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THE BRAVE

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AI, DEEP LEARNING AND BIG DATA USHER IN

A NEW ERA OF MEDICAL IMAGING

ORTHOPAEDICS POLICY SPECIALTIES CASE REPORT

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editor’s note

Dear Doctor,

JANUARY AUGUST 2018 2019 / / Vol: Vol. 55 // Issue: 49

Founder & Editor

CH Unnikrishnan

Executive Editor

S Harachand

Science Editor

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Founder & Editor

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Very happy new year!

Dear

As you

Doctor

know, technology is predicted to completely change the way that

diseases are detected and treated in the next five years. This is a natural

progression We know you of are science busy. that It is makes always things reassuring more precise that the and trust conclusive. and faith With of

systems hundreds like of super-speed patients in your internet, healing cloud touch computing, keeps you deep busy machine this learning noble

and profession. artificial In intelligence, the hectic this practice, process it’s has quite just natural got faster that and you more might targeted. miss

out In on all some this, diagnostics of the latest is the developments area that will in witness emerging the medicine. most accelerated In this era

change. of innovation, Within medical this, radiology science has is getting already redefined seen the paradigm almost by shifting. the day. The Old

answer technologies as to why are being radiology replaced is simple: by the It is new the branch in the blink of medicine of an eye. which Robots will

form and artificial the foundation intelligence of precision are taking healthcare, over a good which part is where of the the procedures, world wants to

move while now. genomics and molecular science unveil the mysteries of life further.

We This are has fortunate been the to motivation have such for breakthroughs this edition that as they takes help you specialists to the brave like new

world you rise of above radiology the and expectations medical imaging. of today’s As we informed look at patient. these developments

closely, it is obvious that technology has actually taken the practice of radiology

far Similarly, ahead, it compared is also a time to the when way India it is practised witnessing in this revolutionary part of the world. growth These in

new healthcare changes industry, range from especially technologies in the private that make sector, the wherein patient experience an increasing more

friendly, number to of scans doctors that are can taking 3D-print up multiple models of roles internal of clinician, organs researcher that are accurate and

enough entrepreneur. for clinical This judgements.

requires expansion of your focus to a wider canvas. In

this While, context, molecular it becomes imaging important has enabled how accurate a busy professional assessment like of drug you can

response keep pace in with cancer these treatment, latest developments interventional in radiology a quick (IR) and provides easy way. an imageguided

approach to diagnose and treat diseases. Similarly, radiomics— AI

enabled At Future radiology Medicine, -- which takes the is conceived world much and closer crafted to precision by a team medicine. of senior

journalists, The other scientists most exciting and doctors, read for you our in aim this issue to help is Dr you Indira do just Hinduja’s that. We

tireless are equipped journey to from bring India’s you the IVF baby latest revolution from the science three decades of care ago from to across her latest

research the world that in an can interesting eventually and produce convenient India’s way, first ‘unibaby’, supplemented in Straight by the Talk. best

of Our views series and on analyses India’s First from & the Most masters Unique in on each DY field. Patil Medical We present Simulation you this

Lab specialised in this issue, knowledge along with vehicle other that features plugs you and into columns, the emerging will make world it a unique of

reading care seamlessly. experience. Come, let’s join hands in this information journey.

Happy CH Unnikrishnan reading,

editor@futuremedicineindia.com

C H Unnikrishnan

editor@futuremedicineindia.com

www.futuremedicineindia.com futuremedicineindia FutureMedIndia

AUGUST 2018/ FUTURE MEDICINE / 3


ORTHOPAEDICS POLICY SPECIALTIES CASE REPORT

Vol 5 Issue 9

January 2019

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VOL 5 | ISSUE 9

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JANUARY 2019

FUTUREMEDICINEINDIA.COM

THE BRAVE

NEW WORLD

OF IMAGING

AI, DEEP LEARNING AND BIG DATA USHER IN

A NEW ERA OF MEDICAL IMAGING

ADVANCED

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RADIOLOGY

NEXTGEN RADIOLOGY

POWERED BY AI

REGULAR FEATURES

06 Letters

08 News updates

32 Drug approvals

46 Research snippets

56 Hospital news

60 Orthopaedics

64 Diagnostics

68 Drug delivery

72 Guidelines

76 Devices&gadgets

88 Events

96 Calendar

97 Book review

98 Holy grail

Columns

14 THE CATALYST

Muralidharan Nair

48 THE CELLVIEW

Dr Rajani Kanth Vangala

66 TRIALOMICS

Dr Arun Bhatt

12

POLICY

THE CONSUMER

PROTECTION BILL 2018

DOCTORS

DISMAYED

Medical practitioners will

have to pay dearly for

medical negligence

36

STRAIGHT TALK

‘UNIBABY’ IS NEXT

IN FOCUS FOR

MOTHER OF

INDIAN IVF

Dr Indira Hinduja

Celebrated gynaecologist

and IVF pioneer


50

SPECIALTIES

SPEARHEAD OF

LESS-INVASIVE

MEDICINE?

Interventional radiology

seeks to maximize

benefit through

quick and bloodless

procedures

40

CASE REPORT

WHAT IT

MEANS TO

HAVE CYSTIC

FIBROSIS

A type of mucopolysaccharidosis

can be easily misdiagnosed

as ADHD or autism

84

D Y PATIL

UNIVERSITY

MEDICAL

SIMULATION LAB

Radiology is not

restricted to

simple diagnostic

tests anymore.

It has become

more complex.

Today, a CT of the

abdomen can be

done in a hundred

different ways.

Dr Rajendran

Vilvendhan

Section Chief

Interventional

Radiology

University of Boston

USA

16

COVER STORY

THE BRAVE

NEW WORLD

OF MEDICAL

IMAGING

Application of artificial intelligence

and big data accelerates medical

imaging technology at an

unprecedented pace


letters to the editor

Look forward to

reading more

Dear Sir

I recently read your article

regarding centre for sports

science, Chennai. It was wellwritten

and as Dr Arumugam

said we needed a sports

medicine specialty centre for

our athletes. The coverage

on use of bNAbs and the

current drug development

claiming for cure of HIV was

a really insighful discussion. I

look forward to reading your

next informative work. Thank

you.

Regards

Dr Philips Varghese,

Pune

Really interesting

Hello,

The story on CSS, Chennai in

the current edition was really

interesting.

Pratyusha

Researcher, Bengaluru

Nice coverage

Hi,

I get the monthly subscription

of this magazine. In fact, the

coverage on Immunotherapy

in NSCLC is nice in the

November edition.

Regards

Swapnil

Bristol-Myers Squibb

Immunotherapy

enlightening

Hi,

Thank you for the new

magazine. Subscribed recently.

I was interested in the cover

story on immunotherapy

of November issue. The

explanation behind subsets

of cancers and the working of

immunotherapy was basic yet

enlightening. Expecting more.

Best Regards

Dr M G Shiva

Coimbatore

Updates on education

Dear Sir

I am a PG student. As a book

reader I find this magazine

a real good start. It helps

me keep in touch with the

latest happenings in the field.

Updates on the education

system is also helpful.

Thanks

Saranya Vivek,

Mangalore

Keep up the good work

Hello Sir

Subscribed to Future Medicine

recently. The story covered on

liquid biopsy in the first issue

and immunotherapy in the

previous issue was really nice.

Best regards,

Shivalik Bhowmik,

Agartala

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AUGUST 2018/ FUTURE MEDICINE / 59


news updates

Karnataka starts

DNB courses at

govt hospitals

K

arnataka has started to

offer Diplomate of National

Board (DNB) courses at

seven government hospitals

as a measure to tackle

shortage specialists across

several public hospitals in the

southern Indian state.

The government hospitals

in the districts of Bagalkot,

Chitradurga, Dharwad, Kolar,

Tumkuru, Vijayapura and

Ballari, besides two general

hospitals— KC General and

Jayanagar in Bengaluru- will

now offer DNB programme in

41 specialities, equivalent to

Doctor of Medicine and Master

of Surgery, under the National

Health Mission and the

National Board of Education,

according to reports.

In October 2017, the state

government passed orders

to start DNB courses at six

hospitals to cover 35 primary

seats and 25 secondary seats.

The NBE approved the course

only recently.

Candidates are selected

through the national

eligibility cum entrance test

(NEET-PG).

A bond of three years has

been given to the students

of July 2018 session to make

them serve in government

hospitals after the successful

completion of the course.

India to ban commercial

surrogacy

Lok Sabha, the lower house of the

Indian parliament, passed the

Surrogacy (Regulation) Bill 2016, which

aims to ban commercial surrogacy to

protect women from exploitation.

Surrogacy, an arrangement where

a woman agrees to carry a pregnancy

for another person, is a legally accepted

practice in many parts of the world for

childless couples.

According to the bill, only childless

couples, legally married for at least

five years, are allowed to commission

surrogacy, and that too, only from a

woman who is a “close relative” of the

couple.

The blood relative should be married

and must have herself borne a child. The

woman can become a surrogate only

once in a lifetime. NRIs and foreigners

cannot hire surrogate mothers in India.

Couples who do not have a large

“close” family — or members who might

be willing to be surrogates for them —

cannot have a baby through surrogacy.

The only available option for them would

be adoption.

The bill makes the provision of

surrogacy exclusively for Indian citizens

and prohibits foreign nationals from

applying for surrogacy in India.

Singles or those in a homosexual

relationship cannot apply for surrogacy.

The child, thus born, will be deemed to

be the legal offspring of the intended

couple.

It was on August 24, 2017, that the

Union Cabinet approved the Surrogacy

(Regulation) Bill 2016. The bill was

introduced in Lok Sabha in November

2016 and was later referred to a

parliamentary standing committee on

Health and Family Welfare in January

2017.

8 / FUTURE MEDICINE / JANUARY 2019


AYUSH practitioners and dentists can use ‘Dr’

All the practitioners of

modern allopathic

medicine, Indian systems of

medicines, as well as dentists

who are recognised by the

central government can use

the prefix “Dr” in the country,

Minister of State (Health),

Anupriya Patel said in the

parliament recently.

The minister was

responding to a question

raised in the parliament asking

whether the persons holding

BAMS, BHMS, BUMS, BSMS,

BDS, BYNS and MBBS degrees

are allowed to prefix ‘Dr’

before their name.

Clarifying the position,

the minister said the Union

government had constituted a

standing committee of experts

under the chairmanship

of Director General, Indian

Council of Medical Research

to consider and give its

recommendations on the

efficacy and merits of various

streams of alternative

medicine.

Among the various

recommendations, the expert

committee suggested that

the term ‘doctor’ should be

used only by practitioners of a

system of medicine recognized

by the government of India.

The recommendations were

accepted by the government.

The Clause 1.4.2 of

the Indian Medical Council

(Professional Conduct,

Etiquette and Ethics)

Regulations, 2002 which is

applicable for the medical

practitioners, provides that

the physicians shall display

as suffix to their names only

recognized medical degrees or

such certificates/diplomas and

membership/honours which

confer professional knowledge

or recognizes any exemplary

qualification/achievements.

Similar provisions are also

available under the Revised

Dentists (Code of Ethics)

Regulations, 2014 applicable

for the Dentists, according to

the minister.

Earlier, a parliamentary

committee recommended

that the AYUSH Practitioners

should be called Vaidya,

Vaidyaraj, Hakim etc. but not

“doctors”.

Oxygen IP in

portable cans

launched in

Delhi

Oxygen I.P. in portable

cans is now available

in India, announced Gupta

Oxygen Pvt Ltd, an industrial,

medical and refrigeration

gases firm.

Measuring 5.9 liters at

1200 kilopascal, the portable

can (MyOxy) is a seamless

aluminum disposable can with

inbuilt mask allowing up to

100-150 inhalations per can.

The cans can be bought

from leading pharmacies

including Apollo pharmacy,

medical stores across Delhi/

NCR and online pharmacies

such as Netmeds at a price of

INR 399 per can.

Suitable for all age

groups, the canned oxygen

is fit for use by children,

expecting and lactating

mothers and elderly people.

At >99% pure oxygen, it helps

supplement low oxygen levels

in the body caused due to air

pollution, high altitude and

breathlessness due to

various reasons such as

stale air, intense workout,

alcohol consumption, jet lag,

stress etc, said a company

release.

The portable oxygen can

is meant to help people in

polluted cities like Delhi/NCR

realize the benefits of fresh

oxygen and make it a part of

their everyday life

for their safety. The can has

been designed in an easy

to use, compact packaging

that is lightweight, weighing

lesser than the mobile

phones, and can be stored

at room temperature, the

release said.

TN and

Telangana to get

new AIIMS

Two new All India Institute

of Medical Sciences (AIIMS)

will soon come up in the

southern Indian states of

Tamil Nadu and Telangana.

The Union Cabinet

JANUARY 2019 / FUTURE MEDICINE / 9


Fluoroquinolones can lead to aortic rupture: USFDA

Fluoroquinolone antibiotics

can increase the

occurrence of rare but serious

events of ruptures or tears

in the aorta, a review of US

FDA found. These aortic

dissections or ruptures of an

aortic aneurysm can lead to

dangerous bleeding or even

death. They can occur with

fluoroquinolones for systemic

use given by mouth or

through an injection.

Fluoroquinolones should

not be used in patients at

increased risk unless there

are no other treatment

options available. People at

increased risk include those

with a history of blockages

or aneurysms of the aorta

or other blood vessels, high

blood pressure, certain

genetic disorders that involve

blood vessel changes such as

Marfan syndrome and Ehlers-

Danlos syndrome, as well as

the elderly.

The US regulatory agency

said a new warning about this

risk was required to be added

to the prescribing information

approved the establishment

of two AIIMS at Madurai,

Tamil Nadu and Bibinagar,

Telangana under the central

scheme Pradhan Mantri

Swasthya Suraksha Yojana

(PMSSY).

The proposed institutions

will have a hospital with a

capacity of 750 beds which

will include emergency/

trauma beds, AYUSH Beds,

private beds and ICU specialty

and super specialty beds.

In addition, there will be a

medical college, Ayush Block,

auditorium, night shelter, guest

house, hostels, and residential

facilities, reports said.

Both Madurai and

Bibinagar AIIMS are expected

to be completed in 45

months. Cost of construction

and the day-to-day

management of the new

AIIMS would be met under

PMSSY.

