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Strategy The Great Indian Healthcare Factories: III Operation Smile Knowledge Battling cervical cancer: Early diagnosis is the key Life A doctor by heart; a friend by nature


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INSIGHT INTO THE BUSINESS OF HEALTHCARE

VOL 7. NO 4, APRIL 2013

Chairman of the Board Viveck Goenka Editor

Market

Strategy

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

Connecting healthcare and finance ....34 Pentavalent vaccine: Doing more harm than good? ..............................35

MARKETING Deputy General Manager

Knowledge

Harit Mohanty Senior Manager Tushar Kanchan Assistant Manager Kunal Gaurav PRODUCTION General Manager B R Tipnis Production Manager

Customised patient instrumentation for total knee replacement ......................38 India lags behind neighbours on key measures of health ....................39

Bhadresh Valia Asst. Manager - Scheduling & Coordination Arvind Mane Photo Editor

Radiology

Sandeep Patil DESIGN Asst Art Director Surajit Patro Chief Designer

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Pravin Temble Senior Graphic Designer Rushikesh Konka

Union Budget 2013 – Implications for healthcare sector ................................14

Layout

'We would like to have 250,000 registered donors in India' ............................16

Vivek Chitrakar

MIMS gets NABH reaccredited ......................................................................17

EOS imaging receives FDA Clearance for 3D Imaging Software ............43

Strathclyde research to improve prostate cancer care ....................................18 CIRCULATION Circulation Team Mohan Varadkar

North India’s first multiple sclerosis treatment centre at VIMHANS ..............19 Narayana Nethralaya opens Dry Eye Lab ......................................................20 Ketogenic diet comes to the rescue of intractable epilepsy..............................22

Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045

Life

Life

Printed for the proprietors, The Indian Express Limited by Ms. Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and

Arts & Commerce of Hospital Management........................47

Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021. (Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021)

A doctor by heart; a friend by nature ....44

*Responsible for selection of news under the PRB Act. Copyright @ 2011 The Indian Express 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.

APRIL 2013

Regulars Letters ............................................................................................................................................................8 People...........................................................................................................................................................46 www.expresshealthcare.in

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Editorial

Healing India's healthcare system nother budget goes by without anything substantial for the healthcare sector. While our cover story in this issue, '(Was the budget anti-climactic?; page 9) analyses the few high notes and the many missed opportunities in this year's budget, the recent uproar over babies with congenital heart defects dying while waiting for open heart surgeries at Mumbai's King Edward Memorial (KEM) Hospital only underlines the deepening malaise of India's healthcare system. To add insult to injury, KEM is being run by reportedly the country's richest municipal body, the Brihanmumbai Municipal Corporation (BMC). They have funds to buy the heart-lung machine vital for such surgeries, but a 2009 proposal to buy a new one remains mired in red tape. It was left to the private sector to step in. Dr Devi Shetty, who has 30-odd heart-lung machines across Narayana Hrudayalaya, offered to conduct 100 surgeries per month and clear the wait-listed cases at KEM. Jolted into action, the BMC authorities went into a huddle with four corporate hospitals, asking them to operate on 200-odd cases on the list in a month. The BMC has promised to not only foot the bill for the surgeries but the post operative care as well. In fact, this could very well be the way forward: a coupling of the complimentary strengths of the private and public sectors. Policy experts are wondering how to apply this logic to multi drug resistant tuberculosis (MDR TB). India is one of four nations (the other three are China, Russia and South Africa), with the highest burden of MDR TB. Inspite of the government's Revised National Tuberculosis Control Programme (RNTCP) covering the whole nation and providing free medication to patients, incidence of MDR TB is rising. Thus there is no doubt that every part of the healthcare sector will have to take long term responsibility to tackle this threat. Perhaps the easy availability of medication is the reason why India has fallen into the MDR TB trap. Troubled by a cough, a patient in India would put off visiting a doctor because of the long queues. Either he will self-medicate or ask the friendly neighbourhood chemist for something for his persistent cough. When that fails to give him relief, he visits a private doctor, who prescribes more antibiotics. At each step, no one checks if the patient is completing his course of antibiotics and the TB could be developing into a more resistant strain so that by the time the patient is finally hospitalised, doctors have very few choices left. Policy makers are today appealing to private practitioners to follow RNTCP guidelines and notify them of suspected TB cases but doctors are torn between protecting the confidentiality of their patient and the greater public good. Of course, they also see this as government interference and do not want to be part of a system perceived as inefficient and cumbersome. Corporate hospitals too are wary of acknowledging that they treat TB patients because other patients might fear infection. Clearly, healing India's healthcare system will need us to apply both mind and heart to solve this riddle.

A A coupling of the complimentary strengths of the private and public sectors could be the way forward

Viveka Roychowdhury viveka.r@expressindia.com

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APRIL 2013


Letters REMOST INDIA’S FO

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ATI RE PUBLIC

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ENT SAFETY, INCREASE PATILITY OF CARE IMPROVE QUA

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Good article

Excellent effort

A very good article. I would like to see a feature on Obstetric ICUs, if possible. (Referring to the article from March 2013 issue, titled 'Prospering birthing centres')

Read your article in the March issue of Express Healthcare. Excellent effort. My compliments. (Referring to the article from March 2013 issue, titled 'Northern (R)evolution')

Shrutin Ulman Principal Scientist at Philips Research shrutin.ulman@philips.com

INSIGHT INTO THE BUSINESS OF HEALTHCARE

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APRIL 2013


UPFRONT UNITAID and TB Alliance collaborate against childhood TB

U

NITAID is funding a TB Alliance project to develop a correctly-dosed child-friendly first-line TB treatment which is expected to be available within three years. This work will also reportedly help speed the development of other regimens for children that are now in the pipeline. UNITAID and TB Alliance warn that in spite of an estimated 500,000 new annual cases of children with tuberculosis (TB), there are no appropriate medicines for them. With no alternatives available, treatment providers for children are forced to adapt medicines for adults as best they can, such as by cutting pills. This leads to improper treatment, treatment failure, spread of this highly-contagious disease, and conditions ripe for the development of drug-resistant strains of the bacteria which causes the disease. The new project by UNITAID and TB Alliance is a measure to counteract the situation, informed a release. “Despite the world’s capabilities to address this disease, paediatric tuberculosis has been ignored for far too long, resulting in a complete lack of appropriate medicines,” said Dr Denis Broun, Executive Director of UNITAID. “This project is designed to spur innovation so that the right kinds of treatments are available as quickly as possible and at affordable prices,” he added. “Developing treatments for children with TB is an urgent humanitarian imperative,” said Dr Mel Spigelman, President & CEO of TB Alliance. “An appropriate formulation for the decadesold drugs is not even available. We need to immediately rectify the situation for the present drugs, and also ensure that the improved treatments in the pipeline will be developed for children soon after they are approved for adults.” In 2010, the World Health Organization released new guidelines for paediatric medications. However, to date, no quality-assured products have been produced to these specifications.

Market Union Budget 2013 – Implications for healthcare sector Amit Mookim, Partner- Healthcare, KPMG in India gives his take on the Union Budget 2013 and analyses its implications and impact on the healthcare sector

'We would like to have 250,000 registered donors in India' Raghu Rajagopal, CEO, DATRI

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EH News Bureau APRIL 2013

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t is that time of the year again when the healthcare industry is left disappointed. Requests and hopes are silenced as the Finance Minister reads out the current year’s allocations and plans. This year, the experts were unanimous in pointing out that the budgetary allocation to health was abysmal and the budget included few concrete measures to improve health in the country. Access to healthcare is critical to improving health status and good health is necessary for empowering the economy drivers of any country. We all know that our medical decisions should be made by certified medical practitioners/specialists with their patients and patients’ families' consent. However, it is not as simple as we are forced to consider many more factors before we make those decisions. Unfortunate our medical decisions are also influenced by finances, insurance companies, religion, access to care, and especially in an election year, politics. Throughout the world, governments have had a significant role in providing and regulating health services and their role is particu-

I

Although the increase in allocation for healthcare is a positive move, it is certainly not enough. For the sector to make significant strides, a minimum allocation of four to five per cent of GDP is necessary Ameera Shah MD & CEO, METROPOLIS HEALTHCARE

The fact is that there are large unspent budgets in the previous years and therefore the focus now needs to be on enhancing the capacity of the government to improve the utilisation of the funds made available Charu Sehgal SENIOR DIRECTOR, CONSULTING, STRATEGY & OPERATIONS, DELOITTE TOUCHE TOHMATSU INDIA

larly important in developing countries with large concentration of poor. The health sector challenges in India, like those in other low- and middle-income

I

t is becoming increasingly evident that any nation aspiring to be at the forefront of the modern world needs to provide access to quality healthcare to all its citizens.This laudable objective would encompass three broad segments: 1) ensuring access to care for the elderly and thus in a philosophical sense recompensing the past 2) strengthening our present through programmes targeting the adult population and 3) securing the future though programmes aimed at children (reducing infant and maternal mortality rates) The 2013 budget has come out as a step in the right direction for achieving such universal health coverage in the country by increasing funds for healthcare setups such as the six ‘AIIMS like’ institutions (Rs 1650 crores). It has also uplifted the geriatric segment with the Rs 150 crore National Programme for the Gautam Khanna Health Care of Elderly. Investing in education and research to CHAIR, FICCI MEDICAL DEVICES FORUM & EXECUTIVE DIRECTORensure a continuous stream of medical professionals as well as HEALTHCARE BUSINESS, 3M INDIA innovation in healthcare will form the foundation for better patient outcomes in the long run. Some short term relief has been granted to a section of the society with RSBY being extended to more categories like sanitary workers, mine workers, taxi drivers, etc. However, some more hard hitting reforms that would have impacted the society at large would definitely have placed the nation on a much stronger footing in this vital sector. The people of India need better accessibility, affordability and quality of healthcare. Accessibility to healthcare is a major concern in rural India and needs to be addressed to curb issues such as infant and maternal mortality. Investment in primary health centres across rural India which are electronically connected with metro cities can make a difference here. Secondly, affordability – India has one of the largest out of pocket expenses in healthcare – innovative models around financing and insurance are the need of the hour. And finally quality – As I said, healthcare as a field is continuously advancing. Almost every day there are better treatments that are discovered for better patient outcomes.There should be sharing of best practices across healthcare providers, as well as incentives for healthcare product companies to transform healthcare practices through continuous medical education programmes targeted at users. There is a dire need for regulation of medical devices and standards of quality across the country which will enable the people to make an informed choice. By framing political agendas around these concerns, parties will be able to address needs of the citizens more effectively, and ensure better healthcare and better quality of life for all strata of society. Ultimately, isn’t better politics about building a better society?

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countries, are formidable. India is home to 16.5 per cent of the world’s population and at any point of time it is estimated that there are over two million people with incurable and other chronic diseases. "The overall priority accorded to healthcare in India is much less as compared to, say a country like US, where healthcare is an important political agenda. No one in India contests elections with healthcare as a propaganda. Understandably, since health is not a priority for developing nations. It is a failure to recognise health as an integral constituent of overall socio-economic development. The Union Budget is a reflection of this fact, with very few words on healthcare and even lesser resource allocation, laments Ameera Shah, MD & CEO, Metropolis Healthcare, Mumbai.

Allocation for healthcare It is widely acknowledged that the health and well-being of a country’s human resource is linked to its economic progress and productivity. Yet, public spending on medical, public health, and family welfare in India is much below what is required. In 2011, the government spent a miserable one per cent of its GDP on healthcare but last year’s

budget promised to hike it up to 2.5 per cent. This year, the Finance Minister P Chidambaram earmarked Rs 37,330 crore for the healthcare sector in the next financial year 201314 budget, up from Rs 30,702 crore in the current fiscal, thus a rise of 22 per cent in allocation. “Of this, the new National Health Mission that combines the rural mission and the proposed urban mission will get Rs 21239 crore [Rs 212,390 million],” Chidambaram said. Although, the industry welcomed the increases budgetary allocation to healthcare, they said it was still not enough to bring about any drastic changes. “Although the increase in allocation for healthcare is a positive move, it is certainly not enough. As I had mentioned earlier, for the sector to make significant strides, a minimum allocation of four to five per cent of GDP is necessary,” said Shah. "While it is encouraging to see the increased outlays, the fact is that there are large unspent budgets in the previous years and therefore the focus now needs to be on enhancing the capacity of the government to improve the utilisation of the funds made available," added Charu Sehgal, Senior Director, APRIL 2013


M|A|R|K|E|T

Consulting, Strategy and Operations, Deloitte Touche Tohmatsu India.

Assuming perfect substitution between private and public spending, this increased budget outlay should reduce the out-of-pocket expenditure by around 10 per cent

More for National Health Mission However, in his budget speech, Finance Minister, P Chidambaram, reiterated that health for all and education will remain the government’s priorities. The government is aware that it has a long way to go to reach its goals relating to investments in health. Recently, President, Pranab Mukherjee had said that the country needed ‘out of the box’ reforms to take medical services closer to people’s homes. Incidentally, the outlay for the National Health Mission (NHM), which will now include the Rural and Urban health missions, has been increased by 24 per cent over the realised expenditure of the current year. This has been welcomed by the industry. This is mainly focussed towards the rural and underprivileged sections of the population as 70 per cent of healthcare spending in India is out of pocket and a leading cause of debt and poverty in India. It is estimated that 64 per cent of the poorest population in India become indebted every year to pay for the medical care they need. The National Rural Health Mission (NRHM) was a rural health initiative started in 2005, to alleviate the healthcare woes of rural India. It was centred on 264 backwards districts which the government picked to improve the healthcare facilities in these places with a more pragmatic approach. This involved training locals as Accredited Social Health Activists (ASHA) and various indicators suggest that it has worked to a certain extent. Last year, the NRHM was allocated Rs 20,822 crores (increased from Rs 18,115 crores in 2011). Like the NRHM, the Rashtriya Swasthya Bima Yojana (RSBY) is mainly for the poor who can’t afford health insurance. It is a smart-card based insurance scheme for every below-poverty line (BPL) family, which allows them to get inpatient treatment up to Rs 30,000 per year. The scheme will cover the main bread earner, their spouse and three dependents. In 2012, the RSBY was allocated Rs 1097.6 crore. Explaining the impact of the increased layout on NHM, Sarang Deo, Assistant APRIL 2013

Sarang Deo ASSISTANT PROFESSOR OF OPERATIONS MANAGEMENT, THE INDIAN SCHOOL OF BUSINESS (ISB), HYDERABAD

Professor of Operations Management, The Indian School of Business (ISB), Hyderabad says, "Let's think of an ideal scenario to estimate the potential impact of this increased expenditure on the most important stakeholder: the patients. First, we need to remember that public spending accounts for roughly 30 per cent of the total healthcare expenditure in India, which is very low compared to other BRIC countries, and even our

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south Asian neighbours." "Assuming perfect substitution between private and public spending, this increased budget outlay should reduce the outof-pocket expenditure by around 10 per cent. This is quite significant given that about five per cent of the total household expenditure is healthcare related. It is even more significant if one were to consider the rural and urban poor, who are the main targeted beneficiaries of the national health mission. Thus, in effect, increased budget outlay should act as a subsidy to these households. In fact, the picture could be rosier considering that the cost of public provision of healthcare is much lower than that in the private sector," he further adds.

It is good to note that the budget has considered the ‘Healthcare of Elderly’ by allocating Rs 150 crore for the programme for eight regional geriatric centres, although the allocation could have been better Dr Sujit Chatterjee CEO, DR LH HIRANANDANI HOSPITAL

FM should have made provisions for incentivising the healthcare providers to create enhanced access in the Tier-II/Tier-III areas as well as in super-speciality areas like cancer care

Education and research The most positive part of this budget was when the FM announced increased outlay for medical research and education. "The added outlay of around Rs 4700 crore on medical education and research is welcome, although we need a much higher investment if we are to meet the huge demand supply gap," said Sehgal. Last year Rs 1124 crores were given to AIIMS, and six new AIIMS-like institutions were also set up which became functional from September 2012. They were given an allocation of Rs 1,670 crores. Also the FM promised that the hospitals attached to the aforementioned colleges would be functional in the current academic year. "We are currently short of nearly one million doctors and two million nurses. The private sector’s suggestion to ease the norms for setting up private medical colleges should also have been considered and can go a long way in bridging this gap and leveraging private investment in this important area," said Sehgal. Another positive was the allocation for elderly. "It is good to note that the budget has considered the ‘Healthcare of Elderly’ by allocating Rs 150 crore for the programme for eight regional geriatric centres, although the allocation could have been better," said Dr Sujit Chatterjee, CEO, Dr LH Hiranandani Hospital, Mumbai. Agreeing with him, Sehgal said, "For the first time, there is a

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Pradeep Jaisingh CEO & MD, INTERNATIONAL ONCOLOGY SERVICES

It is disappointing to see no budget incentives extended to the fledgling primary healthcare private industry, given that the HLEG, appointed by GOI, has recommended that as much as 70 per cent of the total healthcare budget needs to be reserved for primary care Dr Santanu Chattopadhyay FOUNDER & CEO, NATIONWIDE PRIMARY HEALTHCARE SERVICES

focus on the elderly, who due to a higher disease burden coupled with the absence of healthcare financing options are the worst sufferers. The setting up of eight regional geriatric centres is a good start, but this will need to be increased significantly since the number of elderly in India is expected to almost double in the next 20 years." Presenting a different angle to the problem, Dr Santanu Chattopadhyay, Founder & CEO, NationWide Primary Healthcare Services, Bangalore said, "There is a crushing need for increasing the number of post-graduate training seats in family medicine and geriatric care. Without this in place, the Rs 150 crores being allocated to National Programme for Healthcare of the Elderly

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will just get wasted, with no skilled physicians to run the proposed regional geriatric centres.” The industry leaders also expressed concerns on the absence of funds for the Reproductive and Child Health Project, Pulse Polio Immunisation and routine immunisation, National TB Control Programme and National Disease Control Programme. Crucial health issues such as infectious diseases, trauma care and primary healthcare are not even mentioned in the budget. “It is disappointing to see no supportive budget incentives extended to the fledgling primary healthcare private industry, given that the high-level expert group (HLEG) appointed by the Government of India, in its recent report, has recom-

mended that as much as 70 per cent of the total healthcare budget needs to be reserved for primary care,” said Chattopadhyay.

Other neglected aspects The demand for increase tax holidays for hospitals and other medical institutions is still not fulfilled. A tax holiday means that for a said period of time an entity will be exempted from paying taxes. This is particularly important for hospitals as they have huge investments and a very long gestation period. Insiders feel that the tax holiday period should be increased to 10 years instead of the current five. If allowed it will encourage more entrepreneurs to invest in hospitals and India will see a surge in the number of

APRIL 2013


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hospitals providing specialised care. "FM should have made provisions for incentivising the healthcare providers to create enhanced access in the Tier-II/Tier-III areas as well as in super-speciality areas like cancer care. There should be government support for private players setting up cancer centres in the under-served regions of India," said Pradeep Jaisingh, CEO & MD, International Oncology Services. Another area of concern is the excise duty on medical equipment and consumables. Medical professionals feel that the duty levied on medical equipment should be reduced to help bring down treatment costs, particularly of equipment that are not manufactured in India. There was no change in the excise duty levied on medical equipment this fiscal.

Increased surcharge on profits The government has increased surcharges on profits before tax from five per cent to 10 per cent, which will raise the costs of providing healthcare for hospitals and doctors who practise independently. "The increase in surcharge from five to 10 per cent and increase in royalty rates of tax from 10 to 25 per cent (subject to double tax treaty relief) will impact the sector

Medical professionals feel that the duty levied on medical equipment should be reduced to help bring down treatment costs

negatively," says Hitesh Sharma, Partner & National Leader - Life Sciences, Ernst & Young. "Most demands of the sector like tax holiday period increase for healthcare, GST roll out, service tax exemption for clinical trials activity, etc. have not been addressed in the budget," he added. "One would have wanted to see some policy measures that could have enhanced the absorptive capacity of the sector to

utilise this additional expenditure. Else, we might end this financial year with a revised estimate that is an even smaller fraction of the budgeted expenditure," concludes Deo. With some positives and some not-sopositive recommendations the budget this year has received a mixed reaction from the industry. Only time will tell if all the allocated money will be utilised as intended. mneelam.kachhap@expressindia.com

Infrastructure status By far this has been the major bone of contention for the industry. The industry has been campaigning for ‘infrastructure status’ for more than a decade without success. Experts believe that infrastructure status makes it easier for that particular sector to grow because it gets a lot of government subsidies. Currently, sectors like construction, electricity generation, transmission and distribution, gas generation and distribution through pipes, water works and supply, non-conventional energy generation and distribution, railway tracks, signalling system and stations, roads and bridges, runaways and other airport facilities, telephone lines and telecommunications network, waterways, canal networks for irrigation and sanitation and sewerage, etc., have received infrastructure status. This allows them to pay lower interest rates on loans, pay lesser taxes and increased funds for setting up projects. Infrastructure status would allow people to set up more hospitals and labs, hire more doctors and also allow foreign direct investment (FDI) in healthcare. It would also ease up the process of setting up standard medical education and increase public-private partnership (PPP) in the healthcare sector. However, this seems like a distant dream for the healthcare sector in India. APRIL 2013

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Union Budget 2013 – Implications for healthcare sector Amit Mookim, Partner- Healthcare, KPMG in India gives his take on the Union Budget 2013 and analyses its implications and impact on the healthcare sector he Indian healthcare industry is witnessing growth at a rapid pace and it is expected that the sector will touch $280 billion by 2020. The hospital services market is expected to be worth $81.2 billion by 2015. The major factors driving the growth in the sector are increasing population, growing lifestyle related health issues, easier accessibility to healthcare, thrust in medical tourism, improving health insurance penetration, rise in middle income group population, increased disposable income, government social sector initiatives on penetration of health insurance and focus on public private partnership (PPP) models. As the Indian healthcare industry has been displaying strong growth prospects and in view of the prevalent optimistic atmosphere, many foreign companies have been displaying eagerness for investment/setting up their base in India and looking to have an access to the untapped market in Tier-II and Tier-III cities. During the period April 2000 to June 2012, the foreign direct investment (FDI) in hospitals and diagnostic centres is $1395.82 million, medical and surgical appliances is $523.54 million and drugs and pharmaceuticals is $9,659.26 million.

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AMIT MOOKIM Partner-Healthcare, KPMG

Policy initiatives

The year that went by – A quick glimpse ●

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India’s gross domestic product (GDP) growth for 2012-13 was projected at around 7.6 per cent; however, the actual GDP growth estimate is only five per cent. At the same time, the expenditure on health has been increased from 1.27 per cent of GDP in 2007-08 to 1.36 per cent of GDP in 2012-13. The demand for hospital beds in India is expected to be around 2.8 million by 2014 to match the global average of three beds per 1000 population from the present 0.7 beds. India needs 100,000 beds each year for the next 20 years. The Government of India (GOI) has launched a large number of programmes and schemes to address the major concerns and bridge the gaps

out for a brand. During the year, the PE investors have invested $520 million into India’s basic healthcare industry and there is a prediction that PE investments will surpass $1 billion in 2013. The Parliamentary Standing Committee on Health and Family Welfare tabled a report in the Parliament on May 8, 2012 on the functioning of the Central Drugs Standard Control Organization (CDSCO). CDSCO is the agency mandated with the regulation of drugs and cosmetics in India. The report covers various aspects of drug regulation including organisational structure and strength of CDSCO, approval of new drugs, and banning of drugs, among others. Subsequent to submission of the report, the Ministry of Health and Family Welfare has constituted a committee to verify the procedure of drug regulation.

in existing health infrastructure and provide accessible, affordable, equitable healthcare. During the period from April 2000 to November 2012, the share of hospital and diagnostic centres in cumulative FDI equity inflows amounts to 0.82 per cent. The GOI has introduced a new medical visa category for the foreign tourists coming to India for medical treatment. The GOI has also formulated guidelines to address various issues governing wellness centres, covering the entire spectrum of the Indian systems of medicine. Research & Development (R&D) occupies the second position in India’s GDP with consistently high growth at near 20 per cent in the last few years. The GOI has also stressed the need to enunciate a policy for synergising science, technology and innovation and has also established the National Innovation Council. The GOI has announced the www.expresshealthcare.in

Science, Technology and Innovation Policy 2013 and has proposed to increase the gross expenditure on research and development to two per cent of GDP from the current level of less than one per cent. As the Indian healthcare industry has been displaying strong growth prospects, many foreign players are eager to make investments in India. The private equity (PE) firms have made three major investments in the healthcare sector during the calendar year ending December 31, 2012. During the year, the PE investments have made investment of $100 million in the hospitals and clinics sector. The healthcare and life sciences industry attracted $581 million across 14 investments made by the PE investors. The PE investors have quadrupled their investment in India’s primary healthcare, betting the sick and ailing will stop approaching family doctors as the migrants in cities look

Insurance Regulatory and Development Authority (IRDA) expands definition of ‘infrastructure facility’ ● IRDA has expanded the definition of 'infrastructure facility' under its Registration of Indian Insurance Companies Regulations. In a gazette notification, the insurance regulator passed an amendment to the regulation wherein the term 'infrastructure facility' will be replaced by 'harmonised master list of infrastructure sub-sectors', as specified by the Department of Economic Affairs, Ministry of Finance in March 2012. This aforesaid amendment has expanded the investment horizon of insurance companies and will enable them to invest in new categories of infrastructure including the hospitals and diagnostic centres, since the definition has been expanded.

