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Vol.3 Issue 3



Published at Agappe Diagnostics Limited on April 01, 2017 | 62 Pages | ` 20







ORTHOPAEDICS Unravelling Musculoskeletal System Disorders & Its Medical Solutions

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Volume 3 | Issue 3 | April-June 2017 ○

Osseous that Matters

12-15 Arthritis: The Disease of Skeletal System 24-25 Evolution of Kidney Profile & its Recent Trends... 26-29

Osteoporosis: How to prevent, treat and reverse it...?


A Paragon of Mental Strength...


The making of a True Champion

34-36 Reinventing the wheel of Clinical Pathology... 37-39 India’s Blade Runner: A Man with Mettle 40-43 What is New in Knee Replacement?


VISION 2022: A Promise for the Future

Mr. Thomas John

44-46 Health Tips for Healthy Bones... 47-49 How can we eliminate Pre-Analytical Errors..? 50-53 Testimonials 54

Exhibitions & Conferences


Engagements - Special Days


A Positive Mind is the best Possible Healing Aid...

Dr. Ashok Rajgopal

Views and opinions expressed in this magazine are not necessarily those of Agappe Diagnostics Limited, its publisher, or editors. We do our best to verify the information published but do not take any responsibility for the absolute accuracy of the information. We do not take responsibility for returning unsolicited material sent without due postal stamps for return postage. No part of this magazine can be reproduced without the prior written permission of the publisher. Techagappe publishers reserve the right to use the information published herein in any manner whatsoever. Caution: After going through the techniques, procedures, theories, and materials that are presented in Techagappe, you must make your own decisions about specific treatment for patients and exercise personal/professional judgment for further clinical testing or education and your own clinical expertise before trying to implement new procedures. Contact info: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. Contact: Ph: + 91 484 2867065, Mob: +91 9349011309. Published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. Contact: Ph: + 91 484 2867000, Fax: + 91 484 2867222; Printed at Five Star Offset Printers, Nettoor, Cochin-40, for Agappe Diagnostics Limited Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.




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From the Editor’s Desk


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○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

I am very pleased to place this 11

issue of TechAgappe in your hands - the quarterly review of health and laboratory medicine. Previous editions were based on Cardiac diseases, Renal illnesses, Hepatic ailments, Pancreatic disorders, Cancer, Neurological disorders, Gastroenterological complaints, Gynecological maladies, Clinical Haematology and Lung problems in a sequence. I am also happy to report that the laboratory community has warmly welcomed the previous issues of the magazine. This magazine is now regular in publication at an interval of three months. th

The current issue focuses on Musculoskeletal disorders, where you can find three scientific articles. The first article gives an overview of various Arthritic conditions. The second article is on Osteoporosis, a very common condition among the elderly population. The third item is penned by a leading orthopedic surgeon on the present scenario of Knee replacement in India. Then the readers are invited to go through three live stories. One is the saga of a person from Gujarat, now living in Hyderabad, who lost his leg years back. He has overcome this impediment and is now a well-known cyclist with many Limca Book of Records in his name. The second story is of an extraordinary sportsman from Rajasthan who plays badminton representing India for para-sports. He lost his leg at the age of two but now, he is ranked as the world’s second among para-badminton players. The third story is from Punjab about a Major who participated in the Kargil War, who is otherwise known as “India’s Blade Runner’. He lost his leg due to a bomb blast during the war but now, he is a well-known national marathon runner. Despite losing their legs, they overcame the situation and reached great heights of success. All of them are great role models for the younger generation.

Focuses on Musculoskeletal Disorders...

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Thus, I am sure, this issue of the TechAgappe will give useful insights to the problems of various skeletal diseases. I am proud to announce that the ensuing issues of TechAgappe will cover other important topics. Your constructive criticisms to improve the contents will be greatly appreciated. With warm personal regards,

We have also included health tips to improve bone health and another technical article to reduce pre-analytical errors in laboratories.

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Subscription-For subscription queries, write to techagappe@ or call us at +91 484 2867065. Permissions-For permissions to copy or reuse material from Techagappe, write to techagappe Letters to the editor-Email: Postal address: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district, Kerala-683 562, India. Advertisement QueriesEmail:

EXECUTIVE DIRECTORS Meena Thomas Sangeeta Joseph George Varghese Mary Baby Meleth Dr.D.M.Vasudevan


CHAIRMAN Prof. M.Y. Yohannan




DESIGN AND LAYOUT M.T. Gopalakrishnan Dezign Centre, Kochi. 9947144570



EDITORIAL ADVISORY BOARD Gopalakrishnan R. Dr. C.S. Satheesh Kumar Sudhir K. Nair Jofy Paul Suresh Babu Sanjaymon K.R Vijith Kumar V. Mallya Erlin Philip


CHIEF EDITOR Dr. D.M.Vasudevan

EDITOR Meena Thomas


Volume 3 | Issue 3 | April-June 2017 ○

Dr. D.M. Vasudevan





Excellent Journal It

is real ly excel lent to go through your edition on clinical hematology and also on respiratory system. Updating myself with a journal like yours is very good and I am using this for our pathology classes, so it is very useful. I hope, you will continue publishing such a great magazine with elegant subjects in future for a longer time. I am quite enriched with the details about umbilical cord stem cells, which was published in your Gynecology edition. Prof. Dr. V. Pushpaval li, Dept. of Pathology, Karuna Medical Col lege, Chittur.

January 2017 was received from the concerned authority and while I was going through the pages, I could feel that the articles published in the journal is so relevant to present scenario and stimulating to my reading habit. The experience and story of Kusum Malik Tomar, Deepti Chavan and Devanayaki are heart-touching. All other articles are comprehensive and provide serious thinking facility. I wish all the very best for the upcoming issues. Prof. Dr. Suvarnaletha Devi. K, Principal, College of Nursing, Trivandrum.

TechAgappe generates Confidence

Informative and Inspirational Journal I am happily saying that your d iagnostic news journal ‘TechAgappe’ is a very Informative, interesting and inspirational one. The Vol. 3, Issue 2

TI would say with an open mind

in a few words, Agappe’s diagnostics news journal ‘Techagappe’ is very informative, inspiring and confidence generating. I do read every edi-

Enjoyable Reading

tion to enhance my habit of knowledge gathering. Waiting for upcoming editions. Mr. Sony George,

SDS Metropolis, Cochin.

An All-inclusive Magazine Techagappe, as the name says,

is a hitch journal. It is inclusive of all the recent developments occurring in the field of medicine and lab diagnostics. The look and the paper quality are excellent. I appreciate its team for parenting such a beautiful magazine.

Ms. Prathibha, Principal, Udupi Dhanwanthari College of Nursing, Kallianpur.

A PPioneer ioneer in Diagnostic Information Thank you for sending the ex-

I have enjoyed reading the interview with Padmashree Dr. K. M Cherian, “The harder you work, the luckier you become”. The railway hospital at Chennai used to bring the railway employees throughout India because of Dr. K. M. Cherian’s contribution, therefore, he was worshipped as God by many of them. Mr. T. Philip could bring out the best from him about the path way of his career and about his achievement in cardiothor acic surgeries. I wish all the very best for Techagappe. M. Arumugam, Judge Joseph Clinical Laboratory, Palayakotta.



cel lently produced Tech Agappe. It is really an eye opener to see that India can have such a good magazine with diagnostic news. There is a lot to learn. I really enjoyed myself when I was going through the magazine. Dr. Jacob K. B, Jacob Hospital, Kochi.

Impr essive and Impressive informative

I had a nice time going through the magazine. The overall look and feel of the magazine is very impressive. The articles are really informative. I thank Agappe for such a great public supportive initiative as part of knowledge gathering and enhancement. Ms. Dol ly Kuruvil l la, Trivandrum.

A Gr eat Magazine Great for PPublic ublic Well-being Techagappe provides inspirational and informative reading time for its readers. I received the copy of TechAgappe for the first time from my principal to read. As I have gone through the pages, I felt, it is very interesting and informative to read. Life story of Deepti Chavan was great motivating and a sensitive issue is dealt very beautifully. Different aspects of COPD, TB, Lipid Profile, Urine Chemistries are dispensed interestingly. Interview with Dr. K M Cherian is very inspiring. Thank you Agappe for publishing such a great magazine for the public wellbeing. Prof. Urmila D. D., Vice Principal, Ananthapuri Hospital, Trivandrum.


Cover Story

Poem on Healthy Bones

Osseous that Matters No one can envisage his body sans bones

Bones are nothing but connective tissue, The tissue in dynamic equilibrium. Prominent and salient supportive tissue With weight bearing connectivity in movements. Calcium and Vitamin D3, the essentials in body, Both are the inseparable comrades of life in nature, Minerals and micro-nutrients, the encompassing group. Stronger and robust bones essential in day to day life, Whenever Calcium is in dot, Vitamin D3 is in limelight. Calcium deficiency lands up in osteoporosis, Frequent deficiency institutes bone-density-fall in haste Strength of bones, thou need Calcium, D3 bounteous. My dear Calcium-comrade, your absence turns precarious & Thy disappearance brittles down my bones aghast. If Perpetual bone fractures is the outcome of osteoporosis, Calcium deficiency precipitates ‘tetany’, The violent muscular spasm intermittent. Hypocalcaemia prompts depressions and hallucinations and Numbness & tingling of hands, feet and face galore. One can build up Calcium in natural ways lot, Calcium comes natural with leafy and green veggies. Nature is so rich in Vitamin D3, but no time for us to enjoy, Sun light bestows Vit D3 in bounty exposed to skin, Man, in madness, never finds time to bath in the sun for D3. Spinach, soybeans, walnut and ladies finger deliver it magnanimous Cashew, Kiwi, Salmon bequeath Calcium the hero-mineral Tomato, walnut and orange accord again Calcium, the gracious. Weight bearing exercises, yoga contributes high Calcium, unambiguous. Rejuvenation therapy, the mainstay of Ayurveda endows him. Red meat in abundance inhibits Calcium uptake, Caffeine, sugary drinks and high proteins wane out Calcium sure. But mil k not liberates Calcium against normal contemplation, Milk, as of new thought, institutes calcium loss in long run. Health is wealth, be ever active the natural way, my friends.




Agappe MD’s Desk

VISION 2022:

A Promise for the Future... Thomas John, Managing Director, Agappe Diagnostics Ltd.

To strengthen the bonding with our Believers, we have chosen the theme of ‘One Agappe’. It not only reflects towards the relationship which we extend towards our Believers, but also have a wider aspect of ‘one stop solution’. We, at AGAPPE, are emerging to be the one stop solution for all the IVD needs in the industry. Whether it is the products or support, we have a solution for all. Agappe was incorporated in 1995 with a vision of serving

the mankind with high quality innovative products at an affordable pricing. Keeping in mind the wellness which we deliver, we have chosen the word “AGAPPE”, which means ‘The Divine Love’ in Greek, as an appropriate name for our Company. AGAPPE’s aim is to bring all its associates under same category viz. ‘Believers’. Whether it is our employee, stakeholder, a customer or a business partner, we wish to create a bond between all our Believers. AGAPPE is consistently delivering to its Believers the best of its services through its profound core values, which is called “TREC” (Trust, Respect, Excellence and Care). To strengthen the bonding with our Believers, we have chosen the theme of ‘ONE AGAPPE’. ONE AGAPPE, not only reflects towards the relationship which we extend towards our Believers, but also have a wider aspect of ‘one stop solution’. We, at AGAPPE, are emerging to be the one stop solution for all the IVD needs in the industry. Whether it is the products or support, we have a solution for all.




Thomas John, Managing Director, Agappe Diagnostics Ltd.

A Brief on Indian IVD The Indian IVD industry witnessed exponential growth and change in the last two decades. Two decades ago, the customers were usually depending on multiple manufacturers for instruments and reagents and because of this, there was a huge gap in the expectation and reality. In many cases, the manufacturers were mainly concentrated on specific segment offering only products and services to that segment. This made the customer to depend on multiple manufacturers and was always a matter of concern. The technical support to the instruments was provided through third party services and was one of the reasons for increased instrument downtime. The last decade has shown a shift in this scenario where the multinationals in diverse product segments started merging into umbrella brands to have maximum offering to the customers. Even though this was a positive sign, there is not much difference in the Indian IVD since the segment is dependent mostly on imports. The importance of localised manufacturing started emerging and there are a few companies in India that envisioned this scenario. Agappe is one among them and today, we are one of the pioneers in the Indian IVD industry, having the largest IVD reagent manufacturing set up. As per various reports published, India’s IVD market was estimated at ~$650 million in 2015 and expected to grow at a CAGR of ~18% by 2022. Compared to Global IVD market, India accounts for slightly >1% of the global IVD industry and expected to increase its share to ~2% - ~2.5% by 2022. Reports also say that, reagents constitute ~80% of the IVD market in India and are the fastest growing segment. Clinical chemistry, immunology and haematology are the three largest segments comprising of ~70% of the market share. Share of tier-II and tier-III markets are expected to increase to ~75% by 2022. The major customers targeted would be diagnostic laboratories, private and government hospitals, physicians and CROs.

AGAPPE Vision The IVD customers in India are now slowly moving towards looking for companies that can offer products and services at multiple segments with affordability. Fortunately, Agappe is one among those Indian Companies to serve the need of the customer. At present, Agappe can offer products in Clinical Chemistry, Immunochemistry, Haematology, Serology, Urinalysis and Electrolytes covering 60% of the routine laboratory requirements. One of the major advantages with Agappe is the fact that our products can find place in all the customer segments start-

ing from the rural labs with less than 100 tests per day to the bigger laboratories with more than 3000 tests per day. Market segment studies of IVD confirm that the major segmentation is classified to Clinical Chemistry, Immunodiagnostics, Haematology, Blood Glucose Monitoring, Coagulation and Molecular Diagnostics. AGAPPE has a strong presence in the Clinical Chemistry, Immunochemistry, Haematology and Coagulation. With regard to Immunodiagnostics, AGAPPE represents some of the products at present and are actively involved in filling in the product gaps in this segment. By 2022, AGAPPE will be poised to achieve 80% - 85% of the products in the segment, with exploring a reasonable share. Our upcoming focus is targeted on the Molecular Diagnostics segment where AGAPPE is yet to mark its presence. The day to day growing market scenarios and the advancement in the IVD industry is inspiring AGAPPE’s R&D team to explore more opportunities in various segments. AGAPPE’s R&D is also involved in the development activities of POCT products, which are going to be the new trend in the coming years. AGAPPE is also looking forward to enter into the Infectious Disease segment- one of the fastest growing market in India, with rapid testing devices followed by automation during next year. With regard to Agappe’s Laboratory instrumentation portfolio, it is having solutions for Clinical Chemistry, Immunochemistry (Nephelometry), Haematology 3-Part, Haematology 5-Part, ESR automation, Coagulation analyser, Electrolyte analyser and their associated reagents to become one of the few companies in India to offer one stop solution for the customers. Recently, we acquired TurbiQuick range of products from M/s. Vital Diagnostics, Italy, a known brand for specific protein

Belief System We believe in providing high quality diagnostic solutions to our believers, through highest level of customer connect by ensuring innovative and affordable products for an everlasting relationship.





