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Volume V || Issue II || July-August 2014

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Editor’s note

India hiked its health budget by 27% in 2014-15 to `35,163 crore India Mange More; Roti, Kapda, Makan & Healthcare India Expects from New Govt. Healthcare in 5th Gear

I

ndian healthcare sector is undergoing a period of major expansion. In line with his 2023 political vision, Prime Minister Sh.Narendra Modi has set a goal for the country “Health to all “ and to become a global leader in the delivery of healthcare services over the coming decade.

Special focus on improving affordable healthcare for all. The government also hiked the allocation for AYUSH – Ayurveda, Yoga, Unani, Sidddha and Homoeopathy – by 36%. The department under the health ministry was allocated Rs.1,272.15 crore compared to Rs.935.75 crore in the last fiscal. With the focus on health research, the government also allocated more funds for it.

As the health ministry has a separate department for medical research, it was allocated Rs.1,017 crore compared to Rs.880 crore in the last fiscal – a jump of 15 percent. Finance Minister Arun Jaitley in his maiden budget speech said the NDA government wants to move towards ‘Health for All’ and to fulfill this aim on priority by providing free drug service and free diagnostic services. ‘In keeping with the government’s focus on improving affordable healthcare and to augment the transfer of technology for better health care facilities in rural India, 15 Model Rural Health Research Centres will be set up in the states, which will take up research on local health issues concerning rural population.

time to integrate Healthcare with National Infrastructure.

Good Health Contributes to National Economic Welfare.

magazine Volume - V Issue - II July-August 2014

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Cheif Correspondent Design and Layout Sales and Marketing Subscribtion & Cirrculation

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SA Rizvi, Dr. HN Sharma Mohd. Javed Ahmad Amjad Kamal, SY Ahmed Khan, Ranjit Shirsath Deepti Tripathi Jagruti Diddi, Saba Khan 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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July - August 2014

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July - Aug 2014 Contents

Cover Story 22

Budget Planning ensures healthcare for every citizen in the country

News Update 8

Compassion Beyond Borders...

10

Wadhwani Foundation & Narayana Health pilot...

11

Extensive Atherosclerosis involving...

12

A book on “Uttrakhand - Kedarnath Medical...

14

Encephalitis spreading in Muzaffarpur...

16

Symbiosis Centre of Health Care...

18

Vasudev Hospital Making Healthcare Affordable...

19

Kodak alaris achieves microsoft gold competency...

20

Largest ever analysis on the use of a polypill in...

Expert Views

33

IT in Improving Quality in Health Care...

34

Mobile-Enabled Remote Patient Monitoring...

38

Breast cancer is the most common cancer...

40

Homecare Services Open New...

46

Cygnus Medicare exploring New frontiers...

48

Men’s Health as an Integrated...

55

The Era of Smart Hospitals...

Doctor Speak

36

Unusual systemic venous Collateral channels...

42

Endoscopic Ultrasound a poorly understood...

52

Clinical manifestations and treatment of...

Product Line

44

Buy Healthy, Eat Healthy!...

51

Quiet, Efficient Scanners...

Interview

58

July - August 2014

Managing Director, Omron Healthcare India.

8

NEWS Update

Compassion Beyond Borders Doctors at Fortis Noida give 9 year old Pakistani boy a fresh lease of life by performing a combined liver and kidney transplant Noida, June 24, 2014: A well-co-ordinated effort between the High Commission of Pakistan, The Indian High Commission in Islamabad and Doctors at the Fortis Hospital, Noida, has given a fresh lease of life to a 9 year old boy Amaar Asif from Lahore, who was suffering from end-stage kidney and liver disease.

In a gratifying display of compassion, fortitude and medical skill, a battery of 10 surgeons, 6 anaesthetists and 30 nurses, persevered for nearly 10 hours to simultaneously transplant the kidney and liver, in the child, to save his precious life.

The child was suffering from primary hyperoxaluria (excessive urinary excretion of oxalate) and had to undergo a cleansing process (haemodialysis and peritoneal dialysis) prior to the operation to reduce the oxalate levels in the blood. The surgery was collaboratively performed under the guidance of Dr Vivek Vij, Director GI Surgery and Liver Transplant and Dr Dushayant Nadar, Senior Consultant-Urology, at Fortis Noida.

Amaar Asif; the patient along with this family and the team of treating doctors

“We are grateful to the doctors at Fortis who have given a new lease of life to my grandson. Finally, Amaar will be able to play, go to school and lead a normal life”, said Mr. Mubarak Haider, Amaar’s maternal grandfather.

The kidney was donated to him by his paternal uncle while the part liver donor was the patient’s maternal uncle. Amaar’s father is a shop owner and was unable to support his treatment.

The operation was particularly difficult because of Amaar’s severely compromised immunity status. The treatment of the child has been sponsored by the Government of Pakistan. The funding for this has been channelized through the Pakistan High Commission in India.

Dr Vij explained, "Only one in five lakh people are affected by primary hyperoxaluria. This is indeed one of the most challenging cases in transplants as it requires extensive dialysis pre-operatively and then post-operatively. In such an operation, the patient and the two donors are operated in tandem and this needs precision and absolute coordination with After the surgery, the patient was kept under the close no scope for human error.” observation of specialist paediatric hepatologists, urologists “The child has been in pain for the last five years. Over time, and nephrologists who attended on him for nearly 10 days, he has become extremely weak, unable to even do routine nursing him back to health. Amaar is now ready to be activities including playing or going to school. As a result, his discharged and sent home. education has also been suffering. We are glad that the child will soon be able to go back to his daily activities.” said, Dr. Dushyant Nadar.

Granules India’s Primary hyperoxaluria is a rare condition characterized by the overproduction of a substance called oxalate (also called oxalic acid). In the kidneys, the excess oxalate combines with calcium to form calcium oxalate, a hard compound that is the main component of kidney stones. Deposits of calcium oxalate can lead to kidney damage, kidney failure, and injury to other organs.

Primary hyperoxaluria is caused by the shortage (deficiency) of a liver enzyme alanine-glyoxylate aminotransferase (AGXT) that prevents the buildup of oxalate in the human body. A simultaneous transplant of both organs is necessary for success, as a kidney transplant, by itself can fail because of deficient AGXT – produced in the liver.

10 w w w . m e d e g a t e t o d a y. c o m July-August 2014

Paracetamol API Facility completes U.S. FDA Inspection

Granules India Ltd., a fast growing pharmaceutical manufacturing Company, announced its Paracetamol facility successfully passed a U.S. FDA inspection without any 483 observations.The facility has the world’s largest single API production line by volume. Granules’ four API facilities have successfully passed U.S. FDA inspections in the past 12 months. All of Granules’ facilities including its finished dosage and PFI facility are approved by leading regulatory agencies including the U.S. FDA, EDQM, Health Canada and Korean FDA.

NEWS Updat e

w w w . m e d e g a t e t o d a y. c o m July-August 2014 11

NEWS Update

Wadhwani Foundation & Narayana Health pilot ‘game changing’ healthcare training program using ground-breaking learning techniques Pilot revolutionizes job readiness at scale via transformational, learner-centric, and scalable skills training program.

Wadhwani Foundation, in collaboration with Narayana Health (NH), has announced the success of its skills training pilot program for NH’s healthcare support staff. The program aims to fill the void of critical skills needed in the healthcare industry that are currently missing from formal and informal nursing education programs. Using videos and interactive, technologybased lessons, accessible on an online platform, Wadhwani Foundation’s courseware is designed for rapid rollout. To date, WF has reached more than 1,700 nurses and nursing assistants across 20 Narayana Health centers in just a few months. This program is part of Wadhwani Foundation’s larger vision of skilling India by leveraging technology and transformative learning techniques.

India continues to face a growing gap in maintaining a skilled labor force, or knowledge workers, to conduct some of the nation’s most critical – though often overlooked – jobs. Support and paramedical staff represent this segment in the healthcare industry; individuals are required to perform a skilled job without access to a job competency driven curriculum or having undergone formal training. According to industry experts, India’s health care sector faces a shortage of 1 million nursing assistants. Wadhwani Foundation strives to meet this need by producing quality, open source training solutions.

“Our strategic collaboration with Wadhwani Foundation is a step in the right direction. India’s healthcare industry is facing an acute shortage of support staff and I am glad that the skill

L

development initiative of Wadhwani Foundation has already skilled over 1,700 competent staff. This happened despite full shift schedules, because these learner-centric e- modules do not drain experienced teaching nurses’ time and allow the trainees flexibility in taking courses inside and outside the classroom.

Since we seek to expand from 5,000 beds to 30,000 beds in three years, rather than running disparate and traditional teacher driven training courses, this approach of creating and deploying repeatable, modular self and peer- driven lessons can help us realize this goal without diluting the skills of our people or quality of our care,” said Dr. Devi Prasad Shetty, Chairman, Narayana Health.

Levetiracetam best for seizures in pregnancy

evetiracetam is the best of the newer anti-epileptic drugs at controlling seizures in pregnancy, new Australian research finds.

The register-based study looks at seizure rates in pregnant women with epilepsy from 1998 to 2013, a period during which there was a transition from established seizure therapies such as carbamazepine and valproate to the new-generation anti-epileptic drugs (AEDs) levetiracetam, lamotrigine and topiramate.

The proportion of seizure-free pregnancies did not change 12 w w w . m e d e g a t e t o d a y. c o m July-August 2014

substantially over the period. In fact, women taking the newer drugs were more likely to suffer a convulsive seizure (29% versus 19%) as well as a seizure of any type (48% versus 35%).

But the study found a difference among the new-generation drugs, with levetiracetam performing significantly better.

Rates of seizure-affected pregnancies with levetiracetam were similar to those of older drugs while those for lamotrigine and topiramate were 50% and 30% higher, respectively.

NEWS Updat e

Extensive Atherosclerosis involving coronary and carotid vertebral systems managed with hybrid approach : Carotid angioplasty followed by CABG FEHI, New Delhi reinforced its leadership position by managing a complex case of a 60 years gentleman from Jamia Millia Islamia University, Okhla, New Delhi, who was a diabetic presenting with rest angina and transient ischemia attack (left hemiparesis). His coronary angiogram revealed extensive triple vessel Dr. Subhash Chandra disease requiring coronary Fortis Escort Heart Institute artery bypass grafting (CABG). While awaiting his CABG, his preoperative work-up revealed 4 vessel significant diseases of bilateral carotid vertebral systems.

Management issues in this complex situation were to carry out CABG and carotid endarterectomy of both carotids or to do carotid stenting of the culprit lesion (Right internal carotid artery) before CABG. The main challenge was about the risk of periprocedural cerebrovascular accident during surgical endarterectomy being higher than during carotid stenting in a case with 4 vessels atherosclerosis. Hence, the heart team decision favoured hybrid approach, whereby carotid stenting of Right carotid system was undertaken first using distal embolic protection device by Dr.Subhash Chandra, before sending him for CABG. He was taken-up for CABG by Dr.Z.S.Meharwal, two days after successful carotidplasty of right carotid system. Dr.Meharwal used arterial graft for LIMA to LAD and various grafts for other major vessels in an off-pump cardiac surgery. The patient recovered well and was discharged on 7th post-op day. He is awaiting carotid angioplasty of his left carotid system in coming days to ward off future risk of TIAs and major stroke. He is currently on dual antiplatelet drugs and high dose statins.

Novartis convenes 13th annual malaria expert panel with a focus on access to quality antimalarials across Africa Malaria experts from countries across Africa are meeting today at the 13th annual National Malaria Control Program (NMCP) Best Practice Sharing Workshop. The gathering provides a platform to discuss and share knowledge and experiences, and to drive dialogue around improved health outcomes and access to quality antimalarial treatments for patients in Africa. For these workshops, Novartis (http://www. novartis.com) works in collaboration with the Global Fund, World Health Organization, the WorldWide Antimalarial Resistance Network, the Kenya Medical Research InstituteWellcome Trust, Swiss Tropical and Public Health Institute, US Pharmacopeia, Populations Services International, Ifakara Health Institute, and the Pharmacy and Poisons Board.

“These NMCP meetings have led to groundbreaking projects such as the development of SMS for Life to improve antimalarial stock management in rural health facilities,” said Dr. Linus Igwemezie, Head of the Novartis Malaria Initiative (http://www.malaria.novartis.com). “We believe that by bringing together the best minds and leaders in the field, we can help foster new approaches that will help us ensure all patients have access to quality antimalarials and bring us closer to malaria elimination.”

The successful treatment of malaria depends on the public being informed about the risks of the disease, the importance of sleeping under insecticide treated bednets, and having access to health services including appropriate diagnostic tests and quality-assured antimalarial treatments.(3/page v) Unfortunately, in some countries bednet utilization remains a challenge;(3/page ix) while sub-standard antimalarials (3/page 9) and oral artemisinin monotherapies (3/page xii) remain available, primarily through the private sector. These treatments may contain too little or no active ingredient, thereby putting patients’ lives at risk. (4/pages 22&49) Speaking on behalf of the WorldWide Antimalarial Resistance Network, Dr. Ambrose Talisuna says: “It’s crucial that governments take urgent action to ensure patients are not put at risk of sub-standard treatments. We must make sure that the public is made aware of the importance of taking preventative measures as well. The ongoing role of Novartis in facilitating these workshops provides a platform for discussing these important issues, for sharing best practice in public education and for mapping the sources of poor quality antimalarials.” w w w . m e d e g a t e t o d a y. c o m July-August 2014 13

NEWS Update

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A book on “Uttrakhand - Kedarnath Medical Rescue Operations” by

Dr. Pradeep Bhardwaj & Six Sigma Team was released on the first anniversary of the gigantic natural calamity in Uttarkhand in June 2013

The book highlights the spirit of mankind which voluntary reaches out to those affected by natural disaster. It brings out the role of Six Sigma Team in Uttrakhand flood landslides (June 2013) in organizing “Medical Rescue Operations” at Kedarnath & Badrinath and which saved lives of 511 people. This effort was a milestone in the history of the nation as the team members put their lives at risk for providing medical relief services to pilgrims in inaccessible pockets of Himalayan terrain, where crucial roads had suffered extensive damages, landslides had cut off the upper reaches and line of communication were down.

Shri Sanjay Kumar Srivastava (IAS) Chief Secretary of Delhi was the chief guest of the event and Dr. D.S Rana – Chairman Sir Gangaram Hospital, Dr. D. R. Rai -Former President IMA, HQ Delhi, Dr. Rajat Mohan Senior Consultant- Sir Gangaram Hospital, Brigadier KB Chand- Army HQ Delhi, Mr. Rahul Sharma Senior Editor were the Guest-of-Honour at the event.

Shri Sanjay Kumar Srivastava (IAS) Chief Secretary of Delhi launched the book and appreciated the efforts of Six Sigma Medial Camp Volunteers, who worked with the Indian Army for rehabilitation and relief of the survivors of this natural disaster during the initial crucial phase. He also addressed the audience consisting of students, representatives of welfare organizations and non-governmental organizations (NGOs). He applauded the voluntary medical support and assistance rendered to the survivors, and expressed the hope that their effort would be an example for others to follow. “This example of volunteerism is touching and inspiring, and as an Indian, I am proud that Dr. Bhardwaj & Six Sigma Team have made a lasting impression in the hearts of so many” he said.

The last year’s natural calamity of June 16 through 19 that devastated the whole of Uttarakhand and large areas of Himachal Pradesh and western Uttar Pradesh — an area of almost 20,000 sq.km. — was one of extreme rare severities among all the hydro-meteorological disasters to have struck India. Intense point rainfall exceeding 200 mm occurred within a 24-hour spell and continued with lesser intensity for a few more days over several locations in the Alakananda and Bhagirathi basins. Such short-duration intense rainfall in June has a statistical recurrence interval exceeding 500 years.

14 w w w . m e d e g a t e t o d a y. c o m July-August 2014

The contents of the book are enriched by including experiences contributed by volunteers, partners and beneficiaries about their first-hand involvement in the rescue, as well as the team’s focus and plan on rehabilitation through counseling, treatment, the relief & recovery in the initial phase.