Policy measures in the Budget speech by Finance Minister ●

Recognising the importance of the healthcare APRIL 2013


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sector, the Government has allocated Rs 3,73,300 million to the Ministry of Health & Family Welfare as well as Rs 2,12,390 million to the New National Health Mission. Education in health remains a priority and the Government has allocated Rs 16,500 million to AIIMS-like institutions and Rs 47,270 million for medical education, research and training. Additionally, given the landscape of talent availability in medical profession in India, the Government plans to make Ayurveda, Unani, Siddha and Homeopathy (AYUSH) practitioners mainstream and the Budget 2013 proposed to allocate Rs 10,690 million for the same. An allocation of Rs 6,58,670 million is made to the Ministry of Human Resource Development, which is an increase of 17 per cent over the revised estimates of the current year. The National Programme for the Health Care of elderly is being implemented in 100 selected districts of 21 states. The Budget 2013 proposes to provide Rs 1,500 million for this programme. The Budget 2013 proposes to allocate a sum of Rs 1,100 million to the Department of Disability Affairs for the assistance of disabled persons scheme in 2013-14 as against the revised expenditure of Rs 750 million in the current year.

models to help improve infrastructure and healthcare provision. The National Rural Health Mission (NRHM’s) allocation has been increased to $3.82 billion in 2012-13 from $3.32 billion in 2011-12. Under NRHM, over 1.4 lakhs health human resources have been added to the health system across the country upto September 2012 and 10,473 sub-centres, 714

primary health centres (PHC’s), 245 community health centres (CHCs) have been newly constructed. The total plan outlay for the year 2012-13 under the NRHM, is Rs 2,05,420 million and Rs 27,127 million for schemes/projects in the north eastern region and Sikkim. The Indian system of medicines is also being developed and promoted by integration of AYUSH

in national healthcare delivery through an allocation of Rs 9,900 million plan outlays in 2012-13.

Tax proposals for healthcare sector ●

No change in corporate tax rate. However, increase in surcharge from five per cent to 10 per cent on domestic companies (e.g. shipping agency companies, other domestic companies incorporated in India)

and from two per cent to five per cent on foreign companies where taxable income exceeds Rs 10 crores. Also, surcharge increased from five per cent to 10 per cent on Dividend Distribution Tax (DDT). Direct Taxes Code (DTC) Bill is intended to be introduced at the end of budget session after considering recommendations of Standing Committee.

Government initiatives ●

The government is taking numerous measures to encourage investments in the sector. There has been a focussed approach to increase supply of all healthcare professionals, strengthen primary healthcare delivery by incentivising government health workers and to increase health insurance coverage among the lower socio-economic population. In addition to these, some initiatives by the government have been taken, primarily to support private sector participation. There is a growing appreciation for the role that the private involvement may have in meeting public demand, and government are considering the use of PPP

APRIL 2013

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Provisions of General Anti Avoidance Rule to be applicable from AY 201617. TDS on royalty and fees for technical services income payable to nonresident increased from 10 per cent to 25 per cent. However, the tax rate in case of treaty shall prevail wherever applicable. In context of Healthcare sector, this may have huge tax implications in respect of payments for brand, hire charges for equipments etc. especially to non-treaty entities, e.g. Hong Kong. Tax to be deducted at source at one per cent on the value of the transfer of immovable properties

where consideration exceeds Rs 0.5 million. Extension of concessional tax rate at 15 per cent on dividend received by Indian Company from foreign company for AY 2013-14. Further, no DDT shall be payable by Indian holding company to the extent of dividend income received from its foreign subsidiary. This would be beneficial in respect of outbound investments where dividend is receivable from foreign subsidiaries. Profits distributed by unlisted companies to shareholders through buyback of shares shall be subject to final taxes

(similar to DDT) at 20 per cent payable by the Company. The income arising to shareholders shall be exempt. Progress in Goods and Service Tax (GST) legislation introduction with consensus reached between Central and State Governments for drafting Constitutional amendment Bill and respective State GST Bill to be placed before the parliament in few months. MRP-based assessment in respect of branded medicaments of AYUSH and bio-chemic systems of medicine to reduce valuation disputes under Excise Regulations.

Conclusion In light of the strong growth prospects of the Indian healthcare industry and the foreign players displaying eagerness for investment and setting up their base in India, the Government of India and the Ministry of Finance have allocated a substantial amount for health sector. However, certain other expectations of the industry such as granting ‘infrastructure status’ to the sector, extensions of tax incentives for setting-up hospitals in Tier II and Tier III towns of India, etc. have not been met. The Budget thus falls short of direct tax clarifications on the issues faced by the healthcare sector.

30 MINUTE INTERVIEW

'We would like to have 250,000 registered donors in India' Raghu Rajagopal, CEO, DATRI

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n India, bone marrow transplantation (BMT) is being used to treat various disorders like blood and lymphatic system cancers which includes leukaemias such as acute lymphocytic anaemia (ALL), chronic lymphocytic anaemia; acute myelogenous anaemia (AML), and chronic myelogenous anaemia (CML); Hodgkin’s and non-Hodgkin lymphomas and multiple myeloma. It is also used for the treatment of thalassemia and bone marrow dysplasia. The number of patients diagnosed with these disorders have increased in the past decade and so have BMTs. Bone marrow, like other organs, has to be donated either by a sibling, where the human leukocyte antigen (HLA) is a match or an unrelated donor having a matching HLA. Countries around the world have donor registries to help facilitate unrelated BMTs. Currently, there are two bone marrow registries in India, DATRI and Marrow Donor Registry India (MDRI). M Neelam Kachhap spoke to Raghu Rajagopal, CEO, DATRI to know more about their work. When was the organisation formed, and with how much capital? DATRI, a non-governmen-

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tal organisation was set up in the year 2009 in Chennai, with an aim to save lives of people with Indian origin who are suffering from life threatening diseases like leukaemia, lymphoma, etc., anywhere across the globe, through peripheral blood stem cell transplant (PBSC), by maintaining a donors’ registry and doing the matching of the genetic typing of the patient with that of the available donor. Who are the investors? DATRI is an NGO, cofounded by me, Dr Nezih Cereb and Dr Soo Young Yang. I am is the CEO of DATRI and all of us are the directors.The organisation has been supported largely by histogenetics and with the help of contributions from patients, their relatives and CSR of organisations. What is the mission of the organisation, and what are its functional areas? DATRI is striving to reach out and create awareness about the concept of blood stem cell transplantation and its credits, among the general public, physicians and GPs, college students and the government, for society’s benefit. It is also making constant efforts to increase the registered Donors’ database. www.expresshealthcare.in

Which hospitals in India have you tied-up with? DATRI has tied-up with six hospitals across India – Apollo Hospital (Chennai), Narayana Hrudayalaya (Bangalore), Dr BL Kapoor Memorial Hospital (NCR), Indo American Cancer Institute & Research Hospital (Hyderabad), Hiranandani Hospital (Mumbai) and Tata Medical Centre (Kolkata) What are your immediate goals for the organisation? The organisation mainly seeks for the awareness among the public, so that people become aware on the less painful option of treating these life-threatening diseases. The immediate goal would be increasing the number of registered donors. Where do you see your company five years from now? We would like to see awareness increase in every city of India. We would like to have 250,000 registered donors in India. It is mentioned in your profile that you have 29,000 registered donors. Are they from India? Yes. The donors are from India. We just concluded a donor drive in Dubai for Indians residing there to

become part of the registry. What protocols do you follow in donor registration and HLA typing and donor data security? We follow the guidelines of World Marrow Donor Association (WMDA) guidelines to operate the registry. Is this data in public domain? The HLA data alone (not the donor information) is available in Bone Marrow Donor Worldwide (BMDW) for allowing registered physicians all over the world to search for a donor anywhere in the world. Which lab are you associated with? Is it in India? Histogenetics in the US. Is DATRI complying with the ethical and policy guidelines for stem cell transplantation? Yes, we follow the guidelines defined by WMDA. Are you associated with any academic centres? Do you participate in stem cell research? We are registered with Bone Marrow Donor Worldwide (BMDW) and we are a member of World Marrow Donor Association (WMDA). mneelam.kachhap@expressindia.com APRIL 2013


Expansion

M|A|R|K|E|T ACCREDITATION

MIMS gets NABH reaccredited KUL sets up Nova Hospital at Pune

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umar Urban Development Limited (KUL) has signed an agreement with Nova Hospital for a build-tosuit (BTS) project in Pune. Built at Rs 40 crores, the 40,215 sq ft property with ground plus four floors will be given to Nova on rent. Located at Sarasbaug and adjacent to Peshwe Park, the building has two basement levels. Announcing the development, Kruti Jain, Executive Director, KUL said, “We are pleased to build this property to cater to the increasing super specialty needs of Pune city and surroundings. We are sure this will prove to be a real boon for the people of Pune.” With this project, Nova would be offering super specialities like high end cosmetic and replacement surgeries, and breast clinic and pain management centres to Pune. The building will be handed over to Nova shortly and the hospital is expected to be fully operational over the next six months. It will cater to the needs of short-stay surgeries. Nova also plans to set up a Nova Specialty Surgery (NSS) centre as well as a Nova IVI Fertility (NIF) centre at Kidopia, Pune. Reportedly, the Nova Pune centre will have leading surgeons and IVF specialists across India on board. The Pune NSS centre will have 35 beds, five modular OTs, ICU, pre-operative and postoperative rooms, single, twin and deluxe suites, and include the latest in technology for high end surgeries. The Pune NIF centre will cater to the whole range of assisted reproductive services and will be equipped, inpatient and out-patient rooms, modular OT and the finest in IVF technology and equipment.

MIMS Board plans to invest Rs 300 crores in the next three years alabar Institute of Medical Sciences (MIMS), Calicut is reaccredited by NABH for a further period of three years i.e. from October 2012 to October 2015. MIMS is the first NABH accredited multispeciality hospital in India.

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The NABH Assessors reportedly mentioned during assessment that MIMS has the best emergency medicine department among the other leading Indian hospitals. “Quality is in the genes of MIMS,” said Dr Azad Moopen, Chairman, MIMS.

Dr Abdulla Cherayakkat, MD, MIMS said, “With this, Calicut will be known for quality healthcare.” The MIMS Board is planning to invest Rs 300 crores in the next three years. This shall be mainly deployed in the following: ● Women and Children

block at MIMS Calicut Expansion of MIMS Kottakkal with addition of 150 beds and introduction of new departments. New MIMS hospitals at Kannur and Palakkad in Kerala EH News Bureau

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Company Watch

Sleep Management Centre from Nova Specialty Surgery Nova Specialty Surgery has launched a Sleep Disorders Management Centre at its Tardeo facility in Mumbai in collaboration with Eurosleep, a network of ENT clinics from Norway to start this integrated centre. It will provide comprehensive treatment for sleep related disorders through screening, diagnosis, treatment and follow-up under one roof. “In India we lack a systematic approach to the management and diagnosis of sleep diseases. This Centre will allow all the 11 Nova centres across India to do an efficient assimilation of data to create better India-specific guidelines. Standardised management protocols with outcome reports will help us better understand this complex spectrum of diseases,” said Dr Ashim Desai, Sr Consultant, ENT Surgeon, Nova Specialty Surgery, Tardeo. A team of experts consisting of ENT surgeons, neurologists, psychologists, maxillo-facial surgeons and bariatric surgeons will be available for the complete management of sleep disorders at this centre. On the occasion, a day work-shop for ENT surgeons across the city was organised along with three live surgeries to showcase some of the innovative specialised procedures that will be offered at this centre. Speaking at the launch, Dr Mahesh Reddy, Executive Director of Nova Specialty Surgery said, “The Sleep Disorders Management Centre has been opened not only in Tardeo, Mumbai but across Nova centres including Delhi, Hyderabad, Bengaluru and Muscat. Our aim is to establish India’s first comprehensive integrated sleep disorder management centers to serves this unmet need in the Indian population.” EH News Bureau

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M|A|R|K|E|T RESEARCH

Strathclyde research to improve prostate cancer care Prostate cancer will be targeted by a drug developed by University of Strathclyde researchers he Strathclyde team – along with researchers from the Universities of Glasgow and Dundee – have received a share of £691,000 to search for answers to key questions surrounding prostate cancer, which is the most common cancer in men. Scottish institutions will receive three of the 17 grants that Prostate Cancer UK is awarding as part of the first wave of funding through the charity’s ambitious new MANifesto research strategy. The charity is injecting £11 million into research this year to focus on the key areas of understanding risk, improving diagnosis and refining treatment options for men living with the disease. Professor Simon Mackay, from the Strathclyde Institute

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of Pharmacy and Biomedical Science, has received £249,000 to develop a new ground-breaking drug to treat advanced prostate cancer. He said, "We have developed a new drug-like compound which could help improve life expectancy for men with advanced prostate cancer over and above the six months associated with the present 'gold standard' - chemotherapy drug, docetaxel. We are delighted that this new Prostate Cancer UK grant enables our researchers to continue to develop a new drug candidate ready for clinical trials, building on earlier funding from Cancer Research UK.” Professor Rob Mairs from the University of Glasgow’s Institute of Cancer Sciences, has received £205,000 to

improve radiation treatment by directly targeting prostate cancer cells. He said, “Although radiotherapy is widely used in the treatment of prostate cancer, damage to neighbouring tissues and organs limits the dose which patients can receive. With the support of key funding from Prostate Cancer UK, we will develop a more targeted approach to radiotherapy, which will offer a more effective treatment of prostate cancer which has spread to other areas of the body. This new treatment plan, which involves the use of a new ground-breaking drug, will help reduce the risk of normal tissue damage.” Ghulam Nabi, Senior Lecturer, Surgical Uro-oncology at University of Dundee has received £237,000 to

investigate whether new ultrasound techniques could be used to diagnose prostate cancer and identify whether it is aggressive or not. “Thanks to this grant from Prostate Cancer UK our researchers have the opportunity to trial new and innovative ultrasound techniques to better identify cancerous tissues in the prostate, as well as helping to better determine whether a tumour is aggressive or benign. We hope that as a result we will be able to help more men to be diagnosed faster and more accurately in the future.” All 17 of the projects to receive funding were chosen because of their extremely high quality and relevance to men with prostate cancer. EH News Bureau

INITIATIVE

Fortis Hospital launches kidney support group The support group to be a platform for kideny patients for sharing treatment and lifestyle experiences ortis Hospital, Mulund, Mumbai bought in World Kidney Day with the launch of the Fortis Kidney Support Group. The launch took place a day before World Kidney Day which is on March 14, 2013. The support group aims to help kidney ailment patients by providing a platform to share their treatment and lifestyle experiences, and learn from them. The Support Group will also have kidney experts from Fortis Hospital who will lead and support the group in managing their conditions and leading a healthy lifestyle, reported a release. The hospital informed that it is taking an initiative to provide certain benefits on consultations and investigations for the patients and thus encourage early diagnosis and evaluation. The group intends to bring together patients for moral support to each other and encourage participation in improving lives of these patients by various activities. It is expected to help patients and their families to share and care for each other. On the ocassion of the launch, as part of the Kidney Mela, an exhibition of 30 paintings of kidney patients was organised at the hospital premises. The paintings narrated the real-life aspirations of the talented patients currently undergoing kidney-related treatments. The paintings exhibition and the Kidney Mela were opened to the public by Varun Khanna, Regional Director (East & West), Fortis Healthcare, and Dr Haresh Dodeja, Consulting Nephrologist & Transplant Physician, Fortis Hospital,

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Varun Khanna and Dr Haresh Dodeja opened the painting exhibition and the Kidney Mela Mulund. The Kidney Mela saw stalls on kidney disease/ haemodialysis/peritoneal dialysis/diet/transplant/and a screening camp for patients, in addition to the painting exhibition. Khanna said, “At Fortis Hospitals, we strongly believe in our patients and the difficulties faced by them during treatment for which we go all out in extending the encouragement and support to them. The kidney mela and exhibition are such initiatives in this direction. The event is aimed at not only educating the public on various aspects of kidney health but also in helping the patients recover faster and lead a healthy life.” Dr S Narayani, Facility Director, Fortis Hospital, Mulund said, “Renal ailment is one such area where both the patients and their families face difficult times ahead. Through the Kidney Mela, exhibition and the support groups, we hope to increase awareness amongst the patients

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and give them a sense of assurance that such ailments are easily curable. The hospital, in their endeavour to promote early diagnosis and care for such patients, has committed to provide consultation and labs at a concessional rate. We at Fortis conduct more than a 1000 dialysis every month, and will increase our capacity by 40 per cent in April”. Dr Haresh Dodeja, Consulting Nephrologist, Fortis Hospital, Mulund said “The aim is to create awareness amongst the general population about kidney disease and for this we have asked our dialysis patients to share their experiences on kidney related diseases. Another idea of staging this mela is to distribute information on various aspects of kidney disease in a more informal way and through the paintings that these patients have created.” Elaborating on the nature of kidney ailments, Dr Dodeja said that more than 10 per cent of hospital admissions will have kidney disease, and in an intensive care unit, acute kidney injury will develop in more than 25- 50 per cent cases and most cases of infections may require dialysis as well.” At Fortis, there are renal cases, both mild and serious, in nature. Fortis Healthcare’s Centres of Excellence for Renal Sciences offer specialist medical and surgical treatments for andrological, urological, and nephrological conditions requiring dialysis and transplant services for both adults and children. EH News Bureau APRIL 2013


M|A|R|K|E|T HOSPI NEWS

Multiple sclerosis treatment centre launched at VIMHANS The facility allows up to seven medical specialists to attend to a patient at the same time for multi-disciplinary care ew Delhi’s first specialised multiple sclerosis (MS) treatment centre was inaugurated by the Delhi CM Sheila Dikshit at the Vidyasagar Institute of Mental Health, Neuro & Allied Sciences (VIMHANS). The MS center at VIMHANS would reportedly be North India’s first dedicated MS-care centre where patients will get comprehensive management by a team of experts, including neurologists, psychologists, psychiatrists, physical and occupational therapists, urologists, and radiologists, all under the same roof. Dikshit said, “This dedicated multiple sclerosis treatment centre will prove to be a milestone in the way MS is managed in India and would be a shining example of how the patients of MS should be cared for. The Delhi Government, on its part, will ensure that all help is extended to VIMHANS.” An MoU was also signed between VIMHANS and the Multiple Sclerosis Society of India (MSSI) for sharing of resources and supporting each other through dissemination of knowledge. Under this, MSSI will be able to utilise the healthcare facilities of VIMHANS while the hospital, on the other hand, will be able to get access to a diverse MS patient pool from across India. “The treatment and management of multiple sclerosis requires a multi-disciplinary approach and hence a centre like this which brings all the management together is extremely important,” said Dr Shamsher Dwivedee, Sr Consultant Neurologist, VIMHANS. “Until now, MS patients had to manage the disease through multiple doctor visits and counseling that lasted weeks. Now, the same can be completed in the span of a single day.” Bipasha Gupta, Spokesperson, MSSI, said, “MS care is grossly neglected in the country because of which the patients have to suffer even more. This new MS treatment centre at Delhi with its new concept will help accommodate seven medical professionals

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together at the same time to discuss the condition of the patient and find solutions. This will help the patient avoid a lot of hassles and save him the days wasted in

visiting different medical experts from different divisions of a hospital.” Dr Dwivedee said that because MS patients are sensitive to summer heat,

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VIMHANS will provide them with a free air-conditioned shuttle service to the hospital and offer discounted rates for various tests. The MS treatment centre will also

help gauge data on the number of multiple sclerosis patients who need special care in India. EH News Bureau

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Awards

STUDY

Transasia BioMedicals wins Global CSR Excellence and Leadership Award ransasia Bio-Medicals was conferred with the Global CSR Excellence and Leadership Award in the category of 'Innovation in Corporate Social Responsibilty Practices'. Dr Saugata

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Mitra, Chief People Officer & Group HR Head, Mother Dairy Fruit & Vegetable and Dr Sanjay Muthal, MD, Nugrid Consulting presented the award to G Jayaraman-Associate Vice President, HR, Admin & CSR, on behalf of Transasia. Transasia BioMedicals is a leading player in the Indian clinical diagnostic industry and has initiated a host of activities for the betterment of underprivileged children as part of its CSR. The various programmes, emphasising on the importance of education include study class programme, computer education, regular contests, counselling sessions and career guidance, educational assistance, excursions, programmes for teachers and medical camps. As of date, more than 850 children have reportedly benefitted from these programmes. Apart from these, the company also supports the Thalassemia Society in various regions. In the recent past it has supported Parent's Association Thalassemic Unit Trust in Mumbai and the Thalassemic Society of Pune and Delhi, informed a company release. EH News Bureau

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Delayed stenting can help some heart attack patients The study claims that no-reflow and thrombotic events were reduced with deferred stenting elaying putting a stent in patients who have suffered a ‘high risk’ heart attack could aid their recovery, new research has shown. The usual procedure in patients who have suffered a ST segment elevation myocardial infarction (STEMI) – the most serious type of heart attack – and who are at risk of ‘no reflow’ is to immediately insert a stent to reopen the blocked artery. However, a study by Professor Colin Berry and colleagues at the University of Glasgow and the Golden Jubilee National Hospital, presented to the American College of Cardiology (ACC) conference found deferring stenting in such cases was beneficial. A STEMI heart attack occurs when the coronary artery is totally blocked

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resulting in prolonged interruption to the blood supply if not treated promptly. ‘No-reflow’ is a phenomenon where, although blood flow through the blocked artery is restored, blood still cannot return to the oxygenstarved area of the heart. This is because the tiny vessels within the damaged muscle do not allow blood to flow. About 40 per cent of people who have had a STEMI heart attack are at risk of ‘no reflow’. The study, funded by the British Heart Foundation (BHF) and the Chief Scientist Office of NHS Scotland, involved 101 patients who had suffered a STEMI heart attack and were at high risk of ‘no reflow’. In one group of patients the researchers inserted a stent straight away, and in the other stenting was

delayed by up to 16 hours. This trial suggests that waiting for a period of time before putting in a stent in high-risk patients who have had a STEMI reduces the likelihood of ‘no-reflow’ and may improve clinical outcome. Professor Berry, of the Institute of Cardiovascular and Medical Sciences and Honorary Consultant Cardiologist at the Golden Jubilee National Hospital, said, “We are really excited about the potential clinical impact of our trial results. Our evidence suggests that no-reflow and thrombotic events were reduced with deferred stenting. “Deferred stenting means there is a period of time where a healing process of sorts can take place. Because a stent is placed around an area where there has been a

clot, if it is placed immediately some clot material can be dislodged which then cause a blockage in small blood vessels. When the stent placement is deferred, it is placed in better circumstances.“The safety and cost-effectiveness of deferred stenting in selected patients merits further assessment in a multicentre trial.” Professor Jeremy Pearson, Associate Medical Director at the BHF, said, “This is an interesting result suggesting that the outcome may be better for one group of patients who have had a major heart attack caused by a fully blocked artery if stenting is delayed. However, bigger trials with a lengthier follow-up of patients would be needed before there’s a change in clinical practice.” EH News Bureau

NEW LAUNCH

Narayana Nethralaya opens Dry Eye Lab Reportedly Asia's first dry eye lab, it will offer advanced diagnosis and treatment for the latest lifestyle disease through detailed diagnosis arayana Nethralaya, the Bangalore-based super speciality eye hospital has set up Asia’s first laboratory dedicated exclusively towards research, diagnosis and treatment of ‘dry eyes’, a lifestyle disease induced by long-term exposure to computers and also caused by systemic diseases, such as diabetes and arthritis. The evaporative dry eye condition is found commonly among people in the age group of 18-45 years while dryness is caused in the older age group because of systemic diseases. Long standing dryness causes ocular surface problems with chronic redness, irritation and finally causing damage to the stem cells of the eye. “At Narayana Nethralaya, we have set up a Dry Eye lab with advanced machines to study tears both for imaging and also to analyse the tears components. This helps us in understanding the pathology better. Patients with lid problems like meibomian gland

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dysfunction can undergo lid thermal pulsation therapy to open them and this will help to pump good quality lipids to tears. We have invested more than Rs 2.5 crore on this lab and it will benefit the population facing this particular problem,” said Dr Rohit Shetty, Vice Chairman, Narayana Nethralaya. A specialised department called Centre for Occupational Dry Eye (CODE), which explores all the problems of occupational dry eye in a professional way, is also part of the Dry Eye lab. “Though dry eyes can be cured through www.expresshealthcare.in

lubrication, improving lid hygiene and treatment of systemic diseases, we at Narayana Nethralaya present direct evaluation of tears called ‘lipiview’ and the same will assist us in offering customised treatment to the patients. We are the first hospital in Asia to offer this facility,” pointed out Dr Shetty. Tears in our eye consist of three layers, lipid, aqueous and mucin. When the lipid layer is absent, the condition is called evaporative dry eye. In systemic diseases like arthritis, production of tears is deficient in the aqueous layer.

