MEDGATE TODAY Magazine by Medgate Today Magazine

RNI No. DELENG/2010/33833

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Volume II || Issue V || Jan-Feb, 2011

The Gateway to Health & Medical World

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LAPAROSCOPIC SURGERY

MODULAR

OPERATION THEATER

Jan - Feb 2012

Jan - Feb 2012

Editor speak

Volume-II

Issue-V

Jan-Feb 2012

Editor Dr. M.a Kamal

GlobalMedicalDevice Market Prospects

ver the period spanning 2011-2016, the world market for medical devices is forecast to grow at a CAGR of 5%, to eventually reach USD 350 billion. Factors like the every-rising demand for new and effective healthcare technologies coupled with healthcare systems being under constraint to contain escalating costs contribute to this market growth. China, Brazil and India are predicted to be the fastest growing regions among developing countries for the medical device industry. Stronger economic growth, government funding and reforms, changing consumer lifestyles, increasing penetration of medical insurance products, rise in disposable income in these regions are fueling growth. Indian medical equipment industry to grow at 17 percent CAGR over next five years The Indian healthcare market has been valued at Rs. 300,000 crores ($63 billion). Of this, healthcare delivery makes up 72 %, pharmaceutical industry 20 %, health insurance 5 %, medical equipment 1.4 %, medical consumables 1.1%, and medical IT 0.2 percent, respectively. Medical equipments has been valued at Rs. 3,850 crores ($820 million) of the overall Indian healthcare market of Rs. 300,000 crores. The Indian medical equipment market is estimated to grow at around 17 percent CAGR over the next five years and reach about Rs. 9,735 crores ($2.075 billion). In a report, the Indian healthcare industry currently contributes to 5.6 percent of GDP, which is estimated to increase to 8-8.5 percent in FY 13. The domestic market for medical equipment currently stands at Rs. 3,850 crores ($820 million). Annually, medical equipment worth Rs. 2,450 crores ($520 million) is manufactured in India, out of which Rs. 350 crore ($75 million) is exported. Growth of the medical equipment market is directly proportionate to growth of healthcare delivery, Top companies are leaders in the space with 55% share, respectively. However, 45% of the market is addressed by smaller, niche domestic players.

Have an insightful reading. Your suggestions are most welcome! e-Mail: editor@medgatetoday.com 4

Dr MA Kamal Editor-in-Cheif

Chief Editorial Adviser Dr. Pradeep Bhardwaj National Head Afzal Kamal Sr. Manager I.A Khurshid Cheif Correspondent SA Rizvi l Dr HN Sharma Design and Layout Vikas Sales and Marketing Amjad Kamal Rahul Ranjan Neetu Sinha S.Y Ahmed Khan Subscribtion & Cirrculation Pallavi Gupta All right Reserved by all everts are made to insure that the information published is correct, Medgate today holds no responsibility any unlikely errors that might occur.

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Jan - Feb 2012

Contents 36

Cover Story

News Update Schiller India ties up... 06 New research linking... 10 Feet neglected in RA...... 10

A PRACTICAL APPROACH TO SET-UP AN IVF LAB

Design & Implementation Aspects of Operation Theatre Management

New Vistas for Spectacle Removal

42 Modern Dentistry: Dental Implants

44 Feasibility of laparoscopy for small bowel obstruction 6

The Cabinet cleared... 14 KARL STORZ New ........ 16

Kawasaki Disease

30 Asthma in men and women, what is the difference

34 Six innovations that can evolutionize Indian Healthcare System

Preparing and ositioning for LAPAROSCOPIC Kawasaki Disease URGERY Jan - Feb 2012

Jan - Feb 2012

NEWS UPDATE

Schiller India ties up with NeuroLogica, U.S.A. for Radiology

umbai, 14th December, 2011: Schiller India, a leading Swiss Joint Venture Company in the field of Medical Diagnostics has tied up with NeuroLogica Corporation, U.S.A. which deals in medical imaging equipment. According to Sudip Bagchi, Associate Vice President, Radiology, “This tie-up with NeuroLogica Corporation, U.S.A. will enable us to offer cutting edge Computed Tomography imaging with innovative technologies of portability (battery back up) and patient safety. With plug-andplay models like CereTom® (8 slice Head CT), BodyTom™(32 slice whole body CT) and inSPiraHD™ SPECT (Molecular Imaging), we can now bring the power of imaging to the patients

wherever they may be.” Schiller is committed to providing state of the art medical diagnostic equipment and services, and NeuroLogica Corporation’s range of medical imaging equipment increases Schiller’s offerings. NeuroLogica Corporation develops, manufactures and markets medical imaging equipment for healthcare facilities and private practices worldwide. These scanners deliver effective, reliable and flexible CT imaging at the ER, OR, NICU or any location a scan is required. The CereTom® and the BodyTom™

are of course FDA cleared and ETL approved. About Schiller India Schiller India is committed provides medical diagnostic equipment and services that are primarily used in the Critical Care, Cardiology, Radiology, Surgery, Spirometry and Telemedicine fields. Schiller has offices in over 33 locations in the subcontinent including major metros like Mumbai, Delhi, Kolkata, Chennai, and Kathmandu in Nepal. Currently we have a strong network of over 90 sales and service dealers spread across India, Nepal, Bangladesh and Sri – Lanka. Schiller India is committed to offer enhanced levels of customer satisfaction. First level of service is available at all Schiller offices. Service centres are located at Bengaluru and Puducherry. n Jan - Feb 2012

Jan - Feb 2012

NEWS UPDATE

MEDICALL 2012 Gujarat : Taking Indian

Medical Technology to the next level

3rd to 5th February 2012 at Gujarat University Exhibition Hall, Ahmedabad, Gujarat

f one has to pick from a list of successful events which have created a stir within a short span, MEDICALL would turn out to be a winner. Not only is it India’s premier Medical Equipment Expo, but it has emerged as, and earned the envious reputation of being, the first real “supermarket” for hospital equipment and supplies. With India on the fast track to economic growth its healthcare industry is expected to grow from its current $36 billion (approx), growing at 15% CAGR, the Indian Healthcare Industry will be a US$ 280 billion by 2022. In this context the role of MEDICALL assumes even greater significance. This is evident from its awesome and comprehensive range of exhibits. - from Hospital Information System, solutions, surgical and examination furniture, rescue and emergency equipment, to diagnostic / laboratory O.T. equipment dental / ophthalmology equipment, medical disposables and cleaning equipment. MEDICALL reflects the acute vision and entrepreneurial skills of its organizers, in that; it has grown as a brand. It continues to draw the highest percentage of hospital owners, doctors, medical directors and purchase heads in addition to being a proven and highly successful platform for attracting affluent producers, 10

dealers and suppliers. Now in its 8th Edition, MEDICALL 2012has spread its wings to Gujarat and the expo will be hosted from 3rd to 5th February 2012 at Ahmedabad. It will bring together the best in the business ofICU and Operation Theatre equipments, Refurbished equipments, Trolley, wheel chairs, Cots and other furniture, Hospital linen and laundry, Hospital charts and stationary, Office automation equipments, Printers dealing with pamphlet and file designing, Communication equipments, Medical disposables etc. Gujarat is the venue of choice because the state government is taking several initiatives to make Gujarat a Global healthcare Destination. Through use of latest technical equipment, increased health insurance, major corporate investments and services of highly skilled medical personnel, the Gujarat healthcare sector is poised well for a sustained boom. Other impressive feature of MEDICALL 2012 Ahmedabad will be its concurrent conferences namely:

Hospital Constructions:

l Building Hospital according to NABH Standards. l Designing Operation Theatre l Designing an Intensive Care Unit l Basics of Medical Gas Pipeline in Hospitals l Lighting and flooring in Hospitals l Water Treatment and Sewage treatment in Hospitals.

