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Vol.4 Issue 2

JANUARY - MARCH 2018

THE DIAGNOSTICS NEWS JOURNAL

Published at Agappe Diagnostics Limited on January 01, 2018 | 62 Pages | ` 20

AGAPPE: A GREAT PLACE TO WORK Mr. Thomas John

LEPROSY: AN OVERVIEW Dr. D. M. Vasudevan

COMORBIDITIES IN PSORIASIS Dr. Sanjeev Aurangabadkar

“PROPER HYGIENE IS VITAL TO PREVENT SKIN DISEASES” Dr. Rinky Kapoor

CHILDHOOD VITILIGO: AN OVERVIEW Dr. Arun C. Inamadar

“GOOD, BETTER, BEST; SHOULD NEVER LET YOU REST” Dr. Prashant M. Vishwanath

DERMATOLOGY Outlines Leprosy, Vitiligo & Psoriasis with Distinct Medical Articles & Success Stories


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CONTENTS ○

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Volume 4 | Issue 2 | January-March 2018 ○

Dermatology, a Perception!

12-15 Leprosy - An Overview

08-11

20-23 "Proper Hygiene is vital to prevent Skin Diseases" 24-25

AGAPPE

A Great Place to work...

Evolution of Liver Profile

26-29 Comorbidities in Psoriasis 34-36 Good, Better, Best; Should Never Let You Rest... 37-39 The Daring Designs of Life

30-33

Beauty isn’t skin deepThe Story of Alka Dhupkar

40-43 Childhood Vitiligo - An Overview 44-46 Skin Really Matters -Health Tips 47-49 Importance of Automation in Pre-Analytics

52-53 Testimonials 54

Exhibitions & Conferences

55

Engagements - Special Days

58

Moments-Awards

16-19

The Legacy of Social ServiceThe Amte Family...

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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○ ○ ○ ○

From The Chief Editor’s Desk

THE DIAGNOSTICS NEWS JOURNAL

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

Focuses on diseases affecting the skin... I am very pleased to place before you, this 14

issue of TechAgappe, the quarterly review of health and laboratory medicine. Previous editions were based on Cardiac disease, Renal illnesses, Hepatic ailments, Pancreatic disorders, Cancer, Neurological disorders, Gastroenterological complaints, Gynecological maladies, Clinical Haematology, Lung diseases, Musculoskeletal malfunctions, Eye diseases and ENT disorders respectively. This magazine is now regular in publication at intervals of three months. I am also happy to report that the laboratory community has warmly welcomed the previous issues of the magazine. th

This issue focuses on diseases affecting the skin. We have, as usual included three scientific articles, three life stories, two interviews and one technical article. The first scientific article describes the medical features of ‘leprosy’. The second medical article is about the ‘childhood vitiligo’ from Dr. Arun C. Inamadar from Bijapur. The third cover story is on ‘comorbidities in psoriasis’, written by Dr. Sanjeev J. Aurangabadkar from Hyderabad. As usual, we have added three life stories. The first one is on Ms. Alka Dhupkar, who is successfully managing Psoriasis since her childhood days. She is from Mumbai and is working with Mumbai Mirror as Assistant Editor. The second life story is about Miss Kartiki Bhatnagar, 17 years, doing Plus Two in Delhi Public School. She is suffering from Vitiligo but manages it by colouring her skin patches. The third life story is about Baba Amte and his son Vikas Amte, focusing their continuing support to the mankind in eradicating leprosy. These landmark biographies will tell the readers on how to overcome chronic diseases by sheer determination. In this issue, you can also see two interviews. The first interview is with Dr. Prashanth Viswanath, an eminent Biochemist and Head of the Department of Biochemistry of JSS Medical College, Mysuru. The second interview is with Dr. Rinky Kapoor from Mumbai. She has been selected as the best dermatologist in the year 2016 in India. We have a technical article on the ‘Importance of Preanalytical Automation’, which will help the laboratory technologists to function more effectively.

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I am sure, this issue of TechAgappe will give useful insights into the problems of skin diseases and certain special aspects of laboratory practices. I am proud to announce that the ensuing issues of TechAgappe will cover other important topics. Your constructive criticisms to improve the contents will be greatly appreciated.

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With warm personal regards,

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Subscription-For subscription queries, write to 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: techagappe@agappe.in

I am glad to state that we have received very good feedback and appreciating letters for the last issue, where most of the responders stated that they are happy to read TechAgappe and are eagerly waiting for the next issue. The participation in the ‘quiz’ was also very encouraging.

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

MANAGING DIRECTOR Thomas John

CHAIRMAN Prof. M.Y. Yohannan

BOARD OF DIRECTORS

PHOTOGRAPHY Nelson Thomas

WEB MANAGER Sanjaymon K.R

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

PUBLISHING COORDINATOR Jayesh Kumar

LEGAL ADVISORY BOARD Adv. Denu Joseph

EDITORIAL ADVISORY BOARD Rajesh M. Patel Dr. C.S. Satheesh Kumar Sudhir K. Nair Jofy Paul Gopalakrishnan R. Sanjaymon K.R Vijith Kumar V. Mallya Bintu Lijo

CONSULTING EDITOR Rarima N.S

CHIEF EDITOR Dr. D.M.Vasudevan

EDITOR Meena Thomas

EDITORIAL BOARD

Volume 4 | Issue 2| January-March 2018 ○

Dr. D.M. Vasudevan

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JANUARY-MARCH 2018

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LETTERS TO THE EDITOR

A Pleasing Reading Experience The 12

th edition of the diagnostic news journal ‘TechAgappe’ has helped me to update my knowledge on various diseases of the eye. Each edition of the journal is unique. The overall look and feel of the magazine provides its readers a pleasing reading experience. I wish TechAgappe continue its journey smoothly and appreciate its efforts in gathering knowledge and its dissemination.

Dol ly Kuruvilla,

A Useful Guide for Health Professionals The diagnostic news journal TechAgappe is a useful guide for health professionals. It sparkles with current developments. Eye is the most important sense organ that gives wonderful experiences in life. The articles related to eye are interesting and relevant. The articles are beautifully written and it is useful for the health professionals. I appreciate the TechAgappe officials for their efforts to bring us such an ever-shining magazine.

Prof. Dr. Swarnalatha Devi, Principal, College of Nursing, Chakka

Asst. Professor, Ananthapuri College of Nursing, Trivandrum.

TechAgappe-An Excellent Scientific and Literary Blend I always admire and appreciate the poetry column, a literary and scientific mixture. Every special issue brings cover stories of good information in a simple manner. Further, I would say that the health tips are very useful and very relevant these days as it is written in such a way that even layman can understand. For maintaining quality in laboratory practices, GLP column is very excellent. I appreciate all the officials of TechAgappe in continuing this effort for the betterment of medical as well as social community and for their well-being.

Prof. S. Prabhavathi,

Principal, Vellalar College of Nursing, Erode

Comprehensive and Relevant Information T he recent volumes of the Tech- Agappe journal, based on very relevant thematic topics dealing with the different disciplines of medical professions, have been comprehensively presented and we are very much interested especially with the health tips and good laboratory practices. I would say the ophthalmology edition of TechAgappe was excellent. It could yield a new light on many optimum topics of common occurrences such as cataracts and diabetic retinopathy. The content is very elucidating indeed. We look forward to your future editions. Dr. Jude Winston VAZ, Holy Family Hospital, Bandra, Bombay

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Great Magazine with Commendable Value

I am very happy to write that

this magazine is a gift for us because it keeps all the standards of a medical magazine and it spreads new information and techniques about medical field, especially good practices in laboratory medicines. The topic SOP for biochemistry is valuable for me and our team. So we are happy to continue reading TechAgappe. All the best Team TechAgappe.

Prasanth A. S,

Biochemistry Head, Ananthapuri Hospital, Trivandrum


Cover Story

Poem on Skin

“A thing of beauty is a joy forever, Its loveliness increases; will never pass into nothingness”, The golden complexion, glowing visage captivate everyone, Visual radiance, vista drive the first magnetic pull; My hypnotic texture and guise keep the youth evergreen, My smooth and soft appearance pulls you closer. Great poets perpetually glorify me with beauty ever, Indomitable influence to human mind, unequivocal, my dear friends. Epithelial tissues woven in unison, to shape you so nice and attractive, Miraculous sensory organ, the great touch and feel, the solace, The largest defensive organ against environs, germs, enemies, Great excretory organ eliminating toxic bio-wastes thro’ sweat glands, Water resistant barrier and mechanical supports to your system, My Perspiration begets in right temperature control, Supplementation of Vitamin D, the major energy source from me, Dermal absorption, novel mode of therapy of the day, beware pals. Diabetic guys pinch me off and on, ingesting insulin; Thy apply cosmetics upon me to look smarter, The paradox, these toxic creams kill my natural glow, be guarded, Just be vigilant over creams powders, bleachers, my enemies, Most soaps, sprays, dyes disturb my contours, leaving me worn, Sleepless nights, mal-nutrition, Chlorine make me wrinkled, darker, Air conditioners ruin my gleams, and drive me dry, Oh my friend, support me with moderate sunlight, dawn & dusk. White skin never rolls in superior, it’s frail and unsound, Believe me, dark skin is excellent & powerful with great melanin, Tanning, balanced diet keep me healthy & shining, Regular yoga, stress free life open great doors to my glow, Age leaves scars, senescence triggers wrinkles and rumples upon me, Still, the beauty in me nor my signification never cascades down…. Is real beauty skin deep, or it’s in your mind, character or thoughts? Those with beautiful hearts are eternally charming in this universe.

Dr. C.S. Satheesh Kumar, Vice President-Operations, AGAPPE. (Retd. Drugs Controller, Kerala)

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AGAPPE MD’s Desk

AGAPPE

A GREAT PLACE TO WORK... Thomas John, Managing Director, AGAPPE.

W

idening its horizons every day, Agappe believes that employees are the core strength towards its growth. Agappe’s objective has always been providing the best work environment for its employees to meet and exceed their true potential and to thrive in a world of excellence. We, in our earlier editions, have explained about what is Agappe. This is a Greek word which means ‘Divine Love’. We, at Agappe, incorporate this meaning in all our activities. Be it a product, service, employees or customers, we deliver ‘Divine

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Love’ among all equally. In terms of product, it is quality; in terms of service, it is the support on right time; to the customers, it is the highest level of satisfaction and to the employees, it is a great environment to work. Our operations are based on the company’ core values, i.e. Trust, Respect, Excellence and Care, which we call as T.R.E.C. These core values help Agappe in building a strong work culture in tune with its base theme ‘Divine Love’. The core values support all our employees to be open, help to synchronise all the depart-


ments and also assist in reaching out to any senior member anytime in case support or guidance is required in their operation. Agappe provides exciting career opportunities to young and aspiring professionals in the diagnostic and other operational sectors. As a company having global presence, we recruit talents from different parts of the world, which also helps our employees to understand and adapt to different cultures and practices towards their development.

Open Door Policy We serve each other as a family to work towards our common goal – ‘ONE AGAPPE’. The essence of our open door policy is open communication in an environment of trust and mutual respect that creates a solid foundation for collaboration, growth, high performance and success across Agappe. It provides a work environment where: Open and honest communication between managers and employees becomes a day-to-day business practice Employees may seek counsel, provide or solicit feed back or raise concerns within the company Managers hold the responsibility for creating a work environment where every employee’s valuable feed back is welcome. Issues are surfaced early and are candidly shared without any hesitation when this input is shared in good faith. Woman-Friend ly Culture The percentage of women working at Agappe varies from department to department and we have created a comfortable workspace for women who cover 35% of our total strength in the corporate office and production facility. At Agappe, safety of women at work is our utmost concern and we do serious monitoring of the POSH policy implementation at all levels. In terms of policies, we have strict adherence to the norms put forward by the Government towards the Maternity Benefit Act, and ensure smooth back-to-work policy for the women employees. Engagement at AGAPPE To maintain the harmony among the employees, Agappe has initiated many engagement activities in its corporate office and branch offices. This breaks the monotony of job and helps in refreshing the employees while at work. Generally at Agappe, we run various engagement activities throughout the year at various intervals. Tarangam is an initiative where our employees get together on a monthly basis. This event starts with sharing

updates of the organisation for the month with all the employees by the management team followed by cultural activities, interactive game sessions, general information sharing, awareness sessions etc. Quarterly / Half yearly meetings are conducted mainly for the field staff where a detailed review of their sales/services will be done. There are sessions organised with motivational speeches, rewards, recognition and healthy socializing. AGAPPEDAY: In Agappe, we find this day a most awaited occasion where all our employees and their family members spend one full day together away from the official environment. The day is filled with various cultural activities, participation from the dear and near of the employees etc. During the ceremony, we recognise five employees who are voted as ‘Agappean of the Year’ and also, we owe our success to the skill, commitment and loyalty of our people. The Long-term Service Award recognizes and celebrates employees who have been with Agappe for 10, 15 or 20 years and beyond. Each award recipient receives a distinctive memento and a financial reward. AGAPMEET is the annual event organised immediately after our financial year closing where all our field team members come together to relish the achievements of the previous year and to set the goals for the coming year. This is a special event to reward and recognise the top performers in the area of sales, service and support activities. AGAPCON: In view of establishing the ‘One Agappe’ theme across all the connecting links with Agappe, we take utmost care in bringing together our business partners also to this

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AGAPPE MD’s Desk theme. ‘AGAPCON’ is one such initiative where all our business partners come together for the annual conference and Agappe shares its views and plans about the upcoming year. During this event, we recognise the most valuable and most contributing business partners as well.

Celebrations at Agappe As Agappe is a multi-cultured organisation, we ensure that major festivals/special occasions like Onam, Diwali and Christmas are celebrated in the corporate office and the branch offices across the world. This helps Agappe and its employees to get acquainted with various cultures/practices across the globe. In the recent activities, with the ideas and initiatives proposed by our employees, we have planted shady trees in our campus on the occasion of ‘World Environment Day’. Rewards and Recognition Star of the Quarter : We have quarterly as well as annual awards designed for best performers among the field staff as well as the corporate office and branch office staff. ‘Star of the

‘Mind Beans’ is an initiative for encouraging employees to come out with innovative ideas, out of box thinking, effective cost management & process improvements which can support the progress of the organisation. Quarter Award’ is one of our major recognition programs for our employees in which we acknowledge those employees who have walked an extra mile to put forward exemplary performance in their respective disciplines. Mind Beans is an initiative for encouraging employees to come out with innovative ideas, out of box thinking, effective cost management and process improvements which can support the progress of the organisation. The best suggestions are rewarded in terms of motivating the selected employee as well as the rest of the team. The ‘Mind Beans’ invite ideas from all levels of employees at Agappe.

Insight: Insight is Agappe’s in-house biannual magazine. It is the compilation of the immense effort put forward by the invincible employees of Agappe and is also a specimen of their creativity. This helps to recapitulate the employee’s eventful journey with Agappe.

Agappe Chairman Prof. M.Y. Yohannan lighting the lamp for ‘AGAPMEET 2017’

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The colourful pages cover glimpses of all special events happened during the last six months. Each creative edition brings forth new faces with a lot of creative articles like stories, poems, travelogues etc. We cannot ignore beautiful drawings from our mind as they are drawn by cute little stars from employees’ families.


Team Agappe planting trees on World Environment Day 2017 Once it is published, a copy is provided to all the employees in the organisation. We have been continuing this for more than a decade.

Team Outing In a world that is focused on satisfying customers and clients, companies tend to forget their most valuable asset – their employees. Without the hard work of each and every individual in the company, work would never get done and clients couldn’t be made happy. Keeping a team together and function as one cohesive unit can be hard in the long run – which is why team outings at Agappe are organised. As a regular practice, the managers take their team members for a team lunch to an outside location for a delicious

'We are an organization which gives great emphasis on training and treat it as a prime opportunity to enhance the knowledge base of our employees. Our Training Department organizes a wide array of training to strengthen and reskill the capabilities of our employees'.

food, interaction and a fun time. This creates better bonding between the team members, especially the new joinees.