In evaporative dry eyes, though tears are produced in good amount, the quality is low due to poor lipid content and tears dry fast. The symptoms of dry eye condition range from irritation, burning, rubbing of eyes, foreign body sensation, blurring of vision, tiredness, glare while driving, to the thickening of lids. The Dry Eye lab incorporates newer and advanced machines like Tear Science. The study of tears for Osmolarity and check for health of tears are also carried out. “Some patients need advanced Proteonomics to study the inflammatory mediators in tears. If patients are diagnosed with evaporative dry eye then they can undergo thermal lid compression treatment for 12 minutes, called ‘lipiflow’,” Dr Shetty said. In addition to treatment, the lab will enable Narayana Nethralaya to foster research into the rising incidences of dry eye condition among working professionals. EH News Bureau APRIL 2013


M|A|R|K|E|T NEW THERAPY

Ketogenic diet comes to the rescue of intractable epilepsy Cost-effective therapy holds abundant hope for epileptic patients Bangalore-headquartered British Biologicals has introduced Ketokid, a cost-effective therapy that holds abundant hope for epileptic patients. The company is the manufacturer of ketogenic diet, which is effective in reducing seizure frequency in children. Six-year-old Aditya Nadkarni of Mumbai was diagnosed with paediatric epilepsy within months of his birth. The boy’s parents admitted the child to Mumbai’s Hinduja Hospital and he was operated upon, but the disease raised its ugly head within months, affecting the child. His worried parents rushed back to the hospital for a course of ketogenic diet. By age three, the boy was like any other of his age — full of energy and free of all drugs albeit with some speech difficulties.

The Hinduja Hospital team headed by Dr Vrajesh Udani, who treated Aditya, says the ketogenic diet is effective in reducing seizure frequency in children. The programme, started in 1997, has seen the diet being administered to more than 130 children with good results. Some 60 per cent of the patients treated with the ketogenic diet were able to achieve 50 per cent or more reduction in seizure frequency. Of these, half had their fits reduced by more than 90 per cent. VS Reddy, Founder and Managing Director, British Biologicals says, “Ketokid helps epileptic patients lead a normal lifestyle. In fact, to this end, we offer free services of nutritionists and dieticians to all doctors and hospitals treating children through ketogenic diet.”

Leading paediatric neurosurgeon Dr Vykunta Raju KN, an assistant professor at Bangalore’s Indira Gandhi Institute of Child Health, says, “Ketogenic diet, which is recently brought out by British Biologicals as Ketokid, is useful in treating patients with refractory epilepsy. This diet helps in controlling seizures and allows many children to become both seizure-free and drug-free.” This view is endorsed by another leading paediatric neurosurgeon Dr Mahesh Kamate. He says: “Ketogenic diet is a safe and effective option in managing and treating epilepsy among infants and children. Even in ICU care, the ketogenic diet can be used to control refractory seizures. The diet is highly cost effective when compared with other anti-

epileptic drugs.” Ketokid works in the following ways: Ketogenic diet mimics starvation by producing ketosis; Then, ketosis is maintained through high fat, adequate protein and low carbohydrate diet; The degree of ketosis could be modified by adjusting the amount of fat; For instance, a 5:1 (fat:non-fat) diet will result in greater ketosis than a 2:1 diet. Ketogenic diet for treatment of epilepsy was revived by Dr H Keith from the Mayo Clinic and Dr Freeman from the John Hopkins Hospital. Since then, several centres all over the world have started using it and the British Biologicals is the first and the only Indian company to manufacture Ketokid based on ketogenic formula for the Indian market. EH News Bureau

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Healthcare IT India Summit The two day summit aims to enhance IT in Indian healthcare to tackle the challenges and optimise the opportunities in the sector he state of healthcare IT in India is a paradox. While India has state-ofthe-art hospitals of excellence, these are few and far between. Such hospitals are simply restricted to the urban elite and the well to do. India is in a position to offer state of the art healthcare, to those who come to us from other countries but is unable to do so for the millions of Indians living in suburban and rural India. Despite the apparent benefits, it is a matter of grave concern that the use of informatics in the healthcare industry is relatively less than in banking, commerce, travel, automobile or any other industry. The picture, however, is not totally bleak. It is reassuring to see that the central government and several state governments have accepted, integrating healthcare with Informatics as a means to provide healthcare. To understand the best viable progressive model for delivering medical care and expertise, the Healthcare IT India Summit will bring in the industry experts and regulators to discuss and present the scope for the healthcare informatics. The summit, hosted by Fleming Gulf Conferences, will be held at Hyderabad on

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the April 22-23, 2013. The delegates will also share their personal views which are backed with their credibility and exposure to the technological advancements. Dr Thanga Prabhu, General Electric (GE Healthcare IT), Indian Association for Medical Informatics, American Medical Informatics Association, Swansea University, UK, Clinical Director, EC Member, Member, International Ambassador, Adi Codaty, United Healthcare International, Vice President, Global Sites, Syam Adusumilli, United Health Group, VP - Consulting, Products and Solutions, Shri. Sampath Kumar, Sankara Nethralaya, Chief Information Officer, Devender Manral, Fortis Healthcare, Global Head – Information Technology Data Center & Infrastructure Management Services are some of the eminent speakers for the Healthcare IT Summit. Senior healthcare IT representatives from GMV and DELL will also be sharing their take on healthcare IT in India. The two day summit will witness talk given on intriguing subjects like, ‘Issues and www.expresshealthcare.in

Solutions - Implementing Electronic Medical Records’, ‘Mobile clinical computing’, ‘New Age Biometrics: A big data and Mobile view’, ‘Collaborative portals for improved patient experience and quality of care’ and so on. ‘The Evolution of Pharmacy Management in India’, ‘Health information exchange – collaborative portals for improved patient experience and quality of care’ and ‘Real world evidence data’ are amongst the attention-grabbing subjects for the panel discussion. IT in healthcare is all set to bridge the gap between the haves and the have nots. The establishment of the Telemedicine Society of India, Medical Informatics Society of India, the publishing of several journals dedicated to eHealth promise well for the future. India has a long way to go, but then so do scores of other countries. The Government of India has launched the Health Management Information System (HMIS) portal to convert local health data into real time useful information, management indicators and trends which could be displayed graphically in reports. With the commendable

increase in mobile usage and the imminent deployment of 3G, it is vital that broad band wireless technology be exploited and used to develop mHealth. While mBanking, m C o m m e r c e , mEntertainment is becoming a reality India needs to develop mHealth. IT improves patient care, by enabling processes and systems to be introduced and repeatedly monitored. The present digital divide in healthcare, existing between the haves and the have nots, will gradually shrink. The Healthcare IT Summit – Hyderabad, is being sponsored by DELL (Platinum Sponsor) and HTC global Services, United Health Group and GMV – innovating solutions (Bronze sponsors) along with GE Healthcare (Supporting Partner). Express Healthcare is the official media partner for this summit. Contact: Tikenderjit Singh Makkar Deputy Marketing Manager India Email: tikenderjit.singh@fleminggulf.com Tel no: + 91 20 6727 6403 Site: www.fleminggulf.com APRIL 2013


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Seminar@Symbiosis The XVth National Seminar on hospital/healthcare management, medico legal systems and clinical research is expected to be a great platform for knowledge-sharing and networking with an impressive line-up of speakers ymbiosis Institute of Health Sciences (SIHS), a constituent of Symbiosis International University (SIU), Pune will be hosting the XVth National Seminar on hospital/healthcare management, medico legal systems and clinical research on May 3-4, 2013 at Symbiosis Knowledge Village, Lavale, Pune. The Indian healthcare sector is expected to become a $280 billion industry by 2020 with spending on health estimated to grow 14 per cent annually. To elaborate on this phenomenon, a pre-conference symposium on 'Successful Healthcare Models' has been structured and is expected to be attended by stalwarts of the healthcare industry covering the hospital, medical equipment manufacturing, clinical research, pharma and IT sectors. The session will be anchored by Dr Ratan Jalan, Founder & Principle Consultant, Medium Healthcare Consultancy while Dr Nagendra Swamy, MD, Medical services and MHS, COO will represent the hospitals. Other speakers include Dr Shankar Haveri, Head-Siemens Healthcare who will speak on medical equipment manufacturing; Dr Deven Parmar, CEO and Medical Director, Karmic Lifesciences on clinical research; Dr Chaitanya Dutt, Director, Torrent Research Centre, on the pharma sector and Dr Vishal Gupta, VP, Global Health Care Solutions, CISCO who will address the audience on IT. The national seminar will also include master classes wherein delegates will get to interact with stalwarts on a one-to-one basis for knowledge sharing. Eminent speakers like Dr Raajiv Singhal, Regional Director, Fortis and Col SKM Rao, GM HR, Columbia Asia Hospital will speak on ‘the importance of human capital and its viability’. Dr Nagendra Swamy, MD, Medical services, MHS and Dr Santosh Shetty, COO, Kokilaben Dhirubhai Ambani Hospital will speak on 'strategic management'. Dr Amir Shaikh, Founder, ASSANSA and Dr Dhananjay Bakhle, Executive, Vice

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Dr Nata Menabde, WHO Representative to India was the Chief Guest at last year’s National Seminar President, Lupin will speak on 'recent trends in clinical research'. Dr Nikhil Datar, Consultant, Kay Legal & Dr. Sanjay Gupte, Director, Gupte Hospital will speak on 'healthcare and law'. Dr Achintan Bhattacharya, Director, National Insurance Academy, will share his views on 'healthcare insurance'. Dr CL Kaul, Ex Director, National Institute of Pharmaceutical Education & Research (NIPER) will speak on 'clinical trials: phases, tribulations and challenges'. Dr Raman Gangakhedkar, Deputy Director, NARI, will light on 'regulatory affairs in clinical research'. Dr Sanjay Zodpey, Director, Public Health Foundation of India, will speak on 'clinical epidemiology'. Dr Gopinath N Shenoy, Medico Legal Consultant, will share his expertise on legal aspects of healthcare. Dr Vivek Desai, MD, Hosmac, will elaborate on 'futuristic hospital designing'. Zahabiya Khorakiwala, MD, Wockhardt, will give a talk on building a chain of hospitals. Dr Vivek Shukla, Healthcare Marketing Consultant, will discuss 'healthcare communication’, touching on branding and marketing issues while Dr Deepak Phalgune, Consultant, DEP, Public Health, FoHBS will share his expert opinion on 'fundamentals in clinical research'. The seminar will conclude with a valedictory cerwww.expresshealthcare.in

emony. Dr Mohan Das, VC, Kerala University of Health Sciences will be the Chief Guest at the ceremony and advocate Ram Jethmalani, Former Union Law Minister will be Guest of Honour, presided over by Dr SB Mujumdar, President and Founder Director, Symbiosis. In addition to these sessions, this year Symbiosis has organised a consortium meeting which would bring together academia as well as industry experts. It is being organised with a view to reinforce and enhance the overall quality of healthcare education management in India. It will help to study healthcare management programmes being offered across universities in India with regard to uniformity and standardisation of curriculum. The consortium will comprise plenary sessions featuring stalwarts from the hospital sector such as Dr Rajeev Singhal, Dr Nagendra Swamy, Dr Santosh Shetty, Col SKM Rao and Dr (Col) RR Pulgaonkar, CEO, Jaslok Hospital. Representatives from the consultancy sector include Tarun Katiyar, Principal Consultant, Hospaccx; Faisal Siddique, VP, Healthcare Strategy, Technopak and Dr Vivek Desai. Representatives from institutes like Dr D Obul Reddy, Principal, Apollo Institute of Hospital Administration; Dr PN Mishra from Institute of Management Studies;

Indore; Professor RN Saha, Dean, Educational Development Division, BITS, Pilani; Dr Jayant Sonwalkar Professor, Director (Academics) and Director, Directorate of Distance Education, Faculty of Management Studies, Delhi and Dr Anil Naik, Dean, Welingkar Institutes. The pharmaceutical sector will be represented by Satish Mehta, Founder Member, Emcure; MB Kapadia, Senior Executive Director, GSK and Ganesh Nayak, COO & Executive Director, Zydus Cadilla. Exchanging their views on the healthcare management education from the government and NGO sectors will be Dr Abhay Shukla, Senior Programme Coordinator, Socio Educational Health & Allied Team (SEHAT). Also partaking in the plenary sessions, from the insurance and TPA domain will be Gautam Nag, Regional Manager, National Insurance Company. Dr Achintan Bhattacharya and J Hari Narayan from IRDA would also attend the event. Besides Gupta from CISCO, IT industry experts scheduled to be at the event include Gyana Ranjan, Accenture and Shikhar Sood, GE India Technology. Wellness industry experts such as Juhee Sinha, Head, VLCC will also share their expertise. Making the plenary sessions well rounded would be representatives from the medical equipment industry such as Anjan Bose, Secretary General, Healthcare Federation of India and Shankar Haveri, Head of Healthcare Academy, Siemens. The plenary sessions will be chaired by Dr Lakhwinder Singh, Director, IIHMR, New-Delhi; Professor S Parsuraman, TISS; Dr Rajesh Bhalla, Dean, IIHMR and Dr Siddhartha Satpathy, Professor-Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS). With such an exhaustive line up of industry experts as speakers, the National Seminar promises to be a stimulating event sure to open up several opportunities. EXPRESS HEALTHCARE

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ABMH conducts conference on quality and patient safety The National Conference “ABMH QIPS 2013” acted as a platform to review the current status of quality and safety in Indian healthcare, and identify strategies to improve these aspects uality improvement within hospitals shouldn't be aimed at acquiring NABH and JCI accreditation but it should be a continuous process to improve performance and care provision”, reiterated speakers at the National Conference ‘ABMH QIPS 2013’. The two day conference was organised by Aditya Birla Memorial Hospital, Pune on March 910, 2013 and attracted around 270 participants which included veteran industry speakers from renowned institutes like Apollo Hospital, New Delhi; Narayana Hrudayalaya Hospital, Ahmedabad; Max Hospitals, New Delhi; Tata Memorial Hospital, Mumbai; Hinduja Hospital, Mumbai; Sancheti Hospital, Pune; Ruby Hall Clinic, Pune; Jehangir Hospital, Pune; Breach Candy, Mumbai; Saifee Hospital, Mumbai; Care Hospitals, Hyderabad; SRMC, Chennai; & AIMS, Kochi; Jaslok Hospital, Mumbai. Medical administrators, CEOs as well as medical and management students discussed various factors to deliver quality and safe care to the patients. During the two-day conference, various approaches, practices and methodologies were shared amongst the delegates to bring about an improvement in healthcare delivery in their own hospitals, which in turn would result in rendering quality services for better patient care and safety. Paper and poster presentation sessions were also arranged and these enabled the participants to showcase various initiatives undertaken by different hospitals to improve their quality of patient care. Emphasis on the following factors was given to deliver quality and safe care to patients: ● Importance of medical and non-medical quality indicators ● Importance of following the clinical pathways ● Importance of medication management in healthcare ● Group practice in hospital to provide improved

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patient care Quality improvement strategies and initiatives ● Failure mode effect analysis (FMEA) and root cause analysis (RCA) ● Privileging and credentialing of staffs ● Clinical audit ● Role of IT in quality and patient safety ● Importance of triaging in emergency medical services ● Conducting mortality and morbidity meetings in a right and efficient way Day One began with a session on quality and patient safety in clinical practice conducted by Dr Umesh Gupta, Chairman & MD, Niramaya Hospitals, Delhi who laid emphasis on how hospitals should take every required step to maintain quality in its clinical practices to deliver quality healthcare to their patients. This session was followed by a session on Quality Indicators conducted by Dr Tarang Gianchandani, Head, Quality and Patient Relations/Addl Medical Superintendent, Jaslok Hospital, Mumbai. During this session Dr Gianchandani said, “We need quality indicators especially to document the quality of care you provide your patient”. Citing an example of how Jaslok Hospital improved quality in both clinical and non-clinical areas she pointed out that the bottom line for every hospital is patient safety because only if patients are satisfied then will the hospital's rev●

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enue grow. Further, Dr BK Trivedi, CEO, Aditya Birla Memorial Hospital (ABMH) in his session, emphasised on incorporating risk management techniques within a hospital. He also spoke about integrating pathways and preparing a road map to achieve quality oriented goals. Dr Narottam Puri, Chairman, NABH &. President, Medical Strategies, Fortis Healthcare, New Delhi during the inaugural ceremony explained how quality became an integral part of the healthcare sector. He also went on to say that “Accreditation should not be the end point but it should be treated as a tool to achieve quality and excellence. For a long time we have concentrated on quantity, it’s time we lay emphasis on quality”. Further on, he also informed that quality improvement will soon be introduced within the curriculum in medical education. Moving forward with the sessions Dr Anupum Sibal, Group Medical Director, Apollo Hospitals sharing his experience on achieving excellence within Apollo Hospitals, said that every big journey begins with a small step and that's exactly how Apollo Hospital group approached while seeking to improve quality within their hospitals. Drawing attention towards the role of pharmacists within hospitals in maintaining quality, Dr Uma

Maheshwar Reddy highlighted the need to opt for medication therapy management within hospitals in order to increase efficiency within pharmacists. A debate on whether a group practice can be a tool to improve patient care and safety or not was conducted and it highlighted many important advantages and disadvantages of group practice. Day One came to an end with the session conducted by Suresh Lulla and some more industry experts. Day Two saw many interesting paper and poster presentations as well as some interesting insights given by industry experts. Expressing her joy in conducting this fruitful conference, Rekha Dubey, COO, Aditya Birla Memorial Hospital told Express Healthcare, “The event was a grand success. It is a very good platform for all of us from the healthcare sector to review the current status of quality and safety in healthcare programmes in India and identify strategies to improve the quality and safety in healthcare and sensitise the policy makers, health managers and health professionals on the concepts and strategies on quality and patient safety in India. We hope to come up with various such quality improvement initiatives in near future to improve the healthcare delivery of the major hospitals in Pune and the other national hospitals”. APRIL 2013


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Indian Health Summit The Indian Health Summit aimed to provide a common platform to discuss the challenges and opportunities in the Indian healthcare space he Indian Health Summit, organised by Cosmos Forums, a global knowledge company, was held at the JW Marriott, Mumbai on March 14, 2013. The Summit comprised four panel discussions and three of them were moderated by Karthikeyan, Director, PE Insights. The first panel was on ’Indian Healthcare Industry: Challenges and opportunities’ and had experienced practitioner Brig Joe Curian, CEO, Seven Hills Hospitals; VCbacked entrepreneur Vikram Vuppala, Founder & CEO, Nephroplus and Vikram Mahajan, Director, Dolphi Techno Consultants. Brig Curian gave a detailed presentation on the challenges and opportunities for healthcare companies and entrepreneurs. He also shared his experience with examples on what works in the Indian healthcare market. Vuppala then shared his entrepreneurial journey of having started Nephroplus after returning from the US and his thoughts on single speciality vs multi-speciality opportunities. He also argued that hospital chains are better off by outsourcing their dialysis function to focused chains like Nephroplus rather than managing it themselves. Mahajan brought in his perspectives from his experience of working in other emerging healthcare markets like the Middle East and Africa. The challenges discussed included financing, lack of talent, risk of technology obsolesce, regulatory challenges etc. Brig Curian stressed on the importance of financial planning and ensuring that business decisions are made on the basis of financial prudence rather than emotions. He also highlighted the importance of having the right metrics to measure costs and effectiveness of a hospital while stressing on the importance of technology systems to capture and analyse information for better managerial decisions. Vuppala highlighted the importance of transparency especially with relation to pricing to build trust and connect with consumers. Mahajan emphasised the need for detailed planning at the drawing board level before the start of the project to minimise risk of cost and time overruns at the execution stage. Regulatory risks, bureaucracy and delayed approvals remain a significant cause of concern for the panelists, as it greatly hampers the growth and development of this sector. All the panel

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members were in consensus of the fact that the healthcare sector offers tremendous opportunities for healthcare entrepreneurs and companies to create economic and social value. The second panel discussion focussed on ‘Building a successful healthcare business’ and the panelists were Dr Velumani, CEO, Thyrocare; Sanjeev Vashishta, CEO, SRL Diagnostics and Vishal Gandhi, Founder, Gandhi & Associates, a law firm. Dr Velumani shared his entrepreneurial journey of building a company focused on thyroid care and how this focus has helped him build a sustainable pan-India organisation. He highlighted the importance of strategic focus to build successful organisations. He also emphasised the need for employee retention and development to ensure long-term organisational growth. Vashishta offered his insights on following an inorganic strategy for growth. He also shared his views on the differences between the approach and growth strategy of SRL as compared to Thyrocare. Gandhi stressed on the importance of proper documentation and processes from an initial stage of the company’s life so as to enable a smooth transition to faster growth. This becomes even more important when the company is looking for an external investor at a later stage. Dr Velumani also shared his experiences of building a differentiated brand positioning for his company and how this helped him raise PE funding for his new ventures. The panel was of the opinion that the chances of success for a healthcare entrepreneur have increased significantly over the past decade and things will improve as we move ahead. The post-lunch panel was on ‘Technology in healthcare- The way forward’ and dealt with the increasing utilisation of technology in the Indian healthcare sector and how technology investments will help organisations to scale-up and become successful in the longer run. The panel comprised Madhubala Radhakrishnan, Founder & MD, Mcura Inc; Arvind Kumar, Founder & CEO, Attune Technologies and Dr BK Murali, MD, Hope hospitals. Radhakrishnan gave a presentation on how Mcura is transforming the healthcare delivery space. She gave a detailed overview of the product and how it has helped doctors to record crucial information about patients over the treatment

period thereby enabling them to review progress and recommend the right treatment for their patients. She was followed by Dr Murali of Hope Hospitals who discussed his views as a doctor on the relevance of technology systems. He also gave an overview of the SAAS technology product that they had developed internally. He shared his experiences of transitioning his hospital to a technology platform and the common challenges which the hospital owners face during this transition. Kumar talked about SAAS and cloud being the game changers for the price conscious Indian market. He also highlighted the need for proper technology systems with the increasing role played by medical insurance in the industry. To conclude, the panelists agreed that technology adoption is no longer a choice but a necessity for healthcare companies that are looking to grow in the Indian marketplace. The last panel witnessed focused on ‘Capital raising for healthcare companies – working with PE/VC funds’. The panel was moderated by Vishal Gandhi, MD, BioRx Venture Advisors and the speakers included Ameera Shah, MD & CEO, Metropolis Healthcare; PE/VC fund managers Ritesh Banglani, VP, Helion VC and Ashish Mohapatra, VP, Matrix Partners; and Dr Milind Antani who heads the Healthcare practice for the law firm Nishith Desai & Associates. Shah discussed her experiences of working with PE funds and her decision to go in for an external investor to accelerate organisational growth. Banglani and Mohapatra discussed their views as fund managers of the interesting opportunities in the healthcare space and the key parameters that they look for before funding a company. Dr Antani gave his perspectives as a lawyer working with various healthcare companies and how promoters should approach PE/VC funding from a legal perspective. To conclude, the panelists agreed that PE/VC capital is an excellent option for promoters looking at rapid growth but one should understand the long term implications of bringing in a financial partner. The Indian Health Summit offered a good platform for CXOs and promoters from the healthcare industry to participate, network and learn from each other.

