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Vol.3 Issue 2



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





COPD: AN OVERVIEW Dr. V. Kesavan Nair


RESPIRATORY SYSTEM Diagnosis of lung disorders and related therapeutic pulmonary procedures



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Volume 3 | Issue 2 | January-March 2017 ○

Smoking Kills

12-15 A Synopsis of Tests for Lung Disorders...


16-19 He’ll even bring her the moon to make her live...

Why AGAPPE is different?

24-25 Evolution of Lipid Profile & its Recent Trends... 26-29

Tuberculosis: Todays Indian Scenario


Metamorphosis of a Champion from a Malady

44-46 Healthy Lungs gift a Breathful Life... 47-49 Understanding the Urine Chemistries


50-53 Testimonials

A True Born Fighter


Exhibitions & Conferences


Engagemments - Special Days


34-36 We Persue the Art of Diagnostics... Interview 40-42 Chronic Obstructive Pulmonary Disease (COPD)

The harder you work, the luckier you become Dr. K.M. Cherian

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




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From the Editor’s Desk


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Insights into respiratory system disorders... I am very pleased to place in your hands, this 10

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

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Then the readers are invited to three live stories. One is the saga of a woman from Chennai who underwent Lungsand-Heart Transplant in 2014 at Apollo Hospital, Chennai. The second one is regarding a woman from Gurgaon, who is a survivor of Lung Cancer and presently engaged in social activity. The third story is from Mumbai, on a patient cured of tuberculosis, who is now a spokesperson for the causes of tuberculosis patients.

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

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

We have also included two interviews. One is with Dr. K. M. Cherian, Chennai, the doyen on cardiac surgery. The second one is from a famous IVD specialist.

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


CHAIRMAN Prof. M.Y. Yohannan




In this issue, the leading article highlights the quality certifications, a very important aspect for consideration for clinical laboratories.This issue focuses on lung diseases, where you can find three scientific articles. The first one is an overview of tests for lung disorders in general. The second article is on Chronic Obstructive Pulmonary Disease (COPD), by a leading pulmonologist. The third item is penned by another leading chest physician on the present scenario of Tuberculosis in India.

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



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


CHIEF EDITOR Dr. D.M.Vasudevan

EDITOR Meena Thomas


Volume 3 | Issue 2 | January-March 2017 ○

Dr. D.M. Vasudevan




Inspiring Success Stories

Overall, the magazine is very informative. Success stories of people are something unique and inspiring. I would like to have monthly issues even if it comes with lesser number of articles. People would real ly enjoy reading it. Keep going with same spirit and provide us excellent topics like this in future. Dr. Go Bharani, Mother’s Care Diabetes Centre, Vellore

Looking Forwar Forwardd for Futur Futuree Editions The Techagappe magazine is a

most interesting journal for diagnosticians. The thematic issue of recent months dedicated to such varied subjects as Oncol-

ogy, Gastroenterology, Neurology, Hepatology and Gynecology were compact and comprehensive and expertly put together. Well Done!!!...I look forward to pursuing future great editions. Dr. Jude Winston Vaz, Holy Family Hospital, Bandra, Mumbai.

Helpful quiz series

Techagappe magazine is very

useful especially, the quiz competition. The multiple choice questions helped me find out the right answer as well as analyze the other three choices. This is very useful. We have received your gift for winning the last edition Techagappe quiz completion, thank you and waiting for the next edition. Mr. A. Xaviour, Vellore.

Great Stories/Articles Focusing on PPositivity ositivity

Wonderful initiative to start an upbeat journal which focuses on positivity in all aspects! The poem in the beginning gives the theme for the edition. It is very uplifting to see people overcome their worst diseases/ fears by focusing on the inner strength and positivity. The best article in the present (October- December) edition is “Pursuing the True Purpose of Life”. Dr. Apurva Arora, Consultant Pathologist, Guru Nanak Dev Super Specialty Hospital, TaranTaran




An Awesome Reading Guide When I saw Techagappe magazine on my table, I have kept it out by thinking that it is one of the usual advertisement magazine. Today, I was a little free, I thought of glancing at it. I looked first at its contents, then my curiosity had increased. Although, I am a senior surgeon, I always wanted to know about the recent management of blood disease like Hemophilia, Thalassemia, Aplastic Anemia, Leukemia, etc…The latest one is that of stem cell bank. During the last few years, I have sent four patients to Chennai bank. At one stretch, I finished the magazine fully. It was awesome. I have experienced it as great reading friend. I hope to receive it regularly. Congratulations, team Techagappe. Dr. Shreeshail M Byadgi, Sukshema Hospital, Davangere.

A wonder lamp of information I am receiving copy of Tech Agappe since 1 year. I sincerely thank you for the quality information provided by your journal on Diagnostics. I request you to send me soft copies of 2 articles of October - December 2016 issue. 1. Platelets from blood by Mr P. K. Sreekumar 2. Umbilical cord blood stem cells

This will help me to pass on the information to my colleagues. If you can send me the e-copy of magazine regularly, it wil l real ly help to d issipate knowledge. I would also like to know on different bedside card tests available for hospital staff to quickly diagnose d isease. Also, some more light on dry chemistry machines. If possible, please send some articles on digestive enzymes role, it’s disorders especially with aging and how to diagnose? Dr. Jagdip Shah, Mumbai.

Cover Story

Poem for Healthy Lungs

Smoking Kills…

You wake up in the morning coughing and choking. As a direct result of cigarette smoking. You often sat around and ignorantly pretended. You were unaware of all the people you offended. You got into the habit and would often reach out To shove another cigarette into your mouth.

The surgeon general often said, there's only answer. That if you continue to smoke, you're going to get cancer. You often thought this was a very big joke. And now you've become addicted to cigarette smoke. Every night you go to bed, your eyes are blood red. And a cig is the first choice when you crawl out of bed. When you try to give up smoking, you constantly fail. Because of your craving for another white coffin nail. Your cough will get croupy, it'll sound like a hack.

But you'll keep buying cigarettes pack after pack. With your craving for these fags that you continually crave. Your one and only destiny is a very early grave. Try to give up these fags you knows it’s too late. Because you've already made and signed a contract with fate. How many times did you really try to quit. Only to find another cigarette in your mouth, waiting to be lit. The people who grow tobacco, they're not your friend. They're preparing your life for a very untimely end. And the people who manufacture this deadly weed. Are only in business for the money, profit and greed. The young and the innocent and the very weak. These are the victims these manufactures seek So do you know where it leads you to my smart ass friend. It’s leading you to a very early and untimely end.




Agappe MD’s Desk

Why AGAPPE is different? Journeying through a peerless avenue... Thomas John, Managing Director, Agappe Diagnostics Ltd.


he Indian healthcare sector is growing at a faster pace with the increase of the lifestyle diseases and population in the country. Diabetes, cardiac, hepatic and gastric diseases are widespread in the country in the last two decades. Similarly, IVD sector have also seen dramatic changes with the increase in the number of automated instruments and specific tests. India, with the competitive advantage of large pool of well-trained professionals and highly competitive cost, is becoming the hub for medical tourism. Thomas John during the TiE Kerala award ceremony 2016.

In the current scenario, laboratory diagnosis plays a vital role and rather than competitive pricing, the doctors and patients are looking for quality results, which are comparable to international standards. One of the major challenges in the IVD sector is the standardisation of the instruments and reagents used, and primarily, it becomes the responsibility of the manufacturer to meet with the requirements. Manufacturers standardise the materials and machines to the guidelines which are traceable to national or international level to assure the quality of the results. Agappe has well understood the need of quality processes and to deliver the quality products having traceability with national or international standards, it participated in external assessments by world renowned organizations.

NGSP certification A decade ago, the most common test used for diabetes was the Serum Glucose along with Urine glucose and Micro al bumin. HbA1c was considered as a special test and was performed in very few laboratories. Because of the non-standardised methods used in the estimation, the chances of error were very high. In India, there were multiple methods present for estimation of HbA1c from Column Chromatography to Ion exchange resin methods. These methods have shown very low correlation in between giving inconclusive results. This was because of the improper standardisation of the technique used.




UL Certification for ISO 9001:2008 When Indian healthcare opened the windows to the outside world, HbA1c correlation became one of the major issues in the diabetic diagnosis, especially for the clients from Asian continent. In 1996, a programme called as NGSP (National Glycohaemoglobin Standardisation Programme) has begun in US to standardise the HbA1c and it became the reference method. NGSP listing has become mandatory in many countries for HbA1c estimation. HbA1c reagent and instrument manufacturers became part of this programme to standardise their methods through NGSP. Once the method is validated and listed by NGSP, the product gets privileged in the market. Agappe is always bound to bring innovation with quality and has become the only Indian manufacturer who is listed with NGSP for its “Mispa-i” series of instruments and reagents. This shows our commitment to the diabetic society, which is one of the fastest growing segments in India. Agappe holds a major share in the HbA1c market in India excluding the HPLC methods. We are proud that Agappe HbA1c is widely accepted in over 55

UL Certification for EN ISO 13485:2012 countries across globe with the NGSP listing. With the listing in NGSP and excellent quality of results, Agappe was successful in obtaining more than eight awards in the industry for the innovation viz. Mispa-i series instruments and in HbA1c estimation. Mispa-i is a series of instruments which perform Specific Protein Analysis and we refer it as the “intelligent breed” because of the technology used in the system called Unique Channel Shifting (UCS). This technology enables the analyser to choose between Nephelometry and Turbidimetry automatically and deliver the best results. Recently, Agappe has developed a cartridge-based Specific Protein system viz. Mispai3, using the UCS technology, which is setting new dynamics in Protein testing.

Quality Policy We are committed to be the best partner in diagnostics in IVD field by providing innovative and highest quality products & services for customer satisfaction.


IFCC membership The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is a worldwide, non-political organization for clinical chemistry and laboratory medicine. Most of the current enzymebased assays are standard ised to the IFCC reference



Agappe MD’s Desk methods and as an organization, IFCC play an important role in the standardisation of the clinical laboratory practise world-wide to assure quality results to the patient. IFCC membership is considered as one of the most prestigious memberships in the industry Agappe is proud to be the only company from India to become the corporate member in the IFCC since 2012. This shows our commitment to quality products and quality service to the patient. We regularly participate in the programmes conducted by the IFCC to make sure that we are always updated with the latest trends in the industry.

UL listed Established in 1894, Underwriters Laboratories (UL) is

ing CE marking for all our products.

DSIR approved R&D centre For any growing company, R&D department plays a significant role. It’s the vision of the R&D team that gives birth to innovative and economic products for the betterment of mankind. The Department of Scientific and Industrial Research (DSIR) is a part of the Ministry of Science and Technology which came to existence since 1985. The Department of Scientific and Industrial Research (DSIR) has a mandate to carry out the activities relating to indigenous technology promotion, development, utilization and transfer. We are proud that our R&D facility is one of the best in the Industry which is approved by DSIR, which itself shows the quality of work we have in our center.

ISO 9001 For any growing organization in the service sector, it is important to have the best practises to satisfy the customer demand and ISO 9001 is one of the best quality systems which ensures this. ISO 9001:2008 facilitates the organization to become a customer-focused organization, ensures customer satisfaction and increases the effectiveness and efficiency of the organization though continual improvement. As a customer-centric organization, we are following the ISO: 9001 guidelines since 2006 and the effectiveness is evident with more than 15,000 satisfied loyal customers of Agappe.


NGSP Certification for Mispa i3 one of the pioneers in safety consulting and certification. Headquartered in Illinois, USA, UL has offices in 46 countries worldwide. UL is one of the few companies approved to perform safety testing by the US federal agency and maintains stringent audit methods and standards in the industry. UL listing is a prestigious accreditation and very few manufacturers in the IVD segment are UL listed. We, at Agappe, believe that quality systems are the key for quality products. With this vision in mind, we have made the largest IVD reagent manufacturing facility in India. To assure that our systems are at par with the international standards, Agappe has taken Underwriters Laboratories (UL) as our assessment partner for the quality system. We are proud to say that we have ISO 13485 as per the UL standards. Agappe has succeeded in avail-




For any manufacturing organization in the IVD sector, it is important to have the best practises in place so that the products are quality assured and GLP (Good Laboratory Practice) & GMP (Good Manufacturing Practice) have utmost importance. GLP was published in the early 1980 by US FDA which is adopted worldwide to standardise the clinical laboratory practises. Under GLP, a distinct QA department with SOP and Control materials becomes essential, which is the backbone of quality assurance. Similarly, in manufacturing, GMP guidelines were followed to make sure that the products are consistently produced and controlled as per quality standards. Agappe is cGLP and cGMP ap-

proved which make sure that all our products are made as per the available standards in the industry. Nevertheless, to say that compared to the similar manufacturers in the Indian Industry, Agappe is one among those pioneers having the best quality systems in place. We, at Agappe, are dedicated to assure the quality and all our audits and certifications are in line with this philosophy.

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Cover Story Lung Disorders- An Overview

A Synopsis of Tests for


Dr. D. M. Vasudevan,

MBBS, MD, (Biochem), FRCPath Technical Director, Agappe Diagnostics Ltd.

Lung disorders are fairly common. The most common lung diseases include Asthma, COPD (Chronic Obstructive Pulmonary Disease), Lung cancer, Lung infection (pneumonia), Collapse of part or the entire lung (pneumothorax or atelectasis), Inflammation in the main passages that carry air to the lungs (bronchitis) etc. During the physical examination, assessing skin color is important because paleness (pallor) may indicate anemia or poor blood flow and a bluish discoloration (cyanosis) may indicate an inadequate amount of oxygen in the blood. Chronic lung diseases may lead to clubbing of finger tips. Using a stethoscope, airflow obstruction could be detected. By tapping (percussing) the chest, a doctor can often determine if the lungs are filled with air or it contains fluid.The tests for lung diseases may be grouped as tests done by the physician in the surgical settings and as tests done in the laboratory. These tests are described below.