AGAPPE is successful in establishing its In-

ternational division and has attained coverage to over 64 countries across the globe. It has also established a Global Access Point at Switzerland in 2011, which serves as the hub for the international business. As part of enhancing the operations of International division, we made new strategies where the operations are bifurcated to focused regions and semi-focused regions based on the business. We have identified Focus regions as Philippines, Nepal and Egypt & Semi-Focused regions as Indonesia, Sri Lanka, Bangladesh and Kenya. We have presence in following countries. Algeria Argentina Bangladesh Botswana Brazil Bulgaria Bosnia Bolivia

Cameroon China Croatia Cambodia Djibouti Egypt Estonia Fiji

France Germany Indonesia India Iran Iraq Italy Jordan

Kenya Kuwait Lebanon Libya Malawi Maldives Mexico Mongolia

Morocco Myanmar Nepal New Zealand Nigeria Oman Pakistan Peru

Philippines Qatar Romania Russia Rwanda Slovenia Srilanka Sudan

Syria South Africa Somalia Saudi Arabia South Korea Tanzania Thailand Tunisia

Turkey UAE Uganda UK Venezuela Vietnam Yemen Zimbabwe

testing in European countries. In Clinical chemistry automation segment, Agappe is the only player in the Indian IVD to offer 100T/H to 2000 T/H automation.

AGAPPE as part of Indigenization of products, our R&D has initiated the development of Fully Auto Clinical Chemistry Systems and the 3 Part Differential Haematology systems. Our Haematology system is expected to launch by end of 2017 and the Fully Auto sysCONSISTENT GROWTH PERFORMANCE OVER THE YEARS tem by middle of 2018. Our team is also working on the upgraded versions of Mispai3, the specific protein system, which would also be in the Fully Auto category. We are working closely with industrial giants for innovative products to serve the Global IVD industry. With these new additions, we expect to be present ourselves in 90% of the lab diagnosis segment by the year 2022. “Our belief system is yet another way of reminding us that we are not selling products or services to the customers, but a ‘promise’ that we at Agappe want to keep.”




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Cover Story Arthritis - An Overview


The Disease of Skeletal System Dr. D. M. Vasudevan, MBBS, MD, (Biochem), FRCPath, Technical Director, Agappe Diagnostics Ltd.

Arthritis is a term used to mean disorders of painful joints. The term is from Greek arthro-(joint) anditis (inflammation). The word ‘arthritis’ should not be confused with ‘arteritis’ as the latter term means disease of arteries. Evidence of arthritis has been revealed even in dinosaurs. The evidence for human arthritis dates back to 4500 BC; from prehistoric people to mummies of Egypt.

Arthritis is a term used to mean disor-

ders of painful joints. The term is from Greek arthro- (joint) and -itis (infla mmation). The word ‘arthritis’ should not be confused with ‘arteritis’ as the latter term means disease of arteries. Evidence of arthritis has been revealed even in dinosaurs. The evidence for human arthritis dates back to 4500 BC; from prehistoric people to mummies of Egypt.

Incidence Arthritis is the most common cause of disability. Osteoarthritis affects more than 3.8% of people while rheumatoid arthritis affects about 0.24% of people. It is estimated that one in every five adults and one in 250 children are affected by arthritis. One-third of working-age people with arthritis have limitations in their ability to work.

Causes Cartilage is a firm but flexible connective tissue in joints. It protects the joints by absorbing the pressure and shock created by




movement. Normal wear and tear of cartilage causes osteoarthritis (OA). An infection or injury to the joints can exacerbate this natural breakdown of cartilage tissue. Rheumatoid arthritis (RA) is an autoimmune disorder, which occurs when body’s immune system attacks the tissues of the body. These attacks affect the synovium-a soft tissue in joints that nourishes the cartilage and lubricates the joints. RA is a disease of the synovium that will invade and destroy a joint.

Symptoms Joint pain and stiffness are hallmarks of arthritis. Other symptoms may include redness, warmth, swelling and joint stiffness. Osteoarthritis usually occurs with age and affects the fingers, knees, and hips. Rheumatoid arthritis affects the hands and feet. Arthritis at times may affect other organs in the body. These symptoms may include malaise, fatigue, weight loss, poor sleep, anemia, muscle aches and difficulty to move joints. Arthritis is the most common cause of disability. In later stages, the patient may become physical ly inactive and home bound. Physical inactivity may lead to depression and obesity, which in turn causes vulnerability to heart disease. Among people with arthritis, the fol lowing co-morbidities may be seen: Heart disease (24%), Chronic respiratory conditions (19%) and Diabetes (16%).

Diagnosis Diagnosis is made by clinical examination, radiology and blood tests. Imaging techniques (X-ray, CT scans or MRI) of the joints are used to follow progression of the disease. The image will show structural changes in the joint, signs of joint erosions, cartilage loss, soft tissue tears, inflammation, location and amount of fluid, and presence of loose tissue fragments. Blood may be analyzed to check levels of inflammation. In rheumatoid arthritis, rheumatoid factor (RF), antinuclear factor (ANF) and specific antibodies are increased. C-reactive protein (CRP) is increased in all types of arthritis. Uric acid in blood and urine will be increased in gouty arthritis. Total

Osteoarthritis typically affects the weightbearing joints, such as the back, knee and hip. OA is due to wear and tear of the joint; but can also occur as a result of injury. The condition starts with pain during physical activity, later becoming continuous. Osteoar thritis is most commonly a disease of the elderly.

blood count, liver and kidney function tests may be useful. The synovial fluid from the joint may be tapped for analysis.

Classification Joint pain is the main feature of the following diseases: Osteoarthritis (OA) Rheumatoid Arthritis (RA) Systemic Lupus Erythematosus (SLE) Gout Infectious arthritis Psoriatic arthritis Osteoarthritis (OA) Osteoarthritis typically affects the weight-bearing joints, such as the back, knee and hip. OA is due to wear and tear of the joint; but can also occur as a result of injury. The condition starts with pain during physical activity, later becoming continuous. Osteoarthritis is most commonly a disease of the elderly.

Rheumatoid Arthritis (RA) In RA, the body’s own immune system starts to attack the tissues. RA often affects joints in the fingers, wrists, knees and el bows, is symmetrical in appearance. Stiffness in RA is generally worse in the morning. RA occurs mostly in younger age group, aged 20 and above. Bone erosion is a central feature of rheumatoid arthritis. RA is classified according to the American College of Rheumatology (ACR) classification.




Cover Story Arthritis - An Overview Systemic Lupus Eythematosus (SLE) Systemic Lupus Erythematosus is a collagen disorder that can be present with severe arthritis. SLE is an autoimmune disease where the immune system produces antibodies to cells within the body leading to widespread inflammation and tissue damage. It is more common in women. The disease is characterized by periods of illness and remissions. Other features of lupus include a skin rash, kidney problems, lung fibrosis and joint pain. SLE has a relatively high mortality rate among rheumatic disease.

Gout It is also called metabolic arthritis. It is due to the deposition of uric acid crystals in the joint, causing inflammation. This process occurs because of an overproduction or under excretion of uric acid from the body. It commonly affects a single joint or a small number of joints, such as the big toe and hands, and usually affects the extremities. This is thought to be due in part to the increased formation of uric acid crystals in cooler joints, i.e. those not close to the main warmth of the body. Contributory risk factors for gout include alcoholism, obesity, hypertension and diet rich in meat. Most often the big toe is affected, and sometimes knee or ankle joints. It starts with sudden pain, often during the night, described as throbbing, crushing or excruciating. The joint will be painful and tender and appears red and swollen. Gouty arthritis is excruciatingly painful and may lead to crippling disability.

Infectious arthritis It is also called septic arthritis. The incidence of septic arthritis is around 2-10 cases per 100,000 in the general population and as high as 30-70 cases per 100,000 in patients with RA. The following conditions increase the risk of developing




Systemic Lupus Erythematosus is a collagen disorder that can be present with severe arthritis. SLE is an autoimmune disease where the immune system produces antibodies to cells within the body leading to widespread inflammation and tissue damage. septic arthritis such as Artificial joint implants, bacterial infection elsewhere in the body, chronic disease (diabetes, RA, sickle cell disease), medications that suppress the immune system, recent joint injury and recent surgery. It presents with sudden onset of fever and joint pain. The condition is caused by bacterial infection. Organisms that can infect joints include Staphylococcus, Streptococcus, Salmonella, Shigella, Chlamydia, Gonorrhea or Hepatitis C. Joints commonly affected with septic arthritis include the knee and hip. It must be treated promptly to prevent irreversible joint damage. Septic arthritis in RA is associated with a higher mortality rate of 25-30%. Organisms such as Mycobacterium Tuberculosis and Candida Albicans cause chronic septic arthritis, which is less common than acute septic arthritis.

Psoriatic arthritis The prevalence of psoriatic arthritis in the population is less than1%, with a prevalence of 30% in patients with psoriasis. The skin problem develops first and then the arthritis is seen. Psoriatic arthritis occurs when the immune system attacks healthy cells and tissue. The abnormal immune response causes inflammation in the joints and an overproduction of skin cells. The disease does recur with periods of remission. In late cases, the

small joints in the hands are destroyed, leading to permanent disability.

Osteoporosis It is a common complication of all bone diseases including arthritis. After the age of 40-45, calcium excretion is increased and hence there is a net negative balance for calcium. This is reflected in demineralisation. After the age of 60, osteoporosis is seen in almost all persons. Then there is reduced bone strength and an increased risk of fractures. Osteoporosis is more severe and starts early in Indians compared to Westerners. Early diagnosis of osteoporosis is done by bone mineral density (BMD). Currently, dual energy X-ray absorptio metry (DXA) is the gold standard diagnostic tool for BMD measurement. Serum calcium, serum inorganic phosphorus, serum magnesium and urinary excretion of calcium and phosphorus, total al kaline phosphatase and total acid phosphatase levels are the general markers for bone diseases. Vitamin D nutrition should be determined by measuring serum 25-hydroxy vitamin D. Collagen forms 90% of the organic matrix of the bone and therefore breakdown products of collagen (hydroxyproline) in urine is a useful indicator of osteoporosis. The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommend that serum Cterminal telopeptide of collagen (s-CTX) is the marker for bone resorption in clinical studies.

Childhood arthritis Child hood arthritis occurs in people younger than 18 years. These include: a) Juvenile Rheumatoid Arthritis (JRA) b) Juvenile Chronic Arthritis (JCA) and c) Juvenile Idiopathic Arthritis (JIA). The most common form is JRA. JRA involves at least 6 weeks of incessant arthritis in children.

Treatment The focus of treatment for arthritis, in general, is to control pain, minimize joint damage and improve or maintain function and quality of life. Generally, resting of the joint will improve OA. Weight loss and exercise may also be useful. Pain medications may be used. Joint replacement surgery may be required in eroding forms of arthritis. Medications can help to reduce inflammation in the joint which decreases pain. Physical exercise of the affected joint will decrease pain and maintain the health of the particular joint. Exercise could be more effective than medications. Regular exercise will keep your joints flexible. Swimming is often a good form of exercise because it does not put pressure on joints, as in the way running or wal king do. Staying active is important.

Medications The main goal of treatment is to reduce pain. The first-line treatment for OA is analgesics such as paracetamol. Menthol or capsaicin creams will block the transmission of pain signals from joints. Some people find heating pads and ice packs to be soothing. For inflammatory arthritis, non-steroidal anti-inflammatory drugs

(NSAIDs) will be needed. In severe conditions, corticosteroids may be needed to reduce inflammation. Moreover, RA will need disease modifying anti-rheumatic drugs (DMARDS) such as Methotrexate. Starting the treatment for RA should be sooner than later. Combination of antibody (adalimumab / infliximab) with methotrexate has shown superior effect in RA.


The late cases of OA may need knee or hip joint replacements. Surgery to replace hips and knees may be tried. If arthritis is most severe in fingers or wrists, a joint fusion may be performed. Transcutaneous electrical nerve stimulation (TENS) is effective for controlling osteoarthritis pain. Low level laser therapy may be tried for stiffness associated with arthritis.

How to Prevent Arthritis The modifiable risk factors are: Reduce weight in OA Abstain from smoking for RA Reduce alcohol and purines in gouty arthritis.

Long-Term Outlook There is no cure for arthritis. However, the treatment can greatly reduce the symptoms. Lifestyle changes will also help. Weight loss and maintaining a healthy weight reduce the risk of developing OA, and can reduce symptoms if it is already present. Eating a healthy diet is important for weight loss. Exercise is beneficial for managing arthritis and overall health. In addition to remaining active, rest is equally important when the disease is active. Eating foods with lots of antioxidants can help to reduce inflammation. Poor sleep can aggravate arthritis pain and fatigue. Avoid caffeine and strenuous exercise in the evenings.




Life Story Aditya Mehta (Cyclist)

The making of a TRUE CHAMPION Aditya Mehta stands synonymous to mounting hope and determination to fight against all odds in life and stay fit to face the world with unadulterated confidence.

Aditya Mehta stands synonymous to mounting hope and determination to fight against all odds in life and stay fit to face the world with unadulterated confidence.

Aditya Mehta was brought up in a joint family, along with 18 first cousins. “I was incredibly naughty and often got in trouble at home and in school.” He was punished by his father for being a reckless scamp. Once he tried to elope to Goa from Hyderabad fearing punishment as he failed in his Telugu exams. Later he called his parents who took him back home. Being a difficult child to handle, none in his family had high hopes about him and slowly, it dawned on him that he was seen as a total failure in his own household, which hurt him badly. “My family had been in business ranging from Roti, Kapda, Makaan (Food, clothing, housing) for almost a hundred years. I knew the only way to prove myself and change their opinion of me was to start a business of my own and succeed.” But deep down, Aditya knew no one trusted him and with good reason. With the little money he had, Aditya started his textile business from scrap. “I worked like a bull! My days ended at midnight or so. I travelled from town-to-town with garment pieces to sell.” Slowly, his family began to notice his hard work and supported him with minimal funding. A year later, he would turn a modest investment of Rs. 30,000 into a turnover of Rs. 1.5 crores. He was 18 years old then.

Aditya Mehta



His journey was not easy. He was swindled by his friends when he was just 21 years old. They siphoned crores from the company account. “This hurt and upset me, but I decided to not


give up and make it again.” He started from scratch, entered the domain of exporting garments, and earned all his money back – ‘living his dream’ in one year. But fate had a cruel game hidden for him the next year. “One day, I was riding to go meet my stockist. As I was on the road, a bus suddenly hit me from behind. I managed to hold my balance even though I was riding a Bullet.” He was not so lucky the second time – the bus driver continued to rampage on and he was hit again. “I was pushed for almost 200-300 metres. As I fell, the tyre of the bus was coming close to my face. I immediately turned and as I was trying to get my leg out of the way, the tyre of the bus rolled over it.”

But, Aditya decided to move on. A few months after the accident, he decided to go to South Africa and continue developing his business. His leg would bleed badly every day. “I finally had to accept that moving around with garments wasn’t going to be possible.” With a heavy heart, he closed down the business. Back in India, he was fitted with a prosthetic. It took him 67 months to learn to wal k with it. Often, he would buckle and

Aditya lay flat on the road, motionless between two tyres of the bus. He was screaming. His leg had just been crushed under the tremendous weight of the vehicle. “Though there was a crowd witnessing all my agony, no one came to help me. I was crying in pain and screamed that I would pay any of them to help me. Money didn’t matter. My plea fell on deaf ears. No one wanted to answer the police.” Later, as he was losing hope, he was spotted by a store-owner located next to his own store who rushed him to the hospital. Aditya was about to experience pain that was much worse than the accident. “Every second day of the treatment, the dressing of my wound was to be applied without painkillers.” Every time he was being treated, Aditya would scream in agony. “On the third day, I told the doctor that I’d rather have him remove my leg than deal with this kind of pain. He was shocked to hear that. Only I knew what I was going through.” On the 8th day, he experienced the worst of it. “The doctor applied cotton to my wound without the right precautions and then applied Plaster of Paris. The cotton was stuck with the Plaster and he had to remove it from the wound using forceps.” Aditya pauses as he explained with agony and anger filling his eyes. On the 12th day, it was decided to amputate his right leg from above the knee. All his dreams were smashed like a castle of cards.

