Vol.2 Issue 2
JANUARY-MARCH 2016
THE DIAGNOSTICS NEWS JOURNAL
Published at Agappe Diagnostics Limited on January 01, 2016 | 62 Pages | ` 20
GRAND OPENING India’s Largest IVD Reagent Manufacturing Facility
SOARING HIGH ON THE WINGS OF A DREAM Mr. Thomas John
ALZHEIMER'S DISEASE: PERSON IN A PERPETUAL TWILIGHT Dr. D. M. Vasudevan
ROBOTIC SPINAL SURGERIES DO HAVE MORE PRECISION Dr. A. Marthanda Pillai
EPILEPSY: MYTHS AND REALITY Dr. Prithika Chary
METROPOLIS: THE PATHOLOGY SPECIALIST Ms. Ameera Shah
SCREENING FOR INBORN ERRORS OF METABOLISM BY TANDEM MASS SPECTROMETRY Dr. Rita Christopher & Archana Natarajan
NEUROLOGICAL DISORDERS Learn About Symptoms, Diagnosis & Treatment
Introducing mobile application for the ď€ rst time in
INDIAN IVD INDUSTRY
*For more details: +91 9387384152 | productcorp@agappe.in
Privilege CUSTOMER ENGAGEMENT PROGRAM
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AG Privilege is a unique customer engagement program which enables you to easily access information on our products, scientific data and other services 24 X7.
Review Product Catalogues | Check System Reagents | Reference Range At A Glance Know Our Products | Enquire About Parameters
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Volume 2 | Issue 2 | January-March 2016 ○
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Musings of an Alzheimer’s Patient
14-16 Alzheimer’s Disease Person in a Perpetual Twilight 18-20 Beauty with Purpose in a Wheelchair... 21-23 Screening for Inborn Errors of Metabolism by Tandem Mass Spectrometry-An eight year experience 24-26 “Robotic Spinal Surgeries do have more precision” 27-29 A Musical Prodigy!
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08-09 Soaring high on the wings of a
DREAM
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Epilepsy: Myths and Reality
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Recharging A Life... Happy Life with Healthy Mind
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R.C.A: Simple way to improve the laboratory efficiency Testimonials
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34-36 A life sketch with UNIQUE DIMENSIONS
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37-39 Metropolis The Pathology Specialist
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. www.agappe.com 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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TECHAGAPPE
JANUARY-MARCH 2016
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From The Editor’s Desk
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THE DIAGNOSTICS NEWS JOURNAL
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It is my privilege to state that Techagappe, the
quarterly review of health and laboratory medicine, is now regular in publication at intervals of three months.This journal is meant for practicing doctors and technologists in the clinical laboratories. I am also pleased to report that the laboratory community has warmly welcomed the previous issues of the magazine. The following pages will show the interrelation between clinical medicine and the clinical laboratory procedures. In this respect, the laboratory personnel has the greatest responsibility to keep the quality in every sphere of activities. ‘Quality Consciousness’ is behind al l the activities of Agappe.
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Focus on Neurological Disorders and Treatment
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The present issue of the magazine is on Neurological disorders with emphasis on symptoms and treatment. Readers will see articles on inborn errors of metabolism, epilepsy, cerebral palsy, autism and spinal fracture and alzhiemer’s disease. I am sure that readers will be benefited to get an update on the topic, written by senior workers in the field. I do hope that this issue of Techagappe will give useful insights to the problems of various neurological defects.
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The first issue of Techagappe was focused on cardiac issues, second on renal function tests, the third issue was dealing with liver function tests, the fourth issue was devoted to Diabetes mellitus and the fifth one covered some aspects of Cancer.
I am proud to announce that the ensuing issues of Techagappe will cover other equally important topics. Your constructive criticisms to improve the contents will be greatly appreciated.
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With warm personal regards,
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Subscription-For subscription queries, write t o techagappe@ agappe.in or call us at +91 484 2867065. Permissions-For permissions to copy or reuse material from Techagappe, write to techagappe @agappe.in Letters to the editor-Email: techagappe@agappe.in Postal address: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district, Kerala-683 562, India. Advertisement QueriesEmail: pratheesh.jacob@agappe.in
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DIRECTOR Meena Thomas Sangeeta Joseph George Varghese Mary Baby Meleth Dr.D.M.Vasudevan Suresh B Nadkarni
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MANAGING DIRECTOR Thomas John
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CHAIRMAN Prof. M.Y. Yohannan
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BOARD OF DIRECTORS
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PHOTOGRAPHY Nelson Thomas
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WEB MANAGER Pratheesh Jacob
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DESIGN AND LAYOUT M.T. Gopalakrishnan Dezign Centre, Kochi. 9947144570
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PUBLISHING COORDINATOR Jayesh Kumar
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LEGAL ADVISORY BOARD Adv. Denu Joseph
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EDITORIAL ADVISORY BOARD Gangamohan P Dr. C.S. Satheesh Kumar Sudhir K. Nair Jofy Paul Suresh Babu Sanjaymon K.R Vijith Kumar V. Mallya
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CONSULTING EDITOR Rarima N.S
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CHIEF EDITOR Dr. D.M.Vasudevan
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EDITOR Meena Thomas
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EDITORIAL BOARD
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Volume 2 | Issue 2 | January-March 2016 ○
Dr. D.M. Vasudevan
TECHAGAPPE
JANUARY-MARCH 2016
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TopicsCompr ehensive Comprehensive and LLucid ucid
for the Techagappe issues. D. Suresh,
I enjoy reading the assortment of articles in your Techagappe magazine, there is a mix of diagnostics, therapeutics and general topics presented in a comprehensive and lucid manner. I like reading it regularly for upgrading my knowledge. Dr. Jude W Vaz, MD, Chief Pathologist, Holy Family Hospital, Mumbai.
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Rich in information and classy in design! Really, I like Techagappe very much - a good magazine with fantastic design and rich information. Thank you once again
Chief Librarian Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Chennai.
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Informative, Useful, Compact!
Techagappe is a very informative, useful, compact journal. Articles on latest biochemical tests are of great help. I am looking to many more informative journals in future. Thanks for offering this journal to us. Dr. Vidhya Datar Bijoy Laboratory, Hospet.
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Unique in Content and TTopics! opics!
The current edition of Tech
Gr eat Inspiration! Great
I have kept your journal on my table and show it to the cancer patients who lost courage and confidence in them. I explain them the details of Smt. Leela Menon with uterine cancer, Smt. Hemalatha with breast cancer and having a child after operation and treatment and Dr. P A Lalitha with ovarian cancer, who has high will power. Dr. Gopal Archak, MD, Physician and Medical Superintendent, Sri Sujayeendra Arogyashala, Mantralayam, And hra Pradesh
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JANUARY-MARCH 2016
Close to Heart!
I always love reading your articles, but this entire issue on cancer survivors was so close to my heart and so close to my own story. It touched my heart deeply. I am a 31-year-old single girl and an endometrial cancer survivor. The trials of so many people inked down here really touched my heart. Best of luck to all of them. Sangeeta Garg,
Director, Deepak Memorial Hospital & Medical Research Centre, Del hi
agappe is quiet unique in bringing attention towards one of the deadly diseases,� Cancer�. Expecting similar type of articles in future also. Jesmi Binu, PMM Hospital, Kalady
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A Pr ecise and Precise Practical Guide
The book is very useful for the day to day practice. The information in the magazine is very precise and accurate. The selection of pictures is good. The quality of papers used is extraordinary and I want to recommend all my staff to read Techagappe regularly. Dr. S Ramesh, Diabetologist, ABC Medical Centre, Erode
Mor Moree Life Stories Needed With reference to Techagappe, I would like to record my views. The presentation is good The material provided is excellent and useful Worthy reading and preserving I would also like to suggest that more life stories about ordinary people doing extra ordinary work should be added in each issue. With best wishes for keeping up the good work. Dr. Sanjeev Narang,
MD (Path), Medwin Diagnostics, Indore.
Cover Story Poem on Alzheimer’s Disease
MUSINGS OF AN II
ALZHEIMER S PATIENT I
sit and wonder where they went, Leaving me with my wounded spirit Here in this strange prison of past With inmates present so fresh and fast These two gentlemen here with me Strange are they and ‘pa’ they call me And that angel who never leaves me What might be her wet eyes’ plea? I wonder who those cherubs are With throbbing hearts so calmly care Strange anecdotes they do refer And it’s my pleasure they do prefer And at times my angel press my palm With gentle arms that never harm And stares at my eyes too calm To relive thus some forgotten charm I like guests as fresh as moon They light my dark with sweet lollies Elves with them call me pantaloon For what they see is only my follies And why my angel weep inside For those lollies I keep aside And be so cool sitting beside That feeble smile ever reside Still I wonder where they went With no goodbyes ever sent Alone with my barren thoughts With these strange ones…..who care a lot?
TECHAGAPPE
JANUARY-MARCH 2016
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Profile MD’s Desk
Soaring high on the
wings of a
DREAM Thomas John,
Managing Director
A
new industrial revolution is underway with the evolution of India’s largest IVD reagent manufacturing facility with 1,20,000 square feet area in Kerala, God’s own Country. AGAPPE’s state-of-the-art manufacturing facility comply with the stringent global regulatory standards. This would ameliorate all processes to deliver quality services that exceed the expectations of our esteemed customers.
The grand inauguration of this facility was on 19th Dec 2015 by Sri. Oommen Chandy, Hon. Chief Minister of Kerala. Sri. Anoop Jacob, Minister for Food & Civil supplies, Prof. M.Y. Yohannan, Chairman of Agappe & many well-known political leaders shared the dias. Bishop His Grace Dr.Thomas Mar Athanasius blessed the occasion. The business function organized in connection with this grand ceremony was inaugurated by Dr. A Velumani, creator and CEO of Thyrocare, the largest thyroid testing laboratory in India. Mr.C.M.Radhakrishnan Nair, former director of CBI; Dr. Sukesh C Nair, Head, Department of Hematology,CMC Vellore; Mr.C. Balagopal, founder of Terumo Penpol; Dr. Georgy K Ninan, Senior consultant nephrologist; Mr. J F Thomas, Elitech; Dr. Lydia Chen, Mindray; Dr. Akira Hori guchi,Kyowa Medex; Mr. Hiromitsu Tokunaga, Toshiba Medi-
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JANUARY-MARCH 2016
A new industrial revolution is underway with the evolution of India’s largest IVD reagent manufacturing facility with 1,20,000 square feet area in Kerala, God’s own Country. AGAPPE’s state-of-the-art manufacturing facility comply with the stringent global regulatory standards. This would ameliorate all processes to deliver quality services that exceed the expectations of our esteemed customers. cal Systems, Mr. Ugochukwu Nwokedi, Nigeria; Mr.M.S. Anand, CRP groups; Mr. R.S. Swaminathan , Spectrum Pharmatech; Mr. Ravi S Menon, Deputy Drug Controller; Mr. M.R. Pradeep, Deputy Drug controller and Mr.R Devadas, JD Diagnostics delivered their felicitation speech.
The function was witnessed by crowd of more than 1500 people from India and abroad. 25 international business partners, 50 Indian Channel partners, more than 100 top customers, national and international vendors, service providers, bankers & government officials enriched the function.
A Swift Recap… After completing my engineering, I started working with one of the health care giants in IVD sector in Mumbai as a production engineer. During my extensive travel throughout India, I had a chance to meet both urban and rural population and had seen Inauguration of Agappe’s New Reagent Factory by Hon. Chief Minister of Kerala Sri. Oommen Chandy the real scenario in the diagnostic field. The idea of starting a new business hit my mind in multinational giants and the patient’s cost of diagnosis was the early 1990’s. The concept came to my mind knowing the fact very high. I shared my views within my family. My focus and my that the healthcare industry at that time was focused more on the urban population where the spending power was high as com- vision was to take medical diagnostics to the rural areas pared to the rural areas. The dominant players at that time were where small and medium hospitals are functioning. The patients were low and middle income grade. The aim was to provide diagnostic solutions at highest quality at par with global standards and at a much more affordable price, where every patient would be benefited with the right diagnosis and get the right treatment on time. AGAPPE was thus born in the year 1995 at Mumbai. The name AGAPPE was chosen because it represented “Divine Love” in Greek Language, which is very well harmonizing with my vision.
Agappe’s New State-Of-The-Art Reagent Manufacturing Facility
In the initial years itself, AGAPPE got the acceptance among the customers with its remarkable quality products and services. AGAPPE’s devotion and customeroriented service makes it the “Best Partner in Diagnostics”.
TECHAGAPPE
JANUARY-MARCH 2016
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Profile MD’s Desk
Wordsof Motivation
Dr. A. Velumani Creator and Chief Executive Officer, Thyrocare Technologies Limited, Mumbai
“Agappe is one of the few
companies who sensed the market and taken off well. I wish to congratulate the Agappe family to set up the largest facility in India to manufacture reagents in this part of Kerala, which is a wonderful achievement. I would like to come back here in the same place for the same meeting in the year 2020, exactly 5 years from now to tal k about the world’s largest reagent manufacturing facility. An organization grows only if there is an eye for perfection. Agappe products are highly competitive and I am the biggest customer for Agappe in India. I wish to remain as the single largest client of Agappe in the coming years also”.
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JANUARY-MARCH 2016
Journey with Agappe
J F Thomas
Elitech Group, France
“We have around 20 years’ story together. We started association with Agappe on a fine day of April 1995. At that period, Seppim was the primary supplier to Agappe. When Agappe decided to start the clinical chemistry reagent manufacturing, we provided the technical support and technology transfer to manufacture the products here. I am very proud to see the success of Agappe. Agappe is the biggest company in India who can produce clinical chemistry reagents and I am sure that it is going to be a difficult task to all those European companies to compete with such good quality products from Agappe”.
“First of all, on behalf of Kyowa Medex, I would extend our sincere congratula-tions … We are a Tokyo-based IVD company with more than 30 years history. Kyowa Medex is an inventor of an IVD reagent using enzymatic reactions and also enzymatic reagents for measuring HDL cholesterol in blood.
Akira Horiguchi, Kyowa Medex, Japan
Our relationship with Agappe started in 2010. It was at MEDICA fair in Dusseldorf where we met Mr. Thomas for the first time. After that, we signed an agreement and officially started doing business with Agappe in May 2011. Usually it takes more time for us to start doing business with a new partner because we have to go through many steps of evaluation and internal procedures. However, in case of Agappe, it went surprisingly fast to reach the business phase. This is because Agappe is a well trusted company and has a great potential for growth. For eg; Agappe’s quality-consciousness, strong desire to contribute to improve people’s health, attitude to business and so on. Also we were impressed with Agappe’s serious people and clean facilities, which make me feel their usual sincere attitude toward their daily activities. I am convinced that things I mentioned have made Agappe what they are today. Now we would like to and expect to continue our cooperation to contribute to diagnostic area and the improvement of people’s health together with Agappe”.
