Nov-Dec-2016 by Zyaul Designer

EDITOR EVENT SPEAK

Role of Digital India in Healthcare Arena We all know that healthcare plays a very crucial role in our life. Nowadays healthcare has become one of India’s largest sector-both in terms of revenue and employment. The Indian healthcare sector is growing at a brisk pace due to its strengthening coverage, services and increasing expenditure by public as well as private players. Digital health is the key pillar of with which the healthcare management can be made more efficient. Health Information Technology supports health information management across computerized systems and the secure exchange oh health information between consumers, providers and payers. Healthcare IT has improved healthcare quality, increase healthcare productivity, prevent medical errors. It reduces healthcare accuracy and healthcare costs. The digital healthcare market grew at a CAGR of 13.21% in the period 2011-2015,and for 2016-2021 the growth rate is expected to be at 15.05%.Research estimates that the health market will be nearly 18 billion in 2016 alone and its further growth will be 40% over next few years. The digital health market is growing at a significant rate because of growing demand for advanced healthcare information, and grow in investment by healthcare information technology players. The very well known factors like privacy, security issues, inadequate healthcare infrastructure are responsible for the growth of digital healthcare market. Market size-The overall Indian healthcare market is around 100 billion and is likely to grow to 280 billion by 2020.The healthcare information technology market which is valued at 1 billion is expected to grow at 1.5 times by 2020.Across the country 3,598 hospitals and 25,723 dispensaries are offering AYUSH treatment. The Indian medical tourism industry is pegged at 3 billion per annum,with the tourist arrivals at 230,000.The Indian medical tourism is expected to reach 6 billion by 2018. The Prime Minister Shri Narendra Modi has envisioned the digital India programme to transform India into a digitally improved society & knowledge economy. The programme symbolizes to connect and empower 125 crore citizens, creating transparency and accountability in governance. Several initiatives under this programme have been implemented and some of the recent achievements of Digital India are: Have an insightful reading.

Your suggestions are most welcome! E-mail: editor@medgatetoday.com Website: w w w . m e d g a t e t o d a y . c o m

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6 8 52 Identification and enumeration of circulating tumor cells in neuroendocrine �� 10 Man develops *acute hepatitis* from consuming too many energy drinks �� 10 India’s first International Coronary Congress Inaugurated by Hon’ble President of India �� 12 Voice of Healthcare formed a National Healthcare Council to reform healthcare facility �� 14 India’s Next Epidemic: 1.8 Million Die from Stroke Every Year �� 16 BMJ Awards South Asia 2016 �� 20 Common Childhood Diseases in Winter �� 24 How to Manage Erectile Dysfunction (ED) �� 28 Identifying Fibromyalgia A Common Pain Problem in Females �� 30 Pregnancy from Day One? Know your baby genes well �� 32 A New Vision of Architecture to Provide High Comfort Level to Public �� 40 44 Infrastructural Siames Twins �� 43 Designing Of Critical Care Areas �� 46 Total Knee Replacement The Latest Trends �� 50 Identifying Fibromyalgia A Common Pain Problem In Females �� 54 Stent retriever improves outcomes for stroke patients �� 55 Advanced Transport SolutionFor Hospitals & Diagnostics �� 60 Call Systems, Bed-Head Panels, Pendants �� 62 Informed Analytics: The Future of Efficient Healthcare Delivery �� 64 PM2.5 - The darker side of Industrialization �� 66 Hospital & Healthcare Architecture Pneumatic waste and Laundry Collection System (PWLCS) : The Start of A New Era �� 68 TSRI Scientists Discover Antibodies that Target Holes in HIV’s Defenses ��

Healthcare no longer lives in the Metros – Niira Radia ��

DR. PRADEEP BHARDWAJ CEO & MEDICAL DIRECTOR, SIX SIGMA HEALTHCARE NEW DELHI

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TSRI Scientists Discover Antibodies that Target Holes in HIV's Defenses

New Findings Could Lead to New AIDS Vaccine Candidates A new study from scientists at The Scripps Research Institute (TSRI) shows that “holes” in HIV’s defensive sugar shield could be important in designing an HIV vaccine. It appears that antibodies can target these holes, which are scattered in HIV’s protective sugar or “glycan” shield, and the question is now whether these holes can be exploited to induce protective antibodies. “It’s important now to evaluate future vaccine candidates to more rapidly understand the immune response they induce to particular glycan holes and learn from it,” said TSRI Professor Dennis R. Burton, who is also scientific director of the International AIDS Vaccine Initiative (IAVI) Neutralizing Antibody Center and of the National Institutes of Health’s Center for HIV/ AIDS Vaccine Immunology and Immunogen Discovery (CHAVI-ID) at TSRI. The study, published recently in the journal Cell Reports, was co-led by Burton, TSRI Associate Professor Andrew Ward, also of CHAVI-ID, and Rogier W. Sanders of the University of Amsterdam and Cornell University.

A Clue to Stopping HIV Every virus has a signature structure, like the architecture of a building. By solving these structures, scientists can put together a blueprint showing where HIV is vulnerable to infection-blocking antibodies. In the 1990s, scientists discovered that HIV can have random holes in its protective outer shell of glycan molecules. Until now, however, scientists weren’t sure if antibodies could recognize and target these holes. Researchers at Cornell and TSRI had previously designed a stabilized version of an important HIV protein, called the envelope glycoprotein (Env) trimer, to prompt rabbit models to produce antibodies against the virus. In the new study, the plan was to reveal HIV’s vulnerabilities by examining where the antibodies bound the virus. “From work on HIV-positive individuals, we knew that the best way to understand an antibody response is to isolate the individual antibodies and study them in detail,” said Laura McCoy, a TSRI, IAVI and CHAVI-ID researcher now at University College London, who served as co-first author of the study

with TSRI Senior Research Associate Gabriel Ozorowski, also of TSRI and CHAVI-ID, and Marit J. van Gils of the University of Amsterdam. To their surprise, when the researchers examined the rabbits’ antibodies, they found three rabbits had produced antibodies that targeted the same hole in Env. It appeared that antibodies could indeed target holes in the glycan shield. “This opened up a whole new concept,” said Ozorowski. If the immune system was targeting this hole—preferring it to other vulnerable spots on Env—maybe holes would be especially important in designing vaccine candidates 

366 Visitors Turn up to IIFL Home Loans’ Health Camps for Free Check Up With an eye to foster health, happiness & productivity among people, IIFL Home Loans, one of the leading housing finance companies of India successfully organized 7 Health & Eye camps across Maharashtra and Uttar Pradesh under the ambience of specialized health professionals. It deepened its presence in Virar, Boisar and Mumbai MMR (Maharasthra) by successfully organizing health camps

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free of cost. Health conscious citizens also turned to free eye check up camps at Gomti Nagar and Alam Bagh in Lucknow. The total beneficiaries’ count in Maharashtra is 298 and in Lucknow it is 68. This health initiative has been taken for the benefit of the public. The free check up and consultation time at every camp was scheduled from 10 AM to 4 PM.

NEWS Update

Healthcare no longer lives in the Metros – Niira Radia Nayati Healthcare announces commencement of Multi Organ Transplant programme from January 2017 Keeping in line with its vision to provide the best in healthcare to the patients in Tier II & Tier III cities, Nayati Healthcare today announced the commencement of its Multi Organ Transplant programme. The announcement was made during the national level conference that was organised on liver and pancreas titled " New Frontiers in Liver and Biliary Sciences - A Nayati Healthcare Convention" .The conference saw experts from the field share their experience and knowledge with local doctors. More than 400 doctors (physicians, surgeons, Dean of medical colleges, IMA officials) attended the day- long seminar. The event included lectures, panel discussions and master videos. Announcing the commencement of the Multi organ transplant programme, Niira Radia, Chairperson, Nayati Healthcare stated “As we progress in the journey of transforming the face of healthcare in India we are set to create yet another milestone. We will be commencing the Multi Organ Transplant programme for liver and renal from January 2017. The unit will be equipped with state of art technology and best in class doctors and specialists. This region has an acute shortage of expert liver and renal transplant programmes. As a result the patients from the state head to centres in Delhi NCR or other metros. It is the need of the hour to have a Tertiary care centre in the region and create awareness about the disease and treatments available amongst the patients & doctors community. “ “Healthcare no longer lives in the Metros. It is time for the hospitals operating in Metros to move and set up good healthcare infrastructure in tier II & III towns where healthcare matters. Families face huge plight when they have to cope, not only with the disease of a loved one, but the distance adding to the emotional and financial burden of treatment in cities. Our commitment is to get the best care to the patient and thereby reduce the social, emotional and economic burden of treatment.“ she further added. Pioneer of split liver transplant Prof. Mohammed Rela, stated “Unlike in the past where liver transplant had poor survival rates, these days liver transplant success rates is 90%. Modern technology and methods enable that one liver donor can help two to three patients. “ Dr. R K Mani, CEO Medical Sciences, Nayati Healthcare stated “ Nayati will continue to bring in the best in healthcare for the region and we will work with the clinicians in the region on an academic front. This is the first amongst many more which will be organised by us. This unique interactive session saw participation of doctors and surgeons from across the region – Agra, Aligarh, Mathura, Bharatpur, Ettah, Etawa. 8

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Some of the faculties present at the day long interactive session “ New Frontiers in Liver and Biliary Sciences were Prof. Mohammed Rela, Professor of Liver Transplant and HPB Surgery Kings College Hospital, London, Director & HOD, Liver Transplant and HPB Surgery Global Hospital, Chennai; Prof. Samiran Nundy, Dean, Academics & Member, Board of Trustees, Sir Gangaram Hospital, New Delhi; Prof. Shailesh Shrikhande, Head of GI & HPB Surgery, Tata Memorial Hospital, Mumbai; Dr. Hitesh Chavda, Chief, Liver Interventional, Radiologist, Sir Gangaram Hospital, Ahmedabad; Dr. Sanjiv Saigal, Chief, Liver Transplant, Hepatologist, Medanta Medicity Gurgaon; Dr. K. Ilangkumaran, HOD Liver Intensive Care and Anaesthesia, Global Health City, Chennai The Nayati Centre of Excellence for Gastrointestinal and Hepato Pancreato Biliary (HPB) Sciences will be concerned with screening, early detection and management of liver related disorders. The centre has three divisions - Department of Minimal Access Gastrointestinal, Pancreatico Biliary & Bariatric Surgery; Department of Liver Transplantation and Regenerative Medicine and Department of Medical Gastroenterology and Hepatology. Dept. Of Medical Gastroenterology & Hepatology will be primarily concerned with the prevention and medical management of the gastric & liver diseases. The Department of Liver transplant & Regenerative medicine will be concerned with Surgical management of patients having end stage Liver diseases .The surgical management will include the complex hepatobiliary surgeries including Liver transplantation.

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NEWS Update

Identification and enumeration of circulating tumor cells in neuroendocrine tumor patients with GILUPI CellCollector® GILUPI GmbH announces, that in August 2016 a published scientific paper demonstrated for the first time circulating tumor cell (CTCs) isolation in neuroendocrine tumor patients with GILUPI CellCollector®. Isolating and analyzing circulating tumor cells as a "liquid biopsy" can be an additional source of diagnosis, prognosis, evaluation of treatment efficacy and molecular tumor evolution and metastatic sites. CTCs have been, so far, identified in patients with metastatic neuroendocrine tumor (NET) using a comparator method with limited sampling volume that leads to the detection of low frequency CTC numbers. Professor Tim Meyer and his

group from the UCL Cancer Institute, University College London wanted to overcome this limitation and increases CTCs numbers by using the GILUPI CellCollector®. In their study, the researcher used the GILUPI CellCollector® and the comparator method. In total, 34 patients with metastatic NET were enrolled and the GILUPI CellCollector® was used to isolate CTCs in vivo. Applying the GILUPI CellCollector® in 33 of 34 NET patients CTCs were found with a median of 6 CTCs. In comparison, in only 16 of 34 NET patients with a median of 0 CTC could be detected with the comparator method. More importantly, the researcher investigated

the prognostic relevance of CTC count with GILUPI CellCollector®. Using a cut-off of 7 CTCs, the progression free survival of patients with less than or equal 7 CTCs was in median 11 months compared to patients with more than 7 CTCs had a significantly lower progression free survival. Further studies are needed to validate this finding to potentially aid the treatment of patients with neuroendocrine tumors.

Man develops *acute hepatitis* from consuming too many energy drinks The patient developed acute hepatitis most likely due to his intake of energy drinks, and independently of his underlying chronic hepatitis C infection. A 50-year-old man was admitted to the emergency department with acute hepatitis, most likely due to his intake of 4-5 energy drinks every day for 3 weeks, reveal doctors writing in the journal BMJ Case Reports. After the man started consuming energy drinks, he developed malaise, anorexia and worsening abdominal pain, which progressed to nausea, and vomiting. He originally thought his symptoms were down to a flu-like syndrome. However, he became alarmed when he developed dark urine and generalized jaundice. He didn't note any changes in his diet or use of alcohol, tobacco, or illicit drugs, apart from consuming energy drinks. As a construction worker, he used the energy drinks to help get through his labor-intensive workday. Physical examination revealed jaundice and right upper abdominal tenderness. Lab tests revealed high levels of liver enzymes, called transaminases, indicating liver damage, and evidence of chronic hepatitis C infection. Liver biopsy showed severe hepatitis. Doctors who treated the man explain that his development of acute hepatitis was likely due to excessive energy drink consumption, specifically vitamin B3 (niacin). His intake was around 160-200 mg daily, below the threshold expected to cause toxicity, but similar to a previously 10

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reported energy drink associated hepatitis (around 300 mg of niacin daily). Toxicity is likely worsened by accumulative effect. Each bottle of his energy drink contained 40 mg of Niacin, or 200% of the recommended daily value. The patient was treated with close observation, frequent monitoring, and symptom management. He discontinued consumption of all energy drinks and he was advised to avoid any similar niacin-containing products in the future. Around 50% of cases of liver failure in the US are due to drug induced liver injury, explain the doctors. The list of associated drugs and toxins has significantly grown as the market for dietary and herbal supplements continues to rapidly expand. Estimates suggest approximately 23,000 emergency department visits each year are due to adverse events related to dietary supplements. "As the energy drink market continues to rapidly expand, consumers should be aware of the potential risks of their various ingredients. Vitamins and nutrients, such as niacin are present in quantities that greatly exceed the recommended daily intake, lending to their high risk for harmful accumulation and toxicity," they conclude.

NEWS Update

India’s first International Coronary Congress Inaugurated by Hon’ble President of India Shri Pranab Mukherjee Day two of International Coronary Congress 2016 organised by Medanta Hon’ble President of India, Shri Pranab Mukherjee inaugurated the second day of International Coronary Congress, organised by Medanta The Medicity. The ICC 2016 is a three day event that began on November 11, 2016. The ICC 2016 will be a first-of-its-kind comprehensive course on coronary artery disease management bringing together the most eminent cardiac surgeons and cardiologists from the world on the same platform for a comprehensive overview of the subject. The objective of ICC 2016 is to break the stereotype mind set of individualistic approach of coronary artery disease management towards more broad-based approaches built on consensus. It is the most comprehensive course on updated coronary artery disease management to meet the unmet needs of young cardiac surgeons. Highlighting the need of the hour, Dr Naresh Trehan,Chairman, Medanta the Medicity said “I was glad to be a part of the first ever ICC which was first held in New work last year directed by Dr David Taggart and Dr John D. Puskas. Inspired by the initiative, the Medanta team decided to introduce the one HEART TEAM concept in India for best treatment strategies for the patients.” “The ICC 2016 is successful with the presence of doctors from International and National faculty”, he added. While addressing the audience at the first ICC 2016 in India, Shri Pranab Mukherjee, the Hon’ble President of India said “Cardiovascular diseases are a leading cause of deaths globally. Among cardiovascular diseases, Coronary Artery Disease (CAD) has the largest stake in taking lives of the people. The precious assets of our nation – the young population - are becoming increasingly

vulnerable to CAD and heart attacks. By 2020, India may account for 60 percent of the world’s heart patients.” “This international conference, to my mind, is a great platform where steps necessary to strengthen our healthcare system into one that is universally accessible, affordable and effective can be discussed,” he added. Felicitating the guests at the event, Dr Praveen Chandra, Chairman, Division of Interventional Cardiology, Medanta The Medicity said, “ICC 2016 has given a platform to enhance scanning & implementation of best treatment. Today, none of the patients go out of India for complex surgeries such as Angioplasty and Bypass.” This event has brought together the Cardiac surgeons, interventional cardiologists, clinical cardiologists, general practitioners, nurse practitioners, Cath lab technicians, and other healthcare professionals with a special interest in the field of cardiovascular medicine.

Dr. Trehan and Baba Ramdev announced the fusion of modern and ancient medicine at International Coronary Congress 2016 ICC 2016 concluded with a discussion on holistic healing of heart diseases The renowned Yoga Guru, Baba Ramdev and Dr. Naresh Trehan, Chairman, Medanta The Medicity, discussed about holistic healing of heart diseases by Yoga, Ayurveda and meditation along with modern diagnostics on the concluding day of India’s first International Coronary Congress, organised by Medanta The Medicity. The ICC 2016 was a three day event that began on November 11, 2016. During the discussion, the experts viewed that the fusion of modern medical system and ancient medicines will help in healing various heart related ailments like hypertension, high cholesterol, high blood pressure, arthritis, etc. While addressing the audience, Dr Naresh Trehan,Chairman, Medanta the Medicity said “Around six crore people in India already 12

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have heart related diseases and another six crore are in line. The current modern medical systems treat patients using methods like antibiotics, chemotherapy, surgeries, radiation, etc. but even after successful surgeries, the patients’ body is left in great trauma.” He further added, “The fusion of both- modern and ancient medicine- helps strengthen your body and fight diseases. This new-era medicine will emerge from India and will also benefit the people who are unable to access quality healthcare services.” Stressing on the importance of Yoga and Ayurveda, Yoga Guru Baba Ramdev said, “Less physical activity, stress, unhealthy eating habits, smoking & drinking, undisciplined lifestyle, etc leads to mainly heart diseases, obesity, high cholesterol, hypertension, and high Blood Pressure”. He

further suggested, “Denying daily exercises lead to many diseases; correcting lifestyle and adopting simple exercises in your daily routine will build immunity. These practices can cure almost 99 per cent of diseases”. The ICC 2016 will be a first-of-its-kind comprehensive course on coronary artery disease management bringing together the most eminent cardiac surgeons and cardiologists from the world on the same platform for a comprehensive overview of the subject.

