Express Healthcare (Vol.10, No.5) May, 2016

VOL.10 NO 5 PAGES 68

www.expresshealthcare.in MAY 2016, `50

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CONTENTS Vol 10. No 5, MAY 2016

TRENDS IN SOFTTISSUE IMAGING

Chairman of the Board

MARKET

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SYMBIOSIS TO HOLD HEALTHCARE SEMINAR IN PUNE

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ASIA PACIFIC COUNTRIES VOW TO TACKLE ANTIMICROBIAL RESISTANCE

17

IASSA CONDUCTS CONFERENCE ON SLEEP APNEA IN MUMBAI

18

STRAND LIFE SCIENCES PUBLISH STUDY ON UTILITY OF GERMLINE CANCER MULTIGENE TEST FOR HBOC

Viveck Goenka Sr Vice President-BPD

Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das Bengaluru Assistant Editor Neelam M Kachhap DESIGN

KNOWLEDGE

National Design Editor Bivash Barua Asst. Art Director Pravin Temble Senior Graphic Designer Rushikesh Konka Senior Designer Rekha Bisht Artists Vivek Chitrakar, Rakesh Sharma

Dr Sanjay Dhawan, Sr Consultant & Head (Radiology & Imaging), Paras Hospitals, Gurgaon explains the methods available for soft tissue imaging and the advantages of each technique| P31

42

LEARNINGS FROM EBOLA EPIDEMIC

Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - East & West Marketing Team

INTERVIEWS

IN IMAGING

IT@HEALTHCARE

P12: VISHAL BALI Co-founder & Chairman, Medwell Ventures

Douglas Menezes Ambuj Kumar E.Mujahid

P14: DR DHARMINDER

Arun J

NAGAR

Debnarayan Dutta

MD, Paras Healthcare

Ajanta Sengupta PRODUCTION General Manager BR Tipnis

P19: JOHN STUBBINGTON CEO, Medicover

Manager Bhadresh Valia Scheduling & Coordination Ashish Anchan CIRCULATION Circulation Team Mohan Varadkar

34

RECENT ADVANCES IN ULTRASOUND IMAGING TECHNOLOGY

38

ROLE OF USG IN FATTY LIVER DISEASE

P28: AMIT BHANDARI Head, Health & Agri Insurance, Underwriting and Claims, ICICI Lombard General Insurance

44

CONVERGENCE OF TECHNOLOGY AND HEALTHCARE IN INDIA

45

HEALTHCARE IT HAS STRONG FIRST QUARTER: MERCOM REPORT

Express Healthcare® Regd.with RNI no. MAHENG/2007/22045,Postal Regd. No. MCS/162/2016 – 18,Printed for the proprietors, The Indian Express (P) Ltd. by Ms. Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021.

(Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021) *Responsible for selection of newsunder the PRB Act.Copyright © 2016 The Indian Express (P) Ltd. All rights reserved throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.

Meditek: 25+ years and way to go!

“It

all started with a thought – understanding the needs of hospitals completely and manufacturing the best in class hospital beds and other ancillary products to suit the exact needs and requirements of patients, doctors etc that ultimately creates a win-win situation for all of us. And it was with this thought that paved way for setting up of Meditek in the year 1989,” says Anil Phirke, Founder and current Chairman cum Managing Director. A qualified mechanical engineer by profession, Phirke had spent many years working with reputed organisations like Crompton Greaves etc before starting Meditek.

It’s been 25+ years since then and Meditek has already established its brand name in the market. Being a proactive player in understanding the ever changing requirements of the healthcare industry, Meditek has keenly observed and implemented all the relevant requirements and improvisations in their various categories of products to surpass the expectations of the healthcare industry. Situated at Ambernath near Mumbai they are already present all across India and in the international markets as well.

An ISO 9001:2008 and ISO 13485:2003 certified company, Meditek clearly boasts of a strong foothold in quality delivery to its customers that ranges from small and midsized private and government hospitals to big chain global hospitals as well.

“Customer comes First! – is what we have always believed and worked towards,” says Anil Phirke. And that is why Meditek is so much appreciated and accepted in the mar-

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ANIL PHIRKE, CMD, MEDITEK

ket. Delivering the best in class quality products that undergo rigorous quality check procedures across various phases during manufacturing is what gives Meditek an edge over others. The company boasts of modern in-house state-of-theart manufacturing units such as hydraulic bending, shearing and pipe bending machine, eight tank pre-treatment plant, epoxy powder coating plant and a modern assembly and welding set up. Continuous R&D, regular client feedback, backed by prompt sales and service support is what keeps customer delighted and satisfied.

Parag Phirke who joined Meditek later has been instrumental in adapting the products to the real time market requirements. A qualified mechanical engineer, he is a deep thinker as well. “In the current situation of the fast changing healthcare industry, it is imperative for us to customise our products to very much suit the actual needs of customers

PARAG PHIRKE

and for that reason innovation is one thing that we can’t do without.” And truly its been effortless innovative thoughts of Parag that Meditek has been really been able to go the extra mile in transforming their products.

Meditek supplies multiple products in various categories to suit the wide range of OT and Ward Requirements of the Hospitals & Institutions. The range varies from High End Motorised Beds, Manual/ICU Recovery Beds, Ward beds, Trolleys to OT and Ward Equipments. And their continuous R&D keeps developing new ones.

Meditek firmly believes in their highly skilled and trained workforce across all the verticals spanning from sales, marketing, production, HR, administration to all the other supporting staff. And it is because of them that Meditek has been firmly able to hold the ground for so many years servicing the customer end-toend right from the best in qual-

PRIYANKA CHAVAN

ity product supply to taking care of their installation and service post.

“Meditek is like a family,” says Priyanka, who is the latest addition to Meditek. A highly-skilled management graduate in operations from Canada, she worked in the field of supply chain and logistics management there for four years before coming to India and joining Meditek. She adds, “Our prime focus lies in the fact that our customer should always be happy and satisfied and for that we make sure that we take all the possible steps to exceed their expectations.” Priyanka has played a pivotal role in restructuring and implementing relevant operational strategies to catalyse the growth of Meditek not only in India but in international markets as well.

Not only has Meditek evolved and grown in its own way to be one of the established brands in the market, it has also played an important

role in reforming the healthcare industry too.

Meditek is proud to be associated with many of the reputed hospital chains and institutions. To name a few, Fortis Group across Mumbai, Bangalore and Kolkata, AIIMS - Raipur, SL Raheja – Mumbai, Global Hospital Mumbai, SRM – Chennai, JSS - Mysore, Breach Candy – Mumbai, Max Healthcare New Delhi, Hiranandani – Mumbai, NIMS Hyderabad, Nova Hospital chain all over India.

Meditek has a very strong vision to be the frontrunner in reforming the healthcare industry in terms of hospital furniture both in national and international markets.

Like the Meditek’s leadership team puts it in a line, “Meditek should be embedded in the heart of our customers, patients, doctors, nurses and all of them associated with the healthcare fraternity so that they actually feel…..MEDITEK CARES!!!”

EDITOR’S NOTE

Right time for IPOs?

A

s we go to press in end April, Dr A Velumani's Thyrocare Technologies (Thyrocare) looks set to have a successful debut on the Indian stock exchange. More than half of the offered equity shares received bids by the end of the first day itself.

Whether this warm reception will continue is anyone's guess. But an analysis of data from the stock exchange has put to rest one fear that the retail investors might not be interested in the Thyrocare issue, as it followed the super-successful IPO by a competitor, Dr Lal Path Labs last December.

In fact, much of the charge on day one seems to have been led by retail investors, who bid for almost all the 3.76 million shares allocated to this category. In contrast, institutional and noninstitutional investors seemed warm to cool to the issue. While the former category had picked up a mere 11 per cent of their allocation, the latter mostly stayed away till end of day one but this could change in the remaining two days.

As our cover story in the May issue analyses, the preceding IPOs in the healthcare sector seem to have merely whetted the appetite of investors.

And if retail investors missed the earlier IPOs, they might now want to jump on the bandwagon now. (See story: Will IPOs in healthcare sink or soar?, pages 24-27) But market analysts are quick to point out the risks. In Thyrocare's case, even though it has considerable competitor strengths, it could still be tripped up. A report from Motilal Oswal cites

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The preceding IPOs in the healthcare sector seem to have merely whetted the appetite of investors.And if retail investors missed the earlier IPOs,they might now want to jump on the bandwagon

increasing competition from major diagnostic players like SRL Diagnostics, Metropolis and Dr Lal Pathlabs (DLP) as well as many small and independent clinical labs, and labs owned by hospitals and physicians as one of the risk factors.

Secondly, the diagnostics business is technologydriven and players could face risks of the capital intensive technologies going obsolete faster.

Also, the point-of-care test market is bound to see a spike, which will dent the volumes that players like Thyrocare are projecting. These factors could lead investors to question the valuation of the Thyrocare IPO, which at a price band of Rs 420-446, is priced at 47.7- 50.7x price-earnings (PE) ratio for FY2015 consolidated earnings per share (EPS) of Rs 8.8 and 30-32x EV/EBIDTA for FY2015.

But this valuation is similar to DLP and as the Motilal Oswal report points out, after listing, the premium valuations of DLP expanded further due to its strong track record, healthy return ratios and high free cash flows despite the aggressive expansion and exponential growth in the business.

So, the jury is still out on the Thyrocare IPO but with healthcare seen as a defensive sector, most investors would be aware of the longer-than normal gestation periods. Thyrocare too is derisking its model by expanding to water and air testing, in order to create more revenue streams.

VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

A spirit of

INSPIRATION

Breas has been one of the pioneers in ventilation and sleep therapy for over 20 years and the founding spirit is still just as strong.

Breas has been motivated by the desire to improve patients’ lives and help clinicians since 1991, when the company started up in Gothenburg. From humble beginnings, it has grown into a significant player in bi-level and Home and Hospital mechanical ventilation across Europe.

Today we are recognized as one of the leaders when it comes to versatile innovation and Industrial design for the homecare and hospital market. Our brand is based on the same values we started up with – quality, a focus on patients and customers, and a commitment to innovation.

Our range of products

Vivo 30

Vivo 40

Vivo 50

Vivo 60

Z1™ CPAP iSleep 22/25

The world´s smallest, lightest, most integrated CPAP.

© 2014 Breas Medical – All rights reserved.

Breas Medical reserves the right to make changes in specifications and features shown herein, or discontinue the product described at any time without notice or obligation. Contact your Breas representative for the most current information. Breas and the Breas logo are trademarks of Breas Medical AB.

Breas Medical AB · Företagsvägen 1 SE-435 33 Mölnlycke · Sweden Phone +46 31 86 88 00 · www.breas.com

Ved Prakash · D-76, Defense Colony, Jajmau Kanpur-208 010 · Phone +91 99364 17333 vedprakash.bajpai1956@gmail.com

State wise dealers required

MAR-0733-v.0.1

iSleep 20/20+/20i

MARKET I N T E R V I E W

This financial year, Medwell Ventures would invest upwards of $15 million Nightingales Home Healthcare's first centre in Mumbai was launched recently. Vishal Bali, Co-founder & Chairman of Medwell Ventures, spoke to Raelene Kambli at the event and shared his plans for the home healthcare business, the opportunities available in this space and his vision to capture the home healthcare market in India Medwell Ventures has been an early mover in the home healthcare space. How do you see the market shaping?

The market for home healthcare services in India has evolved very rapidly over the last three years and the addressable market is currently estimated to be $ five billion. The evolution of this category in the healthcare delivery ecosystem of the country also shows that the healthcare consumer in India is seeking these services, particularly with a strong clinical interface. We, at Medwell Ventures, took an early position in this and take pride in establishing it in India.

Do you see any white spaces in this space? How does Nightingale fill these gaps?

The category, though highly evolved in the developed world, is a complete white space in the Indian context.

We founded Medwell Ventures with the core idea to incubate and scale healthcare delivery businesses in the out of hospital space. Nightingales, our home healthcare delivery brand has created a niche for itself by defining a space which was hitherto not available in the country. Our speciality-led services, which create a continuum of care and reduce recurring hospitalisations of patients with chronic diseases, is a distinct space.

How would you differentiate Nightingale Home

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Healthcare from the rest of the home healthcare players?

Home healthcare as a category sits in the out of hospital healthcare provision.

Similar to inpatient healthcare delivery where a provider can take a general or a speciality position, in home healthcare too the provider has a choice to either take a general provider provision and give more transactional services of a doctor, nurse or physiotherapy at home or take a speciality position with a high degree of clinical care built into the delivery. We, at Nightingales, have taken a speciality-led position with a focus on treating patients at home with congestive heart failure, COPD, neurohealth issues, musculoskeletal ailments and diabetic wounds.

The company has also invested behind its own network of physiotherapy centres through which services are provided at both, home and the physio clinic.

This ensures that there is continuity of care plans within the Nightingales system.

Nightingales is a highly differentiated model when compared to all other home healthcare providers.

What is the current turn over of the company? What is the kind of investment you have made so far? What has been the ROI? At the end of this financial year, the company would have invested upwards of $15 million in building this

We started our services in Mumbai early this year, so the key projection for this year is to open multiple branches in Mumbai and other cities in Western India. The company has already established deep presence in Bengaluru and Hyderabad.

Do you wish to tap the rural market in India? How? If you look at the growth of corporate hospitals in the country, the phenomenon started in the metros and then spread to tier II and tier III cities across the country. The same will happen in the home health category, we will first see this more in the tier 1/metro push and then the services will percolate to the smaller and rural markets.

New businesses start with an idea which is disruptive but the continuing success of that idea is dependent on sustaining its innovation index category across key cities in India with multiple branches in each city and a very scalable IT platform. This is the growth phase of the company and we expect continuing investments to happen over the next few years before the

measurements of ROI start.

We have gone down the path of a calibrated growth building one city at a time and ensuring that there is deep presence in each city.

What are your projections for this year?

You have immense expertise in building global healthcare delivery organisations.

What is the roadmap you have charted for Medwell Ventures in the global markets?

We are building very strong systems and protocols in Medwell Ventures which can support and add value to home health as a business in any geography. While our primary focus is India, looking at the competencies that we have built in the enterprise there is gaining significant interest from markets outside of India.

What are the risk areas that you see for your business?

Every early stage category

defining business has risks associated with it, the idea is to mitigate them and continue pursuing the path. All services businesses are people dependent, particularly in healthcare people skills become the cornerstone of success. When there are many early entrants in a new category every player has to ensure that they set high standards in the category, not following that risks the growth of the category.

You also have an expertise in building M&A driven growth initiatives. What opportunities do you see in this space for Medwell Ventures? Any M&As in the pipeline?

The origin of Medwell Ventures was through an acquisition. We will pursue growth through both organic and inorganic opportunities.

We have built a very capable and competent team which has the ability to drive multiple initiatives simultaneously and comes from a strong healthcare background.

What is your opinion on the start-up boom in the healthcare sector, especially in the home healthcare space? Any new ideas in this space that have caught your eye? How viable will these models be?

India is finally witnessing an acceleration in healthcare start-ups which will define a new healthcare delivery ecosystem in the country. It is a very exciting time to build new healthcare models in the country and create scale behind them. While infrastructure creation is essential for the growth of the sector we have to move beyond and look for opportunities which fulfill the demand of the consumer.

What's more important to your business- disruptive innovation or sustainable innovation? Why? New businesses start with an idea which is disruptive but the continuing success of that idea is dependent on

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May 2016

sustaining its innovation index, our business has tremendous potential to keep innovating and evolving because the consumer needs are also evolving at the same time. This is the challenge around creating a new

category, one evolves the market while evolving the business.

One important lesson that you have learned when you started off your own business?

When you look at the founding team of Medwell Ventures, decades of healthcare experience reside in the team.

We went down this path of entrepreneurship because we wanted to contribute a new model of healthcare to India.

Status quo has great comfort built into it but one needs to challenge it. So my big lesson in business is that if something does not challenge you, it can never change you. raelene.kambli@expressindia.com

MARKET I N T E R V I E W

‘This year we expect to have the group revenue cross Rs 350-400 crores’ Paras Healthcare recently launched Paras Bliss, a dedicated mother and child facility in Panchkula, Haryana. Dr Dharminder Nagar, MD, Paras Healthcare speaks about the hospital group’s plans to expand it as a chain of mother and child care centres and their strategy to expand their footprint across North India, in an interview with Lakshmipriya Nair

Paras Healthcare recently launched Paras Bliss, a dedicated mother and child facility in Panchkula. How is it different from its counterparts in the country?

Motherhood is not just about delivering a child. It is an experience and a journey which can be enriched and augmented at each step by providing specialised offerings and care. With Panchkula, Paras Healthcare would like to introduce its chain of specialised mother and child care facilities – Paras Bliss that aim to provide 'More for Motherhood'. Paras Bliss would encapsulate all aspects associated with the needs of every woman, an expecting mother and a new mom. The technology and medical expertise rich facilities would act as a haven for the neonates.

Paras Bliss at Panchkula would be the first specialised mother and child care of the region.

Paras Bliss can be characterised as a one-of-itskind chain of specialised mother and child care centres which has understood the needs, challenges and requirements of motherhood.

With specialised programmes, we aim to provide personalised attention.

The urban areas have a number of nuclear families.

As one gets pregnant they still look out for the support of their mother or mother-in-laws.

Some are fortunate to receive their guidance, while some miss out on the same. Our aim is to create a holistic

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environment where every woman feels secure, welcome and heard. With Paras Bliss, we wish to evolve healthcare in becoming a part of the patients’ life – from trying to conceive, to pregnancy, delivery and post natal care.

At the moment, Paras Healthcare is strictly focussing on its new chain of specialised mother and child care centres – Paras Bliss. The aim is to provide specialised maternity and neonatology care in areas where the same is deficient.

Our flagship unit is coming up in Panchkula and it highlights the three tenets of Paras Healthcare – affordability, accessibility and quality.

Keeping the same in mind, Paras Healthcare shall be expanding its footprint in six important cities of North India over the next five years.

What are the hospital group's plans for this fiscal?

What are the strategies to achieve them?

For setting up a new unit, Paras mainly adheres to the following tenets of healthcare – accessibility of healthcare in the region, presence of affordable healthcare facilities at the location and lastly, existence of a specialised quality healthcare provider.

Paras Healthcare tries to address these aspects and provides healthcare facilities that can touch the lives of millions and improve the health infrastructure of the state/region.

Today, healthcare providers

We believe in providing affordable tertiary care services, the best medical technologies and solutions at lower costs have set up their best hospitals in metropolitan cities, leading to mushrooming of tertiary care providers. In India, where 70 per cent of the healthcare facilities are provided by private players, Paras aims at being the first healthcare provider to bring exceptional healthcare services to a region.

Paras aims at bridging this gap in tier-II cities. Our healthcare delivery models are designed

to cater to the common man.

We believe in providing affordable tertiary care services, the best medical technologies and solutions at lower costs, making tier-II cities our obvious choice.