Why Agappe’s
Reagent Manufacturing Facility is the LARGEST in India?
z ISO 9001 & 13485 Quality Management System endorsed by UL z 20,000 Sq. ft. class 1 Lakh production area (ISO Gr-8) z Class 100 Laminar work stations (ISO Gr-6) in Class 10000 (ISO Gr-7) clean rooms z 10% & 20% RH clean rooms for manufacturing rapid kits and lateral flow devices z Fully automated 20,000 liters capacity Hematology plant z Automated filling, sealing, capping and labeling machines z Lyophilisers with 7,000 bottle capacity z Highly purified Type 2 water treatment plant with Reverse Osmosis and De-ionisation z Capacity of more than 2,00,000 reagent kits per shift /month z More than 10,000 Sq. ft. QC & QA area with fully automatic testing equipment z Zero discharge Effluent treatment plant of 1,00,000 LPD (Liters Per Day) treatment capacity z 30 million liters rain water harvesting facility
TECHAGAPPE
JANUARY-MARCH 2016
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Profile MD’s Desk
Lydia Chen,
Chairman-CRP Group, Hyderabad, India
“I am so glad to be here with Mr. Thomas
the dais and off the dais.
John and Agappe team to celebrate the most auspicious inaugural moment of “India’s Largest IVD reagent manufacturing Facility”. Mr. Dean, MD of Mindray India and Mr. Feng, sales manager for IVD segment were with me for the grand opening ceremony. Taking this opportunity, I would like to introduce a little bit about us. Mindray is the biggest medical equipment manufacturer and supplier in China. We have three major product lines, which are life support, medical imaging systems and in-vitro diagnostic products. Till now, our products have been exported to more than 190 countries and regions. In terms of cooperation with Agappe, as Mr. Thomas mentioned during the inaugural ceremony, we have been growing together with Agappe in the market for past near 13 years. From one 3 part cell counter to thousands of installation and from hematology products to semi & fully automatic chemistry products cooperation, Agappe is one of our longest and most important partner. Hope with the inauguration of new manufacturing facility, it could help strengthen our relationship, we could do more business and contribute more to Indian healthcare industry. We, Mindray, sincerely wishes Agappe further success with the grand inauguration of this India’s biggest reagent manufacturing plant”.
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M.S.Anand
Mindray Med ical International Limited, China.
TECHAGAPPE
JANUARY-MARCH 2016
“Greetings from CRP Group to the august gathering on Around a decade back Mr. Thomas (Agappe) came to our office at Hyderabad and discussed about his plans to start an IVD manufacturing unit in Cochin. The volume of the business he discussed with us was very simple, but his intentions were very serious and his passion was enormous. Hence we had agreed then to take his tiny project as a special case and I personally felt that he is a person ‘IN FOR A LONG HAUL’ and to be associated with. Look at the outcome today! Agappe is not only a leading IVD producer in India but also created a world class facility for manufacturing IVD reagents. The man behind the whole show in Agappe is Mr. Thomas John and his attitude is phenomenal. The success of air management is the success of the IVD industry and it is the success of Agappe Facility. Though IVD industries internationally are satisfied with CLASS ISO 8 facility, Agappe has gone ahead and achieved CLASS ISO 7 facility combined with ISO 05 UDF system, which is greater than ISO 8 by ten times. Besides, they have also created a combined facility for 10% RH with ISO 07 classified Clean Room. I am sure that this is the first of its kind in IVD facility in the country. This feather in their cap will definitely make them accomplished to manufacture critical import substitution products. Further as our Honorable Prime Minister is envisaging “MAKE IN INDIA”, Agappe can utilize their world-class facility to produce qualitative products for multinational companies. Our best wishes to Agappe family to grow & branch out globally. We will be their contamination control partner wherever they reach”.
1995
Established
1996 - 2004
History of Agappe
Basic Reagents in Clinical Chemistry | Equipment Division Semi/Fully Automated Clinical Chemstry Analyser | 3 Part Hematology Analyzer & Reagents | Blood Grouping Sera | Serology.
2005 - 2008
High End Auto Analyzer | HbA1c Reagents | System Reagents [Toshiba, Biolis, BS 120/200 Series] | Immunoturbidimetry Reagents.
2009 – 2012
Cystatin C | Nephelometry Reagents through R&D | Nephelometry Segment – Equipment [Mispa i] & Reagents | Mispa i2.
2013 - 2014
AGA1c, a 2 Reagent HbA1c Assay | Full Range of Clinical Chemistry Reagents | Protein Estimation – Different Options |Other Hematology Reagents
2015
New Products Clinical Chemistry | Immunochemistry (IT & Nephelometry) | Microbiology Reagent & Equipment | TurbiQuick Acquisition
TECHAGAPPE
JANUARY-MARCH 2016
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Cover Story Alzheimer’s Disease
Dr. D. M. Vasudevan, MBBS, MD, (Biochem), FRC Path Director - Technical (R&D), Agappe Diagnostics Ltd.
Alzheimer’s Disease
Person in a Perpetual Twilight The Problem About 5-10% of people above 60 years are affected by Alzheimer’s disease (AD). In 2010, there were about 35 million people worldwide with AD. One among three seniors dies with Alzheimer’s. The condition often begins in people over 60 years of age. However, 5% cases are of early onset. As the number of aged persons is increasing, the condition becomes a major health problem in India. It is a chronic neurodegenerative disease. This disease is characterized by slow progression of memory loss, confusion, dementia, hallucinations and personality change. Finally, the patient enters into a vegetative state with no comprehension of the outside world. The abnormal behaviour of the patient affects the whole family and is a serious social issue. Death occurs about 5 to 10 years after the first onset of the symptoms. Shakespearean character, King Lear, loses his memory and becomes disoriented can be treated as a well-known example of this disease in literature. AD has struck many VIPs including former US President Ronald Reagan, Irish writer Iris Murdoch, former UK Prime Minister Harold Wilson, former Indian Prime Minister Atal Bihari Vajpayee, former Indian Central Minister George Fernandez and Nobel Laureate Charles Kao. AD has also been portrayed in many films such as ‘Iris’ (2001) based on the life of Iris Murdoch, ‘The Notebook’ (2004) based on a novel of the same name, ‘Thanmaathra’ (2005) Malayalam film and ‘Still Alice’ (2014) based on the famous novel with the same name.
Ten Warning signs of Alzheimer’s 1. Memory loss disrupting daily life: Patient may forget important dates or events; may ask for the same information over and over. 2. Challenges in planning or solving problems: They may have difficulty in concentrating and will take much longer to do things than before. 3. Difficulty completing familiar tasks at home, at work or at leisure: Patients may have trouble driving to a familiar location or remembering the rules of a favorite game.
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Clinical manifestations
Dr. Alois Alzheimer
Auguste Deter
Historical perspective
The disease was first described by Dr. Alois Alzheimer, a
German physician, in 1906. Alzheimer had a patient named Auguste Deter, who died of progressive dementia. An autopsy of the patient revealed dense deposits (now called neuritic plaques), around the nerve cells in her brain. Inside the cells were twisted strands of fibres (now called neurofibrillary tangles). Since Dr. Alois Alzheimer was the first person to describe the disease, AD was named after him. 4. Confusion with time or place: They may lose track of dates, seasons and the passage of time. Sometime, they may forget their location or how they got there.
Family members also have difficulties in the detection of initial dementia symptoms and often think that the patient is obstinate. It starts with difficulty in remembering recent events. In the pre-dementia stage, there will be mild cognitive impairment and the symptoms are often mistakenly attributed to ageing. Early deficit is short-term memory loss, manifested as difficulty in remembering recently learned facts. Mild depression and reduced awareness are also common. As the disease progresses to early AD, there will be increased memory loss, difficulties with language and problems in perception. Older memories and implicit memory (the memory of how to do things, such as using a spoon to eat) are affected to a lesser degree than the memories of the new facts. The vocabulary shrinks and fluency of word decreases leading to a general impoverishment of communication skills. At this stage, the person is capable of communicating basic ideas. As the disease progresses to moderate AD, the subject is unable to perform common activities of daily life. The longterm memory may also be deteriorated. Speech difficulties will become predominant, characterized by frequent incorrect word substitutions. Reading and writing skills are also
5. Trouble understanding visual images and spatial relationships: They may have difficulty in reading, judging distance and determining colour or contrast. 6. New problems with words in speaking or writing: They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They have problems finding the right word or call things by the wrong name (like calling a watch as a “hand-clock�). 7. Misplacing things and losing the ability to retrace steps: They may lose things and be unable to go back to find them again. Sometimes, they may accuse others of stealing. 8. Decreased or poor judgment: Patients may use poor judgment when dealing with money. They may pay less attention to grooming or keeping themselves clean. 9. Withdrawal from work or social activities: Patients may decrease hobbies, social activities, work projects or sports. They may also avoid being social because of the changes they have experienced. 10. Changes in mood and personality: They can become confused, suspicious, depressed, fearful or anxious. They may be easily upset at home, at work, with friends or outdoors.
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JANUARY-MARCH 2016
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Cover Story Alzheimer’s Disease progressively deteriorated. Person may fail to recognize close relatives. Behavioural changes such as irritability, mood changes, outburst of rage etc. may become more prevalent. Some may develop illusions and delusions.
tests, blood B12, syphilis antibodies, electrolyte levels etc. will rule out such conditions. Early detection may be possible by testing cerebrospinal fluid for beta amyloid and tau protein concentrations.
During the final stages, the patient is completely dependent on caregivers. There may be complete loss of speech, but patient can express and appreciate emotional signals. Although outbursts of rage can still be present, main manifestations will be apathy and exhaustion. Ultimately, patients won’t be able to perform even the simplest tasks independently and become completely bedridden and unable to feed themselves. The cause of death is usually infections, pneumonia or dehydration. The average life expectancy following diagnosis is five to nine years.
Treatment of AD
Pathophysiology and Molecular Defects
There is no definite treatment is currently available to cure or stop AD’s progression. Available treatments offer only symptomatic benefit. Current treatments are pharmaceutical, psychosocial and care giving. Only donepezil is approved for treating advanced AD dementia, with limited success. Memantine has shown to have a small benefit in AD treatment. The drug that antagonizes N-methyl-aspartate receptors is available, which will slow down the progression of the disease to a certain extent. Active research is going on and many drugs are in the clinical experimental stage. Since Alzheimer’s has no cure and it gradually renders people
Alzheimer’s disease is characterized by death of neurons and loss of synapses. This loss results in gross degeneration in the temporal lobe, parietal lobe, frontal cortex and cingulate gyrus. There is reduction in the size of brain regions. The pathological hallmarks of AD are neurofibril tanglesin CNS, senile neuritic plaques and cerebral amyloid deposition. Inflammation within the brain plays a role in the development of Alzheimer’s disease and long-term use of anti-inflammatory drugs was found to reduce the incidence of this disease. The neurofibrillary tangles are paired helical filaments made up of Tau protein. Normal Tau is soluble and catabolized easily but abnormal Tau is insoluble, cannot be degraded and is deposited around neurons. Tau is required for stabilizing axonal microtubules, the communication channels in nerve fibres. As insoluble Tau is deposited, there is loss of microtubules in AD. The synthesis of acetylcholine is also reduced, leading to memory loss. Alzheimer’s disease has been identified as a protein misfolding disease, caused by abnormallyfolded tau protein and amyloid beta protein. About 30% cases have genetic background, called as familial AD. Genes identified with AD are that coding for APP, presenilin-1 (in chromosome number 14), presenilin-2 (in chromosome 1), AD3 (chromosome 14) or AD4 (chromosome 1). Another major susceptibility gene for AD is the Apo-E4 (apolipoprotein E4) gene situated in chromosome 19. The presence of Apo-E4 gene is the major risk factor for AD. ApoE2 gene reduces the risk of AD.
Diagnosis of AD The diagnosis of AD is dependent on the medical history of the patient, details from the relatives and patient’s behavioral alterations. Memory testing, CT, MRI and PET scans etc. are useful to determine the stage of the disease. Alzheimer’s Association has established the diagnostic criteria. Differential diagnosis includes hypothyroidism, Vitamin B12 deficiency, neurosyphilis, electrolyte imbalance in blood and heavy metal poisoning. Appropriate blood tests such as thyroid function
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incapable of attending their own needs, emphasis should be given to care giving.
Prevention Smoking is a significant AD risk factor. Hypercholesterolemia, hypertension and diabetes mellitus are high risk factors for AD. Therefore avoidance of smoking as well as treatment for diabetes and hypertension will delay the onset of the disease. Active mental and physical exercise will reduce the risk of AD. Intellectual activities such as reading, playing chess, playing music etc. are found to reduce the risk of AD in epidemiological studies but this won’t rule out the development of AD in a particular person, even if he is proficient in intellectual activities. Learning a second language later in life has shown to delay the onset of the disease. Long-term usage of non-steroid anti-inflammatory drugs (NSAID) is associated with a reduced incidence of AD. Omega-3 fatty acids may be helpful in prevention of the disease. Coconut oil has been found to be of benefit in some studies. Food stuffs containing flavonoids such as cocoa, tea etc. may decrease the risk.
Perfect Instrument produce
PERFECT RESULTS
Live Story Dr. Rajalakshmi
Beauty with Purpose in a
Wheelchair…
The charm she spreads around is infectious. When she smiles, it fills our hearts with consoling warmth. Dr.Rajalakshmi S. J., the 29-year-old dental doctor moves around in her wheelchair offering the most caring dental services to her patients at her clinic, SJ Dental Square located at Sri Nagar, Bengaluru. The atmosphere gets electrified with positivity just by her presence. She was titled, ‘Miss India Wheelchair 2014’ in a pageant held in Mumbai from among 200 contestants. She stole the show with her beauty, her intellect and her positive attitude towards life.
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orn to doctor parents, Dr. S. Janard han Murthy and Dr. Shobha, her ambition was to become a doctor right from her childhood."I have seen them saving lives and heard people call them ‘devaru’ (‘God’ in Kannada) in my childhood", she recollects with pride. She had every ingredient in her life that would make a girl happy; affectionate parents, two loving elder brothers and a luxurious and trouble-free life. She was her father’s pet. “As I was born after two sons, I was more pampered and my father would say that I was his lucky charm”, she beams with happiness.Child hood days were golden and magical for her. Life was like a sweet-sounding song with her family and friends singing in tune with her.