The first panel discussion on the challenges and oppurtunities in The second panel discussion on building a successful The third panel discussion on technology and its importance in Indian healthcare healthcare business Indian healthcare APRIL 2013

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Jodhpur One World Retreat The event aimed at raising awareness and resources for the Indian Head Foundation he Jodhpur One World Retreat, organised by the Indian Head Injury Foundation and the Showtime Group, was held at Jodhpur in Rajasthan from March 8-10, 2013. The event centred around thoughtful sessions based on the theme—"A Beautiful Mind" and the main objective was to gather support to combat the alarming rise of head injuries in the country. 250 luminaries from across the world, including the Maharaja of Jodhpur, his family and team attended the three-day event. Commenting on the event, the Maharaja of Jodhpur said, "The Jodhpur One World Retreat with its underlying theme of 'A Beautiful Mind' was the propitious coming together of several interests of mine. Above all, it aims to give a new critical impetus to the work of the Indian Head Injury Foundation, a mission very close to my heart." The Maharaja set up the Foundation after his son met with a polo accident some years ago and he discovered that there was a lack of facilities in our country for the treatment of brain trauma and that India was actually the head injury capital of the world. He was determined to do something about that and that's how the Indian Head Injury Foundation was born. The Jodhpur One World Retreat had renowned speakers from across the world including Dr Raj Narayan from North Shore LIJ, New York who spoke on 'Improving Outcomes from Head Injury' and British composer, Nigel Osbourne who held forth on 'Music and the Healing of the Mind' pledged their support to further the work of the IHIF in its mission. Nita Ambani and the Reliance Foundation also pledged their support for the cause. Gayle de Peatro who spoke on behalf of Bloomberg Philanthropies, the Aga Khan Foundation, automotive giant BMW and celebrities like Sachin Tendulkar and Dia Mirza were also present at the retreat. The event was also reportedly graced by many corporate bigwigs like Mukesh and Nita Ambani, Dr Naresh Trehan, Suneeta Reddy, Vikram Mehta, Ajit Gulabchand, Pawan Munjal, Atul Punj, Devaunshi Mehta, Pramit Jhaveri, Sanjay Nayar and Suhel Seth with international expat heads, Rebecca Irvin of Rolex, Raymond Bickson of the Taj and Phillip Von Sahr of BMW etc. Adding a touch of international royalty were

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A panaromic raphsody performance - Nari celebrating the Indian women Princess Hussah-al-Sabah of Kuwait and the Duke and Duchess of York, Prince Andrew and Sarah Ferguson. Apart from the sessions and seminars several entertaining segments such as 'Nari - Celebrating the Indian Woman', a dance performance on the spectacular ramparts of the Mehrangarh Fort, a rock concert by Sting, a thanksgiving lunch hosted by the Maharaja and Maharani etc. were also part of the three-day event. In the words of Michael Menezes, MD, Showtime said, "Showtime has over the years consistently set the standards for the entertainment and experiential marketing industry. I am delight-

ed that the Jodhpur One World Retreat is yet another example of this. It is a truly a pioneering effort in an extremely critical space - fund-raising and cause-related marketing - and is even more timely and relevant because of the new two per cent CSR rule introduced recently. Corporate India is going to need our professional expertise in helping them make a meaningful contribution to transforming the lives of the underprivileged and deprived. The Jodhpur Retreat is an exciting example of how interactivity, networking and dialogue can integrate with leisure, culture and the arts makes this transformation possible."

Sting’s rock concert

Maharaja and Maharani at One World Bazaar

Duke of York Prince Andrew www.expresshealthcare.in

Dr Naresh Trehan and Maharaja Dr Raj Narayan APRIL 2013


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Top international radiologists discuss advances in MR imaging techniques at Fortis Symposium Unique whole body imaging technique combining m-DIXON and DWIBS, for early cancer detection, showcased by Fortis Memorial doctors t an advanced international symposium on MR imaging, organised by the Fortis Memorial Hospital, senior radiologists from around the world deliberated on the latest advances in MR techniques in neurology and whole body imaging. The key speakers were Dr RK Gupta, HOD, Radiology, Fortis Memorial; Dr Taro Takahara, pioneer of diffusion weighted imaging with background suppression (DWIBS) from Japan and Dr Ponnada Narayana, Professor, University of Texas Health Science Centre, US. Top doctors at the Fortis Memorial Research Institute, Gurgaon, also showcased a unique combination of two cutting-edge whole body MR imaging technologies for the first time in the world for the early detection of tumours. These technologies deployed m-DIXON and DWIBS, advancements in magnetic resonance (MR) that provide precision-high resolution images of one millimetre thickness. This enables the sighting and diagnosis of diseased tissues in their infancy, making it possible for targeted therapy solutions to be applied early. Highlighting the advantages of this new innovation, Dr Gupta said, “Nearly three million people suffer from cancer in India and approxi-

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L-R: Dr RK Gupta, Director & HOD –Department of Radiology along with Dr Taro Takahara at the Fortis Memorial Research Institute mately one million new cases are detected every year. Cancer treatment can be more effective if the disease is diagnosed and treated in its infancy much before the physical symptoms manifest themselves and the disease reaches an advanced uncontrolled state. The fusion of the two cutting edge technologies, m-DIXON and DWIBS, in advanced MR application enables the

detection of tiny tumours. One millimeter slicing has been the gold standard in MR investigations, as it provides high resolution images. However the application of these technologies was hitherto limited to specific body parts. With its application on the whole body, tumours or infections that were not revealed in MR imaging earlier, can now be detected easily in as little as 20 minutes

Fortis Memorial Introduces cutting edge imaging technology for early cancer detection APRIL 2013

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and without exposing the patient to radiation.” Explaining further, Dr Gupta said, “Many times patients who have successfully battled cancer may suffer from remission and other systemic infections like tuberculosis making early diagnosis difficult. With the help of Whole Body MR imaging we are now able to detect and pinpoint the exact cause of the ailment. Naturally, this accelerates the treatment protocols.” Radiation free MRI provides a high contrast between the different soft tissues of the body, which makes it especially useful in precision imaging of the brain, muscles, the heart, and cancers compared with older medical imaging techniques. Commenting on the new innovation, Dr Dilpreet Brar, Regional Director, Fortis Memorial said, “At this nextgeneration quaternary care hospital we innovate and strive for clinical excellence to treat complex medical conditions. Our endeavour is to set new benchmarks and bring in the latest technologies in the world to enhance clinical diagnosis and outcomes.” EXPRESS HEALTHCARE

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EVENTS UPDATE Healthcare IT India Summit

Green lean six sigma certification training for healthcare

Date: April 22-23, 2013

Organiser: Fleming Gulf Conferences

First session: 25 April – 5 May, 2013 (9 days, Residential program) Hostel accommodations available on request & on additional charges payment)

Summary: The Healthcare IT India Summit will have a dedicated focus on ICT innovations

Second session: Upgradation to Black Belt (additional 10 days) tentatively in September 2013

Contact: Tikenderjit Singh Makkar Deputy Marketing Manager-India Tel: +91 20 6727 6403 Email: tikenderjit.singh@fleminggulf.com Website: www.fleminggulf.com

Last date to register: March 22, 2013

Venue: Hyderabad, India

iPHEX 2013 Date: April 24-26, 2013 Venue: Mumbai Organiser: The Pharmaceuticals Export Promotion Council of India (Pharmexcil) Summary: iPHEX 2013 is expected to be an industry exposition in India showcasing diverse range of products and will include formulations, APIs, AYUSH, nutraceuticals, health services, biotechnology and biotechnology products, R&D Services Website: www.pharmexcil.com

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Venue: Mumbai: Kalina, Santacruz (East) Organisers: AUM MEDITEC - A hospital planning, management consultancy, Six Sigma deployment consultancy and training organisation Summary: This programme module is specially designed for hospital managers and other healthcare professionals and shall focus on six sigma methodologies, lean concepts in healthcare systems and service delivery. The uniqueness of this program is in it's module that smoothly integrates healthcare service delivery with six sigma, lean management concepts and in its ability to build six sigma professionals to cater to three most important aspects of healthcare service delivery (safety, efficiency and efficacy) and at the same time maintain an equilibrium with customer satisfaction, costs and sustain the quality achieved. Participant profile: Hospital CEOs/COOs, management executives, hospital operations man-

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agers, quality in charge, MHA/ PGDHA/ MBA (HCM) final year students Contact details: Meeta Ruparel Email: meeta@meditecindia.com / meetaruparel@hotmail.com Website:http://www.meditecindia.com/Sixsig ma.htm

XVth National Seminar on Hospital/Health Care Management, Medico Legal Systems & Clinical Research Date : May 3-4, 2013 Venue : Symbiosis International University – Lavale, Pune Organisers: Symbiosis Institute of Health Sciences (SIHS) Summary: Seminar on hospital/healthcare management, medico legal systems and clinical research Participant profile: healthcare industry medical equipment research, pharma and

Representatives of the covering the hospital, manufacturing, clinical IT sectors

Contact: Dr Rajesh Shinde Web: www.schcpune.org Email: info@schcpune.org Call: 020 – 25655023/20255051/ +91 8888892258

APRIL 2013


Strategy 'We hope to double the present bed capacity in next 24 to 30 months'

Connecting healthcare and finance Manish Menda, Director, MYA Health Credit gives an insight into patient financing and its benefits to improve healthcare access Page 34

Dr Krishna Reddy, Director and CEO, CARE Hospitals Page 36

MAIN STORY

The Great Indian Healthcare Factories: III Operation Smile In the third of a series of articles on ‘The Great Indian Healthcare Factories’, featuring stories in healthcare that are exemplary and worth emulating, Gp Capt (Dr) Sanjeev Sood, Hospital Administrator and NABH empanelled Assessor, chooses Operation Smile and traces the reasons that contributed to its success. The first success story covered was that of Narayana Hrudayalaya, (Express Healthcare, November ‘12) and second was of Aravind Eye Care System (Express Healthcare, February ‘13).

GP CAPT (DR) SANJEEV SOOD Hospital Administrator and NABH empanelled Assessor

Surgery under complete asepsis he public healthcare delivery system in India leaves much to be desired. It should be more accessible, equitable, and affordable to the people who need it. Most and above all, it should be patient-centric rather than hospital-centric. Operation Smile, for the management of developmental abnormalities of cleft lip and palate, is one such system that operates with the efficiency of a factory which has high productivity and meets global standards of care, creating smiles and much more. This system is entirely patient-centric and consumer driven, i.e. all healthcare services are provided under one roof to meet the needs of the patients.

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Operation Smile is one system that operates with the efficiency of a factory which has high productivity and meets global standards of care

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Operation Smile’s mission, key differentiators and history, makes this organisation stand out among the top charities around the world.

Cleft lip and/or palateA public health challenge Cleft lips and cleft palates (also called hare lip) are congenital defects that occur early in embryonic development. These are developmental abnormalities, occurring approximately in one out of 700 live births in India. A child is born with a cleft, somewhere in the world, approximately every three minutes. Depending upon the degree of EXPRESS HEALTHCARE

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severity, cleft lip and/or palate disability may lead to interference with sucking in infants, speech articulation, swallowing and more frequent infections of upper respiratory tract, besides significant cosmetic effects. As a result, many suffer from malnutrition as well as medical and psychological problems in the long run. This is a challenging condition to treat since it needs a multidisciplinary team approach with follow up of patients for successful rehabilitation. It is estimated that there are more than one million people in India living with untreated facial deformities. Thus, this condition imposes a significant disease burden in a community and poses a major public health challenge.

Operation Smilechanging lives, healing humanity Operation Smile was created by Dr Bill and Kathy Magee after they participated in a Philippine cleft repair mission in 1982 and recognised a need for more such missions. This is an international medical humanitarian organisation dedicated to providing lasting solutions to this problem by allowing children to be healed, regardless of their financial status– a change that brings about a more positive life along with a healthier self-image. It comprises a dedicated force of active volunteer network of more than 5,000 highly trained medical professionals who donate their time and skills on a regular basis. The organisation is headquartered in Virginia, US and is financed purely by donations and charity. Since its first mission in 1982, the organisation has comprehensively evaluated more than 3.5 million children and young adults as well as successfully treated 200,000 patients, besides training thousands of healthcare professionals worldwide. In 1996, Operation Smile was awarded the first Conrad N Hilton Humanitarian Prize in recognition of its outstanding contribution to alleviate human suffering.

International and local missions- The treatment factories Operation Smile’s standard International Medical Mission comprises a team of medical professionals from around the world who travel to Operation Smile partner countries for treating children during a two-week period.The partner country manages all aspects of the medical mission including physical examinations, surgery and post-operative care. The country

A child with cleftlip before and after surgery secures its own funding, medical supplies and credentialed medical professionals or may be assisted by Operation Smile’s headquarters, a resource country or another partner country.

Operation Smile-India Indian Medical Mission is based on the International Medical Mission model, but is conducted at the local level using Operation Smile-trained volunteers. Operation Smile India was established in 2003 as a registered Indian Trust and is run by a local Board of Directors and Medical Advisory Council. Operation Smile India’s has comprehensive cleft care centres in various parts of India which provide year-

Operation Smile’s volunteers have provided free medical evaluations to more than 12, 000 patients and performed life-changing surgery on more than 7, 700 children in India

Patients getting registered

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round, free reconstructive surgeries to children who suffer from facial deformities. Since the organisation’s first mission to India in 2002, Operation Smile’s volunteers have provided free medical evaluations to more than 12, 000 patients and performed life-changing surgery on more than 7, 700 children. Operation Smile’s team have successfully completed their mission in several locations in India. The author had the opportunity to study their modus operandi, processes and workflows at some of these places. Working together with local partners they are trying to make India a ‘cleft free’ nation through a range of initiatives including the provision of restoration surgery, prenatal education and care, and community awareness programmes. In 2004, Operation Smile India was conferred with the esteemed Diwaliben Mohanlal Mehta Award for alleviating human suffering.

Standardised care, equipment & training- McDonaldisation of healthcare With more than 28 years of experience in repairing facial deformities, Operation Smile have standardised their practices, equipment and anaesthesia, especially as they relate to the special needs of children, to ensure the safest surgical environment possible, the organisation adheres to 14 global standards of care that pertain to preopera-

Team of diverse specialties and nationalities www.expresshealthcare.in

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tive patient screening and assessment, anaesthesia equipment and supplies, surgical equipment, post-operative intensive care, patient consent, surgical priority, prevention of transmission of blood borne pathogens, pain management, a team approach to the care of patients, stringent criteria of selection, credentialing and ongoing mentoring of team members, minimum patient follow up, proper translation and standardised documentation. State-of-the-art equipment and biomedical training is provided to all professionals to ensure that all children treated will benefit from the same quality of technology, regardless of where they receive care.

Team members organising their stuff and handling documentation

Streamlined patient care processes Medical missions usually include: two days of physical examinations, five days of surgery and four days of post-operative care, providing surgeries to approximately 125-150 patients. It costs around Rs 12,500 and can take as little as 45 minutes to repair a child’s cleft lip and change its life for the better. On a typical mission, a team of up to 60 credentialed medical professionals (surgeons, anaesthesiologists, nurses, paediatricians, dentists and others) travel to different parts of country to treat children. The whole process of patient care and treatment delivery is highly standardised and streamlined with efficient flow of patients. This is designed into eight stations through which each patient moves sequentially. An identification number. and file is generated containing personal and medical information of each patient (Station I). Next, patient’s photograph is taken for identification and record (Station II). Thereafter, his/her vital parameters are recorded and nursing assessment is carried out (Station III). At Station IV, patient is examined by the surgical specialist where his/her extent of disability is evaluated and eligibility for surgery is ascertained by the team. Each case is allocated a priority. Next, the case is examined by the paediatrician and anaesthetist to assess his /her fitness to undergo surgery (Station V). Then the case is seen by a dental surgeon to assess dental health and alignment (Station VI). At Station VII, a speech therapist evaluates APRIL 2013

Team members at their workplace

Author with team members the case for speech training and rehabilitation. Lastly, the complete data of the patient is captured in digitised and structured format in a laptop by an electronic data operator (Station VIII). This information can be quickly retrieved any time before, during or after surgery. The initial file thus created moves with the patient along these eight stations.

Safe surgeries, save lives Operation Smile was the first cleft organisation to support the World Health Organization’s Safe Surgery Saves Lives initiative, which includes the WHO’s Surgical Safety Checklist designed to improve the safety of surgical care throughout the world. To ensure the quality of care delivered, the team moves with its own medical equipment and logistics items which are compactly stored in customised boxes. www.expresshealthcare.in

It only uses the venue (like OTs, waiting area) of local hospital. In spite of handling large numbers of patients in a short span of time the surgical site infections are barely minimal. The results of the surgery are excellent. The non-medical support staff of the team engages with children, amusing them with positive distractions like toys and games. The whole atmosphere exuded positive energy, aesthetics and cheerful ambience, as observed by the author.

Focused factory of healthcare The term ‘focused factory’, was introduced in a 1974 Harvard Business Review article by Wickham Skinner. Focused factory concept in healthcare is defined by R E Herzlinger as (multidisciplinary) organisations based on common objectives (e.g. the

treatment of specific patient groups) that focus on patient-centered (and process-centered) care rather than professional-centred or organisation centred care. However, creating these (multidisciplinary) organisational units, might solve some of the problems associated with the traditional hospital organisation, such as; coordination problems, a work-around culture, lack of team-work, and high numbers of handovers. Operation Smile is a patient-centric healthcare system and is geared towards integrated management of developmental abnormalities of cleft lip and palate. Unlike other healthcare systems; it’s not organised towards individual doctors and discrete episodes of care but towards the comprehensive needs of patients, bringing multiple disciplines around patient care. This attribute makes Operation Smile unique from other systems of healthcare delivery.

Conclusion Thus, driven by charity and a mission to alleviate human suffering, Operation Smile affords an excellent example of a unique model for patient care, where quality and patient centric care is delivered at patients’ door step in an efficient manner by a team of professionals, and a major public health problem is being managed with best positive outcomes that radically transforms lives and restores dignity and self esteem. EXPRESS HEALTHCARE

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Connecting healthcare and finance Manish Menda, Director, MYA Health Credit gives an insight into patient financing and its benefits to improve healthcare access

MANISH MENDA Director, MYA Health Credit

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aking healthcare affordable and accessible for all its citizens is one of the key focus areas of a country today. In India where healthcare services still do not reach many pockets of the country, it becomes an even bigger challenge. Many patients even today delay their treatment plans due to lack of funds thereby weaning themselves from a better quality of life. Unlike the West where there are many financing schemes available for patients, India has not caught up to the trend as yet. Also, given the relative absence of insurance reimbursement for expensive treatments such as IVF, dental procedures, hair transplant or bariatric, and the relatively high cost for the same, many people are unable to realise their dreams. Patient financing is a niche area and India is an under-served market. In an environment of low public financing for health in India, the new generation of patient financing initiatives is increasing patient choice, and leveraging private capacity, particularly with an aim of reaching maximum number of people. Additionally, with such financing methods it’s not just the patient who benefits; the advantages to the practice itself are many; ranging from improved doctor-patient relationship to healthier bottom lines. In the quest for assisting patients in their need for good health and understanding the financial burden of one-time costs for various procedures such as IVF and bariatric, there are now certain financing models available in India such as one offered by Mya Health Credit. The heart of any patient financing model is to bridge the gap between healthcare availability and financial accessibility by helping patients receive low interest loans for planned medical procedures. The pay-as-you-go approach is a great model for countries like India where there is no reimbursement system and expenditure on health is largely out-of-pocket. In US, pharma expenses are about 8-15 per cent of total healthcare cost while in India it may go as high as 60 per cent in therapies.

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Millions of middle-class families every day, come face to face with the harsh Indian reality – lack of safety net for health. Few Indians have health insurance (which in turn covers selected traditional medical ailments) and the cost of private healthcare comes at a premium. Offering financial assistance to patients in their time of need at a relatively low interest EMI model is a boon for the middle-class Indian society, specifically during super-speciality treatments such as IVF and orthopaedic surgery.

How can patient financing benefit your practice? ●

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Timely payments, the opportunity to re-invest revenue immediately Empowers your practice to offer patients helpful payment alternatives that are convenient, simple and affordable ❖ Enables patients to access treatments which they might not have been able to afford ❖ Transfers the risk of slow or non-paying patients resulting in lower administrative, personnel, overhead and collection related costs, giving you a strong bottom line ❖ Eliminates the need for negotiated payment arrangements ❖ Avoids the extension of payment beyond the treatment period Builds stronger doctor patient relationships Enables coverage for preexisting conditions Eliminates the need for financial pre-screening which is already done at www.expresshealthcare.in

the loan level.

submission

How does a patient financing model work? With patient financing models, patients have a simple, affordable way to pay for their treatment through a monthly payment plan. Payments are designed to fit within their budgets. The healthcare provider will be paid once the payment request is made for the sanctioned amount. You and your designated staff merely tell the patients that there is a payment option available. The loan can be used to cover all or some portion of the procedure cost. Depending upon the approved amount the patient could choose to pay the balance in cash. Once the loan is approved, a sanction letter is generated and sent to the patient and the healthcare provider. Additionally, if the loan account holder defaults on their account, your practice is not held responsible. It is extremely important to note that there will be no extra charges for the patient in the hospital or clinic. A patient only needs to bear the financing charges for the loan to be paid over a period of time. Patient financing is a revolutionary model in comparison to the regular health insurance as it offers considerably low interest rates and enables patients to access a range of healthcare procedures.

Examples of practices to be considered ● ●

Fertility treatments Bariatric and plastic

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surgery Orthopaedic procedures Dental procedures Hair transplants Urology surgeries Gynaecology procedures Ophthalmology procedures ENT surgery Cancer treatment Cardiology General surgery

Roles and responsibilities A patient financing company, Mya Health Credit intends to offer loans to patients for financing of pharma prescriptions worth over Rs 75,000 for a tenure of 12, 18 or 24 months. This facility will also include financing of medical devices which too can be extremely expensive. Mya Health Credit empowers the practice to offer patients helpful payment alternatives that are convenient, simple and affordable. It is a clear route to heartfelt gratitude.

Promising future of healthcare in India The Indian healthcare sector is here to evolve to a state where it will reach out to patients across varied income groups. People will have multiple options to access healthcare from a variety of different insurance schemes, government schemes or patient financing programmes. Insurance plans are already starting to evolve and the government is working on various healthcare programmes all over India. The key will be consumer choice in the future where the end user will have access to a plethora of options. APRIL 2013


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Pentavalent vaccine: Doing more harm than good? Jacob Puliyel, Head of Paediatrics, St Stephens Hospital Delhi, questions whether the time has come to stop using pentavalent vaccine for immunisation

mmunisation with the new Pentavalent vaccine resulted in the recent death of two babies in Kerala. This combination vaccine was to replace the trivalent DPT (against diphtheria, whooping cough, tetanus vaccine) and additionally protects against Haemophilus influenzae type b and Hepatitis B. The post mortem certificate in both babies stated: “Based on the findings in the autopsy, preliminary reports of microbiological and histopathological findings, no definite opinion as to the cause of death can be furnished. Death due to natural disease, injury and aspiration pneumonia are ruled out. However, death as a result of post vaccination sequelae could not be ruled out.”1 Vaccines are administered to a large number of healthy children to protect against illness and death. The autopsy reports suggest that the vaccine was the most likely cause for the deaths but stopped short of saying the vaccine definitely caused the deaths. All drugs have side effects, it has to be decided if the adverse effects are unacceptable. As children die from other reasons, unrelated to the vaccine there it is possible that coincidentally children may die of other disease on the day they were immunised. However, for children noted as dying after pentavalent vaccine no ‘alternate and sufficient cause’ was found to explain the death in spite of diligent investigations. Even if no alternate cause of death is established the possibility of ‘Sudden Infant Deaths Syndrome’ (SIDS) exists where deaths happen without explanation.