We shall be focussing on providing healthcare in tier-II cities of North India. We are looking at cities with a population of more than two million supported by a medical college. It will help in ensuring a pool of medical professionals.

Five years from now, we will have a bed strength of 1500.

This year, we expect to have the group revenue cross Rs 350-400 crores, and that should become Rs 1,000 crores within the next five years with additional beds, services and hospitals being added.

How will the funds be raised to achieve the goals?

The funds to propel expansion shall be part equity and debt associated. We are looking for stakeholders that match our mindset in healthcare growth and return on investment. As and when we find a partner whose expectations match ours we shall be open to equity funds. Moreover, we sincerely believe that healthcare is a long-term association. It is built on the strong trust of the doctors and the city in which it is associated, hence instant results in healthcare are difficult to achieve.

What are the major healthcare gaps in North India? How is Paras

Healthcare contributing to mitigate these challenges The most challenging aspect is to bring specialised, medical professionals and administrative staff, followed by acceptability as an exceptional tertiary care provider by the public.

The acceptance of costs associated with healthcare is also a major challenge. People usually accept spending the same amount at different cities, but they need to understand the advantage of the availability of specialised tertiary care services in their city, at their doorstep. Unprofessional approaches by existing small players are also an important challenge. Moreover, one has to run around for various licenses, approvals and sanctions. The government needs to streamline the systems and provide a one-window model to all healthcare providers.

Moreover, when all the aspects and factors are clear the availability of suitable land and cost of real estate prove to be deterrents.

Paras Patna has been successful in overcoming all the major hurdles. Today, we are a well established and recognised healthcare provider with the largest employee base in the state of Bihar. We have also been successful in bringing medical professionals of repute back to their roots and provide state-of-the-art facilities and latest technology to the common man. lakshmipriya.nair@expressindia.com

MARKET PRE EVENT

Symbiosis Institute of Health Sciences to hold healthcare seminar in Pune The XVIII National Seminar in Hospital & Healthcare Management, Medico Legal Systems & Clinical Research will be held on May 6-7, 2016

SYMBIOSIS INSTITUTE of Health Sciences (SIHS), a constituent of Symbiosis International University (SIU) is conducting the XVIII National Seminar in Hospital & Healthcare Management, Medico Legal Systems & Clinical Research on May 6-7, 2016 at Symbiosis International University (SIU), Lavale, Pune. Reportedly, the event has been accredited by the Maharashtra Medical Council (MMC) as well.

The seminar will be inaugurated by Thumbay Moideen, Founder President, Thumbay Group, UAE. Dr Rajani Gupte, Vice Chancellor, Symbiosis International University (SIU) and Dr Vidya Yeravdekar, Principal Director, Symbiosis will also grace the occasion.

This highlights of this year's seminar will be CONNEXIONS – a workshop and placement drive, Master Classes, Star Alumnus Awards and Healer of Mankind Award. It would cover pertinent topics such as Role of Six Sigma in Healthcare, Game Changers: Telemedicine in Healthcare, Sustainable Healthcare Models, Changing Paradigm in HR, Enterprise Performance

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MARKET

Management, Special Laws related to Healthcare etc.

This year’s edition will feature four intensive, domainspecific master class sessions as well.

It will also see the introduction of two awards which would be given to individuals who have made commendable contributions in the field of healthcare and thereby to the society. The 'Healer of

Two awards would be given to individuals who have made commendable contributions in the field of healthcare Mankind' award would be a lifetime achievement award while the other one will be

given to a ‘Star Alumni’ of Symbiosis who has contributed significantly to

the society. The valedictory ceremony is expected to be graced by renowned advocate Ram Jethmalani, Former Union Law Minister as the Guest of Honour It will presided by Dr SB Mujumdar, Founder & President, Symbiosis and Chancellor, SIU. Thus, the XVIII National Seminar promises to be a must attend event for professionals from all verticals of healthcare.

Contact Dr Rajiv Yeravdekar Dean, Faculty of Health & Biomedical Sciences, SIU Phone: 91-020-25655023, 20255051, 08888892258, 09552588162/ 92 Email: info@schcpune.org, dep@schcpune.org, ic.symbiosis@schcpune.org, hod_academics@schcpune.org Website: www.schcpune.org

POST EVENTS

Asia Pacific countries vow to tackle antimicrobial resistance together Health ministers from 12 countries of the region agreed to improve the way information on antimicrobial resistance is collected and shared to guide effective policies and actions COUNTRIES IN the Asia Pacific region have pledged to collaborate to combat the increasing threat of antimicrobial resistance which transcends borders and endangers global health by making lifesaving antibiotics ineffective.

Health ministers from 12 countries of the region agreed to improve the way information on antimicrobial resistance is collected and shared to guide effective policies and actions; to strengthen and harmonise how they regulate the production, sale and use of antibiotics and other antimicrobial medicines; and to take innovative approaches to stimulate research and development of new antibiotics, diagnostic tests, vaccines and other technologies, a communique issued on the Tokyo Meeting of Health Ministers on Antimicrobial Resistance said.

“Antimicrobial resistance is a threat to global security and economic stability. It is a looming health and economic crisis that requires both global and

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Ministers acknowledged that antimicrobial resistance is a byproduct of system failures and strengthening these systems is a critical component of the SDGs local solutions. Since drug resistant genes can travel, countries with higher levels of economic and social organisation have a stake in the success of measures taken by less developed countries. In the fight against antimicrobial resistance, we are only as strong as the weakest link,” Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, told ministers at the meeting.

The ministerial meeting followed a two-day brainstorming session among experts and organisations representing public health, agriculture and

animal health, was organised by the Government of Japan and WHO, in collaboration with the Food and Agriculture Organization of the United Nations and the World Organisation for Animal Health.

“Antibiotic resistance is one of the biggest threats to human health today. Having effective antimicrobials is also critical to the social and economic development of nations. We have a limited window of opportunity to take action and avoid a postantibiotic era. WHO is supporting countries across the Asia Pacific region to take critical steps to preserve the effective-

ness of these life-saving medicines. We must strengthen health systems’ response and cooperation with the agriculture sector to contain this threat, and improve understanding of the problem among the public. The Tokyo meeting has provided a platform to move forward with this important agenda,” said Dr Shin Young-soo, WHO Regional Director for the Western Pacific.

Rapid economic development and socio-demographic and cultural changes, coupled with the health status, puts the population of the Asia Pacific region at higher risk for emerging drug-resistant infections, evident by the spread of multidrug resistant strains of malaria and tuberculosis.

Ministers acknowledged that antimicrobial resistance is a by-product of system failures—from regulation of medicines to agricultural and trade controls—and strengthening these systems is a critical component of the Sustainable Development Goals.

They agreed on the need for urgent action to raise awareness across all sectors of the need for responsible use of antibiotics. The region’s health ministers pledged to take a multi-sectoral approach, with effective governance mechanisms, to enable all stakeholders to work collectively and effectively.

Accelerating progress towards universal health coverage—to ensure people across the region have equitable access to quality health services, including the prevention and control of infections and rational prescribing of antibiotics—was another key initiative emphasised and agreed upon by ministers.

Ministers or senior officials from Australia, Bangladesh, China, India, Indonesia, Japan, Malaysia, Myanmar, Philippines, Republic of Korea, Thailand and Vietnam, and representatives of WHO and other partner organisations attended the meeting.

MARKET

IASSA conducts conference on sleep apnea in Mumbai Surgical guidelines to treat obstructive sleep apnea issued on the eve of the conference THE INDIAN Association of Surgeons for Sleep Apnoea (IASSA), issued surgical guidelines for Indian ENT surgeons treating obstructive sleep apnea (OSA) across the country, on the eve of the 4th National Conference of Indian Association of Surgeons for Sleep Apnea 2016 held in Mumbai recently. IASSA is an associated society of World Association of Sleep Medicine and promotes all aspects of sleep research and sleep medicine.

Reportedly, the conference witnessed congregation of over 400 ENT specialists from around the globe looking to gain insight in the field of OSA research, treatment and diagnosis.

Innovation and upgrades in diagnosing obstructive sleep apnea syndrome (OSAS), future

perspectives in OSA surgery, controversies in management and prevention of litigation, instructional course on do’s and dont’s of OSA were some of the important topics discussed in this three day conference.

Opening the conference, Dr

Vikas Agrawal, President, IASSA said, “IJMR already has physician guidelines. IASSA has focussed on surgical guidelines, while also sharing detailed methods to diagnose sleep apnea correctly. Over 90 per cent of sleep apnea cases

are misdiagnosed, in India, because sleep apnea is a relatively new subject.”

According to ENT experts, incorrect diagnosis is one of the biggest concern areas when it comes to OSA treatment in India.

The new OSA clinical guidelines have included standards for diagnostic techniques, treatment options and followups for Indian surgeons and clinics performing evaluation and management, including surgery for OSA. Dr P Vijaya Krishnan, Secretary, IASSA said, “Sleep related disorders are high in the Indian population and the accessibility for diagnosis and treatment is still not enough.

However, this scenario is slowly changing with the advent of cost effective diagnostic and surgical options for treating OSA. Drug Induced Sleep Endoscopy (DISE) is one such diagnostic tool which helps in identifying the obstruction in the airway and improve patient management and treatment success.”

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MARKET RESEARCH

Strand Life Sciences publish studyon utilityof germline cancer multi-gene test for hereditarybreast and ovarian cancer As part of this study, 141 unrelated patients and families with breast or ovarian cancer were tested for mutations in 13 genes associated with high inherited risk, using NGS STRAND LIFE Sciences, precision medicine diagnostics provider, has published a study in the Journal of Human Genetics titled, “Detection of high frequency of mutations in a breast and/or ovarian cancer cohort: implications of embracing a multi-gene panel in molecular diagnosis in India.”

As part of this study, 141 unrelated patients and families with breast or ovarian cancer were tested for mutations in 13 genes associated with high inherited risk, using next-generation sequencing (NGS). 36.2 per cent of the cases showed clear inherited risk, with the number going up to 52 per cent for cases with a family history of breast

HEAD OFFICE Express Healthcare® MUMBAI Douglas Menezes The Indian Express (P) Ltd. Business Publication Division 2nd Floor, Express Tower, Nariman Point Mumbai- 400 021 Board line: 022- 67440000 Ext. 502 Mobile: +91 9821580403 Email Id: douglas.menezes@expressindia.com Branch Offices NEW DELHI Ambuj Kumar The Indian Express (P) Ltd. Business Publication Division Express Building, B-1/B Sector 10 Noida 201 301 Dist.Gautam Budh nagar (U.P.) India.

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cancer. Both numbers were higher than expected. Most were on account of mutations in the commonly tested BRCA1 and BRCA2 genes. However, 28 per cent of the mutations detected were in other genes, indicating that Strand’s multi-gene germline cancer test provides increased diagnostic sensitivity, and possibly better patient outcomes, as compared to previous approaches of testing single genes or just the BRCA1 and BRCA2 genes. In addition, 37 per cent of the mutations detected have not been reported earlier in patients, indicating novel variation in the Indian population. These trends continue to hold on more than 300

CHENNAI Arun J The Indian Express (P) Ltd. Business Publication Division 8th Floor, East Wing, Sreyas Chamiers Towers New No 37/26 (Old No.23 & 24/26) Chamiers Road, Teynampet Chennai - 600 018 Telephone (Board): +91 44 24313031/32/34 Fax: +91 44 24313035 Mob: +91 9940058412 Email id: arun.j@expressindia.com BENGALURU Amit Tiwari The Indian Express (P) Ltd. Business Publication Division 502, 5th Floor, Devatha Plaza, Residency road, Bangalore- 560025 Board line: 080- 49681100 Fax: 080- 22231925 Email id: amit.tiwari@expressindia.com HYDERABAD E.Mujahid The Indian Express (P) Ltd. Business Publication Division 6-3-885/7/B, Ground Floor, VV Mansion, Somaji Guda, Hyderabad – 500 082

further cases tested after the study was submitted.

These findings are important for patient care, as breast and ovarian cancer patients with a strong inherited risk, and their related family, can take steps for cancer prevention and increased surveillance. Recent and upcoming promising developments in systemic therapy for such patients might also yield better outcomes. These findings also help in growing the knowledge base of genetic variants in the Indian population.

Dr Vijay Chandru, Executive Chairman, Strand Life Sciences, said, “We are happy to announce the publication of our study on hereditary cancer risk in South

Board line- 040- 66631457/ 23418673 Mobile: +91 9849039936 Fax: 040 23418675 Email Id: e.mujahid@expressindia.com KOLKATA Ajanta Sengupta The Indian Express (P) Ltd. Business Publication Division JL No. 29&30, NH-6, Mouza- Prasastha & Ankurhati, Vill & PO- Ankurhati P.S.- Domjur (Nr. Ankurhati Check Bus Stop) Dist. Howrah- 711 409 Mobile: +91 9831182580 Email id: ajanta.sengupta@expressindia.com KOCHI Arun J The Indian Express (P) Ltd. Ground Floor, Sankoorikal Building, Kaloor – Kadavanthra Road Kaloor, Kochi – 682 017 Mobile: +91 9940058412 Email id: arun.j@expressindia.com COIMBATORE Arun J The Indian Express (P) Ltd. No. 205-B, 2nd Floor, Vivekanand Road,

Asian women in the Journal of Human Genetics. Studies such as these will provide physicians much needed evidence on clinical utility of NGS-based multigene panels for incorporation into routine genetic testing in clinical oncology practice.” Dr Chandru added, “With the increased financial burden of cancer care on self-paying patients and the Indian healthcare system, our approach of using affordability as a driver of innovation has resulted in developing cost-effective genetic testing solutions, for diagnosis and early detection of HBOC.” Speaking about the study, Dr Kas Subramanian, Chief Scientific Officer, Strand Life

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Sciences, said, “This study underscores the incidence of cancer risk mutations that are prevalent in the Indian population. In certain types of therapies, including platinum-based therapies and PARP inhibitors, where the genetic background plays an important role in treatment success, the Strand Germline Cancer Test offers the ability of identifying patients who are likely responders. More importantly, hereditary cancer genetic testing when performed in accordance with guidelinebased ethical practices, coupled with expert genetic counseling consultations can greatly benefit cancer patients and their family members.”

Important: Whilst care is taken prior to acceptance of advertising copy, it is not possible to verify its contents. The Indian Express (P) Ltd., cannot be held responsible for such contents, nor for any loss or damages incurred as a result of transactions with companies, associations or individuals advertising in its newspapers or publications. We therefore recommend that readers make necessary inquiries before sending any monies or entering into any agreements with advertisers or otherwise acting on an advertisement in any manner whatsoever.

MARKET I N T E R V I E W

‘Medicover will have four clinics in Delhi in the next two months’ Medicover, European private healthcare provider, is set to enter India with the fertility business.

John Stubbington, CEO, Medicover was in India recently and spoke to M Neelam Kachhap about the company’s plans for India Why did you choose to invest in India?

The Medicover businesses were launched by the Swedish family which also runs the Oriflame cosmetics brand. The brand has a strong presence in India. We have been in India for a decade, so we evaluated the market and decided to invest here. There are more than

30 million infertile couples in India. So, it seemed like a significant opportunity for us to bring the best clinical practices, trust, transparency and high quality services by leveraging our European experience and expertise.

This is a large but fragmented market with lack of regulations. The IVF

market in India has grown at a fast pace, with IVF cycles growing at 18 per cent CAGR. But, the penetration of the IVF market is significantly low in India.

There are only 2,800 cycles/million infertile women in the reproductive age group (20 – 44 years) as compared to China which has 6,500, US’ 46,042 and

Germany's 50,884. The key challenges are lack of awareness, affordability and accessibility.

How is the Indian IVF market different from the European market?

We analysed that the Indian fertility market is focussed on IVF, with a high number of cycles before people

either give up or achieve success. We don’t work that way and this is the difference we could bring to the market. With our model, we basically look at fertility in a wider context.

We try to identify what the problem could be; some times it’s stress; sometimes people just need counselling. At

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times, it is the need for lifestyle changes like improving the diet. We try to identify the problem and treat it with the right approach. We are proud that 90 per cent of the couples who come to us seeking help are successful in having a baby. We also have a broad proposition in other areas of care. We also feel that the fertility segment is different.

It is an emotional journey and people really need the right kind of environment and the best possible channel to be able to create a family. We just make sure that the whole experience is a positive one for our customers.

There is a big difference in terms of clinical facilities available in India as compared to the developed markets. In India, air quality is very poor. We once saw that dust from a construction site was entering a lab facility, this can create serious problems.

Some facilities allow people to enter the clinical environment. For instance, I hadn’t worn the appropriate clothing go into a sterile environment but was still allowed. So, I feel that clinical standards are very high in Europe and it affects our outcomes.

Tell us about your fertility business.

We bought our first fertility business in 2012 and we are competing with business that have experience of over 15 years. Medicover Fertility represents Medicover’s first step in bringing the brand’s comprehensive range of healthcare services to the Indian market. What will make us stand out in India is our unique model of patient care which is 'Right Care, Right Place, Right Time, Right Outcome'. I have a very simple motto; if the care that we give is not good enough for my mother then it’s not good enough for my customers. Therefore, we constantly micromanage our business to look at aspects

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we can improve. In our fertility business we offer modern facilities in an environment that is positive for doctors and we make sure we implement our standards of care. We work very closely with local market clinicians so that we can improve the clinical outcomes of our customers.

Your services are backed by insurance in other markets whereas in India it would be out-of-pocket expenditure?

Not necessarily. In Poland, where we are a leading provider of fertility services over the last three years the government has a programme to fund fertility treatment but majority of the patients choose to not go through the government programme. They pay out of pocket so that they have more freedom in terms of the choices available to them. Funding is available, but they have concerns on the quality of the services they get. In UK, we see 100 per cent out of pocket expenditure even though a government funding programme is available. We have managed to succeed in countries where there is funding and no funding. We want to be a premium healthcare service provider and everything we do leads to it. We would want to focus on right outcomes, we don’t want to compromise. We don’t feel healthcare is about discounts. Even in India we will keep our rates comparable and appropriate.

What are your plans for India?

Medicover is committed to becoming the leading patient-centric fertility solution provider in India.

We will open nearly 50 clinics in three years – 10 in the first year alone. We are first establishing clinics in Delhi NCR, and then we’ll move to Punjab, Haryana, Uttarakhand and Uttar Pradesh. Clinics in

we will double this in the next few years. India is an exciting market for us and we expect 10-15 per cent of our total revenues to come from India in future.

What will make us stand out in India is our unique model of patient care which is ‘Right Care, Right Place, Right Time, Right Outcome’.

We work very closely with local market clinicians so that we can improve the clinical outcomes of our customers Maharashtra and Rajasthan will follow. We will have four clinics within the next two months, all located around Delhi. The first two will come up at Gurgaon and then Noida. Medicover Fertility expects to generate revenues in excess of $100 million in five years. A total of $50 million will be invested to build the Medicover Fertility network of clinics.