Dr. Rajalakshmi S.J
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Extremely good at studies, she equally indulged herself in sports and cultural activities. She was a district level Table Tennis player, used to go for Salsa, swimming and frequent rides with friends.
With strong familial support to make her ambition come true, she joined for BDS (Bachelor of Dental Surgery) at Oxford Dental College, Bengaluru. At the end of four years, she came out in flying colours with a rank and started on with her oneyear internship, which was mandatory. During her internship, her teachers wanted her to submit a paper at a national conference which was held at Chennai in 2007. A group of four members went to Chennai in a hired cab and their journey was intervened by fate, the benefactor-turned-renegade of her life.Their cab collided with a stationary lorry and her life took a jerking turn from that spot. Though they were rushed to a nearby hospital, they were not taken in there as their condition was quite bad. Immediately, they were taken to CMC, Vellore with better facilities. “Soon after the accident, as I was a medical student, I realized that my spinal cord is affected. I was unable to feel my legs”, she recalls. From CMC, She was taken to another hospital where a surgery was done on her spinal cord in an attempt to repair the damage. As spinal cord injuries are fatal, she was left a paraplegic and re-
Dr. Rajalakshmi in a Dental Med ical Camp
Finalists of Miss India Wheelchair 2015 turned home after a month’s hospital stay. From then on, she was confined to her bed for a year. She states, “I was not sure about my life. I was afraid that I wouldn’t be able to treat patients in that condition”. This uncertainty made her join open courses in MSc. Psychology and later Fashion Designing from Indian Institute of Fashion Technology (IIFT), both subjectswere hidden passions in her for a long time. At first, she was reluctant to use a wheelchair but necessity prompted her to use it for moving around without anyone’s aid. Slowly, it became an inevitable part of her life. Now, she handles it like an extra pair of hind limbs directly from God. Movement instilled confidence in her and the ambition to pursue the profession of a doctor was re-kindled in her. She applied for MDS (Master of Dental Surgery) in PH (Physically Handicapped) quota at the Govt. Dental College, Bengaluru. The college authorities replied that as the only seat in that category was already filled in, she would not get an admission. She discovered that it was not a lone seat but the PH quota had 3% of the total seats. She went to court to get the policy implemented, won the case and the policy was implemented all over India for the first time. She came out as the topper in MDS and bagged the gold medal in the MDS National Examination bringing glory to the whole of Karnataka. Sitting in a wheelchair, objectified as an emblem of helplessness, is just not her idea of living. She has more life in her now. She has applied for a job in Government Hospital which is reserved for the physically challenged. Again, she got a negation in reply as the policy was not yet implemented. She is making a legal fight for that cause now. Simultaneously, she has opened a dental clinic in Bengaluru with the support of her family. She drives to the clinic and returns home in her customized car. Occasionally, she goes for long trips with her
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Live Story Dr. Rajalakshmi friends and she has visited more places after the accident than before. Life is not something to be whined about according to her. The extreme optimism and confidence she exhibited and her go-getter attitude has caught the public eye. She received Dr. Batra’s Positive Health Award in 2010 for displaying outstanding courage in the fight against disease and disability. The panel of jury included prominent personalities like Maneka Gand hi, Anu Aga, VivekOberoi, R.Bal ki, Rajiv Bajaj and Dr.MukeshBatrawhile. The famous cine actress VidyaBalan presented her the award. She also bagged the International Women’s Day award, the same year. Currently, she has a busy schedule. Though she gets up a bit late in the morning, she spends her time in the clinic till evening. She has a load of personal assignments awaiting her after that. She goes to the rehabilitation centres in the afternoon. She also associates with Mobility India, an NGO at Bengaluruwhere she serves the disabled persons as a wheelchair trainer. Mobility India focuses on empowerment, inclusion and participation of people with disabilities. It conducts courses to physiotherapists and other occupational therapists on disabilities and other related areas. Classes are conducted to educate them on the selection and usage of appropriate wheelchairs. Since she is an expert in wheelchair use now, she too takes practical lessons for them. “My life hasn’t changed much if you ask me how it is before the accident and after it. I still freak out with friends and am as happy and ambitious as before. But when I confront the infrastructural barricades like steps, escalators etc., I feel a bit uneasy”, her words are accompanied by acatching smile. For the past four to five months, she was busy making arrangements for the Miss India Wheelchair 2015 that took place at Indira Nagar Club Convention Hall, Bengaluru on Dec 5, 2015, organized by SJ foundation (SJ foundation was started by Dr. Rajalakshmion May 2015 to work for the welfare of disabled). “Fundraising was a Herculean task, but I never thought it as an impossible feat”, she stated with confidence. PriyaBhargava (Noida)was crowned the Miss India Wheelchair 2015. ManuvitaBawa(Chandigarh) and Chaya (Benguluru) were the first and second runners up respectively. She advises her peers to face life boldly than complaining about it. “The best you can do about your life is to face it with a smile. Never think that your life has come to a screeching halt. Actually, it’s a new beginning”, she means what she says as she is a living example of her words. She thinks that the society can do many things for the physically challenged,
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Dr. Rajalakshmi with Kannada film actress Tara
to the minimum of giving social acceptance if not any financial assistance. Dr. Rajalakshmi likes to take life as it comes and she never plans ahead when it comes to her future. When asked about her experience as Miss India Wheelchair 2014, she recollected that she came to know about the event while surfing through net. Her positive attitude urged her to send a 3-minute video for audition and was selected for the event. She too visited the gym and made alterations in her diet to keep fit.The event took place in Mumbai and they had two rounds with different costumes along with personality tests. Beating 200 contestants, she became the Miss India Wheelchair 2014 and was crowned by the renowned film director,NageshKukunoor. During the event, she was asked: ‘If you had an opportunity to live someone else’s life, whose lifewould itbe?’ Her reply came promptly which won her the hearts of the audience and jury alike. “I am blessed to lead two lives, one of a normal person and the other of a disabled, in one lifetime. Disability has moulded me in a different way with a different perspective of life. So, I have already got the opportunity to live someone else’s life in this lifetime itself’.For her, disability and inability are poles apart. Her new passion is guitar and is determined to play it perfectly soon. As a virtuoso who adds the best notations to her life, she would do that without much delay.
Cover Story Tandem Mass Spectrometry
Screening for Inborn Errors of Metabolism by
Tandem Mass SpectrometryAn eight year experience T
Dr. Rita Christopher Professor and Head
Archana Natarajan Junior Scientific Officer
Department of Neurochemistry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka.
he term ‘Inborn Errors of Metabolism’ (IEM), coined by Sir Archibald Garrod in the beginning of the twentieth century, refers to a group of rare genetic disorders that affect one or more of the hundreds of biochemical pathways in the human body. These heterogeneous groups of disorders are caused due to a single gene defect which can affect the key enzymes of various metabolic pathways leading to accumulation of compounds. These compounds follow an alternate metabolic pathway resulting in the accumulation of toxic metabolites. Patients with these disorders are unable to properly use or synthesize fatty acids, amino acids, organic acids, or macromolecules, because of the defects in the enzymes or other components of various metabolic pathways. These conditions are frequently identified in infants and young children with acute or chronic symptoms. When possible, early diagnosis with timely and effective interventions are essential for preventing adverse clinical outcomes such as permanent neurologic disorders, disabilities, irreversible mental retardation, physical disability and even death in affected babies. It is therefore extremely important to detect and accurately diagnose these disorders as soon as possible after birth. Screening for inborn errors of metabolism involves measuring the levels of specific metabolites present in the dried blood spot (DBS) specimens. The presence of abnormal levels of certain metabolites (amino acids and acylcarnitines) suggests the presence of particular metabolic disorders. Tandem Mass Spectrometry (TMS) is being used for several years to identify and measure amino acids and acylcarnitines in dried blood spots. TMS has been prov ed to be a rapid, sensitive, specific and an accurate method for the screening of multiple metabolic disorders of genetic origin. Electrospray ionization tandem mass spectrometry (ESI-MS/MS) has made
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Cover Story Tandem Mass Spectrometry ber are detected by a photomultiplier detector. The output is in the form of a spectrum or a plot with intensity/abundance against m/z (mass spectrum). Tandem mass spectrometry-based screening for IEM has been carried out in the Department of Neurochemistry at the National Institute of Mental Health & Neuro Sciences (NIMHANS), Bengaluru since February 2007. NIMHANS is a tertiary care referral centre for neurological disorders in South India. We have screened more than 23,000 newborns and high-risk symptomatic patients with clinical features suggestive of Inborn Errors of Metabolism. Majority of these children were from Karnataka, Andhra Pradesh, Tamil Nadu, Kerala and Delhi.
it possible to screen newborns and symptomatic children for many rare IEM’s. For measuring the concentration of these compounds, discs are punched out of the DBS and analysed by a validated bioanalytical TMS. DBS are whole blood samples that are spotted on a filter paper. S&S 903 (Schleicher and Schuell) filter paper is used to spot the samples. Mass spectrometer is a device that separates and quantifies ions based on their mass/charge - m/z ratio. MS has two quadrupole mass spectrometers in tandem separated by a collision cell. The sample mixture is aspirated by the liquid chromatography autosampler. This sample is first subjected to ionization (Electrospray Ionization- ESI) and then guided to the first mass analyzer- MS1. Here, the ionized sample mixture containing the parent ions is sorted by the mass/charge (m/z) ratio. The selected ions are guided to the collision cell where fragmentation of the parent ions takes place. These fragmented ions pass through the second mass analyser (MS2) where they are sorted based on their respective m/z ratios, which are unique for each ion. The ions coming from the MS2 cham-
Did YYou ou know? AGAPPE’s Bilirubin TAB: By the TAB method, user can analyse total bilirubin without sample blanking and offers excellent sensitivity of 0.05mg/dL and very high Linearity of 25 mg/dL. This makes Bilirubin TAB the most suitable method for paediatric and neonatal sample estimation.
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Dried blood spots are collected by a heel or a finger prick and spotted on S&S 903 filter paper. 3mm spots are punched out from these spots after drying them for four hours. The assay solution and internal standards used for extracting the amino acids and acyl carnitines from these dried blood spots are procured from M/s Perkin Elmer. A set of 10 amino acids (Glycine, Alanine, Valine, Leucine, Methionine, Phenylalanine, Tyrosine, Ornithine, Citrul line and Arginine) and 28 acylcarnitines and free carnitine are measured. Each sample is analyzed in 2 minute and 22 seconds. The intensity of the analyte is used for calculating its concentration. The results are quantitative and the concentrations are reported in µmol/ L (micromoles/litre). Biological reference interval was set up in the laboratory specific for the Indian population with respect to age. Our lab has been participating in the external quality assurance program (Proficiency Testing and Quality Control) for newborn screening provided by Centres for Disease Control and Prevention (CDC), Atlanta, Georgia, USA, from the year 2008. We have identified 752 cases of inborn errors of amino acid metabolism, fatty acid oxidation disorders and organic acidemias. Among these identified cases, 449 were males and 303, females. 406 cases were above one year of age and 346 cases were below one year of age. Of these 752 cases, 329 (43.8%) had disorders of amino acid metabolism, 332 (44.5%) had organic acidemias and 85 (11.3%) had disorders of fatty acid oxidation. Among the disorders of amino acid metabolism, Phenyl ketonuria (PKU- 101 cases ) was the most common one followed by Maple Syrup Urine disease (MSUD-73 cases), Tyrosinemia Type I (41 cases ), Citrullinemia (34 cases) and Non-ketotic Hyperglycinemia (NKH- 24 cases). Phenylketonuria (PKU) is an autosomal recessive disorder caused by mutation of the genes for the enzymes involved in phenylalanine metabolism. In children with PKU, the levels of phenylalanine in the body build up to toxic levels, causing mental retardation. However, early diagnosis and exclusion of phenylalanine from the diet allows affected babies to grow into normal, healthy adults.
Some disorders detectable by Tandem Mass Spectrometry Amino acidemias
Organic acidemias
Fatty acid oxidation disorders
Phenyl ketonuria Biopterin cofactor defects (BH4 defects)
Propionic acidemia
Short-chain acyl-CoA dehydrogenase deficiency
Methylmalonic acidemia
Medium-chain acyl-CoA dehydrogenase deficiency
Homocystinuria (cystathionine b-synthase deficiency)
3-Methylcrotonyl-CoA carboxylase defciency
Very long-chain acyl-CoA dehydrogenase deficiency
Maple syrup urine disease
Glutaric acidemia, type I
Trifunctional protein deficiency
Hypermethioninemia
Multiple carboxylase deficiency
Carnitine palmitoyltransferase I deficiency
Hyperornithininemia, Hyperornithinemia,Hyperammonemia Hyomocitrullinuria (HHH) syndrome
3-hydroxy-3-methylglutarylCoA lyase deficiency
Long-chain 3-hydroxyacyl-CoA dehydrogenase
Argininosuccinic aciduria
Isobutyryl CoA Dehydrogenase deficiency
Carnitine palmitoyltransferase II deficiency
Tyrosinemia, type I, II,III
2-methyl butyryl-CoA dehydrogenase deficiency
Multiple acyl-CoA dehydrogenase deficiency (Glutaric acidemia type II)
Argininemia
Ethylmalonic encephalopathy
Carnitine-acylcarnitine translocase
Citrullinemia & Hyperglycinemia
Mitochondrial acetoacetyl-CoA thiolase deficiency (3ketothiolase)
Primary Carnitine Deficiency
Glutaric Acidemia Type I (GA Type I– 108 cases) was the most common organic acidemia followed by Propionic acidemia (PA- 96 cases) and Methyl Malonic acidemia (MMA- 48 cases).
ciency (VLCAD - 17 cases) was the commonest, followed by Medium Chain Acyl-CoA Dehydrogenase deficiency (MCAD - 14 cases) and Multiple Acyl–CoA Dehydrogenase deficiency (MADD - 13 cases).
Among the Fatty Acid Oxidation (FAO) disorders, Very Long Chain Acyl-CoA Dehydrogenase defi-
The results of all these patients were confirmed by repeat testing and quantitative estimation of the specimens in plasma/ urine. These cases have been referred to us by clinicians from various hospitals in India. Clinical details of the patients have been filled in the request form which has been designed to capture relevant clinical details. The most important ones being age, parental consanguinity, previous history of any clinical symptoms, history of sibling death, medications, clinical symptoms and results of routine investigations including imaging studies. Our experience shows that TMS is useful in identifying inherited metabolic disorders which are not rare anymore in our country. Although, a lot of progress has been made in identifying and diagnosing these cases there is a need for a nationwide program for newborn screening. Sample collection and transport, cost, establishment of an appropriate biological reference interval according to age, collection of relevant clinical details and proper expertise required for interpretation of results are few of the challenges faced during the establishment of this method.