NEWS Update

Voice of Healthcare formed a National Healthcare Council to reform healthcare facility & delivery in India New Delhi : VOH formed National Healthcare Council aimed to act as key strategic and advisory body for the organisation.The council members have been chosen with the view to ensure representation from diverse sectors within the healthcare industry including providers,medical education institutes,diagnostic firms, healthcare VC firms, healthcare IT and allied health institutions with the objective of bringing them together to exchange ideas, business concepts and solutions for improving healthcare. The meet also saw representation from government organizations including NSDC and various consulting/ talent management firms. The session was opened by Dr. Naveen Nishchal, Chairman, VoH, by discussing the short and long term goals of VoH along with the need to form sector wise committees at the state and district level.

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The council members then discussed the broad areas of work for VoH over the next six months and deliberated on opportunities for promoting the organization amongst the larger healthcare community. The NHC meet was graced by Dr. Wali, Physician to the President of India, as Chief Guest and Chief Advisor, VoH. Dr. Dinesh Batra, appointed as President, NHC, threw light on the genesis of VoH,which is to shorten the learning curve of healthcare organizations through dissemination and exchange of knowledge. The Council members unanimously appointed Dr. Vinod Shah(Dean, NIMS Jaipur) as Sr. Vice President and Mr. Mohd. Afzal Kamal (Founder, Medgate Today magazine) as the General Secretary, NHC. Mr. Himanshu Laiker, Director, Strategy, at Medtronic, cited the need for taking medical diagnostics to non-metro cities

NEWS Update

and the role that VoH can play in this area through advocacy and collaboration with providers. This was supported by Mr. Prakash Sharma, Chief Financial Officer, NSDC, who emphasized on skilling and capacity building initiatives in these regions. Dr. Sachin Gupta, stressed on the need to include upcoming organizations such as home health care and patient advocacy groups in the VoH community. Mr. Sanjay Jain, Director, Akhil systems, and Dr. Ravi Gupta, Saral Diagnostics, spoke about the importance of platforms such as VoH in bringing together diverse organizations for voicing the pressing healthcare issues in the country. Mr.Vikram Anand of Capbuild joined as a knowledge partner.

The meeting concluded with potential themes and discussion areas for the upcoming conference on payer and provider collaboration being organized by VoH in January, 2017.Meeting was concluded by vote of thanks given by Mr.Manish Rastogi -of Hosconnn Consultancy (Bengaluru)

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NEWS Update

India’s Next Epidemic: 1.8 Million Die from Stroke Every Year

Dr. Amit Aslam Khan is an eminent neuro-vascular interventionist currently associated with Max Super Speciality Hospital, Shalimar Bagh, New Delhi

Stroke is the second most common cause of death after coronary artery diseases globally. It is also the most prevalent cause of chronic adult disability. However, while stroke threatens mankind all across the globe, developing countries like India account for more than four-fifths of all strokes. The stroke incidence rate in India is much higher than in other developing countries with approximately 1.8 million Indians out of a population of 1.2 billion suffering from stroke every year. Previous hospital-based data from India observed a high proportion of young stroke (first-ever stroke onset below 40 years of age), ranging between 15 and 30 percent. In a recent study at All India Institute of Medical Sciences (AIIMS), out of the 2,634 patients admitted for ischemic stroke, 440 (16.7%) were in the age range of 18-45 years. Stroke is not limited to the elderly only.

In India, common risk factors such as hypertension, diabetes, smoking, and dyslipidemia are prevalent and insufficiently controlled due to low awareness levels of the disease. Another major challenge is that treatment for stroke is still evolving in India. Until recently, physicians have been using intravenous tPA, a clot-busting drug to open blocked blood vessels, as the first line of defense. Five global clinical trials have shown that the addition of stent retriever therapy to IV-tPA improves functional disability in patients and is now recommended as a first-line treatment for acute ischemic strokes. Many people affected by stroke are unable to access treatment and rehabilitation due to lack of awareness. People generally tend to ignore the symptoms of stroke. However, early detection is very crucial because in stroke, 32,000 brain cells are damaged every second the disease goes untreated.

World Heart Federation previews global ‘Roadmap’ to tackle cholesterol The World Heart Federation’s (WHF) Cholesterol Roadmap is being previewed today at the American Heart Association (AHA) Scientific Sessions 2016 in New Orleans, USA. In the Roadmap the WHF calls for more awareness of healthier lifestyles and diet, increased screening and testing for cholesterol in communities; more effective initiation of statin treatment and adherence to drug treatments in primary and secondary prevention of CVD; better detection and treatment of patients with familial hypercholesterolaemia (FH)*; better physician education and support; and reform of drug availability and affordability. The Cholesterol Roadmap forms part of a series produced by WHF to help meet targets set by the World Health Organization (WHO) to reduce premature deaths from non-communicable diseases, including cardiovascular disease (CVD), by 25% by 2025. Reducing the risk of 16

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But ignorance about stroke symptoms, poor infrastructure, and hesitancy about hospital admission even when infrastructure and access are available often leads to delay. Stroke is treatable and its impact can be significantly reduced. The addition of stent retriever technology has reduced disability, improved neurological outcomes and increased the rate of return to functional independence in patients suffering stroke. While stroke is a major public health concern worldwide, the burden on India has been increasing at an alarming rate over the past few decades. The startling statistics show that there is an urgency with which the phenomenon of stroke needs to be addressed in India for reducing the huge stroke burden that the country is facing. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized.

Roadmap is latest in series dedicated to achieving the 25% reduction in cardiovascular disease by 2025 Aims to reduce cholesterol in secondary and primary prevention of cardiovascular disease and in patients with familial hypercholesterolaemia

cholesterol-related CVD has an essential role to play in achieving this goal. Previous WHF Roadmaps have focused on secondary prevention, hypertension (primary prevention), tobacco control, rheumatic heart disease and non-valvular atrial fibrillation, the most common form of cardiac arrhythmia. Professor David Wood, President Elect of the World Heart Federation, said: “Our Roadmap initiative aims to help international efforts to beat cardiovascular disease. We have focused on the main CVD risk areas and produced the Roadmaps to help support individual countries in implementing appropriate health measures.” Cholesterol is a fat-like substance that is found in all cells of the body. If too much bad LDL (Low Density Lipoprotein) cholesterol builds up in the arteries, it can restrict blood flow to the heart, brain and the rest of the body, increasing the risk of heart attack and stroke.

Cholesterol levels vary enormously between populations around the world, a result of both diet and genetic predisposition, and the traditional Mediterranean diet will lower average cholesterol levels, a WHO indicator** to achieve ’25 by 25’. For primary prevention WHO recommends a total risk approach to identify people at high risk of having a heart attack and stroke, taking account of all the major risk factors including blood cholesterol, but most people are unaware of their cholesterol levels or their overall cardiovascular risk. For patients who have already developed CVD reducing cholesterol is central to secondary prevention. But a large treatment gap exists in proportions of patients achieving national targets for cholesterol lowering despite the overwhelming evidence that statins reduce risk and improve life expectancy.

NEWS Update

2 kg baby becomes the World’s smallest to undergo successful liver transplant: Medanta liver doctors create history 2 kg baby cured of liver and bone marrow failure by liver transplant in a world’s first

The dilemma was whether HLH would let us do a successful transplant at all. We cautiously treated HLH and infection for The Medanta Liver Team led by Dr. A.S. Soin, Chief Liver 3 days and proceeded with a high risk transplant which would Transplant Surgeon, and Dr Neelam Mohan, Chief Liver give him at least a 70% shot at life. The usual success rate of Transplant Physician made their way into the record books by transplants at our center is 95%. Without a transplant, the baby successfully operating on David, who at a mere 2.1 kg, became was unlikely to survive beyond a few days.” the world’s smallest recipient of a liver transplant. Prior to this Recounting the several new challenges in David’s case, Dr. Soin one, the smallest reported successful case in medical literature said, “Apart from the poor general condition and medical risk, was 2.45 kg. we knew that such a small baby had never been successfully “Davidwas in severe liver and bone marrow failure when he transplanted before. Similar rare previous attempts elsewhere reached us, malnourished and barely alive. He and his parents had ended in failure in 1-2 weeks. David’s father James, the traveled from Nigeria in the hope that we could save him. While only suitable donor, was about 43 times as heavy. There were the odds weighed heavily against him, we decided to proceed no previous reports of a successful transplant with donor heavier with the rare, first of its kind transplant,” said Dr. Soin, Chairman than 25 times the recipient’s size. This meant we could use only 5-6% of James’ liver for the transplant, whereas usually, about of Medanta Liver Institute. Explaining his disease,Dr. Neelam Mohan, Director of Childrens’ 10-20% of the donor’s liver is used for transplanting children.” Liver Diseases and Transplant, said, “Since birth, he was suffering Dr. Soin further added,“Another problem was that the internal from a rare metabolic disorder called Neonatal Hemochromatosis structure of James’ liver was not conducive to liver reduction (NH) which caused excessive iron deposition in his liver, causing to a very small size. Using novel liver reduction techniques, he it to fail. While his birth weight was 3 kg, the disease ravaged and his team Drs. A Rastogi, Thiagarajan and V Raut managed to him, leading to malnourishment and weight loss. As we are one remove only 6% of the donor liver (termed hyper-reduced monoof the few teams in the world with expertise in transplanting segment 2), without harming its remaining portion. Before the very small babies, the Nigerian doctors referred the baby to us. transplant, we tested our operative strategy by virtual surgery on He came with severe jaundice, bleeding tendency, anemia and a 3D model of the donor liver on CT scan. Once the small piece low blood counts. Detailed evaluation not only confirmed liver of donor liver was removed, it was transplanted into David using failure due to NH, but also revealed bone marrow failure due to high magnification microscopic surgery.” a condition called hemophagocyticlymphohistiocytosis (HLH). vistas of treatment for such little ones who would otherwise die.”

Smt Commences Talent Randomized Clinical Trial of Its Supraflex Stents

Becomes the first Indian Medical Devices Manufacturing company to initiate RCT

SMT (Sahajanand Medical Technologies Pvt. Ltd.) India’s largest manufacturer of cardiovascular medical stents, sets a new benchmark in the Indian industry with the commencement of Talent Randomized Clinical Trial (RCT) for their Supraflex Stents product line. This study will be conducted across 7 countries i.e. United Kingdom, Netherlands, Poland, Spain, Italy, Hungary and Bulgaria in 26 centres with a sample set of 1430 patients. Speaking on the occasion, Ganesh Sabat, CEO, SMT said “We take immense pride to be the first Indian company to have commenced Randomized Clinical Trial in Europe. We are absolutely thrilled and confident from our experience of last 15 years that our product will match the safety

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and efficacy of the best of the technology available in the market. This study will also put Indian medical device industry on the world map and has the potential to make India as a hub for medical device. The biggest challenge faced by medical device player from India is perception factor due to our origin and we believe we can prove beyond doubt about the high quality of our product. We are thrilled and looking forward to the results. This study will enable SMT to aggressively pursue large market share in interventional cardiology market in Europe.” Talent RCT is a clinical trial in which there are minimum two treatment arms. The patient once enrolled will be randomized to either of the treatment arms. The study will be chaired by Prof Patrick Serruys, who is

a prominent opinion leader in the world. He has been at the helm of the biggest and the most important landmark trials which have shaped the current practises in Interventional cardiology. Commenting on the occasion, Bhargav Kotadia, Vice Chairman, SMT said, “Our core value has been bettering the healthcare infrastructure in India and making it affordable and accessible to all. In a move to enlighten our key stakeholders across customers, medical fraternity, and policy makers, we decided to commission this study. The study will compare our product Supralex Stent against globally accepted product from MNC. This trial will set a benchmark and change the perception of people about the Indian stents.

NEWS Update

Awards South Asia 2016 The Most Awaited Healthcare Event in South Asia culminates in New Delhi Recognizing the Stars of South Asian Healthcare

Improving healthcare is difficult and requires courage – this is one of the credos which The BMJ Awards South Asia seek to uphold. The Awards endeavor to recognize individuals and teams who have worked tirelessly to champion the cause of healthcare in South Asia. After the success of BMJ Awards South Asia 2015, this year too, nominations were invited from the south Asia region including India, Sri Lanka, Nepal, Bangladesh, Pakistan, Bhutan, Myanmar and Maldives in numerous categories like healthcare quality, medical education, healthcare innovation and primary healthcare. More than 1500 high-quality nominations were received for the Awards from across South Asia and these were shortlisted to 30 nominations across 10 categories. Winners were presented with a trophy and certificate amongst India’s most senior healthcare professionals, industry executives, government officials, academicians, and researchers.

The winners of the 3rd edition of prestigious BMJ awards were as follows: PG thesis of the year:  Marie Gilbert Majella from JIPMER Pondicherry for her thesis on tuberculosis continues to be a major cause of mortality in developing countries The awards ceremony was attended by top healthcare dignitaries in South Asia and an esteemed panel of jury members, which consisted of eminent thought leaders, senior experienced doctors, and industry veterans from various healthcare organizations.  Excellence in medical education - Dr. Frederick Moutappa, Pondicherry Aravind eye hospital for structured stimulator based surgical training program to tackle cataract blindness in india. N on communicable disease initiative of the year - Dr. Atul Ambekar , AIIMS Delhi for strengthening drug de addiction programme.  Quality improvement team of the year- Dr. Manisha Acharya , shroffs eye institute for improvement in eye bank tissue utilisation through quality assurance initiatives.  Recognition for promoting integrity in healthcare- Mr. Syed Nazakat , health analytics india , a pioneer in promoting data driven reporting on healthcare. R esearch paper of the year - Dr.. Govind Makharia from AIIMS Delhi for intermittent supervised therapy for abdominal tuberculosis. S urgical team of the year- Dr. Bidya Prasad from tipitaka chalupala eye hospital Myanmar for free cataract surgical program.  Infectious disease initiative of the year - Dr. Sanjeev Singh , Amrita institute of medical science kochi for antibiotic stewardship program.  Healthcare innovation- Dr. Senthil Amudhan from NIMHANs Bangalore for development of mental health care delivery model and manual for accredited social health activist in india.  Non communicable disease Initiative - Dr. Atul Ambekar , AIIMS Delhi for strengthening drug Addiction program.

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The BMJ Awards South Asia received support from organizations like the Royal College of Physicians, London, National Health Portal, National Accreditation Board for Hospitals & Healthcare Providers (NABH), NATHEALTH, & South Asian Health Foundation among other organizations. Chief Guest at the awards, Minister of State - Health and Family Welfare, Mrs. Anupriya Patel lauded the BMJ Awards and said, 7"It gives me immense pleasure to be present at the 3rd edition of BMJ Awards in India, that started in the UK 2009. The awards have been lauded as the Oscars of medicine and do reflect the unique vision in the very best of healthcare achievements. The vision provided by the jury and the overall meticulous evaluation elevates the value of this award. This is one of the most sought after awards and the BMJ publishing house has been doing a great job in propagating a great cause." The Awards this year consisted of a diverse mix of categories spanning healthcare quality, medical education, healthcare innovation, research, and primary healthcare. Fiona Godlee, Editor In Chief, the BMJ said “India is at the forefront of many technological innovations and has been involved in some extraordinary research programmes. I think, India has a huge advantage with all its inventiveness to lead the way.” This year, BMJ India also hosted the first ever Healthcare Improvement Summit in partnership with the Public Health Foundation of India. This half day event, on November 19, brought together healthcare leaders and influencers from the government, social healthcare enterprises, healthcare organizations, and academia to address issues, such as primary healthcare, affordable healthcare technologies, and public private partnerships. Prashant Mishra, Managing Director, BMJ India said ““Our vision is to create a healthier world and we consistently create opportunities and platforms that can bring important stakeholders together in healthcare. The Healthcare Summit & Awards reflect our desire to highlight cases of South Asian clinical excellence and raise questions that determine the further of healthcare.” BMJ prides itself on the credibility of its awards and winners. The awards are given solely on merit and are awarded to commend those who are the most deserving for their work in healthcare, distinguishing them from their competitors and proving them worthy of recognition.

NEWS Update

Breakthrough in Prostrate

Cancer research

Research by an Indian couple at Deakin and leading to cardiac arrest/heart University brings ray of hope to failure.” Prostate Cancer patients According to her, prostate cancer A protein found in cow and human is one of the few cancers where milk, coupled with Doxorubicin can chemotherapy is not the primary successfully treat prostate cancer, treatment. This is because these negates toxic side effects particular cancer cells are able to flush A medical scientists’ team, at Deakin out the drug and become resistant to it, University, Australia, has recently while the administered Dox continues announced that they achieved a to kill off the body’s normal cells breakthrough in prostate cancer resulting in a range of side effects, treatment. Dr Rupinder Kanwar and her the most damaging of which is heart husband Professor Jagat Kanwar, along failure. with two others, revealed that by piggy “With this latest study we have shown backing a chemotherapy drug onto a that by coupling Dox with lactoferrin well-known milk protein could create the cancer cells take in the drug a combination that is lethal for cancer rather than pump it straight out,” Dr. cells without the toxic side-effects. Rupinder added. When coupled with the milk protein Lactoferrin is an iron-binding protein lactoferrin, the Dox can be delivered found in cow milk and human milk. directly into the nucleus of prostate It is known for its immune boosting cancer cells and will kill the cells as and antimicrobial properties making well as drug resistant cancer stem it an important part of the body’s cells, without any side-effects. This protection against infection. It is also has been published in the prestigious added as a key ingredient in baby international journal Scientific Reports, formula. It is lactoferrin’s ability as recently (To read more, please visit: an iron transporting protein to mop h t t p : / / w w w. n a t u r e . c o m / a r t i c l e s / up much needed iron for growth of srep32062). microbes (bacteria and parasites) from According Dr Rupinder Kanwar, a the site of infection and its cancer cell senior research fellow with the Deakin killing activities that are exploited Medical School’s Centre for Molecular by the Deakin scientists to create an and Medical Research, doctors had anticancer bio-drug that has no sidestopped using Dox to treat prostate effects and improves the immune cancer because of the side-effects. She system. said, “Dox is used widely for treating Previous work by the team with several types of cancers and known for other types of cancer, funded by the causing toxicity to heart, brain, kidneys Australia-India Strategic Research

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Fund (AISRF) to Prof. Jagat Kanwar and Dr Rupinder Kanwar, found that lactoferrin is not digested by the gut enzymes when fully saturated with iron and given as smart nano-capsules. Prof. Jagat Kanwar said, “This latest study builds on this previous work, whereby to target toxicity and drug resistance, we coupled the Dox with lactoferrin which was then fed to a particular breed of mice that naturally develop prostate cancer. Rather than being pumped out by the cancer cells, Dox was taken to these cells by lactoferrin through its receptors which then stays in the nucleus of the cancer cells to perform its lethal action.” He added, “Within 96 hours all the cancer cells were dead when grown in 3D cancers in a culture dish from drug resistant and cancer stem cells. In feeding experiments, as an added benefit, there was an increase in red blood cells, white blood cells and haemoglobin indicating that the immune system had also been boosted. Interestingly, this combination not only targeted the prostate tumour development in mice, it also led to repair of the Dox induced damage to vital organs including heart and brain.” The main goal of the research team now is to move to trials with real patients. “The results of our research to date show great promise that we could soon develop personalised medication for prostate cancer patients,” Dr Rupinder said.

