioners and trainees, officials from the NRHM, NHSRC and MOHFW Government of India, and other stakeholders from the private health sector discussed the following topics: ● Making family medicine a preferred career choice for Indian Medical GraduatesChallenges and Solutions ● Consultation and communication skills required to improve patient satisfaction ● Expanding scope of family medicine in nursing ● Governance and regulatory issues ● Emerging models in family practice in India EXPRESS HEALTHCARE

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Imperia Health conducts a panel discussion on driving mid-size hospitals towards sustainability Its new model of Hospital Operations Management aims to assist and partner with a network of healthcare establishments in the small and mid size range to make them more sustainable ndian healthcare sector is estimated to reach $100 billion by 2015, growing 20 per cent yearon-year, as per rating agency Fitch. Yet, paradoxically there are a large number of small and mid-size hospitals of different capacities that remain grossly under subscribed. Imperia Health, a Hospitals Operations Management Company for Mid-Size Hospitals in India, hosted a panel discussion on this topic. Held at Hotel Oberoi, New Delhi on April 21, 2013, the discussion was lead by Dr Naresh Trehan, Chairman & MD, Medanta, Medicity; Shekhar Gupta, Editor-in-Chief, Indian Express; Dr Giridhar Gyani, Director General, Association of Healthcare Providers India; and Shiv Khera, Motivational Speaker. These experts conducted a detailed discussion on the declining market of mid–size hospitals and its effects over the population and healthcare indicators for the country. The event was attended by a large gathering of distinguished medical professionals, leaders from different industries and media personalities. The discussion started over the emerging demand for better healthcare facilities and advanced solutions in the field of medicine. Dr Naresh Trehan stated, “Healthcare in India has transitioned from family doctors, local or community hospitals to the corporate hospitals over the years. The problem that we are facing today is that there is a dearth of frontline hospitals that can cater to the middle and lower strata of society with efficient and affordable health facilities and treatment. A majority of our population that comprises these people are therefore left with no choice but to go to tertiary hospitals as a result of which hospitals like AIIMS, Safdarganj etc. are booked to full capacity.” Dr Harsh Mahajan, MD, Mahajan Imaging elaborated, “Almost one-fourth of midsize and multi-super speciality hospitals in India are on the verge of collapse and are

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either shutting shop or seeking mergers or sell out. While corporate hospitals are cashing on this trend, it is the middle and lower income groups that are finding it hard to meet their health requirements due to financial constraints.” Dr Randhir Sud, Chairman, Institute of Hepatobiliary Sciences, Medanta added, “The market is ripe for the entry of a leading enabler and provider of high quality affordable healthcare services in the mid and small range healthcare providers.” Dr Girdhar J Gyani, the well known quality expert of India and driver for NABH standards, now heading the Association of Healthcare Providers (India) (AHPI), expressed concerns over the declining financial performance of the mid-size community hospitals and emphasised the need for introducing professional management systems into these assets along with focused training inputs for ensuring patient safety and quality issues. He stated that his association is also working towards strategising means to make available capacity building system for these hospitals. Speaking at the occasion, Shiv Khera also emphasised that it is the need of the hour that these mid size hospitals are given due focus for develwww.expresshealthcare.in

oping the skills of the staff and are trained towards higher motivation levels for fulfilling the goals of the health sector. In a bid to tackle the situation, IPE Global, a multi-disciplinary consulting company has seeded a new model of hospital operations management through its venture Imperia Health in a bid to provide good and safe healthcare services at affordable cost. This venture aims at assisting, managing and partnering with a network of healthcare establishments in the small and mid size range to especially catering to the needs of all economic stratas of the society. The model is expected to play a crucial role in driving hospitals that are on the decline in Tier 1 and II cities towards sustainability through manpower management, asset management, marketing and quality assurance. The venture will also support new entrants to set up green field projects matching the demand and quality of services required. Speaking of the venture, Dr Trehan said, “Imperia Health can play an assured role of building and creating a network of mid-size hospitals with better assistance in daily operations. Our healthcare management services can outshine people running the sector presently who lack proper knowledge of

accountability, hygiene and cost maintenance.” Dr Mahajan's view on the venture is that Imperia Health is set to cater to the section of the middle and lower income groups of the society with its model of hospital operations management. It targets such declining hospitals to improve their manpower, infrastructure, capacity for treatment and ability to deal with emergency and terminal cases. “Imperia plays a pivotal role as it aims at providing best and safe services to middle class patients at their door steps. Imperia would act as a huge support to the middle and lower strata of the society with its high quality services at reasonable prices, ” opined Dr Sud. Dr Devi Shetty, Chairman & MD, Narayan Hrudayalaya, in a message to Imperia Team, stated, “The path you have chosen is vitally important for the endurance of health sector in India. Large healthcare players together do not even form one per cent of the total number of beds in this country. Majority of the players run with 30-60 beds and they are the ones who offer healthcare to majority of the population. It is important that professional help is available to them the way you are planning. I would wish you all the success in your endeavour.” MAY 2013

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EVENTS UPDATE 2nd Annual India Hospital Expansion Summit, 2013

11th National Conference of IART Date: November, 22-24, 2013

66th Annual conference of Tamil Nadu and Pondicherry Chapter of IRIA

Date: May 9-10, 2013 Venue: The Hilton Eros Hotel,New Delhi Organiser: Noppen Conference & Exhibitions Summary: The 2nd Annual India Hospital Expansion Summit will lay emphasis on the ongoing and upcoming hospital expansion projects, global trends in designing hospitals and the enthusiasm of big hospitals to invest in world class healthcare equipments, thus proving their commitment towards ensuring high quality patient welfare Contact: Samantha Dasgupta Regional Marketing Manager Tel: +91 80 4333 4012 Email: samantha@blr.noppen.com.cn

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Venue: Jawahar Lal Nehru Auditorium, AIIMS, New Delhi Organiser: Department of Radio-diagnosis, AIIMS, New Delhi Summary: The 11th National Conference of IART will bring together experts from the field of radiology to deliberate on topics such as radiography, radiological imaging, radiology equipment, professional issues related to the subject, radiation protection, patient care and many more Contact: Organising Secretary Department of Radio-diagnosis, AIIMS, Ansari Nagar, New Delhi-110029 Tel: 09868398808, 01126546230 Email:ramesh_sh@hotmail.com

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Date: December, 13-14, 2013 Venue: Scudder Auditorium, CMC Campus, Bagayam, Vellore Organiser: Department of Radiology, Christian Medical College, Vellore and the Vellore subchapter of the TN & PY chapter of IRIA Summary: The 66th Annual conference of Tamil Nadu and Pondicherry Chapter of IRIA will lay emphasis on the ongoing and upcoming trends in the field of radiology and diagnostic imaging. Contact: Department of Radiology, Christian Medical College, Vellore Tel: 0416 228027 Email: registration@iria2013vellore.in; radio@cmcvellore.ac.in

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Strategy Consider hypothetically… a cervical cancer-free India! Dinesh Gupta, PhD., Clinical Consultant, CureHealth Diagnostics Lab, HPV & Preventive Health opines that Provision of a preventive healthcare system is a State responsibility Page 33 MAIN STORY

Innovating for good health Dr VK Singh, Adjunct Research Professor of Ivey School Of Business, University of Western Ontario, Canada talks about innovation and its impact on the health scenario in India

nnovation is a process of translating an idea into goods or service that create value for which the customer is ready to pay. Idea is to be replicable and the economic cost must satisfy a specific need. Innovation involves deliberate application of information, imagination and initiative in deriving greater or different values from resources, and includes all processes by which new ideas are generated and converted into useful products. Innovations have two broad categories: (1) evolutionary innovations (continuous or dynamic evolutionary innovation) that are brought about by many incremental advances in technology or processes and (2) revolutionary innovations (also called discontinuous innovations) which are often disruptive and new. Innovation is synonymous with risk-taking and organisations that create revolutionary products or technologies take on the greatest risks because they create new markets or models for Environmental and operational dimension of healthcare innovation

implementation. Innovation in manufacturing is known to exist since decades. However, its entry into the healthcare delivery system is of recent origin, after technology has crept into the health domain to assist qualitative outcome and effect reduction of cost. Innovation could be considered at three levels, firstly, at process improvement level to remove waste, reduce cost and improve outcomes. Known as lean theory of quality, many such improvements made in process and behaviour modification or cultural changes impacting organisation is called transformation. Arvind Eye Hospital is an example of improving process to reduce cost and waiting time considerably for patients. Second level is to take the help of technology in improving processes, this can be seen in clinical or non-clinical areas of hospital departments or public health institutions in the form of hospital information system (HIS), telemedicine, ehealth, barcoding, radio frequency identification device (RFID), electronic

DR VK SINGH Organizational Culture

Environmental Dimensions

Improved Clinical outcome Improved Quality

Cost Containment

Organizational Leadership

Nursing & Staff Shortage

Aging Population

Dimensions of Healthcare Innovation

Improved Productivity

Improved Efficiency

Patient Safety

Partnership and Collaboration

Regulatory Acceptance

Adjunct Research Professor of Ivey School Of Business, University of Western Ontario, Canada

Improved Profit Improved Effectivness

Physician Acceptance

Patient Satisfaction

Complexty of Innovation

Courtesy: The Innovation Journal: The Public Sector Innovation Journal, Volume 15(1), 2010, Article 2.

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Operational Dimensions

health records and use of various other devices. Third level is product or technology development for improvement of process like developing smart phone application for use by Accredited Social Health Activist (ASHA) worker, getting a ECG tracing of a patient through mobile telephone for assessment at hospital, development of Information & Communication Technology (ICT) and mHealth to aid operation is product innovation. Concepts like lean transformation and innovation overlap, but these are two sides of same coin. A book titled ‘Jugaad’ compiles few such innovations in India in various sectors impacting social outcomes. ‘Jugaad’ is a colloquial term for innovation in India. CK Prahalad, in an article published in 2006 stated,“to create an impossibly low-cost, high-quality new business model, start by cultivating constraints. Once the “sandbox” of constraints is defined, unconventional thinking can occur in many directions at once. The result is often breakthrough innovation that doesn’t just change processes; it changes lives. India’s healthcare system is on a similar trajectory, with innovation coming from a national objective of providing poor people the same world-class healthcare as the rich. The author describes a set of self-imposed constraints, which can vary by industry and are derived from previously ignored consumer insights. For India’s healthcare industry, the sandbox is constrained by four sides: ● Innovation must produce products or services of world-class quality; ● It must achieve a significant price reduction of at least 90 per cent; ● It must be scalable to serve both rural and urban environments; and ● It must be affordable by all, regardless of income. That sounds like a good model for a healthcare system, so there are many lessons we can learn from innovation in India and the sandbox model. Health innovation is having two components, environmental and operational dimensions, contents of each is explained in the adjacent figure. Continued on Page 34 MAY 2013

S|T|R|A|T|E|G|Y INSIGHT

Consider hypothetically… a cervical cancer-free India! Dinesh Gupta, PhD., Clinical Consultant, CureHealth Diagnostics Lab, HPV & Preventive Health opines that provision of a preventive healthcare system is a state responsibility

DINESH GUPTA, PhD., Clinical Consultant, CureHealth Diagnostics Lab, HPV & Preventive Health

MAY 2013

I get to attend any number of international, national or regional clinical meetings in gynaecological oncology and I have come to understand how different countries are preparing to tackle the menace of cervical cancer and cope with growing needs on their limited resources. The success stories not only come from the Western, supposedly resourceful world but many Asian neighbours too, the latest being Bangladesh. The Bangladesh Cancer Society has recently established a visual inspection (VIA) of cervix by three to four per cent acetic acid (by well-trained community level health workers) training and service centre in its own premises. These community volunteers organise VIA camps in different areas of the country and refer the VIA positive cases to Bangladesh Cancer Hospital & Welfare Home for further management. Awareness is being created among the people regarding the risk factors, symptoms of the disease and prophylaxis/prevention. The Society aspires to screen minimum 50 per cent of rural women population in the age group of 30 to 59 years by 2020, and also intends to maintain effective call-recall system to provide long-term effectivity to the programme. Kudos to this Society that truly cares for their folks! While success stories inspire us deep inside, the knowledge that we in India contribute a mind boggling quarter of a global burden is a demotivator as well. Factors like country-size, target women population, preventive healthcare system are deterring factors in taking a progressive step forward towards women’s health. But, is there an inherent apathy for women and their health concerns in our country? We too have built up success stories on HIV/ AIDS, hepatitis, tuberculosis, malaria, dengue, H1N1 and so forth. Why has then cervical cancer remained one of the major causes of cancer-related deaths among our women? India’s healthcare system is largely self-sustained. Preventive public healthcare essentially in the area of oncology is non-existent. Public health programme allocation in India declined from 1.3 per cent GDP in 1990 to 0.9 per cent in 1999 but has increased to close to 3.0 per cent GDP by 2012. Central government contribution to public health expenditure is 15 per cent of GDP while the rest is made up by the respective states in India, thereby making public healthcare essentially a state subject. The private healthcare sector still contributes to over three fourth of the GDP. Hence there are striking inequalities observed between different states. Lack of community ownership of public health programmes also impacts levels of efficiency, accountability and effectiveness. The healthcare insurance sec-

tor in India is heavily biased towards curative reimbursement than preventive one. Only 10 per cent Indians have some form of health insurance, which is grossly inadequate given the population of the country. Once hospitalised for major disease, an average Indian spends about 58 per cent of the total annual household expenditure. Over 40 per cent of hospitalised Indians resort to borrowing of funds or loans and even sell assets to cover costs of expenses. Over 25 per cent of hospitalised Indians fall below poverty line because of hospital expenses.

A sorry situation I cannot forget the face of a woman I met many years ago, a secondary school teacher from Faridabad and a mother of two young children, who came to our reference laboratory to collect her HPV report after nearly one and a half months of sampling when she was seen in a great hurry to receive a report. Her report was positive! Upon being questioned why she delayed collecting her report, she went into tears to reveal very reluctantly that almost every day she insisted her husband to fetch a report from the lab but he never paid

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adequate attention, let alone collecting the report from a lab in Delhi! The day when she arrived to take a report, she did not have the money to go back home! The anguish of many such women extends beyond the asymptomatic pains to their lower genital, pelvis or back pain or occasionally symptomatic precancer stage that slowly destroys their otherwise healthy body. Though they suffer internally, their major concern still remains their family. The devastation of cervical cancer is hard to express in words. But seeing the number of strong women whose lives it claims, hearing their stories, and comforting them in their critical hours, should reinforce our conviction that India must do something sooner to end this medical tragedy for our women folks. It is so much more bewildering since that India has world class clinical practices and state of the art, modern care medical facilities. Hordes of diseased patients from rest of the world look at us as a global healthcare destination. The world’s biggest democracy where every individual voice is heard, a country where female foeticide is a serious legal offence, yet why is there an apathy for EXPRESS HEALTHCARE

S|T|R|A|T|E|G|Y

our women who undergo deep anxiety? Our women have contributed 50 per cent to our own national GDP, earned as much as their male counterparts or have grown more agricultural produce than men did, but we seldom have cared for their good health! Equally intriguing is an aspect of cervical cancer is that these womendeaths are 100 per cent preventable. The paradox is that however it continues to soar alarmingly with the rise of every middle class. There were 132,000 new cases of cancer cervix in the year 2002, of which 74,100 cases resulted in death. The incidence is further likely to increase to 139,864 women by the year 2015. Nevertheless, we now have better tools and technology to save our women than ever before. Critical factors for primary prevention are low awareness about preventive healthcare and regular screening by pap smear test but most of our women in India lack access to quality screening. Although this test has brought down the incidence of cervical cancer drastically in the Western world, it is only half as accurate in identifying women with preinvasive disease. And because this test requires experienced cytopathologists, it is apparent that India could never adopt it in our screening programmes due to the number of grey areas in this branch of medical science. So, what are the affordable cervical screening options available to us in India?

Screening algorithm with ensured reduction in the cervical cancer incidence Healthcare is essentially a state sub-

ject and a consensus national preventive healthcare policy is not likely to be in place before 2020. The government and quasi-government sectors benefit from free care at the government hospitals to cost reimbursement at the private hospitals on referral basis. On the contrary, a larger section of the society in the private sector has to self-sustain healthcare provisions. The major focus of our current services in any given sector is directed towards curative and palliative aspects than the preventive one. In the absence of national guidelines, the patients get considerably confused by the diagnoses, treatment and management of dreaded diseases like cancers. The disease prognoses differ from hospital to hospital, physician to physician and even experts in the given speciality, leaving financially poorer and socially detached. On the other hand, our healthcare centres continue to be overwhelmingly burdened with loads of patients at the outpatient clinics, hospital beds insufficient for those who require critical care and even the infrastructural preparedness continues to appear deficient or lacking. The time has now perhaps come to rationalise our healthcare priorities and available resources, probably by allocating appropriate funds to upgrade the standards of preventive healthcare. It is now well realised that the incremental benefits, of upgrading capital-intensive tertiary care facilities are going to be miniscule, as compared to enormous benefits even a meagre resource would bring in, if directed towards upgrading preventive care diagnoses and treatment facilities in India. The most doable and financially less demanding VIA-based screening algo-

rithm could be applied to low-resource settings which may include primary and secondary healthcare centres such as rural hospitals, taluk and sub-district hospitals, district hospitals, and state medical college hospitals. The opportunistic screening and voluntary healthcheck camps could be conducted by any of these centres. This approach ensures cost feasibility that allows screening maximum number of people at a given time. The VIA based programme will allow risk factor identification as a single-visit approach, establish severity of assessed factors only from among those who show screen-positive outcomes, and modify risk factor by simple outpatient procedures at the clinics or the health camp itself. Though the test may be ineffective among meno- and postmenopausal women, it is well qualified to be applied to the reproductive age group. Generally VIA is followed with a Lugol’s iodine test for better demarcation of lesion. This technique assumes better adaptability within “See-andTreat” concept as a single visit approach. The test results could be obtained immediately and spot decision can be taken to treat. The severity of assessed risks through VIA could further be ascertained by pap testing and testing for integrated form of HPV DNA (E6, E7 gene expression) at the few nodal state medical college hospitals. The E6, E7 gene expression test shows correlation with precancer disease with more than 90 per cent specificity. Thus, implementation of a nationwide programme of cervical screening of women between 30 to 40 years holds significant promise to reduce the cervical cancer burden in India, even as it may look hypothetical for now!

Innovating for good health Continued from Page 32 In India we handle volume in healthcare as too many patients are consuming limited resources available. However we continuously innovate in process improvement. Some of the innovations adopted by organisations that have positively impacted the Indian healthcare system are as follows :● Arvind Eye Hospital is one example as it is the world’s largest provider of cataract surgery, performing 240,000 procedures per year with no waiting and providing qualitative care at 20 per cent cost. ● Life Spring Hospitals is the another good example of providing quality of healthcare at affordable cost by innovation where deliveries are conducted for Rs 4000 and caesarean section for Rs 9000. ● Narayana Hrudayalaya is one of the world’s largest

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providers of cardiac care and heart surgery, performing dozens of surgeries per day. It’s a very efficient system that charges a fixed rate of just $1,500, about seven per cent of what a typical US hospital might charge. ● Jamkhed rural healthcare providers is another example of how a community can be provided with preventive, promotive, curative and rehabilitative services under one roof at affordable costs ● Chiranjivi project has innovated in Gujarat for safe deliveries in best hospitals at minimum cost to reduce infant and maternity mortality rate. It was a great success and is replicated in other places. ● Jaipur Foot is a prosthetic foot made of rubber for below-the-knee amputees. Such a prosthetic in the US would cost $8,000-$10,000, it costs just $30 in India. The foot and other prosthetics are distributed and fitted for free www.expresshealthcare.in

by nonprofit organisations. Healthcare needs more innovation in process to reduce cost, increase efficiency and remove waste rather than product development. There is 90 per cent waste in the health sector and it is mostly in processes. Process innovation adoption can be seen in hospitals enumerated in the preceding paragraph. Innovation has to be market driven and a quest for new technology to improve operation, transparency, accountability and reduction of waste would ultimately benefit healthcare providers and patients by reducing cost. Innovation is of four types e.g. product innovation, process innovation, marketing innovation and organisational innovation. Technology is used for streamlining process and development of new technology is based on healthcare providers and patients need. Innovation in healthcare is

ultimately in product, process and structure. National Innovation Council has been created by the Government and funding is provided to incubate newer ideas and innovation. It would bring out talents for the benefit of society. Innovating in the health sector would impact India by providing qualitative healthcare delivery system for masses at affordable cost. There is a need to use common sense which can be translated in scientific concepts like ‘dabbawala’ (tiffin delivery service of Mumbai) got six sigma rating unknowingly. There are innumerable examples in India to show healthcare providers, entrepreneurs and planners that innovation is the key for qualitative healthcare at affordable cost and breakthroughs occur when clusters of innovation overlap, taking place through small experiments over time. MAY 2013

S|T|R|A|T|E|G|Y INTERVIEW

'We will soon be partnering with members of Indian National Cancer Grid” Arnie Purushotham, DIRECTOR OF THE KING'S HEALTH PARTNERS INTEGRATED CANCER CENTRE (ICC)

ing's College London, has recently forged a partnership with the Tata Memorial Centre to promote research and education activities. Arnie Purushotham, Director of the King's Health Partners Integrated Cancer Centre (ICC) gives more details on the partnership and shares some insights on cancer treatment in India, in conversation with Raelene Kambli

Give us some details about King's College London and your association with it? King’s College London is one of the top 30 universities in the world (2012/2013 QS international world rankings), the Sunday Times’ 'University of the Year 2010/11' and the fourth oldest in England. A researchled university based in the heart of London, it has more than 24,000 students (of whom nearly 10,000 are graduate students) from 150 countries and more than 6,100 employees. King’s has an outstanding reputation for providing worldclass teaching and cutting-edge research. In the 2008 Research Assessment Exercise for British universities, its 23 departments were ranked in the top quartile of British universities; over half of our academic staff work in departments that are in the top 10 per cent in their field in UK and can thus be classed as world leading. The college is in the top seven UK universities for research earnings and has an overall annual income of nearly £525 million. The division of Cancer Studies at King's College London is part of one of the leading cancer centres in Europe, the King's Health Partners' Integrated Cancer Centre. The division itself forms the major research activity of the Centre. Our multidisciplinary research portfolio maps onto and spans the entire cancer patient journey. By fostering a culture of innovation in cancer patient care through research excellence, we aim to break down traditional clinical and academic boundaries and draw together members of the division and our associated major NHS partners to achieve a fully integrated cancer research pathway. This is reflected in the coordinatMAY 2013

ed strategic planning that provides the foundations for our Integrated Cancer Centre. The Integrated Cancer Centre's mission is to combine first class clinical care with groundbreaking research to bring direct benefits to our patients and those from around the world. Staff in the Division and associated NHS partner hospitals foster a culture of innovation in cancer patient care through multidisciplinary research excellence. Our research covers programmes including those in haematooncology, breast cancer, epidemiology, cancer cell biology, thoracic cancer, prostate cancer, imaging and palliative care. Research teams are developing alternative and individualised patient care options, extending the clinical trials portfolio and palliative care programmes designed to optimise quality of life, as well as rigorously quantifying benefits for patients. The Division benefits from unique resources such as the Bio-Bank and the Thames Cancer Registry and the infrastructure support afforded through the Experimental Cancer Medicine Centre, the Comprehensive Cancer Imaging Centre and the Biomedical Research Centre (BRC) cancer theme. As Director of the Cancer Centre, I have led the strategic partnership with the Tata Memorial Cancer Centre and continue to develop closer relationships with the 26 regional cancer centres in India. I am also the lead for the Cancer Clinical Academic Group, Professor of Breast Cancer and Consultant Breast Surgeon.