As per data of current

functional AIIMS, it is expected

that each new AIIMS would

cater to around 1,500 outdoor

patients per day and around

1,000 indoor patients per

month.

The Union government

has the plan to set up around

22 new AIIMS across India.

The ruling Bharatiya Janata

Party (BJP) announced the

establishment of two new

AIIMS in Jharkhand and

Gujarat in 2017-18 and the

setting up of 20 new “AIIMSlike”

hospitals.

DCGI clears apomorphine

for PD patients

The Drug Controller General

of India, the country’s top

drug regulator, has approved

apomorphine hydrochloride

infusion for Parkinson’s Disease

patients. The drug approval,

which was long awaited in

India as there were only limited

options of treatment available

for the patients in the country,

through the drug developed

by UK-based Britannia

Pharmaceuticals has been in

the Western markets for long.

“So far the country

had only two options of

treatment for Parkinson’s

disease — levodopa oral

medication and Deep Brain

Stimulation (DBS) surgery.

Both these options have

their limitations. For example,

levodopa has its side effects

when the diseases progress

after the initial stage and

DBS is expensive, and Indian

patients are typically averse to

surgery and chip implantation

in the brain,” said Dr Anil

Venkat, senior neurologist at

Nanavati Hospital, Mumbai,

which launched apomorphine

treatment in association with

Kings College in London in

December.

Though levodopa is still

the gold standard treatment

to manage Parkinson’s

disease, there are other issues

associated with the oral

medication for late-stage and

elderly patients. This includes

difficulty in swallowing and

decreased movement of the

stomach, called gastroparesis,

Dr Venkat said in an interview

with Future Medicine.

Though apomorphine

treatment was approved in

the West long ago, approval

in India was pending for

long. The drug, a dopamine

receptor agonist and a highly

selective dopamine receptor

stimulator, is administered

through an infusion pump with

a subcutaneous needle as per

the dosage requirement of the

patient.

“Typically, a single injection

of apomorphine lasts for 100

minutes, which is short acting.

So, in the West, early stage

patients are normally given an

10 / FUTURE MEDICINE / JANUARY 2019


and patient medication guide

for all fluoroquinolones.

Fluoroquinolone

antibiotics are approved

to treat certain bacterial

infections and have been used

for more than 30 years. They

work by killing or stopping the

growth of bacteria.

FDA arrived at the

conclusion following a review

of cases reported to the

agency and four published

observational studies that

showed an increased risk

of aortic aneurysm or

dissection associated with

fluoroquinolone use.

The results of all four

studies provide consistent

FDA-APPROVED SYSTEMIC

FLUOROQUINOLONES

Moxifloxacin

Delafloxacin

Ciprofloxacin

Gemifloxacin

Levofloxacin

Ofloxacin

evidence of an association

between fluoroquinolone

use and aortic aneurysm or

dissection. The underlying

mechanism for this risk

cannot be determined

from these studies, and the

background risk of aortic

aneurysm can vary depending

on the population.

The background risk has

been estimated from nine

aortic aneurysm events per

100,000 people per year in

the general population to

300 aortic aneurysm events

per 100,000 people per

year in individuals at the

highest risk. Because multiple

studies showed higher rates

of about twice the risk of

aortic aneurysm rupture

and dissection in those

taking fluoroquinolones, FDA

determined the warnings

were warranted to alert

health care professionals and

patients.

US FDA approved

changes to the labels of

fluoroquinolone antibacterial

drugs for systemic use in 2016

finding that these medicines

are associated with disabling

and potentially permanent

side effects of the tendons,

muscles, joints, nerves, and

central nervous system that

can occur together in the

same patient.

Though levodopa is

still the gold standard

treatment to manage

Parkinson’s disease,

there are other issues

associated with the

oral medication for

late-stage and elderly

patients.

Dr Anil Venkat

Senior Neurologist

injection in the early morning

when they wake up very rigid

and stiff and they can’t take

any oral medication. This

shot will help them start the

day and move on. But this is

only in the initial stage, and

they would require repeated

injections as the disease

progresses, and they start

to freeze and not be able to

move. Then, patients would

require a continued release

of the drug into the body

using an infusion pump just

like an insulin pump. That is

the point of transition from

injection to infusion,” says Dr

Venkat.

“With apomorphine, we

have the advantage of giving

it with a pen as well as an

infusion pump, with regulated

release of doses as per the

requirement of the patient.

And the other most important

advantage with apomorphine

is that the result is pretty

obvious as you will know if the

patient is responding to the

medication or not,” he said.

Parkinson’s disease is a

progressive nervous system

disorder that affects movement.

Symptoms start gradually,

sometimes starting with a

barely noticeable tremor in

just one hand. Tremors are

common, but the disorder also

commonly causes stiffness or

slowing of movement. Although

a complete cure is not possible

as of now, the disease can be

managed with medications with

significant improvement in the

symptoms.

JANUARY 2019 / FUTURE MEDICINE / 11


policy

THE CONSUMER PROTECTION BILL 2018

DOCTORS DISMAYED

Medical practitioners will have to pay dearly for medical negligence

With the Lok Sabha passing

The Consumer Protection Bill

2018, medical practitioners in

the country are concerned over various

provisions in the bill.

The bill, which is sent to Rajya Sabha

for passage, will replace the threedecade-old

Consumer Protection Act of

1986. Medical practitioners fear that if

Rajya Sabha too passes the bill in the

same form, it will trigger several issues

in the medical field.

“The Indian Medical Association, the

umbrella organisation of all modern

medical practitioners in the country, is

very much concerned about many of the

provisions of the Consumer Protection

Bill 2018 and we feel that this move

will cause further increase in treatment

costs, make healthcare unaffordable

and inaccessible to weaker sections of

the society, promote corporatisation of

healthcare, eliminating smaller hospitals,

and will make implementation of public

funded health programmes difficult,”

said Dr Jayakrishnan A. V., Chairman, IMA

Hospital Board of India, Kerala Chapter.

Though the Consumer Protection Act

of 1986 passed by the parliament didn’t

bring the medical profession under its

purview, it was brought under the act

following the verdict of Supreme Court

in Indian Medical Association vs V. P.

Shanta and Ors. Since then, the topic

has sparked off numerous discussions.

It has once again become a topic of

discussion among medical fraternity and

consumer activists with the Lok Sabha

passing the bill.

Hefty penalty

The bill proposes consumer disputes

redressal commissions at national, state

and district levels to deal with consumer

THE BILL EMPOWERS THE

DISTRICT LEVEL CONSUMER

DISPUTES REDRESSAL

COMMISSIONS TO AWARD

MONETARY COMPENSATION

OF UP TO RS 1 CRORE

complaints. The district level body will

comprise a president and at least two

members and the state and national

level bodies will have a president and

at least four members. The president

and members will be appointed by

the central government as per the bill.

A major highlight of the bill is that it

empowers the district level consumer

disputes redressal commissions to

award monetary compensation of up

to Rs 1 crore against Rs 20 lakh in The

Consumer Protection Act 1986. The

state-level body can award up to Rs

20 crore against previous Rs 1 crore.

As per the bill, not only individuals but

associations and other bodies can also

file a complaint with the consumer

forums.

Even though IMA proposed certain

suggestions regarding the draft bill

2015 that was put in the public domain,

it was not considered in the 2018

bill. Now, the body has approached

Rajya Sabha members to consider

the suggestions made by them in the

bill. The suggestions made by IMA

include seeking expert opinion before

taking up a case of medical negligence

by consumer fora. According to the

association, it has been emphasized by

the Supreme Court in Martin F. D’ Souza

vs Mohd. Ishfaq case.

No judicial concept?

The association feels that the very

high compensation proposed in

the bill may result in an increase in

frivolous litigations. “The medical

profession will have to bear the brunt

of higher compensation proposed in

the bill. The compensation awards

in medical negligence cases need to

be capped,” said Dr Jayakrishnan.

Medical practitioners also demanded

that litigations against the medical

BILL HIGHLIGHTS

The salient points in the

Consumer Protection Bill

2018 passed by Lok Sabha on

20/12/18 which will have an

impact on the health sector

are:

• District consumer

redressal fora also named

as commission, jurisdiction

increased from Rs 20 L to Rs

1 crore.

• District, state and national

fora do not require judicial

members.

• Jurisdiction of State

Consumer Commission

increased from Rs 1 crore to

Rs 20 crore

• Not only individuals but

associations and other bodies

can complain to consumer

fora

• Consumer Mediation

Cells at district, state and

national level

• District, state and national

councils which are advisory in

nature

• Central Consumer Authority

which has judicial powers can

conduct investigations, search

and make judgements

12 / FUTURE MEDICINE / JANUARY 2019


professionals by organisations or

associations should not be allowed. They

further demand that representatives of

IMA have to be included in the consumer

mediation cells, and district, state and

national consumer councils. “At present,

consumer forums comprise judicial

members. But the new bill does not have

the judicial concept. We are not against

judicial scrutiny, but it should be done by

civil courts,” he added. Another demand

of the medical practitioners is for

imposing sufficient penalty for frivolous

complaints against medical professionals.

Meanwhile, consumer rights

protection activists feel that the bill

will make the medical profession more

accountable. “The provisions in the bill

will enable people to approach district

forums within 48 hours in cases of

medical negligence by accessing medical

records under Right to Information,”

said activist and advocate D. B. Vinu.

However, he said that some of

the concerns raised by medical

practitioners are justifiable. “Now

the district forums can award

compensation up to Rs 1

crore. But the question

is whether the forum is

professionally capable

to deal with such

cases,” he said.

WHAT IMA WANTS

TO INCLUDE*

1. Expert opinion should be sought

before taking up a case of medical

negligence by consumer fora. This has

been emphasized in the judgement by

Martin D’Souza Vs Mohammed Ishaq

read in 2009(3) SCC-1

2. Very high compensation awards in

some cases have given rise to a greater

number of frivolous litigations and hence

the compensation awards in medical

negligence cases to be capped

3. Litigations against medical

professionals by organisations or

associations should not be allowed.

4. Representatives of Indian Medical

Association have to be included in the

consumer mediation cells and district,

state and national consumer councils.

5. Provisions for imposing sufficient

penalty for frivolous complaints against

medical profession to be introduced.

*The Indian Medical Association placed

certain suggestions regarding the draft

bill 2015 which were not considered in

the 2018 bill.

JANUARY 2019 / FUTURE MEDICINE / 13


column

the catalyst

2018 – A year of hope

and apprehension

The foregone year generated a great deal of aspirations,

while also creating a considerable degree of anxiety

MURALIDHARAN NAIR

The year 2018 was an extraordinary year

for the Indian healthcare industry for

the attention it received from both the

highest levels of the government as well as

the regular public, and for the aspirations,

apprehensions, anxiety and even the agony

it created among different stakeholders.

Undoubtedly, healthcare has never been in

so much limelight in the past, and no one

remained untouched by the heat and the

hope it generated. The most defining feature

of last year’s developments, for me, was

the irreverence with which the agenda of

affordable healthcare was being pushed by

governments (at the centre and the states).

Naturally, this meant striking a blow to the

status quo and the prevailing order. This

naturally resulted a diversity of perspectives

among different stakeholders, depending on

their assessment of themselves as victims or

beneficiaries from the intended change. To

sum up my thoughts within the limits of this

column space, I have picked what I believe are

a few good and some not-so-good aspects of

what happened during the year 2018.

The Good

1. Scope and Political will behind Ayushman

Bharat: I have always believed that providing

government-sponsored health for BPL

population is necessary, though far from

sufficient, in the Indian context, where there

is a large segment of the population above

the poverty line for whom the prevailing

healthcare services are prohibitively expensive.

Hence, the intent of AB to progressively cover

up to 70 percent of the population, starting

with approx. 40 percent, and its focus on rural

areas is most appropriate. So is the coverage

amount of Rs. 5 lakh per family. But what is

truly unprecedented is the political capital

invested behind the scheme by a highly

image-conscious and the most popular leader

that India has seen in several decades. This

has, in no small measure, helped the adoption

of the scheme by states and smoothened

WHAT IS TRULY UNPRECEDENTED

IS THE POLITICAL CAPITAL

INVESTED BEHIND THE SCHEME

BY THE MOST POPULAR LEADER

THAT INDIA HAS SEEN IN

SEVERAL DECADES

its roll out, though we still have a long way

to go. More importantly, this has led to an

unprecedented focus among private players

on non-urban expansion and on evolving

appropriate affordable healthcare models

with much greater urgency and seriousness

than before

2. Changing mindset towards “Health”care

from “Sick”care: I am most happy to see a

real and tangible increase in people pursuing

good health, more than ever in the past.

Importantly, this is seen across all age groups.

A simple survey among your friends and

neighbours will reveal the increasing number

of people adopting yoga, exercise regimens,

smart fitness trackers and a generally

more proactive approach towards health

management. This is a very welcome and

significant change. Of course, this attitude

14 / FUTURE MEDICINE / JANUARY 2019


is getting further catalysed by technology

products that have made measuring and

monitoring much easier, leading to more

effective health management.

3. Coming of age of the Indian medical device:

Except in pharmaceuticals, where Indian

companies have built a robust capability

that has significantly contributed to cost

competitive and MNC-equivalent products,

Indian companies have been marginal players

in other medical categories like implants,

medical equipment and consumables, with

a reputation for manufacturing inferior

products. Hence, the conclusions of a

10-year study by a German cardiologist

that rated Indian stents on par with their

higher-branded global counterparts is a

very significant development which has the

potential to unleash unprecedented aspiration

and investment into developing the local

medical device industry along the lines of the

Indian pharmaceutical industry, seen today as

the pharmacy of the world.

The Not-So-Good

1. Populism overshadowing patient safety:

The flip side of the political relevance that

affordable healthcare is gaining is the

unbridled populism guiding health policies.

An overwhelming focus on cost, without

an appropriate framework for defining and

enforcing quality standards, has the potential

to compromise the quality of the healthcare

provided. In a country where clinical pathways

can be highly subjective and the regulatory

regime does not assure equivalence between

equally qualified medical products, such

populism is a serious threat to patient safety.