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Expert Views on

Common Childhood Diseases in Winter Dr. Rajiva Kumar

Child Specialist (Muzaffarpur)

The common Diseases In Winter Among Children. Winters are like a break from long days of summer and to get an opportunity to chill out in foggy winter nights but on the other side cold in winters bring a host of illnesses that seems to affect everyone especially children who are more vulnerable towards the disease and are more likely to affect by such illness. Common coldchildren are more prone towards getting common cold in winters due to low humidity, dryness thus developing -conditions. Flu-commonly known as influenza is a more stern disease than common cold. It is caused by viral infection and can be transmitted from one person to another. Bronchitis-it is an inflammation or swelling of the air passages between the nose and the lungs caused by virus. In this disease people breathe less air & oxygen. Sinusitis-it's the inflammation of the sinuses caused by bacteria, virus or fungus. Pneumonia-it is a serious condition in which lungs are affected when it comes to children. It is caused by virus & bacteria.

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Here is a list of more common winter diseases in children  Common cold  RSV/Bronchiolitis  Influenza or Flu  Croup  Pneumonia  Strep throat A cold is a viral infection marked by runny nose or nasal congestion, sore throat, cough, or headache. Children may also have fevers early in the illness. The fevers are usually low grade. Colds are caused by many different types of virus and can occur year round, although they are most frequent in the winter months. Most colds worsen over 3-5 days and then begin to improve with complete resolution of symptoms in about 7-10 days. Children often get 10 or more colds per year!

RSV/Bronchiolitis

Bronchiolitis is a common viral respiratory infection in young children. It is most frequently seen in children less than 12 months old. Symptoms include nasal congestion, cough, lowgrade fevers, and wheezing. RSV, a particular virus, is one common cause of bronchiolitis, although many different viruses can cause bronchiolitis. It often starts similar to a common cold and then can progress into a more serious illness with wheezing, difficulty breathing, and dehydration. Similar to a cold the symptoms tend to worsen over the first several days and then slowly begin to improve. Most children do well at home, but some children will need to be hospitalized due to breathing problems or dehydration. The cough following this illness can last two weeks or more.

Influenza

Influenza is more commonly known as “the Flu”. It usually comes on quickly with high fever, cough, sore throat, headache, and muscle aches and pains. The fever often lasts up to 5 days. There are some antiviral medications available to help fight the flu; however, these mediations only shorten illness duration by 1-2 days and must be started promptly to be helpful. Generally, these mediations are only recommended for children at risk for more serious complications or hospitalization from the flu. The best way to avoid this illness in yourself and your family is to make sure every gets their annual flu vaccine..

Croup

Croup often comes on suddenly in the middle of the night. You may wake up to your child coughing loudly. The croup cough often is described as “barking” or “like a seal”. Your child may also be making a high-pitched noise while breathing – physicians call this stridor. Children with mild and moderate coughs can often be supported at home. Frequently, croup symptoms will improve with exposure to cool dry air (bundle your child up and take them outside) or hot humid air (steam up the bathroom). For children with moderate to severe cough or trouble breathing, croup often leads to a middle of the night ER visit. Luckily, croup can usually be easily treated in the ER with nebulized treatments and steroids.

Pneumonia

Unlike the other common winter illness, pneumonia is often caused by a bacterial infection. It can present in many different ways. Sometimes it starts as a cold that

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just continues to worsen, other times it will seem like your child was initially getting better when suddenly they will worsen again. If your child has had a cold for several days and suddenly develops a high fever and worsening cough, this could be a sign of pneumonia and you should bring your child in for evaluation. Any time you feel that your child is having trouble breathing you should seek prompt healthcare evaluation and pneumonia can quickly worsen. Most of the time pneumonia can be treated on an outpatient basis with antibiotics, but some children with more severe cases will require hospitalization.

Strep Throat

Strep is most often seen in schoolaged children. Children frequently present with sore throat, headache, and stomachache. Some children will get high fevers or vomit. Strep throat does not cause cold symptoms or coughing. It can usually be easily treated with antibiotics, and children with strep throat should be treated to help prevent later complications from this infection. Children should stay home from school and other activities until after they have been on antibiotics for 24 hours. Keeping kids healthy and out of the doctorâ&#x20AC;&#x2122;s office can be a challenge in the winter months. Teach your children good hand hygiene and how to cover their mouths (with their elbow) with coughing or sneezing. If you have a young infant at home, try to avoid crowded areas or visiting with people who are known to be ill. If your child is sick, please keep them home from school or daycare so you donâ&#x20AC;&#x2122;t spread the illness to other children or staff members. In general, your child can return to school once their fever has been gone for 24 hours (with no Tylenol or Ibuprofen needed) and when symptoms are otherwise improving. winte

Dr. Sudhakar V. Kankal Pediatrician- Mumbai

Winter bring respite from the scorching tropical heat, but it comes with fair share of health hazards. Childhood illnesses can be classified into two main categories i) environmental, ii)winter infections. We are familiar that the relative lack of rainfall in winter makes the environment dry, which help suspended particulate matters which leads to late, unprecedented challenges to our respiratory tracts. Many myths and archaic health beliefs keeps our children captive to their illness. We have globally pioneering researches under the world health organization, which is recently adopted by 10 other

Myths Winter poses too many illnesses

nations in this bio psychosocial model of diseases and health. Readers of this article need to appreciate that, your child must not suffer from Winter Willows. None of your patients do after they have followed our scientific procedure, which is rather made easy to follow by the ever busy parents

Dr. Anjan Bhattacharya Consultant Paediatrician Apollo Gleneagles Hospital, Kolkata

Facts One Airway, One Disease (usually)

We need to cover up our children to protect from cold

Just comfortable clothing. Too much clothing just compound the illness

Children should not have ice-creams

Childhood is incomplete without Ice-creams! Treat the disease instead!

No good treatment is available

Complete control and remission is possible

We could not find cure in allopathy

You did not find the right allopathic doctor

We have done everything, still of no use

You might have missed the other causes of Treatable winter ailments

A cold is a viral infection marked by runny nose or nasal congestion. Children have fevers of low grade. Children get 10 or more colds per year. Bronchiolitis is a common viral infection. It often starts similar to a common cold and then can progress into a more serious illness with wheezing and dehydration. Influenza known as flu comes quickly with high fever, cough, sore throat, muscle aches and pain. Croup comes suddenly in the middle of night. Croup symptoms will improve with exposure to cool dry or humid air. Pneumonia is caused by a bacterial infection. Pneumonia can be treated on an outpatient basis with antibiotics, but some children with more severe causes will require hospitalization. Strep throat-it is seen in school aged children. Some will get high fevers and vomits. Keeping kids healthy and out of the doctors office can be a challenge in the winter months. Teach your children good hygiene and how to cover their mouths with coughing.

There are certain diseases which are more common in winters like one such condition is common cold. Swine flu is a related illness caused by influenza virus. It can be prevented by avoiding or coughing and sneezing. Sometimes the child start breathing fast, this happened due to pneumonia. A similar illness in smaller children may occur due to bronchitis. Sinusitis is common in older children in winters. In this disease a child may have runny nose, headache and nasal stuffiness. Asthma also tends to worsen in winters. Please do not take antibiotics yourself. Don't take medicines from old prescriptions as they may do more harm than good in present illness.

Dr. Mayank Rawat Assistant Professor Santosh Medical College Ghaziabad

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Healthy Lifestyle changes for women post 40 Diet Plans and other lifestyle changes that help women above 40 be healthy attention is paid it would not be a difficult task to overcome these problems. Healthy habits like eating right, exercising regularly, getting enough sleep, not smoking, etc can help reduce the risk for a number of chronic medical conditions including those mentioned here. Here is a broad guideline for such women which can help them maintain a healthy and distress free life.

Dr. Ridwana Sanam

Chairperson and Managing Director, KRV Healthcare and Physiotherapy Pvt Ltd

urning 40 is a milestone and often a time for transition, but when women, reach this age certain health issues begin to crop up. Weight gain, Reduced bone density, Increased fatigue and Increased risk of heart diseases are some major causes of concern for a majority of women who have crossed this age.

If ignored, these issues can actually become quite worrisome, but if timely 26

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Diet Plan:

The most important area to focus upon is the diet. At the age of 40 or above, most women require between 1,800 and 2,200 calories daily to maintain healthy weights, depending on their activity levels i.e.  Women with sedentary lifestyle-1800 calories daily  Moderately active lifestyle-2000 calories daily  Highly active lifestyle-2200 calories daily  Those seeking weight-loss in this age group would require 1,200 to 1,600 calories a day

A perfect health plan will include 40 plus women to derive nutritional requirements from Proteins, Carbohydrates & Fat and Vitamins and Minerals and to limit Foods with highfat content, high-sodium and deli meats. Also, they should desist from having high-fat dairy products, sweets, sugary drinks, baked goods and refined grains, such as white bread and white rice.

Diet women over 40 should include:

 Proteins: Eating plenty of protein-

rich foods helps 40-year-old women maintain a lean muscle mass. This also helps in keeping their metabolism high. Proteins are also known for boosting satiety and energy expenditure. The recommended daily dietary allowance for protein is 0.46 grams per pound of body weight. But, those who have an active lifestyle can ramp up their intake to 0.64 to 0.91 gram of protein per pound. Thus, an active 140-pound woman in her 40s can eat up to 127 grams of protein daily.  Source of healthy Proteins: Egg Whites, Skinless poultry, Seafood,

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Lean Meats, Low-fat dairy foods, Soy products, Nuts, Seeds, Legumes and Seitan  Carbohydrates and fats: Women

in their 40s obtain 45 to 65 percent of their calories from carbohydrates and 20-35 percent from fat. This equates to around 200 to 292 grams of carbohydrates and 40 to 70 grams of fat daily when eating the recommended 1,800 calories daily.

 Source of healthy Carbohydrates:

Whole grains, legumes, fruits, vegetables, nuts, seeds, milk and yogurt.

 Source of healthy Fats: Plant-

based oils, fatty fish, nuts, seeds, nut butters, avocados and olives.

 Vitamins

and Minerals: Key micronutrients for women in their 40s include iron, calcium, vitamin D and vitamin C. These are extremely essential to boost the immunity, fight diseases and reduce fatigue.

 Sources of Vitamins and Minerals:

For Calcium: Foods such as milk, yogurt, cottage cheese, leafy greens, clams, oysters, broccoli and almonds works with vitamin D to support bone health. For Vitamin D: Food such as herring, tuna and cod fish and some fortified foods. Ones’ body also can synthesize it after with exposure to sunlight. For Iron: Food such as lean meats, iron-fortified breakfast cereals, spinach and legumes.

Diet for women over 40 should avoid:

Women who are 40 should limit or cut entirely certain foods to help maintain healthy body weights and reduce their risk of chronic diseases, such as heart disease, high blood pressure, high cholesterol and type-2 diabetes. Foods that should be limited or avoided include high-fat, high-sodium meats such as bacon, deli meats and sausage, high-fat dairy products, sweets, sugary drinks, baked goods and refined grains,

such as white bread and white rice. Apart from including various elements in their diet and refraining from those which are dangerous, women over 40 should also include the following in their routine for best results:  Regular Exercise: The best way of weight management and gaining strength is to exercise daily. It helps in improving muscle strength, muscle contours, reducing fat and improves fitness.  Sound Sleep: A sound sleep provides our mind the well deserved rest and thus helps in reducing our stress levels. So it is of utmost importance for an individual to sleep for minimum 8 hours a day. So, if you've been making healthy lifestyle choices, keep it up in your 40s, and if you haven't, now's the time to start. You'll stay healthier, sharper, more energetic, and more fulfilled for years to come 

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Erectile Dysfunction (ED) Is erectile dysfunction just a part of old age? Erectile dysfunction doesn’t have to be a part of getting older. It’s true that as you get Older , you may need more stimulation to get an erection. You might also need more time gap between erections. But older men should still be able to get an erection and enjoy sex.

Dr. Anurag Khaitan Chief of Urology

Men who have a problem with their sexual performance may be reluctant to talk to their doctor, seeing it as an embarrassing issue. However, modern medicine has revealed numerous medical and psychological explanations for erectile dysfunction, including the possibility of serious underlying conditions that it is important to address.

What is erectile dysfunction ? Erectile dysfunction, sometimes called “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. Erectile dysfunction can occur at any age, but it is more common in men older than 65. ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED.

How dose an erection occur? The penis contains two chambers called the corpora cavernosa, which run through out the length of the organ. A spongy tissue fills the chambers. The corpora cavernosa is surrounded by a membrane, called the tunica albuginea. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, expanding the penis & making it stiff.

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What causes erectile dysfunction? Erectile dysfunction is due to many causes. Uncontrolled blood pressure and sugar can aggravate this condition. Many commonly prescribe medicines like those used to control BP, anti ulcer medicines, antidepressants, tranquillizers etc can also affect erection. Other causes are listed below:  Alcohol and tobacco use  Fatigue  Brain or spinal-cord injuries  Hypogonadism (which leads to lower testosterone levels)  Liver or kidney failure  Multiple sclerosis  Parkinson’s disease  Radiation therapy to the testicles  Stroke  Some types of prostate or bladder surgery  Diabetes (high blood sugar )  Hypertension (high blood pressure)  Atherosclerosis (hardening of the arteries) Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem and fear of sexual failure cause 10 to 20 percent of ED cases. Problem in your relationship with your sexual partner can also cause this you might try therapy to see if improving your relationship helps your sex life. Depending on examination findings, few blood test & urine analysis along with other specialized tests might be ordered. Therapy will probably be most effective if your sex partner is included. Couples can learn new ways to please one another and to show affection This can reduce your anxiety about having erections.

Feelings that can lead to erectile dysfunction  Feeling nervous about sex, perhaps because of a bad experience or because of a previous episode of impotence

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 Feeling stressed including stress from work family situations  Being troubled by problems in your relationship with your sex partner  Depression  Feeling so self-conscious that you can’t enjoy sex  Thinking that your partner is reacting negatively to you

What other option do I have? If the medicines aren’t right for you, you could also try using vacuum devices. Mechanical vacuum devices cause erection by creating a partial vacuum, which Draws blood into the penis, engorging and expanding it. Implanted devices, known as prostheses, can restore erection in many men ED. Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood.

How is erectile dysfunction diagnosed? Points to Remember Your doctor will probably start by asking you some questions and doing a physical examination. Medical and sexual histories help define the degree and nature of ED. A physical examination can give clues to systemic problems.

How is erectile dysfunction treated? Treatment of erectile dysfunction depends on examination findings. After ruling out chronic ailments or medications that lead to this problem, your doctor may prescribe some medicines .Most physicians suggest that treatment should proceed from least to most invasive. For some men making a few healthy lifestyle changes and removal of precipitating cause may solve the problem. Quitting smoking, losing excess weight and increasing physical activity may help some men regain sexual function. Psychotherapy and behavioral modification in selected and behavioral modification in selected patients are considered next if indicated drugs. Not everyone can use these medicines. Your doctor will help you to decide if you can try them. Sometime in occasional patient surgery may be an option.

 Erectile dysfunction (ED) is the repeated inability to get or keep an erection  Firm enough for sexual intercourse.  ED affects large number of men and is more common than thought.  ED is due to psychological or organic reasons and is easily treatable.  ED is treatable at all ages.  Treatments include psychotherapy, drug therapy, vacuum devices and surgery.

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IDENTIFYING FIBROMYALGIA A COMMON PAIN PROBLEM IN FEMALES Fibromyalgia is a chronic pain condition that causes widespread diffuse body pains. It is the most common cause of generalised musculoskeletal pain in women between 20 and 55 years. Many patients also experience fatigue, sleep disturbances, headaches and mood disturbances such as depression and anxiety. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by conditions such as anxiety or stress, poor sleep, exertion or exposure to cold or dampness. Muscle stiffness is typically present upon awakening and tends to improve as day progresses. Persistent fatigue occurs in more than ninety percent people along with complains of unusually light non-refreshing or non-restorative sleep. Patients may also feel numbness, tingling or unusual crawling sensations in arms and legs. Other pain syndromes such as migraines or muscular headaches, irritable bowel syndrome or urinary complaints such as bladder pain and urinary urgency and frequency are commonly seen. Fibromyalgia is thought to be the result of change in pain perception, a phenomenon termed ‘Central sensitisation’, which might be due to genetic predisposition, stressors including physical or emotional trauma, sleep disturbances or other medical conditions. There is no specific laboratory or imaging test used to diagnose fibromyalgia as no abnormalities are detected in underlying muscles or other tissues. 30

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Fibromyalgia is a treatable condition. The objectives of treatment are to reduce pain, improve sleep, restore physical function, maintain social interaction and re-establish emotional balance. To achieve these goals patient will need a combination of social support, education, physical modalities and medication. A multidisciplinary team comprising of a Pain Physician, Psychologist and a Physiotherapist would be ideal for managing the condition of patient. While a positive attitude change is needed in patients, the attitude of family members, employers, policy makers all have an impact on patient’s condition. Clinicians must be prepared to accept fibromyalgia syndrome as a real condition that exerts a tremendous impact on the patient’s life and must approach with empathy. Patients need to be educated and understanding is power when it comes to maintaining a proper attitude, adapting to limitations and taking active role in therapeutic program. Aerobic exercises not only helps to maintain function in everyday activities but also to reduce pain, improve sleep, balance mood, restore cognition and facilitate a sense of wellbeing. The application of heat

in the form of hot bath, hot water bottle, electric heat pad or sauna can relax muscles, facilitate exercise and improve a sense of well-being. There have been new medications that have been developed and tested for this condition which include analgesics, antidepressants in low doses and a few anticonvulsant medications which are useful in managing this condition. Fibromyalgia should not therefore be a diagnosis of exclusion. A correct diagnosis along with a multidimensional approach to management and with patient and family education and participation can help these patients’ lead better lives.