Training & Development We are an organization which gives great emphasis on training and treat it as a prime opportunity to enhance the knowledge base of our employees. Our Training Department organizes a wide array of training to strengthen and reskill the capabilities of our employees. There are trainings specially designed towards induction of new employees, knowledge enhancement training for field team, enhancement in management and leadership skills for managers and general awareness and enhancing programs for their soft skill in specific discipline for other employees. We also ensure that every staff in our organisation undergoes a minimum of seven hours of training a year.

Library To back-up our training and development activities, we have set up a library where our employees can access and refer to those books which are related to the industry and their respective field.

Food and Savouries Agappe has organised a common cafeteria for all its employees at the corporate office. Here, all employees share the same food and share their tables with others irrespective of their positions. All the above initiatives are some of the initial steps which Agappe has implemented to promote it to be a ‘great place to work’.

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Cover Story Leprosy - An Overview

LEPROSY-

An Overview

Hansen’s Disease

Dr. D. M. Vasudevan, MBBS, MD, (Biochem), FRCPath, Technical Director, AGAPPE.

Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by Mycobacterium leprae, a microorganism that has a predilection for the skin and nerves. It is highly contagious. There is a lot of stigma and prejudice regarding this disease. Leprosy affects mainly the skin and peripheral nerves. It is diagnosed by skin and neurologic examination of the patient. Early diagnosis is very important. The timely and proper implementation of treatment will prevent sequelae and physical disabilities that have an impact on the individual’s social and working life. Leprosy is the biggest cause of preventable disability in India today. Statistics indicates rising numbers of deformities in newly detected cases since 2005. History Reports of leprosy are available for the past 3000 years. DNA taken from the remains of a man from a tomb in Jerusalem around 50 AD shows him to be the earliest human proven to have suffered from leprosy. The disease probably was present in Egypt and other Middle Eastern countries as early as 2400 BC. Leprosy is believed to have been introduced to Europe from India by the troops of Alexander the Great, in 300 BC. Its incidence was high in Europe and the Middle East during the Middle Ages. The number of cases was dramatical ly reduced in Europe around 1870 because of the socioeconomic development. Leprosy is assumed to have been introduced during the colonization period by French people in the United States and by Spanish and Portuguese people in South America. African slave traffic was the major cause of the spread of leprosy in the Americas. Over the past 20 years, the WHO imple-

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mentation of MDT has rendered leprosy a less prevalent infection in 90% of its endemic countries with less than one case per 10,000 people. Still, it continues to be a public health problem in countries like Brazil, Congo, Madagascar, Mozambique, Nepal etc. The Bacillus Mycobacterium leprae, the causative agent of leprosy, was discovered by G. H. Hansen in Norway in 1873. It is an acid-fast bacillus. In addition to humans, leprosy has been observed in armadillo and three species of primates. The bacterium can also be grown in the laboratory by injection into the footpads of mice. Mycobacteria are slow growing, with a doubling time of 14 days. (For ordinary bacteria, doubling time is about 15-30 minutes). The genome of M. Leprae has been sequenced in totality. M. Lepromatosis is a newly identified mycobacterium which is described to cause disseminated leprosy and its significance is still not clearly understood. Transmission of Disease Two exit routes of M. Leprae from the human body are the skin and the nasal mucosa. Large numbers of M. Leprae are found in the superficial keratin layer of the skin of lepromatous leprosy patients. The quantity of bacilli from nasal mucosal lesions in lepromatous leprosy ranges from 10,000 to 10,000,000. Majority of lepromatous patients show leprosy bacilli in their nasal secretions. The entry route of M. Leprae into the human body is thought to be the respiratory route. Incubation Period The average incubation period is between three and ten years.The maximum incubation period reported is as long as 30

years or over, as observed among war veterans known to have been exposed for short periods in endemic areas but otherwise living in nonendemic areas. Clinical Manifestations M. leprae primarily infects covering of peripheral nerves leading to nerve damage and the development of disabilities. The susceptibility to the mycobacteria and the clinical course of the disease are attributed to the host immune response. Disease Classification Clinical, histopathological and immunological criteria identify five forms of leprosy: tuberculoid leprosy (TT), borderline tuberculoid (BT), midborderline (BB), borderline lepromatous (BL) and lepromatous leprosy (LL). Patients were divided into two groups for therapeutic purposes: paucibacillary (TT, BT) and multibacillary (BB, BL, LL). In paucibacillary (PB) cases, the number of skin lesions will be less than or equal to five; while the number of skin lesions will be greater than five in the

M. leprae primarily infects covering of peripheral nerves leading to nerve damage and the development of disabilities. The susceptibility to the mycobacteria and the clinical course of the disease are attributed to the host immune response.

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Cover Story Leprosy - An Overview patient’s face has a peculiar appearance (leonine facies), characterized by diffuse infiltration. Skin smear shows plenty of bacteria. Lepromin test will be negative. Clinical Features of Indeterminate (I) Leprosy

multibacillary (MB) form.

It is characterized by illdefined, bizarre hypopigmented macules with a smooth or scaly surface. The sensations over the macule may or may not be impaired. The nerve proximal to the patch may or may not be thickened.The skin lesions of the BB subgroup exhibit characteristics of the TT and LL forms, with asymmetrical distribution and moderate nerve impairment.

Clinical features of Tuberculoid leprosy (TT)

Polyneuritic Leprosy

In the TT form, the disease is limited due to the good cellular immune response of the host to M. leprae, with the patients showing single skin lesions or a small number (up to 3) of asymmetric lesions. They are characterized by erythematous plaques, often with elevated external borders and hypopigmented centre. The lesions may have thickening of the nearby nerve sheath and ulceration in the compression areas. Sensations are reduced or absent. Skin smear test will be negative. Lepromin test will be strongly positive.

Here there are only neural signs without any evidence of skin lesions. It is well recognized in the Indian subcontinent. The affected nerves are thickened, tender or both. Localized involvement of the nerves may form nerve abscesses.

Clinical features of Lepromatous Leprosy (LL) In the LL form, M. Leprae multiplies and spreads through the blood because of the absence of cellular immune response to the bacillus. Antibodies are produced but they do not prevent bacterial proliferation. Skin lesions tend to be innumerable and symmetrical, preferably located in the colder areas of the body. Lesions are characterized by hypochromic, erythematous spots with indefinite borders. Loss of sensation is minimal. As the disease progresses, lesions infiltrate forming plaques and nodules (lepromas). In the advanced stages of the disease, the

Dapsone is the primary drug indicated for treatment of leprosy. Two of the most common additional drugs for leprosy management are Rifampin and Clofazimine. A single dose of combination therapy has been used to cure single lesion paucibacillary leprosy.

Histoid Leprosy It is seen in multibacillary leprosy. It may occur as a consequence to secondary drug resistance to dapsone following irregular and inadequate monotherapy. It manifests as numerous cutaneous nodules and plaques primarily over the back, face, and bony prominences. Histopathology Skin lesions from tuberculoid patients are characterized by inflammatory infiltrate containing well-formed granulomas with differentiated macrophages, epithelioid and giant cells, and a predominance of helperT cells at the lesion site, with low or absent bacteria. Patients show a positive skin test (lepromin or Mitsuda reaction). Lepromatous patients present with several skin lesions with a preponderance of suppressorT cells, absence of granuloma formation and high bacterial load. Cell-mediated immunity against M. Leprae is either modest or absent, characterized by negative skin test and diminished lymphocyte proliferation. Human genetic factors influence the clinical course of disease. The genes associated with susceptibility to leprosy are Lymphotoxin-alpha (LTA), Vitamin D receptor (VDR), TNF alpha, IL-10, TLR1 and PARK2. Leprosy Reactions They are the acute episodes of clinical inflammation occurring

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during the chronic course of disease. They are classified as type I (reversal reaction; RR) or type II (erythema nodosumleprosum; ENL) reactions. Type I reaction is characterized by edema and erythema of existing skin lesions, the formation of new skin lesions and neuritis. It is a naturally occurring delayed-type hypersensitivity response to M. leprae. Clinically, it is characterized by ‘upgrading’ of the clinical picture towards the tuberculoid pole, including a reduction in bacillary load. Type II or ENL only occurs in BL and LL forms. Chemotherapy, pregnancy, concurrent infections, emotional and physical stress have been identified as predisposing conditions to reactions. Type II reaction is characterized by the appearance of tender, erythematous, subcutaneous nodules located on apparently normal skin and is frequently accompanied by systemic symptoms such as fever, malaise and enlarged lymph nodes. The ENL reaction is thought to be related to the deposition of immune complexes. A massive infiltrate of polymorphonuclear cells (PMN) in the lesions is observed during ENL. Treatment of leprosy With the introduction of sulfone in the 1940s and its use in the treatment of leprosy due to its effectiveness, cure rate of leprosy is very high. Therefore isolation was no longer mandatory. Because of cases of resistance to sulfone monotherapy, noted first in 1970, the World Health Organization (WHO) suggested the use of multidrug regimens. Therefore, since the early 1980s, the disease has been treated with multidrug regimens in outpatient settings and patients are considered cured after treatment. Dapsone is the primary drug indicated for treatment of leprosy. It is bacteriostatic against M. leprae. It works by preventing

the formation of folic acid, thereby inhibiting the organism’s replication. When taking Dapsone, it is necessary to perform weekly blood counts (first month), then perform white blood cell counts monthly (for 6 months) and then semi-annually. The Dapsone treatment should be discontinued if significant reduction in platelets or leukocytes occurs. Phototoxicity may occur when exposed to UV light. Dapsone was the mainstay treatment for leprosy for many years until widespread resistant strains appeared. Nowadays, combination therapy has become essential to slow or prevent the development of resistance. Two of the most common additional drugs for leprosy management are Rifampin and Clofazimine. Rifampin is one of the main drugs used in treatment of tuberculosis. Rifampicin inhibits DNA-dependent bacterial RNA polymerase. Crossresistance may occur. Rifampicin may cause liver disease. Serious health risks occur such as cerebral haemorrhage. It may cause red-orange discoloration of urine. The child with a single lesion takes half the adult dose of the 3 medications. Clofazimine inhibits mycobacterial growth, binds preferentially to mycobacterial DNA. It has antimicrobial properties. Patients should be warned that clofazimine may discolour skin; colour ranging from pink to brownish-black. Patients may also suffer from gastrointestinal problems, such as abdominal pain or diarrhea. Any patient with a positive skin smear must be treated with the MDT regimen for multibacillary leprosy. The regimen for paucibacillary leprosy should never be given to a patient with multibacillary leprosy. Therefore, if the diagnosis in a particular patient is uncertain, treat that patient with the MDT regimen for multibacillary leprosy. A single dose of combination therapy has been used to cure single lesion paucibacillary leprosy: rifampicin (600 mg), ofloxacin(400 mg), and minocycline (100 mg). All three medications are taken orally and can be administered on an out-patient basis. Multidrug regimens are recommended for 6 months (for paucibacillary) to 2 years for multibacillary type. Ideally, the patient should go to the leprosy clinic once a month so that the clinic may supervise administration of the drugs prescribed once a month. However, monthly supervision of drug administration by healthcare workers may not be possible. It is important to educate the patient regarding the importance of compliance with the regimen and to give the patient responsibility for taking his or her medication correctly and for reporting any untoward signs and symptoms promptly. The patient should also be warned about possible lepra reactions.

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Life Story Dr. Vikas Amte (Social Activist)

The Legacy of Social Service-

The Amte Family... The life of Muralidhar Devidas Amte, popularly known as Baba Amte, is an inspiration to scores of generations. Born to Devidas, a powerful bureaucrat in the pre-independence British period and a wealthy landowner and Laxmibal Amte as their eldest son, Baba Amte had a luxurious and idyllic life. Hunting in the forest with his own gun was his passion which later turned into expensive sports cars. Amte took his LLB from a Law College in Wardha and set up his law practice in his native place, which soon became successful.

To know the value of the service which Amte provided to the society, we should know how leprosy patients were treated in those times. There was a widespread belief that leprosy was highly contagious and as a result, patients with leprosy were isolated and often left to die without any med ical treatment or care. Baba Amte understood the miserable plight of leprosy patients when he chanced upon one of them once while wal king back home after work. Amte decided to provide him the necessary care when he saw the man lying out in the open, drenched in rain with no one to pay heed. But the patient soon died. This made

Baba Amte

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hen Indian freedom struggle became intense, Baba Amte became involved in it and used his skills as a lawyer to release the leaders of the movement whom the British authorities had imprisoned. The involvement with freedom fighters and leaders later took him to Sevagram Ashram which followed the principles of Gandhism. It changed his view of the world completely and he embraced the Gandhian way of life. Following Gand hi’s concept of self-sufficient village, Amte established ‘Anandwan’ which literally means Forest of Joy. He focussed his attention towards serving patients suffering from leprosy and most of his life aiming to provide better treatment facilities as well as social awareness towards the disease.

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Amte dedicate his life to the betterment of leprosy patients. Located five kilometres away from Warora in Chandrapur d istrict, Maharashtra, Anandwan was Amte’s ideal self-sufficient village in a typically Gandhian way. It worked as an ashram and a community rehabilitation centre for leprosy patients and the disabled people of the society. The ashram now has various small-scale industry units run by the residents that generate income to cover additional requirements. Two hospitals, a college, an orphanage, a school for the blind, a school for the deaf and a technical wing are also present at Anandwan today. The nation bestowed him with Padma Vibhushan and Gandhi Peace Prize. Ramon Magsaysay Award, Templeton Prize and Jamnalal Bajaj Award are some of the awards he received for his service to humanity. Baba Amte passed away in 2008. As per his wish, his body was buried in the soil after death instead of cremation. Through this, he passed on the message of less impact on the environment.

Continuing the legacy Following the footsteps of their father, Dr. Vikas Amte and Dr. Prakash Amte, the two sons of Baba Amte, rendered their services to Anandwan to fulfil their father’s vision. Today, Dr. Vikas Amte heads Maharogi Sewa Samiti, Warora (MSS) established by Baba Amte in 1949 aiming to provide a livelihood through productive work to the rehabilitated leprosy patients. Realising that these patients will never be accepted by the society, he created a complete assimilation of a virtual society composed of disabled individuals.

From the beginning itself, Dr. Vikas Amte was endorsing the idea that Anandwan requires ‘Parity and not Charity’. Like other organizations, he didn’t wait for the governmental help for their rescue. Instead, he looked at other available options.