Business Intelligence for Hospitals:

l What is Business Intelligence l Why use business intelligence l How to Choose a regular vendor for Business Intelligence

Lean Six Sigma in Healthcare

l Quality Methodology in Healthcare l Lean management in Hospitals. l Six Sigma in Healthcare l Case Presentation Lean Six Sigma management is a new concept in the healthcare industry where industry experts will speak about the Case Studies. Expo on Hospital Infrastructure called Archimedes will focus on new trends in building a hospital. The high point of these conferences will be the presentations by eminent international speakers with a string of achievements to their n own credit. For more information we welcome your opinion online at info@medicall.in, panchal@ medicall.in or visit our website www.medicall.in Jan - Feb 2012

Jan - Feb 2012

NEWS UPDATE

New research linking statins to diabetes won’t change guidelines : Experts

uidelines on the prescription of statins for postmenopausal women should not be changed despite evidence linking the medications with an increased risk of diabetes, Australian experts say. An American study of more than 150,000 postmenopausal women aged

50 to 79 found those taking the lipid-lowering medications had 48% greater risk of developing diabetes. “Somebody considered to be at high-risk should still be prescribed statins because the risk of a cardiovascular event is far higher than the risk of developing diabetes.”

Feet neglected in RA disease activity scores

ommonly-used scores to assess response and remission in rheumatoid arthritis can over-estimate the benefits of treatment, and leave patients with a continued risk of joint damage unless they consider active disease in the feet, according to a study by Adelaide rheumatologists. They reviewed 123 patients with early RA who had been included in an earlier trial of DMARDs, reported by Associate Professor Susanna Proudman and colleagues in 2007. Remission at six months was assessed by DAS28(ESR), the Simplified Disease Activity Index (SDAI)and the Clinical Disease Activity Index (CDAI), none of which included a measure of synovitis in foot joints. Apollo Endosurgery’s SuMO endoscopic tissue access and resection system. The FDA cleared Apollo Endosurgery’s SuMO, which stands for Sub-Mucosal Operation, endoscopic tissue access and resection system earlier this month. The system allows surgeons to remove large, flat precancerous gastrointestinal lesions and polyps during endoscopy procedures without leaving scars. The SuMO system was developed through a partnership between Apollo Endosurgery and the Mayo Clinic, Johns Hopkins University, the Medical University of South Carolina and the University of Texas Medical Branch. The system includes flexible injection needles, balloons and cutting tools to help the surgeon tunnel underneath the lesion and resect, 12

seal off and remove the unwanted tissue through a traditional endoscope. Preclinical proof-of-concept studies showed the device to be effective in the removal of gastrointestinal tissue up to 7 cm in diameter. Intuitive Surgical’s EndoWrist One Vessel Sealer for da Vinci Surgical System. The FDA cleared Intuitive Surgical’s EndoWrist One Vessel Sealer instrument for use with the da Vinci Surgical System earlier this month. The vessel sealer is a wristed, single-use instrument for bipolar coagulation and mechanical transection of vessels up to 7 mm in diameter and tissue bundles that can fit in the jaws of the instrument. The sealer is compatible with all da Vinci Si Surgical Systems by purchasing a dedicated radio frequency energy n generator. Jan - Feb 2012

Jan - Feb 2012

NEWS UPDATE

Jan - Feb 2012

NEWS UPDATE

Welcome to Asicon 2012 KOLKATA

t gives us Immense pleasure to invite you all to national Conference of the association of Surgeons of India {asicon 2012}.hosted by the west Bengal State Chapter of the Association , will be Held from 25-30th December at Kolkata, the city of joy. Kolkata is a very interesting venue for Asicon . Kolkata is a very well connected Metro police. We are encouraged by the interest being shown by the delegates from the country and being shown by the delegates from the country and beyond. Expectation from delegates about the cultural profile and tourism Opportunities are very high and we are Confidant to live up to it. We assure you that you will have have a pleasant stay in Kolkata. We once again invite you all to ASICON 2012. Thanking yoy, Wishing you All a Happy & New Year 2012. Prof. Tamonas Chaudhuri Org. Secretary, ASICON 2012

Jan - Feb 2012

Dr. Somnath Ghosh Treasure , ASICON 2012

NEWS UPDATE

nion health secretary P K Pradhan said, “We expect the Bill to come up in Parliament next week since it got cleared by the Cabinet on Tuesday. It will then go to the standing committee.” According to the Bill, an overarching body will have under it the Medical Council of India (MCI), Pharmacy Council ...of India (PCI), Nursing Council of India (NCI), Dental Council

The Cabinet cleared the National Council of Human Resources in Health (NCHRH) Bill

of India (DCI) and the proposed Central Councils for Paramedical and Allied Medical Sciences Education. “Currently, all councils are working separately and are over burdened with evaluation, assessment of institutions, monitoring academic standards and regulating the profession. The 21-member body will bring synergy to all these councils. It will have under it

a National Board for Health Education that will put in place academic standards, a National Evaluation Committee and a professional Council,” an official said. The Bill makes it mandatory for state councils to maintain live registers of the available strength of nurses and doctors. This will help correct regional imbalance n of human resources.

Jan - Feb 2012

NEWS UPDATE

ARL STORZ E n d o s c o p y America, Inc., a leader in endoscopy and operating room integration solutions, is pleased to announce that its new VisitOR1(R) telepresence technology was a key element in a landmark educational presentation at the American Association of Gynecologic Laparoscopists (AAGL) 40th Global Congress of Minimally Invasive Gynecology. The VisitOR1(R) system combines the KARL STORZ OR1(R) Operating Room Integration System with remote presence telemedicine solutions to give surgeons and other medical professionals seamless, live connectivity and interaction with surgeons in operating rooms, critical care units and emergency rooms from locations outside those facilities, and even outside the hospital. During a live demonstration on November 8, 2011, a live surgical procedure being performed at Columbia St. Mary’s Hospital in Milwaukee was linked using innovative remote presence technology via high-speed Internet connection to over 1,200 participants who were able to view the procedure from a ballroom at the WestinDiplomat Hotel in Hollywood, Florida. This event is the first time this type of technology has been used to train and educate a group of this size. The VisitOR1(R) System includes a unit in the OR installed either on a cart as a portable device or on a boom arm above the surgical field and linked by high-speed Internet to a remotely located laptop computer that functions as a viewing and control station. The laptop allows surgeons to 18

KARL STORZ New New

Telepresence Telepresence Technology Technology Highlight Highlightof ofLive LiveSurgical Surgical Demonstration Demonstration at at AAGL AAGL Annual Annual Meeting Meeting

“project” their presence into the OR during live surgeries, viewing the surgical procedure and even interacting with the OR team. The viewer is able to remotely rotate and control the visual perspective of the VisitOR1(R) unit above the OR table, and can use a laser pointer as a visual aid to communication. The result is that surgeons using the laptop station can experience an immersive and collaborative experience, as they observe complex cases and interact with those in the OR. More importantly, the technology provides a tool for sharing knowledge, and for training and education. Olympus, Fujinon, Endo GaOlympus, Fujinon, Endo Gastric Solutions Dominate $1.9 Billion U.S. Gastrointestinal Endoscopic Market Fueled by Colon Cancer Screening, AntiReflux Procedures Anti-reflux

procedure growth, doubleballoon endoscope sales to fuel market growth through 2018 according to a report by iData Research. According to a new report by iData Research (www. idataresearch.net), the leading global authority in medical device market research, the U.S.. gastrointestinal endoscopic device market was valued at almost $1.9 billion in 2011. Gastrointestinal (GI) endoscopy is one of the most widely performed medical procedures in the U.S. and growth in this market will be fueled by an increase in colon cancer screening and anti-reflux procedures. In addition, the adoption of newer technologies such as double-balloon and ultrasound endoscopes, will drive sales. By 2018, the market is expected to reach annual sales of over $2.7 billion. Jan - Feb 2012

Jan - Feb 2012

EXPERT VIEWS

Ask a Question from Healthcare Industry Expert “Medgate Today, introduce a Special Section : Ask a Question from industry expert in Hospital & Healthcare Planning, Operations, Management, Quality, Medical Education, Medico Legal & Materials Management”.