Dr. Pushpinder Singh Mehta Associate Consultant Pain Medicine, Indian Spinal Injuries Centre, New Delhi

DOCTOR SPEAK

Know

your baby genes well

www.m e d e g a t e t o d a y. c o m Nov-Dec 2016

DOCTOR SPEAK

Is your pregnancy checklist missing something? A prenatal screening, might be! A healthy baby is a happy baby. As parents, one would always want to ensure good health for their baby even before the baby is born. The best way to ensure good health of the baby, before it’s birth is by talking to your doctor or a genetic counsellor and taking up prenatal tests. Out of the 50 babies that are born, one has some defect. That constitutes 2% of the total number of new born babies. The causes for these birth defects may be genetic i.e. passed on from parents or chromosomal or it may be due to exposure to environmental factors such as viral infections, drugs, or a medical condition affecting the mother. In some of the cases, there is no apparent cause. Testing during pregnancy is optional and should be discussed with a doctor, or a genetic counsellor. Making a decision to have a test or not is always up to the couple. In general, there are two main types of prenatal tests – a screening test and a diagnostic test. Many birth defects in infants can be identified early during the pregnancy through prenatal testing. Such tests are often recommended by a gynaecologist or sonologist. The recommendations can be based on family history, personal history or pregnancy history of the mother. Screening tests are offered to all pregnant women irrespective of the personal medical or family history, and these results give an estimate of the probability that a baby has a health problem. Examples of screening tests are ultrasounds, non-invasive prenatal testing, first trimester screening, and second trimester screening. When a higher than usual risk is identified by a screening test, couples are often referred to a genetic counsellor or a clinical geneticist for a genetic consultation. The clinical geneticist or genetic counsellor helps the couple in the decision making process of whether or not to pursue diagnostic tests and supports them through the testing process. During a genetic counselling session, the genetic counsellor helps the couple understand the intricacies of the identified risks and what it could result into. Details about how such conditions are diagnosed, strategies on how a family may cope with the risk of a genetic condition during pregnancy, are shared to help them to deal with the issues associated with a genetic condition after birth, should it be present in the baby. Diagnostic tests provide accurate results and are always offered as a follow up to a screening test where a higher than moderate risk is identified for a certain genetic condition or anomalies are identified on ultrasound scan. These tests are conducted to confirm the diagnosis in the baby. Such tests may have associated risks in some cases. Examples of diagnostic tests include chorionic villus sampling (CVS) and amniocentesis.

The screening and diagnostic test reports are made available at the earliest possible that is within 2-4 weeks, depending on the type of test and considering the nature of urgency. The reports are handed to the couple by a genetic counsellor or a clinical geneticist who understands the report, and can help with the further course of action. When a baby is found to have a problem before birth, the parents are given information about the health problem that has been identified. Depending on the stage of the pregnancy, a couple will be able to discuss options of planning for the birth of the baby or ending the pregnancy. Whether one decides to continue or end a pregnancy, support and information will be offered. Pregnancy can be terminated up to 20 weeks if the baby is diagnosed to have a genetic problem. Although the doctor or genetic counsellor can never guarantee the birth of a healthy baby, couples often feel reassured about their assessed level of risk, and are likely to feel more confident in their decision-making about screening and testing options. Although the mention of a prenatal test may be quite daunting, the benefits of undergoing screening can be reassuring and helpful. Talk to your doctor or genetic counsellor to learn more about prenatal testing options for yourself.

Some of the factors which increase the likelihood of a baby having health problems are:  The When the mother is in her mid-30s or older (not necessarily her first pregnancy)  Where there is a close relative or a previous child with a serious health problem  There has been exposure to some chemical or other environmental factors during the pregnancy  One or both parents of the baby has a health problem that may be passed on  One or both parents of the baby are known ‘carriers’ of a particular faulty gene  Where the parents are related by blood (e.g. first cousins)

Niby Jacob Elackatt, Genetic Counsellor, Strand Life Sciences Pvt. Ltd., Bangalore

w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

Hospital Watch

ArchitectureArt of Healing Healthcare is an important part of the society and needs utmost care while being designed. We at Architect Hafeez Contractor believe that despite being very technical in its own accord lot of creativity and vitality can be added to the architecture to make it functional and yet pleasant for the users. While the whole ambiance of the hospital resonates some sort of gloominess and mundanity its design can restore vitality and nourishment for the users. The major points that have to be kept in mind while designing a hospital is simplified planning, importance of natural lighting, sustenance during hazards, stimulating interiors, signage planning and handicap friendly environment. The planning of the hospital is very vital in proper functionality of the architecture. The different major zones viz. Out-patient department, In-patient department and emergencies should be effectively segregated and overlapped inorder to prevent chaos and easy accessibility. The important point to be kept in mind while planning is to take care of the services and common areas like waiting and canteens. This has been aptly done in our Healthcare projects at AHC, like in Apollo Indraprastha hospital, Delhi; the core idea of creating a central spine atrium plaza from which the entire design sets off. The plan is also an early example of the central circulation spine, two major 34

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blocks of the hospital are connected by the atrium of huge volume, which acts as the large waiting area. The outpatient departments and diagnostics flank the atrium on both sides. The less complex out patient department is separated by the pedestrian atrium from the complex acute care, diagnostic and in-patient areas; easing the pressure on the hospital machinery while making the whole hospital experience simpler, faster and more convenient for the outpatient. The other major considerations while planning is to discern zones sterile, semi-sterile and public effectively. Proper waiting spaces wherever required should be provided creating least commotion for the patients and the staff. Public common facilities like toilet, lounge, cafeterias should be well placed at proper junctions for better accessibility. Properly planned wide corridors for movement should be provided as they act as are major spines for such organizations. It should also be planned for hazards like floods, curfews etc. having extra energy resources for its functioning even in critical situations. Bringing in natural light is also very indispensable in Healthcare architecture as it affects the psychology of the patients and the staff as well. Thus the structure should be oriented responsive to the local climate. This has been competently been addressed in the design of Hiranandani hospital,

Architect Hafeez Contractor AIIAGD Arch, MS Arch & UD (USA) Doctor of Architecture (Honoris Causa) Doctor of Architecture in Housing (Honoris Causa) Padma Bhusan Awardee

Mumbai; The design capitalizes on vast, open spaces, beautifully landscaped large balconies in rooms and lounges. The lighting and ventilation planning aspire to cheer recuperating patients and showcase the vistas of the Hiranandani Gardens. The rooms are airy, vibrant with natural light and boast of an effective ventilation system. Another major consideration for Healthcare structures is interiors; use of in-house and overlooking courtyards for the patients to bring them closer to the nature. Decent ambient lighting and calm soothing colours help invigorating the mental health of the users. Special care should be taken while designing for nuclear medicines. In TATA Memorial hospital, high radiation equipments are used and so the materials incorporated had to be radiation proof. Itâ&#x20AC;&#x2122;s walls and ceiling are also around 1.7m thick in order to stop radiation from the room below. Healthcare architecture is a very momentous and needs utmost care and deliberation while designing as many issues and aspects has to be addressed while designing for an unmitigated and efficient architecture that helps to heal and exhilarate the health of its users.

Apollo Indraprastha Hospital

COVER STORY

he sides. T n both destrian o m iu e atr by the p ank the t ostics fl ent is separated and in-patien n g ia d d c n ti tm a n s r o a ts no a tower tient dep partmen re, diag ve de complex out pa plex acute ca conceived as nical and ti a r o b a less ent; cli the com also primarily is a coll ospital spitals and the atrium from s in basem er floors while a H s w e a ic n th v s r ig a rapr o ho ver 15 areas. The des with all its se immediate upp he outpatient ollo Ind nowned Apoll reads o p s l cture The Ap and rs. T e t e r I . e the initia ority ium stru es in ground per floo the need of th of th d p th to o u t u r p c A io je in r t o P r s s n e n e p o e te s i. iv n z s a m ia o lh n t p z r v e n a te b as f at o evelo atme uth D d ex rsing Delhi D ime land in So itects conducte e primary tre ing all the nu ontained unit th spital building rest of -c th pr ep ho the ch acres of lisation, the ar of hospitals and wards the ke artment is a self ring the main partment from chinery e te to p a d n e ts t m t tu e d e h n l p c nt ug fa tie ita a conce various e a serious tho io, the families day-care patie ating the outpa re on the hosp r, faster and to in h c v r g r u resea scena ons ga . Segre e simple ied by e press e Indian eliberati compan possible al has eased th pital experienc s design d ial milieu. In th nts are often ac ignored by it o d has the hosp ing the whole h tpatient. lly oc tie k every be ed Indian s nit and most pa ontext was tota subcontinent u a o d m n e a e th n il r o h o w e lc tf ek oup lati are clos ves. This socia al designs in th onment was nvenien ss-venti e wards are gr ced o o r c c e e r v o a h ir ti m it h la v T tdoors. their rela e previous hosp outpatient en nd are p nt wards in-patie ction to the ou urseâ&#x20AC;&#x2122;s station a nical zone te th e ia f h r o T p t o r s li mo app al conne rived at central n podium. The c re located ating an itects ar a from a visu gly around a a h e s c r a and cre th a e r . a e in y one d, th plaz ssurin riorit -care z a n p te e anned, u l m r a u a o c r r iu ic a g e tr n k v s a d e li ne de p-sp the bac e c c an sciou pine ti in th is s n s h o o l th e it c a n v w g tr a o to n b t ia e e a se sing ed ing ac mad ent hou ices.Â stablish consisting of th on theatres and m Respond ea of creating ff. The design e e s d a n b a ti id to ers serv uble f e opera the core entire design se eds of the us nt and most o of a do of the various th p h it to w n deo g ne sa e l m floor, t zone consistin been to us which th prioritise the e humane, plea . The peacefu iu s d a o h p r n r o to o h suppo the aim of bold, vivacio l attempt ment that is m on and relaxati al atrium, whic complex omplex c n ti tr d o a n e e ir n e use e heerfu tt e v c th o v n d e e reju an rea, hout in th es by th tablishing a c ome. a g to c d t u a li o e te p r c s y iv h e c k e T fl n s u s e e th h ereby e all cond is especially r nts. It is a vast ative of gard onalise y from c n n instituti nd patterns, th f a home awa ucture aims e o a io m v e h it le s it e o s w e p ir dis ital s a cha ng o scap n str s and ral land ple colour the hosp d a feeli e moder erent in such has seve ght iron table trium enlivens tting allows am a atmosphere an ifestation of th y all inh stic a e se rou rnal man omplexity norm lly, the simpli l te with w This pedestrian e. The flexible their lunch, tak x e e h c a T n e r r r e t e . th te a h e w x n r e E w po fu osp x, furnitu break do tional spaces.Â an incredibly like atm visitors to rela tto e e tr e s tu ity. d is spin almost rge insti riented form ced facil ulation tients an k nap. n la c a a ir p v c d r l e a o a h f y o T ll ntr space a quic f the ce designs. of geometry of technologica or catch ample o dian hospital n x m e io iu s tr ly s r breather a e a r exp an e in In y this n is also ational device re connected b he outpatient The pla is T a n . l a a an org hospita iting are used as blocks of the large wa e th s r a jo two ma me, which acts lu o v e g u h

w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

Hiranandani Hospital, Mumbai Located at the northwest corner of the Hiranandani Gardens, the multi-speciality hospital is distinguished by the characteristic neoclassical architecture of the development. The rectangular hospital structure comprises of a basement, a ground floor and 6 upper floors With a built up area of 19,500 sq m, the hospital has 130 beds of which 37 are exclusively dedicated to critical care. The design arrangement effectively separates distinct functions like diagnostic/treatment block, the ambulatory-care block and the inpatient department. The design capitalises on vast, open spaces, beautifully landscaped large balconies in rooms and lounges. The lighting and ventilation planning aspire to cheer

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recuperating patients and showcase the vistas of the Hiranandani Gardens. The grand double height public lobby features a reception area in the centre. The hospital has a comparatively large outpatient department with 35 consulting rooms. The rooms are airy, vibrant with natural light and boast of an effective ventilation system. Introducing day light sensors and double glazed window glass has assured energy efficiency. The hospital also employs rainwater harvesting and water recycling plant for gardening, cooling tower and bathroom flushes. Clean air concept is implemented by way of high and frequent air-exchange in air-conditioning to augment circulation of fresh and pollution free air.

COVER STORY

Tata Memorial Hospital, Mumbai The Tata Memorial Hospital initially commissioned in 1941 constructed a new 14 storey block â&#x20AC;&#x201C;'The Tata Clinic and Faculty Block' on the premises vacated by the CRI. This facility houses site specialty clinics, 75 additional beds, Minor theatre complex, day care beds, academic offices, post graduate education, seminar rooms and a Telemedicine Centre. The construction of this building was challenging as the high radiation equipments are used by the hospital and so the materials used had to be radiation proof. The new tower erected, connects the old building via the atrium at the first level. The magnificient atrium is made using steel trusses and ACP and gives the hospital a top notch look. The new block also has a completely sterile corridor which connects the OTs in the old building. The ground floor of the new block has the major cancer treatment and

equipment room (LA/Clinac) and hamalite concrete was used to construct it. Its walls and ceiling are also around 1.7m thick in order to stop radiation from the room below. The building has a glazed look from the outside with a prominent crown made from aluminium louvers. These louvers camouflage the machine room inside. The entrance lobby also has a free standing wall which was made from steel and is cladded in granite. It has a glass canopy to add to its beauty. The building has a structural provision for a helipad which may be executed in the future. The entire development is around 20,000 sq. mt. Every year nearly 43,000 new patients visit the clinic from all over India and neighbouring countries. Over 1000 patients attend the OPD daily for medical advice, comprehensive care or for follow-up treatment in this cancer treatment hospital. w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

Healthcare Expansion Strategy

Healthcare Consultancy

Greenfield, Renovation or Replacement

he most common dilemma every owner or promoter of a healthcare organisation faces is whether to expand his existing setup or go in for a Greenfield project away from his existing setup. Expansion pressures arise due to variety of reasons. Increased demand for the existing services is the commonest and the most heartening for any owner or promoter. These demands are further accentuated by the need for operational efficiency, reorganisation and/or addition of services, addition of new technology and most importantly for better financial returns. So let us look at how these complex decisions are made. The foremost of the factors is the availability of capital. If the capital is available, the other important factors in favour of a new construction to be considered include:  The sustainability of the expansion on an existing aging structure,  The availability of land for expansion  Whether renovating an existing structure results in a suboptimal solution.

avoid disruptions in the functioning of the existing organisation. However, not all organisations would find going for a Greenfield project a viable alternative and the prominent reasons are:

Greenfield Expansion

 A logical and convenient movement of people, materials and vehicles is needed, along with adequate parking. A focal center of campus and a clear and easy way finding should be planned.

A Green field project becomes more attractive to the promoters because of the ability to build in a single phase, creating a new brand identity (in case old brand loses public faith) and to 38

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 Having attachment to the community (catchment area) around the existing place,  The emotional attachment of the owners or  The political, economical and other strategic benefits of engaging the existing place  The cost savings in renovating the existing place. While looking at the key elements it is important to set goals for successful growth and development. The key elements to success are illustrated below.  The zoning should be clear, easy to understand and should support efficient operations. This is the initial planning that should determine the relationship of individual areas.

 There should be a logical method for expansion of the campus allowing for flexible planning and phased incremental growth.  Relatives and family of patients are an integral part of the patient experience. This part is almost forgotten in the Indian scenario where planners and administrators have played scant attention. It is important to remember that along with the patients even these sub segments of people are important ambassadors of the organisation.  Increasing market share is the primary goal of any expansion project. While implementing programs to outreach and also attract the best medical talent, one has to keep an eye on the newer technology in diagnostics and therapy and the space these newer technologies would need.  Planning for capital flows for all these is the final frontier. The cost considerations would include construction, phasing, financing, fees and long term operational costs. Once an overall goal is established, a matrix can be developed to analyse all the factors. Each institution will have different planning approach with different goals. Yet, finally, cost will be crucial factor in arriving at the final solution.

COVER STORY

Replacement of Existing structure The argument for total replacement of the campus would be based on the following points  Though not an easy choice however best choice if promoters look for futuristic structural compliances & efficiency prospects. They should not compromise with short-term + short cuts as business would suffer for some time. However, without a good phasing strategy, replacement option should not be exercised.  An old campus with aging facility will require excessive capital to modernize with marginal potential of payback in the years of service. Column spacing is too tight and inflexible for efficient space planning. Floor-to-floor height is inadequate for modern ventilation requirements. Building systems and power are insufficient to support modern healthcare spaces. There is no “domino” space to allow modernisation of existing spaces.  No space. Very often it so happens that the institution has consumed all the available space both horizontally and vertically with the necessary program components and whatever services that can be outsourced have been done. There is no contiguous real estate available and without expansion the institution will stagnate.  The incremental growth of older institutions causes inefficiencies in zoning and adjacencies. This causes key elements to be farther away from the departments they are supposed to serve. The resources are thus strained, decreases efficiency and increases operational costs.  At times another institution may see more value in this existing campus and the owners might find it more profitable to sell out and move to a new campus offsite.  A perfect location sometimes becomes suddenly available which allows for incorporation of all aspirations and which is without zoning or neighbourhood encumbrances. Availability of money is one of the key drivers of decision making. Occasionally a supportive donor will be ready to fund majority of the cost of the project making the financial barriers to a new construction fade.