We won't franchise and we won’t outsource. We are passionate about providing right quality of service, we

can't do that unless we employ the right people, they work with us to improve our service and thereby improve clinical outcomes.

Our investment per clinic is around $2 million per clinic and in the next three years, we will invest $100 million into this.

Medicover as a group, generated a revenue of $500 million last fiscal, which will be $600 by the end of the year. Currently, fertility business is about five per cent of our total turnover,

How will you bridge the manpower gap, which is crucial for your business?

That’s very true. Manpower is crucial to our success. If you look at our history you will find that we provide excellent environment for our doctors to work in. Since we create the right environment for doctors where clinics are equipped with modern equipment, good computing process, we expect doctors to give us excellent IVF cycles and provide the best service to our customers. We provide a progressive environment for the clinician to work in. We are confident that after our first wave of recruitment our doctors will help us find more doctors who would want to work with us.

Secondly, we are experienced in this area of health; we have a network of doctors in our existing business who will come over and help us train people. We will be making investments in terms of training. We will recruit experienced fertility specialists. Build capacity.

We will be developing training programmes at all levels.

There are other international fertility services providers in India? How is Medicover different from them?

We have experience in different markets across 14 countries. In fact, we are present in locations, where most providers haven’t gone to. We are the first European family-owned organisation bringing in 100 per cent investment in healthcare delivery. We take time to build our business.

Medicover owners have already invested in several businesses in India over the last few years. mneelam.kachhap@expressindia.com

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Sciences (SIHS) Summary: This highlights of this year's seminar will be CONNEXIONS – a workshop and placement drive, Master Classes, Star Alumnus Awards and Healer of Mankind Award. It would cover pertinent topics such as Role of Six Sigma in Healthcare, Game Changers: Telemedicine in Healthcare, Sustainable Healthcare Models, Changing paradigm

in HR, Enterprise Performance Management Special laws related to healthcare etc.

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MEDICALL 2016

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technologies, for the benefit of all hospitals including smaller hospitals, clinics, nursing homes and physicians setting up group practice.

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cover )

IPOs in healthcare have gained momentum, with four players going down this route in the past few months. An analysis of the trend and its sustainability

BY RAELENE KAMBLI

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(

FO C U S : I P O U P D AT E

$280

`144

`638

`1000

BILLION

CRORES

CRORES

CRORES

INDIA’S HEALTHCARE SECTOR IS POISED TO GROW AT 16 PER CENT TO REACH $280 BILLION BY 2020

THYROCARE TECHNOLOGIES' IPO GOT OFF TO A GOOD START AND GARNERED RS 144 CRORES ON THE VERY FIRST DAY

THE RS 638 CRORE DR LAL PATH LAB'S IPO MADE A BLOCKBUSTER DEBUT. THE OVERALL SUBSCRIPTION WAS 33.41 TIMES OF THE ISSUE SIZE IN THE INITIAL THREE DAYS

NARAYANA HRUDAYALAYA'S IPO MANAGED TO APPRECIATE BY 30 PER CENT BY ISSUE CLOSING DATE,THEREBY RAISING PROMOTERS' WEALTH BY NEARLY RS 1,000 CRORES

n April 27, 2 0 1 6 , Thyrocare technologies' initial public Offering (IPO) hit the capital market and got off to a good start. On the very first day, the IPO covered 55.13 per cent crossing halfway mark and garnering Rs 144 crores.

Market analysts say that the IPO has attracted retail individual investors (RIIs) and Non-institutional investors during its premiere. On the second day, the IPO got fully subscription by receiving bids for 84.53 lakh shares against a total issue size of 75.21 lakh shares. The IPO was up for sale till April 29, 2016.

Thyrocare is the fourth

consecutive IPO that has got a good ride in the stock market.

In December 2015, the Rs 638-crore Dr Lal Path Lab's IPO made a blockbuster debut with an overall subscription of 33.41 times of the issue size in the first three days.

The company came into the market with an price band of Rs 540- 550 per share on the National Stock Exchange (NSE) and was trading at around Rs 966.80 per share (till April 25, 2016). Narayana Hrudayalaya's IPO, which got on to a slow start, managed to appreciate by 30 per cent by the issue closing date, resulting in the promoters' wealth rising by nearly Rs 1,000 crore. Narayana Hrudayalaya had fixed its price band be-

tween Rs 245-250 per share and is trading at Rs 300 per share (till April 25, 2016).

This demonstrates that the stock market, even though battling with volatility, has been conducive to the growth of healthcare companies in India. It also reflects that the current IPOs in healthcare are driven by private equity players wanting to exit as most of these IPOs are structured using the offer for sale mechanism. In the case of Alkem Laboratories, a total of 18 individuals diluted their stake in the company by selling the shares as part of the IPO. Similarly, Dr Lal Pathlabs saw a few promoter entities selling their shares along with investors such as Wagner, WestBridge

Crossover Fund, and Sanjeevini Investment Holdings.

Meanwhile, Narayana Hrudayalaya saw JP Morgan Mauritius Holdings, among others, selling its shares to the public to make an exit from its holdings.

But after achieving initial success, will these IPOs continue their strong run on the stock market listing? Moreover, will this present momentum stimulate more healthcare companies to take the IPO route in 2016? What has led to the emergence of this trend?

Let’s understand how healthcare companies stand to benefit from going IPO.

Going IPO: A good move?

According to a report pub-

lished by FICCI and KPMG, India’s healthcare sector is poised to grow at 16 per cent to reach $280 billion by 2020.

The report also mentions that investment opportunities in the sector have increased significantly and the overall healthcare industry is expected to be one of the most attractive investment targets for private equity (PE) and venture capital (VC) companies. The growth story is backed by innovation within the sector, corporatisation of hospitals, numerous acquisitions, expansions and partnerships, increasing focus on infrastructure, rising NCDs that leads to increased demand for specialised health services and the need to address gaps within the current

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healthcare system.

Going IPO can be a good option to further this growth momentum. Usually, IPOs help a company to increase its profit margins, brand building, expansion of its current business, and capturing market share. As Purvi Shah, Pharma Analyst, informs, “An IPO offer is mostly used by companies to raise capital for expansion, possibly to monetise the investments of early private investors, and to become publicly traded enterprises. A company selling shares is never required to repay the capital to its public investors. An IPO, therefore, allows a company to tap into a wide pool of potential investors to provide itself with capital for future growth (availability of cheap funds help boost profitability), repayment of debt, or working capital (strengthens balance sheet). It also helps to increase the company its exposure, prestige and build a public image or brand, which in turn helps them capture larger market share.”

On the same lines, Munish Aggarwal, Director, Equirus Capital expounds, “While over the immediate term, the IPO money has to be deployed in keeping with the objective of IPO- which may seem restrictive, over a medium to long term, public markets offer equity capital without exit related obligations which provide significantly higher flexibility to managements as compared to private capital. Being listed, the company has broader avenues to fund expansion and invest in medium to long term goals. Like for other consumer companies, the investor universe and con-

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sumer set overlap, and thus an investment in building brand for one set of audience has a rub-off effect on the other set.”

So what can be derived from the successful IPOs in the last few months?

Amit Mookim, Services Head, South Asia, IMS Health, replies, “It shows that a number of these companies have scaled and matured to a level that they can go public.

It is a confirmation of a fact that healthcare can be a sustainable and scalable business in India. Further, given the recent companies going for IPOs were backed by PEs, it will also help generate funding for companies in the growth phase and vying for private equity. However, given the success of the IPOs, the valuations may rise in the short term”.

So how do investors look at the current trend?

Investors’ take Most of the investors call healthcare a defensive bet.

They are of the opinion that healthcare as a sector is recession-proof, less prone to market risk and can have long term gains. Also, there is a paucity of listed assets in the healthcare sector. According to a leading business journal, Apollo Hospitals and Fortis Hospitals are the only large listed assets; other larger assets have stayed away from the market up till now. There are three other listed firms - Lotus Eyecare, Kovai Medical Centre and Fortis Malar but analysts are of the opinion that these companies are more micro-caps with concentrated risks which may or may not contain long term gains for the

Munish Aggarwal Director, Equirus Capital

SHIFT FROM A CLOSED SHAREHOLDER GROUP TO A LISTED COMPANY IS AN IMPORTANT TRANSITION. OVER COMMITMENTS MADE AT THE TIME OF IPO, COUPLED WITH UNDERDELIVERY CAN ERODE LONGTERM INVESTOR INTEREST IN THE COMPANY

investors.

Jaya Sankar, Senior Executive Director, during the HCG's IPO road show had spoken about the benefits of investing in healthcare stocks. He had mentioned that healthcare IPOs is a welcome trend. Healthcare is a burgeoning sector with long term gains for investors. He also said that these healthcare companies have a very strong track record which makes reduces market risk to certain level. Nishant Tiwary, Senior Vice President, Head of Consumer and Healthcare, Edelweiss during the Thyrocare road show also confirmed that IPOs give a good push to the sector. He finds immense potential for future growth of the sector and for healthcare companies. He reiterated the successes of the healthcare companies who have received positive results on the stock markets and said that he hoped for better prospects for companies such as Thyrocare.

This makes it certain that the healthcare IPOs get a thumbs up so far. Yet, it is definitely not risk-proof.

Risk factors In an IPO, the risk is mainly borne by the investors. Which is why every red herring prospectus warns of the risks entitled to the offering and investors are therefore, urged to analyse them well. Explaining further, Aggarwal says, “Equity is inherently risky and company specific risks are something that the investors need to consider before making an investment.

Specific to healthcare, the investors need to understand the capital intensity of the business - if the business is

too capital intensive or making cash losses then the investment horizon has to be longer, till the business stabilises. Moreover, there may be a subsequent dilution which can impact investor returns.”

Does this mean that healthcare companies which are highly capital-intensive may not fare well in the stock market?

Well, this is an area of concern and raises doubts on the sustainability of the trend.

Also, do all healthcare companies' stocks perform well in the stock market after the issue is closed for sale? Not really.

The HCG IPO Healthcare Global Enterprises (HCG) IPO entered the market this March with a price band of Rs 205 - Rs. 218 per equity share. On the first day, the IPO received a muted response from investors, nevertheless managed to sail through. However, currently the company's stock have slumped(the stocks have been trading between 180-188 points in the last week of April 2016). The reason could be due to the capital-intensive nature of its business as the hospital chain caters to cancer care. Setting up a fullfledged cancer hospital of around 100-beds in a metro city could reportedly cost as much as Rs 50 crores. According to analysts, HCG's IPO seems pricey and only long term investors with high-risk appetite would consider bidding for the issue.

Timing is another crucial factor that determines the success of an IPO. Just two months before HCG issued its public offering, Dr Lal's and

(

FO C U S : I P O U P D AT E

Narayana Hrudayalaya's IPOs had already booked immense profits in their debut and were still ruling the healthcare stocks. This could also be a another reason for HCG’s dip currently at the stock market. Having said this, HCG still got the funds they were looking to raise and the company is already on the expansion spree. HCG has recently launched their cancer care centre at Visakhapatnam, this April end.

As a word of advice Shah says, “How the IPO is priced matters. If the company is valued the right way, if it’s profitable and growing, then maybe the first-day price on the exchange is a good one”.

She adds, “We feel that there is still money to be made in IPOs, but the focus has to be shifted from the quick buck to the long-term outlook. And when it comes to healthcare sector, the investment horizon has to be long term given the nature of business which involves innovation, research and development and patents.”

Pointing out common mistakes that companies commit while going IPO, Aggarwal cautions, “Shift from a closed shareholder group to a listed company is an important transition. At times the company and the promoters are not prepared to cede their hegemony over the operations of the company - something that having minority shareholders requires. Companies that don't see minority shareholders as partners in company's growth with proportional ownership and rights, tend to suffer in the medium to long term. Also, over commitments made at the time of IPO, coupled with

Amit Mookim Services Head, Services Head, South Asia, IMS Health

IT SHOWS THAT A NUMBER OF THESE COMPANIES HAVE SCALED AND MATURED TO A LEVELTHAT THEY CAN GO PUBLIC. IT IS A CONFIRMATION OF A FACT THAT HEALTHCARE CAN BE A SUSTAINABLE AND SCALABLE BUSINESS IN INDIA.

under-delivery can erode long-term investor interest in the company.”

Dealing with market conditions With all the pros and cons of taking the IPO route one should also pay heed to market conditions especially, when volatility is depreciating stocks of many industries. “Market conditions do tend to impact IPOs, but IPOs of companies with strong proven track records, good corporate governance and management and good future prospects have been rewarded well by the markets even in weak conditions”, opines Shah.

Meanwhile, the entire IPO buzz has also caused market valuations of some healthcare companies to shoot up.

Lately, a business news daily reported that the sale of 34 per cent stake held by PE investors in SRL Diagnostics, has attracted many large funds in the backdrop of the successful IPO floated by Dr Lal PathLabs. According to this report, fund managers who are in discussions to acquire a stake in SRL, say that the valuation of SRL is too high in comparison to its peers. SRL Diagnostics with a Rs 180 crore EBITDA (earnings before interest, taxes, depreciation and amortisation) is looking for a valuation of 20-22 times EBITDA, as compared to 13-14 times from its earlier valuation.

This also indicates that these healthcare IPOs are also set to disturb the current investment scenario within the sector, with for reaching impacts.

Moving forward It seems that the IPO fever

has caught on and more healthcare companies are gearing to take this path.

Next in line, is New Delhi Centre for Sight and VLCC .

They have already filed theDraft Red Herring Prospectus (DRHP) and received SEBI approval for the same.

Reportedly, both these transactions should hit the market in next six months. Additionally, Aster DM Healthcare is also mulling about going IPO. However, when contacted, the company choose to not comment on this development. An industry source informed

Also, increased number of stock competing in the same market can drive down sales of shares, in turn leading to low share prices of healthcare assets in the stock market.

Moreover, IPOs certainly provide quick money to those companies seeking to have huge expansions. It also helps the brand building; however, with a brand image comes the need to have brand equity.

Therefore, healthcare companies seeking to go IPO need to take stock of their business models, financial stability and stay focussed on

Increased number of stock competing in the same market can drive down sales of shares, in turn leading to low share prices of healthcare assets in the stock market

that Aster’s IPO may hit the market this year itself.

Therefore, it's certain that the heat is on and healthcare companies are geared to take the plunge into the stock market world. But, it's imperative to have cautious approach. It might serve to remember, that the successes enjoyed by Dr Lal's, Narayana Hrudayalaya, Thyrocare and so on is because there was a paucity of healthcare stocks in the market for a long time. The moment the number of healthcare companies trading at the capital market increases, investors will get more finicky with their choice of investments.

long term gains.

For those who wish to rethink on IPO, opt for other strategies to provide profitable exists to your PE investors. Aggarwal suggests that a sale of the investment by the PE fund to another PE fund or a strategic sale of the business can be another option if a company does not want to enter the stock market.

Above all, the changing environment within the healthcare sector has made it essential for every organisation to have a sound business model which will propel sustainable development. raelene.kambli@expressindia.com

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May 2016

STRATEGY I N T E R V I E W

‘Health Advisor portal is targeted towards removing information asymmetry in healthcare’ ICICI Lombard General Insurance recently launched a web-enabled platform called ‘Health Advisor to gauge the quality of healthcare treatment at over 1000 hospitals across primary, secondary and tertiary segments. The insurance company has made this possible by sourcing feedback and ratings from customers who had availed treatment at these hospitals.

Amit Bhandari, Head, Health and Agri Insurance, Underwriting and Claims reveals more about the initiative and its objectives, in conversation with Raelene Kambli

What is the rationale behind launching such a platform?

How would this initiative add value to your health insurance business?

ICICI Lombard Healthcare Advisor is an initiative that is in line with our philosophy of offering end-to-end solutions to consumers. It aims to increase transparency in healthcare and enable consumers to make informed decisions. We have launched this unique platform that is open to all consumers (and not restricted to ICICI Lombard customers) purely to meet the latent demand of consumers who seek information on the right hospital to approach for their treatment. Being a health insurer, we found that hundreds of customers were calling us to understand which hospitals to approach for treatment. We realised that there was a clear gap and there was no platform available to help consumers on this front. Hence, we took up the onus of introducing a robust information and rating platform that consumers can use to find out the right hospitals for specific treatment in their vicinity.

Having said this, we hope that consumers, equipped with the

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right information will approach the right category of hospitals e.g. tertiary hospital only in case of critical ailments and not simple ailments e.g. fever. This will in the long term help bring healthcare expenditure under check, which will positively impact health insurance premium and ensure a win-win situation for customers and insurers.

How will you utilise this platform to increase penetration of your health insurance product?

Yes certainly! In the long run we will increase our penetration of health insurance products.

The health advisor portal is targeted towards removing information asymmetry in healthcare. It’s accessible to both insured and non-insured.

Apart from providing information and hospital reviews/ratings, we believe that the platform will be a critical source of information and advice for consumers. We expect that it will drive penetration as more and more consumers understand and get convinced of the need to buy health insurance.

proximity of the hospital, quality of treatment, cost of treatment, doctors associated with the hospital and the infrastructure in place.

This will drive penetration as more and more consumers understand and get convinced of the need to buy health insurance What are the five things that customers usually search for?

Consumers primarily search

for the hospital where they intend to avail treatment.

Deep diving into this behaviour, consumers look for

Your website gives the service rates of the hospitals, have you thought about also providing your rates to give a fair chance to customers to make their choice?

The website provides the average rate of treatment for specific ailments at various hospitals. This is an indicative figure that is intended to help consumers get an understanding of the expense that one is expected to incur at the said hospital. Having said this, the actual cost will depend on the severity of ailment, doctor, implants if any etc. When it comes to providing our rate, the same is a function of the hospital rates given that they are the healthcare providers and the insurer merely reimburses or pays for the expenses incurred on the treatment. We do push hospitals to offer cost effective treatment which gets communicated to the customer at the appropriate time. raelene.kambli@expressindia.com

STRATEGY I N T E R V I E W

‘It is our endeavour at Roche to continuously innovate’ Roche Diagnostics aims to capture the global glucose monitoring market. Sidhartha Roy, Business Unit Head – India & Neighbouring Markets, Roche Diabetes Care India reveals the company's strategy for its star product Accu-chek Active, in an interview with Raelene Kambli Tell us about Roche’s offerings in diabetes care?

Roche is a world leader in blood glucose self-monitoring solutions, providing people with diabetes the ease and benefit of monitoring their blood glucose accurately at home. This helps them plan their lifestyle.

Accu-chek is a well-known home blood glucose monitoring device in the market. So, what is its market share in India?

The market share data for every country varies depending on various factors including diabetes prevalence, SMBG penetration, health and lifestyle awareness etc. It may be tough to place a market share number to emerging markets as a whole. In India, Accu-chek is the market leader in the selfmonitoring of blood glucose (SMBG) market.