UR EXPERT : DR. PRADEEP BHARDWAJ, CEO & Executive Director, Six Sigma Healthcare Limited, Delhi will answer your questions through his expertise knowledge & experience in Hospital & Healthcare Management. He is an expertise Healthcare Planning, Management, Medico Legal Consultant, Author’s and Visiting Professor & Faculty in leading Healthcare Management Colleges / Universities like Harvard, IIM – Lucknow, IIM-A, ISB – Hyderabad, Amity University, Symbiosis International University, AIIMS, National Board of Examinations etc. He is also Board of Advisory in many healthcare organizations / management institutes / universities. . Dr. Bhardwaj is renowned hospital and healthcare management expert, recipient of many prestigious awards like Rajiv Gandhi Award -2010, Best Medico Legal Expert – IBN 7 20

Q. Can you elaborate Six Sigma in Healthcare ? How Six Sigma is Different ? What are the most popular outcomes of Six Sigma ? - Dr. Ganesh Thakur MBBS, MS, Hyderabad, A.P

Expert View: Corporatisation and competition in Healthcare sector are forcing healthcare organizations to look for new ways and means for improving their processes. This is for improving quality of the hospital’s products and services and reducing patient dissatisfaction. Organization must delight their customers and constantly look for new ways to exceed their expectations. But how they do it ? the answer lie in Six Sigma, a buzzword in corporate healthcare management circles. If you make Six Sigma a strategy in your hospital, the end result will get reflected in sustainable bottom line improvement. Sigma is a Greek symbol for standard deviation in statistics. Six Sigma coined by Motorola

Dr. Pradeep Bhardwaj CEO, Six Sigma Health Care

in 1980s popularized by GE. Six Sigma simply means a measure of quality that strives for perfection. It is disciplined, has a data-driven approach and methodology for eliminating defect in any process. Six Sigma provides a methodology to continue our improvement in everything we do. It is an organisational philosophy in establishing the belief of ‘doing things right, first time and every time’. Six Sigma is really different from other approaches. Six Sigma gives you: l A top-down approach, linked to strategy, sponsored by leaders l Applicable to all business processes - administrative, HR, Marketing, R&D, etc. l Fact based, data driven l Results-oriented, hands-on way to develop critical managerial skills l Projects based on top and bottom-line impact Jan - Feb 2012 Sep Oct 2011

EXPERT VIEWS

l Exponential improvement targets When done correctly, Six Sigma becomes a way toward organization and cultural development. It is more than a set of tools! Some of the most popular outcomes include: Increased Patient Satisfaction and Care l Higher satisfaction scores l Fewer complaints l Improved billing l Reduced wait times and variation l Increased prescription accuracy l Safer, more efficient emergency departments l Fewer defects, medical errors and prescription errors Increased Physician Satisfaction l Fewer physician complaints l Dramatically improved throughput l Reduced scheduling delays l Higher clinical resource retention l Improved working conditions for clinicians and staff Reduced Costs / Cost savings l Better financials and higher annual savings l Less rework and waste l Optimized supply chain management l Better recruiting and retention power - both clinical and administrative Stronger Growth l The elimination of system redundancies, bottlenecks and waste l A greater ability to address challenges across the system For further details, please visit www. n sixsigmahealth.org.

Q. What do you think are some basic prerequisites necessary before any Hospital plans to go for Quality Accreditation? - Ms. Nimisha Bhagadia Manager Operations Seven Hills Hospital, Mumbai Quality improvement is not a one time phenomenon, but a dynamic process , which needs to be continuous & sustained. Accreditation is the process of assessment of an institution of the extent of its conformance to a set of standards to ensure quality. Although it is only a public recognition of measurable level of excellence, the process itself improves performance by what is known as the ‘Hawthorne Effect’ Every organisation should concern itself with providing quality care to its patients , but it must ensure it has: 1. Necessary infrastructure 2. Trained personnel 3. Ongoing training & development progam 4. Leadership committed to excellence, which results in a committed workforce & thus ultimately results in establishment of Quality Culture. Q. Is brand communication required for big hospital only or can a small set up like us also do it? - Dhiman Sarkar Manager Operations & Corporate Rajshree Hospital And Reseach Centre Indore

Brand communication doesn’t mean only for bigger hospitals. The main purpose of this is to create awareness among the public about your organization. Due to the continuous

Mr. Tarun Katiyar Principal consultants

evolution in the space of information technology, communication and direct marketing, the patient has now transformed into a prospective consumer for any healthcare provider. Some of the parameters which prominently shape the mindset of a consumer in need of healthcare services are, cost of treatment visà-vis service standards on offer, quality and accessibility of the medical staff, and perception of healthcare provider mindset as communicated by the brand marketing initiatives. Most of the time it is very difficult to determine which of the three aspects comes first, but it very clear that brand building activities, consumer mindset and healthcare provider mindset all go hand-inhand. Nowadays day care centres(opthalmology, urology etc) too are involved in brand communications and this has yielded n very good results for them.

You can mail your query at editor@medgatetoday.com Jan - Feb 2012

COVER STORY

Design & Implementation Operation Theatre The innovative features like Generic Dynamic Template for capturing various types of data, Generic Consent forms, Alert Facility, Vital Monitoring and Graph Plotting facility, etc. have been integrated in this module.

he Operation Theatre is a critical area of the hospital. Therefore, Operation Theatre Management System (OTMS) is an important component of the Hospital Information Management System (HIMS). The innovative features like Generic Dynamic Template for capturing various types of data, Generic Consent forms, Alert Facility, Vital Monitoring and Graph Plotting facility, etc. have been integrated in this module. Design aspects 22

related to check list facility, patient monitoring utility, video streaming, and decision support system, etc., implemented as a part of this module are also presented. Introduction The World Bank reported that , 11% of the entire disease burdens were attributable to surgically treatable conditions. Surgical care is an integral part of health care throughout the world, with an estimated 234

million operations performed annually. Operation Theatre is one area of the hospital where clinician provides the surgical services to the patients by using its resources. The most important function of the Operation Theatre module is streamlining the flow of operations performed in the hospitals. The OTMS contains information about the availability of all the theatres, and equipment/ tools. Scheduling of operations is Jan - Feb 2012

COVER STORY

Aspects of Management

and implementation aspects of the OTMS Module developed as a part of HIMS package. It is organised as follows. Section II describes the work flow of the hospital. Section III describes the design and implementation aspects. Section IV describes the dynamic template utility and Section V describes the check list facility. Patient Monitoring Utility is described in Section VI. The decision support system developed for effective inventory management in the OT is described in Section VII.