The Next MEDICAL FAIR INDIA Dr Pradeep Bhardwaj stated that “as their commitment towards serving nation, this year Six Sigma Team is organizing medical camp for devotees undertaking the arduous annual Amarnath yatra”. “The situation has changed considerably over the last few years as the weather remains unpredictable most of the time there and those caught in between the way should have the physical strength to counter all odds and adversities”. Former MLA Bhai Bharat Singh was the guest for Sh. Amarnath Ji Yatra Medical Camp Training program and had motivated the volunteers & appreciated the efforts of Dr. Bhardwaj and team Six Sigma. The groups of volunteers were given brief sessions by six sigma experts and training about preparedness for high altitude medical camp services & how they can keep themselves safe and healthy for tough physical activities. Initially training explained the mean & measures so that before departure every volunteer becomes fit to walk at a stretch without any stopovers and help other yatris in medical emergency.

NEWS Updat e

w w w . m e d e g a t e t o d a y. c o m July-August 2014 15

NEWS Update

Encephalitis spreading in Muzaffarpur and adjoining districts

The majority of patients who have encephalitis go on to have at least one complication, especially elderly patients, those who had symptoms of coma

Medgate today spoke person talk about encephalitis to Dr.Rajiva Kumar

Figure 1. Union Health Minister Dr Harsh vardhan with Dr Rajiva Kumar

T

he suspected encephalitis death toll in Bihar's Muzaffarpur district is increasing by the day and according to the report, many children have died in the last two months.

Now, the outbreak is spreading to some of the adjoining districts. Three-year-old Salman, from Bihar's Sheohar district, has been at a government hospital in Muzaffarpur for over two days now, brought in with the familiar symptoms of fever, shivering and body ache, that affects hundreds of children in these parts each year, and has resulted in many deaths from what doctors suspect is acute encephalitis.

Figure 2. Chief Mimister of Bihar Jitan Ram Manjhi with Dr Rajiva Kumar

Some of cases seen in Muzaffarpur as follows: ÂÂ SKMCH: Admitted -319 ÂÂ Died:

108

ÂÂ Cured:

198

ÂÂ Kejriwal: Hospital- admitted -189 ÂÂ Died:

39

ÂÂ Cured:

115

ÂÂ Referred: 25

But over two decades after this disease started hit Muzaffarpur, Encephalitis is acute inflammation (swelling up) of the brain no cause or cure has been found yet. resulting either from a viral infection or when the body's own immune system mistakenly attacks brain tissue. The most Encephalitis can be life-threatening, Says Dr.Rajiva Kumar common cause is a viral infection. In medicine acute means The Bihar government says it has provided an ambulance at it comes on abruptly; of abrupt onset, develops rapidly, and each block office within Muzaffarpur so that children exhibiting usually requires urgent care. Encephalitis occurs in 1 in every any of the symptoms can be rushed to the designated hospitals. 1,000 cases of measles.

Currently, two hospitals in Muzaffarpur, one government and one private children's hospital have the required facilities and Encephalitis generally begins with fever and headache. treatment available. However a dedicated encephalitis ward The symptoms rapidly worsen, and there may be seizures at the government hospital has not been set up but authorities (fits), confusion, drowsiness and loss of consciousness, and evencoma. says it will be created soon.

The Union Health Minister announced a series of measures to tackle encephalitis including a bigger effort to identify the cause of the disease and a five-year action plan similar to the one implemented for polio.

16 w w w . m e d e g a t e t o d a y. c o m July-August 2014

When there is direct viral infection of the brain or spinal cord it is called primary encephalitis. Secondary encephalitis refers to an infection which started off elsewhere in the body and then spread to the brain.

NEWS Updat e

w w w . m e d e g a t e t o d a y. c o m July-August 2014 17

NEWS Update

Symbiosis Centre of Health Care Punekars’ welcome the palakhi of Shri Sant Dnyaneshwar Maharaj & Shri Sant Tukaram Maharaj with much zeal and gusto in the month of June/July every year which starts from Alandi & Dehu respectively . The Palakhis’s then proceed to Pandharpur, the home of Vithoba – Rukhamai.

This year too, the Palakhis of Shri Sant Dnyaneshwar Maharaj & Shri Sant Tukaram Maharaj started its 23 day journey from Alandi & Dehu respectively to the home of Lord Vithoba. This grand procession was welcomed by Punekars’ on 21st June 2014.

From 21st June to 23rd June 2014, Symbiosis Centre of Health Care (SCHC) and Symbiosis Institute of Health Sciences (SIHS) in association with Mrs. Sheela Salve Memorial Trust, arranged four mobile medical units to offer free medical services by emergency medical practitioners for warkaris. Whilst the MBA students of Hospital & Health care Management, SIHS looked after the overall logistics & management of the event.

Dr. Rajiv Yeravdekar, Dr. Vidya Yeravdekar with a few teaching & non-teaching staff of Symbiosis walking with the palkhi

The Inaugural ceremony was organized at Vishwabhavan, Symbiosis. Mr. Sharad Ranpise, MLA, inaugurated the medical services by Symbiosis for the warkaris and delivered an inaugural speech. This was followed by an address by Mr. Sumeet Sharma, Divisional Railway Manager, Pune. Dr. S. B. Mujumdar, President & Founder, Symbiosis elaborated on the Symbiosis initiative in the Community Outreach Program. Mrs. S. S. Mujumdar Hon. Director, AMM Symbiosis; Dr. Vidya Yeravdekar, Symbiosis Mobile Medical Unit- A team of 120 doctors treated over Principal Director, Symbiosis; Dr. Rajiv Yeravdekar, Dean, 25,000 patients Faculty of Health & Biomedical Sciences, Symbiosis and Mr. Avinash Salve, Ex- Corporator PMC and many different kinds of minor injuries, aches / pains etc. The dignitaries attended & expressed their opinion on this event was successfully managed by SCHC Medical noble initiative spearheaded by Symbiosis & Sheela Salve Officers, Emergency medical practitioners’ and the MBA Memorial Trust. students which was applauded by one and all.

This was followed by the departure of the mobile medical Standing true to the saying, “Leader by example”, on 21st units for the wari from Symbiosis campus to specified June 2014, Dr. Vidya Yeravdekar, Dr. Rajiv Yeravdekar locations. encouraged the teaching & non-teaching staff members of Last year the total number of warkaris served were 12,552. Faculty of Health & Biomedical Sciences to join & walk This year the total number of warkaris served has increased with the wari which was nearly 15 K.M. This as cited later to 26,950. Warkaris were treated for various ailments like by many employees of Symbiosis was an experience of a Acute Gastro Enteritis, Fever, Acute respiratory infection, lifetime.

18 w w w . m e d e g a t e t o d a y. c o m July-August 2014

NEWS Updat e

w w w . m e d e g a t e t o d a y. c o m July-August 2014 19

NEWS Update

Vasudev Hospital Making Healthcare Affordable First Hospital Inaugurated in Bijapur, Karnataka

In an effort to make secondary healthcare services affordable and within reach of common people of tier II & tier III Vasudev Hospitals Pvt. Ltd. (VHPL) has been inaugurated their first hospital on 29th June 2014 in the gracious presence of Shri Shanta Mallikarjun Swamiji, Member of Parliament Shri Ramesh Jigajinagi, MLA Shri C S Nadagounda, North region IGP Shri Bhaskar Rao and SP Bijapur Shri Ram Niwas Sept.

VHPL`s Managing Director Mr. Tarun Katiyar stated the purpose of VHPL is founded with the noble motto of “Living for Others”.

people. While the cost of treatment is increasing worldwide, “The concept of Vasudev Hospital is derived from Lord the effort for low cost and high end hospital is commendable.

‘Krishna’, the soother of all pain, the strength of all noble Among the dignitaries, MP-Bijapur, Shri Ramesh Jigajinagi and the sprit behind the righteousness” – Vasudev. emphasized on the need of private hospital in the area and According to the Managing Director Mr. Tarun Katiyar the need of extending healthcare services to the poor at the vision of VHPL is to be the most preferred healthcare affordable cost. He pointed out that the poor are not able to provider for patients, medical practitioners and healthcare afford the high cost of cooperate hospital but they need the professionals by providing state-of-the-art medical care kind of medical care provided at such hospital. Shri Shanta with compassion and dignity. He emphasized on the need Mallikarjun Swamiji stressed on the importance of good of increasing the reach of affordable medical services to the health care and medical services in the area.

3D mammograms catch cancer earlier Three-dimensional mammograms can catch breast cancer earlier and reduce false positives, a new study has found. The American study found the technique - known as tomosynthesis - helps increase breast cancer detection rate when used alongside traditional 2-D mammograms.

And the combination of the two methods also decreases the proportion of patients called back for more tests, the study published in JAMA found.

The combination is especially good at finding small invasive cancers that are most likely to be lethal. There was a higher cancer detection rate in the combination method which could mean fewer unnecessary tests and biopsies, the authors wrote.

But while tomosynthesis is likely to be better than traditional mammography, some fundamental questions about when to screen, how often and with what tools remain, the paper said. The technique uses less compression and takes about 20 seconds longer than standard mammography.

20 w w w . m e d e g a t e t o d a y. c o m July-August 2014

NEWS Updat e

Kodak alaris achieves microsoft gold competency Kodak Alaris today announced that it has attained a Gold Application Development competency, demonstrating a “best-in-class” ability and commitment to meet Microsoft Corp. customers’ evolving needs in today’s dynamic business environment. By achieving Gold-level competency, Kodak Alaris has distinguisheditself within the top one percent of Microsoft’s partner ecosystem.

the latest Microsoft technology,” said Phil Sorgen, Corporate Vice President, Worldwide Partner Group at Microsoft Corp.

“These partners have a deep expertise that puts them in the top one percent of our partner ecosystem, and their proficiency will help customers drive innovative solutions on the latest Microsoft technology.”

Earning the Application Development competency helps partners differentiate themselves as a trusted expert to their customers through development and deployment of commercial or custom applications built using core Microsoft technologies such asSharePoint, Windows Server and Windows 8 operating systems, the Windows Azure platform, Microsoft Visual Studio 2012 development system, Microsoft BizTalk Server and emerging cloud-based and web business models. By gaining access to a comprehensive set of benefits through the Application Development competency, partners can acquire new customers and help them be more productive “Achieving a Microsoft Gold competency showcases Kodak and profitable through deployment of business applications, Alaris’ expertise and commitment to being a leader in advanced web portals or rich client user interfaces that run on information management and technology, while demonstrating premises or in the cloud. our deep knowledge of Microsoft and its products,” said Dolores Kruchten, President of Kodak Alaris’ Document The Microsoft Partner Network helps partners strengthen their Imaging division (kodakalaris.com/go/dinews). “We plan to capabilities to showcase leadership in the marketplace on the increase our customers’ success by serving as technology latest technology, to better serve customers and, with 640,000 advisors for their most challenging business demands.” “By Microsoft partners in their ecosystem, to easily connect with achieving a gold competency, partners have demonstrated one of the most active, diverse networks in the world. the highest, most consistent capability and commitment to To earn a Microsoft gold competency, individuals from partner organizations must successfully complete a series of examsto prove their expertise, resulting in the Microsoft Certified Professional credential. Gold Partners must designate these certified professionals to one Microsoft competency, ensuring a certain level of staffing capacity. Partners also must submit customer references that demonstrate successful projects, implement a yearly customer satisfaction study, meet a revenue commitment and pass technology or sales assessments.

CABG better than PCI for diabetes heart patients Diabetes patients undergoing coronary artery bypass grafting (CABG) for multi-vessel disease were 38% less likely to have died within three years compared with those who had had a percutaneous coronary intervention with a drugeluting stent (PCI-DES), data from nearly 5,000 patients showed.

CABG patients also had a significantly lower risk for myocardial infarction and were three times less likely to need revascularisation, cardiac or cerebrovascular events (MACCE) at three years was 35% lower in CABG patients. Although several recent trials have explored the difference between the two techniques in diabetes patients, they were often too underpowered to demonstrate effectiveness. The current study was the largest meta-analysis to date. It provided evidence of the prolonged effectiveness of CABG versus PCI-DES in a diabetes setting, with CABG “unambigiously associated with lower risk of MACCE”.

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NEWS Update

Largest ever analysis on the use of a polypill in cardiovascular disease shows potential for improvements in patient care Almost 1 in 4 Patients Adhered Better to Treatment; Significant Improvements in Blood Pressure and Cholesterol New data presented for the first time today at the World Heart Federation’s World Congress of Cardiology 2014 shows a significant improvement in both patient adherence and risk factor control when patients at high risk of heart attack or stroke receive a polypill, compared to usual care. A polypill is a fixed dose combination of commonly-used blood pressure and cholesterol lowering medications, along with aspirin, which helps prevent cardiovascular disease (CVD).

The Single Pill to Avert Cardiovascular Events (SPACE) project, led by researchers from The George Institute for Global Health, analysed data from 3140 patients with established CVD or at high risk of CVD in Europe, India and Australasia. The results showed a 43 per cent increase in patient adherence to medication at 12 months with the polypill, in addition to corresponding improvements in systolic blood pressure and LDL-cholesterol that were highly statistically significant.

The largest benefits were seen among patients not receiving all recommended medications at baseline, which corresponds to most cardiovascular disease patients globally. “These results are an important step forward in the polypill journey and management of cardiovascular disease”,commented Ruth Webster of the George Institute for Global Health, Sydney. “Most patients globally either don’t start or don’t continue taking all the medications they

need, which can lead to untimely death or further CVD events.

An important finding from our analyses is that the greatest benefits from a polypill were for currently untreated individuals.

Although the idea of a polypill has always been appealing, we now have the most comprehensive real-world analysis to date of this treatment strategy in high risk CVD patients. Given the potential affordability, even in low income countries, there is considerable potential to improve global health.”

CVD is the number one cause of death globally, killing 17.3 million people each year and it is expected to remain the world’s leading cause of death in the near future. Access to effective treatment like polypills can play a key part in achieving the bold World Health Organization (WHO) target of at least a 25 per cent reduction in premature mortality from NCDs by 2025, especially as a polypill can be cheaper than several individual drugs.

Professor Salim Yusuf, Presidentelect of the World Heart Federation said: “These results emphasize the importance of the polypill as a foundation for a global strategy on cardiovascular

22 w w w . m e d e g a t e t o d a y. c o m July-August 2014

disease prevention. It will improve patient access to essential medications at an affordable cost and wide use of the polypill can avoid several millions of premature CVD events. The polypill is however not a replacement for a healthy lifestyle and should be combined with tobacco avoidance, a healthy diet and enhanced physical activity. This broad strategy, if adopted widely, can reduce cardiovascular disease to a large extent.”

SPACE combined results from three clinical studies which took place from 2009 – 2013: UMPIRE (Europe and India), Kanyini-GAP (Australia) and IMPACT (New Zealand). Importantly, in the Australasian trials, half the patients were indigenous. Further analysis of this unique data source is underway to investigate the effect of the polypill on major patient groups and the results of this are expected over the coming year.

NEWS Updat e

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“Budget Planning ensures healthcare for every citizen in the country” Dr Harsh Vardhan Union Health Minister

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Highlights of Healthcare Budget: ÂÂ T wo National Institutes of Ageing to be set up one at AIIMS Delhi other at Chennai. ÂÂ A national level research and referral institute to be set up for higher Dental Studies ÂÂ A IIMS like Institutes to be developed in West Bengal, Maharashtra, Purvanchal and Andhra Pradesh ÂÂ 12 New Govt Medical Colleges to be set up ÂÂ D istrict Hospital will be converted into Medical college ÂÂ New Drug Testing Laboratories to be made ÂÂ Rota Virus & Inject able polio vaccine for children ÂÂ 15 model rural health research centres to be established. ÂÂ National programme in mission mode to halt deteriorating malnutrition status in India. Total capital expenditure of 500 cr (within the overall budget allocation for health and family welfare) is budgeted for these new institutions

A

iming to ensure “Health for All,” government promised to take up on priority initiatives like providing free drugs and diagnostic services besides earmarking Rs 500 crore to set up four more AIIMS-like institutes and earmarked Rs 39,237.82 crore for the sector.