Tell us about the MOU between King’s College London and Tata Memorial Centre. What is the focus of this partnership? The MOU with Tata Memorial Centre (TMC) builds on a strong three year partnership between our institutions. The focus is very much on a mission of mutually beneficial programme of research and education that benefits patients in both India and the UK. We have an exciting and active exchange programme of healthcare professionals at all levels studying and visiting respective colwww.expresshealthcare.in

leagues. Most recently two of our cancer centre’s lead lung cancer specialists spent time at TMC to learn how treatment and research opportunities in the field of lung cancer could be applied in the UK setting. We have active research programmes in breast cancer, epidemiology, clinical trials, cancer policy and public health.

Why did the Institute choose to partner with TMC in India? TMC, Mumbai is one of the world’s finest centres for clinical cancer care. At King’s Health Partners Integrated Cancer Centre we have a unique focus on global cancer which aims to partner major cancer institutions and organisations in emerging economies. This global cancer health twinning approach, built on real collaboration around education and research is the best way to build the network for future cancer control.The experience of cancer in India has a great deal to teach and inform about care and research to high income countries as well as other emerging economies. The partnership with TMC, Mumbai has been a very effective way for our respective centres to work together on this ‘grand challenge’.

How do you plan to take this partnership forward? We will continue driving forward programmes in key areas of research and training. We are engaging with the National Cancer Grid, a partnership of 26 regional cancer centres in India, particularly on major pan-India public policy issues such as healthcare manpower planning and developing systems of affordable cancer care. We are also currently working on a major review of cancer research across India with TMC and other members of the National Cancer Grid. This work is being led by Professor Richard Sullivan, Chair in Cancer Policy and Global Health at King’s College London.

Are there any more partnerships in the pipeline? We will soon be partnering with the members of the Indian National Cancer Grid – 26 regional cancer centres.

What is your opinion about cancer treatment in India? The burden of cancer in India is very different from what places like the UK experience. There are far higher volumes, cancer patients often present with more advanced disease, and the spectrum of the types of cancer (for example head and neck cancer is a major public health burden in India) makes cancer one of India’s most important health challenges. Many centres like TMC, Mumbai provide excellent care in highly challenging environments. Indeed, India has been a major innovator in rising to this challenge, from developing cost-effective cobaltbase radiotherapy (Bhabatron II), to driving the generic medicines research agenda through companies such as Cipla. However, India is hugely challenged in terms of being able to provide enough cancer care to meet the present and growing demand, delivering equitable care to all its citizens, irrespective of the ability to pay and creating affordable cancer care for all. One of the privileges of working with TMC, Mumbai and other regional cancer centres in India is being able to share mutual learning on how to develop such systems for the future.

How do we find a cure fo cancer and get new treatments to patients faster? We need to do more research, and the review of the cancer research agenda in India we are carrying out with our colleagues in TMC, Mumbai and other regional cancer centres within the National Cancer Grid will, we hope, help to inform and frame this essential area of public policy. Research is the only solution to delivering affordable treatments and new ways of prevention for the future. Getting new treatments to all patients is a huge challenge and can only really be achieved once the systems for delivering affordable and equitable care are in place. Our experience with TMC and other Indian cancer centres has shown us that the cancer community in India is unequivocally dedicated to achieving this; what they need is political and financial support to deliver on this. Social justice for cancer in India is entirely achievable. raelene.kambli.g@expressindia.com

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Knowledge MAIN STORY

Women’s healthcare in India Dr Arvind Lal, Chairman & MD, Lal Pathlabs expounds on women's health issues with emphasis on cancers that are more common in women and advises on the means to curb their incidence

DR ARVIND LAL

Chairman & MD, Lal Pathlabs

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omen in India belong to various socio-economic backgrounds and are sometimes marginalised or neglected when it comes to basic healthcare. Women however are the backbone of our society and if one needs a healthy society, then it is essential to have healthy women. The status of women in India has been subject to many great changes over the past few millennia. From equal status with men in ancient times through the low points of the medieval period, to the promotion of equal rights by many reformers, the history of women in India has been eventful. In modern India, women have adorned high offices including that of the President, Prime Minister, Speaker of the Lok Sabha and Leader of the Opposition. Contrary to common perception, a large percentage of Indian women are working. In urban India, women comprise an impressive number of the workforce. For example, in the software industry, females comprise 30 per cent of the workforce. They are at par with their male counterparts in terms of wages and position. According to a World Bank report published in 2012 - females constitute 48.37 per cent of the population in India. This means that women constitute nearly half of the population- they are not called the better half without reason. In the current environment, it is pertinent to focus on women’s health. This involves acknowledging the differences between men and women, without overshadowing the commonalities. Women and men have many of the same health problems, but they affect women differently. Some diseases such as osteoarthritis, obesity, anaemia and depression are conditions more commonly found in women while some conditions, such as menopause and pregnancy are unique to women. Today, several young women experience the early onset of hormone imbalance and associated symptoms such as depression, extreme fatigue, allergies, endometriosis, hair loss, facial hair growth, pre-menopausal symptoms (PMS), and osteoporosis. If the symptoms are ignored in the early stages, they worsen as time goes by. Incidence of cancer in women is also on the rise. In India, breast and cervical cancers are still the most prominent, primarily due to lack of preventive screening (pap smears and mammography) unlike in the West. Indian Council of Medical Research’s (ICMR) National Cancer Registry Programme predicts a rise of cancer in females by 24 per cent (75,289 in 2010 to 93,563 in 2020). Other cancers that are on the increase are carcinomas of the colorectum, thyroid and lung, together adding upto nine per

cent of all cancers in Indian women. Scientists claim to have identified a genetic variation that makes some women seven times more vulnerable to cervical cancer. The concerned gene known as p53, normally defends the body against tumours. But its variant form, p53Arg, is more easily blocked by HPV, the virus which doctors blame for almost all cervical cancers. Most cases of cervical cancer are easily preventable with regular screening tests and follow-up. They are also highly curable when detected and treated early. Now vaccines are available to protect against the commonest cause of cervical cancer. An estimated five to ten per cent of all breast cancers are hereditary. Variations of the BRCA1, BRCA2, CDH1, STK11, and TP53 genes increase the risk of developing breast cancer.

Role of a pathologist In no area of diagnostics does the pathologist play a more important and crucial role than in the diagnosis of tumours as in histopathology (tissue diagnosis). Patients and lay men are often entirely ignorant of this role and imagine that their surgeon or oncologist is the true diagnostician. The reality is that in any patient found to have a tumorous swelling, the histology report is the principal determinant of diagnosis, probable clinical course and therapy. Tumour pathology is expanding at an unprecedented rate. Skilled morphologic examination by an expert pathologist remains the gold standard in anatomic pathology for – ‘the final diagnosis’. Immunohistochemistry (IHC) i.e. specialised chemical staining of the tumour tissue on a slide, is a vital and useful adjunct to morphologic diagnosis of cancer. Use of IHC for identification of potential therapeutic targets (e.g. c-kit, EGFR, CD-20, HER-2 –NEU etc) is of considerable importance in cancer treatment. Molecular genetic techniques are emerging as valuable tools in tumour pathology and are a vital adjunct to surgical pathology. More often than not, women neglect their own health and focus instead on

Indian Council of Medical Research’s (ICMR) National Cancer Registry Programme predicts a rise of cancer in females by 24 per cent (75,289 in 2010 to 93,563 in 2020)

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their partner's and their children's. It is important that they take care of their health and keep in mind the following – ● Plan for pregnancies and see the doctor regularly ● Have regular mammograms ● Get regular health checkups and screenings for breast, cervical, uterine and ovarian cancer Comprehensive and advanced testing techniques can help the treating doctor in determining the choice of cancer treatment. HER2 is a protein found on the surface of certain cancer cells. Some breast cancers have a lot more HER2 receptors than others. Tumours that are HER2-positive tend to grow more quickly than other types of breast cancer. Knowing if a cancer is HER2-positive can sometimes affect the choice of treatment. As expected, most of these are rare mutations and may be found in one to two per cent of the population. Some of these mutations are found only in five per cent of cells. Using comprehensive genomic analysis we can now find out how every patient is different and we can actually tailor therapy based on each tumor's molecular subtype. Many good old techniques like FISH, IHC and PCR need to be supplemented with genetic level testing. Human carcinogenesis is a multi step process involving complicated genetic events in which several oncogenes and onco-supressor genes are involved. Current trends are now shifting towards testing a patient for multiple genes and not a single gene related to cancer. Today, we know of many genes like APC, PIK3CA, CCL2, FOXQ1 and around 200 other genes that play a role in either causing cancer or could potentially aid treatment decisions. We, at Lal Path Labs are striving to provide a comprehensive and complete profile for cancer diagnostics at the stateof-the art surgical and anatomic pathology unit at NRL, Rohini. A panel of 12 skilled surgical pathologists provide complete and detailed cancer pathology reporting in accordance with international guidelines with a large panel of IHC antibodies for diagnosis, prognosis and therapeutic purposes. Molecular and cytogenetic techniques for gene expression and determining karyotyping abnormalities and mutation analysis are well established diagnostic tools in the fight against cancer. The annual number of biopsy (histopathology) samples at Dr Lal Pathlabs has increased enormously in the last two years i.e. from 74,349 in 2010 to 99,512 in 2011 and 1,18,496 in 2012, nearly 400 biopsies a day. Of these nearly 30 per cent i.e. approximately 120/day represent cancer related workloads every year - including biopsy diagnosis, reporting of large cancer surgical specimens and IHC. MAY2013

K|N|O|W|L|E|D|G|E INTERVIEW

40 per cent of Indians are already infected with TB bacilli in the form of latent TB L Masae Kawamura, SENIOR DIRECTOR, MEDICAL AND SCIENTIFIC AFFAIRS, QUANTIFERON GLOBAL

he WHO estimates that TB, one of the oldest and deadliest diseases, kills 1.4 million people a year and costs the global economy nearly $12 billion in lost productivity and wages – with India and China making up half the burden. Shalini Gupta finds out more in an interview with L Masae Kawamura, Senior Director, Medical and Scientific Affairs, QuantiFERON Global

While medical discovery has reduced TB from a death sentence to upto two million deaths per year, the development of MDR TB and XDR TB, which account for one fourth of treatment costs, highlights the importance of adherence to disease treatment. Your comments. The treatment of TB is long and complex, and is extremely labour intensive, resembling treating a curable yet infectious cancer. A normal TB drug regimen generally varies between six to nine months, as patients gradually feel better, they may not stick to the regimen, and this is where the journey of drug resistance begins. Management errors by doctors not expert at treating TB and ignorance of providers and patients on the nature of TB are also reasons why drug resistance spreads. Patients with partial drug resistance are very prone to MDR-TB, even with the WHO recommended regimens. This is because drug susceptibility testing as per WHO is not universal for all cases of TB and is recommended for only relapsed cases or patients failing treatment.This is a big gap, since there is no confirmation on whether some or all of these medicines will work, hence failing treatment is the only way to drug susceptibility. Treating MDR TB takes 1.5 to two years in the US, is expensive with frequent toxicity that is much worse and therefore, it is important to get it right the first time when the disease is easier to treat and cure. XDR treatment is much longer and even more complicated. Hence, adherence, education, appropriate provider MAY 2013

care and monitoring is the key to preventing MDR-TB in a patient with regular TB and all the costly downstream financial, societal and human consequences. The patient and doctor also need to know the drug susceptibility pattern from the start.

How much of a public health challenge is TB? What factors further complicate it in India? TB is a huge public health challenge. India accounts for more than two million active TB cases, which is ~20 per cent of the world’s regular and MDR-TB. 40 per cent of Indians are already infected with TB bacilli in the form of latent TB. For a normal person there is 5-10 per cent lifetime chance of conversion from

through screening and more is done to prevent TB among the most vulnerable.

How much of a threat is latent TB and how could diagnosis address transmission? Individuals with latent TB silently carry the bacteria that cause TB in their body, but show no symptoms. They are neither sick nor contagious. While not all people with latent TB will develop active TB, all active TB patients progress from latent TB at some point (10 per cent). In addition, immuno-compromised patients such as those with HIV, diabetes, end stage renal disease, silicosis, patients on steroid therapy, TNF alpha therapy and cancer chemotherapy etc. and people with weak-

The infrastructure that provides patientcentred DOT, contact investigation, prevention, expert care, oversight of care being provided in the community, and patient/community education is what really needs focus. The new pharmaceuticals, tools and technologies would only serve to enhance this infrastructure and ability to cure patients. latent TB to active TB. And although this 10 per cent risk may not seem so bad, the sheer magnitude of the problem and dangerous co-factors that exists in India literally guarantees future TB and MDR-TB a big comfortable home in India. Diabetics are thrice likely to break down with active TB malnutrition (including lack of balance diet), HIV and consumption of new biologic agents for autoimmune diseases or immunosupressants for organ transplants are some more causes. Given the ease of airborne transmission in the crowded cities of India, this vast reservoir of silent carriers will continue to grow and future TB cases are guaranteed unless transmission is stopped www.expresshealthcare.in

er immune systems such as children, the elderly, malnourished, heavy smokers, and drug abusers, have a much higher chance of progressing from latent to active TB. For major impact on TB disease rates we must address latent TB infection. Previously, the only tool available for identifying latent TB infection was the Tuberculin Skin test (TST) or Mantoux, invented in 1907. It has many limitations, especially in countries that routinely vaccinate with BCG vaccination. This is where the new Interferon –gamma release assays (IGRAs) come in. Not only can they distinguish between TB and BCG as well as common environmental mycobacteria, it requires only

one patient visit to get a result instead of two for the Mantoux. Best of all, IGRAS provides an objective laboratory result using a specialised and calibrated instrument, unlike the subjective interpretation of reading the bump on the arm from the Mantoux, which can be highly variable based on the skill and training healthcare worker. Screening high risk populations for TB symptoms and using tools like the QuantiFERON TB-Gold, in conjunction with other tests have been very effective in other countries for this purpose. In my city of San Francisco, I definitely saw the impact of targetted screening and preventive treatment of latent TB. This is a strategy that reduced the rate and burden of TB by two-thirds over two decades by comprehensively cutting the line of transmission and killing the seeds of future TB by treating both active and latent TB. QuantiFERON TB-Gold was focussed on the homeless and BCG-vaccinated populations beginning 2003 and was well accepted by providers and patients. In the Indian scenario it would be impractical to screen and treat the entire population; however, like other countries, in the beginning India should focus on screening high risk groups, those vulnerable to TB disease development and those in high-transmission environments. This would help reduce the amount of people who will develop active TB and, therefore, help disrupt the ongoing cycle of spread of TB infection in India.

FDA recently approved the first drug to treat MDR TB. How will such medicines impact treatment? We are finally seeing breakthroughs in drug development for TB, however, if adherence to treatment cannot be assured, these drugs will be squandered like our current second line agents as patients develop resistance to them.The infrastructure that provides patient-centred DOT, contact investigation, prevention, expert care, oversight of care being provided in the community, and patient/community eduEXPRESS HEALTHCARE

K|N|O|W|L|E|D|G|E cation is what really needs focus. The new pharmaceuticals, tools and technologies would only serve to enhance this infrastructure and ability to cure patients. That said, there are newer shorter regimens for MDR-TB that are being studied that we hope will help in preventing XDR-TB and its subsequent forms.

What corrective and preventive steps are needed in order to control the transmission of TB? The WHO has acknowledged that the current practice of treating cases that are passively found is not giving the desired results of reducing cases. Patients present themselves with symptoms before a diagnostic work up having already transmitted TB to an estimated 8-10 people, while their disease may have advanced beyond full recovery or may result in life long debilitation. What needs to be urgently addressed is “active case finding”, TB education of private providers, prevention of disease in those with TB cofactors and infection control at health care facilities. “Active case finding” helps find cases early before broad

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transmission or none and consists of screening high risk groups for TB. This includes examining the contacts of TB cases or the screening of individuals with TB co-factors (risks) like HIV, diabetes, end stage kidney disease and those placed on medicines that suppress the immune system. Screening of people and employees in congregate settings, such as homeless shelters, dialysis rooms, healthcare facilities, schools, colleges, and densely populated work sites with poor ventilation is another high impact area.

TB algorithms integrate processes cross several platforms. What criteria need to be kept in mind while designing an algorithm? Algorithms are nice because they can align different groups quickly, however, there is the danger of people to stop thinking or become confused when there are scenarios that do not fit the algorithm. With technology changing so quickly in the field of diagnostics for TB, flexibility will need to be built in around clear goals and outcomes. Algorithms need to be realis-

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tic, scalable and feasible to implement in different settings without compromising on quality and effectiveness.

could dramatically help decrease the rate of TB.

How do you see the Indian Government’s Revised National TB Programme (RNTCP)?

TB is a long-term problem that needs huge investment and social mobilisation. The current investment in TB control infrastructure in India has greatly improved but in my opinion, remains woefully inadequate to match the scope of the problem and the interventions needed. As one example, universal drug susceptibility testing on every TB case to avoid” treatment in the dark” and active case finding will require massive scale up of laboratory infrastructure and public education. Also, the private sector needs to be fully engaged in true partnership in developing its role of screening, treatment and prevention. Funding, knowledge and commitment are the key drivers here. Technologies for diagnosis and new drugs will help but its impact will be limited if the system and partners are inadequately equipped to use them, or are unwilling to pay them, and policies are not developed to facilitate proper use.

In India, even though the incidence of TB hasn’t changed, the steps taken by the Indian government for the treatment of TB has significantly decreased the number of deaths caused by the disease. That’s a huge achievement by itself. However, the prevention of the disease among those with latent TB infection with some exception of child contacts and HIV infected persons hasn’t really been addressed as the RNTCP must focus on detecting and treating all cases of active pulmonary TB. This is of course appropriate, given the limited budget. We, at QIAGEN, believe that a possible way forward to address the prevention of TB disease is to adopt a public and private sector partnership with the private sector taking the lead on effective screening and prevention. Finding cases earlier and latent TB treatment,

What could be the future roadmap to TB control?

shalini.g@expressindia.com

MAY 2013

IN IMAGING

W H AT â&#x20AC;&#x2122; S INSIDE

A C O M P E N D I U M O N T H E L AT E S T I N R A D I O L O G Y

'Operation of e-LORA would be a big milestone for regulation of medical X-ray practice' PG50 Dr Bhavin Jhankaria: Mover and Shaker PG57 Apollo's pride PG60 Myrian: Multifaceted and multifunctional PG62 MRgFUS: Novel' No-touch' technology PG64

I|N|I|M|A|G|I|N|G adiology in India is booming. Radiographic technology has seen rapid development in the past two decades. The imaging that began with one modality, X-ray, has evolved into more complex ultrasound, Doppler, CT, MRI, etc., to PET-CT and PET-MRI. Everyday, new advancements in these modalities are reported. This has resulted in the increase in not only in-house radiology departments, both in private and public sector hospitals, but also in standalone diagnostic imaging centres. Unfortunately, the growth of human resources for diagnostic and image interpretation services in radiology is not keeping pace with the growth in the number of machines and centres that are budding in the country. Although it is good that radiology is a highly competitive postgraduate degree today and attracts the best medical graduates, availability of teaching hospitals and centres is a cause of concern. This, coupled with anecdotal stories about high capitation fee for PG seats, paint a bleak picture of radiology education in India. Further, the standard of teaching may not be uniform across India. “The standard of radiology training in India is not the same across all hospitals. There are government colleges and private centres doing phenomenal work in radiology, but training is far from adequate,” laments Dr S Radhesh, Chief Radiologist, Medall Healthcare, Bangalore. Agreeing, Dr Deepon Patel, HeadDept Of Radiology, Bhatia Hospital, Mumbai says, “There are significant differences in the level of training in urban and rural areas with respect to training in the newer modalities e.g. Colour Doppler, CT, MRI and Interventional Radiology.”

Training in India However, they both agree that radiology and imaging training in India is on the ascendent. In fact, the teaching has also evolved but the pace has been slow. “The good news is that the standard of radiology training in India has significantly improved since the time I was a PG,” says Arjun Kalyanpur, CEO/Chief Radiologist, Teleradiology Solutions, Bangalore. “In the 1980’s when I was doing my radiology residency at AIIMS, there were very few programmes that gave PGs exposure to MRI or even CT. Most government medical colleges which conducted training programmes had neither of these, and so the residents had to typically travel great distances in rotations at private centres where they would obtain very limited CT or MRI experience as an observer. Most radiology graduates in those days learned conventional radiology and ultrasound thoroughly, and the rest was learned from books and journals (centres such as AIIMS which had state-ofthe-art equipment were of course an exception),” he explains. MAY 2013

Expecting a radiologist today to master all of radiology is akin to expecting a general practitioner to practice everything from ophthalmology to cardiac surgery Arjun Kalyanpur CEO/CHIEF RADIOLOGIST, TELERADIOLOGY SOLUTIONS, BANGALORE

DMRD or MD radiology And then there is the age old dilemma whether the students should opt for DMRD or MD Radiology or DMRD+DNB. Like the 'chicken and the egg' problem there is no right answer to this dilemma. It is a sensitive issue and most radiologists feel strongly about it. Yet, they don't like to discuss it in an open forum. Many radiology practitioners opine that MD is better than DMRD as preference at the time of teaching recruitment is given to the former. However, there are others who believe that DMRD is the route to quick certification and therefore the quicker road to practice. “Definitely MD or DNB since the course is of longer duration and ensures better grounding and conceptual clarity. And like everything else one becomes better only with time and experience,” opines Dr Patel. In fact, the difference between these two courses is in the duration of the course and the exposure to the subject matter. But DNB qualification is the minimum requirement for applying to private hospitals in India and many foreign countries where radiologists migrate for monetary reasons. “DNB (Diplomate of National Board) is accepted all throughout India and outside India as well,” informs Dr Patel. A section of practitioners feel that

MCI suggested that every doctor should regularly participate in CME activities, 30 credit hours every five years. It is mandatory for doctors to have 30 credit hours for re-registration with the medical council of some states

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Clinical experience is required before embarking training in imaging, and appropriate training in specific clinical specialities may also be needed Dr Nikhil Kapoor HOD, MOOLCHAND IMAGING CENTRE, MOOLCHAND MEDCITY, AND NEW DELHI

the question is redundant as experience, and not qualifications, matter. They feel that there are many DMRD candidates who are good, perhaps even better than MD candidates but do not get the preference MDs enjoy. Some also question the purpose of having two degrees and suggest instituting only one of them. “I think this debate is irrelevant,” says Dr Kalyanpur. “What matters is that the Boards follow uniformity and fairness in assessing the candidates, and that the criteria for passing are neither too lax nor too stringent, either of which can currently be the case. The goal should be to assess for competence and not for impossible brilliance,” he adds. He further explains that having a very high failure rate, as has been the case in the past, does not help the situation, as radiologists who are competent and could be productive members of the medical community end up wasting a lot of time retaking their exams, which does not necessarily translate into increased competence, and can significantly affect the confidence and morale of an individual candidate. “For a population of 1.2 billion in India, the patient to radiologist ratio is far from adequate. Medical Council of India (MCI) and Diplomat of National Board (DipNB) should be liberal in radiology training, hence, there is a need to increase the number of radiology seats,” says Dr Radhesh.