2. Health of corporate hospital chains:

Private sector healthcare has contributed

to 70 percent of the capacity growth in

the last decade, with a vast majority of the

population depending on them for highend

care. However, the financial health of

the corporate chains is under severe stress,

with leverage moving north of 5 times the

EBITDA for several chains. This is owing to

challenges in growth from traditional markets

and pricing pressure, coupled with increasing

costs and interest burden. I see this as a

part of transient turbulence accompanying

any transformational change. I am sure the

industry will focus on efficiency and redesign

their operating models to come out stronger

and bigger with time.

3. Patient Voice is still fragmented and

powerless: I am a firm believer that more than

regulations, it will be the voice of the patients

that will transform the industry in the times

to come. Something like a TripAdvisor for

representing the patient voice is a crying need

of the hour, but I am yet to see any initiative

of great promise in this regard.

The Bad

1. Budget for AB: I think it was unfortunate to

see the government and policy makers quote

completely irrational and inadequate numbers

as the required expenditure for a project of

such significance. Very unfortunate. Period.

2. Make in India: There was a lot of hope that

the “Make in India” programme will unleash

an environment of much-needed localization

of medical products, particularly medical

devices and equipment. With four years of

the current regime already over, the sad

truth is that Make in India has not delivered

anything at all for the industry in the absence

of a compelling value proposition.

3. State of public healthcare: The less said

about this, the better. Barring a few states in

the South, and perhaps with the exception

of Delhi which has witnessed some degree

of improvement, public healthcare in the

rest of the country continues to be in a state

of apology. With the inherent dependence

on public health for the success of the AB

scheme, this is a very serious concern.

The author has long-standing association with

EY India but the views are strictly personal.

JANUARY 2019 / FUTURE MEDICINE / 15


cover story

THE

BRAVE

NEW

WORLD

OF MEDICAL

IMAGING

Application of artificial intelligence and big data accelerates

medical imaging technology at an unprecedented pace

16 / FUTURE MEDICINE / JANUARY 2019


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10000110000101110111100001011111011111001000010110100101011110000101101010001010111111101111010111000011101001001

1110101011000100100111010101100010010111010000110000101011010011011101100011000100100111010100110001001001110

10000010001001010100000010111111001111111110001111101111011111011001111001

S HARACHAND

Medical imaging is on the threshold of a new era,

thanks to new boundary-pushing tools such as

artificial intelligence, machine learning and

big data.

Accelerated processing speed is essential for creating

high-quality images. Even as new imaging techniques

provide greater anatomical and clinical details on the one

hand, radiologists, oncologists and other diagnosticians

also get faster access to imaging reports. This is one of the

places where deep learning and artificial intelligence play

crucial roles. These tools help to bring relevant information

out of the electronic medical record and present it in

a meaningful way, facilitating better-informed clinical

judgment. Incorporating this information directly into the

report can really add value as radiologists use deep learning.

It will not only streamline workflows, but also be a major

step towards more personalized medicine in radiology,

experts in the field say.

Besides, incorporating AI and deep learning into

JANUARY 2019 / FUTURE MEDICINE / 17


operating systems helps to automate workflow.

Automation is especially important for measurementintensive

procedures in specialties like cardiology and

ob-gyn.

Diving deep down images

It was in late 2000 that the industry started taking

notice of the high relevance and applicability of AI to

medical imaging. The first system with embedded AI

capabilities, the Logiq E10 by GE Healthcare ultrasound,

secured approval from USFDA a decade later. This

followed the CAD platform for evaluation of breast

abnormalities, software meant for detection of diabetic

retinopathy (IDx), AI triage software for stroke detection

(Viz.AI), wrist fracture CADx software (Imagen Tech)

etc. The USFDA decisions represented major drivers to

global market development.

Since then, there has been an explosion of

technologies that led to automation, acceleration,

augmentation, on-demand access, intelligent machines

and cognitive workflow applications.

Other than accelerating basic imaging exams, AIbased

image analysis is employed in diverse scenarios

such as high-volume routine imaging, time-sensitive

imaging (especially in trauma cases) as well as for

enhancing complex investigations.

CT, MRI and X-ray are the most preferred modalities

for AI imaging companies. As many as 41 companies are

tracking these types of images first, according to

the report Artificial Intelligence for Medical Image

Analysis — Companies-to-Action, 2018 by Frost and

Sullivan, a global market research firm. Image analysis

using deep learning facilities has been the first and the

foremost use case for AI.

Oncology is currently the hottest area for clinical

PHOTO: UMESH GOSWAMI/ COURTESY: RELIANCE HOSPITAL

IMAGING MODALITIES:

PREFERENCE

CT is the most preferred

imaging modality, followed by

MRI and X-ray. Globally

41 companies are tracking

CT images first

41

32

23

COMPUTED TOMOGRAPHY

MAGNETIC RESONANCE

IMAGING

X-RAY

IMAGING

18 / FUTURE MEDICINE / JANUARY 2019


application of medical imaging AI. The

availability of a large amount of imaging

data, coupled with the rising incidence

of cancer, is fuelling demand in oncology.

Presently, 31 companies are focusing on

covering brain tumours, oesophageal,

colorectal, liver, lung and prostate cancer,

shows the report.

Among the target disease areas, lung

cancer, breast cancer, cardiovascular diseases,

stroke and neurodegenerative diseases are

of prime focus. Paediatrics and orthopaedics

are the emerging areas.

In terms of organs, the brain is the most

focused for medical imaging AI solutions.

Lungs and breast follow.

However, abdominal organs like kidney,

liver and prostate have very few solutions

focusing on them, says the report.

Applications are predicted to move

beyond the current core-imaging modalities

and key clinical areas to more challenging,

niche and underserved imaging areas in the

future.

Big data analytics has gained prominence

in the medical imaging arena, critically

contributing to the care continuum, along

with other electronic health record (EHR)

data. The imaging algorithms are capable

of deriving metrics using intensive analysis

of patterns in a given digital image and

detecting specific patterns identified with

a specific pathology. Data analytics has

been extensively used to complement

the analyses made by the radiologist. The

9

MAMMOGRAPHY

ULTRA SOUND

ECHOCARDIOGRAPHY

FUNDUS

IMAGING

6 4

8 7

3D BREAST

TOMOSYNTHESIS

GENERAL

ULTRASOUND

1

POSITRON EMISSION

TOMOGRAPHY

SOURCE: FROST & SULLIVAN

INNOVATIVE APPROACHES

TO IMPROVE PATIENT

EXPERIENCE

Leaders in the segment are experimenting

with novel approaches to make imaging

sessions more easy and patient-friendly.

Recently, Siemens Healthineers has introduced

Magnetom Altea 1.5T MR Scanner which

features the Innovision in-bore infotainment

system, which is designed to travel with the

scanner table while immersing the patient in a

unique exam experience. In addition to creating

the illusion of an enlarged bore, it is designed

to provide a video experience with excellent

sound quality and display the remaining scan

time to improve patient satisfaction in MR

exams.

The system completely transforms the

patient experience from its wide 70-cm bore

to its lightweight, flexible coils and new speed

applications that enable the provider to get the

patient on and off the table faster, Siemens said

in news release.

In December last, GE Healthcare came out

with the Invenia automated breast ultrasound

(ABUS) 2.0 system, the first USFDA approved

ultrasound supplemental breast screening

technology, according to GE, specifically

designed for detecting cancer in dense breast

tissue. Both cancer and dense tissue appear

white on a mammogram, so looking for

tumours in women with dense breasts can

be like looking for a snowball in a snowstorm.

Because of this, tumours are often unseen on

mammography exams.

The device has the Reverse Curve

transducer that follows the natural contour of

the breast, providing patient comfort, thorough

contact and helping ensure comprehensive

coverage. Since no two women are identical,

exams can be customized with programmable

scan protocols, adjustable scan depths and

compression levels to improve the patient

experience.

JANUARY 2019 / FUTURE MEDICINE / 19


future of analytics in diagnostic imaging data may rely on

radiology information system (RIS) and picture archiving and

communication system (PACS) systems, especially those in

the cloud.

Molecular imaging to predict drug response

The advent of molecular medicine has fundamentally

changed the treatment of cancer. Molecular imaging has a

bigger role to play as personalized medicine seeks

more effective ways to assess tumour response, given the

current imaging standards are often inadequate to reliably

quantify the changes in the tumour microenvironment.

Recent advances in imaging science have made it now

possible to visualize previously inaccessible and even

unrecognized biological phenomena in cells and tissues in

vivo.

The AI space is still mostly focused on whether a machine

can recognize a disease condition such as identifying a

nodule. However, radiologists are trying to determine what AI

can offer and whether AI can make a diagnosis.

Radiomics, which deals with the extraction of data

from medical images using algorithms to uncover disease

characteristics, is generating a lot of interest as a field of

medical study. Studies are underway to find ways to make

cancer prognosis and to predict the response to therapy on

the basis of imaging.

Molecular brain imaging, using new PET technologies such

as non-fluorodeoxyglucose (FDG) PET tracers, is also being

explored.

Ultra-high-speed, low dose CTs

Along with developing faster CT scanners, efforts are also

ongoing to limit the radiation load to the patients as the CT

technology is based on ionizing radiation.

Dual and multi-energy CT enhances image quality by

improving material differentiation. Both provide functional

information above and beyond CT imaging of morphology

alone. Dual-energy CT imaging has several clinical

applications.

Siemens Healthineers Somatom Drive CT system is a dual

source scanner designed to drive precision in diagnostic

imaging with potential to reduce examination time,

preparation and follow-up care.

Allowing for more targeted beam focusing, the technology

enables CT lung scans at an extremely low dose. It is also

useful for spinal diagnostics and orthopaedic examinations.

The scanner’s dual energy mode can help clinicians accurately

differentiate between tissue and bone. With the system’s

ultra-fast scanning speed, the patient’s heart and lung

movement do not compromise diagnostic imaging quality,

according to a Siemens release.

Multi-energy CT imaging improved clinical differentiations,

such as distinguishing blood from calcification and

calcification from iodinated contrast. It can also create

Dr Hemant Patel

PHOTO: RAVI KUMAR

20 / FUTURE MEDICINE / JANUARY 2019


“Challenges of education research

are multiplied in radiology”

Dr Hemant Patel is President Elect,

Indian Radiological & Imaging

Association (IRIA) — a national

body promoting the study and the

practice of diagnostic, radiological

and imaging modalities. A recipient

of molecular imaging award and

prestigious cum laude award from the

Radiological Society of North America

(RSNA), Dr Patel has done extensive

work in MRI, CT scan and fusion

imaging. A renowned academician,

entrepreneur and professional

sportsman, he is currently working as

a Consultant Radiologist in Gujarat

Imaging Centre. Excerpts from his

conversation with FM

The role of radiologists is getting

bigger by the day with the integration

of advanced technology into clinical

practice. How do you see the situation

evolving in India?

Radiology has come a long way from

the era of radiographs and conventional

barium procedures to state-of-the-art

cross-sectional imaging modalities

with increased spatial and temporal

resolutions and digitization with ‘filmless’

technology.

Despite the immense advancements

in imaging technology, we still have

a large population in rural India that

does not have access to these newer

advancements. Progressively, imaging

modalities through refurbished

machines or old-generation scanners

are being installed and facilities are

coming up in these parts of the country.

Telemedicine and web-based remote

viewing systems are bringing them

a step forward, facilitating access to

expert opinions in remote locations

and reducing expenses, thus improving

patient care and management.

Some radiologists say that the

decision as to what imaging modality

is required for a particular case should

be taken by the radiologist and not

the referring clinician. What is your

comment?

I believe that referring clinicians

and surgeons ask the right questions

to which they need answers from the

radiologist to help in the management

of the patient and can rely on the

radiologists to correctly use the optimal

imaging modality to provide the most

satisfying answers, thus benefiting the

patient.

THE TIME IS NOT FAR

WHEN CATHETER-BASED

DELIVERY OF TAGGED STEM

CELLS TO TARGET LESIONS

BECOMES AN ESTABLISHED

PROCEDURE

Only through continuous liaising

and communication with our referring

colleagues can we keep pace with

the progressive understanding of the

science, learn and find answers to the

ever-increasing demands and thus

provide better and higher standard of

care to our patients.

Interventional radiology is coming

up as a subspecialty to radiology.

What is the current status of IR

training in India?

IR definitely has a promising future

with the continuing advances in the

emerging field – namely clinical gene

therapy – which is rapidly developing

and a promising therapeutic modality.

Interventional radiologists should

also recognize and be aware of the

ongoing advances in the development

of novel treatment technologies,

commonly used targeted tracers and

probes, and of the visualization tools

employed to analyze targeted therapy.

The time is not far when catheterbased

delivery of tagged stem cells to

target lesions becomes an established

procedure.

As president-elect of IRIA, what

areas of the profession and the

practice do you think deserve

immediate consideration?

The radiological community needs to

invest in the future through education,

participation and by creating relevant

research facilities. I have taken a lead

and started with IRIA Research and

Education Foundation. Today, medical

education research is not as well

understood or established in India.

Compared with medicine in general,

these challenges are multiplied in

radiology, where there are relatively less

extramural research money available

and fewer skilled investigators to carry

out radiology education research.

IRIA Research & Education

Foundation’s mission is to improve

radiology education, training, orations,

fellowships, journals and research

projects within India.

But it is not just research – clinical

radiologists have to be aware of the

ongoing innovations in the profession,

and support the training and education

of the next generation. We need to

make vigorous efforts for the motivation

of students and radiology residents in all

the leading Indian medical institutions so

that we can create the next generation

of super-specialized diagnostic and

interventional radiologists who can

gradually step into the shoes of the

current practitioners, as is happening in

many other countries.

JANUARY 2019 / FUTURE MEDICINE / 21


COMBINED

MODALITIES

TO OBTAIN

BETTER

ACCURACY

The rapid development of positron

emission tomography (PET) and MR

technology in the last few decades has

led to multimodality imaging devices.

Combining PET and CT scanning,

radiologists can better detect changes in

lesions over time. This can also provide

information on the nature of growth. The

clinician will be able to know whether the

growth is stable, quick, and if the patient

is not responding to treatment.

A new generation of hybrid scanners

with integrated PET and single-photon

emission computed tomography (SPECT)

with CT is a considered option for

patients with recurrent ovarian cancer.

PET/CT detects more lesions than PET

or CT alone. PET/CT permits the exact

anatomical localisation of pathologic

tracer uptake. This will help the oncologist

to direct treatment to the precise site of

tumour recurrence. Hence, PET/CT should

be considered for follow-up of patients

with ovarian cancer.