In his maiden budget speech, Finance Minister Arun Jaitley said the government has also decided to set up 15 model rural health research centres in states for better healthcare facilities in rural India.

Jaitley said Rs 500 crore has been allocated for a plan to set up four more AIIMS-like institutes in Andhra Pradesh, West Bengal, Vidarbha in Maharashtra and Poorvanchal in Uttar Pradesh.

He also proposed to add 12 government medical colleges, where dental facilities would also be provided. At present, w w w . m e d e g a t e t o d a y. c o m July-August 2014 25

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58 government medical colleges have been approved.

Health Research Rs 1,017 crore, against 1,008 crore in the last budget.

The allocation to the health sector was up by merely 5 per cent from Rs Rs 37,330 crore proposed in the last budget Government’s flagship programme for providing universal by the previous Congress-led UPA government in the last access to equitable, affordable and quality health care – The National Health Mission has been earmarked a total of Rs budget.

21,912 crore, up 16 per cent from Rs 18,880 crore proposed “In order to achieve universal access to early quality for it in the last budget. diagnosis and treatment to TB patients, two National Institutes of Ageing will be set up at AIIMS, New Delhi and For the first time, the Government will provide central Madras Medical College, Chennai. A national level research assistance to strengthen the States’ Drug Regulatory and and referral Institute for higher dental studies would be set Food Regulatory Systems by creating new drug testing up in one of the existing dental institutions,” Jaitley said. laboratories and strengthening the 31 existing state laboratories, he said.

Of the total allocation for the health sector for 2013-14, the Department of Health and Family Welfare got the major “In keeping with the Government’s focus on improving share of Rs 35,163 crore that includes Rs 30,645 Plan outlay. affordable health care and to augment the transfer of technology for better health care facilities in rural India, This is up from Rs 33,278 crore proposed in the last budget 15 Model Rural Health Research shall be set up in the that includes Rs 29,165 crore of Plan outlay. states, which shall take up research on local health issues The Department of Ayush got an outlay of Rs 1,272.15 crore concerning rural population,” Jaitley said enumerating (against Rs 1,259 crore in the last budget), the AIDS Control steps for the health sector in the budget.Some highlights Rs 1,785 crore (same as last year), and the department of of Health Budget.

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India Still Lives in Villages Walking 5Km to get to a Doctor is not a Sign of a Healthy Nation

I

n India, every opinion piece on health talks in terms of medical colleges, GDP, doctor population ratios etc.

India needs to talk health in terms of infant mortality rates (IMR), maternal mortality ratios (MMR) and life expectancies. In India health means medical care. The word ‘health’ very often misused for the word ‘medical’.

Producing healthcare professionals in large numbers is not the same as making them available where their services are needed.

Dr. Ramakanta Panda Vice Chairman Cardio Vascular Thoracic surgeon Asian eart Institute

In 2013, the Union Cabinet approved the government’s plan for the creation of a specialised cadre of health care workers for rural areas by instituting a three-year-course in State universities. The Bachelor of Science (Community Health) course will create a cadre of Community Health Officers who will be posted at sub-centres, functioning under the Ministry of Health and Family Welfare, where they can provide basic health care.

This approval recognises that India’s MBBS doctors have not been stepping into villages. India seems to be thinking in terms of alternative professionals to its rural population. This is a good move, but they need to integrate seamlessly into the current rural healthcare structures.

India does live in its villages. According to census 2011, of the 121 crore population in India, 83.3 crore people live in the villages. According to

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the proposal, persons belonging to rural areas will study a three-year course on basic anatomy, and diagnosis and treatment of basic ailments.

the burden of disease. India has just 130 beds per 100,000 population against a world average of 270 beds &WHO mandate of 350 beds.

The emphasis on training will be on conducting normal deliveries, pre-and anti-natal care, handling diarrhoea, pneumonia, vaccination, providing tuberculosis treatment and treatment of fevers and skin infections.

The idea is, that walking 5km when in ill-health and pain, is not practical. There should be a doctor available nearby.

According to World Bank data, India spends 4% of its GDP on health, which is among the lowest in the world (the average for LMICs is 5.7%- denotes those countries within Sub-Saharan Africa, South-east Asia or South Asia (with the exception of India.)

The Health Ministry has also stated that these professionals will eventually be absorbed by the State Health Departments and will subsequently be posted to higher levels of health care facilities.

Universal Healthcare

The important goal for the new Government is that of “universal healthcare.” As the new Government takes over, the glaring reality is that India needs universal health coverage - to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.

History has shown that wherever universal health has truly established itself, and has treated rich and poor alike, it has been a huge leadership effort- something that the present Government with a thumping majority can work towards.

When efficient healthcare providers like Sweden (ranked 10th on the Bloomberg Healthcare survey, 2013) and Spain (ranked 5th on Bloomberg Healthcare survey, 2013) started their universal health policies they were at their poorest. That these countries prospered subsequently, underlines the mantra ‘Health is wealth’.

India’s Healthcare Reality India is a smouldering cauldron of inequities, a rapidly developing economy with a very small super-rich class, fast expanding middle class and 22% still under the poverty line.

India is burdened with a twin epidemic of infectious and non-communicable diseases. Even as we tackle diarrhoea and tuberculosis as causes of large scale death, we face the dubious distinction of being the heart disease and diabetes capital of the world. In the year 2015, India is projected to lose 237 billion dollars as income loss attributable to the burden of chronic disease.

India’s healthcare infrastructure is inadequate to meet

Not only is this a low amount, but out of this, 61% is out-ofpocket expenditure (response to calamities and problems as opposed to planned expenditure) as opposed to 37% in LMICs- which leads us to a much lower effective spend.

We need a concrete healthcare agenda that includes ÂÂ a. With 626 millions openly defecating, India has the dubious distinction of accounting for 59% of 1.1 billion people worldwide who practice it. According to UN this is the riskiest sanitation practice , one of the main cause of diarrhoea. Each day 3000 children before age 4 die from this. Diarrhoea related illness deprive India of 73 million working days each year. The supply of potablewater along with radical improvements in sanitation and waste controlshould be priority areas. ÂÂ C urrently less than 15% of the Indian population is covered under some form of health insurance, including government-supported schemes. Only around 2.2% of the population is covered under private health insurance, of which rural health insurance penetration is less than 10% .At the current rate of growth only 50% of India’s population would have health insurance coverage by 2033. Public and private sector players need to be incentivised & need to come out with innovative insurance products to cater to all segment of population , especially non affording population. ÂÂ W e have discussed the Bachelor of Science (Community Health). There is also a desperate need to increase the number of doctors in various specialities. To this end the government should allow private hospitals to impart post-graduate education ( MD,MS, DM,MChetc ), as is the practice in many countries in the world. ÂÂ T here is a severe shortage of other important human resources such as nurses and paramedical staff – skills required across the entire healthcare delivery system. While creating infrastructure to produce human resources to catch up with healthcare growth will take time, temporarily the gap can be reduced by making it mandatory for all healthcare workers to work in the country for a limited period before they are allowed to go outside India.The government must

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work actively to encourage a reverse ‘brain drain’ as has occurred in the I.T. sector. ÂÂ We should also consider allowing foreign trained doctors to work in India after they clear our medical board exams. After all, are we are living in a global world and are using professionals from other countries, such as pilots and IT experts, so why not in healthcare too, especially when Indian doctors are allowed to work in many countries in the world. ÂÂ T he infrastructure needs to be put in place for preventive, primary and secondary healthcare. A large part of preventive care can be delivered through mass education programs, along with appropriate policy changes. ÂÂ P rimary and secondary care are more dependent on physical infrastructure being in place, and an increase in hospital bed capacity is the need of the hour. In India, there are approximately1.3 hospital beds for every 1,000 persons in the population, while the WHO recommendation is 3.5. In other words, we need to almost triple our current capacity to adequately meet the needs of the population. Over the last decade most of the growth in hospital beds has been in the private sector, and will continue to do so. The government needs to encourage public-private partnerships, with very transparent and clear guidelines, otherwise several of these will falter after a promising start.

ÂÂ

ÂÂ

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As Anais Nin has famously said, “and the day came, when the risk to remain tight in a bud was more painful than the risk it took to blossom.” free or subsidizedmedication should be a priority, especially to citizens below thepoverty line. This is vital, since medicines make up about 70% ofout-ofpocket healthcare expenditure. Tamil Nadu, Kerala, andRajasthan are some of the states which have taken up this project andhave had varying degrees of success in implementation. Centralizedprocurement by the states, in direct negotiation with pharma companies, along with decentralized distribution seems to be theappropriate model and should be implemented across the country.

Rural Health Care and Bsc (Community Health)

India’s public sector rural healthcare (RHC) consists of a sub centre (SC) for every 3000 to 5000 population and a primary health centre (PHC) for every 20,000 to 30,000 population and an Accredited Social Health Activist (ASHA) for every 1000 population.

A SC is an interface with the community at the grassroot level. It is manned by two female multipurpose health assistants (MPHAs) and one male MPHA. Before launching of MPHW programme, the designation of female MPHA was Auxiliary Nurse Mid Wife (ANM). They are called as Front line Health Workers. Most of the curative, preventive To encourage capacity building, tax free infrastructure and promotive services are provided at the SC level. A PHC status for hospitals could be granted. In addition, is the corner stone of Rural Health Services, the first port a robust Clinical Establishments Act needs to be of call to a qualified public sector doctor in the rural areas. framed and enforced. It should simplify the process Paramedical staff play a crucial role in rural health of establishing hospitals instead of increasing the number of licences and permissions needed for one. and medical care. Small pox eradication is due to their committed work and sacrifices.

The Act should focus more on improving quality of patient care rather than rules to increase bureaucratic Due to their hard work, India is free from the endemic of processes. Transparency should be the hallmark poliomyelitis. An ASHA is capable of diagnosing deadly and public reporting of medical outcomes should be falciform malaria and initiating treatment within 15 encouraged. Clinical aspects, such as infection control minutes, a great public health revolution. But, as the medical and antibiotic use policies should be emphasised. officers do not lead them, they do not work adequately. They Replacing multiple regulatory bodies like MCI, Nursing don’t have a role model to follow and the net result is all council, dental council with a single regulatory body round dysfunction. & giving them a tenure of 3 years with clearly defined deliverables. An independent body should be created While it is not at difficult to position a MBBS at PHC, to nominate these members from among the best in we need to evaluate how the new Bachelor of Science the field (who normally shy away from elections).

(Community Health) will fit in.We should also have proper Under the universal health coverage, supplying policy on creating MBBS and their deployment.

ÂÂ I n addition, digitisation of medical records would prove to be a great boon to patients, besides improving healthcare delivery and reducing cost. India has the advantage of being a leading BPO provider to the world, and could achieve this at a comparatively low cost. ÂÂ

I would like to conclude by saying that I am optimistic of our future in general and healthcare in particular.

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NEWS Updat e

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Expectation from new government-Health for All Health care will drive the economy of the world since it is going to create the largest number of jobs. ÂÂ Major commitment from the government to reduce the IMR and MMR by half within 5 years. This again cannot be done without having adequate number of gynecologists, anesthetists, pediatricians and radiologists.

Dr. Devi Shetty xxx

Priorities for the government

Once we have adequate number of these specialists they will ensure that the rest of the support system comes up on its own.

ÂÂ 3. We have to Cap malpractice compensation. Rs. 12 crore of malpractice compensation given by the supreme court for a patient’s death in Kolkata will reset the compensation from consumer court and this will result in major shutting down of small nursing homes where most of the children are born in tier II cities. ÂÂ 4. Universal health care and health insurance should be offered through a mobile phone health insurance scheme by collecting Rs. 20/- from each mobile phone subscriber every month. This will cover health care of 850 million people.

Yashaswini health insurance of Karnataka started 10 years ÂÂ Without reforms in medical education health care ago with a premium of five rupees per month and that has reforms cannot happen. The biggest problem India saved lakhs of life. is facing it not the lack of beds or the medical equipments, it is the lack of doctors at the right place with ÂÂ 5. Create a career progression for the nurses. Otherwise nursing profession will die in India. Admission to nursing right qualification. colleges in Southern part of India has come down by 50%

We have created first world regulatory structure with third because nursing has become a dead end job and they are is world infrastructure. We prevent doctors with MBBS degree no career progression like in the west where they can become from anesthetizing the patient by law. And we only have nurse anesthetist, nurse intensivist, nurse practitioner or they less than 40,000 anesthetists across the country. Without can choose to became even doctors. anesthetists no surgery can happen. ÂÂ 6. Create a state wise paramedical university only for

We hardly have radiologists across the country and without a radiologist’s no diagnosis can be made and no patient can be treated.

MD radiology is worth Rs. 5 crore. There is something seriously wrong with medical education, I am not talking about the way medicine is taught, I am talking about how the students are chosen and the lack of adequate number of PG seats.

Like in the west, we must have more PG seats then UG seats to offer better health care to tier II cities without that maternal mortality and infant mortality will not go down.

32 w w w . m e d e g a t e t o d a y. c o m July-August 2014

paramedical education. Behind every doctor there are 5 technicians who are helping the process of safe health care.

Unfortunately the paramedical and nursing bodies are controlled by the medical councils and doctors in the medical universities who do not want to empower the paramedical professionals and nursing professionals.

Unless they stand on their own, paramedical profession will not get its due recognition.

My most important point is the commitment by the government to halve the maternal mortality and infant mortality within 5 years.

COVER St ory

Union Budget 2014-15:

Budget Expectations

T

here are a significant number of expectations from the new finance minister in his maiden budget. The new government with its mantra of ‘minimum government and maximum governance’ had already announced a few measures to change the mode of governance.

Given that the government might have a new modus-operandi, we do expect some surprise measures in the Union Budget 2014-15.

Dr. Arun Singh Sr. Economist Dun & Bradstreet India

Since the consensus for growth this year would be around 5.0% – 6.0%, we expect the government to present a more realistic budget on these lines which would help in reducing the gross borrowing for the year partly reducing the strain on availability of finances for the private sector. The biggest challenge would be therefore to set the path for fiscal consolidation while focusing on revival in growth. India needs a robust fiscal policy to support growth and monetary policy going ahead. Expectations are high on how the government will present an adjustment to the former government’s budget and execute and implement its own strategy. It would be worthwhile to note that provisioning of food subsidy and the implementation of the 7th Pay Commission would be the two major road blocks towards attainment of fiscal deficit target going ahead.

Given that growth is expected to recover at a modest pace during the year, there would not be a significant revenue augmentation. Nonetheless, if the government announces any definite measures which would either lead to broadening of the tax base or increase in tax compliance, a modest increase in revenue cannot be rule out. However, improvement in tax buoyancy could w w w . m e d e g a t e t o d a y. c o m July-August 2014 33

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offer certain incentives to revive public healthcare system in India which is currently plagued with poor access to care and high out-of-pocket expenditure on healthcare. ÂÂ H ealthcare spending is likely to step up so as to strengthen public health facilities. ÂÂ I n an attempt to encourage private sector participation, the Union Budget could extend tax incentives for settingup hospitals in Tier II and Tier III towns of India. ÂÂ Certain key initiatives are likely in the area of health insurance, waste management and sanitation.

Nonetheless, the focus would be on how the government charts out its expenditure. There is a need to reassess the quality of expenditure and rebalance the composition of expenditure to achieve higher capital formation. Hopefully, this time the plan capital expenditure receives a greater share of the overall plan expenditure.

We expect more focus on the infrastructure sectors and announcement of some measures to facilitate infrastructure financing. ‘Investment-linked incentives could incentivize the private sector investments during the current period of slowdown.

Sector-wise coal, power with special focus on nuclear power as well new and renewable energy, transport and information technology besides urbanization is expected to receive a boost in the upcoming budget.