On the 8th day, he experienced the worst of it. “The doctor applied cotton to my wound without the right precautions and then applied Plaster of Paris. The cotton was stuck with the Plaster and he had to remove it from the wound using forceps.” Aditya pauses as he explained with agony and anger filling his eyes.



17 17

Life Story Aditya Mehta (Cyclist) fall as he was learning to walk. “His father, however, helped him see things from a different perspective. “He would tell me that I needed to think like a child. Children don’t complain when they try learning to walk. When they fall, they just get up again. These words really helped me. My parents were of complete support and helped me through everything.” Eventually, he was able to wal k up to a kilometer , slowly he walked five kilometres and was eventually able to walk up to ten kilometres, even with the discomfort. On one of these wal ks, Aditya came across the hoarding of a local cycling club. The picture of a healthy young man in a cycle reminded him of his limitations.

Aditya’s next target was to win a medal from the Asian cycling championship that was to be held in Delhi. In the training period, Aditya started making modifications to his bike to make it lighter. Though his coach was very concerned, he told him that he was just experimenting and had no plans to use it in the championship.

“It hurt me. I started to reminisce about the days in school when I had the best cycle in class. The thought that I couldn’t ride a cycle anymore was too hard to bear.”

Five days before the championship, something worse happened. As Aditya was cycling against the And hra Pradesh champion at that time, his prosthetic leg got stuck in the spokes of the front wheel. “My leg immediately came off, and I flew off the cycle. I was riding at 40 km/hr. I smashed against the ground and couldn’t move”.

Aditya wanted to come out of the cocoon of utter helplessness. He wanted to cycle once again. “My father supported me in this and said I should give it a shot.” For his very first ride, Aditya rode his cousin’s cycle for about a kilometer, after falling five times. “Every fall made me stronger. I learned from every fall. I never stopped”. There was no turning back for Aditya from this point.

Upon examination, it was revealed that Aditya’s tail bone was severely impacted. “I couldn’t even sit on a chair as it hurt terribly.” The doctor announced that Aditya should skip the Asian championship. Everyone stood with the doctor’s advice but he had solid dreams about it as he was the first Indian amputee to participate. Three days before the big day, Aditya had to ride in the trials. He rode for 20-25 km bearing the agonising sores.

He worked hard to become a Limca Record holder. He is now the first amputee cyclist to complete a 100 km ride in 5.5

“Before the race started on the championship day, I sat on the saddle despite the sores. I decided to give it my best.” Nothing

Aditya Mehta and his crew are under training.


hours. “Now I can even do it in 4-4.5 hours. Hitting this record was a turning point in my life. I knew that I could do everything I wanted to.” As of today, he has cycled over 40,000 kilometres in a period of 2.5 years – with a prosthetic leg.



could stop him and he rode as fast as he could without a break. When he finished the race, he asked his coach what the results were. “You are absolutely useless!’ my coach said. I was in shock when I heard those words. Suddenly he smiled and said, ‘You only got a silver!” Aditya was overwhelmed and wept in joy when he heard this. The first race was an individual time-trial of 10 km. The second promised to be far more strenuous – he had to cover 40 km in one go. With his tail bone facing severe trauma and in the midst of the worst pain, he gave his best and won silver again! “There were no words to express my joy. I was the first amputee cyclist in the championships to win a double-silver. I’d achieved more than I’d set out for.” He wanted more challenges and eventually rode from London to Paris and climbed 9000 feet in the process, which came in the Limca book of records yet again. He went on to ride from Kashmir to Kanyakumari facing a very gruelling journey. One of his biggest achievements so far has been to ride from Manali to Khardung La. Standing at 17,582 feet, Khardung La is believed to be the highest vehicle-accessible pass in the world available to the general public. “Any cyclist knows that this is one of the toughest routes to tread on.” He took off on the 1st of August with the goal of reaching on the 15th of August. Throughout this ride, his challenges went far beyond cycling. He suffered from nose-bleed, his flesh would get cut while riding given his prosthetic leg, and he had to use Indian style toilets, which was the worst challenge for him.

His target was to hoist the Indian flag on Khardung La on our independence day and he made it.

THE ADITYA MEHTA FOUNDATION In his new-found life path, Aditya came across several people hit with a stroke of bad luck. “I met so many para-athletes who were suffering. They simply had no support. I really wanted to help them as I was fortunate enough to have the backing to make it all the way. Encouraged by his mentors, he soon realised that a foundation could raise al l the money that our para-athletes required. “My Kashmir-Kanyakumari trip was actually a fund-raising event. Eventual ly, we raised money for

three amazing guys who were physically challenged- they needed two cycles and one prosthetic leg.” His ultimate dream is to start a sports academy for those not as fortunate. “In our country, there is literally no support for para-athletes. I must thank the armed forces who offered to support me and take care of my accommodation wherever I go. My ultimate dream is to support the para-athletes in the next few years and change the landscape.” Aditya’s philosophy in life is ‘Never, ever give up. Try until you die’.





Dr. Ashok Rajgopal

A Positive

Possible Team Agappe: Could you please share some of your memorable experiences during your child hood and academic days with us? What exactly triggered the passion to become a doctor?

An acknowledged orthopedic surgeon and a Padma Shri recipient, Dr. Ashok Rajgopal is credited with doing 25,000 total knee replacement surgeries in his 30 years of practice. He has also the honour of becoming the first orthopaedic surgeon in India to carry out vir tual total knee replacement, employing patient-specific instruments and also the first bilateral total knee replacement surgery in the country back in 1987. He was also the honorary surgeon to the former President of India- Dr. K R Narayanan and several other national athletes and sportsmen. Apart from Padma Shri, he was also awarded the Knee Ratna Award from IMA and Bharat Shiromani Award for professional excellence in the field of orthopedics in India. He is also a coveted member of a renowned panel of the international knee surgeons engaged in the development of advanced knee implants.




Dr. Ashok: My interest in medicine was fuelled by my father. He wanted to become a doctor but couldn’t. Right from the age of 14, the only career I knew or I wanted was in medicine. Interestingly enough, at that point in time in 1967-68, the first heart transplant was performed by Dr. Christian Bernard in Cape Town, South Africa. In my 11th standard, I managed to get Dr. Bernard’s address and wrote him a letter telling him of my fascination with his work. I told him that I would like to train under him and become a cardiac surgeon like him. The letter was an innocent one from a mere student. To my utter surprise, after two months, I got a reply from him. I still have that letter with me and consider it as one of my most valued treasures. In that letter, he explained to me that I was very young and would have to go through several years of studies and training to become a cardiac surgeon. For me, the choice of my career was never in doubt. I always wanted to become a doctor, specifically a surgeon. I did my undergraduate studies from the Armed Forces Medical College, Pune (1970-74) and my internship from the Northern Railways Hospital in New Del hi. I did my MS Orthopaedics from the All India Institute of Medical Sciences more by default than by choice, because there was no direct admission to Cardiac surgery and I did not get admission to General surgery. I did my Senior Residency in Orthopaedics at Safdarjung Hospital in 1979-1980. Thereafter I went to the UK and worked as SHO and subsequently Senior Resident in South Port Infirmary, Merseyside, UK. I did my M.Ch. from Liverpool in 1985. Subsequently I came back to India and started independent practice. Team Agappe: What about the first total knee replacement surgery- do you remember your first patient? Dr. Ashok: I remember very vividly the first bilateral total knee replacement surgery I did on 24th April 1987. The name of the patient was Ms. Susheela Jain. She was the principal of a school in

Mind is the best Healing Aid...�

Dr. Ashok Rajgopal

Malerkotla, Punjab. At that time, it was very difficult to convince an individual to undergo a knee replacement surgery as a cure for knee arthritis, because people were unaware and skeptical of surgery. Ms. Jain had very severe osteo arthritis with deformity of both the knee joints and I convinced her that surgery was the cure for her problem. When she was admitted for surgery, we found that her blood sugar were almost 500. She was unaware of it and we had to discharge her. She came back after 3 months and to my surprise, her sugar levels came down as she had taken some local herbal medicines.

At that time we had a choice of only two types of implants. Today, we have almost 24 implants of different sizes. The patient did extremely well after a six-and-a -half-hour surgery. Since she was a principal and a highly respected woman, when she returned home after surgery, the news spread among people by word of mouth. We started getting more and more patients ready for joint replacement surgery. In the first ten years, we did about 300 surgeries. Now in a month, we do almost 200 surgeries.

Dr. Ashok Rajgopal sharing his experiences with Mr. Sanjay Chabra, Zonal Manager, Agappe.





Dr. Ashok Rajgopal

Team Agappe: Who would you say are your mentors? Dr. Ashok: In my professional career I would say that there are three individuals who mentored me. The first person whom I call my friend, philosopher, guide and the man I absolutely worship, was my consultant in England, Mr. Graham Hayes. He is a Welsh man and lived in Liverpool. Mr. Hayes got me interested in knees. In 1982, when I joined him, knee replacement had just started to gain world wide popularity as a treatment for arthritis. In England, he was one of the biggest names in knee surgery. As with all new things there was the inevitable learning curve- We learned from our mistakes. We would discuss our shortcomings at every at every step so that we could take measures to avoid repeating them. My second mentor is Dr. Arjun Dev Sehgal, a neurosurgeon in whose clinic, I started my practice in New Delhi. He encouraged me when I was a very young orthopedic surgeon. The third and the person to whom I owe a lot is Dr. M G Abbott, my senior colleague, and co-consultant. He is like a father figure to me. He encouraged me to do whatever I wanted and stood by me when everybody was skeptical about me. I remember the first time I listed a patient for bilateral total knee replacement in the hospital I was summoned to the Chairman’s office for an explanation! There was a lot of excitement in the hospital. Fortunately, the surgery went off well and the rest as they say is history. We had a wonderful anesthetist who backed

If you think that you have accomplished everything in life, then it is time to retire. I believe that one should be restless and continue to work as long as you can. I’m extremely interested in research and academics. For me, education is an ongoing process and I’m still learning. I learn something new everyday. us and also a supportive instrumentation department. Team Agappe: We have heard about the use of Trabecular Metal in joint replacement surgery- what is trabecular metal? Dr. Ashok: Trabecular Metal Material is a unique, highly porous biomaterial made from elemental tantalum. The interesting thing about Trabecular metal is that it mimics normal human bone in terms of properties and characteristics. It has the same porosity. We were introduced to this in 2005and we did use it in total knee replacement surgeries for a brief period. Non availability of the implant used in conjunction with Trabecular metal forced us to suspend its use. However we do use trabecular metal in other Dr. Ashok Rajgopal receiving Padmasree Award from the Hon. President of India Shri. Pranab Kumar Mukherjee.

situations like revision surgeries, where we use it to augment the existing bone stock instead of using bone cement. Cementless options on trabecular metal are making a comeback in terms of availability and I foresee that in the years to come, I will be using them again. Team Agappe: There is lot being said about a new knee implantthe Persona knee?. What is different about this knee design? Dr. Ashok: Persona knee system is the latest knee system from Zimmer. I was privileged to be a part of its designer team. We started the research and designing process




in 2009. The team consisted of 26 surgeons from all over the world. We looked it from a bio-mechanics point of view. We selected the best design of plastic for it. In 2013, at the American Academy, the company officially launched the Persona knee system. The USP of the Persona knee system is that it is almost like a personalized or custom made knee system. Its’ design mimics the anatomical knee so closely and such close increments in sizing are available that the surgeon can almost replicate the individuals normal knee anatomy. As a result post operative discomfort is minimized. We have been using it for the past 3 years with extremely gratifying results. It is a wonderfully adaptable system. We haven’t yet released the entire range of all the implant sizes. Within the next 3 years, I believe, we will have the entire range of Persona knee system and implants available. Team Agappe: Looking back at awards& recognitions! How does it feel to be recognized for your hard work? Dr. Ashok: It is humbling. At the end of the day, being recognised for your work is an honour. I haven’t run after an award. With each award comes an added responsibility- the responsibility to to continue to deliver at the same level. It’s been a wonderful journey and whatever awards I have got are because of the blessing of my mentors, teachers, parents, my family’s support and my colleagues’ team work. I hope I can do justice to the recognition that I have got. Team Agappe: What in your mind is an ideal doctor-patient relationship? Dr. Ashok: When I started my career my parents told me “treat your patients like members of your family”. It is not the number of surgeries you do but it is the ability to connect with your patients that counts. I believe healing happens in the mind. A positive mind is the best healing aid. Team Agappe: Your future plans? Dr. Ashok: If you think that you have accomplished everything in life, then it is time to retire. I believe that one should be restless and continue to work as long as you can. I’m extremely interested in research and academics. For me, education is an on-going process and I’m still learning. I learn something new everyday. I’m really grateful to God, my seniors, parents and colleagues for what I have achieved and I hope to continue in my career path for a little longer. Team Agappe: Any suggestions to Agappe? Dr. Ashok: As the number of total hip and total knee replacements are increasing, one complication that surfaces is prosthetic joint infections. The tests to diagnose early prosthetic joint infections are a researchable area. Some tests are available but they haven’t become popular. I believe that these tests will increase epidemically. My suggestion is that you should look into the area of prosthetic joint infections. If we can have a locally, indigenously produced test, it will be really helpful for the doctors to treat the patients at an earlier stage.

Susheela Jain Rathi

The Longest Survivor of Knee Replacement Surgery in India Meet Susheela Jain Rathi (88) from Del hi. Coming April, it will be 30 years since she underwent her left total knee replacement surgery by Dr. Ashok Rajgopal, at an age of 58 years, when surgeries weren’t as popular as it is now. She, along with her family, was confused with continuing the treatment for knee pain management before they came to know that the best option was a knee replacement. That snippet of information had driven them to search the best doctor in the city. Patient testimonials on successful knee replacement surgeries and medical knowledge about it were not enough to convince their muddled mind. “With the first consultation itself, Dr. Rajgopal made an impression on us. I made my decision to undergo a total knee replacement surgery then and there itself”, she recollects with complacency. It was a successful case of knee replacement and she became able to walk normally as she used to during her younger ages. “Many years later, I had to undergo my second knee replacement surgery and we didn’t have to think a second time where to go. Both the legs work fine and I have no issues with my knees now. One thing I have noticed is that he takes time to listen to his patients’ worries without any reluctance. He dedicates his precious time sort out his patients’ issues and finds out proper and apt solutions”, her words are loaded with sincere gratitude to Dr. Ashok Rajgopal.




Promotion Evolution

Evolution of Kidney Profile & its Recent Trends...

Early kidney disease usually does not have signs or symptoms. Testing is the only way to know how your kidneys are functioning. The National Kidney Foundation (NKF) and the National Kidney Disease Education Program (NKDEP) recommend to get checked for kidney disease if you have the key risk factors – diabetes, high blood pressure, heart disease or a family history of kidney failure. The incidence of kidney failure (or chronic kidney disease) has doubled in the last 15 years & almost 66% of kidney failure occurs due to hypertension or diabetes. Here, we try to provide comprehensive history of kidney profile in three stages.