What is your USP? ‘Accuracy’ is the core benefit

of Accu-chek Active, and is the crucial factor of self-monitoring. Only if the readings are accurate, will the person with diabetes be able to make lifestyle decisions in consultation with his/her physician. Accu-chek Active has significant large number of loyal users in India, who have won their fight with diabetes through constant SMBG. In India, Accu-chek Active has touched the lives of millions of people with diabetes.

What scope do you see SMBG in India?

In India, the concept of SMBG is in a nascent stage, compared to developed countries. Out of the over 63 million people with diabetes in India, SMBG penetration is very low. So, there is vast scope for expanding the SMBG market in India.

While it is heartening for us to note that we are market leaders in this space, we also

realise the need to touch more people with diabetes, so that we help them manage their condition better. So, we undertake awareness programmes on the benefit of SMBG. We launched a mass media campaign covering print publications, online and radio channels on ‘Real Heroes vs Diabetes’, where we featured people with diabetes leading a life of their choice, with the help of SMBG. This campaign enables us to reach out to people with diabetes across India, with the SMBG message.

In India, Accu-chek Active has touched the lives of millions of people with diabetes

How is the market for blood glucose monitoring devices currently?

Across the world, Roche is the market leader in SMBG, offering interesting and advanced SMBG solutions, including Accu-chek Connect, which enables store and maintain their monitoring data at a location where their

physician can access it, and guide them on diet and lifestyle.

We are also present in the insulin pump business.

Both India and China have very large number of people with diabetes and Roche is committed to make a difference in their daily lives by offering our diabetes monitoring solutions.

What is Roche's strategy for the glucose monitoring market in India?

Our primary objective is to build awareness on the benefit that SMBG can have in the lives of people with diabetes.

We build awareness on the benefit of SMBG through an integrated awareness-building programme which would include pharmacist education, presence on social media to educate consumers, doctor communication and using mass media to reach out to people with diabetes. raelene.kambli@expressindia.com

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IN IMAGING INSIGHT

Trends in soft tissue imaging

DR SANJAY DHAWAN Sr Consultant & Head (Radiology & Imaging) Paras Hospitals, Gurgaon

Dr Sanjay Dhawan, Sr Consultant & Head (Radiology & Imaging), Paras Hospitals, Gurgaon explains the methods available for soft tissue imaging and the advantages of each technique

T

he last two decades have witnessed remarkable advancement in diagnostic imaging techniques which have led to significant improvements in the evaluation of soft tissue disorders. This has enabled an early, accurate diagnosis and optimal treatment.

Soft tissues in relation to the musculoskeletal system consists of the muscles, tendons, ligaments, bursae, cartilage as well as the neurovascular structures (arteries, veins and nerves) associated with them. In addition, assessment of the adjoining bones and joints is a mandatory part of imaging protocol.

A typical patient with a soft tissue lesion would present with a lump or a bump. This could be due to trauma, sports related injuries, infective conditions or tumour masses. The biggest impact of the modern imaging has been in the field of sports injuries.

An armamentarium of imaging techniques is available for evaluation of soft tissues which include conventional radiography, ultrasound (USG), magnetic resonance imaging (MRI), computed tomography (CT scan), and positron emission tomography (PET).

Conventional Radiography (X-ray) Conventional X-rays play a limited role in imaging of soft tissues as the X-rays pass through the not-so-dense soft tissues. They are used as an initial screening to rule out an associated bony lesion or to reveal mineralisation of the soft tissues.

Ultrasound Scan (USG) Ultrasound is a readily available, radiation-free and costeffective imaging technique.

CONVENTIONAL RADIOGRAPHY (X-RAY)

ULTRASOUND SCAN (USG)

MAGNETIC RESONANCE IMAGING (MRI)

COMPUTED TOMOGRAPHY (CT SCAN)

POSITRON EMISSION TOMOGRAPHY (PET-CT)

» Limited role in imaging

»Evaluation of Tendon

It is used to assess:

» Provides great contrast

» Its role in staging of soft

Pathology

» Sports Injuries » Arthrography » Articular Cartilage » Soft Tissue Infections » Soft Tissue Tumours

of soft tissues

» Used as an initial screening to rule out an associated bony lesion or to reveal mineralisation of the soft tissues

» Evaluation of Ligament Pathology

» Evaluation of Muscle Pathology

» Evaluation of Nerve Pathology

» Detecting Soft Tissue

between bones and soft tissues

» Helps assess associated bony lesion/remodelling, periosteal reaction, mineralisation and presence of air/gas n the lesion

tissue tumours is debatable due to overlap with inflammatory conditions

Tumours

The availability of high resolution linear probes has contributed immensely to imaging of soft tissues. It is a simple bedside scan, and is very useful for apprehensive, claustrophobic patients and children The availability of high resolution linear probes has contributed immensely to imaging of soft tissues. It is a simple bedside scan, and is very useful for apprehensive, claustrophobic patients and children.

It is ideally suited for superficially placed soft tissue structures. Ultrasound also has the ability to perform a dynamic study. For example, the af-

fected part is imaged in real time, observing for pathological movement in a tendon, muscle or joint. This is a feature unique to ultrasound and is not possible with other modalities. The major drawback of ultrasound is that it is highly dependent on the skills of the operator. Secondly, it is less useful for deep placed structures and in obese pa-

tients.

Ultrasound in tendon pathology: Evaluation of tendon pathology is probably the most common indication for obtaining a musculoskeletal ultrasound. Two commonly visualised tendons for tears are rotator cuff (shoulder) and the Achilles tendon. Ultrasound has been reported to have near 100 per cent sensitivity for diagnosing full thickness tear of rotator cuff but the sensitivity to diagnose partial thickness tear is much lower.

Ultrasound in ligament pathology: Diagnostic ultrasound is used to good effect in evaluation of ligament tears in athletes. The ligaments commonly imaged are the ulnar collateral ligament at elbow, anterior talofibular ligament at ankle and the medial/lateral collateral ligaments of the knee.

Ultrasound in muscle pathology: It is estimated that

30 per cent of sports injuries affect muscles. Additionally, ultrasound can also detect a nontraumatic or primary muscle pathology like myositis. In ultrasound, the sonologist can visualise the entire length and in case of a complete tear, can detect the site of retracted muscle. The gap in a torn muscle is hypoechoic (dark) and when compressed gently by the transducer, can reproduce pain. This technique is called sonopalpation and is an example of dynamic evaluation by ultrasound.

Ultrasound in nerve pathology: There has been a recent interest in evaluation of nerves by ultrasound. Common indications are for evaluation of carpal tunnel syndrome at wrist and Morton’s Neuroma in foot.

Ultrasound in soft tissue tumours: Ultrasound can assess the size, shape, location and anatomical relationships of the

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IN IMAGING lesion. In addition, it can comment on the composition of the lesion – solid or cystic (fluidcontaining). By using colour Doppler as an adjunct to ultrasound, the vascularity of the lesion can be determined.

Ultrasound in intervention: Ultrasound is an excellent modality to guide interventional procedures like FNAC, aspiration from a fluid collection, local steroid injection and injection of contrast for MR arthrography.

MRI is extensively used in localising and characterising deep seated soft tissue infections. It can differentiate between abscess and cellulitis, thereby enabling correct treatment

Magnetic Resonance Imaging (MRI) Magnetic resonance imaging is a radiation-free modality which involves magnetic field, radiofrequencies and computer applications to create detailed images of structures within the human body. The evolution of MRI has led to a paradigm shift in imaging of soft tissues. The inherent soft tissue contrast as well as multiplanar capability has rendered MRI as the ideal investigation of soft tissue pathology. In addition to localisation of the lesion with respect to other anatomical structures, it can also comment on predominant tissue component as well as whether it is likely to be benign or malignant. This has been facilitated by recent advances like Diffusion Weighted MRI and MR Spectroscopy.

The administration of gadolinium intravenous contrast (dye) is useful in diagnosing infections and tumours of soft tissues.

An MRI scan is performed by obtaining multiple imaging sequences by applying radiofrequency pulses and gradients after placing the patient in a magnetic field. A typical MRI examination consists of T1 weighted, T2 weighted, PD weighted, fat suppressed and Gradient Echo (GRE) sequences in axial, coronal and sagittal planes. An additional contrast enhanced scan may be done if clinically indicated.

MRI is a very safe procedure and the magnetic field or the radiofrequency pulses are not harmful to the human body.

The presence of a pacemaker, drug infusion pump and ferrous implants are a contraindication for an MRI. Patients in first trimester of pregnancy are advised to avoid MRI exam.

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gin viz, muscle, cartilage, fat etc. They are further sub-categorised as benign, intermediate (locally aggressive) and malignant. As a first step, the lesion is assessed with respect to size, shape, margins and distance form a chosen anatomical landmark. Tissues like muscle, fat, cartilage and bone have different signal characteristics on spin echo (T1 weighted and T2 weighted) sequences, which help in ascertaining the tissue of origin. Subsequently the lesion is characterised as benign and malignant on basis of vascularity (contrast enhanced MRI) and invasion of adjacent structures. It would be prudent to mention that MRI is the modality of first choice for local staging of a musculoskeletal tumour.

Computed tomography (CT SCAN)

Picture used for representational purpose only

Impaired renal function as determined by estimation of low glomerular filtration rate (GFR) is a contraindication for administration of intravenous contrast medium.

MRI in sports injuries: MRI in sports medicine is a rapidly developing field due to its ability to provide accurate diagnosis and because of better understanding of disabilities associated with the injury. Early treatment has led to prevention of disability and early resumption of sporting activity. Common sporting injuries include a hamstring tear, Achilles tendon rupture and knee ligament injuries. Biceps tear and labral injuries are also common in power-lifters and throwers.

MRI is both sensitive and specific for detection of a tear involving a muscle, tendon or a ligament. These tears can be further categorised as partial or full thickness and a grading has been devised to comment

on the severity. This is of huge consequence in recovery and rehabilitation of the sportsperson. In addition, associated problems like a fluid collection or a haematoma are well visualised. An interesting bit of trivia on this aspect is that a couple of stadiums hosting NFL games in USA have MRI scanners on site in the stadium!

MR Arthrography: It is a specialised technique wherein a small amount of contrast (dye) is injected in the joint space under imaging guidance. It is particularly useful in diagnosing labral tears in shoulder and hip joints.

MRI in imaging of articular cartilage: Articular cartilage imaging is of increased importance in a setting of an ageing population wherein osteoarthritis is a leading cause of chronic disability and joint pain. MRI can accurately detect the extent of articular cartilage denudation as well as ab-

normalities in the underlying bone.

MRI in soft tissue infections: MRI is extensively used in localising and characterising deep seated soft tissue infections. It can differentiate between abscess and cellulitis, thereby enabling correct treatment. Many a time, infection in soft tissues is a consequence of infection in the adjoining bone.

In this respect, MRI is the only imaging modality which can detect abnormalities in the bone marrow. This ability of MRI is also useful in marrow infiltrative disorders like haematological malignancies.

If appropriate hardware is available, MRI guided aspiration of the deep seated infected collections leads to early resolution of the disease process.

MRI in soft tissue tumours: Soft tissue neoplasms are a large group of tumours divided into nine different categories depending on the tissue of ori-

CT scan provides excellent contrast between bones and soft tissues. It has given way to MRI because CT scan involves radiation and for the fact that the contrast between two adjacent soft tissue structures is suboptimal in comparison to MRI. However, it is useful to assess associated bony lesion/remodelling, periosteal reaction, mineralisation of the lesion and presence of air/gas within the lesion. Last though not the least, it is useful for a patient in whom MRI is contraindicated.

Positron Emission Tomography (PET-CT) Positron emission tomography uses radioisotopes that undergo positron emission decay.

While PET-CT is well established for staging of many visceral neoplasms, its role in staging of soft tissue tumours is debatable due to overlap with inflammatory conditions.

To conclude, it would be fair to say that advances in imaging technology have led to rapid strides in management of soft tissue pathology. It has enabled early institution of appropriate therapy, causing significant reduction in disability. The choice of imaging modality is determined by the cause, location in the body and clinical diagnosis.

The future is even more promising, given the advancements in technology which are happening by the day.

IN IMAGING I N T E R V I E W

MRI scans are better than MDCT while evaluating hepatic disease Imaging is a process that is essential to understand the dynamics of transplantation.

It also reveals the intricate biological aspects that determine graft survival.

Dr Sonal Asthana, HPB and Multiorgan Transplant Surgeon, Aster Integrated Liver Care group, Aster CMI Hospital, Bengaluru speaks to M Neelam Kachhap about the trends in solid organ imaging

What are the recent trends/new technologies for imaging solid organs?

Broadly, imaging for solid organs can be static or dynamic. Ultrasound is an older tool, but is extremely useful in experienced hands.

Recent advances include the use of contrast enhanced ultrasound (CEUS), which uses microbubbles to better define the blood flow in the organs studied. An ultrasound variant called a fibroscan gives us an assessment of liver stiffness (fibrosis) by using shear stress. The most common modalities of cross sectional imaging are CT scans, MR scans and their variants (PET-CT and fMRI).

longer life expectancy, the odds that children will develop cancers from X-ray radiation may be significantly higher than adults. It has been estimated that children less than 10 years of age are several times more sensitive to radiation than middle-aged adults.

CT scans can subject patients to 10-800 times the amount of radiation compared to an X-ray, hence need to be used with caution.

Secondly, imaging tools which have long processing times are not suitable for very small children. Children often need sedation or anaesthesia for imaging procedures such as MRI due to long scan times.

Which modalities are used for evaluation of liver?

All three modalities mentioned are useful for liver imaging. CT is more commonly used because of familiarity of interpretation.

Most clinical specialists are well versed with CT interpretation. MRI scans are more useful, but less commonly used.

Which modalities are preferred for pediatric patients as compared to adult patients?

As I mentioned earlier, radiation exposure is a primary concern while dealing with paediatric patients and hence measures that do not subject children to ionising radiation like ultrasound and MRI are preferred. However, MRI scans are noisy and take a long time to process images.

So, it is difficult to work with childeren around this. They get scared and they move so children may need to be sedated for the process.

Incidently, the newer generation MRIs have tried to work around these problems with virtual reality

What are the challenges during imaging of paediatric patients?

There are very specific concerns that need to be kept in mind when dealing with paediatric patients. Firstly, radiation exposure should be minimised. Because they have more rapidly dividing cells than adults and have

Ultrasound and MRI do not subject children to ionising radiation. Hence, they are preferred to reduce radiation exposure in paediatric patients headsets (to avoid claustrophobia). They also offer faster processing times and are better.

and malignant liver tumours with more than 95 per cent accuracy, without the need for a biopsy.

Are MRI scans better than MDCT while evaluating hepatic disease?

Yes. MRI scans can evaluate fat, fibrosis and general state of the liver. They are much more useful in obese patients and provide much better imaging cover of the liver as compared to MDCT. In fact, MR specialists can distinguish between benign

How has imaging changed for transplant procedures in recent years?

Several new technologies have benefitted through the transplant field over the past few years. One of them is the intraoperative ultrasound with high frequency probes.

This equipment helps us to check the vascular joints (anastamosis) at the time of

surgery which is crucial for favourable outcomes.

Another one is the portal vein flow cuffs. This is a cuff like device placed around the main vein of the liver (portal vein) after surgery. It measures the flow through the vein and alerts the surgeon in case of low flow or risk of blockage. Another important development is CT scan. Faster processing speeds and better clarity have reduced the minimum resolution to < 5mm. A new dye (cholograffin) allows the surgeon to assess the biliary anatomy, which previously could only be assessed by MRI. There have been a large number of exciting developments in MRI. Firstly, 3T machines have much better resolution than previous 1.5 T machines. MR spectroscopy can alert us about the content of certain chemicals (e.g. choline) in a mass, which gives one an idea of whether it is benign or malignant.

MR steatography can measure the fat content in liver. MR elastography measures fibrosis of the liver in a very reliable manner. I might add fibroscan as well since it allows us to measure stiffness (fibrosis) in livers both before and after transplant. All these modalities provide useful information during surgery and are important for good clinical outcomes. mneelam.kachhap@expressindia.com

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IN IMAGING

INSIGHT

Recent advances in ultrasound imaging technology

DR D UMASHANKAR Chief Radiologist, Padmashree Advanced Imaging Services, Bengaluru

Dr D Umashankar, Chief Radiologist, Padmashree Advanced Imaging Services, Bengaluru outlines the evolution of ultrasound technology and its growing implementation across different segments of healthcare

WITH EVER-increasing concerns about radiation dose and the appropriate use of diagnostic imaging tests, doctors are continuously looking for ways to better image their patients.

Advances in ultrasound are making the technology appear more attractive for certain clinical applications, from breast health to cardiology, thanks to their non-invasiveness, cost-effectiveness and lack of radiation. Some of the emerging innovations in ultrasound, such as advanced applications in 3D imaging, newer applications of ultrasound contrast, shear wave elastography, development of wireless transducers, app based ultrasound technology, fusion with CT/MR, laparoscopic ultrasound, are set to keep the market excited for the near future.

Because of constant improvements and better iterations of existing technologies and new developments, the overall costs of high-end ultrasound systems is lowered in comparison to other modalities which add to their costeffectiveness and appeal to many hospitals.

Engineering advances Early engineering advances in ultrasound were limited primarily by what could be done, economic factors are now in control. Iterative improvements that reduce vendors' costs are sought after, with no technical achievement more prized than the one that cuts cost while at the same time offering design and upgrade flexibility, without any sacrifice in

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image quality. The miniaturisation of electronics is one of these improvements, and the replacement of hardware with software is another.

The impact of miniature, high-performance electronics is apparent in the appearance of the handheld ultrasound scanner. Manufacturers of these products want to put ultrasound in the hands of primary-care physicians and emergency medical personnel to enable quick screening or assessment of patients. It's an ambitious goal that could change the practice of medicine. Meanwhile, conventional practitioners will benefit from the trend toward smaller, lighter, and easier-to-operate diagnostic equipment.

The other side of the technological coin is the digital signal processor (DSP).

Linkedin parallel, DSPs promise to deliver similar speed with markedly greater flexibility than application-specific integrated circuits. Whereas ASICs perform repetitive tasks because they are hardwired, DSPs are controlled by software instructions. Because these chips are driven by algorithms, new clinical developments can be added to scanners in the form of software upgrades.

Increased spatial resolution from more sensitive transducer arrays and improved contrast agents could make diagnostic conclusions easier.

Real-time volumetric scanning could reduce the need for operator skill, making ultrasound more reproducible and

Picture used for representational purposes only

productive. Advanced computing platforms might even make automatic feature recognition possible, as lesions and tissues are outlined, measured, and compared to databases containing normal and abnormal ranges.

These technical advances form the basis for many of the recent trends you will read here.

Handheld/point-of-care

ultrasound Improving ease of use has been an essential factor in the growth of ultrasound imaging, particularly as the demand for POC solutions has expanded.