The wish list can be long and expectations can be higher, nevertheless, what we would want from the government is outlining a clear strategy and also stating its execution plans as it is the implementation that holds the key to success.

Budget Expectations for the Social Sector

ÂÂ The Union Budget 2014-15 is expected to

34 w w w . m e d e g a t e t o d a y. c o m July-August 2014

ÂÂ E ducation, particularly girl’s education, could receive a huge impetus in the upcoming Union Budget. Skill development will remain another key area where some new initiatives could be announced. In an effort to boost and provide further impetus to the skill development programme, a mechanism is likely to be put in place in order to give academic equivalence to vocational qualifications. 

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only result from bringing about structural changes in the tax structure such as implementation of GST and DTC. We also expect the government to take a strong stance on some of the impending tax-related disputes relating to retrospective changes to tax laws, transfer pricing laws and General Anti-Avoidance Rules (GAAR). We would also expect the government to give a clear outline of its intentions on disinvestment which would also help in assessing the resources available for its expenditure.

EXPERT Views

IT in Improving Quality

in Health Care

H

for voice traffic with greater mobility as an added ealth today has become more technology-driven advantage. Ensuring secure access of VoIP can enable as compared to the past. Today’s providers and an organization to comply with patient privacy and data consumers are information-powered with the help security standards. of innovative tools and technology. Technology has ensured the access to health within the reach of the ÂÂ Wearable Technology: Electronics like VESAG smart watch or Google Glass have made Remote Health unreached including remote and rural population. Technology Monitoring and Mobile Personal Emergency Response has helped in meeting consumer expectations while maintaining System (MPERS) a reality. With the help of such wearable the costs within limits. Health care organizations are relying technologies one can monitor almost all the body vitals increasingly on technology to improve the efficiency and in real-time. It not only helps the consumer but also the thereby the outcome of care. Technology has changed the providers to deliver the best. These devices are minute in way health care is delivered and accessed. Advancement in size hence wearable and have a wide social acceptance technology in the field of diagnostic medicine is revolutionary. in the society.

A sample of examples are presented below. ÂÂ Pocket-sized lab or labs-on-a-chip: Unlike conventional laboratory investigation procedure, lab-on-a-chip (LOC) can provide the results in real-time and save the time and hassle on visiting the laboratory for giving samples and collection of reports. One can perform multiple investigations using a same chip while having equivalent or higher accuracy than a conventional laboratory. Further, these chips are significantly cheaper. ÂÂ Virtualization: Virtualization can save on costs and infrastructure. It provides the means of running multiple applications and operating Systems on a single hardware.

Sharing of the resources is combined with security of sensitive patient health information and cost reduction. ÂÂ Convergence: Converging the infrastructure can not only save the cost and time but can also be useful in improving the quality and efficiency of systems. It can help in integration of data including audio and video records pertaining to the patient care. This digital data provides optimal storage cost, smooth and high on efficiency data exchange. Data can be transferred and assessed in real time. ÂÂ Voice over IP: Popularly known as VoIP. It enables health organizations to leverage the available infrastructure

ÂÂ Screen-less Display: With the devices becoming virtually invisible and adaptable to the shape of human body parts, display screens have been replaced by screen-less display ensuring better comfort and functionality. Screen less displays enable one to work on a projected surface without compromising the quality and adding bulk to the equipment.

ÂÂ mHealth: Mobile technology users can record, access and share their health related information through mobile technology on the go. Sophisticated mobile applications provide real time information and access to health related data, thereby empowering the patients and opening a channel for patient-provider interaction. ÂÂ Cloud Computing or Health Care Clouds: Cloud computing enables on-demand broad network access and storage of information and serves the purpose of resource pooling in more efficient, flexible and secure manner. It serves the patients, physicians and health care organizations by providing them a common platform to access health related and other records with better access, control and security. Health providers have already started migrating their data to cloud for better safety and accessibility while sharing IT infrastructure and reduction in the costs.

-Dr. Balbir Singh (Asst. Professor)

w w w . m e d e g a t e t o d a y. c o m July-August 2014 35

EXPERT V ie w s

Mobile-Enabled

Remote Patient Monitoring

G

rowing elderly population and the increase in diseases, along with the rising treatment costs,are driving the need for remote care delivery solutions. With the chronic diseases on the rise, the overall expenditure on the healthcare facilities is increasing; thereby, increasing the pressure for a constant lookout for alternative methods to provide better healthcare and control the rising costs.

Solutions like mobile based remote patient care are intended to help in reducing the patient’s visits to hospitals and the overall cost on the healthcare facilities as the treatment can be provided at home. It also enables the care providers to effectively extend their services to the patients who may need care at home because of various medical conditions.

Some of The Main Factors that are Driving the Mobile Based Health Care Include Somenath Nag Director-ISV & Enterprise Solutions, Alten Calsoft Labs

ÂÂ T he increasing awareness about chronic diseases and their management with better medical practices and cost effectiveness ÂÂ T he evolving market of smartphones and tablets and the growing adoption ÂÂ A vailability of the advanced connectivity interfaces such as Bluetooth, Wi-Fi, 3G and 4G networks

However, there Exists Challenges, as Well ÂÂ The adherence to the stringent regulations of FDA and EU ÂÂ Security concerns particularly related tosensitive patient data 36 w w w . m e d e g a t e t o d a y. c o m July-August 2014

EXPERT Views

$399.9 million by the year 2016 with 11% growth per year. ÂÂ Automation of the existing manual process of providing This growth is due to the rapidly increasing numbers of patients with cardiovascular disorders around the world. services ÂÂ Providing a timely and cost effective patient care

mHealth Solutions

Example Solution: Mobile Remote Patient Care

Connected Healthcare solutions enabled by mobility, cloud, analytics, and social computing have been gaining lot of acceptance and popularity among consumers& care providers. Care providers, payers and the governments see a lot of promise in offering mobile enabled healthcare solutions to improve availability, accessibility and convenience of healthcare at a reduced cost. Experts believe that mobile enabled healthcare (mHealth) will usher a new transformative era, in delivering technology enabled connected healthcare solutions. Mobile technology is sure to change the care delivery landscape for patients, providers, payers and governments.

A mobile based remote patient care solution can enable the care providers to automate their existing manual process of remote patient care by empowering their care givers with smart phone based solutions with the feature set as mentioned below:

Adoption Rate of Mobile Healthcare (mHealth)

ÂÂ R emote Patient Care – Cross Platform Mobile Application for iOS, Android and Windows

ÂÂ Secured authentication and login mechanism ÂÂ Tracking care givers location using GPS ÂÂ Integrated Google maps for directions ÂÂ Client / Server architecture for scheduling mechanism ÂÂ Push notifications for care givers activities

ÂÂ Ability to configure the application for care givers A survey by Xerox has revealed that by 2016, 4.9 million activities and provide restrictions patients worldwide will use remote health monitoring devices such as cardiac monitors and glucose monitors that Components communicate vitals data through a cloud enables server or ÂÂ The Hospital / Nursing Home Server - Web Application data hub. ÂÂ The Agency Server - Web Application

The forecast for the remote patient monitoring market for devices is predicted to reach $556.9 million by 2016 at with a 10% growth rate per year.

About Healthcare Practice Calsoft Labs leveraging its 20+ years of strong healthcare

ÂÂ The market for mobile healthcare includes connected industry and product engineering experience has been a medical devices, healthcare applications, and related pioneer in providing “Connected Healthcare” solutions mobile technologies

leveraging new age technologies like Cloud, Mobility &

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ÂÂ The monitoring services segment contributed to about About Calsoft Labs 63% of the global mHealth market revenue in 2012 and Calsoft Labs provides specialized concept to market will continue to be a major contributor going forward Product Engineering services to product and technology

The main factors contributing to this growth are, the increasing patient count with chronic disorders like cardiovascular illnesses, diabetes and the rise in the elderly population. These patients prefer / need monitoring at home as it doesn’t involve travelling and waiting in the queues at hospitals.

companies in select market segments. Our team comprising of both technical & functional experts take customer requirements and transform into solutions that address industry challenges on time and within budget.

Calsoft Labs is a wholly owned subsidiary of ALTEN. Set up in 1988, ALTEN is a European leader in Engineering Secondly, the remote monitoring for cardiac patients is and Technology Consulting (ETC) with 16,000 employees another segment of the industry that is expected to reach in over 16 countries worldwide. w w w . m e d e g a t e t o d a y. c o m July-August 2014 37

DOCTOR Speak

Unusual systemic venous Collateral channels to left atrium causing desaturation after Fontan operation closed percutaneously Ashutosh Marwah, Sanjay Khatri, Savitri Shrivastava, Krishna S Iyer Department of Pediatric and Congenital Heart Diseases, Fortis Escorts Heart Institute, Okhla Road, New Delhi, India

We present an unusual cause of progressive cyanosis in a child appearing 2 years after successful Fontan surgery for tetralogy of Fallot with hypoplastic right ventricle. The cause of cyanosis was identified as one large venous channel draining into the left atrium. The channel was closed by Amplatzer vascular plug resulting in improvement of oxygen saturation.

These communications result in progressive increase in cyanosis because of either a reduced effective pulmonary blood flow or an increased admixture of pulmonary venous return. In most cases, it is possible to detect the anomalous channel and offer catheter‑based intervention.

CASE REPORT

Dr. Ashutosh Marwah Department of Pediatric and Congenital Heart Diseases, Fortis Escorts Heart Institute

A 7‑year‑old girl child, had tetralogy of Fallot with hypoplastic right ventricle and adequate branch pulmonary arteries (tricuspid valve measured 8.5 mm, “Z” score ‑4.2 at the time of Fontan completion). She had undergone modified right Blalock–Taussig (BT) shunt in infancy followed by bidirectional Glenn shunt and ligation of pulmonary artery and takedown of BT shunt at 16 months of age. She was regularly followed up and underwent extracardiac Fontan at the age of 5½ years.

R

ight to left shunt across the fenestration is the commonest cause of desaturation after Fontan completion.[1] Rarely, other causes have been described, which include a right to left shunt across tunnel leak after total cavopulmonary connection, anomalous connection between systemic veins and pulmonary vein or pulmonary venous atrium, and pulmonary arteriovenous malformation, or a pulmonary vein– hepatic vein fistula.[2‑6]

38 w w w . m e d e g a t e t o d a y. c o m July-August 2014

Figure 1 (a, b). AP and lateral views of large venous channel arising from the IVC and draining into the left atrium. VC: Venous channel, LPA: Left pulmonary artery.

DOCTOR Speak

Pre‑Fontan cardiac catheterization had revealed normal left ventricular (LV) filling pressure, mean pulmonary artery pressure, and pulmonary vascular resistance index.

She had a smooth postoperative course and was discharged after 9 days of surgery. Her oxygen saturation at the time of discharge was 95% in room air. A gradual return of cyanosis, exertional dyspnea, and easy fatigability was noted by the parents for the past 6 months. Her saturation was 85% at rest and 78% after (10 min) walking.

Cross‑sectional echocardiography revealed normally Figure 2. Balloon sizing of the Figure 3. Vascular plug in situ with occlusion of the venous channel. functioning Fontan circuit. The ventricular function venous channel. was normal, and there was no atrio‑ventricular valve incompetence and no pericardial or pleural effusions.

One small venous channel was seen arising from the catheterization performed Preoperatively. During cardiac brachiocephalic vein. catheterization, both the venacavae are selectively injected Patient underwent cardiac catheterization; intracardiac and anomalous venous channels, if any, are occluded or pressures and Fontan pressures were normal. There was ligated intraoperatively. no fenestration. Innominate vein angiogram revealed a small venous channel descending on the left side. On selective injection, the venous channel was found to be communicating with the left atrium (LA). This channel was occluded using 0.038‑inch, 5 mm × 5 cm Cook coil.

Inferior vena cava (IVC) angiogram revealed a large tortuous venous channel arising at T8‑T9 level and draining into the LA [Figure 1a and b]. Selective venous channel injection was also done which showed maximum diameter of venous channel 12 mm and the opening into LA measured 9.5 mm. An additional small vein was seen connecting the larger venous channel to the LA separately.

Larger venous channel was test occluded using a 15 mm × 4 mm Tyshak balloon [Figure 2]. During occlusion, no hemodynamic instability was noted.

Various authors have described occurrence of anomalous venous connections causing steal of systemic venous blood flow directly into the atrium or pulmonary vein, leading to progressive desaturation after Fontan completion.

According to Sugiyama et al., brachiocephalic vein was the commonest site of origin of these vessels, followed by the left phrenic vein. A longer time from surgery at 3.3 ± 3.4 years was associated with identification of collaterals larger than 4 mm. Mean pulmonary arterial pressure was also higher in patients with the larger collaterals.[2] These channels are often amenable to catheter interventions. Cook coils, duct occluders, and plugs have been used to close these channels. Though immediate results are satisfactory, a long‑term follow‑up is necessary to look for recanalization or opening up of newer channels.

In our patient, preoperative cardiac catheterization had not revealed any anomalous venous connection; also, she had maintained good oxygen saturation in the postoperative period. It is likely that this anomalous venous channel may have been inconspicuous at the time of Fontan completion, and enlarged gradually over a period and started causing The smaller venous channel was first occluded using a significant desaturation.

0.35‑inch 5 mm × 5 cm Cook coil, whereas an 18‑mm Amplatzer vascular plug was deployed in the larger channel References [Figure 3]. Post‑deployment IVC angiogram revealed 1. Masura J, Bordacova L, Titte P, Brenden P, Podnar T. complete occlusion of both the venous channels. Patient was Percutaneous management of cyanosis in Fontan patients discharged after 48 h of observation and has remained well using Amplatzer occluders. Catheter Cardiovascular Interv at 6 months follow‑up without any evidence of desaturation.

2008;71:843‑9.

2. Sugiyama H, Yoo SJ, Williams W, Benson LN. DISCUSSION Characterization and treatment of systemic venous to 192 Annals of Pediatric Cardiology 2013.

All patients undergoing Fontan at our center have cardiac There was no significant rise in systemic venous/Fontan pressure. The Fontan pressures before and after balloon occlusion were 12 mmHg and 13 mmHg, respectively.

Systemic arterial saturation improved to 94% on balloon occlusion.

w w w . m e d e g a t e t o d a y. c o m July-August 2014 39

EXPERT V ie w s

Breast cancer

is the most common cancer in women in India

Risk of female getting breast cancer is 12.29%

W

omen play many roles as a mother, a sister, a wife, a daughter & a friend.

We all know the phrase “ Matrudevo bhava� it means that mother is equal to God. Also no one can deny the fact that our mothers gone through thick and thin to groom us to be who we are today. Women across the globe play many significant roles in life. However for every role there is a need of healthy life. One of the foremost barriers between women and a healthy life is breast

40 w w w . m e d e g a t e t o d a y. c o m July-August 2014

EXPERT Views

cancer. According to experts breast cancer is one of the leading diseases affecting women today and believes that this issue must be immediately addressed. The International Agency for Research on Cancer (IARC), WHO’s specialized cancer agency, has released the latest data on cancer incidence, mortality and prevalence worldwide.

The new version of IARC’s GLOBOCAN 2012 provides the most recent estimates for 28 types of cancer in 184 countries and offers a comprehensive overview of the global cancer burden. It reveals striking patterns of cancer in women and highlights that priority should be given to cancer prevention and control measures for breast and cervical cancers globally.

Dr. Shalin Dubey , General Consultant & laparoscopic surgeon from Sterling Wockhardt Hospital Vashi said “Last ten years or so, breast cancer has been rising steadily, and for the first time now, breast cancer is the most common cancer in women in India because the risk of females getting breast cancer is 12.29 %. Early diagnosis and treatment can cure it completely Since more patients in India turn up in later stages, they do not survive long irrespective of the best treatment they may get, and hence the mortality is fairly high. There are lots of reasons for late presentations including lack of awareness, shyness on part of patients, social stigma, ignorance by family members and many other causes.”.