 Many of the locations are such that supportive partner institution, academic centres and research institutions are in the vicinity. In such circumstances it makes sense to make the current location work for the organisation.  If an alternative large site is not easily available relocation may not be such a good idea. The exception would be locations where “vertical” expansion is possible. In such circumstances the existing location offers better alternatives than a newer limited site.  Money is the real driver for any renovation or replacement decisions. The demands for capital for a replacement project are huge. The planners have to account for many hidden elements such as utilities requirements, roadways, equipment, furnishings etc. When funding is limited renovation makes for a better choice.

How does one make a choice? The choice of expansion strategy (Greenfield, replacement or renovation) is based on many interconnected operational issues, internal strengths & weaknesses, and public perception & expectations It should be made thoughtfully and methodically covering all aspects. A thorough master plan needs to be in place. Accurate and comprehensive costing gives financial clarity & enables a better expansion decision.

Renovation At times a variety of conditions exist which make renovation and up gradation of existing campus preferable. These may include:  If the existing structures are less than 25 years old and there is a lot of life left in them, then renovating makes sense. However, there should be enough space to expand and the departmental planning should be relatively recent.  Area enough to double the available square footage, either vertically or horizontally, will ensure that the organisation will have comfortable years of growth ahead. Healthcare organisations seldom need to expand immediately after a major build. However all of them eventually need to expand and grow.

Dr. Aniruddha Chimote Consultant Anaesthesiologist Senior Consultant- Hospital Planning & Design Hosconnn healthcare consultancy

w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

A New Vision of Architecture

to Provide High Comfort Level to Public The 100 bed Hospital in Kabul, Afghanistan is planned as a part of the Heart research center, to provide health care for the public of Kabul and the surrounding areas. The vision of Dr. Mirwais Amiri was to provide a modern sophisticated hospital which uses the latest techniques and can cater a larger population. The Amiri Medical complex is the First Modern Hospital with high and low diagnostics, Nuclear Medicine and multispecialty OPD. The hospital will provide a complete range of sophisticated and advanced clinical diagnostic and therapeutic services under one roof for cardiac-related diseases, with the provision of medical and surgical equipment of international standards. The design of the Medical complex is modern with sustainable features like rainwater harvesting plant, STP, and grey water treatment plant. The solar panels installment on the terrace generates 9% of the total energy consumption of the complex.

Reception area

The design facilitates accommodating masses of 600 people to wait in waiting areas around the main atrium and the landscaped gardens. It is divided into 4 areas - emergency services, diagnostic services, OPD facilities, and wards. The height of the building is 25 m. OPD has 1 floor, emergency - 1 floor, wards - 2 floors and basement is in 1 floor. The building is slated to be a green building. The 750 bed Hospital at Uttar Pradesh is planned to be a medical campus with hospital and teaching facilitates. The campus is spread over 24 acres of land with Hospital, MBBS College, Dentistry, Engineering, and Pharmacy. The vision was to provide international standards of health care for the public of Uttar Pradesh and the surrounding areas. This is a multi-specialty 750-bed hospital with teaching facilities for a batch of 150 students and has classrooms, seminar rooms, and auditorium. This hospital has multispecialty OPD and indoor treatment for various specialties. The multidisciplinary hospital will provide a complete range of sophisticated and advanced clinical diagnostic and therapeutic services under one roof, with the provision of medical and surgical equipment of international standards. The design facilitates accommodating masses of 5000 people to wait in waiting for areas around landscaped courts. It is divided into 6 areas - emergency services, diagnostic services, OPD facilities, wards, Rehabilitation

Front view amiri medical complex

www.m e d e g a t e t o d a y. c o m Nov-Dec 2016

COVER STORY

Rama Hospital & Research Centre Hapur Rd, Gironi, Uttar Pradesh

wards, Intensive care units and operation theaters . It also serves as a teaching hospital. The height of the building is 37 m. OPD has 2 floors, emergency - 2 floors, wards - 5 floors and basement is on 2 floors. The Services and maintenance of the hospital are controlled from the basement. The campus is spread out with landscaped gardens and quiet zones for the students; it has 4 libraries, accommodations for single and married students and separate accommodations for professors. “Progressive Universal Society pioneering reform in medical education system” India shares a rich history of advanced medical sciences that is reflected in ancient texts written by Sushruth and Charak. Students from different parts of the world studied in universities like Nalanda and Taxila that existed around 2500 year ago. However, many of these treasures were lost due to invasions. While reviving the ancient knowledge of medicine remains a challenge, the present medical education in India, for the most part, focuses on Allopathy. Now days most of the medical institutes run as commercial ventures, making them out of reach for many brilliant students. Similarly, good medical facilities remain out of bounds for those who can't afford to pay huge bills. Rural areas, especially lack good hospitals. Progressive Universal Society (PROUS) aspires to pioneer the cause of composite medical education in India. With an aim to usher a new momentum in the field of medical education PROUS has conceived its forthcoming project, PROUS Institute of Medical Sciences (PIMS), located about 60 kilometers from Jaipur on NH8 near shahpura, covering all the villages and towns in the vicinity of 20 kilometers. By rediscovering the ancient medical science of India and combining it with modern medical science, PIMS will set the grounds for state-of-the-art facilities with modern infrastructure made available to rural parts of India. The institute will combine all three aspects of one's existence i.e. physical, psychic and spiritual, and aim at training a person into best human beings in the form of doctors, who will be able to build and utilize their skills for all round welfare of the creation. The proposed Medical college will fulfill the need of medical doctors in a rural area it will house medical college 100 seats intake every year with 500 bedded

Proposed medical college and hospital campus, NH-8, GHASIPURA , NEAR SHAHPURA

hospital, hostels, staff accommodation, and meditation center. With interactive spaces like, open air theaters and 24 hours on campus library.

Virender Kumar Sharma

Principal Architect and Urban Designer Bachelor of Architecture

Nishant Sharma

Associate Architect and Urban Designer Bachelor of Architecture

w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

Healthcare Consultancy

The Collaborative Healthcare

CHANGING TRENDS IN HEALTHCARE

Dr. Salil Choudhary

BDS, MBA (HA) Senior Consultant- Healthcare Strategy and O&M Hosconnn Healthcare Consultancy

Market Dynamics Healthcare market presently is the most dynamic market and the changes in the trends are very evident. Major IT & Non-IT companies are entering this industry which has led to the development of an all new segment. Companies like IBM-Watson, Cerner, Zeomega, etc are coming up with EMR of high standards helping the hospitals maintain the patient data in paperless format. The changes are driven by many factor ranging from age demography to chronic diseases, infrastructural funding to technology funding etc. Mapping & Catering Patients Needs Healthcare is looking at addressing very specific needs of patients and has broadened its spectrum of reach. 42

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Concept like telemedicine, home care, rehab centers, healthcare apps etc are coming up in the market. As the industry copes with the continued influx of the newly insured, the rising burden of medical costs, and a host of new technologies for patients and doctors alike; startups and entrenched companies will look for new ways to reach customers. Patients, meanwhile, will be looking for better methods to manage their medical expenses and their health.

The Age Demography The age demography is shifting globally towards the age bracket of 60+. Ageing population in both emerging and developed nations is driving the demand for healthcare. The future is looking for a more customized care plans for these individuals in terms of chronic disease managements, home care etc. So, it becomes essential for the healthcare provider to shift gears and come up with the innovations to cater this sector for long term care plans. On the other hand, the middle class sector is growing at a rate of 30-40% in developing nations. This puts an additional pressure on healthcare as it comes with its own advantages and disadvantages. The increase in purchasing power has offered a better lifestyle. However, it has also led to lifestyle diseases like Obesity, Hypertension, Diabetes, Cardiac diseases etc.

Driven by these changes the healthcare market is seeing a change in trend of partnership. Healthcare sector is collaborating with retail, telecommunication, and fitness etc. to cater to the need of individuals’. As the population grows, technological innovations in mobile health (m Health) will advance to provide cost-effective health solutions. Technology and analytics are ushering in new ways of promoting wellness, preventing disease and providing patient-centric care.

Digital Health Records More people are adopting digital health apps to manage their care, whenever and wherever they want it. Patient adoption of health-related apps nearly doubled over the past two years. About 43% of consumers had at least one health app on their phones in 2016, up from only 30% in 2015. The change in management of health record by patient can become a reality soon, provided the government machinery put the regulations in place to make it mandatory for hospitals to store patient records under a universal UHID number, even if the patient moves across hospitals.

IOT Another change which is taking the healthcare market like a storm is the rapid use of IoT connected devices. IoT Connected devices would go well beyond a fitness tracker– think ECG monitors, glucose trackers, and connected pacemakers–would spur greater adoption of apps that help patients monitor their health better. These apps would be especially valuable in sharing information directly with doctors for controlling chronic conditions.

COVER STORY

Healthcare Consultancy

INFRASTRUCTURAL SIAMES TWINS

S.V. Satyanarayna Strategic Advisor Hosconnn Healthcare Consultancy

Facts Not Fables Dr. Srinath planned for 100 bed hospital with an estimated Capex of 20.00 Cr. He was funded with 1:3 debt Equity ratio. To make it more aesthetic as per the advice of his Architect he spent extra 3.5 Cr more than the planned cost on both interiors and exteriors. The funds provisioned for initial working Capital, Pre -operative expenses and Medical equipments was cut to fund this excessive interiors. Over few months it started hitting the project completion resulting into more time and cost escalation. Bank put pressure on him to complete the project. Dr. Srinath was forced to complete the project by taking private loan on a high interest. All these had a cascading effect on all the plans. Project was postponed with high accumulated losses and hospital was up for Sale. Well this not a fictional scene but a regular feature of most of the Projects. We all know SIAMES TWINS. Two psychological entities but physiologically together if one gets cold others sneezes, if one eats bad food other gets affected. So for proper and healthy coexistence, survival and growth both have to compromise with each other’s preferences. Well Every Hospital project also have these Siamese twins namely building & financial architectures

Building Architecture Financial Architecture

and

Despite being different entities of any healthcare project both the architectures have to accommodate each other in healthcare project economics. The hospital promoter has to be careful and prudent on ROI for any unplanned investment in both interiors and exteriors. This happens most of the times when the promoter takes impulsive decisions on interiors & exteriors while overlooking long term financial implications of these decisions. This is a common phenomenon which needs to be studied extensively and shared amongst Hospital promoters. This mismatch in Building and Financial Architecture affects not only small and medium projects but also large projects.

Blurred Vision & Absolute Confusion When this compatibility is lost between Building & Financial Architecture the Promoters & Project both are at cross roads.  Promoters would be forced to race against time as the projects get postponed. They would be forced to take aggressive/defensive decision rather than assertive decision.

 This incompatibility would have a cascading effect on OPEX, CAPEX, and Revenue & Profitability.  This would lead to credibility loss amongst Investors, Bankers and Sundry Creditors etc.  Promoters would be forced to recover this extra investment through increase in the hospital tariff at the risk of losing out to competitors.

Solution through Resolution  Correlate interior expense to the financial prudence  Define (monetize) interiors contribution to top-line and bottom line  Analyze the impact of interiors on affordability of healthcare services (by patients)  Calculate potential/Guesstimated loss due to un affordability of patients (number of patients who prefer /opt for other hospitals )  Envisage interior maintenance expenses and its impact on financial health of hospitals Segregate service areas and Interiors expenses based on Service requirement. w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

HOSPITAL & HEALTHCARE ARCHITECTURE

THE LATEST TREND IN OPERATION THEATRE (OT) PLANNING & OPERATIONS DR. PRADEEP BHARDWAJ CEO & MEDICAL DIRECTOR, SIX SIGMA HEALTHCARE NEW DELHI

Architecture would have a very significant impact upon the operational and maintenance expenditure in the years ahead. It has to provide a congenial, safe, secure and infection free environment with ample scope for expansion. Architecture of any hospital and the departments has not only to specifically cater to the disciplines for which it has been designed but for general areas like, say, the approach and entrance from the road to the parking. The ambience of the Hospital and the various departments would depend upon the designs and layouts chosen. The architecture has to ensure that the buildings blend with the surroundings and has to cater for the prevailing weather conditions throughout the year which not only temperature and humidity but the direction and speeds of the wind during various seasons. This is necessary for the proper orientation of the buildings. It has to ensure that the above requirements are optimally addressed but also that the stipulations of the legal and statutory requirements like, safety, security, structural strengths etc are fully complied with. It has to cater for all that within the strict constraints of the financial budget and implications.

PLANNING PUBLIC SPACES FOR HEALTH CARE FACILITIES During the Industrial Age when it was learned that germs cause illness and that pollution can trigger disease in immune-stressed patients, public spaces for healing were replaced with private spaces. The sick were separated from the healthy and buildings became more compartmentalized. Today, the assumption that patients should be separated and isolated is evaluated in the interests of safety and best practices. And there is also much more emphasis on the patient as a customer with rights and desires for selfdirection, family inclusiveness and participation in caregiving and healing.

within a hospital within which surgical and other operations are carried out. The patient is the centre point of a functioning OT complex. He / she is in isolation for varying times, away from his near and dear ones and is physically sick. Efforts are directed to maintain vital functions, prevent infections / promote healing with safety, comfort and economy. On an average, operation theatres cater to 50% of the needs of total healthcare seekers. Anaesthesia-con trolled time typically represents a small fraction (10-20%) of the total case time, the remainder (> 80%) being surgeon and nursecontrolled To explain the importance of architecture in Hospitals, we will discuss the various considerations, in the following pages, while planning an operation theatre com plex. [Functioning of an OT complex including scheduling, administration, staffing, sterilization techniques and data / audit management are out of purview of this topic]

PURPOSE OF OPERATION THEATRE COMPLEX OT complexes are designed and built to carry out investigative, diagnostic, therapeutic and palliative proce dures of varying degrees of invasiveness. Many such set ups are customized to the requirements based on size of hospital, patient turnover and may be speciality specific. The aim is to provide the maximum benefit for maximum number of patients arriving to the operation theatre. Both the present as well as future needs should be kept in mind while planning. DIFFERENT ZONES OF OT COMPLEX The location and flow of the patients, the staff and the materials form the three broad groups to be consid ered during all stages of design. Four zones can be described in an O T complex , based on varying degrees of cleanliness, in which the bacteriological count progressively diminishes from the outer to the inner zones (operating area) and is maintained by a differential decreasing positive pressure ventilation gradient from the inner zone to the outer zone.

(1) Protective zone: It includes  Change rooms for all medical and paramedical staff with conveniences  Transfer bay for patient, material & equipments  Rooms for administrative staff  Stores & records OPERATION THEATRE COMLEX An operation theatre complex is the "heart" of any major  Pre & post-operative rooms hospital providing surgical services. An operating theatre,  I.C.U. and P.A.C.U. operating room, surgery suite or a surgery centre is a room  Sterile stores 44

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COVER STORY

(2) Clean zone: Connects protective zone to aseptic zone and has other areas also like  Stores & cleaner room  Equipment store room  Maintenance workshop  Kitchenette (pantry)  Firefighting device room  Emergency exits  Service room for staff  Close circuit TV control area (3) Aseptic zone: Includes operation rooms (sterile) (4) Disposal zone: Disposal areas from each OR & corridor lead to disposal zone TYPES OF OT COMPLEXES There are THREE main categories of operating theatres [4] :  The single theatre suite with OT, scrub area (and gown ing), anaesthesia room, trolley preparation, utility and exit bay plus staff change and limited ancillary accommodation.  The twin theatre suite with facilities similar to 1, but with duplicated ancillary accommodation immediate to each OT, sometimes sharing a small post anaes thesia recovery area.  OT complexes of three or more OTs with ancillary accommodation including post anaesthesia recovery, reception, porter's desk, sterile store and staff change. CONCLUSION In the present era of evidence based medicine, it becomes imperative to give maximum importance to architectural planning any facility like an Operation Theatre Complex. Within the limitations of finance and space, the best results can be obtained and anaesthesiologist with multiple roles inside the operation theatre complex, should be consulted in the process. Efforts should be made to conform to the standards laid down by local bodies and international agencies,

as healthcare facilities in India are now catering to more and more inter national clientele. However, new OTs and hospitals that are being established cannot be expected to fulfill all theo

retical requirements as new ideas are constantly being developed. By the time they are incorporated into build ings, fresh ones take their place on the drawing board. w w w.medegatetoday.com Nov-Dec 2016

COVER STORY

DESIGNING OF CRITICAL CARE AREAS The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare designers have experience in this process that most healthcare professionals do not.

THE CRITICAL CARE UNIT ICU design is complex and should include both clinically oriented and design based multi-professional team members.  Ideally 6 to 8 bedded ICU is recommended for operational efficiency.  Space per bed has been recommended from 150 to 250 sq ft area per bed in the patient care area. CLEAR FLOOR AREA  Clear floor space is space not occupied by the patient, fixed room furnishings, and equipment.  The purpose of this area is to allow room for services that are brought to the bedside, such as portable imaging, ECG, doppler examination equipment, dialysis equipment, and more WINDOWS  Natural light is essential to the wellbeing of patients and staff.

 Each patient care space should provide visual access to the outdoors, other than skylights, with not less than one window of appropriate size per patient bed area Window coverings should be easy to clean, providing patients an outside view– preferably overlooking a garden, courtyard, or other natural setting – may help relieve anxiety and stress, improve care, enhance patients’ comfort, and improve patient orientation. In cases where a patient’s bed must face the interior of the unit to permit close observation by staff, an adjustable mirror mounted on the wall or ceiling may provide the patient a view of the outdoors. equipment, bronchoscopy carts, and other specialty carts), materials management and Housekeeping Functions, Staff Support Functions, Seminar room, relatives area etc to be considered.