Need for sub-specialisation The field of radio-diagnosis has evolved so much that today sub-specialisation has become a necessity. “Expecting a radiologist today to master all of radiology is akin to expecting a general practitioner to practice everything from ophthalmology to cardiac surgery! The field has become truly vast and complex. Sub-specialisation therefore allows a radiologist to focus on a clinical sub-specialty such as neuro, cardiac or paediatric radiology and achieves a higher level of expertise than a general radiologist can possibly EXPRESS HEALTHCARE

I|N|I|M|A|G|I|N|G achieve,” explains Dr Kalyanpur. Adding to this Dr Kapoor says, “It is virtually impossible today to remain a radiologist with competence in all areas of speciality. For example, if an individual specialise in interventional radiology, then sub-specialist training is needed to gain deeper knowledge, new techniques and practical experience to provide a high level of clinical service.” In India, the sub-specialisation trend is yet to catch-up. “Sub-specialisation in India has a long way to go. In a country like India where it is difficult to find radiologists and more so radiologists to reach out to Tier-II and Tier-III cities, specialisation has taken a back seat. Radiologists in India are by and large modality specific, specialised in Ultrasound, CT and MRI than organ specific,” laments Dr Radhesh. “Sub-speciality focussed (as opposed to the traditional modality focussed) radiology training is important for radiologists to develop a better clinical understanding and learn to communicate more effectively with their clinical counterparts. Sub-speciality (or fellowship) training is important to allow radiologists to live and breathe their sub-speciality in an intense clinical environment and be able to practice it at the highest level,” says Dr Kalyanpur. “Having said this, the role of a good general radiologist in a country like India cannot be overemphasised. Given the shortage of radiologists we face, it is necessary for radiologists to be able to multi-task effectively. Especially in the emergency setting, an understanding of imaging in acute care scenarios spanning all sub-specialities can truly impact patient care,” he sums up.

Continued Medical Education (CME) CMEs are a part of the growth of any medical practitioner. MCI suggested that every doctor should regularly participate in CME activities, 30 credit hours every five years. It is mandatory for doctors to have 30 credit hours for re-registration with the medical council of some states. These CMEs are conducted by various associations and private groups and hospitals. The radiology CME scene in India is dynamic. “CME programmes in radiology are being conducted in India by private groups and hospitals. These programmes help in increasing the awareness of newer modalities in radiology and also help interpret the patient information. CME credits are encouraging doctors including radiologists to attend CME’s and conferences,” informs Dr Radhesh. “CME scene in India is booming!” says Dr Kalyanpur. “There are a number of CME courses in radiology now across the country and new ones are coming up literally every week. The traditional CME courses such as those conducted by state radiology associations were allencompassing and general in their content; however, the recent trend is for sub-speciality focused CME on subjects

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MCI and DipNB should be liberal in radiology training, hence, there is a need to increase the number of radiology seats

There are significant differences in the level of training in urban and rural areas with respect to training in the newer modalities

Dr S Radhesh

Dr Deepon Patel

CHIEF RADIOLOGIST, MEDALL HEALTHCARE, BANGALORE

such as foetal medicine, musculoskeletal ultrasound, and the like which is a positive trend. At our centre, Radgurukul, we have conducted subspeciality CME training in emergency radiology, cardiac imaging and imaging in clinical trials, all of which have been well received,” he explains. Some of these CMEs are more popular than others and attract many participants from across the country. “The most popular courses for CME are offered by Indian Radiological and Imaging Association (IRIA), Radiological Society of North America (RSNA) and International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG),” says Dr Kapoor. Agreeing Dr Patel says, “Modality specific CME courses, with emphasis on problem solving of diagnostic dilemmas in routine clinical practice are popular. Some of these are CUSP, Ultrafest, USKON, Annual IRIA conferences etc.” However, on a slightly lighter note, Dr Kalyanpur disagrees saying, “The most popular courses tend to be the ones which package a beach (or other) vacation along with CME, such as the Spiral CT conference in Goa. These allow radiologists to party as well as to partake of learning, if they should be so inclined.”

New age learning tools Stiff competition in the field has led radiologists to explore newer methods of learning and Internet is one powerful too in this regards. From teaching websites to case libraries to e-lectures and live reading sessions, technology is

From teaching websites to case libraries to e-lectures and live reading sessions, technology is aiding learning in many ways

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HEAD- DEPT OF RADIOLOGY, BHATIA HOSPITAL, MUMBAI

aiding learning in many ways. “E-learning, in the form of an online portal such as our Cisco driven teaching portal is a powerful tool in an era of radiologist (and particularly teacher) shortages,” says Dr Kalyanpur. “Using an elearning platform enables the teacher to greatly extend their reach to a nationwide audience simultaneously, using a simple laptop and web camera. It also makes sense for postgraduates who can attend such sessions from their homes or duty rooms, after the day’s work has ended without having to commute long distances.” he adds. YouTube is an effective tool for radiology training as well and several of our electures can be accessed on youtube (www.youtube.com/trsradiology) Teaching websites such as our teaching website (www.radguru.net) also contain case reference material and learning content that can be extremely useful to radiology postgraduates and even practising radiologists during their workday. “Online websites like Pubmed, Medscape, auntminnie.com, learningradiology.com, radiologyassistant.nl, etc. are also helpful,” says Dr Patel.

Areas of improvement Presently, availability of equipment may not be the problem but availability of teachers may need some serious thought. “Today, the government hospitals are much better equipped and many private diagnostic centres conducting DNB training have state of the art imaging equipment, so certainly the level of exposure to these modalities is significantly higher now. The challenge today is radiologist and especially teaching radiologist shortages,” says Dr Kalyanpur. “In many hospitals the radiologists are too busy to teach, and so the training suffers, and residents simply learn on the job by observing their seniors and peers, rather than with focussed didactic training and conferences,” he explains. Further, there is growing concern MAY 2013

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that fresh radiologist on-the-block are not interested in reading simple X-rays. “With new technologies now becoming available, the radiology postgraduates of today are getting very well trained in cross-sectional imaging, namely ultrasound, CT and MRI. However, ironically what is now suffering as a result is training in plain film interpretation, which has taken a back seat as in many teaching hospitals the xrays do not end up being reported at all but are simply despatched to the clinical services for review by the ordering clinicians. The fresh graduates of today are lacking in plain film interpretation skills, and this forms the basis for a major potential area of improvement,” elaborates Dr Kalyanpur. In addition to evolving technology the field of medicine itself is advancing rapidly and radiologists are expected to understand and know about newer disease and clinical symptoms, findings to be able to aid the clinician. “Today radiology covers variety of diseases at all age groups; from the foetus to the multimorbid aging population, from prostate to the pituitary gland etc. No single person can master all the available knowledge,” says Dr Nikhil Kapoor, HOD, Moolchand Imaging Centre, Moolchand Medcity, and New Delhi. “However, physicians need a clinical interaction with the imaging specialist. In order to create added value for the referring clinician, the radiologist must fully understand the clinical problem. The radiologist is expected to be able to do this at a different level and for all MAY 2013

medical specialities. Therefore clinical experience is required before embarking training in imaging, and appropriate training in specific clinical specialities may also be needed,” he explains. “Radiology should be able to change their attitudes and adapt new modules of professional training to keep a pace with the dramatic revolution and evolution of radiology,” he further adds. Agreeing Dr Kalyanpur says, “Radiology residents need to be taught to think and analyse their observations, tying them into a clinically relevant and concise differential diagnosis. While our radiology education system trains PGs in detecting findings, especially radiologic signs, the second and equally important thought process of tying disparate findings into a coherent diagnosis is a skill which I for one learned only during my residency in the US.” In terms of training, the current training system could be improved if the exams would shift their focus from the-

In addition to evolving technology the field of medicine is also advancing rapidly and radiologists are expected to understand newer disease and clinical symptoms, findings to be able to aid the clinician

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oretical spotting to practical relevance. “Instead of having an examination system that is focussed on testing students on their ability to rare and esoteric disease entities in the form of spotters, it is important to focus on practical relevance and competence in evaluation of common clinical entities where radiology can today contribute to better patient outcomes. Standardising the examination process across the country is of importance,” opines Dr Kalyanpur. Adding to this, he says that training radiologists to develop good communication skills is a key area of improvement. 50 per cent of radiology lies in effective communication of the results to the clinician, which includes the ability to convey effectively the degree of certainty or uncertainty, and to recommend appropriate follow up and to guide the course of subsequent management. Similarly soft skills training, focussed on making radiologists capable of reassuring concerned patients, communicating critical findings with sensitivity (as in screening mammography) should also be focus areas of improvement in radiology postgraduate training. “The training goal today should be to develop radiologists who are technologically competent to deal with the current electronic work environment, i.e. who are familiar with PACS, Teleradiology, voice recognition, structured reporting and the tools that enhance radiologist productivity and efficiency,” he concludes. mneelam.kachhap@expressindia.com

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I|N|I|M|A|G|I|N|G HIGHLIGHTS

Indraprastha Apollo Hospital gets G Scan – an open standing MRI scanner The new open standing MRI machine is a revolutionary platform for musculoskeletal applications including the spine

ndraprastha Apollo Hospitals has installed a G (Gravity) Scan – an open standing MRI scanner. This new open standing MRI machine is a revolutionary platform for musculoskeletal applications including the spine, which provides surgeons a unique additional diagnostic element. When lying down, the patient hardly puts weight on the lower limb because of which a conventional MRI scan cannot detect some vital problems and deviations. This technology enables true weight-bearing examination which was not possible before and was one of the greatest challenges to MRI. By allowing scanning in standing position, the technology also helps doctors diagnose functional alignments of patients’ joints—how they are and they progress and whether the condition will get worse. In addition, the machine is open and thus most friendly for patients who have claustrophobia (fear of small closed-in space). This new machine incorporates latest technological innovations at the international level. One can have various tilting positions such as 45 degrees, 90 degrees etc., on this machine—the

standing MRI, which uses the principle of gravity in giving added advantages in diagnosing spinal diseases and musculoskeletal disorders of the patients including joints.

Dr Prathap C Reddy, Chairman, Apollo Hospitals Group said, ”This open standing MRI Machine would be very critical for patients who continue to experience pain after spine surgery because it can evaluate the role and effect of patients' weight on the curvature of spine, which cannot be accurately analysed with conventional MRI machines. Such patients can now hope to get proper and accurate spine surgery done as with this scan the surgeons would have an exact idea and better analysis of the extent and nature of injury, visualised along with the effect of gravitational forces.” Close to one million spine surgeries are performed each year, but the outcomes are not good with a substantial failure rate. This technology would help improve the outcomes of these surgeries by identifying the pain generating pathology. In addition to serving as a diagnostic tool, the technology would further help doctors understand the patient's recovery process after the procedure including joint surgeries, especially knee joints. EH News Bureau

MrgFUS at Womens Center, Coimbatore This technology uses sound waves to perform bloodless surgery and treat uterine fibroids non-invasively and help preserve fertility omens Center, Coimbatore has procured a non-invasive therapeutic tool for uterine fibroids, a common gynecological condition among women. Magnetic Resonance guided Focused Ultrasound technology (MrgFUS), an device from InSightec, uses high intensity focused ultrasound waves to treat uterine fibroids instead of surgery requires hospitalisation and long recovery time. The MRgFUS treatment, reportedly, is carried out as an out-patient procedure. It has a shorter recovery time and allows women to return to normal daily activities almost the next day. “Most patients’ opt for treating a uterine fibroid based on their respective clinician’s knowledge on the same topic.

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Due to the lack of awareness of better treatment options, many patients undergo hysterectomy- a highly invasive surgical procedure that entails the loss of a reproductive organ, long hospital stay and a longer recovery time,” said Dr Mirudhubashini Govindarajan, Clinical Director, Womens Center. “MR guided Focused Ultrasound has lower risk with maximum gain! This technology ablates uterine fibroid tissues without cutting the body or losing a drop of blood and avoids prolonged hospitalisation and other costs! It is a blessing for women, who seek a better quality of life without the impediments of losing their reproductive organ thereby preserving their fertility, “ she added. MRgFUS combines therawww.expresshealthcare.in

peutic acoustic ultrasound waves with continuous guidance and treatment monitoring by MRI. Reportedly, MRgFUS offers non-invasive, non-ionising radiation treatment with minimal discomfort and trauma in a single session of two to three hours. GE Healthcare is a minority shareholder of InSightec and is a distributor of ExAblate in many countries around the world. InSightec’s ExAblate system is exclusively compatible with GE Healthcare’s normal and wide bore systems such as Signa HDxt 1.5T, Signa HDxt 3.0T, Optima MR450 and 450w, and Discovery MR750 and 750w. Speaking on the occasion of the launch, Dr Karthik Kuppusamy, Director, MRI, GE Healthcare, South Asia said,

“Operating room of the future is here in India already. Women's Center, Coimbatore is the fourth hospital in India to be equipped with MRgFUS. InSightec and GE’s MRgFUS can cut tumors and fibroids without cutting the body! It is the best thing that happened to medicine since the scalpel. It is a dramatic change for women, a proven technology and has already helped treat 400 women with uterine fibroids successfully in the country”. This technology is CE marked for pain palliation treatment for bone metastases, and clinical trials are under way to determine if the technology could be an alternative treatment for a number of cancers including breast, brain, liver, and prostate. EH News Bureau MAY 2013

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Nueclear Healthcare opens its first molecular imaging centre in Navi Mumbai GE Healthcare, as technology partner will be associated with the venture which aims to establish 120 affordable molecular imaging centres around the country ueclear Healthcare, in association with GE Healthcare as technology partner, announced the opening of its first molecular imaging centre for early and affordable cancer detection in Navi Mumbai. NHL is establishing a mega network of 120 molecular imaging centres in India by 2015 with GE Healthcare as its technology partner. The hub and spoke model is expected to help scale up affordable access to advanced molecular imaging technologies such as PET/CT required early detection of cancer. NHL proposes to offer PET/CT imaging at just Rs 10,000/compared to approximately Rs 18000- 25000 patients pay today for same services. “At GE, we envision a day when cancer is no longer a deadly disease. Today’s event reinforces our commitment to cancer and reflects our current integrated portfolio and GE Healthcare’s $1B R&D investment to advance oncology solutions by 2016,” said John Dineen, President & CEO, GE Healthcare. “Scaling up of cancer diagnosis and treatment requires disruptive innovations and willing partners. By partnering with Nueclear Healthcare, together we can be at work for a healthier India by providing access to advanced affordable early cancer detection technologies to more people of India.” The NHL network of molecular imaging centres will have 12 medical cyclotrons that produce bio-markers required for cancer imaging and 120 GE Discovery PET/CT imaging scanners. While the first centre is opened today at Navi Mumbai, five more centres is expected to be commissioned in 2013. GE Discovery PET/CT systems installed at the centre will help doctors determine whether a suspicious growth is cancerous or benign in a single exam. Previously, doctors had to put patients through two separate scans to get similar information—with limited success. “Cost has been one of the

MAY 2013

biggest barriers in advancing early cancer detection. We have removed the barrier of cost by reducing the cost to patient by half. We are follow-

ward and the sheer volume will take care of our capital investments. We have a great partner in GE Healthcare and our visions match—make

ing the same concept which made Thyrocare, a household name today. If we make detection and treatment affordable, more people will come for-

India a healthier country,” said Dr A Velumani, Founder & MD of Nueclear Healthcare. EH News Bureau

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Global Hospitals installs Innova IGS 530 by GE Healthcare It is supposedly the country’s first image guided system for cardiovascular and interventional imaging lobal Hospitals, Mumbai has introduced the first Innova IGS 530 Cath Lab in association with GE Healthcare. It is an advanced cardiovascular and vascular X-ray system which reportedly provides excellent imaging performance for a full range of interventional X-ray. This technology will aid the best diagnostic for angiograms, device placement and nonvascular procedures. John Dineen, President & CEO, GE Healthcare said, "I would like to congratulate Global Hospitals for being the first to acquire our latest

IGS image guidance system for delivering better cardiac care to the people of India. I am very pleased that India is an early adopter of such revolutionary technologies and have partners like Global

Hospital who shares our vision of are lowering India's huge cardiac burden.” Speaking about this technology; Dr Ravindra Karanjekar, CEO, Global Hospitals Mumbai said, “The

Innova IGS 530 is equipped with intravascular ultrasound (IVUS) and fractional flow reserve (FFR) which will help our experts in better identification of coronary blockages and to avoid unwanted angioplasty” The Innova IGS 530 is expected to help in viewing anatomy more clearly, making it suitable for cardiac, electrophysiology, neurology, angiography, peripheral angiography and intervention. In other words provide a patient-focused user friendly interface. EH News Bureau

Carestream wins Frost & Sullivan's award for 2013 Asia Pacific Market Leadership The company’s digital radiology (DR) business recognised for solid customer success rost & Sullivan, a global research company, has recognised Carestream Health for market growth, this time with its 2013 Asia Pacific Market Penetration Leadership Award for the digital and computed radiography market. Frost & Sullivan presents this award to the company that has demonstrated excellence in capturing the fastest rate of change of market

share within its industry from one year to the next. The award recognises how fast a company increases its penetration of a market relative to its competitors, in terms of revenues or units, and is a measure of its success in taking market share away from its competitors from one year to the next. “Carestream’s DRX technology is a successful product that aided in market pen-

etration in the region. It accommodates clinical needs and financial capabilities of the radiology departments, allowing facilities to go digital while still retaining their existing analogue system without the need for additional retrofits,” said Poornima Srinivasan, Consultant at Frost & Sullivan. “We are honoured to receive this recognition that

highlights our growth in this region,” said David Chambers, General Manager, Asia Cluster, Carestream. “Our market success is built on exceptional customer service, exciting new product development and focused marketing initiatives that have resulted in more healthcare providers choosing Care stream for a long-term partnership.” EH News Bureau

GE Healthcare Life Sciences and Sigma-Aldrich announce distribution partnership in India Expands availability of GE Healthcare’s Whatman products to India E Healthcare has signed a new agreement with Sigma-Aldrich to distribute its Whatman range of products in India. The Whatman range of papers and filters includes sample collection and storage cards (FTA cards), filter papers, and specialist diagnostic membranes used in a wide range of applications such as forensics, neonatal screening, environ-

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mental screening, quality control of pharmaceuticals, food and beverage production and in the manufacture of in-vitro diagnostic tests. Many leading Indian companies and institutions use Whatman products for advancing their life sciences research and medical technology applications. Anurag Gupta, MD, GE Healthcare Life Sciences South Asia,

said, “We are delighted to announce this distribution agreement with Sigma Aldrich which will allow GE Healthcare to bring its innovative Whatman products to a much wider range of customers in a variety of academic and industry settings across India.” Raja Ram, MD, Sigma-Aldrich, India said, “Continuing to deliver on

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our mission of enabling science to improve the quality of life, we are excited at the partnership we have forged with GE Healthcare Life Sciences to distribute Whatman products. The partnership will enable customers to benefit from Sigma-Aldrich’s established standards of service and operational excellence within India.” EH News Bureau MAY 2013

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FEHI organises 3D Echo Imaging and Foetal Echocardiography Workshop 2013 International cardiologists deliberate on applications of foetal echocardiography in detecting congenital cardiac defects, a significant cause of neonatal mortality ortis Escorts Heart Institute conducted a three-day workshop on the importance of Foetal Cardiography and the advantages of Foetal Echo in diagnosing heart defects in the unborn baby. The conference was conducted in association with Philips Healthcare forum; Learning for Life, the workshop was chaired by Dr Ashok Seth, Chairman Cardiac Sciences, Fortis Escorts, Dr Smita Mishra, Senior Consultant, Paediatric Cardiology, Fortis Escorts and Dr John M Simpson, Consultant in Paediatric and Foetal Cardiology, Evlina

unborn baby without opening the uterus. In near future, this technique will be available in our country and we hope to save many unborn lives

through this technique.” Jitesh Mathur, Senior Director Philips Healthcare said, “Technology is now enabling more accurate diag-

nostics of foetal heart defects and anomalies. We are bringing these technologies to India and want more and more people in India to bene-

fit from these lifesaving technologies by educating doctors on the best clinical practices.” EH News Bureau

The conference focussed on importance of Foetal Cardiography and the advantages of Foetal Echo Children’s hospital UK. Foetal echocardiography is used in ruling out the serious structural cardiac defect and life threatening arrhythmias, a condition when the heart does not beat to the steady rhythm. The diagnosis and management protocols of foetal arrhythmias are based on echo guided evaluation. On the occasion, Dr John M Simpson, Chief Facilitator, of the Foetal Echocardiography workshop said, “The most important consideration in all foetal intervention is the safety of the mother. The intervention is designed to correct cardiac defects of the unborn baby minimising the risk on mother’s health. Through this event, we want to train doctors on best clinical practices available in the future.” Commenting on the initiative Dr Smita Mishra, Senior Consultant, Paediatric Cardiology, Fortis Escorts said, “Foetal Intervention is the latest technique in treating heart disorders in the MAY 2013

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I|N|I|M|A|G|I|N|G INTERVIEW

‘Operation of e-LORA would be a big milestone for regulation of medical X-ray practice’ Dr Avinash U Sonawane, HEAD, RADIOLOGICAL SAFETY DIVISION,ATOMIC ENERGY REGULATORY BOARD

n order to minimise unwanted radiation exposure to patients as well as technicians, the Atomic Energy Regulatory Board (AERB) this February embarked on a project that involves bringing thousands of unregistered medical X-ray facilities under its control in the next three years. Raelene Kambli seeks to know more on the available government regulations for diagnostic radiology in India, AERB's role in setting them and its way forward in an interview with Dr Avinash U Sonawane, Head, Radiological Safety Division, AERB

What are the available government regulations for diagnostic radiology in India? What is the role of AERB in setting them? The present regulatory framework for controlling safe use of ionising radiation sources, including medical X-rays, is based on the following: ● Atomic Energy Act, 1962 ● Atomic Energy (Radiation Protection) Rules {AE(RP)R}, 2004 ● Notification No. GSR 388 on, ‘The Radiation Surveillance Procedures for Medical Applications of Radiation, 1989’ ● The Safety Code for Medical Diagnostic X-ray Equipment and Installations {No AERB /SC/MED-2 (Rev.1), 2001}. The national regulatory authority, i.e., AERB was set up in November 1983 to carry out certain regulatory and safety functions envisaged under Sections 16, 17 and 23 of the Atomic Energy Act 1962. Chairman, AERB has been notified as the competent authority for the enforcement of radiation protection provisions in the country. The mission of AERB is to ensure that the use of ionising radiation in India does not cause undue risk to the worker, public and the environment. Thus, AERB has put in place an effective regulatory mechanism based on scientific assessment of the magnitude of the hazard potential of different practices

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involving ionising radiation. With respect to diagnostic radiology in particular, it is a statutory requirement that a licence for CT and interventional radiology practices (because of higher hazard potential) as well as registration for general X-ray diagnostic practice (because of low hazard potential) should be obtained from AERB for operation of equipment.