He further added “ Around 70% of all breast lumps are first found by woman herself. Most breast lumps are harmless. Approximately three out of four breast lumps turn out to be benign. There is no need to panic, just consult an expert. Decisions about which treatment is most appropriate, are made on sound judgment, which should be the responsibility of both you and your doctor.

Awareness about how your breast look and feel normally will make it easier for you to spot and identify any suspicious change at an early stage. Early detection improves

the overall cure rate and survival. Early Breast cancer usually has no symptoms Regular breast self-exams and mammograms are important. Although the incidence of breast cancer is increasing. If diagnosed early it is curable provided the right treatment choices are made. ” Non Preventable Breast cancer factors like if a family member has developed breast cancer , women in that immediate family have a high risk for breast cancer than those without family history. Women who experienced their first menstrual cycle before age 12, had their menopause after age 55, and/or never had children are at an increased risk of breast cancer. At the same time preventable breast cancer factors like smoking, diet & alcohol habit also increased risk of Breast cancer.

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w w w . m e d e g a t e t o d a y. c o m July-August 2014 41

EXPERT V ie w s

Homecare Services

Open New Doors For Nurses Job at a hospital is the ultimate goal for a nursing aspirant. While hospitals polish their skills, homecare services can enhance them in many ways. The concept is gaining momentum in India, and how it is favorable for nurses, writes Usha Prabhakar, Nursing Director, HealthCare at Home

T

here was a human touch in the way she dealt with people. Striking an emotional chord with others had always been such an effortless thing for her. This is how Sunidhi Ramanathan was – affectionate and caring, polite and loving. Therefore, when she had to zero in on a career, nursing was a natural choice.

Being a nurse would allow her to be herself, she thought. Her gregarious self, she presumed, would let her excel in her profession too, as it required serving patients who, on top of everything else, would need a lot of emotional support to be able to fight with their health conditions. She inarguably was very good at it.

With all that in mind, Ms Ramanathan went ahead to pursue nursing. After her graduation, she was excited to join hospital and put theoretical knowledge into practical use as also lend support to patients and help them deal with their health problems.

But there was more to what Ms Ramanathan had thought. In her role as a nurse in the hospital, she had a diversified work profile, which required her to look after patients, keep their records, take care of drugs’ availability and their storage, doctors’ round and housekeeping, among umpteen other things.

42 w w w . m e d e g a t e t o d a y. c o m July-August 2014

EXPERT Views

Initially, she put in extra efforts to fulfill all the responsibilities without being stressed, and drew a lot of satisfaction out of it. The excitement, however, started to wane with the passage of time. She had 15 patients to take care of and the other responsibilities to be met started taking a toll on her mental health. Ms Ramanathan found that she had more on her plate than she could handle. What was adding to her woes was her inability to interact with her patients and give them more time – all this in the face of excess workload.

Though her doctors and team were very supportive, Ms Ramanathan felt that she was not being true to her job, especially to her patients, who demanded her undivided and individual attention. However, there was no option, she thought, and that she would have to continue like that not too satisfied, yet carry on with her ‘monotonous’ job. Just when she thought it was the end of the road, she stumbled upon an opportunity that changed her course of professional life.

Ramanathan’s senior recommended her for a job in HealthCare at Home. Apprehensive initially about how a nurse would fit in such a company, she went for an interview.

What came next was her appointment with us the very next week. A nursing-led company, Ramanathan was more than convinced about the growth and myriad opportunities that would come with her way while being with HCAH. However, the fact that she will be able to spend more time to spend with patients remained the primary reason for her to join HCAH. Ramanathan knew this what she was looking for. Suddenly, her job gave her a purpose, a purpose of doing something for others.

Homecare Services: Exciting new avenue for nurses!

Patient-centric nursing and professional satisfaction: Nurses’ first and foremost aim is to ‘take care’ of their patients. But the large number of patients they have to look after in hospitals sometimes bogs them down. Though the intention is always to be by their patients’ side, nurses find it difficult to actually do so. Again the work pressure!

Homecare service providers usually assign less patients to their nurses with a view to ensuring maximum and undivided attention to those in need. Mostly, the number is as less as one patient. When the number of patients is less, the scope of interaction with the patient and the care that could be provided is invariably high. The feeling of doing the core job of nursing, i.e. taking care of patients boosts nurses’ professional satisfaction level. Besides, they also find time to impart health education to patients, inform them about the treatment being followed and do their counseling.

Being associated with homecare service provider is the extension of what nurses learn during their stint at a hospital

and practice those individually.

Learning, training and high exposure: At HealthCare at Home, nurses are hired with minimum experience of two years of having worked with a hospital.

The basic understanding of work is one of the pre-requisites.

After that the aim of HCAH is to polish their skills for homecare environment. After the recruitment process is over, the nurses go through a six-week homecare training course consisting of two weeks of nurse refresher course, one week course for each homecare training and IT training and two-week course where in pay shadow visits to patients’ home while assisting trained nurses. At the end of the scenario-based training, which HCAH provides in partnership with Berkley HealthEDU, competency check is performed. Apart from the training, nurses also get exposed to all kinds of patients ranging from cancer (oncology), heart (cardiology), orthopedics, critical care, bariatric, post-operative, mother and child care to elderly care, home pulmonolgy, IVF, infertility, home dialysis and diabetic (VAC dressing). Such a vast exposure expands their learning curve and they gain insight into dealing with patients with varied ailments. They later on have the choice to choose specialization depending upon their choice of field. This cement their career prospects as well.

Financial satisfaction and growth prospects: Job benefits apart from work remuneration are a way to make employees feel cared for. At HealthCare at Home, we offer additional incentives like insurance, pension and provident fund. If there is any overtime, nurses are compensated for it monetarily. The salary also is better that what is offered elsewhere. On employee and patient referrals too, they are rewarded. Also, if a nurse holds extra qualification, then on every extra degree or diploma, incentive is paid to them. Besides, there is a policy in place for permanent promotions. Hierarchy wise, nurses have can become nursing director and they can even get elevated to the level of Chief Executive Officer (CEO) due to the availability of cross-sectional opportunities. As HealthCare at Home is planning to go pan-India in the next two years and set up operations abroad, our nurses will also gain experience of handling different territories apart from handling different kinds of patients. So, the exposure they will gain is huge.

While hospitals are the ultimate calling for nurses, the concept of homecare services is another area that ensures promising careers for nurses. While hospitals are always a training ground, homecare services is turning out to be a new professional arena to enhance and sharpen skills. For nurses, now there is more than hospitals! w w w . m e d e g a t e t o d a y. c o m July-August 2014 43

DOCTOR Speak

Endoscopic Ultrasound

A poorly understood and poorly utilized investigative tool

E

ndoscopic ultrasound (EUS) is a relatively new modality for most physicians, though it has been in existence for almost 3 decades. In gastroenterology and oncology it has become an essential tool just like ERCP, Endoscopy and colonoscopy. EUS was born in 1980s with the marriage of upper endoscope and Ultrasound. First 10 – 15 years were spent trying to identify the sensitivity, specificity, techniques of assessment and instrument modifications.

Since mid 1990s it came into common clinical use. In India it has become widely available in most metros in the last 5 – 10 years.

EUS has the unique ability to evaluate structures in the wall of esophagus, stomach, duodenum etc. as well as all structures within 4-5 cm outside the wall of GI tract. It also gives a very high resolution and can give detailed view of different layers of intestinal wall like mucosa, muscle layer, serosa, akin to performing an electronic dissection of the wall. It also give a great opportunity to perform real time ultrasound guided FNA of lesions in the wall and vicinity of GI tract. It is one of the best modalities to evaluate Pancreas, CBD, Gall bladder, Mediastinal nodes, peri-rectal nodes etc.

It is a very safe procedure with minimal complication rate.

Main Indications for Endoscopic Ultrasound ÂÂ Diagnosis, including FNA, of Mediastinal Lymph nodes (TB, Sarcoid, Metastatic etc)

ÂÂ Diagnosis, FNA, Staging of pancreaticobiliary tumors (Malignant and Benign) ÂÂ Diagnosis of many benign pancreatic diseases like Chronic pancreatitis, Cystic lesions of pancreas, etc ÂÂ Diagnosis of Choledocholithiasis, where its sensitivity and specificity is higher than MRCP, and risk far lower than ERCP. ÂÂ Staging of Esophageal cancer, Rectal cancer ÂÂ Diagnosis of submucosal lesions of esophagus, stomach, colon ÂÂ S taging of Lung Cancer. It is complementary to Endobronchial ultrasound for this indication ÂÂ Therapeutic indications including Celiac Plexus block, drainage of Pancreatic pseudocyst, , transgastric Biliary system access for drainage or assisted ERCP etc ÂÂ A number of new therapeutic indications are emerging like placement of radioactive seeds into tumors, EUS guided RFA ablation

Dr. Vivek Raj Director & Sr. Consultant Dept. Gastroentrology & Hepatology MAX Super Speciality Hospital

44 w w w . m e d e g a t e t o d a y. c o m July-August 2014

Since the equipment is expensive and training curve is long, EUS has yet to find its due place in the mindset of many physicians. However over the last 4-5 years, now it is easily available in most large hospitals in India, specially in metros, and the cost has also become reasonable. What is needed is a better understanding of its true value and a dialogue between gastroenterologists and non gastroenterology physician fraternity so that this valuable tool can be used to its full potential.

ers W or kC Glo ul ba tu lE re mp loy ee s Speak

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July-August 2014 45

PRODUCT Lin e

Buy Healthy, Eat Healthy!

Sticking to ‘healthy eating’ regimen requires a lot of control as tempting food can make anybody flout self-imposed restrictions. If just having a look in the refrigerator shoots up your hunger pangs, then what you store around is of great importance. Stacking nutritious food is the best to stay healthy, writes Kanika Malhotra, Sr. Clinical Nutritionist, HealthCare at Home

S

ome people eat to live, while some live to eat. No matter which category you belong to, till the time what you are eating is “nutritious”, things are fine. But fact of the matter is how many of us bother about eating anything nutritious? Perhaps, only a handful.

With hectic lifestyles, junk has become a norm in daily meals. People are falling prey to growing urbanization, and in all this, nutrition has taken a backseat. However, there is always a clamor for healthy eating and no doubt, people love to hear about it.

But when time is a constraint, nutrition is less thought about and cooking and eating something healthy become secondary.

Nevertheless, some do find time to introspecting their eating patterns and switch to healthy products. For instance, there had been a sudden spurt in the use of Olive oil on account of it being healthy. However, due to lack of knowledge even virgin and extra-virgin olive oils are used for hightemperature cooking, when only refined olive oil is suitable for that.

Not knowing that olive oil’s smoke point, a temperature at which oil starts to smoke, is higher as compared to other varieties; they are even used for deep frying, which kills the healthy properties of the oil. Even in cases where there is a mindset to prepare something healthy, half knowledge becomes a stumbling block. When time is scarce, unhealthy eating and no physical activity lead to innumerable lifestyle-

46 w w w . m e d e g a t e t o d a y. c o m July-August 2014

related disorders.

S t r e s s compounds the problems even further.

One cannot do without eating. To live healthy, one should eat healthy. But before resorting to “healthy eating”, people should first make a move to “healthy buying”. What we buy is what we use in our food preparations. Thus the motto should be to buy right and explore the usage of the products to avoid “olive oil –like” situations.

Mindful Buying: Stacking your kitchen closets and refrigerators with unhealthy items is a grave mistake. When eating items are aplenty, they find their way to stomach. The starting point is

PRODUCT Line

Buy Healthy

Stack Healthy

Eat Healthy

Evaluate: Take stock of what is needed and what isn’t. Do not store unnecessary stuff that does not fit your healthy bill.

Throw Out: Whatever seems non-nutritious, throw that immediately without a second thought. Sometimes items remain in the to prepare a shopping list. Jot down what all do you want to kitchen closets with expiry dates as well. purchase, keeping in mind yours and your family members’ preferences. Consulting a professional nutritionist is always Replace: a good idea as it provides valuable insights. She can help Fill the space hence created with healthy items of your choice. draw out an individual plan taking into account various Replace white bread with brown bread, soft drink with juices factors like age; weight; diseases suffering from, if any, and chips and unhealthy snacks with low-fat eatables. etc. Based on the inputs, shopping list can be compiled. Professional nutrition counseling, as provided by HealthCare Colorful, seasonal fruits and vegetables and sprouts should at Home (HCAH), comes handy for those who are looking be the “must have” in the shopping list. for guidance support about right diet and various issues related to it. The at-home nutrition services provided by Your determination to indulge in buying healthy eating HCAH give a wholesome picture of “what to eat” and “how items will show up in your kitchen closets and refrigerator much to eat”. The services are categorized into disease as well. In the end, when you would have only healthy items management and wellness management: available around you, the choice to eat, ultimately, would be healthy and nutritious. To be able to eat healthy, a two- Diet counseling at home provides an opportunity for patients and their families to have a one-on-one with a nutritionist pronged strategy works: who can answer their queries and make recommendations.

Also, jumping on to quitting everything at once leads to The nutritionists evaluate intake of food items, calculate more impulsive eating, which does more harm than good. nutrient needs and develop individualized meal plans.

Switching to eating nutritious food should be a systematic Besides, the HCAH nutritionists do a survey of the kitchen affair. Once you have made up your mind to say ‘no’ to and refrigerators of the subscribers to suggest what they anything unhealthy, start slow but stick to the regimen. need to get rid of and what they need to replace.

Gradually, it will set into the habit. Beginners should follow the process of cleaning, evaluating, throwing out In case of disease managemment, like any other HCAH serviceour nutrition service is also doctor-driven. Treating and replacing. doctor is always kept in the loop and variations are made if they suggest any changes. This is for the first time in India Clean: that any at-home nutrition servicehas been launched. Besides, Remove the junk from the kitchen cabinets to make way for HCAH also offers tele- and video-conferencing for the same. healthy supplements and food items.

Disease Management

Wellness Management

Critical Care Plan

Healthy Heart

Renal Care Plan

Weight loss Management

Diabetic Care Plan

Weight gain Management

Cholesterol management Plan

Get that Glowing Skin

Celiac Disease

During the Pregnancy

Post-Operative Care

Post-delivery Management

The at-home service offers customized solutions that deliver results and helps manage a healthy lifestyle; and delivers convenient-services at doorstep, educate specifically diabetic patients and the family about issues related to diet, foot care education, how to take care of their skin, self-monitoring of blood glucose etc. It also provides instruction on grocery shopping and food preparation to elderly individuals with special needs, and children as well.

When it comes to nutrition, professional counseling is a must. Once into the mould, control is the key as it is difficult to resist tempting food. And for making sincere efforts, you can once in a while treat yourself to junk. Remember: progress, not perfection will lead you to your “healthy” goal. w w w . m e d e g a t e t o d a y. c o m July-August 2014 47

EXPERT V ie w s

Cygnus Medicare Exploring New Frontiers in Healthcare

We Endeavour to Provide the Highest Quality of Healthcare to our Patients and aim to run centres for Specialised Surgeries in the areas where Super Specialty Care may be missing

Dr Sudhir Gupta

Director Cygnus Hospitals

Dr Dinesh Batra

Director Cygnus Hospitals

Cygnus Medicare A super specialty hospital chain with their recent flagship hospitals, now have nine hospitals under their belt. A company formed in 2010, by a group of four highly-skilled doctors to create super specialty healthcare hubs to cater to all the sections of the society, has carved a niche for itself in a very short span.

Observing the Paradigm Shift Observing the change in health care scenario during the 1990s, when there was emergence of multi-speciality corporate hospitals offering critical care, handling medical complications and emergency services all under one roof, the Directors of Cygnus observed that the district headquarters and towns remained untouched by this revolution in the healthcare services with all the major chains focussing on metropolises and category A cities. The passion to bring superspeciality healthcare to everyone’s doorsteps resulted in the creation of the Cygnus goup of Hospitals.