OPERATION THEATRE COMPLEX On an average, operation theatres cater to 50% of the needs of total healthcare seekers. Anesthesiacontrolled time typically represents a small fraction (10-20%) of the total case time, the remainder (>80%) being surgeon and nurse-controlled The three broad groups to be considered during all stages of OT design:

 The location and flow of the patient  Staff movement  Materials movement Four zones can be described in an OT complex, based on varying degrees of cleanliness, in which the bacteriological count progressively diminishes from the outer to the inner zones (operating area) and is maintained by a differential decreasing positive pressure ventilation gradient from the inner zone to the outer zone.

Other areas: Staff room - Men and women change dress to OT attire where lockers and lavatory are essential The anesthesia gas / cylinder manifold room / storage area Rest rooms- Pleasant and quiet rest for staff should be arranged. Seminar room- Since staff cannot leave an OT complex easily, it is better to have a seminar room within the OT complex for Intra-departmental discussions, teaching and training sessions for staff (with audiovisual aids) may be conducted here. Store room- There should be storage space for special equipment after cleaning Scrub area- This is planned to be built within the restricted area. Theatre sterile supply unit (TSSU) For sterilization & storage of theatre items. CONCLUSION Design of critical care facilities has an impact on organizational performance, clinical outcomes, and cost of care delivery. Organizations involved in design and construction projects are advised to engage experienced consultants who will collaborate with the users and make key design decisions on the basis of best current evidence 

Dr. Vinod Singh

Hospitech Healthcare Consultancy

www.m e d e g a t e t o d a y. c o m Nov-Dec 2016

DOCTOR SPEAK

Should You Get a Knee Replacement Surgery?

Dr. P.P Kotwal

M.B.B.S, M.S (Ortho) HOD, Orthopaedics, PSRI Hospital

Knee Replacement Surgery has always been associated with skepticism around the potential risk benefit ratio. This surgery has its own share of associated risks and entails a recovery and rehabilitation process. The final take on whether or not to undergo total knee replacement is both a practical and personal decision. While there may be not set criterion to evaluate when a knee replacement surgery becomes compulsory, an experienced orthopedic surgeon would usually follow a methodical procedure to evaluate the benefits of the surgery vis-a-vis the risks. The prime consideration for surgery happens when other alternatives options no longer help in addressing the physical challenges. Even then there might be few patients who cannot undergo surgery because of their age, weight, medical conditions, even though a surgery would have been beneficial for them.

Few generalized conditions, where surgery is necessary are:

A persistent pain in the knee joint that has worsened over time.  Pain that prevents you from sleeping. Y our ability to exercise has worsened over time and leads to knee aches. 48

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 Your mobility has decreased over time with difficulty in walking and climbing stairs.  Medications like NSAIDS aren’t offering enough relief.  Your basic life activities have become painful.  You feel pain in rainy weather.  The pain prevents you from sleeping.  You have restricted knee motion and degree to which you can bend your knee has decreased.  Your knees swell in the morning lasting for about 30 minutes.  Your joints make a grating sound.  Any previous knee injury.  According a Dr. Prakash Kotwal, an ex-AIIMS orthopedic surgeon currently practicing at PSRI Hospital,  You must not delay or decline a knee replacement surgery after your physician has recommended it. Delaying might eventually lead

to difficulty to perform routine activities due to persistent pain, loss of functionality, extension of deformities beyond the knee joint and overall reduction in quality of life. To summarize, when all preventive and supportive measures like lifestyle changes, use of medication and injections, strengthening exercises, alternative treatment methods including acupuncture, as well as surgical procedures, like arthroscopy, fail, knee replacement surgery is advised.

DOCTOR SPEAK

Total Knee Replacement The Latest Trends The most important factors to look in as latest improvements in knee replacements are mainly 4 as follows

Dr. Gaurav Bhardwaj MS, FRCS (Ortho) Uk, MCh (Liverpool), MRCS (Edinberg) Cheif Knee/Hip Replacement & Arthroscopy, PSRI Hospital

otal knee replacement surgery is well established surgery which provides a pain free, independent life back to the patients who are crippled by pain and immobility because of arthritis. According to the American Academy of Orthopedic Surgeons, 90 percent of people who have a knee replacement have excellent pain relief. These people are able to perform daily activities and stay active. In many cases, they’re able to resume activities like golf and walking that their arthritic pain made them give up years ago. About 85 percent of artificial knees still work after 20 years. Their endurance is one reason that this procedure is so popular. Most people who undergo a knee replacement are between the ages of 50 and80.The average age is about 70. About 60 percent of the recipients are women. The procedure has a high success rate and is considered very safe and effective. But as demands from knee replacement increase, the research is continuously going on to improve the outcome of the knees in 100 percent of cases and give them a very long lasting knee replacement with a normal life where patient can be allowed to do all activities like kneeling down and even squatting and running.

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kneeling down, as this is important for religious reasons and social life style in several part of world. These implants, known as Hi Flex knees are very successful in returning the normal knee movements when compared before surgery.

 Exact alignment of new knee implant so they last longer ( similar to fitting in new tyres in car with  Now a days, more emphasis is on exact alignment and balancing ). For quicker recovery and minimum pain this purpose navigation systems after the surgery. For this smaller were used but could not prove to incisions and aggressive pain make any significant difference in control measures are being used with results and therefore are not of much excellent outcomes. Now a days clinical significant benefit and their patient stay in hospital is decreasing use is mainly as marketing tools. and patients are being sent home Expertise, training and experience of earlier due to quicker recovery. your surgeon is most important factor in achieving alignment consistently.  Partial replacements are gaining popularity as rather than changing  Other important aspect is implants the whole knee only part of knee size and shapes matches to which is damaged is changed. individual patients to ensure proper This is called unicondylar knee fits. as one size fits all approach replacements. In suitable patients does not work in all. So far only this procedure results in quicker patient specific instrumentations recovery and almost full normal are being offered. They are only functions of the knee. Not all instrumentation to aid surgeons but patients are suitable for this partial this is NOT patient specific implants replacements. though this is not uncommon This is exciting times as knee for patients to misinterpret them replacement. Now a day this is very otherwise. Companies are bringing common to get impressed by aggressive gender specific knee replacements marketing claims. Therefore, when for male and female patients. choosing the surgery for knee  To aid and to gain near normal replacement, the most important factor movements at replaced knee, the is to trust on expertise and experience new designs are being used which of your surgeon and discuss the best can full bending of knee like option for you.

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How to Manage

Pregnancy from

Day One? Dr. Seema Sharma

Obstetrician-Gynecologist Srishri- The Gynae clinic, New Delhi

Pregnancy is a unique lifetime situation for everyone especially for women. This is a joyous experience as a human life is developing inside you, so enjoy and have the fondest memories ever. Though pregnancy is a normal physiological phenomenon, it is important to know about the changes happening at this time and how best we can tackle any problems to reduce complications. On an average we should maintain a doctor’s visit and checkup schedule to once every month till the first 7 months, then once in 15 days till 36 weeks and weekly till delivery. In exceptional situations or high-risk pregnancy sometimes we may ask a pregnant woman to visit the doctor more frequently.

Handling your First Trimester of Pregnancy

are rapidly changing, while your blood sugar and blood pressure tend to the lower. The extreme sleepiness usually tapers off by eight to 10 weeks and rarely lasts beyond 13 weeks. It is important to take folic acid supplementation to avoid certain problems in the baby. As soon as your baby’s heart activity is established or by 8-10 weeks of pregnancy, you will be asked to get your blood and urine tested. The common investigations that are ordered in a normal healthy pregnancy are:  Blood group (if you are Rh negative then your husband’s blood group should also be checked)  Full blood count to check for anemia and its type.  HPLC (this takes care of sickle cell anemia, thalassemia and the 3 monthly blood sugar values)

 HIV, HCV Exhaustion, nausea, sore breasts, constipation, urinary  Australia antigen to rule out hepatitis B frequency and tiredness are very common during the first lucose challenge test or random blood sugar 3 months of pregnancy. Building a baby uses an incredible  G amount of your body’s resources, your hormone levels  Urine test to rule out infection. 52

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DOCTOR SPEAK

The most important advice for first trimester is to slow down. Take rests, go to bed early, and let the housecleaning slide for now. Try and have 3 main meals and three snacks in a day to give you constant supply of energy. Cornflakes, fruits, Chilla, poha, sprouts and eggs make good snacks and have high nutrient value. Avoid overindulging in cereals like wheat and rice as these result in a high sugar surge followed by a sudden drop, making you lethargic and low in energy. Add veggies and fresh fruits like mango, ripe banana, pumpkin, tomatoes, water melon, pomegranate etc. in your diet. Certain foods like raw pineapple and raw papaya should be avoided in the first three months. Avoid blue cheese, sea water fish (if not cooked properly) and canned food containing monosodium glutamate. Exercise regularly – swimming, walking, yoga are all great in pregnancy. Begin doing pelvic floor exercises, helping you tolerate pregnancy and labor better. You need to stay hydrated with at least 8-12 glasses of water a day.

Second Trimester of Pregnancy During the 2nd trimester – week 13 -28 of pregnancy – is the best and stable phase of pregnancy. You can plan to spend time with your partner and go on vacation. Suddenly, the nausea is gone, your appetite returns, and your energy is back. Plus, now you start looking pregnant. You will experience a range of new physical changes. Your moods start to smooth out and get even better when you feel your baby’s first fluttery kicks. The threat of miscarriage decreases and women feel their baby move (at about 18 weeks) or see him on an ultrasound, many begin to relax and truly embrace their pregnancy. Sexual intercourse at this time is generally safe. In fact, lots of couples admit that they enjoy sex more during this time because there is no risk of pregnancy. Take gentle walk every day and gentle exercises. Boost your iron intake with lentils, cereals, eggs, red meat and plenty of green leafy vegetables. Go for the routine checks with your doctor to monitor your weight and blood pressure and manage any potential complications in your pregnancy with various investigations like measuring your baby, Glucose Tolerance test, iron level test, etc.. Leg cramps become more common from the fifth month of pregnancy onwards. During a cramp, gently stretch the calf of your leg by curling your toes upward, toward your knee. Alternately squeeze your calf muscles gently for one or two minutes. To avoid constipation drink plenty of fluids and eat foods with lots of fibre, such as fruits, vegetables and bran cereal. If you have nasal congestion and nose bleeds ,Place warm, moist towels on your face. Breathe steam from a hot shower, a pot of boiling water, or a vaporizer. Tiny purple, pink or red marks may appear on your abdomen, breasts, and thighs and there is very little that you can do to prevent them. Moisturize your skin regularly and wear

loose cotton clothing. A moisturizer containing Calamine or Aloe Vera may be particularly soothing. You could also try massaging your skin with coconut oil before a bath. To avoid back pain maintain good body posture while sitting or standing. Sit in straight backed chairs and wear low heeled shoes. Sleep on your left side with a pillow under your upper leg for support. Try heat or cold on your back or get a massage.

The Third Trimester of Pregnancy (28-36 weeks) By now you should have signed up for a prenatal class, in which you learn what to expect in this final stage of pregnancy and during labor and delivery. As you head into the final stretch, remember to keep eating right and exercising so that your baby gains the proper amount of weight and you're in the best possible shape for labor and delivery. Activities for your third trimester Start paying closer attention to your baby's movements and let your doctor know right away if you notice a decrease in movement. Your baby can hear your voice now, and talking to him or her is a great way to start the bonding process. Be strict about your pelvic floor exercises and learn about coping with labor pain. There's no one right way to deliver a baby. Every woman's experience with pain is different and every labor is different but being active will go a long way to achieve normal delivery.

Packing your Hospital Bag  Have your bags packed by the time you are about 36 weeks pregnant. Here’s what you need:  2 comfortable nightdresses for the days after your delivery.  Old Underwear for 2-3 days in the hospital and maternity sanitary pads.  Nursing bras and breast pads to soak up leaking milk.  Toiletries, hairbrush, towel  A going home outfit. Choose loose and comfortable that allows you to breastfeed discreetly.  Things to help you relax during labour such as music, a book and magazine, oil for back massage, etc.  Weather- Appropriate outfits for your baby. Also pack innerwear for your baby  Baby blanket  Baby toiletries and towel  Nappies, a changing mat, wipes, and nappy rash cream. A change of clothes for your husband so he can freshen up. Even if you get premature labor and haven’t had time to pack bags yet, please do not panic as you are not delivering in a jungle. Most big hospitals have a baby shop in the premesis where you can buy the emergency stuff. So relax and enjoy your baby free moments  w w w.medegatetoday.com Nov-Dec 2016

DOCTOR SPEAK

IDENTIFYING FIBROMYALGIA

A COMMON PAIN PROBLEM IN FEMALES Fibromyalgia is a chronic pain condition that causes widespread diffuse body pains. It is the most common cause of generalised musculoskeletal pain in women between 20 and 55 years. Many patients also experience fatigue, sleep disturbances, headaches and mood disturbances such as depression and anxiety. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by conditions such as anxiety or stress, poor sleep, exertion or exposure to cold or dampness. Muscle stiffness is typically present upon awakening and tends to improve as day progresses. Persistent fatigue occurs in more than ninety percent people along with complains of unusually light nonrefreshing or non-restorative sleep. Patients may also feel numbness, tingling or unusual crawling sensations in arms and legs. Other pain syndromes such as migraines or muscular headaches, irritable bowel syndrome or urinary complaints such as bladder pain and urinary urgency and frequency are commonly seen. Fibromyalgia is thought to be the result of change in pain perception, a phenomenon termed ‘Central sensitisation’, which might be due to genetic predisposition, stressors including physical or emotional trauma, sleep disturbances or other medical conditions. There is no specific laboratory or imaging test used to diagnose fibromyalgia as no abnormalities are detected in underlying muscles or other tissues. Fibromyalgia is a treatable condition. The objectives of treatment are to reduce pain, improve sleep, restore physical function, maintain social interaction and re-establish emotional balance. To achieve these goals patient will need a combination of social support, education, physical modalities 54

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and medication. A multidisciplinary team comprising of a Pain Physician, Psychologist and a Physiotherapist would be ideal for managing the condition of patient. While a positive attitude change is needed in patients, the attitude of family members, employers, policy makers all have an impact on patient’s condition. Clinicians must be prepared to accept fibromyalgia syndrome as a real condition that exerts a tremendous impact on the patient’s life and must approach with empathy. Patients need to be educated and understanding is power when it comes to maintaining a proper attitude, adapting to limitations and taking active role in therapeutic program. Aerobic exercises not only helps to maintain function in everyday activities but also to reduce pain, improve sleep, balance mood, restore cognition and facilitate a sense of wellbeing. The application of heat

Dr. Pushpinder Singh Mehta Associate Consultant Pain Medicine, Indian Spinal Injuries Centre, New Delhi

DOCTOR SPEAK

Stent retriever improves outcomes for stroke patients

Dr. Sannareddy Rajesh Reddy Brain, Spine & Endovascular Neurosurgeon, Apollo Institute of Neurosciences, Hyde

troke is a leading cause of death and disability in India, largely driven by the increasing prevalence of diabetes, high blood pressure and obesity. Stroke affects men and women and does not discriminate on the basis of age; the young are equally at risk of stroke as are older people. A stroke can be devastating at any age. It is commonly observed that stroke patients do not realize the gravity of early signs and symptoms, and tend to delay treatment until more â&#x20AC;&#x2DC;dramaticâ&#x20AC;&#x2122; symptoms are present. Even more critical is that most of these early stroke cases wait to see if the symptoms will go away on their own. Stroke is treatable and its impact can be significantly reduced, provided the patient receives medical treatment in time. About 85 percent of the time, the cause of a stroke is a clot that blocks an artery and restricts blood flow to the brain, or an acute ischemic stroke. Because brain tissue begins to die immediately when blood flow is deprived, it is critical to open the artery quickly. In treating stroke it is critically important to restore blood flow as soon as possible. Until recently, physicians have been using intravenous tPA, a clot-busting drug to open blocked blood vessels, as the first line of defense. Five global clinical trials published in 2015 have shown that the addition of stent retriever therapy to IV-tPA improves functional disability in patients and is now recommended as a first-line treatment for acute ischemic strokes.

Stent retrievers are inserted via a catheters through a pin hole in the groin area to the targeted vessel in the brain, where it is used to manually remove the clot and re-establish blood flow. The stent retriever is then removed from the patient. Stent retrievers are a major advance in stroke care. The addition of stent retriever technology has reduced disability, improved neurological outcomes and increased the rate of return to functional independence in patients suffering from ischemic stroke. Stent retrieval therapy for acute ischemic stroke patients is a very promising approach that is now being used at leading hospitals across India. A growing number of specialists have developed or are developing the expertise to perform these procedures ď ą

w w w.medegatetoday.com Nov-Dec 2016

EXPERT VIEWS

Opportunities amidst

the huge cancer burden in India

ndia is facing a huge cancer burden. The prevalence of cancer is estimated at 3.9 million people in 2015 with reported incidence of 1.1 million (or 94 people per 1 lac population). However, the real incidence is expected to be much higher (1.5-2.0x) than reported incidence affecting 1.6 - 2.2 million people. The difference between reported and actual incidence can be primarily attributed to under-diagnosis and delayed diagnosis of cancer in India. Lack of awareness and inadequate infrastructure are key barriers to timely and accurate diagnosis in India. To put this in perspective, India has a mere 0.1 PET CTs per million population compared with 0.3 in China and 6.2 in the U.S. Adverse cancer mortality rates observed in India can be attributed to poor diagnosis and inadequate treatment landscape. 1 The profile of cancer in India is changing and is mirroring trends seen in more urbanized nations. In 2000, the most prevalent cancers in India were head and neck cancers in men (associated with all forms of tobacco use) and cervical cancer in women. Breast cancer has now surpassed cervical cancer as the most prevalent female cancer, and incidence rates of gastrointestinal cancers which have traditionally been low in India have been showing an increasing trend. Breast and cervical cancers among women, and head and neck, lung, and GI cancers among men, represent more than 60% of the incidence burden of solid tumors.