Proper safety principles and practices should be followed in medical X-ray installations - now for this we need to know how many X-ray installations are there in India? Is there any data available on that? We have a fair idea about the number of all of the X-ray installations in the country, i.e. about 41, 000 based on data provided by major manufacturers/suppliers of X-ray equipment. Also, AERB has initiated a many-pronged approach towards radiation safety in the practice and building a firm database which involves: a) Decentralisation by formation of regional regulatory centres (RRCs) and under state control, Directorate of Radiation Safety (DRS) b) Commissioning of an eGovernance system by AERB. The software system named electronic Licensing of Applications of Radiation (eLORA) would regulate all radiation sources, including medical X-ray facilities in the country. c) Bringing the manufacturers and suppliers of X-ray equipment under AERB control d) Enhanced regulatory inspections e) Bringing all utilities under AERB purview by simplifying regulatory requirements We know that more than 70 per cent of X-ray utilities are general purpose X-ray equipment and dental-related equipment which are of low radiation hazard potential in diagnostic radiology. As CT and interventional radiology equipment are of a higher hazard potential, most regulatory efforts are www.expresshealthcare.in

directed towards bringing them under effective regulatory purview. This ensures radiation safety in the practice to a large extent.

Is it mandatory to get AERB certification after installing an X-ray machine? Is there any punishment/penalty for non-compliance or unregistered X-ray units? It is mandatory to get an AERB license to operate any type of X-ray unit in the country. Our observation is that most of the institutions with high footfalls, such as government hospitals and private NABHaccredited hospitals do satisfy AERB requirements with respect to radiation safety, though some hospitals may not have obtained formal licenses from us. This is more due to lack of awareness on their part, rather than wilful non-compliance. The sections 24, 25 and 26 of the Atomic Energy Act, 1962 stipulates that whoever contravenes any provisions of rules made under the Act and any of the terms and conditions of license/registration issued under the rules, shall be punishable with imprisonment or with a fine or with both.The Rule 10 of AE (RP) R, 2004 empowers the Competent Authority to suspend, modify or revoke license/registration issued for handling of radiation sources.

Are the AERB norms updated regularly to suit the changing healthcare environment in the country? AERB has recently issued an amendment to its code AERB/SC/Med-2, 2001(Rev-1), bringing various facets of the changing scenario in diagnostic radiology, such as introduction of new modalities, new technologies etc. AERB is also in an advanced stage of issuing the revised safety code on medical diagnostic practice.

How does AERB create awareness on radiation safety among healthcare providers and patients? AERB

has

taken

full

cognizance of the vital role that awareness plays in radiation safety. Hence, it has in its regulations roped in its stakeholders, such as suppliers, who interact with the utility and are best poised to percolate the safety information. Media is the other important channel. On its part, AERB has conducted several awareness programmes on safety aspects in diagnostic radiology in major hospitals and medical institution. AERB experts also participate in such programmes organised by medical institutions, associations of medical professions, manufacturers of X-ray equipment, FICCI etc.

Has the AERB undertaken any special project on radiation safety recently? Yes. AERB has made many landmark steps with respect to radiation safety in diagnostic radiology. a) The signing of MoU with many states to form the Directorate of Radiation Safety. b) AERB has also had policy level talks with Directorate General of Foreign Trade (DGFT) to ensure that no nondesign approved equipment enter the country. c) The existing requirements of national safety code on medical X-ray diagnostic installations have been revised to bring simplification in their implementation and to facilitate the registration/licensing process of medical X-ray facilities without compromising safety of patients, workers and the public. d) AERB periodically publishes announcements (recently in July 2012 and on April 19, 2013) in all the leading national and local news papers in the country highlighting the need of AERB license/registration of medical X-ray facilities and the mandatory regulatory requirements to be complied with from radiological safety viewpoint. e) It has been observed that a number of pre-owned/refurbished X-ray equipment are being procured and installed and their market is growing rapidly in the country mainly due to low cost and easy availability. AERB MAY 2013

“Spinal Injury Management is the most complex, because it requires a multi-disciplinary team. Nothing, we do is ever enough. Until, we have revived hope and joy in the heart of every patient, we have not completed our jobs. It is not sufficient to perform a successful surgery or provide an effective prosthetic. We, must transform the lives of the families who come to u s. He a l i n g t h e s p i r i t i s a s important as healing the body. We truly believe that inner peace and joy are the best healers.” - ISIC Team

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I|N|I|M|A|G|I|N|G has therefore framed guidelines to bring such X-ray equipment under regulatory surveillance for ensuring their safe use. f) Several research projects on radiation safety as well as quality assurance and dosimetric studies, mainly for the safety of patients, occupational workers and the public are being carried out in the country by various medical institution, with the support of AERB and involvement of its experts.

action plans of AERB which are under implementation are summarised below: a) Steps are being taken to decentralise the process though formation of statelevel Directorate of Radiation Safety (DRS). The Department of Health and Family Welfare, Government of Kerala, has already set up Directorate of Radiation Safety) in 1996. The process of formation of DRS is underway in Mizoram, Madhya

Pradesh, Chhattisgarh, Punjab, Tamil Nadu, Goa and Karnataka. AERB is following up with other States to set up similar DRSs. b) AERB has established RRCs in the country to further strengthen the regulatory control over radiation sources including medical X-ray installations. RRCs have already been established at Chennai and Kolkata. One is planned in the northern region. DRS and RRCs are expected to cover

the medical X-ray facilities of respective regions for getting X-ray units registered and contribute in increasing regulatory inspections. c) The regulatory inspections, i.e., radiation safety audits of the medical X-ray installations are the most important part of the compliance assurance programme (CAP) of AERB. AERB conducts, under the relevant provisions of regulations, the periodic inspections on sample basis, of medical

X-ray facilities d) The Radiological Safety Officer (RSO) is responsible for maintaining periodic QA records of medical X-ray equipment. AERB is in the process of accrediting independent QA service providers, besides manufacturers/suppliers of X-ray equipment, to ensure satisfactory performance and radiation safety of X-ray equipment. raelene.kambli@expressindia.co

What can be done to resolve issues related to safety? There are certain areas where additional efforts are necessary to ensure satisfactory radiation safety for medical X-ray installations in the country. Someof them include the necessity of good co-operation with regulatory body from the X-ray equipment manufacturers/suppliers/quality assurance (QA) service providers; establishment of effective regulatory control over all the stakeholders (i.e.manufacturers/ suppliers of new/pre-owned/ refurbished X-ray equipment, utilities and QA service providers); issuance of licenses/registrations to existing and upcoming X-ray installations; generation and appointment of adequate number of relevant medical professionals and X-ray technologists; provisions of personnel monitoring services to the operating staff; ensuring adequate number of QA kits; expediting the establishment of DRS in all the states and the RRCs of AERB in different parts of the country; organisation of more awareness programmes on radiation safety and QA in the field of diagnostic radiology. A special regulatory model is being established by AERB to deal with the above issues. This model would ensure radiation safety at every stage of the use of medical Xray equipment

What are AERB's plans for the coming year? Operation of e-LORA would be a big milestone for regulation of medical X-ray practice and other applications of radiation sources like nuclear medicine, radiotherapy, industrial radiography, radiation processing facilities etc. However, few major MAY 2013

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I|N|I|M|A|G|I|N|G ONE-ON-ONE

'I wanted to device techniques which required minimal surgery and takes less of patient’s time in hospital' Dr Pradeep Muley, HEAD & SENIOR CONSULTANT INTERVENTIONAL RADIOLOGIST, FORTIS HOSPITAL, VASANT KUNJ, NEW DELHI

adiology in healthcare is rapidly advancing and interventional radiology is a sub-speciality which shows great potential. It is being touted as a better and superior treatment option for several ailments and health conditions which earlier could be cured only through open surgery. Dr Pradeep Muley, Head & Senior Consultant Interventional Radiologist, Fortis Hospital, Vasant Kunj, New Delhi talks about the progress of interventional radiology, its various applications, benefits to patients and more, in an interaction with Lakshmipriya Nair

How has interventional radiology progressed over the years? Interventional radiology is a subspeciality of radiology in which minimally invasive procedures are performed using image guidance. Some of these procedures are done for purely diagnostic purposes (for example, angiography), while others are done for treatment purposes (for example, embolisation). Images are used to direct these procedures, which are usually done with needles or other tiny instruments like small tubes called catheters. The images are like a map that allows the radiologist to guide these instruments through the body to the area where the procedure is to be done. After the introduction of needle replacement of a catheter in 1953 by Dr Sven Seldinger's, Dr Charles Dotter, at the University of Oregon, began to use catheters as surgical instruments. Dr Dotter said, “The angiographer who enters into the treatment of arterial obstructive disease can now play a key role, if he is prepared and willing to serve as a true clinician, not just as a skilled catheter mechanic. He must accept the responsibility for the direct care of patients before and after the procedure. In 2004, the American College of Radiology published a white

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paper on interventional radiology clinical practice.The white paper outlined the features and resource needs of interventional radiologists for providing patient care. As technology advances and highquality imaging equipment becomes more widely available, interventional radiology is able to offer patients and referral physicians a host of new treatment options.

What have been the most notable achievements in this sphere in the last decade? Interventional radiologists are specialists who use various imaging and catheterisation techniques in order to diagnose and treat vascular issues in the body. Interventionalist techniques include injecting arteries with dye, visualising these via X-ray, and opening up blockages. The rapid new development of imaging technologies, mechanical devices, and types of treatment, have certainly been beneficial to the patient and without surgery various diseases can be treated like uterine fibroids, uterine adenomyosis, opening of blocked fallopian tubes, varicocele, chronic pelvic pain (pelvic congestion syndrome), varicose vein in leg, opening of blocked arteries, bleeding from mouth due to tuberculosis in chest. The most recent development is treating enlarged prostate by non—surgical method called as prostatic artery embolisation.

What are the benefits of interventional radiology over traditional surgery? Interventional radiology has several benefits over conventional surgery. Some of the major ones are as follows: ● It is performed under local anaesthesia. No general anaesthesia. ● Requires only a tiny niche in the skin (no surgical incision of abdomen). ● Recovery in a very short time in comparison to any open surgery. www.expresshealthcare.in

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Virtually no adhesion or scar formation has been found. But in surgery adhesions are common. Even two medical problems are treated in one sitting. Less expensive than surgery. Short hospitalisation. Emotionally, financially and physically—interventional radiological procedure have an overall advantage over surgical procedures for the patient as the body part is not removed.

What are the challenges in its advancement as a medical sphere? What are the measures to overcome them? The development of interventional radiology leads to a tug of war between surgeon and interventional radiologist. If patient has uterine fibroids, the gynaecologist offers only removal of uterus not the nonsurgical method called uterine artery embolisation. While these practitioners can be in competition with each other, cooperation and communication are the most advantageous methods to deal with these "turf wars." All the interventionalists are needed to deliver the best medical care to patients, now and in the future.

Since when has Fortis Hospital, Vasant Kunj, Delhi been operating an interventional radiology department? What issues does it address (the various treatment offered through various technological advancements)? The Interventional Radiology department is my brain child and since its inception in 2005, I have been taking care of the entire functioning of the department here. I am assisted by a team of trained nurses and practicing radiologists. Having done my specialisation in body and neuro interventional radiology from KEM Hospital Mumbai, AIIMS, Delhi, Johns Hopkins Medical Institute, US and

Singapore General Hospital, I wanted to device techniques which required minimal surgery and takes less of patient’s time in hospital. Through the technique of interventional radiology, I am using a number of techniques here including uterine artery embolisation for fibroid/adenomyosis, varicose vein, infertility treatment for opening of blocked fallopian tube, varicocele, enlargement prostate, bronchial artery embolisation for bleeding lungs, chemo embolisation of liver tumour, lower limb blockage of artery.

You are a proponent of uterine artery embolisation. Can you please tell us more about the technique of and its advantages? The interventional radiologist makes a small nick in the skin (less than a cm) at groin, inserts a catheter, identifies blocked artery by using angiography with contrast medium injection and then use balloon or inject embolisation particles (polyvinyl alcohol) that block the tiny vessels or open a diseased artery by balloon. The advantages are: It is performed under local anaesthesia, requires only a tiny nick in the skin, recovery is shorter than any surgery, no scar, recurrent growth is uncommon, emotionally, financially and physically—nonsurgical treatment have an overall advantage over open surgery as the body organ is not removed.

What is your message to other interventional radiologists? All interventional radiologists are needed to deliver the best medical care to patients, now and in the future. Till today, I alone have treated more than 20000 patients without surgery with excellent results, and I am sure, these techniques will soon become the only popular treatment with little role of traditional surgeries. lakshmipriya.nair@expressindia.com

MAY 2013

I|N|I|M|A|G|I|N|G SPOTLIGHT

Dr Bhavin Jhankaria: Mover and Shaker As an entrepreneur and an intrapreneur, Dr Bhavin Jankharia has been a major contributor to the radiology sector in India. Raelene Kambli catches up with him to understand his growth chart and plans for the future

is story is different from the usual success stories. Success that cannot be gauged in numbers, rupees or volumes but only by the name he has earned for himself as a virtuoso in the field of radiology. He is among those few radiologists in India who have taken the private practice of radiology to a different level. He is known as the man who sparked a trend of specialised diagnostic imaging centres in India under the flagship of Dr Jankharia’s Imaging Centres. A great teacher and a thought provoking writer, he has acted as the voice of the industry in several ways. In fact, some within the industry also refer to him as a brand, in himself. He is Dr Bhavin Jankharia, President – Radiology, SRL Diagnostics - Jankharia Imaging, the man with the X-ray eye for radiology in India.

MAY 2013

Dr Jankharia’s Imaging Centre under the guidance of Dr Bhavin Jankharia has played a vital role in the radiology sector, in terms of making radiology a stand alone business segment. He introduced sophisticated technologies such as the first 64 slice CT scanner in Asia, first High-Intensity Focused Ultrasound Therapy (HIFU), as well as a PET scanner in Indian private practice, raising the bar for diagnostic imaging in India. With his diagnostic skills he has earned a high amount of respect among his patients and fellow radiologists, who not only approach him for diagnosis but also for consultation. Just the way he refers to his practice as, a tertiary referral for radiology. Well, this is but a small description of a man with a multi-layered and com-

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plex personality and hence we train our focus on him to understand his vision for his baby- Dr Jankharia’s Imaging Centres and the radiology sector at large.

From a radiologist to an entrepreneur After completing his MD in 1991, Dr Jankharia had been working with Bombay Hospital, Mumbai for three years when he decided to study further. He completed his sabbatical in the US and worked with a couple of hospitals there for a year. “When I returned to India, I was supposed to rejoin Bombay Hospital, however, things didn’t work in my favour and so I was jobless for sometime. Circumstances then compelled me to take on my dad’s business- Dr Jankharia’s X-ray clinic now well-known as Jankharia’s Imaging Centre which EXPRESS HEALTHCARE

I|N|I|M|A|G|I|N|G was established in Girgaum and Central Mumbai in 1969,” he admits. He joined the Dr Jankharia’s Imaging Centre to look after the CT scanner and since then, his growth chart took different turns. Although it was his situation that made him don the mantle of an entrepreneur, he used the opportunity to himself as an adept radiologist and an inventive businessman. Under his guidance, the Centre underwent a sea change in September 1995, with the acquisition of a Siemens ARC CT scanner that was installed in Sir Hurkisondas Nurrottumdas Hospital & Research Centre. However, he recalls that getting funds for this machine was indeed a herculean task. “In the mid 90s, banks did not understand the industry and so were not willing to finance; after a lot of effort we finally managed to get it and so got into a contract with Sir Hurkisondas Nurrottumdas Hospital & Research Centre and the partnership worked out well, so we kept expanding,” he remembers.

Spreading his wings To augment his company’s growth, Dr Jankharia chose acquire high end technology that would facilitate to magnify the scope of his diagnosis. In the year 1996, he started the teleradiology facilities, which allowed him to transfer CT scan images from the CT centre to his residence. This was the first feather in his cap, as Dr Jankharia’s Imaging Centre became the first imaging centre in the private practice to opt for this technology. Around the same time, his wife Dr Bijal Jankharia, specialising in breast imaging also joined him. They, then, put a new mammography unit. The following year they installed Dexa Scanner used for measuring bone mineral density. Recalling the risk he had taken in investing in this expensive technology, he says, “This was the second Dexa scanner in the country. The first one was installed by a dealer who has kept it is as a demo product in Chennai and so this made our centre first in the country to conduct these tests. It was a huge investment, yet giving it a shot worked in our favour”. Thereafter the expansion continued, with the incorporation of a CR system, then an OPG machine and the first open MRI system in Mumbai, adding many more feathers to his cap. Introducing the 1.5 tesla MR was the biggest achievement for Dr Jankharia’s Imaging Centres because it was a huge investment of Rs 6.5 crore and apart from setting higher standards for the centre, it also marked the beginning of their sub-speciality practice. This was a huge leap for the company as they had bowled-over, all legal, technical and financial issues in order to install the magnet. After this, the company also branched out to different areas of radiology including cardiac imaging, neurocardiac MR and more. As a matter of fact, these were the years when Dr

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Dr Jankharia’s Imaging Centre under the guidance of Dr Bhavin Jankharia has played a vital role in the radiology sector, in terms of making radiology a stand alone business segment Jankharia’s ardour to be the most premium institute for radiology imaging was at its peak. His business strategy for expansion was also replicated by some new entrants in the field. It was looked at as an opportunity by laboratory diagnostic players to venture into. Acquisitions and upgrading of these high-end technologies helped him expand his business further. Next in 2005, he incorporated the 64 slice CT scanner, a first in Asia, which set in motion the trend within the radiology sector to incorporate the world fastest CT scanner at that time. After acquiring the success he had wished for, Dr Jankharia decided to reach out to newer heights.

From an entrepreneur to an intrapreneur His next aim was to replicate his business model across the nation. However, he needed the finance to do so. At the same time, Piramal Group agreed to invest in his ability and business strategy and so he sold his practice to the group in 2007, taking a stake in a larger company. With this strategic alliance he was able to take radiology diagnostics across the country. Under the banner of the Piramal Group, Dr Jankharia’s Imaging Centre became the largest diagnostic imaging chain in the country with about 17-18 centres nationwide.

Learning lessons Becoming the largest imaging diagnostic chain has its own glory, but this new path taught him several lessons about the business of radiology. “In a span of 18 months of the contract with Piramal Group we were able to extend our business across India; however, it had its own challenges attached with it. One thing that I learnt from this alliance is that radiology as a business is not scalable. Reaching economies of scales is a daunting task,” he opines. When asked the reason behind his view, he replied, “Each centre has to function as an independent centre, then it needs a radiologist, technicians etc., so it becomes a bit difficult. Being a nationwide chain gives you no benefit as such. Of course you are sure to leverage your expertise in the field. In the true sense it needs a business model wherein, one can have a radiologist handling a centre at a tier I city, servicing centres in Tier-II and III cities.

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However, for that one will require to set up a system that can help connect the radiologist with other centres”. So, if partnering with Piramal Group had its own set of challenges, then why did he opt for partnership with SRL diagnostics? Well, the reason is that lessons from the past have helped him develop a better business strategy for his current partnership with SRL diagnostics. Partnering with SRL, Dr Jankharia continued widen his scope. He introduced advanced technology called the MR-guided high intensity focused ultrasound (HIFU) solution to treat uterine fibroids in India.

Still broadening the horizon.. When asked about his plans for the future he goes on, “In the next five years we want to continue to be cutting edge in terms of technology by having the best of diagnostic machines that are available and using that to provide the best imaging to the patients, both in terms of the quality of the images as well as the reporting we provide. At Dr Jankharia’s Imaging Centres, we have always been a sub-speciality imaging group, currently having 13 radiologists doing specific organ imaging. So, because of the sub-speciality group we have become a tertiary referral centre. It is a known fact that 80 per cent of diagnosis is routine, what matters is the 20 per cent of diagnostic reporting that needs expertise and we are pretty much the best in the country for this. We have built ourselves in such a way that even though there is competition around, when people are stuck and they need a problem to be solved from all over the country either they come to us or they send their reports for opinion. So that’s where we would place our focus, on making that area better and better.” When asked what is it that he would like to convey to the young turks of this industry, he expounds that a radiologist has to be a physician first and has to answer the question ‘why’ in radiology. Elaborating on it, he says that radiologists need to ask themselves, ‘Why am I performing this study?’ or ‘Why was this study requested?’ If the answer to this question is clear, almost everything else falls into place. Moving back to his vision for himself, he owns that given a chance, he would like to take on Dr Jankharia’s Imaging Centres independently. He says, “Being an independent business entrepreneur has its now euphoria. You have the freedom to take your own decisions and act accordingly for good or for bad.” So is this an indication that Dr Jankharia’s trajectory will soon take a new turn? Well, it’s difficult to decipher what's on his mind. However, be it as an intrapreneur or an entrepreneur, Dr Jankharia will continue to influence radiology in India with his expert knowledge and creative skills. raelene.kambli@expressindia.com MAY 2013

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Gen – X in imaging! Dr Raviraj Gujarati, Head-Medical Services and Dr Vinubhai Shah, Radiologist, BAPS Hospital, Vadodara, give an insight on the advancements in radiology and its applications ince the time Wilhelm Roentgen, German physicist discovered Xrays in 1895, and used as a medical imaging technique to create pictures of body structure like tissue and bones by passing electromagnetic ways through the body, imaging has advanced by leaps and bounds to become what it is today in healthcare and we would like to refer to it as ‘Gen X’. Innovations and transformation in radiology never cease, be they in diagnostic methods or technology. Be it fluoroscopy, practice of ventriculography, advanced neuroradiology, or normal chest X – Ray through metal shields to modern cathlab procedure, PET scan, and DEXA – Scan, radiology and imaging have also advanced over the years. In the long term, radiology along with all other medical disciplines will move massively into the molecular age and use all its available technologies. The main function of a medical imaging unit is to assist the clinician in the diagnosis and the treatment of diseases. In the recent past, there has been a dramatic advancement in imaging and digitalised information technology including digital archiving. Depending on the type and size of the healthcare facility, the medical imaging unit may provide extra diagnostic investigation through technologies available in today’s generation such as picture archiving communication system (PACS), diagnostic screening (fluoroscopy), ultrasonography, mammography, computerised tomography or interventional radiographic procedures. Today we will talk about the various imaging techniques and technologies available to the public. X-ray: In X-ray, processing of the film begins from developing tank in the dark room. In day light, processing is done with the help of self contained film developing units. Cassettes are loaded into the unit from the X-ray room and passed through the processor unit to finally emerge developed from the opposite side. In digital radiology imaging, Xrays are read directly from the X-ray machine through computer monitors. The images can be read from any networked computer. Mammography: In mammography, low level radiation is utilised to identify tumour calcification, cysts and/or lumps in the breast tissue. Nuclear medicine room: Nuclear medicine’s diagnostic procedures involve introducing low strength, short lived; radiation emitting isotopes into human body. The emissions are captured by a camera and translated into

DR RAVIRAJ GUJARATI

Head-Medical Services, BAPS Hospital, Vadodara

DR VINUBHAI SHAH

Dr Vinubhai Shah, Radiologist, BAPS Hospital, Vadodara

MAY 2013

images. Computerised tomography (CT) scanning: In conventional X-rays, the transmitted X-rays are recorded on a sheet film, whereas in CT scanning the transmission is picked up by a detector and the information is reconstructed by the computer in a video screen. CT examinations involve cross sectional imaging of the body. Magnetic resonance imaging (MRI): MRI displays individual electromagnetic properties of the atoms within tissues. Angiography: The latest advancement in cardiac X-ray is angiography. The angiography unit may be located within the medical imaging unit or as a separate unit, to provide facilities for diagnostic X-ray investigation of the heart and blood vessels. Interventional radiology is already in a state of flux, employing all the presently available imaging modalities for guidance, combining them for greater precision, and applying them with multiple treatment technologies (e.g. thermal, radiofrequency, and laser ablation tools). Teleradiology: Teleradiology has the ability to send images through ‘information superhighway.’ It uses informationnetworking capabilities to transmit images from one place to another. However, it is more difficult than sending a written document because the digitised, computer radiology image

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contains so much more information than the printed word. Interpretation of medical images via teleradiology is an area that has gained a lot of significance in recent times. It allows diagnostic imaging centres working in a remote location, to leverage advances in the field of medical software and transfer patient medical images to radiologists for image interpretations and consultation. Hospitals are also increasingly looking at teleradiology as a solution to the problem of in-house manpower shortage as the annual rate of growth in number of radiologists is around 1.5 per cent to two per cent whereas the annual rate of growth in the number of radiology images that need to be interpreted is around six per cent to 12 per cent. Teleradiology has resulted in improved patient care and better utilisation of resources and is currently the most common form of telemedicine.