48 w w w . m e d e g a t e t o d a y. c o m July-August 2014

Dr shuchin bajaj

Director Cygnus Hospitals

Dr Naveen Nischal

Director Cygnus Hospitals

Dr Dinesh Batra, Director, Cygnus Hospitals, while explaining the importance of the hospitals, says, “Cygnus boasts of the largest chain of multi specialty hospitals in Haryana and Delhi bringing together the finest doctors and medical technologies. We intend to provide global standards in healthcare to masses at affordable prices.” For us it is more of passion rather than profession.’

He further adds, that “everyone has a right to receive best healthcare, therefore we endeavour to provide the highest quality of healthcare to our patients by creating, using and spreading knowledge through research and education.” We further aim to run centres for specialised surgeries in those areas where super specialty care may be missing.

‘The focus is to provide international standards in healthcare to masses at affordable price and bring super specialty healthcare to B and C category towns of North India.

Dr Shuchin Bajaj, Director, Cygnus Hospitals, says that the Core value of Cygnus is to deliver excellence in all the fields of treatment, teaching and research by focussing on a

EXPERT Views

humane approach and going that extra mile for its patients, doctors and workers. With patients coming in from different parts of the world for treatment, Cygnus has the best doctors and clinical staff from all parts of the country, adept at treating individualized health conditions. These multiple super-specialties aim to provide best treatment to patients coming in with the rarest disease.

the management of surgical cases remains the relentless motive of Cygnus.

Best performing hospitals Cygnus lays an emphasis to make all their hospitals as multisuper specialty, with best infrastructure.

E.g. Bensups Hospital in Dwarka Sub-City is a 138- bed multi-specialty hospital (14 beds for the economically Emergency care and Trauma weaker section). The hospital is equipped for handling Cygnus Hospitals offer a state-of-the-art facility, modern emergencies (E4E). infrastructure, trained faculty, advanced ICU, NICU labs, modular operation theatres, fully digital cardio During the last 12 months, the hospital has helped 1,124 catheterization lab and advanced infrastructure. cases of heart emergencies, 147 cases of neuro-emergencies, 3,228 cases of trauma, and a total of 28,000 casualties.

By recognizing the golden rule of medical emergency, i.e. to waste minimum possible time in giving urgent medical Accreditations in quality healthcare care to the patient, Cygnus has trained doctors to treat the With the pre-assessment already been done, all Cygnus most complex trauma cases. hospitals are in the process of NABH accreditation.

Vision With five hospitals in Haryana at Sonipat, Panipat, Karnal, Krukshetra and Bahadurgarh respectively where they receive almost 200 trauma cases daily, there are plans for strengthening the E4E (equipped for emergency services) set up further. Dr Naveen Nishchal, Director, informed that Of 21 districts in Haryana, only 3 can claim medical coverage by way of tertiary care. Cygnus endeavours to bridge the gap for the remaining 18 and come up with healthcare facilities so that everyone benefits.

Mission It is to make a distinguished mark in medical care, with benchmarked quality, affordable cost and efficient human resources. Having acquired 10 hospitals already, the plan is to further expand. The goal is to run centres for specialized surgeries in the areas where super specialty care isn’t available. Dr Sudhir Gupta, Director, has a passion for quality and says offering quality protocols for

Growth capital partners Somerset Indus Capital Partners, a private equity firm making healthcare investments in India provided and supported the initial funding. The company now plans to go in for a second investment for further expansion.

Current Cygnus Network: ÂÂ Cygnus Bensups Hospital, Dwarka ÂÂ Cygnus J K Hindu Hospital, Sonipat ÂÂ Cygnus Hemraj Jain Hospital, Pitampura ÂÂ Cygnus Sanjiv Bansal Hospital, Karnal ÂÂ Cygnus Super Speciality Hospital, Krukshetra ÂÂ Cygnus Magnus B S Sanjivini Hospital, Bahadurgarh ÂÂ Cygnus Maharaja Agarsain Hospital, Panipat ÂÂ Cygnus Sonia Hospital, Nangloi ÂÂ Cygnus Orthocare Hospital, Hauz Khas w w w . m e d e g a t e t o d a y. c o m July-August 2014 49

EXPERT V ie w s

Men’s Health as an Integrated Specialization In the older era Men’s Health was considered only from the Sexual Perspective. Man was Considered and Portrayed as a stronger sex and there was a lack of awareness about other aspects of health. In the modern society there has been a paradigm shift in the way male health has been projected based on data and evidence.The older beliefs have been recognized as flawed and followed by transition to modern day practices. It is evident that average lifespan of men is 5 years less than women and is attributable in large part to a number of known and unknown factors apart from increased genetic susceptibility, stress of ‘being the provider’ for the family, Increased risk of hypertension, coronary artery disease, depression, associated risk factors and high risk behavior, professional hazards and certain gender specific diseases and cancers.

There is a need to integrate various specialties and provide an integrated and Comprehensive Package of Health Care (CPHC) to men under the label of integrated men’s health program (IMHP) pertaining to the low likelihood of men seeking consultation for health issues due to social beliefs, taboos and various other reasons. Incidentally erectile dysfunction has been found to proceed or correlate with a number of diseases affecting men at an early stage including major morbidities like coronary artery disease, depression and metabolic syndrome and its screening and prevention may be new avenues in preventive health. Men’s health should be projected as a new specialty with erectile dysfunction as a ‘Sentinel Marker’ of ‘Male Health’.

Prof (Dr) Rajeev Sood President MHSI

The Historical Perspective on Men’s health Men’s Health has come a long way from the era when Hippocrates (5th-4th century BC) described the high incidence of impotence and infertility and attributed it to continuous trauma to the genitilia due to horse riding in “De aëre aquis et locis” or when Aristotle (384 till 322 BC) like many other Greek authors debated that air or ‘pneuma’ was the initiator of erection. It was not until the 15th century that 50 w w w . m e d e g a t e t o d a y. c o m July-August 2014

EXPERT Views

Leonardo da Vinci described the increase in blood flow to the penis as a basic principle of erection. Similar to Greek medicine the Indian system of medicine also acknowledged impotence in around 8th century BC, and a humble attempt was made to described the cause of this condition classified as voluntary, congenital, praecox and disease of genital organs. The Indian system described the various doshas and qualities of fertile semen. Chinese medicine also described sexual impotence and attributed it to the constriction of yang. Most of the ancient available literature focused on sexual dysfunction among males in the name of men’s health. Until the 18th century Men’s health remained confined to male sexuality and everything ranging from potions to electric current was applied to improve those sexually weak.The 18th century focused on overindulgence as one of the causes of impotence and poor sexual health and young men were subjected to preputial infibulation as a means of precluding masturbation and for a very long duration sexual practices remained flawed with myths and misconceptions.

The Recent Revelations Based on a mortality survey done in the recent past in Western Europe from 1625 to 1900 it was realized that women were the focus of attention in terms of preventive healthcare. Many organizations and societies identified the lacunae and the need to address women related issues and began to focus on health of women. In this endeavor the focus on Men’s health was completely lost in the modern society. Man was projected in the society as a stronger sex and thus felt constrained

by Social Taboos. There was an inherent embarrassment to discuss health related issues which were further strengthened by doubtful needs about Specialty for Men’s Health due to lack of a Stronger Evidence Base. There is little evidence of effective interventions to target male Illness in the past and the agenda has traditionally been to prevent venereal diseases and cure impotence.

In the 21st century we have enough data to prove that the focus of men’s health needs to move from sexual dysfunction to see the bigger picture. The facts are that Men use health services less frequently than women, visit a doctor later in the course of condition thus bearing poorer health outcomes. They die, on average, 4.9 years earlier than women and suicide, and Homicide four times as often as women. Extreme differences have been observed in Russia (12 years) and India (2 years) in favor of women. Men die in accidents about twice as often as women and mortality due to acquired immune deficiency syndrome (AIDS) is three times the rate of women. Men are likely to engage in more high-risk behaviors and work at more dangerous occupations which makes them more vulnerable.

To top it all, Men are less informed about health issues, less likely to utilize preventive and healthcare services, suffer from the effects of substance abuse at a higher rate ,have a greater

tendency to engage in antisocial behavior, and more likely to be uninsured, lack a social support network and be homeless.

We are at an early phase of studying gender differences in health and risk factors.

The Indian Situation India has the second largest population in the world after China with current population in 2013 being 1.24 billion. As per 2011 census the sex ratio is 940 females per 1000 male’s life expectancy at birth for males is 65.77 years and for females is 67.95 years. Men have shorter life span due to their risk taking habits like smoking, chewing tobacco, drinking alcohol, higher suicidal tendency, drugs in take, rash driving, unsafe sex and health hazards at work place. There are a few findings that need to be considered: ●●On average men live about 3-5 less years than women ●●1 in 2 men, while 1 in 3 women, will be diagnosed with cancer in their lifetime ●●Men lead in 9 out of the top ten causes of death Urologists / Andrologists along with major stakeholder specialties like Cardiology, Oncology, Psychiatry, Endocrinology, Orthopaedics, Reproductive Medicine, and Rehabilitation Medicine are on a mission to improve the health of men and empower them to pursue healthier lives. The reason for this greater interest in men’s health is the overwhelming irrefutable evidence from many scientific studies of the significant disparity in gender health. All over the world, men live shorter than women and suffer more from heart disease and cancer. This disparity in utilizing preventive healthcare is more pronounced in populations of low socioeconomic status. Moreover, prostatic ailments, andropause, Urinary Tract Infections, urethral inflictions (urethra being longer and more vulnerable than female), significant osteoporosis incidence etc. pose more gender specific problems where Urologists and Andrologists have to interact. Realizing this, the urological society of India had also conceptualized PDAP (Prostate Disease Awareness Program), an Indian awareness program for prostate diseases. When the administrators in Govt. of India admit that for decades India has been struggling to achieve National Health Program unmet targets related to women, children and communicable and non-communicable diseases, men’s health has been inadvertently ignored.

As stated Men suffer more than Women as far as Oncological disease burden is concerned. Not only this, the Oncological outcomes in men are worse than women. Men specific Prostate Cancer which was at no. 6 or 7 in India in male populations has already risen to number 3rd-4th position in different cities and can any time become the number 1 Cancer in Indian Male.

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EXPERT V ie w s

got neglected with no concerted efforts being currently undertaken by the health care system for its promotion on the national front. Urologists along with other major specialties can contribute immensely to the endorsement of this cause as we frequently deal with problems of men in the geriatric and adolescent age group.

In the current situation there is a need to find markers to assess men’s health and provide tools which can contribute to promoting male health. Erectile dysfunction is one such potential marker. Risk of Erectile Dysfunction is higher among men with low socioeconomic status, high body mass index, those who were sedentary, current smokers and those with diseases including diabetes, heart disease, and depression anxiety. ED is a potent predictor of all-cause death and the composite of cardiovascular death, Myocardial infarction, Stroke and Heart failure. The peripheral cavernosal arteries are end arteries, and thus do not have the ability to form collaterals to compensate for decreased blood flow, as does the heart.

This loss of vasodilation may be recognized earlier in the microvascular penile bed than in coronary arteries.

Erectile Dysfunction (ED) thus heralds to the more ominous cardiovascular accidents. In fact ED is now recognized as the Sentinel Marker which precedes Cardiac Event by two years. The endothelial dysfunction is common precursor to both cardiovascular disease and erectile dysfunction14.

In a study among newly diagnosed type 2 diabetics, 20% of the patients reported having used ED drugs, but more than 50% had abandoned therapy because of the drug’s ineffectiveness or high cost. About 20% of these patients also had depression and many had hypogonadism. It has been suggested that Subclinical endothelial dysfunction and insulin resistance may be the underlying pathogenesis of ED in young patients without well-known etiology. Mean IIEF-5 scores were lower for the men with depression and anxiety indicating a strong relationship between erectile dysfunction and mental state. Patients with ED had significantly lower 5-year stroke-free survival rates and erectile dysfunction has also been referred to as a marker for cerebrovascular accidents. There is an increase in evidence from multiple epidemiological studies that lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are correlated18. Screening for Erectile dysfunction is thus a powerful tool in the hands of a Men’s Health expert to assess risk of future morbidity from coronary artery disease, diabetes, stroke, depression and metabolic syndrome. It is an integrated marker of overall health.

Programs. National Health Programs in India are presently concentrating on communicable and non-communicable diseases and also maternity and child health and there is no national health program dedicated to Men’s Health. India is going to host the 10th Men’s Health World Congress (MHWC) in 2015 and the challenge faced is that we lack epidemiological data of male dominated diseases.

We have to have our own Men’s Health Country report before planning and targeting Men’s Health related morbidity and mortality issues in the country. It is our endeavor to convert this thought process into a mission to ensure a Men’s Health Aware India and to lead remedial interventions for reaching the logical end in the pursuit to improve men’s health and empower Indian Man. Our men also suffer from a peculiar premarital anxiety. Many of these young men have been exposed to fallacious ideas and suggestions which are in fact detrimental to their psyche and result in sexual dysfunction. These men end up feeling guilty about past sexual practices and thus result in psychogenic ED. Another prevalent disorder often neglected is dhat syndrome which destroys the productive years of a number of young men in this country. Awareness is the only hope and answer to the future that is plagued by misconceptions.

In infertile couples, the male factors are responsible in about 50% cases. It is important to recognize these factors and educate doctors and public at large to minimize health related problems in males and to improve their quality of life and longevity.

So let us all pledge and put our head together in the pursuit of achieving our goals to enable men to ‘Celebrate the Manhood’ and develop Men’s Health as an Integrated Specialization. What we need is Men’s Health friendly facilities and integration of this specialty in the main stream.

This not only requires an effort form the health sector but all sections of the society including women who have a big role in influencing how men perceive themselves and their health. There is a need to establish a dedicated Integrated Men’s Health National Program and Male Genitourinary Men’s health so far has been on the back burner in India. Disorder (Male GUD) National Program which shall Belatedly though, the concept of Men’s health now seems include research, epidemiological studies, prevention and to be all set to be considered for inclusion in National control of male morbidity and mortality.

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PRODUCT Line

Quiet, Efficient Scanners Help Employees Accelerate Face-to-Face Business Transactions to Provide a Better Customer Experience

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o address complex document capture and management needs in a transaction-based business environment, two new scanners are joining the successful KODAK SCANMATE family—the KODAK SCANMATE i1150 and KODAK SCANMATE i1180 Scanners.

These introductions follow careful observation and understanding of customer needs, reflecting the commitment Kodak Alaris has to developing targeted solutions for specific business applications. The KODAK SCANMATE i1150 Scanner is designed for use in customer-facing business transactions, where an employee needs to scan documents as part of a business process. Employees using these solutions are typically interacting with customers and need to keep the transaction moving to reduce wait times and increase customer satisfaction. At the same time, businesses want to increase the number of transactions they complete each day.

“Business managers have enough to worry about today, from delivering prompt customer service to streamlining transactions, so tools that can speed and simplify the information capture process are extremely valuable in maintaining customer satisfaction,” noted Tony Barbeau, General Manager, Document Imaging, Kodak Alaris. “Scanning and managing documents can be a potential bottleneck in the office, but our two new scanners are making it easier than ever to focus on serving customers.” For example, a business might accept applications from customers at a service window or agent’s desk. The complete application may consist of a small amount of paperwork and an identification (ID) or other account card.

In this case, an employee needs to quickly scan the documents and cards without slowing down their interaction with the customer or slowing down the transaction itself. Recognizing that a majority of transactions involve 10 or fewer documents to be scanned, the KODAK SCANMATE i1150 Scanner (www.kodakalaris.com/go/scanmatei1150News) features a special Transaction Mode, enabling 60 percent faster capture speed for the first 10 pages. The KODAK SCANMATE i1180 Scanner (www.kodakalaris.com/go/scanmatei1180News) extends the concept of an intelligent device by embedding Perfect Page image enhancement technology into the device

to reduce processing demands on the user’s PC, making the i1180 a PC-friendly offering for today’s evolving business environments. Plus, the SCANMATE i1180 Scanner is a fully licensed device for the EMC® CAPTIVA® Cloud Toolkit, making it easy and cost effective for customers or developers using this software development kit (SDK) to write and enable browser-based capture applications.