Tests done by the physician in the surgical settings Bronchoscopy It is a direct visual examination of the voice box (larynx) and airways through a flexible




viewing tube (bronchoscope). The instrument has a camera at the end that allows a doctor to look down through the larger airways (bronchi).The throat and nasal passage are sprayed with an anesthetic and the bronchoscope is passed through a nostril or mouth and into the airways of the lungs.During examination, specimens can be taken from any suspicious areas that look cancerous. Bronchoscope can also be used to remove secretions, blood, pus and foreign bodies. Bronchoalveolar lavage is a procedure doctors can use to collect specimens from the smaller airways and alveoli that cannot be seen through the bronchoscope. After placing the bronchoscope into a small airway, a doctor instills saline through the instrument. The fluid is then suctioned back into the bronchoscope, bringing cells and any bacteria with it. Examination of the material under the microscope helps in diagnosing infections and cancers. Transbronchial lung biopsy involves obtaining a specimen of lung tissue by using forceps passed through a bronchoscope. Transbronchial need le aspiration is the procedure, when a needle is passed through the bronchoscope into the bronchial wall. The needle may be passed through the wall of a large airway under direct visualization or through the wall of a small airway using an x-ray machine for visualization. A doctor may be able to extract cells from suspicious lymph nodes to examine under a microscope.

Needle Biopsy of the Pleura or Lung Pleura is the covering of lung tissue. In the pleural biopsy, using a larger cutting needle, a doctor takes a small sample of tissue from the pleura and sends it to a laboratory for diagnosis of cancer or tuberculosis. About 80 to 90% of the time, a pleural biopsy is accurate in diagnosing tuberculosis, but it is less accurate for diagnosing cancer.

Thoracotomy It is an operation in which the chest wall is opened to view the internal chest organs, to obtain samples of tissue for laboratory examination, and to treat disorders of the lungs or heart. The sample site can be seen and selected because large tissue samples can be taken. Thoracotomy is also often used when cancerous tissue is to be removed from the lung. If necessary, a lung segment, a lung lobe, or one side of the lung can be removed.

Laboratory Tests Arterial Blood Gas (ABG) Analysis

To take a lung tissue, after anesthetizing the skin, a doctor, often using chest ultrasonography for guidance, directs a biopsy needle into the suspected tumor and obtains cells or a small piece of tissue to be sent to the laboratory for analysis.

This measures the levels of oxygen and carbon dioxide in the arterial blood and determines the acidity (pH) of the blood. These are important indicators of lung function because they reflect how well the lungs are getting oxygen into the blood and getting carbon dioxide out of it.


Pulse Oximetry

This is done to remove pleural effusion (fluid collected abnormally in the pleural space). The two principal reasons to do thoracentesis are to obtain a fluid sample for diagnostic testing or to relieve shortness of breath caused by fluid compressing lung tissue. The doctor inserts a needle between two ribs into the chest cavity, but not into the lung, and withdraws some fluid into a syringe. The collected fluid is analyzed to assess its chemical makeup and to determine whether bacteria or cancerous cells are present.

Oxygenation of the blood can be monitored without taking a blood sample by using a sensor placed on a finger or an earlobe. Doctors may do pulse oximetry as the person walks around or climbs a flight of stairs to see if exertion causes oxygen levels in the blood to decrease.

Exercise Testing This is done to evaluate people with a possible lung disor-




Cover Story Lung Disorders- An Overview der. The two most common forms of exercise testing are the 6-minute walk test and full cardiopulmonary exercise testing.

phy (CT) magnetic resonan ce imaging, nu clear scanning, ultrasonography and positron emission tomography (PET) scanning.

Six-minute walk test

Chest x-rays

This simple test measures the maximal distance that people can walk in 6 minutes on a flat surface. The test assesses the person’s overall function but the test does not tell which organ is the limiting factor (heart, lungs, muscles or bones). This test is used before and after lung surgery, to monitor response to treatments.

Cardiopulmonary exercise testing This test analyzes heart function and provides information, such as how much air flows through the lungs, how much carbon dioxide is being produced and how well the lungs are getting oxygen into the blood and removing carbon dioxide from it. The test is done while the person is at rest and then the test is repeated while exercising on a treadmill. The intensity of the exercise is increased gradually until symptoms prevent further exercise.

Chest Imaging Chest imaging studies include x-rays, compu ted tomogra-

This routinely taken from the back to front. Often a view from the side is also taken. Chest x-rays provide a good outline of the heart and major blood vessels and usually can reveal a serious disorder in the lungs, the adjacent spaces or the chest wall, including the ribs. For example, chest x-rays can show most pneumonias, lung tumors, chronic obstructive pulmonary disease, a collapsed lung (atelectasis) and air (pneumothorax) or fluid (pleural effusion) in the pleural space.

Computed tomography (CT) It provides several views in different planes od chest, such as longitudinal and cross-sectional views. High-resolution CT may reveal more detail about lung disorders.

CT angiography It uses radiopaque dye injected in a vein to produce images of blood vessels, including the artery that carries blood from the heart to the lungs (pulmonary artery). CT angiography is also done to diagnose blood clots in the pulmonary artery (pulmonary embolism).

Magnetic Resonance Imaging (MRI) It also produces highly detailed pictures that are especially

useful to see blood vessels. MRI does not use harmful radiation.

Ultrasonography It creates a picture from the reflection of sound waves in the body. Ultrasonography is often used to detect fluid in the pleural space (the space between the two layers of pleura covering the lung and inner chest wall).

Pulmonary artery angiography This is done by injecting a radiopaque dye directly into the pulmonary artery through a long, thin plastic tube (catheter) passed through a vein, into the heart and then into the pul-




monary artery. Angiography is the most accurate test for diagnosing or excluding pulmonary embolism

Pulmonary Function Tests (PFT) They measure the lungs' capacity to hold air, to move air in and out and to exchange oxygen and carbon dioxide.

Spirometer It consists of a mouthpiece and tubing connected to a recording device. The person’s lips should be held tightly around the mouthpiece, and nose clips should be worn to ensure that all the air inhaled or exhaled goes through the mouth. A person inhales deeply, then exhales forceful ly as quickly as possible through the tubing while measurements are taken. The volume of air inhaled and exhaled and the length of time each breath takes are recorded and analyzed.

Lung volume measurements It reflects the stiffness or elasticity of the lungs and rib cage as well as the strength of respiratory muscles. The lungs are abnor-


C-REACTIVE PROTEIN Precise detection of infections and inflammations through the technical superiority of Latex Enhanced Immunoturbidimetry, that eliminates prozone effect, provided with a linearity of 200mg/dL and sensitive to 1mg/dL, with calibrators free of cost.

mally stiff in disorders such as pulmonary fibrosis. Various neuromuscular disorders such as myasthenia gravis can cause weakness of the diaphragm and other respiratory muscles. Abnormally small lung volumes can result from pulmonary fibrosis and disorders affecting the nerves and muscles that control breathing. The measurements are abnormal in chronic obstructive pulmonary disease and asthma.

Flow volume testing Most spirometers can continuously display lung volumes and flow rates during a forced breathing maneuver. These flow rates can be particularly helpful in detecting abnormalities that partially block the voice box (larynx) and windpipe (trachea).

Maximal voluntary ventilation (MVV) It measures a person's maximum ability to breathe. This test is done in the sitting position. A person is instructed to breathe as rapidly and deeply as possible through a spirometer for 30 seconds. The volume of air moved over that period of time is measured. Further, heart disorders may also cause shortness of breath; similarly lung disorders can affect the heart. Therefore electrocardiography (ECG) and echocardiograph also are usually included in the diagnostic tests.




Life Story Kusum Malik Tomar

He’ll even bring her the moon to make her live‌ Cancer is a dreadful disease which affects not just the patient but takes down the whole family with it to the abysmal depths of darkness and void. Some unlucky few succumb to it and a lucky few, fight with it and succeed to move on. Kusum from Gurgaon is a living example of this fact and the gladiator in this fight against her disease is her husband, Vivek. Cancer is a dreadful disease which affects

not just the patient but takes down the whole family with it to the abysmal depths of darkness and void. Some unlucky few succumb to it and a lucky few, fight with it and succeed to move on. Kusum from Gurgaon is a living example of this fact and thegladiator in this fight against her disease is her husband, Vivek.

Kusum Malik Tomar




Kusum, a non-smoker, at the age of 29, was diagnosed with stage IV lung cancer metastatic to brain. In 2014, her disease got resistant to all available applicable medicines in India (though they were available in western countries via approval or clinical trials). She almost lost her life to this wretched disease due to unavailability of any medicine. To get any cancer medicine approved in India, it should go for clinical trials, whether it is already approved in other countries or not. In India,

there are only 1.4% of global trails going on, which leads to almost no access of the latest medicines/ treatment options for Indian citizens. Fortunately, after 3 months of battle of survival, Kusum came across a new clinical trial in India and decided to participate. The story of Kusum’s fight starts around 5 years back. Kusum hails from Gurgaon, close to Delhi and was having a peaceful life with her loving family consisting of Vivek, her husband, and their son. One day, while on a shopping spree, Kusum felt a weird twitching in her face.As she was a migraine patient, they thought of consulting a neurologist who in turn suggested an MRI scan. The results came up showcasing six nodulesat the right side of her brain. Vivek and Kusum were shattered literally. A pharmacist by qualification and a Kusum Malik Tomar pharmaceutical regulatory professional, and Vivek Tomar with Vivek from Shamli, UP, met Kusum from a their son. small town Rohtak, Haryana, during her stint as a researcher at a pharmaceutical company in Ahmedabad, Gujurat. They were married in 2007 and blessed with a baby boy in 2009. Hailing from a middle class family, he left his family as he was posted in Hyderabadby lung cancer-metastatic to brain at stage IV, Vivek and Kusum his firm. After 4 years, he had just been reunited with his family shared the details of the disease with their parents. and life had been running smooth until this life-shattering incident Doctors advised Kusum to have brain radiation. She unhappened. derwent whole brain radiation followed by 3 cycles of chemoTreatments followed suit. After 5 months, they took another MRI and to their utter dismay, found out that those six nodules have increased to an alarming ten. To correct their wrong diagnosis, Kusum was directed to an oncologist without delay. Till then, Vivek and Kusum hadn’t revealed anything about her disease to their parents. In September 2012, after the biopsy which confirmed

“We went for innovative products instead of generic medicine because we wanted to try our best and leave no stone unturned. We chose Alimta along with Cisplatin, a harsh but powerful drug against lung cancer. She stood very strong during the treatment,” says Vivek who was the staunch pillar of support for Kusum.

therapy. “We went for innovative products instead of generic medicine because we wanted to try our best and leave no stone unturned. We chose Alimta along with Cisplatin, a harsh but powerful drug against lung cancer. She stood very strong during the treatment,” says Vivek who was the staunch pillar of support for Kusum. But after a few days, she started having complaints of shoulder pain and this was worrisome. After a 2D Echo Test, she was directly taken to operation theatre as her condition had become critical. She had a severe level of pericardial fluid accumulated in the pericardial cavities which might block the blood pumping to her heart at any time. By then, Kusum had become unconscious and while in the ICU, doctors removed around 1.925 L of cancerous fluid in two days from around the heart and lungs. The fluid was tested and they confirmed that the medicine had no effect on the disease.

Further testing suggested that Kusum has a rare type of cancer mutation that is ALK mutation of NSCLC. From the doctors, Vivek and Kusum came to know about a medicine from Pfizer called Crizotinib, which recently got approved as molecular therapy for ALK mutation. “We decided to give it a




Life Story Kusum Malik Tomar try. We brought the medicine from Germany. During that time, clinical trials were not mandatory for medicines like that. From December 2012 to September 2014, the period we used that medicine,with a good quality of life. There were some side effects but mostly negligible,” Kusum recollects. In Sept 2014, they came to know that the new medicine also failed. It has begun to grow resistance. “But it was quite normal with Stage IV disease. At some point of time, the disease grows resistance against the medicine. We needed a better medicine. We begun the search and found that a next level drug from Novartis named Zykadia (Ceritinib)approved and available in US,” adds Vivek. By then, laws had been changed after the Supreme Court directed the health ministry to bring clear guidelines for clinical trials. Some NGO had submitted a Public Interest Litigation (PIL) on the number of deaths occurred during clinical trials. The government had made it mandatory to have clinical trials for new medicines and the laws were so difficult that only a few medical companies, doctors and research institutions went on for clinical trials in India. For months Vivek did everything to contact and get latest medicine for Kusum for whom there was lack of time. “My routine work those days was to take laptop to the hospital and to contact and pursue number of doctors, hospitals and medical companies for clinical trials of new medicines in India but nothing worked out,” Vivek looks back at those difficult moments. In November 2014, Del hi hosted the SAARC Countries On-

cology meet. Vivek came to know about it. He and Kusum attended the meet and during the question-answer session, Kusum got a chance to share her heart-wrenching plight. She was almost on the verge of tears as she concluded asking what her fault was for not allowing to get the needed medicine to sustain her life. For a moment, pin drop silence prevailed at the venue. But Kusum’s voice reached to right stakeholders.When one door closes, another surely opens. The couple found another solution to their problem. Novartis Company representatives who were present for the conference took the topic and the company pushed their medicine for clinical trials in India for Kusum. Finally in December, the clinical trial was approved. Rajeev Gand hi Cancer Institute and Research Centre, New Del hi was the only hospital approved for clinical trial. Since the calcium level of Kusum was not matching as per the protocol of trial, two times they had to return. Finally on January1st, 2015, she became the first patient of clinical trial for this medicine. She was just going to lose her life before that clinical trial saved her life. Since two years, Kusum is part of this clinical trial. And it is because of Kusum and other patients participated in clinical trial, Ceritinib is now approved in India and available at a very economical rate compared to western countries. However; now Kusum is again in requirement of next level medicine as the current drug started to get resistance in the brain. There are around 18 next level treatment options available either as approved or via clinical trials for ALK +ve patients in other countries but in India, there is nothing. Meanwhile Kusum’s condition grew more difficult as four

What are Clinical Trials? Clinical trials are experiments done

in clinical research. Such prospective biomedical or behavioral research studies on human participants are designed to answer specific questions about biomedical or behavioral interventions, including new treatments (such as novel vaccines, drugs, dietary choices, dietary supplements, and medical devices) and known interventions that warrant further study and comparison. Clinical trials generate data on safety and efficacy. They are conducted only after they have received health authority/ethics committee approval in the country where approval of the therapy is sought. These authorities are responsible for vetting the risk/benefit ratio of the trial - their approval does not mean




that the therapy is 'safe' or effective, only that the trial may be conducted. Depending on product type and development stage, investigators initially enroll volunteers and/or patients into small pilot studies, and subsequently conduct progressively larger scale comparative studies. Clinical trials can vary in size and cost, and they can involve a single research center or multiple centers, in one country or in multiple countries. Clinical study design aims to ensure the scientific validity and reproducibility of the results. Trials can be quite costly, depending on a number of factors. The sponsor may be a governmental organization or a pharmaceutical, biotechnology or medical device company. Certain functions necessary to the trial, such as monitoring and lab work, may be managed by

months ago, she began to develop seizures.