Adding CT perfusion (CTP) imaging

is a safe and powerful tool to improve

the accuracy and the positive predictive

value of coronary computed tomography

angiography (CTA) alone, shows current

evidence. The combination of CTP

with CTA not only provides anatomic

information concerning luminal stenosis,

plaque morphology, and total plaque

burden but also provides data on

myocardial tissue hemodynamics.

Different acquisition protocols for CTP

imaging can assess myocardial perfusion

in a qualitative, semiquantitative, or

quantitative manner. It holds immense

potential to evaluate almost every aspect

of the broad spectra of ischemic heart

disease with the possibility of guiding

treatment decisions for a patient on an

individual basis, researchers say.

Recently, cardiovascular PET-CT has

emerged as an imaging technology

with the potential to simultaneously

describe both anatomical structures and

physiological processes in vivo. PET-CT

has tremendous clinical application.

Studies are underway to explore these

possibilities.

“Fusion imaging is now catching

up very fast among various clinical

disciplines,” says Dr Shanmugham, a

consultant radiologist from Tuticorin, Tamil

Nadu. “Almost all the imaging modalities

have their own limitations. Combining

different technologies can provide better

characterisation and clarity in many

clinical situations where an assessment

becomes challenging.”

In some cases, for example in a bone

tumour, CT/MRI can be preferred. “It

harnesses the strength of both CT and

MRI. While one modality helps determine

the status of bone marrow, the other

gives a better view of the bone tissue.

Combining both, the clinician will get a

highly detailed picture of the condition,”

virtual mono-energetic images for clinical

evaluation. Multi-energy CT expands on

spectral imaging.

Infervision, a big data and AI company,

announced the launch of InferRead

CT Chest, a product that detects four

different conditions with just one set of chest

scans.

InferRead CT Chest will allow a doctor

to review an image only once to perform

multiple disease screenings in the chest,

including lung nodule, chest fractures, bone

metastases and bone tumor, chronic lung

disease (such as emphysema) and cardiac

calcification. The lung nodule screening has

been enhanced to provide a complete view

of the nodule, including volume and density.

This product can automatically compare

similar cases from a case report bank to

Elastography can

detect liver cancer

even in the very early

stages.

Dr A Anbarasu

Consultant Radiologist

and Imaging Specialist

provide further information and diagnostic

information to physicians.

Tracer PETs

In PET-CT, positron emission tomography

combines information about the metabolic

function with that of the body’s anatomy

captured by CT in a single session to provide

a more detailed picture of cancerous tissues

than either test does alone, with a high level

of accuracy.

PET scanning using the tracer fluorine-18

(F-18) fluorodeoxyglucose (FDG), called FDG-

PET, is widely used in clinical oncology. PET

is also used to diagnose some degenerative

brain diseases. Continued development

of new radiotracers will lead to a growth

in clinical applications for PET/CT both

in the field of oncology and in functional

22 / FUTURE MEDICINE / JANUARY 2019


CT

MRI

informs Dr A Anbarasu, a consultant

radiologist and imaging specialist from

Coimbatore, Tamil Nadu and the author

of Oxford Handbook of Head and Neck

Imaging - an introduction to the theory

and practice of head and neck radiology.

Ultrasound has its limitations in

poorly echogenic patients or organs.

Such difficult-to-visualize lesion can

be rendered visible by Smart Fusion,

a technique that combines imaging

modalities. Smart Navigation, a needle

tracking technology, allows for oblique

needle paths and real-time monitoring at

the patient’s bedside without exposing

him or her to ionizing radiation. Both

Smart Fusion and Smart Navigation are

more accessible and less expensive than

a procedure performed under CT or MRI

guidance. This modality is especially

useful in interventional radiology settings.

PET/MR imaging can be beneficial to

improve early and differential diagnosis

of Alzheimer’s disease, studies show.

Through combining the metabolic and

molecular information from PET, and the

structural and functional information

from MR imaging, PET/MR imaging is

considered to have the potential to

broaden diagnostic power. With new

emerging PET radiotracers and MR

imaging techniques, it could become

a conventional first-line one-stop-shop

clinical imaging tool to improve the

current understanding of AD

neuroimaging such as amyloid PET screening for Alzheimer’s

disease etc..

PET-MRI scanners are also being tested on an

experimental basis in the clinical setting. PET/MRIs lead to

lower radiation exposure compared to a PET-CT. PET-MRIs,

however, come with a much higher price tag than PET/CTs.

Some studies show that PET/MRI scans of the brain can

detect abnormal findings that PET/CT misses in more than

50% of patients scanned.

MRI: Defining pathology

Magnetic resonance imaging (MRI) can detect diseases and

pathological tissue. The superior soft tissue contrast in this

cutting-edge imaging modality allows better definition of the

pathology.

MRI is also increasingly used for guiding, monitoring

and controlling percutaneous procedures and surgery. It is

billed a as faster and more accurate method of imaging.

More demanding interventional radiology procedures utilize

the MRI approach.

Magnetic resonance angiography (MRA), an MRI technique

which specifically looks at blood vessels, has been used to

image cerebral and renal arteries and other vessels in the

head and neck, the aorta and its branches, etc.

Recent MRI allows scans of the lungs. Traditionally, MR

imaging has not been possible in the lung since the lungs

are filled with air and there is a low density of the hydrogen

atoms required to create MR images. Now, Ultrashort Echo

Time (UTE) sequence for dedicated pulmonary MRI has been

introduced for clinicians to view high susceptibility regions of

the lung tissue where signals generally disappear too quickly.

The simultaneous multi-slice application software enables

acquisition of MR images simultaneously as opposed to

sequentially. With the use of the new software, physicians

can bring down the length of MRI brain examinations

considerably, which usually vary significantly.

Similarly, cardiac MRI has been made simple with the

introduction of new technology. The new MRI software helps

JANUARY 2019 / FUTURE MEDICINE / 23


automate the image sequences to perform a full 3D chest

volume scan, including the full motion of the myocardium

during the cardiac cycle and blood flow. It also speeds the

imaging time from 70 minutes to about 10 minutes using a

single, free-breathing exam, according to reports.

Quantitative diffusion-weighted imaging (DWI) and

diffusion tensor imaging (DTI), which offer visualization of

the exact location of tumours, is found to be beneficial in the

neurosurgical planning and postoperative assessment.

Quantitative imaging is becoming more and more

important in clinical practice today, comments Dr C Kesavadas,

Professor of Radiology, Sree Chitra Thirunal Institute of

Medical Sciences and Technology, Thiruvananthapuram, India.

“Differentiation between an infection and a tumour is possible

through perfusion technology neuro imaging. Infections and

granuloma have mostly low perfusions.”

Clinical researchers have recently demonstrated restingstate

functional MRI (fMRI) to develop a prognostic index

of clinical response to antipsychotic drug treatment in a

cohort of schizophrenia patients. Since clinical response to

antipsychotic drug treatment is highly variable, prognostic

information can serve as a potential biomarker of treatment

response.

The USFDA cleared the first 7 Tesla (7T) MRI device toward

the end of 2017. The Magnetom Terra from Siemens more

than doubles the static magnetic field strength available. This

advanced ultra-high-field scanner is intended for patients

over 66 pounds of body weight. The scanner has two coils

optimized for clinical neuro and knee imaging. It also features

the hyper-fast image reconstruction technology for speeds

that are up to 20 times faster than previous generations of 7T

research scanners.

New frontiers in real-time US

The use of real-time 3D US imaging has been expanded

in scope with improvements in acquisition techniques,

24 / FUTURE MEDICINE / JANUARY 2019


TARGET ORGANS

Brain, lungs and breast tend

to be targeted the most, with

33 companies focusing on the

brain, presently.

Eyes

9

Brain

33

Heart

14

Breast

18

Liver

7

Lungs

28

Bones

10

MRI TECHNIQUE TO

OBVIATE BIOPSY?

Joints

2

Kidney

1

Prostate

2

Cancer

of

all types

6

SOURCE: FROST & SULLIVAN

new MRI technique that could

A potentially obviate the need for

biopsies to identify composition and

aggressiveness of a tumour.

A recent study using multiparametric

MRI or mpMRI involving a standardized

diagnostic algorithm evaluated specific

MRI images of a targeted renal mass.

A cohort of 110 patients, who

underwent MRI and partial or radical

nephrectomy, showed 50% of the lesions

with malignant clear cell histology. The

MRI images evaluated factors including

the presence of microscopic fat in

a tumour and signal intensity in T2-

weighted imaging.

The multiple types of images

obtained from the renal mass could

reveal more about the histology of

the tissue with 80% specificity, aiding

in their risk stratification. Though the

research does not suggest that mpMRI

will replace all biopsies, it does say

that it could help avoid unnecessary or

painful examinations done to determine

malignancy of tumours to a large extent.

JANUARY 2019 / FUTURE MEDICINE / 25


econstruction algorithms, rendering methods and

computer GPU acceleration approaches. In obstetrics,

abnormalities of the foetal face, rib anomalies and fluid

accumulation can be detected. The technology is also

used to quantitatively measure left ventricular volume,

to diagnose ischemic and congenital heart disease

(cardiology), bone erosions in small joints, enthesitis

and partial tear of tendons (rheumatology), bladder

cancer recurrence and as an alternative to voiding

cystourethrography (VCUG) (urology) as well as for

surgical guidance and vascular imaging

Foetal HQ heart and vascular software from GE

Healthcare for foetal ultrasound now helps evaluate the

foetal heart shape, size and contractibility. Radiant Flow

shows the blood flow in a 3D view and image slow-flow

blood such as neuro-vascular circulation.

Elastography for early detection

Elastography is a newer technique that is based on study

findings that a pathological process alters the elastic

properties of the involved tissue. When ultrasound

is used to assess elastography, it is termed sonoelastography.

MRI-elastography uses shear waves to

assess tissue displacement in all directions, making it

more precise than sonoelastography. The modality is

widely used in cases of liver fibrosis, where larger lesions

can be easily assessed even in the presence of ascites.

Elastography is very useful in detecting liver cancer.

Even the very early changes in the liver tissue, before

it starts getting hardened, can be pictured using this

imaging modality, said Dr Anbarasu, a consultant

radiologist and imaging specialist from Tuticorin, Tamil

Nadu.

It is also used to differentiate malignant and benign

neoplasms in the breast and in identifying early traumatic

changes in muscles and tendons.

X-rays: Yet untapped?

X-ray technology has advanced toward reducing

radiation doses and time in the acquisition of scan.

The advent of automatic exposure detection (AED)

has transformed radiographic image capture. With

the help of AED, digital radiography can be adapted

to computed radiography. Wireless DR detector offers

advanced image quality, greater reliability, and faster

capture speeds.

Tomosynthesis is an advanced application of DR

where the X-ray tube sweeps across the patient to

get a series of exposures during the pass. The

imaging computer draws out a 3D image from the

views acquired. Tomosynthesis is presently used in

mammography.

Dual-energy imaging is another advance in X-ray

technology which is becoming popular. This imaging

TOP CLINICAL APPLICATION AREAS

Oncology is the dominant clinical area

for imaging followed by breast care

Breast care

Stroke & trauma

Lung care

Neurology*

Cardiac care

Oncology

20.2%

20.2%

19.1%

18%

15.7%

9%

9%

6.7%

3.4%

3.4%

Opthalmology

Orthopedics

Abdominal

Pediatrics

Vascular

3.4%

2.2%

2.2%

1.1%

Radiation Therapy

Gynecology

Urology

Metabolic

34.8%

*Excluding stroke

SOURCE: FROST & SULLIVAN

26 / FUTURE MEDICINE / JANUARY 2019


makes it possible to get three images

produced by subtractive software: Just

the bones, or just the soft tissues and

internal organs, or both together.

Experts say that DR is yet an

untapped opportunity and X-ray will

find new avenues of clinical usefulness

in the future.

“Digital radiology platform has

dramatically changed the reporting

scenario. Today, images can be sent

to the physician sitting anywhere in

the world for assessment and further

treatment course,” says Dr Anbarasu,

consultant radiologist and imaging

EXPERTS SAY THAT DR

IS YET AN UNTAPPED

OPPORTUNITY AND X-RAY

WILL FIND NEW AVENUES

OF CLINICAL USEFULNESS

IN THE FUTURE

specialist, Aran Diagnostic Imaging,

Coimbatore, Chennai. Teleradiology can

be effectively utilized for the people

dwelling in the remote areas of India,

he added.

INDIA-MADE PORTABLE MRI

Tata Trusts’ Foundation

for Innovation and Social

Entrepreneurship (FISE)

launched a portable MRI

scanner in India in June

2018.

The scanner is

developed by VoxelGrids, a

Bengaluru based Magnetic

Resonance Imaging

(MRI) technology start-up

supported by FISE.

The MRI machine can

be mounted on a truck

and transported to the

remotest villages. The 1.5

Tesla whole-body scanner

is three to four times faster

than other MRI machines,

said Tata Trust in a press

release.

The machine cuts down

the cost of MRI significantly

besides enabling

exceptional acceleration of

the scans. 2D scans can be

accelerated by factors of

6-12 while 3D scans can be

accelerated by factors of 18

or more.

The two-hour switch-on

feature of the made-in-

India portable MRI scanner

is also an added attraction.

MRI scanners usually take a

week to be made functional

if fully turned off as they

lose all their liquid helium.

This makes the turn-off

and turn-on process quite

expensive and timeconsuming.

The current MRI

scanners are heavy.

They are also expensive

and unaffordable to

many people. Moreover,

these MRI machines have

limited ability to image

moving organs like the

human heart, which

results in failure to

diagnose heart diseases.

This MRI scanner addresses

these limitations, according

to VoxelGrids.

Adding dimensions

Although CTs and MRIs can provide a

treasure of information, the planning

of the resection line may be difficult

when relying on conventional twodimensional

images. 3D imaging

techniques are of great value, especially

in liver resections. Three-dimensional

appearances of liver structures may

further improve the results of curative

liver surgery. More studies are still

needed before 3D becomes a routine

clinical procedure.3D models are

likely to play an important role in the

preoperative planning in many surgical

procedures.

New 3D and 4D software increase

the contrast of soft tissues and reduce

the visibility of metal artifacts compared

to traditional CT images.