“Frequently, organizations are turning to web-based architectures to speed the adoption of new business applications and minimize support costs,” said Roger Markham, Product Manager, Document Imaging, KodakAlaris. “The SCANMATE i1180 Scanner is designed to keep up with these changing technology environments. Image processing is done in the scanner, minimizing the need to purchase and support high-end PCs. And because Kodak Alaris includes the EMC CAPTIVA Cloud Toolkit with the scanner, users can write their own customized web capture application.” The new SCANMATE models (http://youtu.be/1a_4yTa20sI) share many unique features such as a simple icon-based color interface that helps quickly identify where to send captured images. The builtin card ledge on the front of the scanners helps keep track of cards and associated loose materials so nothing gets lost during processing. And the small footprint and extremely quiet operation mean users don’t have to interrupt customer conversations while scanning.

Both SCANMATE Scanners are supported by a wide range of Kodak Alaris software, including one-button Smart Touch functionality and KODAK Capture Pro Software Limited Edition, which are included for quick and easy capture. Users can upgrade to the full version of KODAK Capture Pro Software.

For remote monitoring and maintenance, the KODAK SCANMATE Series Scanners work seamlessly with optional KODAK Asset Management Software. The dashboard makes monitoring the scanners’ status and performance simple. The SCANMATE Scanners also support additional accessories for greater versatility and ease of use, including the KODAK Legal Size Flatbed Accessory and the KODAK A3 Size Flatbed Accessory.

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DOCTOR Speak

Clinical manifestations and treatment of

hepatitis-B virus infection THE spectrum of clinical manifestations of hepatitis B virus (HBV) infection varies in both acute and chronic disease. During the acute phase, manifestations range from subclinical or anicteric hepatitis to icteric hepatitis and, in some cases, fulminant hepatitis. During the chronic phase, manifestations range from an asymptomatic carrier state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma.

Extrahepatic manifestations can also occur with both acute and chronic infection..

ACUTE HEPATITIS Approximately 70 percent of patients with acute hepatitis B have subclinical or anicteric hepatitis, while 30 percent develop icteric hepatitis. Fulminant hepatic failure occurs in approximately 0.1 to 0.5 percent of patients..

Dr. Manoj Kumar Senior Consultant, Gastroenterology

PSRI Hospital, New Delhi

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The rate of progression from acute to chronic hepatitis B is determined primarily by the age at infection. The rate is approximately 90 percent for a perinatally acquired infection, 20 to 50 percent for infections between the age of one and five years, and less than 5 percent for an adultacquired infection.

DOCTOR Speak

Treatment of Acute Hepatitis B— Treatment for acute HBV PHASES OF CHRONIC HBV INFECTION is mainly supportive. In addition, appropriate measures Chronic HBV infection generally consists of two phases: an should be taken to prevent infection in exposed contacts. early replicative phase with active liver disease, and a later CHRONIC HEPATITIS - Many patients with chronic hepatitis phase with low replication and remission of liver disease.

B are asymptomatic (unless they progress to decompensated In patients with a perinatally acquired HBV infection, there cirrhosis or have extrahepatic manifestations), while others is an additional immune tolerance phase in which virus have nonspecific symptoms such as fatigue. Some patients replication is not accompanied by active liver disease. In experience exacerbations of the infection which may be some patients, reactivation of HBV replication occurs after asymptomatic, mimic acute hepatitis, or manifest as hepatic a varying period of quiescence. failure.

Physical examination may be normal, or there may be stigmata of chronic liver disease. Jaundice, splenomegaly, ascites, peripheral edema, and encephalopathy may be present in patients with decompensated cirrhosis.

Laboratory tests may be normal, but most patients have a mild to moderate elevation in serum AST and ALT. During exacerbations, the serum ALT concentration may be as high as 50 times the upper limit of normal, and alfafetoprotein (AFP) concentrations as high as 1000 ng/mL may be seen. A progression to cirrhosis is suspected when there is evidence of hypersplenism (decreased white blood cell and platelet counts) or impaired hepatic synthetic function (hypoalbuminemia, prolonged prothrombin time, hyperbilirubinemia).

Treatment of Chronic Hepatitis B The rationale for treatment in patients with chronic HBV is to reduce the risk of progressive chronic liver disease, transmission to others, and other long-term complications from chronic HBV such as cirrhosis and hepatocellular carcinoma.

Expert recommend that treatment be considered in patients with HBeAg positive or HBeAg negative chronic hepatitis. Patients with compensated cirrhosis and HBV DNA >2000 int. unit/mL and those with decompensated cirrhosis and detectable HBV DNA by PCR assay should be considered for antiviral therapy, regardless of the serum ALT level. w w w . m e d e g a t e t o d a y. c o m July-August 2014 55

DOCTOR Speak

hepatitis B immune globulin and vaccine immediately after Treatment strategies for chronic HBV include interferon delivery. Healthcare workers who are HBeAg positive should (standard and pegylated), lamivudine, adefovir dipivoxil, not perform invasive procedures without prior counseling and advice from an expert review panel. telbivudine, entecavir, and tenofovir.

Choosing among the available options

Compensated cirrhosis In patients with clinically and biochemically compensated cirrhosis, interferon may be used with caution but nucleosides/nucleotides are safer. Because of the need for long-term treatment, entecavir or tenofovir is preferred.

Decompensated cirrhosis Patients with decompensated cirrhosis should be considered for treatment with lamivudine, telbivudine, entecavir, or tenofovir. Interferon is contraindicated in these patients.

In view of the need for long-term treatment, lamivudine and telbivudine are not optimal treatments unless used in combination with adefovir or tenofovir. Adefovir is not recommended because of its weak antiviral activity and risk of nephrotoxicity. Renal function (creatinine every one to three months) should be monitored closely in patients receiving adefovir or tenofovir. Entecavir may be a preferred option. Although a case series reported the occurrence of lactic acidosis in patients with severe liver dysfunction, this is likely a class effect of nucleos/tide analogs. Furthermore, several larger studies did not observe any clinical cases of lactic acidosis, although lactate levels were not monitored in those studies. Treatment of such patients should be coordinated with a transplant center.

COUNSELING AND PREVENTION Heavy use of alcohol (>40 g/day), has been associated with worsening liver disease and an increased risk of HCC. The exact amount of alcohol that can be safely consumed is unclear. Thus, advising patients to be completely abstinent is reasonable in those who have substantial liver injury.

Patients with chronic HBV should receive appropriate immunizations.

Carriers of HBV should be counseled regarding the risk of transmission to others. Patients should be advised regarding prevention of sexual transmission (ie, vaccination of spouses and steady sex partners in individuals with monogamous partners, and safe sex practice including use of condoms in subjects with multiple partners), perinatal transmission, and risk of environmental exposure from blood.

Household members should be vaccinated if they test negative for HBV serologic markers. HBsAg positive pregnant women should inform their providers so that their infants can receive 56 w w w . m e d e g a t e t o d a y. c o m July-August 2014

Vaccination For pre-exposure prophylaxis against hepatitis B in settings of frequent exposure (health workers exposed to blood; hemodialysis patients and staff; residents and staff of custodial institutions for the developmentally handicapped; injection drug users; inmates of long-term correctional facilities; persons with multiple sexual partners; persons such as hemophiliacs who require long-term, high-volume therapy with blood derivatives; household and sexual contacts of HBsAg carriers; persons living in or traveling extensively in endemic areas; unvaccinated children under the age of 18; and unvaccinated children who are Alaskan natives, Pacific Islanders, or residents in households of first-generation immigrants from endemic countries), three IM (deltoid, not gluteal) injections of hepatitis B vaccine are recommended at 0, 1, and 6 months. Pregnancy is not a contraindication to vaccination. In HBV-hyperendemic areas (e.g., Asia), universal vaccination of children has resulted in a marked 10- to 15-year decline in hepatitis B and its complications, including hepatocellular carcinoma.

For unvaccinated persons sustaining an exposure to HBV, postexposure prophylaxis with a combination of HBIG (for rapid achievement of high-titer circulating anti-HBs) and hepatitis B vaccine (for achievement of long-lasting immunity as well as its apparent efficacy in attenuating clinical illness after exposure) is recommended. For perinatal exposure of infants born to HBsAg-positive mothers, a single dose of HBIG, 0.5 mL, should be administered IM in the thigh immediately after birth, followed by a complete course of three injections of recombinant hepatitis B vaccine to be started within the first 12 hours of life.

For those experiencing a direct percutaneous inoculation or transmucosal exposure to HBsAg-positive blood or body fluids (e.g., accidental needle stick, other mucosal penetration, or ingestion), a single IM dose of HBIG, 0.06 mL/kg, administered as soon after exposure as possible, is followed by a complete course of hepatitis B vaccine to begin within the first week. For those exposed by sexual contact to a patient with acute hepatitis B, a single IM dose of HBIG, 0.06 mL/kg, should be given within 14 days of exposure, to be followed by a complete course of hepatitis B vaccine. When both HBIG and hepatitis B vaccine are recommended, they may be given at the same time but at separate sites.

EXPERT Views

Medical Technology and Quality of Care

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edical technology is the key to achieving better clinical outcomes. The healthcare industry now has the financial incentive to invest in an interoperable infrastructure. The investment would enable electronic medical records, electronic prescriptions and information exchanges, as well as mobile point-of-care solutions that deliver patient histories, diagnostic information, and decision support in real time. What the health care industry needs now are partners. For the complex healthcare organisations to succeed, the industry needs imagination, system-wide collaboration and transformative changes in the market incentives that currently exist.

Role of Medical Equipment in Improving Health Care

Indian Health care system has notched up several significant achievements over the past 50 years particularly in dealing with several dreaded diseases and ailments requiring surgical intervention. However, easy accessibility of quality health care and affordability to the citizen at large are key concerns.

The opening up of the Indian economy during the 1990s brought unprecedented growth within the domestic/Indian healthcare sector.

The influence of medical technology has reached not only the upper crust of society but has also helped the poorer section of the society in reducing the infant mortality rate (IMR) as well as maternal mortality rate (MMR) through the usage of right technology like incubators, warmers and better operation theatre equipment.

use of resources. It is highly recommended that workshops and continuing education programmes be organized for both technical and non-technical healthcare personnel on the proper selection and prioritization of medical devices.

Improving Penetration of Medical Technology

It is essential to improve the penetration of medical technology to improve health outcomes. In order to achieve this objectives, there must be innovation supported by the government funding to both industry and academia. There should be lowering of cost of the product delivery. There is a need for business model innovation across the value chain- manufacturing, distribution, marketing, etc. In addition, attention should be paid to frugality which can often generate significant benefits to all stakeholders including patients and end users. There should be collaborations among stakeholders in the medical technology ecosystem as it (collaboration) is a key factor for success. The medical equipment industry must move from “company centric” innovation toward “co-creation.” There is an urgent need to review the ambiguous regulatory framework which has no distinct legal status for the medical technology industry. This is a key constraint.

Medical Technology: The Game Changer

According to Dr. Preetha Reddy, Managing Director of Apollo Hospitals Group, “Indian health care is at a tipping point with a busy pace of new clinical protocols and new technologies being introduced into the country signaling an environment According to the World Health Organisation (WHO), there of improved care for the patient. The surging demand for is an urgent need for capacity building. Health technology healthcare as a fundamental right could prove to be a game assessment combined with reputation and management of changer for healthcare delivery in the country.” health training in a developing country like India will lead to -Prof. Lakshmi B. better organisation of health technologies and a more efficient Dean, Administrative Staff College of India Hyderabad

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EXPERT V ie w s

The Era of Smart Hospitals

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oday’s hospitals are plagued by communication problems. Frustrated, overworked nursing staff and unsatisfied patients create a compelling need for a solution that will improve communication flow while enabling advances in mobile applications. A variety of new frameworks are available for healthcare organizations interested in streamlining communications and improving patient care. By bringing smart phones to the point of care, healthcare organizations can simplify communications, increase nurse job satisfaction, improve patient care, and position hospitals to benefit from a new generation of game-changing mobile applications.

What Are Smart Hospitals?

Prof. M. Habeeb Ghatala Dean, Apollo Hospitals Group (Retd.)

Hyderabad

Smart Hospitals are technologically driven hospitals designed to improve the quality of healthcare for the patients and the environment in which healthcare services are provided. The concept for Smart Hospital has been designed from the ground up to achieve the following goals: Safety and clinical quality, Productivity, Ease of use for patients, families, and caregivers, Service excellence, and Optimal use of technologies for medical, management information and consumer.

The goals of Smart Hospitals are achieved by taking integrated and current information and communication technologies and combining them with careful design of the facility to be accessible and efficient, initial engineering and continued redesign of clinical and business processes to operate reliably and safely, constant emphasis

58 w w w . m e d e g a t e t o d a y. c o m July-August 2014

EXPERT Views

on patient and family service and satisfaction, and (4) fervent ÂÂ It ensures the higher levels of competence, confidence, attention to providing a superior workplace for physicians and critical thinking skills. and staff. ÂÂ It helps to manage the complex and changing healthcare system.

The Smart Hospital uses wireless technology and digital imaging to facilitate communication internally and externally. ÂÂ It also supports the faculty for developing and evaluating Its consumer technology improves the flow of information to new educational models, modalities, and teaching-learning customers using text messaging, smart devices, tablets, and strategies at no risk to patients. customer internet access. The concept of Smart Hospital is about adding intelligence to the traditional hospital system by ÂÂ It also supports the faculty for developing and evaluating new educational models, modalities, and teaching-learning covering all resources and locations with patient information. strategies at no risk to patients.

Information Technology in Smart Hospitals

ÂÂ It also helps to integrate the better combination of ICT The convergence of information technology systems in technologies, products, and services. healthcare systems building is resulting in finding ways and means to look at more effective integration of technologies. Designing a Smart Hospital Facing increased competition, tighter spaces, staff retention, In order to respond adequately to a technologically driven environment of care and prepare for its evolution in the and reduced reimbursement, future, healthcare providers must consider strengthening the It makes it necessary for proactive hospitals to look at strategic patient experiences both inside their facilities and out through ways to use technology to manage their systems called Smart a keen focus on connectivity, communication, and access to Hospital. The key solution to the Smart Hospital is online information. identification of all patients, doctors, nurses, staff, medical equipments, medications, blood bags, blankets, sheets, Healthcare architects and designers have a unique opportunity to unite architecture and technology by creating dynamic and hospital rooms, etc. engaging settings that cater to the individual needs of patients and opportunities for staff and administrators that broaden Major Problems The major problems with the healthcare environments are treatment options as well as where the treatment is provided. related to the information flow and storage of the patient’s data A well designed Smart Hospital will provide patients a digital and other entities of the healthcare system. These problems can portal for secure 24-hour access to electronic medical records, scheduling, billing, registration and educational materials from be categorized as follows: any connective device. A sample of facilities in a well designed ÂÂ One problem is there is when there is information gap Smart Hospital can feature Check-in kiosks, Connective among the medical professionals, users/patients and furniture, Hybrid exam/consult modules, Education zones, various data sources.

Telemedicine, EMR scanning room, etc. ÂÂ Another problem is that there is a need to present and organize the information flow among the hospital Conclusions members and other entities so that information can The opportunities for developing Smart Hospital are plentiful. The progressive Dubai Health Authority (DHA) be accessed at any time and any place. has already taken the initiative by discussing smart healthcare ÂÂ Other problems are related to various types of opportunities by encouraging hospitals to move toward a data used and no common format for holding it in a paperless environment. The long-term plan for Dubai health common way. sector includes electronic connectivity for all hospitals in Advantages of Smart Hospital Dubai and a single electronic file per patient.