Dr. Vikas Amte He turned them from mere leprosy patients to meaningful contributors to the society through combined work. From a capital of mere Rs.14 when it was founded in 1949, Anandwan currently has assets worth Rs.27 crores - all created by the fingerless hands of these leprosy-stricken humans under the guidance of Dr. Vikas Amte. From the beginning itself, Dr. Vikas Amte was endorsing the idea that Anandwan requires ‘Parity and not Charity’. Like other organizations, he didn’t wait for the governmental help for their rescue. Instead, he looked at other available options. Anandwan has now become a living experiment in sustainable rural development and community living. In 2006, they were awarded the Nirmal Gram Award from the President of India. In the last 68 years, around 2.5 million disadvantaged individuals have been benefitted by Anandwan. Dr. Vikas Amte is a man of many talents. Apart from being a qualified medical professional who has done a Post Graduate Certificate Course in Leprosy, he turned out to be an expert engineer, architect, agriculturist and a human rights activist for the people of Anandwan. His idea of low-cost earthquake-resistant housing methods was well received by societies of earthquake-prone areas. He has accepted new trends of 21st century as a challenge and is tackling the issues faced by Anandwan in the most eco-friendly manner. Blending his vision of modernization harmoniously with nature, he has developed many innovative programs like ‘Rid the weed’ for replacing the farm weeds with better, useful fodder-yielding-

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Life Story Dr. Vikas Amte (Social Activist) ciety at large to take note of them. The positive response it created is reflected in the lives artists of this group along with the whole Anandwan residents. In a way, it has been successful in filling the otherwise dull and drab lives of the performers as well as the entire leprosy-stricken and physical ly-chal lenged residents of Anandwan, with colours of music and gaiety. In 2016, Anandwan began a new project for propagating Baba Amte’s legacy of protecting and caring the environment by afforestation of an area. For this project, Shri. Baba Amte with H. H. Dalai Lama Dr. Vikas Amte chose a Japanese method called Miyawaki method, which has been stabilized in weed, thus improving farm productivity. His idea of low-cost timberless houses created a win-win India by Afforestt’s Shubhendu Sharma. These forests are planted situation for both the consumers and the manufacturers. through a very nature-friendly method. All native tree species in Customised to Indian needs by simplifying the technology and the region in various layers such as tree, sub-tree and canopy are constructed by employing disabled artisans, it provided a live- selected and included in a justifiable manner. lihood to many. By making use of plastic and rubber along with organic waste for the construction of check dams for helping distressed farmers acted as a driving force that provides economic viability and job opportunity to the inmates of Anandwan. Venturing into new endeavours, Dr. Vikas Amte launched ‘Swaranandwan’ at Anandwan in 2002. A unique musical orchestra with the talented leprosy patients and physically-challenged residents of Anandwan, Swaranandwan is a platform to showcase their skills and forget their inhibiting handicaps. It has performed over 3000 times all over Maharashtra and Delhi. The three-hour musical extravaganza includes popular Marathi and Hindi songs, Assamese Bamboo dance, tribal dance, mimicry, fol k dances and much more. More than 400 people are part of this fun-filled musical troupe. This orchestra is believed to build an extraordinary bond between the healthy hearts of the disabled and the society, thus creating a ‘Pain-Friendship’ between the two! Dr. Vikas Amte likes to cal l Swaranandwan as a ‘Therapeutic Theatre’ which provides them a psychosocio rejuvenating therapy by harnessing their latent talents. It has become a medium for these differentlySaji Thomas Flying Aircraft abled artists to unleash their untapped potential, which has obligated the so-

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Another peculiarity is that all these trees are planted at a very close distance after soil testing with appropriate mulching and usage of natural manure. This scientifically proven method has been replicated multiple times by Scientist Miyawaki and Afforestt in various countries of the world. In another 10 years, it will be a fully grown forest creating hundreds of tonnes of food for birds and oxygen for human beings. You can call it a process of balancing the carbon we emit and to gain back mother earth’s natural vigour.


Energy conservation, energy efficiency and adoption of renewable energy were in the forefront of Anandwan’s principles. It was also quick to adopt renewable energy measures in every possible area like cooking, electricity etc. Recognising the efforts of Anandwan including solar cooking, solar heating, solar electricity and solar pumping, it was chosen for AEE’s most prestigious Asia Subcontinent Region Innovative Energy Project Award 2016 which was presented in the USA on September 20th, 2016 prior to the opening of the World Energy Engineering Congress, at the Washington Convention Center in Washington, DC. Anandwan is also planning to launch a project called ‘Legacy Forests’ where people can donate a certain amount of money for afforestation. Under different slabs of Rs.5 lakhs and Rs.2.5 lakhs for 1 acre of forest and half an acre respectively, people can pay to create forests. The smallest patch that can be planted is a 100 m by 5 m patch which requires a cost of Rs.1 lakh. This is an ideal way to create a lasting impression on earth even after someone’s death.

Dr. Vikas Amte receiving honorary doctorate degree on behalf of his father Shri Baba Amte from the former Prime Minister of India Dr. Manmohan Singh at Tata Institute for Social Science

Anandwan is also proud that some of its innovative ideas are well received by global entities like the UN, World Economic Forum and World Energy Congress. After demonetization in India, Anandwan has helped over 1000 aged leprosy afflicted persons with disability to open bank accounts and is spreading financial literacy among the poorest of the poor now so that they can secure their financial future. A holistic rehabilitation centre for people with disabilities, that will cover areas right from prevention of disabilities, formal and vocational education, marital and genetic counselling, leading an independent and positive family life and geriatric services tailormade for them, is also in the pipeline. It will be the first of its kind in India or perhaps in the world. The implementation of the project- Converting Anandwan into a Smart Village-was acknowledged by World Energy Congress with an award for the ‘most innovative solar-based project’ at village level in Asia-Pacific. As a part of Anandwan Smart Village Project, apart from launching smart health cards, planting smart& fast growing forests, setting up model farms, sewage treatment plants & building accessible toilets, Anandwan is doing reenvisioning of their signature products that will be launched next year. Praises have been showered

upon Anandwan, the self-sufficient village from different parts of the world. A UN official has said that in today’s scenario where there is an ‘urgency for peace’, a community like Anandwan, that is free of caste, creed, religion and barriers should come out and give a design for a new world based on love, peace and harmony. Dr. Vikas Amte aspires to make Anandwan an excellent small village model which can be replicated not only in India but also beyond the borders. Following the vision of his father, Dr. Vikas Amte dedicates his life to the betterment of the society with the loving support of his family consisting of his wife Dr. Bharati, a paediatrician who looks after medical and general administration at Anand wan and their two children, Kaustubh who is also the Assistant Secretary of Anandwan and Dr. Sheetal.

Dr. Vikas Amte and his daughter Dr. Sheetal Amte

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A life of selfless service, embellished with an adventure of purpose, pouring unconditional love on al l the wounded souls, ded icated to uplift the poorest of the poor and to promote national integration and communal harmony, Dr. Vikas Amte is truly one of the greatest visionaries of our nation.

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Interview

Dr. Rinky Kapoor

Dr. Rinky Kapoor MBBS, DDV, MD (FellowNational Skin Centre, Singapore and FellowStanford University, USA) is regarded as one of the best dermatologists in the country. Based in Mumbai, India, Dr. Rinky Kapoor in a short while has earned her name as a Cosmetologist, Dermatologist, Dermato surgeon, Skin laser expert and Trichologist. She dexterously fulfills the growing demand for Hair, Skin and Nail care. She is also the Co-Founder and Director of The Esthetic Clinic, Mumbai. Dr. Kapoor is also the Consultant Cosmetic Dermatologist at the SL Raheja Fortis Hospital, Mumbai.

Proper " prevent

AGAPPE: Can you tell us a little about your childhood and family? Dr. Rinky Kapoor: My schooling was done at Mumbai and I had always wanted to become a doctor. There was nothing else I could think of as my ambition. My family had doctors which further influenced me. I always liked the idea of giving injections. Since I was good in academics, I could choose Medicine for higher studies. Our family was typically North Indian. My parents made no restrictions or discriminations between my brother and me, and they gave us good education. I had no hurdles as far as academics was considered. My parents were supportive of me to pursue higher education. After completing my MBBS, I went for Post Graduation in Dermatology. I got married after completing my PG and my husband and in – laws were also supportive and encouraged me in doing my fellowships abroad. Upon my return, I started practicing and things have been all good. AGAPPE: Tell us about your journey as a doctor? Also, is there a specific reason for selecting Dermatology? Dr. Kapoor: In the Post Graduate entrance exam, I had a very good percentage. I could choose whatever I liked. Since I’m a woman and may have to equally balance professional and family life, I thought of something which could let me achieve this. Unlike other streams which focussed on emergencies and lots of investment, Dermatology also had the advantage that you can have clinical practice, meet your patients, interact with them, treat them, while managing your family as well. Another thing was that at that point of time, Dermatology had started gaining a certain quotient of glamour. I took the opinion of many experienced superspecialists before entering into the field of Dermatology. Many were not in favour of it and they asked me to choose something lucrative like Surgery or Cardiology. There was also a general misconception 15 years ago from today, that only people who did not get other specialties, choose Dermatology. However, that has changed now, remarkably.

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Hygiene is vital to Skin Diseases"

Dr. Rinky Kapoor

Dr. Rinky Kapoor sharing her experiences with Vikrant D. Bhagwat, Zonal Business Head, AGAPPE. Today, it is among the most demanded specialities with manifold expansions. I’m grateful to those specialists who gave me the correct direction advising me that Dermatology would be the next big thing in the next 10-15 years. In my opinion, it is the best choice for women as they could manage their professional as well as family life. In terms of return on investment of time and money, Dermatology is a branch which is very well rewarding.

practice in dermatology? Dr. Kapoor: I have concentrated in Cosmetic Dermatology. That forms around 80% of my practice like Laser treatments, Dermatologic surgery and super specialities in Cosmetic Dermatology.

AGAPPE: You were recognized as the best Dermatologist in AGAPPE: Which are the key areas which you would like to India and won the extremely prestigious National Health

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Interview

Dr. Rinky Kapoor Dr. Kapoor: Most infectious diseases of skin are related to hygiene issues. Our Prime Minister’s Swachh Bharat is a very good initiative in this regard. Another alarming thing is that leprosy is coming back. Until recently, our authorities had almost declared its elimination from India. Skin diseases also include leprosy, genital diseases and venereal diseases. Of course, HIV is a bigger threat as these patients are prone to many skin infections. Lifestyle diseases like allergies, eczema are also increasing. AGAPPE: You are credited with many articles related to Dermatology in various journals and newspapers. How do you enjoy your status as a professional writer?

Dr. Kapoor: For me, writing is a part of educating the fraternity. My writing can be classified into twomedical writing and writing for the public. The latter is my bridge to connect with a wide variety of people. Apart from spreading awareness for the public, readers get to know about my work with Receiving award for Best Cosmetic Dermatologist in India 2016 my regular columns. Medical writing, on the other hand, helps my colleagues understand what I do Care Excel lence Award 2016 by CMO Asia. What was your and what else they could do. They can take and share inputs from reaction in securing this award at a young age? what I write. I had been also part of a few TV shows related many skin health issues in the past. Dr. Kapoor: It was very satisfying. I was very happy that I got this award from a much-esteemed organization. When they AGAPPE: As a socially committed healthcare specialist, informed me about the award, I was wondering how they chose you have been delivering many services to the society, me. It was based on a voting system where the general public especially for the socially weaker sections, for their can vote to select their favourite doctor. I’m grateful to my healthcare benefits and enhancing their knowledge in patients and public for choosing me for this award. It is a huge preventing skin care diseases. What are the social initiatives encouragement to go forward. Cosmetic Dermatology is an you are clubbed with for the betterment of society? emerging specialty. The reason why there are many young docDr. Kapoor: We have a foundation which works for the underprivitors now in this specialty is that they get more exposure than leged. It was established in my Father-in-law’s honour, as it was the senior practitioners in Dermatology had, and they are exhis dream to return service to the society. He was a doctor as well posed to it right from their time of studies, as the branch is in and extremely loved by his patients. We conduct many medical a mode of constant innovation. camps through this foundation. We do it with the help of local AGAPPE: Can you elaborate on your passion for Cosmetic government authorities. They organize camps and we provide free Dermatology? medical service. We do free medical checkups almost every month in Mumbai and its suburbs for the underprivileged, not just for Dr. Kapoor: I want to treat people and make them more healthy, the skin diseases but also for other diseases. For these, we also beautiful and confident, externally and thus, psychologically. recruit our ever ready doctor friends for the camps. Aimed at That is my passion. I personally like when patients tell me about women empowerment, we provide educational support to girls the transformation occurred to them after the treatment. It is through the foundation. This is our latest initiative. We are planvery satisfying and unlike many other medical specialties, it is ning to take our camps to other parts of the state. visible. In other treatments, it might not be external but on skin and hair, you can see the result. It raises their confidence. It AGAPPE: Prevention is better than cure! What is your advice changes their lives. Appearance has got a lot to do with your to TechAgappe readers to prevent skin diseases? well-being. There are also innate hassles in this field, especially Dr. Kapoor: The first thing is to manage hygiene. That is the most in Cosmetic Dermatology, if something goes wrong, it is also important step in prevention of skin diseases as most of them similarly visible and it can devastate the person’s appearance spread through contamination from one person to another as in and confidence. infectious diseases like scabies, fungus and genital diseases, which AGAPPE: Do you see any threatening rise in the case of are sexually transmitted diseases. Public in India still needs a lot skin diseases in India? Is that a matter of concern? of awareness and we have a really long way to go. Unless the

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concept and importance of practising cleanliness and hygiene is not inculcated in every child from school, we cannot achieve a healthy India. It is important to give sex education to children after a certain age after 7th or 8th Grade. It is a fact that many teens in Urban India, are sexually active now at an earlier age, and it is important to make them aware about the diseases which are transmitted sexually and how to safegauard oneself from disease. Basically, everything like this comes under hygiene and preventive measures. You might have noticed posters reading ‘Hygiene to prevent leprosy’ or ‘Hygiene to prevent Tuberculosis (TB)’. The number of reported Skin TB (Cutaneous TB) is increasing. Earlier, TB used to affect lungs or stomach. Recently, there was a case where skull bone was involved and it was considered a tumor, when it had spread to the skin and finally it was diagnosed as TB. Diseases like eczema rise from lifestyle issues. With people having dry skin, chances to develop eczema are high if they are sitting in AC room continuously. A disease like psoriasis is genetic. You can’t do much about it and it is saddening to watch that the number of psoriasis patients is on the rise because of lifestyle problems. Maintaining a healthy lifestyle is important. Parents and schools must ensure that children are fit enough health wise and not to be obese. Eating junk food, no exercise, long exposure to TV, mobile phones and laptops make the kids sedentary. Their immune system will suffer as a result. AGAPPE: What are your associations with other social/ professional bodies? Also, tell us about your future plans? Dr. Kapoor: Of course, it is essential to be a part of other professional bodies. I’m part of the Indian Association of Dermatologists, the Indian Society of Cosmetic Dermatology as well as international societies like The American Society of Dermatologists and European Society of Dermatologists. You need to be part of

"A disease like psoriasis is genetic. You can’t do much about it and it is saddening to watch that the number of psoriasis patients is on the rise because of lifestyle problems. Maintaining a healthy lifestyle is important. Parents and schools must ensure that children are fit enough health wise and not to be obese". national and international societies so as to gain knowledge on the latest trends in our field. We need to update ourselves constantly by attending seminars or conferences. Recently we received a patent from the US for our hair growth molecule. It is an injection completely formulated in India by myself and my colleague. It is one of a kind in the world. We have the exclusive patent of it for the next10 years. It is creating waves in the hair growth market. We are planning to make it big. The good part is that it is a product that comes under ‘Make in India’ as urged by our Prime Minister. I believe we need to export something unique to the world rather than always bringing in technology or products from abroad. It is high time we make a mark of ‘Indian make’ in the world market. The hair growth molecule called the ‘QR678’ is the beginning of this journey. We also plan seriously on Medical Tourism. As you know that the field of cosmetic medical tourism is increasing because of the better world class services and the cheaper rates in our country. Apart from getting more patients, it also makes us proud that we are able to provide world class healthcare to patients from abroad for half the price. I also feel the necessity of more inventions from our side. In the future, we want to invent new medicines and new technology by equally concentrating on research as well as practice. We plan to collaborate with IIT Mumbai for our future research. They were part of our hair molecule injection in its initial stage. We have everything from world class technical brains to world class healthcare experts in our India, just the right coordination and effort is required to club them together and work wonders!

Receiving award for Best Cosmetic Dermatologist in India 2015

We need to train young Dermatologists to take the field of Dermatology to great heights and to work towards a healthy and beautiful society!

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Promotion Evolution

Evolution of Liver Profile... Bintu Lijo, Product Manager, AGAPPE.

Most liver diseases cause only mild symptoms initially. Sometimes, there are no symptoms at all. This makes it extremely important to do a liver profile in cases where liver disorders are doubted. A liver profile is used to screen for liver damage and help to diagnose liver diseases by measuring the levels of proteins, liver enzymes or bilirubin in blood. These tests reflect different functions of the liver, that is, to excrete anions (bilirubin), hepatocellular integrity (transaminases), formation and the subsequent free flow of bile (bilirubin and ALP), and protein synthesis (al bumin). A liver function test is often taken in the fol lowing situations: To screen for liver infections, such as hepatitis C To monitor the side effects of certain medications known to affect the liver To monitor the liver disease and how well a particular treatment is working To measure the degree of scarring (cirrhosis) on the liver During symptoms of a liver disorder Here we are attempting to provide a comprehensive history of liver profile. In 1761, anatomic pathologist, Gianbattista Morgagni identified a peculiar transformation of the liver. One hundred years later, scientists understood the exact transformation of liver cirrhosis (Greek -orange colour).