Conclusion To conclude, our Gen X is the new generation of imaging techniques that are the future of healthcare. With better facilities and growing imaging technologies, the future of radiology is more than promising. It will greatly depend, however, on our ability to give proper education and training to upcoming young radiologists and ensure that they are at par with the changing times and trends in this sector. EXPRESS HEALTHCARE

I|N|I|M|A|G|I|N|G DEPARTMENT SCAN

Apollo’s pride M Neelam Kachhap reviews the radiology department at Apollo Hospital, Chennai and finds it to be a well equipped and well run unit hat do good radiology and imaging departments strive for? They strive for timely access to the most advanced medical imaging technology, in a commiserate setting, to quickly deliver accurate electronic medical reports to referring doctors; and provide an unsurpassed educational experience to residents and medical students. Apollo Hospital Chennai’s radiology and imaging department does this and more. Established in 1983, along with the flagship hospital of Apollo Group at Chennai, the department was headed by eminent (late) Dr Professor Arcot Gajaraj. “He was a doyen amongst the radiologists of our country and perhaps the only radiologist in the country who was proficient in all branches of radiology,” remembers Dr Chidambaram Nathan, present HOD, Radiology Department, Apollo Hospital. “At that time we relied on X-rays and ultrasound and provided only conventional radiology to the patients,” he further adds. He has been with the department for the past 26 years and has seen the department evolve. The department has moved from conventional to digital radiology with state-of-the-art equipment and facilities. Today, the doctors in the Department of Radiology at Apollo Hospital in Chennai provide a complete range of diagnostic and treatment imaging services. Using state-of-the-art equipment, a skilled team of specialists provide caring, safe and efficient imaging services that are fully coordinated with the patients' medical care. “Imaging plays a vital role in determining the accuracy of diagnosis and the subsequent planning of treatment. The clarity and sophistication of the images help doctors and surgeons plan every aspect of surgery in advance. In other words, imaging is the ‘the visual inspection of internal organs without incision,” Dr Nathan says. No expense has been spared to equip the department with the most advanced facilities, The department got its first CT in 1986, MRI in 1990. “Technology in radiology has evolved very rapidly in the past decade and our department has kept pace with those developments. Advances in imaging technology is pushing the speciality to greater heights – allowing us to detect diseases earlier, offer minimally invasive treatment option to patients and provide an overall enhanced level of care.” says Dr Nathan. “Although we had started with very basic technology today we have 3T MRI and 320-slice CT,” he adds. The department started interventional radiology in 1988 as they already had a

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cath lab since 1986. Nuclear imaging was also done since 1987 and neuroimaging started in 1990. Today the department has gained prominence in acute trauma imaging, osteoarthritis imaging and neuro-interventional radiology. Treatment with ablation and cancer therapy is also done at the hospital. The radiology department is fully supported by competent doctors and technologists. The department boasts of well qualified technicians and radiologists who support 10 consultants. There are 30 radiologists, 45 technicians, and 40 support staff. Apollo Hospital’s radiologists work with doctors in other departments to promptly diagnose and treat health conditions. Radiologists perform and interpret more than three lakh examinations yearly. This large number of cases, integrated with ongoing research and education, results in broad expertise in imaging and treatment of diseases affecting people of all ages. “Our department offers a complete range of diagnostic and interventional imaging services that are fully coordinated with patients’ medical care and

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surgery. Doctors perform examinations safely and efficiently interpret and deliver results to the doctor, on the same day in most cases,” Dr Nathan says. The department is well connected with IT systems. “IT makes the department more efficient, enables increased productivity, and allows the department to serve hospital staff, patients, and referring physicians more effectively,” informs Dr Nathan. “It forms a comprehensive, fully-integrated solution that meets all digital needs,” he adds. In addition to RIS, the system features state-of-the-art picture archiving and communication system (PACS), medical reporting, solution monitoring & management services (SMMS), and audit services. Integrated with other hospital systems, such as hospital information systems (HIS) and electronic patient records (EPR), the benefits of RIS extend well beyond radiology. The department is also in the forefront of radiology education. The hospital got DNB accreditation in 1986 and since then has been training two candidates per year. Along with this the department also had two residents and four technologists training with them every year. Research is an integral part of Apollo Hospital. Residents within the Department of Radiology conduct basic science and clinical research, working closely with clinical departments throughout the hospital and other affiliated institutes. The department has published about 100 papers in various journals of repute till date. About six to seven research projects are in progress at the department every year. The department doctors participate in various city, state and national level seminars and conferences every year and take part in regular CMEs. Radiation protection infrastructure in the hospital is on very sound footing and is constantly being strengthened, based on experience and continued research and development activities. At present they have AERB certification and NABL certification along with JCI accreditation. In-house safety committee audits the safety measures monthly. Overall its a well maintained, secure department which works like a well oiled machinery. The state-of-the-art department not only helps patients coming to Apollo but also helps referral patients from around the place with many small and medium hospitals utilising the department thereby making it one of the most sought after departments at the hospital. mneelam.kachhap@expressindia.com MAY 2013

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MAY 2013

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I|N|I|M|A|G|I|N|G TECH SCAN

Myrian: Multifaceted and multifunctional Myrian, a multimodality radiology workstation, brought to India by Modi Medicare, is fast gaining popularity in the Indian radiology sector. Lakshmipriya Nair reviews the product with inputs from its users ach issue we bring you one product that is gaining acceptance in the radiology sphere and give an insight into its applications and benefits. This time we trained our scanner on Myrian, a multimodality workspace launched by French firm, Intrasense and brought to India by Modi Medicare, a renowned Indian company dealing in surgical and medical imaging products. Myrian is a full-fledged multimodality workspace/workstation with an interface and features which can reportedly handle high level functions and protocols to optimise clinical workflows and boost productivity. A comprehensive set of clinical modules are also available as options for liver, lung, colon, vessels, breast, heart, vessels and brain, and these different modules, based on different necessities of daily routine for each department, can ease the planning work and yet be accurate. The makers of this product claim that the workstation's applications are not only very accurate but are very user friendly as well. It reportedly also has a fast learning curve and additionally do not require very sophisticated hardware. It can be loaded on regular laptop computers – making workstations inexpensive and very portable. These softwares are also Cella, FDA, CE and ISO 13485 certified. Thus they claim that it is a key asset for radiologists, surgeons, oncologists and specialists to: ● Improve the efficiency of image reading and the accuracy of diagnosis ● Support surgery and therapy planning and assessment ● Allow the early and accurate evaluation of a treatment Patrick Mayette, Co Founder and General Manager of Intrasense says, “Myrian is the first true multimodality workstation in the market with the capacity to combine, compare and process images from several modalities simultaneously. This is essential to allow the comprehensive analysis of patient information, particularly in chronic diseases. Myrian is also a very versatile and customisable platform that perfectly adapts itself to the exact needs of each user and each hospital.” But the best reference for any product are its users, and with a view to know more about the software, its effectiveness, and its benefits, we spoke to some doctors and radiologists who have

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introduced this workstation into their practice and have been using it regularly to streamline their operations.

Users speak Jupiter Hospital, a multi-speciality tertiary care hospital in Thane has introduced Myrian in their set up. Dr Nikhil Kamat, Consulting Radiologist, Jupiter Hospital and Imaging Centre has been using it regularly for an year. He opines, “The software helps us to get volumetry and details of vascular anatomy fast and precisely, a process which would be cumbersome, labour intensive, time consuming and less precise without it.” He adds, “The direct volume acquisition and colouring of the portal and haepatic venous radicals helps us to give precise results for transplant surgeons.” Medanta-The Medicity, New Delhi has also adopted Myrian and their Sr Consultant Radiologist & Head CT Scan, Dr Tarun Piplani is all praise for the software. He has been using the software for 18 months and claims, “Intrasense from Myrian has revolutionised the field of 3D post processing in medical imaging. Its various applications can be run even from a laptop or a desktop, providing cutting edge technology to radiologists anytime, anywhere. The ease of operation of this system has simplified the procedure, particularly in liver, cardiac and neuro imaging.” “We, at Medanta - The Medicity are using this system particularly for the Institute of Liver Transplantation and Regenerative Medicine. Myrian is used to solve complex issues in liver surgeries, for various tumours and in liver transplant workup. It is being routinely used to perform virtual surgery in liver cancer patients and in liver donors,” he elaborates. Rahul Kakodkar, Senior Consultant Surgeon, Suasth Liver Centre, Institute of Liver Disease, Oncology & Transplantation is another user of Myrian. He reiterates the view offered by the other users and states that the software's speedy reporting as opposed to manual methods minimises pre-operative stay for patients. Easy fusion between phases and studies, versatility with CT and MRI studies and the ability to review the images in the operation theatre that adds to safety and accuracy, are some other features of the software that has impressed Dr Kakodkar who has been

using it for around two years now. Jupiter Hospital's Dr Kamat further informed about the operational benefits that he has accrued from Myrian and said that without the workstation the CT technician can take two to three hours post processing to get results but this times gets reduced to half an hour with Myrian. He also claimed that the results are more precise, and volumes are more accurate despite the reduced time. Dr Piplani agrees with these views and adds, “This system has an intelligent software which has drastically cut down the time required to perform analysis of complex cases by virtual surgery. The time consuming technique of volumetry is now possible with only few clicks on the laptop. Plus, portability of the system means a lot to the radiologist who can now perform 3D postprocessing of their cases while on the move, emergencies can be tackled from home and urgent cases can be done from outstation while attending conferences.” He further elaborates on the unique features of the software, “The ease of operability has made this system very popular amongst my surgeon colleagues and the imaging technologists. Thousands of images generated from a single imaging study, be it CT scan or MRI, are easily handled and converted into 3D coloured maps and videos which are easily understood by the surgeons in their operation theatres, helping them in performing complex surgeries with utmost confidence.” Dr Kakodkar finds that Myrian's quick automatic liver volume measurements, elegant 3D displays and multiple 3D modes, simulation tools that are easy to use, demarcation of liver vascular territories and vessel extraction are its best features that give it an edge over its counterparts.

The verdict Thus, while the users have found different uses and benefits from Myrian they are all united in the opinion that it is a very useful product and has helped them to streamline as well as improve their operations. It gets a high score on technology, user-friendliness, performance and image quality and but a slightly lower score on cost-effectiveness, which seems to be its only detractor. lakshmipriya.nair@expressindia.com

User ratings scale: 1-5 ( 5 being the highest) Name of the Doctor Technology Durability Dr Nikhil Kamat 5 5

Image quality 5

User-friendliness 5

Value for money 4

Dr Tarun Piplani

Dr Rahul Kakodkar

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MAY 2013

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MAY 2013

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I|N|I|M|A|G|I|N|G IMAGING TECHNIQUES

MRgFUS: Novel ‘No-touch’ technology Dr Shrinivas B Desai, Director – Department of Imaging and Interventional Radiology, Jaslok Hospital & Research Centre gives an insight on MR-guided Focused Ultrasound Surgery and its advantages over other conventional forms of surgery in treating various ailments

DR SHRINIVAS B DESAI

Director – Department of Imaging and Interventional Radiology, Jaslok Hospital & Research Centre

R-guided Focused Ultrasound Surgery (MRgUS) is a noninvasive, outpatient procedure which uses high doses of focused ultrasound waves (HIFU) to treat lesions inside the body without surgery or operation. MRgFUS machine consists of a combination of a MRI scanner and HIFU transducer. MRI is able to accurately localise the lesion and guide the HIFU beam that destroys the target tissue safely and accurately. The MRI scanner allows 3D visualisation of the lesion and this allows the doctor to pinpoint, guide, and continuously monitor the treatment. The HIFU transducer focuses sound energy on the area to be treated and destroys the abnormal cells. Imagine using a magnifying glass to focus the sun’s energy on a single point to create a flame to burn a leaf. The focused ultrasound energy is directed at a small volume of the lesion (abnormal area) raising its temperature high enough to cause thermal ablation (killing of the cells) without impacting other tissues. Pulses of energy are repeated until the entire volume is treated.

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Post treatment post contrast MRI images allow the doctor to confirm that the treatment is completed. Following the treatment the body gradually removes the treated tissue over a period of months. MRgFUS was installed in Jaslok Hospital in May 2010. Since its inception we have treated more than 200 patients with conditions like uterine fibroid, adenomyosis, early prostate cancer, facet arthropathy and painful bony metastasis. But these are just numbers and real successes are measured by improvement of patient’s lives. Here are some of their and our success stories. Ashwini Sule (name changed), 35year-old works in Jaslok Hospital as a Personal Relations Manager. She started noticing a vague lower abdominal pain during her menses which slowly increased in intensity over a year. The bleeding during her menstrual cycle had become very heavy for almost days with passage of clots. She had come to dread those five days of heavy bleeding where every aspect of her life became difficult. Routine tasks like travelling in a train, counselling

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patients or even just having a regular conversation with a colleague became a strain due to the discomfort, leaving her frustrated at the end of the day. When her menstrual cycles became irregular she realised something was wrong and went to see the gynaecologist. An ultrasound and MRI pelvis showed that she had a small submucosal (below the endometrial lining) fibroid or myoma. The thought of surgery for the fibroid deepened her anxiety to such an extent that she avoided it for almost six months and bore the discomfort. Luckily for her MRgFUS was subsequently installed just next door in the Radiology Department at Jaslok Hospital and MRI pelvis with contrast showed that her fibroid was treatable in a single session itself. The treatment took just two hours and in fact much to her colleagues’ surprise and hers she was able to resume work on the same afternoon. By her next cycle she had considerable reduction in pain and by six months she was back to her normal painless cycle. Seeing her every day as I enter the hospital smiling and serving patients gives me a deep sense of satisfaction. MAY 2013

I|N|I|M|A|G|I|N|G Ashish Ahuja (name changed), 53year-old corporate magnate from South Africa had been feeling weak and lethargic. This was quite out of character for this dynamic personality. His routine blood tests showed an elevated PSA (blood marker for prostate cancer) leading to an ultrasound, MRI and biopsies revealing that he had an early prostate cancer without metastasis or spread. On meeting a local cancer specialist he was told that considering his age and medical condition it would be better for him to avoid surgery and the risks of general anaesthesia. He was advised to just wait and follow up the cancer with yearly scans. Ahuja left the doctors consulting room feeling dejected and anxious wondering when the cancer will decide to spread to his entire body. After a day of depression he decided this wait and watch policy was not for him. After extensive research he found out about MRgFUS and having visited Jaslok Hospital before he decided to consult us. His prostate cancer was amenable to treatment by MRgFUS. He underwent treatment during which care was taken to preserve his neurovascular bundles (which controls sexual potency) and urinary sphincter (gives control over urination). Post treatment he retained his potency as well as continence. He is now back at work without the sword of cancer hanging over his head. His six month scan shows complete ablation (treatment) of the prostate cancer with normal PSA levels. Sushant Singh (name changed), 26 year old carpenter was accustomed to strenuous work days with normal occasional post work mild back pain. He started experiencing back pain on waking up in the morning which would gradually diminish on regular activity to a constant dull ache by the end of the day. There was a gradual increase in pain intensity and duration essentially leaving him in pain throughout the day. He visited a doctor who gave him some pain medication which lead to temporary relief. He then consulted an orthopaedic surgeon (bone specialist) who advised him to undergo MRI of the spine. His scan in our department at Jaslok Hospital showed no intervertebral disc (cushioning between the spine bones) prolapse which is a common cause of pain. Rather he had facet joint (joints between spine bones) arthropathy which can also cause pain due to the irritation of pain-carrying nerves adjacent to these joints. This is actually the commonest cause of low backache in India. MRgFUS has the ability to ablate (treat) these nerves so as to eliminate the pain. This was explained to him and he was asked to consider this treatment option. He had a NRS (pain scoring system) of nine out of 10 before the treatment which is high. The fact that this treatment was non-invasive and could be performed as an out-patient MAY 2013

MRI is able to accurately localise the lesion and guide the HIFU beam that destroys the target tissue safely and accurately. The MRI scanner allows 3D visualisation of the lesion which allows the doctor to pinpoint, guide, and continuously monitor the treatment procedure led to him choosing MRgFUS. After the treatment he was able to return to work in three short days. He is currently pain free (NRS is one) and is able to work normal hours without any medication. Capt Bejoy Roy (name changed), 63-year-old merchant navy captain was diagnosed with inoperable cancer of the prostate. He was undergoing chemotherapy and radiotherapy when he started experiencing excruciating pain in his buttocks more on the right side. He was unable to sit even after taking multiple pain medications. His CT scan showed a destructive lesion in the right ischial tuberosity (bone which bears the body weight when we sit). He was offered radiation therapy which involves 21 sittings consisting of consecutive daily sessions. This meant he would have to lose 21 work days with gradual reduction in pain. He was referred to us for radio-frequency ablation in which a needle is put into the lesion and ablated (treated). Since treatment was for only pain palliation (not for cure of the disease) we offered him the option of MRgFUS. After hearing about this technology, where without inserting a single needle or any incision we were going to ablate the lesion and relieve his pain, he was sceptical but faith of our good intentions won through. His treatment under mild sedation lasted a short one hour and post treatment scan showed good ablation. He made a remarkable recovery and within a short 24 hours he was completely pain free. Post pain relief he became his regular jovial magnanimous self, making me realise there’s an even bigger evil than cancer and that’s pain. He is currently retired and as he puts it “sitting at home” pain free. Dr Sumathi Rajan, 37-year-old gynaecologist from Hyderabad noticed a distinct change in her menstrual cycle. Her menstrual cycle had shortened with heavy bleeding for about four days with spotting lasting for almost 14 days. The heavy bleeding was accompanied by lower abdominal

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cramps that wouldn’t subside without considerable medication. She was going through the monthly nightmare that she had treated so many women for and knew what she had to do. An ultrasound revealed that she had diffuse adenomyosis, which is invasion of the normal uterine muscle with endometrial glands that bleed every cycle into the muscle leading to immense pain. Unfortunately the treatment options for diffuse adenomyosis are limited and these women usually end up with hysterectomy (complete removal of the uterus). Being an up to date gynaecologist she had heard of MRgFUS and its wonders. She visited us for a consult and I had to impart the bad news that so far we only had US FDA approval to treat focal adenomyosis not diffuse adenomyosis. I was quite surprised the following week when she told me that she had decided that MRgFUS was the only treatment for her. Despite my extensive counselling for probable treatment failure I could tell that her mind was made-up. Her treatment consisted of two sessions each of three hours duration. To my absolute delight she responded wonderfully to the treatment and within six months was pain free with near normal menstrual cycle. This last story is the closest to my heart as it truly illustrates “Fortune favours the brave”. This patient led me into unchartered territory and I cannot describe my joy that it reaped rich dividends for her. The advantages of this treatment are it is non-invasive (without the need for any incisions). The treatment is completely safe as MRI guidance allows visualisation of lesion and surrounding area. This key technological amalgamation of MRI and HIFU allows accurate lesion targeting and provides real time feedback about temperature changes in the treatment area and outside to make sure that only the abnormal tissue is treated and the surrounding normal tissues are unharmed. This procedure is conducted under mild sedation which means that the risks of anaesthesia are avoided and that the patient is conscious during the treatment and can provide feedback during the procedure to the physician. This live feedback gives the patient absolute control over the treatment and helps the doctor make this treatment more patient-friendly. However, there are some treatments like those of early prostate cancers and brain tumours where spinal anaesthesia is required. The future of MRgFUS is bright with emerging applications for almost every part of the body. We at Jaslok Hospital have always been on the forefront of technology and will soon have a brain module which will allow us to treat lesions in the brain without surgery. There are as many neurons in our brains as there are stars in our galaxy, I wonder what they will come up with next. EXPRESS HEALTHCARE

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Rays against cancer Dr D Ghosh, Director - Batra Cancer Centre, Batra Hospital & Medical Research Centre gives an insight on the various technologies available for radiation therapy in oncology at Batra Hospital and their applications as well as benefits

DR D GHOSH, DIRECTOR Batra Cancer Centre, Batra Hospital & Medical Research Centre

ancer is considered to be a deadly and incurable disease with dismal outcomes. But with newer treatment technologies and early detection this notion is changing in todayâ&#x20AC;&#x2122;s era. The treatment of most of the cancers is multimodality. The field of radiation oncology is an ever changing branch with new technological innovations. Delivery of radiation therapy is a team work which includes the radiation oncologist, who after evaluating the patients decides the best course of treatment for the individual patient, medical physicist who makes the best possible plan and makes sure that the proper dose gets delivered to the tumour and maintains the quality assurance, and last but not the least, the radiation therapist technologist who operates the

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machine and delivers the dose according to the plan made. The greatest challenge to a radiation oncologist is to attain high probability of cure with minimal possible morbidity. The field of radiotherapy has evolved over a period of years. The multileaf collimator (MLC), along with intensity modulated radiotherapy (IMRT) is a major breakthrough.