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Interview Dr. A. Marthanda Pillai
E
xcerpts from an interview with Dr. Marthanda Pil lai:
How do you evaluate the growth of neurosurgery in India? Are we at par with global standards? In India, the quality of surgery and surgical skills are very good and at par with the rest of the world. Now, even the Arab nationals, who visited European nations for neurosurgery, are coming to India due to our global standards and more affordable treatment packages. A major share of medical tourists coming to India chose Kerala, particularly Thiruvananthapuram. Most major hospitals attend at least such 20 to 30 medical patients/ tourists a day. Maldives patients prefer Thiruvananthapuram for neurosurgery. From Arab nations Oman tops the list of patients to Kerala followed by UAE and Kuwait.
Born in Thiruvananthapuram (1946), Dr. Marthanda Pillai took his MS (Neurosurgery) in 1978 from Christian Medical College, Vellore and went to UK for higher training in Neurosurgery in 1980. In 1983, he got FRCS and had training in CT scan and Micro Neurosurgery at Royal Free Hospital, London and Atkinson Morley Hospital, Wimbledon, where CT scan had been installed for the first time in the World. Later, Dr. Pillai joined as a tutor is the Kerala Medical Education Service and served as the Professor and Head of the Department of Neurosurgery in Medical College Hospital, Thiruvananthapuram from 1996 to 2002. Currently, he is the Chairman & Senior Consultant Neurosurgeon of Ananthapuri Hospitals and Research Institute (AHRI), Thiruvananthapuram. He was the National President of Indian Medical Association (IMA) for the year 2015. He has published 84 scientific articles in various national and international journals, contributed chapters in 8 text books and works as the editor of IMA Drug Formulary, which is a ready reference book on drug prescription. He has also edited two well-known books, Medical Records Documentation and Consent and Recent Advances in Medicine. Altogether, he has presented 161 scientific papers in state, national and international conferences. He was the State Secretary of Indian Medical Association from 1986 to 1988 and State President of Indian Medical Association, Kerala State in 1990. He was also the Chairman of the Board of Studies, Medicine, University of Kerala.
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Since you are one of the lead ing figures in Neurosurgery, what is your opinion - which sector has got prominence in neurosurgery - the Government sector or private sector? It used to be with Government sector. If you refer history you can see that Neurosurgery was started in Madras Government General Hospital (now Madras Medical College) and simultaneously in Christian Medical College, Vellore. But today when the Government Health care sector becomes dull, private health care sector has taken over the role with effective interventions. Today 80% of healthcare delivery is by private sector. Particularly with Tertiary care, private sector overtakes the government sector. AHRI, Thiruvananthapuram is one of the biggest neurosurgical hospitals in South India. Especially with Health Tourism, we get a number of patients. Is neurosurgery suited only for degenerative elderly patients or is it for al l age groups? Neurosurgery is for all neurological problems and it has got scope with all age groups. Right from stroke (complicated strokes), there are instances where neurosurgery is required for middle aged people. For revascularization, tumours and trauma, neurosurgery is quite common. Degenerative diseases like epilepsy, psychiatric diseases, pain management, vascular diseases, congenital anomalies, spinal anomalies, other than stroke, require neurosurgery. Cerebral palsy also demanded surgical interventions in the past. Now with advanced medicines, you can avoid surgical intervention in most cases. There is a perception that in neurosurgery chances of survival especial ly with elder people is low. Is it true? If you take any cell in your body, liver for example, the regenerative capacity is tremendous. Compared to other cells in the body, the neurons in the brain don’t have that much regenerative capacity. A Neuron may have up to 50,000 connections with another neuron. It is like a hyper-super computer network. Re-establishing all these connections isn’t
“Robotic Spinal Surgeries
do have more precision” Padma Shri Dr Dr.. A. Marthanda Pil lai
possible. That’s why there is morbidity whenever there is a neurological disorder. Complete functional recovery is not possible. What are the major chal lenges faced by a Neurosurgeon? Regenerative capacity of the neurons in the brain is the main problem faced by a neurosurgeon. There are two zones in the brainCentral Zone and Peripheral Zone. In the central zone, if the neurons are completely damaged, it is impossible for a recovery. In the peripheral zone, partial regeneration is possible. Besides this, there is a third zone where comfortable regeneration is possible. If the tumour is in the vital part of the brain, it also lessens the possibility of recovery. Certain areas of brain are dispensable. Some use brain as a type writer and some, in its full capacity. So
depending upon the personal use of brain, we calculate the recovery chances. It’s not much harmful to dispense off certain terminal parts or polar parts of lobes, but when it comes to deeper structures like brain stems or spinal cord, recovery is tough. Is early diagnosis possible with neuro related disorders? Earlier, impairment in hearing, vision or paralysis signalled the disease. Today with the advancement of technology like imaging, electro physiological studies, electromagnetic studies and tools, we can identify the symptoms in an early stage itself. We have even functional MRI where the pathological diagnosis can be done. These investigations are available for common men and are affordable to them.
Dr. Marthanda Pil lai sharing his thoughts with Mr. Gangamohan P.N, Executive President, Agappe and Dr. C.S. Satheesh Kumar, Vice President-Operations, Agappe.
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Interview Dr. A. Marthanda Pillai Positron Emission Tomography (PET) scan, Isotope studies tool and biopsy (covering deeper parts of brain tissues) are available today. The quality of survival is definitely there but awareness about these tools is very less even among medical practitioners. In Kerala, comparatively, things are better. How does lifestyle affects neurological disorders these days? Lifestyle disorders have begun to contribute to neurological diseases, particularly stroke. Hyper tension is a major disease which contributes to neurological disorders along with cardiological disorders. Though obesity, cholesterol, blood pressure may not cause a degenerative d isease like memory loss, they can possibly contribute in the degenerative issues. The more you are active mentally and physically, the more your chances of neurological recovery. When complete rest is advised during other medical conditions, neurological recovery demands brain activation. Although we have no definitive treatment for Dementia, if you are physically and mentally active you can ward off the ultimate. When you tal k or move your hands, blood supply increases in that part of the brain facilitating more oxygen supply. Increased activities to enable more oxygen availability are advised for elders to keep the brain part activated. How far does genetics play a part in neurological diseases? Genetic factors do have a crucial role and has an influence in the disease process and recovery. Chromosomal studies can definitely predict disease conditions at an early stage. Anatomical variations are equally important. We call it the ‘Circle of Willis’ where the blood vessels get connected and provide supply for the whole brain. A normal person may have 30% abnormality even if one connection goes missing. If more connections are missing, his recovery chances are less. All these anatomical variations and genetic factors can definitely affect the recovery chances where even doctors become helpless. How do you see the future of neurosurgery? The initial Stereotactic neurosurgery procedure we used was with frame. Now we use frameless Stereotactic neurosurgery procedure. Keep the gadget on head and you can detect or localize the tumour on the head. We have also electro physiological monitoring. Earlier, there was no clear cut difference between normal and abnormal brain. Sometimes, the normal brain can get damaged during the surgery. Now with modern gadgets, a simple touch can trigger messages though the normal brain. It all makes the job of a neurosurgeon easy. With the arrival of Robotics, even fixing of the spine can be
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Dr. Marthanda Pil lai receiving Padma Shri Award from former President of India Smt. Pratibha Pattil
done through this. Surgeries have become more precise under supervised Robotics. Earlier, for a stroke patient, you can give medications and just pray for his recovery. With interventional radiology, you can monitor the block and put a stent to avoid the block. The issue is that these are not affordable to common man. You have received the prestigious Padma Shri award. A life ded icated to service - can you elaborate more on it? Soon after my PG at UK, I was offered a Senior Registrar post there. I could easily become a consultant in UK a few years later if I had accepted the offer. I strongly believe that our first duty is to serve our own country. Hence, I came back to my country refusing an offer which was hard to resist. I have refused many offers to work abroad later also. Only after my full term in Government service, I ventured out into Anathapuri Hospitals. I joined the Neurosurgery Department in the Medical College, Thiruvananthapuram, during the time of Dr. Sambhashivam and team who were experts in the field. At that time, there was no ICU unit in the medical college. I was instrumental to the evolution of the competent neurosurgery department. A lot of hard work has gone into the approval of funds for the current infrastructure. The reason behind fund approval is my systematic planning which facilitate smooth progress of procedures. We operated 3 days a week and I was awarded the ‘Best Doctor’ for my efforts. Actually, the right mindset is what matters. Indian Medical Association (IMA) is a platform to fulfill our social commitment and to do many things helpful to public health. As recognition to its merits, the government and health department identify IMA as a group which can bring about a healthy, positive change.
Live Story Sukesh Kuttan
A MUSICAL PRODIGY! Sukhesh didn’t start speaking at the right age as other children”, recalls Kuttan. Being a boy, they thought the delay is just natural. Months passed by but he didn’t make any progress in speaking. When they came to Kerala for a vacation, they consulted a doctor who was a family friend and he revealed the shocking news to them that the child was autistic.
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ears back, in the venue of a prestigious musical reality show, spectators sat with bated breaths. Millions were eagerly watching the show as it was the Grand Finale of that musical journey. All eyes were set on the stage, all hearts beating for a particular contestant who got maximum number of SMS votes. The long wait went in vain as the contestant refused to sing. If prayers could bring him back on stage, the waiting audience would have brought him on stage within seconds. Though he didn’t sing that day, it was not taken as an act of arrogance and on the contrary, people carried him in their hearts for the exemplary talent he displayed. He never sang in public after that. No one, including his family members, knows the exact reason behind his shying away from public performance even now. The prodigy was Sukhesh Kuttan, a native of Palakkad, who was then residing in Dubai. Sukhesh was born to K.K. Kuttan and his wife Smitha and spent most of his child hood in Dubai, where Kuttan was working as an executive for a logistics company. Sukhesh has a sibling, Jishnu. To fulfill his dream of establishing his own firm, Kuttan and family came down to Palakkad now putting an end to their long stay of 23 years abroad. “Sukhesh didn’t start speaking at the right age as other children”, recalls Kuttan. Being a boy, they thought the delay is just natural. Months passed by but he didn’t make any progress in speaking. When they came to Kerala for a vacation, they consulted a doctor who was a family friend and he revealed the shocking news to them that the child was autistic. While they
Sukesh Kuttan
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Live Story Sukesh Kuttan sat in front of the doctor without being able to digest what they heard, he explained to them that it is practically impossible to cure the disease and the only way out is to accept the condition. “Sukhesh will live in a world of his own because the neurological issues will remain with him all through his life”, the doctor told them. “He may exhibit uncommon skills and talents in the areas of his interests”, the words of the doctor turned true within some years. The perplexed parents took him to Christian Medical College (CMC), Vellore where a proper diagnosis was made. As per the doctors, autism was a condition that happened to one among 10,000 children then though the proportion has come down to one among 1,000 nowadays. They opined that
To horn his musical talent, he was sent to a musical institute in Dubai but he remained inattentive in the classes. The next day, he would make the teachers wonderstruck by reciting the whole song which they taught in the previous class. His skill got polished by them with patience and he knows innumerable verses and has mastered many ragas now. He identifies a raga instantly when he hears it and sings another song in the same raga without much delay. as the condition is incurable, the only solution left was to give proper training to the child to manage himself and face the world. “He didn’t make eye contacts with us at first. If we called out his name, he used to echo his name back to us without knowing that Sukhesh was his name. He didn’t know to express his hunger or other needs”, recollects Kuttan. The need for training was essential and he was given training to express his daily, basic needs like food and water. Thus, he started to utter words slowly. After completing the training, they returned to Dubai. At home, he regularly watched musical programs and started humming with the songs when he was just four or five years of age. He made cries of ecstasy when he heard his favourite melodies. He learnt them with his heart and hence didn’t need a paper of pencil or any assistant to write the lyrics down. Sukhesh got admission in a special training school, ‘Special Needs Centre’ in Dubai where he was given utmost care by a malayali teacher, Santha. The training in the school sharpened his talent and he started to sing melodiously at the slightest behest. A microphone was all he needed to sing in public without any inhibition. Once started, he would stop only when he finished the whole song. He hated anyone interrupting him to tell him that he got the lyrics wrong. He would stop singing abruptly if such an instance happened. For him, the lyrics which he learned
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at the first hearing was always correct. The doctors had warned his parents not to say ‘No or Don’t’ bluntly to his face but to make very tactical and soft refusals if needed. While at school, he was not very cooperative even though he wrote well and was good at mathematics. He often had unpredictable mood swings and didn’t like his teachers or others paying undue attention to him. On weekends, the family used to visit the Karama Center Mall and they got acquainted with the key members of the adSukesh Kuttan and his family with South Indian ministrative staff. When they knew about play back singer K.S Chitra Sukhesh’s zest for singing, they gave him a chance to render songs at the shopping Once he competed in a music competition where the schedmall. Then on, every Friday, he got a chance to sing one or two uled time was 8 minutes for a song. Sukhesh finished the song songs before the public – a feat which gave him immense delight. He needed no preparation and usually, it was his mother who in 10 minutes and this strict time factor made him not eligible chose the song for him at the spot, which he obliged as his mother for the award. The judges told his parents that he was a real talent and his father takes this as an award in itself. was his closest companion. To horn his musical talent, he was sent to a musical institute in Dubai but he remained inattentive in the classes. The next day, he would make the teachers wonderstruck by reciting the whole song which they taught in the previous class. His skill got polished by them with patience and he knows innumerable verses and has mastered many ragas now. He identifies a raga instantly when he hears it and sings another song in the same raga without much delay. He plays keyboard well and knows a little of Tabla. Sukhesh displayed unbelievable memory and identified places that came in song sequences. Kuttan recollects one such incident. “Once, we went to Singapore and visited a shopping mall there. Sukhesh started singing a song inside the mall. Only when our host told us that the particular song was filmed at that shopping mall and Sukhesh approved it with his gestures, we were sort of surprised by his skill”. He attended the special school till he was 16 and remained at home then on. He always donned a headphone and listened to music endlessly. He even composed music to three songs and one of them grabbed a gold medal in Dubai.
Kuttan recollects one such incident. “Once, we went to Singapore and visited a shopping mall there. Sukhesh started singing a song inside the mall. Only when our host told us that the particular song was filmed at that shopping mall and Sukhesh approved it with his gestures, we were sort of surprised by his skill”.