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Routine Liver Profile

Hundreds of years before, scientists had observed bilirubin staining of body tissues. In 1847, Rudolf Virchow discovered Bilirubin molecule in blood. In 1923, scientists identified an enzyme which functions best under al kaline pH environments and later named as alkaline phosphatase. In 1948, scientists identified physiological role of al kaline phosphatase and later, it was used as an indicator of liver disease.

Few years after, in 1954, Arthur Karmen measured Serum Glutamate-Pyruvate Transaminase (SGPT) or Alanine Transaminase (ALT) & Serum Glutamate-Oxaloacetate Transaminase (SGOT) or Aspartate Transaminase (AST) and identified them as biomarkers for liver health. Scientists identified that proteins are produced by liver & liver disease decreases protein production. Albumin is produced only by the liver. It is the most abundant protein in blood. So, Al bumin test & total Protein test are also included in liver profile. Routine Liver Profile SGOT (AST) : AST is an enzyme that helps to metabolize alanine, an amino acid and it is normal ly present in blood at low levels. When liver cells

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are damaged, SGOT leaks into the blood stream, raising the level of this enzyme in blood. SGPT (ALT) : ALT is an enzyme found in the liver that helps your body metabolize protein. When the liver is damaged, ALT is released into the bloodstream and its level increases in blood. ALP : ALP is an enzyme in the liver, bile ducts and bone. Higherthan-normal levels of ALP may indicate liver damage or disease, such as a blocked bile duct or certain bone diseases. Bilirubin : Bilirubin is a substance produced during the normal breakdown of red blood cells. Bilirubin passes through the liver and is excreted through stool. Bilirubin test helps to determine the cause of jaundice and to diagnose conditions such as liver disease, hemolytic anemia and blockage of the bile ducts. Total Protein : The total serum protein test measures all the proteins in blood. Low total protein levels can suggest a liver disorder, a kidney disorder or a disorder in which protein is not digested or absorbed properly. Al bumin : This test measures the amount of albumin in blood and it indicates how wel l liver is working. Lower-than-normal levels of al bumin might indicate liver damage or disease.


LIVER FUNCTION TEST PARAMETERS FROM AGAPPE SGOT (AST)

Bilirubin Direct

IFCC Method

Modified Diazo method

High Linearity up to 1000 U/L

Linearity up to 20 mg/dL

Tris Buffer for optimal reaction SGPT (ALT)

Fast incubation 5 minutes at room temperature Al bumin

IFCC Method High Linearity up to 1000 U/L Tris Buffer for optimal reaction

Bromocresol green Methodology Succinate Buffer for optimal Reaction

Al kaline Phosphatase (ALP) - IFCC IFCC method An amazing linearity 2000 U/L Ready to use liquid stable two reagents Note: ALP DGKC method is also available Bilirubin Total TAB Modified Jendrassik-Grof Method with TAB Total bilirubin estimation without Sample blanking Wide measuring rage of 0.05 - 25 mg/dL

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Linear up to 6 g/dL Total Protein Direct Biuret Method Copper Sulphate reacts with Protein in Alkaline media to give stable end point Linear up to 15 g/dL Gamma Glutamyl Transaminase (GGT) Szasz Methodogy Wide measuring range of 1.5 - 232 U/L Result standardized to IFCC LDH - P SCE recommended method Ready to use liquid stable two reagents Wide measuring range of 0.2 - 2400 U/L PT (SL) (Prothrombin Time) Liquid stable reagents Anticoagulant is provided with kit Excellent sensitivity indicated by ISI value Transthyretin (Preal bumin) LEIT method Wide measuring range 5 - 80 mg/dL Calibrator provided -Multi point calibration

Standard Liver Profile If liver is not making the right amount of blood clotting proteins, the clotting process takes longer time. A high Prothrombin Time or PT usually means that there is serious liver damage or cirrhosis.

In 1970s, scientists identified Lactate Dehydrogenase (LDH) which is found in muscles & liver, which can be used as a biomarker. Elevated LDH activities have been reported in numerous muscle disorders as well as a variety of liver disorders.

Gamma-Glutamyltransferase (GGT) : GGT is an enzyme in the blood. Higher-than-normal levels may indicate liver or bile duct damage. It is more sensitive and its rise occurs earlier compared to other enzymes and persists longer. Studies have emphasized the value of serum GGT levels in detecting alcohol-induced liver disease.

Lactate dehydrogenase (LDH) : LDH is an enzyme found in the liver. Elevated levels may indicate liver damage but can be The link between Gamma Glutamyl elevated due to many other disorders. Transaminase and liver carcinogenesis Prothrombin time (PT) : PT is the time was discovered by Fiala and co-workers in for blood to clot. A chronic condition such 1972. A GGT level of twice the normal as severe liver disease may affect hemowith an AST/ALT ratio of 2:1 or more is stasis. Increased PT may indicate liver highly suggestive of alcohol abuse. damage.

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3 Extended Liver Profile Few years back, scientists suggested to include serological tests (to demonstrate antibodies) and DNA tests for hepatitis & other viruses and tests for antimitocho

ndrial and smooth muscle antibodies, transthyretin (preal bumin), protein electrophoresis, bile acids, alpha-fetoprotein to differentiate necrotic (characterized by death of tissues) versus obstructive liver disease.

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Cover Story Psoriasis - An Overview

COMORBIDITIES IN

PSORIASIS...

Dr. Sanjeev Aurangabadkar, MD, Dr. J.W. Aurangabadkar’ New Skin Clinic, Hyderabad.

Psoriasis is a multi-system inflammatory disease where the skin and the joints are the primary targets. There are many reports that psoriatic patients tend to have concurrent illnesses that are termed as comorbidities, though there are remarkably few studies from India. The choice of therapy of psoriasis may be influenced by their coexistence, and the systemic treatment of psoriasis with certain drugs may impact them negatively. Dermatologists should be aware of these associations as they may be in a position to detect them early, thus, allowing early intervention Courtesy to IJDVL and Wolters Kluwer Medknow Publications that may improve the overall quality of life of the patient. Moderate to severe psoriasis is associated with concomitant diseases that may have a significant impact on patients. It is necessary for the treating physician to recognize these concomitant diseases, known as comorbidities, early as they influence the management options. Important comorbidities are psoriatic arthritis, metabolic syn-

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drome, Crohn’s disease, depression, and cancer. Patients with severe psoriasis may be at an increased risk for myocardial infarction and this subgroup of patients tends to have a reduced life expectancy. The presence of comorbid diseases is associated with an increase in concomitant med ication, some of which may worsen


psoriasis; conversely, systemic treatment of psoriasis with certain drugs may impact the co-morbid conditions. As dermatologists are the primary health-care providers for psoriasis, adequate knowledge of comorbidities helps in choosing the appropriate therapy as well as timely intervention.

Comorbidities in Psoriasis Comorbidities can be classified as physical and psychosocial and Researchers observed that the severity of psoriatic skin disease portends a serious risk for the development of these comorbidities; patients with moderate to severe psoriatic skin disease have a higher association with these comorbidities, which may be related through common pathogenic mechanisms. Comorbidities may increase with age; one recent study found that patients older than 65 years had a statistically significant higher prevalence of hypertension, left ventricular hypertrophy, waist-hip ratio, diabetes mellitus and raised blood glucose levels. Psoriatic patients had a 4-fold increased risk of type 2 diabetes, 3fold risk of myocardial infarction and life expectancy shortened by 4 years compared to healthy controls. Nearly half of all the psoriasis patients above 65 years of age have at least three comorbidities. In one study, patients with severe psoriasis were found to die about 3-4 years earlier than patients without psoriasis.

Pathogenesis of psoriasis and comorbidities While the numerous susceptibility loci for psoriasis and psoriatic arthritis (PsA) explains only a part of the heritability of the disease, newer models of psoriatic pathogenesis combine skin barrier function, T-helper 17 (Th17) pathway, innate immunity, signaling pathways, Th2 pathway, and adaptive immunity involving CD8 T cells. These studies illustrate the importance of both the keratinocytes and the immune system for the pathophysiology of psoriasis. Additional studies investigating the role of psoriasis activity and severity as an independent risk factor for developing metabolic disorders, atherosclerosis and myocardial infarction and the role of psoriasis treatment in altering the risk of developing these serious morbidities are urgently needed. In addition to a genetic correlation, common inflammatory pathways exist for psoriasis and IBD. Psoriasis and CD are mediated by T-helper 1 (Th1) lymphocytes producing cytokines such as TNF-á and interferon (IFN)-ã. Th 17 cells also play a vital role in psoriasis and CD, producing IL-17, IFN-ã, and IL-21 cytokines. Increased levels of IL-17 and IL-23 in the intestinal lamina propria of patients with CD, in the serum, and in the cutaneous lesions of psoriatic patients have been noted.

Psychosocial Comorbidities Psoriasis is associated with a variety of psychological problems, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation, reported as high as 67% in one

study. This is not surprising since psychosocial comorbidities are more likely to occur in any chronic disease, especially the one which is visible, and with the attendant problems of smoking and alcohol abuse. These psychosocial co-morbidities are not always proportional to or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. It has been suggested that it is essential to include measures of psychosocial morbidity when assessing psoriasis severity and treatment efficacy because of the substantial role that psychosocial burden plays in patient’s perception of disease severity, quality of life, and disease course. Multiple studies have concluded that psoriasis sufferers feel self-conscious, disturbed or inconvenienced by the shedding of the skin, live in a constant fear of relapse, and avoid social interactions. In one study, the disease affected their social functioning and led to decreased efficiency and subjective distress at work in more than half of the subjects. Those who develop psoriasis at a younger age may have stronger feelings of stigmatization than those with a similar clinical

Additional studies investigating the role of psoriasis activity and severity as an independent risk factor for developing metabolic disorders, atherosclerosis and myocardial infarction and the role of psoriasis treatment in altering the risk of developing these serious morbidities are urgently needed.

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Cover Story Psoriasis - An Overview picture later in life. Specialists found that patients with psoriasis were significantly more at risk of developing psychiatric disorders versus control subjects (5.13% vs. 4.07), especially depression (3.01% vs. 2.42) and anxiety (1.81% vs. 1.35%). Other studies have demonstrated up to a 45% prevalence of anxiety among psoriasis patients, more commonly in women. One study also found that psoriatic women were more depressed than psoriatic men. Depression and suicidal ideation are relatively more common in patients with extensive psoriatic disease than in milder ones. Experts noted that patients with psoriasis have a higher prevalence of smoking and alcohol consumption. Psoriasis appears to be exacerbated by drinking habit. The amount of alcohol consumption may be related to both a higher incidence and severity of psoriasis. The mechanisms by which alcohol affects psoriasis include the production of pro-inflammatory cytokines, stimulation of lymphocyte and keratinocyte proliferation, and increased susceptibility to infections. TNF alpha has been found to play a crucial role in alcoholic hepatitis. Alcohol misuse can predispose to an increased risk of liver disease and drug interactions. Alcoholic and nonalcoholic liver diseases have both found to be common in patients of psoriasis. Thus, psoriasis leads to significant psychosocial disability and psychological comorbidities lead to poor treatment outcomes and worsening or precipitation of disease. This facet of the disease should be addressed by psychological and behavior therapy.

Metabolic Syndrome Psoriasis is associated with metabolic syndrome, which encompasses obesity, raised triglycerides, low high-density li-

poprotein (HDL), insulin resistance, and hypertension. Its importance lies in its ability to predispose sufferers to CV disease. There are some reports that the association is stronger for severe psoriasis than for mild psoriasis, but this association has still not been established beyond doubt as the number of studies are few and some studies have conflicting results. The updated Adult Treatment Panel III (ATPIII) criteria for the diagnosis of metabolic syndrome includes three or more of the following: triglyceride e” 150 mg/dl (1.7 mmol/l), HDL cholesterol < 40 mg/dl (1.03 mmol/l) in men and < 50 mg/dl (1.29 mmol/l) in women, fasting glucose e” 100 mg/dl (5.6 mmol/l) or previously diagnosed with type 2 diabetes, blood pressure e” 130/85 mmHg or on antihypertensive medication, and central obesity (defined as waist circumference e” 90 cm in men and e” 80 cm in women, according to the ethnic criteria for Asians). The International Diabetes federation (IDF) requires central obesity (defined as waist circumference e” 90 cm in men and e” 80 cm in women for Asians, except for Japanese) plus two of the following four factors: triglycerides e” 150 mg/dl, HDL cholesterol < 40 mg/dl in men and < 50 mg/dl in women, fasting glucose e” 100 mg/dl or previously diagnosed with type 2 diabetes, and blood pressure e” 130/85 mmHg or on treatment for hypertension. The most common feature of the metabolic syndrome among patients with psoriasis was abdominal obesity, fol lowed by hypertriglyceridemia and low levels of HDL cholesterol. The prevalence was higher in women than in men with psoriasis. Obesity itself is an independent risk factor for developing psoriasis. Experts found that obese patients were more likely to have severe psoriasis (i.e. >20% body surface area). Intraabdominal obesity was directly linked to the metabolic syndrome. Several studies have shown that psoriasis is associated with atherogenic dyslipidemia with increased blood levels of total cholesterol, triglycerides, low density lipoprotein (LDL), very low-density lipoprotein, and lipoprotein A, and low levels of HDL and apolipoprotein B. Women with psoriasis showed a 63% increased risk of future diabetes compared with women without psoriasis. In addition to a relationship between psoriasis and elevated blood glucose and blood pressure in the context of metabolic syndrome, observational studies have detected independent associations between psoriasis and hypertension and diabetes.

CV Disease and Psoriasis Data support the association of psoriasis with CV risk, especially in cases of severe psoriasis, where patients are on long term systemic drugs and/or have been hospitalized for psoriasis. The higher prevalence of CV risk factors may predispose to an increased risk of atherosclerosis as well as myocardial infarction. Psoriasis confers an independent risk for myocardial infarction,

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the relative risk being greatest in young patients with severe psoriasis.

Psoriasis patients over 65 years have a threefold increase in lymphomas. Other cancers are also more prevalent in psoriasis: carcinoma of the oral cavity and pharynx, oesophagus, liver, pancreas, lung, skin (squamous cell carcinoma), bladder, kidney, female breast, male genital cancers and mycosis fungoides in men.

CV conditions significantly associated with psoriasis are ischemic heart disease, angina and myocard ial infarction; cerebrovascular disease, transient ischemic attack, and stroke; and peripheral vascular diseases. CV conditions sporadical ly associated with psoriasis are arrhythmia, structural heart disorders, and pulmonary hypertension. Subclinical CV changes significantly associated with psoriasis are coronary artery calcification, arterial stiffness, and increase in intima-media thickness.

Psoriasis and Liver and Gastrointestinal Tract Non-alcoholic fatty liver disease (NAFLD) is more prevalent in obese patients without exposure to an obvious cause. It includes a spectrum of conditions ranging from simple fatty liver to nonalcoholic steatohepatitis (NASH), which can give rise to fibrosis, cirrhosis, and eventually hepatocarcinoma. NAFLD is now regarded as the hepatic manifestation of the metabolic syndrome. It also leads to endothelial dysfunction, thus leading to CV disease.

Psoriasis and Cancer The cancer risk is elevated in severe psoriasis cases. Patients who have used systemic therapies have a higher incidence of nonmelanoma skin cancers and lymphoproliferative diseases. Systemic PUVA treated patients too are at an increased risk of nonmelanoma skin cancers, and this risk remains increased up to 15 years after stopping PUVA. Bath PUVA is not associated with this risk. Psoriatics with mild disease also have a slightly higher incidence of cancer. Psoriasis patients over 65 years have a threefold increase in lymphomas. Other cancers are also more prevalent in psoriasis: carcinoma of the oral cavity and pharynx, esophagus, liver, pancreas, lung, skin (squamous cell carcinoma), bladder, kidney, female breast, male genital cancers, and mycosis fungoides in men.