JANUARY 2019 / FUTURE MEDICINE / 27


adiology

NEXTGEN

RADIOLOGY

POWERED BY AI

Radiomics, which integrates AI into radiology, offers

great promise to accelerate precision medicine

DR RAJANI KANTH VANGALA

Radiomics, the application of

artificial intelligence (AI) to

radiology, may well be the trail

blazer that the rest of the specializations

in healthcare have been waiting for. In

November 2018 M*Modal announced

a cloud-based version of its radiology

reporting solution designed with the

help of Microsoft and Aligned Imaging

Solutions, a radiology company

focused on X-rays. In March 2018, GE

Healthcare introduced the LOGIQ E10,

its next-generation radiology ultrasound

technology. This digital system integrates

artificial intelligence, cloud connectivity

and advanced algorithms to gather and

reconstruct imaging data faster than

ever before.

The progress of radiology since

Wilhelm Roentgen’s discovery of X-rays

in 1895 can now be propelled into

the next century if we can use AI with

good practice guidelines and validated

biomarkers. Radiologists are not new

to the concept of AI, as there has been

pioneering work in this field since

1985 (Krupinski, Elizabeth A, Academic

Radiology, 2003), when several symbolic

interpretations of medical images

based on human decisions were used

for high-level assessments (Matsuyama

T, Comput Vision Graph, 1989). This

approach involved simple processes;

for example, binarising / thresholding

geometric structures in an image

and evolving a set of logical rules for

further diagnosis. This approach had

a strong human involvement as the

decision is taken based on human

medical knowledge. However, it did

not prove to be a successful decision

support system. The second approach

‘RADIOMICS’ IS A DATA-

DRIVEN APPROACH, WHERE

A SET OF CHARACTERISTIC

LABELED OR UNLABELLED

APPEARANCES OF ORGANS

ARE USED FOR TRAINING

of probabilistic interpretation of

medical images was driven by models

which used combinatorial systems.

This statistical approach depended

on human decision-making expertise

along with labeled parameters from the

reference data set using probabilistic

methods that are likely to determine

the best solutions. This approach has

numerous strengths, like aggregation of

information across populations, expert

knowledge and human-understandable

models. However, the

choices of the statistical

methods and the process of

building appropriate models which

successfully form a reference data-set

have become huge challenges.

Data-driven approach

The limitations of the above methods

lie in the requirement for expert human

knowledge. Moreover, converting

this into a model system can be

challenging, especially when the said

expertise/knowledge is incomplete.

‘Radiomics’ is a data-driven / modelfree

approach, where a set of

characteristic labeled (supervised) or

unlabelled (unsupervised) appearances/

representations of organs are used

28 / FUTURE MEDICINE / JANUARY 2019


for training. In both learning methods,

large datasets of image features are

automatically extracted from each

data point/image. By using these

approaches of machine learning —

along with statistical tools like logistic

regression, support vector machine and

decision trees — a better, feature-based

separation between normal and disease

conditions are achieved (Cortes C,

Vapnik V. Mach Learn 1995).

In radiology, the data-driven

approaches work by using specific

features designed to reflect the

properties of data, such as density,

heterogeneity of tumours, shape etc.

Newer approaches are being developed

using deep learning (Chartrand G,

et al, Radiographics 2017), which

are improving the feature-based

methods by using artificial neural

networks (ANNs). These ANNs work by

introducing a hierarchy of non-linear,

multi-layer data nodes including the

pixel values in an image. Thousands of

these nodes with millions of networks

become the best way of training the

algorithms to respond to the new

inputs for diagnostics. This approach

moves ways from a hypothesis-based

approach to a data-driven model, which

is more powerful and leads to novel

discoveries. The first sets of features,

called engineered features, are specific

characteristics of disease tissues which

are used by domain-specific experts. In

case of scarcity of data, a pre-trained

network can be used to perform

transfer learning. For any deep learning

approach, data normalisation is

an essential preprocessing

step. This ensures better

numerical stability

and quicker

JANUARY 2019 / FUTURE MEDICINE / 29


convergence into the required output.

This step could be achieved by principal

component analysis (PCA) or a sample

wise, feature-wise normalisation, making

sure that “internal covariance shift” is

understood. This shift can be mitigated

using batch (Ioffe s and Szegedy C.

Ithaca (NY): Cornell University 2015) or

layer normalisation (Ba JL et al, Ithaca

(NY): Cornell University 2016 ).

Overcoming overfitting

In deep learning, prediction

performance can be influenced by

several parameters and architectures like

dimensionality and feature extraction.

The selection of architecture may

depend on the data size, statistical

properties of data and the underlying

scope of the analysis. One of the major

challenges in deep learning is overfitting,

which can influence the network’s

ability to generalise unseen data. This

kind of black box treatment and not

giving enough attention to technical

requirements can lead to undue

complications. However, using shallower

networks to avoid overfitting may

result in underfitting due to insufficient

learning of the training algorithm. In

such scenarios, data augmentation

by transformations and other

regularisations, such as dropout, can

be used, which reduces the individual

parameter/node weights and hence

increases the robustness of the network.

Similarly, penalising large parametric

weights can also enable better network

generalisations (Pereira F et al, Advances

in neural information processing systems

2012 and Srivastava N et al SIGKDD

Explor Newsl 2007). For identifying

the best biomarkers along with

above steps, a cross-validation-based

early-stopping approach can help in

reducing overfitting (Orr GB et al. Neural

networks: tricks of the trade. Berlin/

Heidelberg (Germany): Springer; 1998).

Biomarker validation using

machine learning and deep learning

models needs more than just avoiding

overfitting and data leakages. The

approaches must include locked

validation cohorts and blinding them

BIOMARKER VALIDATION

USING MACHINE LEARNING

AND DEEP LEARNING

MODELS NEEDS MORE

THAN JUST AVOIDING

OVERFITTING AND DATA

LEAKAGES

during the training and hyperparameter

tuning. Important accuracy classifiers

must be accurately evaluated in multiple

performance metrics such as AUC (area

under the curve), sensitivity, specificity,

positive predictive value, negative

predictive value etc. Along with these

aspects, when we perform multiple

testing or testing hundreds of features,

corrections like Bonferroni (Bonferroni

CE. Pubblicazioni del R Istituto Superiore

di Scienze Economiche e Commericiali

di Firenze 1936) and Benjamini and

Hochberg (Benjamini Y, Hochberg Y. J R

Stat Soc Series B Stat Methodol 1995)

must be applied. To understand the true

clinical value of biomarkers, it is also

important to statistically compare them

to present standard markers for the

additive increase in the computational

models.

Data science and big data are

going to play a major role in healthcare

applications and will have an impact

globally at industrial as well as academic

settings. The radiology committees from

professional colleges and societies must

take such data and knowledge base to

create frameworks and define required

advance steps. Individual radiologists

play a very pivotal role as the integration

of machine learning workflows will

need their undivided attention and

can help them in clinical outcomes. A

mindful approach of radiomic analysis of

imaging data can lead to patient-specific

data, leading to precision medicine.

The author is medical

scientist and former

director of SGRF,

Bangalore

30 / FUTURE MEDICINE / JANUARY 2019


drug approvals

Sanofi and MSD’s hexavalent

vaccine in US

US FDA has approved diphtheria and

tetanus toxoids and acellular

pertussis adsorbed, inactivated poliovirus,

haemophilus b conjugate and hepatitis B

vaccine (Vaxelis) for use in children from 6

weeks through 4 years of age.

The combination vaccine indicated for

active immunization to prevent diphtheria,

tetanus, pertussis, poliomyelitis, hepatitis B,

and invasive disease due

to haemophilus influenzae type b. It is

approved for

use as a 3-dose series in children 6 weeks

through 4 years of age (prior to the 5th

birthday).

Sanofi and MSD are working to

maximize production of Vaxelis to allow for

a sustainable supply to meet anticipated

US demand. Commercial supply will not be

available in the U.S. prior to 2020.

The hexavalent vaccine was developed

as part of a joint venture established in

1991 between Merck & Co, Inc and Sanofi

Pasteur, the vaccines unit of Sanofi

significant improvement

in motor function at the

Week 12 visit, as measured

by a reduction in Unified

Parkinson’s Disease Rating

Scale (UPDRS) Part III score

for Inbrija 84 mg compared to

placebo at 30 minutes postdose.

The onset of action was

seen as early as 10 minutes.

The drug was also studied

in a Phase 3 long-term,

active-controlled, randomized,

open-label study assessing

safety and tolerability over

one year. This study showed

the average reduction in FEV1

(forced expiratory volume in

1 second) from baseline was

the same for the Inbrija and

observational cohorts.

Inbrija is expected to be

commercially available by

prescription in the U.S. in the

first quarter of 2019.

Levadopa

inhalation

powder for

Parkinson’s

Levodopa inhalation powder

(Inbrija) has been granted

marketing approval by US FDA

for intermittent treatment of

OFF episodes in people with

Parkinson’s disease, Acorda

Therapeutics, Inc announced.

OFF episodes, also known

as OFF periods, are defined

as the return of Parkinson’s

symptoms that result from

low levels of dopamine

between doses of oral

carbidopa/levodopa,

the standard oral

baseline Parkinson’s

treatment.

FDA

approval of the inhalable

levadopa was based on a

clinical programme that

included approximately 900

people with Parkinson’s on a

carbidopa/levodopa regimen

experiencing OFF periods.

The Phase 3 pivotal

efficacy trial – SPANSM-PD –

was a 12-week, randomized,

placebo controlled, double

blind study evaluating the

effectiveness of INBRIJA

in patients with mild to

moderate Parkinson’s

experiencing OFF periods.

The SPAN-PD trial met

its primary endpoint, with

patients showing a statistically

Ravulizumab

injection for

blood disorder

R

avulizumab (Ultomiris)

injection secured approval

from the US FDA for the

treatment of adult patients

with paroxysmal nocturnal

hemoglobinuria (PNH).

Ravulizumab is a longacting

complement inhibitor

that prevents haemolysis in

the life-threatening blood

disease.

The FDA approval was

backed by a clinical trial of

246 treatment naïve patients,

who were randomized to

be treated with ravulizumab

or eculizumab, the current

standard of care for PNH.

The results of the

trial demonstrated that

ravulizumab had similar

results to eculizumab.

The patients did not

receive a transfusion and

had similar incidence of

haemolyses measured by

the normalization of lactate

dehydrogenase (LDH)

levels in patients’ blood.

In addition,

32 / FUTURE MEDICINE / JANUARY 2019


avulizumab was studied

in a second clinical trial

of 195 patients with PNH

who were clinically stable

after having been treated

with eculizumab for at least

the past six months. These

patients were randomly

selected to be treated with

ravulizumab or to continue

eculizumab. Ravulizumab

again demonstrated similar

effects to eculizumab based

on several clinical measures

including haemolysis and

avoiding transfusion.

The FDA granted the

approval of ravulizumab to

Alexion Pharmaceuticals.

Calaspargase

pegol for ALL

The US FDA has cleared

calaspargase pegol-mknl

for acute lymphoblastic

leukaemia as part of a

multiagent chemotherapeutic

regimen for paediatric and

young adult patients.

Calaspargase pegol-mknl

(Asparlas) is an asparagine

specific enzyme that is proven

to have a longer interval

between doses compared with

other approved pegaspargase

products. Cal-PEG would

provide a treatment that has

an extended shelf life beyond

that of the current PEGylated

asparaginase treatment,

helping ensure availability to

patients.

The corresponding study

that supported the approval

analysed the drug with

multiagent chemotherapy

in 124 patients with B-cell

lineage ALL.

Olaparib to treat

BRCA-mutated

ovarian cancer

Olaparib has been given

the nod by US FDA for use

as maintenance treatment of

adult patients with deleterious

germline or somatic BRCAmutated

(gBRCAm or

sBRCAm) advanced epithelial

ovarian, fallopian tube or

primary peritoneal cancer.

Patients with gBRCAm

advanced epithelial ovarian,

fallopian tube or primary

peritoneal cancer are selected

for therapy based on an

FDA-approved companion

diagnostic for olaparib.

This is the first regulatory

approval for a PARP inhibitor

in a first-line maintenance

setting for BRCAm advanced

ovarian cancer, according to

AstraZeneca and MSD.

The approval was based

on positive results from the

pivotal Phase 3 SOLO-1 trial

in which olaparib (Lynparza)

reduced the risk of disease

progression or death by

70 percent in patients with

BRCAm advanced ovarian

cancer who were in complete

or partial response to

platinum-based chemotherapy

compared to placebo.

In the SOLO-1 trial,

with median of 41 months

of follow-up, the median

progression-free survival for

patients treated with olaparib

was not reached compared

to 13.8 months for patients

treated with placebo. In the

trial, 60 percent of patients

receiving olaparib remained

progression-free at three

years, compared to 27 percent

of patients receiving placebo.

Fast track status

to lupus drug

Baricitinib, which is

being studied for the

treatment of systemic lupus

erythematosus (SLE),has been

granted fast-track designation.

Eli Lilly is currently

studying two doses of

baricitinib in phase 3 SLE

trials. Additionally, Lilly is

investigating baricitinib as

a potential treatment for

moderate to severe atopic

dermatitis, a serious form of

eczema, with Phase 3 results

projected to be shared during

the first half of 2019.

Baricitinib is approved in

over 50 countries globally as

Olumiant for the treatment

of adults with rheumatoid

arthritis

Baricitinib 2 mg is

indicated for the treatment

of adult patients with

moderately to

severely active

rheumatoid

arthritis who

have had an

inadequate

response to one or

Oxcarbazepine as monotherapy for seizure

Supernus Pharmaceuticals said

USFDA has approved the company’s

supplemental new drug application

(sNDA) for the anti-seizure drug

oxcarbazepine extended release.

Currently, oxcarbazepine is indicated

as adjunctive therapy in the treatment

of partial-onset seizures in adults and in

children 6 to 17 years of age.

Oxcarbazepine (Oxtellar XR) is an

oral once-daily formulation.

Supernus currently markets

extended-release topiramate

(Trokendi XR) for the prophylaxis of

a migraine and the treatment of

epilepsy besides Oxtellar XR. It is also

developing

several product candidates including

SPN-810 for the treatment of impulsive

aggression in ADHD patients, SPN-812

for the treatment of ADHD, and SPN-604

for the treatment of bipolar disorder.