Ms. Bintu Lijo, Dy. Product Manager, Marketing, Agappe Diagnostics Ltd.

1 Routine Renal tests Aristotle (384-322 BC) refers to the kidney in two of his works. Galen (130-200 A.D.) of Pergamon, known as ‘Prince of Physicians’ rejected the possibility that the kidneys filtered urine from the blood in a sieve-like fashion and instead concluded that the kidneys ‘attracted’ urine. Frederik Ruysch, in 1701, was the first to recognize the capillary tuft of the kidney. Richard Bright discovered kidney disease in 1800s and in 1886, Max Jaffe discovered a reaction of creatinine with picric acid in an alkaline environment, and in the next year, Wheatley described direct colorimetric determination of urea in biological fluids for understanding kidney function. Urea (Urea nitrogen or BUN) Urea is a waste product formed from the breakdown of proteins. Urea is usually passed out in the urine. A high blood level of urea (uraemia) indicates that the kidneys may not be working properly, or that the patients have a low body water content (dehydrated). Creatinine It is a waste product made by the muscles. Creatinine enters the bloodstream and is usually excreted in urine. A high blood level of creatinine indicates that the kidneys may not




be working properly. Creatinine is usually a more accurate marker of kidney function than urea. The effect of muscle mass needs to be considered. Uric Acid Higher than normal uric acid levels in the blood is called hyperuricemia and can be caused by the over-production of uric acid in the body or the inability of the kidneys to adequately remove enough uric acid from the body. Uric acid can also form crystals or kidney stones that can damage the kidneys.

Agappe’s Renal Profile Urea · Optimised Urease GLDH Method · Purified Enzyme & Coenzymes are used to offer a linearity up to 300 mg/dL · Urea & BUN value can be calculated with same kit

Enzymatic Creatinine · Enzymatic reaction with stable end point with 4 weeks calibration stability · No interference for Bilirubin up to 40mg/ dl, Cephalosporin · Non-Toxic reagent, low sample volume (5 microLt) & high linearity up to 200 mg/ dL

Creatinine · Modified Jaffe Method with de-proteiniser · No Bilirubin interference up to 10 mg/dL due to Surfactant · 2 Reagent system, option of 1:1 reconstitution

Microalbumin · Turbidimetric Immuno assay method

Uric Acid · Stable Uricase – TOPS Method offers high linearity of 25 mg/dL · TOPS is used to accelerate the end point reaction to offer stable Violet coloured complex for reproducible results · Stable Phosphate Buffer for optimal enzymatic reaction for accurate results

In the middle of 90s, a new enzymatic method for the measurement of serum and urine creatinine is described. The new method is simple and specific and shows excellent sensitivity and reliability. Recently, scientists identified that Microalbumin in urine is an early indicator of Glomerular lesions. Enzymatic Creatinine Recent studies proved that the enzymatic creatinine estimation method exhibited several advantages over Jaffébased methods namely smaller sample size, reagent stability and improved specificity. The enzymatic method has clinical application in neonates, diabetic ketotic patients and those receiving cephalosporins. Microalbumin Presence of very small quantity of albumin (less than 300 mg / 24 hrs) is known as microalbuminuria. It is the early warning symptom of kidney disease. Albumin in urine is used for early detection of kidney damage in diabetes and high blood-pressure. 15 % of all dialyses of diabetes patients could be avoided by early detection and adequate therapy. Test strips or Routine Reagents for albumin & total protein cannot detect most microal buminuria cases.

Wide measuring range 4-395 mg/L


No Prozone effect up to 6000 mg/L

Cystatin C

2 Standard Renal tests



Latex enhanced Immunoturbidimetry offers better sensitivity & reproducibility


Tris buffer offers optimal Reaction for Accuracy


Wide measuring range from 0.1-10 mg/L

3 Extended Renal tests Research studies suggest that creatinine is inaccurate at detecting mild renal impairment and levels can vary with muscle mass but not with protein intake. Urea levels might change with protein intake. Based mainly on cross-sectional studies & longitudinal studies, Cystatin C is now established as the most precise test of kidney function. Cystatin C It is removed from the bloodstream by glomerular filtration in the kidneys. If kidney function and glomerular filtration rate decline, the blood levels of Cystatin C rise. More than that, Cystatin C levels are less dependent on age, sex, race and muscle mass compared to creatinine. It has been suggested that Cystatin C might predict the risk of developing chronic kidney disease, thereby signalling a state of ‘preclinical’ kidney dysfunction. Research is ongoing to learn more about Cystatin C as an indicator of risk of end-stage renal disease, heart failure and death. Studies have also found that in diverse populations, Cystatin C may improve the estimate of GFR when combined in an equation with blood creatinine.




Cover Story Osteoporosis - An Overview


How to prevent, treat and reverse it ? Dr. V. Ramachandran, MS Ortho, D.Ortho, Professor of Orthopaedics & Associate Dean, MES Medical College, Perinthalmanna.

The word ‘osteoporosis’ is derived from Latin and it means ‘porotic bones’. This indicates the essential clinicopathological feature of the disease and is a pointer towards its subsequent clinical behavior. The problem, now, is global and has already started impacting the economies of major developed countries. In coming years, India will also have a major social health problem, considering our mammoth population and steadily increasing life span. What is Osteoporosis? WHO defines osteoporosis as a common metabolic disease of human skeletal system with ‘relative decrease in bone mass with progressive micro architectural deterioration and increased fragility of bones leading to fractures’.

Incidence The incidence of osteoporosis is global and all age groups are involved, but mostly beyond 50 years. There is a greater incidence among Caucasians and Asians compared to blacks and Hispanics. Sex wise, the incidence is more in female when compared to males. According to US statistics, one out of three females and one out of five males beyond the age of 50 years, sustain osteoporotic fractures in their remaining lifetime.

Pathophysiology Osteoporosis is essentially a relative decrease in bone mass. Normally, this bone mass is the net effect of the continuous ongoing process of bone formation and bone resorption. In a healthy young individual, these are nicely balanced. When the balance is tilted in favour of bone resorption, osteoporosis is the result. In a normal individual, the bone mass is on the increase in early life and reaches its peak by about 25–30 years. This peak




Classification of Osteoporosis A. Primary osteoporosis (Involutional osteoporosis)

andropause and advanced age.

There are two types. Type I – Post menopausal and Type II – Senile osteoporosis. Most of the discussions in the medical literature are centered around primary osteoporosis, that too about postmenopausal osteoporosis. This type of osteoporosis is usually not associated with any apparent reason and is considered part of physiological processes of menopause /

B. Secondary osteoporosis This is a relatively rare form of osteoporosis which you may encounter occasionally and is always due to some known cause. In this context, the drug-induced osteoporosis especially the one due to steroid administration has already gained a lot of attention. The primary cause of secondary osteoporosis may include: 1. Hormonal Hyperparathyroidism Hyperthyroidism Hypercorticism Hypogonadism Low Oestrogen Low Testosterone 2. Drug-Induced Glucocorticoids Anticonvulsants Phenytoin sodium Phenobarbitone Anticoagulants Heparin Warfarin Omeprazole Pantoprazole Rabeprazole Antacids

bone mass has a bearing on subsequent involutional osteoporosis and is mostly depended on your genetic makeup, nutritional status and physical activities. After 35 years, the bone mass starts decreasing and assumes pathological proportion after menopause and during senility. In Type I Osteoporosis, the osteoporotic bone loss is mostly involving trabecular cancellous bone and usually involves vertebral bodies and the wrist area. In Type II Osteoporosis, both cortical and cancellous bones are involved with frequent clinical involvement of hip area and shoulder region and in general, all the other bones.

Clinical features Osteoporosis is frequently described as ‘Silent Thief’, stealing your bone mass without your knowledge. It is a slowly progressive condition running over several years, without symptom, only to surprise you one day with some sudden onset severe localized bone pain, heralding the occurrence of a fracture. The fracture is usually following an insignificant trauma like a minor fall, a bump or strain. This is the usual type of presentation, occasionally another type of presentations like increasing

3. Nutritional Low dietary intake of Ca+ Vit D Malabsorption syndromes 4. Disuse Stroke Paraplegia 5. Overuse In young female athletes Amenorrhea Anorexia Nervosa Over exercise 6. Inherited disorders Osteogenesis imperfect Marfan’s Synd: Ehler-Danlos synd: Hyperhomocysteinemia 7. Inflammatory arthritis Rheumatoid Arthritis Ankylosing spondylitis

forwards stoop, or loss of height may be the mode of presentation. A proper history analysis and detailed clinical examination may give you the clue regarding the diagnosis. Localized bone tenderness may indicate a bone fracture. The presence of deformities, limitation of movements, loss of height, limb length discrepancies, neurological deficits etc. may be looked for. The osteoporotic fractures, generally called as Insufficiency Fractures or Fragility Fractures, frequently involve vertebral bodies, wrist, hip, and shoulder bones and rarely at other sites of ribs, pubic rami, lower femur, upper tibia, and el bow region even though no bone is immune.

Investigations Routine blood tests – CBC with ESR, CRP Biochemical blood tests – Serum calcium, P, Alk.Po4ase Serum vitamin D Urine – Routine examination, 24/hr urine calcium and P. Bence Jones Proteins Serology – RA factor HLAB27 estimation




Cover Story Osteoporosis - An Overview Treatment of Osteoporosis Drug Treatment Generally, this is indicated when, T-Score is < - 2.5 If fragility fracture is present Fracture risk tool predicts high risk of fragility fracture There are two groups of drugs for osteoporosis. They are: 1. A - Antiresorptive drugs 2. B – Bone forming drug A – Antiresorptive Drugs Most of the drug treatment in osteoporosis, now, belongs to this group. They include: Bisphosphonates Hormonal treatment – HRT

useful for vertebral osteoporosis alone. Alendronate and Rizedronate are administered orally on a daily or weekly basis. Ibrandronate can be given oral ly on daily or weekly basis. Zoledronate is administered as a single injection per year whereas Ibandronate can be given orally on daily or weekly basis and as injection, once in 3 months. The problem of oesophagitis, ulceration and oesophageal strictures along with some rare side effects like avascular necrosis of mandible and subtrochanteric femoral fractures may be borne in mind while prescribing these drugs 2. Hormone Replacement Therapy Oestrogen is known to prevent bone loss and this beneficial role is taken advantage when it is prescribed. But the unfavourable effects of oestrogen on Uterus, breast, and venous thrombosis force

SERM Calcitonin Denosumab All these drugs exercise their beneficial effect by preventing osteoclastic bone resorption and reduce the progressive decline in bone mass. 1. Bisphosphonates They are the most popular group of drugs currently in use. They include Alendronate, Rizedronate, Ibandronate, and Zoledronate. Aledronate and Rizedronate are oral preparations requiring close monitoring while using them. Ibandronate is available as oral/parenteral form. Zoledronate is usually given as parenteral infusion. Alendronate, Rizedronate and Zoledronate are useful for both vertebral as well as non-vertebral osteoporosis where as Ibandronate is generally found X-rays- Skeletal survey, thoracic and lumbar spine, Skull Chest X-ray (PA and AP views) Pelvis including both hips and proximal femur, Shoulder bilateral.

Fracture risk assessment When analyzing a case of osteoporosis, there are known sets of risk factors both Non-Modifiable and Modifiable. Non-modifiable factors 1. Age-more than 50 years vulnerable 2. Sex-increased incidents in females 3. Ethnicity-increased incidents in Asians and Whites, Decreased incidents in blacks and Hispanics 4. Positive family history 5. History of osteoporotic fractures in parents. Modifiable risk factors 1. Ca+ Vit D intake inadequate




2. 3. 4. 5.

Lack of weight bearing exercises Smoking Excessive alcohol or cola drinks Offending drugs like steroids

Fracture risk tools In osteoporotic individuals without fracture, the future risk of fractures can be assessed clinically over an extended period of time using clinical methods. Two popular methods currently available are: FRAX tool and Q Fracture tool. Frax tool WHO, in collaboration with the university of Sheffield, UK, in 2008, has come out with this clinical tool for assessment of potential fracture risk in the age group of 40–90 years. The potential risk over the next 10 years is assessed using criteria like age, BMI, and variable clinical risk factors with or without BMD. The risk is assessed as low, intermediate or high and the treatment is offered

the clinician to exercise restraint in prescribing them. Nowadays, oestrogen preparations are generally prescribed in Postmenopausal osteoporosis with acute postmenopausal symptoms and that too, for a short period. 3. SERM (Selective Oestrogen Receptor Modulator) An oestrogen analogue – RALOXIFENE – is the popular drug of this group. It retains the beneficial effect on the bone, but is without the adverse effect on breast and uterus. However, thromboembolism is a problem like oestrogen and the Serum Cholesterol level, less favourable than oestrogen. This restricts its use to the early phase of Type I osteoporosis. 4. Calcitonin This is a physiological hormone from parafollicular C cells of the Thyroid gland, found useful in the treatment of osteoporosis. However, the antiresorptive property is generally weak and finds its role when all other drugs are contraindicated. It is generally administered as a nasal spray or as a subcutaneous injection. 5. Denosumab A new drug – monoclonal antibody – is currently available as an antiresorptive. This drug acts by preventing the activation of Preosteoclasts to osteoclasts by blocking the RANK – RANKL mechanism. It is administered as 6 monthly injections. Even though it is quite an effective drug both for vertebral and non-vertebral osteoporosis, it is expensive and is known to be associated with major side effects of serious infections, the occurrence of lymphoma, CNS complications and worsening of osteoporosis at times, AVN of mandible and subtroch, femur fracture. 6. Bone forming drug There is only one well-accepted drug in this category and that is based on that.If the risk is low - dietary regulation, exercise and lifestyle modification. If the risk is high - apart from the above, drug treatment of osteoporosis. If the risk is intermediate - do DXA hip region and plan treatment accordingly. Q Fracture Tool In 2009, Julia Hippisley Cox and her team recommended the use of the new fracture risk tool. Here BMD is not considered. Apart from the usual criteria line, age, sex and BMI, an extended version of clinical variables are incorporated into the tool. They include the history of falls, cardiovascular diseases, chronic liver disease, tricyclic antidepressants, menopausal symptoms etc. By and large, Q fracture tool is considered more useful.

Complications of Osteoporosis Osteoporotic fractures: These are the most common complication. Even though the healing process is normal, it is at a lower rate and may take longer time. Surgical fixation of these fractures

Teriparatide. This is a parathormone analogue. The observation that the administration of parathormone in very small doses may cause new bone formation has led to the development of this drug. It is now available as a daily subcutaneous injection. FDA restricts its use for not more than 2 years, at present. Its usefulness for hip osteoporosis is questionable. C. Surgical treatment The role of surgery is limited and it restricts itself to the treatment of fracture. The surgical procedures may include internal fixation of fractured bones especially of hip, shoulder and wrist, arthroplasty – total or hemi-replacement - for fracture of femoral neck or surgical neck humerus and occasional surgical treatment for vertebral osteoporotic fractures. The two surgical procedures for osteoporotic vertebral body fracture are Vertebroplasty and Kyphoplasty. is often challenging and is not without complications like nonunion, malunion etc. Deformities can occur. For example: Dowager’s hump in osteoporotic vertebral fracture Loss of height Problem of prolonged immobility Occasionally, neurological deficit due to fracture Prognosis Osteoporosis is not a curable disease in most situations. Treatment is primarily targeted towards prevention of fracture. Once fractured, prompt fracture management and early mobilization should be the goal of treatment to reduce morbidity and mortality. Increased awareness of the silent nature of the disease, its global presence, the tendency for fragility fractures and prompt and effective treatment will go a long away in tackling this silent epidemic.