In 2006, Kuttan organised a formal musical program for Sukesh at the Indian Consulate, Dubai. The hall was brimming with an impatient audience longing to hear him sing. His name was announced and unfortunately, he refused to come to the stage. Sukhesh’s mood changes were erratic and instantaneous. Meanwhile, one of the gulf channels aired a program, “Voice of Arabia’ and Sukhesh got third price for the euphonious melody he presented. He got selection for another channel program, ‘Gand harvasangeetham’ also. The music reality show in which he participated finally, all the other contestants went through rigorous grooming like voice training, breath control, yoga and so on. Sukhesh never attended these sessions and he came to the show only five minutes before the shoot. He loved to sing melodies and hated fast numbers. His parents have a hunch that Sukhesh might have surfed the net to watch his program in the channel and gone through the comments that he was autistic which in turn made him refuse to sing anymore. Though his parents are anxious about his future, they are happy that his case has thrown some awareness into the public conscience. They have come across parents of other autistic children taking inspiration from him. A few centres for autistic children have opened in Palakkad and Thrissur in Kerala after Sukhesh came to limelight. His parents leave an optimistic message to the world. For them, it is the present that matters. If Sukhesh finds happiness in music, they will go to any level to make him pursue his passion and will keep on encouraging him to sing for the world, once again.
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Cover Story Epilepsy
EPILEPSY
Myths and Reality Dr y, Dr.. Prithika Char Chary
MD, DM, PHD, MNAMS, MCH
Dr. Prithika Chary, Chief neurologist at Kauvery hospital has specialized in the care of patients with epilepsy. She has transformed, over the years, anxious lives of hundreds of epileptic women into stress-free study, work, marriage and safe pregnancy. All of them with a sense of joy and fulfilment now 'live a full life, with everyone, like everyone in spite of epilepsy'. Having completed MBBS in 1971 from the Government Kilpauk Medical College, Dr. Prathika Chary rapidly completed her MD in General Medicine in 1974, her DM in Neurology in 1978 and a PhD in 1981 becoming a triple doctorate, creditably, by the age of 35 years. In addition, she underwent training and completed her M Ch in Neurosurgery (Madras Medical College) between 1986 and 1990, becoming the first and only lady in India to be qualified as both a neurophysician and neurosurgeon.
E
pilepsy is a brain disorder. It is a common condition occurring in one among 150 individuals and cuts across class, economic status, age and sex. It is imminently treatable in majority of patients and people with epilepsy are normal between seizures and can often lead fairly normal lives in every way. It affects different people in different ways and maybe due to different causes. It is the third commonest neurological emergency after stroke and head injury and is the commonest neurological disorder in adolescents. It manifests as fits, seizures, convulsions, faints and spells of unawareness. It is commonest in the first two decades of life, plateaus in adulthood and again is seen more in the sixth decade and beyond. The occurrence of epilepsy therefore seems to be more in the developing and the degenerating brain. There are a lot of misconceptions about epilepsy which leads to fear and stigma and marginalization. Epilepsy is neither a visitation from the devil or spirits, nor is it contagious. Because most seizures occur without warning and are dramatic events if generalized, the diagnosis creates fear. It is also believed that once you have epilepsy one has to suffer for life and there is no chance of leading a normal life. This is not true as epilepsy can be treated medically with drugs and also surgically in some patients. Seizures stop in 70% of patients with medical treatment for 3-5 years, and of the remaining 30% at least half can be improved with surgery and other treatments like vagus nerve stimulation and ketogenic diet. The causes of epilepsy vary with age. Below one year of age, birth injuries, lack of oxygen or blood supply at birth, B6 and Calcium deficiency, infections and congenital causes result in epilepsy. In the older child, head injury, infections, oxygen and blood supply lack, alterations in the immune status etc. often lead to epilepsy. Also certain hereditary diseases cause epilepsy and are associated with certain other problems and constitute the epilepsy syndromes. In the elderly, stroke is an important cause. Brain tumours can occur at any age and can cause seizures.
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Many cases of epilepsy are not preventable, but appropriate clinical management could prevent much of the handicap that results. There is emerging consensus on the management of epilepsy. Given that epilepsy is a disease which still carries a stigma, and has huge lifestyle implications in work, education, leisure, driving, contraception, pregnancy and parenting, primary care has a vital role to play in its management. Women with epilepsy have unique problems due to their gender. A variety of epilepsy which occurs during the menstrual period called catamenial epilepsy can be present at puberty. Girls with epilepsy can marry and have children under medical supervision. Polycystic Ovarian Disease which leads to obesity, excessive growth of hair in the body and menstrual irregularities is seen in 35% of normal women but may be a little more in women with epilepsy especially if they are taking a drug called SodiumValproate. The incidence of infertility is higher in these women. The use of oral contraceptives together with certain anticonvulsants can lead to changes in blood levels and contraceptive failure. Sexual dysfunction can occur in both men and women, and while a small percentage can be due to the anticonvulsant drugs, in most individuals it is psychological in basis. Certain anticonvulsants are relatively safe during pregnancy and women with epilepsy can conceive and bear children. Having seizures during pregnancy can cause harm to mother and child, hence being seizure-free on medication and medical supervision with the obstetrician and the neurologist likely to ensure a safe pregnancy and good outcome. Women with epilepsy can breastfeed most of the time. Menopause can either reduce or worsen seizures in women with epilepsy due to hormonal imbalance. If hormone replacement therapy is considered, there can be some aggravation of the seizure disorder. There are several lifestyle adjustments needed as certain behaviours can trigger epilepsy. Missing sleep and meals can cause increased seizures and is even used as a trigger to induce epileptic activity in recording EEG for diagnosis. Prolonged television or computer screen viewing, especially with bright moving images, sitting close to the screen can trigger seizures in some patients,
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especially those with a rare form of epilepsy called photosensitive epilepsy. Prolonged exposure to sun, undue physical exertion, emotional stress, fever, intercurrent infections can all trigger seizures and can be easily avoided by suitable lifestyle adjustments. Stigma and marginalization are common with people with epilepsy. Inadequate knowledge about the facts of epilepsy, unwillingness to take responsibility if a student or employee has seizure, shame of having seizures in public, can lead to ridicule and neglect. Ensuring quality of life so that a person with epilepsy is able to live like everyone and with everyone is an important aspect of treating people with epilepsy. This is possible by public education through awareness programs, proper counseling of the patient and his/her family and friends, improving primary care of epilepsy, encouraging patients through support groups and being proactive and helpful in dealing with day to day issues. Children with epilepsy, especially if due to birth problems may sometimes have associated developmental delay, learning disability and may be hyperactive. The incidence of ADHD (Attention Deficit Hyperactivity Disorder) is more in children with epilepsy. Most children with epilepsy are cognitively normal, though some anticonvulsants can impair cognition. They can go to school and should be treated as a normal child. People with epilepsy also face issues in employment. Jobs involving working with moving machinery, driving motor vehicles, work
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Cover Story Epilepsy ing at heights, working in or near water are all not desirable for people with epilepsy. When seizures are controlled by medicines, they can do almost any other job and it has been repeatedly observed that a person with epilepsy is more sincere and committed to the job. Night duties are hazardous as they can provoke seizures due to sleep deprivation. It is desirable that people with epilepsy do not engage in violent or contact sports like football, boxing, wrestling etc. Swimming is permitted under strict supervision if the person is seizure-free on medication for one year or more, as also driving. People with epilepsy should avoid extreme sports like bungee jumping, white water rafting, etc. Modern research in epilepsy has discovered that many of the unexplained epilepsies may have special genes underlying the disorder and these are activated by various environmental factors which results in certain epilepsy syndromes. The range of drugs available to treat epilepsy effectively and safely has increased in the past two decades and now drugs with good efficacy and little side effects are available. Surgery for epilepsy is of two kinds – respective and palliative. When a scar or lesion (benign developmental tumours like cavernoma, dysembryoplastic neuroepithelial tumour (DNET), arachnoid cysts, etc.) is present and can be localized to be the origin of the seizure by MRI, EEG, neuropsychology
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and clinical diagnosis, removing that diseased area can bring about ‘cure’ of the epilepsy. There is an entity known as mesial temporal sclerosis which causes seizures resistant to drug treatment and removal of this ‘bad brain’ is also very effective in making patients seizure free. Sometimes the brain development is faulty in a localized area of the brain – this is called focal cortical dysplasia – which is also surgically removable in many instances. Palliative surgery like corpus callossotomy and transpial resection prevents spread of the seizures. Other treatments available, for those where it is difficult to treat seizures or not suitable for surgery, are vagus nerve stimulation and ketogenic diet. Vagus nerve stimulation is an implantable device which stimulates the vagus nerve in the neck and this stops seizures. In ketogenic diet a high protein and high-fat meal, low in carbohydrates is given to induce ketosis and this seems to help improve seizure control especially in children. In conclusion, epilepsy is a brain disorder which occurs at different ages across geographical and economic boundaries, which can be treated with drugs in most patients and others with surgery and other means. People with epilepsy can study, work, marry and have children and are normal between seizures. So seizure prevention by treatment and lifestyle adjustments is the way to ensure quality of life and normalization. Hiding the diagnosis, not accepting the limitations due to epilepsy, being ashamed of the disorder are detrimental to the welfare of the individual with epilepsy. Having epilepsy is a journey of hope and with proper medical supervision, every person with epilepsy can “Live a full life, with everyone, like everyone, in spite of epilepsy”.
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Live Story Anjan Sathish
A Life Sketch with
UNIQUE DIMENSIONS When the Master Blaster of Indian Cricket, Sachin Tendulkar, visited Kaloor International Stadium, Kochi, to watch his team,‘Kerala Blasters’, play in Indian Super League 2015, it was a rare reunion of two masters .one being the God of Cricket he himself with another genius in art Anjan satish , whom he had met some back 20 years back as a young child with multiple challenges at the same city.For Sachin, it was an unbelievable feat when he learnt that Anjan had turned to be a wide known cartoonist, caricaturist and an animator beating all his challenges. Anjan and his father were called to the VVIP pavilion for a selfie with Sachin when hepresented thecartoon caricature of Sachindrawing instantaneous to him. The next day dawned with most of the leading newspapers and medias featuring the story of meeting of these two legends .When Sachin posted this event picture in his official pages in his Facebook , Insta gram and Twitter it was another feat in Anjan’s life. Anjan is now the National award winner as the 'most Outstanding Creative Adult with Disabilities' instituted by the Ministry of Social Justice and Empowerment for the year 2015. The Award was presented to him by the Central Finance Minister Mr. Arun Jaitley in a colourful function at Vigyan Bhavan, Delhi recently. Anjan who is also the ICON of Kerala Cartoon Academy had also got an opportunity to have meeting with the first person of Ind ia , The Hon’ble President of India , Sri Pranb Mukherji at Rashtrapathi
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Bhavan after the award function ceremony He presented him a book of cartoon collections, “Cartoon Pranam”a book containing caricatures and cartoons of the Hon’ble President Sri Pranab Mukherji , in which Anjan is also a contributor, Anjan received sincere blessings and wishes from the President on the occassion. When Anjan was born in 1987 as the second child to Sathish (Senior Manager, Federal Bank, Marine Drive, Kochi) and Lathika (Court Officer ,Kerala High Court, Kochi), they never suspected or expected any d isability in their son.
and Anjan’s parents wanted to enroll him in a normal school. Many schools refused admission for him but St. Mary’s Convent, Cochin, admitted him without much fuss. “He needed an enrolment but he was taught by us as it was a difficult task for the teachers, given his disabilities. Hence, my wife, Lathika, also went to school with him and a special seat was given for her in his class”,Sathish stated. Malayalam medium was selected for his learning to facilitate easy lip reading for Anjan and Lathika took a long leave of six years to assist his education. As he could lip read well, he wrote like normal students and had a good handwriting. Then one day, they noticed him drawing pictures where Anjan Receiving National Award for Most Outstanding Creative he couldn’t express Adult with Disabilities from Central Finance Minister Sri. Arun Jaitley himself properly. At Unfortunately, Anjan had Cerebral Palsy (CP) first, they didn’t encourage it much for fear as a congenital condition and as he went of Anjan losing his interest in normal comthrough the different milestones, the condi- munication. tion slowly exhibited itself to his parents. At His education came to a halt while he first, his parents consulted the doctors forhis was in 7th standard. His parents noticed eye problem, congenital glaucoma. The docthat he was unwil ling to play with his tors revealed, adding to their trauma, that he friends. They found out that his legs were was deaf also. Till the time when they told getting increasingly curved. Alarmed, they them about a doubt that Anjan might be a CP took him to ManipalHospitals, Karnataka, kid, they were not at all aware of such a condiwhere almost 14 surgeries were done for tion. correcting this problem. The surgeries At the Al l India Institute of Medical pinned him down to the bed for some time Sciences(AIIMS), the hard truth that Anjan and this confinement made him draw pichad Cerebral Palsy was diagnosed and was tures with increased enthusiasm. After the revealed to the parents . They were told that last surgery, Anjan presented one of his CP was a condition withoutany effective treat- pictures to the doctor. During this period ment and proper training was the only solu- he coducted his first exhibition of his painttion for this problem. ings with more than 100 paintings for the His parents accepted their son’s condi- event. He continued his studies normal tion with fortitude and started their attempts schools and passed his SSLC. Higher eduat training him. They took him to aninstitute cation for him was a real problem considat Kadavanthra, Cochin, where he learnt lip ering the normal syllabus and the multiple reading as they firmly believed that this was challeges he was facing. a better way for moving with society and of understanding what others talked than sign language. Compared to other children there, Anjan had multiple disorders and his legs had an unusual posture. His parents concentrated on building a vocabulary scheme for him. As a result, news paper became his early morning habit through which he slowly came in tune with the date, month and year. Two years passed by like this
Sathish, being a bank manager, used to bring the rejected ATM print rolls to make rough calculations on them at home. One day, to his great surprise, he noticed innumerable near-perfect caritcatures on the roll which he still keeps as a treasure. The artist in Anjan was so lively that Sathish contacted TOONZ Animation executives in Cochin who were impressed by his caricatures and wanted to meet Anjan. They
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Live Story Anjan Sathish took Anjan to the TOONZ centre at Thiruvananthapuram. When they realized that Anajn knew how to use a computer, he was given admission where he spent almost one year learning Photoshop, 3D Max, Maya, 2D etc. “He completed the course without understanding any of the classes like others. The teaching methodology was in English with many a foreign faculties as such there was nopossibility of lip reading also”, Sathish points out. After the course, Anjan wanted to work independently as his mind was full of animation movies. Though his parents knew that it would be difficult for him, they took him to a firm at Cochin. There, Anjan realized the practical difficulties of doing a group job which needed a lot of coordination and communication. He gave up the idea of working there and joined for plus two through open course. It was 'Adarsh Charitable Trust' a Special School for children with Cerebral Palsy, Autism and Down Syndrome at Kureekad, Ernakulam District Kerala, that offered a job for him to depart training to the children of the school in computers and drawing. Anjan's drawings and paintings were getting media and public attention during this period while he conducted various exhibitions and presentations of his work at various centres. Magazines and newspapers, published cover stories on Anjan and his mother giving special focus on CP. He was awarded the Amritha Bala Prathibha Puraskar, Rotary Club Special Talents Excellence award etc during these period for the uncommon skill he exhibited overcoming his disabilities. In 2005, the new build ing of Adarsh
Charitable Trust was inaugurated by the former president, Late A.P.J. Abdul Kalam. The inaugural building was decorated by one of Anjan’s paintings. When the district collector introduced Anjan to him,and his abilities in drawings When the President posed before him for a sketch finished it and handed over to him within a few minutes . Though Anjan’s father was tensed for a while, Anjan’s sketch of Sri. Abdul Kalam was perfectly done. Later, he called Anjan to the stage and introduced him to the audience and the waiting media displaying the picture he had drawn. Anjan was all over in the newspapers the very next day. This incident is rightly reflected when Sri A P J Abdul Kalam has put their photo in his book “The Turning Points”. The Kerala High Court gave a Full Court Honour to Anjan, after an exhibition of his paintings there. He became the favourite face for many media channels instantly. This incident paved his way to the Kerala Cartoon Academy. Receiving his membership, he shared the dais with the Oscar award winner Resul Pukkutty, who was being felicitated by the academy. Anjan, who was the youngest member of the academy then, drew a caricature of Resul Pookkutty and inaugurated the event. In 2011, when the Kerala Cartoon Academy organized a program to help Endosulfan victims, Anjan drew for three days continuously contributing his share for the noble cause .Anjan has innumerable fans and friends in the cyber world which include many a national and international cartoonists and artists he follow and admire. Asked about memories of bringing him up, Lathika recollects that it was not an easy cake for her. Once while they were passing a pond, she tried to show him a lotus in the pond. Anjan couldn’t locate it as the bus passed the spot soon. Seeing this attempt, a co-passenger asked her whether Anjan had an exam going on. She replied, “Each passing day is an exam for both of us”. The hardships that Lathika has gone through are well reflected in her words. On another occasion, he asked her whether she could hear the crow cawing outside. When she replied that she could hear it, he asked her why he was unable to hear it. Lathika couldn’t answer him as the answer to it remains unknown to her even now. Anjan’s achievements can be credited to his parents, Sathish and Lathika. They encouraged his talents and took him everywhere - to public places, exhibitions, cricket matches, trips and so on. They gave him maximum public exposure. “There is nothing called disability. We should find out their skills, promote it and be a supportive companion. They will surely succeed”, Lathika comments. When asked how he defined his parents, Anjan’s reply, as interpreted by his mother, was,“They have suffered a lot for me”. He just lapsed to a meaningful silence after that. He might be offering his gratitude to the Almighty for bestowing him with such loving parents who coloured his life with bright shades of love.