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Deaths in several countries where the vaccine is used The two deaths whose autopsy reports are discussed above are not the only deaths associated with this vaccine. This vaccine is used mostly in developing countries. There were eight deaths in Bhutan.2 There were 25 instances of serious adverse events in Sri Lanka including five deaths.3 There were three deaths in Pakistan.4 There were 10 children who suffered serious adverse events of whom seven died in Vietnam.5 There were at least 15 deaths in Kerala6 and two in Tamil Nadu 7and one in Haryana8 making the total 18 deaths in India. These deaths, in differAPRIL 2013

ent countries using vaccine from varied manufacturers, rules out defects in some specific batch of the vaccine, and also indicate that they are unlikely to be because of incorrect administration of the vaccine. The WHO considers two deaths due to vaccination as a cluster9 that mandates rapid evaluation of the risk to public safety.10 That there are 41 deaths are a matter of serious concern. Should the programme be now suspended?

Infant mortality rate and coincidental death on day of immunisation Information obtained under the right to information suggests that in the first six months, when the vaccine was administered to 40,000 children in Kerala, five children died. If this is extrapolated and the 25 million babies in India born each year are vaccinated we can expect 3125 deaths. These deaths from the vaccine would seem to outweigh any benefit that immunisation can yield. In Kerala 14 babies die before their first

for immunisation. Each baby is examined by healthcare personnel before vaccination. So sick babies are unlikely to receive vaccination. Babies who die are usually severely ill. The deaths in these vaccinated babies are deaths in apparently healthy babies who no one anticipates will die in the next few hours. Another possibility is the rare SIDS, the death of an apparently healthy baby without explanation. SIDS may be the explanation for a very small number of deaths. Here the ‘unexplained deaths’ following immunisation, are four times the number that usually die after the first month of life. SIDS is very unlikely to be the explanation for these deaths following Pentavalent vaccination. Furthermore, the SIDS rate in the third month of life is higher than that in the second month, and if these deaths were merely coincidental with the Pentavalent vaccine there should be more deaths after the second dose rather than the first. However, four of the five deaths in the first six months in Kerala, were after

Information obtained under the RTI suggests that in the first six months, when the vaccine was administered to 40,000 children in Kerala, five children died birthday per 1000 live births. This is called the infant mortality rate (IMR). Half of these deaths occur in the first month of life. The other seven deaths per 1000 occur in the remaining 11 months. Pentavalent vaccine is administered after six weeks of age, and so it is administered to babies who have survived the first month of life. Four out of five deaths occurred with the first dose of the vaccine and on the day or the next day of vaccination. The death of babies in the first day after vaccination works out to be four times higher than the expected number. The vaccine meant to save lives seems to be increasing mortality rather than reducing it.

Deaths from SIDS Pentavalent vaccine is given to healthy babies. Mothers in Kerala don’t ordinarily bring very sick babies www.expresshealthcare.in

the first dose. This also argues against all these deaths being SIDS deaths.

Lives lost to adverse events against lives saved by vaccination One method to decide on continuing the programme would be to see if more harm is done than the benefits (reducing disease deaths in the community) by vaccination. Pentavalent vaccine provides protection against Hib disease. Evidence from the World Health Organization studies in India suggests that seven children in 100,000 get Hib meningitis of which 10 per cent die. If the 25 million babies born each year are immunised it will prevent 8750 cases of Hib meningitis and 875 deaths over the next five years. Vaccination also protects children against pneumonia: more children get Hib pneumonia but few die of

it. If we double the estimated deaths about 1750 children in the country die each year from HIb disease and these can be saved by immunisation. We cannot estimate the lives saved by Hepatitis B immunisation as they do not happen in childhood. The deaths from the vaccine (3125) seem to outweigh the benefits. (1750 lives saved).

The parallels with Rotavirus vaccine withdrawal In 1999 the newly introduced Rotavirus vaccine in the West was suspected of increasing ‘intussusceptions’ (a surgical condition of the small intestine). Ordinarily one in 10,000 children would get intussusception. This went upto 2/10,000 in the two weeks after the first dose of Rotavirus vaccine was administered. When 15 extra cases of intussusceptions were noticed (and when not even one baby had died) the vaccine was withdrawn.11 Product liability rules are so stringent in the West that the manufacturers voluntarily removed the vaccines before they were asked to.

Noel Narayanan Commission and underestimation of adverse events Before starting the programme in Kerala the Government set up theNoel Narayanan Committee.12 It recommended the Government collect data on each child immunised with the vaccine, for 48 hours after immunisation. A government affidavit to the Delhi High Court suggests this was not done in a systematic way but reporting of adverse events was left to voluntary ASHA workers.13 They are given incentives depending on the number of children receiving Pentavalent vaccine in their area. This could be a disincentive for reporting adverse events as, such reports could reduce vaccine uptake and her earnings. There are the Government Standard Operating Procedure (SOP) for adverse events following immunisation (AEFI).14 The numbers reported suggest severe under-reporting: while over 100 serious adverse reactions of various types would be expected with the standard DPT (triple antigen) vaccine in six months, only two were reported with Pentavalent vaccine that EXPRESS HEALTHCARE

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incorporates the DPT. In addition it appears there was an attempt to blame the parents of the first child who died following immunisation in Kerala. The press reported that the baby did not die of vaccine reaction but was smothered15 to death and later a spokesperson for the Health Department claimed the mother’s breast-milk feeding killed the child.16 It took the post-mortem report to clear the parents of these accusations. Given these circumstances it is clear that adverse events are likely to be under-reported and we can anticipate that the 15 deaths reported from Kerala, is an underestimation.

Post-marketing surveillance and concluding remarks Notwithstanding any deficiency in the Government reporting system, the vaccine manufacturer is obliged to provide the Drug Controller with a listing of all side effects in the first few years of marketing a newly licensed

drug. The Drug Controller is the regulatory authority which has to ensure such reporting is made available. Most of the information presented here pertains to the first six months of the programme in Kerala for which information was made available under the RTI. The public must insist that data for the 14 months the vaccine has been in use in Kerala and Tamil Nadu is carefully evaluated in a transparent manner before decisions are made for the health and safety of our children. In December 2009 a former Union Health Secretary Professor KB Saxena and eight others filed a public interest petition in the Delhi High Court to ask the Government of India to formulate an evidence-based rational vaccine policy for introducing new vaccines and to ensure that the basic EPI vaccines are provided to every child without discrimination or constraints of funds. The author is one of the petitioners. Since August 2010, he is a

member of the National Advisory Group on Immunization (NTAGI). The opinions expressed in this article are those of the author

References: 1.http://articles.timesofindia.i n d i a t i m e s . c o m / 2 01 3 - 0 2 25/thiruvananthapuram/37288777_1_pentavalent-vaccine-infant-deathsmortem 2.http://bhutannews.blogspot .in/2010/07/pentavalentkiller-is-back.html 3.http://www.bmj.com/rapidre s p o n s e / 2011 / 11 / 02 / s r i lankan-deaths-following-pentavalent-vaccine-acceptablecollateral-dama 4.http://www.bmj.com/rapidresponse/2011/11/02/suddendeaths-after-pentavalent-vaccination-vaccine-really-safe 5.http://www.thanhniennews.com/2010/pages/201301 17-7-deaths-in-two-monthswho-deems-vaccine-in-vietnam-safe.aspx 6.http://articles.timesofindia.i n d i a t i m e s . c o m / 2 01 3 - 0 2 05/thiruvananthapuram/36764202_1_pentava-

lent-vaccine-immunization 7.http://articles.timesofindia.i n d i a t i m e s . c o m / 2 01 2 - 07 13/chennai/32662981_1_pentavalent-vaccine-immunization-programme-aefi 8.http://articles.timesofindia.i n d i a t i m e s . c o m / 2 01 3 - 01 12/chandigarh/36295667_1_p entavalent-vaccine-vaccination-programme-jhajjar#inbox 9.www.rho.org/HPV-vaccineimplementation.htm 10.http://www.who.int/bulletin/archives/78%282%2917 0.pdf 11.http://www.cdc.gov/mmwr /preview/mmwrhtml/mm484 3a5.htm 12.http://jacob.puliyel.com/ed it.php?id=264 13.http://jacob.puliyel.com/ed it.php?id=278 14.http://jacob.puliyel.com/ed it.php?id=258 15.http://archive.asianage.co m/india/kerala-infant-diedsmothering-510 16.http://articles.timesofindia.indiatimes.com/2011-1221 / t h i r u v a n a n t h a p u ram/30542007_1_pentavalent-autopsy-report-expertteam

INTERVIEW

‘We hope to double the present bed capacity in next 24 to 30 months’ Dr Krishna Reddy, DIRECTOR AND CEO, CARE HOSPITALS

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are Hospitals, a fast growing chain of hospitals have entered a new phase of growth and has set an expansion plan worth Rs 400 crores. The recently inaugurated new standalone outpatient centre is a part of the expansion strategy. Dr Krishna Reddy, Director and CEO, CARE Hospitals throws more light on the growth strategy outlined by the hospital chain and its objectives, in discussion with Lakshmipriya Nair

Tell us about the rationale behind moving the Outpatients Centre? Would this serve as a precursor for more such outpatients clinics? Primary reason was to decongest the main hospital. Secondary reason was to evolve a facility that addresses the long felt need of our patients – a facility that is not a hospital, as most of these people are not sick – they are either coming for health

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assessment and management or for getting evaluated for simple symptoms or for chronic management of some of the underlying chronic conditions like hypertension, diabetes, asthma etc.Third objective was to disengage those procedures that can be done out of a hospital on a day-care basis like dialysis, IVF, plastic surgery, eye surgery, minimal invasive diagnostic and therapeutic procedures. Medicine will witness these trends of increasingly taking care to the community away from the hospitals.

How is the new centre likely to enhance Care Hospitals’ existing service portfolio? Are there plans for standalone outpatients centres in future? The main hospital was mainly designed with speciality services in mind and all other services were of support nature. OP and daycare facility has more comprehensive services – health management; www.expresshealthcare.in

women’s wellness; adult vaccination; advanced physio and rehab programme; advanced eye and dental care; dialysis centre; advanced diagnostic facilities; special clinics for chronic disease management; consulting rooms to accommodate ~100 consultants at a given time; 12/7 facilities; six day-care operation theatres etc. We have plans to replicate such centres in existing hospital locations. We will wait and study the model to decide upon standalone centres in future.

Are there any plans to foray into new spheres of services? Instead of foraying into new services, we are looking at new methods of delivering current services in response to changing expectations and needs of people. The emphasis will be on the experience of a home away from home.

What are the hospital’s plans and strategies for the

next fiscal? We will continue to focus on optimising operations through systems approach. Our efforts will be in maximising value to patients in terms of quality per cost. We have commenced our project plans to double bed capacity and create centres of excellence over next three years. Given our philosophy, we are evolving strategies to reach out to patients, people and physicians.

Are there any expansion plans in the offing? If yes, how do you plan to raise funds for the same? We have raised funds from Advent International in April 2012 to meet our medium term plans, which consist of upgrading existing facilities, enhancing capacity in existing locations in five states, and creating centres of excellence. We hope to double the present bed capacity in next 24 to 30 months. lakshmipriya.nair@expressindia.com APRIL 2013


Knowledge Customised patient instrumentation for TKR

'FFR is unique technology which can improve outcomes in multivessel disease'

Dr Vivek Mittal, Sr Consultant, Fortis Hospital talks on a new method for total knee replacement

Kaustav Banerjee,Country Manager, St Jude Medical- India Page 40

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Battling cervical cancer: Early diagnosis is the key Cervical cancer is a silent killer in India, claiming about 70,000 women every year. But prevention is easy and cheap through regular screening by tests such as pap smear and LBC, says Dr SK Das, Sr Consultant, Gynae Oncology, Action Cancer Centre

DR SK DAS

Senior Consultant Gynae-Oncology Action Cancer Hospital

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s a young, healthy woman chasing the dreams of the modern world, it is often easy to forget about the most important person in your life – you. In the full flush of youth, you can be forgiven for thinking that disease is something that happens only in old age, but you cannot be more wrong. Cervical cancer, which is the cancer of the cervix (the lower portion of the uterus that opens into the vagina), is a threat to women of all ages. It can hit below the belt even in the 30s and 40s when a woman is leading an active lifestyle and least expecting any health problem. It is therefore essential to take proactive steps to safeguard one’s health and get regular check-ups done to catch diseases early when they are creeping up stealthly. Cervical cancer is the third most commonly diagnosed cancer in women, with over five lakh cases every year worldwide, most of which occur in developing countries. There is very low level of awareness of cervical cancer in India, but the disease is nothing to scoff at. It kills a staggering 70,000 women every year in the country. This figure is much lower than the actual figures because many cases do not get diagnosed or reported at all, especially among the poor and in the rural areas. According to one estimate, about 45-80 per cent women can be carrying the cervical-infection caused by human papilloma virus (HPV) at any point of time. There are many strains of this virus, --some of which are high risk and can change the cells of the cervix, creating abnormalities and triggering the cancer. Women may carry the HPV for years and not be aware of it, developing the disease much later. Most of the time, the body’s immune system manages to

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kill the virus, but it is the rest of the time that may prove to be dangerous. 80 per cent of the infection contracted at adolescent age will spontaneously disappear so the first requirement is persistence of HPV infection. Later other factors also contribute in production of disease. Early detection of cervical cancer can save thousands of lives every year because, thankfully, it is one of those rare types of cancer which are detected in precancerous stage and if treated can be completely curable. Its symptoms include abnormal vaginal bleeding, post coital bleeding, inter menstrual bleeding or post menopausal bleeding, excessive vaginal discharge not cured in two to three weeks treatment. 25 per cent of patients remain asymptomatic and can be picked up by routine PAP test. Often, by the time the symptoms of cervical cancer occur and a diagnosis gets done, it may be too late to save the patient. In the US, the five-year relative survival rate of patients with cervical cancer is 91 per cent. If detected at a late stage, the www.expresshealthcare.in

rate drops to just 17 per cent. This shows how crucial it is for this disease to be detected as soon as possible. In early stages, cervical cancer can actually be cured in a single sitting of just one hour and at a fraction of the cost that otherwise would be spent to treat it later using surgery, chemotherapy and radiation therapy. This can save many families from an easily preventable tragedy. A simple pap smear test, costing a mere Rs 350, can diagnose the disease even in the pre-cancer stage by detecting minute changes in cells. It is recommended that every woman above 21 years. should get herself screened every two years as a matter of routine, especially if she is sexually active, even if she is young and has no symptoms or discomfort. The effect of regular screening on cervical cancer deaths is illustrated by the example of the UK where the disease used to claim 150,000 women every year in the 1970s. After the government got aggressive with testing women for cervical cancer, the death toll has now crashed to just 2,000 annually.

To detect cervical cancer even better, a new technology called liquid-based cytology (LBC) has been developed. It has a better prediction value than a pap test and it is worth while the effort to get yourself screened using this because of its many benefits. HPV DNA test can be done from the same sample. In LBC, the sample from the patient is taken in the same way as the pap smear test by collecting cells from the cervix using a spatula/cyto brush-like device. The sample is however not smeared on a microscopic slide (hence the name ‘pap smear’) but put in a glass vial containing preservative fluid. It is then sent to the lab where it is cleaned of pus, mucus and other obstructing material. Once done, a thin layer of cells is deposited on a slide and examined under a microscope to detect the cancer. LBC has resulted in considerable reduction in inadequate rates of cervical samples. It has saved women from a lot of anxiety and the need to go for repeated tests because the sample was found inadequate, which is often the case with the pap smear test. In inadequate cervical samples, obstructing material such as blood and pus do not allow cytologists to see the cells properly and no results can be arrived upon. As a result, the patient has to be called for a re-test. LBC is a major advance in screening for cervical cancer and has proved hugely successful worldwide since its introduction. It today accounts for over 90 per cent of all screening tests done in the US for cervical cancer. Preventive HPV vaccination and screening every alternate year through LBC or pap smear can keep you safe from the scourge of cervical cancer. It is a small price to pay for your health. EXPRESS HEALTHCARE

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

Customised patient instrumentation for total knee replacement Dr Vivek Mittal, Sr Consultant and Joint Replacement Surgeon, Fortis Hospital Shalimar Bagh elucidates on customised patient instrumentation, a new technique for total knee replacement (TKR)

steoarthritis of the knee is a very common problem all over the world. In US alone every year 6,00,000 knee replacement surgeries are done and are increasing at approximately three per cent annually. In Australia, last year approximately 3,80,000 knee replacement surgeries were performed (Australian National Joint Registry 2012), which was approximately 4.5 per cent more than in the previous year. In India, around 20 to 30 crore people suffer from this problem. However, only one lakh total knee replacement surgeries were performed last year. This is proof of the fact that despite a large patient base the number of surgeries is low. High cost of surgery with implants accounting for approx. 40 to 50 per cent of the cost of the package is a deterrent. Though Indian implant is now available and is less expensive, however, it lacks survivorship (longevity) data that is available with the imported implants. The technique is very precise and hence joint replacement surgery is not practised by all orthopaedic surgeons.

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Myths/ apprehensions DR VIVEK MITTAL

Sr Consultant and Joint Replacement Surgeon Fortis Hospital, Shalimar Bagh

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Myth 1: Many people believe that avoiding activities or spending life in bed will preserve their knee joint from damage, or more activities will quickly damage their knee joint Reality: Nothing can be farther from the truth, as “saving the joint” by becoming totally sedentary will not slow down the arthritis. On the contrary, sedentary lifestyle will weaken bones and muscles thereby predisposing your joint to early deterioration. Also routine activities including walking will not make the knee joint vulnerable for arthritis earlier. If you avoid surgery to the very last, then not only will the deformity be complex and severe, however, patient will take that much more time for physiotherapy and to recover completely from surgery. Myth 2: Is there any harm in living with the damaged joints? Reality: Knee replacement surgery is considered only for severely damaged knees and when conservative treatment is not helping any more. Knee replacement surgery reduced pain, corrects deformity, gives independence in activities and brings change in life style for better. However if you choose to live with your damaged joints: 1. You continue to live with pain and walk with difficulty through life - due to the deformed joints. 2. If damaged joint becomes unstable, then you may fall and sustain fracture either around your hips or develop stress fracture along the shinbone (tibia). Your osteoporosis may also worsen as a result of inactivity thereby making your bone more prone to fractures. 3. Deformities and instability will only worsen with age or passage

of time. 4. As pain will force patients for regular consumption of analgesics and antiinflammatory drugs – very likely to damage kidneys and cause ulcers in stomach if taken for long. Myth 3: I am afraid of getting operated in my old age and also the pain thereafter! Reality: Please understand that knee replacement surgery is considered mainly for elderly people. However, this should not create any undue apprehensions. Majority of patients in late 60’s or early 70’s with knee osteoarthritis believe that their life span is too short, unlike the true reality that majority live on for 90 years! Most of the patients believe that they will either have a lot of pain during operation or that after operation they will get up in severe pain. On the contrary they feel no pain during surgery and also within four to five days after surgery (during hospital stay itself), almost all of patients are comfortable enough to ambulate (with support initially), start going to the toilet and are able to climb steps. Myth 4: I am scared that I can become worse after the surgery and are there any risks from the surgery? Reality: Total knee replacement is a highly successful and predictable operation. It has a success rate of over 95 per cent. This means that an overwhelming number of patients reap the benefits of surgery. Most of our patients may be suffering from one or more of the followings ailments, i.e., hypertension, diabetes mellitus, coronary artery disease (MI/angina/heart surgery), asthma, and hypothyroidism. They all are thoroughly medical evaluated by an anaesthetist and intensivist before surgery. As with any major surgery, potential risks are also involved with total knee replacement surgery, however their incidence is small.

Customised patientspecific TKR procedure The techniques in TKR have been constantly evolving although the principles remain the same. Two major ways to perform TKR today are conventional TKR and computer-assisted TKR, and of late, customised patient-specific TKR. Patients are clinically evaluated before operation and then they undergo MRI of the knee and long standing X-rays of both lower limbs. The films and knee MRI are processed through specific programmes to generate a 3-D reconstruct of the patient knee. This 3-D

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reconstruct is then used to create specific zigs to give precise cuts of lower end of femur and upper end of tibia. These zigs also provide accurate sizing of the implant and precise rotational alignment of the implant in patients’ deformed knees. In the end, zigs helps to provide bony cuts which eliminate the patient’s existing deformity and provide perfect longitudinal as well as rotational alignment, thereby restoring good functions.

Merits vs demerits of other techniques 1. Conventional method ● Large number of surgical steps is required for surgery ● Medullary canal of the femur gets violated hence more blood loss ● Implant placement accuracy after surgery is not as good 2. Navigation assisted TKR: Per operation, computer is used to help surgeons achieve more accuracy during surgery. The disadvantages are ● Equipment cost is Rs 60 – 70 lakhs ● Extra time is required to map the operated area on the computer ● Upto 10 per cent outliers, more operation time ● Gives accurate axial alignment but does not give rotational alignment accurately ● Possible risk of fracture after surgery at the site of navigational pins 3. Patient specific zig ● Extra cost of approximately Rs 45000/- per knee ● Gives component sizing, rotational and axial alignment accurately ● Reduced operation steps, less blood loss, less operation time by almost 40 per cent This technique improves alignment and sizing by using computer-generated images of the patient’s anatomy to determine precise bone cuts, and implant positioning during the surgery. It eliminates the need to violate the intra-medullary canal, thereby reducing blood loss during and after surgery and serious complications like fat emboli. As many operative steps are reduced in this technique, and excessive dissection is not required, the operative time for the knee replacement procedure is reduced by half. Less surgery time, less bleeding, less post-operative complications and less dissections allows quick post-operative recovery. As sizing of the implant is done before surgery and many operative steps are not required, less instrumentation is needed in operative room, thereby reducing burden of inventory and autoclaving which in turn reduces burden on the institution. Customised patient-specific instrumentation technique is good for all and includes patient, surgeons and institutions as well. One major downside is the cost involved in the manufacture of this device. It is around $1000, and takes around three to four weeks to deliver. APRIL 2013


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

India lags behind neighbours on key measures of health New online tools announced by Bill Gates and the Institute for Health Metrics and Evaluation show a worrisome picture for Indian health. Ischaemic heart disease is leading cause of death; diet is biggest risk factor. Road injuries’ toll on health is greatly increasing. Excerpts...