the main function of the OTMS. It has specific transactions for Pre Anaesthesia checks (PAC), Request Raising, PAC Result Entry, Operation List Raising, maintaining records about operations and anaesthesia done by corresponding departments. Operation Theatres are high cost centres and therefore, resources are to be allocated and scheduled properly. This module handles both major and minor operations performed in IPD as well as OPD. This describes the design Jan - Feb 2012

Workflow of the Operation Theatre Module When a Patient visits OPD and the treating consultant considers him/her for an operation, the PAC request is raised. The Anaesthesia Department performs a PAC and enters the PAC result. The OT List is raised prior to or after PAC request. When a patient is referred to Operation Theatre from the IPD, he/she is accepted in theatre and this time is considered as wheeled in Time. After the Operation is performed, patient is sent back to IPD (ward, ICU etc) and this time is considered as Wheeled out time. During the operation, pre and post-operation records are also maintained. Within the OT, the Anaesthetists maintain Anaesthesia Record. The OTMS

also maintains the Minor operations performed in OPD. The Module covers functionality of Scheduling of an Operation for a particular patient, Online status of Operation Slot, Automatic search for the earliest available appointment, List of scheduled patientâ&#x20AC;&#x2122;s for operation, Appointments based on the availability of the doctors in hospital with a facility to define number of appointment slots. It has ability to track the completion of pre-requisites for the service prior to the scheduling such as status of PAC during operation appointments for patients. It also has the provision for viewing Operations schedule for specific dates and locations, making inquiries about Operating Theatre Bookings using Location, Operation Theatre Status, Department, and Date etc. The Operation Theatre is managed with provision for overbooking as per conditions laid down by the appropriate authority. According to circumstances raised operations can be postponed or cancelled. Design Aspects of OT Module Modern day Operation Theatres are powered with latest technology and equipped with high-end gadgets. OTMS not only facilitates operations using specialised equipments 23

COVER STORY

but also enable streaming of live videos for telemedicine and telerobotics which can be used for consultancy/cross reference, education and research purposes. The time adherence, discipline and absence of errors are the most important considerations for designing of any OTMS. All these aspects have been given due consideration during the design. Figure 1 gives the opening screen of the Module developed. From this, doctors, and other hospital staff will be able to communicate with other specialised services. It is also possible to create dynamic templates so that the screen could be customised as per the needs. A Check List facility is provided to ensure that nothing is missed out at the start of the operation. The Patient Monitoring Utility is provided to give an overview of the intake, outtake and vitals of the patient before, during and after the operation. Telemedicine is facilitated by the Video Streaming Facility provided which streams images of the operation to doctors participating from remote locations and/or students viewing it from their classrooms. Decision Support System is provided to enable the doctors to take quick decisions, in case of emergencies. Further details of this module are given in remaining sections of this paper. Dynamic Template Utility The dynamic template has evolved from the concept of Control toolbars that was available in front ends applications like Visual Basic/ Power Builder. The same concept is being extended to medical 24

fraternity through the dynamic template utility. It provides a designer area where doctors can represent the specific parameters of clinical check up for various specialities by placing various controls like Text boxes, Labels, Text Areas, Combo Boxes etc. The desired look and feel may be achieved by setting the attributes of these controls. Making fields mandatory and setting limits to values also can be accomplished by the dynamic template utility. Being a super speciality hospital each department had its own requirements as regard to the capturing of clinical findings of the patient. We initially prepared static screens for capturing the patient details in Outpatient for different specialities, Inpatient and Operation Theatre. The next hospital we worked was a government hospital, which in addition to having a very large number of patient inflow had specific needs for the teaching wing of the hospital, which

required to train the medical students on elaborate routine examinations with the exhaustive parameters for each patient. This was in contrast with the requirements of super speciality hospital, which considered only a subset of parameters and had certain additional specific parameters. Thus we encountered a major challenge of having highly dynamic requirements changing hospital wise, department wise and more specially the way doctor worked. This had a major impact on the Operation module, as the facility required effective data capturing at the stage of Outpatient and Inpatient. However the requirements were so dynamic in nature that the design of dynamic templates became a necessity. This facility provides the doctors with a tool to create their own templates of information capturing rather than being constrained by the static templates developed based on few doctorsâ&#x20AC;&#x2122; requirements. n Jan - Feb 2012

Jan - Feb 2012

COVER STORY

Why Sliding Doors for Hospitals?

he operating department in any modern hospital represents one of the most complex designs in the hospital construction. It has to provide the surgical team with a wide range of mechanical and electrical devices and at the same time a very sophisticated environment to meet the demands of hygiene and cleanliness standards. There are multiple factors which needs attention to maintain such high demanding sterility in OT. And one of the vital factors is an Operating room DOOR, which is the most used & abused part of an operation theatre. A door to be used for an operating room must be specifically designed to suit the purpose. The options available are Sliding doors or Swing doors, but the choice should always be of a Sliding Door which obviously saves on space and reduces the movement of air. The door, during an operation, should only cut through the air and not give any kind of air turbulence as the case may be with hinged doors. A picture depiction below shows how air turbulence is created when hinged doors are used. Traditional swing doors create uncontrolled movements of air during opening and closing. This uncontrolled air can accelerate the spread of airborne microorganisms by air currents and may infect susceptible hosts in operating theatres and isolation wards. An Operating room door must 26

have a smooth and flush finish so that it is very easy to keep sterile. After all, every edge or seam is a potential breeding ground for germs. The door should be made from inorganic materials, so that any kind of bacterial growth is not possible. The doors should be able to seal hermetically so that the door supports the pressure hierarchy in an operating suite and contributes to considerable cost savings. A hermetic door prevents cross-contamination of air between two rooms. On closure the door must seal against the floor and also against the walls, thus providing an airtight sealing on all four sides. The efficiency of the Seal should be officially tested and show it to be over 99% effective thus reducing cross contamination, dirty air entering the clean room and expensive air handling costs. These doors are supplied with standard manual operation and can be equipped with electric automation enabling automatic operation.The doors can be automated with the safe reliable electrical operator which has several unique features. The

intelligent automation senses if an obstruction is present and prevents the door from closing thus eliminating the need for a dirty safety strip leaving the leading edge clean and ledge free. The opening and closing speeds and the time delay closing are easy to adjust and a selfdiagnostic coded system makes fault finding simple reducing expensive down time. Doors can be locked or interlocked to suit individual client requirements. Metaflex paid special attention to all the above factors in designing of their Mak healththe hermetically sealed door to be used in operating rooms, clean rooms & laboratories. The special features of Mak Health are: l User Friendly l Large openings l Creating a room without obstacles l Saving expensive space in the room l Preventing air turbulence l Easier movement for wheel chair l Safer operation, less risk of hitting people. Jan - Feb 2012

Jan - Feb 2012

PRODUCT LINE

Caddo 16 B Infusion Pump

cientech Medicare, a Scientech Group Division offers Caddo 16B, Infusion Pump which is used to deliver fluids, nutrients or medications into a patientâ&#x20AC;&#x2122;s body in a controlled manner. It is used in various departments of hospitals, such as medicine, pediatrics, gynecology, obstetrics, neurology, ICU and CCU and for use in chemical and biomedical research for delivering insulin or other hormones, antibiotics, chemotherapy drugs, pain relievers, etc. It is capable of pumping fluids in large or small amounts. Caddo 16B is compatible with IV sets of any brand and having automatic calibration facility for IV sets. It has three working modes i.e. Rate Control Mode, Time Control Mode and Drop Counting Control Mode. It comes with alarm functions for monitoring occlusion, air-in-line, infusion complete, empty container, door is open, waiting time is over, no drop been detected operational errors, low battery, etc. It also has KVO function which prevents patient from thrombus. Other features of Caddo 16B include high resolution unique-color LCD screen, eight hours internal battery backup and built-in rechargeable lithium battery.