Clinical trials in India Kusum’s condition made Vivek an activist now. After experiencing how clinical trial proved vital in her life and the struggle associated to get access to latest medicines and clinical trial, Kusum and Vivek have started to work actively with patients, NGOs, industry organizations, regulators at FDA/ government and doctors on clinical trial awareness and raising support to change the current clinical trial situation in India so that no Indian patient should die due to unavailability of medicine that is available somewhere in world. “

Kusum Malik Tomar and Vivek Tomar with their son. (File Picture)

“Clinical trials is the only way to get the latest, better and safest medicine. Not only western countries but many Asian countries like Malaysia, South Korea and Singapore are 10 years ahead of us in clinical trials. Actually, why do we need clinical trials for drugs that are approved by other countries? We should try to avoid the delay,” Vivek points out.

an outsourced partner, such as a contract research organization or a central laboratory. Only 10 percent of all drugs started in human clinical trials become an approved drug. Clinical trials are one of the final stages of a long and careful research process. The process often begins in a laboratory (lab), where scientists first develop and test new ideas. If an approach seems promising, the next step may involve animal testing. This shows how the approach affects a living body and whether it's harmful. However, an approach that works well in the lab or animals doesn't always work well in people. Thus, research in humans is needed. For safety purposes, clinical trials start with small groups of patients to find out whether a new approach causes any harm. In later phases of clinical trials, researchers learn more about the new approach's risks and benefits. A clinical trial may find that a new strategy, treatment, or device. All of these results are important because they advance medical knowledge and help improve patient care.

He puts up his case with Oncology.” In India every treatment starts with Chemo therapy for Oncology. The third state is mostly radiation. But molecular therapy is not used as first line treatment. But in many countries, especially western countries,treatment start with molecular therapy. The new method they are working now is molecular therapy and immunotherapy combination. You know the side effects of chemo therapy- irrespective of good or bad cells, it destroys everything. In molecular therapy, only bad cells are destroyed and immunotherapy, they help the good cells to destroy the bad cells,” Vivek makes his point with the thorough knowledge in this realm. He invites the attention to a case of a patient at Chennai whom he met during his search for clinical trials in India. Unfortunately, the patient died last week because all approved medicines in India failed. “He was just 29 years old. In his case, there was a medicine already approved in US, Canada and Japan. It was available by approval / trial in Singapore, Thailand, Taiwan and whole Europe, but not in India. We believe that every Indian’s life is important,” comments the activist inside Vivek. Vivek and Kusum today are strong advocates of approving clinical trials in India. He actively takes part in discussions in social media and works with several NGOs in promoting clinical trials. For him, you should never give up hope. “Fight is the best hope. I will not leave any stone unturned for my love, my wife. I will try every possible extend to save her from the clutches of this wicked disease,” Vivek is brimming with confidence and optimism.




Interview Dr. K.M.Cherian

The harder the luckier Agappe: Could you please share some of your memorable academic and child hood achievements with us?

Dr. K. M. Cherian, Founder and Managing Director of Frontier Lifeline & Dr. K. M. Cherian Heart Foundation, Chennai is well renowned for performing country’s first successful lung transplantation in India during 1999 at Madras Medical Mission, Chennai. Pioneering pediatric cardiac surgery in India, this leading cardiac surgeon has held prestigious positions in India and abroad and is also credited for the first heart transplant in India after the legislation of Brain Death, the first bilateral lung transplant, the first Pediatric Heart transplant, the first Auto transplant and the first Heart and Lung transplant. Nation honoured him with Padma Shree, the fourth highest civilian order in 1991 for the contributions he had made in the medical realm. He finds some time to chat with TechAgappe readers.




Dr. K. M. Cherian: I was born at Kayamkulam, Kerala at my mother’s home. There is an interesting childhood memory as told by my mother and grandmother about my birth. When she was pregnant, my father was working at Kannan Devan Tea Estate, Munnar and she was residing with him there. Remember, it was almost 74 years back and at that time, Munnar wasn’t as developed as now. The tribal people used to come to the market,close to our place, during weekends to sell their goods and to buy essential items especially tobacco for them. On one such occasion, the tribal leader saw my mother vomiting as she was almost four months pregnant. The tribal leader enquired whether my mother was pregnant and when he came to know that she was, he made a prediction. He said that she would deliver a boy child on a Sunday around midday and that the boy would become a doctor of heart. He also said that the boy would be having a black mole on his right hand fist. My mother forgot all about this and left Munnar for better medical care to her home. Months later, on a Sunday morning, she had the delivery pain and around midday she gave birth to me. Readers may wonder on how we can precisely tell that the time was midday. Since our home was close to the church, and the church bell rang during each hour to mark the time. It was later when my grandmother was giving me a bath on the third day, she noticed the mole on my right hand fist. She conveyed this to my mother and it was then she recalled all those events. I began my career as a lecturer at Christian Medical College (CMC) and later migrated to Australia. After practicing medicine for almost 6 years, I came back and got an opportunity to go to USA. My stint at USA was short and I came back to India to join as a doctor with Indian Railways. But in the same year, an Emergency was declared in India. I’m really happy to be a part of initiating several hospitals in India. I was the Founder Vice President and Director of Madras Medical Mission, Chennai and also, the Founder Chairman of Pondicherry Institute of Medical Sciences (PIMS), Puducherry. St. Gregorios Cardiovascular Centre, at Parumala, in Kerala, was also our contribution. I pioneered Lifeline Healthcare Foundations

you work, ” you become

Dr. K. M. Cherian

at Chennai and we have got a medical science park-Frontier Mediville, Elavur, Tamil Nadu. We have also got an educational society- Dr. K. M. Cherian Educational Society which runs a school at Pondicherry – “The Study” CBSE International School.

not be put on oxygen for 24 hours and thus the patient can recover easily. In other words, it is half load taken away. That is quite successful now. We have many patients for lung transplant here mainly foreigners, especially from Middle East.

gappe: Tel l us about the first successful lung transplant in Ind ia?

gappe: Frontier Lifeline at Chennai had hit international news by successful ly performing complex heart surgeries for 20 Iraqi children during 2004. Tell us more about the incident.


Dr. K. M. Cherian: The patient who underwent the transplantwas a Sri Lankan national working with a hotel group at Coimbatore. He had heart and lung damages. So we corrected his heart and did bilateral lung transplant. Months later, he went to work as usual. Unfortunately, after two years he died, probably of lung infection. I don’t know the correct condition as we had not been in touch. We started to perform single lung transplant for idiopathic intestinal fibrosis later on. The benefit of doing so is that the patient need


Dr. K. M. Cherian: In 2004 February, I got an e-mail from a friend at US. In that mail, he had written that he has got 20 Iraqi children with difficult heart condition. He enquired whether we could do something about them. By then, he had contacted several hospitals around the globe. It was a time when we were trying to open Frontier Lifeline at Chennai. So

Dr. K.M. Cherian sharing his experiences with Mr. T. Philip Eapen, General Manager, Agappe.




Interview Dr. K.M.Cherian the international arena. Three Indians who were working as drivers at Kuwait were held hostages at Iraq- one from Haryana and two from Kerala. E. Ahmed, who was then the Minister of External Affairs,asked us to give a voice clipping to All India Radio requesting Iraqi community to release hostages as we had helped 20 Iraqi children with complex heart problems. Our voice clipping was taken to Iraq and broadcasted through all media in Iraq and the very next day those hostages were released. Dr. A.P.J.Abdul Kalam who was the President of India during that time personally appreciated us for this. Also, he made a special visit to Parumala and spent some time with us. For the next Republic Day, during his speech from Red Fort, he appreciated our efforts at a small village in Kerala.


gappe: What are your suggestions for a successful lung transplant?

Dr. K.M. Cherian receiving Padmasree from the Hon. President of India.

Dr. K. M. Cherian: Size match is very important in Lung Transplant. It is as important as the blood group match. The lungs of a 10-year old wouldn’t match for an adult person. The second thing is that the donor shouldn’t be in a ventilator for more than 24 hours. The commonest and the most dreadful issues in lung transplant are lung infection and rejection. If you put one infected lung to a normal body,there is a possibility to spread it to the other uninfected lung also. The third suggestion is that the donor must also be a non-smoker. For heart transplant also, there must be size match. If a young boy’s heart is taken to a man, it might not be able to pump blood to the full body. The maximum mismatch could be up to 30%.

Agappe: What do you think of the government policies regarding organ transplant? Do you think state government’s policies regarding the same are conducive enough?

I thought it was a good deed to do so. The total cost was around Rs.50 lakhs. So we decided to cancel the advertisement in the newspapers about the opening of hospital. Hon. Chief Minister Jayalalitha, who was then CM, came to help us. She fixed the surgery to take place on February 18th after discussing with us. Since CM Jayalalitha came to light the lamp, the event was covered by all media. That was the first group operation we did. A Jewish NGO working at Baghdad was behind this noble act of helping these destitute children. Since they couldn’t find all the expense, they requested help from CBN Network in New York. The next day, 40 air tickets were ready- for 20 children and the ones who accompanied them. CBN Network covered the whole event from Chennai and we were all over international media. There was also another incident which took our name in




Dr. K. M. Cherian: As far as Tamil Nadu is concerned, it has taken the lead in policies regarding organ transplant. All other states in the country follow Tamil Nadu in this matter. It has initiated all the transplantation and they have got one of the best transplant coordination programs. There is total transparency and the transplant request goes only by seniority. All other states follow Tamil Nadu in the Organ Transplantation Program. I think Kerala government is also doing well in matters related to organ transplant. Tamil Nadu State even arranges facilities like Green Corridor for faster organ transplant. The State Police Department once made it possible to take a heart to our hospital from Vellore by road in one hour and 27 minutes by controlling the traffic. The normal time a vehicle takes to reach the same is two and half hours. The first interstate transplant we did had the help of State Police Department in arranging and controlling traffic. Every single minute is precious in an organ transplant. Tamil Nadu government is very receptive to the whole process.


gappe: Is there a connection between pulmonology and card iac diseases in India?


Dr. K. M. Cherian: Cardiac diseases and lung diseases are different. They have a separate disease pattern. The lung pressure can go up because of cardiac issues and because of high lung pressure, heart failure can happen. So in that way, all are interconnected.

PROCALCITONIN(PCT) Diagnose Sepsis using highly stable, whole blood PCT detection with fast immunofluorescence method and obtain quantitative results within STAT complying to NACB laboratory guidelines through versatile analyzer Mispa Revo.


What are the most common cardiac and

pulmonology diseases in India? Dr. K. M. Cherian: From our experience, it is ischemic cardiomyopathy or idiopathic cardiomyopathy. Basical ly, people with multiple heart attacks get ischemic cardiomyopathy. People with genetic problem are usually idiopathic cardiomyopathy. It’s the same with lungs too. If the heart is damaged or if there is a hole in the heart which has caused the lung pressure to go up, that is a different thing. The reason is unclear but we have found that women of a particular religious community to have this problem throughout KeralaPrimary pulmonary hyper tension.

Agappe: Tel l us about the new technologies and trends in treatment?

Dr. K. M. Cherian: It all depends on what you are dealing with. The latest technology is stem cells. There is also artificial heart. But the point is that, these are all quite expensive. A mechanical heart today costs Rs.98.2 lakhs. Tell me, how many people can afford this in India? So we are trying to build one of our own. In fact, we will have Sputnik Heart Technology transfer from Russia this month itself.


gappe: What is the success rate of pulmonary or cardiac transplant?

Dr. K.M. Cherian

Dr. K. M. Cherian: I would say that in a cardiac transplant, if the selection is good, nothing will happen on the operation table. In my view, the risk factor is less than 2 per cent. If at all something happens, it is acute rejection or chronic rejection. The case is similar with lungs also. This is when we have a team which is familiar with it.

Agappe: Your work motto?

Dr. K. M. Cherian: The harder you work, the luckier you become.




Evolution Lipid Profile

Evolution of Lipid Profile & its Recent Trends... Ms. Bintu Lijo, Dy. Product Manager - Marketing, Agappe Diagnostics Ltd.

The evolution of lipid profile – the group of blood tests to assess Cardiac risk assessment is fascinating and dates back to thousands of years. The lipid science is progressing daily and helps better manage your health. Today, it is estimated that 50% of the population have cardiovascular disease and lipid profile becomes an important part of Cardiac risk assessment to help determine an individual’s risk of heart disease. Here, we try providing a comprehensive history of lipid profile in four stages.