Life Story Girish Sharma (Badmintonist)

A Paragon of

Mental Strength...

Life can be so unpredictable sometimes. Miseries come as uninvited guests and shatter the joy of life. Yet, some recover from the wistful experiences with sheer willpower and determination. Girish Sharma’s story is the tale of a man traversing from a disabled person to the No.2 para-badminton player in India. Born in a middle-class family to Jayanthilal Sharma and his wife Sagarben, Girish was the second child with an elder and a younger brother. Jayanthilal was working as a Goods Train Guard with Indian Railways at Rajkot, Gujarat and Girish was born at Nandwai, Rajasthan.

Life can be so unpredictable sometimes. Miseries come as unin-

vited guests and shatter the joy of life. Yet, some recover from the wistful experiences with sheer willpower and determination. Girish Sharma’s story is the tale of a man traversing from a disabled person to the No.2 para-badminton player in India. Born in a middle-class family to Jayanthilal Sharma and his wife Sagarben, Girish was the second child with an elder and a younger brother. Jayanthilal was working as a Goods Train Guard with Indian Railways at Rajkot, Gujarat and Girish was born at Nandwai, Rajasthan.

Girish Sharma

During a pleasant holiday season, the children were sent to their mother’s house at Mad hya Pradesh. The grandfather took care of the boys there. On one such occasion, a 2-year old Girish ventured out to the railway track crossing not less than 200m from the house. By accident, his right leg got stuck in the track and quite unexpected ly, a train passed by taking his leg along,




knocking him down unconscious. The accident happened in 1989. He was rushed to the hospital and the surgeons had to amputate his right leg. Girish’s grandfather was emotionally hurt beyond words. Even though no one could be blamed for the destiny’s cruelty, his grandfather took it as his fault and never recovered from that shock. Within two weeks of the accident, he passed away. Later, Jayanthilal took his family to Gujarat where he was posted that time, Girish underwent studies there. Until 10th Grade, he played every game with the support of his friends and family. “I’m really grateful to my parents for they never discouraged me from doing something. Instead, they constantly supported me and behaved as if I was a normal boy,” says Girish. From his school days, Girish cherished the dream of joining the army. Soon it became clear to him that disabled persons weren’t allowed in the army. “During my eighth standard, I seriously gave a thought about my life. There is only one life and what am I going to do with it. I refrained from tal king to my father, brothers or friends for a few days. During those days, I watched TV especially sports channels and then it occurred to me that players also represent the country. Like Indian Army, there are Indian Players representing the nation in different sports at several venues. That thought actually gave me a new life altogether,” Girish recollects. Determined to become a sportsman, he took Badminton as his choice in 2002. He took Badminton with a specific purpose in mind. “Badminton is a game which requires high stamina and quick movements. I told my father that I’m going to play and train for Badminton. He was skeptical at first. But I was confident. The first few days were really hard but my father supported me in going through all that suffering. I was practicing with normal players and that made it even harder,” he states. By then, Girish had a coach to train him to play Badminton. His coach Vikramsai Sarvaiyaa was also a Railway Employee and a sports instructor. The coach was a friend of his father and he regularly enquired about his son’s progress in the game to the coach. “My coach was very confident about my progress in the game. It was he who first discovered that a champion resides in me. I also worked hard to improve. Apart from daily exercises, cycling for 4 km was also part of the practice and I never missed it,” says Girish. To those who wonder how he cycles with one leg, Girish also rides a bike. He is also the only recognized Paralympian playing Badminton on a single leg. Other Paralympic players use wheelchairs. After twelth grade, he ended his academics and began to concentrate fully on games.

Girish Sharma playing Badminton




Life Story Girish Sharma (Badmintonist) “My father used to ask me about this earlier but when he saw my determination in it, he let it go” says a confident Girish. Girish ventured seriously into Paralympic Badminton matches in 2006 at Bangalore for Para National Badminton Tournament. He used crutches as an aid to go places instead of the wheelchair and took it to Bangalore also. People at the venue, when they came to know that he was a Badminton player wondered how he managed to play the game with his one leg and crutches. Several coaches from other states reminded the rule that no crutches were allowed inside the Badminton court. After several discussions with coaches of different states, the referee came to him and said that he couldn’t allow Girish to play if he used crutches. Girish politely replied that he didn’t need crutches in the court and that he could play with his one leg. The referee was astonished. The astonishment turned into shock and awe when Girish started playing Badminton with his one leg. The onlookers, as well as other coaches, were also in the similar state. His opponent was representing Karnataka State. Girish, who represented Gujarat State won the match easily. Girish has just begun his winning streak. Soon after, Girish won 2 Gold Medals at the National Championship for physically challenged. He participated only in Singles game as he couldn’t get a suitable partner to play with him in Badminton. He also played against regular and normal players in open national level. His friends who supported him asked him to try a hand in Open National Tournaments. Girish promptly accepted the challenge not for the sake of creating sympathy but for the spirit of the game. Thus in 2007, he participated in All India Open Badminton Tournament conducted in the memory of the politician, Late Pramod Mahajan by his family members. During that time, he was lucky to get the prize money for the tournament from the former President of India Late Dr. A P J Abdul Kalam. After seeing him playing, he arranged Rs.10,000/- also and congratulated him personally. Girish was also lucky to hear good words about his style of play from the former Indian Badminton player, Prakash Padukone. He personally congratulated Girish after he saw Girish playing at the Asia Championship 2008. He also got a partner for playing Doubles in Badminton. “We become runners-up continuously for 4 times. My partner is Neeraj from Kerala who lost his left leg and I lost my right leg and we believe we are perfectly balanced. At first, he was skeptical in playing Badminton with one leg. It was me who gave him confidence and took him into the court. I promised to take him to semi-finals and we reached the finals. We were also one among the best three pairs,” Girish comments with pride.

Girish Sharma at his home town




His first international match was in March 2007. “I got a letter from Para-Badminton Association announcing that I was selected to represent India in the World Para-Badminton match at Israel. The expense for the match mentioned in the letter was around Rs. 1,70,000/-. Neither I nor my father was able to make that much amount in a short time. I was disappointed. But my friends stood by me and raised funds for me. In the very first International ParaBadminton Championship I played, I won two silver medals, both in Singles and Doubles. The tournament took place at Jerusalem.

Girish Sharma at an international tournament

Though people comment about my luck to bag two medals, little do they know about the hard work and commitment I put in for the game. I worked and trained hard and I believe that the good results are gifts for that hard work and perseverance,” Girish beams with optimism and happiness. The gold medal which he secured in Paralympics Asia Cup for Disabled held at Bangalore is his favourite victory. From 2009 to 2012, he was the National Champion continuously for the three years. Despite securing medals representing the country and state, Girish blames that the government has done little to support Paralympic players. “I think disabled persons aren’t getting any recognition they deserve. I hate being called as a ‘disabled’. I’m a Paralympic player. During training, I used to attend the training for normal players and not something specific for Paralympic player. I’m really happy that 22-year-old Mariyappan Thangavelu from Tamil Nadu made India proud by winning gold in Men’s High Jump at the Rio Paralympics2016. With that incident, the central government has begun to encourage disabled persons,” comments Girish. Girish feels that Paralympic players have a long way to go in the matter of sports and achievements.”State and Central governments could do more about it. You take Cricket- they never have

Yet, ask him what he dreams of. “I dream to play for India in 2020 Paralympics and win a gold medal for the country,” Girish becomes an optimistic and cheerful spirit. In Paralympics, Badminton will be included as an item only in 2020 to be held in Tokyo, Japan.

any difficulty in finding a sponsor. When they win a World Cup, you might be wondered at the amount gifted by different boards and government to them. But what happens when a Paralympic player wins a medal for the country. Hardly do media report those. Even if they report, there is a dearth for sponsors. Most often, corporates or companies don’t want to sponsor a disabled player. Neither the authorities nor the politicians do anything for the disabled sportsmen. We are representing the country but there aren’t either sponsors or jobs for us,” says an enraged Girish, at the biased attitude towards the disabled. Yet, ask him what he dreams of. “I dream to play for India in 2020 Paralympics and win a gold medal for the country,” Girish becomes an optimistic and cheerful spirit. In Paralympics, Badminton will be included as an item only in 2020 to be held in Tokyo, Japan. Girish missed the Asian Championship 2016 held in China due to an accident. A bike rider from the wrong direction hit him and damaged his leg. He is undergoing complete bed rest to recover now. As soon as he recovers, he will join the training for his dream goal. “The harder you work, the luckier you become!.” He currently trains under the coach from Mumbai, Srikanth Wad. His message to the society is simple- there’s only one life. Nothing should come in between your disability and your dream. Those who are physically challenged can also dream big and achieve it. You will be rewarded for the efforts you put in any field. Don’t just waste your life over counters and applications of reservations for physically challenged. “Once in a life, everybody should think what if they become a disabled person one day. What if I lose my one arm or leg? Take a look around and see for yourself how the society treats the disabled. Then, for the rest of your life, you will never ignore a physically challenged person. Let our authorities and politicians wake up to this cause,” Girish dreams of a sound and happy world for him and his peers.





Mr. Amit Sharma

Reinventing the wheel of clinical pathology... Face to face with Mr. Amit Sharma, Director, HS Pathology Pvt. Ltd.

Established in 2010, H S Pathology Pvt. Limited is a fast emerging ultimate diagnostic service provider with a focus on cutting-edge technology, accuracy, efficiency, dedicated customer service and above all, stringent ethical practices. The state-of-the-art Central Clinical Reference Lab of H S Pathology Pvt. Ltd. at Thane, Maharashtra is par with global diagnostic laboratories with its highly automated and sophisticated diagnostic equipments. H S Pathology Pvt. Ltd. offers almost the entire range of Clinical Diagnostic Testing possible across the globe with accuracy and at an affordable price. At present, the lab chain has got 10,000 collection points spread in different states and projects are in pipeline for further expansion. Amit Sharma, Director Operations, H S Pathology Pvt. Ltd. talks with Team Agappe.

Agappe: Could you please explain the growth

graph of HS Pathology Pvt. Ltd. which has been cherishing many success stories over the last few years?

Amit Sharma




Amit Sharma: Even though H S Pathology Pvt. Ltd. was established in 2010, I had begun the efforts long ago. I am a management graduate and had been in laboratory business for almost 21 years working for many major laboratory groups. During that time, it occurred to me that

I must also do something of my own and should do it big. Even though I had no technical knowledge, my experience with major laboratories came in handy here. I still remember that seven years back, when we began the number of samples, what we had were just 50 and now we deal with almost 5000+ samples every day. In 2012, we installed TBA40 FR (1st in Maharashtra) at our lab. The next year, we upgraded lab instruments and there were installation from Siemens, Abbott, Beckman, Diasorin. In 2014, we established regional processing lab at Nashik. We procured Modular Biolumi first across the globe at our lab in 2015. By 2016, Molecular Lab was installed and the regional processing lab at Dhule was established. We have expanded our processing centres at Nashik, Dhule and Panvel. We are also coming up with a laboratory at Pune. Not everything was fine and smooth for us. The first one year consisted of lot of hardships and miseries. Only hard work and confidence pulled us out from it. There were times when I had worked almost 18 hours a day at the office. Now looking back, it gives me immense pleasure in taking H S Pathology to such heights. Agappe: In a short span of time, H S Pathology Pvt. Ltd. has been hailed as the best diagnostics healthcare facilities provider to rural communities in a financially responsible manner. What is your vision and mission? Amit Sharma: To provide accurate testing results at an affordable price, to strengthen relations and to build trust with all our clients through committed business practices and to be recognised as a diagnostic leader in the healthcare service industry are part of our vision. To pursue these goals, small towns are what we aim. Most of these small towns don’t have adequate number of labo-

SELFIE is another kit which has got several unique products we developed. The word ‘selfie’ is so popular now. So, we have used this word for our products. A selfie which helps you to take inner health selfie- this is what we mean by it. ratories and the cost for several tests is usually very high. Our laboratory in Dhule can serve almost 14 talukas and 3 districts nearby. Till now, the samples are taken to Mumbai and there is a delay of two to three days to get the reports. We give them an advantage at a low cost, maintaining the quality. We have got unique profiles that could be beneficial both for society and individuals. By 2025, we aim to establish 100 labs across the country. If you take metropolitan cities, you always face huge competition. Also our main customers are small scale laboratories that are scared of corporates. 80% of our business is brought by them. Unlike corporate laboratories, we don’t have any sales or marketing person employed by our company. We encourage and motivate these small scale laboratories to grow on their own with unique ideas. If our customers are benifitted, then we are also benefitted. Although we do have problems, we are rectifying them and improving on our own.

Amit Sharma and his crew.





Mr. Amit Sharma

Agappe: Habitually, organisations run on its core values which might mostly be the strength behind their success. What are your core values? Amit Sharma: We focus on four core values. The first is Quality and it should begin from day one. Second comes the cost as everyone is cost conscious, you can say as “quality blood testing at affordable price” the third is Service because we are in the service industry and if you are at par with all the first three then you develop the fourth that is Relationship with our customers .

Amit Sharma with Toshiba's TBA 120 FR from Agappe.

Agappe: How does H S Pathology Pvt. Ltd. facilitate health services to the needy? Amit Sharma: Our focus is in providing the best diagnostic health care facilities to the public without any compromise in quality. For that sole aim, we have developed many unique profiles that consist of several tests at an affordable rate. Slowly, the acceptance of profiles is increasing and it is both beneficial to physicians and patients. For physicians, early diagnosis of diseases will help them to prevent the disease from developing further. Agappe: Research and Development in global IVD industry has resulted in many dynamic changes in various test methods. How does H S Pathology Pvt. Ltd. adopt such changes? Amit Sharma: For us, it is not possible to do a lot of research and development right now. Since we have expansion plans with more central laboratories, what we do is, we generate some unique products. For example, we have developed a product called Liv Ever. We are the only people doing this profile. All these are concept making products. We stand unique with our products from the competitors. Also, we educate the customer as well as the physician about the product. You might have noticed that the tag line for our laboratory’s is ‘reinventing the wheel of clinical pathology’. The way you present your product is what matters as we all have the same products. SELFIE is another kit which has got several unique products we developed. The word ‘selfie’ is so popular now. So, we have used this word for our products. A selfie which helps you to take inner health selfie – this is what we mean by it. If you go with this alphabet ‘S’, it is for secure and means secure a birth right. A lady who is pregnant can secure her self with accurate selfie of prenatal health. S-Secure a birth-right E-Expertise; livEver L-Laboratory; advanced, innovative, dependable and precise F-Focus; sweeTest I-Intelligent; a tension E-Efficient; heart solutions Why this is unique because if you compare this product with our competitors - first, it is cost effective and it has got every-




thing a pregnant lady needs. In short, it is a comprehensive test series with value additions and almost 50% reduced rate for tests. We started this concept two years back and the results have been amazing. Apart from these, Prenatal Care, SweeTest, LivEver Profile, Health Watch, A Tension, Heart Solutions, JI-O etc. are our other profiles. Agappe: Tell us about the accreditations H S Pathology Pvt. Ltd. secured? Amit Sharma: We have an unflinching commitment to quality and never compromise on accuracy by strictly ad hering to ISO 15189 standard, CLP, CLSI, FDA and WHO guidelines. We are certified and accredited by the following: Quality Management System (ISO 9001:2015). Quality Council of India Certified under NABH norms. Health Solutions had commenced its participation in external quality assurance programs conducted by RANDOX & BIORAD & ONE WORLD ACCURACY ISO 15189 -2012 pre-audit completed successfully, final audit awaited. Agappe: H S Pathology Pvt. Ltd. has been dealing with Agappe for so many years. How is your overall experience with Agappe so far? Amit Sharma: I have been dealing with Agappe since 2012 and I am quite satisfied with Agappe. I only have this suggestion that Agappe should increase its menu. There should be more specialisations apart from bio-chemistry. Agappe: Today, Agappe with its new expansion of production facilities, is having the largest and most modern plant in the Indian sub-continent. Agappe is privileged in claiming that we are “the best partner in diagnostics”. What would be your advice to Agappe for strengthening its tag line your best partner in Diagnostics? Amit Sharma : New parameters should be there. It should be like a departmental store and a one stop solution. The focus should be broad and not on a single parameter or segment.