Scientech Technologies Pvt. Ltd. Indore Tel: 0731-4211100, Fax: 0731-2555643 Mob: 07389910103 Email: info@scientech.com Website: www.ScientechWorld.com

Jan - Feb 2012

DOCTOR SPEAK

Kawasaki

Dr. Rajiva Kumar Child Specialist Muzaffarpur 30

awasaki disease, also known as mucocutaneous lymph node syndrome, c a u s e s inflammation of blood vessels throughout the body. What causes Kawasaki disease is not clear. Some researchers believe it is an infection, others an autoimmune disorder stimulated by an infection or exposure to an environmental toxin. Most cases of Kawasaki disease (80 percent)

occur in children younger than four years old, but occasionally it may occur in very young infants or adolescents. Children of Asian ethnicity are at higher risk for developing the disease. The inflammation caused by the disease can lead to coronary aneurysm and heart attack, making Kawasaki disease the most common cause of acquired heart disease in children in developed countries. Up to 25 percent of children with untreated disease will develop Jan - Feb 2012

DOCTOR SPEAK

Disease Leading cause of acquired heart disease in children. “Kawasaki disease causes skin to peel on the hands and feet” heart problems. Fortunately, only 5-10 percent of children with Kawasaki disease who are treated before the tenth day of illness will develop heart disease. Symptoms Kawasaki disease has a typical set of symptoms that occur in 90% of children affected by it, including: l High fever for at least five days l Eye irritation (conjunctivitis) without pus Jan - Feb 2012

l Dry, red lips that crack and bleed and/or bumpy red tongue (“strawberry tongue”) l Palms of hands and soles of feet are red; skin starts to peel off fingers and toes about two weeks after illness starts l Red rash on body Other symptoms may include enlarged lymph nodes in the neck (50-75 percent of children), extreme irritability, joint pain or swelling, and poor appetite.

Diagnosis Diagnosis of Kawasaki disease is based on the child having a high fever for five days plus four of the other signs. Very young infants may not show as many of the typical signs of the disease. Blood tests will show elevated erythrocyte sedimentation rate (ESR), C-reactive protein, and alpha-1 antitrypsin levels. An echocardiogram (ultrasound of the heart) is done to check for any aneurysms or heart disease. 31

? DOCTOR SPEAK

men

Asthma in and women, what is the difference

Dr. Suman Bijlani Director at Gyneguide

s Asthma Different In Men and Women? The hormonal connection Asthma is found to be more common in boys than girls. At the time of puberty, asthma occurs in boys and girls equally. After puberty, women are more likely than men to have asthma, and this incidence again declines after menopause. Therefore as a womanâ&#x20AC;&#x2122;s hormonal system matures it may play a role in the changing prevalence of asthma. Many women report that the most severe attacks usually occur three days before and four days into the menstrual period. This suggests a hormonal connection. The sharp decline in the hormone progesterone just before the menstrual period may be responsible. Similarly, synthetic hormone replacement therapy may as much as double the risk of developing asthma in postmenopausal women. In one research released by the European Respiratory Society , women on HRT were 40 to 50% more likely to suffer from asthma or to exhibit asthma symptoms. An interesting fact is that, over the last decade, the incidence of asthma has risen much more in women than in men. And women seem to have more severe attacks and require more frequent admissions to the ICU for this condition. Asthma in pregnancy â&#x20AC;&#x201C; special concerns: Asthma affects about 7-8% of pregnant women in India. It is one of the most common lung problems in pregnancy. Effect of pregnancy hormones on asthma: During pregnancy, hormonal effects on the respiratory tract can change the severity of her asthma. On the upside: l The hormone progesterone (the dominant hormone in pregnancy) and an increase in steroid levels in pregnancy open up the respiratory passages, thus increasing oxygen transfer to the lungs. Jan - Feb 2012

Jan - Feb 2012

DOCTOR SPEAK

l The effect of certain inflammatory chemicals in pregnancy is suppressed, which reduces inflammation of the bronchial tree.

On the downside: l Pressure by the growing uterus on the lungs can lead to decrease in the overall ‘capacity’ of the lung to hold air. l Gastrointestinal reflux disease (GERD), or regurgitation of stomach contents up the “food pipe” is common in pregnancy and can trigger asthmatic attacks in some women. The effects of pregnancy on asthma are variable. About 28% of women improve, 33% remain unchanged and only 35% deteriorate, usually between 24 and 36 weeks of pregnancy (7th and 8th month). This coincides with the highest level of cortisol (steroid hormone) in pregnancy. Severe asthmatics are more likely to experience deterioration of symptoms, while mild asthmatics tend to improve. During labour and delivery, only 10% women report symptoms and only half of those require treatment. After delivery, the severity of asthma becomes the same as prepregnancy level. Effects of asthma on the unborn baby and mother’s health: The unborn baby depends for its oxygen on the air that its mother 34

breathes. When the mother has an asthma attack, the baby may not get enough oxygen. This can put it in great danger. More severe the asthma, greater the risk to the fetus. In rare cases, the fetus can even die from oxygen deprivation. Asthma attacks can have a number of negative effects on pregnancy outcome. Poor asthma control is linked to premature delivery, low birth weight, and stillbirths in the fetus; and hypertension in the pregnant woman, an increased risk of caesarean section and increase in bleeding post delivery. The newborn of a mother whose asthma is poorly controlled, has a higher risk of complications like fits and sudden drop in sugar levels. Management of asthma: Asthma can be controlled during pregnancy. If asthma is controlled, there is as good a chance of a healthy, normal pregnancy and delivery as a woman who does not have asthma. Prepregnancy planning – Women should discuss with their doctor the effects of pregnancy on asthma and of asthma on the baby, as well as the medications and their dosing and effects. The doctor may switch to another medication or adjust the dosage, as per needs. The rule is to use a minimum effective dose. During pregnancy – As a rule, most women are advised to continue with their prepregnancy regimen of drugs. However, certain medicines are best avoided in the first trimester or towards the end of pregnancy or in labour. For example, the drug terbutaline can inhibit uterine contractions in labour. Long term use of oral steroids can affect the unborn baby or have untoward effects on the mother’s health. The patient should discuss the medications with her doctor as soon

as the diagnosis of pregnancy is made. The woman should take care to avoid all trigger factors which may precipitate an attack. Which means, treat that cold early on, quit smoking, prevent acidity by consuming small frequent meals and avoid all known personal triggers. Regular steam inhalations and yoga/pranayam are other measures which help, esp in a city like Mumbai which has a high level of pollutants in the air. Acute attacks may be more severe than they have been prior to pregnancy. She should have access to health care facilities round the clock, and her inhaler on her at all times. Throughout pregnancy, evaluation of fetal growth and well being are important. During labour and delivery, the doctor would take special care of monitoring the baby’s health and maintaining adequate oxygen supply to the mother. In case of caesarean section, general anaesthesia is best avoided. Certain drugs like Inj Prostaglandin F2 alpha can cause ‘bronchospasm’ i.e. constriction of the respiratory passages. Medications: Most people with asthma take at least two medications: one for long-term prevention and control of asthma symptoms and one for quick “rescue” in case of an attack. The long-term medications are taken on a daily basis, even if there are no symptoms. Rescue medications are taken only when symptoms appear. The use of inhalers in pregnancy is very important during an acute attack to prevent prolonged oxygen deprivation to the fetus. The risk to the fetus from most medications is tiny compared to the risk from a severe asthma attack. n Jan - Feb 2012