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What are the key barriers limiting diagnosis and treatment in India?  Affordability: Cancer treatments on an average cost INR 3 lacs - INR 4 lacs (can go upto INR 14-15 lacs with innovator targeted therapy drugs and advanced radiation treatments). India has low average household income levels with ~20% of households having an annual income >INR 200,000. Insurance coverage is low with only ~30% of the population covered by state and private insurance schemes  Access: Low density of diagnostic and treatment facilities and significant geographical skew with 40-60% of the facilities and oncologists in the top metro cities  Awareness: Low awareness about cancer, its symptoms and self-examination

Cancer incidences to rise going forward Cancer incidence is expected to increase going forward due to three key main factors – demographic changes (ageing population), higher exposure to risk factors (sedentary lifestyles, increasing pollution) and gradual improvements in awareness and access. Reported cancer incidence in India is estimated to increase from ~90 per 1 lac population to ~150 by 2020. This will result in cancer incidence increasing from 1.1 million in 2015 to 2.1 million in 2020, a CAGR of 14% . The prevalence is expected to increase from 3.9 million in 2015 to 7.1 mn in 2020E.

EXPERT VIEWS

Significant demand supply gap in the Industry both in Diagnosis and Treatment While on the one hand, there is increasing incidence, on the other, there is a huge demand-supply mismatch across diagnosis and treatment landscape in India. As of 2015, there are only 121 PET-CT scanners installed in India with ~50% installed in metropolitan cities. Only 10-12% of new patients in India can potentially get PET CT scans done based on current installed capacity.

Radiation therapy still at a nascent stage: A key requirement for successfully providing radiation therapy is the availability of Linear Accelerator (LINAC). Yet again, India faces the issue of under-penetration and geographical skew (One-third installed in top 7 metros). Due to poor access to cancer care and low affordability, only 15-20% of cancer patients in India receive/opt for radiation treatment, versus 50-60% globally.

Limited penetration of Comprehensive cancer care centers (CCC): As of 2014, only 200-250 CCCs offered diagnosis, treatment and post-treatment care at a single location. This results in ~180 CCCs per million incidence compare with 875 in the U.S. Around 40% of these centres are located in top eight metropolitan cities and ~85% are owned by private players/ trusts. Government hospitals currently do not have adequate infrastructure to meet the growing burden of cancer care in the country – signaling significant opportunity for private/ for-profit players.

Limited Oncologists: Additionally, significant gap exists in terms of availability of oncologists in India compared with other developed countries. There is just one oncologist per 1,600 people in India, as against one per 100 people in the U.S.

Market Opportunity: High growth expected in treatment landscape as barriers are addressed The already existing demand-supply gap in the system and improving demand factors fuelling growth of treatments will further increase the need to augment cancer treatment infrastructure in India. Rising income levels, increasing insurance, evolving technological landscape (PET CT, Molecular diagnostics, targeted therapies) and government focus are expected to drive huge growth in treatments. (Radiotherapy, Chemotherapy, Surgery). Radiotherapy is expected to be the highest growth category as shown below: Treatment

Estimated no. of patients (2015E)

Estimated no. of patients (2020E)

CAGR (2015-2020E)

Surgery

355,000

675,000

14%

Chemotherapy

350,000

550,000

Radiotherapy

155,000

475,000

25%

The overall cancer treatment market in India is estimated at USD 1.7-2 billion in 2015, including all modalities of treatment and is poised for strong growth. In line with the growth projected, it is estimated that an additional 8001,300 day care beds and 200-350 comprehensive cancer care centers will be needed by 2020. The geographic skew in the distribution of facilities and infrastructure will necessitate that a large proportion of the new centers are set up in nonmetro cities to fill in the current gap. 1 The huge growth potential and under-penetration highlights a significant opportunity for private players. With government hospitals inadequate to provide the quality of treatments needed, private players have played a key role in shaping the treatment landscape in India. Historically, private multispecialty hospitals have focused on Cancer as a Center of Excellence – major corporate hospitals that have focused cancer treatment centers include Apollo Hospitals, Manipal, Fortis, Max etc. In addition, there have been specialized hospital chains focusing on cancer that have been gaining ground. Healthcare Global Enterprises (HCG), set up in 2006, operates the largest network of Comprehensive Cancer Centers in India with 17 centers Pan-India and 1 Center of Excellence in Bangalore. HCG has adopted a differentiated model designed to provide quality/comprehensive cancer care at competitive prices on a pan-India basis, with focus on non-metro locations (e.g. Cuttack, Nasik, Baroda, Hubli, Ranchi, Vijaywada, Trichy). 2 HCG attracted huge private equity interest owing to attractive market opportunity and differentiated business model. The company raised ~USD 30 mn from Temasek in 2013 in addition to an earlier round raised by Premji Invest and India Build Out Fund3. In recent times, the healthcare sector has seen some high profiles IPOs that have received strong investor interest (e.g. Narayana Hrudayalaya, Dr. Lal Path Labs, Alkem Labs). HCG also had a successful IPO in March 2016 giving part exit to the existing investors. Some other notable specialized cancer chains that have caught investos’ fancy include:

Key PE Deals Date

Name

Apr 2016

Cancer Treatment Services International (CTSI)

Apr 2013

Amrish Oncology

Jul 2012

International Oncology Services

Description • Operates cancer treatment facilities focused on India and South Asia • I ts flagship center, American Oncology Institute, is based in Hyderabad offering comprehensive cancer treatments •P art of the US-based Comprehensive Blood & Cancer Center

PE Activity • TPG bought a majority stake (65%) in CTSI for USD 33 mn

•O perates 6 cancer centers, primarily within hospitals

• Raised USD 6 mn (~Rs 33 cr) from Singapore-based Prem Investment

•O perates Cancer Therapy Centers at partner hospitals in Noida, Mumbai, Jodhpur, Aurangabad, Kerala (e.g. Fortis Noida, Hiranandani Powai)

• Raised USD 3.7 mn (~Rs 20 cr) from Rajasthan Venture Capital Fund

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EXPERT VIEWS

IVF: High potential baby making business in India

Nandini Agarwal Executive Team Member

Current Infertility market in India

ncreasing participation of women in work force, rapid urbanization and an emerging middle class, while shaping the economic growth of the country, also have important social connotations. Changing lifestyles, preferences and aspirations that transcend beyond the boundaries of a traditional Indian family system are defining the growth trajectory of the In-vitro fertilization (IVF) industry in India. There is a new generation of young, professionally oriented women who are prioritizing their career over marriage and children. Increase in the age of marriage is one of the major factors contributing to infertility, in addition to higher prevalence of contraceptive use and other medical factors. While most Indian households would attribute the cause of infertility to women, male fertility is on the rise and accounts for 30%-40% of the cases. Rising levels

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of tobacco and alcohol use are risk factors that are strongly associated with male infertility. Additionally, sedentary lifestyles and easy food options have driven the obesity count, making India the third-largest obese country after US and China. Increasing obesity levels and sexually transmitted infections also lead to increased infertility in both the genders. The confluence of the above factors has resulted in India staring at a huge infertility burden. Infertility is a medical condition has a high prevalence affecting nearly 10-15% of married couples in India. It is estimated that there are 2233 million couples in the reproductive age suffering from lifetime infertility in 2015.1 With the risk factors not showing any signs of improvement, the burden is only expected to rise further.

The social stigma attached to infertility and low levels of awareness has resulted in only ~1% of infertile couples coming forward for evaluation. The treatment market for infertility is estimated at ~100,000 in-vitro fertilization (IVF) cycles in 2015, and has grown at a CAGR of ~18% in the last decade from 19,000 cycles in 2005. While the growth has been fast, the penetration of the IVF market is significantly low in India compared to other countries, with only ~2800 cycles/million infertile women in the reproductive age (20-44 years) compared with ~135,000 in Japan, ~46,000 in US and ~6,500 in peers such as China.1 Key challenges that have limited treatment in India include  Low awareness: of ART procedures among Indian couples  High cost of treatment: IVF treatments on an average cost INR 150,000 - INR 200,000 including medicine, treatments etc. India has low average household income levels with ~20% of households having an annual income >INR 200,000. Majority of public and private insurance programs do not cover infertility  Access to qualified IVF specialists: India has a small pool of senior IVF specialists with limited brand portability. Also, there is limited organized training or fellowship programs for building a pool of skilled IVF specialists and embryologists  Assurance and Trust: Success rate is low with most couples having to undergo an average 1.5 cycles for successful pregnancy. Couple also have concerns on quality and safety in the absence of a regulatory framework  Lack of regulatory framework: Currently the sector is unregulated with the ART bill 2014 pending with the government. There is no legal

EXPERT VIEWS

registration required for infertility clinics and not mandatory to report details on success of the procedures. There are also issues around surrogacy which need to be addressed such as number of pregnancies allowed for a surrogate mother, compensation, rights of a child born through surrogacy

Growth potential of the market Notwithstanding the challenges, the market has tremendous potential given the huge infertility burden and underpenetration. Assuming an average price of Rs 150,000 and 1,00,000 cycles p.a., the market is estimated at ~INR 1,500 cr (~USD 230 mn) in 2015. As more infertile couples come forward for treatment, the IVF market is estimated to grow by ~20% to reach ~260,000 cycles by 2020. Assuming a moderate growth in pricing of 5% over the next few years, the market will reach ~Rs 5,000 cr (USD 760 mn+) by 2020. Another factor fuelling the IVF industry is the huge demand from international patients. India is fast becoming a hub for fertility tourism attracting nationals from Britain, the United States, Australia and Japan, to name a few. The combination of the low cost of infertility treatment in India and the modern ART available here make India a top choice for infertility treatments. An average IVF cycle in the US cost USD 10,000 whereas in India it is available for about USD 3,000. The easy availability of egg donors and surrogates in India has also encouraged international patients to consider India as one of the suitable countries to pursue their treatment. However, the ART bill proposes to narrow the surrogacy services to Indian couples or a foreigner married to an Indian citizen. IVF has also found flavor with investors globally and has emerged as a preferred choice for the fertility treatments. IVF centers offer attractive dynamics such as high volumes (as IVF becomes more acceptable and treatment costs are reduced), better margins and lower capital intensity. The global IVF market is expected to reach USD 11.3 billion by 2021, at a CAGR of 10.8% from 2015 to 2021. Changing lifestyles, delayed

pregnancy, commercialization of costeffective treatments and emerging medical tourism are expected to drive the market. In terms of number of IVF cycles performed, Asia-Pacific region dominates the global IVF market with China accounting for majority of the market.2 Australia is at the forefront of IVF market with two companies (Monash and Virtus) witnessing successful IPOs on the Australia Stock exchange giving exit to the PE investors.

Operating models in the industry The lack of a regulatory framework requiring registrations or reporting of clinical outcomes has resulted in the industry being largely unorganized. The market is highly fragmented with host Name

Scale

Nova IVI Fertility

No of centers: 16

of solo practitioners setting up shops. Most IVF clinics operate at sub-optimal levels performing less than 100 cycles per annum. It is estimated that there are ~1,000 IVF clinics with the organized clinics accounting for 75% of the IVF volumes. 1 However, there are few chains that have been able to achieve scale (table below). Most of the successful names have tieup with international chains or headed by a reputed doctor. Notably, the major players in the industry have raised private equity money to fund their expansion plans. Bourn Hall India is backed by private equity firm TVM Capital MENA and Goldman Sachs is an investor in Nova Medical Centers. Background/Future Plans

• Subsidiary of Nova Medical Centers • Technical collaboration with IVI Spain (IVI operates 28+ centers across 8 countries) • Plans to expand to 40 centers in tier II and III cities Bourn Hall India

No of centers: 3

•F ully owned subsidiary of Bourne Hall UK, one of the pioneers in IVF UK

Morpheus IVF

No of centers: 24

• JV with Morpheus, Germany • Associated with leading gynaecologists

Bloom IVF

Indra IVF

•H eaded by Dr. Hrishikesh Pai and Dr. Nandita Palshetkar No of centers: 5 IVF Centers, 2 Fertility Centers, • H as 3 models (IVF centers , Fertility Centers and Associate Clinics) 5 Associate Clinic •O perates IVF units within hospitals (e.g Fortis, Lilavati) No of centers: 13

• Founded by Dr. Ajay Murdia in 1988 • Focus on affordable treatments

Even hospitals have forayed into IVF to cater to the growing need of IVF services. Tertiary hospitals such as Apollo, Max have IVF centers as well as specialized secondary hospitals such as Cloudnine offer IVF services. Manipal entered the IVF space through the acquisition of Ankur Healthcare to expand into the lucrative single specialty segment. The ART Bill aims to regulate the IVF industry providing for safe and ethical practices and disclosures on outcomes. We believe that the new regulatory standards should drive consolidation and make the market more organized (with small players unable to cope up and forced to shut down). Also international chains will increasingly look at India increasing the competition in the industry. Sweden's Medicover has already announced plans

to launch its fertility centers in India with an investment of USD 100 mn to open 50 clinics. The population dynamics and the huge infertility burden alone make India a difficult market to ignore. Thus, in the long run, only those domestic firms that meet the regulatory guidelines, follow transparent and ethical practices with standard operating procedures for scalability will survive in the high growth IVF industry.

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PRODUCT LINE

Advanced Transport Solution For Hospitals & Diagnostics “AIROX has been a pioneer in Health Care Sector in India with its quality products. Airox is associated with Airsep Corporation, USA and Telelift, Germany to promote their cutting edge technology in India. Telelift ETV system will revolutionize hospital logistics solution in India. AIROX now works at PAN INDIA level with 225+ Indian satisfied customers, which are increasing every passing day. Airox with 100 employees and 20 distributors has been awarded as Fastest Growing Indian Company Award at International Achievers Conference in 2014. ETV (Electric Track Vehicle) is most advanced transport solution for hospitals with more than 100 beds. This system moves in horizontal and vertical direction with one single system of flexible modular construction and has intelligent and disinfecting containers with constant monitoring of transport activity designed to transport hospital goods and can take load up to 10 kg. We can transport 90% of hospital small goods up to 10 Kg load. Major material in hospital like surgical instruments (from CSSD to O.T. keeping it completely disinfected), intravenous drips, blood samples including LDH & ASAT analysis, blood packs without damaging plastic packing material, consumables, disposables, patients files, X-ray films, C.D., folders, radionuclides, syringes, needles, gloves, dressing,

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pharmaceuticals, tissue & laboratory samples, all these items can be transported in big quantities. So except food & linen we can transfer almost all hospital goods upto 10kg. This system helps in increasing workflow & prevents infection in carrying O.T. instruments and other transportation to O.T. and ICU. A 300-bedded hospital generally has 350 staff except nurses & doctors. This system help reduce at least 20% manpower in the hospital. If we consider average salary including P.F. & other expenses of staff as Rs.10000/per month, it amounts to reduction of Rs.1 Crore per annum. If we install this system we can reduce 1 or 2 elevator installation, which amounts to Rs.22

to 44 Lac. The average electricity consumption of 300 bedded hospital is Rs.1 to 1.5 Crore which can be reduced by 15% with this system. Hospital can reduce 2 elevators & 50 trolleys in a 300-bedded hospital. The product is robust with 35 to 40 years of life & has negligible maintenance. The product will help hospitals improve work-efficiency. Considering it’s huge success across the globe we are assured about it’s same success in India." More than 1500 hospitals like Singapore General Hospital, Central Hospital Augsburg, Germany & Nigurda Hospital, Italy are global users of ETV - Telelift.”

Innovation Makes You Leader

AIROX OXYGEN GENERATOR Now Running With 225+ Indian Satisfied Customers Cost Saving : The hospital has a return on investment in a very a short period (from 6 months to 3 years) No Price Fluctuation, No Surprise : The cost is directly related to real hospital consumption Safety : No more explosion or fire hazards Space : Compact system System Designed for 24/7- 365 days continuous use & Airsep have systems operating for 24 + years The Oxygen Purity from our PSA meets USP (93%+-3%) which is monitored in the system Modularity : Broad range of generators. As per increased consumption additional model can be added. Autonomy : Produce only what you use

ETV - ELECTRIC TRACK VEHICLE Have 1500+ Installations Across The Globe Return On Investment (ROI) : Get your ROI from 6th month onward Manifold Transport : Transports all kinds of IV bags, blood bags, surgical instruments & all other major& minor hospital goods up to 10kg Reduced Cost : System reduces manpower cost by 20-25% and electricity cost by 10-25% Time : Reduces transportation time and operates with same efficiency round the clock Quality : High quality standards of hygiene & sterilization are maintained due to less manpower handling Safety :- Enhances workplace safety Life Span :- The life span of system which is based on latest German technology is more than 30 years

For Enquiries Contact

PRODUCT LINE

Call Systems, Bed-Head Panels, Pendants Nurse-Call Systems

Medisystems Electronic Nurse-Call Systems are modern microcontroller based digital systems. System features have been designed to cater for hospital practices prevailing in India. Hence, the basic audio visual arrangement has been deliberately simplified through an easy to understand red-yellow-green lamp mode with easily recognisable audio chimes. All calls are acknowledgeable, to relieve patient stress, and no call can be cancelled or reset except by visiting the patient bedside. Even trainee nurses placed on ward duty at short notice can adapt to the system in minutes. The system is modular, comprising a Central Display Console at the nurse-station counter (Optionally, also with Ward Graphic Displays), a Bed Unit module behind each patient's bed and a Handset which reaches out to the patient through a length of flexible cable. A Door Display Unit can also be mounted at the room entrance â&#x20AC;&#x201C; with Nurse-Presence Registration. An Emergency Alert Unit can be mounted within the toilet and / or also within the shower stall. Optional features include Nurse Help Request, PatientNurse Intercom, Code-Blue Alert, IV-Drip Alert, Instrument Alarm Relay, Additional Call Signals, Call Transfer Facility, Multifunction Handsets, Corridor Display Modules, Nurse Call Response Monitoring and an SMS Alert facility for selected emergency calls to be forwarded directly to cell phones.