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Interview
Ms. Ameera Shah
METROPOLIS The Pathology Specialist Read on the excerpts from an interview with
Ms. Ameera Shah, the Managing Director and CEO of Metropolis Healthcare Ltd.-The Pathology Specialists in Mumbai. Under her prudent leadership, Metropolis has evolved to a multinational chain of 130 diagnostic centres with 1000 collection centres round the globe, starting from a single pathology lab. The purpose of the interview is to help readers understand the industry and its possible trends. Ms. Ameera Shah shares her thoughts and provides valuable advises to the readers, mostly the ones emerging out of her personal experience in making Metropolis what it is today. Being the daughter of the legendary Dr. Sushil Shah, who conceived a novel idea of starting a specialised laboratory, what made you think of multi-lab chains and what principles drove you to achieve this enviable feat of more 125 labs in India and abroad? As a child, I was always inspired by my dad and our family culture and values also promoted and encouraged entrepreneurial values, unlike most other Indian families. After completing my graduation from University of Texas, I wanted to take up something, which will make a meaningful difference to the society. So, instead of reinventing the wheel, I decided to transform the pathology laboratory of my dad into a professionally run diagnostic company and started investing in the process, people and machinery. Today, Metropolis is Ms. Ameera Shah
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Interview
Ms. Ameera Shah
present in seven countries across the globe. Today, we have more than 130 laboratories and over 1000 collection centers In India and abroad with more than 4500 test menu. We have grown organically and inorganically and still looking for good partnerships always. What was the patients’ expectation in the lab diagnosis then, what is the expectation now and how did it influence your thinking of expanding aggressively to become one of the largest lab chain in India? In earlier days, the patients were less inquisitive and would only visit a lab if they are ill or on family physicians’ recommendation for certain blood tests. Also, they would not care if the report is delayed. Today, the patients are more evolved and lots of preventive tests are being undertaken by individuals themselves. When we started expanding, we realised that there is a serious gap between the patients’ expectations and the delivery they were getting and hence, we proactively added a lot of specialised and super specialised tests to our menu (most of which are still not available with majority of players). In short, we invested in the technology of the future, and today we are
ahead of our competition. We are known for delivering accurate test results consistently, every time and we take pride in that. Which are the major changes seen in last few years in the Indian diagnostic testing? What was the one significant change you can recollect quickly? How do you find these changes helping the needy patients in India? The diagnostics and pathology testing market in India represents one of the most lucrative markets in the world. The market has grown robustly in past few years on the back of increasing disease prevalence and rising consumer awareness. Previously, sample testing would either take significantly longer or the pathogen would go undetected due to lack of testing methods.Companies are trying to create specific testing products in the form of health and disease panels which generally include a bouquet of tests for general health check-up or particular ailments. The most significant change in the last one decade could be the advancement in technology and there are certain tests, where no human intervention is required and you can process the samples with 100 % accuracy. The needy patients need not travel to far distance as the labs are reaching them at their doorstep, which saves them lot of efforts and money as well. What are the emerging trends in disease diagnosis and their testing that you think will guide the near future? What is your view on Preventive Diagnosis? How does Metropolis as a corporate see it? Preventive diagnosis is aimed at foreseeing likely future faults in a physical system before they actually occur. Although this task is extremely important in several practical application domains, there is currently no general theory of preventive diagnosis. Preventive care gives you and your doctor a snapshot of your current health, and helps to prevent against future illness. With a simple test and/or screening, your doctor can check for health problems—even when you’re symptom free and feeling healthy. Preventive care also includes vaccines and immunizations, which can help to keep you well and protect you from catching major (and potentially deadly) diseases like chicken pox, measles, HPV and more. Metropolis is one of the wellrespected brands in laboratory diagnosis. What is the biggest competitive edge of Metropolis? We are the Pathology Specialists
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Metropolis has been dealing with Agappe for couple of years with specific protein analyser Mispa-i2, what is your experience with Agappe? Metropolis is using Mispa-i2 in more than 35 centers in India and a couple of centers abroad.Agappe is providing us good service and technical support.The machines are very efficient and we could rely on test reports generated for their accuracy and a good turnaround time.
delivering over 30 million tests a year, catering to more than 10,000 Laboratories, Hospitals, Nursing homes and 2,00,000 Consultants. With 34 years of experience in delivering accurate reports, Metropolis has earned the reputation of being India’s most respected and only multinational chain of diagnostic centers with presence in UAE, Sri Lanka, South Africa, Kenya, Mauritius and Ghana. Today, we are one of the few laboratories to have received the CAP (College of American Pathologists), accreditation, the global gold standard in Laboratory Accreditation. We have also received the NABL Accreditation (National Accreditation Board for testing and Calibration Laboratories). In addition, we also adhere to CLIA (Clinical Laboratory Improvement Amendments) program and follow the guidelines laid by GCP and GLP. Our unit in South Africa is accredited by SANAS (South African National Accreditation System is the only accreditation body approved by South African Government). Metropolis is at the forefront in adopting cutting-edge technologies and services that contribute new revenue streams and has positioned the company on the pedestal it is today. What is your vision on Metropolis? To be the Pathology Specialist amongst doctors, patients and consumers. By pioneering new technologies, innovating new tests and models, delivered through best in class people, we are contributing in improving the health index of our consumers. In emerging markets, to be the most respected, growing and profitable Indian company. Helping people stay healthy, by accurately revealing their inner health. What is your expectation from an Indian diagnostic manu-
Agappe takes pride in claiming that we are “The Best Partner in Diagnostics”. We strive hard to retain it. What is your advice to Agappe to enable us to usefully fill the slot as “The Best Partner in Diagnostics”? Agappe is known for its innovative products like Mispa-i2, it would be great if Agappe introduces such newer and advanced technologies in future that enables the operations of a lab and continue to support us in providing quality reports.
facturing company on R&D, manufacturing and final product delivery? How it would be of value in Indian context? From a diagnostic industry perspective, our business is hit very badly due to rupee depreciation because 30 % of our P&L goes in chemicals to conduct tests. These chemicals are imported and are heavily taxed. We pay almost 25-30 % of tax on these imported chemicals. Today, the problem is that as the rupee fluctuates, our cost of importing these chemicals goes up and we can’t pass on the cost burden to our patients. The other problem is that we don’t have good indigenous chemical manufacturers in India from whom we can buy these chemicals and reagents. So, if the industry is encouraged to produce these chemicals in India, it will not only benefit these manufacturers but also the entire diagnostic industry and off course patients at large as this will even help in reducing the cost of diagnostic tests. Therefore, the Make in India campaign should not only focus on equipment but also diagnostic chemical and reagents. What would be your advice to the medical profession and to the diagnostic industry as a whole? The diagnostic industry is growing by 10-15 % every year. The industry, about few years ago, was a fragmented industry but today leading players are headed towards its consolidation. The growth in the sector is driven by an increase in awareness among consumers. One advice that I would like to share is that the industry requires, both technical and non-technical manpower. The technical requirements including professionals in the field of research and development, pathologists, molecular biologists, etc. while non-technical requirements include facility managers, people in administration,logistics, IT. The combination of both can be best used for diagnostic industry.
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Live Story Edward Sigamani
Recharging A Life...
There is one omnipresent entity, whom we blame as the sadistic perpetrator who cunningly fabricates our miseries and misfortunes – Destiny. When anything negative happens in life, we forcefully attribute the responsibility to destiny. The 35-year-old Edward Sigamani from Vellore has proved that no matter what happens in life, one’s positive approach towards life can become the winning factor over destiny. Contrary to the present social milieu, corrupted by negative shades of animosity and selfishness, Edward disperses his positive thoughts around which makes him lead a happy life despite his disabilities. His positivity is reflected back to him and helped him to resurrect slowly from his ashes. Being the eldest in the row of three children born to Bhagyaraj and Saradha, Edward assisted his father in electrical works after completing his 12th. His brother also worked in a hollow bricks unit as the economical situation of his house demanded it. Edward also went for other electrical and painting jobs on daily wages. Edward’s family were communicate members of a Catholic church in Old Town. Through a project of the church, a small tworoomed house was built for them by missionaries from abroad. In 2005, he fell in love and married Parveen, a lady from a Muslim family that made her family denounce her. This made conditions worse as he had one more family member to feed. The couple was blessed with two children –Jenita Mary and Immanuel. By this time, Edward started getting small contracts for electrical and painting work and his monetary condition was slightly improved. The tables turned in 2010 when he fell off a ladder seven feet down hitting his head while doing a painting work. As falls are common among workers, he didn’t take it seriously though he remained unconscious for a while after the fall. His co-workers took him home asking him to take rest. He had pain during the night and realised that he was unable to move his leg. He asked his wife to touch or pinch his legs but he couldn’t feel anything. Fear began to creep up his mind and the next day, they went to the GovEdward Sigamani ernment Hospital nearby.
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“I was unaware what the accident had done to me until the doctors explained my condition in the hospital. The revelation was life-shattering to me”, Edward states. The doctors told him that his spinal cord is injured and advised him to go to Madras Government Hospital. His family couldn’t bear the expenses of going there at that time and hence, they went to another hospital in the vicinity. Check ups and scans confirmed his spinal cord injury. His family came to know about a Government Health Plan (Chief Minister’s Health Insurance Scheme) ensured free operation to deserving persons at Christian Medical College (CMC), Vellore. With raised hopes of a free surgery, they went to the Department of Orthopedics, CMC. He was admitted and a series of scans and tests were followed. As Edward couldn’t voluntarily pass urine after the accident, a catheter was inserted. The doctors suggested an immediate spine surgery but they told him that he would never wal k again even after the surgery. The Government Health Plan didn’t work out for some reason and they couldn’t afford to pay the hospital bills. Later, the hospital laid off his treatment charges. The doctors advised him to be seen in the Department of physical medicine and Rehabilitation (PMR)that exclusively treats & rehabilitates patients affected by Spinal Cord Injury & Brain Injury for further management.
take my life away”, the trauma once he experienced was vivid in his words. The power of humanity came to his rescue unexpectedly. Suryakala, a volunteer of Vellore old town based CBR - Community Based Rehabilitation of the PMR and LCECU of CMC came to his neighbourhood to see a patient there. Knowing about Edward, she visited Edward and the family and inquired how long he had been using the catheter. She came to know that he was using the same catheter for more than four months as they had no money to replace it. This was a serious lapse. Suryakala immediately brought this to the notice of the Outreach team. The next day the team visited Edward. They asked him how they managed to meet the daily expenses and asked him how they could help him. Edward revealed his earnest desire to wal k again and support his family. “Later Dr. Sushil John, a consultant, Dr. Guru Nagarajan and, Augustine - Social Workers of the Outreach team & PMR, came to see me. They asked me to get admitted at PMR Q3 ward at the earliest. I got proper attention and treatment than any paid patients there”, Edward recollected gratefully. They asked him to shift his lying positions at regular intervals to treat his bed sore which was neatly dressed as and when required. After proper bedsore management, they moved on to treat his affected lungs. His health slowly began to improve and he was slowly moved to Rehabilitation Institute where exercises were scheduled for disabled patients. Edward was discharged after the necessary treatment and training sessions. As he had become very lean by that time, they advised him to consume 10 eggs a day. Aware of his poor economic condition, the Outreach team arranged free food for him. Edward couldn’t gather words when he recalled how Augustine, the social worker, paid the local store every week so that Edward’s family could buy provisions from there. Edward recharging mobiles on his bed. His visiting card is seen above.