Life Story Major D. P. Singh (Marathonist)


D.P. Singh

India’s Blade Runner A MAN WITH METTLE

What can be disheartening for a disabled person? His disability? Major D P Singh, a young major in Indian Army who lost his leg during Operation Vijay in 1999, will say that it is nothing but the sympathetic glances from others.

The story of Major Devender Pal Singh, India’s ‘Blade Runner’, is

inspiring from its core. Fulfilling his sole ambition to become a soldier, Singh was serving the Indian Army when the destiny took a detour in Singh’s life. He was in his prime of youth – just 25 years old then. Posted at Akhnoor sector on LOC (Line of Control) during Kargil War time, he was part of the Operation Vijay to tackle and clear the infiltration of Pakistani soldiers and Kashmiri militants from the Indian side of the LOC .There were 28 soldiers under him. Heavy bombing was a daily affair to them. Pakistani post was just 80m away. During one such day, a shell exploded next to Major D P Singh. However, his colleagues managed to carry him from a pool of blood




Life Story Major D. P. Singh (Marathonist) to a safety spot and transferred him to a medical facility soon to get quick medical attention. At the Army Hospital, they declared that he was dead for the shrapnel from the mortar bomb had hit his vital organs and there had been the heavy blood loss as it took almost 2 and half hours to reach hospital from the war zone. But just in time, another doctor found that he was breathing and they managed to save him by amputating his right leg. On seeing his leg before amputating, Singh once told in a motivational speak. “When they removed the bandage I saw it. There was nothing much left. It was like a piece of chicken. Half eaten, half bone!”Other injuries like partial hearing loss to both ears, partial removal of the intestine in two operations, left knee derangement owing to ligament implant, 40 non-removable shrapnel pieces still inside various body parts, urinary bladder operated for tumour – the list is long enough. Singh is wrestling with all these odds even now. Moreover, his emotional stress was very high although it was in control at first. Twice he was admitted in Psychiatric Ward. Then he understood that only he could fight it out and eventually, he did. After enduring the agonizing hospital days, the question was about the life ahead for Singh. What was more annoying for him was the sympathetic glance from others. In countless interviews Singh had said that facing the reality and overcoming the trauma could be really difficult for many but for a soldier, it was a sense

of pride. They undergoes the traumas to safeguard the country. Slowly, he had started to walk with the help of crutches. Singh thought of ways to return to his normal life or at least something to inspire people around him. That was how he turned to running after 10 years of the incident. In the Army, Singh was more into ral ly sports. Since it was expensive and needed sponsors, he looked for other options. He started with golf but felt it more of a game for the old. He then turned to squash. He felt quite tired after a good game of squash. But still the athlete inside him was craving for more. That was when he saw the advertisement about Delhi Half Marathon in a newspaper. He had around 40 days for preparing to take part in the marathon. He used prosthetic leg for it which was a hard and painful trial for him. Yet, he managed to train with it. Slowly, he could cover three or four km at a stretch with his prosthetic leg even though it was not meant for running. But he continued training and thus managed to run the first half-marathon in 2009. Even though there was immense pain, bleeding and injuries after the marathon, Singh was happy that he could achieve the feat.

It was after the third marathon, Singh heard about the blade runner- Oscar Pistorius, the South African amputee runner. What attracted Singh more to him was his fibre blade prosthetic leg. Singh made efforts to get one for him as he found out that it could reduce his pain and is the best suited for amputee runners like him. Eventually, Singh got one fibre blade prosthetic leg. After proper training, Singh signed up for his first half marathon using his fibre blade prosthetic leg. But fibre blade prosthetic leg wasn’t as easy as Singh had thought it to be. It takes almost one and half hours for Singh to get ready with his prosthetics and to clean the bowel (due to intestinal injuries). 3 or 4 rounds of toilet is required to clean it daily. One can easily understand the difficulties of doing so daily as a part of his training. But the strong-willed soldier in Singh endured all that pain and suffering. Getting used to the vibration of the body and prosthetic while running was the second thing which he had to tolerate next. Often, he fell down. But every time, he rose back like a Phoenix from the ashes. He had said that every time it was a battle with his mind and body. Initially at the end of every run, there were wounds on the stump. But they came under control after a few runs as he wasn’t ready to give up running owing to injuries. QuitMajor D. P. Singh ting was never an option to him and under training. later he shared his knowledge in overcoming the injuries and




getting adjusted to the new prosthetic to similar people. For his first blade run and his 4th Half Marathon at Del hi half-marathon run, Singh was recognised by Limca Book of Records as the first Indian to run a half marathon with a blade. Media and wellwishers called him ‘India’s Blade Runner’. Improvisation is Singh’s blood and he wasn’t going to be satisfied with a single half-marathon. It was just a beginning. For many of us, taking part in the marathon is a fun moment- an occasion to take selfies, put them in the social media and grab maximum likes. Let alone completing the marathon, we will be gasping for air and complaining of aching muscles. You will wonder at the number of half-marathons attached to Singh’s credit with his prosthetic leg. It’s more than 20! Running a full marathon is next in the list of Singh. Meanwhile, his half marathon timings have improved from 3hrs 40 min to 2hrs 26 min in 2009. In 2013 he clocked his best time at 2hrs 10 min. He celebrated his last birthday on 13th Jan 2017 with a solo 42 km run. Singh has fallen in love with running. He believes running to be a spontaneous activity where your mind and body work in harmony. Everything else diminishes. He enjoys in running and attributes it all to his training at Indian Army and his upbringing in the Sikh religion. Both are his institutions which taught him about survival and instilled hope and courage inside him. “Indian Army and Sikhism are synonyms as both work on the principle of serving others, sacrificing self for others, duty above self. The history gives out such proofs,” says Singh. In 2011, Singh began the group called ‘The Challenging Ones’ as a platform to pass similar attitude towards life with many people like him. “People like me are known as “Challenged” but I say, we are “Challengers”, we can give challenge to many on the basis of our ability. With limited/restricted mobility we can do many things which other able bodied people don’t dare. So, who is really disabled? And when a group of “Challengers” came together, it is known as “The Challenging Ones”, says him. It is also a platform for discussion where amputees and their families can come together to inspire and support each other. He believes that it is not only the individual but also the society that needs to be educated on treating a disabled person like a normal person. Singh believes that sports is a wonderful medicine for inspiration and a platform to rise above the difficulties and disabilities. Apart from that, it is also a motivational tool. Singh is also sought as a motivational speaker by many NGOs, schools and companies.

Major D. P. Singh under training.

‘The Challenging Ones’ actively encourages its group members in different sporting events like swimming, badminton and so on. For Singh, the fuel to run all marathons is nothing else but the encouragement he gets from all sides for participating in each marathon. His legs and mind are propelled forward by the people cheering for him. Many of the amputees in ‘The Challenging Ones’ have now taken part in numerous sporting events and have won medals. The NGO supports almost 1300 now, out of which 200+ have already participated in various marathons. Singh admits that there has been a positive change in how media portrays physically challenged people now but still, much more can be done. He says, “Every person has limitations in some areas. So let’s not categorise people based on their limitations. We need to focus on what people are good at and not the other way round.” Singh is now behind SwachhAbility Run. It is a celebration to encourage abilities over disabilities and lead by example towards Swachh (clean) India. In other words, it is a sporting event combined with a mission to cleanse the environment. It covered small cities where no such platform existed. Various schools and general public were encouraged to participate in the event and later to adopting the place to keep it clean. The second phase of this run is already planned for South India.




Cover Story Knee Replacement - An Overview

What is New in


M.D., DNB (Orthopedics), Additional Director of Fortis Bone & Joint Institute, Fortis Group of Hospitals, NCR, India.

Advances in the past two decades have been able to give the surgeons the tools to satisfy their patients over the whole spectrum. In this article, we shall try to enumerate the recent advances in total knee replacement and how they help the patients. The knee is the largest joint of the human body and it supports

majority of the body weight while performing activities of daily living. Consequently, it is prone to repetitive microtrauma leading to wear and tear of the cartilage, which in turn leads to osteoarthritis of the knee joint. As a result the knee tends to become stiff, painful to wal k on and inhibits an individual from performing activities of daily living. Exercises, physiotherapy and over-thecounter pain killers do help initially, but with time, it becomes imperative to think about knee replacement. In recent times, due to increased awareness, more and more patients are opting for this surgery not only to maintain but also to improve their quality of life. In the past two decades, the average age of the patients undergoing knee replacement surgery has come down resulting in an increased demand on the knee joint. The challenges for an orthopaedic surgeon are manifold. Not only does he need to correct the deformity and enable the patient to get back to a normal life but also think about life of the prosthesis. This increased demand has forced the surgeons to deliberate and research extensively in order to overcome the drawbacks of the older conventional knee systems and also meet the challenges faced by them in their daily surgical practice. Advances in the past two decades have been able to give the surgeons the tools to satisfy their patients over the whole spectrum. In this article, we shall try to enumerate the recent advances in total knee replacement and how they help the patients.

Structure of the Knee Implant Let us start with the structure of the knee implant and what it is made of. In 1860, Verneuil proposed interposition arthroplasty,




involving the insertion of soft tissue to reconstruct the joint surface. Since then, pig bladder, nylon, femoral sheath, anterior bursa of the knee, cellophane, and many other materials have been used, but results were disappointing. The use of metallic interposition arthroplasty began in the late 1930s. Early implants were crudely made, rough in texture and did not pay attention to the complex interplay between each component. They were merely resurfacing the damaged cartilage surface of the joint. Today implants are made of a highly polished cobalt chrome alloy, which is a very strong alloy, well tolerated and accepted by the human body. The polyethylene insert, which is placed between the two metal components, is highly cross linked which prevents its wear and tear. The polished surface of the metallic components also helps reduce wear and tear of the polyethylene insert. This wear material has been shown to cause problems within the knee joint causing early failures of the procedure. Sterilization methods have also helped reduce the wear and tear rate of the insert. Gamma steril-

Dr. Vivek Dahiya Dr. Vivek Dahiya is the Additional Director of Fortis Bone & Joint Institute, Fortis Group of Hospitals, NCR, India. Dr. Vivek Dahiya has completed his graduation from Odessa State Medical University, Ukraine & Post Graduation as DNB in Orthopedics from DDU Hospital, New Delhi. He has over 14 years of experience in treating patients with Orthopedic problems and has worked at various prestigious hospitals including Fortis & Medanta. He has special interest in Knee Joint replacement & Sports Medicines/ Knee injuries. He has over 11 years of experience in treating Knee joint problems. He has presented papers in several national and international meetings. He has keen interest in reading, travelling & trekking.

ization in the past led to early catastrophic wear and breakdown of the insert. Nowadays, ETO sterilization has solved the problem. Addition of vitamin E in the substance of the insert is said to delay its degradation.

Design of Knee Implant Design of the knee implant has a bearing on the result of the surgery-both in the survivorship of the implant and in terms of patient satisfaction. The knee joint has three bones that articulate with each other. For the implant to be successful, the components have to be well synchronised with each other and also perform their own functions independently. The femoral component (part of the lower thigh forming the knee) should be well fitting on the host bone, and should not over hang the bone otherwise it will rub with the soft tissues causing pain. It should also provide a good and friendly surface for the knee cap (patella) to glide on. Modern designs take care of this aspect. The Persona implant from Zimmer has femoral components in 2 mm increments and each size comes with a standard and a narrow option. The number of sizes available is in 2 mm increments in both planes, a design which helps in providing a better fit of the implant. No two individuals are alike so why should two knees be the same? To facilitate this, there are several permutations and combinations available to the surgeon, which provide for the ideal fit. The Persona implant is also the most patella-friendly implant available. This allows for ease of gliding of the patella on the femoral component helping to achieve a better and more efficient thigh muscle




Cover Story Knee Replacement - An overview function. This in turn leads to better knee joint range of motion and gait pattern. The tibial component (part of the leg bone which participates in the knee) is also an important part of the knee. Traditionally, they were made symmetric whereas the normal human anatomy is asymmetric. What this means that the shape of the tibial component should closely approximate the original anatomy of the bone. In the Persona Knee system, the tibial component comes in 9 sizes with 1mm increments again allowing the surgeon much more flexibility in choosing the exact size of the implant for the patient. As with the femoral component, overhang is going to rub against the soft tissues and cause pain.

Bone Cement and Issues Traditionally, all knee implants were put in using bone cement. This allowed for a fairly secure fixation and immediate weight bearing on the joint. But a potential drawback is the possibility of allergy to the cement. Also it causes extensive bone damage at the time of a revision surgery. Implants were then designed to be used without cement. A special coating was put on the surface to allow for bone to grow into the implant making it a more physiological bond. There is also less bone loss at the time of a revision surgery. Newer metals, like trabecular metal, have in fact revolutionized the area of knee replacement. These metals are extremely

porous and have elasticity of modulus approximating that of natural bone. The porosity allows for growth of bone into the implant. This helps in better integration of the implant to the bone and thus increasing the life of the implant. Also there is no need to use bone cement to fix these implants to bone. It has found use in revision surgery of the knee too. Revision surgery is needed when the original total knee replacement fails and a new surgery is needed to address all the myriad issues where trabecular metal cones are helpful to reconstruct the lost bone. They are used to build up the defect in bones and allow for the host bone to grow into them to achieve a more biological end result.

New Technology and Devices Computer assisted surgery has been in use for a long time. Earlier devices were large in size (Brain Lab) and cumbersome to use resulting in an increase in surgery time. Newer devices are gravitating towards hand held devices such as the iASSIST (Zimmer) or eNdtrac (Stryker). These are surgical guidance systems engineered to improve the accuracy and alignment of total knee replacement surgery. They are also less invasive and more surgeon-friendly. Once the learning curve is over, there is hardly any change in surgery time as compared to before. Upto 20% of patients needed blood transfusion after a TKR. This was due to bleeding from the knee joint. It increased pain in the knee and reduced knee range of motion. Blood transfusions, though pretty safe, carry a small risk of disease transmission. Use of med icines like tranexamic acid, either given locally around the knee or intravenously, help reduce bleeding which in turn reduces pain and the need of blood transfusions.

Unicompartmental Knee Replacement Awareness is leading younger patients to opt for knee surgery. Every knee arthritis does not need a total knee replacement. In case only one compartment is involved, then only that part can be replaced. This is called unicompart mental knee replacement. It is a smaller procedure which allows the patient to recover faster and gives a more natural feel of the knee. It also allows the patient to continue with a fairly aggressive life style.