JANUARY 2019 / FUTURE MEDICINE / 33


more tumour necrosis factor

(TNF) antagonist therapies.

Baricitinib is a oncedaily,

oral JAK inhibitor for

the treatment of rheumatoid

arthritis who have had an

inadequate response to

one or more TNF inhibitor

therapies. Olumiant has shown

in non-clinical studies greater

inhibitory potency at JAK1,

JAK2 and TYK2 relative to

JAK3, the four known JAK

enzymes dependent cytokines

have been implicated in the

pathogenesis of a number of

inflammatory and autoimmune

diseases.

CF drug for

children in

Canada

Health Canada has granted

market authorization for

lumacaftor/ivacaftor (Orkambi)

to include use in children ages

2 through 5 years with cystic

fibrosis (CF) who have two

copies of the F508del CFTR

mutation.

Approval is based on a

phase 3 open-label safety

study in 60 patients that

showed treatment with

lumacaftor/ivacaftor was

generally well tolerated for 24

weeks, with a safety profile

similar to that in patients ages

6-11 years. Improvements in

sweat chloride, a secondary

endpoint, were observed at

week 24.

The phase 3 study also

demonstrated changes in

key growth parameters,

which were also secondary

endpoints in the study.

Lumacaftor is designed

to increase the amount of

mature protein at the cell

surface by targeting the

processing and trafficking

defect of the F508del CFTR

protein, and ivacaftor, which

is meant to enhance the

function of the CFTR protein

once it reaches the cell

surface.

Orkambi was approved by

Omalizumab pre-filled syringes in EU

European Commission (EC)

has approved omalizumab

(Xolair) prefilled syringe for

self-administration, allowing

patients with severe allergic

asthma (SAA) and chronic

spontaneous urticaria (CSU)

to administer their own

treatment.

Omalizumab (Xolair) is

the first biologic to offer the

option of self-administration

for SAA and CSU.

Omalizumab, which targets

immunoglobulin E (IgE), is the

first and only biologic to be

approved in the EU, Iceland,

Norway, and Liechtenstein

for self-administration for the

treatment of SAA in patients

6 years of age and older that

have difficulty in controlling

the US FDA in August of last

year for use in patients ages

2 to 5 years who have two

copies of the F508del CFTR

mutation.

Orkambi is marketed by

Vertex Pharmaceuticals Inc.

Gilteritinib to

treat AML with

FLT3 mutation

Gilteritinib

(Xospata)

has been granted

approval for the

treatment of adult

patients who have

relapsed or refractory

acute myeloid

their asthma symptoms

and for CSU in patients 12

years of age and older who

continue to have hives that

are not controlled by H1

antihistamines.

Studies in severe

allergic asthma and chronic

spontaneous urticaria have

shown that appropriately

trained patients can effectively

self-administer omalizumab at

home.

The efficacy of Xolair

has been demonstrated in

large-scale clinical trials and

real-world studies. Xolair

has been shown to reduce

severe exacerbations and

corticosteroid use in SAA,

as well as rapidly reduce

symptoms in CSU.

leukemia (AML) with a FLT3

mutation.

The US FDA also approved

an expanded indication

for LeukoStrat CDx FLT3

Mutation Assay, developed by

Invivoscribe Technologies, Inc.

and used to detect the FLT3

mutation in patients with AML.

The efficiency of gilteritinib

(Xospata) was studied in a

clinical trial of 138 patients

with relapsed or refractory

AML having a confirmed FLT3

mutation.

Twenty-one percent of

patients achieved a complete

remission or complete

remission with partial

hematologic recovery with

treatment. Of the 106 patients

who required red blood cell

or platelet transfusions at

the start of treatment with

gilteritinib, 31 percent became

transfusion-free for at least

56 days.

The FDA granted this

application Fast Track and

Priority Review designation.

Gilteritinib also received

Orphan Drug designation.

Xospata is marketed by

Astellas Pharma.

Plitidepsin to

treat multiple

myeloma in

Australia

T

he Australian Regulatory

Agency (TGA) has given

approval plitidepsin (Aplidin)

for the treatment of multiple

myeloma in combination with

dexamethasone.

The indication has

been approved for the

treatment of patients that

relapse after three lines

of treatment, including

proteasome inhibitors or

immunomodulators. It can

also be administered as

3rd line treatment when

the patient has already

received two prior lines and

is refractory or intolerant

to proteasome inhibitors or

immunomodulators.

Plitidepsin is an anticancer

agent of marine origin,

originally obtained from the

ascidian Aplidium albicans.

It specifically binds to the

eEF1A2 and targets the non

-canonical role of this protein,

resulting in tumour cell death

34 / FUTURE MEDICINE / JANUARY 2019


via apoptosis. Plitidepsin

has received orphan drug

designation in the EU and the

US.

Glasdegib for

adult patients

with leukemia

The USFDA approved

glasdegib (Daurismo),

a once-daily oral medicine,

for the treatment of newlydiagnosed

acute myeloid

leukemia (AML) in adult

patients who are 75 years or

older.

Glasdegib is taken in

combination with low-dose

cytarabine (LDAC), a type of

chemotherapy.

Pfizer said glasdegib

is the first and only FDAapproved

Hedgehog pathway

inhibitor for AML. The

Hedgehog signalling pathway

plays an essential role in

embryogenesis.

In the pivotal, randomized,

international Phase 2 BRIGHT

1003 trial, 115 patients

with newly diagnosed

AML were randomized 2:1

to receive glasdegib plus

LDAC or LDAC alone. Of the

77 patients treated with

glasdegib plus LDAC, more

than half had secondary

AML, or AML that develops

as a result of prior blood/

bone marrow conditions or

previous anticancer therapy.

Eleven of the 39 patients

with secondary AML received

prior treatment with a

hypomethylating agent.

Historically, the prognosis is

poor for these patients and

treatment options have been

limited to clinical trials or

palliative care.

Emapalumab for

primary HLH

Emapalumab has been

cleared for the treatment

of primary haemophagocytic

lymphohistiocytosis (HLH).

Emapalumab (Gamifant)

is the first and only treatment

for HLH, according to Swedish

Orphan Biovitrum AB and

Novimmune SA, a Swiss

biotech company.

Emapalumab-lzsg is an

interferon gamma blocking

antibody for the treatment

of paediatric and adult

patients with HLH. The drug is

a monoclonal antibody (mAb)

that binds to and neutralises

interferon gamma (IFNy).

Primary HLH is an

ultra-rare syndrome of

hyperinflammation with high

morbidity and mortality and

for which there was previously

no approved drug.

The FDA approval is based

on data from the pivotal

phase 2/3 study

which enrolled patients with

primary HLH. The study’s

primary endpoint in patients

with either refractory,

recurrent, or progressive

disease during conventional

HLH therapy or who were

intolerant of conventional

HLH therapy was achieved,

with a clinically meaningful

and statistically significant

proportion of patients

demonstrating an overall

response at the end of

treatment. In addition, 70

percent of patients proceeded

to haematopoietic stem-cell

transplantation (HSCT).

reSET-O app for opioid use disorder

The US FDA has cleared reSET-O

to treat opioid use disorder,

Sandoz Inc and Pear Therapeutics, Inc

announced.

reSET-O is intended to increase

retention of patients with opioid

use disorder (OUD) in outpatient

treatment. It provides cognitive

behavioural therapy (CBT), as an

adjunct to outpatient treatment that

includes transmucosal buprenorphine

medication-assisted-treatment (MAT).

reSET-O is a 12-week interval

prescription digital therapeutic

(PDT) for OUD. reSET-O is modelled

on the community reinforcement

approach (CRA) and engineered to

deliver CBT for patients with OUD.

reSET-O delivers CRA therapy as a

series of interactive therapy lessons.

Each therapy lesson is comprised

of a cognitive behavioural therapy

component and skill-building

exercises. Therapy lesson content is

delivered primarily via text or audio,

and may include videos, animations,

and graphics.

reSET-O is intended as an adjunct

to standard of care for patients

with OUD. It is limited to persons

with a valid prescription from their

licensed provider. reSET-O supports

clinician-patient communication

between visits, by providing a means

for patients to self-report cravings

and triggers, and buprenorphine

use/non-use. reSET-O reinforces the

importance buprenorphine use.

JANUARY 2019 / FUTURE MEDICINE / 35


straight talk

‘UNIBABY’ IS NEXT IN FOCUS

FOR MOTHER OF INDIAN IVF

India’s first scientifically documented

IVF baby Harsha Chawda is 33 years

old now and is the mother of two —a

boy and a girl, who were also born

in the same hands that gave birth

to their mother three decades ago.

While Harsha’s birth was a medical

wonder in India then, the magic hand

that made it happen, DR INDIRA

HINDUJA, is still active in her tireless

journey of creating such breakthroughs

in the field of assisted reproductive

techniques. Dr Hinduja is the country’s

most celebrated gynaecologist and the

mother of India’s IVF, who again made

history with India’s first GIFT (Gamete

intrafallopian transfer) baby in 1988

and the country’s first baby through

Oocyte Donation technique in 1991.

Now, Dr Hinduja is part of another

ambitious research project. It aims to

create eggs and sperm from human

skin cells — a much bigger dream that

the world of biomedical research is

currently chasing in the field of assisted

reproduction. In this edition’s Straight

Talk with CH UNNIKRISHNAN, Dr

Hinduja says our country has got the

brains that can create even greater

wonders with a little more support and

hard work. Edited excerpts:

You pioneered IVF in India in the eighties. It has become

a big industry now and many players are there to provide

treatment. Although many childless couples have benefited

from it, do you think it is being over-exploited by the

industry with a commercial motive, and the passion for

further research is lost among the providers?

The ART segment has grown big in India today and there

are also research initiatives happening side-by-side, though

it is not in proportion to the big ‘business’. But, as it is in any

other industry, there are black sheep in this field as well and

patients have been exploited with no proper treatments,

overcharging and other unethical practices. However, with

the new set of guidelines laid out by ICMR, I believe most

organised players follow them.

But, when I look at my own experience at the time,

it was sheer passion to pursue research that led to such

breakthroughs in a developing country like India where we

didn’t have proper infrastructure, money or motivation. I got

interested in it when I was doing my MD. That was the time

when the world’s first test-tube baby was born and there

were media reports all around. I used to read such reports

with much curiosity and followed every development taking

place in this area across the world. I remember IVF was then

perceived as a miracle and the doctors who were involved in

it were considered like Gods. So, I used to always think, is it

possible?

How was the beginning?

I tried to read all available literature related to earlier

research, especially how they did it in animals like rats,

mice etc.. At that time, India had no infrastructure and

opportunities for one to pursue research in this field. So, I

thought I will go to the UK once I finish my MD, to pursue

this. It was at that time that I happened to notice that there

is an ICMR Institute of Research in Reproduction near the bus

stand close to KEM Hospital in Mumbai, where I was doing

my MD. Though it excited me, I had no guts to approach it as

it was a government organisation and there the regulations

are different. One day I went and met Dr Peter at the institute

who was doing reproduction in animals, in hamster etc., as

part of his Ph.D. I asked him if I can know exactly how he is

doing it and why it’s not done in humans. He was excited

when I offered that, since we do sterilisation in women at

KEM and sometimes we find ovulation and collect the egg,

we could give it to him to be used in his research. That was

36 / FUTURE MEDICINE / JANUARY 2019


pursue the same project with Dr Peter as he

left Mumbai when I was back from the US.

But later, I had to register for Ph D under

Dr Anant Kumar from ICMR to continue

the project and literally struggled between

my working hours in KEM for MD and the

additional time at ICMR institute for Ph.D.

Those days were tough but exciting.

I would collect the ovulation fluid from

hospital and come running to the lab to

keep it in the incubator and again come

in the afternoon to screen the egg. This

is how I started, with a grant from ICMR

and also with active support from KEM. I

actually went through a lot of struggle. And,

when I got the first pregnancy in vitro, I just

couldn’t believe it and I came running to

Kusum (my friend) and to my hospital to

say that I got it positive. The pregnancy test

[result] was announced and flashed in the

media. At the same time, I got a firing from

my team at ICMR for giving it to the media,

though it all happened accidentally after a

media person picked up the news at a KEM

meeting. Shortly after that, I got the second

result, and another day, three conceptions

together. Without any infrastructure, I

used to distil and autoclave the water and

prepare the media, though all these are

readily available today.

the beginning. It was in early 80s, and we designed a long

spiral needle to collect eggs, though many of my attempts

to collect the human egg failed. Finally, I managed one and

we tried to see the difference between the hamster egg and

human egg and if they required the same medium to grow

etc. Since that was a breakthrough, we wanted to present it

in a Boston conference. I had no money to go to Boston and

one of my friends bought a ticket for me. While we presented

the paper, there was overwhelming response as we were

there from a developing country. But unfortunately, I couldn’t

Dr Indira Hinduja

PHOTO: UMESH GOSWAMI

IVF has revolutionized the field of

reproductive technology, providing hope,

faith and a chance at parenthood to

childless couples suffering from a variety

of causes including male factor, who

struggle with various medical and social

aspects of infertility. Could you elaborate

the process that you followed in this

revolution?

Infertility is a multifactorial disease

in which couples are unable to achieve

a pregnancy even after being sexually

active and not using any contraception. In

vitro fertility in India was inspired by the

success of Dr Patrick Steptoe and Dr Robert

Edwards — the scientific team that created

the world’s first ‘test tube baby’ — Louise

Brown — in 1978. We, under the aegis of

the Institute of Research in Reproduction

of the Indian Council of Medical Research

(ICMR) and Kings Edward Memorial

Hospital (KEM) in Mumbai, started testing

the therapeutic and surgical procedures

JANUARY 2019 / FUTURE MEDICINE / 37


initially on laboratory animals. Success in

animals was followed by extensive work

for an attempt to achieve the same in

humans. From August to December 1985,

a number of cycles were taken up for IVF-

ET. Each cycle of failure taught us what

could be further improved in our methods

and techniques. The patient, Maniben, was

then 23 years old and married, and whose

fallopian tubes had been damaged due

to a tuberculous infection and subsequent

surgery. Consolidating the lessons that we

learnt from previous patients, we used the

following procedure.