Edward was brought home from the hospital and was completely bedridden. Fearing further medical charges, the family didn’t go to PMR. Meantime he caught frequent colds due to his static position for long hours on the floor mat and his left lung was clogged with phlegm. Moreover, a bedsore appeared on his back. Though they thought that it would heal by its own, it grew in size day by day. Blood started oozing out of it. “Life became a hell. I got obsessed with the idea of suicide. One day, I even tried to take off the urine catheter thinking that it would
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Live Story Edward Sigamani Edward was unable to withstand extreme hot or cold climates. In 2011, during Vellore’s harsh summer days, Edward had a heat stroke. His doctor of the Outreach team, Dr. Sushil John says, “He had a bleeding in the brain resulting in stroke. He cannot tolerate much heat or sweating”. Again, at PMR, he was given 15 days’ training to take food through the tube inserted through his nose. Six months passed by and Edward was fed up of sitting inert. ]}}A resident of old town & one of the participants of the first Life Skills Training Programme Mr. Thamizh, came up with the idea of mobile recharge. “He asked me to begin with gift recharge which worked well. We started with Airtel SIM”, Edward comments. When doctors from PMR came to visit him, they encouraged him to do the business in a big way. Dr. Guru Nagarajan introduced him to Ganga Trust, which lent him an amount to start a small business. They even printed a visiting card with his photo in it enabling more business for him. The doctors and nurses contributed to his business by getting recharge only through him. Meanwhile, his business was interrupted for one month as he got seizures resulting in unconsciousness. The doctors identified the reason to be the low salt content in his body. At this time, he was given adequate laptop training and finger exercises. Currently, Vellore has 32 Airtel recharge points and Edward came to the fourth position in the category of g a i n ing maximum business to the company. He started
Edward Sigamani with family
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Currently, Vellore has 32 Airtel recharge points and Edward came to the fourth position in the category of gaining maximum business to the company. He started Vodafone recharge and the company offered him a 4% cut if he did business of one lakh a month. “Mobile recharging works like a network. Those who know me bring more people to me and thus my business network widens”, Edward emits a proud smile. Vodafone recharge and the company offered him a 4% cut if he did business of one lakh a month. “Mobile recharging works like a network. Those who know me bring more people to me and thus my business network widens”, Edward emits a proud smile. Augustine, Dr. Sushil John and many CMC staff and others become strong chains in his network who redirect their team members to Edward for mobile recharge. His father, brother or wife helps him collect the amount. Now his business has diversified into online Railway ticket booking, online shopping at Flipkart, Snapdeal, Amazon booking, online Electricity bill payment and so on. Nowadays, Edward has become the destiny changer of many. He gives free training on mobile recharge business to disabled persons. Ten of them have started doing business on their own. “My life has acquired more meaning after the accident. Now, life means not just my family, it includes many people like me”, Edward beams with confidence and satisfaction. His wife, with the experience in taking care of Edward, is the much sought after care taker in CMC for spinal cord injury patients. He dreams of his own shop, good education for his children and more Community Based Rehabilitation (CBR) centres to help beneficiaries like him. The doctors at the Low Cost Effective Care Unit at CMC, who treat him without expense, are on constant watch as he is prone to pneumonia and ensure that the bedsore never returns. “Doctor’s are a cal l away and people stand by me like guardian angels. What else can I ask for in this life”, Edward looks up to the heavensas if in a pra yer.
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Health Tips
HAPPY LIFE with Healthy Mind Neurological disorders are multifarious in the modern society and are significant in these days due to burgeoning stress and strain. Basic factors like lifestyle and dietary habits do affect the neurological health to a great extent resulting in stroke and consequent paralytical disabilities, Alzheimer’s and dementia related disorders. These are some of the strategies to defend the neurological disorders.
N
eurological disorders are multifarious in themodern society and are significant in these days due to burgeoning stress and strain.Basic factors like lifestyle and dietary habits do affect the neurological health to a great extent resulting in stroke and consequent paralytical disabilities, Alzheimer’s and dementiarelated disorders. These are some of the strategies to defend the neurological disorders.
Always be active: Not only does exercise help you lose/maintain weight, it also lowers blood pressure, increases high-density lipoprotein (HDL, the good cholesterol) and helpsus keep blood sugar levels in control. Just 30 minutes of moderate activity, five days a week, can dramatically lower your risk of heart disease, stroke, and diabetes. It has been reported that men who participated in moderate to high intensity activities such as tennis, swimming, and running were 63 percent less likely to have a stroke than those who were mostly sedentary. At least, go for a wal k regularly. Moderate amount of exercise can provide huge health benefitsin terms of neurological disorders. Those who continue learning new things throughout life and challenging their brains are less likely to develop Alzheimer’s disease and dementia and so make it
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a point to stay mentally active. In essence, you need to “use it or lose it.”Learn something new. Study a foreign language, learn sign language, practice a musical instrument, read the newspaper or a good book or take up a new hobby. The greater the novelty and challenge, the larger the deposits in your brain reserves.Practice memorization. Start with something short, progressing to something a little more involved, such our state capitals of our country. Create rhymes and patterns to strengthen your memory connections.Enjoy strategy games, puzzles, and riddles. Brain teasers and strategy games provide a great mental workout and contribute to your brain capacity in forming and retaining cognitive associations. Do a crossword puzzle, play board games or cards, or work word and number games such as Scrabble or Sudoku.
memory and mental alertness and slow brain aging. Folic acid, vitamin B12, vitamin D, magnesium, and fish oil are believed to preserve and improve brain health. Intake of vitamin E, ginkgo biloba, coenzyme Q10, and turmeric may also be beneficial in the prevention or delay of Alzheimer’s and dementia symptoms.
Lose weight: One of the most important steps you can take to reduce stroke and added longevity is to keep excess
It’s common for people with Alzheimer’s disease to have insomnia and other sleep problems. But new research suggests that disrupted sleep isn’t just a symptom of Alzheimer’s, but a possible risk factor. An increasing number of studies have linked poor sleep to higher levels of beta-amyloid, a sticky brain-clogging protein that in turn further interferes with sleep—especially with deep sleep necessary for memory formation. Other studies emphasize the importance of uninterrupted sleep for flushing out brain toxins.Activities involving multiple tasks or requiring communication, interaction and organization offer the greatest protection. Set aside time each day to stimulate your brain.
Eat better: Think of our body as an engine. The higher-
octane fuel you put into it, the better it runs. Major risk factor for stroke comes from cardiac problems like uncontrollable BP.That’s why the American Heart Association calls for to fill half their plates with fruits and vegetables, fuel up on fiber-rich whole grain and increase fish intake. Again, one has to minimize sodium and added sugar intake. Research shows eating fresh fruits and vegetables lowers blood pressure, reduces inflammation and protects the heart and brain too. Experts claim eating 8 to 10 fruits and vegetables a day as part of a low-fat diet can lower blood pressure almost as much as most blood-pressure medications. Consuming foods such as ginger, green tea, fatty fish, soy products, blueberries and other dark berries may protect these important cells from damage.Avoid trans fats and saturated fats. These fats can cause inflammation and produce free radicals—both of which are hard on the brain. Get plenty of omega-3 fats.Regular consumption of green tea may enhance
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Health Tips pounds at bay. Heavier people are more likely to have high blood pressure, diabetes, and elevated cholesterol levels -all of which increase the risk of stroke. A study of more than 20,000 male health professionals found the risk of stroke was 30 percent higher in those who were overweight.
and cause problems. As soon as you quit smoking, your health improves. According to study reports, within a few years of quitting, your risks of stroke and heart disease are similar to nonsmokers.
Manage blood pressure: According to a study published
Avoid weekend binge drinking at any cost.
in the journal ‘Stroke’, people who had ideal blood pressure levels had a 60 percent lower risk of future stroke. When blood pressure runs high, blood courses through your body with too much force, stretching out the arteries and creating microscopic tears in brain. The scar tissue that forms to heal those tears traps plaque—resulting in blockages, blood clots, and hardened arteries, al l of which can deprive the brain of needed blood.
Less Salt Intake: The
AHA recommends limiting sodium to 1,500 mg per day to help lower blood pressure and reduce the risk of stroke.
Control cholesterol:
Cholesterol is used by our bodies to make cell membranes and hormones. Too much bad cholesterol promotes the formation of plaques in the veins and arteries impeding blood flow to your heart, limbs, and brain. “An increase in triglycerides can also promote plaque formation and increase the risk of stroke”. Lowering low-density lipoprotein (LDL, the bad cholesterol) and triglyceride levels helps ensure your whole body gets adequate blood.
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Limited Alochol: Limit alcohol intake to 2-3, 60ml units a day. Protect your head: Studies suggest that head trauma, at any
point in life, significantly increases your risk of Alzheimer’s disease. This includes repeated hits in sports activities such as football, soccer and boxing, or one-time injuries from a bicycle, skating or motorcycle accident. Protect your brain by wearing pro perly fitting sports helmets, buckling your seatbelt and trip-proofing your environment.
Be smart about napping: While tak-
ing a nap can be a great way to rechar ge,it can make insomnia worse especial ly for older adults. If insomnia is a problem for you, consider eliminating napping. If you must nap, do it in the early afternoon and limit it to thirty minutes.Create a relaxing bedtime rit ual. Take a hot bath, do some light stret ches, write in your journal or dim the lights. As it becomes habit, your nightly ritual will send a powerful signal.
Reduce blood sugar: Our bodies convert most of the food we eat into blood sugar (glucose) for energy. When your body stops making insulin, diabetes sets in. Diabetesgreatly increases the risk of heart disease and stroke. Ideal fasting blood sugar for both children and adults is below 100 mg/dL. If your levels are higher than that, work with a healthcare professional to get them in check.Watch the sugar in foods like candy, soda and white bread (aim for less than 450 calories per week). Too much sugar in the bloodstream begins to attach with proteins and make them sticky, like putting cotton candy in your gas tank. Sugar also raises insulin levels, which locks fat cells into place, making it more difficult to lose weight.
Schedule daily relaxation activities: Keeping stress under
Stop smoking: Smoking, one of the nation’s top causes of early death, contributes to plaque buildup in the arteries and reduces HDL levels, which makes the blood more likely to clot
Keep your sense of humor: This includes the ability to laugh
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control requires regular effort. Make relaxation a priority, whether it’s a walk in the park, playtime with your dog, yoga or a soothing bath.Nourish inner peace. Most scientists acknowledge a strong mind-body connection and various studies associate spirituality with better brain health. Regular meditation, prayer, reflection and religious practice may immunize you against the damaging effects of stress.
Make fun a priority: All work and no play is not good for your stress levels or your brain. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano or working on your bike.
at yourself. The act of laughing helps your body fight stress in a number of ways.
Cover Story Good Laboratory Practices
Root Cause Analysis
Simple way to improve the laboratory efficiency T
Root cause analysis is done to trace a problem to its origin and to under stand the problem clearly so that actions can be taken to prevent recu rrence of such incidents (Preventive Action)
oday’s modern laboratories are equipped with the latest, innovative and sophisticated instruments to satisfy the needs of the clients. Most of these instruments are computer controlled by specific software to reduce the human interface and also to increase the efficiency and accuracy of the diagnostic procedures. One of the nightmare of all such laboratories are the breakdown of these sophisticated instruments. In many cases the uncertainty of results is majorly associated with the hardware malfunction which in turn increase the TAT (Turn Around Time) and the recurring cost. In real practice the laboratory initiates an immediate action (corrective action) to bring back the work to normal but fails to analyze the real cause behind such incidents. This is one of the reason for repeated incidents happening in the same laboratory. Here comes the importance of the Root Cause Analysis (RCA).Root cause analysis is done to trace a problem to its origin and to understand the problem clearly so that actions can be taken to prevent recurrence of such incidents (Preventive Action). RCA uses specific steps and tools to identify the real problem so that we can understand What happened Why it happened What to do to prevent such events happen again RCA works on the assumption that the system and the events are interrelated and any action in one area triggers the action in other. The best way to find out the real reason is to trace back these actions The most common tool used in RCA is the 5 whys. The maximum data is col lected and analyzed with brain storming and the final conclusion is arrived. Let us consider some examples to understand the RCA process:
Eg.1 - Machine is stopped while run-ning This is one of the most common problem that happens in the laboratory, where the fully automated system shut down abruptly while running. This hap-
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Cover Story Good Laboratory Practices pens mainly during the power failure where the machine is running on UPS. Let us trace back the events: Machine stopped during running on a day when there was continuous power failure for 2 hours. It has been found that the machine was connected to an online UPS with a battery backup of 4 hours. The UPS was down and is not starting up. It was connected to battery and the connections are firm& no connection problems. The UPS is connected to mains for battery charging and there is no loose connections. Service engineer of the UPS is called for checking the UPS and found the battery water was not proper
Why?
Machine is down
Why?
UPS failure
Eg.1 AMC was not paid to the UPS service agency
Why?
(Real cause of the problem)
Preventive maintenance of UPS not done
Why?
and hence the battery was not charging properly. The battery was changed with new ones and the power to the machine is restored ( Corrective Action). It has been found that there was no log of battery water change for the last 6 months, no preventive maintenance was done for last 6 months and no person was accountable for the UPS/battery maintenance. UPS is not under maintenance contract. Now let us put these events in a chart with questions asking in each event. In the case above the real cause (Root cause) of the problem was the improper maintenance of UPS. In order to prevent such incidents, the laboratory needs to maintain a maintenance log book and assign a person to check that the AMC (Annual maintenance Contract) is taken back to Battery not back well in advance to all the instruments charging to have smooth operation (Preventive Acproperly tion). Why? With new d igital gadgets l ike smartphones and tabs in place it is always Battery easy & better to keep a reminder in the Water calendar for al l those hardware AMC/ drained CMC/PM dates so that this kind of events can be prevented (Preventive action).
Eg.2 - Machine has given wrong result for certain parameters
Eg.2
Calibration failure for certain parameters
Why?
Water used for Why? calibration d ilution was not of good quality
Calibrator is contaminated
Why?
There was no log Feed water book/systems in Why? conductivity is place to check the higher than the water quality recommended regularly
Result not Why? correlating for a single patient
Sample is diluted
Eg.3 There is no proper training Why? for the new joiners
Staff is not trained
Why?
Why?
Water plant is not working well
Let us trace back the events: Machine started to give wrong values
Why?
Reagents are calibrated with freshly prepared calibrator. The calibrators are prepared as per the manufacturer recommendation and the calibration is done as per the instrument protocol. Calibrator is diluted using the de-ionized water from the new water plant installed.The new water plant is checked and found that the conductivity of the water output is above the acceptable range.