Jan - Feb 2012

EXPERT VIEWS

Six innovations that can revolutionize Indian Healthcare System

Manish Nachnani Health IT consultant

ealthcare in India is in dire need of innovation. The healthcare system currently is inefficient, expensive and paralyzed. Healthcare services are not for the faint hearted, the bills you may receive and the explanations of benefits and other clauses have the potential to give you a heart burn. This makes itâ&#x20AC;&#x2122;s a prime candidate for innovative solutions, to turn it upside down and revolutionize the entire healthcare ecosystem. Letâ&#x20AC;&#x2122;s look at the crystal ball and look at six innovations that could potentially make our healthcare system work seamlessly and perfectly. Cloud Computing is a big thing, every one talks about its pros and cons , but rarely do we realize how much empowerment can it bring to our patients , doctors and payers. Today patients have their individual health data in form of PHR , in a country like India where everything is paper based the move will be easier as we have no baggage to carry , providers have their EMR systems and then the payers have their claims system.

How much times is the data replicated, keep counting. Its not just the cost of storing this data, but the price these entities pay to protect it , to follow HIPPA laws. Imagine a nation where entire health data is stored on a cloud and a single source of truth exist, everyone pulls in data from their. This is not impossible; iTunes by apple did exactly the same thing with music files via cloud services. So why not sync up all our health data on the cloud and dance to the tunes of cloud computing. It will reduce costs to a great extent by freeing up numerous IT resources and budgets. Social Media has changed the world around us, they way we communicate and the way we share information. Social media had empowered consumers in every sector and provides detailed consumer insights to businesses. When it comes to healthcare social media has not been exploited to the fullest because of stringent security requirements and kind of data that can be shared over the web. That said there are numerous social media based communities that are emerging and evoking great response. The biggest successes Jan - Feb 2012

EXPERT VIEWS

Social Media has changed the world around us, the way we communicate and the way we share information. Social media had empowered consumers in every sector and provides detailed consumer insights to businesses. stories that are well know across nation are Mayo Clinic, patients like me and many more. Social media empowers, engages and enables sharing between patients, doctors and caregivers. The challenges that we face in care management, disease management can be easily solves using social media. Moreover patient education and preventive care gets the biggest thrust from active use of social media. Telemedicine , have come at a stage beyond video and audio conversation , they are now capable of providing microscopic views of patients ailments via HD cameras , using remote devices to diagnose particular ailments . Its hearting to see numerous payers and providers adopting telemedicine for visits that do not need physical presence. Why would you need to go to a doctor physically for a follow up visit , it makes perfect business case of Jan - Feb 2012

virtual visit. Telemedicine thrives on three stakeholders the technology, patient’s faith in virtual medium and doctor’s capability to deliver over the virtual medium. Thankfully technology is present, patients are smarter and they realize telemedicine is the future and doctors too are comfortable with delivering care n virtual medium. Telemedicine is growing, and its only a matter of time when it will reach its tipping point. Telemedicine now means bring healthcare in your dinning room and workplace. You can chat with doctor, see them, share symptoms, use digital stereoscopes, digital thermometers, blood pressure machines and most of the visits will be migrated online. Its simpler, its easier and its better. Patient Portals are no more static source of reports and bill receipts they are dynamic and interactive. The features and user interface on patient’s portal will emerge as a key differentiators while selecting payers. Today patient portals allow you to organize all your health information from multiple sources, analyzes it and provides suggestion on lifestyle changes. Sharing medical records, lab results, renewing prescription are the basic features everyone will provide. Smart portals will have integrated care management and disease management platforms. Estimators to find the cost for particular treatment, best doctor for particular treatment from the network, smart appointment scheduling services and much such value add services that provide joy to consumers. Behavioral Economics is the science on which every business thrives. We can’t act rationally

always, how many times we got tempted to buy a new release of an iPhone when we have a functional phone of similar capabilities. Similar things happen with our health behavior and eating habits, we take irrational decisions for our health. We miss medications, we miss appointments and the cost of such behaviors is estimated in billions of dollars. Simple tools and games can be used to influence human behavior. Influencing behavior has become easier thanks to the technological interference in our life, so alarms buzz of taking medicine, reminders for doctors appointment, auto refill for prescriptions. Behavioral economics integrated with social media can use social pressure, the most powerful weapon that ever existed to change human behavior. Accountable Care Organizations, yes finally accountability is here in the healthcare organizations. We always paid a dry cleaner when our clothes looked shining new or a car mechanic for repairing a car but we paid for our health irrespective of the outcome , which is about to change and is the game changer in true sense. So here is the fun now your doctors be rewarded if you don’t visit them, yes you read it right, which means you are healthy, so he will be rewarded. Now the job of hospitals is to keep you away from them and healthy. This has created a buzz across the nation, because it simply uses a carrot and stick approach we have grown up on. Its simple meet the quality, lower the cost and share the benefits and if you don’t meet the targets be ready to bear the stick. All the six forces combined together hold the true potential to revolutionize our Indian healthcare n system upside down. 37

EXPERT VIEWS

A PRACTICAL APPROACH TO SET-UP AN IVF LAB

Ar. Preeti Chauhan

Associate Director DDF Healthcare Consultants

well-designed IVF laboratory is an asset to an IVF programme. Technological advances have made todayâ&#x20AC;&#x2122;s instruments more accurate and reliable. The availability of ready to use culture media and disposable tissue culture labware have taken out uncertainties from an In Vitro Fertilisation (IVF) programme. With careful planning and equipment selection , it is possible to reduce cost and run a good IVF lab in almost any part of the country. The various aspects that need planning are : l Location of the Lab, Lab Areas and basic infrastructure. l Laboratory equipment and consumables, Quality control. l Laboratory maintenance and future expansions. LOCATION OF THE LABORATORY : The laboratory should be close to the operation theatre. It should be away from traffic to reduce dust and noise pollution. Moisture prone areas such as basements should be

avoided. Availability of daylight reduces the requirements of artificial light in a lab. Access to the laboratory should be restricted and if possible should be through air locks. Bulky instruments need to be moved in and out of the lab during installation and maintenance. Hence, access to the lab needs to be large enough to accommodate them (6m). The main areas in the laboratory are culture area, sperm preparation area, cryoware washing areas and sterilization areas. Space for micromanipulation and media preparation may be required depending on the requirements of the programme. These areas should be well separated and adequate space should be provided for movement of the laboratory personnel. Each of these areas should have access to scrub facilities. Adequate room for storage should be considered while planning the laboratory. The total area requirement would be approx 160-200sqm (along with the waiting area) BASIC INFRASTRUCTURE : Electricity : Power points should be made available at regular distances over the working benches. They should be provided in numbers over and above the estimated requirements. Supply from different electric phases and provision for uninterrupted power supply or a generator will help in case of power failures. Water Supply : Scrubbing and washing areas will need adequate water supply and well-concealed drainage. Clean Air : Filtered air supply with regular air changes will help maintaining a sterile environment. Comfortable and constant temperature should be maintained by air conditioning systems. It is preferable to have a room with HEPA Filtration. The latest CODA Filters, which promise to eliminate all types of contamination from the lab air, are highly recommended. Jan - Feb 2012