Ovaries of women contain millions of

eggs since birth, and a number of eggs start

growing in each menstrual [cycle], one egg

matures in a single cycle and releases eggs

(oocytes) for the purpose of fertilisation.

For in-vitro fertilisation, we needed that

the ovaries should release more than one

egg. Hence, the ovaries were stimulated by

giving Oral medication namely, (clomiphene

citrate 100mg) from day 3 to day 7 of the

menstrual cycle. The oral medication was

supported by administering an injection of

human menopausal gonadotropin, which

was also given intramuscular daily from

day 5 to day 10 of the cycle in a dose of

75 IU per day. The number and size of the

growing follicles was monitored by doing

transabdominal sonography. The growth of

these follicles suggested that multiple eggs

were maturing in the ovary. We correlated

this with levels of blood oestradiol, a

hormone released by growing follicles.

An increase in the level of this hormone

means that ovaries are responding to

treatment and the eggs are growing. In this

manner, we were able to see at least four

growing follicles in each of the ovaries of

the patient.

When the follicles were adequately

grown, an injection of Human Chorionic

gonadotropin (hCG) 10,000 IU was

administered to the patient on day 13 to

mature the egg within the follicle. This

was in order to make the egg ready for

fertilization. Thirty-four hours after hCG, the

eggs were retrieved. Using an abdominal

approach, the ovaries were seen, and a

needle was inserted in each follicle to

remove the fluid collected in the follicles.

This fluid was screened under microscope

for the presence of oocytes / eggs. In this way, we found 5

mature eggs and 3 immature eggs.

Simultaneously, the semen of the husband was taken,

washed and centrifuged. This helped us to isolate the

best and most rapidly motile sperm from the sample for

fertilisation. The eggs that were retrieved were combined in

a laboratory dish with her husband’s sperm. The eggs were

seen after 24 hrs for penetration of sperm in it and it was

checked after 48 hours and 72 hours for further growth, i.e.,

2-4 cells and 6-8 cells. Shortly, (on November 30, 1985), we

transferred the embryos into the patient Maniben’s uterus. On

December 18, we did BhCG testing, which indicated a positive

pregnancy test and subsequently confirmed the pregnancy by

redoing the BhCG test on 26 December 1985. Ultrasound was

done on January 6, 1986 which showed a healthy growing

pregnancy.

Have you ever wondered why none attempted this

before you in India even as the world’s first test tube baby

was born in 1978?

I think there were many reasons, including the lack of

infrastructure and a focused effort from the larger institutions,

as well as the controversies surrounding artificial reproduction

in humans. We all remember the strong opposition and the

uproar against artificial reproductive techniques and IVF in

1978 from key religious bodies like the Vatican Church and

some Muslim organizations.

What about the other ART breakthroughs that came your

way after IVF?

The later projects, such as the first case of GIFT in 1988

and the first case of egg donation in 1990, enabled the

use of somebody else’s egg in women whose ovaries can’t

produce eggs for natural fertilisation. In the case of GIFT, the

egg and the sperm are inserted in the fallopian tube of the

mother before fertilisation. Whereas, under the egg donation,

a woman’s ovaries are stimulated to produce multiple mature

eggs, which are then harvested and donated, usually for the

purpose of assisted or third-party reproduction. These eggs

may also be frozen for later use or for in vitro fertilisation.

There are apprehensions, even among gynaecologists,

about defective or multiple pregnancy in IVF and future

health issues in ART children. Any comments?

Such fears are baseless. In IVF, there are rare possibilities of

pregnancy happening in the tube, which you cannot prevent,

because the embryo that is inserted into the uterus may

migrate into the fallopian tube. This happens in the natural

process as well, and it has nothing to do with IVF in particular.

In order to ensure the success rate in ART, we put in multiple

eggs, where chances of multiple pregnancy are more. But

mostly, the patients do accept it or rather they wanted it.

The concerns about future health issues in both ART as well

as natural pregnancy are mostly addressed by the latest

38 / FUTURE MEDICINE / JANUARY 2019


PHOTO: UMESH GOSWAMI

NGS technologies and parental and neonatal

screening and tests.

What is next in focus?

While stem cell treatment to rejuvenate

ovaries to produce eggs is one of the latest

focus areas in the field of biomedical research,

another revolutionary concept that is currently

being worked on in the world, including

India, is to create eggs and sperm from

human somatic cells like the skin, fertilise it

and preserve it. It has been proved in animal

studies. We have created in our lab stem cell

from the skin, but we haven’t differentiated it

into egg and sperm. We will start that work

once we get the required permissions. There

are additional processes required to extract

stem cells from the skin and then stimulate it

in such a way that they differentiate into egg

and sperm, which has been proved. We have

already got a grant from BARC to create a

We have created

in our lab stem

cells from the skin,

but we haven’t

differentiated it

into egg and

sperm. We will

start that work

once we get

the required

permissions.

stem cell from women’s skin.

Stem cells are the first cells to come from

the embryo. Before the embryo becomes a

baby, you can create organs using the stem

cells in it. Now, from the skin, you can create

tissues similar to the embryo, and from this,

stem cells can be sourced to create any

organ such as the heart or the liver, and

now, eggs and sperm. This can overcome

the ethical issues surrounding embryonic

stem cells. We have already created stem

cells from skin biopsy. This revolutionary

technique offers help to couples eager to

have a child that is genetically theirs, but

who lack the eggs or sperm to make it. This

project is inspired by the path-breaking

finding of a Japanese research team led by

biologists Shinya Yamanaka and Kazutoshi

Takahashi. It could also result in any one of

the couple providing both the sperm and the

egg, creating a ‘unibaby’.

JANUARY 2019 / FUTURE MEDICINE / 39


case reports

WHAT IT MEANS TO HAVE

CYSTIC FIBROSIS

An inherited autosomal recessive disorder, CF has few treatment options

Gurvinder Kaur and Devender Singh gave birth to

a normal 3.5 kg baby boy, Angad Singh, on 2 Nov

2011 in Raipur. While everything was normal at birth,

Angad Singh did not pass stools in the 24-48-hour window

as expected. Angad’s abdomen was soon distended and

he started vomiting green colored fluids. Based on these

symptoms, Angad was thought to have Hirschsprung’s

disease and he was referred to a paediatric surgeon who

performed a colostomy and biopsy of the intestine. After the

surgery, Angad now had a problem of loose stools and within

2 months of age, he had lost considerable weight and was

at 1.8 kgs. He was then presented to Dr K. N. Shah, a senior

consulting paediatrician at Lilavati Hospital and Research

Centre, Mumbai.

At Lilavati, Angad underwent another biopsy, which

turned out to be normal, and Hirschsprung’s disease was

ruled out. Based on his history and the normal biopsy

results, Dr Shah suspected that the child had meconium

ileus, which is a bowel obstruction due to

a sticky meconium in the intestine. The

symptoms for meconium ileus are similar to

that of Hirschsprung’s disease – distended

abdomen, green vomit and no stools.

Meconium ileus is most often associated

with cystic fibrosis, and Gurvinder Kaur was

counselled to have Angad undergo genetic

testing to confirm the case.

ABERRANT CFTR RESULTS IN

AN ION MISBALANCE WHICH

CAUSES THE FORMATION OF A

THICK AND VISCOUS MUCOUS.

SUCH MUCOUS CAN AFFECT

THE FUNCTIONING OF THE

PANCREAS AND LIVER, CAUSING

DIGESTIVE SYMPTOMS

Cystic fibrosis is an inherited autosomal

recessive disorder caused due to a

homozygous mutation in the gene for the

cystic fibrosis transmembrane conductance

regulator (CFTR). The most common gene

mutation is the deletion mutation, ΔF508,

which results in a non-functional CFTR

protein. CFTR is a chloride ion channel

required for creating sweat, digestive juices

and mucous. Aberrant CFTR results in an ion

misbalance which causes the formation of a

thick and viscous mucous. Such mucous can

affect the functioning of the pancreas and

liver, causing digestive symptoms, or allow

bacteria to hide from the immune system

in the lungs, causing repeated respiratory

infections. People with cystic fibrosis also

40 / FUTURE MEDICINE / JANUARY 2019


have salty skin due to high levels of salt in their sweat.

Mucous buildup results in blocking of passages of affected

organs. In the pancreas, it results in the accumulation of

digestive enzymes and prevents proper digestion of food,

causing diarrhea and consequently weight loss, as was

observed for Angad. Pancreatic enzyme replacement therapy

has been shown to be helpful in improving absorption

of nutrients. Genetic testing confirmed that Angad was

homozygous for ΔF508. Since Angad’s condition had to

do with digestive symptoms, he was started on pancreatic

enzyme replacement therapy. The diarrhea stopped, and

Angad started gaining weight within 1 month of starting

therapy.

At 3 years of age, Angad started showing symptoms

of lung dysfunction with a sticky sputum that was difficult

to come out. This was part 2 of cystic fibrosis that was

now affecting the lungs. Thick mucus in the lungs results in

repeated respiratory infections and repeated pneumonia with

foul smelling sputum and may even lead to lung collapse. For

lung involvement, treatment revolves around administration

of antibiotics — oral, intravenous as well as via inhalation.

Typically, the patient will recover temporarily, but will again

succumb to new infections. The patient starts losing weight

because of poor appetite due to infections. Currently, there is

no cure for cystic fibrosis. When the condition worsens, the

only option is a lung transplantation.

Gurvinder Kaur and

Devender Singh also

underwent the same

genetic testing and

were found to be

heterozygous for the

ΔF508 and hence

carriers of cystic fibrosis.

When they decided

to conceive again,

extra vigilance was

demanded, and it was

mandatory that the

foetus also underwent

ANTIBIOTICS ARE HIS FRIENDS

AND ENEMIES AT THE SAME

TIME. UNTIL NEW AFFORDABLE

TREATMENTS HIT THE

MARKET, HIS CONDITION IS

LIKELY TO CONTINUE FOR THE

REST OF HIS LIFE

genetic testing for the CFTR gene mutation. This test was

carried out after 20 weeks of pregnancy and as fortune

would have it, the second child was normal. If the foetus

would have been carrying a homozygous mutation, it would

have to be aborted. Even the knowledge of a heterozygous

mutation would be an important aspect for the child, as the

child would be a carrier. Gurvinder Kaur and Devender Singh

were however much relieved with the results and proceeded

to have a healthy baby girl.

While Angad is doing much better now, he is a constant

visitor at the AIIMS, Raipur. He has just come home from

another respiratory infection where he was diagnosed with a

double infection of Staphylococcus and Klebsiella. Antibiotics

are his friends and enemies at the same time. His doctors

have learnt the hard way that he is allergic

to both vancomycin as well as lizonide. Until

new affordable treatments hit the market,

his condition is likely to continue for the rest

of his life. Meanwhile, there are some new

drugs in the market. Orkambi is a lumacaftor/

ivacaftor combination drug which has

recently been approved in Europe. However,

the drug is extremely expensive and

practically unaffordable for patients in India.

Interestingly, Gurvinder Kaur is now

so involved in everything to do with cystic

fibrosis that she is researching on her own

and trying to stay abreast of the current

treatment options for cystic fibrosis in the

hope of being able to tackle her son’s

disorder. She has found a Facebook page for

other cystic fibrosis patients in Delhi and has

recently been added to a WhatsApp group

with about 115 patients from all over India.

She believes that more such support groups

are needed in India, especially for families

who may find a genetic disorder such as

cystic fibrosis a drain on their financial

situation. “The government should look

after such patients, and genetic disorders

should be covered by insurance companies,”

advocates Gurvinder Kaur.

DR SHIVANEE SHAH

42 / FUTURE MEDICINE / JANUARY 2019


case reports

FACTS ON FANCONI

How bone marrow transplant gave a new lease of life

to a rare case of aplastic anaemia

Two-year-old Aarav was constantly getting fever and

appeared tired and lethargic for over a month. His

parents were worried about him and finally took him

to Lilavati Hospital and Research Center in Mumbai. The

pediatrician referred the patient to Dr Swati Kanakia, a

paediatric haemato-oncologist.

On clinical examination, Aarav had fever with low

hemoglobin, low WBC and low platelets, which were initially

attributed to an infection, which Aarav did have at the time.

While there were no other obvious abnormalities, Aarav

showed pallor and had macrocytosis (large RBC), slightly

smaller stature, darkness around the lips and 4 Café au

lait spots on his chest and back. In combination with these

observations and the pancytopenia, Dr Kanakia ordered a

hemoglobin chromatography. The results showed very high

Hb F levels, which are indicative of stressed erythropoiesis

and of bone marrow failure or aplastic anaemia. Aplastic

anaemia can be inherited or acquired following infections.

A bone marrow biopsy was done to confirm bone marrow

failure. Bone marrow results also showed a pancytopenia

and the aplastic anemia was likely to be inherited. Further,

placing the family history in this light, Aarav was born to

a 3rd degree consanguineous marriage, and an inherited

syndrome was suspected.

Inherited bone marrow failure syndromes are a group

of heterogeneous disorders involving bone marrow failure.

These are often presented during childhood and are

associated with somatic abnormalities. Fanconi anaemia

is one of the most frequently reported of such inherited

bone marrow failure syndromes and it typically manifests

before the age of 10. However, it is still very rare and only

1 out of 1.3 million children are diagnosed with Fanconi

anaemia. Classical features include short stature, abnormal

thumbs and hyperpigmentation of the skin. About 30% of

Fanconi anaemia patients have no somatic abnormalities,

while about 80% develop bone marrow failure by age 20.

The primary signs of hematologic origin are petechiae and

bruises, which may graduate to a pale appearance and

infections.

Fanconi anaemia is an autosomal recessive genetic

disorder, requiring 2 copies of the mutant gene. At least 17

genes have been identified to carry mutations that result

in Fanconi anaemia. These genes encode for a cluster of

proteins important for DNA repair. Mutant genes result in

abnormal proteins, such that the repair

of the DNA is less effective and it is easily

damaged by cross-linking agents. Bone

marrow is particularly sensitive to such

defects.

To determine the type of possible bone

marrow failure and to see if Aarav had

Fanconi anaemia, a cytogenetic stress test

was done. Diepoxybutane analysis is the

preferred test for Fanconi anaemia. As part

of the test, chromosomes are exposed

FANCONI ANAEMIA

CAN BE TREATED WITH

ANDROGEN THERAPY OR

AN ADMINISTRATION OF

GROWTH FACTORS

to a stress agent such as diepoxybutane

or mitomycin C and the number of

chromosome breakages are assessed.