A representation of the country specific data visualisation online tool

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ndians are living longer lives, but illness and disability of a very high order and relatively early death is a cause of concern. Healthcare planners and providers are also concerned that with the fact that India appears to be lagging behind many of its South Asian neighbours as well as China on key parameters of health. These are some of the findings from the Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), a collaborative project led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. These findings detail the causes of death and disability – across age groups and genders – for 187 countries around the world. GBD 2010 encompasses researchers from 303 institutions in 50 countries. The work, which generated one billion estimates for health challenges large and small, was funded by the Bill & Melinda Gates Foundation. The full range of dynamic visualisations of GBD findings for India and other countries can be found at http://www.healthmetrics a n d e v a l u a t i o n . o rg / g b d . According the the study, Indians are living longer for sure. Life expectancy at birth was 58.3 in 1990; it went up to 65.2 in 2010. However, most of India’s neighbours were ahead on this measure in 1990, when life expectancy was 58.8 years for Nepal, 58.8 for Bhutan, 58.9 for Bangladesh, 62.3 for Pakistan, 69.3 for China, and 72.3 for Sri Lanka. All of these countries remained ahead of

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India in 2010. Life expectancy at birth in 2010 was 65.7 years for Pakistan, 69.0 for Bangladesh, 69.2 for Nepal, 69.4 for Bhutan, 75.5 for Sri Lanka, and 75.7 for China. In terms of age-standardised death rate, per 100,000 population, India ranked 155 out of 187 countries in 1990. Between 1990 and 2010, there was significant improvement in India in terms of death rates. The number of deaths per 100,000 had come down, in 20 years, from 1,447.43 to 1,096.92. Its neighbours had a mixed record, but they remained ahead. India was ranked 139 out 187 countries in terms of death rate in 2010. Pakistan was ranked 127, Bangladesh 113, Nepal 108, Bhutan 107, Sri Lanka 68, and China 63. All had lower death rates than India. Much of the illness and death in India is caused by a short list of ailments. GBD researchers examined more than 300 diseases, injuries, and risk factors and found that a limited number of distinct causes account for the bulk of the Indian health burden, measured as the number of years lost to disability and premature death. The top cause of death in India, as measured in 2010, was ischaemic heart disease, followed by chronic obstructive pulmonary disease, stroke, diarrhoeal diseases, lower respiratory infections, tuberculosis, pre term birth complications, self-harm, road injury, and diabetes. The presence of road injury in the list of top causes of death is not surprising, given that Indian roads are among the most danger-

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ous in the world with more deaths due to road accidents recorded here than in any other country. India has had great success in driving down the number of young children who die of communicable diseases. The top causes of death of children ages one to four in 1990 were diarrhoeal disease, lower respiratory infection, measles, malnutrition, and meningitis. These top five held relatively steady in terms of rankings over the next 20 years, but the number of deaths due to these ailments decreased by more than 60 per cent for each illness. In terms of sheer numbers, more than 800,000 Indian children ages one to four died in 1990. By 2010, that number was down to 300,000. India has made specific progress in tackling diarrhoeal diseases. No longer the nation’s number one killer; in 2010, it was number four. Indian women are suffering from other distinct health threats. Suicide rates for women ages 15 to 49 are on the rise; in 1990, deaths of young Indian women attributable to self-harm was under 5 per cent, and by 2010 it had reached nearly 10 per cent. Interpersonal violence – usually men assaulting their female partners – also accounts for a rapidly growing portion of health burden for young women in India. Non communicable diseases and injuries are creating more strains on health as communicable diseases and maternal health problems become less threatening. Illnesses such as diarrhoeal disease, lower respiratory infections, tuberculosis, pre term birth complications, malnutrition and neonatal sepsis, and neonatal encephalopathy are all decreasing in terms of rankings and number of lives that they claim each year. Ischaemic heart disease is showing an opposite pattern, growing in terms of number of deaths and relative rankings of diseases. Heart disease was the number four killer of Indians in 1990; it was number one in 2010. The rise of stroke as a cause of death is a matter of concern, as is an increasing number of suicides. In terms of risk factors for death, four of the top five in 1990 remain in the top five risk factors in 2010, though the rankings have changed. In 1990, the top five risk factors were household air pollution from solid fuels, dietary risk

factors, childhood underweight, smoking, including second-hand smoking, and high blood pressure. In 2010, dietary risk factors became number one, followed by high blood pressure, household air pollution from solid fuels, tobacco smoking, including second-hand smoking, and ambient particulate matter pollution. The impact of malnutrition has been greatly reduced. Evidently, while much had changed in 20 years, a lot remained the same – an observation that applies across the board to life in India. The rise of ambient air pollution and hypertension as risk factors can be linked to increased urbanisation and poor lifestyle choices. On the other hand, remarkably, childhood underweight has been pushed down from being the number three risk factor for death in 1990 to number 11 in 2010. And for all the efforts, across platforms, to fight smoking it remained the number four risk factor for death, the very same slot it held 20 years earlier. In terms of disabilityadjusted life years (DALYs), which have been described as a measure of overall disease burden, expressed as the number of years lost due to ill health, disability, or early death, the top five causes in 1990 were diarrhoeal diseases, lower respiratory infections, pre term birth complications, chronic obstructive pulmonary disease, and tuberculosis. But in 2010, the top five causes for DALYs were pre term birth, diarrhoeal diseases, lower respiratory infections, ischaemic heart disease, and chronic obstructive pulmonary disease. “India is facing a difficult set of health challenges. While we have made substantial progress against some diseases and hunger, we still have significant work to do in combating major infectious diseases such as diarrhoea, pneumonia, and tuberculosis, as well as diseases of the newborns. At the same time, we must prepare to grapple with the dangerously increasing burden of non communicable conditions like heart disease, stroke, diabetes, obstructive lung disease, depression, and road traffic injuries. Making lasting health gains in the face of this variety of challenges will require wise planning for universal health coverage in India,” said Dr Srinath Reddy, President of the Public Health Foundation of India. EXPRESS HEALTHCARE

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K|N|O|W|L|E|D|G|E 30 MINUTE INTERVIEW

'FFR is a unique technology which can improve outcomes in multivessel disease' Kaustav Banerjee, COUNTRY MANAGER, ST JUDE MEDICAL- INDIA

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t Jude Medical, a global medical device company, recently conducted a study on the benefits of fractional flow reserve (FFR)-guided stenting in India, the results of which were presented during India Live 2013, the fourth annual National Course on Cardiovascular Interventions organised by Cardiovascular Educational Research Trust. Kaustav Banerjee, Country Manager, St Jude MedicalIndia explains about the study and its findings, in conversation with Raelene Kambli

What were the findings of the study based on FFR-guided stenting in India? The detailed analysis for India was based on the results of the fractional flow reserve (FFR) vs angiography in multivessel evaluation (FAME) study, statistics from country-specific percutaneous coronary intervention (PCI) registries and from published literature. FAME is a randomised, prospective, multi-centre trial which enrolled 1,005 patients with multivessel coronary artery disease. The FAME study compared outcomes for patients whose treatment was guided by FFR to those whose treatment was guided only by angiography using SJM’s PressureWire Certus technology. The 12-month results, published in the January 15, 2009 issue of the New England Journal of Medicine, demonstrated that instances of major adverse cardiac events (MACE) were reduced by 28 per cent for patients whose treatment was guided by FFR rather than by standard angiography alone. What was the rationale behind conducting this study? What were the preparations undertaken to conduct it? What about its funding? St. Jude Medical is driven by the vision to address epidemic diseases (such as atrial fibrillation, heart failure, hypertension, stroke, and chronic pain) with solutions that reduce the economic burden on healthcare systems worldwide. Because of this drive, we sponsor research such as the FFR cost analysis that

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Results from the FAME study demonstrate that after two years, patients with multivessel disease who received FFR-guided treatment had a 34 per cent risk reduction in death or heart attack enables a better understanding of the broader economics of technologies. As the sponsor of not only the cost analysis but the complete FAME family of studies, St Jude Medical is proud to provide the medical community with additional evidence of the important role that the PressureWire FFR measurement technologies play in improving patient care. What are the benefits of FFR guided stenting? How does the use of FFR technology improve health outcomes for patients with multivessel coronary artery disease? Kindly elaborate. There is a growing body of evidence demonstrating improved outcomes and costsavings with PressureWireguided stenting. Some clinical findings about the benefits of FFR: ✦ The recent economic analysis found that PressureWire FFR measurement can improve patient outcomes and potentially save a projected Rs 310 million in healthcare costs over two years. Further, in addition to improving quality of live, use of the PressureWire potentially reduces treatment cost by an average of about $1,250 (Rs 67,700 ) per patient. ✦ The original FAME trial sought to determine the outcomes of patients with multivessel disease whose treatment was guided by FFR to those whose treatment was guided only by angiography, and found that FFR-guided treatment was better than angiography alone. From this study we learned that instances MACE were reduced by 28 per cent for patients whose treatment was guided by FFR rather than by standard angiography alone. www.expresshealthcare.in

Two-year results demonstrated that patients with Multivessel disease who received FFR-guided treatment continued to experience improved outcomes over time, including a 34 per cent risk reduction in death or heart attack. ✦ The FAME II trial sought to confirm that it is beneficial for patients with one, two and three vessel disease whose ischemia has been documented by FFR. In this study, all patients received PressureWire measurements, and were then randomised into PCI plus medical treatment (MT) to MT alone. The FAME II trial demonstrated that when there is a significant blockage of blood in the heart, that stenting is better than medical treatment alone when treatment is guided by FFR measurement using the PressureWire. Initial results also suggest that there is a highly statistically significant reduction in the need for hospital readmission and urgent revascularisation which can be considered a surrogate for a repeat heart attack or death - when FFRguided assessment was used to direct treatment in patients. You also say that this technology prevents heart attacks and saves lives. Kindly provide rationale for this statement. Results from the FAME study demonstrate that after two years, patients with multivessel disease who received FFR-guided treatment had a 34 per cent risk reduction in death or heart attack when compared to the group who were treated with only angiography. Is this a cost effective technology? If yes, how?

The PressureWire is a cost saving technology. The cost analysis in India found that an FFR-guided approach to stenting is cost-saving within the Indian healthcare system. This means that use of FFR technology improves health outcomes for patients with multivessel coronary artery disease at lower costs when compared to using only angiography. The Indian results are consistent with previous analyses, which revealed that use of the PressureWire technology to guide stenting procedures can improve patient health while significantly saving money in the context of the Australian, French, German, Italian, Swiss, Belgian, UK., and US healthcare systems. These lower healthcare costs were a result of reduced procedural costs, reduced follow-up costs for major adverse cardiac events and shorter hospital stays. What kind of response did you receive for this study when you presented it at the India Live 2013, the fourth annual National Course on Cardiovascular Interventions? When the study was presented by Dr Upendra Kaul, Executive Director & Dean, Fortis group of hospitals in NOIDA and New Delhi there were approximately 200 doctors present in the audience. Most of the doctors were keen on understanding how the cost savings of Rs 310 million was arrived at as per the cost effectiveness study and were discussing with Dr Kaul to understand more. We could see a healthy consensuses among the participants that FFR is unique technology which can improve outcomes in multivessel disease while at the same time being cost effective for the patient. Are there any specific plans in the pipeline in relation with the study? FFR is an important technology, and we expect that additional data from the FAME and FAME II studies will be presented as and when it is available. raelene.kambli@expressindia.com

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K|N|O|W|L|E|D|G|E 30 MINUTE INTERVIEW

‘Creating awareness is the key to bring down HIV/AIDS within any country’ Christine Bowtell-Harris, CLINICAL NURSE SPECIALIST AT ALFRED HOSPITAL, MELBOURNE AREA, AUSTRALIA

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Adele Lee-Wriede, SUPERVISING SCIENTIST, CLINICAL RESEARCH LABORATORY CENTRE FOR VIROLOGY, MELBOURNE, AUSTRALIA

t is imperative that every healthcare professional working in the field of HIV/AIDS have adequate training on HIV/AIDS clinical care - its epidemiology, pathogenesis, good laboratory practices and a humane approach to dealing with the concerns of stigma that the HIV positive patient may face. Raelene Kambli catches up with Christine Bowtell-Harris, Clinical Nurse Specialist at Melbourne’s Alfred Hospital, Adele Lee-Wriede, Supervising Scientist at the Melbournebased Clinical Research Laboratory Centre for Virology, and Alison Duncan, Senior Clinical Pharmacist, at Melbourne’s Alfred Hospital who recently conducted a national programme on HIV/AIDS and antiretroviral therapy in association with CII and the Australian India Council. The clinical session acted as a platform for medical professionals to know more on the subject.

Excerpts...

Alison Duncan, SENIOR CLINICAL PHARMACIST, ALFRED HOSPITAL, MELBOURNE, AUSTRALIA

What is the current status of HIV/AIDS globally and particularly in India? There are approximately 34 million people in the world living with HIV and 2.4 million in India.About 50 per cent of those infected with HIV are women. In India, the epidemic started later than in many other parts of the world and initially the focus was on sex workers and truck drivers. Now, the HIV epidemic affects all parts of the Indian society. Why is it so difficult to cure HIV and AIDS? What are the treatment options available to Indians? HIV is an unusual virus. In an infected person the HIV replicates in immune cells and during replication it changes its genetic material. This means the immune system is always "on the back foot"- it cannot keep up with the changing virus to control it. So antiretroviral therapy (antiHIV drugs) are needed to try and slow down HIV replication so that it is present in very very low levels in the blood and organs.Then the damage to the immune system caused by HIV is so minimal that people on treatment can live a normal

APRIL 2013

life span. India is incredibly fortunate as it has a number of companies, e.g. Cipla, that make drugs to treat HIV. So excellent treatment is available and at a fraction of the cost than in countries like the US. There is currently no cure for HIV. Research to find a cure is still at a very early stage. What is antiretroviral therapy? How is it helpful in treating HIV/AIDS? Antiretroviral therapy is a treatment that suppresses HIV to undetectable levels in the blood and organs. If people with HIV, who have evidence of some damage to their immune system are prescribed antiretroviral drugs then they must take them without missing a dose. Missing doses, even one pill per month, can result in the development of resistance so that the drugs don't work.Taken regularly, the drugs stop the virus from replicating and thus keep the immune system healthy so that people don't get AIDS. This means that they can potentially have a normal survival. A young man aged 20 years old with HIV who starts treatment and doesn't miss doses of his pills can expect to live until he is about 70 years old. Is antiretroviral therapy the only treatment available for HIV/AIDS? And what are the benefits of antiretroviral therapy over other available vaccines? There is no HIV vaccines that works at present although there is an ongoing research happening in this sphere. The drugs can prevent AIDS from developing and prevent people from dying: no vaccine can do this. Are there any precautions that need to be taken before initiating antiretroviral therapy? Are there any side-effects associated with this therapy? Before starting antiretroviral therapy the HIV+ person should have a blood test to make sure he/she fits the Indian government criteria for treatment. It means taking a CD4 test which shows that there has been some damage to the immune system. It is particularly important that if any pregnant woman seeks www.expresshealthcare.in

medical advice to see if she has HIV infection and then receives appropriate treatment then her baby can be protected from HIV infection. Many people do not know that they have HIV infection as some people have no symptoms until significant immune damage has occurred. Every drug potentially has side effects and antiretroviral drugs are no exception. The benefits of antiretroviral drugs generally outweigh the risks of side effects. Many harmful side effects can be prevented by careful monitoring in the clinic. Today, experts around the world speak of highly active antiretroviral therapy. So is this therapy available in India? Yes, highly active antiretroviral therapy is available in India and is the usual treatment that is provided when HIV treatment is advised. How is highly active antiretroviral therapy better than antiretroviral therapy? Highly active antiretroviral therapy or HAART is a combination of drugs and it has been shown that resistance to HIV is less likely when a combination of drugs is used.This is the same for TB treatment. HAART is even available in a single pill (that is three drugs in one pill) to save the person from taking multiple pills. Are we any close to finding a complete cure for HIV/AIDS? While we hear about seeking a possible cure for HIV we should acknowledge that this is a long way off and indeed may never happen. Instead we should reflect on how well we can control HIV infection these days with highly active antiretroviral therapy. HIV is just like diabetes: good treatment is available and that can keep the person healthy for life. India is particularly fortunate in having excellent pharma like Cipla who produce these drugs at a fraction of the cost and as a result have dramatically reduced mortality from HIV infections in resource limited countries around the world. Moving forward, please tell us about your reason to visit India?

We were here to conduct capacity building clinical care session in collaboration with the CII, Indian Business Trust for HIV/AIDS (IBT) and the Australia India Council (AIC) for medical professionals to enhance their skills while providing care and treatment to people living with HIV/AIDS. So please tell us more about the programme and its key focus areas? The programme was conducted to bring together the medical professionals on a common platform to learn from each other’s experiences in dealing with the issue of HIV/AIDS, to provide an interactive and educative environment to discuss various issues related to the treatment of HIV/AIDS patients. Topics covered over the one day programme included the epidemiology and pathogenesis of HIV, basic anti-HIV treatment, opportunistic infections, HIV infection and laboratory tests for HIV monitoring, medication counselling, psycho-social issues, HIV in pregnancy, post exposure prophylaxis and universal precautions. What was the response you received for the programme? We received a very good response. What we felt is that doctors, nurses and other medical professionals are very interested in learning more on how to provide better care to people living with AIDS. You having been conducting this programme in India since 2003.What are the changes that you have seen in treatment available and perspective of people toward AIDS? The outlook of people in India is changing. They have become more aware about the disease and are socially excepting people living with AIDS. I will say that this credit goes to the Government of India and the healthcare professionals from the country who have taken continuous measures to bring down the toll and especially in creating more awareness. Creating awareness is the key to bring down HIV/AIDS within any country. raelene.kambli@expressindia.com

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Radiology HIGHLIGHTS

US FDA to review Piramal Imaging’s investigational PET amyloid imaging agent [18F] florbetaben is being studied to determine its potential ability to detect beta-amyloid plaques in living subjects with cognitive impairment iramal Imaging, a division of Piramal Enterprises, recently announced that the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have accepted its applications for review of the investigational PET amyloid imaging agent [18F] florbetaben. A New Drug Application (NDA) was submitted to the US Food and Drug Administration (FDA) and a Marketing Authorization Application to the EMA for [18F] florbetaben use in the visual detection of beta-amyloid in the brains of adults with cognitive impairment who are being evaluated for Alzheimer's disease and other causes of cognitive decline. [18F] florbetaben binds to beta-amyloid plaques in the human brain, a hallmark characteristic in Alzheimer's disease. Today, Alzheimer's disease is usually diagnosed after a person with a cognitive impairment undergoes an extensive clinical examination which typically includes family and medical history, physical and neurological examinations, laboratory tests, and imaging procedures such as computed tomography (CT) and magnetic resonance imaging

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(MRI) scans. Still, a definitive diagnosis of Alzheimer's disease can only be made after death where an autopsy can reveal the presence of beta-amyloid plaques and neurofibrillary tangles in the brain. However, postmortem studies looking for accumulations of beta-amyloid in the brain have shown that 10 to 30 per cent of diagnoses based on clinical examinations are incorrect. [18F] florbetaben is being studied to determine its potential ability to detect beta-amyloid plaques in living subjects with cognitive impairment. The submission of [18F] florbetaben is based on the results of a broad clinical programme including a pivotal multi-centre Phase III trial. This was the first study of a direct comparison between in-vivo PET imag-

The acceptance for review of [18F] florbetaben marks an important milestone in clinical research on Alzheimer's disease

ing of the brain using [18F] florbetaben and the postmortem analysis of brain tissue. The study was performed to confirm that [18F] florbetaben binds to betaamyloid in the brain at the regional level and is diagnostically useful on the subject to exclude Alzheimer's disease. The presence of betaamyloid in histopathological sections taken from the brains of deceased subjects was directly matched to [18F] florbetaben uptake in the identical regions of interest. The visual assessment procedure proposed for routine clinical practice demonstrated 100 per cent sensitivity, 92 per cent specificity, and excellent inter-reader agreement (kappa = 0.88). In addition, a subsequent study looked across 461 images from Phase I, II, and III studies to validate that the visual assessment method, taught by an electronic tool, is reliable (kappa = 0.87). “The acceptance for review of [18F] florbetaben marks an important milestone in our clinical research on Alzheimer's disease. The addition of [18F] florbetaben PET imaging to the current clinical evaluation of people suffering from cognitive decline may help to increase

the diagnostic confidence of physicians addressing a significant medical need by providing earlier and more robust information to people and their caregivers. We also see a potential for our product to contribute in the future to the early detection of Alzheimer's disease and facilitate specific treatment decisions,” said Dr Ludger Dinkelborg , Director of the Board, Piramal Imaging. Renaud Dehareng, CEO, IBA Molecular, also welcomed the acceptance for review of [18F] florbetaben. In 2012 IBA Molecular and Piramal Imaging signed an agreement to the effect that IBA Molecular would manufacture and distribute [18F] florbetaben upon regulatory approval in both the US and Europe. The company owns and operates a network of 54 PET isotope facilities worldwide, a network that is unique in both size and scope. Dehareng said, “We believe our network of PET isotope facilities is well positioned to maximise patient access to [18F] florbetaben and is strongly committed to providing our customers and their patients with the best quality product and service possible.” EH News Bureau

MRI shows brain abnormalities in migraine patients According to WHO more than 300 million people suffer from migraine new study, published online in the journal Radiology, suggests that migraines are related to brain abnormalities present at birth and others that develop over time.

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Migraines are intense, throbbing headaches, sometimes accompanied by nausea, vomiting and sensitivity to light. Some patients experience auras, a change in visual or sensory function www.expresshealthcare.in

that precedes or occurs during the migraine. More than 300 million people suffer from migraines worldwide, according to the World Health Organization. Previous research on

migraine patients has shown atrophy of cortical regions in the brain related to pain processing, possibly due to chronic stimulation of those areas. Cortical refers to the cortex, or outer layer of APRIL 2013


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the brain. Much of that research has relied on voxel-based morphometry, which provides estimates of the brain’s cortical volume. In the new study, Italian researchers used a different approach: a surface-based MRI method to measure cortical thickness. “For the first time, we assessed cortical thickness and surface area abnormalities in patients with migraine, which are two components of cortical volume that provide different and complementary pieces of information,” said Massimo Filippi, Director of the Neuroimaging Research Unit at the University Ospedale San Raffaele and Professor of neurology at the University Vita-Salute’s San Raffaele Scientific Institute in Milan. “Indeed, cortical surface area increases dramatically during late fetal development as a consequence of cortical folding, while cortical thickness

changes dynamically throughout the entire life span as a consequence of development and disease.” Dr Filippi and colleagues used magnetic resonance imaging (MRI) to acquire T2-weighted and 3-D T1weighted brain images from 63 migraine patients and 18 healthy controls. Using special software and statistical analysis, they estimated cortical thickness and surface area and correlated it with the patients’ clinical and radiologic characteristics. Compared to controls, migraine patients showed reduced cortical thickness and surface area in regions related to pain processing. There was only minimal anatomical overlap of cortical thickness and cortical surface area abnormalities, with cortical surface area abnormalities being more pronounced and distributed than cortical thickness abnormalities. The presence of aura and white matter hyperintensities—areas of

high intensity on MRI that appear to be more common in people with migraine— was related to the regional distribution of cortical thickness and surface area abnormalities, but not to disease duration and attack frequency. “The most important finding of our study was that cortical abnormalities that occur in patients with migraine are a result of the balance between an intrinsic predisposition, as suggested by cortical surface area modification, and disease-related processes, as indicated by cortical thickness abnormalities,” Dr Filippi said. “Accurate measurements of cortical abnormalities could help characterise migraine patients better and improve understanding of the pathophysiological processes underlying the condition.” Additional research is needed to fully understand the meaning of cortical abnormalities in the pain processing areas of migraine

patients, according to Dr Filippi. “Whether the abnormalities are a consequence of the repetition of migraine attacks or represent an anatomical signature that predisposes to the development of the disease is still debated,” he said. “In my opinion, they might contribute to make migraine patients more susceptible to pain and to an abnormal processing of painful conditions and stimuli.” The researchers are conducting a longitudinal study of the patient group to see if their cortical abnormalities are stable or tend to worsen over the course of the disease. They are also studying the effects of treatments on the observed modifications of cortical folding and looking at pediatric patients with migraine to assess whether the abnormalities represent a biomarker of the disease. EH News Bureau

EOS imaging receives FDA clearance for 3D imaging software Features post-operative hip implant assessment existing EOS customers as a software upgrade and will be included in all new system sales. Marie Meynadier, CEO, EOSimaging, said,“The introduction of hip arthroplasty post-operative 3D imaging to the EOS System answers growing challenges in orthopedic surgery postop evaluation. It also provides the first weight-bearing 3D solution to enhance the understanding and, ultimately,treatment of total hip replacement complications such as dislocations and wear. Ongoing research supports the unique value of EOS in understanding the relation between implant position, pelvic mobility and patient function,therefore improving treatment and patient outcomes in joint arthroplasty.”