Adaptability is the key for this market segment that is moving radiology outside the walls of the imaging lab to first response scenes, the emergency department and even the patientâ&#x20AC;&#x2122;s bedside.

Two new innovations have

come to the fore to address these issues. One of which is the introduction of touchenabled ultrasound systems, which enhance mobility by sacrificing cumbersome keyboards. The other innovation happening is the emergence of using a customer android or an apple device as an ultrasound scanner. The Clarius ultrasound scanner is wireless and works with a mobile app that is compatible with most iOS and Android smart devices. With automated adjustments and an intuitive interface, the personal ultrasound device is designed to be carried around for quick exams and to guide procedures such as nerve blocks and targeted injections. Philips Healthcare also introduced Lumify, a mobile app-based ultrasound system. The concept turns any Android-based smart phone or tablet device into a hand-held, portable ultrasound system simply by plugging a Philips transducer into the deviceâ&#x20AC;&#x2122;s USB port and downloading the Lumify app.

The transducer performs all of the acquisition functions and a portion of the image reconstruction processing, with the smart phone serving as the display screen and the connection link to the cloud storage archive.

Turning a consumer-grade smart phone into an ultrasound system provides hospitals, urgent care centers and doctorâ&#x20AC;&#x2122;s offices with a highly flexible point-of-care solution with a low total cost of ownership. These devices can per-

IN IMAGING

form scans of the gall bladder, abdomen and lungs, in addition to having OB/GYN, vascular, superficial, musculoskeletal and soft tissue functionality.

The other innovation in some of the other manufactures devices, feature an all-touch control panel that combines the speed and flexibility of a soft user interface with the tactile feedback of traditional keys. Etched markings for primary controls help the user easily locate key functions without looking away from the display monitor. Users can choose from several different exam presets with a single touch, including cardiovascular capabilities like continuous wave (CW) Doppler, and a series of emergency departmentspecific exams. Image optimisation is also a one-touch function. All these advances are bringing in a lot of excitement in the POC segment.

Wireless transducer Siemens Healthcare introduced an ultrasound system with wireless transducers, the Acuson Freestyle. Completely untethered from the console, the productâ&#x20AC;&#x2122;s wireless transducer can reportedly be used to image from up to 10 feet away, and is built to endure any potential falls or mishaps. The system is targeted toward use in interventional applications such as in radiology and cardiology, and it can also be used to aid in vascular access procedures as well as needle visualisation. The system uses a proprietary 8 GHz ultra-wideband radio frequency to transmit data to the main console, and also includes Bluetooth wireless control.

Fusion Fusion technology provides the ability to synchronise ultrasound imaging with computed tomography (CT) or magnetic resonance (MR) image, improving the detection of hardto-find lesions.

The FDA cleared technology helps interventional radiologists and surgeons perform minimally invasive biopsies and other diagnostic and therapeutic procedures. through an intelligently integrated display of

fused ultrasound and CT images. The system is available as an accessory, which can be retrofitted on most existing ultrasound machines.

This technology was developed in response to a clear need for simpler multi-modality imaging using ultrasound while minimising the number of CTs and hence improve patient safety by reducing radiation dose. By showing the clarity of CT with the real-time visualisation of ultrasound, users experience the benefits of both modalities simultaneously.

The newer commercially available systems also incorporate a novel fully automated registration process which do not require special needles or new imaging equipment, preserving the customary work-flow and maximising the productivity of existing capital equipment.

These devices were made to address the myriad challenges associated with working with CT and ultrasound images simultaneously. The older fusion systems require long and complex registration processes while the newer iteration eliminates this step through automated registration and system fusion, which is continuously updated throughout the procedure. The time required for registration drops to seconds.

Moreover, clinical recommendations to reduce CT radiation doses heighten the importance of good ultrasound visualisation. With CT precisely overlaid on the ultrasound plane, deep and challenging lesions can be visualised and targeted efficiently.

The ability to see the target lesion clearly before, during and after a procedure means procedures can be reliably performed in ultrasound with realtime imaging, freeing up the CT suite for diagnostic imaging and mitigating exposure to ionising radiation for the patient and staff. Many of the first time users of this technology have called it a " a game-changer."

Shear wave elastography SWE differs from traditional strain elastography, which relies on manual compressions by the examiner to assess tissue displacement. The SWE tech-

patients.

Thus, non-invasive methods for assessing liver fibrosis are of great clinical interest. In the last decade, techniques to noninvasively estimate the stage of liver fibrosis have become commercially available. They all have the capability to evaluate differences in the elastic properties of soft tissues by measuring tissue behaviour when a mechanical stress is applied. Ultrasound and magnetic resonance have been used for elasticity imaging. Magnetic resonance elastography, even though promising, has some disadvantages. It cannot be performed in a liver with an iron overload because of signal-to-noise limitations, the examination time is longer with respect to ultrasound elastography, and it is also a very costly procedure.

Shearwave elastography in breast Picture used for representational purposes only

nique instead captures shear wave generation with patented Imaging technology to quantitatively measure the stiffness of local tissues. By being less dependent on an experienced operator, SWE can record elasticity more accurately than conventional elastography and produce a more objective, realtime colour-coded map to show tissue stiffness.

With the advent of a realtime adjustable numerical scale for the technology, which allows clinicians to adjust the scale to optimise visualisation of elasticity according to the organ of interest, the clinical applications of this technology have exploded many fold. This also adds to the appeal of SWE, since stiffer tissues can vary among different pathologies.

Currently it is widely used and studied in breast, liver, thyroid and musculoskeletal applications. Latest results from a multi-centre study, published in the Radiology and European Radiology journals, showed the technology improves breast ultrasound specificity when detecting breast lesions in patients. Other studies have

demonstrated its exemplary utility in the detection of liver fibrosis and to differentiate it from the omnipresent diagnosis of fatty liver.

Shearwave elastography in liver Liver disease is an important problem worldwide. Accurately diagnosing liver fibrosis and inflammatory activity are the most important factors for determining the stage of the disease, assessing the patient's prognosis, and predicting treatment responses. This is true for a wide range of disorders, including viral hepatitis, alcoholic and non-alcoholic fatty liver disease, drug-induced liver injury, primary biliary cirrhosis, and autoimmune hepatitis.

Liver histologic analysis is still considered the reference standard in the assessment of liver fibrosis despite the intraobserver and interobserver variability in staging.

Liver biopsy is a painful technique that is not well accepted by patients, has morbidity and mortality risks, and is not an ideal method for follow up of

Mammography has been the standard of care for screening women for breast cancer since 30 years. However, it often fails to pick up lesions when used to image women with dense breasts who form about 40 per cent to 50 per cent of all women undergoing mammography. That dense breasts mask and miss cancer in mammography further compounds the clinical effectiveness of this modality as an accurate screening modality.

With the heightened focus on imaging women with dense breasts, interest is growing as well in other breast imaging modalities, including elastography ad other modalities like MRI and molecular breast imaging.

With strain elastrography, a malignant lesion appears larger than on conventional ultrasound, and a benign lesion appears smaller. However this technique is limited by operator dependence.

Shear Wave elastography imaging removes this anomaly.

If results are concordant between strain and shear wave, then there is a high confidence that a positive result is accurate. In fact, this information achieves positive biopsy rates approaching 75 per cent.

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IN IMAGING

Considering that with mammography 80 per cent of biopsied lesions are benign, Ultrasound elastography can make a dramatic impact on reducing unnecessary biopsies.

by improving the image contrast resolution through differential uptake.

Contrast ultrasound in cardiology Other important clinical use of ultrasound contrast is in cardiology, where it will potentially compete with thallium nuclear scans. Myocardial imaging using ultrasound contrast agents provides an assessment of the coronary arteries and of the coronary blood flow reserve, as well as collateral blood flow that may exist.

Shearwave elastography in tendons Shear-wave elastography provides an objective, quantitative assessment of tendon integrity and might be useful to guide treatment and develop new treatment approaches.

Insertion tendinopathies of the Achilles and patellar tendons are common orthopaedic diseases, especially among young athletes. While sonographic imaging has traditionally been used in these patients to assess morphologic changes via B-mode and perfusion changes via power Doppler, shear-wave elastography has recently been shown to be able to differentiate between symptomatic and asymptomatic tendons.

Diseased tendons are softer than normal tendons. This fact which is leveraged as an advantage to demonstrate the extent and stage of disease by using shearwave technology Beyond assessing for the presence or absence of tendon pathology, shear-wave elastography yields quantitative data that can be correlated with clinical symptoms, Dirrichs said. The shear-wave elastography values correlated closely with clinical exam scores over the course of treatment for those patients whose symptoms had improved.

Contrast enhanced ultrasound The field of diagnostic ultrasound is again on the cusp of major change. In the last decade, drug companies, ultrasound scanner manufacturers, and academic centres have invested manpower and funding in developing efficacious ultrasound contrast agents and new contrast-specific imaging modalities. Now, by bringing contrast media to the clinic, these efforts appear on the verge of success. As in MRI, CT, and conventional x-ray, the use of contrast media is changing the way ultrasound is per-

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Contrast ultrasound in infertility Hysterocontrast salphingography (HyCoSy) was compared to established, more invasive techniques such as chromolaparoscopy and 91 per cent agreement was found. HyCoSy is rapidly becoming the screening test of choice to determine tubal patency.

Picture used for representational purposes only

formed, opening new and unique diagnostic opportunities.

Vascular enhancing ultrasound agents were first introduced by Gramiak and Shah in 1968, when they injected agitated saline into the ascending aorta and cardiac chambers during echocardiographic examinations. Strong echoes were produced within the heart, due to the acoustic mismatch between free air microbubbles in the saline and the surrounding blood. However, microbubbles produced by agitation are both large and unstable, diffusing into solution in less than 10 seconds.

Most vascular contrast agents are stabilised against dissolution and coalescence by the presence of additional materials at the gas-liquid interface. Air, sulfur hexafluoride, nitrogen, and perfluorochemicals are used as microbubble-filling gases, most newer agents use perfluorochemicals because of their low solubility in blood and high vapour pressure. By substituting different types of perfluorocarbon gases for air, the stability and plasma longevity of the agents have been markedly improved, usually lasting more than five minutes.

Several cardiac and vascular ultrasound contrast agents are commercially available.

Most agents also improve gray-scale visualisation of the flowing blood to such a degree that the tissue echogenicity increases (parenchymal enhancement). Microbubbles within the small vessels of an organ can thus provide a qualitative indication of perfusion.

Contrast should also be useful for evaluating vessels in a variety of organs, including those involved in renal, hepatic, and pancreatic transplants. If an area of ischemia or a stenosis is detected after contrast administration, the use of other more expensive imaging modalities, including CT and MRI, can often be avoided.

Contrast ultrasound in neurology Transcranial Doppler (TCD) studies suffer from a poor signal-to-noise ratio and so contrast-enhanced TCD is receiving attention.

Contrast ultrasound in oncology Contrast kinetics (i.e., the uptake and washout of contrast over time) may become important parameters in helping to differentiate benign from ma-

lignant tumours. In a published study on ultrasound contrast, they found that neovascular morphology (i.e., arterial-venous tumour vessel shunts) as well as contrast washout times were statistically significant in discriminating between malignant and benign lesions and also increased both sensitivity and specificity to 100 per cent.

While such results are clearly limited by the number of cases, they still indicate that vascular ultrasound contrast agents could have a major role in the future diagnosis of breast cancer, and possibly other cancers.

Neoangiogenesis (creation of new blood vessels) is common to all malignant tumours, and these new vessels are usually abnormal-irregular in size, branching, and distribution, with flow in bizarre directions.

Ultrasound alone cannot detect these small vessels but with the addition of ultrasound contrast media, they may be visualised. This has already been demonstrated in breast cancer and undoubtedly will move into other areas like ovarian cancer screening.

Exciting new clinical possibilities arise from tissue-specific ultrasound contrast agents, which may improve the assessment of certain organs

Contrast ultrasound in paediatrics Vesico-ureteral reflux (VUR) is a common problem in children.

Reflux sonography, as an alternative to micturating cystography, detects or excludes VUR. This method detected VUR in children at the lowest cost.

Contrast ultrasound in drug delivery Other concepts being explored include targeted drug delivery via contrast microbubbles. Tissue-specific ultrasound contrast agents are most often injected intravenously into the blood and taken up by specific tissues, such as the reticuloendothelial system, or they adhere to specific sites such as venous thrombosis.

The disadvantages of contrast agents are their cost and the requirement for an intravenous injection. Also, with more sensitive Doppler instrumentation, blood flow enhancement may not be as important as it has been in the past.

Laproscopic ultrasound Laparoscopic ultrasound (LUS) is better than CT at detecting liver tumours, especially smaller ones, according to a study published in the Au-

IN IMAGING

gust Archives of Surgery.

The finding opens the door for expanded use of the technique in a wide variety of surgical procedures.

LUS detected every tumour seen on preoperative CT and found nearly 10 per cent that had been missed. Patients were upstaged by the use of ultrasound. This study points out that intra-operative ultrasound is better than anything else for detecting lesions.

LUS detected 9.5 per cent additional tumours in 20 per cent of patients. The lesions missed by CT were broken down by size: more than a quarter were smaller than 1 cm and none were greater than 3 cm. CT was more likely to miss tumours in the falciform ligament of the liver and along the liver's periphery. The lesson here was to pay special attention to those areas where

The overall costs of high-end ultrasound systems is less in comparison to other modalities. This adds to their cost-effectiveness CT scan might be a little less effective.

Intravascular ultrasound Drug-eluting stents have helped to significantly reduce in-stent restenosis and repeat revascularisation; however, percutaneous coronary intervention (PCI) of diffuse long coronary lesions remains difficult, as these have higher rates of in-stent restenosis and stent thrombosis than lesions that are shorter in length. Implantation of drug-eluting stents un-

der IVUS guidance has been shown in four meta-analyses to be associated with reduced major adverse cardiac events, but the procedure's effect on clinical outcomes remains uncertain due to the limited number of randomised trials with sufficient statistical power.

The authors also noted that the overall major adverse event rate was lower than they anticipated.

They concluded that among patients requiring long coronary stent implantation, the

use of IVUS-guided everolimus-eluting stent implantation, compared with angiography-guided stent implantation, resulted in a significantly lower rate of the composite of major adverse cardiac events at one year.

Lung ultrasound Lung ultrasound has been shown to be highly effective and safe for diagnosing pneumonia in children and a potential substitute for chest radiograph.

Results are currently published in a reputed medical journal.

WHO estimates three-quarters of the world’s population does not have access to radiography.

Ultrasound is portable, costsaving and safer for children than an X-ray because it does not expose them to radiation. The results of this study could have a profound impact in the developing world where access to radi-

ography is limited.

In the era of precision medicine, lung ultrasound may also be an ideal imaging option in children who are at higher risk for radiation-induced cancers or have received multiple radiographic or CT studies.

As more and more handheld ultrasound machines come to market, lung ultrasound has the potential to become the preferred choice for the diagnosis of pneumonia in children. Further research is needed to investigate the impact of lung ultrasound on antibiotic use.

Conclusion If the past is any indicator, these advances are only a sampling of what's to come, as technologies are combined in new and creative ways. But it will always be the clinician's skill and art that count most.

HIMSS Analytics and ESR showcase digital imaging adoption model at European Congress of Radiology The DIAM will identify potential infrastructure or workflow gaps, monitor technological progress over time and create a roadmap for future investments

A DIGITAL imaging adoption model (DIAM) which supports users and buyers of medical imaging technology with their operational and strategic decisions was showcased at the European Congress of Radiology in Vienna earlier this year. The model was jointly developed by HIMSS Analytics in Europe and the European Society of Radiology (ESR). DIAM comprises of eight stage sand aims to provide guidance to IT supported processes in medical imaging and will encourage the healthcare IT market to adopt the right digital strategy and improve health and patient outcomes.

Jörg Studzinski, Senior Consultant, HIMSS Analytics said, “This model will be able to

address important challenges which imaging departments and centres all over Europe face today. It has specific compliance goals for each of the maturity stages and will help users to adopt the right digital strategy and improve health outcomes. HIMSS Analytics and the ESR are already carrying out the first pilot assessments and we look forward to revealing the first results soon.

The assessment tool and a framework for results reporting are already available and a bigger rollout to imaging departments and centres in Europe is planned for the second quarter of 2016”.

The model is the first of its kind worldwide and comprises ten focus areas that remain essential to the digitisation in

imaging IT. These areas include patient engagement, personalised medicine and clinical documentation, amongst others. Similarly to the HIMSS Analytics EMR and Continuity of Care Adoption Models, the DIAM has 8 stages, with Stage 0 indicating low maturity and Stage 7 representing advanced maturity. One significant difference is that the highest three stages in DIAM reflect specialised branches that can be achieved separately. Organisations will need to master at least one of these for Stage 5, two of them for Stage 6, and all three for Stage 7.

Peter Mildenberger, Professor for Radiology at University Hospital Mainz and Chairman of the Sub-commit-

tee on Professional Issues and Economics in Radiology at the ESR, added, "There are two important aspects about the DIAM assessment that radiology departments need to keep in mind. First, the detailed GAP analysis shows potential deficits in the implemented IT-infrastructure, such as security aspects within patient identification. Second, bearing the model in mind, it is helpful to plan further IT projects on a strategical level, focusing on precision medicine or patient involvement, for instance. There is guidance on relevant topics for this kind of development, which might also be very helpful in negotiations with administration."

The DIAM can be used by any hospital that has an imag-

ing department, as well as imaging centres outside of hospitals. In its first edition, the assessment addresses the challenges of radiology imaging, but it can be easily adapted to measure and benchmark other imaging services such as Cardiology, Pathology or Dental Care. Organisations undergoing the assessment will receive their individual DIAM score as well as a report highlighting current gaps, future investment areas and metrics for benchmarking.

Subject matter experts from HIMSS Analytics and the ESR will be available to help organisations with their imaging IT strategy development or educational matters related to imaging IT maturity.

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IN IMAGING INSIGHT

Role of ultrasonography in fatty liver disease

DR AVIK BHATTACHARYYA Consultant Vascular & Interventional Radiologist, The Calcutta Medical Research Institute and BM Birla Heart Research Center, Kolkata

Dr Avik Bhattacharyya, Consultant Vascular & Interventional Radiologist, The Calcutta Medical Research Institute and BM Birla Heart Research Center, Kolkata gives an overview on the usage of ultrasonography in detecting fatty liver diseases and outlines its advantages FATTY LIVER or hepatic steatosis is the term used to describe a spectrum of conditions in which triglyceride accumulates within hepatocytes.

The most common condition associated with fatty liver is alcohol abuse. In addition, a variety of etiologic factors are associated with fatty liver, including obesity, diabetes, hepatitis, and drug toxicity.