Routine Lipid Tests In 1852, plaque was first noted in the blood vessels and

described it as atherosclerosis in 1854.The presence of cholesterol in human blood was identified in 1838 but the link between cholesterol and atherosclerosis was discovered in early 1900s.In 1930s blood tests for cholesterol & Triglycerides were developed Total cholesterol —this test measures all the cholesterol in all the lipoprotein particles. Cholesterol helps our body to build new cells, insulate nerves and produce hormones. When there is too much cholesterol in blood, it builds up in the walls of arteries, causing a process called atherosclerosis, a form of heart disease. Triglycerides — measures all the triglycerides in all the lipoprotein particles; most is in the very low-density lipoproteins (VLDL)& Chylomicron. Triglycerides store unused calories and provide our body with energy but high triglycerides may contribute to hardening of the arteries or thickening of the artery wal ls (atherosclerosis).




Standard Lipid Profile In 1970s scientists identified two particles, HDL

& LDL which play a major role in heart health. HDL & LDL are the forms in which cholesterol travels in the blood.

High-density l ipoprotein cholesterol (HDL-C) — measures the cholesterol in HDL particles; often called “good cholesterol” because it removes excess cholesterol and carries it to the liver for removal. Low-density l ipoprotein cholesterol (LDL-C)-measures the cholesterol in LDL particles; often called “bad cholesterol” because it deposits excess cholesterol in walls of blood vessels, which can contribute to atherosclerosis.

Agappe’s AGLIPIDS – The Dependable Lipids. AGLDL

Cholesterol · Time tested CHOD – PAP Methodology in convenient pack sizes · Lipid clearing agent to reduce interference, offers Accurate Results · Offers Linearity of 600 mg/dL

Triglycerides · Stable GPO – TOPS Method · Contains Lipid Clearance factor to check the interference · High Linearity of 1000 mg/dL& high shelf life

AGHDL · Selective Inhibition method (with out Mg+) using Polyanions & Cation ensures 100% specificity · High correlation with Gold Standard Ultra Centrifugation Method& high Linearity of 150 mg/dL · CDC Reference for Standardization ensure high level accuracy

· Selective Solubilization method · Highly correlate with Gold standard Ultra Centrifugation Method & High Linearity of 700 mg/dL · Accuracy traceable to CDC reference

Apo A1 · Turbidimetric Immuno assay method · Wide measuring range 4-300 mg/dL · No Prozone effect up to 5500 mg/dL

Apo B

· Turbidimetric Immuno assay method · Wide measuring range 8-330 mg/dL · No Prozone effect up to 5000 mg/dL


· Latex Enhanced immunoturbidimetry method · Wide measuring range of 12 - 80 mg/dL · No Prozone effect up to 250mg/dL

CRP Ultra

· Latex Enhanced Immunoturbidimetry method · Wide measuring range of 0.13-10 mg/L · No Prozone effect


3 Extended Lipid Profile Approximately two decades ago, scientists identified

different Apolipoproteins & the ratio between them are useful in the assessment of cardiovascular risk. They have particular value in monitoring lipid lowering therapies where HDL-C and LDL-C alone are less predictive of future cardiovascular events. Apo A- It is a component of HDL particles and is often used as a biomarker for prediction of cardiovascular diseases. This test is important especially if a person has low level of high density lipoprotein (HDL-C). Apo B-It is a component of LDL particles and it may eventually prove to be a better indicator of risk of cardiovascular disease (CVD) than LDL-C The ratio ApoB/ApoA had a stronger correlation with myocardial infarction event rates than lipid and lipoprotein concentrations.

Emerging Risk Factors Research studies suggests two emerging risk factors of heart disease recently, CRP Ultra & Lp(a). CRP ultra– this test accurately measures low levels of C-reactive protein to identify low but persistent levels of inflammation and thus helps to predict a person’s risk of developing CVD. A recent study found that elevated levels of C-reactive protein led to a three-times-greater risk of a heart attack. Lipoprotein(a)- One in five people has high levels of Lp(a) from birth based on genetic factors. As high levels of Lp(a) travel through the bloodstream, it collects in the arteries, leading to gradual narrowing of the artery. It can increase the risk of blood clots, heart attack or stroke.




Cover Story Tuberculosis


Today’s Indian Scenario

Dr. Thirupathi K,

Consultant, Pulmonary Medicine, SIMS Hospital.


he TB epidemic is larger than previously estimated, reflecting new surveillance and survey done from India. As per WHO Global TB report 2016,India has 2.8 million people diagnosed with tuberculosis. It is nearly one third of Global TB burden. Deaths due to TB are doubled in the country from 2.2 lakhs in 2014 to 4.8 lakhs in 2015. India has more patients living with drug-resistant TB than any other country in the world — with an estimated 79,000 persons becoming sick with this disease each year. India must do whatever it can to stop the transmission of TB both within and beyond its borders, and this can best be accomplished with early diagnosis and effective treatment. In order to manage this crisis, we need to diagnose tuberculosis at the earliest using newer techniques currently available and manage the disease with proper regimens, and most importantly, we have to ensure that the patients are completing the full course of treatment. The primary method for TB diagnosis in lowand middle-income countries is the detection of Acid-Fast Bacilli (AFB) using smear microscopy, namely ZN stain. It is simple, affordable, quick and also provides results within hours. Fluorescence microscopy with fluorochrome staining and light emitting diode technology improves the sensitivity of TB detection. Still the gold standard for diagnosis of TB is isolating M.tuberculosis in culture. Solid culture (LJ medium) takes longer time to grow. Liquid culture media using automated systems, such as BACTEC radiometric method and mycobacterial growth indicator tube (MGIT) are even more sensitive and can detect growth in 1–3 weeks. Currently, we prefer to




use liquid culture media for respiratory and extra pulmonary samples in view of faster results. Molecular Methods such as Gene Xpert MTB and Line Probe Assay are available for clinical use in India both in government as well as private sectors. The introduction Nucleic Acid Amplification Tests has been one of the major developments in the diagnosis of M. tuberculosis. WHO has advocated universal use of Xpert MTB/RIF for the diagnosis of TB. Xpert MTB/RIF is a commercially available diagnostic test to test specimens for genetic material specific to Mycobacterium tuberculosis and simultaneously detects a gene which confers resistance to rifampicin, rpoB. Unlike other commercial PCR-based tests, it is a fully automated test.Results wil l be usual ly within 2 hours. Line Probe assay is another Nucleic Acid Amplification Test, which detects resistance to Rifampicin and INH in addition to detecting M.tuberculosis. It is not useful in testing extra pulmonary samples where the bacillary load is less. Extra-pulmonary tuberculosis (EPTB) accounts for about onefifth of all cases of tuberculosis and a major health burden in

Dr. K. Thirupat hi

works as Consultant Pulmonolo gist at SRM Institute of Medical Sciences (SIMS hospital), Chenn ai. He has years of practice in the field of Pulmonology. His area of expertise consists of treatment of Asthma, Chronic Obstructive Pulmonary Disease (COPD) & Interstitial lung disease patients. He was graduated from Mohan Kumaramanga lam Medical Col lege, Salem and MD (TD& RD) from Madras Medical College and he was a gold medalist in his university. He has also publish ed articles in National and International journals.

many forms of extrapulmonary TB (EPTB) are paucibacillary and the diagnosis of EPTB is therefore challenging. Acid-fast bacilli (AFB) smear of biological specimens is often negative. A high level of suspicion is important in evaluating a patient with presence of risk factors. The firm diagnosis of TB requires culturing of Mycobacterium tuberculosis and is important for drug-susceptibility testing. Appropriate specimens are obtained and tested microbiologically and histologically. Chest x-ray should be part of the basic initial workup and may show evidence of active or old TB. Testing of extra pulmonary samples with Gene Xpert MTB is currently recommended for lymph node samples and CSF samples. IGRA assays namely Quantiferon Gold TB and T spot ELISA are used for detecting Latent TB infection. As they eliminate false positive results due to BCG vaccination and NTM infection, they are more specific than the conventional tuberculin tests. But at the same time, they are expensive, not standardized and they also not useful in diagnosing active disease. RNTCP India has come out with a new recommendation to use daily ATT in treatment of drug sensitive tuberculosis. The initial phase should consist of two months of Isoniazid (H), Rifampicin (R), Pyrazinamide (Z) and Ethambutol (E). The continuation phase should consist of three drugs, Isoniazid (H), Rifampicin (R) and Ethambutol (E) given for at least four months. Bedaquiline, known as the ‘miracle drug’, is the first TB drug to be approved by Food and Drug Administration (FDA) in over 40 years. The treatment has been rolled out under the Revised National Tuberculosis Control Programme for treatment of MDR TB patients. The drug is made available in six public hospitals in Delhi, Mumbai, Chennai, Guwahati




Cover Story Tuberculosis and Ahmedabad. HIV and TB are, in fact, partners in crime, and the world’s deadliest duo. In India, people living with HIV accounted for 1.2 million of all new TB cases. HIV poses several challenges to TB control. Tackling the problem of HIV and TB coinfection presents both diagnostic and therapeutic challenges. It results in more risk of infection, disease, drug resistance, adverse drug reaction and paradoxical reaction. Tuberculosis is the most important cause of death in patients with HIV-AIDS. It is very important to diagnose tuberculosis at the earliest and screen all TB patients for HIV to address these issues. Paradoxical reactions and IRIS (Immune Restitution Inflammatory Syndrome) in TB infection has long been observed in both HIV-positive and HIV-negative TB patients. Multiple definitions of paradoxical reaction exist in the literature, but essentially this term refers to the phenomenon of

clinical (or radiological) deterioration of TB lesions or the development of new lesions in a patient with TB, who has initially improved on ATT occurring in the early phase of treatment (during the first 3 months). Paradoxical reactions manifest in a wide variety of ways and can sometimes be life threatening or lead to increased disability in EPTB survivors. Both paradoxical reaction and IRIS pose significant challenges to physicians treating TB patients in India. In India since 2011, there were 61.3 million people living with Diabetes and the incidence keep on rising to epidemic levels. If we do not seriously think about the link between TB and Diabetes, it may begin to derail some of the good advances made in TB control especially in India. The link between TB and Diabetes mellitus has established what is needed now in good quality implementation of knowledge to screen for both diseases and monitor this dual burden of disease. It will be a meaningful strategy to screen diabetic patients for the symptoms or signs of TB and submit them for necessary investigations to make early diagnosis of tuberculosis. Not only that, it is also important to screen for Diabetes or Impaired Glucose Tolerance in TB patients as maintaining good glycemic control is important for faster cure of TB. A significant proportion of tuberculosis cases




were being treated by private practitioners in India. There was no mechanism to follow the patients treated by them, which results in poor clinical outcomes. Finally, this situation affected the cure rates and development of drug resistant TB. If the TB patients diagnosed and treated under private sector are reported to public health authorities, the mechanisms available under the programme can be extended to these patients also to ensure treatment ad herence and completion. The impending epidemic of M/XDR TB can only be prevented to a large extent by this intervention.

mandatorily to the public health authorities in a specified format. With increasing number of health facilities, registered notification of TB cases also increased many fold. To conclude, early diagnosis of TB using the available tests and appropriate molecular and culture methods is very important to cut the chain of transmission of TB. By ensuring that the patients are completing treatment, drug-resistant TB will be definitely reduced. Notification of tuberculosis patients will be an important step in ensuring follow-up. Effective management of various immunosuppressive disorders like diabetes, HIV and organ transplant recipients is essential in handling various infectious diseases and reducing the communicable nature of those infections.

To address this situation, Government of India declared Tuberculosis as a notifiable disease where in, all TB cases diagnosed are to be reported

Symptoms of Tuberculosis and its complications if untreated in time

Although your body may harbor the bac-

teria that cause tuberculosis, your immune system usually can prevent you from becoming sick. For this reason, doctors make a distinction between: ·Latent TB. In this condition, you have a TB infection, but the bacteria remain in your body in an inactive state and cause no symptoms. Latent TB, also called inactive TB or TB infection, isn't contagious. It can turn into active TB, so treatment is important for the person with latent TB and to help control the spread of TB. An estimated 2 billion people have latent TB. ·Active TB. This condition makes you sick and can spread to others. It can occur in the first few weeks after infection with the TB bacteria, or it might occur years later. Symptoms of active TB include: Coughing that lasts three or more weeks,

Coughing up blood, Chest pain, or pain with breathing or coughing, Unintentional weight loss, Fatigue, Fever, Night sweats, Chills, Loss of appetite.

complications include: ·Spinal pain. Back pain and stiffness are common complications of tuberculosis.


·Joint damage. Tuberculous arthritis usually affects the hips and knees.

Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your lungs, but it can spread to other parts of your body through your bloodstream. Examples of tuberculosis

·Swelling of the membranes that cover your brain (meningitis). This can cause a lasting or intermittent headache that occurs for weeks. Mental changes also are possible. ·Liver or kidney problems. Your liver and kidneys help filter waste and impurities from your bloodstream. These functions become impaired if the liver or kidneys are affected by tuberculosis. ·Heart disorders. Rarely, tuberculosis can infect the tissues that surround your heart, causing inflammation and fluid collections that may interfere with your heart's ability to pump effectively. This condition, called cardiac tamponade, can be fatal.




Life Story Deepti Chavan

Metamorphosis of a Champion from a Malady At the age of 16, what would be a teenager’s dreams? Stylish dresses, modern gadgets, partying with friends and lots of fun, isn’t it? But Deepti Chavan of Borivali, Mumbai, was dreaming about a normal life where there are no more agonizing coughs and painful injections. She was infected with TB, that too a dangerous drug resistant form- multi drug resistant TB or MDR – TB.