Radiation therapy at Batra Hospital Batra Hospital, established in 1987, is a pioneer institute in the field of oncology with the most experienced faculty. Today, it is fully equipped to treat several types of cancers with the help of several high-tech equipment used in radiation oncology. The Varian clinic 2100 C linear accelerator at Batra Hospital is a state-of-the-

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art machine. It has dual photon energies 6X and 15X, with 5 high electron energies 6, 9,12,16,20 MeV. The dose rate varies from 100MU/min to 400MU/min and has a 120 micro multileaf collimator which can take the shape of tumour under treatment. The department is fully supported by well equipped medical physics department which is approved by AERB/BARC. Some of the available radiation therapy techniques at Batra Hospital are as follows: CT simulation for radiation therapy planning, 3D conformal radiation therapy (3DCRT), intensity modulated radiation therapy (IMRT), image guided radiation therapy (IGRT), rapid arc, cone beam computed tomography (CBCT), high dose rate brachytherapy (HDRBT), and 3-dimensional brachytherapy. MAY 2013

I|N|I|M|A|G|I|N|G Conventional 2-dimensional radiation therapy (2-D): This is a simple treatment delivered with two to four beam angles and beam shapes being either rectangular or square. The dose was limited by the normal structures lying along the path of beam which also receives the same radiation dose. Blocks, wedges and compensators were used in the path of beam for sparing the critical organs and better dose distribution in the tumour. 3-dimensional radiation therapy (3DRT): With the availability of CT scan the tumour could be visualised in three dimensions and with the help of automated multileaf collimators the normal tissues could be spared in a better way, simultaneously delivering curable dose to the tumour. Intensity modulated radiation therapy (IMRT): A type of 3-dimensional conformal radiotherapy that focuses multiple radiation beams directly on the tumour itself. Beam intensities vary, so that the highest possible doses can be used to destroy cancerous tissue keeping the dose to the critical normal tissues to the minimum. This technique is best for tumours which are surrounded by the normal and critical organs like head and neck, prostate, brain tumours close to visual pathway, abdomen tumours surrounded by normal organs like kidneys, spinal cord etc. This results in very low complication rate following extended radiotherapy treatments because dose is modulated and adjusted with the help of multileaf collimator. Computer-aided optimisation derives desired treatment plan with intensity modulated beams so special planning software is required to determine the most accurate treatment. Image-guided radiotherapy (IGRT): The organs in the human body are not static and the range of movement varies from organ to organ (most organs move a few millimetres or more in all the directions). When the radiation oncologists plan specialised treatments like 3dimensional conformal radiotherapy (3DCRT) or intensity modulated radiotherapy (IMRT), they keep the margins around the tumour very tight in order to reduce dose to the surrounding normal tissues. However, there is a possibility of the treatment field to shift on either side by a few millimetres everyday, particularly in organs like lungs, prostate, urinary bladder which moves with respiration. Taking this into account bigger margins around the tumour are required, thus including more surrounding normal tissues thereby compromises the purpose of highly precise treatment. With IGRT facility, very tight margins can be taken, since the treatment fields and organ position will be verified by image guidance every day by taking the image in the treatment room itself by KV and CBCT ( imaging facilities) just before the treatment is given and adjustments made for field and organ shift on a daily basis before delivery of radiation. Thus MAY 2013

The greatest challenge to a radiation oncologist is to attain high probability of cure with minimal possible morbidity. The field of radiotherapy has evolved over a period of years. The multileaf collimator, along with intensity modulated radiotherapy is a major breakthrough IGRT helps in reducing the side effects dramatically in patients and is the ultimate in precision radiation therapy. Rapid arc: It shapes the radiation beam to match the exact contour of the tumour, ensuring the maximum prescribed dose of radiation delivered to the tumour and protects the surrounding healthy tissue. The technique is non-invasive and lasts for five to 10 minutes, rather than long treatment time as with conventional techniques, which makes the treatment delivery comfortable. It reduces the likelihood of patient and tumour movements thus ensuring the highest possible level of accuracy and reducing the side effects which in turn results in improved quality of life. With these newer techniques, tumours which were initially considered to be untreatable can now be treated very well. Computed tomography (CT): It is an immobilisation device that is fabricated in the mould room for each individual patient to ensure a better set up during the treatment delivery. Data from the CT simulator ensures that patients get the appropriate dose of radiation before treatment begins. Each patient will undergo a CT scan (CT simulation) for planning a radiotherapy procedure. Treatment planning based on CT scans is the most accurate method available all over the world today. Some patients with brain tumours and prostate carcinoma may require MRI scans along with CT scans, where the CT and MRI images are fused for treatment planning. Facility is also available for fusing data obtained from PET scan for an excellent tumour target delineation and refined treatment planning. Brachytherapy: It is defined as a form of radiation therapy where radiation is delivered by arranging the radioactive sources in a geometrical fashion, in and around the tumour. It is used as an adjunct to external beam radiation therapy. The advantage is prescription of high dose to a small limited region in shorter time period and sparing of the normal tissues because of rapid dose fall

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off. HDR brachytherapy has high dose rate delivery system and the treatment gets completed in few minutes. Various forms of brachytherapy are available in form of intracavitary (cancer cervix), intraluminal (oesophagus) and interstitial (head and neck, soft tissue sarcoma, breast cancer). Radioactive sources are placed into the tumour through the applicators in situ. Now the concept of 3-dimensional base brachytherapy is growing, wherein normal organs are contoured and accurate dose is identified through specialised treatment planning softwares.

Role of imaging in oncology The development and use of computed tomography (CT) and magnetic resonance imaging (MRI) to define the target volume and map the patientâ&#x20AC;&#x2122;s external contour, as well as internal organs and target volumes have an unprecedented impact on radiation therapy. The use of CT images as an aid in calculating the effect of tissue in homogeneities has improved the accuracy with which the dose can be calculated. The precision with which radiation therapy can be delivered has been greatly improved and may have an impact on the cancer cure rates. CT scans for treatment planning is different from diagnostic images because they are obtained with the patient in the treatment position on the flat table insert on the CT table and with some external reference marks that are visible on the CT image. As mentioned above, every organ in the human body has a tendency to move with respiration and some organs like bladder and rectum changes their volume with filling and evacuation. These movements can be divided into interfraction motion which means the changes in the position caused by dayto-day set-up conditions and intrafraction motion which are the changes in position during a treatment session because of respiratory and organ motion. Both these types of motions create treatment uncertainties. If the motion is greater than the treatment planning margin, the prescription dose to the target may not be achieved or the tolerance dose to the normal tissues may exceed. This would defeat the very purpose of treatment. kV imaging uses high resolution, low-dose digital imaging in the treatment room. With digital kV radiographic, cone -beam CT (CBCT) and fluoroscopic images one can very well manage the patient and target movement. Cone beam CT is designed for fast image acquisition to speed up the clinical process. Image acquisition is fast using a single, one minute rotation around the patient regardless of the patient anatomy being scanned. Hence, it would not be wrong to say that imaging is the backbone of radiation oncology which provides improved tumour targeting and better treatment delivery that is the ultimate goal of radiation therapy. EXPRESS HEALTHCARE

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Fuji's Amulet for good health Fuji's Amulet – its latest full field digital mammography, offers several great features to help in improving the accuracy of diagnosis mulet”, derived from the Latin word “amuletum” means “an object that protects a person from troubles, brings good luck and fortune”. Fujifilm supports a healthy fulfilling life for all women hence, has innovated Amulet- the guardian of women’s healthcare. “Amulet” is Fujifilm’s latest full field digital mammography that employs a newly developed direct-conversion flat panel detector (FPD) with world’s smallest* pixel size, 50 µm. This enhances visualisation of the breast and offers greater details of abnormal areas such as micro calcification and tumours, thus helping more accurate diagnosis.

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Optimised workflow and quick, comfortable examination. Shorter intervals between exposure. The ergonomic design of the system offers comfort for women for different positioning. Armrests offer full and well-balanced support. The handles allow optimum stability for CC view and secure support of the body MLO view. Specially designed AWS integrated with X-ray exposure control offers a more effective environment for mammography examination. A valuable digital support system— the most advanced digital mammography CAD system

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Targeting Guide functions on stereo images Various image processing to make targeting accurate and easy Various in-built safety functions Warning indications of needle depth within the breast A diagram that shows target position on the display screen

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A valuable digital support system. Enhancing efficiency with soft-copy exams Readily distinguishable CAD marks 90.6 per cent true positive rate with 2.5 false positive for four images Increased productivity in reading exams with parallel processing

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Greatly enhanced breast imaging capability with CE and USFDA approved FFDM Amulet. The world's smallest pixel pitch of 50µm*-Direct-conversion FPD system FPD has two size variations. 18 x 24 cm, 24 x 30 cm Exclusive FUJIFILM technology: Direct Optical Switching feature a dual layer of amorphous selenium (a-Se) Fujifilm’s new patented flat panel detector offers superior DQE, achieving both higher image quality and lower radiation dose.

A simple and efficient environment for mammography examinations ● A console that optimises your workflow ● Integrated X-ray control allows settings and confirmation of imaging conditions on one screen ● Portrait-type monitor enhances both image viewing and operability ● Examination screen can be split and switched between 1, 2, or 4 sections ● Automatic and manual left/right image position adjustment ● Density and contrast can be adjusted with both left/right images ● Supports DICOM Ver. 3 ● Referral Image (from PACS) Viewing function and Precise Enlargement function with Dual monitor system. ● Streamlined workflow and clinician efficiencies with three exposure modes- full auto, semi auto and manual. ● AEC auto select function. ● Automatic decompression after exposure. ● Automatic optimisation of compression force. Amulet uses the mammography image processing technology from our proven FCR system. It provides high quality images that enhance visualisation of the mammary tissue and greater detail of abnormal areas. Thus, Amulet helps ease the diagnostic process.

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Easy and accurate positioning of patients Ergonomically designed arm rests and disposable soft pads that help to make patients more comfortable Review of previous examination by referral image viewing function (Optional) Targeting Support functions with high resolution dual display system

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Mammography QC programme for digital mammography with superior quality and reliability FUJIFILM Mammography QC programme is a dedicated quality control (QC) programme applicable to the both FCR and FDR mammography system based on IEC61223-3-2 Ed. 2.0. This QC programme enables quantitative measurements, visual inspections and functional checks on the entire mammography system through the installation test, followed by daily/weekly, quarterly, semi-annual and annual tests. This programme provides the ability to detect gradual changes in the entire mammography system before potential problems occur and thus enables the system to keep a stable image quality for both screening and diagnostic mammography.

3d mammography viewer: Mammography enters a new stage of diagnosis Fujifilm's 3D mammography creates 3D images by using two high resolution images taken from different angles. One of these images is a conventional 2D image. The images are presented on a special viewer. 3D images enable the internal anatomical breast structures to be identified more clearly as compared to a 2D image. This is possible due to tissue separation and micro calcifications stratification. With this system, it is expected that image interpretation is as quicker even quicker than 2D mammography and false positives are reduced. Fujifilm’s 3D mammography with minimised dosage and examination time:This new 3D system realises more precise diagnosis with only 1.3 to 1.5 times larger X-ray dose in a slightly longer time than 2D mammography MAY 2013

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aycan's new age solutions An overview of aycan OsiriX PRO plug-ins and options ycan continually develops clinical and workflow plug-ins to further enhance aycan OsiriX PRO’s capabilities. Additionally, aycan cooperates with other plug-in development companies to provide tested and certified solutions. A full list of plug-ins with FDA clearance and CE marking are listed below. With these plugins/options, and tools for general diagnostic reading and advanced post-processing, OsiriX PRO makes the perfect solution wherever there is demand for fast and easy access to medical images.

workstation in the areas of curative treatment and screening.

DICOM Print Film Composer The film composer plugin for OsiriX PRO offers a

“what you see is what you get” user interface for managing your DICOM print jobs. The simple- to-use interface allows you to add and manipulate the layout and several parameters and print single images, key images, or the

complete series

Ejection Fraction The optional Ejection Fraction plug-in calculates the left ventricle ejection fraction according to the "Dodge Correction" method.

(This plug-in does not serve as a tool for computer-aided diagnosis.)

Image Recalculation The Image Recalculation option for OsiriX PRO allows you to manipulate data to

11-Bit Monitor Support With this OsiriX PRO plug-in, you will attain more detailed gradiation in grayscales in the 2D and 4D Viewer when using special 11-bit- capable monitors.

4D ROI Statistics With the optional 4D ROI Statistics plug-in for OsiriX PRO, you can evaluate voxel values of MRI and CT multiphase series from different acquisition times.

Media Importer The Media Importer plugin allows you to better manage the data you import to OsiriX PRO. You can choose specific studies and series, change patient demographic information, route data to a different DICOM node, or burn your data to CD/DVD.

Advanced Hanging Protocols Ideal for mammography workstations, the optional advanced hanging protocols plug-in allows you to save display layouts and settings in the 2D Viewer, so when reopening a study (or similar studies) you’ll always get the same view. This standardisation brings greater efficiency to routine diagnoses. This OsiriX PRO plug-in also automatically opens up prior studies, which further increases the speed of the daily workflow. With this plug-in, OsiriX PRO can now be used as a mammography MAY 2013

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I|N|I|M|A|G|I|N|G suit your particular needs, so you can work quicker and easier. Within the option, you can manipulate and edit a series by adding custom formulas. The option also let’s you reduce the size of a series, so it’s easier to work with. Whichever way you recalculate the image, the option lets you export the results as a new DICOM series.

RECIST The RECIST plug-in with FDA 510(k) clearance for OsiriX PRO allows you to quickly and easily quantify and analyze lung tumors according to the Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 guideline, the WHO guidelines, and by the volume of the tumors. (This plug-in is not a tool for computer-aided diagnosis.)

Vessel Analysis aycan’s OsiriX PRO vessel analysis plug-in supports segmentation of vessels in CTA data sets and provides center lines for vessel assessment. The plug-in is used to mark specific areas for vessel segmentation so that vessels can be displayed separately in different views. Based on the determination of the center line and direction, an interactive assistant takes you through the individual segmentation steps to isolate tiny arteries (e.g., coronary arteries) as well as large arteries in the area of the pelvis and legs. The diameters and lengths can be determined in a final step (3D Curved MPR).

aycan mobile iPad app

CT/MRI); reviewing images with patients at their bedside; teleconsulting with colleagues; distributing images inhouse; and much more.(FDA 510(k) cleared)

Concurrent License Server Ideal for large environments, such as hospitals, the optional Concurrent License Server allows multiple users to access OsiriX PRO at the same time for easy license sharing, management, and cost savings. In addition to saving costs by minimizing thenumber of licenses you purchase, further cost benefits can be achieved over time as installation, administration, and maintenance-time are minimised.

Contact

Designed for the easy, fast, and secure transfer of DICOM images from hospitals and imaging centers to on-call and other radiologists and referring physicians with an iPad, aycan mobile’s intuitive user interface and robust feature set make it the ideal tool for remote review, interpretation, and diagnosis of radiological images (intended use:

250, Powai Plaza, Opposite Pizza Hut, Hiranandani Gardens, Powai, Mumbai – 400 076. Branch Office : Saldhana Providence, Balmatta Road, Mangalore - 575 001 Tel: +91 90047 45674 / +91 77383 69799 Email: healthcare@mapledti.com

3D Post-processing workstations from Terarecon Need for a post processing workstation for every radiologist and across the Enterprise emember the old days when modality workstation was the only means of advanced visualisation and volumetric analysis. The so called 'workstation' was perceived as the most valuable resource and was the only means by which multi-slice CT, MRI and PET/CT procedures could be efficiently interpreted and reviewed. Generally speaking, nothing is wrong with it as far as it goes. Most CT scanners come bundled with a 3D workstation offered as part of the package, and these workstations

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Integration of advanced visualisation tools with PACS is not essential, but it does help smooth the workflow

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often have good software for providing 3D interpretation support. The problem is that there is usually only one supplied per CT or MR, and purchasing an additional one is very expensive. The CT technologist usually needs access to the workstation for various management tasks, and so there is competition for this valuable resource that can only be used by one person at a time. As a result, physicians often have to interpret from 2D viewer looking at static images created by technologists, precluding the possibility of pursuing a MAY 2013

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diagnostic decision tree that requires multiple consecutive questions to be addressed in 3D. The key problem that has arisen with the introduction of MDCT is how to provide cost effective volumetric interpretation support to interpreting and referring physicians, and this is where the 'bundled' workstation falls down. Failing to plan for an Enterprise Advanced 3D solution is planning to fail. So let us understand how modern technology and software innovation would make this 3D advanced visualisation available to all.

Inbuilt automation Nowadays, software innovation alongwith client-server architecture, allows automatic preprocessing of datasets. The server automatically pre processes datasets performing assigned tasks such as bone removal, rib cage removal, CT table removal, automatic vessel extraction and drawing centerlines, etc. When these tasks are automated and performed off-line, results are delivered to a technologist or physician without them having to initiate the process and then wait for it to complete, and hence, valuable time is saved.

Technological challenges and innovation in medical imaging Making advanced visualisation available to a broad enterprise poses some technological challenges. This is not like browsing the web where the processing power required is small and the data volume transferred is manageable. Modern MDCT datasets can run to gigabytes and the processing power needed to render them in real time 3D pushes the very limits of modern computing technology. As a result there is tremendous value in being able to avoid moving the large CT datasets around to multiple computers across the enterprise, and in being able to avoid reliance on the processing power of whatever computer may be available out there to do the 3D rendering itself. This is where the client-server architecture comes in and this is where it brings such an advantage. All the data can be centralised into one server, which can easily be located close to the modalities or PACS, such that the transfer is fast. This server, if equipped with a huge amount of processing power, can then provide rendering services to many computers across the enterprise which can run a simple application to control the server and receive a real time stream of images for display. This effectively turns every computer in the enterprise into a 3D workstation and if the power and feature set of the server is adequate, this becomes a really elegant, viable and cost-effective solution for delivering advanced image processing to everyone who needs it. This 'thin client' approach, when implemented properly, is also excellent for PACS integration because, since it makes no significant demands on the client-side hardware, it can easily run alongside the PACS software without impairing its performance and still be available for instant access in 3D.

Volume rendering technique and client-server architecture The key differences between the 3D technologies in the market relate to the technology used for 3D rendering and the general architecture of the system. When the CPU of a computer is used for MAY 2013

PACS with 3D capabilities enhances workflow Pranav Shah, Regional Sales Manager Terarecon 3D rendering, a general purpose processor designed for Microsoft applications performs a specialised medical imaging task, often with poor efficiency and performance, even when compromises are made in image quality. The same is true for GPU rendering, as 'video cards' in most computers are mainly designed for computer games. These cards deal primarily with 'polygon' graphics and typically do a poor job on anatomical data, with compromises in terms of performance and image quality. As a result, such systems usually have to calculate additional information about every dataset that is received, just to prepare it for 3D rendering, which takes time, memory and CPU power, and the results must then be stored on the hard drive, consuming additional space. The alternative is to use a dedicated hardware processor specifically designed to perform medical visualisation where the slice data can simply be downloaded to the boardâ&#x20AC;&#x2122;s memory without any delay or additional processing, with real time 3D following. Such a system can have the power and scalability to manage a true client-server deployment powerful enough for an imaging enterprise. Third-party 3D vendors generally have some architecture to address the enterprise solution, which has an emphasis on client-server and dedicated board based rendering technology platform. Usually they are designed for such enterprise wide advanced 3D visualisation and when packaged with advanced clinical applications makes physicians less dependent on the modality workstation. A truly capable enterprise solution based on a client-server solution enables multiple users to use any networked standard PC as a 3D workstation and use

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Integration of advanced visualisation tools with PACS is not essential, but it does help smooth the workflow and it can save a few additional seconds of locating the patient for a second time when you want to work in 3D. If you have a PACS, check if the 3D vendor can integrate and if so, how easy is that to realise? Is there a cost on the PACS vendor side? If you have not yet purchased your PACS, think ahead and ensure advanced 3D clinical capabilities is part of the PACS package!

Seeking access to 3D tools outside your hospital? Look to the cloud There is definitely a challenge and it may also sound expensive for centres with low volume to provide advanced visualisation to all. Hospitals have to invest into hardware and software solutions to deploy such server-client solution. Moreover, it is confined to your hospital and if you need to reach outside your hospital to share or collaborate it can get complicated. With true clientserver technology, healthcare providers are now offering cloud based advanced visualisation. Wherein as a customer you donâ&#x20AC;&#x2122;t need to invest in purchasing entire solution but enroll for a subscription. It is like software as a service (SaaS). Physicians have to upload their cases through secured gateway onto the cloud servers provided by vendor and by any web browser a physician can access entire suite of clinical applications. A strong Internet bandwidth of 3-5Mbps is essential for using cloud accounts and with recent IT and telecommunications regulations, and there are no foreseen major challenges in getting such Internet connections. There are companies which provide smart uploader facility by which the time taken to upload your studies is minimised. Using secured browserbased access, mobile devices like iPhone and iPads can also be used to access cloud servers. Contact Pranav Shah Regional Sales Manager, Terarecon Email: pranav@terarecon.com, Tel:+91-9819192754 EXPRESS HEALTHCARE

IT@Healthcare MAIN STORY

Electronic health record for quality healthcare Sachin Tare, Head-Indian Subcontinent, Zebra Technologies identifies the benefits of implementing EHR and the role barcode technologies play in enabling EHR

Page 73 Dr J Sivakumaran, Senior VP, SPS Apollo Hospitals gives an insight on the growing advent of technology in hospitals and its manifold benefits in enhancing healthcare delivery

Technological prowess for healthcare progress echnology plays a very important role in hospitals. Though it is no substitute for a doctor’s expertise and a nurse’s healing touch, technology does play a very vital role in enhancing the quality of care and treatment of patients. We are familiar with telemedicine, health alerts on SMS, archiving of digital images, hospital billing, financial applications, physician billing, electronic medical records etc. There are many more technological developments taking place. Let’s take a look at some of them that are interesting and beneficial to patients:

e-ICU DR J SIVAKUMARAN, Senior VP, SPS Apollo Hospitals

An ICU setup will consist of patient beds, monitors/equipment, trained nurses and at least one intensivist per shift. Most of the bigger hospitals manage to get nurses and doctors, but smaller hospitals/nursing homes/peripheral centres do not find it easy to have a full-fledged ICU setup. Patients who need to be under ICU care are being referred to the nearest best hospital of their choice, depending on how much the patient can afford to spend. By adopting e-ICU, the smaller hospitals can run an ICU department, without having an Intensivist and trained ICU nurses. A tertiary care hospital is hooked up with smaller nursing homes and peripheral centres where they have patient load but do not have ICU specialists on board. The tertiary care hospital will have a command centre equipped with few

servers and bigger monitors/terminals, where the readings of different patients from different hospitals are displayed. The command centre will monitor the patients of other centres, 24x7 through a communication network. The smaller hospitals can have only an on duty doctor/nurse, who can understand the instructions and directions from the intensivist to administer the medicine/carry out procedures. These hospitals will be equipped with high resolution cameras attached with movable carts. While the vital parameters are being transmitted to the command centre continuously, the intensivist at the tertiary care centre can get connected to the other hospitals, at the click of a button. If at any point of time, the intensivist wants to see the patient to observe something, the movable cart will be kept by the side of the patient at the referred hospitals and focussed on the desired position. By having the history of the vitals and physical observations, the intensivist will be able e-ICU Command Centre

to take an appropriate decision. The tertiary care centre will be paid on a per bed per day basis by the referring hospitals.