Staff is un aware of the sample col lection
A new calibrator is prepared using commercially available distilled water. Machine is recalibrated, the control values are within range(Corrective action)
Sample is col lected through the IV cannula where saline was present
Why?
This is another common problem that happens within the laboratory where on a fine day, the automated system starts to give erratic results after repeated calibration with fresh calibrator and even after a new reagent lot the problem persists
Now let us put these events in a chart with questions asking in each event.
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In this case, the real reason (Root cause) is the lack of documented systems to check the quality of water from the in house water treatment plant which is used for calibrator/control dilution. In order to prevent such incidents, the laboratory needs to maintain a log book for daily checking both feed water as well as the output water quality using a conductivity meter. There are online conductivity meters available which can continuously monitor the TDS. In most cases, laboratory checks the output conductivity but fails to check the feed water to the water plant. The water plants are custom made based on a maximum conductivity of the feed water in mind and a higher feed water TDS may spoil the water plant (Preventive Action)
Eg.3 - Machine has given wrong result for certain parameters for a single patient This is one of the random error that can be seen in hospital associated laboratories where even if the calibration, Control values are within range only a few sample or one sample can give erratic values for the tests performed Let us trace back the events: Machine started to give wrong values for a single patient Controls are good. All other sample results are correlating. Only one sample is giving error. Sample is collected in vacutainer with proper identification and serum is separated properly. The patient is in the MICU (Medical ICU) and saline IV is going on . The sample is collected by a new employee and collected from the same IV cannula through which the saline was given. A repeat sample is taken from the other hand and the results are correlating (Corrective Action) Now let us put these events in a chart with questions asking in each event. From the above case it is evident that the root cause is improper training of the new joiners. All laboratories should have a proper training schedule for the new employees. Before assigning them for independent work, it has to be checked that the employee is properly trained and competent to take the responsibility. It is always better to have a duty calendar prepared only after checking the training history so that there is no mismatch (Preventive action) Like in the above cases it is easy to find out the root cause of each and every problem within the laboratory through collecting maximum data associated with the event and analyzing them properly.
TIMELY MAINTENANCE is very important
time. This will increase the laboratory efficiency in terms of turnaround time, accuracy of results, recurring cost and man power usage. The best way is to make sure that all the concerned persons involved in the event are well explained about the root cause and had given adequate training to prevent such cases. Laboratory also should give the responsibility of quality checks to a person who is regularly performing the task rather than giving the task to a person who only supervises the organizational work. The quality checks needs to be documented properly and should be checked at least once in a month to prevent major breakdowns in the laboratory.
Did YYou ou know? AGAPPE’s ALP DGKC method recommended by German Society of Clinical Chemistry is the most preferable one for the estimation of Alkaline Phosphatase due to its high linearity and high reagent stability.
It is always better that the laboratory conducts an RCA for all those major problems to take the preventive actions at the right
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Brand Reach Customer Speaks
1
Highly Accurate and Inter -lab Comparable Inter-lab Agappe's products are excellent, particularly Mispa-i2, the results of various protein parameters like CRP, RF Factor, Microalbumin are highly accurate and inter Lab comparable. So far the experience has been good with respect to product quality.
Dr. Vipul Jain, Precision Diagnostic Centre New Delhi, Delhi
3
Our lab is equipped with BC 3000 Plus 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. We wish Agappe more growth in future.
We are using Agappe blood grouping, HDL and SGPT regularly in our laboratory and we are satisfied with quality of reagents and will continue the same.
Frontier Lifeline Hospital Chennai, Tamilnadu
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High Pr ecision Pr oducts Precision Products
Excellent Quality
R Rajesh,
We have been using Agappe products since 2000 and we are very much satisfied with the performance.
Complaint-fr ee, Err or -fr ee and Complaint-free, Error or-fr -free Simple to Use
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JANUARY-MARCH 2016
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Dr. Keerti Geol, Unique Clinical Lab New Delhi, Delhi
Very Satisfactory
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 product.
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Dr R S Bhatia, Sigma Diagnostic & Imaging Centre New Delhi, Delhi
Dr. Monika Agarwal, Metropolis Healthcare Kolkata, West Bengal
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Mr. Bharat, Nidaan Healthcare New Delhi, Delhi
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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.
Accurate Results and Excellent Service
I am pleased to say that we are using Agappe reagents for the last 7 years. We are satisfied with the results and accuracy of the products. Presently, we are using Agappe Glucose, Cholesterol, Triglycerides, HDL direct, LDL direct, SGOT, SGPT, Bilirubin, Alkaline Phosphate, Amylase, Lipase, Urea, Enzymatic Creatinine, Uric Acid, Albumin, Total protein, CRP SensIT, RF SensIT, control and calibrators in our fully auto Mispa Nano and semi auto Merck 300 analyzer. The result is excellent. Agappe provides good after-sales services and application service support. I expect more new quality products from Agappe in future.
Mr. A Debnath, Healthcare Diagnostic Centre Kolkatta, West Bengal
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Good in Quality and Accurate in Results
Dr. N K Pehlajani, Shanti X-Ray and Pathology Centre Bhopal, Madhya Pradesh
Gr eat Quality in RResults, esults, Pr ecision and Great Precision Quality Contr ol Control
8
I have been using CRP of Agappe Diagnostics for last one year with full satisfaction on its quality results, precision and quality control.
Satisfactory Results I am using Agappe HbA1c (AGA1c) kit in our laboratory for the last six months. We are using it in our automated random access analyzer. The kit is giving satisfactory results.
TECHAGAPPE
Dr. Abhijith, Narendra Seva Trust Kolkatta, West Bengal
JANUARY-MARCH 2016
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Brand Reach Customer Speaks
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High Quality Results I have been associated with Agappe Diagnostics for its quality reagents for the last fifteen years. Now, very confidently, using AGA1c kit. We are very satisfied with the product for its quality result.
Dr. Dhabali Singh, Babina Diagnostics Imphal, Manipur
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H. Edward Sam, Viji Laboratory Thuckalay, Tamilnadu
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.
High Quality in Results, After Sales and Application Service Support I am pleased to say that we are using Agappe reagents from last 4 years. We are satisfied with the results and accuracy of the products. Presently, we are using Agappe Glucose, Triglycerides, HDL direct, LDL direct, SGOT, SGPT, Amylase, Lipase, Urea, Enzymatic Creatinine, Iron, TIBC, Creatinine Kinase, RF, control and calibrators in our fully auto analyzers. The result is excellent. Agappe provides good after sales services and application service support.
Dr. Paras Kothari, Kothari Diagnostic Centre Bhopal, Mad hya Pradesh
Agappe products are just excellent Dr. Devyani, Pendharkar, Asian Globus, Bhopal
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TECHAGAPPE
We have been experiencing the quality and accuracy of Agappe products for the last 2-3 years. With that confidence, we use more of its products like Agappe Glucose, Cholesterol, triglycerides, HDL direct, LDL direct, SGOT, SGPT, Bilirubin, Alkaline Phosphate, Amylase, Lipase, Urea, Enzymatic Creatinine, Uric Acid, Albumin, Total Protein and controls and calibrator in our fully auto Mispa Nano and semi auto analyzer. Top quality products with excellent service too. Wishing Agappe all the best for its future endeavours.
JANUARY-MARCH 2016
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Ms. Deepthy K Dinesh, Mother Hospital Thrissur, Kerala
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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.
Speedy and Pr ecise RResults esults Help to Save Precise Lives 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.
Dr. G K Agrawal, Agrawal Clinical and Diagnostic Centre, Ajmer, Rajasthan
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Dr. Jigar R Mehta MD (Path), Asutosh Multi specialty hospital Surat, Gujarat
Pr ecise RResults esults Giving Us Mor Precise Moree Customers We have started using Agappe’s HbA1c Direct with calibrator recently at our diagnostic centre. We found 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 are increasing day by day. Thanks to Agappe for supporting us with quality HbA1c kit.
Very Satisfactory RResults esults and Helpful Service Team We are very satisfied with the Agappe products, especially LFT profile for the last four years. Our doctors are also satisfied with the results. We are provided with great support from Agappe’s service team and we wish all success to them in future.
TECHAGAPPE
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Mrs. Christy Rajan,
Laboratory In-Charge, Catherine Booth Hospital, Nagarcoil, Tamilnadu
JANUARY-MARCH 2016
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Engagements Exhibitions & Conferences
MORE PLACES TO KNOW ABOUT US ARAB HEALTH 2015 Agappe’s Participation in Medica, Germany 2015.
Agappe’s Participation in 42nd National Conference of Association of Clinical Biochemists of India (ACBICON 2015), Chandigarh.
25 - 28 January 2016, Stal l No.Z4J30, Dubai International Convention & Exhibition Centre, Dubai. Arab Health Exhibition & Congress, organised by Informa Life Sciences Exhibitions, began 40 years ago as a small trade show under canvas on a patch of land in Dubai, United Arab Emirates. As Dubai and the UAE developed and grew, so did the need for healthcare facilities and infrastructure. The rapid expansion of Arab Health as an exhibition and congress followed suit and it is now recognized as one of the most important global events in the healthcare calendar. It is the second largest healthcare exhibition and congress in the world and the largest in the Middle East. It offers important opportunities to build relationships within the healthcare industry to showcase progress and Covering 62,059 sqm of exhibition space, Arab Health hosts exhibiting companies from 70 countries across the globe.
MEDLAB ASIA PACIFIC 22 - 24 March 2016, Booth No. H01 in Marina Bay Sands, Sands Expo & Convention Center, Singapore. MEDLAB Asia Pacific is the largest laboratory conference and exhibition in Singapore. It is the ultimate platform to promote and launch the latest diagnostic innovations and services, engage with target audiences, generate sales leads and maximize return on investment. The exhibition will provide a true business, yet informal environment in which to do business and to entertain. Exhibiting at MEDLAB Asia Pacific is the best way to generate fresh influential leads and grow your client base.
Agappe’s Participation in 64th Annual Conference of IAPM & Annual Conference of IAP-ID (APCON 2015), Cochin.
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Engagements Special Days
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Operations Product Launches
ESR ANALYZER The smart way of doing ESR test in 20 Seconds with 100 µl sample. You just simply insert the primary EDTA tubes and walk away.
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*Dedicated Test Cards are available
ESR IN 20 SECONDS
MISPA VIVA SEMI AUTO CLINICAL CHEMISTRY ANALYZER Mispa Viva is a symbol of superior technology and convenience, designed to deliver high accuracy, quality results with least turnaround time and low maintenance.
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PC Compatibility
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DMAX Technology
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EMF (energy Matched filter)
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Direct Access Key to the test menu
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ERA Flow cell with Copper flow cell holder - Auto temperature maintenance
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ALD Function - Ensure extended life for the lamp & power saving
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Aspiration air gap and Auto Empty Function - No more worries on carry over
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Dual Power supply - Smooth & convenient work flow
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Direct switch off
CONVENIENCE / TECHNICAL SUPERIORITY / ECONOMY
Moments Reagent Factory Inauguration
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TECHAGAPPE
JANUARY-MARCH 2016
Medical Quiz
Quiz
1) a)
Father of Modern neurology ………. Jean – Martin Charcot b) Sir Archibald Garrod c) Aristotle d) None
2) a)
According to WHO, neurological diseases and disorders pertain to…. Central Nervous System b) Peripheral nervous system c) Central and Peripheral nervous system d) None
3) a)
How many neurons are there in human brain? Approx. 100 billion b) approx. 100 million c) 1 million d) 10 million
4) a)
Alzheimer’s disease is the most common cause of …….. Brain tumour b) Parkinson’s c) Migrain d) Dementia
5) a)
Main cause for Stroke …………… Ischemic b) Hemorrhagic c)Thrombotic & embolic d) All the above
6) a)
Ischemic and Hemorrhagic stroke can be reduced by early detection of ……. Hypertension b) Lipids c) LPA d) All the above
7) a)
Thrombotic stroke can be prevented by early detection of ……. PT b) D Dimer c) Coagulation factors d) All the above
8) a)
Complement C3 and C4 tests help to diagnose …….. Multiple Sclerosis b) Heart failure c) Liver function d) None
9) a)
Sir Archibald Garrod coined the term…….. Cerebra vascular system b) Inborn errors of Metabolism c) Neuron d) Myeloma
10) a)
If inborn errors of metabolism is not detected early in infants and children, it will lead to ……. Neurologic disorders b) Physical disabilities c) Irreversible mental retardation d) All the above
Quiz Answers of Jul-Sept Edition
Winners will get their prize by post
Q1-C, Q2-B, Q3-D, Q4-D, Q5-A, Q6-B, Q7-D, Q8-D, Q9-A, Q10-A Quiz Winners of Jul-Sept Edition 1. Mr. Parmod Kumar, Parmod Computerized Laboratory, Sardulgarh 2. Dr. Biswajit Batabyal, Kol katta 3. Ms. Jesmin Binu, PMM Hospital, Chengal 4. Dr. Vidya Datar, Bijoy Laboratory, Hospet 5. D. Suresh, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur 6. Dr. Jude W Vaz, Holy Family Hospital, Mumbai.
Answers of this quiz contest will be published in the next edition 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 techagappe@agappe.in or post a mail to The Manager-Corporate Communication, Agappe Diagnostics Limited, Agappe Hil ls, Pattimattom PO, Ernakulam district, Kerala-683562.
TECHAGAPPE
JANUARY-MARCH 2016
59
Editorial Submissions What do you think of this edition of Techagappe? Are you happy with the overall 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 edition’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: techagappe@agappe.in Mob: +91 9349011309
Kindly let us know which edition you like more
60
TECHAGAPPE
JANUARY-MARCH 2016
Cystatin C testing is easy with Mispa-i2
Ÿ Ready to use reagents Ÿ No sample dilution required Ÿ Linear up to 10 mg/L Ÿ 3 min user friendly procedure Ÿ Convenient pack size
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Mispa-i2 is a Specific Protein Analyzer with Unique Channel Shifting technology to ensure high sensitivity, linearity and accuracy in specific protein testing.
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Mispa-i2 is flexible to all kind laboratories through its 22 parameter assay panel.
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Mispa-i2 uses 'Smart Card Calibration' system which eliminates calibration error and subsequent reagent wastage.
"Kidney function can be assessed by measuring Cystatin C in blood".
RNI No.: KERENG/2015/62113
www.agappe.com
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.
Sharp for accuracy and smooth in procedure open to all and no closed loops bright as future and simple as present