Psoriasis and Chronic Obstructive Pulmonary Disease (COPD) Increased rates of chronic obstructive pulmonary disease (COPD) have been detected in patients with psoriasis. A Taiwanese study observed that psoriasis patients were at a greater risk of developing COPD with significantly lower COPD-free survival rates than the comparison cohort. Another large, population-based case-control study found that the prevalence of COPD was signifi-

cantly higher in patients with psoriasis (5.7% vs. 3.6%, P < 0.001, odds ratio [OR] 1.63). The authors recommended that dermatologists caring for patients with psoriasis should be aware of this association, consult a physician or a pulmonologist, and advise patients to stop smoking and reduce additional risk factors for COPD.

Psoriasis and the Eye Eye inflammation, especially uveitis is a prominent feature of spondyloarthropathies. Uveitis associated with undifferentiated spondyloarthropathy, inflammatory bowel disease, and psoriasis may be less characteristic in its presentation, with a higher tendency of the posterior pole involvement, bilaterality, and chronicity.

Longevity Psoriatic patients may have decreased longevity. Riech reported that co-morbidities are likely to contribute to the 3- to 4year reduction in life expectancy, in patients of severe psoriasis. The mortality may be related to the age of onset of psoriasis; the decrease in longevity may be as much as 20 years in patients whose psoriasis begins before 25 years of age.

Conclusion The awareness of comorbidities associated with psoriasis, particularly severe psoriasis, has led to a paradigm shift in the understanding of the disease and its management. Dermatologists should not just recognize and treat the signs and symptoms of psoriasis but should also screen patients to detect the existence of comorbid conditions such as PsA, metabolic syndrome, and CV disease. A multidisciplinary approach, with coordination between dermatologists and other specialists, is needed due to the systemic nature of inflammation in psoriatics. This will minimize co-medication, prevent overlap and improve compliance, improving the standards of care of psoriasis patients.

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Life Story Alka Dhupkar (Journalist)

Beauty isn’t skin deepThe Story of Alka Dhupkar

Twenty years back, a girl with some large patches on her body,was accused of spreading it to her close friend. She was blamed furiously for something which she was completely innocent. In this context, anyone would be heartbroken and go into deep misery. Alka Dhupkar, who was not sure of how to react to other people’s reactions on her skin condition, was no different.

A

lka Dhupkar from Mumbai, currently working as an Assistant Editor at Mumbai Mirror, had gone through this heart-wrenching situation while she was a school kid. The strange disease was psoriasis. Even though psoriasis is not contagious, her friend blamed it on her. The funniest part is that her friend’s disease was not psoriasis and it was just some kind of allergy, which later got cured. And undoubtedly yes, she is still Alka’s friend. “I can’t blame her. People don’t know much about the disease. Some say it is hereditary. But all I know and understand is that it is a chronic disease,” states Alka from her experience. In 2014, Alka’s article on a website on how she is coping with psoriasis went viral. When most people even hesitate to talk about it, Al ka posted an article about it. “I was not looking for any publicity. Tell me, what difference does publicity make on my disease? It was simple peer sharing. Only when you are in my shoes, you will understand the pain of living with this disease. I wrote that article because I stresses about certain things in my life at that time. Whenever I got stressed, I turned to writing as a tool of stress relief. I sent that article to a website, they approved it and published it with my photograph. And as you know, it went viral,” recollected Alka.

Al ka Dhupkar

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Some people, who had read her article on her life as a psoriasis patient, wrote to her that they had thought of suicide when they were first diagnosed with the disease. They had pointed that their partners were rejecting them because of psoriasis. Al ka replied to them that as they had accepted this condition, their partners also must accept it. “Mere sympathy won’t work out. If your friend is


not accepting you because of psoriasis, it is good in a way. They are not your true friends. Pack your bag, go somewhere or invest your time in something else,” she comments boldly with a smile. Alka’s way of getting over such feelings is by setting different goals related to professional, financial and personal life. She had set a goal to make a solo trip abroad and last month, she successfully completed it by visiting Bali. Now, she is busy setting up smal l temporary goals and fulfilling it. “Don’t depend on others too much. If you lack an understanding companion, it should not upset you to the level of thinking about suicide or judging yourself”, comments Alka.

The First Stage Al ka recollects that the symptoms started during her 7th standard. “Something started to appear on my skull, my leg and some other body parts. We thought it was some kind of allergy or some reaction caused by mosquito bite or so. We tried some home remedies for it. Since it didn’t help, we consulted a few local doctors. Dissatisfied with their treatment, we went to a skin specialist. It was there for the first time that my disease was diagnosed as psoriasis. We had no idea about the disease that time,” she said. The doctor suggested it could be hereditary but no one in her family had a history of such a disease called psoriasis. Within a few months, it started spreading on her body. Those patches were very rough, thick and painful. The itching was another constant problem. More than physical pain, it was the mental pain that Al ka couldn’t cope with. She had long silky hair which everyone admired. “I had to cut it down as I found it difficult to apply medicine. Even though the patches on the body wouldn’t bleed, often due to dry skin, it turned reddish as if it would bleed and created unwanted attention. Again, during my school days, when we had to wear a skirt, people used to look with a mixed feeling of curiosity and helplessness. Even now, if unknown people

keep staring at my visible psoriasis patches, I feel uneasy because I am uncomfortable with unwanted sympathy,” Alka’s tone became grim saying this. The incident in the opening paragraph happened when she was in 10th standard. Some patches on her friend’s skull made her blame Alka for it. She recalls how painful it was to bear the responsibility for something which she had no part to play. “The guilt feeling was so high that I thought that the disease would spread to others also. I left the class midway crying and ran back home. One of my sister’s friends saw me and asked why I was crying. I couldn’t explain it to her as I was still crying. Even at the home, my mother was helpless as she had no idea why I was crying,” she said. When she explained

Some people, who had read her article on her life as a psoriasis patient, wrote to her that they had thought of suicide when they were first diagnosed with the disease.

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Life Story Alka Dhupkar (Journalist)

Receiving Ram Nath Goenka Award in 2012 the situation to her mother, she immediately took her to the Ayurvedic doctor whom they were consulting at that time. Dr. Suvinay Damle was all ears and heard her problem patiently. Alka told that she no longer wanted to go school or to appear in the board examination. Slowly, the doctor explained her that psoriasis was not at all a contagious disease. He promised to give it in writing which she could take to the principal as an affidavit. He assured Al ka that he would tal k to the principal about this in person. The doctor even asked her to bring her friend to him so that he could explain the same to her. Literally, he was giving her the confidence which she very much required. “It was only because of the doctor’s advice that I appeared for the board examination. My parents, brothers and sisters were super-supportive in my condition. Nobody treated me different in my family. We belong to a typical Marathi village family and there was no discrimination between my sisters or brothers. From modern medicine, we moved to Ayurvedic treatment as I developed some allergies. The modern medication regimen resulted in developing several kinds of allergies.

She is really grateful to all the Ayurveda doctors who treated her. "It was Dr. Anand Tendulkar who gave a new insight to me. He told me not to waste time on people who judge you on the basis of your skin".

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We used to order medicines from Mumbai. My father was working as a clerk in a high school and as we own a small parcel of land, he also had to take care of other responsibilities too like supervising the farming and workers etc. The repeated incidents of my allergies gave him a hard time. He had to take me on a cycle to the nearest telephone booth to call and enquire about the remedy for the allergy every time. But he never complained. Looking back, I feel very much grateful to my father for not even once blaming me. The other person was my mother who cooked a different meal for me as I had a special diet and with all painstaking efforts ensured that I applied the medicines on my body every day”, Alka expresses her gratitude to her supportive parents.

Later, they shifted to Ayurveda completely as psoriasis is a chronic disease and might have a lifelong impact. She is really grateful to all the Ayurveda doctors who treated her. “It was Dr. Anand Tendulkar who gave a new insight to me. He told me not to waste time on people who judge you on the basis of your skin. Don’t let people decide what you are going to be. He also encouraged me to read more books other than my textbooks and explore life to the fullest. I also volunteered in camps conducted by Dr. Anand Tendulkar for arthritis patients. I was introduced to people who underwent pain maybe not because of psoriasis but due to other diseases. It helped me to understand the real and different difficulties of people,” Alka comments. Her decision to become a journalist was due to the influence of her political science teacher, Mr. Tople, who asked her to expand her horizons by reading and updating her knowledge.

Managing Psoriasis Tal king about coping with the disease, Alka states that she experiences disappointment and unwanted stress even now. “Sometimes I think I could have done things differently if I hadn’t been under the clutches of this disease. But since long back, I have accepted the situation. I don’t carry my stress points for long and I don’t feed irrational thoughts. I have accepted myself and now I don’t get flustered thinking whether other people will accept me because of my skin disease,” she says confidently. She is also grateful to her friends who tolerated her in different mood swings due to the stress which the disease had thrust on her during the initial days of treatment. “I didn’t quite realize it then and only now, I understand the gravity of the situation. My friends made me aware of my weaknesses,” she says. “I was selected for Asia Journalism Fellowship, Singapore in 2015 and now I have journalist friends from 14 countries worldwide. I used to


During her career as a news anchor, her psoriasis patches used to flare up because of the makeup. But, slowly she and her makeup artists knew how to manage that situation. send postcards to one of them. We do discuss stories and happenings across globe as journalists on the Whatsapp group and Facebook. We are just a phone call away as friends “, Alka’s eyes gleam with joy. During her career as a news anchor, her psoriasis patches used to flare up because of the makeup. But, slowly she and her makeup artists knew how to manage that situation. Once she overcame that little issue, nothing was ever a hassle in her career. This made her believe in her abilities more and forget her skin condition. Of the many psoriasis treatment choices, Alka suggests choosing something which is apt for the particular patient. She is quick to clarify that till date she hasn’t read any book on psoriasis and she is in no position to suggest others a treatment. “I underwent Ayurvedic Panchakarma treatment and it was really good to my condition. Positive thinking, exercises like walking and cycling also has helped me a lot. My doctor has also advised me to follow a strict diet, sleep pattern and positive mindset to keep the disease under the control. Now, it has reduced my patches to really small ones compared to what I had before 15 years,” Alka cheerfully explains. Cycling is a new hobby which Alka pursues now with vigorous interest. She has made around 100 friends through this new hobby. Gardening is another area which she would love to pursue. Tal king about her advice to others, she says, “Pay attention to your body. Take good care of it. I insist you do regular check-ups. Take bath twice a day. Make some good friends who accept you and with whom you can share your feelings. Follow your hobbies and stay positive”.

Alka with her journalist friends during Asia Journalism Fellowship

Al ka adds that the CNN anchor Zain Verjee has psoriasis and she too is vocal about it. “Peer sharing helps a lot. Unless we speak about our condition, how do other people know about it? We may get more acceptance in the society if we discuss our issues”, Alka drives home a strong point.

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Interview

Dr. Prashant M. Vishwanath

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Good, Better, Best; Should Never Let You Rest...â&#x20AC;&#x153; Chit-chat with Dr. Prashant M. Vishwanath, MBBS, MD-Biochemistry

Read on the excerpts from an interview with Dr. Prashant M. Vishwanath, Professor and HOD, Department of Biochemistry, Jagadguru Sri Shivarathreeshwara University (JSS University), Mysuru. Under his prudent leadership, the laboratory facilities in JSS medical college has become a very supportive centre for Mysuru people and its neighboring villages for monitoring their health status. The purpose of the interview is to help the readers understand the diagnostic industry and its possible trends. Dr. Prashant M. Vishwanath shares his thoughts and provides valuable advises to the readers of Techagappe. AGAPPE: Could you please explain the improvements which happened in your department since your joining with JSS?

Dr. Prashant M. Vishwanath

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Dr Prashant M. Vishwanath: The developments were focused on all three aspects of Biochemistry: viz. Academics, Research and Clinical Diagnostic Services. On the academic and research front we have made great advances and set up a Centre for Excellence in the Molecular Biology and Regenerative Medicine (CEMR) with funding from several Governmental agencies. But, here I would like to remain focused on the diagnostic aspect. I think we have slowly evolved since past few years, our first step was to focus on the instrumentation and that is when we looked out in the market and after due deliberations AGAPPE seemed to be the one we decided upon for the collaboration with Toshiba 40 FR and 120 FR. We have expanded our chemistry profile from the basics to advanced chemistry and we have recently started with Complements using Mispai2. On the other hand we have our partnership for immunoassay based parameters with other MNC and we must say are the only lab in Mysuru to perform special assays like tumor markers, procalcitonin, ACTH, Insulin and cpeptide. We also offer services for some special parameters like homocysteine, G-6PD,


Copper and Zinc on the chemistry platform. We have been successfully taking part in EQAS programs al l these years and with a stringent internal quality system in place we expect to face NABL audit early next year as a part of accreditation process. We have moved from a small 350 Sq. feet area in the old hospital building to a new area of more than 6000 Sq. feet and being one of the largestclinical biochemistry laboratories in the country. The laboratory workload also Dr. Prashant M. Vishwanath with his team at JSS Medical Col lege, Mysuru has increased tremendously and we thank JSS Medical College and Hospital for having AGAPPE: As an end user, how do you define the need provided us with the right kind of infrastructure and financial sup- for reagent’s precision, accuracy and linearity? port to maintain the momentum of growth in all aspects in the Dr. Prashant: I think precision, accuracy and linearity are the department. foundation stones of laboratory management. In an era of AGAPPE: Since your entry into the diagnostic industry, evidence based medicine and an increase in consumer because of continuous research and development by IVD awareness, these factors aid us to validate our results and corporates like AGAPPE, the industry had undergone a lot we are more confident in reporting and believe that we are of changes. What are the major changes you have noticed in contributing to the exactitude of patient management. the last decade as Head of biochemistry and how do you AGAPPE: You could publish an article on “Role of find these changes helping the needy patients in India? Cystatin-C in assessing the cardiovascular risk among Dr. Prashant: There have been tremendous developments in the overweight and obese individuals” in the year 2012. How IVD sector and a good progress has been made in manufacturing do you judge AGAPPE’s Mispa I2 which can provide reagents in India which has led to a decrease in prices of many accurate and precise results for Cystatin C? essential tests which were earlier very expensive. The healthy competition and technological advances has maximally benefitted the Dr. Prashant: When we did the study, we did not have Mispa i2 patients by providing a vast array of tests within afford of a com- available with us and hence used immunoturbidimetric mon man. I think the vast evolution in effective and affordable method. But with our experience of cystatin C on Mispa i2 in automation has bought a lean patch of over more than two de- the recent past, we are satisfied with the performance of cades to an end especially in India, where the health sector is Cystatin C on Mispa i2 divided into public and private partnership. The R&D in IVD indus- AGAPPE: What are the emerging trends you have been try has not only increased the affordability, but has also made watching in biochemistry disease diagnosis which will guide newer biomarkers available for earlier diagnosis and better treatment of diseases. As a Medical College hospital which caters to multi-specialties we have a strong base of patients, especially from "I think precision, accuracy and linearity rural areas of Mysuru and neighboring districts. Our hospital has are the foundation stone of laboratory succeeded in a huge way to satisfy the immediate diagnostic ways by minimizing the turnaround time and at the same time we have management. In an era of evidence widened our scope to tailor the needs of physicians to arrive at the based medicine and an increase in probable diagnosis and aid in early management. We are now moving towards a genetic lab-molecular diagnostics as this asconsumer awareness, these factors aid pect of diagnosis has been lacking its presence in this region. We us to validate our results". are heading towards certain aspects of community based projects like new born screening and genetic counselling.

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Interview

Dr. Prashant M. Vishwanath your department help your local public in Mysore to make them aware the importance of preventive diagnosis?