The prevalence of non-alcoholic fatty liver disease in the general population is estimated to be 6â&#x20AC;&#x201C;35 per cent1.

This prevalence is also partly related to the growing epidemic in childhood obesity during the past decades.

Although fatty liver is wellknown in developed countries and is typically associated with the 'industrialised' or 'Western' lifestyle of low physical activity, alcohol abuse, calorically dense diet, and obesity; the prevalence of this disease is also rising in the developing world. A population based study by Das2 and colleagues showed 8.5 per cent of the population in rural West Bengal had fatty liver without being either alcohol consumers or overweight or obese. They have concluded that a nonobese, even non-overweight, supposedly physically active individual, with or without a bulging waistline, can have a fatty liver.

Many patients with fatty liver have no symptoms or signs of liver disease at the time of diagnosis, and are often found incidentally on cross sectional imaging. In other patients, fatty liver can be the cause of hepatomegaly and ele-

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vated liver enzyme levels, prompting a sonographic study of the liver. Here, we need to know that fatty liver encompasses a spectrum of histopathology ranging from simple steatosis to steato-hepatitis and has the potential to progress to fibrosis, cirrhosis, and end-stage liver disease and even hepatocellular carcinoma2,3. Fatty liver disease is an independent risk factor of cardiovascular disease and also prompts the clinician to search for associations with diabetes mellitus, hypertension, and hypertriglyceridemia4.

Thus, the diagnosis is of great clinical interest and it is certainly a challenge.

Even though liver biopsy is considered to be the 'gold standard' for the diagnosis of fatty liver, it has its limitations, including risk, high cost, and invasiveness. We always prefer

to assess fatty liver in a needlefree, non-invasive way by using ultrasonography. It is the first choice for screening for fatty liver1. However, it is operatordependent, and the sonographic evaluation of fatty liver is based mainly on the subjective impression of hepatic echogenicity and posterior attenuation of the ultrasound beam.

Liver echogenicity normally equals or slightly exceeds renal cortical echogenicity, but this factor relies on the visual perception of the radiologist. We use a grading of fatty liver into mild, moderate, and severe degrees of steatosis based on an increase in hepatic echogenicity, impaired visualisation of hepatic vessels and diaphragm, and poor penetration of the posterior aspects of the liver as below1.

Mild: Slight increase in liver

echogenicity and with clear visualisation of intrahepatic vessel wall and diaphragm.

Moderate: Slightly impaired visualisation of intrahepatic vessel wall and the diaphragm.

Severe: Marked increase in hepatic echogenicity, poor penetration of the posterior segment of the right lobe of liver and poor or no visualisation of the hepatic vessel wall and diaphragm. The reported sensitivity and specificity to diagnose fatty liver by sonography is >90 per cent and 77â&#x20AC;&#x201C;95 per cent respectively.

Estimation of liver fibrosis is also important in patient with advanced fatty liver disease because the prognosis and treatment decision often depends on its severity. Noninvasive methods are developed nowadays for evaluation of liver fibrosis. One important method is Acoustic Radiation for Impulse (ARFI) elastography. This is a type of elastography using acoustic radiation force to generate images of the mechanical properties (stiffness) of soft tissue. This method has many advantages like non-invasiveness, shows immediate result and generally comparable with other investigating method for assessing fibrosis5.

We perceive that the prevalence of fatty liver disease is rising in our country as a result of economic prosperity and the Westernisation of diet and lifestyle. This is an emerging problem and expected to be responsible for consumption of a significant proportion of healthcare facilities in near future6. In this situation, we

hope that improvement and refinement of ultrasonography as a diagnostic modality will make it suitable for objective and reliable assessment of fatty liver in near future.

References 1. Koplay M, Sivri M, Erdogan H. Importance of imaging and recent developments in diagnosis of nonalcoholic fatty liver disease. World J Hepatol 2015 Apr 18; 7(5): 769-776.

2. Das K, Das K, Mukherjee PS et Al. Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease. Hepatology. 2010 May; 51 (5): 1593-602.

3. Das K, Chowdhury A. Lean NASH: distinctiveness and clinical implication. Hepatol Int. 2013 Dec;7 Suppl 2:806-13.

4. Ajmal MR, Yaccha M, Malik MA, Rabbani MU, Ahmad I, Isalm N, Abdali N. Prevalence of nonalcoholic fatty liver disease (NAFLD) in patients of cardiovascular diseases and its association with hs-CRP and TNF-a.

Indian Heart J. 2014 Nov-Dec; 66(6):574-9.

5. Guerra JA, Trippia M, Pissaia A et Al. Acoustic radiation force impulse is equivalent to liver biopsy to evaluate liver fibrosis in patient with chronic hepatitis C & nonalcoholic fatty liver disease. Arq Gastroenterol. 2015; 52(3):234-8.

6. Majumdar A, Misra P, Sharma S, Kant S, Krishnan A, Pandav CS. Prevalence of nonalcoholic fatty liver disease in an adult population in a rural community of Haryana, India.

Indian J Public Health. 2016 Jan-Mar; 60(1):26-33.

IN IMAGING INSIGHT

Imaging in trauma

DR (BRIG) AKSHAY BHARGAVA Director, Radiology & Imaging at Nayati Hospital, Mathura

Dr (Brig) Akshay Bhargava, Director, Radiology & Imaging at Nayati Hospital, Mathura highlights the role of imaging for rapid detection and assessment of damage in trauma patients TRAUMA IS a sudden, and most often, wholly unexpected phenomenon. The consequent injury to any or multiple parts of the body requires immediate, expert medical attention to minimise morbidity. Rapid detection and accurate assessment of the severity of damage to any part(s) of the body is best done by imaging.

Trauma to the body can range from trivial to grievous, and can occur to any part of the body, the most susceptible being the head, neck, chest, abdomen and pelvis, the lower spine and the limbs.

Trauma imaging almost always commences with plain Xrays, which take minimal time or preparation, and are used to diagnose fractures of the bones of the skull, limbs, spine , chest or pelvis, and also provide additional vital information about injuries to the chest, such as lung contusions, lung collapse or pneumothorax following rib fractures, traumatic hemothorax or hemopericardium (accumulation of blood in the linings of the lungs or the heart), and reveal the presence of penetrating foreign bodies damaging the lungs or heart.

Plain X-rays are also used to diagnose injuries to the abdominal organs such as the intestines, when a perforation can cause the leakage of intestinal gas into the peritoneal cavity, and consequent detection on radiology.

Frequently, though more details are required to assess the damage to deeper structures within the body, and the eminent modality to detect these is a CT. CT takes only a few seconds to perform, and its diagnostic yield is phenomenal. From head to toe, a plain

Ingenuity 128 Slice CT Scanner

In trauma imaging, time is of paramount importance. Alongside, accuracy in diagnosis is vital to prevent further morbidity in the injured patient. The radiologist must at all times be well trained and aware of what to look for in every circumstance, and also has to be clinically oriented CT will confirm any fracture of the skull bones, underlying extradural or subdural hematomas (collections of blood in the linings of the brain) or frank intracerebral or intraventricular haemorrhages, with attendant features causing compression or shift of vital internal struc-

tures, all of which necessitate urgent neurosurgical intervention. Injury to other intracranial structures such as the eyes, middle and internal ears, nose and paranasal sinuses, teeth and jaws are also eminently detected by a CT that takes barely 8-10 seconds to perform.

Fracture dislocations of the vertebrae of the neck or lower spine that can have catastrophic consequences such as paralysis are easily diagnosed on CT, especially with new elegant reconstruction techniques in sagittal, coronal or oblique planes that picturise the images in 3D, providing

surgeons with a round-theclock view of the spine before surgical intervention.

Trauma to the chest , abdomen and pelvis is exquisitely demonstrated on CT, outlining even sub-millimeter rents of pleura, liver, splenic or kidney capsules, deeper parenchymal injury to the organs contained within, collections of blood or bile, or leakage of blood or urine from vascular or renal trauma - a single intravenous administration of non-ionic contrast can then demonstrate the site of vascular trauma and leak , or discontinuity of tissues in the kidneys, ureters or urinary bladder causing leakage of urine.

Likewise, damage to the pelvic organs can be accu-

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IN IMAGING rately assessed without delay, and any trauma to the uterus, ovaries or vasular structures delineated as a road map for the gynaecologist or the surgeon.

Oftentimes, fractures of long bones, notably the femurs cause large attendant collections of blood (hematomas) in the surrounding soft tissue/muscle compartments, and a CT can quantify the extent and severity of the same, as well as demonstrate any nerve or vascular compression that may compromise the viability of distal structures. The road map is then of vital importance to the orthopedician.

Again, simple contrast administration can reveal any vascular trauma, discontinuity or leak for the surgeon to repair with alacrity.

While CT is rapid, and patient throughput takes minimal time, an MRI takes longer to perform. Its employ is eschewed in trauma imaging except when there is damage to vital organs such as the brain and spinal cord. An MRI is a far superior modality and thus essential to accurately assess the extent of damage to gray matter, and assist the neuro-

surgeon in deciding whether to relieve pressure, or compression on the same surgically.

Many cases of traumatic quadriparesis, or Cauda Equina syndrome with bladder and bowel involvement have been rescued from lifelong debility by timely imaging and surgical intervention.

At times, when the patient is badly injured and moving him takes time, a bedside ultrasound performed by the radiologist in the emergency is invaluable in imaging damage to abdominal and pelvic or-

gans, providing image guidance for draining a pleural (chest cavity) collection, or assessing a soft tissue hematoma or collection. The practice of FAST, or Focussed Assessment by Sonography in Trauma, has proved itself time and again in emergency situations, and localised the site and extent of trauma to organs for doctors in emergency and surgeons to act upon without delay.

In trauma imaging, time is of paramount importance.

Alongside, accuracy in diagnosis is vital to prevent further morbidity in the injured patient. The radiologist must at all times be well trained and aware of what to look for in every circumstance, and also has to be clinically oriented.

Indeed, radiologists are the pathfinders in imaging in any situation. The essence of film interpretation lies always in the trained eye of the radiologist. At Nayati, the team is dedicated to excellence in performance, committed to bringing medical care to every patient, and indeed, in sending them home in better shape than they came to the hospital in.

Ingenuity PET- CT system

Multiva 1.5Tesla MRI

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KNOWLEDGE I N T E R V I E W

Early diagnosis and appropriate treatment translates to more lives, eyes, and vision being saved Dr Swathi Kaliki, Head - The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad highlights the dangers of retinoblastoma, the need to diagnose it on time to improve survival rates, the various measures undertaken by LV Prasad Eye Institute to spread awareness about the disease and offer quality treatment etc, in an interaction with Lakshmipriya Nair

How common is the incidence of retinoblastoma in India?

The incidence of retinoblastoma is one in 15,000 to 18,000 live births. As per studies from worldwide, there is no difference in the incidence of retinoblastoma based on the region of origin.

However, in India we see more number of cases probably due to higher population rate.

What are the causes for its occurrence? How curable is the disease?

Retinoblastoma occurs due to mutation in chromosome 13q14. This can be a sporadic mutation (90 to 95 per cent) or inherited from one of the parent (5 to 10 per cent).

Retinoblastoma treatment is a great success story. The survival rate of children with retinoblastoma was only five per cent about 50 years ago, but today with improved treatment modalities, the survival rate is 95 per cent.

The death is mostly related to delayed diagnosis and treatment.

Any measures which can help in its prevention?

We can certainly not prevent the genetic mutation but should create awareness about early detection and appropriate treatment.

Patients with retinoblastoma have a risk of passing on the genetic mutation to their

offsprings. They should undergo genetic testing and be given adequate genetic counselling so that the risk can be assessed in the prenatal period and the delivery can be planned appropriately.

And those who already have delivered a child, the child should be screened for retinoblastoma by a trained ocular oncologist immediately after delivery.

What are the challenges in diagnosing the disease? Are Indian children more susceptible to it due to certain reasons? If yes, kindly elaborate.

The challenge in India is early detection of retinoblastoma.

Most children are referred to us when the disease is already advanced, and thus minimising the chances of saving the eye and vision, although the life can be saved in most cases. All registered medical practitioners and nurses in every urban or rural area should be made aware of the early signs of this disease so that they can be referred to us in the early stage, so as to achieve the goals of saving life, eye, and vision in these children. The parents should be made aware of this deadly cancer so that they seek medical help at the earliest.

What is the line of treatment generally adopted to cure

The survival rate of children with retinoblastom a was only five per cent about 50 years ago, but today with improved treatment modalities, the survival rate is 95 per cent

retinoblastoma?

Retinoblastoma can be intraocular (within the eye) or have extra ocular extension (tumour extending outside the eye). If intraocular, then it can be grouped into five groups.

Group A and B can be treated with transpupillary thermotherapy or cryotherapy. Group C and D can be treated with systemic chemotherapy or intraarterial chemotherapy. Group E might need enucleation (removal of the eye). If there is extra ocular extension, the child needs combination treatment of systemic chemotherapy, enucleation, and radiotherapy.

What are the new technologies that have aided in diagnosis and treatment of this disease?

Prenatal diagnosis of retinoblastoma (diagnosis of retinoblastoma before birth) is possible with amniocentesis or chorionic villus sampling and genetic testing. In later stages of pregnancy, the diagnosis can be done by ultrasonography. After birth, a good clinical examination helps in accurate diagnosis.

Ultrasonography, CT scan, MRI scan, optical coherence tomography also aid in diagnosis.

The treatment modalities of retinoblastoma include transpupillary thermotherapy,

cryotherapy, plaque radiotherapy, external beam radiotherapy, systemic chemotherapy, intra-arterial chemotherapy, periocular chemotherapy, and intravitreal chemotherapy.

Intra-arterial chemotherapy is the new form of treatment where chemotherapy is directly delivered to the affected eye by arterial route.

What are the measures needed to spread awareness about this ailment and its impact?

Electronic and print media play a big role in spreading awareness about retinoblastoma. Regular news bytes and patient stories are needed to make general public aware of the disease. We at LV Prasad Eye Institute hold regular awareness programmes to train our vision technicians, optometrists, anganwadi workers, and all health care staff in recognising the disease early. Our vision technicians who work in the remote areas are able to identify the disease and refer patients to The Operation Eyesight Universal Institute for Eye Cancer at LV Prasad Eye Institute, so that early treatment can be offered.

Early diagnosis and appropriate treatment translates to more lives, eyes, and vision being saved. lakshmipriya.nair@expressindia.com

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KNOWLEDGE

CASE STUDY

Learnings from Ebola epidemic Excerpts from MSF’s Ebola-related research, highlighting the various operational challenges during the epidemic and MSF’s measures to tackle them

The Ebola outbreak in West Africa was the most significant medical challenge that Médecins Sans Frontières (MSF) faced between 2014 and 2015. There were a series of medical and logistical challenges to prevent infections and manage Ebola patients, and there was very little scientific knowledge to back decisions up.

As of February 2016, 28,603 people had been infected and 11,301 patients died in the three most affected countries of Sierra Leone, Guinea and Liberia. A limited number of additional cases were reported in Nigeria, Mali, the US , Senegal, the UK, Spain and Italy due to the repatriation of infected citizens by medical evacuation and persons entering countries well and then becoming sick from the virus causing further spread among close contacts.

Two years after the Ebola outbreak was declared in Guinea, MSF has published a review of its Ebola-related research including clinical, epidemiological and anthropological research. During the outbreak, MSF cared for more than 5200 Ebola confirmed patients, of which 2500 patients survived the disease.

The epidemic can be divided into four phases. The first phase was from December 2013 to March 2014, during which the first infections occurred in a remote region of Guinea. The inadequate health infrastructure present and the first time appearance of the virus in this region resulted in cases presenting unrecognised and therefore spread occurred undetected.

The second phase from March to July 2014 heralded the

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confirmed spread of Ebola to the neighbouring countries of Liberia and Sierra Leone. During this phase hundreds of healthcare workers became infected and died from the virus.

The third phase of the outbreak from August to December 2014 saw an exponential rise in the number of cases across the three most affected countries, including for the first time outbreaks in major urban settings. On August 8, the Director-General of the World Health Organization (WHO) declared the Ebola outbreak a public health emergency of international concern. The fourth phase, from December 2014 to January 2016 was characterised by decreasing numbers of new cases. This was achieved through a combination of community, national and international efforts.

MSF used six pillars in its approach to tackle the outbreak: ◗ Isolation of cases and supportive medical and mental health care in dedicated ETC’s ◗ Contact tracing ◗ Awareness raising in the community ◗ A functioning surveillance and alert system ◗ Safe burials and house spraying ◗ Maintaining healthcare for non-Ebola patients However, this Ebola outbreak posed many challenges, not only for MSF but also for other actors involved in the response. An analysis on the operational challenges and the measures adopted by MSF to tackle them.

Recording patient information: Recording clinical notes in

Testing a patient’s blood for Ebola in Kailahun

an ETC was a complex process.

Paper-based records were completed by staff in the high risk zone while attending patients but these paper records could not be sent to the low risk zone for review and entry onto a database because of the risk of transmitting infection. As a result staff from the high risk zone had to shout the results of ward rounds across the fence to staff in the low risk zone on the other side who recorded the information on clean paper. This process was slow and sometimes inaccurate, which led MSF to trial a scanning system based on mobile phones mounted on custom made stands and positioned in strategic places across the ETC. Clinical notes from the high risk zone could then be scanned and transmitted over a secure wireless network to a printer in the low risk area. This new method improved the quality of data being collected and reduced the time required for transmitting information. Additionally, infection risks were minimised.

In Liberia, MSF staff commenced using personal digital assistants (PDA) to record clinical information during ward

rounds in the high risk zone.

This information could then be transmitted in real time to the medical office in the low risk zone, negating the need for paper. It was found that PDA’s reduced the overall time staff had to spend recording information during ward rounds. The novel use of technology for recoding information is dependent on having appropriate technical expertise available to fix it should it fail in an emergency humanitarian setting.

Laboratory testing: The traditional way of diagnosing Ebola involved taking a blood sample from the patient using a needle and syringe (venipuncture).

This blood sample was then tested for the Ebola virus using a technology called polymerase chain reaction (PCR). Sometimes healthcare staff found it very difficult to obtain a blood sample by venipuncture from very young children who were also dehydrated. Occasionally patients refused to have venipuncture performed due to religious or cultural reasons.

Staff that carried out this procedure while wearing personal protective equipment (PPE) were also at risk of needle stick

injuries that could in turn cause them to become infected with the virus. Fingerstick tests are used to check patient’s for malaria by making a small puncture in the skin of the fingertip with a lancet and then squeezing out a drop of blood for analysis. Fingerstick blood samples are much easier, faster and safer to take than venipuncture samples. MSF questioned whether fingerstick samples could be used instead of venipuncture for diagnosing EVD in ETC’s. MSF staff in Guinea collected data on patients being screened for admission using both venipuncture and fingerstick blood tests and found that fingerstick samples were able to detect 87 per cent of the Ebola cases confirmed using venipuncture samples. As a result of this research it was recommended that fingerstick blood sampling, while less accurate than venipuncture for diagnosing Ebola, could be used in situations where it was not possible to perform venipuncture.