Deeptis’ story is inspiring as it teaches us how to remain strong

even when we know that any minute you could succumb to this much dreaded and most common disease. She embodies hope and her ‘never give up’ attitude that makes her a true champion now.

Deepti was giving her Board exams when she first fell sick. Some regular treatments followed with no results. After some time, her doctor asked to take her chest x-ray and it clearly revealed Tuberculosis to their utter dismay.” I was just 16 and was not aware of the social stigmas related to TB. Doctors told me that after taking a course of medicine for around 6-8 months, I will be fine. At that time, I never thought that almost 6 years of my life are going to be wasted.”

Deepti Chavan

Deepti recalls that those were the most nightmarish years of her life. She was not sure whether she would wake up the next morning. At one point, she had accepted the fact that she had to live like that but for her, it was more heart wrenching to see her family suffer. Though she was ready to fight the physical battle




with the disease, it hurt her to see her family fighting a mental battle as the cost of the treatment was mounting higher to an unreachable level. They had to depend on heavy loans to meet the expenses of her treatment. Even after a long duration of time, Deepti was not getting the expected results with the medicines. Tests revealed that she had another form of TB, MDR–TB (Multi Drug Resistant TB). Some of the medicines that would work well in drug sensitive TB are not effective in this disease condition making recovery a challenge. Her parents were told that there was only one option remaining and that would be a surgery as a part of Deepti’s lung was damaged. Deepti recalls that actually the real problem was not the disease, but the lack of a precise diagnosis. When one drug stopped working, she was started on another antibiotic and this followed as a chain. When finally, the actual problem was diagnosed, her condition was quite worse. She was coughing out blood every day and the stitches of a previous surgery started coming out in her efforts to cough.

Deepti Chavan and her father with Amir Khan during Satyameva Jayate TV programme. “I had to take an injection evShe remembers herself being a pretty child. Due to the ery day which was extremely painful. In six years, I took about 400 such injections. Every day was literally a struggle for me”, recol- medications, her complexion became dark. She was around 28 kilos that time and looked almost like a skeleton. Mirrors lected Deepti serenely. scared her those days and she never wanted to peep into her reflection.

“I had to take an injection every day which was extremely painful. In six years, I took about 400 such injections. Every day was literally a struggle for me”, recollected Deepti serenely.

As her first surgery was not a success and she continued to deteriorate, doctors advised to go for a second surgery. Just as many doctors were unwilling to take up her case as it was almost a ‘gone case’, she googled about the doctors who specialized in the treatment of TB. She found out a doctor in UK who told that if she wanted to get her treatment in UK, it would be unaffordable for her. So he recommended her to a friend of his who was practicing in Mumbai, Dr. Zarir Udwadia. After being briefed about her disease, he told them that though the case seemed a bit difficult, he would surely give a try to cure her. This ignited a fire of hope in them as one among the doctors whom they approached previously blankly




Life Story Deepti Chavan asked her father whether he was mad to treat his daughter as she was incurable and had only 6 months to live in his estimation. He went on telling him to give her good food and spent the remaining 6 months happily with her, fulfilling all her wishes. As medications were changed every two weeks and her symptoms like fever, cough and loss of weight didn’t disappear, she had to drop out of her engineering course. “Though I underwent two lung operations, I had to wait for over four months to find a surgeon willing to operate on me the second time,” Their search to find a surgeon who could do the surgery on her the second time ended with Dr. Sripal Doshi in Jaslock Hospital. He also predicted a 1% chance for her survival. Though it was expected as a 4-hour long surgery, it took almost 8 hours to complete it was out of the ICU the very next day. For him to remove her affected lung, he had to remove 3 of her ribs. She was quite disfigured in this process. Seeing

As medications were changed every two weeks and her symptoms like fever, cough and loss of weight didn’t disappear, she had to drop out of her engineering course. “Though I underwent two lung operations, I had to wait for over four months to find a surgeon willing to operate on me the second time,”

the big scar on her side, she had only one question to the doctor. “How am I going to wear my favouritesarees now?” Now, Deepti lives with only one lung and that too half of it. While she was taken to the operation theater, when her family was all tensed, she was peacefully singing a song and promised her family that she would be back alive in a few hours.”I was relaxed thinking that after the operation, my problems willbe over either way – if I die, that’s the end of my misery and if I live, that’s the end of my dreaded disease”, she gives a smile of a winner. Deepti says that it is only not the patient who falls ill, and looses hope but the whole family’s happiness goes down the drain during the course of the treatment. Deepthi says, “While I was hospitalized, I witnessed patients committing suicide. Once a patient just got up from the next bed and jumped through the window before my eyes. People give up hope very soon. The stigma against this disease and the prolonged treatment makes them pessimistic. I believe that if I am given a chance to live once again, I should live it with a purpose. So, now I give counseling to the disheartened patients and ask them to fight against this disease and win back their lives with courage”. She believes that the real enemy of this disease is the stigma against this disease. In India, the stigma associated with the disease leads to the individual facing societal disapproval. When patients are diagnosed with diseases such as TB, the fear of the social and economic consequences following diagnosis can make them reluctant to seek and complete the treatment.

Deepti Chavan with her husband




Deepti Chavan is just not a TB survivor. She is now a committed spokesperson for TB patients and their rights in India. She has a message to the people who

are affected with TB. She comments, “TB has taught me a lot. It has made me brave. I started accepting pain due to this disease. If I could make it, surely everyone can. Just don’t miss your medications. My mantra is simple -‘Do not let TB win.”. Of course, her most valuable victory and asset is her husband, Neeraj Musale, whom she got familiar through her online chats. She had the habit of browsing the net while admitted in hospitals. She found him during one such surfing. Though she stayed strong before her family, she shared her apprehensions, pangs and pains to him through chats. Finally, after knowing her thoroughly, he proposed her over phone and they got married as a happy ending to her story. Till they decided to get married, they never had met even once. Deepti says, “He was and is my best friend for life”. When before Deepti Chavan receiving momento from Hon. Union Health Minister Sri. J.P. Nadda. their wedding, her father asked his parents about the gifts they expected, his parents told him to definition to Deepti in one sentence and the words come from explain them how they could take care of their daughter-in-law in his heart. “She is the strongest woman I have ever met”. Yes, she beams at this comment from her husband,looks up at the best way possible and that they expected nothing else. him cheerfully, conjuring all the happiness and optimism to Neeraj says that he has learned a lot from his wife. He gives a share to this world.

Some facts about TB in India India has the highest TB burden in the world with 2.2 million new cases each year. TB kills almost a 100 people every day and 3 lakh people every year in India. Treating MDR - TB can cost anything between 1.5 to 4 lakhs. An MCR_TB has only 50% chances to be cured. Most people lack the access to appropriate diagnosis and treatment for TB in India.


More than 100,000 women lose their status as mothers and wives because of the social stigma to TB. India has close to 100, 000 cases of drug resistant TB, a majority of which remains undiagnosed.





Mr. Mani Mariappa

We Pursue The Art of Diagnostics...

Face to face with Mr. Mani Mariappa-Director, Microbiological Laboratory

Mr. M. Mani, popularly known as Micro Mani, Medical Microbiology from Christian Medical College, Vellore, established Microbiological Laboratory in 1977 at Coimbatore with a vision to contribute something to the field of microbiology. Director and Chief of Microbiology Laboratory, Mr. Mani, today, leads the chain that has been now well established in South India with the modern technologies in diagnostic methods and acts as a reference laboratory for several laboratories across Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Agappe: Tel l us about the beginning of Microbiological Laboratory? Mr. Mani: I began operations of Microbiological Laboratory in 1977 at a small scale in a car shed. Microbiology was the major focus. I was focusing only on bacterial infections and serology. Slowly, in 1980, I expanded it into semi-automatic analyzer and started doing biochemistry checkup. We moved into a new building and introduced Auto Analyzers in Routine Chemistry in 1990 and by 1994, participated in Biorad quality control program.In 1999, we introduced drug assays and by 2000, I introduced lot of automations. The Biochip array technology was introduced in 2004. In the last 16 years, there have been a lot of introductions in my lab. In 2005, we introduced integrated models like coagulation automation, molecular biology and many others. I felt molecular biology to be very advanced and found out that not many laboratories have facilities for doing so. I wanted to be unique and so focused more on molecular biology. Regular biochemistry and microbiology were other focus areas. All virus, bacterial molecular biology works were started be analyzed. By 2014, we indigenously developed a panel with my own staff with our thesis project in molecular biology and my staff has got a PhD out of the product. The product we developed from the thesis was launched in-house. The technology used is molecular biology followed by a high resolution melt curve. By doing HRM technology, I don’t use conventional




probe technology and so, the cost is almost one fourth of the cost of molecular biology cost. The cost reduction is thus possible and the technology is very economical compared to real time PCR technology. We amplify the product and instead of going for probe detection, we do the HRM and identify the pathogen present in the given sample. The advantage of the technology is that we do multiplex assignments rather than single assignment. In multiplex assignments, we do multiple pathogens- virus or bacteria or even combined including a parasite. We can do it in a single tube with a single run and can identify the cause in one or two hours’ time. The same test can be used for different samples, be it blood, urine or sputum. Doctors need to tell us the clinical symptoms and accordingly the sample is taken. We have made a lot of validation and conducted many trials before using it. Agappe: Microbiological Laboratory is known for providing the very best healthcare facilities to a rural community in a financially affordable manner. What is your vision and mission? Mr. Mani: I’m a Microbiologist and believe, I have to do something for microbiology in my lifetime. Molecular biology is growing and in future, microbiology will be phased out slowly. Now, we are looking into DNA analysis to find out the particular pathogen. That way, we will never miss the diagnosis. In another 10 years, I’m going to give service of microbiology department in 3-4 hours with results specifying species in-

volved and possible suggestion of effective antibiotics. It will be more reliable and patients can have better treatment and their agony can be minimized. I believe that one day microbiology will be acceptable like biochemistry. The department of microbiology will gain value like those departments.

Agappe:Research and Development in world of IVD industry has resulted in many dynamic changes in various test methods. How do you adapt such changes?

Mr. Mani: Changes have to occur. I’m a technology oriented person. During 90’s, I used to get information from jourAgappe: Habitually,organisations run on its core values which nals. Now, the internet has opened up a new and easy world of might mostly be the strength behind their success. Tel l us about information. I carefully watch the technological news and thorthe core values of Microbiological Laboratory? oughly check whether all scientific communitiesaccept those technologies. Once they accept, I assume it could be helpful to Mr. Mani: Success depends on mainly the person involved. us. I know modern technologies are expensive, but to stay upThe qualification gives you a base. After that, it is your own interdated you need to pay for it. I attend CMEs regularly and keep in est which allows you to gain success in other areas. I’m a micro touch with several professors both inside and outside the counbiologist but I believe in a few years time, my name will be known try. Doctors are also happy with results using modern technolwith genomic area- identifying disease in the DNA level. From ogy as it is helpful to get best treatment possible. Also, there microbiology, I have grown to molecular biology, bio chemistry, are customers who inform us about new technology. Once, it cytogenetics and so. You should also be passionate and stay upwas a customer from Coimbatore who informed us about dated with the latest news in the industry and to adapt them accordingly. Today, we have presence in all districts of Tamil Nadu with 60 centres. In Kerala, we have centres at Thiruvanathapuram and Ernakulam. There is also a well-equipped lab with the best diagnostical ly qualified people at Bangalore, Karnataka. I recently became one among the Top 10 leading industrial persons in Coimbatore and the recognition was given by Coimbatore Management Association. Now, Tamil Nadu Government along with Times of India and FICCI has recognized us as the leading health care provider in Coimbatore.

Mr. Mani Mariappa





Mr. Mani Mariappa

a new technology which was prevalent abroad and soon we introduced that tech nology to our lab. Agappe:Tel l us about your CSR activities? Mr. Mani: Named after my son, Dinesh, who is no more, we have a trust- Dinesh Memorial Trust. It sponsors the research projects of several students. We sponsor whole educational expenses of several students undergoing medical, engineering and college studies. We have one laboratory sponsored by the trust attached to the temple whereby village patients can take free diagnosis and consultation. Agappe: Microbiological Laboratory has been dealing with Agappe for so many years. How is your overal l experience with Agappe? Mr. Mani: I’ve been associating with Agappe for the past 20 years. We had been purchasing many products related with routine chemistry for many years. I was very happy with the products of Agappe. But due to our technological change, we couldn’t make use of products from Agappe after a while. Usually, we stick to a particular company, if satisfied with the product quality and we had a wonderful association with Agappe. We still use some products of Agappe and are very satisfied with the results. I had visited its manufacturing facility, R&D in Kerala and was impressed with the standards which Agappe maintain. I’m very happy to learn that Agappe has grown into international level now. Also, our comparisons show that Agappe parameters are almost matching. In fact, it is very acceptable and economical. The quality of Agappe products is good as any international products.My only request to Agappe is to do more products focused on genetics and also molecular biology. Agappe: What are your future plans for Microbiological Laboratory? Mr. Mani: My new area of focus is Genomic. So far, the genomic labs are run by life science division,mainly of Pharma companies,which have R&D departments. If we take human DNA mapping, we can predict the genetic diseases and those can be prevented. If we do DNA mapping before marriage, we




Mr. Mani Mariappa with his team could reduce the genetic disease spreading. Genetic screening of a new born baby will help to identify diseases of children at a young age.Oncology treatment is another area which can benefit much with this. The chemotherapy will have good and bad effects. If we do DNA Mapping of cancer cells, then the mutant cells can be identified and proper chemotherapy can be given. It is a growing area and will have a lot of controversies surrounding but it can bring on a great change on oncology treatment. We are also allowed to open up the first lab inside the security area of Coimbatore Airport Terminal. Microbiological Laboratory is the first lab to do so in India and can boost medical tourism. Patients who want a quick disease diagnosis can make use of such lab service and can return to their native place and within one hour, the report is send via email or available in our website - accessible by using the bill Id and password given in the bill. Most often,people would not find time to visit the lab or hospital for checkup in their city due to work pressure, traffic and distance particularly in Metros. The advantage of our service is that within their return flight they will have their result. We are also planning to introduce it in Chennai Airport later. Projects are in pipeline to open Microbiological Laboratory in Hyderabad soon. Agappe:What wil l be your advice for IVD companies? Mr. Mani: All IVD companies should enhance customer relationship. There should be prompt service offered on the products. Quality of product that IVD companies supply should be good. Technological advancement should be passed on to small time customers (here small scale & medium laboratories) so that it is accessible to the public. IVD companies should also conduct CME’s for awareness on new technology.