Experience and hospital management systems have helped us evolve faster rehabilitation programs. They consist of patient education prior to surgery, ultrasound-guided nerve blocks to reduce the intensity of post-operative pain, earlier and more aggressive rehabilitation and earlier discharge from the hospital. Muscle strengthening before the surgery helps the patients recover faster. These exercises prepare the patient for all the exercises to be done after the surgery. With a low apprehension, the patients are able to cope up better and there is less pain.

Post-Operative Pain Management Multimodal pain management programs help in alleviating post surgery pain and anxiety. This leads to better compliance with exercise and a cheerful pain-free patient. Devices like Game Ready, that combine cryotherapy with dynamic intermittent compression, help reduce post operative pain and reduce bleeding from the knee joint. All these contribute to making the whole process more patien- friendly and efficient for the hospitals to manage. These advances have helped surgeons to satisfy their patients and have allowed the patients to achieve their goals and expectations to a large extent.

5 Tips to Make your Knee Replacement Surgery a Success Take Your Recovery & Rehab Seriously It’s important to not let your routine slide. Use your continuous passive motion (CPM) machine as advised by your doctor, and perform all the exercises your physical therapist prescribes. Attend your follow-up appointments with your surgeon and go to all your physical therapy sessions, even when you don’t feel like it. Take medications as prescribed and do not stop any medication without checking with your doctor. Improve Your Extension and Flexion Bend and straighten your leg as much as possible. One way to improve your extension is to lay down, with a rolled towel placed underneath your ankle while lying down—try to keep your leg as straight as possible. You can improve your flexion by sitting on a chair and bending your

knee back (i.e., curling your leg underneath the seat of the chair). Also, talk to your physical therapist to learn if they recommend continuing use of the CPM machine to help you expand your range of motion. Avoid Unnecessary Stress on Your Knee Avoid lifting heavy objects that could place an excessive amount of stress on your artificial knee—and possibly damage it. Also, when you turn to face a different direction, make sure you turn your entire body and avoid twisting your knee. It is important to monitor your form when you bend down, kneel, and sit. Perform these regular movements with your physical therapist, so that he or she can help you learn how to do them safely and efficiently. Take Supplements and Vitamins Talk to your doctor about vitamins or supple-

ments that might help. One study found that 43 percent of patients scheduled to undergo orthopedic surgery have insufficient levels of vitamin D. Also, many orthopedic patients take iron to help replenish blood count after surgery. Since you might be compensating with your non-operated knee during the early stages of rehab, you may want to consider supplements that can aid in muscle recovery. Wear Compression Stockings If your doctor suggests that you wear compression stockings post-surgery, keep them on at night or while lying down. They can help reduce the risk of blood clots. Make sure you wear them until your doctor says that it’s okay to stop.




Health Tips

Health Tips for

HEALTHY BONES & MUSCLES... Dr. C.S. Satheesh Kumar, Vice President-Operations, Agappe Diagnostics Ltd., (Retd. Drugs Controller, Kerala)

Bone is a connective tissue providing structure, protecting organs, anchoring muscles and storing calcium. Our bones are continuously changing new bone is made and old bone is reabsorbed. When we are young, our body makes new bone faster than it breaks down the old bone, and our bone mass increases. Generally, 90% of bone mass is acquired by age 18 in girls and age 20 in boys. After that, bone remodelling continues, but you lose slightly more bone mass than you gain, leading to erosion of the strength. This leads to the state called Osteoporosis, a condition that causes bones to become weak and brittle which depends on how much bone mass you attain by the time you reach age 30 and how rapidly you lose it after that.

Adults (women 18-50 years and men 18 -70 years) should

aim for 1,000 mg of calcium per day. Older men and women can aim for 1,200 mg of calcium a day. Men and women under the age of 50 should aim to consume 400-800 IU of vitamin D per day. People over the age of 50 should aim for 1,000 IU of vitamin D daily. Non-dairy fortified mil ks like soy, almond or coconut mil k is an option. Primarily, we should resort to get vitamin D from sunlight exposure. WHAT LEADS TO WEAK BONES 1. Loss of Bone mineral density Bone loss occurs when more bone is reabsorbed than is formed by the body.




Many factors determine how much old bone is reabsorbed and how much new bone is made. Ageing, Menopause, Alcohol consumption and Tobacco use, Calcium deficiency, High Protein Intake, High Caffeine Intake, High Sodium intake, Soft drinks consumption and Insufficient Vitamin D lead to loss of calcium from bones. 2. Medical conditions and disorders People who have eating disorders (anorexia or bulimia) are at risk of bone loss. In addition, stomach surgery (gastrectomy), weight-loss surgery and conditions such as Crohn’s disease, celiac disease and Cushing’s disease can affect your body’s ability to absorb calcium. 3. Hormone levels: Too much thyroid hormone can cause bone loss. Prolonged absence of menstruation (amenorrhea) before menopause also increases the risk of osteoporosis. In men, low testosterone levels can cause a loss of bone mass. 4. Certain medications Long-term use of corticosteroid medications, aromatase inhibitors to treat breast cancer, selective serotonin reuptake inhibitors, methotrexate, some anti-seizure medications such as phenytoin (Dilantin) and phenobarbital and proton pump inhibitors cause decalcification. NUTRITION FOR STRONGER BONES Our bones require specific nutrients to stay strong and healthy. Calcium and vitamin D are the two big ones that most people recognize, but magnesium, protein, omega-3 fatty acids and vitamins A, C, D and K are also essential for bone health. High consumption of olives, olive oil, vegetables, fruit, legumes, moderate consumption of dairy and fish with bones such as salmon, sardines, tuna, whitebait and a low consumption of meat and meat products are ideal. Almonds, dried figs, fortified tofu and soy mil k are also calcium-rich choices. Fatty fish, soy milk, cereals, nuts, liver, egg yol k and mushroom are good sources of Vitamin D. Spinach is an excellent source of just about every nutrient because it’s high in calcium and vitamins A, C and K. Cashew nuts have a little bit of calcium and vitamin K, but what makes them so good for our bones is the magnesium and other minerals they offer, plus some healthy plant-based protein. Kiwi fruit is very high in vitamin C, and it is rich in magnesium. Kiwi fruit also adds some calcium and vitamins A and K to our daily intake.

Salmon is rich in vitamin D and omega-3 fatty acids that your bones need to stay strong and healthy, and it’s also an excellent source of protein. Pumpkin seeds contain some calcium and protein, but they’re an excellent source of magnesium and omega-3 fatty acids. Tomato juice is high in several vitamins and minerals, including magnesium and vitamins A and C. It also has some calcium and a little vitamin K. Fresh tomatoes are good too, of course, but tomato juice has a concentration of all that nutrients. Kale is a cruciferous vegetable good for your bones because it’s high in calcium and vitamins A, C, and K. Walnuts are a good source of calcium, protein and magnesium. Oranges are rich in vitamin C, which is needed for collagen formation and contributes to bone health. An orange is also an excellent source of vitamin A, which is essential for normal skeletal growth and cell differentiation. Don’t ignore Potassium: Potassium may neutralize acids that remove calcium from the body. A diet high in potassium can improve bone health. Load up on potassium by eating foods like sweet potatoes, white potatoes (with the skin on), yogurt and bananas. Calcium rich foods (range) 1. Col lards-1 cup boiled and drained-357 mg calcium 2. Rhubarb-1 cup cooked with sugar-348 mg calcium




Health Tips physical properties of water allow to engage in a water therapy exercise program that reduces the weight placed on your spine. This is possible because the buoyancy of water supports your weight by counteracting the force of gravity. Additionally, exercising in water minimizes your risk of injury due to unintended movements and allows you to perform a greater range of movements. Yoga to the rescue: The general benefits of yoga are greater flexibility, stronger muscles, better posture, reduced emotional and physical stress and increased self-esteem. Unlike other weight-bearing activities, yoga doesnâ&#x20AC;&#x2122;t damage cartilage or stress the joints. Instead, it helps to strengthen and maintain bone health. Here are a few asanas that are good for the bones.

3. Sardines-3 oz / 85 grams-325 mg calcium 4. Spinach-1 cup boiled and drained-291 mg calcium 5. Turnip Greens-1 cup boiled and drained-249 mg calcium 6. Blackeye peas-1 cup cooked-211 mg calcium 7. Kale-1 cup boiled and drained-179 mg calcium 8. Soybeans, 1 cup boiled-175 mg calcium 9. Chinese Cabbage (pak-choi)-1 cup boiled and drained-158 mg calcium 10.Beans, with pork and tomato sauce-1 cup-142 mg calcium 11.Lad ies Finger-1 cup boiled and drained-136 mg calcium 12.Shrimp-3 oz / 85 grams canned-123 mg calcium Since many nutrients are important for bone health, it is important to eat a well-balanced diet containing a variety of foods, including grains, fruits and vegetables and meat or beans each day. KEEP MOVING FOR HEALTHY BONES Weight bearing exercises and activities force you to work against gravity which wil l strengthen the bones by stimulating bone-building cells called osteoblasts. High-impact exercises like running, tennis, basketbal l and kickboxing strengthen bones faster. Opt for brisk walking or simple vertical jumps instead if one cannot resort to heavy exercises. Any exercise that helps build muscle (lifting weights, using resistance bands, doing yoga) will also help build bone density and strength. Indoor exercises like strapping on 1- or 2-l bs wrist and ankle weights at home is good. To boost your bone strength, try running, jogging, high-impact aerobics, repetitive stair climbing, dancing, tennis and basketball. Water therapy is recommended for lower back pain - the




Tadasana (Palm Tree Pose): Stand with feet 10 cm apart. Raise hands over the head, interlock the fingers and look straight. As you inhale slowly, stretch the arms upwards. Keep stretching till you are on your toes. Exhale as you lower your hands and bring your toes back to the floor. Repeat 10 times. Kati Chakrasana (Waist Rotation): Stand with legs 2 ft apart, arms stretched to the sides at shoulder level. Exhale while twisting to the right. Place the left hand on the right shoulder and wrap the right arm around your back. Hold for a few seconds, and twist to the centre position. Repeat on the left side. Do 7-10 rounds on each side. Trikonasana (Triangle Pose): Stand with legs 2 ft apart. Turn the right foot to the right side and stretch the arms sideways at shoulder level. Bending sideways, bend the right knee and bring your right hand to touch the right foot, while raising the left arm up in line with the right arm. Look up towards your left palm pointing to the sky. Hold for a few seconds. Stand up slowly. Repeat on the left side. Do 3-5 rounds on each side. Bhujangasana (Cobra Pose): Lie on your stomach, with your forehead on the floor and feet together. Place your hands underneath your shoulders, palms pressed flat on the floor. Raise your head, neck and shoulders off the floor as you slowly inhale, arching the back. Try to look upwards, and stretch as much as you can. You may bend your elbows slightly. Exhale as you lower yourself. Repeat 5-7 times. Ayurvedic treatments like Panchakarma and other regenerative/rejuvenative treatments also claim to support bone health very much. Anywhow, bone health is important at every age and stage of life. No matter how old you are, a balanced diet, adequate calcium intake and exercise can limit bone loss and increase bone and muscle strength for a better quality of life.

Cover Story Good Laboratory Practices

How can we eliminate Pre-Analytical ERRORS... Sanjaymon K.R., Asst. General Manager, Marketing, Agappe Diagnostics Ltd.

The modern laboratories today are equipped with the latest analytical automated instruments to give the best result to the clients. Since most of these instruments are controlled by dedicated software, it is easy for the technologist to operate the instrument and to understand the analytical errors if any. The modern laboratories today are equipped with the latest analytical automated instruments to give the best result to the clients. Since most of these instruments are controlled by dedicated software, it is easy for the technologist to operate the instrument and to understand the analytical errors if any.

The major concern in todayâ&#x20AC;&#x2122;s laboratory is the control of pre-analytical errors (mostly sampling errors) which accounts for 70% of the total errors that happen in the laboratory. Most of these errors are out of the complete control of the laboratory and become a major concern in the assurance of the quality of results. Let us consider certain scenarios to understand this.

Prothrombin Time Prothrombin time is one of the sensitive tests performed in the laboratory. The test procedure is simple but due to the criticality of the test, in most of the cases, the test is done in duplicates to validate the results. The test is performed in citrated plasma using trisodium citrate as an anticoagulant. One of the major factors that affect this test is the sam-




Cover Story Good Laboratory Practices pling, which includes the sample container, the sample collecting and separation. The sample needs to be collected in citrated tubes with whole blood to citrate ratio as 9:1. Any change in this ratio will alter the result. It is recommended to use commercially available citrate tubes to have the control on the ratio rather than making the tubes locally in the laboratory. Prothrombin is a labile factor and hence needs to be separated immediately after collecting the sample in the proper container. The ideal time is within 15 minutes. The laboratory should make sure that the sample is separated within the stipulated time and in case of outside samples, the same is not received if not brought within the stipulated time.

24-hour Urine Samples In 24-hour urine sample collection, each test has its own preservatives. Laboratories should make sure that the exact volume of such preservatives are used and proper instructions are given to the patient prior to the sample collection. The major error happens in 24-hour estimation is the higher protein results due to the bacterial growth because of the absence of proper preservatives.




Lysed sample is one of the nightmares for technologists where the haemolyse will interfere with many test parameters. Glucose Estimation Glucose the simplest test in hospitals and sometimes, gives unexpected results. In most cases, the low value of the sugar, especially in the IP patients, is due to the delay in bringing the sample to the central diagnostic laboratory. The best way to elude such issues is to use fluoride tubes for sugar samples. With pneumatic systems for transportation, the delay in sending samples can be eliminated. The laboratory can also use gel tubes to eliminate such errors.

Sodium/Potassium Electrolyte estimation is one of the critical parameters and in many cases, the error in plasma sodium seems to be of the sam-

pling tube. Normally, the hospital will collect the blood in heparin for the plasma samples so that the samples can be proce ssed immediately. There are two types of heparin available namely, sodium heparin and lithium heparin. Care should be taken by the laboratory to make sure that the sample is collected in lithium heparin for the sodium testing.

Lysed Samples Lysed sample is one of the nightmares for the technologists where the haemolyse will interfere with many test parameters. By using the proper collection tubes and needles, lysing can be prevented to some extent.





Urea and uric acid

Values are increased

Circadian rhythm

ACTH, Cortisol, TSH, Testosterone, Growth hormone

Time of collection should be mentioned


ALT, AST, Creatinine, ACP, Phosphate, potassium

15-30% increase may be seen


Uric acid, triglycerides and GGT

Increased values are seen


Free fatty acids, Total lipids, Glucose

Increased values are seen


Triglyceride, Growth hormone, cortisol, Glucose

10-20% increase in values are seen


Uric acid, Protein, Glucose

Increased values are seen


Sodium, Creatinine

Decreased values are seen

Tourniquet keeping more than 2 minutes

AST, CK, ALK, Total protein, total lipids and cholesterol

20-30% increase in values are seen



Increased values are seen

Improper Sample Container As mentioned above, there are specific sample containers used for specific tests. The laboratory should make sure that the sample is collected properly in the specific container before performing any tests.

Improper Sample identification Proper sample identification is important for proper testing.

This is one of the major challenges in the laboratories. In many cases, improperly marked sampl- es create chaos in the diagnostic centres. This is also one of the reasons for the increased TAT where there are cases of repeat sample collection to ascertain the sample identity. The major issues in sample labelling are: Short names on tube Illegible handwriting Missing names on the tube


ALKALINE PHOSPHATASE â&#x20AC;&#x153; Agappe Alkaline phosphatase uses DEA buffer with a working reagent stability of 1 monthâ&#x20AC;?