Jan - Feb 2012

EXPERT VIEWS

Floors & Walls and Ceilings: The floors should be nonslip and cleanable, walls can be covered with ceramic tiles, which are easily washable. The tiles should be such that there are fewer joints and surfaces, which may accumulate, dust particles. Application of Epoxy paint is not essential. False Ceiling in IVF lab is not advisable for its inaccessibility for maintenance in future. Furniture : The working benches should be of a correct height (750mm). The surface should be non-porous and cleanable. Chairs and stools with adjustable height add to the comfort of the scientists and reduce fatigue. Easy sliding drawers with adequate capacity for storage should be installed in the lab under the working benches. It is preferable not to put shelves on the walls as dust can collect on top of them and go unnoticed. LABORATORY EQUIPMENTS : (a) Incubators (b) Laminar Flow Hoods (Clean air station) (c) Stereo Zoom Microscope (d) Inverted Microscope (e) Compound

Upright Microscope (f) Microscope Stage Warmer and Dry Baths (g) Centrifuge (h) Programmable Biological Freezer (i) Ultra Pure Water System (j) Miscellaneous Instruments: Instruments like the hot air oven, liquid handling systems, and heat-sealing machines (for Poly bags and freezing straws) are important. (k) Consumables and Culture Media (l) Ovum Pick-up / Embryo Transfer QUALITY CONTROL AND MAINTENANCE : Sperm survival tests are commonly used to test the culture conditions. Mouse embryo assay is difficult to perform in every laboratory. Meticulous attention to the laboratory techniques and good housekeeping habits are a key to maintaining sterile environment. The working areas should be wiped with alcohol and ultrapure water. Incubators should be cleaned at regular intervals, with a frequent change of water in the humidifier pan. The incubator temperature should be checked daily. Carbondioxide concentration should be counter checked by Fyrite kits or Capnography. Laminar

flow hoods should be checked for particle contamination and serviced at regular intervals as advised by the manufacturers. Qualified personnel should service all the equipment only. Minor spares like fuses, bulbs etc should be available in the lab for emergencies. It is prudent to opt for an Annual Maintenance Contract for major instruments in your lab. Various accreditation agencies abroad are ready to help you with their quality control standards and it is worth thinking in terms of ISO9000 certification for your lab. However, self quality control is the best way to maintain standards of your project. FUTURE EXPANSIONS : Lab expansion will be needed to handle increasing number of IVF cycles. Micromanipulation equipment may be acquired at a later stage if not included in the basic set-up. Now various techniques like Laser are available for assisted hatching and FISH/PGD (Pre-implantation Genetic Diagnostics). You should make provision of space and equipment for future if the need arises for such technique.

Jan - Feb 2012

EYE CARE

New Vistas for Spectacle Removal

Dr. Sharad Lakhotia 42

f you are wearing glasses, be it small number or very high number, a lot of options are available. One can go for contact lenses. A variety of disposable lensesdaily, fortnightly and monthly are available. One can go for Lasik in which cornea is reshaped. In C-Lasik, natural aberrations present in human eye are also removed, thus enhancing quality vision often referred as “Eagle’s

Eye Vision”. In Femtosecond Laser, thin corneal flap can be made. The New LASIK For years, conventional LASIK was performed identically for patients with similar glasses prescriptions. Conventional LASIK worked well but failed to account for subtle differences between eyes. This, in combination with irregularities that can arise when Jan - Feb 2012

EYE CARE

cutting the corneal flap with a microkeratome blade, led to occasional side effects, such as vision problems in low light and other visually challenging situations. Today, the use of IntraLase® and CustomVue™ for LASIK procedures has significantly improved visual results and has reduced the potential for night vision problems. How Bladeless LASIK Works The LASIK surgeon uses computer software to guide the femtosecond laser beam, which applies a series of tiny bubbles within the central layer of the cornea. The resulting corneal flap is created at a precise depth and diameter pre-determined by the surgeon. As occurs with a mechanical microkeratome, a small section of tissue at one edge of the flap Jan - Feb 2012

is left uncut, forming a hinge that allows the surgeon to fold back the flap so the cornea can be accessed and reshaped for vision correction. How Bladeless LASIK Compares With Blade Flap LASIK With bladeless LASIK, people with thin corneas who once were deemed unsuitable for LASIK may now be candidates. Most people have corneas that are between 500 and 600 microns thick. To maintain corneal stability and avoid serious LASIK complications such as ectasia, surgeons want to leave as much corneal thickness under the flap as possible. So, generally speaking, the thinner the corneal flap the better, because this leaves a greater amount of corneal tissue under the flap for treatment. Most microkeratomes

previously cut flaps that generally ranged in thickness from 140 to 180 microns. Femtosecond lasers, on the other hand, can create flaps as thin as 100 microns. So at one time, bladeless LASIK had a distinct advantage over microkeratomes in terms of the ability to make thinner flaps. This meant that people with thinner-thanaverage corneas who may not have been good candidates for conventional LASIK could safely have all-laser LASIK performed on their eyes. Femtosecond lasers create corneal flaps with more defined, angled edges, unlike the thinner, microkeratome-cut “knife-edge” flaps that might tear more easily. If number is very high then an artificial lens can be implanted in Eye (ICL). Thus for any number, n a solution is available. 43

DENTAL HYGIENE

Modern Dentistry:

Dental Implants

Dental implants involve using an artificial tooth that is mounted to a post, generally made out of titanium.

eople with missing teeth are often extremely self-conscious about their appearance. They also keep people from enjoying socializing and favorite foods. However, dental implants are an appealing alternative that can help individuals to regain a beautiful smile once again.

Dental Implants Explained Dental implants involve using

an artificial tooth that is mounted to a post, generally made out of titanium. Through the use of moulds, the dentist ensures that the tooth is a good fit and match to the surrounding teeth. The post is then surgically inserted into the bone beneath the gums to become a permanent fixture in a personâ&#x20AC;&#x2122;s mouth. Not only is it more convenient than dentures that are removed, it also has a natural appearance that

is attractive. There is no longer an unsightly gap in someoneâ&#x20AC;&#x2122;s mouth. Types of dental implants range from a single tooth to a couple side by side or there is the All in Four method. The All on Four procedure is an alternative which is recommended for candidates that need complete replacement of their teeth on the top, bottom, or both. Rather than having dentures Jan - Feb 2012

DENTAL HYGIENE

There no need to worry about dentures falling out at embarrassing moments or causing discomfort if they do not fit properly. made that are removed each night and have the possibility of slipping or not having a good fit, All in Four implants involve using four posts or screws to attach a grouping of teeth, whether it is a complete set of teeth, for the top, or for the bottom. It is a permanent solution that will not be removed.

Pros for Dental Implants Jan - Feb 2012

Dental implants are beneficial in that they are permanent. Rather than choosing a bridge that is removable or which has cement that can be loosened over time, patients should only need implants inserted once. When they choose the All in Four implants over conventional dentures, they enjoy a natural appearance and all of the features of a sturdy set of teeth that are not going anywhere. There no need to worry about dentures falling out at embarrassing moments or causing discomfort if they do not fit properly. The implants allow the pressure of a bite to be taken by the jaw bone, as with normal teeth, unlike dentures alone that spread weight across the gums. This can make the experience much more comfortable for the user. Also by having an implant, thus replacing a missing tooth, the receiving party can benefit hugely as they are less likely to lose adjacent teeth- which they would be at increased risk of had

an implant not been placed.