Life Story R. Deivanayaki

A TRUE BORN FIGHER She is the “Iron Lady of Recovery”. She is willpower incarnate. R. Deivanayaki earned this title after the transplant of her two lungs and heart. When transplant patients take months or sometimes years to recuperate, Deivanayaki recovered from her “not so common” multiple organ transplants in almost two weeks. What’s her story? Let us find out.


Deivanayaki from Kalpakkam, around 80 km from Chennai, was working as a Scientific Officer at Indira Gand hi Centre for Atomic Research, Kalpakkam. She was diagnosed with Idiopathic Pulmonary Hypertension. Idiopathic pulmonary arterial hypertension (IPAH) is a rare disease characterized by elevated pulmonary artery pressure with no apparent cause. When her disease was diagnosed in 2004, her parents and sisters couldn’t believe it that they went arguing with the doctors. Born to P. Rajabathar, an electrical supervisor, and Padmavathi, home maker Deivanayaki was the most active among the five daughters. From child hood itself, she used to take part actively in sports, cultural and social activities. Deivanayaki loved trekking and she loved adventure activities. She did her schooling at Kalpakkam and graduation in B.Sc. Chemistry like her two sisters at Chennai and took on teaching while pursuing her higher studies through correspondence. Wanting to take her career to a new level, she looked for another job and ended up at Bhabha Atomic Research Centre (BARC), Mumbai and worked there for almost one year. Later, when her mother fell in ill, she took transfer to Kalpakkam in 2001. She married M. Krishnamoorthy from Coimbatore, who was working in the pharmaceutical industry at Chennai in February 2002. Adding bliss to their happy life, they were gifted with a baby daughter, Shruthika, next year. The doctors were of opinion that patients with this disease, which happens to only one among 1,00,000, will have symptoms like tiredness and frequent fevers during their childhood itself. “The signs of my disease first appeared when I was pregnant contrary to what doctors say,” says Deivanayaki. “In my case, I was the healthiest child among my sisters and our father doesn’t re

R. Deivanayaki




Life Story R. Deivanayaki member a single incident where I was admitted to hospital for such reasons,” she recollects. Since she had conceived Shruthika, she thought that the breathlessness, palpitation and the sense of burning inside could be because of the pregnancy. “I thought it will subside after my delivery. I had a normal delivery which doctors said was a miracle. Also when the problem didn’t subside, I thought it could be owing to my weak health after delivery. I went to the hospital thinking that the doctor will prescribe me some tonic but instead, I was given this shocking news. I could still picture the doctor checking my heartbeat by using his stethoscope again and again and the concerned face of technician who took my ECG,” Deivanayaki recollects with a smile. Later they understood why the disease is called ‘idiopathic’. It will not show any symptoms and will shoot up suddenly. Only after many years, it might show symptoms. “It was right in my case. I was diagnosed with the disease during my 30s. If I climb steps, I will not be able to speak. I had to rest for at least 2 minutes to regain normal breath. At some point, even reaching my flat on the second floor became difficult.” she recalled with the agony of the events showing on her face. Her pulmonary arterial pressure was so high that the doctors explained that closing the hole in the heart has very little benefit in reducing the pressure. At that time, transplants weren’t as common as now. So, they didn’t consider that option seriously. The normal pulmonary arterial pressure is considered to be 18-25 mmHg and hers was at 150 mmHg. She was prescribed a medicine to control the pulmonary pressure temporarily, which wasn’t for pulmonary hyper-

R. Deivanayaki with her family




tension but had been found out effective for pulmonary hypertension. The medicine gave her severe migraine-like headaches initially. Meanwhile, she went for a second opinion from various hospitals and all were of the same opinion. The doctors advised that she should continue the medication strictly and in her condition, transplant was the only option available in the worst case of her disesase. They also assured that by the time symptoms worsen, transplant would become a common practice in India. At regular intervals, the dose of medicines was raised by the doctors according to worsening of symptoms. Deivanayaki is really grateful for her organisation and her colleagues for providing her full support. As a central government employee and a rare case, they made sure that all options were checked for her. Owing to her condition, she was given work place change where she could work comfortably based on her symptoms. Her condition deteriorated further that the doctors suggested her to use oxygen cylinders as her oxygen level in blood declined during hard jobs. The oxygen requirement increased as she began to get tired often. Hence, she opted for an Oxygen Concentrator which works all day long. Her organization provided her with a spare oxygen concentrator. After a while, she bought an oxygen concentrator supplying 5L/min oxygen. The doctors kept on asking her to register for transplant as there are several tests and formalities for transplant that have to be certified. For several reasons including economical issue, she deliberately delayed it. By 2014, she became very weak. She had to take a break from office and had to be in bed rest. She submitted her detailed medical condition through their hospital to the organsiation for treatment and tran splant approval. The organisation had formed a committee to review her condition and later approved her cond ition, which came as a huge economical relief for Deivanayaki and her family. In December 2014, Deivanayaki’s sisters’ marriage was fixed. So Deivanayaki planned to join the procedures for organ transplant registration after the marriage. Few days before the marriage she had severe pain and a pul l ing sensation in the

Dream Big and Dare to Fail

chest. She was taken to the hospital straight away. The doctors explained the seriousness of her condition and asked her to register for transplant immediately as she had reached the worst state. Fortunately, she had no other problems except for her lungs and heart. She was enrol led and asked to remain at Chennai close to the hospital. Getting a donor with all required specification was a big question. Now literally, oxygen was pumping to her at every minute. “Even if I just go to the washroom and come back to bed, my oxygen level in blood will reach around 7780 per cent, while the normal was around 99 per cent. During that time, I was taking 10L/min oxygen,” Deivanayaki recalls. Before getting discharged from the hospital, the doctor asked her to buy a 10L/min Oxygen Concentrator as the current 5L/min oxygen concentrator would not be enough for her. Also, there should be an alternate option as Oxygen Concentrator had to work 24 hours a day. One of her sisters arranged for her stay at her house close to the hospital at Chennai. She was shifted to the sister’s home from hospital in an ambulance on 12th December 2014. Two days later, on 14th December 2014 morning, Deivanayaki was having the coffee when she got a call from the doctor. He said, “Be ready, the ambulance is coming. Start immediately. We have got the donor and if it matches then we will proceed with transplantation.” Her husband was away at Kalpakkam and hence her sister accompanied her to the hospital. Before going to the transplant, she told her anxious relatives, “Don’t worry, I will come back. I’m a fighter.” The next day morning, she woke up to the following words of the doctor, “Deivanayaki wake up. Your surgery is over and your husband has come to see you.” She opened her eyes slowly and showed the thumbs up sign. She recovered at a rapid pace. Doctors were in fact amazed at the speed of recovery. They said, “Your daughter is the reason for your recovery. Only because of her, you are fighting so fast.””I never wanted to live for 100 years but I wanted to be alive until my daughter could accept the fact,” she comments with motherly love. On 28th December 2014, she was discharged from hospital. In fact, she was shifted from Critical Care Unit (CCU) to Ward in 10 days, which was a rare thing and then later to her home. Another

sister’s home, near to the hospital, was arranged for her to stay. One room was readied as per doctor’s specification to prevent infection. She stayed there for almost one year. Once during that time, her hemoglobin level dropped down due to infection and she was admitted to hospital and underwent blood transfusion and later recovered. Her husband always kept saying this to her, “We will overcome this soon. Don’t worry”. Although Deivanayaki planned to go back to Kalpakkam in June and to join back her office in July, a virus infection altered their plans. But she recovered from that too. Her last hospitalization was in December 2015 during the time of the devastating floods in Chennai. “We sought the help of a private FM channel for routes that weren’t affected with flood and they led us all the way till hospital. By January 2016, I rejoined my office,” she smiled with her eyes sparkling. Now Deivanayaki can walk normally and can climb steps. The doctors have asked her to wal k more so as to gain more strength. She is really grateful for the support extended by her husband, their daughter, parents, in-laws and sister’s family and friends in bringing her back to normal life. Her daughter Shruthika is now studying in 9th grade. “I’m almost back to normal life now. I thank the hospital, doctors and team in giving me a second chance in life. My colleagues say that now they see old Devi (as she is called in the office),” she comments confidently. Till now, she has no idea about the organ donors as in Tamil Nadu, they never reveal neither the donors nor the recipients. Deivanayaki and her family include the donors and their families in their prayers for giving her a chance to live a normal and happy life – once again.




Cover Story An overview on COPD

Chronic Obstructive Pulmonary Disease (COPD) An Overview Dr. V. Kesavan Nair M.D., D.T.C.D.M.Phil(Clinical Epidemiology), F.C.C.P. Professor of Respiratory Medicine & Senior Consultant, Kerala Institute of Medical Sciences (KIMS), Trivandrum, Kerala.

Chronic Obstructive Pulmonary Disease (COPD) is a condition

characterised by chronic airflow limitation which is progressive,only partially reversible with bronchodilators and is one of the common conditions that is referred to a chest physician. Though the condition mimics Asthma, there are many differences between the two,but now a new terminology,Asthma COPD overlap syndrome has come upwhich includes features of both. India contributes a significant and growing percentage of COPD mortality, which is estimated to be amongst the highest in the world.It is very difficult to get the exact figures for the disease burden in India. Smoking has been proved to be the most important risk factor for COPD, but there are others like air pollutants,occupational exposure to dust and chemicals, child hood respiratory infections and asthma. In young patients who come with features of moderate to severe emphysema, Antitrypsin deficiency, a rare condition, it should be suspected and investigated.The hallmark of COPD is chronic progressive airway narrowing, which is only partially reversible even with bronchodilators. Asthma is episodic and shows good reversibility with inhaled bronchodilator. The basic pathology is inflammation of the airways. The earlier a person starts to smoke and the longer one smokes, the worse and severe the COPD. But there is a great variation in susceptibility. COPD should be suspected in any person above the age of forty, current or past smoker,who has chronic cough or winter bronchitis, and has breathlessness on exertion or wheeze (musical sounds in chest). COPD includes chronic bronchitis,which is associated with cough lasting for more than 3 months for 2 consecutive years and emphysema where the lung structure is damaged and the lung elas-




ticity is lost. The diagnosis is confirmed by Chest X-ray and Spirometry. Chest X-ray may show the ‘dirty chest’ appearance of Chronic bronchitis or hyperinflation with bullae(empty airspaces with no function) in Emphysema.Spirometry is the gold standard for diagnosing COPD and also to monitor the progre ss and response to treatment. This ‘blowing test’ gives the lung volumes and capacities and shows airway obstruction. It is standardised, reproducible and is the most objective measurement of airflow limitation available. The important parameters that are looked for are the Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), FEV1/FVC,Peak Expiratory Flow Rate (PEFR)etc.FEV1/FVC <70% is indicative of airflow obstruction. If there is airway obstruction, inhaled bronchodilator is given to see for reversibility. In COPD, the rever- sibility will be less than 12% whereas in asthma it will be above 12%. The other tests which may contribute to diagnosis are blood examination which may show secondary polycythaemia, an increase in the number of RBCs due to chronic hypoxaemia (low level of oxygen in blood); Pulse oximetry may show fall in oxygen saturation (SaO2) especially on exercise. More sophisticated tests are High Resolution CT thorax to assess the extent and severity of emphysema and Diffusion Coeffi-


ALPHA-1 ANTITRYPSIN Diagnose alpha-1 antitrypsin(AAT) deficiency as the cause of early onset of emphysema by Gold Standard Nephelometric Immunoassay. Linear up to 400mg/dL and lower detection level of 40mg/dL. Ready to use reagents with smart card calibration in Mispa I2-Specific Protein Analyzer

cient of Lung for CO, (DLco) which is done in moderate to severe COPD to find out impaired oxygen transfer. To assess the performance status or the exercise capacity,a ‘6-minute walk test can be done. Moderate to severe COPD patients are prone to ‘exacerbations’ of their condition which increases their breathlessness, sputum quantity and pus- staining of sputum.This usually follows an infection, exposure to cold, dust etc. This can be mild or severe enough to lead to respiratory failure or affect the heart leading to heart failure (Cor Pulmonale). These patients require Arterial blood gas estimation (ABG) and Echocardiography in addition to other tests mentioned. After confirming the diagnosis of COPD, we come to the management part. This includes drug therapy, during stable condition and during exacerbations and specialised treatment modalities whenthere are complications or to prevent them. Above any therapy, the first aim should be to stop smoking by smoking cessation aids like drugs. To discuss the treatment options completely will be beyond the scope of this article.So an overview is given. The most common complaints of COPD patients are dyspnoea or breathlessness and cough. After Spirometry, as first line treatment, they are put on inhaler therapy. Inhalers contain medications in very small quantities which are delivered directly to the airways which are narrow. Inhalers can be in Dry Powder form(DPI) or in gaseous form (Metered Dose Inhaler (MDI). Because the dose is low, side effects are also few. DPIs require the ability to inhale the powder properly to the lower respiratory tract, which may be difficult for moderate to severe