Hybrid operation theatre/room Suppose a patient needs both stenting and bypass surgery, the patient has to get into cathlab for stenting and has to be shifted to an operation theatre to undergo bypass surgery. This prolongs the stay of the patient, entails his frequent movement, thereby increasing the overhead budget of the hospital and a resultant increase in the patient’s bill. Assume that if the theatre is attached with a cathlab, the physician and the surgeon will work as a team to undertake the respective procedures in the same setting; thereby immensely benefitting the patient. These theatres are called Hybrid Operation Theatre/Room. It is a minimally invasive approach combining the features of a cathlab and a standard operating theatre room with state of the art imaging facilities. In hybrid OT, both physician and surgeon work as a team. If, during the diagnostic procedure any complication arises, the patient could be operated upon immediately, without any loss of time. Surgeons can take real-time decisions during surgery. This is very useful in specialties like cardio, neuro, ortho and trauma cases. The hybrid theatre will be highly beneficial for a trauma patient who requires procedures from multiple specialities where diagnostic images are needed frequently. Hybrid minimally invasive approach is very cost effective,

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Hybrid Operation Theatre/Room

avoids unnecessary transfer of patient from one place to another, reduces medical errors, decreases hospital stay, facilitates faster recovery, yields better outcomes, enhances patient safety, aids better utilisation of resources and enhances efficiency.

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Reducing medication errors Medication error ranks amongst the top 10 reasons for mortality in the world. In India, these errors are not declared and shared due to a lot of extraneous factors, not related to the patients’ well-being in the least. However, using technology errors could be effectively kept under control. The medication management activity can be broadly classified into the following four steps: ● Prescription by doctor: Medication errors occur due to illegibility of handwriting, non-mention (remembering) of drug reactions, not taking care of drug-to-drug reactions, dose, route, dosage form etc., in the physician’s order. A computerised physician order entry (CPOE) with integrated information system will overcome this problem.

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Transcription: When manual orders of the doctor are transcribed by the nurses or assistants, due to illegibility, chances of errors are high. But if the order is through a computer, this problem could be taken care of. Dispensing: Errors happen during the dispensing of medicines and drugs due to volume of work. To overcome this problem, automated dispensing cabinets (ADC) could be installed. ADC cabinets are robots which can dispense any volume of prescriptions accurately and at a faster rate. Administration: Errors occur at this stage if the right patient is not given the right medication with the right dosage. The bar code of the medicines and the patient ID need to be reconciled and electronically matched before administering the medicines. If any mismatch is found between physician’s order and medicines, the system would raise an alarm so that errors could be avoided.

Disadvantages/challenges of technology Technology has several advantages

but it is not without its share of challenges as well. The prime challenge is the capital investment. Many of these investments will not have tangible benefits but indirectly help the hospitals in delivering quality healthcare. The main challenge is to convince the stakeholders on the advantages of technology for 100 per cent compliance. Though ADC robots are efficient and faster, the manual system also should be in place as a stand-by. In case the robot is having any technical problems, then the entire hospital system will come to a halt. How many hospitals can afford to have diagnostic machines inside OT and a hybrid OT? Regular patients cannot be diagnosed in a sterile area like OT. Being heavy in size, it cannot be moved from one place to another frequently. In the final analysis, the machines will be underutilised, if sufficient patient load is not there. Though hybrid OT will benefit patients and many lives could be saved, the viability of the project would always be the most supreme consideration before capital is committed for such investments.

INSIGHT

Electronic health record for quality healthcare Sachin Tare, HeadIndian Subcontinent, Zebra Technologies identifies the benefits of implementing EHR and the role barcode technologies play in enabling EHR

MAY 2013

ealthcare worldwide is constantly undergoing changes due to new research findings, new medical technologies and new business models. It has evolved into an information intensive field and data must be timely, accurate and reliable since it could make the difference between life and death. The potential of IT and its influence on Indian healthcare has been much talked about. However, implementation of Electronic Health Records (EHR) which enables healthcare institutions both in public and private sectors to analyse and keep track of a patient's medical history remains an unexplored area1. The ageing populations as well as the rising need for chronic care and an increase in patient awareness call for quality and affordable healthcare.

Resource constraints have led governments and hospitals to turn to technology in order to ensure patient safety and quality care. Implementing the EHR particularly, can help healthcare providers improve their ability to make well-informed treatment decisions quickly and safely, improve patient outcomes and increase efficiency.

anytime, across healthcare delivery organisations and across geographies, EHRs can help healthcare providers manage patient care more effectively. With more complete patient information and by making it easier to use and share information, EHRs ensure seamless patient experience and safety across the entire healthcare value chain.

Healthcare organised around an individual

The benefits of implementing the EHR include:

Personal statistics, medical history and laboratory reports are just a few examples of important data stored in the EHR. As this data can be electronically available to authorised healthcare providers and the individual anywhere,

1) Informed decision making With the EHR, patients are presented with complete and accurate information about their medical history. Providers can also electronically offer follow-up information like self-care instructions, reminders for follow-up

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SACHIN TARE Head-Indian Subcontinent, Zebra Technologies

care and links to web resources. Quick and easy communication between patients and providers can help healthcare providers make informed decisions. 2) Improved patient outcomes With reliable access to a patient's complete health information, healthcare providers can identify symptoms earlier and diagnose patients' problems sooner. EHRs also help to reduce errors and improve patient safety. For example, EHRs automatically check for problems whenever a new medication is prescribed and alert the clinician to potential conflicts2. Sentara Hospital in Norfolk, Virginia, completed implementing EHR in six hospitals in 2009. In the first six months post implementation, about 41,000 potential medication errors were avoided when nurses cancelled medication administrations due to barcoding

alerts3. 3) More efficient healthcare practices and cost savings Unnecessary duplication of tests and medical procedures are prevented as information is shared across hospitals, reducing time wasted and patient expenditure. For example, the aforementioned Sentara Hospital saw a five per cent reduction in inpatient lab tests as duplicate orders were eliminated. EHRs also reduce administrative tasks that represent a significant percentage of healthcare costs. Asian countries recognise the benefits of implementing the EHR and are catching on to the trend. Countries are also realising that technologies like barcodes are the first layer to helping healthcare organisations connect with patients through the EHR.

Barcode technologies enable EHRs 2

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Barcode technologies provide patients, assets and healthcare practitioners with a virtual voice by turning physical elements into digital ones, acting as prime enablers of the EHR. They are a highly accurate, convenient, and quick method of data entry. For example, a nurse may scan a barcode from a master sheet for any services or actions performed, thereby electronically entering the action into the EHR. Zebra Technologies lay the first layer in EHR with Automatic Identification and Data Capture (AIDC) technologies, particularly barcode technologies. Systems developed for the EHR are enabled by barcode technologies. Zebra’s barcode labels give healthcare practitioners the right information to provide every aspect of their treatment from administering medication, transfusing blood to carrying out surgical procedures. For example, referring to the Closed Loop Medication Administration diagramme4 below, with barcode technology, nurses can check the patient’s idenwww.expresshealthcare.in

tity and verify medication with a simple scan of the patient wristband at the bedside. This practice ensures the medication about to be administered at the point of care aligns with the care plan prescribed by the doctor through the Computerized Physician Order Entry (CPOE). Brigham and Women’s Hospital, a teaching affiliate of Harvard Medical School, reported that medication errors were reduced by 41 per cent after they implemented a barcoding system in their hospital. In 2004/5 alone, the UK's National Health Service (NHS) faced over £400 million worth of clinical negligence claims— one of the key causes being patient misidentification that can be reduced or even eliminated through implementing the EHR. A core component of the implementation is barcodes that help clinicians identify the patient by simply scanning unique patient barcode labels.

Governments will continue to implement EHR Convinced of the benefits that EHR provide, governments will continue to implement EHRs. Singapore is a prime example of a nation quickly moving towards quality healthcare through EHR. Bar codes technologies are key to enabling EHR and Zebra Technologies is primed to meet the increasing demand across Asia.

References 1.http://www.siliconindia.com/showne ws/EHR_Can_India_and_its_IT_deliver_it_for_the_best-nid-74738-cid-2.html 2.http://www.healthit.gov/providers-professionals/improved-diagnostics-patientoutcomes 3.http://www.himssanalyticsasia.org/e mradoptionmodel-stage7hospitalscasestudySentara.asp 4.A Frost & Sullivan Whitepaper (The Real Action Is Still At The Bedside) by Jesse Sullivan and Greg Caressi MAY 2013

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www.thevest.com www.hill-rom.com References: 1. Smith MC, Ellis ER. Is retained mucus a risk factor for the development of postoperative atelectasis and pneumonia? – Implications for the physiotherapist. Physiother Theor Prac 2000;16:69-80. 2. Arens R, Gozal D, Omlin K, Vega J, Boyd K, Keens T, Woo M. Comparison of high frequency chest compression and conventional chest physiotherapy in hospitalized patients with cystic fibrosis. Am J Respir Crit Care Med 1994; 150: 1154-1157.

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Hospital Infra MAIN STORY

Global Hospital-Mumbai: The unveiling The 17-storeyed Global Hospital, Mumbai is finally close to being fully operational. Dr R V Karanjekar, Executive Director, Medical Services & CEO shares some learnings and future plans with Viveka Roychowdhury

OPD

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lobal Hospital's Mumbai facility opened its doors to its first patients in October last year and will be fully operational this October. But its impressive 17-storeyed glass facade is a testimony to the fact that the best laid plans can go off track. And how perseverance and experience finally pays off. Dr RV Karanjekar ED-Medical Services & CEO, Global Hospital, Mumbai was (and remains) the man in the hot seat. In a career spanning more than three decades, he has been on the clinical side as well as hospital administration, in both private hospital like Fortis, Lilavati Hospital, as well as civic hospitals like Tata Memorial Hospital-Mumbai, before he joined the Global Hospitals Group around three and half years back. In line with the positioning of the Group, the Mumbai facility too is a high end super speciality tertiary care facility. The Group's special focus is multi-organ transplant surgeries which is the expertise area of Dr K Ravindranath, Chairman & MD, Global Hospitals Group. As Dr Karanjekar points out, Mumbai clearly lacked such a facility in 2007, when the Group did a feasibility study and first broke ground at the site in Lower Parel. This was underlined when Maharashtra's former Chief Minister and Union Minister, Vilas Rao Deshmukh had to be flown to Global Hospital, Chennai for his liver transplant last year. Since its inception in 1998, the Group has positioned itself as a leader in performing liver, heart, lung, kidney and heart-lung transplantation, as well as bone marrow transplantation. The Mumbai centre aims to continue this tradition, as a high end super-speciality centre of excellence in digestive, liver, kidney, urological diseases, organ transplants, cardiology and orthopaedics as well as related oncology offering comprehensive, end-to-end therapeutic, surgical and diagnostic services, all under one roof. Dr Karanjekar points out that while there may be many other high end tertiary care facilities in Mumbai, they aim to differentiate themselves by being “super specialists in sub speciality areas”. This is based on their gap analysis of Mumbai as a healthcare destination where they zeroed in on certain treatment lacunae in the city. This is the path to growth, says Dr Karanjekar, as without these sub specialities, diseases may go undiagnosed and under-treated. For instance, the Baldota Institute of Digestive Sciences inaugurated at the Mumbai facility last October offers advanced gastroenterology and GI endoscopy under Dr Amit Maydeo. Similarly, Mumbai also got its first adrenal disorders clinic on January 31 this year, with a multidisciplinary team of endocrinologists, cardiologists, radiologists, pathologists, nephrologists and urologists – all under one roof at Global Hospitals. A

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vascular clinic and diabetic foot clinic are also on the cards, according to Dr Karanjekar. Global Hospital, Mumbai has already conducted some of the most complex cases like India’s first incision-free surgery, called Per Oral Endoscopic Myotomy (POEM), performed by Dr Maydeo. This procedure treats achalasia, a distressing disorder which causes severe difficulty in swallowing, reflux, chest pain and eventually oesophageal cancer. This innovative surgery was performed through the mouth with no external cuts. So also Dr Prashant Rao, Director of Gastro Intestinal & Minimal Access Surgery, Global Hospital performed the State’s first Whipple’s procedure also known as Whipple’s Surgery, which is a very complex abdominal operation done with an extensive resection followed by extensive reconstruction involving four to five organs and three to four anastomoses. A Whipple’s procedure is also called pancreaticoduodenectomy and is done for duodenal/ampullary/lower end bile duct (jointly called periampullary) and head pancreas malignancy. Dr Rao performed this complex surgery laparascopically through five small incisions instead of a single large incision. Compared to classic procedures, laparoscopic procedures may result in less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. At the other end of the spectrum, the Group will also promote prevention. Dr Karanjekar says the Group's philosophy is to promote a culture for health management rather than disease management. The Mumbai facility has already started implementing this by signing up some corporates in their locality and educating the staff on healthy lifestyle choices, organising free general health screening camps, etc.

The core team The Mumbai facility seemed to have everything going for it when construction started in mid 2007. The promoter-doctor team, besides the Chairman of the Group, comprises globally trained and reputed super specialists like Dr Amit Maydeo (a specialist in gastroenterology – medical with many first-in-India procedures to his name), Dr Prashant Rao (Chief of the Centre of Excellence for Minimal Access and Bariatric Surgery), Dr Bharat Shah (a nephrologist who heads Global Hospital's Institute of Renal Sciences and Transplant), and Dr Pradeep Rao who heads the Department of Urology. Dr Sushil Shah and Ameera Shah (of the Metropolis Group) as well as Harsh Mariwala, Founder of the Marico Group are also co-promoters of the Mumbai facility. Lobby

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By October this year, all 17 floors of Global Hospital's Mumbai facility should be fully operational Dr R V Karanjekar EXECUTIVE DIRECTOR, MEDICAL SERVICES & CEO GLOBAL HOSPITALS - MUMBAI

The core team came as board as full-timers and collectively own 30 per cent equity stakes in the facility with Dr Ravindranath, on behalf of the Global Hospital Group, holding the rest. The trend of promoter-doctors investing in and having stakes in such facilities is catching on in India and serves to assure patients of a continuum of care at the same facility. For the hospital management, this arrangement provides a certain amount of stability as these key super specialists cannot be poached away by rival hospitals. This allows the hospital to standardise treatment protocols which results in better health outcomes as well. From a footfall point of view, these super specialists moved their practices and patients to Global Hospital,Mumbai. And thus, patient footfalls were assured from day one.

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Location wise too, the hospital is at a prime location. Centrally located in Lower Parel, Global Hospital-

Mumbai is less than a kilometre away from older medical facilities like Mumbai's pioneer municipal hospital, the almost century old KEM Hospital, Tata Memorial Hospital that specialises in treatment of cancer, Wadia Hospitals, (one each for children and women), and MGM (an ESI hospital). With Mumbai's long defunct cotton mills of Lower Parel making way for luxury hotels like ITC Hotel-The Grand Central as well as high end malls like High Street Phoenix, the area is considered prime real estate. Global Hospital, Mumbai, with a

planned built-up area of over 2,67,000 sq ft spread over 17 floors, is tucked away down the tree-shaded Dr E Borges Road, within walking distance from the ITC Grand Maratha. Thus it is conveniently located for the premium medical trave l l e r segment as well. The prime site is on a 99year lease from Ajai Verma, a philanthropist who set up a trust to allocate prime real estate for the construction of a hospital. This is in line with his vision to provide Mumbai's citizens with better healthcare facilities. Verma is carrying forward the vision of his father, the late Mangaldas Verma who founded the Maharshi Dayanand College, also in Parel, with a similar objective with education as well as other similar projects. The facility was planned to accommodate around 425 beds. 150 wards plus 50 ICU beds were to be commissioned by end-2010, in the first phase, at an initial budget of Rs 175 crores. But a delay of 25-30 months, meant that Phase one was finally completed in April this year, with 210 beds (of which 85 are ICU beds) and 10 floors commissioned. Initially the cost of the first phase was estimated to be Rs 175 crores but this ballooned to Rs 240 crores due to the delays and design changes. However, the bulk of the capital expenditure seems to be behind the Mumbai facility, as this represents almost 85 per cent of the facility. Dr Karanjekar says most of the heavy capex facilities like the radiology and pathology labs, operation theatres and all ICU beds are already in place. According to Dr Karanjekar, work is on in full swing to get the remaining floors functional, at an estimated Rs 2.5 crores per floor and Rs 60-70 lakhs per bed. By October this year, all 17 floors of Global Hospital's Mumbai facility should be fully operational. He estimates a total investment of Rs 260-265 crores and predicts that they will reach cash break even within six-eight months, and financial break-even in a minimum of two years.

In hindsight Dr Karanjekar breaks down the 25-30 month delay into phases. The initial delay of four-five months was due to the sudden and temporary non-availability of sand, a vital ingredient in the construction process. This in turn led to the management and architects re-thinking the hospital's blueprints. In an attempt to reduce the amount www.expresshealthcare.in

of wall space to be constructed, the revised blueprint incorporated a fair amount of glass, but this meant a complete recalibration of measurements and further slowed down the construction process. As the management was eager to start treating patients in the first 10 floors, they applied for a partial Occupation Certificate (OC) with the usual labyrinth of paper work adding a further two-three months time lag to the process. The fourth cause of delay was the lack of construction manpower. Dr Karanjekar narrates the frustration of putting in place all the equipment and material, only to realise that all migrant labour disappear from cities for six months, from May to the end of the monsoons, when they moonlight as farm labour in India's hinterland.

Tips to peers None of these obstacles are permanent hindrances; in fact, in the long run, they will most likely go down as merely a small bump on the facility's march towards many more medical milestones. But they hold some vital learnings and Dr Karanjekar shared a few tips for hospital managements planning greenfield facilities. Firstly, he strongly advises them to have on board all the heads of the key speciality areas from the blueprint stage. The specialists should be encouraged to participate in the planning and design of the hospital and specifically their domain areas as they know best the congestion points, etc. Breaking down and reconstructing after the hospital is commissioned adds to the cost and is not desirable from the quality and patient safety perspective as well, he points out. Secondly, his maxim is to choose utility rather than aesthetics. â&#x20AC;&#x153;Don't go fancy unless you have the money in place or delays are guaranteed,â&#x20AC;? he says harking back to the decision to add the glass facade. A smaller hospital chain would have had the additional burden of financing the increased

Twin sharing room costs as well, which thankfully was not a constraint for the Global Hospitals Group. Thirdly, he advises that managements should commission the hospital in stages, as each phase is completed after getting partial OCs from the civic authorities. This is crucial especially for smaller groups as having a revenue stream open up will ease the pressure and reassure financiers that they've made a good investment. And his fourth suggestion is about putting in place the 'soft' infrastructure. He advices that hospital managements should hire directly rather than go to recruitment agencies. Discovering the right medical manpower will not be a problem in metros, but will be a constraint in smaller locations. Smaller hospital groups may also be hampered by the lack of personal contacts with reputed senior medical talent or the fact that their brands may not be strong enough to attract and retain key medical staff. His final piece of advice is to plan ahead, harking back to an oft repeated yet very apt phrase: If you fail to plan, you are planning to fail.

Fast forward Work on the remaining floors at Global Hospital's Mumbai site seems to be in fast forward mode, even as the lobby sees a steady stream of patients and their families. No doubt the management will meet its deadline to be fully functional by October this year. Today when Dr Karanjekar and his colleagues view the imposing glass facade already accepted as a part of the Lower Parel skyline, they have clearly put aside the frustration of the past months. Instead, there is a quiet pride that they will be part of a legacy that will serve Mumbai, nay the world, well in the decades to come. viveka.r@expressindia.com EXPRESS HEALTHCARE

BOOK REVIEW

Unlocking the secret ‘Communicate. Care. Cure. A Guide to Healthcare Communication’, aims unlock the key to good communication with a view to improve healthcare delivery and benefit the most important stakeholder – the patient. Lakshmipriya Nair reviews the book to find how far it has been successful in its objective t is a long established fact that communication is a key factor to the success of any venture. Yet, it is often overlooked, even in healthcare set ups where it has an extremely vital role to play. ‘Communicate. Care. Cure. A Guide to Healthcare Communication’, a book put together by the teams at Bangalore Baptist Hospital and Mudra Institute of Communications in Ahmedabad, seeks to highlight this fact and give insights on the role of communication in effective healthcare. The book begins with a foreword from the eminent cardiac surgeon and healthcare entrepreneur, Dr Devi Shetty. He says, “This book...is like a Google map for a society that has lost direction”. Thus, it raises high hopes with such a glorious recommendation, lures you to read it and...keeps you hooked! The title of the book itself is an indication of this fact and gives the readers a clear idea about its content and objectives. The book has 10 chapters dealing with crucial issues in effective communication, wherein each chapter is dealt by a different author/s. Written in simple, lucid language which can be easily understood and assimilated by its readers, the book, a guide in effective communication, has managed to hit the right note and communicate exactly what it wants to convey. The topics covered in each chapter are also very pertinent and comprises issues that arise in day-to-day dealings between the various stakeholders in a hospital i.e. the patients, their families, doctors, nurses, technicians, healthcare administrators and support staff. Dr Alexander Thomas and Elizabeth Rajan, the authors of the first chapter, ‘First Impressions Matter: Creating Memorable Experiences for Patients’, very succinctly brings to light how essential it is to create a favourable first impression for patients coming to the hospital in order to ensure to create trust in their minds and retain them. They also list down six guidelines for the hospital staff to promote and propagate the right idea about the hospital and its services. The next two chapters, ‘Verbal Communication Styles: The Role of Assertiveness in Healthcare Communication’ and ‘Actions Speak Louder than Words: Nonverbal Communication:’ by Dr V Kingsley R Gnanadurai are all about being a good communicator through words and action. The author gives various examples of good and bad verbal communication, with suggestions on the right way to use your words to give the right effect and impact. He also gives an insight on good nonverbal communication through eye contact, body language, tone and volume of voice and even

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silence. The fourth chapter, ‘Listening with Undivided Attention: An Effective Prescription for Healing’, authored by Dr Ajay Shetty concentrates on listening with all your senses to distinguish and make the difference between curing and healing. The fifth chapter by Mercy Christudas, Gory Dennis and Dr Gnanadurai, is all about removing the barriers hindering effective communication in healthcare and hence is aptly titled as ‘Bridging the Gap: Removing Communication Barriers in Hospital Settings’. The sixth and the seventh chapters, titled ‘Tread with Care: Breaking Bad News to Patients, Their Family and Relatives’, and ‘Sorry Works: The Disclosure of Medical Errors’ are penned by Dr Rajnish Samal and Dr Ajay Shetty respectively, and deal with the challenges of disclosing bad news and the effective means to deal with them as well as owning up to the mistakes that have happened and going about the right way to rectify them to lessen the negative impact. While the other chapters teach about things to do to communicate well, chapter eight, authored by Dr Badari Datta, is all about what not to do. Hence it is aptly named as ‘Knowing Where to Draw the Line: What Constitutes Unacceptable Communication’. Chapter nine is called ‘In the Spirit of Please and Thank You: Courtesy and Etiquette’, wherein authors Dr Narendra S and Dr Ajay Shetty teach the value of courtesy and etiquette as well as its role in healthcare settings. The last chapter, by Sunny Kuruvilla, is on addressing the challenges in a hospital’s intra-communication and hence is called as ‘Hospital Talk: How Communication Flows in Healthcare Organisations’. The prologue and epilogue, written by Dr Nagesh Rao, connects each chapter and binds them together to give a very good flow to the book. Apart from simple, easy to understand and unambiguous language and content, the book is also filled with various illustrations of real life scenarios, conversations and graphs that the readers can easily identify with and understand and hence they effectively assist in conveying the right information and message. Another noteworthy factor is that the book is written for healthcare professionals by healthcare professionals – different members of Bangalore Baptist Hospital, including their Director, doctors, nurses, a pharmacist and a chief administrative officer was involved in its creation and it is filled with their own experiences and learning. The editing of the book also deserves a menwww.expresshealthcare.in