Cons for Dental Implants

Dental implants can be an expensive option that may not be affordable for all individuals. They involve a time-consuming surgery as well as the risks inherent in any surgical procedure. There will be discomfort after the procedure during healing time and it varies for every individual. In addition, the false teeth, also considered crowns, do eventually need to be replaced although it is a much less invasive procedure.

Celebrities Implants

with

Dental

Celebrities are in the business of making the most of their appearance as part of their livelihood. It is no surprise that many have chosen dental implants, whitening, and alignment procedures to beautify their smiles. It has been suggested that Kate Beckinsale had dental implants although she will not confirm which type of cosmetic dental procedures she has acquired. n 45

SURGEONS CORNER

Feasibility of

laparoscopy for small bowel obstruction Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn’t always represent only a therapeutic act, but it is always a diagnostic act, which doesn’t interfere with abdominal wall integrity. 46

he feasibility of diagnostic laparoscopy is high (60–100%), while that of therapeutic laparoscopy is low (40–88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies ≤2, nonmedian previous laparotomy,

appendectomy as previous surgical treatment causing adherences, unique band adhesion as phatogenetic mechanism of small bowel Jan - Feb 2012

SURGEONS CORNER

obstruction, early laparoscopic management within 24 hours from the onset of symptoms, no signs of peritonitis on physical examination, experience of the Jan - Feb 2012

surgeon. Conclusion: Laparoscopic adhesiolysis in small bowel obstruction is feasible but can be convenient only if performed by skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay and a lower postoperative morbidity. Although a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients. The small bowel is the most frequent intestinal occlusion site and adherential pathology represents the most common cause of small bowel obstruction (80%). Other less common causes are: peritoneal carcinosis, Crohn disease, GIST, internal hernia, diaphragmatic hernia, Meckel’s diverticulum, and biliary ileus. Laparoscopy in small bowel obstruction has not a clear role yet; surely it is a diagnostic act and sometimes also a therapeutic act, which does not interfere with abdominal wall integrity. The first laparoscopic adhesiolysis for small bowel obstruction was performed by Mouret in 1972 . Following this first case, the use of laparoscopy for treating small bowel obstruction was accepted by other surgeons and the indication was represented by patients with unique band adhesion and no clinical signs of bowel ischemia or necrosis. In laparoscopic adhesiolysis for small bowel obstruction the first trocar needs to be placed

using Hasson’s technique for open laparoscopy in order to avoid accidental bowel perforations related to bowel distension and adhesions with the abdominal wall. Two 5 mm trocars must be introduced under vision in order to explore the peritoneal cavity. Dilated bowels are moved away to find out the obstructed bowel segment by the band adhesion. If the surgeon notices ischemic or necrotic bowel he performs a laparotomy, on the contrary if the bowel appears healthy the laparoscopic procedure can be delivered and an atraumatic grasp can be used to isolate the band adhesion, which is coagulated by bipolar coagulator and then sectioned with scissors. These manoeuvres result in the liberation of the obstructed small bowel segment. In order to perform an emergency laparoscopic adhesiolysis, three factors are fundamental: l Early indication for surgical treatment. l Exclusion of patients with history of multiple abdominal surgical procedures. l Exclusion of patients with suspected strangulation or small bowel torsion associated with ischemic or necrotic bowel. It is often not possible to achieve a preoperative diagnosis of mechanical small bowel obstruction caused by peritoneal adherences [6]. For this reason the number of patients and the quality of the studies published in literature on this topic are both low, resulting in poor scientific As study shows that while the feasibility of diagnostic laparoscopy is high (60–100%), that of therapeutic laparoscopy n is low (40–88%). 47

SURGEONS CORNER

Preparing and Positioning

for LAPAROSCOPIC

SURGERY

he positioning of the patient hit laparoscopic surgery, and the positions of the surgeon, assistants and scrub nurses differ in many ways from conventional oper¬ations. These differences must be taken into account 48

when preparing the patient for anaesthesia, since they frequently interfere with routine management and impair the anaesthetist’s access to the patient’s head and extremities. A simple example in point is the pos¬itioning for a laparoscopic herniotomv. In the conven¬tional procedure, the surgeon stands

at the level of the groin, and the anaesthetist has unimpeded access to the arms and head. For the laparoscopic procedure, on the other hand, the surgeon stands at the patient’s head in order to guide the instruments from above, into the hernial orifice. One or even both of the patient’s arms are positioned Jan - Feb 2012

Jan - Feb 2012

SURGEONS CORNER at his side, his head is almost com¬pletely covered and the operating table is brought into a steep Trendelenburg position. The result of this is that the anaesthetist has difficulties in accessing the venous cannulae and the endotracheal tube, as well as monitiiring the patient’s skin colour and pupils. At the same time, there is a higher risk of endotracheal tube movement relative to the carina with endobronchial intubation without the anaesthetist being unable to confirm or correct it .

Preparing the patient

Preparing the patient for anaesthesia — from selecting the venous cannullation site, to the choice of endotra¬cheal tube and the monitoring modes — must take the above -mentioned set of problems and risks as well as the particular routine of the individual hospital into account. For the anesthetist, it is important to retain access to at least one of the patient’s arms and to the head and endotracheal tube. Unfortunately, this is not always possible, either because it would interfere with the operation, or simply because that is just the way things are done. In some hospitals, for example, the video monitor for laparoscopic cholecystectomy and other upper abdominal procedures is mounted on a bridge that spans the patient’s head. Both of the patient’s arms are positioned at his side, and access to his head in the event of an emergency is nearly impos¬sible impeded One arm is all one needs for venous access, but if both arms are fixed at the patient’s sides, one can either connect an extension with an access port to a catheter in a peripheral vein, or one can

cannulate the external jugular vein, which usually remains fairly accessible even \slum the patient is completely draped. In more extensive operations, and especially with older patients, the use of a central venous catheter might be indicated in any case. Infusion lines from the syringe pumps for intravenous anaesthetics should be connected as closely as possible to the catheter to avoid infusion deadspace. When the patient’s head is covered with drapes, particular care must be taken to protect the eyes from abrasions and other injuries. This is usually done by taping the eyelids shut with a strip of non-irritating surgical adhesive tape. This does not always prevent corneal abrasions, but not taking this kind of precaution might be construed as negligence. We do not use eye ointment, since the patients complain of postoperative visual impair¬ment caused by corneal oedema or conjunctivitis. there is any danger of the patient’s eyes being exposed

to pressure (e.g. members of the surgical team leaning on the patient’s head), plastic eye protectors can be applied The position of the endotracheal tube and the presence of bilateral breath sounds must be confirmed by careful auscultation after intubation, and then checked at regular intervals during the operation, since the tube can migrate into an endobronchial position. A double-lumen endotracheal tube, usually a leftsided tube, is usually required for thoracoscopic operations to allow one-lung ventilation with collapse of the lung on the affected side. When the patient is in a steep head-down position, padded shoulder supports must be used to prevent him from slipping. These should not be attached either too far laterally or too far medially, so as to avoid damage to the brachial plexus, a common com¬plication of the trendelenburg position . For the same reason, the patient should not be fas¬tened by the wrists. Jan - Feb 2012

Jan - Feb 2012

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Jan - Feb 2012

WINDOW SECTION

Jan - Feb 2012

World Heart Federation World Congress of Cardiology

Scientific Session 2012

18 - 21 April 2012

Dubai, United Arab Emirates

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Jan - Feb 2012

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