Cover Story An overview on COPD COPD patients. MDIs, if used with a spacer device will be able to overcome this problem and they need to be inhaled slowly only. The inhaled drugs used are grouped into beta agonists and anti cholinergics. The long acting ones called LABA (Long Acting Beta Agonists) and LAMA (Long Acting Muscarinic Antagonists) are used in stable COPD for control and maintenance therapy whereas the short acting ones are used for acute episodes. LABAs like Formoterol and Salmeterol have action lasting for about 12 hours. Indacaterol has action lasting for 24 hours. The LAMA which has found favour among Indians is Tiotropium bromide, which is to be only once daily. Indians have tolerated oral and injectable Theophyllines much better than the westerners and so it has always had a firm footing in the Indian scenario. A LAMALABA combination along with or without a long acting Theophylline is the treatment of choice among the Indian chest physicians. Addition of inhaled Corticosteroids is also favoured by many as it reduces the rate of exacerbations. This happens very often in the state of Kerala in the southern-most part of

India where there are frequent weather changes which bring in viral infections. Rhino virus which produces the ‘common cold ‘ is notorious for precipitating exacerbations of COPD and asthma. Some of the newer drugs that have come to the market are Vilanterol, Glycopyrronium and phosphodiesterase inhibitor, Roflumilast etc. Exacerbations usually require a course of antibiotic, inhaled and nebulised and sometimes injectable bronchodilators and a course of corticosteroids. Nebulisation of drugs gives a larger dose of drug than inhaler and are effective even when patient has severe wheezing. During exacerbations, if the patient goes on to respiratory failure, he may require admission to an intensive care for oxygen and sometimes non invasive ventilatory support in addition to the medications mentioned above. The specialised treatment modalities are pulmonary rehabilitation, home oxygen therapy, surgery for removal of bullae in emphysema (Lung volume reduction surgery) and Lung transplantation. Pulmonary rehabilitation is a group of manoeuvres focussing on exercise, nutrition etc. to improve the physical and social performance of the patient. Long term oxygen therapy prolongs survival of severe COPD patients. To prevent infections like ‘flu’ and pneumonia due to pneumococcus bacteria, in moderate and severe COPD patients, especially those above 60 years may be given Influenza vaccine yearly and Pneumococcal vaccine once in 5 years. COPD is a preventable disease and the stress should be on smoking cessation, which is the best intervention for preventing COPD. It is the duty of every physician to advocate smoking-cessation, which will bring down the menace of COPD.




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Health Tips

Healthy Lungs gift a BREATHFUL LIFE...

Dr. C.S. Satheesh Kumar, Vice President-Operations, Agappe Diagnostics Ltd., (Retd. Drugs Controller, Kerala) The lungs are made of hundreds of thousands of branching tubes that end in tiny air sacs or alveoli. There are over three hundred million of these tiny sacs in our lungs, offering roughly the surface area of a tennis court to keep up with the respiratory demands of the body. The membranes of these tiny air sacs are also thinner than tissue paper to maximize the exchange of gases.

Our lungs make up a large part of our immune system.

Pollutants and infection-causing microbes are captured by mucus in the lungs and shuttled upward by tiny cilia for us to cough out or swallow. Sneezes are another way the lungs help rid us of infection or pollution, often before these invaders even pass beyond the sinuses. Function is to transport oxygen from the atmosphere into the bloodstream and to release carbon dioxide from the bloodstream into the atmosphere. The lungs never rest, either in sleep or activity. In just one day, a healthy person breathes nearly 25,000 times. Some common lung disorders are asthma, chronic obstructive pulmonary disease (COPD), bronchitis, pneumonia, emphysema, cystic fibrosis, tuberculosis, lung cancer and acute respiratory distress syndrome (ARDS). People with lung disease have difficulty breathing and some diseases can even lead to respiratory failure.

1. Active and Passive smoking is the major cause of serious lung diseases like lung cancer and COPD, as it contains thousands of harmful chemicals. Cigarette smoke can narrow the air passages and make breathing more difficult. It causes chronic inflammation or swelling in the lungs. With time, cigarette smoke can destroy lung tissues. More than active, passive smoking is highly toxic and can cause havoc to your lungs and your overall health.




2. Harsh cleaners and cleaners with strong fragrances cause irritation and it is detrimental. Avoid using aerosol sprays. Ensure adequate ventilation. 3. Belly fat can harm your lungs. Having excess abdominal weight may lower ones lung function, regard less of a personâ&#x20AC;&#x2122;s age, smoking history or body mass index. One factor that may contribute to the problem is the inflammation associated with fat tissue. But excess fat may also constrict the lungs, making it harder to breathe. The weight of the fat on the chest wall decreases the amount of room for the lungs. It also pushes up on the diaphragm, restricting its movement, particularly when bending over or lying down. 4. Lack of exercise slackens lung capacity. For individuals who are physically fit, exercise is important for good lung health. It reduces weight gain, strengthens the heart and respiratory muscles, helps deal with shortness of breath and increases overall activity, which makes it easier to perform everyday tasks like walking up stairs. If the muscles of the rest of the body are well conditioned, the burden on the lungs to do a task is less, and if the muscles they use to breathe are conditioned, they are less likely to get respiratory muscle fatigue, which is one cause of respiratory failure. 5. Occupational hazards: Many jobs can put your lungs at risk, from construction work to hair styling. In fact, occupational asthma accounts for approximately 15% of cases. Potential culprits include dust particles; diacetyl, a chemical that adds a buttery flavor to food; paint fumes and diesel exhaust, granite powdering dust, asbestos particles among others. Better use protective equipment masks. Protect yourself by choosing safer products, working in a well-ventilated area and using a dust mask. Avoid oil-based paints, which release volatile organic compounds (VOCs) and choose water-based paint instead. Cleaning products can contain harmful chemicals too like ammonia and bleach; read labels before you buy. Although itâ&#x20AC;&#x2122;s

It is found that people who consumed the most cruciferous vegetables (broccoli, cauliflower, cabbage, bok choy, kale and more) had almost half the risk of lung cancer compared to those who consumed the least. All those nice, leafy green vegetables that have lots of antioxidants do seem to have a protective effect.

true that smoking is responsible for 80 percent of all lung cancer cases, lung cancer among people who have never smoked is the sixth leading cause of cancer death worldwide. Some of the leading causes of lung cancer among non-smokers are exposure to radon gas released from soil and building materials, exposure to asbestos, coal, diesel exhaust and/or industrial chemicals etc.

Measures to control Lung Insufficiency (1). Food Habits: It is found that people who consumed the most cruciferous vegetables (broccoli, cauliflower, cabbage, bok choy, kale and more) had almost half the risk of lung cancer compared to those who consumed the least. All those nice, leafy green vegetables that have lots of antioxidants do seem to have a protective effect. Garlic and Onions, Ginger, Chili Peppers, Cruciferous, Pomegranates, Turmeric, Apples, Grapefruit, Beans, Seeds and Nuts, Carrots, Oranges, Pumpkin, Red Bell Peppers etc. are rich in antioxidants and other contents. Pistachios and plantain leaf are foods that promote healthy lung function. Pistachios contain gamma-tocopherol, a type of vitamin E that is believed to reduce risk of lung cancer. Plantain leaf, popular in Latin American cuisine, is useful suppressing mucous and may help respiratory problems that involve congestion. Cayenne pep-




Health Tips pers are potent foods whose benefits are equal to their heat. Cayenne has been shown to relieve irritation, which is great news when you’re suffering from coughs and sore throats. (2). Stress can exacerbate COPD symptoms like shortness of breath, so it’s important to manage the stress level at any cost. So, we have to manage stress by hobbies, music, yoga etc. Laughing is a great exercise to work the abdominal muscles and increase lung capacity. It also clears out your lungs by forcing enough stale air out that it allows fresh air to enter into more areas of the lung. (3). Yoga, Meditation and Stress release techniques : Deep breathing is always strengthen the lung muscles very much, lack of physical work or exercise give no room for deep breathing in present era. It is always advisable to learn Yoga from a good teacher. Pranayama is the most important and formal practice of controlling the breath, which is the source of vital life force. Meditation is a unique and powerful tool for stress release. Generally, stress exacerbates asthmatic disturbances very often along with hypertension. Following Yoga practices are some of the specially good for lung health in general. 1.Trikonasana (triangle pose).2.Naukasana (Boat Pose).3 Malsysana or Fish Pose. 4.Arthsmatsendrasana (sitting half spi-

Pure, clean water is essential to keep blood flowing to and from the lungs. It also keeps our lungs hydrated and the mucus flowing. Staying well hydrated by taking in fluids throughout the day helps keep the mucosal linings in the lungs thin, this thinner lining helps the lungs function better.




nal twist). 5.Bending exercises. 6. Pranayama. 7. Simhasana (Lion Pose). With regular deep breathing exercises, you can easily strengthen your lungs. It can also help clear out toxins that may have built up in the lungs. To practice, sit down in a relaxing and quiet place. (a). Close your eyes, and breathe in deeply through your nose. (b). Count to five, slowly inhaling the entire time. (c). Hold your breath for a few seconds, then exhale slowly. (d). Repeat this breathing exercise 6 to 8 times. Perform this deep breathing exercise on a daily basis to help cleanse your lungs and keep you stress free. (4). Counting (holding) on your breath: You can also increase your lung capacity by increasing the length of your inhalations and exhalations. Start by counting how long a natural breath takes. If it takes to the count of five to inhale it should take to the count of five to exhale. You’ll want them to be of equal length. (5). Indoor plants such as a fern, spider plant, peace lily, bamboo palm, aloe vera, English Ivy, dracaena and others do help in lung health. Make sure to grow them in your living area and keep the foliage dust-free. Also, do not overwater the plants as it may lead to mold growth. (6). Staying hydrated: Water plays a huge role in health and is the base of any cleansing action. Pure, clean water is essential to keep blood flowing to and from the lungs. It also keeps our lungs hydrated and the mucus flowing. It may sound disgusting, but that mucus is important and needs to be the right consistency for the cilia to move it—along with toxins, microbes, and pollutants out. Staying well hydrated by taking in fluids throughout the day helps keep the mucosal linings in the lungs thin, this thinner lining helps the lungs function better. Patients shall take care to take preventive medications, such as inhaled corticosteroid which can cut the risk of asthma attacks, and rescue medications, such as al buterol inhalers, to stop symptoms like coughing or wheezing. Abstinence of the essential medication will pave way for cardiac complications.

Guidelines Good Laboratory Practices

Understanding the Urine Chemistries... Sanjaymon K.R., Asst. General Manager - Marketing, Agappe Diagnostics Ltd.

Chemical examination of urine is one of the simplest ways to

understand many disorders associated with kidney. Unlike serum, the excess volume of urine makes it easy to perform the tests. In general, there are two kinds of estimation. Spot urine estimation 24-hour urine estimation Spot urine estimation is the commonest or the simplest way to check the chemical nature of the urine and the most common tests include the chemistries like Protein, Glucose, Ketones, Bilirubin, Nitrite, Occult blood, Urobilinogen; electrolytes like Sodium, Potassium and Chloride; Ions like Ca, Phos-

phorous, Uric acid and sometimes Magnesium. With the advancement in technology, most of the chemical tests are performed using Urine chemistry strips (e.g.Ultrastik), which have specially treated areas with specific individual testing parameters. The strip is dipped in urine, the specific change in the colour is compared to the colour chart and the analytes are expressed in semi quantitatively. A fresh urine sample is preferred for the urine chemistry estimation. In some particular cases, instead of spot urine, clinicians may ask for 24-hour urine sample to have a better understanding of the condition. The major parameters required are




Guidelines Good Laboratory Practices Protein, Urea, Creatinine, Calcium, Uric acid & Phosphorus.

24-hour Urine Protein A 24-hour urine protein test is required when the patient has symptoms of glomerulonephritis or nephrotic syndrome. It may also be needed in conditions like uncontrolled diabetes, high blood pressure, urinary tract infection etc. To perform the test, urine excreted during 24 hours is collected in a big sterile container. The container has to be clean and usually a 5 litre can willbe sufficient for this purpose. Since the normal flora seen in the urine will start protein production up on keeping for long time, a 25-30 mL of toluene is added to the jar as a preservative. Laboratory personnel should convey the patient not to throw out the toluene inside which will elude the purpose of the test. The patient needs to be instructed to make sure that all the urine passed during 24 hours is collected into the container without fail. After the completion of 24 hours, the sample needs to be collected and tested immediately for accurate results. For testing, the sample needs to be measured for the total volume and needs to be written along with the sample demographics for further calculation. There are many methods available today for protein estimation and the simplest way is using Pyrogallol Red method. Before quantitative estimation, a qualitative estimation of the protein needs to be performed using strips or any other simple protein tests. In case the qualitative test is negative, the urine can be used directly for the final protein testing and in case the qualitative test is positive (protein trace or above), the sample needs to be diluted 1: 10 to 1:100 in distilled water based on the degree of qualitative protein results. It is always recommended to use at least 1 mL of urine for making the dilutions since a higher volume will always give better results compared to lower volume dilutions. It is always better to have two different dilutions in case the protein is high and the mean of concordant values can be reported. The results are usually expressed in mg/L and or in mg/ 24 hours. Let us take a sample where the volume is 1980 mL and supposing we got the protein value as 12 mg/dL from the analyser, the result is calculated and expressed as below: Protein Concentration = 12 x 10 = 120 mg/L 24-hour Protein Excretion= 120 x 1980/1000 = 237.6 mg/ L/24 hours




Urine Creatinine Creatinine is a waste product that is continuously filtered out of the blood by our kidneys. A creatinine urine test evaluates how well your kidneys are working by measuring the amount of creatinine in your urine. Urine creatinine is performed to understand how well the kidneys are functioning and a 24-hour urine is estimated to have a better understanding. It also helps to rule our late stage muscular dystrophy. While collecting the urine, care should be taken to avoid high protein diet which may falsely elevate the results. As in the earlier case, the urine needs to be collected in the specific container containing preservative. After completion of 24 hours, the sample needs to be processed immediately. Since the amount of creatinine will be high in the urine, the recommended dilution is 1:50 or above using double distilled water. Creatinine can be estimated using Jaffe Creatinine method and now a dayâ&#x20AC;&#x2122;s Enzymatic creatinine with linearity of 200 mg/dL is used to test the urine without dilution. The result is used to calculate the creatinine clearance using the formula below: Urine Creat(mg/dl) Serum Creat (mg/dl)


Vol. of Urine {ml) Collection Period (min)

Let us take a case as below: Urine volume = 2040 mL Urine Creatinine = 180 mg/dL Serum Creatinine = 1.2 mg/dL Creatinine Clearance = 180/1.2 x 1980 /24x60 = 206 mL/min

One among the other calculated tests is Protein Creatinine ratio where the Urine Protein to Creatinine ratio is calculated as indicator of glomerular filtration rate.