Sample collected in the wrong container Care should be taken by the laboratories to make sure that the phlebotomists are trained to label the tubes properly and is handed over to the specific department in the stipulated time. A sample collection log book will ensure that the samples are traceable. The best way to reduce such labelling errors is using the bar-coded labels for samples. This will ensure that the sample is traceable and it becomes easy for performing the tests. The new generation automated instruments are equipped with positive sample identification and hence the bar-coded sample label will eliminate the errors and will improve the TAT. With the primary tube sampling facility in the automated instruments, laboratories can assure that the sample is traceable. This also will reduce the manual labour and will increase the laboratory efficiency. Laboratories should give importance to the pre-analytical variables and should make sure that these variables are addressed properly. This will give the assurance of quality and will increase the efficiency of the laboratory and confidence of the technical personnel within the laboratory.




Brand Reach Customer Speaks

‘Quality pr oducts with no err ors’ products errors’


We are using Mispa i2 for almost a year now. We are very surprised to find one Nephelometry instrument providing high quality and high precision of results. No complaints, no error till date and very simple to use. Thanks Agappe for this support.

Dr. Monika Agarwal, Metropolis Healthcare, Kolkata, West Bengal.

‘Best quality results' Mispa count has smaller aperture size which provides me the best quality results compared to other instruments.

Atul Chaud hari,

Managing Director, Shreeram Clinical Laboratory, Jamner.



‘High pr ecision and economical pr oducts’ precision products’ We have been using your reagents like HbA1c, TGL and cholesterol since last few years. Reagents are having high precision and are economical. We are highly satisfied with Agappe products. results and Dr. Ram Mohan, Chief Pathologist, cost effectiveness. They provide good after sale service backup ITMR Specialty also. I expect more quality products from Agappe in future. Diagnostics, Hyderabad.

'Compact, user-friendly products with speedy results'

Dr. Jigar R Mehta MD (Path), Asutosh Multi Specialty Hospital, Surat, Gujarat.



The gap in laboratory diagnostic menu for cardiac and septicemic patients has been bridged by Mispa Revo of Agappe Diagnostics. Results of immunofluorescence technology is very accurate. Machine is compact,operator friendly and concept of QC smart card with each lot, nullifies the error. Furthermore, due to speedy results, patients can be managed in ‘The Golden Hours’ following heart attack, to prevent damage to cardiac muscles and impact patient’s survival in a positive way.




‘Innovative pr oducts and good after sale service backup’ products I personally believe that Agappe is dedicated in producing high quality products, either machines or reagents. I am using Mispa i2 and Mispa Neo for nearly one and half years. Mispa i2 is one of the best products available in diagnostic field in terms of innovative design, high quality results and cost effectiveness.

Dr. Neyaz Ahmad, Care Diagnostics, Purnea.

‘Grateful to Agappe for the superior quality and err or -fr ee error or-fr -free pr oducts’ We are using Mispa i2-Specific Protein analyzer for the last two products’ Dr. B.Y Shinagare

Chief Patholgist, Shinagare Laboratory, Pune.



years and we would like to share with great pleasure that our experience has been good and the instrument is giving satisfactory results with highest accuracy and precision. Additionally, as far Agappe reagents are concerned, I have been using it for the last 10 years and experiencing best linearity and accurate test results.

‘V ery convenient to use and expect mor oducts’ ‘Very moree innovative pr products’ I am using Mispa i2 Nephelometry analyzer for the past one and half years. I am very much satisfied with the results. now I am using small pack size like 15 tests, for parameters like HbA1c, ASO, CRP, RH factor and micro albumin. I am sure this kind of small pack size is useful to all kind of Medium sized laboratories. We are waiting for ELISA and CLIA testing instruments from Agappe in the coming years.

Mr. V. Sivakumar Director, Vijaya Diagnostics, Centre, Chennai.

Happy with Lipid PParameters arameters Dr Suma M.N.,

Department of Biochemistry, JSS Medical College, Mysore.

This is to certify that the Clinical Biochemistry Laboratory, JSS Hospital, Mysore, is running the lipid parameters on Toshiba Accute 400 from Agappe Diagnostics and we are satisfied with the results and their service.





Brand Reach Customer Speaks

‘High Pr ecision Pr oducts’ Precision Products’


Our lab is equipped with BC 3000 + hematology analyzer and Mispa-i. We are very happy with the excellent performance of these instruments. We are also using Agappe reagents which give good accuracy and high precision.

Dr. Vipul Jain,

Precision Diagnostic Centre New Delhi, Delhi

‘Good in Quality and Accurate in Results’ Mr. Bharat,

Nidaan Healthcare New Delhi, Delhi


We are using Agappe reagents which are very good in quality and accurate in results. We are using LFT, KFT, Lipid profiles. All the reagents are highly accurate. It is an excellent experience with Agappe.

‘Compact, User -Friendly and Fast’ User-Friendly We had recently installed Agappe’s Mispa-i2 and we are happy with its performance till now. Mispa-i2 is compact, user-friendly and fast. We are also happy with the training provided and the customer service.

Dr. Dhabali Singh, Babina Diagnostics Imphal, Manipur

‘V ery satisfactory and no complaints yet’ ‘Very Viswajith Chatterjee,

Lab in charge, Digital Path Lab, Jharkand


I am using Agappe reagents for the last one and half years and results are very much satisfying to me, especially, HbA1c. I do not have any complaint against any product of Agappe.


‘Easy oducts with Suppor tive ‘Easy-- to-handle Pr Products Supportive Service’ We are using Agappe Biolis 24i premium. It is very easy to handle and getting accurate results. Especially, I am telling Agappe’s service is very supportable. I appreciate Agappe for maintaining their quality.





Ms.Deepthy K Dinesh, Mother Hospital Thrissur, Kerala.


‘W onderful and trustwor thy’ ‘Wonderful trustworthy’ We used HbA1c Pack size 2x15/2x5, 4x.5/2 x 63 ml for the last two years. I am satisfied with all the report that comes with Agappe Brand HbA1c. We found that it is 98% better than any other brands. Thanks to Agappe for bringing such a wonderful products.

Dr. Jagadish Domaria, Pooja Pathology Laboratory, Bhavnagar

‘R eliable and quality pr oducts’ ‘Reliable products’ Dr. B.N. Prasad, Sri Krishna Diagnostic Laboratory, Muzaffarpur.


I have been using Agappe’s products like SGOT, SGPT, GGT, RF, LDL and HDL for quite some time. The products are good, stable and giving good results. I am very much impressed and satisfied with their quality and after sales service.


‘Appr eciable service and fair standar ds’ ‘Appreciable standards’ Reagents are made of satisfactory standards and provide accurate results. I have been associating with Agappe reagents for the last few month and I am very much impressed with the service provided by its service team, and moreover, I could honestly say that the test results are very accurate with Agappe reagents especially HbA1c. All wishes to Agappe team.

Dr. T.K. Senthil kumar, Annamalai Hospital, SankaranKovil, Tamilnadu

‘Incr eased customers due to pr ecise rresults esults ‘Increased precise of Agappe pr oduct’ product’

Dr. G K Agrawal,

Agrawal Clinical and Diagnostic Centre Ajmer, Rajasthan.

We have started using Agappe’s HbA1c direct with calibrator recently at our diagnostic centre. We found that the product quality is up to our satisfaction mark. Our referring doctors and patients are also happy with the reports. We are using it for the last three months till date, no adverse comments has come to us with regard to its result. The number of our HbA1c patients is increasing day by day. Thanks to Agappe for supporting us with quality HbA1c kit.





Engagements Exhibitions & Conferences

Team Agappe in attendance at world’s largest laboratory exhibition and congress “Med lab (Midd le East), Dubai International Convention & Exhibition Centre, Dubai in February 2017.


HOSPITALAR 2017-THE LEADING HEALTHCARE EVENT IN THE AMERICAS 16 - 19 May 2017, Stal l No. RUA2-11 AZUL, Expo Center, Norte, Sao Paulo, Brazil.

As the key event for the healthcare sector in the Americas, and entry point for the South American market, Hospitalar is ideal for launches, product innovations, as well as solutions and services for hospitals, laboratories, pharmacies, clinics and medical centers. The event attracts 90,000 professional attendees from the healthcare industry, with decision makers and influencers representing 58% of that figure. With more than 50 parallel sessions, leaders in the sector and the most advanced thinkers from Brazil and around the world attend Hospitalar’s congresses. Highlights include: the Digital Healthcare International Forum, which debates the changes in the doctor-patient relationship, and CISS – The International Healthcare Services Congress, which will examine how the healthcare industry can get the best out of its processes and reduce costs while still serving the market with high levels of excellence. CISS presents experiences from countries at the cutting edge of healthcare and from the industry as a whole.




MEDLAB ASIA PACIFIC 2017-THE LEADING HEALTHCARE EVENT IN ASIA 03 - 05 April 2017, Stal l No. 401-402, Suntec Singapore Convention & Exhibition, Singapore The 4th MEDLAB Asia Pacific Exhibition & Congress taking place 3-5 April 2017 at Suntec Singapore Convention & Exhibition Centre brings together leading laboratory experts, scientists, researchers and clinicians to exchange and share their experiences and research results on all aspects of laboratory medicine and clinical research. From new methods of effective lab management to the development of techniques in detecting diseases, the MEDLAB Asia Pacific conferences will cover an extensive range of topics guaranteed to educate and enlighten all. Conference Tracks Supported by the Academy of Medicine, Singapore - Asia's largest medical laboratory Congress will feature 11 CME-accredited conferences on laboratory medicine and clinical diagnostics. From new methods of effective lab management to the development of techniques in detecting diseases, the MEDLAB Asia Pacific conferences cover an extensive range of topics guaranteed to educate and enlighten all.

Engagements Special Days






Focus Product




Focus Product






World Health & Wellness Congress Award

Dear Readers, It is with great privilege we would like to inform you that Agappe’s Managing Director, Mr. Thomas John was selected among the “100 Most Impactful Healthcare Leaders – Talent Listing Globally” held on 14th February 2017 at Hotel Taj Lands End, Mumbai. He was recognized with an award during the ceremony organized by World Health and wellness Congress with CMO Asia.

World Health and Wellness Congress and Awards is an international organization representing Senior Members and Leaders joined by a common interest in driving economic development and understanding health and wellness industries. Delegates from diverse sectors, including health and wellness, medical, manufacturing and technology attend the Summit from across the Globe.

Emerging Entrepreneur of the Year-2016 Agappe's Managing Director Mr. Thomas John has been awarded with the "Emerging Entrepreneur of the Year" Award by TiE Kerala during their annual conference TiECON 2016 held at Le Meridian Cochin on 18th November 2016.




Medical Quiz 1)

First person who developed the concept of bone remodelling………. a) John Hunter b) Louis Pasteur c) Aristotle d) Socrates


Dr. Fuller Albright was the first to explain ………… a) Rheumatoid Arthritis b) Post-menopausal osteoporosis & oestrogen c) Myeloma bone d) none


A healthy Bone is made up of ………….. a) 70% minerals & 30% organic b) 50% minerals & 50% organic c) 30% minerals and 70% Organic d) 95% minerals and 5% organic


General laboratory test to detect osteoporosis is……… a) Calcium b) Phosphate c) ALP d) All the above


Osteomalacia is a disorder because of ………….. a) Vitamin K deficiency b) Vitamin D deficiency c) Vitamin B complex deficiency d) Vitamin E deficiency


Major Orthopaedic procedures have the risk of developing …….. a) DVT b) PE c) DIC d) All the above


Early detection of PE, DVT and DIC can be done by …………. a) Factor 12a b) Factor 11a c) factor 10 d) D-dimer


75% - 100% of patients with GFR < 60 ml/min report …….. a) Heart attack b) Cerebral ischemia c) Pancreatitis d) Metabolic bone disease


Bone ALP is an isoenzyme……. a) ALP – 1 b) ALP – 2 c) ALP - 3 d) ALP - 4

10) ALP is widely distributed through the body in ….. a) Bone b) Liver c) Placenta d) All the above

Quiz Answers of January-March Edition

1-a, 2-c, 3-a, 4-d, 5-a, 6-a, 7-c, 8-d, 9-d, 10-d

Winners will get their prize by post

Quiz Winners of January-March Edition Dr. R. Aishwarya Meenaloshini, Virudhunagar | Dr. Chitta Ranjan Prasad, Sambalpur | Dr. Geo Francis, Thrissur | Dr. Pushpawalli, Chittur | Dr.S.G.S. Krishna Rao, Guntur | Prof. Dr. Suvarnaletha Devi. K, Trivandrum | Prof. Urmila. D. S., Trivandrum | Dr. Biswajit Batabyal, Kol kata | Mr. Sony George, Perumbavoor | Ms. Prathibha L. Braggs, Kallianpur | Mr. M. Arumugam, Tirunelveli | Dr. K. B. Jacob, Kochi | Dolly Kuruvilla, Trivandrum | Dr. Rafiq Mohamed, Kochi | Parmod Kumar, Mansa | Dr. Krupal Pujara, Rajkot | Go Swami, Bhavnagar | Ms. Mini Shaji, Chalakudy | Ms. Prasanthi, Hyderabad | Mr. Anoop M. A, New Delhi | Kamlakant Mohanandia, Rayagada.

Answers of this quiz contest wil l be published in the next ed ition along with details of the winner and the prize. Participants can either hand over the answers to Agappe’s staff or send in their responses directly to TechAgappe at or post a mail to The Manager-Corporate Communication, Agappe Diagnostics Limited, Agappe Hil ls, Pattimattom PO, Ernakulam district, Kerala-683562.




Editorial Submissions What do you think of this edition of

Techagappe? Are you happy with the overal l look and feel of the magazine? Do you recommend any change of style with regard to presentation of articles? You can share your views with us in the space given below. All you have to do is to post this sheet of paper to the address given below. The best letter shall be featured in the next editionâ&#x20AC;&#x2122;s letters to the editor section.

Pull your thoughts together and get started right here... ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ ................................................................................................................................................................................ Name........................................................................................................................................................................ Address........................................................................................................................................................................ PIN....................................Mob.............................................Mail ID..................................................................

Postal address:

The Manager - Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562. Email: Mob: +91 9349011309

Kind ly let us know which section of the magazine you like more... Poem Cover Stories




Life Stories Good Laboratory Practices

Health Tips Interviews


LyphoCHEK Biochemistry

Point of Care Testing

LiquiCHEK Biochemistry

Controls & Calibrators

ChemCHEK Biochemistry

KidSCREEN Urinalysis

SensIT Immunochemistry

HeamoCHEK Hematology

CoagTHREE Coagulation


SeroCHEK Latex Agglutination


CORPORATE OFFICE Agappe Hills, Pattimattom P.O, Dist. Ernakulam, Kerala - 683 562, India. Tel: +91 484 2867000. Fax: +91 484 2867222; Branches: Delhi | Bangalore | Kolkatta

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Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, â&#x20AC;&#x153;Agappe Hillsâ&#x20AC;?, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.

Sharp for accuracy and smooth in procedure open to all and no closed loops bright as future and simple as present

Techagappe 11th Edition (April - June 2017) Ebook.  

Agappe Diagnostics Limited is the first Indian IVD company publishing an International Diagnostic News Journal “Techagappe” for the public t...

Techagappe 11th Edition (April - June 2017) Ebook.  

Agappe Diagnostics Limited is the first Indian IVD company publishing an International Diagnostic News Journal “Techagappe” for the public t...