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Bed-Head Panels

Medisystems Bed-Head Panels are specially fabricated for hospital use and designed to converge all the essential utilities around a patientâ&#x20AC;&#x2122;s bed. Standard panels are available for ICU, Wards, Private Rooms / Suites. The circuit protected panels carry provision for electrical power, illumination, communications, Bio-signals, data, time and medical gas. A stainless steel universal medical rail is also provided for holding a range of accessories like Utility baskets, Case sheet holders, Blood Pressure instrument holders, I-V Poles, etc. Patient-Bed Lamps may also accompany the panels. Constructed from light weight extruded aluminium sheets and sections and stainless steel, and surface treated with an epoxypolyester powder coat ensures a lifetime protection to the metal surface. It facilitates ease of cleaning and ability to withstand damage from common hospital fluids like saline, drugs, blood etc. These light weight panels can also be mounted on non brick walls made of siporex or gypsum board. All panels have safety metal partitions between high voltage, low voltage and medical gas outlets. Medisystems manufactures a very wide range of such panels to meet practically every kind of need. Such panels are also available in custom configurations which include horizontal, vertical or wall angular orientation, in colours and finish of choice.

PRODUCT LINE

OPD Patient-Call Systems

Medisystems OPD Patient-Call Systems are the ideal solution for queue management in busy crowded OPDs. Their configuration is based upon the number of consulting rooms and waiting areas of the OPD. The system consists of a Main Display Unit for the waiting area; door display units and desk units for the consulting rooms. The receptionist or cashier can also be connected to this system with additional desk units. The system scrolls all un-answered calls and can also remind for any un-attended calls. A lower programmable display line can carry social or promotional messages for the hospital. Bilingual displays can also be given. The system once installed is user-friendly, costeffective and needs minimal support.

OT/ICU Ceiling Pendants

Medisystems manufactures OT and ICU Pendants in rigid, single arm and double arm configurations. They are fabricated from Aluminium or pure 304 Grade Stainless Steel sheets and extrusions. The suspension limb is a seamless extruded SS 304 tube of 100 mm dia. mounted with anchor bolts at the true ceiling and a cosmetic flange at the false ceiling. The main pendant body can be made in stainless steel or powder coated aluminium, as desired. The pendants carry provisions for upto six medical gas outlets, eight electrical outlets and data terminals. The pendant can provide entry of medical gas lines, data and electrical terminals on all sides. Electrical outlets can be mounted on a utility backbone which supports upto 4 shelves. These shelves can be employed for placing monitoring, anaesthesiology or other diagnostic/ therapeutic instruments. A utility pole for I-V dispensation can also be provided alongside the shelf array.

CR Medisystems Pvt. Ltd. Mumbai, India. Tel: 91-022-23094416, 23004930 E-Mail: medisystems@gmail.com Web: www.medisystems.in

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PRODUCT LINE

Vikram Anand

Director CapBuild Clinical Skills Pvt. Ltd.

Informed Analytics: The Future of Efficient Healthcare Delivery Indian healthcare sector faces a unique paradox. While it is witness to an acute shortage of healthcare facilities and a staggering need gap, many existing providers are struggling to become profitable. Despite high demand for healthcare services, providers face issues of poor bed occupancy, underutilized diagnostic equipment, vacant OTs, and overall financial sustainability. We, at CapBuild, strongly believe that one of the major reasons for this conundrum is that the senior management teams in hospitals do not have access to the hospital’s performance report on an on-going basis. The result being that strategic decisions are often taken intuitively instead of being based on robust analysis. While it is certainly encouraging to see Indian healthcare providers increasingly deploying hospital information systems (HIS), these systems are transactional in nature and limited to data storage capabilities. They are not utilized for developing critical insights into a hospital’s operational and clinical performance. It has been proven at multiple hospitals across the world that “Informed Analytics” has the power to transform this situation, by enabling management teams to continuously stay updated with their current and expected performance. If integrated successfully into the health sector, analytics

Looking Inwards: Insights into one’s own data Healthcare providers can harness the power of analytics to optimize revenue, control costs, and enhance patient experience.

can go a long way in providing more efficient healthcare to patients by optimizing hospitalization costs and improving revenue for providers. Some of the most successful healthcare providers globally have used analytics to achieve positive impact in areas of financial planning, supply chain management, human resource management and quality of clinical care.

Focus Areas of Healthcare Analytics

Analytics can lend insights into the payer mix and surgical case mix, identify trends for overall payer and specialty driven volumes, and help understand their impact on the top line and increase the ROI. It also helps organizations

improve their administrative and financial performance, design and plan organizational policy and programs, and align improvement projects to hospital goals based on unique insights. Analytics help providers optimize

Analytics can help answer some of these critical questions across key areas of operations 64

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PRODUCT LINE

their costs by minimizing wastage and improving asset and staff utilization. Healthcare analytics can also support providers focus on patient engagement by improving clinical outcomes and enhancing overall patient journey.

Looking outwards: Data sharing and benchmarking with peers The future of healthcare delivery lies in patients and payers having access to providers’ performance report, to be able to choose the hospital which matches their quality and cost preferences. We believe that this would necessitate providers to share their performance data with each other, and external stakeholders involved. This would not only promote better coordination among providers, but also help in establishing India-specific

industry benchmarks for operational, financial and clinical performance. At present, Indian hospitals follow international benchmarks derived largely from the developed world, and this often results in a misalignment of management’s goals and achievable targets. Data sharing will also provide market insights about current and projected healthcare trends, payer mix of target population and understanding consumer behavior for new entrants and for providers looking to expand into new geographical territories. In line with this need, we, at CapBuild, are committed to the cause of making Indian healthcare providers analyticssavvy, to help them realize their complete potential.

About CapBuild Clinical Skills Pvt. Ltd. CapBuild has been conceptualized with the passion and vision of strengthening healthcare ecosystem in India through a systemic approach of:  Providing robust data analytics solutions to healthcare providers  Enhancing clinical, leadership and management capabilities across healthcare organizations  Improving clinical and operational performance of providers We work with providers as their BI (Business Intelligence) partners, providing customized monthly dashboards to help them understand their business & clinical performance, and brainstorm with the senior management teams in identifying underlying issues to be addressed and the desired enablers for implementation

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EXPERT VIEWS

PM2.5 - The darker side of

Industrialization Particulates that have a diameter of 2.5 micrometers or less are called PM2.5. These particles are so small that they can only be viewed under a microscope. Their small size makes them much deadlier than PM10.

Where does PM2.5 it come from?

eduction of Air pollution levels is the need of the hour, globally. Globally, Air-Pollution has been the major cause for the premature deaths of thousands of people both in developed as well as Developing countries. Most of the cities in developing countries the outdoor air pollution do not meet the World Health Organization (WHO) guidelines for acceptable pollutant levels. Risks of stroke, heart disease, lung cancer, chronic and acute respiratory diseases (including asthma) and other health problems has increased for people who live in these cities, with an estimate of nearly 3.5 Million people dying due to these diseases every year. 13 of the top 20 most polluted cities in the world are in India. On an average PM2.5 reduces the life expectancy of humans by almost 3.5 years. The deaths in India in the last 5 years due to air pollution effects has increased by almost 15%. Traffic (especially diesel vehicles), industrial sectors (from brick making to oil and gas production), power plants, cooking and heating with solid fuels (e.g. coal, wood, crop waste), forest fires and open burning of municipal waste and agricultural residues are the major sources of air-pollution and PM2.5. Particulate matter (PM2.5), refers to particles in the air that cause pollution. These particles are released from a variety of sources, both indoors and outdoors. Though the atmosphere will always have PM2.5, certain levels are considered dangerously high.

Why is it called PM2.5? The ‘2.5’ in PM 2.5 refers to the size of the pollutant in micrometers. Particulate pollutants vary in size and the smaller they are, the more damage they cause to your health. Particulates that have a diameter of 10 micrometers or less are called PM10. Dust particles are the main source of PM10. 66

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P M2.5 is produced through: C ombustion in vehicles and machinery  I ndustrial processes, particularly those involving coal E missions from power plants C hemical processes in the atmosphere which happen when gasses and other pollutants from power plants interact S ources inside the home, such as candles, lamps and fireplaces V ehicle emissions C rackers burst during festivals F orest fires and coal burning.

What are the negative effects of exposure to PM 2.5? PM2.5 (Particulate matter 2.5 micrometres or less in diameter) is produced by incomplete combustion of fossil fuels and biomass and is one of the biggest concerns. PM2.5 (which is one-hundredth the thickness of a human hair) can penetrate deep into the lungs and blood stream and is dangerous at any concentration.

How can I protect myself against PM2.5? In many areas of the world, concentrations of ambient air pollutants exceed levels associated with increased risk of acute and chronic health problems. While effective policies to reduce emissions at their sources are clearly preferable, some evidence supports the effectiveness of individual actions to reduce exposure and health risks. Personal exposure to ambient air pollution can be reduced on high air pollution days by staying indoors, reducing outdoor air infiltration to indoors, cleaning indoor air with air filters, and limiting physical exertion, especially outdoors and near air pollution sources. Evidences have also suggested that the use of respirators and not masks will only be effective in such circumstances. However it is essential to have an awareness of the difference between Masks and Respirators. Masks are more like a Sieve like structure which would prevent bigger particles to be stopped while smaller particles (anything less than PM10) would still pass through. The word Surgical mask or mask (which normally people use in a PM 2.5 situation) would not serve any purpose due to the following differences and only respirators should be used to prevent the effects from inhaling PM2.5.

INTERVIEW Pneumatic waste and Laundry Collection System (PWLCS) : The Start of A New Era What is Pneumatic and Pneumatic force:

Pneumatic is air and Pneumatic force is a force of air which is used to transfer material from one place to another in a controlled environment. In our case, we use this force of air in a controlled environment (tubes) to transport waste or laundry from one place to another.

How it works:

Harshil Narula Director Med Freshe Pvt. Ltd

Greenvac Pneumatic Waste & Laundry Collection System allows to transport solid waste (garbage) & Laundry to a centralized collection point pneumatically (suction) through pipes. This central collection point can be at any distance. Waste (garbage) & Laundry from all floors of a building/ multiple buildings is transported via these network of tubes running in a building vertically and horizontally throughout the facility. The public dustbins are large in number. A network of underground tubes connects all these dustbins. Once the dustbin is filled with garbage, a sensor activates and the garbage is transported via this network of tubes to a central collection point. Thereby removing all manual practices of emptying and cleaning the dustbin. What it also does is it makes sure no waste is exposed in the public areas thereby improving hygiene, aesthetics, etc.

Why it should be used:

Solid Waste (garbage) Handling, Transportation and Collection are one of the most key factors in a facility. With a proper solution, various benefits like hygiene, odor control, green building accreditation, USP, safety, cleanliness etc. can be achieved. Greenvac PWLCS is an ideal way to transfer waste (of any kind) or laundry from multiply source points to a centralized 68

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collection area. Multiple buildings can be easily connected with this system reducing operation time and increasing efficiency and hygiene. Also adhering to SWACH BHARAT MISSION and in lines with SMART CITY development. Indian Green Building Council (IGBC) has accepted Greenvac Pneumatic Waste & Laundry Collection System PWLCS as a best practice for collection and transportation of waste and has also incorporated the same in their recently launched health care rating system.

Where it can be used:

Greenvac PWLCS can be incorporated into new or existing building design. Whether a single building, a multi building facility or a city center, our engineers design and install a system tailored and customized as per the facility. Retrofitting into existing buildings or up-gradation of existing gravity chute systems is also possible. It can be used in: • Hospitals • Hotels • Golf Courses • Housing Complex’s • Airport’s • Railway/Metro Station’s • Township’s • Stadium’s • Parks • Beaches or any Public area

What are its benefits:

• Hygiene is maintained • Facilities are kept cleaner • Reduced carbon footprint • No odor • No rodents, insects, flies due to waste • Emphasis on aesthetics • Limited exposure to waste

INTERVIEW • Automated Solution • Space traditionally dedicated to trash collection can be reclaimed • Improvement in Lifestyle • Less visible Trash/Linen - Minimizes human contact • Less staff required for collection & segregation • Less traffic of trucks in the facility • Green solution • Sealed automated solution for transportation • Cleaner environment – inside a building & outside • No air pollution • Eliminates cross contamination • Adhere to SMART CITY or SMART INFRASTRUCTURE • Adhere to SWACH BHARAT MISSION • Adhere to IGBC Health ratings, etc.

Other quantifiable benefits of Manual v/s Automated (Pneumatic): an automated system include: Manual collection is a very tedious • Vital part of the “green building” technology • Increased management tools via secure logins for system access • Detailed management, reporting, and control over the working of the staff and required areas. Etc.

Is it User- Friendly:

Greenvac PWLCS is a totally sealed automated system for collection of waste and Laundry throughout facilities maximizing performance, efficiency and reliability while delivering exceptional convenience and value. Every system provides simple access and ease of use while minimizing exposure of waste and dirty Laundry to users of the facility and the environment around. It also has economic savings operationally, as compared to conventional manual systems.

and time-consuming process in larger facilities. Every source point needs to be accessed from where waste can be collected. Since it is such a tedious process usually collection can only take place once a day thereby creating large reserves of waste at source points. Also all public areas are exposed with the waste and thereby exposing people as well. Pneumatic transportation of waste or laundry minimizes environment & public exposure time by more than 90 percent since the entire system is automated & sealed. A study analyzing Manual collection Vs. Pneumatic Waste Collection System keeping in mind the exposure time of Waste. Exposure time by manually removing waste was 1,344 minutes compared with 102 minutes for an automated process in a 500 bedded hospital.

Comparison S.no 1 2 3 4 5 6 7 8 9 10

Description Odor Exposure to waste Labor required Insects/Rodents Infection Green Solution Automated Solution Availability (24/7/365) Central Collection point Truck Access required within the facility

What is Greenvac Solutions (GVS):

Greenvac Solutions along with its technology partner provides leading pneumatic technologies and smart design engineering that increases a facility's efficiency and improves cleanliness and aesthetics. It brings a powerful continuum of solutions, technology, innovation and execution. Greenvac design and engineering professionals work with facility owners, developers, architects and consultants to create cleaner, greener

Conventional System(s) Yes Yes Yes Yes Yes No No No No Yes

and healthier environments through the efficient collection, transport and disposal of waste and dirty linens. An experience of many years in pneumatic automation in various extensive and diverse backgrounds, Greenvac and its technology partner has perfected the development, installation and maintenance of state-of the-art pneumatic solutions. Greenvac is a unit of Unison Narula Group (UNG) which has been catering the health sectors since 1953.

Greenvac PWLCS No No No No No Yes Yes Yes Yes No

UNG also offers solutions in Central Sterile Supply Department (CSSD), Pneumatic Tube System (PTS) Nurse Call System (NCS), Bio Medical Waste Treatment System (ISS), Patient Care Furniture, Modular Operation Theatre (MOT)/ ICU's/ER's, Medical Gas Pipeline System (MGPS), OT Lights & Tables, Burns Ward, Designing of hospitals, Healthcare Consultancy, Turnkey Jobs, etc.

For Any Enquiry Email: healthcare@medfreshe.com w w w.medegatetoday.com Nov-Dec 2016

POST EVENT

National Conference on E- Governance: Deliveries on Transparency, Compliance and Good Governance PHD Chamber in collaboration with NeGD (National EGovernance Division) organized National Conference on E-Governance: Deliveries on Transparency, Compliance and Good Governance on 8th September 2016 at PHD House, New Delhi. The objective of the Conference was to discuss the roadmap for effective and robust e-Governance implementation and how India can upgrade its current structure of E-Governance. It also discussed the issues in E Governance with focus on Health and come up with strategies and suggestions on the policies and implementation side. The Conference was inaugurated by Prof. Suptendra Nath Sarbadhikari, Project Director, National Institute of Health and Family Welfare (NIHFW) and Mr. Milan Narendra, Partner, Ernst &Young India Mr. Sanjeev Shriya, Chairman, Committee on Electronics and ICT, PHD Chamber in his welcome address said that the rise of e-governance has been one of the most striking developments of the web and it presents national governments with a number of challenges and opportunities. Elaborating further Mr. Shriya said that with the increase in Internet and mobile connections, the citizens today are expecting more and more information and services online from governments and corporate organizations and thereby strengthening the new “e-citizenship” model. Mr. Shriya also said that E-Governance has the potential to benefit India’s citizens exponentially and maximize the return on the government’s investment in it. It offers benefits such as Speed, Cost Reduction, Transparency, Accountability, Convenience and Increased access to information. Mr. Atul Anand, Co-Chairman, Committee on Electronics and ICT, PHD Chamber in his theme address of the Conference said that E- Governance essentially is integrated governance which integrates people, processes and information technology in achieving good governance Mr. Anand said that considerable initiatives in E-Governance were taken by the State governments in India with a special mention of Andhra Pradesh which has done a commendable job in this sector. He added that states like Madhya Pradesh, Gujarat, Karnataka, Delhi have also undertaken innovative projects which have brought in transparency to the governance system. Mr. Anand was optimistic and said that India is likely to soon emerge as a leader in E-Governance especially when

the country is focused on e-commerce and Information Technology (IT) and given the current high level of political commitment and largely adequate sources of funding. He also added that Prime Minister Narendra Modi ji’s call for ‘Digital India' and a ‘Paperless Government’ has created ripples in the domestic market and the vendors and manufacturers should not waste this big opportunity which can propel India on the world stage. In his Address in the Inaugural Session, Mr. Milan Narendra, Partner, Ernst and Young India spoke on the theme ‘Global Learning for Feasible and Sustainable model of UHC in India’. Mr. Narendra mentioned that there are 6 pillars of UHC defined by World Health Organisation which are: Healthcare Financing; Availability of essential medicines and healthcare products; Policies; Motivated Workforce; Proactiveness in providing healthcare delivery and Availability of Information Statistics & Information systems. Mr. Narendra said that there has been a lot of work happening in India with respect to healthcare delivery which is at par with the global practices. He mentioned that IT today has a major role in effective healthcare delivery. Adding further he said that IT has a key role in mitigating frauds. Mr. Milan Narendra said that Ministry of Health is running a program with United Nation Development Programme (UNDP) on vaccination where cold chain handlers and vaccines are being managed across different states which is an encouraging sign. Mr. Narendra cited the example of countries including Bangladesh, Singapore and Thailand as to how proper planning and execution in phases made their healthcare delivery models successful. Mr. Milan Narendra stressed that from India’s perspective there is a requirement for Integrated Health Management which covers various aspects including predictive analytics, personalised records and information exchange system. w w w.medegatetoday.com Nov-Dec 2016

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