OS imaging, the pioneer in 2D/3D orthopedic medical imaging, announced that its nextgeneration sterEOS3D imaging software, sterEOS 1.5, has received 510(k) clearance from the US Food and Drug Administration (FDA). The sterEOS software provides 3D modelling of the spine and lower limb based on scans taken with the EOS System, and automatically calculates over 100 clinical parameters relevant to diagnosis and surgical planning. The new sterEOS 1.5 offers expanded calculation and analysis, with new capabilities to measure hip implant component position for surgery control and revision. Other key features include 3D modelling of severe scoliosis (Cobb angle above 50°). It will be made available to

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HOT SEAT

A doctor by heart; a friend by nature Knowledgeable, dependable, compassionate, realistic and spirited are just few ways to describe Dr BS Singhal who has completely dedicated his life to serve people by ridding them of ailments that afflict the most complex of organs: the brain. Raelene Kambli meets this expert neurologist to know more about his life's journey eople living with Parkinson’s Disease lead an extremely difficult life. Apart from the typical motor symptoms, these patients also suffer from acute depression and treating such patients requires a lot of expertise. Hence, it is a comforting prospect that we have noble doctors who work to mitigate the suffering of these patients. Dr BS Singhal, Director of the Neurology Department at the Bombay Hospital and founding member of the Parkinson’s Disease and Movement Disorder Society is one such doctor who has spent more than 50 years in service of people suffering from neurological disorders. A pioneer in the field of modern neurology in India, he has worked very hard and burnt the midnight lamp in order to decipher the brains of several such people. In fact, he is much admired for his ability to deal with patients suffering from Parkinson’s, Multiple Sclerosis, Megalencephalic Leukodystrophy, Myelopathy associated with Eales’ disease and Myasthenia Gravis. Within the industry, Dr Singhal has a reputation as one of the most active neurologists. He has been the postgraduate teacher for DM Neurology of Bombay University since July 1970 and an examiner for DM neurology for several universities in India and for the National Board, New Delhi. Additionally, he has been organising ‘Neurology Updates’ (continuing medical education programmes) since 1996 by inviting leading experts in neurology from overseas for the benefit of neurologists from India and neighbouring countries. He is also on the Editorial Board of Neurology India, Annals of Indian Academy of Neurology and is a member of the International Advisory Committee of the Archives of Neurology. Dr Singhal has several prestigious awards in his kitty that includes: Dr BC Roy National Award for Development of Neurology in India, Priyadarshini Academy National Award for outstanding contribution in the field of Medicine, the Wockhardt Award for Medical Excellence in Neurology [organised by the Harvard Medical International] and

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the Dhanvantri Award. Fellow neurologists revere him as a guide and for his patients, he is no less than a saviour. Recently, he was bestowed with the 27th RD Birla National Award for his contribution to the field of modern medicine and neurology. And this occasion gave me an opportunity to meet with this distinguished man in person. I didn't want to lose my lucky chance. So, I convinced him to spare an hour for me and he acquiesced, asking me to proceed to his office and wait for some time. While I waiting to interact with Dr Singhal, I had a hundred questions popping in mind. Questions about the human brain, its functions and its aliments, about Parkinson’s and Multiple Sclerosis as well as of his life’s experiences as an expert neurologist of the country. Amidst this medley of thoughts, he arrived and invited me inside his office. My first impressions about Dr Singhal was that he has a radiant personality and his poise was a testimony

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to his experience and achievements earned through these years. His deep yet soothing voice had the ability to put anyone at ease. A great quality for a doctor to possess. Certainly, his patients would be delighted to have him as their doctor-cum-friend and would find it very easy to confide their problems to him. With a warm smile he asked me about purpose of this meeting and thus began this interesting tète-à-tète. I started of by asking him about the transitions that he has witnessed in the field of neurology; especially in India. On this he replied, “The practice of neurology has evolved in leaps and bounds. The study of the human brain is very complex and has many facets that still remain mysterious, but while aiming at treating the physical disorders of the brain, there have been many breakthroughs.” He then spoke on the neurological disorders that are affecting the Indian population and informed, “Epilepsy and stroke are some of the common worries in India. Among the medical conditions affecting the aged population are dementia and Alzheimers, which are known to all. But there is another illness called the Parkinson’s that has being increasing in India because of the demographic changes within the country and a growing number of aging population. This particular disease needs a lot of attention, especially in India and Parkinson’s Disease and Movement Disorder Society is working towards providing a better life to these people. Under the Society, we have introduced various holistic programmes for these patients such Iyengar yoga, dance and music that helps these patients regain their mobility, self control and confidence. We also reach out to people who cannot come to us. In such cases, we go to their house to provide them with the care that they need. I believe that treating Parkinson's disease is beyond medicine, we have to have a holistic approach in treating this disease. Our motto is, ‘I have Parkinson’s but Parkinson’s does not have me,’ which means that patients should live a normal life even with the disease. For this, on APRIL 2013


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the April 11, which is World Parkinson’s Day, we as a Society will be organising various programmes to create more awareness about the disease as well as help more patients in managing the disease.”

Growing up Our conversation then moved on to his early days of schooling, medical education and becoming an established neurologist. Reminiscing about his childhood days he said, “I was born in Mount Abu and my school was adjacent to the Adams Memorial Hospital serving the population. Everyday, my friends and I, after finishing all our school activities visited the hospital. As young lads we used to volunteer to assist the hospital staff in providing services to the patients. Though we couldn't do anything much, this somehow cultivated the aspiration of becoming a doctor within me.” Then he revived the memories of his medical education and the initial days of his career. He recollected, “I graduated from Grant Medical College, where I also did my post graduation studies in internal medicine. During those days, I was working under Dr Noshir H Wadia who was also my teacher and my role model. Dr Wadia and Dr RV Sathe really groomed me and got me interested in the field of neurology. So after completing my studies I went to England and started working in the neuro department and finally I was selected as a resident neurologist associated with the Institute of Neurology at England, which was the mecca for neurology at that time. There I got further training in treating and caring for the patients after which I returned to India in 1962 and was very lucky to be appointed at the Grant Medical College as a Honourary Doctor for Neurology. I also worked at the JJ Group of Hospitals and the Bombay Hospital. I have spent 50 years at Bombay Hospital which I regard as the most precious years of my career. As I continue to work at the Bombay Hospital I feel that my learning period is still on.”

Dr BS Singhal with his family is acknowledged to be an excellent teacher. People say that he is among those teachers who act as a bridge over which their students can cross and after having facilitated their crossing, joyfully collapses, encouraging them to create bridges of their own. So I asked him how he feels about being a teacher and how would he define the role of a teacher. He reciprocated, “I love teaching. Teaching plays a very important part of my life. For me, teaching is like learning. When I prepare myself to give a lecture I spend a lot of time doing research based on the topic so this helps me update my knowledge as well. Moreover, students these days pose different kinds of questions related to neurology and this keeps me on my toes. I have to keep reading a lot for this reason.”

A family man too.. More like a friend.. Knowledge, attitude and skill is the triad, which define a good doctor and Dr Singhal possesses each of these attributes. This became very clear when Dr Singhal shared few incidences which helped him grow as a specialist in neurology. He said, “What I enjoy most is listening to the patients. I don’t like to interrupt them when they talk and I like to keep my eye contact with them. This makes them feel at ease when they are with me. Patients should not feel that they are visiting a doctor; instead they should feel that they are visiting a friend who is there to help them in times of need. When my patients find their comfort, I feel very satisfied.” So, this is how Dr Singhal builds an amiable relationship with his patients, where he treats them just like a friend and help them find comfort in sharing their difficulties with him.

For the love for teaching Taking the conversation forward, he shared his experience as a teacher. He APRIL 2013

We then spoke about his family. Interestingly, Dr Singhal comes from a family of doctors. His wife, Dr Asha Singhal is a renowned gynaecologist working with the Bombay Hospital. Their daughter, Dr Seema Singhal is an expert in Multiple Myeloma and is responsible for changing the treatment for this disease by introducing thalidomide. She is currently working as the Professor of Oncologist at the North Western University in Chicago. Her husband, who is also a physician, has worked along with her to conduct research in myeloma. Dr Singhal's son, Dr Anish Singhal is currently the Associate Prof of Neurology at the Howard University and specialises in the field of stroke management. Dr Singhal is very happy that his children have also chosen a vocation that will help people deal with difficult medical conditions. He is a proud father when he delightfully informs about his son’s vision for India. He says that his son has initiated a collaborative programme with five

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institutions of India in order to promote treatment for stroke. This collaboration is done between National Institute of Health, US and the Government of India. While Dr Singhal was speaking about his family, his love and pride in them was quite evident. Indeed, Dr Singhal is very close to his family. He then spoke about the most inspiring person in his life- his mother. He has great reverence for her and says that his mother has been the wind beneath his wings. He recalls the time he spent with her and says, “I lost my father when I was very young and my mother raised me up single-handedly. She gave the encouragement I required to become what I am today. She had a heart of gold indeed. Even when I made my choice to travel to Mumbai and London to seek further education, she acceded to my will. As our talk became a bit emotive, we quickly moved to discussing his hobbies.

The other side of him Dr Singhal is an avid traveller. He loves to see the world. He is also a people's person and does take time off from his busy schedule to socialise. But when is not travelling or socialising you will find him reading a book. His favourite reads include autobiographies of scientists and famous personalities such as the former presidents of various countries. On a lighter note he prefers to read fiction. Engrossed in knowing about the multiple facets of Dr Singhal's intriguing personality, I didn't realise that quite some time had elapsed and now I had to bid adieu. Though disappointed at having to culminate our interesting conversation, I was also happy at having met an interesting personality who was was not only an expert neurologist whose aim is to heal a diseased body, but also a good social being whose practice contributes to the betterment of the afflicted. raelene.kambli@expressindia.com EXPRESS HEALTHCARE

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People Dr Devi Shetty bags IMC Juran Quality Medal 2012 The award was given away by the Chief Guest Dr Justice CS Dharmadhikari

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MC’s Ramkrishna Bajaj National Quality Award Trust presented the IMC Juran Quality Medal to Dr Devi Shetty, Chairman, Narayana Hrudayalaya Group of Hospitals, recently at the YB Chavan Centre. The IMC Ramkrishna Bajaj National Quality Awards were also presented at the same event. The awards, presented to 25 organi-

Technology gives the rich what they already have and the poor something which they could never get sations from manufacturing, service, small business and education were given by the Chief

Guest for the ceremony, Dr Justice CS Dharmadhikari. Viren Prasad Shetty,

Sr President, Narayana Hrudayalaya Group of Hospitals accepted the award on behalf of his father Dr Devi Shetty. “Technology gives the rich what they already have and the poor something which they could never get. We have to invest a lot in technology and this award will make us achieve our goals faster,” read Dr Shetty’s message.

Utkarsh Palnitkar joins KPMG He takes charge as KPMG India's new National Head of Transactions & Restructuring and Life sciences practices

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PMG in India has appointed Utkarsh Palnitkar as Partner & National Head of Transactions & Restructuring practice and National Head of Life sciences practice. Utkarsh Palnitkar joins KPMG from Centrum Capital, where he was an Executive Director. Prior to this, he was associated with Ernst & Young (E&Y)for 15 years. During this period, he was the leader of Advisory, as well as the Life sci-

ences practice, while also being the office managing partner of E&Y’s Hyderabad practice. Speaking on his appointment, Utkarsh Palnitkar said, “I am honoured to be given the opportunity to lead this tremendously talented group of professionals at KPMG. I am also very optimistic about our combined ability to grow both the businesses in this environment. We seek to capitalise on these positive fundamentals through

further deepening our sector skills, while expanding the spectrum of deal services to add value to our clients.” Richard Rekhy, Chief Executive Officer, KPMG in India said, “We are delighted to welcome Palnitkar into the KPMG family. An industry veteran, Palnitkar has a vast experience across life sciences, business advisory, government, real estate and infrastructure advisory. Several of the practices he

led were market leaders amongst the Big Four. I am confident that under his able leadership, the Transactions & Restructuring business will see exponential growth in the coming phase.” Co-chairman of the National Biodesign Strategy Committee of the Government of India, Palnitkar has also been a member of several life sciences committees in India and overseas.

Sunil Kapur joins Rockland Hospitals He would join as a Director (Business)

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unil Kapur has joined Rockland Hospitals as Director (Business). He is credited with successfully introducing the best sales and marketing practices from diverse domains into the healthcare domain. He is known for his pioneering efforts in making India a preferred destination

for international patients and for his contribution in linking remote areas to centers of excellence within India in the best interest of the patients. A senior professional with over 32 years experience, Sunil has spent a significant time in healthcare operations as well as marketing in leading institutions. He

has worked across diverse industries viz. hotels, automobiles, retail, media, healthcare and pharmaceuticals. Sunil has had a successful track record working with companies like Oberoi Hotels, Hero, HT, Reebok, Apollo Hospitals, RG Stone, Fortis Healthcare and Nova Specialty Surgery.

Dr VK Singh joins Canadian University Appointed as Adjunct Research Professor of Ivey School of Business, University of Western Ontario, Canada

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urgeon Rear Admiral (Retd) VK Singh has been appointed Adjunct Research Professor of Ivey School of Business, University of Western Ontario, Canada. He would be engaged in teaching and research of health innovation. Thus Dr Singh would be instrumental in bringing this new initiative to the

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Indian health sector. Dr Singh has extensive experience in various fields including hospital designing and planning, quality principles, patient safety, hospital acquired infection, disaster planning, strategic management, health care innovations, rural health planning etc. He is on the advisory

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board of many hospitals and is a visiting faculty, as well as an examiner of many reputed institutes and universities. He has served as Dy Chief Medical Officer of United Nations and has received many awards and accolades. Currently, he is the Chairman, Health Care Division of Quality Council of India;

Member of International Working Group on Biosafety; Executive Member of Telemedicine Society of India; Member of National Health Committee of Confederation of Indian Industry (CII), and Director Healthcare Asia for Lean Healthcare ExcellenceSimpler.

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Arts & Commerce of Hospital Management The book provides unique approach to managerial issues based on structure, strategy and system and the organic model built on the development of purpose, process and people aving ushered into the second decade of the new millennium, the healthcare sector has introduced cutting edge technology replacing the obsolete ones. This publication was launched in view of the fact that hospitals are facing a dearth of managerial skills, stringent competition, resource crunch and losing touch with patients. The need of the hour is knowledge-based performance that considers management issues in par with medical issues. The book is divided into two parts. The first part deals with a series of psychosocial paradigms of hospital management penetrating areas such as: leadership, motivation, morale, human relations at work and industrial relations. This text enables healthcare managers to develop expertise in motivating workforce for attaining better results. A unique feature of this book is on decision making as hospitals of today require accuracy and mere guess work and lose unpaid opinions could be expensive and risky. Formation of hospital policy manual is equally important and managers can develop the art of writing hospital policies and implement in their set up. The book provides a unique approach to managerial issues based on structure, strategy and system and the organic model built on the development of purpose, process and people. It gives an insight into the intricacies of hospital management with suitable illustration and case study more than what one could get in a regular course. Readers could find answers to some of the mind boggling questions faced by healthcare sector such as: ✤ How can hospitals optimise costs and resources through profit centres? ✤ How can hospitals retain doctors and knowledgeable staff happy on the jobs? ✤ How can hospitals deal with VIP customers? ✤ How can hospitals develop technical skills to convince patient’s attendants in case of death? ✤ How to control costs and yet provide quality care? ✤ How can hospitals develop leadership style that encourages teamwork?

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Title: Arts & Commerce in Hospital Management Author: Joshua Khan P.G.D.H.A. H.R. (Italy) Edited by: Late Dr PN Ghei Preface by: Dr (Brig) OP Khanna (AIIMS) & Dr AP Chaudhari Price: Rs 395/-

The second part of the book deals with promoting and commissioning of new hospitals. It reflects current thinking of leading promoters and gives an overview of the future trends in medical profession. The key to success of any hospital vests in patient satisfaction and the scope of this book is to make hospitals fully conversant with this device. The concept has brought about significant improvement in the rate of occupancy and turnover as the country witnesses a shift in patient’s preference for private and voluntary hospitals over government hospitals. Hospitals aspiring to compete for a substantial market share would have to adopt scientific management and marketing techniques. Patients, who were not too long ago, were satisfied with what was given, now desire much more. If a hospital is not able to come up to their expectations, they have no hesitation in trying out another. Hospitals would therefore, have to direct their efforts towards optimum utilisation of resources: man, money, machinery, materials market and matching skills. However, an alignment of these factors does not come automatically with complex factors in the environment. A good sense of coordination between management, staff, consultant and public awareness is pre-requisite for achieving the ultimate goals. The entire organisational strength must focus on attaining the target market. Questions that hospitals may like to contemplate are: ✤ How to attract potential customers and retain the present ones? ✤ How to plan in order to secure future customers for available facilities? ✤ How to develop a pricing structure and communicate as a user friendly hospital? ✤How to differentiate your services so as to create preference in the minds of public? ✤ How to gear up yourself to face a competitive situation? ✤ How to get public response that fulfills hospital’s objectives?

Instant Solution To Hospital Problems The book makes healthcare providers realise the importance of streamlining their processes with an eye on the bottom line odern hospital care essentially involves three parties: the consumers (patients), the professional medical care provider and the management professional. The consumers expect state-of-the-art medical care at an affordable cost, tempered with humanitarian considerations. Medical professionals face constant pressure and demand for competent care and hence need to keep abreast with rapidly advancing technology in their chosen fields of specialisation. Given these requirements, professional managers need to provide expert inputs to fulfill the aspirations by optimising management of personnel, money, material and most of all, time. The current scenario of hospital care in the country leaves much to be desired. The consumers complain of exorbitant cost and poor communication by the busy doctors. Hard pressed for time, the medical professional can barely upgrade his knowledge and

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Title: Instant Solution to Hospital Problems Author: Joshua Khan P.G.D.H.A. H.R. (Italy) Edited by: VV George, Manager, Bank of India Preface by: Dr Kanwar K Kaul, Prof Emeritus of Pediatrics and Former Dean of NSCB Medical College Price: Rs 325/-

APRIL 2013

skills and spend time with his family. The situation is worse if he happens to be the owner and manages hospital himself, little realising the need for expert management for which he is not competent and at best be left to professional manager. The increasing cost of quality medical service and equipment have pushed hospitals run on limited charities into oblivion as it is being realised that such care cannot be provided cheaply. Private hospitals have therefore, emerged rapidly and in large numbers. In view of lack of quality control, not all of them provide the desired quality care but certainly serve the needs of some less privilege communities at lower costs with somewhat better personal attention than they get in government hospitals. Professional managers need to address themselves to the scenario described with the object of optimising management personnel, equipment, time www.expresshealthcare.in

and money. They also need to find instant solution to problems arising in day-today working. Times have changed and so should the healthcare providers. Large numbers of hospitals are opened by doctors thinking that healthcare is something that will sell irrespective of what is being sold. In today’s scenario patient is king and he can afford to choose what he wants. Transparent processing can win the heart and mind of the public at large. However, this calls for formidable skills on the part of the promoters, which includes knowledge, communicative skills and an insight/foresight into present and future prevalence of the disease in a given community. The book makes healthcare providers to realise that economics is the bottom line of everything which cannot be flouted. Hospitals of today and tomorrow can no longer operate manually and requires a system that is fun-

damental for its success. With phenomenal advancements in digital and high imaging technology that has dramatically transformed the way medical practitioners and specialists diagnose and treat morbidities. There has been a paradigm shift in the speed, accuracy and ease with which diseases are being treated today. We can only expect exponential increase in its power and applicability in the coming years. Over the last three decades, IT has been very effectively used in commercial enterprises to streamline business processes, for managing large volume transaction processing supply chain and customer relationship management. With large number of transactions in departments such: as outpatient registration, operation theatre, inpatients data file, pharmacy, investigations and accounts demands for computerised system to store and retrieve data as and when needed. EXPRESS HEALTHCARE

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Trade & Trends Early rehabilitation: Reducing the financial impact of intensive care M An article outlining how to improve and optimising the operations of ICU and cut costs at the same time

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uch has been written regarding the negative impact both physically and psychologically as a result of a period of critical illness. From a physical perspective, muscle wasting and weakness are common and are more likely with prolonged periods of mechanical ventilation. In fact, muscle mass has been shown to decrease at a rate of between two and four per cent per day during the initial two to three weeks of ICU admission (Helliwell et al 1991; Brower, 2009) although in some patients the loss is as much as six per cent per day (Bloomfield, 1997). This physical morbidity is associated with prolonged weaning from mechanical ventilation, longer ICU and hospital stays and increased mortality levels. In the longer term, this physical morbidity can leave a lasting impression with recovery taking a number of months or even years. An observational study by Herridge et al (2011) found persistent functional disability over five years following discharge from critical care in a group of ARDS patients. Prolonged ventilation in critical care is also associated with impaired health related quality of life up to three years after discharge, even when patients are living independently at home (Combes et al 2003). From a psychological perspective, the prevalence of anxiety and depression in critical care survivors have been demonstrated at 22-47 per cent and may still be present nine months following hospital discharge (Sukantarat et al, 2007; Scragg et al, 2001). Levels of cognitive dysfunction such as problems with memory, attention and problem solving have been reported to be as high as 75 per cent and still present at one year following critical care discharge (Hopkins, 1999, Jones

et al, 2006). There is also an incidence of post traumatic stress disorder (PTSD), with levels identified as ranging from 15-51 per cent in survivors of critical illness (Scragg et al, 2001; Jones et al, 2001). This psychological impact is not isolated solely to patients, with a survey of relatives identifying high levels of anxiety and depression (Young et al, 2005) as well as PTSD as high as 49 per cent (Jones et al, 2004). In the UK it is estimated that one or two per cent of the total NHS hospital budget is spent treating critically ill patients (Bion, 1995). What is not fully understood is the longer term impact and subsequent cost on the wider health and social care services. An analysis of critical care survivors at the point of hospital discharge has shown a physical function at only 50 per cent that of an aged matched healthy population (Benington et al, 2011), and suggested only 40-60 per cent are functionally independent at this time (Schweikert et al, 2009). This level of debilitation places high demands on secondary care services such as GP’s, social care services, community rehabilitation and welfare benefits. Despite this, support and follow up after hospital discharge remains rare with only 30 per cent of UK based intensive cares providing follow up clinics for survivors of critical illness (Griffiths, 2006). There are approximately 100,000 admissions to ITU per year in England of whom circa 75,000 leave hospital. 17,500 of these ITU admissions stay in the Unit for longer than five days. About 35,000 of these patients stay in hospital for more than 17 days and about 17,500 for over 35 days. These are significant lengths of stay in both ITU and hospital that have major cost implications both in terms of hospital servwww.expresshealthcare.in

ices (and resources) and community costs post discharge.

Improving outcomes and reducing costs

Early measures The evidence base for early rehabilitation within critical care is growing. The term early mobilisation in the ICU refers to focused interventions that begin as soon as hemodynamic and respiratory problems have stabilised, frequently within the first few days after ICU admission. Numerous studies have demonstrated rehabilitation to be safe, feasible and an important measure in improving both short term outcomes and long term recovery in critical care patients. Specifically, early and structured rehabilitation programmes have been shown to decrease both ICU and hospital length of stay (LOS), reduce incidence of delirium (Schweikert et al 2009; Needham et al, 2010) and lead to improvements to both respiratory and peripheral muscle strength (Chiang, 2006). In a study completed in a North American intensive care unit, Morris et al (2008) demonstrated the implementation of an early rehabilitation programme to be associated with a reduction in both mean ICU (1.4 days, P<0.05) and hospital LOS (3.3 days, P<0.01). Following the introduction of a quality improvement programme for early rehabilitation programmes, Needham et al (2010) demonstrated a similar reduction of 2.1 days on ICU and 3.1 days in hospital. This positive impact of early mobilisation is even more pronounced when specifically looking at those with longer stays on ICU. McWilliams and Westlake (2011) analysed the impact of structured rehabilitation for patients with a LOS of > 5 days within a UK based level 3 intensive care. Over a three

year period following introduction of the programme they demonstrated a reduction of 6.2 ICU days and 31.8 days in hospital in response to the structured rehabilitation programmes. These studies support the theory that early mobilisation whilst still in intensive care units and the associated improvements in global muscle strength, alongside improvements in cardio respiratory fitness can help to facilitate weaning and thus reduce ICU LOS. Perhaps more importantly, alongside a reduction in ICU LOS, McWilliams and Westlake (2011) demonstrated a higher level of mobility at the point of critical care discharge. Specifically, this meant the average patient was now standing and stepping to a chair at the point of ICU discharge in comparison to data obtained prior to the introduction of structured rehabilitation programmes which had shown an average mobility level of being hoist dependent for all transfers from the bed to a chair at the same time point. This meant that the patients analysed were not only being discharged sooner but also more physically able. This is particularly the case when the early rehabilitation is led by physiotherapists (Garzon-Serrano et al, 2011). In real terms a patient who is more mobile on return to the ward is also likely to spend shorter periods in hospital as they will be significantly further in their recovery period (McWilliams and Macdonald, 2011), as well as being more functionally independent at the point of hospital discharge (Schweikert et al, 2009).