The PCR test used to diagnose EVD is very accurate, that is, it is very good at identifying those people who have Ebola, while excluding those who have not.

Very rarely, the PCR test can give incorrect results. MSF in collaboration with other organisations produced research that highlighted an Ebola case in Monrovia with a false negative PCR result.

A false negative result occurs when the PCR test indicates that the virus is not present while in reality it is.

Research such as this underscores the need to always interpret test results in combination with the clinical and epidemiological history of each patient.

KNOWLEDGE

Regarding the PCR test for Ebola, the time taken between obtaining a blood sample and getting a result can be considerable. This is due to a number of factors including the location of the laboratory in relation to the ETC. MSF assessed the feasibility of using a different Ebola test (called the Xpert Ebola Assay) and locating the testing device within the ETC. It was found that using the Xpert Assay compared to traditional PCR testing reduced the waiting time between sampling and result notification by over 50 per cent.

This is a significant improvement in turnaround time for test results especially for those patients waiting in the suspect area to be admitted or discharged.

Triage: When patients first arrived at an MSF ETC, a doctor or nurse at triage assessed them. This step was used to figure out which patients presenting were likely to have Ebola or not. Those who met the criteria of a suspect case using the WHO/MSF case definition were admitted to the suspect area of the ETC for blood testing. Individuals not fulfilling the case definition were discharged from triage. If the triage step was not carried out appropriately with an accurate case definition, then some potentially infected persons could be sent home while non infected ones could be admitted to the suspect area. Such a scenario posed a threat for further spread of the virus.

MSF contributed to research that investigated which combination of clinical signs and history of contact best discriminated between cases and non – cases. What is especially lacking is an accurate point of care Ebola diagnostic test that staff could use in the suspect area to find out there and then if a patient has Ebola or not.

Infection control: Preventing the spread of Ebola virus within the ETC’s to staff and other personnel was a priority during the outbreak. Strict procedures were put in place to ensure MSF staff had access to PPE and appropriate training on how to put it on and remove it in a safe manner. The minimum level of PPE that is required when treating Ebola patients is still

WHAT WE LEARNED

WHAT NEEDS TO BE DONE NEXT

The use of Personal Digital Assistants (PDA’s) for recording patient information in an Ebola Treatment Centre (ETC) was shown to be more efficient and safer than paper based methods.

Further research is needed to develop a fast and reliable point of care test for the Ebola virus so that patients can be tested safely and quickly for the disease.

Fingerstick blood tests were found to be slightly less accurate than venipuncture tests for detecting Ebola virus. However, fingerstick tests are easier to perform and act as a suitable alternative when venipuncture is not possible.

It is necessary to investigate what minimum level of PPE is required to prevent Ebola infection while at the same time being suitable to wear in tropical environments.

The waiting time between patient sampling and results notification was reduced by over 50 per cent when using the Xpert Ebola assay for detecting the virus compared to the traditional PCR technique.

Infection control procedures in the suspect zone of an MSF ETC were adequate to prevent transmission of infection between individuals with and without EVD while awaiting blood test results.

not fully understood. In general, the higher the level of PPE, the more difficult it is for staff to attend patients in tropical environments due to heat illness. MSF participated with a number of organisations to explore what the optimal PPE should be and this research is ongoing at present.

Infection control was critical for patients admitted from triage into the suspect area of the ETC. While in the suspect area, patients had blood tests performed to check for the presence of Ebola with a positive test causing the patient to be admitted to the confirmed ward of the ETC and a negative test resulting in discharge from the facility. Therefore within the suspect area, there were patients with and without Ebola present at the same time. If infection control measures were poor in the suspect area, it is possible that negative cases awaiting blood test results could contract the virus from positive cases also awaiting test results. MSF researched this important issue and found there was no evidence of it occurring in MSF ETCs. Plexiglass partitions were introduced to ETCs during the outbreak. This allowed staff to assess how patients were progressing without having to put on PPE. The plexiglass partitions facilitated greater interaction between patients and staff and also strengthened infection control measures within ETCs. It is not only in ETCs were

infection control was important.

During the height of the outbreak in Monrovia, when there was no bed availability in ETCs, MSF decided to distribute over 65,000 Ebola protection and disinfection kits to households, frontline workers and other targets in the poorest areas of the city. These kits included a bucket, chlorine, surgical gown, mask and gloves and were to be used while caring for any sick person in the community or to handle any dead body while awaiting the ambulance to arrive. The kits were essentially a way of creating infection control procedures in the community at a time when there was no bed availability in ETC’s. In close association with the distribution of the kits, MSF carried out intensive health promotion activities in the community to ensure people understood how and when the kits should be used.

MSF follow up research indicated that 99 per cent of community respondents agreed that the kits were useful and had no problem using them. The Hazard Analysis of Critical Control Points (HACCP) is a tool used in other disciplines such as the food sector to prevent contamination by biological or environmental material.

MSF in association with other researchers found that the HACCP protocol could potentially be used in the community setting as an infection control measure to reduce the risk posed by human waste in areas of Ebola transmission.

Way forward This Ebola outbreak and all previous ones have shown the urgent need for accurate rapid diagnostic tests, effective treatments and a working vaccine.

International research institutions must continue to prioritise these areas of investigation even though this outbreak has ended.

Now is also the appropriate time to agree ethical clinical trial protocols for the next humanitarian/medical emergency.

Finally, how the international community can better respond to a major infectious disease outbreak is an area of research that needs to be urgently addressed.

References - Moon S. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. The Lancet.

2015.

- Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, et al. Emergence of Zaire Ebola Virus Disease in Guinea Preliminary Report. N Engl J Med. 2014.

- MSF. Pushed to the limit and beyond: a year into the largest ever Ebola outbreak. 2015.

- MSF. Data collection in a high risk infectious zone: challenges and lessons learned in an Ebola clinical trial in Conakry, Guinea - Gallego M. Project ELEOS (Ebola Link Emergency Operational Support): A barcode/handheld computer

based solution for Ebola management centres.

- Strecker T, Palyi B, Ellerbrok H, Jonckheere S, de Clerck H, Bore JA, et al. Field Evaluation of Capillary Blood Samples as a Collection Specimen for the Rapid Diagnosis of Ebola Virus Infection During an Outbreak Emergency. Clin Infect Dis. 2015;61(5):669-75.

- Edwards JK, Kleine C, Munster V, Giuliani R, Massaquoi M, Sprecher A, et al. Interpretation of Negative Molecular Test Results in Patients With Suspected or Confirmed Ebola Virus Disease: Report of Two Cases. Open Forum Infect Dis. 2015;2(4):ofv137.

- Van den Bergh R, Chaillet P, Sow MS, Amand M, van Vyve C, Jonckheere S, et al. Feasibility of Xpert Ebola Assay in Médecins Sans Frontières Ebola Program, Guinea. Emerg Infect Dis. 2016;22(2):210-2106.

- Zachariah R, Harries AD. The WHO clinical case definition for suspected cases of Ebola virus disease arriving at Ebola holding units: reason to worry?Lancet Infect Dis. 2015;15(9):989-90.

- Kuehne A. Differentiating high and low suspect Ebola cases based on clinical presentation and history of contact.

- Vogt F. Is there added value in separating admitted Ebola patients into suspect and highly suspect wards pending laboratory confirmation? An assessment of the triage system at the MSF Ebola management centre, Kailahun, Sierra Leone.

- Sprecher AG, Caluwaerts A, Draper M, Feldmann H, Frey CP, Funk RH, et al. Personal Protective Equipment for Filovirus Epidemics: A Call for Better Evidence. J Infect Dis. 2015;212 Suppl 2:S98-S100.

- Fitzpatrick G, Vogt F, Moi Gbabai O, Black B, Santantonio M, Folkesson E, et al. Describing readmissions to an Ebola case management centre (CMC), Sierra Leone, 2014. Euro Surveill.

2014;19(40).

- Ali E. Ebola kits distribution during the Ebola epidemic in Monrovia, Liberia. The MSF experience.

- Edmunds K. Dealing with Ebola infected waste: a Hazard Analysis of Critical Control Points for reducing the risks to public health.

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IT@HEALTHCARE INSIGHT

Convergence of technology and healthcare in India

GRANT KUO MD of India, MediaTek Inc

Grant Kuo, MD of India, MediaTek Inc elaborates on the way technology is transforming healthcare significantly and predicts the trends that would emerge in Healthcare IT

ONE OF the biggest drivers slated to accelerate the spread of potent medical products and services across tier I and tier II centres in India is the Internet of Things or IoT. Elsewhere in the world, IoT is making it easier for medical and government institutions to reach out to people and deliver quality healthcare facilities that aid in delivering more accurate and timely diagnosis and response for various ailments. These solutions are able to modernise current medical practices, reduce costs, eliminate any duplication of tests as well as streamline processes and update medical records in real time. The latter has created a significant level of opportunity for providing more improved infrastructure to store data and make it available at different locations for specialised practitioners to analyse.

In order to reach greater levels of efficiency, precision and patient safety, healthcare providers need real-time visibility and intelligence in their data.

Coinciding with this need, many industry analysts point to the Digital India campaign, which they view will help provide further impetus to IoT in rural healthcare. In fact, government will also be seen encouraging the use and implementation of IoT in the healthcare market very soon. The E-health initiative, which is a part of Digital India drive launched by Prime Minister Narendra Modi, aims at providing effective and economical healthcare services to all citizens. The programme aims to make use of technology and portals to facilitate people, maintain health records and book online appointments with

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various departments of different hospitals using eKYC data of Aadhaar number.

According to McKinseyâ&#x20AC;&#x2122;s report, a rapid rise in growth for devices and systems for in-home monitoring of patients is expected, particularly for those with chronic conditions such as diabetes. These devices have already demonstrated their potential to improve health outcomes and reduce healthcare costs among patients with acute forms of chronic heart failure, diabetes, and chronic obstructive pulmonary disease (COPD).

Related to this, an estimated 130 million consumers worldwide use fitness trackers today. The number of connected fitness monitors is expected to exceed 1.3 billion units in 2025 with the rise of smart watches and other wearable devices. More so, by implementing solutions such as radio frequency identification and mobile scanners connected with cloud technology, organisations can gain visibility into these assets, providing real-

time information to people and transactions that require them ensuring hospitals have what they need, where they need it, when they need it. IoT also makes it easier to integrate data from consumer devices such as fitness band into hospital systems, which help organisations gather more data and deliver better care.

Further, various devices and enablers which can help in integrating technology in the healthcare segment towards vitality and advancement are cheaper consumer off-the-shelf (COTS) software applications.

Within this, fitness bands would work as tracking devices for daily analysis of patients. From the data generated by third party administrators would be able to manage and oversee data warehousing and mine it when required. However, looking ahead, improvements in collaborative data exchange, workflows and mobility and need for better financial management are the next phase of technological evolution in healthcare.

In addition, the shifts occurring in mobile devices, wireless technology and cloud computing would need to be accounted for, as they would hold a crucial key towards spreading better healthcare for the masses.

In fact, our firm in collaboration with World Health Partners (WHP) has been engaged in leveraging mobile technology to provide more effective healthcare solutions to rural populations in two central Indian states. This campaign works two-fold. Firstly, it reaches out to about 1.3 million people to spread awareness about symptoms of cardiovascular maladies through measures like screening a Bollywood movie to attract audience. Secondly, it makes use of a cloud-based auto solution, developed by MediaTek, which shall work as a screening tool to help remotely select probable patients, who can then seek further professional advice and consultation via WHPâ&#x20AC;&#x2122;s telemedicine services. With the help of this tool, the requirement of doctorsâ&#x20AC;&#x2122; resource will

become more specific to only those people who are identified as suffering with a heart malady.

Further, distance barriers will be eliminated thereby improving access to medical services that are not always available in distant rural communities.

Though such campaigns help, at present, the industry still faces operational challenges such as cost, complexity of implementation and usage, absence of efficient computerisation at urban clinics/hospitals, inadequate storage facilities for capturing data etc. More so, over 30 million have now been diagnosed with diabetes in India. In rural areas, the prevalence is approximately three per cent of the total population.

Large percentages of rural populations are still unable to access basic healthcare facilities. In rural India, where the number of primary healthcare centres (PHCs) is limited, eight per cent of the centres do not have doctors or medical staff, 39 per cent do not have lab technicians and 18 per cent PHCs do not even have a pharmacist technology can help bridge the gap.

Today, healthcare organisations need to streamline their technological infrastructure, to provide simple, quicker and more efficient healthcare service or delivery. The convergence of healthcare with upcoming technologies will play a key role in improving accessibility and mitigating manpower shortage.

The coming years are expected to witness greater deployment of tools like telemedicine, teleradiology, hospital information systems/hospital management information systems, online or electronic medical records, etc.

IT@HEALTHCARE REPORT

Healthcare IThas strong first quarter with $1.4 bn in VC funding: Mercom report A total of 318 investors, including three accelerators/incubators, participated in healthcare IT deals this quarter MERCOM CAPITAL Group, a global communications and research firm, released its report on funding and mergers and acquisitions (M&A) activity for the healthcare IT (IT)/digital health sector for the first quarter of 2016. Mercom’s comprehensive report covers deals of all sizes across the globe.

Venture capital (VC) funding, including private equity and corporate venture capital, in the health IT sector increased 27 per cent quarter over quarter (QoQ), coming in at $1.4 billion in 146 deals compared to $1.1 billion in 145 deals in Q4 2015; it was also up 74 per cent compared to the same quarter of last year. Total corporate funding raised in the sector including VC, debt and public market financing for Q1 2016 came to $1.5 billion.

“The Health IT sector is off to an impressive start this year with significant funding activity in the first quarter led by wearables, data analytics and telemedicine. Data analytics and telemedicine companies reached a significant milestone, each crossing $1 billion in funding raised to date.

Health IT public companies, meanwhile, continued to underperform,” commented Raj Prabhu, CEO and Co-Founder of Mercom Capital Group.

Healthcare practice-centric companies received 42 per cent of the funding in Q1 2016, raising $569 million in 49 deals compared to $360 million in 44 deals in Q4 2015. Consumercentric companies received 58 per cent of the funding this quarter, bringing in $796 million in 97 deals compared to $711 million in 101 deals in Q4 2015.

There were 58 M&A transactions in the health IT sector this quarter compared to 53 transactions in Q4 2015. This quarter had the highest recorded number of M&A transactions in a single quarter Top funded areas in Q1 were – Wearables/Sensors with $260 million, Data Analytics companies with $197 million, Telemedicine with $171 million, mHealth apps with $120 million, and Consumer Health Information/Education

with $100 million.

There were 53 early-stage deals at or below $2 million, including 14 accelerator and incubator deals.

The top VC deals this quarter included the $175 million raised by Flatiron Health, $165

million raised by Jawbone, $95 million raised by Healthline, $70 million raised by Health Catalyst, $46 million raised by inviCRO, and $40 million raised by higi.

A total of 318 investors, including three accelerators/in-

cubators, participated in healthcare IT deals this quarter. A total of 27 investors participated in multiple rounds this quarter. Chicago Ventures, Jazz Venture Partners, Jump Capital, Lux Capital, Sequoia Capital, Social Capital, Tribeca Venture Partners and UPMC were involved in the greatest number of funding deals with three each.

Health IT VC funding deals were spread across 16 countries in Q1. There were two IPOs this quarter; Oneview Healthcare and Senseonics together accounted for $91.5 million.

There were 58 M&A transactions (nine disclosed) in the health IT sector this quarter compared to 53 transactions (13 disclosed) in Q4 2015.

This quarter had the highest recorded number of M&A transactions in a single quarter. mHealth apps companies were involved in the most M&A transactions with nine, followed by Practice Management companies and Personal Health companies with seven each, Data Analytics companies with five, EHR companies with four and Telemedicine companies with three.

The Top 5 disclosed M&A transactions were the $2.75 billion acquisition of MedAssets

by Pamplona Capital Management, the $2.6 billion acquisition of Truven Health Analytics by IBM, the $950 million acquisition of Netsmart Technologies by Allscripts, the $140 million acquisition of CenTrak

by Halma, and the $119 million acquisition of MedicalDirector

by Affinity Equity Partners.

There were a total of 615 companies and investors covered in this report.

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LIFE PEOPLE

WHO India honours public health champions The scope of the awards covered contributions to significant advances in population and person-focused services and inter-sectoral actions THE WHO Country Office for India gave out awards for Public Health Champions at a national consultation held recently jointly with the Ministry of Health & Family Welfare (MoHFW), Government of India (GoI) to commemorate World Health Day 2016. The awards comprised two categories: sustained contribution to the field of public health, and innovation.

The award winners were Dr Paresh Vamanrao Dave, Government of Gujarat; Mahan Trust, Maharashtra; and SEARCH, Gadchiroli, Maharashtra for sustained contribution to public health. In the category of innovation, the awardees were Dr Bindeshwar Pathak, Sulabh International and Sangath, Goa.

The awards comprised two categories: sustained contribution to the field of public health, and innovation Amongst other dignitaries, present on the occasion were Jagat Prakash Nadda, Union Minister of Health & Family Welfare (MoH&FW); Shripad Naik, Minister of State for Health & Family Welfare and Minister of State (IC), AYUSH; Dr Jitendra Singh, Minister of State for the Ministry of Development of North Eastern Region (IC), Prime Minister Office, Personnel, Public Grievances and Pensions, Department of

Atomic Energy and Department of Space; BP Sharma, Secretary, MoH&FW; Dr Soumya Swaminathan, Secretary, Department of Health Research & Director General, Indian Council of Medical Research (ICMR), MoH&FW; KB Agarwal, Additional Secretary, MoH&FW; Dr Arun Panda, Additional Secretary, MoH&FW; CK Mishra, Additional Secretary and Mission Director, National Health Mission, MoH&FW; Dr Jagdish

‘Entrepreneur of the Year’award for Malvinder Mohan Singh The award recognised Singh as a dynamic business leader who has made a mark on the global landscape MALVINDER MOHAN SINGH, Executive Chairman, Fortis Healthcare was conferred with “Entrepreneur of the year Award” at the Asia Pacific Entrepreneurship Awards (APEA 2016) function in Delhi. General (Retired) V K Singh, Minister of State for Statistics and Programme Implementation (Independent Charge), External Affairs and Overseas Indian Affairs, Government of India presented the trophy to Singh.

The recognition underscores exemplary leadership and vision, indomitable enterprising spirit, passion for innovation and strong commitment to social responsibilities.

This award is a platform recognising and honouring business leaders who have shown en-

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trepreneurial excellence, innovation, fair practices and growth of business. This particular award was given under a special category to recognise Singh’s leading role in ‘impacting, touching lives and making a positive difference to society.’ The award further recognised Singh as a dynamic, young business leader who has

made a mark on the global landscape by combining the twin objectives of business for profit and public good in ways that can positively impact lives.