Dr. Prashant: The mindset in India has always been to approach the doctor when the problem arises. Though with increasing awareness, the urban population to a certain extent undergoes preventive testing, by and large this concept has not reached the rural India. As a part of being in the medical school, we have mobilized health care professionals to reach the rural and tribal populations in and around Mysuru and have been promoting the concept of preventive diagnosis. Though the initial efforts have not yielded the desired results, we believe that this needs to be continued and the concept of preventive diagnosis would be accepted over a period of time. Also, promotional campaigns through media such as FM radio, newspapers and television interviews have helped in promoting the conDr. Prashant with Jiby Kuriakose, General Manager, AGAPPE cept of preventive diagnosis the near future? AGAPPE: JSS has been dealing with AGAPPE for couple of years with many biochemistry parameters, what is your Dr. Prashant: The Global Clinical Chemistry Analyzer Market is overall experience with AGAPPE? expected to exceed more than US$ 16 Billion by 2025 and I am positive and looking forward to more and more innovations Dr. Prashant: I think our partnership with Agappe saw the light of which are not only have a cutting-edge technology but also af- the day about six years ago, and this relationship has been bolfordable. The mantra for a country like India should be “afford- stered by many factors like quality kits, great supporting team of able quality care”. I think POCT (point of care testing) is one area service engineers, application manager, timely services, open to which can be probably explored more as this provides a pa- constructive feed back, interpersonal relationships and the overtient-centered approach in health care delivery system. I also all positivity has helped both JSS and Agappe to grow individually. think molecular diagnostics is another aspect which needs more AGAPPE: We take pride in claiming that we are “The best attention from the industry. Fully automated molecular platpartner in diagnostics”. We strive hard to retain it. What is forms are required for better understanding of diseases and your advice to Agappe to enable us to usefully fill the slot as for customized treatment options which will provide better cure “The best partner in diagnostics”? and carefor patients. Dr. Prashant: I have always believed that 'good, better, best; should AGAPPE: What is your view on Preventive Diagnosis? never let you rest, because good can become better and better the Being a part of India’s biggest medical college, how does best'. So once you call yourself as “the best partner in diagnostics”, the expectations would be no less from you. My advice to Agappe would be to provide comprehensive solutions to laboratories right from establishing of a laboratory to providing day to “I have always believed that day assistance in running of laboratories so that the consumer does look at you as the best partner in diagnostics. ‘good, better, best; should never

let you rest, because good can become better and better the best’. So once you call yourself as ‘the best par tner in diagnostics’, the expectations would be no less from you”.

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AGAPPE: What would be your advices and suggestions to the IVD professionals and to the diagnostic companies? Dr. Prashant: My advice for IVD industry would be an age old one, that is to take time and cultivate the core values of honesty, sincerity and most important of all “trust”. Because it is something which is the basis of the business dealings in health care sector. As at the end of the day patients have that unfathomable trust on care providers and it’s our responsibility to deliver on that promise, in turn we are dependent on the IVD industry to fulfill this promise.


Life Story Kartiki Bhatnagar

THE DARING DESIGNS OF LIFE!

Kartiki Bhatnagar is a no nonsense girl who has seen how gruelling life can be from the tender age of 7. But gone are the days of bafflement and aloofness. Now, 10 years later, when Kartiki Bhatnagar creates aesthetic art out of her disease, the people around her could do nothing else but applaud her courage, positivity, confidence and of course, her talent. Kartiki Bhatnagar, from New Delhi, is a girl of diverse talents. Apart from taking part in dramas, debating and blogging, she likes to engage herself in poetry, film making and photography. This 17year-old beauty is currently attending class 12 in the Delhi Public School Rohini and has created many ardent fans after she started transforming the white patches on her body to pieces of artistic designs. She actually started this unique body designing to chase off the bullies who taunted her skin condition, Vitiligo.

Vitiligo is a disease that causes loss of skin colour in the form of white or depigmented patches of skin anywhere on the body. Melanin, which gives the colour to hair and skin in the body, doesn’t function properly for those who are affected with Vitiligo, which causes the skin to develop white patches. It is estimated around 2% of the total population in India is affected by it.

Kartiki Bhatnagar

In Kartiki’s case, the symptoms appeared when she was just seven years old. At an age when she could barely understand what vitiligo was, she was isolated by her friends and classmates as they feared it was contagious. The little girl was almost treated like a social outcast. “It first appeared on my face and soon developed on my legs, hands, stomach, knees and other ‘secretive’ parts of my body. It was a difficult time. I was unable to fathom whether I was the one who was not friendly enough, whether I made a mistake, whether I ate too many chocolates which was why I was treated like this. There were times where I felt like the loneliest person on Earth. I also struggled to accept my

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Life Story Kartiki Bhatnagar condition because I didn’t know what was happening,” reflects Kartiki about those disheartening days. Her parents gave her all sorts of medications hoping that the patches would disappear and even performed ‘havans’ for her. Frequent visits to the doctors followed and for years, she underwent allopathic, ayurvedic and homeopathic treatments. Regular prayers followed at home and temple. But nothing helped. The stint with medicines was quite hard for her. Different medicines had different set of rules and side effects. After eight years of fighting vitiligo and medicines, Kartiki stopped taking medication as she understood that her situation could neither be changed nor it was contagious. Upon her mother’s behest, her school conducted a special session for her batchmates to create awareness among her peers that it was not a contagious or fatal disease. As she was labelled as a ‘safe child’ by the counsellor, her friends began to talk to her again. Thus after several years of loneliness, she started finding her pace in life. When Kartiki learnt more about her disease condition, she felt less guilty about it as nothing she had done could have caused it. One day, Shreyes Kishore, her friend, looked at the patches on her feet and said, “Wow! I love that dual tone of your skin!” This made her see herself in a new light. He sometimes spotted the ‘Apple logo’, ‘a ghost’ or a ‘floating cloud’ on the white patches on her leg. At first, she thought he was making fun of her. She kept on denying it for a long time and then realized that actually they resembled his imagination. Her friend suggested outlining them with a pen. Thinking more about it, she got a feeling that her body was trying to communicate something to her. This inspired her to make designs on the white patches. When ordinary people around found it as just white patches, Karitiki found different things like a man who is crouching or a snail, a heart, majestic mountains on a clear brown sky, a cute little ghost with its hands flapping around with a heart in the middle and so on. Adding a splash of cre-

ativity, she began to paint them with all her heart as an answer to the harassment she suffered for years. When she went for the tuitions with this art work on her leg and arm, the reaction of her friends was mixed. It was then she thought of taking it to the social media. Some appreciated her for publicly tal king about vitiligo and taking it positively. She owes much credit to her parents who had never asked her to cover up her white patches using full sleeves. Ankur, Kartiki’s mother, recalls her experience on seeing her child sitting alone in a corner of the classroom isolated by her classmates and friends just because she had those white patches on her body. Till then, Kartiki was loved by everyone as she had an excellent academic record. Just like any other student of her age, she enjoyed roaming around with her friends. Ankur points out about the absence of practical

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examples in our society. “Even when they knew nothing about the disease, some relatives and many others came up with advices which could have only worsened the situation”, comments Ankur. Her blog ‘EmbracingLifeBlog.com’ was her channel for communication to people out there. She even coined a term 'Vitiloger' for herself. Her blog deals with positivity of life although you can find body positivity as a part of it. When asked why the blog is named so she replied with a beaming smile, “Embracing life wants to connect with you. Embracing life wants you to know that we all are in this together. Because life is just too simple, but we always tend to complicate it a little. Life is not about being granted your wishes, but being satisfied with what you have. Life is not about being lost, trying to find purpose, or crying about the road not taken, but putting one foot in front of another and going in every direction. And life is to be embraced”. Kartiki’s blog space grabbed much media attention. Several media groups, around the world, wrote articles on her fiery spirit in chasing the bullies away by turning her body into spectacular art although she clarifies that she is a writer and not a painter. Kartiki, who today enjoys a fairly good fan base, relies on social media to change the social taboos which she feels to be eliminated. Her latest endeavour is on desexualising the tummy. People treat girls as witches if a part of their tummies are visible through their dress. She has started an Instagram thread called #Barethemidriff to make her point strong. The decision to do something about it was sparked after her journey on the metro train. She recalls wearing a short shirt on her journey and when she raised her hand to tie her hair, she realised that a few people were staring at her as if she had done some crime. She wanted this situation to change. She has put up her own pictures and encouraged others to post too. Today, she is hailed as the ‘Vitiligo Queen’ for her efforts to turn her skin condition to beautiful art work and to inspire a lot more who were affected by vitiligo. “I am so glad that my main aim of making people aware of vitiligo is coming to the forefront and I can dispel its myths”, states jubilant Kartiki. In the future, she wants to get into the field of psychology. She says after getting to know more about vitiligo, she realised why people behaved towards her the way they did once. As there is no cure for vitiligo, she believes that it is very important to provide emotional support to those who go through this situation. She is also thinking of getting her white patches tattooed provided her mother nods her consent for that.

Currently, she is happy with her own work and what it has done to change her life. Kartiki is of opinion that people who are distressed about their diseases need to tal k to others honestly because regret and misery would only break people in the process. She has every right to say so as she is a fighter who has punched and defeated her opponents with the feathery touch of unique and bold art.

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Cover Story Vitiligo- An Overview

CHILDHOOD VITILIGO Childhood vitiligo is often encountered in dermatological practice. When present in infancy or early childhood, various nevoid and hereditary disorders are to be differentiated. In many cases, familial aggregation of the disease is seen and other autoimmune disorders may be associated. Segmental presentation is more common, and limited body surface area involvement is usual in this age group. Children with vitiligo often suffer from anxiety and depression because of their unusual appearance. Management of vitiligo in children is difficult as therapeutic options are restricted when compared to that in adult patients. Selection of treatment should be careful in these patients with the aim to achieve best results with minimal side effects as well as relieving patients’ and parents’ anxiety.

Courtesy to IJDVL and Wolters Kluwer Medknow Publications

Dr. Arun C. Inamadar, MD, DVD, FRCP (Edin)

Professor and HOD, Department of Dermatology, Venereology and Leprosy, Sri. B.M. Pattil Medical College, Hospital and Research Center, BLDE University, Bijapur, Karnataka, India.

V

itiligo is an acquired pigmentary disorder occurring irrespective of age, sex and race. The most important aspect of vitiligo is the cosmetic concern it arouses in the psyche of patients and their family members because of the stigma associated with it. This is more so among dark races for the obviousness of the disease. Vitiligo may present anytime in life, including the neonatal period and child hood. Child hood vitiligo deserves special attention as frequently (50%), the disease onset is before 20 years of age and, in 25% of the cases, it starts before the age of 10 years. In general, childhood vitiligo differs from the adult disease in the fol lowing aspects: a female preponderance is observed, segmental presentation is more common and associated other autoimmune or endocrine disorders are rarer. CLASSIFICATION In most of the epidemiological studies, childhood vitiligo has been categorized as “segmental” and “nonsegmental” types. Segmental vitiligo (SV) implies occurrence

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of depigmented macules and patches along dermatomal or quasi-dermatomal pattern, without crossing the midline. In non-segmental vitiligo (NSV), the skin lesions may be generalized (vitiligo vulgaris, universal vitiligo) or localized (focal, mucosal, acrofacial, acral). Vitiligo vulgaris implies widely scattered depigmented lesions, whereas almosttotal depigmentation of skin is termed as universal vitiligo. Focal vitiligo is the occurrence of one or few depigmented lesions localized to one body area not corroborating to a dermatome. Acral vitiligo is confined to the distal extremities in combination with facial lesion it is of the acrofacial type, and mucosal vitiligo involves one or multiple mucosae. CLINICAL FEATURES Vitiligo is characterized by asymptomatic, well-demarcated, ivorywhite macules and patches that may be localized or generalized. Any of the clinical variants of vitiligo may occur in child hood. Vitiligo vulgaris is the most common clinical type observed in various clinical studies, followed by focal vitiligo and SV. Acrofacial and mucosal vitiligo have a lower incidence in childhood. Different studies have quoted variable incidence of mucosal vitiligo in children; Halder et al 0%, Handa et al 0.6% and Jaisankar et al 13.8%. Of the mucosal sites, oral mucosal vitiligo is rarer in children as compared to adults. The rarest type seen during child hood is the universal vitiligo. Common initial site of onset of both NSV and SV in children is the face and neck. In NSV, initial lesions are periocular, perinasal or perioral, and gradually spread to other body parts, in a more or less symmetrical manner. Perineum, perianal area and, in infancy, the diaper area may be the initial site of occurrence of skin lesions Individual vitiligo macules may enlarge attaining a geographic pattern or there may be appearance of new lesions at other sites. Although extensive areas of depigmentation may be present, majority of the children have <20% body surface area (BSA) involvement. Focal vitiligo may subsequently evolve into generalized disease. In the series of patients with SV studied by Hann et al, trigeminal segment was the most common dermatome involved, followed by thoracic, cervical, lumbar and sacral. Majority of the children in this series (87%) had a single lesion. In white-skinned children, vitiligo lesions may remain unapparent initially and may become evident for the first time following suntan during a holiday. In dark-skinned children, typical multishaded trichrome patches may be present. MazereeuwHautier, an expert,recorded the occurrence of a hyperpigmented

rim around the depigmented lesions only among the children with NSV (8.99%). ASSOCIATIONS Vitiligo may be associated with other autoimmune disorders like alopecia areata, diabetes mellitus, pernicious anemia, Addisonâ&#x20AC;&#x2122;s disease and thyroid disorder. An Indian study has quoted associated autoimmune disorders in 1.3% of the children with vitiligo. Several authors have reported vitiligoassociated autoimmune disorders occurring exclusively in children suffering from NSV. Mazereeuw-Hautier et al have reported associated thyroid function abnormalities without clinical disease in 11.23% of the children with NSV but in none with SV. In the study by Hann et al, associated autoimmune disorders were found in 3.4% of the children with SV. Among adult patients with vitiligo, autoimmune thyroiditis (Hashimotoâ&#x20AC;&#x2122;s) resulting in hypothyroid ism is more

In the series of patients with SV studied by Hann et al, trigeminal segment was the most common dermatome involved, followed by thoracic, cervical, lumbar and sacral. Majority of the children in this series (87%) had a single lesion.