Conclusion From the minute a patient is admitted to intensive care the body is in a state of muscular and cardiovascular decline. This decline continues on a daily basis, with APRIL 2013


T|R|A|D|E & T|R|E|N|D|S longer admissions leading to higher levels of muscular weakness, patient dependence and poorer outcomes. Historically the mainstay of treatment has been the physiological stability and recovery of patients, supported by period of mechanical ventilation and bed rest. With new technologies and developments within medical management more patients are now being admitted to and surviving periods of critical illness. However, the physical and psychological sequelae of critical illness can leave a long lasting legacy in terms of long term health, quality of life as well as a costly impact on both health and social care services. This begins with the daily cost of intensive care due to expensive drug therapies, technology and an array of specialist staff from a variety of professions to name but a few. On discharge to the ward, patients often present with significant physical and psychological rehabilitation needs requiring ongoing intervention from various members of the MDT. At the point of discharge from hospital, patients will often require ongoing rehabilitation either in specialist units or in their own homes. This whole journey can have a significant impact on the income of families, with 1/3 of families losing their main source of income and 1/3 losing the majority of their savings, whilst it frequently takes 9-12 months for ICU survivors to return to employment (Eddleston, 2000). It is fair to say that to maximise the impact of early and structured rehabilitation programmes within intensive care additional investment is required to ensure an adequate number of appropriately trained staff and appropriate equipment is available. This would however prove to be a sound investment, as aside from significantly improving patient outcomes and quality of life, programmes of structured and early rehabilitation can have significant potential for cost savings. Firstly, early mobilisation has been demonstrated to reduce ICU LOS. In reality, although the cost per case may be reduced these costs may still exist as another patient is undoubtedly admitted into the empty bed. Benefits may still be observed APRIL 2013

due to a reduction in the number of occupied or so called ‘blocked beds’. This would subsequently reduce the potential for any cancelled surgical activity, or a reduced pressure to discharge patients who perhaps aren’t quite ready or during unsocial hours when a bed needs to be created, both of which can lead to increased mortality levels (Duke et al, 2004). Speaking in general terms, even small changes in terms of LOS can have a huge impact on ICU costs. Assuming a critical care bed costs in the region of £1700 ($2.228) per day, on a relatively small unit with 250 admissions per year, a mean reduction of 1.4 days as seen by Morris et al (2008) would equate to a cost saving of almost £600,000 ($940.674) or an additional 350 free bed days within critical care.. When you next consider in the ward environments, patients who are less debilitated will require less intensive rehabilitation and are less demanding on the nursing staff. Coupled with this, they will also be ready for discharge much sooner than a patient who is bed bound and dependent for all care, and as such post ICU costs and bed occupancy will also decrease. The higher level of functional independence at hospital discharge may also reduce any burdens felt on community rehab and support services. When compared to the cost of an additional physiotherapist and appropriate equipment required in order to deliver these programmes the additional resource would seem extremely economically justified to generate cost savings in the longer term. The key message is prevention or at least limitation is better than cure.

References Benington S, McWilliams D, Eddleston J, et al (2012) Exercise testing in survivors of intensive care--is there a role for cardiopulmonary exercise testing? J Crit Care. 27(1):89-94. Bion J. (1995) Rationing intensive care. BMJ.; 310(6981):682–683 Bloomfield SA. (1997) Changes in musculoskeletal structure and function with prolonged bed rest. Med Sci Sports Exerc 29 (2) 197-206 Brower RG. (2009) www.expresshealthcare.in

Consequences of bed rest. Critical Care Medicine . 37 (suppl) S422-S428 Chiang LL, Wang L, Wu C et al. (2006) Effects of Physical Training on Functional Status in Patients With Prolonged Mechanical Ventilation. PhysTher. 86 (9): 1271-1281 Coombes A, Costa M, Trouillet J, et al. (2003) Morbidity, mortality and quality-of-life outcome of patients requiring greater than or equal to 14 days of mechanical ventilation. Critical Care Medicine. 31 (5) 1373-1381` Duke GJ, Green JV, Briedis JH (2004) Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors. Anaesth Intensive Care. 32(5):697-701. Eddleston J.M., White P., Guthrie E. (200) Survival, morbidity and quality of life after discharge from intensive care. Crit Care Med. 28: 2293-99 Griffiths JA, Barber VS, Cuthbertson BH et al. (2006), A national survey of intensive care follow-up clinics. Anaesthesia, 61: 950–955. Helliwell TR, Wilkinson A, Griffiths RD, et al (1998) Muscle fibre atrophy in critically ill patients is associated with the loss of myosin filaments and the presence of lysosomal enzymes and ubiquitin. Neuropathology and applied neurobiology 24:507-517. Herridge MS, Tansey CM, Matté A et al (2011) Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 364(14):1293-304. Hopkins RO, Weaver LK, Pope D, et al (1999) Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Resp Crit Care Med. 160:50–56. Jones C, Griffiths RD Humphris, et al. (2001) Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine. 29 (3): 573-580 Jones C, Griffiths RD, Slater T, et al. (2006) Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness. Intensive Care Medicine. 32:923–6. Jones C, Skirrow P, Griffiths RD, et al. (2004) Post-traumatic stress disorder-related symptoms in relatives of patients

following intensive care. Intensive Care Medicine. 30:456–60 McWilliams DJ, Macdonald EC (2011) Is a simple bedside mobility score a useful predictor of long term outcome in critically ill adults. Intensive Care Medicine, October supplement McWilliams DJ, Westlake EV (2011) The effect of a structured rehabilitation programme for patients admitted to critical care. Intensive care Medicine, October Supplement Morris PE, Goad A, Thompson C, et al. (2008) Early intensive care unit mobility therapy in the treatment of acute respiratory failure.Critical care medicine. 36:2238-2243 Needham DM, Korupolu R, Zanni J (2010) Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Arch Phys Med Rehabil Vol 91, April 2010 Schweickert W, Pohlman M, Pohlman A, et al. (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 373:1874-1882` Scragg P, Jones A, Fauvel N et al (2001) Psychological problems following ICU treatment. Anaesthesia. 56(1):9-14. Garzon-Serrano J, Ryan C, Waak K (2011) Early Mobilization in Critically Ill Patients: Patients’ Mobilization Level Depends on Health Care Provider’s Profession. American Academy of Physical Medicine and Rehabilitation Vol. 3, 307313 Sukantarat KT, Williamson RC, Brett SJ. (2007) Psychological assessment of ICU survivors: a comparison between the Hospital Anxiety and Depression scale and the Depression, Anxiety and Stress scale. Anaesthesia. 62:239–43 Young E, Eddleston J, Ingleby S, et al. (2005) Returning home after intensive care: a comparison of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives. Intensive Care Medicine. 31:86–91 Contact Pankaj Vadhavkar Hill Rom International Tel: +91 9987267889 Email:pankaj.vadhavkar@hill -rom.com EXPRESS HEALTHCARE

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BOC India rebrands to Linde India On the occasion of re-branding from BOC India Limited to Linde India Limited, Biswarup Ghosh, Head of Healthcare, India shares his views on the Linde India, the healthcare market in India now, and the future he foresees for Linde India’s healthcare division he re-branding of erstwhile BOC India Limited to Linde India Limited adds a new milestone to the history of our company. We have a long legacy in this industry spanning over seven decades and running. In 2006, the global acquisition of the BOC Group by the Linde Group helped form one of the largest industrial gases companies’ world wide, combining the Linde Group’s worldleading technology and BOC’s deep understanding of cus-

T BISWARUP GHOSH

Head of Healthcare Linde India

tomers and markets. Linde Healthcare is present in 70 countries worldwide, this massive footprint ensures solutions are always delivered and serviced to the highest possible standards of safety, quality and efficiency. Similarly, our aggressively growing Indian healthcare market at the rate of 12-15 per cent per year offers Linde India the scope to serve its array of comprehensive and state-of the-art healthcare solutions. We at Linde look to

On time delivery, product service offering and safety have been our key operating practices

cater to our existing and prospective customers with our wide range of medical gases such as liquid medical oxygen, compressed medical oxygen and nitrous oxide. On time delivery, product service offering and safety have been our key operating practices. The takers for medical gas pipeline have been on steady rise owing to the rapid increase in the numbers of specialty hospitals all over India and I see this as a lucrative move for the future.

CONTRIBUTOR’S CHECKLIST ●

Express Healthcare accepts editorial material for the regular columns and from pre-approved contributors/ columnists. ● Express Healthcare has a strict nontolerance policy towards plagiarism and will blacklist all authors found to have used/referred to previously published material in any form, without giving due credit in the industryaccepted format. As per our organisation’s guidelines, we need to keep on record a signed and dated declaration from the author that the article is authored by him/her/them, that it is his/her/their original work, and that all references have been quoted in full where necessary or due acknowledgement has been given. The declaration also needs to state that the article has not been published before and there exist no impediment to our publication. Without this declaration we cannot proceed. If the article/column is not an original piece of work, the author/s will bear the onus of taking permission for republishing in Express Healthcare. The final decision to carry such repub-

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lished articles rests with the Editor. Express Healthcare’s prime audience is senior management and professionals in the hospital industry. Editorial material addressing this audience would be given preference. ● The articles should cover technology and policy trends and business related discussions. ● Articles by columnists should talk about concepts or trends without being too company or product specific. ● Article length for regular columns: Between 1300 - 1500 words. These should be accompanied by diagrams, illustrations, tables and photographs, wherever relevant. ● We welcome information on new products and services introduced by your organisation for our Products sections. Related photographs and brochures must accompany the information. ● Besides the regular columns, each issue will have a special focus on a specific topic of relevance to the Indian market. You may write to the Editor for more details of the schedule. ● In e-mail communications, avoid www.expresshealthcare.in

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large document attachments (above 1MB) as far as possible. Articles may be edited for brevity, style, relevance. Do specify name, designation, company name, department and e-mail address for feedback, in the article. We encourage authors to send a short profile of professional achievements and a recent photograph, preferably in colour, high resolution with a good contrast.

Email your contribution to: viveka.r@expressindia.com Editor, Express Healthcare APRIL 2013


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Become an ECG expert with ECG Academy India ECG Academy India is the first online portal offering online ECG courses in India.

he ECG Academy India, an online portal offering ECG courses, teaches you how to expertly interpret an electrocardiogram (ECG/EKG) at your own pace. It couldn’t be easier! Excellent for beginners or for experienced readers who want to improve their skills at analysing complex ECGs. Its benefits are as follows: ✦ Easy to understand video lessons in ECG interpretation ✦ Step by step instruction from basic to advanced ✦ Learn from a physician specialist/electrophysiologist ✦ Weekly practice “ChalkTalk” sessions ✦ Now with special pricing for India, Sri Lanka, Bangladesh, Nepal and Pakistan

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Idea behind starting up ECG Academy India “Earlier, I was involved in importing and marketing of medical equipment under West Coast Corporation. Two years back I was involved in a project for developing a teleECG device with technical know-how from BARC. When the product was launched it was a shock to come across qualified medical professionals who by all means could acquire ECGs but could not interpret them. Hence they required the help of a specialist to analyse the ECG. On further interaction it was found that there is not much exposure to the medical students in their MBBS course to ECGs. The paramedical and nursing staff had no clue whatsoever even about a basic interpretation in case of an emergency. This is where the idea of online training for ECG analysis and interpretation emerged,” informs Vijhay J Shetty, CEO, Managing Partner, ECG Academy India.

How it works Two levels of courses are offered, which are purely online. Any candidate on registration gets a specific user name and password to access the information APRIL 2013

comprising videos and chalk talks for two months. During this period the candidate can visit the site and spend unlimited time to learn and take an online test which is evaluated by www.expresshealthcare.in

our principal set up ECG Academy US. On clearing the test with 75 per cent + marks the required credit and certification is issued to the candidate.

Who all can get benefit from this website? Medical students, nursing students and para medical professionals are offered the Level 1 course and for qualified practicing doctors the EXPRESS HEALTHCARE

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T|R|A|D|E & T|R|E|N|D|S Level 2 is offered. LEVEL1

What makes ECG Academy India different? ECG Academy India is the first online portal offering online ECG courses in India. The advantage of Internet by which the student can access at any given time from anywhere and any number of times. This gives a complete exposure to the student before he takes the final test. Moreover the subsidised rates are applicable for all candidates enrolling from India, Bangladesh, Sri Lanka, Nepal and Pakistan. It is the first online ECG training course in India for medical professionals.

Advantages, charges, levels and syllabus LEVEL 1 - Arrhythmias/ Rhythm Strip Analysis This ECG Course begins with basic concepts of electricity, ECG systems, and cardiac physiology. It covers basic ECG measurements and reviews all cardiac arrhythmias that might be seen on a rhythm strip. Basic concepts in 12-lead interpretation are also included. It also includes nine hours of video lessons. You will receive an email con-

Best suited for:

Nurses, Telemetry Technicians, Ambulance Squads, Students, BLS/ACLS

taining a link to the final exam. Participants who achieve a passing grade on the exam will be sent a Certificate of Proficiency. Includes weekly ChalkTalks. Fees: $50 or Rs 3300 LEVEL 2 - 12-Lead ECG Interpretation This ECG Course begins with basic concepts of electricity, ECG systems, and cardiac physiology. It covers basic ECG measurements and reviews all cardiac arrhythmias that might be seen on a rhythm strip. The second half teaches all necessary concepts in 12-lead ECG interpretation. Includes 14 hours of video lessons. You will receive an email containing a link to the final exam. Participants who achieve a passing grade on the exam will be sent a Certificate of Proficiency. Includes weekly ChalkTalks. Fees: $75 or Rs 4800

LEVEL1

LEVEL2

ChalkTalks (both levels)

Interns and Attending Residents, Physicians, Cardiac Nurses, Medical Residents, Medical Cardiology/EP Students, Fellows, Clinical EMTs, Nurse Specialists, Paramedics Nurse ractitioners

Background information Affiliated to ECG Academy US and division of Westcoast Corporation, specialising in state of the art medical innovations and equipment. Recently launched a digital radiography retrofit system to convert conventional X-ray machines to direct digital radiography systems, PC-based ECG machine.

Faculty associated with teaching The ECG Academy (US) was established by Dr Nicholas Tullo, a cardiac electrophysiologist with a passion for teaching. Dr Tullo has been reading ECGs since he was a medical student on cardiology rotation in 1979. Sitting for hours with plenty of ECGs to read, he learnt how to analyse the degrees and the art of understanding this very common medical

You know the basics but you're looking to become an ECG expert (Included in all courses)

exam. Almost every individual in the healthcare field has to be acquainted with the ECG. Dr Tullo has been teaching physicians and nurses how to read them for decades now. He provides his lectures with videotapes and uses very effective audiovideo tools to accomplish this. With the help of digital recording and editing, he realised that he was able to take a relaxed, easy mode of teaching and capture it as a series of video clips that we now present at the ECG Academy India. Contact Vijhay J Shetty CEO & Managing Partner ECG Academy India Div: Westcoast Corporation Email: vijhay@ecgacademyindia.com Website: www.ecgacademyindia.com

Schiller India launches CARDIOVIT AT-102 plus It is a 12 Channel ECG Machine with several advantageous features

chiller India, a leading company in the field of medical diagnostics, has launched CARDIOVIT AT-102 plus, a 12 Channel ECG Machine with Colour LCD display. It has computer-aided interpretation, measurement and thrombolysis software for adult and paediatric ECGs. It also has internal memory of 300 ECG recordings. According to V Balakrishnan, Sr Vice President, “This revolutionary ECG machine with a bigger colour display, direct function keys that are spill proof, is very rugged in design and especially targeted for use in large general hospitals.”

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Contact Thushara Vasudevan Schiller India, Advance House, 2nd Floor, Makwana Road, Off Andheri-Kurla Road, Andheri East, Mumbai - 400 059 Phone: 022 61523333 / 29209141 Fax: 022 29209142 Email:thushara@schillerindia.com, sales@schillerindia.com /support@schillerindia.com

Features of CARDIOVIT AT-102 plus: ● ● ● ●

Simultaneous 12 lead ECG acquisition 8.4” colour LCD screen with LED backlight Water resistant/dust proof alphanumeric keypad Detailed interpretation, measurement and thrombolysis software ● Pacemaker detection ● Rhythm recording ● Internal memory of 300 ECG recordings ● Various printout formats on internal thermal printer ( A4 size)

Optional ● Spirometry ● SEMA – Schiller Data Management

System.

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www.expresshealthcare.in

APRIL 2013


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T-Ring: The safest tourniquet in wound care for digit injuries 3

The T-Ring is a US FDA approved tourniquet which provides a bloodless operating field for emergent and elective medical procedures involving the digits and lower extremities

Cube introduces T-Ring, a digital tourniquet designed to give health care providers a safer and more effective option to current digital tourniquet methods. While current digital tourniquet methods are effective, they all have the risk of complications associated with their use such as excess pressure and necrosis due to

prolonged application. The TRing is the only digital tourniquet that automatically adjusts to the size of the digit, resulting in a safe, reliable pressure with each use. In fact, the T-Ring has been shown to effectively provide haemostasis while applying less pressure than any other tourniquet method! This makes the “T-Ring” the

T-Ring vs other methods

safest, most efficient and effective digital tourniquet in use today. The T-Ring instantly exsanguinates as it is slid onto the digit, providing immediate haemostasis and ideal wound visualization. The device comprises a brightly-coloured outer plastic ring within which is a flexible disc which itself con-

tains a hole. This is supplied in a sterile packet and can be pushed over the lacerated digit to exsanguinate it and provide haemostasis. The ring has two “cutaway” sections on it, which allow its two halves to be separated, pulled apart and gently moved over a larger laceration if appropriate. Similarly, the device can either be gently slid off the finger or the plastic outer ring can be broken and the inner flexible portion cut. There are a number of other methods to stop bleeding. A study has shown that this device provides sufficient pressure to provide haemostasis but at a pressure which is lower than that of a Penrose drain or surgical glove tourniquet and therefore is less likely to cause tissue injury.

Indications The T-Ring has been developed to provide a bloodless operating field for emergent and elective medical pro-

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T|R|A|D|E & T|R|E|N|D|S The T-RING Advantage!

cedures involving the digits of the upper and lower extremities. In the evaluation and management of acute problems, its uses include: ✦ Wound exploration for foreign bodies, or underlying tendon, bone or joint injuries ✦ Wound repair of lacerations, avulsions, and tip amputations ✦ Management of nail and nail bed injuries ✦ Achievement of complete haemostasis to allow closure of smaller wounds with adhesive strips; eliminating the need for painful injections and costly, time consuming suturing ✦ Drainage of paronychia, and finger and toe abscesses The T-Ring is also indicated for the management of the following elective procedures: ✦ Elective tendon, bone or joint surgery ✦ Excision of tumours, warts and other deformities ✦ Wound or scar revisions ✦ Biopsies

The T-Ring has numerous advantages when compared to current digital tourniquet methods: ✦ Automatically adjusts to any size digit ✦ Safe pressure - every time ✦ Unlike other methods, it cannot be over tightened ✦ Immediate haemostasis provides ideal wound visualisation ✦ Highly visible, will not be forgotten on the digit ✦ Slides over lacerations, avulsions and traumatic skin flaps ✦ Faster and easier to use than any other method ✦ A breakthrough in digital tourniquet safety! Contact 3 Cube Biomed Services 305 Maker Chamber V Nariman Point, Mumbai-21 Tel No: +91 22 6576030/1/2 Website:3cubeservices.com Email: info@3cubeservices.com

Carestream’s new DRYVIEW 5950 laser imaging system available for order It is a tabletop laser imager for general radiology, mammography imaging applications

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arestream's new DRYVIEW 5950 laser imaging system is now available for order in India. The advanced imager reportedly produces 508 pixels-per-inch output for general radiology and mammography images. The new imager can support efficient printing and time-saving film cartridges that can benefit healthcare providers of all sizes in India. The DRYVIEW 5950 laser imager can also deliver an enhanced quality control system for mammography images. This internal quality control system that includes a built-in densitometer will produce test prints and display data needed to support mammography quality control charting—which can eliminate the need for an external densitometer and can greatly reduce the time required for mammography quality control. Carestream’s imager offers DICOM connectivity and can be used to output images from a PACS network or from any DICOM modality. Carestream’s Smart Link remote technology solutions can remotely provide software updates and enables real-time response and analysis of service issues from a remote location. The DRYVIEW 5950 laser imager will offer two film cartridges on-line and will support five film sizes: 14 x 17 inch (35 x

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43 cm), 14 x 14 inch (35 x 35 cm), 11 x 14 inch (28 x 35 cm), 10 x 12 inch (25 x 30 cm) and 8 x 10 inch (20 x 25 cm). Daylight-loading film cartridges make changing sizes fast and easy, and the imager can output up to 110 films per hour for 8 x 10 inch images. This new imager complements Carestream’s family of printers which currently includes: DRYVIEW 6850 Laser

www.expresshealthcare.in

Imaging System, DRYVIEW 5700 Laser Imaging System and DRYVIEW Chroma Imaging System. Contact Nilesh Dattatray Sanap Carestream Health India Tel: 022- 67248816 Email: nilesh.sanap@carestream.com Website: www.carestream.in APRIL 2013


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Your alertness can save a life Ruchika Beri, Assistant Marketing Manager at Ziqitza Health Care, says that by following simple health and safety guidelines and a little bit of common sense, one can help prevent accidents eople don’t really realise that serious accidents can happen at home/outside/office environment. But in fact, accidents are just as likely to happen in anywhere in office as they are on a construction site or in a factory. The sad thing is that most of these accidents are preventable by following simple health and safety guidelines and a little bit of common sense.

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Tips to tackle a medical emergency in office At some prominent place display all emergency information and telephone numbers, which are required to be called upon in case of any emergency which includes: ● Fire fighting department ● Number of nearest hospital and ambulance service ● Location of first aid kit at the workplace ● Number of the nearest police station At the time of emergency first check the pulse and then

make sure that the heart beat and breathing has not stopped. And if, this would be the case, remember every second counts. Try to calm down yourself. Your undue hurry and turbulence can even worsen the situation. Most of times, an affected person can safely be moved to a more suitable position. However, this is not the case with someone with neck or back bone injuries. In such a situation, try not to move that person, unless there is something bad expected. (e.g. risk of fire or extreme cold etc)

Have someone call for medical assistance while you apply first aid and stay calm. Your calmness can allay the fear and panic of the patient Try not to give any liquids to an unconscious or semiconscious person, they may enter the windpipe of the victim and cause suffocation Ziqitza Health Care is India’s leading organisation which provides first responder programme to schools, colleges and corporate. The workshops seek to dispel common misconceptions on how to treat medical emergencies and aims at educat-

ing people on general principles of first aid which can play a crucial role in emergency situation. The company has trained over 24,000 people from various schools, colleges and corporate sectors till date. Contact Ziqitza Health Care AAA CSSC, MN Roy Human Development Campus, 2nd Floor, C Wing Plot No 6, F Block Bandra Kurla Complex Mumbai - 400051 Tel: (022) 26578800 Email: contactus@zhl.in

Fora Care Suisse signs deal with Truworth Health Technologies To launch diabetes and home health care products in India

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t. Gallen, Switzerlandbased Fora Care Suisse has partnered with Mumbaibased Truworth Health Technologies to bring Fora Care's diabetes and home health care products to the Indian market. The deal was signed via memorandum of understanding to provide exclusive distribution rights for the Indian market to Truworth. Fora Care Suisse is an established supplier of innovative and secure healthcare products internationally. Truworth Health Technologies, a India's leading health and wellness management company, provides products for biometric

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screening solutions, mobile and cloud-based health and chronic disease management solutions in the space of mHealth, Tele-health and health informatics. Together, this distribution partnership provides extensive reach for Fora Care into the Indian market. “More people suffer from diabetes in India than in any other country and this is a situation where we, industry leaders, should devise a strategy to help prevent the continued increase of the disease,” said Ty-Minh Tan, Chief Executive Officer, Fora Care Suisse. “To that end, we believe our diabetes care range of home health devices www.expresshealthcare.in

The deal was signed via MoU to provide exclusive distribution rights for the Indian market to Truworth is among the best in the world and together with Truworth Health and their connectivity solutions, we are well positioned to meet the challenge.” “In India, the preventive

healthcare market, especially with respect to the diabetes management segment, is experiencing a complete overhaul as technology solutions are creating an ecosystem with a holistic approach. It goes beyond people just measuring their blood glucose,” said Rajeish Moondraa, MD and CEO, Truworth Health. “Our strategic collaboration with Fora Care allows us to offer a comprehensive mobile-enabled diabetes management solution. This suite of products provides unique and simpleto-use solutions so pharmacies, hospitals and diabetologists can enable their patients to have better outcomes.” EXPRESS HEALTHCARE

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REGD. WITH RNI NO.MAHENG/2007/22045. REGD.NO.MH/MR/SOUTH-252/2013-15, PUBLISHED ON 8th EVERY MONTH & POSTED ON 9, 10 & 11 EVERY MONTH, AT IND.EXP.PSO.

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Express Healthcare April, 2013  

Express Healthcare April, 2013

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