Urine Calcium Calcium is one of the most common mineral in the body. The major use of calcium is to build and repair bones and teeth. It also helps in clotting of blood and nerve function. The major amount of calcium is stored in bones and in circulating blood. When calcium levels in the blood get too low, the bones release enough calcium to bring the level in the blood back to normal and when calcium levels get too high, the surplus of calcium is either stored in bones or expelled from the body through your urine or stool. Estimation of calcium in urine is used as a tool to understand development of kidney stone, to check the dietary intake, to understand absorption of calcium, check calcium loss from the bones, to check the parathyroid gland and to know the kidney function. Since the amount of calcium will be very low in urine normally, a lower dilution (1:5) is recommended while performing the test. Care should be taken that the apparatus used is acid-washed since calcium is a very sensitive test. It is preferred that the sample is refrigerated for preservation; however, toluene can also be used as a preservative for 24-hour collection. Urine phosphorus and uric acid are the other tests usually used to understand the presence kidney stone, which is also performed similarly as that of calcium. Uric acid also helps understand gout. In most cases, clinicians prefer complete test profile to have a better diagnosis rather than doing the tests individually. Even though the tests described above are very simple to perform, the common errors happen during sample collection and handling rather than at the analytical level.

Creatinine is a waste product that is continuously filtered out of the blood by our kidneys. A creatinine urine test evaluates how well your kidneys are working by measuring the amount of creatinine in your urine. In most of the cases, the error happens in protein where the patient throws out the preservative in the container due to lack of knowledge and this, in turn, will give rise to higher protein level in the sample due to the bacterial actions. Strict instructions need to be given to the patient to collect the entire samples in the container without fail or else this can lead to improper calculations and inconclusive results. There are chances of error while measuring the urine where the person may fail to properly note down the total volume of the measured urine. It is recommended to use a litre measuring jar to measure the sample and immediately transfer approx. 25 mL of the sample to two containers with proper labelling after the first measurement. This is to prevent the accidental discarding of samples completely. It is recommended to give patient complete instructions in advance and dietary restrictions if any to have the proper sample collection. Even though the tests are very simple to perform, in 24hour urine estimations, laboratories should take care that the sampling is performed well with proper instructions to the patient. Care should be taken to ensure that the proper preservatives are used for the assured quality of results.

Urine Analyzer It offers ideal urine analysis solutions for smal l laboratories 11 assay parameters with Micro al bumin Large capacity of 1000 Patient memory for reviewing Through put is 120 strips/Hour Built in thermal Printer can print result automatically 4 wave length cold light source ensures the result accuracy




Brand Reach Customer Speaks


Very user -friendly pr oducts user-friendly products “Recently, we purchased Agappe’s FAA, Mispa Ace. It’s very user-friend ly to operate and we are quite happy with the performance as well. Both the internal and external QCs come in target/1sd rang.

Atul Chaudhari, Managing Director, Shreeram Clinical Laboratory, Jamner.


Mr. Prakash Pinto, Senior Lab in charge, Colaco Hospital, Mangalore.


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

Touchstone standar ds standards I am using Mispa Ace for last 5 months. I am satisfied with the working of the machine. We are working with other higher end fully automated machines also but I am using ACE as a reference machine for abnormal samples.

Mr. Raghu, Managing Director, Poly Lab, Thalassery.

Quality pr oducts at par with products International standar ds standards Dr. Shreyas Modi, Clinical Pathologist, Modi Laboratory, Vadodara.




We had recently instal led Agappe med ium throughput clinical chemistry analyser, Mispa Ace in our lab. We are very much satisfied with the machine’s performance and the overall support provided by Team Agappe. I am also happy to endorse the quality of reagent provided by Agappe since it’s at par with quality of International brands and yet economic.


Thank you Agappe for Mispa Ace Dr. C. Bharath Chandran, Managing Director, Royal Hospital, Trivandrum.


I am using Mispa Ace, Agappe’s 100 throughput clinical chemistry analyser for the last 6 months. We are happy with the machine’s performance and the quality of test results. I have noticed that the machine is very well suited to perform immunoturbidimetry parameters. Thanks to team Agappe for your extensive support.


Accurate rresults esults and excellent after after-sales service I am pleased to say that we are using Agappe reagents for the last 7 years. We are satisfied with the results and accuracy of the products. Presently, we are using Agappe Glucose, Cholesterol, triglycerides, HDL direct, LDL direct, SGOT, SGPT, Bilirubin, Alkaline Phosphate, Analyze, Lipase, Urea, enzymatic creatinine, Uric Acid, Albumin and Total protein, CRP SensIT, RAF SensIT and control and calibrators parameters in our ful ly auto Mispa Nano and semi auto Merck 300 analyzer. The result is excellent. Agappe provides good after-sales services and application service support. I expect more new quality products from Agappe in future.

Dr. N. K. Pehlajani, Shanti X-Ray and Pathology Centre, Bhopal, Madhya Pradesh.

Compact, user -friendly pr oducts user-friendly products with speedy rresults esults

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


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




Brand Reach Customer Speaks


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

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

High quality pr oducts products Dr. Keerti Geol, Unique Clinical Lab, New Del hi.


We are using Agappe blood grouping, HDL and SGPT regularly in our laboratory (Unique path lab) and we are satisfied with quality of reagents and will continue the same.

Best quality rreuslts euslts I have been associated with Agappe Diagnostics for its quality reagents for the last fifteen years. Now, we are very confidently using HbA1c kit. We are very satisfied with the product for its quality result.

H. Edward Sam, Viji Laboratory, Thuckalay, Tamilnadu.

Incr eased customers due to pr ecise Increased precise results of Agappe pr product oduct Dr. G K Agrawal, Agrawal Clinical and Diagnostic Centre Ajmer, Rajasthan.





We have started using Agappeâ&#x20AC;&#x2122;s HbA1c direct with calibrator recently at our diagnostic centre. We found that the product quality is up to our satisfaction mark. Our referring doctors and patients are also happy with the reports. We are using it for the last three months till date, no adverse comments has come to us with regard to its result. The number of our HbA1c patients is increasing day by day. Thanks to Agappe for supporting us with quality HbA1c kit.


Innovative pr oducts and good after products sale service backup


I personally believe that Agappe is dedicated in producing high quality products, either machines or reagents. Dr. Neyaz Ahmad, Care Diagnostics, Purnea.

I am using Mispa i2 and Mispa Neo for nearly one and half years. Mispa i2 is one of the best products available in diagnostic field in terms of innovative design, high quality results and cost effectiveness. They provide good after sale service backup also. I expect more quality products from Agappe in future.


Gr eat service â&#x20AC;&#x201C; machine wise and Great after sales wise! I am a user of Mispa i2 for the last 2 years and very much satisfied and impressed with the performance of the machine. I really appreciate the prompt service provided by their service team and their attitude in responding to any of my query. A good team with quality products!

Dr. B.N. Prasad, Sri Krishna Diagnostic Laboratory, Muzaffarpur.

Excellent pr oducts, especially the products, HbA1c kit

Dr. R.D.Antani, Omkar Healthcare and Diagnostic Center, Mumbai.

We have been using Agappe products, ie. their reagents and equipments for a long time. Amongst the machines, we have Mispa Nano-A fully automated chemistry analyzer, two BC 3000+ the three parts blood cell counter and Mispa Clog-A single channel Coagulometer. Their equipments are in use for a period of 3 to 5 years. The performance of the machines as well as the service is much more than satisfactory. Reagents of almost all routine chemistry that we perform are almost exclusively of Agappe for the last three years. I have found them to be satisfactory. Special mention should be made regarding HbA1c kit which I feel is excellent. Hereâ&#x20AC;&#x2122;s, wishing Agappe all the best and hope you keep up the good work.





Engagement Exhibitions & Conferences

Agappe’s participation in Medica 2016 on 14th - 17th of November 2016 at Exhibition Centre, Dusseldorf, Germany.

Agappe’s participation in AMBICON 2016 on 18th - 20th of November 2016 at Hotel Radisson Blu, Guwahati.

Agappe’s participation in 65th Annual Conference of IAPM and Annual Conference OF IAP-ID (APCON 2016) on 1st-4th of December 2016 at B. M. Birla Auditorium, Jaipur.

Agappe annual business partner conference (AGAPCON 2016) was conducted very successfully from 14th - 16th of October 2016 at Hotel Marriot, Hong Kong.

MORE PLACES TO KNOW ABOUT US MEDLAB (MIDDLE EAST)-LARGEST LABORATORY EXHIBITION & CONGRESS IN THE WORLD 6 - 9 February 2017, Stal l No. Z4-E20, Dubai International Convention & Exhibition Centre, Dubai.

MEDLAB is the world's largest medical laboratory exhibi-

Agappe’s participation in 43rd Annual Conference of Association of Clinical Biochemists of India (ACBICON 2016) on 12th -15th of December 2016 in Mangalore.




tion. Arab Health and MEDLAB have always co-existed as a flagship healthcare event. However, due to 15 years of successful growth, the upcoming edition of MEDLAB is now independent of Arab Health, and wil l take place from 6-9 February 2017 at the Dubai International Convention & Exhibition Centre as a stand-alone show.

Engagement Special Days JANUARY


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



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



SPECIAL DAYS March 03 World Wild Life Day March 10 World Glaucoma Day March 10 World Kidney Day March 15 World Disable Day March 20 International Day of Happiness March 21 World Down's Syndrome Day March 23 World Tuberculosis Day


New Product Be in touch with us at our toll free number


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Haemostasis determination (Coagulation Analyses) The only instrument in the segment with smart card technology Photometric detection with mixing for accuracy ISI value in the smart card Dual channel technology for accurate results


Test Panel


Tests per kit











Bi-Level Coagulation Control

2x1 mL (Pack Size)



Focus Product Be in touch with us at our toll free number


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100 Test/hour | Compact in size | Reverse optic with 8 wave length Real time monitoring of reaction curve | Spot photometry with high speed digital transmission system | Precise and accurate testing results



Awards Indywood Medical Excellence Awards 2016 Agappe Honoured with Indywood Excellence Awards 2016 organised in association with World Medical Council for its efforts and significant achievements which has contributed towards improving the quality of healthcare facilities and disease diagnosis.

Product Innovation Award-2016 The ABP News has selected Agappe's Mispa-i3 towards the "Product Innovation Award" during the award cer-emony held on 23rd Novem-ber 2016 at Hotel Taj Lands' End, Mumbai. Dr. D. M. Vasudevan, Technical Director, has received this recognition on behalf of AGAPPE.

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




Medical Quiz


Who is the father of Respiratory Medicine in India ………?


Dr. Farokh Udwadia b) Dr. Rangabashyam c) Dr. K A Ashok Pai d) Dr. Jacqueline Perry


What is Haldane effect?


Nephrons degeneration b) Hepatocytes dysfunction


Deoxygenated Hemoglobin binding with Co2 d) None


A normal healthy person breaths ……… times per minute


12 – 16 b) 8 – 10 c) 15 – 30

d) 5 – 10


A healthy man can inspire or expire approximately …….. ml of air per minute


2500 – 3000 ml b) 500 ml


D-Dimer assay can be used to exclude ………..



b) CHF


c) 1000 – 12000ml d) 6000 – 8000 ml



Form of Pulmonary edema is caused due to ………….


Heart failure


Severity of heart failure can be diagnosed by …………..


Trop T

b) Cerebral ischemia c) Hepatitis d) None

b) Trop I

c) NT pro BNP d) CK MB


Symptoms of Chronic Obstructive Pulmonary Disease


Increased breathlessness b) frequent coughing & Wheezing c) Tightness in chest d) All the above


Alpha 1 antitrypsin is the most commonly known genetic risk factor for…………..




Early respiratory tract infection or severity of it can be diagnosed by ………….



b) Liver problem

b) PCT

c) CBC

c) Emphysema

d) All the above

d) All the above

Quiz Answers of October-December Ed ition 1-a, 2-a, 3-c, 4-b, 5-c, 6-d, 7-a, 8-d, 9-b, 10-d

Winners will get their prize by post

Quiz Winners of October-December Edition Dr. R. V. Arun, Vellore | Jose Mary. K, Mangalore | Dr.Apurva Arora, Taran Taran | Mini Shaji, Thrissur | Arshiya Banu | Dr. Sfoorti Goswami, Bhavnagar | Mr. Mohan Kumar, Bagalur | Chinnu Poulose, Angamaly | Dr. Biswajit Batabyal, Kol kata | Dr. Jude Winston Vaz, Bombay | Dr. Rajkumar Palani, Puthur | Dr. Go Bharani, Vellore

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




Editorial Submissions What do you think of this edition of

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

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

Postal address:

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

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




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

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

Techagappe January - March 2017 E-Book  
Techagappe January - March 2017 E-Book  

Techagappe 10th Edition (January - March 2017) Ebook. Agappe Diagnostics Limited is the first Indian IVD company publishing an International...