There will be many advantages of Smart Hospital when it is able to share the domain’s knowledge with same or In the November 25, 2013 meeting in Dubai, high level other domain and fulfill the requirements of information healthcare professionals from all public and private hospitals from different environments, referred to as ubiquitous and took part in a forum organized by the DHA and IBM to discuss pervasive environment. The Smart Hospital offers a number ways to implement smart healthcare opportunities. The model includes three components: of advantages; ÂÂ It provides a beneficial strategy for the better education Smart Operations, Smart Applications and Smart Hospitals. and training simulation among the healthcare For those interested in Smart Hospitals, a visit to DHA is professionals. recommended. w w w . m e d e g a t e t o d a y. c o m July-August 2014 59

INTERVIEW B y Mt

Medgate today Correspondent taken

Exclusive

INTERVIEW Brief about the spokesperson.

MR. SHINYA TOMODA Managing Director, Omron Healthcare India

As Managing Director, OMRON healthcare India, Mr. Tomoda has been instrumental in conceptualizing and executing business strategies and steering the growth and expansion of OMRON’s healthcare business in India.

Mr. Tomoda joined OMRON Healthcare India as the Managing Director in 2012. A graduate from Meiji University (Tokyo) in Business Management, Mr. Tomoda started his career with OMRON and now has over 20 years of experience. He has gathered invaluable know-how and expertise by playing strategic roles in many important assignments on varied aspects of Healthcare monitoring and management domain, across the globe, such as Japan from 1992 to 2007 in domestic sales, Taiwan - from 2007 to 2008 as President of the sales operations and China - from 2009 to 2011 in the sales strategy department.

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INTERVIEW B y Mt

About the company?

What is the market size of BP monitor/GluEstablished in 2010, OMRON Healthcare India is a key cometer in India & what is your contribution? player in the health care segment providing innovative medical technologies for Monitoring and Therapy. Inspired with the statement “All for Healthcare” , OMRON Healthcare Portfolio comprises of home healthcare products such as blood pressure monitors, body fat monitors, pedometers, digital thermometers, respiratory therapy devices, etc. The company has also recently entered the medical devices segment with a range of vascular monitors and professional BP monitors. Today, OMRON has the highest market share in the home-use digital BP monitor in India and across the globe.

Company policy to market in India?

India is an important country in the overall strategy of OMRON Healthcare across the globe. Home monitoring is OMRON healthcare’s core domain in the country and one of the focus areas of the company is to manage lifestyle diseases at home such as hypertension, obesity, and diabetes.

We started offering our products in the country in 1997 (BP Monitors) and so far have increased the product portfolio manifold by including many more products such as body fat monitors, pedometers, digital thermometers, respiratory therapy devices, etc. Since last year (2013) we have also initiated entry to hospitals and clinic by providing high quality and useful medical devices such as BP monitors.

The market size for BP Monitors in India in terms of amount is around INR 886 million. OMRON holds the highest market share approximately 70 % of this amount in India.

Future plans?

The company aims to clock in a turnover of INR 110 crore in this FY which indicates a growth of around 54 % over the previous FY. We enjoy the highest market share in digital BP monitor segment. This FY, we have charted out strategies to scale up further in the home glucometer segment the way we have been doing in the home BP monitoring domain. Along with home monitoring, we also aim to penetrate the hospitals and clinics domain with quality and useful medical devices.

The company shall expand the network of its traditional channel (read pharmacies/ chemists) by covering 45000 tier 1 and 2 cities in this FY through 100 distributors across the country. And in order to further expand our reach, we aim to enter new distribution channels – online shopping portals and electronics retail chains – this FY. We have also intensifies our pan India marketing efforts to give a boost to the brand awareness and penetration. One of the major initiatives in this regard is a TV commercial campaign which shall be rolled out in August -14 (till September) this year. w w w . m e d e g a t e t o d a y. c o m July-August 2014 61

TENDERS Update

Ref Number: 11148303 Tender Number: Tender Prod. No: 06141206 Buyer/Seller: Integral Coach Factory Requirement: Supply of Gear type major head-end control hydraulic surgical operating table model SS.251 Location: Chennai - Tamil Nadu - India Closing Date: 11/08/2014 at 00:00 Hrs. Contact Details: Integral Coach Factory ________________________________________ Ref Number: 11193465 Tender Number: Buyer/Seller: Government Medical College Requirement: Supply of Bovine Surfactant 5ml (Calf) or Bovine Surfactant 4ml or Porane surfactant 1 5ml, Local purchase of medicines/ Drug and Dressy Material, Surgical consumables. Disposable Items, Heated Humidified High Flow Nasal Cannula, Neonatal Multiparameter Monitor, Neonatal Multiparameter Monitor, Electronic Haematology Counter 5 Part Differential with Reticulocyte Count, Haemodalysis Machines, Emergency Patient Recovery Trolley with Mattress, Autoclave (Table Top Rapid Sterlizer), Knee & Shoulder Arthroscopy stations for skill lab, Furniture, Computerized Brief Pulse ECT Machine, Advance Nursing Manikinm, ARC for Kits, Intense Pulsed Light System , Two Body Mortuary Chambers, Disposable Syringe with Needle (20ml and 50nml), Disposable Syringe with Needle (1 mland 10ml), Biological Safety Cabinet, High Frequency and High Resolution C-Arm for Pain Management, Triple Blood Bags (450ml) , Double Blood Bags, Intelligent Tourniquet-Dual Cuff, IV Cannula , Disposable Syringe with Needle, Polythene Bags, Vacuum Suction Set, LV Sets Location: Chandigarh - Punjab - India EMD: Rs.29,600 Closing Date: 12/08/2014 at 00:00 Hrs. _________________________________________ Ref Number: 11181384 Tender Number: Tender Prod. No: 4115140185 Buyer/Seller: Northern Railway Requirement: Supply of O.T. Table Location: Multi Location - Multi State - India Document Fees: INR1,000 EMD: INR43,500 Closing Date: 11/08/2014 at 11:30 Hrs

Hospital Contact Details: Northern Railway _________________________________________ Ref Number: 11086571 Tender Number: Buyer/Seller: Karnataka State Drugs Logistics And Warehousing Society Requirement: Procurement of ophthalmology equipments - indirect ophthalmoscope, eye o.t. Table, slit lamp, keratometer, a scan, operating microscope, auto refractometer, vision drum, tonomete Location: Bangalore - Karnataka - India Document Fees: Rs.550 EMD: Rs.5,000 Closing Date: 18/08/2014 at 17:00 Hrs _________________________________________ Ref Number: 11177792 Tender Number: Tender Prod. No: ME/2014-15/IND629 Buyer/Seller: Medical Education Requirement: Procurement of Medical Equipments - Tables With Marble Or Stainless Steel, Half Standard Size To New Medical Colleges Location: Bangalore - Karnataka - India Document Fees: INR550 EMD: INR3,750 Closing Date: 30/08/2014 at 16:30 Hrs. _________________________________________ Ref Number: 11181912 Tender Number: Buyer/Seller: Tamil Nadu Medical Services Corporation Limited Requirement: Supply of ECG Machine Computerized, Anesthesia Machine, Dental Chair, Semi Auto Analyzer, Operation Table Hydraulic, Shadow less Lamp (Ceiling suspended), ICU Cots with Mattresses, Crash Cart, Pediatric Cots with Mattress, Cots, Eclampsia railing cots, Mattress, Pillow, Pillow Cover, Bed sheet, Cardiac Monitor, Pulse Oximeter Multipara Monitor, OT light - Shadow less type, OT Table - Hydraulic Major, Pulse Oximeter, Electrocardiography -Computerized, 100mA X-ray Machine with Accessories, Anesthesia Machine, Infusion Pump, Autoclave Vertical 2 Bin, Autoclave Vertical single bin, Stretcher Trolley, Color Doppler Machine with buy back existing Color Doppler Machine, Advanced Computerized PFT System, ICU Ventilator, Apheresis Machine, Laser Welding Unit, Autoclave Sterilization, Lyophilizer, Mil-

62 w w w . m e d e g a t e t o d a y. c o m May - June 2014

lipore Distillation Unit, Air Handling unit, Ultrasonic cutting and Coagulation Device with Temperature Controlled Advanced Bipolar Technology, Sentinel Node Nuclear Detector.

Location: Chennai - Tamil Nadu - India Document Fees: Rs.5,725 Closing Date: 8/08/2014 at 15:00 Hrs Document Sale From: 9-7-2014 Document Sale To: 7-8-2014 _________________________________________ Ref Number: 11105131 Tender Number: Tender Prod. No: 2014_ILBS_60200_1 Buyer/Seller: Institute Of Liver And Biliary Sciences Requirement: Establishment of annual rate contract of ripple bed. Supply, installation and commissioning of medical equipment ripple bed.

Location: New Delhi - Delhi - India EMD: INR3,080 Estimated Cost: INR154,000 Closing Date: 23/07/2014 at 11:10 Hrs Document Sale To: 23-7-2014 at 11:10 Hrs __________________________________________ Ref Number: 10950011 Tender Number: Tender Prod. No: 06/14/OT/5056 Buyer/Seller: Southern Railway Requirement: Supply of Operating Table Location: Chengalpattu - Tamil Nadu - India Document Fees: INR1,000 EMD: INR30,400 Estimated Cost: INR1,517,250 Closing Date: 23/07/2014 at 14:00 Hrs. Document Sale To: 23-7-2014 at 14:00 Hrs __________________________________________ __ Ref Number: 11050670 Tender Number: Buyer/Seller: Hospital Services Consultancy Corporation [ India] Limited Requirement: Procurement of Equipment - Electronic Weighing Balance, Digital ABBE’s Refractometer, Sigma balance, Digital Viscometer, Melting point apparatus (Digital type), Sieves 10 to 120 with sieve shaker, Stability testing chamber (Digital display & per G.M.P. Standard) for C.R.T.Study & Accelerated Study, Fume hood, UV VIS spectrophotometer, AAS, HPLC, HPTLC, GCMS, Water purification system, Binocular microscope with camera, Stereo microscope, Cryostat,

TENDERS Updat e

Furniture Tender SLR Camera, Other related silica crucible equipments, Binocular microscope with camera, DM Water Plant, D.M. Water tank.

Location: New Delhi - Delhi - India Document Fees: Rs.500 EMD: Rs.800,000 Estimated Cost: Rs.40,000,000 Closing Date: 23/07/2014 at 14:30 Hrs. Contact Details: Hospital Services Consultancy Corporation [ India] Limited Plot No. 6-A, Block-E, Sector-1(U.P.) Noida Uttar Pradesh India 201 301 Tel # 0120-2540153, Fax # 0120-2542447 www.hsccltd.com Document Sale To: 22-7-2014 at 17:30 Hrs ________________________________________ ___ Ref Number: 11196053 Tender Number: Buyer/Seller: National Rural Health Mission Requirement: Supply of Physiotherapy Equipments & Instruments - Infrared Lamp - Qnty 5 Nos, Adjustable Walker- Qnty 10 Nos, WalkerQnty 418 Nos, Walking Stick- Qnty 1029 Nos, Parallel Bars - Qnty 1275 Nos, Cervical Traction (Wall Mount) - Qnty 5 Nos, Cervical Traction (Wall Mount) - Qnty 5 Nos, Shoulder Pulley Set (Wall Mounting) - Qnty 1290 Nos, Dual Channel Tens- Qnty 5 Nos, Ultrasound Therapy Unit (Single Head) - Qnty 5 Nos, Static Cycle Exerciser- Qnty 246 Nos, Short Wave Diathermy UnitQnty 5 Nos, Short Wave Diathermy Unit- Qnty 5 Nos, Shoulder Wheel- Qnty 1452 Nos Location: Guwahati - Assam - India Document Fees: Rs.2,000 Closing Date: 24/07/2014 at 14:00 Hrs. _______________________________________ _____ Ref Number: 11111474 Tender Number: Buyer/Seller: North Eastern Indira Gandhi Regional Institute Of Health & Medical Sciences Requirement: Procurement Of Neonatal Resuscitation Mannequin, Neonatal Intubation Trainer, Electronic Neonatal / Infant Weighing Scale, Electronic Weighing Scale, Infantometer And Stadiometer Location: Shillong - Meghalaya - India Document Fees: Rs.1,000 EMD: Rs.20,000 Estimated Cost: Rs.1,000,000 Closing Date: 24/07/2014 at 14:00 Hrs _____________________________________ _______ Ref Number: 11081499

Tender Number: Buyer/Seller: North Eastern Indira Gandhi Regional Institute Of Health & Medical Sciences Requirement: Procurement Of Stores /Items - Neonatal Resuscitation Mannequin, Neonatal Intubation Trainer /Heads, Electronic Neonatal / Infant Weighing Scale, Electronic Weighing Scale (Adult/Pediatric), Infantometer, Stadiometer for Institute Location: Shillong - Meghalaya - India Document Fees: Rs.1,000 EMD: Rs.20,000 Closing Date: 24/07/2014 at 14:00 Hrs. ___________________________________ _________ Ref Number: 11074322 Tender Number: Tender Prod. No: 2014_NES_9909_1 Buyer/Seller: Department Of Health Requirement: Procurement Of Neonatal Resuscitation Mannequin, Neonatal Intubation Trainer, Electronic Neonatal / Infant Weighing Scale, Electronic Weighing Scale, Infantometer & Stadiometer.

Location: Shillong - Meghalaya - India Document Fees: Rs.1,000 EMD: Rs.20,000 Closing Date: 24/07/2014 at 14:00 Hrs. Document Sale To: 24-7-2014 at 14:00 Hrs _________________________________ ________________ Ref Number: 11155072 Tender Number: Buyer/Seller: Ayurvedic And Unani Services Requirement: Supply of Equipments, Furniture & Tools Equipments etc for Government Ayurvedic & Unani Hospitals.

Location: Dehradun - Uttaranchal - India Closing Date: 25/07/2014 at 00:00 Hrs. Contact Details: Ayurvedic And Unani Services Dehradun, Uttaranchal, India Document Sale To: 25-7-2014 __________________________ _______________________ Ref Number: 11096179 Tender Number: Buyer/Seller: Department Of Medical Education Requirement: Supply of Arthroscopy Set, OT Table for Minor OT Location: Guwahati - Assam - India Document Fees: Rs.5,000 EMD: Rs.100,000 Closing Date: 21/07/2014 at 14:00 Hrs ___________________ ______________________________ Ref Number: 11096077

Tender Number: Buyer/Seller: Department Of Medical Education Requirement: Supply & installation of Equipments/Machines, Cardio Toco Graph (CTG) Machine, Hysteroscopy Set(Bipolar Electrosurgical), Laparoscope, OT Table - Manual Hydraulic Location: Guwahati - Assam - India Document Fees: Rs.5,000 EMD: Rs.200,000 Closing Date: 21/07/2014 at 14:00 Hrs. ____________ _____________________________________ Ref Number: 11171241 Tender Number: Buyer/Seller: Nalanda Medical College Hospital Requirement: Supply of Hospital Goods, Line, Furniture & Other Items.

Location: Patna - Bihar - India Closing Date: 22/07/2014 at 00:00 Hrs. Contact Details: Nalanda Medical College Hospital, Patna, Bihar, India _____ __________________________________________ __ Ref Number: 11072159 Tender Number: Tender Prod. No: 82145013 Buyer/Seller: South Eastern Railway Requirement: Supply of S. S. Saline Stand. S.S. Quality to IS-404 with wheel. High Adjustable Location: Multi Location - Multi State - India Closing Date: 22/07/2014 at 00:00 Hrs. Contact Details: South Eastern Railway ________________________________________ _________ Ref Number: 11157654 Tender Number: Buyer/Seller: Department Of Health Requirement: Supply of necessary Medicine, Chemical, Test item, Consumables & Furniture Equipment, etc for various program under National Health Mission in year 2014-15 Location: Fatehpur - Uttar Pradesh - India Closing Date: 14/07/2014 at 15:00 Hrs. Contact Details: Department Of Health Fatehpur Uttar Pradesh India

w w w . m e d e g a t e t o d a y. c o m

May - June 2014 63

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