Title: Communicate. Care. Cure. A Guide to Healthcare Communication Author: Dr Alexander Thomas, MS (Orthopaedics) M.Phil, PGDMLE; Dr Nagesh Rao, PhD, President & Director, Mudra Institute of Communication, Ahmedabad; Dr Ajay Shridhara Shetty, DNB (General Surgery), DNB (Urology); Dr Badari Datta H.C MS (ENT), DNB, MRCS (Edinburgh) DOHNS (London); Elizabeth Rajan, BPT, NHSM; Glory Dennis, RNRM, Pc BSc (N); Dr V. Kingsley R. Gnanadurai, MD (International Medicine), MBA (Hospital Administration) PGDMLE; Mercy Christudas, RNRN, DNEA, Pc BSc (N); Narendra S, B Pharm, MSc (Psychology); Dr Rajnish Samal, MD (Obstetrics & Gynaecology), Sunny Kuruvilla, MPA, MBA (TQM), M Phil (HHSM) Edited by: Dr Alexander Thomas & Dr Nagesh Rao Publisher: Bangalore Baptist Hospital, Hebbal, Bangalore Pages: 152 ISBN: 978-93-5104-107-8 Price: ` 320/-

tion, especially since it had multiple authors and yet good and effective editing by Dr Alexander Thomas and Dr Nagesh Rao has ensured consistency and uniformity of content without detracting from the authors’ individual styles. Thus, the book is an excellent example of good teamwork and communication and it would be apt to reiterate Dr Devi Shetty’s words, “This book, on how to improve communication to improve healthcare, will, without doubt, help achieve that goal.” It would indeed serve as a very efficient guide for a wide range of readers – healthcare providers, administrators, policy makers, medical students, teachers, etc to improve their communication for the best interests of those they all aim to serve – the patients. lakshmipriya.nair@expressindia.com MAY2013

L|I|F|E

People Dr Vivek Nangia, Fortis Vasant Kunj felicitated by Her Royal Highness the Princess Royal The felicitation was on the successful completion of Masters in Sciences in Infectious Diseases from the prestigious London School of Hygiene and Tropical Medicine

r Vivek Nangia, Director Pulmonology and Infectious Diseases at Fortis Flt. Lt. Rajan Dhall Hospital was commended in a ceremony by Princess Anne, Her Royal Highness, Princess Royal on the successful completion of Masters in Sciences in

Infectious Diseases from the prestigious London School of Hygiene and Tropical Medicine (LSHTM) through the Royal University of London.The ceremony was attended by more than 3000 delegates from around 180 countries. Dr Nangia was one of five physi-

cians from across the globe and the only one from India to be felicitated by Her Royal Highness Princess Royal on successfully completing the prestigious programme. According to Dr Nangia, "In order to cope with the growing challenge of infectious dis-

eases in India, a formal, wellstructured training programme in this super speciality is the need of the hour. The absence of qualified Infectious Diseases specialists in most multi-speciality tertiary care centres is a very grave situation.”

Jayanth Bhuvaraghan takes charge as Chief Corporate Mission Officer at Essilor He would expected to coordinate and accelerate CSR initiatives by Essilor to fight poor vision

ssilor International has created a Chief Corporate Mission Officer position within the Executive Committee of the company. Jayanth Bhuvaraghan, President of South-East Asia and India, is entrusted with the new position as of April 1, 2013. The creation of this new position is with an aim to

develop a global Corporate Social Responsibility approach directly related to the company’s long-term strategy. Many initiatives to improve awareness and access to vision correction have already been launched by Essilor teams to fight poor vision, one of the most widespread disabilities in the world.

He would be reporting to the Chairman and CEO, and is expected to coordinate and accelerate such initiatives, help create awareness by working closely with various global organisations that are already acting in this area and create new inclusive business models to address the needs of all hence bridging the gap of

uncorrected visual impairment. Bhuvaraghan is a seasoned executive in Essilor with diverse experience in various markets like India, Asean, Middle East and Africa. He is also credited with developing various innovative and successful social business models like providing access to vision cor-

rection for remote populations. Jayanth Bhuvaraghan, taking up the challenge, added, "I am greatly excited to take on this new position. Providing better vision to everyone who needs it, is Essilor’s central driving force. I will endeavour to help bring about improved answers to unmet needs throughout the world.”

Kartar Lalvani conferred with the Healthcare Businessman of the Year Award 2013 He received the honour from UK's Home Secretary Theresa May at the ceremony

artar Lalvani, the Founder-Chairman of Vitabiotics, UK's supplier of minerals and vitamin supplements to the retail trade, has been awarded as the Healthcare Business of the Year at the Asian Business Awards ceremony.

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The Asian Business Awards, commended Lalvani, a chemist by training, for "creating Vitabiotics in the 1970s and overseeing the company's remarkable growth to become the UK's largest supplier of minerals and vitamin supplements to the retail trade."

"The company is at the forefront of scientific developments in key sectors, including nutrition and women's health, and exports to over 100 countries," it added. Amit Bhatia, Chief of the Swordfish Group of companies and son-in-law of steel

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tycoon Lakshmi Mittal, was declared the Young Entrepreneur of the Year 2013. The Lifetime Achievement Award 2013 went to Indianorigin entrepreneur Sudhir Choudhrie. In a message, British

Prime Minister David Cameron hailed the work done by Asian businessmen in the UK, adding that the awards "will be an opportunity to celebrate the enormous contribution that the Asian community makes to the UK economy."

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Trade & Trends Inbody: An intelligent device from Biospace Biospace’s body composition analyser, InBody, has several advantageous features which are making it a globally successful and well accepted product

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ith the continuing increase in standard of living, the focus on quality of life has am-plified in recent times. In particular, obesity is a health issue featured in the mass media that has been warranting more attention than ever before. More and more people are coming to realise that obesity is at the root of all habitual illnesses, and because of this correlation interest in obesity treatment is on the rise. Biospace's body composition analyser, InBody stands at the centre of this anti-obesity movement. With ‘InBody’ which is operated by an exclusive technology, Biospace is a total-healthcare enterprise that ranks first in Korean body composition analyser market and second in body composition analyser market for experts. Up until recently, most people believed that obesity could be precluded by simply losing a certain number of kilograms in body weight. However, with the development of the InBody, Biospace has made the terms, "body composition" and "body fat," popular and has spread the knowledge that the prevention of obesity hinges on the reduction and control of body fat. As a main product of Biospace, InBody analyses body composition by measuring bio impedance that is created when passing minute currents in human body. InBody measures muscle mass, body fat mass, total body water, protein and mineral with a basic principle that currents tend to go through muscles well and not fat (due to the different amount of body water). Biospace's trailblazing activities in this area are evi-dent in the label of "InBody test", a commonly given body composition analysis that has recently increased in popularity. Body composition analyz-

ers have existed for many years, but Biospace developed ‘Direct Segmental Measuring Method’, reportedly first in the world, improving accuracy and reproducibility. InBody is the world's first body composition analysis device that uses the 8-point tactile electrode method. Having received FDA approval in the United States and approval of other countries' authorities, such as in Japan, this product's high quality and accuracy has been validated. With the unparalleled performance of the InBody in the domestic obesity diagnosis www.expresshealthcare.in

market Biospace has solidified its foundation as a professional medical device manu-facturer. With its accuracy, high reproducibility rate and fast simple measurement method, InBody is being used to measure basic health conditions in over 20,000 hospitals and sports centres in Korea. The plan for the future entails the company's ongoing development and expansion into a comprehensive professional healthcare organisation. After the success in Korea, InBody is developing fast in the world market with a global network including local

subsidiaries in Japan, US, China and 40 agencies all around the world. In particular, the company is striving to achieve superior competitiveness that will facilitate success in advanced markets around the world, such as those in the United States, Japan, and Europe. Biospace is not only continuously investing in body composition analysing research, but also developing extra services such as providing a nutrition and exercise guide software ‘Lookin’Body’, a health enhancement system ‘u-town’ and others. MAY2013

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Indigenous innovation from Kaustubh Enterprises K Kaustubh Enterprises’ ETO sterilisers and cartridges serve various segments of healthcare and are acclaimed and accepted by many leading surgeons and scientists’ world over

austubh Enterprises have been pioneers in the production of ethylene oxide sterilisers and pure (100 per cent) ETO cartridges. Their products, marketed under the brand name Rujikon (registered trademark), have been widely approved and acclaimed by a wide spectrum on clientele ranging from the academic and research fields to industrial and healthcare segments, both in India and abroad. Their motto is "Excellence is not a skill, it is an attitude." The firm has been instrumental in the development and manufacture of ethylene oxide sterilisers (steriliser) and ETO cartridges. The ETO sterilisers are available in the following modes:● Manual ● Semi-automatic ● Fully automatic They meet the requirements of all private surgeons i.e. general, eye, orthopaedic, cosmetic, neuro, cardiovascular, all small nursing homes, medium and big hospitals, medical institutions and the entire health care sector. They cater to all size hospitals, cath labs, medical institutions, eye specialists, ortho specialists, general surgery centers, gynaec care units, cardio thoracic surgeons, interventional cardiologists, plastic/cosmetic surgeons, neuro surgeons, research centers, speciality laboratories, private surgeons’ nursing homes and day care centers.

The beginning Kaustubh Enterprises was the brainchild of their mentor MV Bhagwat. He started the organisation in 1980. Having been associated with many prestigious R&D institutions known worldwide for more than 42 years, he handled numerous R&D projects and developed wide range of appliances and equipments for the PhD students of pure and applied sciences faculties. Later he went on to become the first person in India to develop and subsequently manufacture the ‘ETO steriliser’. MAY2013

The present day

Today the organisation is headed by their CEO, Kaustubh Bhagwat, the son of MV Bhagwat. He has a Masters Degree in pure sciences. He joined the organisation in 1986 and took over the upgradation and marketing of ETO sterilisers. Moving ahead in the footsteps of his father, Kaustubh Bhagwat developed the 100 per cent ethylene oxide cartridges, on his own. This cartridge is used in ETO sterilisers. He also developed the ‘unique cartridge puncturing device’ whereby the cartridges can be punctured in vacuum conditions inside the ETO steriliser. The invention/developments made by Bhagwat and his son are acclaimed and accepted by many leading surgeons and scientists world over. Kaustubh Enterprises’ product offerings include: ● Manual model “KB Series” ● Semi automatic model with inbuilt aerator ‘KANC Series’ ● Semi automatic model with inbuilt aerator ‘KANC Series’, especially for cath labs ● Fully automatic model with inbuilt printer and aerator ‘KA – 2 Series’ ● fully automatic model “KA – 2 Series” for cath lab ● Rujikon 100 per cent (Pure) ETO cartridges ● They also supply the following accessories: ● Sealing machine ● Indicators ● Packing material (Paper and Plastic) ● Sterican (100 per cent pure ETO cartridges) as a start up kit.

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tem whereby the cartridges can be punctured inside the chamber under vacuum conditions, thereby eliminating risk posed by pure ethylene oxide. They also offer a very unique dual operation model whereby the user has the flexibility to either use refillable cylinders or disposable cartridges. Available chamber capacities are from 1.5 cu.ft. to 8.0 cu.ft. The first company in India to have introduced a genuinely semi- automatic model, with almost fully automated functions, having chamber depth of 54” (137 cm), can conveniently accommodate up to 130 cm long cardiac catheters without bending or coiling thereby leading to its enhanced life has become extremely popular with the cath lab fraternity. The company manufactures “semi automatic” Rujikon ETO steriliser with inbuilt aeration facility which does not require external compressed air making the working noiseless and hassle free The company also manufactures ‘fully automatic’ Rujikon ETO sterilisers with inbuilt printer and inbuilt aeration facility unit that are extremely easy to use and maintain.

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For the first time in India, Kaustubh Enterprises introduced the fully indigenous ethylene oxide gas steriliser Since then nearly 1000 such sterilisers have been manufactured and supplied by the company and are working successfully at various hospitals, medical institutions in India and abroad. Developed a world class cartridge puncturing syswww.expresshealthcare.in

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We have been the proud recipients of the prestigious● ●

G. S, PARKHE INDUSTRIAL MERIT PRIZE in 1981 DAHANUKAR ENTREPRENUER AWARD in 1982

Our notable clientsAchievements

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CATH LABS - In India & Abroad. Private / Govt. Hospitals, Medical Institutions all across India & abroad. IIT’s all over India. National centre for Biological Sciences (TIFR). Bangalore. Large number of Eye Surgeons.

Why us? ●

ETO Sterilisers in various

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sizes and with different combinations ie. Manual model, Semi–Automatic ETO sterilizer with Aerator, Fully Automatic with inbuilt printer & Aerator available. All types and sizes of Ethylene Oxide Sterilizers available to suit your budget. First fully indigenous Ethylene Oxide Sterilizer was developed by us way back in 1980 acclaimed for its TIME TESTED performance. World Class ETO CARTRIDGE PUNCTURING SYSTEM, Our USP – ETO Cartridge is punctured inside the chamber in vacuum conditions in all our models. We understand the need of various research & health care institutions and have designed units which are safe and simple to operate. Requires Less Foot Print, Stand provided to mount the unit. Operates on Single Phase, 230 Volts AC. Quality of products is tested using special purpose machines. Participated in numerous national level trade fairs/ expositions and Medical conferences of eye surgeons, interventional cardiology, general surgeons, orthopedic etc. Extremely good and assured technical backup. The same team is at your service for continuous 32 years .

Contact Kaustubh Enterprises, Rujikon Contact Person: Mr. Kaustubh Bhagwat Address: A/6, Nutan Vaishali, Bhagat Lane, Matunga (WR) Mumbai – 400 016, Maharashtra (India) Mobile:+(91)-9820422783 Phone:+(91)-(22)-24309190 Fax:+(91)-(22)-24375827 E-mail: rujikon@gmail.comkaustubh4307@gmail.com EXPRESS HEALTHCARE

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Ziqitza@Jaipur Forum of FICCI-FLO J

Intro: Sweta Mangal, CEO- Ziqitza Health Care and other women entrepreneurs were given a platform to showcase their success stories before other budding entrepreneurs at the Jaipur Forum of FICCI-FLO held recently

aipur Forum of FICCIFLO was Saturday, April 6, 2013. For the uninitiated, FLO is a division of the Federation of Indian Chambers of Commerce and industry (FICCI) which is the apex body of industry and commerce in India. The primary objective of FLO is to promote entrepreneurship and professional excellence in women. On this day women entrepreneurs from across the

nation came together to hear the success stories of those achievers who stood up for everything they believed in. They shared their experiences as to what makes them tick and how each and every woman can bring the change they want to see in the society. Sweta Mangal, CEOZiqitza Health Care, a leading emergency service provider across the country, was also amongst the esteemed guest speakers for this event. Here,

she not only recalled what triggered her to set out on this journey to provide emergency medical aid across the nation but also the triumphs, the hurdles, the joy, the sorrow, the challenges and those defining moments that make Ziqitza Health Care what it is today. She also got an opportunity to interact with budding women entrepreneurs and while sharing her experience with them, also got a lot to learn from them. The

place was abuzz with enthusiasm around the exciting times that lie ahead for us as a country. Contact: Ruchika Beri Assistant Manager – Marketing Ziqitza Health Care Limited Sunshine Towers 23rd Floor, Ambedkar Road Elphinstone Road (W)Mumbai- 400013, India. Website: www.zhl.org.in

The Vest: Useful tool for effective CPT in ICU Dr Prasad Rajhans, Director ICU, Deenanath Mangeshkar Hospital, Pune elaborates on the The Vest, a high frequency chest wall oscillation system from Hill Rom and informs how it serves as a great and effective alternative to traditional methods of airway clearance in patients with respiratory problems

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ll tertiary care intensive care units have large number of patients with respiratory problems, either primary or secondary. Chest physiotherapy (CPT) plays a vital role in the management of these patients. However, CPT in ICU patients is challenging. For patients with altered sensorium and receiving mechanical ventilation, the respiratory therapist (RRT) face challenges in delivering an effective CPT. Postural drainage of secretions may not be possible in all ICU patients. The Vest, from Hill-Rom, is useful in these kinds of patients where effective chest physiotherapy cannot be given by routine manual methods. The Vest delivers high frequency chest wall oscillation (HFCWO) therapy. It consists of an inflatable jacket/wrap (garment) which is connected to an air pulse generator through tubes. This air generator causes rapid inflation and deflation of the garment, compressing and releasing the

chest wall. This action creates an oscillating airflow (we call them ‘mini coughs’). These mini coughs help to dislodge the secretions from the bronchial walls and also help in moving the secretion from www.expresshealthcare.in

the peripheral airways to the central airway. The Vest provides a safe and effective alternative to the traditional methods of airway clearance. It is a caregiver independent form of CPT. We,

at Deenanath Mangeshkar Hospital, has been using The Vest in our ICU for almost a year. The Vest can be used on patients with bronchectasis, cystic fibrosis, neuromuscular disorders and several other conditions requiring airway clearance. It is effective in inpatient, outpatient as well as homecare settings. MAY2013

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EXER-KING The Total Power An exclusive exercising chair for cardiac rehabilitation, physiotherapy and occupational therapy from Fluid Tech Fitness

he technical knowledge of how the body works has increased dramatically in the past decade. FLUIDTECH FITNESS’s hydraulic fitness equipment is the first break through in what some chiropractors think will be the ideal conditioning equipment of the new century. FLUID-TECH FITNESS’s Hydraulic Multigym - EXER-KING The Total Power, 6 in 1 multi exerciser is here, which is an ideal, most compact and safest multigym. A complete body workout from legs to abs to shoulders is what you get while working out on EXER-KING, that too in just 15 - 20 minutes. This piece of fitness equipment operates on the revolutionary hydraulic system, which means it is selfadjusting to the user’s strength and no weights, no pulleys, no electricity and no instructor required. EXER-KING The Total

Power based on hydraulic principle is having six independent resistance level settings and display panel with six eye level read out gauges, which is unique in the world. The space occupied by EXERKING The Total Power is only 3 feet x 5 feet. One can perform Shoulder Press, Lat Pull, Chest Press, Seated Row, Leg extension, Leg curl, Abdominal Back, Abdominal toner, Dip Shrug and many more, in a single machine without getting up and covering different body muscles and joints of the complete body. There are six numbers read out gauges for indication of resistance for all six different independent movements. This provides instantaneous feedback, so that the user/patient can see immediately the force they are generating throughout the full range of motion. Eye-level read out gauges allow the

user to see precisely how much force is being exerted. In other words, as the user's strength increases, his capacity also increases and the same is displayed on the gauges. There are six control knobs provided on the left side of the seat for six independent movements and the resistance can be varied. Resistance depends on the knob setting and the speed at which you push / pull. Higher the speed at which the force is applied, higher the resistance will be and lower the speed at which the force applied, lower will be the resistance. In no case it can over strain the muscle groups. The secret is the self-adjusting hydraulic cylinders, which keeps on adjusting automatically and continuously to the strength, power, speed output and

Just 3 x 5 feet space is what you need

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Gauges for indication of resistance

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the need of the person using it. Gauges for indication of resistance

Why EXER-KING . . . . Equipment is based on the technologically advanced hydraulic principle. There is no weight stack in our equipm e n t . Because of self-adjusti n g hydraulic cylinders the resistance keeps on adjusting automatically and continuously to the strength, power, speed output and the need of the person using it or with the capacity of the user. ●EXER-KING is most Compact and designed for safety, simplicity, and effectiveness. To increase resistance, you simply push or pull harder. The

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result is an effective strength training method that reduces soreness, and eliminates the potential for injury. EXER-KING gives maximum conditioning with full range of motion in minimum space and time. You get a combined cardio-vascular, resistance training, strength building, flexibility and endurance in one workout session of maximum 15 - 20 minutes. The resistance of the machine is set by how hard the user pushes and pulls, each participant can work at his/her own level. No preset start position. A person can start his workout from any position and can leave even mid-way very safely while workout, without any fear of accidents/injury. Machines adjusts automatically to any level of fitness The doctors/physiotherapist need not to check the capacity of a person, as the same will be indicated on the gauges provided on the machine, i.e. on EXER-KING – The Total Power at the very first use by the patient. Progress of the patient can be monitored and can see how fast he recovers.

Six control knobs provided on the left side

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100 per cent safe - There are no cables to break, weight stacks to slam or dumbbells to fall so it is very safe to use and requires less maintenance. Can be used by a five year old child to an 85 year old person. The person utilises his maximum capacity each and every time he/she uses the machine. No instructor/supervisor is required while workout. Body soreness/body pain is not possible in this equipment as the user can never apply more force than this capacity even if he is doing his workout after a gap of 10 - 15 days. It adjusts to the capacity of the user immediately on the very first use and keeps on adjusting every time he uses the equipment. Effectiveness of the medicine/treatment given to the patient can be easily monitored. It doesn’t need any foundation/fixation and can be placed anywhere any time. You can even have granite flooring, thus keeping the gym hygienic. Suitable with any type of clothing without any fear of accidents or injuries. It is specifically designed for rehabilitation from injuries i.e. for muscle or bone injury and for paralytic patients. Regulates and improve overall body functions. It is portable and can be moved anywhere at any time. There is no sound while workout. No electricity required. Equipment is virtually maintenance free.

What few of the doctors say about EXER-KING “It is compact and occupies very little space. It is self-adjusting and user friendly and thereby saves the therapist time. It does not require much maintenance. It is beneficial in treating patients with early osteoarthritis and in post operative cases also” Dr Anuradha Daptardar (Tata Memorial Hospital, Mumbai, Head of Physiotherapy Department) “Find it very useful as it helps in flexing the muscles and mobilization of various joints. Constant use will definitely help in the body becoming more supple and light. I do recommend this equipment for the various organisations” Bhagavathi Krishna (Tata Memorial Hospital, Mumbai, Nursing Superintendent) “Has been regularly using the EXERKING for various patients having shoulder, upper back or knee problems” Dr. Ali Irani (Dr. Balabhai Nanavati Hospital, Mumbai, Head of Physiotherapy Department) Contact: Fluid-Tech Fitness, Mumbai, INDIA. Phone: +91-22-28478855 / 9321798899 Website; www.fluidtechfitness.com e-mail : sales@fluidtechfitness.com

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