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Cover Story Vitiligo- An Overview common (30%) as compared to the general population (10%). Lacovelli et al have studied the relevance of thyroiditis and other autoimmune diseases in 121 pediatric patients with vitiligo. The significant findings of this study were as follows: Sixteen percent of the children with NSV showed altered thyroid function parameters, but none among the children with SV. Altered thyroid parameters were more common in girls than in boys. Hypothyroidism was the more common association of childhood vitiligo as compared to hyperthyroidism, in the ratio of 6:1. COURSE OF THE DISEASE The course of child hood vitiligo is mostly stable or regressive; only few patients experience progressive or recurrent disease. Complete spontaneous repigmentation of NSV is unusual. However, as compared to adults, the rate of spontaneous repigmentation is more in children, especially in tropical countries and during summer months. Repigmentation may be diffuse, marginal or perifollicular. Following the initial onset, SV spreads fast only along the affected dermatome. Thereafter, it remains stationary for the rest of the patientâ&#x20AC;&#x2122;s life. In a large series of patients of all ages suffering from SV, progression was seen among 55.3% of patients, lesions were stable in

40.9% patients and minimal regression without treatment was seen in 3.8% of patients. DIFFERENTIAL DIAGNOSIS Various nevoid and hereditary disorders with depigmentation may simulate vitiligo in children. It is important to differentiate hereditary disorders from early-onset child hood vitiligo as these are usually multisystemic. Moreover, therapeutic intervention is possible in vitiligo but not feasible in nevoid and hereditary conditions. Table 1 presents the list of various congenital and acquired conditions simulating vitiligo and the important differentiating features. Vitiligo as a component of hered itary syndromes Vitiligo in older children and adolescents may be one of the components of certain syndromes. Vogt-Koyanagi-Harada syndrome: It is a rare syndrome affecting children, especially of southeast Asian origin. Characteristic features are uveitis, aseptic meningitis, dysacusia, alopecia, poliosis and vitiligo. Uveitis is the presenting feature and vitiligo may appear later, during the chronic stage (fourth stage) of the disease (adolescence or adulthood). Vitiligo lesions tend to be symmetrical, involving the head, neck and trunk. The sacral region is a common site of involvement with vitiligo. Poliosis may involve the scalp, eyebrows and eyelashes. Alezzandrini syndrome: This syndrome is characterized by SV (cheek), poliosis, ipsilateral uveitis resulting in decreased visual acuity and samesided partial hearing loss. Manifestation starts during adolescence. In both these disorders, uveitis and related ocular manifestations are the main clinical features. Vitiligo appears later and is usually persistent, despite therapy. MANAGEMENT Diagnosis Diagnosis of vitiligo is mostly clinical. Invasive and sophisticated investigations are not required to confirm the diagnosis. In children with fair skin, it may be difficult to differentiate a lesion of vitiligo from the surrounding normal skin. In these cases, examination under Woodâ&#x20AC;&#x2122;s lamp is helpful. Complete blood count and fasting blood sugar should be performed as a routine work-up for all patients. In case of diagnostic difficulty, skin biopsy may be taken; histopathological examination shows total absence of melanocytes in established lesions of vitiligo. In early lesions, melanocytes are still retained but with multiple abnormalities like vacuolization, dilated endoplasmic reticulum and granular deposits. Presence of mild inflammatory infiltrate is sometimes seen, and is indicative of disease activity. Associated autoimmune disorders should be ruled out in the pediatric age group. Screening for autoantibodies may be performed if facilities are available. Antinuclear antibody may be positive even in normal children. Thyroid function status of the child is assessed by estimating T3, T4 and TSH levels. Coexistence of autoimmune thyroiditis may be ruled out by the estimation of antithyroglobulin antibody (anti-Tg) and

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antithyroperoxidase antibody (anti- TPO). Kakourou et al have proposed a management protocol for children with vitiligo and positive antithyroid antibodies. Therapy Various therapeutic modalities are available for the treatment of vitiligo; however, all of these cannot be used in children. Medical therapy is considered as the first line of management in this age group. All children with widespread vitiligo should undertake photoprotection preferably with opaque sunscreens during daytime outdoor activities. In general, localized vitiligo is treated with topical therapy. Widespread or generalized disease is managed with phototherapy or systemic therapy. Surgical methods may be chosen for stable (size of the lesion is stationary for > 2 years and no new lesion has developed recently) localized vitiligo and SV. Different therapeutic options available for the treatment of childhood vitiligo are presented in Table 2. Certain clinical features are poor prognostic markers for treatment. These include acral vitiligo, presence of leukotrichia over vitiliginous area and lesions over bony prominences like elbow, knee and ankle. Treatment of vitiligo in hereditary disorders Vitiligo lesions in hereditary disorders like Vogt- KoyanagiHarada syndrome and Alezzandrini syndrome are usually resistant to treatment. These patients would be on long-term systemic corticosteroid and various immunosuppressive agents for the treatment of uveitis. Topical steroid may be used for localized lesions of vitiligo. Sunscreens should be used regularly and cosmetic camouflage may be used. Phototherapy should be used with great caution in these patients as this may enhance ocular inflammatory disease. All children with vitiligo, especially among dark races, require thorough counseling as they may be the victims of peer-teasing and avoidance at schools. This may lead to anxiety, introvert personality and childhood depression. In a qualitative psychosocial development survey of children with vitiligo, Schwartz have recorded a higher frequency of fear to strangers and predominant fear and shyness to a change in close relative in them as compared to their healthy siblings. The childâ&#x20AC;&#x2122;s perception about the illness and difficulties in interaction with other children should be discussed in detail during routine follow-up. Parents of affected children should also be counselled regarding tackling such issues. A well-counseled child with vitiligo may render full cooperation to the treating physician, making his job easier. Mulekar have observed that all the children with localized vitiligo in their series, treated by non-cultured cellular grafting technique, ac-

Treatment of vitiligo at any age remains a challenge for clinicians, more so during childhood. None of the available therapies is absolutely effective, and the disease runs a relapsing course.

cepted the treatment procedure willingly, even if it was a repeat session. Childhood vitiligo requires special consideration. Many of the adults with vitiligo had disease onset during the first or early second decades of life and had grown up with the psychological trauma associated with this stigmatizing disease. Early institution of medical care (therapy and/or counseling) in all cases of childhood vitiligo ensures better cope up with the associated stress as well as understanding the nature and course of the disease during adolescence and adulthood. Conclusion Treatment of vitiligo at any age remains a challenge for clinicians, more so during childhood. None of the available therapies is absolutely effective, and the disease runs a relapsing course. With any of the treatment modalities, >75% repigmentation (achieved by approximately 60% of treated children) is considered as the best therapeutic response. Longterm treatment requirement is the rule with chance of cumulative side effects of the drugs. Some patients remain unresponsive to all treatment and even in responsive cases, there are treatment-resistant body sites. Often, multiple therapeutic modalities may have to be used to obtain optimum result in a given patient. The art of treatment of childhood vitiligo is a fine balance between addressing all these issues and achieving the best result out of the available modalities.

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Health Tips

Skin Really Matters... Dr. C.S. Satheesh Kumar, Vice President-Operations, AGAPPE. (Retd. Drugs Controller, Kerala) Itâ&#x20AC;&#x2122;s important to remember that your skin is our largest and the most permeable organ. Skin has lots of essential functions like protection of body form environment, temperature control by sweating, sweat glands to detoxify different toxic materials, sense of touch, temperature, pressure etc. It gives shape and strength to the body. Dermal route of drug administration is also very common these days. There is no fountain of youth but the food we eat and how we take care of ourselves can affect skin health. Like body, skin also needs nutrients to fight off damage. Processed food, stress, toxins and low-nutrient diets will accelerate aging. Protect yourself from harmful chemicals. Have enough sleep, relaxation and exercise to maintain a healthy skin.

Care shall be taken to keep our skin glowing and healthy. 1. Diet: Antioxidants are good resources to fight disease and aging by reducing damage, inflammation and wrinkle formation. Sources of antioxidants include fresh fruits, vegetables, dry fruits, nuts, dark chocolate etc. Organic food is good for skin health. Foods such as avocados, olive oil, flax seeds, pomegranates, acai berries, spinach, raspberries, purple grapes and fish are important for body and skin. If we can avoid sugar, we can avoid damaging collagen and elastin, which cause wrinkles. The different nutrient-rich foods neutralize free radicals in our bodies avoiding major damage to cells. You need to consume the widest variety of antioxidants to fight off the free radicals. Try to incorporate all colorful fruits & vegetables in diet. Look for fruits that are a combination of sweet and tart like pineapple, cherries, kiwi and grapes. Eat more cooling foods like cucumber, watermelon and pears. Vitamin C-rich diet leads to fewer wrinkles. Researchers have found that skin exposed to vitamin C for long periods of time can produce up to eight times more collagen.

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Lycopene (the phytochemical making tomato red), helps boost collagen; those who eat five tablespoons of tomato paste daily showed 33 percent more protection against sunburn. Carrots have plenty of beta-carotene and vitamin A, an antioxidant which prevents overproduction of cells in the skin’s outer layer. Consumption of red and orange vegetables keeps the skin shining. Turmeric fights against cancer and it’s a good antioxidant, effective anti-inflammatory and free-radical fighting agent. Turmeric can lighten dark pigmentation blotches or scars caused by aging, hormone imbalance or sun exposure by inhibiting an enzyme in the skin that produces pigment and it is a good face mask. Papaya contains a plethora of active enzymes which pass on their healthy benefits to your skin. Coconut oil is used in many natural beauty products as it is a naturally antibacterial and antifungal and excellent moisturizer for skin. Almonds contain vitamins for skin care, mainly vitamin E. This helps repair scarred cells and defends against sun damage. For proper hydration of skin, we can use coconut, sunflower, grape seed, liquorice root, lavender, rose, and tea tree oils. You can also use soothing herbs like neem or sandalwood. Keep your liver calm reducing alcohol, soda and junk food. 2. Engage in activities that rel ieve stress: High levels of stress will compromise your skin. Exercise increases the circulation of oxygen and nutrients and releases toxins through sweat, which leads to clearer and firmer skin. Remember to smile - it’s the best exercise for your face. Consider yoga or meditation. Eliminate negative people and activities from your life. Confide in your friends and openly tal k to them about your worries and troubles. Ayurvedic oil massage helps to increase vascularity and thus help to maintain the tone of skin. 3. Cosmetic’s trap: As per reports, almost 12,000 chemicals are used in cosmetics and only about 10 percent is properly evaluated for safety. The average women in developed nations use 12 personal care products a day, containing 150-170 different chemicals. While most men use fewer products, they’re still exposed to about 80-90 such chemicals daily. These body sprays and chemicals include carcinogens, neurotoxins and reproductive toxins, which act as endocrine disruptors affecting your endocrine, reproductive, neurological and immune systems. When choosing moisturizers or makeup, research the ingredients in them to confirm that they’re safe. Use unscented baby powder to keep areas where skin meets skin—like the inner thighs, underarms, beneath large breasts to keep skin clean and dry. This is important to prevent a common skin condition called intertrigo, which occurs when

such areas remain moist, fostering the growth of bacteria or fungi. If you’re gearing up for a day in the sun, steer clear of scented lotions and perfumes. Scented products can lead to blotchy skin when exposed to the sun. Apply smooth aloe vera gel over extra-dry skin. The acids in aloe eat away dead skin cells and speed up the healing process. Cut off an end of an aloe leaf, split open and spread the gel on the dry area. Soaps are not good for skin. Most soaps are al kaline, which can change the delicate pH balance of your skin and cause itching, redness, flaking and dryness. Instead, opt for smooth, liquid cleansers and cleansing creams with natural ingredients like beeswax and mineral oil to dissolve dirt. Other moisture-replenishing ingredients include vegetable and fruit oils and less-irritating surfactants such as coconut oil. Synthetic fragrances often contain phthalates are synthetic chemicals commonly used to stabilize fragrances. These endocrine disrupters mimic hormones and can disrupt genital development. Try phthalate-free preparations. Parabens used in

Efficacy of sunscreens lasts only for 3 hrs and you have to reapply. But best sunscreens are the clothes. Just combine long gloves, sleeves for sunlight, esp. for bike riders.

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Health Tips skincare as preservatives cause hormone-disruption. Urea used in skincare is preservatives that release formaldehyde causing contact dermatitis. Dioxane, a chemical carcinogen, is created when ingredients are processed with petroleum-derived ethylene oxide. Petrochemicals, such as petrolatum, mineral oil and paraffin form a barrier when applied to the skin can arrest skin breathing and can clog pores. Ammonia compounds in skincare can form harmful nitrosamine causing allergic reactions, eye irritation and dryness of the hair and skin. Lather-forming Sulfates like sodium lauryl detergent cause eye irritation and skin rashes. Chemical sun screens such as oxybenzone and octyl methoxycinnamate disrupt endocrine activity. Antibacterial compounds, such as triclosan and chlorphenesins, cause bacterial resistance. Synthetic colors, made from coal tar containing heavy metal salts, are toxic to the skin, causing skin sensitivity and irritation. Animal studies have shown almost all of them to be carcinogenic. They will be labeled as FD&C or D&C, followed by a color and a number. Chelators, such as d isod ium EDTA and tetrasodium EDTA, used in personal care products do not readily bio-degrade in the environment. Hundreds of personal care products already contain nano-sized ingredients, and thousands more contain ingredients that are available in nano form but donâ&#x20AC;&#x2122;t include information about particle size on the labels, according to a Skin Deep analysis. Since nano-sized ingredients are absorbed differently into the body, they require separate safety studies. Manufacturers seem to be following the pattern they established with conventional chemical ingredients and this may be potentially dangerous on applicaton. 4. Limit your sun exposure: Moderate amount of daily sun produces vitamin D and is beneficial but excessive sun exposure will damage skin. Donâ&#x20AC;&#x2122;t forget to wear sunglasses and use zinc or titanium dioxide sunscreen, when you are in hot sun. 5. Grow a plant: Indoor pollution levels can be even higher than outdoor levels. A plant in your home or by your desk at work will act as an air filter. 6. Drink plenty of water: Even with a small amount of dehydration, our body functions in a less optimal way, causing it to look dull, flaky, saggy and loose. Exposure to air conditioning definitely cause dehydration, especially if temperature is lower than 25* C. Drink plenty of water to keep you hydrated. 7. Sleep: Skin rejuvenates and repairs itself mostly while we

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are asleep. Do sleep for at least eight hours a night and make sure that it is quality sleep. 8. Quit smoking: Smoking narrows the tiny blood vessels in the outermost layers of skin, which decreases blood flow, depletes oxygen and nutrients, damages collagen and elastin (the fibres that give your skin strength and elasticity) and makes skin look older and contributes to wrinkles. If you smoke, the best way to protect your skin is to quit. 9. Treat your skin gently: Daily cleansing and shaving can take a toll on your skin. Hot water and long showers or baths remove oils from your skin. Limit your bath or shower time, and use warm rather than hot water. Avoid strong soaps. Strong soaps and detergents can strip oil from your skin. Instead, choose mild cleansers. Shave carefully. To protect and lubricate your skin, apply shaving cream, lotion or gel before shaving. For the closest shave, use a clean, sharp razor. Shave in the direction the hair grows, not against it. Pat dry. After washing or bathing, gently pat or blot your skin dry with a towel so that some moisture remains on your skin. Moisturize dry skin. If your skin is dry, use a moisturizer that fits your skin type. Check the dryness of your skin by scratching a small area on your arm or leg with your fingernail. If it leaves a white mark, your skin is indeed dry and needs both moisture and exfoliation. 10. Facial Yoga Exercises: Facial exercises are plenty as per Yoga therapy. For sagging skin around cheeks, for eye puffiness etc. special exercises are available. Besides, any yoga pose for better blood circulation like Halasana, Sarvangasana or Sheershasana etc are better to give better circulatory output to vital organs. Obesity normally causes stretching of the skin. Later, when body weight is reduced, wrinkles and skin lines can be precipitated. 11. Maintaining skin health: Numerous things in the environment are harmful to your skin. Environmental pollution, ultraviolent light from sun, extreme temperatures, wind, sweating and use of wrong skin products can all damage that important outer layer. Always apply oil, creams on skin after bath, otherwise, it has reverse effect. First hydrate the skin, and after that (bath), apply oil or cream. Only on scalp, you apply oil before bath. Remember, your skin is one of the most important components in your quest for good health. Just as you take care of your body from the inside by eating well and exercising, you need to take care of your body from the outside also, by protecting your skin from the preventable damages.


Cover Story Good Laboratory Practices

Importance of Automation in

PRE-ANALYTICS Sanjaymon K.R., General Manager, AGAPPE.

In todayâ&#x20AC;&#x2122;s world, the modern laboratories are equipped with the latest analytical automated instruments to give the best result to the clients. Since most these instruments are controlled by dedicated software, it is easy for the technologist to operate the instrument and to understand the analytical errors if any. Advancement in the development of electronics, imaging, in- by dedicated software, it is easy for the technologist to operate formation technology, microfluidics and robotics are the key for the new trends in the IVD industry. The innovative products and solutions in automation are changing the way by which diagnosis is made.

the instrument and to understand the analytical errors if any. The major concern in the laboratory sector is the control of pre-analytical errors (majorly sampling errors), which accounts to 70% of the total errors that happen in the IVD laboratory.

In todayâ&#x20AC;&#x2122;s world, the modern laboratories are equipped with the latest analytical automated instruments to give the best result to the clients. Since most these instruments are controlled

Most of these errors are out of control of the laboratory and becomes one of the major concerns in assuring the quality of results.

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Cover Story Good Laboratory Practices

The most common pre-analytical errors are: Issues due to Sample Container Specific sample containers are required for specific tests. For example, sample should be collected in citrated tubes for coagulation tests like PT /APTT. Accuracy of the result depends on the sample to coagulant ratio and the concentration of the anti-coagulant used. There are instances where the PT/INR test is repeated with a freshly collected blood due to improper sampling which increases the TAT of the test and affects the customer satisfaction level. Issues related to Sample identification Sample identification is one of the major and important fac-

Specific sample containers are required for specific tests. For example, sample should be collected in citrated tubes for coagulation tests like PT /APTT.