The APEA is a regional award for outstanding entrepreneurship, and recognises efforts to continuously innovate and sustain their leadership. Over 1200 top business leaders and entrepreneurs have been awarded the prestigious Awards since 2007 in Malaysia, Indonesia, Brunei, Singapore, Hong Kong, India and China as part of its continuous efforts to recognise and honour individuals who have shown great entrepreneurship spirit in leading, growing and contributing to their organisations, communities and countries.

Prasad, Director General Health Services; Anshu Prakash, Joint Secretary, MoH&FW and Dr Henk Bekedam, WHO Representative to India.

Dr Henk Bekedam, WHO Representative to India said, “Public health is key to improving people’s health. The individuals and organisations who toil hard to bring about impactful, innovative and sustainable changes in this field are often unsung heroes. These awards are our attempt to bridge this gap and recognise the talented individuals and organisations in public health.

We do hope that the Public Health Champions awards will encourage others to emulate them.”

The rationale for recognising public health champions is to honour efforts of both, individual(s) and institution(s) who have made an outstanding contribution to public health through advocacy for and involvement in impactful health policies and programmes with proven public health achievements and substantial improvement in equitable health outcomes in the country.

Reportedly, the scope of the awards covered contributions to significant advances in population and person focused services and inter-sectoral actions. In addition, contributions that have assisted WHO in performing any one of its six core functions were taken into consideration.

Dinesh Lodha takes charge as Sutures India’s CEO He was formerly Country Manager for the HME Division of Samsung India Electronics SUTURES INDIA, surgical sutures manufacturer, announced that it has named Dinesh Lodha as its new CEO. Lodha was formerly Country Manager for the Health and Medical Equipment (HME) Division of Samsung India Electronics. He has held leadership roles at GE Healthcare and GE X-ray India before steering the growth of Samsung’s HME business.

“The combination of skills and experience that Dinesh brings to Sutures will be key to advancing the company’s next phase of growth. He has

deep experience scaling businesses across multiple product categories and building high-performing teams,” said LG Chandrasekhar, Chairman, Sutures India.

“I am excited to work with the team at Sutures to continue expanding and enhancing the company’s operating capabilities and scale. There is great momentum behind Sutures and a strong foundation that we can build upon,” said Lodha.

Lodha takes on the CEO role from YS Prabhakar, effective immediately.

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TRADE & TRENDS

Carestream showcases OnSight 3D Extremity System at AAOS The product is intended to offer high-quality, low-dose 3D imaging for orthopaedic practices and other healthcare providers

CARESTREAM RECENTLY showcased its CARESTREAM OnSight 3D Extremity System that uses cone beam CT (CBCT) technology to capture weight-bearing and other types of extremity exams at the American Academy of Orthopaedic Surgeons (AAOS).

This affordable system is intended to offer high-quality, low-dose 3D imaging for orthopaedic practices and other healthcare providers. The CBCT system is being designed to include advanced image reconstruction and artifact correction technology.

“Our CBCT system is designed to allow orthopaedic practices to capture high-quality 3D extremity images and conduct a patient consultation in a single visit,” said Helen Titus, Carestream’s Worldwide Marketing Director for X-ray & Ultrasound solutions. “This is highly productive for orthopaedic specialists while simultaneously delivering greater patient convenience.

Pre-surgical and post-surgical exams can also be performed by this system.”

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Titus adds that orthopaedics is a major area of focus for Carestream because of the prevalence of musculoskeletal conditions among people of all ages.

The company is currently conducting trials and research studies of the CBCT system in the US and Europe. UBMD Orthopedics & Sports Medicine (Buffalo, NY), Erie County Medical Center (Buffalo, NY) and Carestream are conducting an institutional IRB-approved clinical study designed to help

orthopaedic surgeons more accurately and objectively diagnose the degree of instability of the patella (knee cap).

“We compare images obtained on a conventional CT scanner to those obtained on the prototype CBCT scanner while the patient is standing, the quadriceps is active and the knee is flexed to 30 degrees,” said Dr John Marzo, a physician with UBMD Orthopedics & Sports Medicine, Associate Professor of Clinical Orthopedics, Jacobs School of Medicine

& Biomedical Sciences, University at Buffalo and former Medical Director, Buffalo Bills.

“The orthopaedic specialists involved in the clinical study are extremely satisfied with the image quality from the CBCT scanner and have provided positive feedback on the benefits delivered by the use of this technology for weight-bearing exams,” he adds.

Radiologists, technologists and other team members at Erie County Medical Center (ECMC) have provided valuable feedback on the system’s design and performance during research studies and trials conducted at their facility. Medical staff from Great Lakes Medical Imaging—a leading radiology group and official imaging service of the Buffalo Bills and the Buffalo Sabres— also have provided support to these patient studies.

ECMC includes an advanced academic medical centre with 602 inpatient beds, on- and off-campus health centres, more than 30 outpatient speciality care services and a 390-bed long-term care facility.

It is a major teaching facility for the University at Buffalo.

HUS Medical Imaging Center, based in Helsinki, Finland, is the site of the first European clinical study of Carestream’s 3D extremity system in pre- and post-operative cases. During the six-month project, experienced radiologists will evaluate the system’s image quality in bone structure, fractures and the level of metal artefacts. In addition, a medical physicist will assess the physical image and radiation exposure.

These clinical studies and other research projects will help guide Carestream’s development of new CBCT systems that use less radiation than traditional CT; are compact, affordable and portable; and could be used in a wide range of facilities.

“This CBCT scanner has the potential to become a noninvasive tool to evaluate a host of orthopaedic conditions that affect the biomechanical behaviour of the joints, such as arthritis, meniscus loss, instability and malalignment syndromes,” Titus reports.

TRADE & TRENDS

Ruby Hall Clinic,Hinjewadi: A comprehensive healthcare organisation Dedicated to quality, devoted to the community, Ruby Hall Clinic, Hinjewadi, seeks to be a holistic healthcare provider in Pune

YEARS OF planning, construction and designing every minute detail will finally come to fruition in early 2016 in the form of Ruby Hall Clinic, Hinjewadi. Located in the IT hub of suburban Pune, the satellite medical institute will be the first holistic healthcare provider in this area. In alignment with the gleam of technology exuding from the IT giants it is surrounded by, the hospital’s charcoal grey structure will reflect the perfect

amalgamation of healthcare and technology.

The glass facade of the building encompasses within itself an 100-bedded facility coupled with services and amenities focused on the health and well-being of the IT residents dominating the area.

Ultra-modern features such as X-ray, CT scan, endoscopy suite, ECG, colour doppler, TMT, dental sonography, physiotherapy, trauma centre, ICU, labour delivery and a modular

operating theatres are housed at this facility. Consisting of the most advanced diagnostic, therapeutic and surgical technologies, Ruby Hall Clinic Hinjewadi is a compact, but complete hospital.

Harnessing latest technology, this Wi-Fi-enabled branch of the institute will be well-connected to the parent branch ensuring smooth co-ordination between both units. The Hinjewadi hospital will deliver a model of coordinated care

that’s built around the unique physical and emotional needs of each and every patient. Modern equipment and information communication systems will work to enhance the patient experience and support the culture of safety and improve patient outcomes.

Upholding its tradition of over five decades, Ruby Hall Clinic is Pune’s most comprehensive healthcare organisation, dedicated to providing the highest quality, most com-

passionate care to patients not only in India, but also throughout the globe. As India’s largest critical-care set-up, it boasts of 500 consultants treating over 1.2 lakh OPD patients and more than 30,000 IPD patients every year. Consistently recognised as a leader in patient-centric clinical care, Grant Medical Foundation’s Ruby Hall Clinic is all set to mark another milestone with its newest undertaking.

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TRADE & TRENDS

Immature platelet fraction: Aclinical parameter in managing thrombocytopenia Kanchan Jeswani, Product Manager-Hematology, Transasia Bio-Medicals, elaborates on how Transasia Bio-Medicals, the sole distributor of the Sysmex haematology instruments in India, can monitor Immature Platelet Fraction in all cases of thrombocytopenia THROMBOPOIESIS IS a dynamic process which has varying physiologic responses in different clinical conditions. In newly diagnosed thrombocytopenic patients, or patients that have thrombocytopenia secondary to disease or drug therapy, it is crucial for a clinician to understand its underlying mechanism.

Thrombocytopenia results when the bone marrow has slowed or stopped production of new platelets or it could be a destructive or consumption problem such as ITP. Care pathways differ in each case.

Fig 1: Zucker showed that IPF is an earlier indicator of platelet recovery at nine days, and the difference is statistically significant when compared to IRF at 10 days, Platelet count at 12.5, and ANC at 13.2 days

Immature Platelet Fraction Immature platelet fraction (IPF) is an index of thrombopoiesis and can help determine the mechanism of thrombocytopenia. An increased IPF in the presence of thrombocytopenia is indicative of platelet destruction or consumption. A decreased /low normal IPF in the presence of thrombocytopenia is indicative of decreased marrow production thereby getting to the pathogenesis of thrombocytopenia. Thus, IPF values serve as differentiator between increased consumption and decreased production.

Highest values of IPF are seen in DIC, AITP, TTP followed by patients with reconstituting marrows post chemo and bone marrow transplantation. IPF is a potential tool for monitoring thrombocytopenia in dengue fever case and acts as a platelet transfusion regulator.

Most often an impaired production is due to bone marrow insufficiency. After chemotherapy, radiation therapy, stem cell or bone marrow transplantation, it takes a certain while until the bone marrow produces platelets at a sufficient rate again. Nor-

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Fig 2 IPF on XE/XN-L Analyzer

Fig 4: IPF levels in Consumptive v BM suppression

mally, the immature platelets count rises two to three days earlier than the total platelet concentration. Hence measurement of immature platelets fraction will be helpful to check whether the bone marrow's platelet production has started again. (See Fig) Possibly, this approach will help to save expensive platelet transfusions in the future.

Immature platelet fraction measurement on Sysmex XN Analyzer A reportable parameter IPF can now be measured on the Sysmex XN /XN-L series as a part of complete blood count. It has now

Fig 3: IPF on XN Analyzer

instruments in India.

Conclusion

Kanchan Jeswani

become possible to monitor IPF in all cases of thrombocytopenia.

Transasia Bio-Medicals, Indiaâ&#x20AC;&#x2122;s largest in-vitro diagnostic company, is the sole distributor of the Sysmex haematology

Since destruction-mediated thrombocytopenic diseases are fairly rare, IPF is most useful in environments that service a large number of patients. Good examples include laboratories of large hospitals with haemato-oncologic units, paediatric units/ neonatology units for differential diagnosis of juvenile thrombocytopenia and/or monitoring of the course of thrombocytopenia.

IPF is most useful in laboratories/hospitals with intensive

care units, haemato-oncologic units, paediatric units/neonatology units for differential diagnosis of juvenile thrombocytopenia and/or monitoring of the course of thrombocytopenia in dengue cases.

References 1. www.sysmex.co.in 2. Assessment of an immature platelet fraction (IPF) in peripheral thrombocytopenia.- Briggs C1, Kunka S, Hart D, Oguni S, Machin SJ. 3. Zucker, M. Laboratory Hematology, 2006 12:125 â&#x20AC;&#x201C; 130

TRADE & TRENDS

Medico legal conference held in Pune The conference was based on the theme of creating synergy between doctors and patients

CORE INDIA Institute of Legal Medicine and the Indian Medical Association, Pune branch recently organised a medico legal conference, 'The Doctor Patient Synergy. The concept of the medico legal conference was based on the theme of creating synergy in the relationship between doctors and patients.

With this objective in mind, interactions were organised with the highest police official of the state and judicial authorities at various levels. The two-day conference achieved success in thought provoking concepts and plan of action has been conceptualised. The audience had around 350 visitors including doctors, advocates and others. It was successful due to the active involvement of IMA office bearers, conference secretariat and CIILM executive Board members Dr Avinash Bhutkar, Dr Sanjay Patil, Dr Aarati Nimkar, Dr Padma Iyer, Dr Santosh Kakade, Dr Jayant Navarange, Dr Sanjay Gupte and Dr Bhagyashri Kakade.

The objective of this conference was to create synergy between doctors and patients. The conference dealt with a range of medico legal issues including violence against doctors, various medico legal concepts and how judiciary looks at them. The role of media and film industry in portraying images of doctors in society was also discussed during the conference.

The first session was on 'Violence against medical professionals and hospitals.' Dr Sanjay Gupte, Chairman, Ethics Committee, Maharashtra Medical Council, Mumbai in his opening speech, narrated various incidences of violence against doctors and hospitals and suggested that it is the police who can help and prevent the violence. Dr Neeraj Nagpal, President, Medico legal Action Group, Chandigarh spoke on 'Violence against medical professionals:

Case Studies: Why?/How?/ When?', Dr Sanjay Oak, Vice Chancellor, DY Patil University, Mumbai suggested that active participation and meticulous involvement of medical professionals in developing the doctor patient relationship proves to be fruitful and in the long run prevents violence. This was followed by a lecture by Dr KH Sancheti, Founder Chairman, Sancheti Institute of Orthopaedics and Rehabilitation and Chairman of Executive Board of CIILM, Pune, Pravin Dixit, Director General of Police, Maharashtra took part in the session speaking on 'Role of Police in violence against Medical Professionals.'

The session on 'Law governing Medical Negligence' had Dr Neeraj Nagpal, President, Medico legal Action Group, Chandigarh, talking about 'Medical Negligence Indian Perspective,' Rajyalakshmi Rao, Former Member, National Consumer Disputes Redressal Commission, New Delhi, on 'Doctor as Consumer,' Justice Ashok Bhangale, President, State Consumer Disputes Redressal Commission, Mumbai on 'Consumer Protection Act and Healthcare' and Justice MB Shah, Former Supreme Court Judge and former President, National Consumer Disputes Redressal Commission, New Delhi elaborating on 'Evolution of Law Governing Medical Negligence.'

The next topic was on 'Dispute resolution in healthcare and healthcare risk management'. Dr SM Kantikar, Member, National Consumer Disputes Redressal Commission, New Delhi, spoke about 'Prevention of Litigation,' Adv Uday Wavikar, Advocate, Mumbai High Court and Vice President of Maharashtra Consumer Bar Association, Mumbai, on 'Grievance Redressal System â&#x20AC;&#x201C;Safety Valve in Risk Management,' Sanjeevani Behere, Regional Manager, the New India Assurance Co.

Glimpses of the event where a range of medico legal issues were discussed

Pune, on 'Indemnity Insurance for Risk Management' and Justice Mohit Shah, Former Chief Justice of Mumbai High Court, Mumbai, on 'Dispute Resolution in Healthcare.'

The session on 'Social Aspects of Doctor Patient Relationship' had Dr Mohan Agashe, Actor and Psychiatrist who spoke on 'Role of films in

highlighting doctor patient relationshipâ&#x20AC;&#x2122;. Prataprao Pawar, Chairman, Sakal Media Group, Pune, talked about 'Outlook of print and digital media', Dr VN Shrikhande, Senior GI Surgeon, Mumbai on 'Reflections: Decades of Experience,' Justice SR Bannurmath, Former Chief Justice of Kerala High Court and Chairperson, Maharashtra

Human Rights Commission, Mumbai on 'Doctor patient relationship in the eyes of human rights.'

The two-day of the conference ended on a positive note.

The stalwarts in the medico legal field and those responsible for actual execution of the law, i.e., police and the judges appreciated the event.

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May 2016

TRADE & TRENDS

Philips Intuis: Anew age cathlab The system is designed to perform a wide variety of diagnostic and interventional procedures ROYAL PHILIPS has introduced Philips Intuis, its latest innovation in image-guided therapy. Intuis is an advanced, entry level catheterisation lab (cathlab) designed, developed and manufactured at the Philips Healthcare Innovation Center (HIC) in Pune, India. Intuis is an offering from Philips under interventional X-ray systems to fulfil the needs of evolving cardiac care locally and other growth markets.

The Made in India Philips Intuis, with its state-of- the-art live image guidance technology will open up new possibilities in interventional procedures in India and empower interventional cardiologists and vascular specialists to decide, guide and confirm theright therapy for their patients in real-time.

It is a clinically versatile midtier cathlab designed to meet the challenges of diagnosing and treating most prevalent cardiovascular diseases. The system is designed to perform a wide variety of diagnostic and interventional procedures, including cardiac, vascular, and EP interventions, as well as a biopsy, drainage, and vertebroplasty procedures.

With a focus on patient care, the Philips Intuis comes with exclusive BodyGuard patient protection mechanism which uses capacitative sensing to enhance safety. To reduce X-ray dose, Philips SpectraBeam technology filters out soft radiation at the Xray tube level.

Product features/details ◗ Live image guidance ✚ It enhances patient care by intelligent and intuitive integration of live imaging, optimisation and real time therapy guidance ◗ Advanced 15 inch flat detector ✚ This technology brings the new frontiers of diagnostic imaging within reach of increasing numbers of cardiac care providers. ✚ It produces wider anatomical

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coverage with excellent image quality ✚ By reducing the number of extra imaging runs, it saves on dose and enhance procedure times ◗ Clinically versatile ✚ Cardiac - Carry out evidencebased decision making with the optional Quantitative Coronary Analysis ✚ Electrophysiology Procedures (EP Procedures) - High performance tube with heat exchanger supports longer procedure times ✚ Vascular procedures - The Digital Subtraction Angiography (DSA) can subtract bone information to obtain excellent information about vasculatu ◗ Remote diagnostic capability ✚ Intuis can be remotely monitored by Philips team, ensuring high uptime of the system and preventive maintenance especially in tier-II and III cities. ◗ Philips DoseWise Philosophy ✚ A set of techniques, programs, and practices that support excellent image quality, while protecting people in Xray environments

Other specifications ◗ High performance and throu ghput with powerful X-ray generator and high capacity heat exchanger X-ray tube ◗ Excellent viewing with 19 inch medical grade monochrome monitors for high contrast and brightness ◗ Quickly export clinical images to third party PACS via the DICOM image interface ◗ Monitor Ceiling Suspension easily integrate monitors into the procedure room ◗ Monitors can be freely rotated and positioned in a concave set-up at a comfortable viewing angle The all new compact Philips Intuis offers ample space in the procedure room. Its small footprint can easily fit in small procedure rooms, thereby reducing the need and expense of specialised room modifications.

BENEFITS FOR DOCTORS Offers head-to-toe imaging which allows patient access from all sides ✚ Comfortable viewing angle ✚ Enhanced procedure time ✚ Fast and accurate diagnosis ✚ Efficient clinical work flow ✚ East access to patient data and demographics

BENEFITS FOR PATIENTS

✚

Low dose of radiation Impeccable diagnosis ✚ Fast cardiac care ✚ Reduces patient wait time ✚ ✚

Sanrad Medical Systems

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