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tor for proper testing. This is one of the major challenge for the laboratories. In many cases, improperly marked samples create chaos in the diagnostic centres especially where the number of samples is high. This is one of the major reasons for low TAT in central diagnosis centres of the high-volume hospitals where there is good volume of both inpatient and outpatient samples. In many cases, a repeat sample collection is made to ascertain the sample identity which increases the cost of testing.

The major issues in sample identification are: Short names on tube: This is one of the most common reasons for error in sample identification. In many cases, the phlebotomist fails to write the complete name on the tube. This may create identification problem in cases where there are patients having the same first name. Technicians need to check for both name and other identification numbers like PID, Hospital ID or Lab ID before performing the test. Il legible handwriting: This is another issue in sample identification where the sample is not identified properly due to illegibly written names. Low sample volume: In usual practice, the phlebotomist


collects blood and transfers them to the specific containers based on his or her individual assumptions. There are cases where the vol-ume of blood collected is insufficient, particularly in cases where multiple tests are performed from the same sample. One of the best ways to reduce such sampling error is using the barcoded samples. This will ensure that the sample is traceable and becomes easy for performing the tests.There are two ways to have the barcoded samples like: Using a barcode printer: This is one of the most common ways of labelling the sample where the sample ID and patient demographics are printed using a barcode printer and pasted on the primary tube manually. One of the limitations of this method is that the barcodes are not placed exactly on the same way and sometimes fails to read when placed in the fully automated systems due to improper sticking of the labels (angle), wrinkle in the barcodes or the damaged barcode while pasting. This process is time-consuming and requires more labour in high volume laboratories. Using automation in label ling: This is the latest trend where the sample ID with patient demographics is pasted automatically using robotics. Since the barcodes are placed on the same way with the exact angle, rejection by the fully automated system is very minimal. The process is faster than the manual method. Pre-Analytical Automation – ‘Tube Label ler’ Pre-analytical automation is one of the best way to prevent

Pre-analytical automation is one of the best ways to prevent preanalytical errors due to improper sampling. The most common preanalytical system is called as a ‘Tube Labeller’. pre-analytical errors due to improper sampling. The most common pre-analytical system is called as a ‘Tube Labeller’. These systems are robotic systems usually installed in the phlebotomy stations or in the nursing stations in which primary blood collection tubes are prefilled in the specific compartments. These automated systems are connected to the LIS or HIS interface and deliver the specific tubes (primary tubes) with barcoded sample ID and patient demographics when the patient ID is entered manually or using a barcode reader. Since the system communicates with the LIS/HIS interface, it makes sure that the proper volume of sample is collected based on the tests requested by the physicians. With the new generation automated instruments that are equipped with positive sample identification, the barcoded sample label using the pre-analytical automation will eliminate the errors and will improve the TAT. By using barcoded primary tube sampling facility in the automated instruments, laboratories can assure that the samples are traceable. This kind of automation will help to archive the samples for further testing if necessary. Since both the pre-analytical and analytical systems are connected to the LIS/HIS interface, the manual labour is considerably reduces and will increase the laboratory efficiency with decreased TAT and with better financials. It is advisable that the Central Diagnostic Laboratories especially in the hospitals should give importance to the preanalytical variables and should make sure that these variables are addressed properly using pre- analytical automation.

TECHAGAPPE

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HIGH CHOLESTEROL When there is too much cholesterol - a fat like substance - in your blood, it builds up in the walls of your arteries and increase your risk of developing heart diseases. Know your total cholesterol, your LDL (BAD) cholesterol, and your HDL (good) cholesterol, and triglycerides through Lipid Prole testing with Agappe reagents.

CHANCES OF HIGH CHOLESTEROL BY AGE...

20s 30s 40s 50s

22%

NEARLY 1 IN EVERY 2 WOMEN HAS HIGH OR BORDERLINE HIGH CHOLESTEROL.... TOTAL CHOLESTEROL NUMBERS Make an appointment today at a nearest laboratory to get it

TESTED

240 MG/DL & ABOVE HIGH 200 - 239 MG/DL BORDERLINE HIGH LESS THAN 200 MG/DL DESIRABLE

The data focuses on high cholesterol in women and explains how high cholesterol increases the risk of developing heart disease. An estimated 1 in 2 women has high or borderline high cholesterol. Here, it also lists the ranges of total cholesterol numbers for high, borderline high, and desirable cholesterol levels, and breaks down the percentage of women who have high cholesterol in their twenties, thirties, forties, and fties. Sources: National center for health statistics (2007-2010), USA.

38%

50%

62%


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·High sensitivity and linearity

·Linearity up to 700 mg/dL

·Accuracy traceable to CDC reference

·Accuracy traceable to CDC reference

“An ounce of prevention is worth a pound of cure”

Toll Free Number

1800 425 7151


Brand Reach Customer Speaks

Dr. Renjith Thomas,

Thomas Clinic, Paravur, Ernakulam

2

Very TTrustwor rustwor thy Pr oduct rustworthy Product Few months back, I have purchased Agappe Mispa Count (Hematology Analyzer) and the equipment is very compact & user-friendly. The results were accurate and I have no complaints till date. I trust Agappe & Mispa Count.

Simple to use and Pr ecise Precise I’m glad I decided to work with this equipment, Mispa Ace. It’s really great to know this product and the software is easy to manage. The QC results are very accurate and the way QC summary is shown is very clear to understand. It’s so simple. Thanks Agappe.

Mrs. Joby Saju,

Lab-in-Charge, SUT Royal Preventive Clinic, Trivandrum

4

HOD-Laboratory, Colaco Hospital, Mangalore

Agappe Diagnostics Ltd. supplied us a Fully Automated Biochemistry Analyser, model Mispa Ace. The equipment was installed, commissioned and handed over to us on 15.06.2016 and since then, the equipment has been working to our entire satisfaction.

Perfect and Pr ecise RResults esults Precise

TECHAGAPPE

Mr. Prakash Pinto,

Highly Satisfactory PPerformance erformance

We are using Mispa i3 of Agappe, a much needed analyzer for labs and hospitals focusing on result accuracy of proteins at all measuring ranges, especially the parameters like CRP & RF.

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Dr. Nayyar Khan MD, Wellcare Diagnostic Clinic, Thane

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Ms. Afsana Hakim, Lab in-Charge, Glow Vision Diagnostic Center, Pune

6

Commendable Pr oduct PPerformance erformance and Product Pr ompt Service Prompt I am using Mispa Ace, the fully automated biochemistry analyser from Agappe Diagnostics Ltd. since one year. The performance of the machine is excellent for all parameters and also the service is excellent.

Gr eat Experience and Satisfaction Great I am delighted to announce that I am using Mispa Ace since last 6 months and it was a great experience with this machine. I am very much satisfied using this machine.

Mr. Dayanandan K, Lab-in-charge, Tely Medical Centre Ltd., Thalaserry

8

5

Mr. Chiranjib Das Gupta, Lab-in-Charge, North Tripura Clinic, Rajbari.

Exemplary RResults esults and after -sales Suppor after-sales Supportt

7

I have been using Mispa Revo Immunofluorescence analyser for last two years. The equipment is quite user-friendly and compact. Iâ&#x20AC;&#x2122;m more than happy with the results, reagent stability and after-sales support Agappe has provided.

Accurate Results, Always I have been using Agappe AGA1c for the last 3 years and run AGA1c in both the semi-automated & fully- automated analyzers. The results I get are always accurate. Iâ&#x20AC;&#x2122;m also using C3, C4, Ceruloplasmin in the semi automatic. Agappe offers appreciable after-sales support also. I would delightfully recommend Agappe products to my peers in the IVD segment.

TECHAGAPPE

Dr. Akbar Lirani MD, Medipath Pathology, Raipur

JANUARY-MARCH 2018

53


Engagements Exhibitions & Conferences

AGAPPE @ MEDICA 2017, Germany.

AGAPPE @ AMBICON 2017, Mysuru.

AGAPPE @ ACBICON 2017, Lucknow.

AGAPPE @ APCON 2017, Bhopal.

MORE PLACES TO KNOW ABOUT US MEDLAB (MIDDLE EAST) 2018 - LARGEST LABORATORY EXHIBITION & CONGRESS IN THE WORLD 5th – 8th February 2018, Hall No. Z5-E30, DWTC, Zaabeel 1-6, Dubai.

AGAPPE @ GLOBAL PARTNERSHIP SUMMIT, New Delhi.

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As the largest attended laboratory expo worldwide, MEDLAB stems from 15 years of growth alongside the MENA region’s largest healthcare gathering, Arab Health. Moving into its 2nd year as a stand-alone show given its vigorous growth, this annual laboratory meeting is set to welcome over 600 exhibitors and more than 25,000 attendees from 129+ countries.


Engagements Special Days JANUARY

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SPECIAL DAYS January 10 l World Laughter Day January 12 l National Youth Day

SPECIAL DAYS February 04 l World Cancer Day February 04 l World day of social justice February 28 l National Science Day

SPECIAL DAYS March 3 l World Wild Life Day March 10 l World Glaucoma Day March 10 l World Kidney Day March 15 l World Disable Day March 20 l International Day of Happiness March 21 l World Down's Syndrome Day March 23 l World Tuberculosis Day


Promotion

New Product

Website: www.agappe.com

AGAPPE, The manufacturer of an extensive range of diagnostic reagents of highest quality & is now coming up with New Parameters…

Alkaline Phosphatase IFCC Ÿ

IFCC (International Federation of Clinical Chemistry) method – Widely Accepted method, Accuracy Guaranteed.

Ÿ

pNPP (p-Nitrolphenyl Phosphate) buffer: Providing an amazing linearity 2000 U/L & sensitivity of 6 U/L , Safe reporting.

Ÿ

AGAPPE launched

Gen 2

Ready to use liquid stable two reagents with working reagent ratio of 4:1 & High working reagent stability of 1 month – High accuracy & Convenience .

Ÿ

Excellent compatibility in both Fully automated & Semi automated systems – Convenience.

Ÿ

ALP

No interference from Bilirubin upto 40 mg/dL – Accuracy guaranteed even with high Jaundice samples.

Ÿ

D-Dimer:

D-Dimer is the most specific marker for DVT. Pack size : 10T

Ÿ

Ceruloplasmin:

Ceruloplasmin widely accepted marker for Wilson disease. Pack size : 10T

New Parameters for

MISPA-i3

Ÿ

Haptoglobin:

Haptoglobin is used to detect and evaluate hemolytic anemia. Pack size : 10T

MASTERPIECES OF INSPIRED INNOVATION


Promotion

New Product

*

Toll Free No: 1800 425 7151

AGGlucose The Gold Standard in Glucose Estimation by

HEXOKINASE METHOD . AGGlucose is coming with the highly specific Hexokinase method. The hexokinase method was developed by the American Association of Clinical Chemistry and has been accepted as the reference method for GLUCOSE DETERMINATION

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Hexokinase Method - The Gold standard method to estimate glucose, Accuracy guaranteed

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Uses Purified NAD & safer reagents, so no substrate interference – High Accuracy

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Provides 2mL Calibrator along with kit - Accuracy ensured with no extra cost

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High Linearity of 900 mg/dL – Reduce rerun of the high sample, saves time & cost

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Fast Reaction - Only 5 minutes to complete reaction, faster reporting.

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High accuracy, CV <2% - Excellent CV shows the reliability of method.

THE GOLD STANDARD IN GLUCOSE ESTIMATION


Moments

Awards

With great pleasure, we would like to inform you that, AGAPPE has participated in the CII Industrial Innovation Awards 2017 and has selected among the Top 26 Innovative Companies in India by the Grand Jury. It gives us great privilege and happiness to announce that, with all your support and hard work, the product developed in our R&D – “Mispa-i3” the cartridge based specific protein analyzer, has created another history. For the innovation of this Product, AGAPPE has been selected and awarded with “CII Industrial Innovation Awards 2017 – one of the Top 26 Innovative

Organisation”. The grand Jury was consisting of 12 well-known personnel and was headed by Shri. S. Gopalakrishnan, Cofounder, Infosys. The function was held in a grand way and was attended by industry giants viz. TATA, L&T, Siemens, Godrej and may others. It is really a proud moment for us that our Company is creating landmarks in the history of diagnostic industry and bringing the brand AGAPPE to the heights of the IVD Segment. We, AGAPPE Management value your continued support and contributions in our journey towards success…

Emerging Entrepreneur of the Year 2016 Mr. Thomas John, Managing Director, AGAPPE has been awarded with the “Emerging Entrepreneur of the Year 2016 Award” by Dhanam Business Magazine during the “Dhanam Business Summit & Award Nite 2017” held at LeMeridien, Kochi on 28th July 2017.

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Medical Quiz 1.

Al binism is mainly observed by the defect of …………enzyme a. Lipase b. Tyrosinase c. Gyrase d. Hexokinase

2.

The major active ingredient in Calamine is………… a. Copper Oxide b. Aluminium Oxide c. Zinc Oxide d. Nickel Oxide

3.

Ceruminous glands are mod ified ………glands a. Eccrine b. Endocrine c. Apocrine d. Paracrine

4.

Mycobacterium leprae was discovered by……… a. Gerhard A. Hansen b. Alexander Fleming c. Robert Koch d. Leeuwenhoek

5.

The antigen presenting skin cel ls are ………… a. Melanocytes b. Keratinocytes c. Merkel Cells

6.

Major protein present in hair is ……………… a. Melanin b. Keratin c. Casein d. Chitin

7.

Common Warts are caused by ………… a. HPV b. HCV c. HBV d. HIV

8.

Vitamin D3 is primarily synthesized in …………… a. Hypodermis b. Apocrines c. Keratinocytes

9.

Dermatology

Quiz

d. Langerhans Cells

d. Meissner’s corpuscles

The oldest skeletal evidence with leprosy was found in ………… a. India b. Egypt c. China d. Australia

10. Lunula is ……………. a. a skin disease b. a part of hair

Winners will get their prize by post

c. a part of nail

d. a part of tooth

Quiz Answers of October-November Edition 1-D, 2-D, 3-A, 4-D, 5-A, 6-C, 7-C, 8-D, 9-B, 10-C Quiz Winners of October-November Edition N. Girish Kumar, Adoor | Dolly Kuruvilla, Trivandrum | Dr. Jude Winston VAZ, Bombay | A. Ragarendra Kint, Udupi | Prasanth A. S, Trivandrum | Dr. Biswajit Batabyal, Kol katta | Dr. Suvarnalatha Devi, Chakka | Dr. Nilesh Kapadia, Rajkot | Dr. Thilaga, Tirunelveli

Answers of this quiz contest wil l be published in the next ed ition along with details of the winner and the prize. Participants can either hand over the answers to Agappe’s staff or send in their responses directly to TechAgappe at 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 2018

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Editorial Submissions What do you think of this edition of

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

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

Postal address:

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

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

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Life Stories Good Laboratory Practices

Health Tips Interviews


FIB

PT PT

APTT

APTT FIB

Smart Hemostasis Analyser Ÿ

Smart Card Calibration.

Ÿ

User friendly, easy to operate software.

Ÿ

Control & sample mode are available.

Ÿ

Display of number of test done, remaining tests & stability of the reagent.

Ÿ

Low CPT - Minimum volume required for any test is 200 µL only.

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

REGISTERED OFFICE Office No : 401 & 402, 4th Floor, Jaisingh Business Centre, 119, Sahar Road, Parsiwada, Andheri (East), Mumbai - 400099, India. Tel : 022-4300 8000, Fax no: 022 - 4300 8050 | mumbaioffice@agappe.in

* Toll Free No: 1800 425 7151 GLOBAL ACCESS POINT AGAPPE DIAGNOSTICS SWITZERLAND GmbH, Knonauerstrasse 54 - 6330, Cham - Switzerland Tel: +41 41 780 60 10 | Fax: +41 41 780 60 11, info@agappeswiss.com


RNI No.: KERENG/2015/62113

www.agappe.com Toll Free

1800 425 7151

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

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

Techagappe 14th edition (January - March 2018) E-book  
Techagappe 14th edition (January - March 2018) E-book  

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

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