The test showed that Aarav had a 7- to

14-fold increase in the number of induced

breaks compared to the control, and

Aarav was suspected to have Fanconi

anaemia. This was then confirmed by

genetic testing, which showed that he was

homozygous for a mutation in the FANCL

gene, one of the most common mutations

in India.

Fanconi anaemia can be treated with

androgen therapy or an administration of

growth factors. Androgen therapy helps

improve blood counts, but can result in

a long list of side effects ranging from

vomiting, and behavioral changes to liver

toxicity. Growth factors such as G-Colony

Stimulating Factor or GM- Colony Stimulating

Factor can temporarily improve white blood

44 / FUTURE MEDICINE / JANUARY 2019


cell counts. Neither androgen

therapy nor growth hormone

administration are curative

options. The only known cure

is a stem cell transplant or

bone marrow transplant. The

success of a bone marrow

transplant is dependent on a

close match with the donor;

with the best donors being

healthy siblings. In addition,

Fanconi anaemia makes

FANCONI ANAEMIA MAKES

INDIVIDUALS SENSITIVE

TO CHEMOTHERAPY AND

RADIATION THERAPY

REQUIRED AS PART OF

THE BONE MARROW

TRANSPLANT

individuals sensitive to chemotherapy and radiation therapy

required as part of the bone marrow transplant. Thus,

bone marrow transplant may not be suitable for all Fanconi

anaemia patients. Several reduced intensity conditioning

options have been standardized to aid bone marrow

transplant in Fanconi anaemia patients.

In Aarav’s case, his parents and 2 siblings were

screened for the mutation and all 4 were found to be

heterozygous. Since Aarav needed immediate treatment

and one of his siblings was found to be a good match, a

bone marrow transplant was performed

from the matched sibling at a specialized

centre in Pune. Aarav is doing very well

now. However, he will need to be under

surveillance to ensure that the transplant is

not rejected.

Dr Kanakia has major hope for bone

marrow transplantation in India. “Bone

marrow transplant is the way forward

for many malignant and non-malignant

conditions. More and more centres for bone

marrow transplant for paediatric patients

are coming up and that is the need for the

hour.” As the technique becomes more

affordable and popular in coming decades,

it may become as simple as a blood

transfusion and is likely to be a commonplace

treatment for many different types of

conditions.

DR SHIVANEE SHAH

JANUARY 2019 / FUTURE MEDICINE / 45


esearch snippets

Lateral OFC stimulation

found effective in treating

mood disorders

Rao et al unveiled an effective

target in the brain for

electrical stimulation to improve

mood in people suffering

from depression. Using direct

neurophysiological recordings, the

scientists revealed that unilateral

stimulation of the lateral

orbitofrontal cortex

(OFC) produced acute, dosedependent

improvement

among patients who had

baseline depression. The

study was performed in a

small cohort of 25 individuals

who suffered from epilepsy.

Intracranial electrodes were

implanted in the participants

for seizure localization by

subjecting to continuous

electroencephalography

(iEEG). Mood-state changes

were assessed with the iEEG

recordings which showed

acute improvement in the

mood of the patients. The

study showed lateral OFC as

a promising new stimulation

target with therapeutic potential

suggesting to set the stage for

next generation of stimulation

therapies.

Source: Current Biology https://

doi.org/10.1016/j.cub.2018.10.026

VOLUME 28, ISSUE 24, P3893-3902.E4,

DECEMBER 17, 2018

New radiomics method

may reduce need for

breast biopsies

Karen Drukker et al developed a novel

technology that uses mammography

to determine the biological tissue

composition of a tumour that could help

reduce unnecessary breast biopsies.

The new technique, called threecompartment

breast (3CB) imaging,

measures the water, lipid and protein

tissue composition characterising the

tumour. The researchers acquired dualenergy

mammograms from 109 women

with Breast Imaging Reporting and Data

System category 4 or 5 breast masses.

The 3CB images were combined with

mammography radiomics which showed

positive predictive value in large breast

masses. The combined method improved

positive predictive value from 32% for

visual interpretation to almost 50% with

a reduction in biopsies to 36%. The 3CBradiomics

method missed one of the 35

cancers for a 97% sensitivity rate. The

research suggests the need for further

progress in studying how the combined

approach would help radiologists in

making their final determinations.

Source: Radiology.rsna.org n Radiology: Volume

00: Number 0—2019https://pubs.rsna.org/

doi/10.1148/radiol.2018180608 Dec 11 2018

Cancer DNA’s affinity to

gold paves way for new

detection test

Abu Ali Ibn Sina et al have found a

novel method for detecting cancer

46 / FUTURE MEDICINE / JANUARY 2019


y exploiting the methylscape biomarker

found in cancer types, which allows

higher DNA-gold affinity compared to the

normal genome. The foundation of the

research was based on the difference

in solvation property of normal and

cancer epigenomes. Methylcytosines

found in cancer epigenomes give them

a methylation landscape (methylscape).

These methylcytosines have a higher

affinity towards gold than regular

cytosines which tend to aggregate in

aqueous solution due to hydrophobic

property of methylcytosines. The study

was performed on a large cohort of

over 200 human samples from celllines

representing various cancer types.

Using electrochemical and colorimetric

techniques, the simplified test could

enable detection of the biomarker

through naked eyes. The test

claims to detect cancer in less

than 10 minutes as a non-invasive

cancer detection method from plasma

with high specificity. Researchers

proclaim that methylscape in its current

form is only able to determine the

presence of disease and a detailed

analysis is required

to fully understand the type, stage

and disease recurrence.

Source: Nature Communications volume

9, Article number: 4915 (2018) https://

www.nature.com/articles/s41467-018-

07214-w 04 December 2018

Impaired clearance

of mucin linked to

lung fibrosis

Laura A. Hancock et al found evidence

suggesting that impaired clearance

of mucus in lungs due to overexpression

of MUC5B gene may lead to pulmonary

fibrosis, identifying it as a potential

therapeutic target. Researchers reveal

that the MUC5B, a mucin thought to

be restricted to conducting airways, is

co-expressed with surfactant protein C

(SFTPC) in the type-2 alveolar epithelium

in humans, indicating their role in

developing idiopathic pulmonary fibrosis

(IPF). Overexpression of Muc5b in a

fibrosis induced mice model showed

a reversal effect in the presence of

mucolytic agent P-2119. With mucolytic

agent, the mucociliary clearance (MCC)

was restored with acute clearance of

inflammatory cells from the lungs. The

findings suggest that targeting MUC5B

in the terminal airways of patients with

preclinical stages of interstitial lung

disease represents a rational strategy to

prevent the progression of pulmonary

fibrosis.

Source: Nature Communications volume 9, Article

number: 5363 (2018) https://www.nature.com/

articles/s41467-018-07768-9#Sec6 18 December

2018

New gene target found for acute myeloid leukemia

Konstantinos Tzelepis et al

demonstrated a plausible therapeutic

potential of splicing kinase gene (SRPK1)

in treating acute myeloid leukemia (AML).

Scientists found that inhibition of the

SRPK1 altered various gene isoforms,

including BRD4 specific to mixed lineage

leukemia (MLL), rearranged AML. BRD4,

which is thought to be involved in antileukemogenesis,

is already a validated

drug target for leukemia. The study found

the effect of a specific agent SPHINX31 to

have a remarkable effect in the inhibition

of SRPK1. The effect on BRD4 isoform

suggests that it acts as a key mediator of

the anti-leukemic effects brought about

by SPHINX31. This was demonstrated

in immunocompromised mice by

transplanting the patient-derived

human MLL rearranged AML cells.

Treatment with SPHINX31 was shown to

prolong the survival of mice, which was

brought about by cell cycle arrest of the

leukemic cells without any noticeable

toxicity to healthy cells. The scientists

propose that inhibition of SRPK1 should

be investigated in the treatment of

other malignancies where BRD4 isoform

balance plays a role as in metastatic

breast cancer.

Source: Nature Communications volume 9, Article

number: 5378 (2018) https://www.nature.com/

articles/s41467-018-07620-0

—Compiled by Divya Choyikutty

JANUARY 2019 / FUTURE MEDICINE / 47


column

the cellview

Can India take AI road to

excellence in radiology?

To enable true implementation of AI in radiology, it is

important to develop a multi-stakeholder plan

DR RAJANI KANTH

VANGALA

The author is medical

scientist and former

director of SGRF,

Bangalore

Artificial intelligence (AI) has made

several strides in recent years, allowing

machines to interpret complex data

leading to advances like self-driving vehicles

to natural language processing.

AI is the much-needed tool to make

healthcare reach all segments in India as it

can reduce costs, improve reach and clinical

outcomes.

New applications like big data analysis in

DNA and RNA sequencing will help improve

healthcare and India’s computational

capabilities can certainly make it a hub

of AI in healthcare. Imaging in fields like

pathology, dermatology and ophthalmology

have already started benefiting through the

implementation of AI. The application of AI

in radiology is called radiomics, and it must

be prioritised in India due to the fact that we

have a skewed doctor-to-patient ratio and an

ever-growing population.

There is an urgent need to leverage

technology to face this huge task of adoption

of digital healthcare in day-to-day clinical

decision-making, which will make patient care

more affordable. By combining teleradiology

and AI in India, we can provide better

approaches in reaching out to rural areas.

According to a recent publication by CIS (The

Centre for Internet and Society), AI could

potentially add $957 billion (15% of current

gross value added) to the Indian economy by

2035.

One of the main obstacles in

implementing AI in Indian healthcare is not

technological, but related to data access.

Other obstacles include consent and ensuring

clean, uniform and digitized data. As hospitals

are typically only contact centres for illness,

and care is often delivered through multiple

physicians, it makes AI less penetrative

despite India being relatively data-dense.

Furthermore, even though India started

adopting electronic healthcare records

(EHR) policy, the same is not robust enough

and is in fact highly inconsistent and not

harmonized, leading to several difficulties.

Along with the above problems, radiologists

are overloaded with work and left with no

time to do research on incorporating AI

into their practice, which in turn results in

industries not having enough backing and

support from clinical practitioners. Another

aspect of the adoption of AI in radiology

is that startup companies are often forced

to show proof of concept in the form of

clinical trials/studies and this takes enormous

investments of both money and time. A

possible solution to this problem could be

for the industry to have strong collaborations

or partnerships with radiologists to perform

clinical trials and studies.

In order to enable true implementation

of AI in radiology, it is important to develop

a multi-stakeholder plan incorporating all

relevant sectors to formulate comprehensive

guidelines. It is also imperative to encourage

digitization and open data systems, and

set standards for data collection, privacy

and safety. This can encourage research

and development in AI applications, while

promoting public-private partnerships. India

is presently in a unique position to be in the

driver seat in radiomics and digital healthcare

in general with a flourishing startup

community and a realisation by clinicians,

scientists, policymakers and the general

population about the importance of AI. We

have joined the revolution of AI and will have

to clear each obstacle as we move forward.

This can be sustainable only with robust

skill development and the establishment of

an ecosystem of interdisciplinary research

continuum of AI in healthcare.

48 / FUTURE MEDICINE / JANUARY 2019


specialties

interventional radiology

SPEARHEAD OF

LESS-INVASIVE

MEDICINE?

Interventional radiology seeks to

maximize benefit through

quick and bloodless procedures

S HARACHAND

Interventional radiology (IR), which

is emerging as a subspecialty to

radiology, provides image-guided

interventions to diagnose and treat

diseases. Practitioners of the new

discipline see the specialty at the

spearhead of modern medicine,

providing maximum benefit to the

patient with minimal invasion.

“IRs are the real innovators in

medicine, because they have found

techniques to treat several tough-totreat

conditions,” says Dr Lijesh Kumar,

Consultant Interventional Radiologist,

PVS Memorial Hospital, Ernakulam.

“Many of the techniques practiced by

cardiologists or urologists are offshoots

of what IR discovered.” Making use of

imaging techniques such as X-rays, MRIs,

fluoroscopy, CT and ultrasounds, IRs

perform a broad range of diagnostic as

well as treatment procedures, including

taking organ biopsies and placing stents.

They can also treat tumours by inserting

tiny instruments and catheters into the

body via a percutaneous route. Since

images are used to guide the catheters

and instruments to the exact location

where the procedure or treatment is to

be performed, it obviates the need for

open or even keyhole surgery.

IR is an innovative field where

50 / FUTURE MEDICINE / JANUARY 2019


practitioners play multiple roles,

comments Dr Amar Mukund, Additional

Professor, Institute of Liver and Biliary

Sciences, Delhi. An IR specialist may be

able to block an internal bleeding simply

by putting a needle directly into the

bleeding site without an open surgery.

Similarly, there are cases tackled by IRs

where patients start bleeding postsurgery.

“In fact, IRs can help bridge

the gap in between... It is a subject that

helps all clinicians when they are in a

difficult situation where they can’t offer

anything,” he explains.

From inoperable to operable

Patients with certain liver conditions

are not good surgical candidates. If

surgery is done on such patients, there

IR IS A SUBJECT THAT HELPS

ALL CLINICIANS WHEN

THEY ARE IN A DIFFICULT

SITUATION WHERE THEY

CAN’T OFFER ANYTHING

is a high risk of complications. These

patients have to be treated either with

endoscopy or interventional radiology.

Again, in situations where a patient has

to undergo organ transplantation but

cannot do the surgery immediately, IRs

can offer him some treatment in the

interim so that he can buy time and plan

for the transplant.

Earlier, many patients had just one

option — surgery. Now, IR provides

multi-optional situations, prolonging the

quality time of the patient.

“Many a time, IRs can make an

inoperable patient operable,” says Dr

Hemant Patel, president-elect, Indian

Radiological & Imaging Association

(IRIA). “The role of IRs will increase day

by day.”

For patients referred by clinicians,

IRs do interventions on the brain,

interventions for the abdomen and for

peripheral arteries. Unlike earlier days

EMBOLISATION

AN INDISPENSABLE OPTION

Embolotherapy, which is used

for inoperable haemorrhage

or pre-operative management

of highly vascular neoplasms,

has become an indispensable

treatment option for a variety of

conditions and an integral part of

IR practice.

Radioembolisation or Selective

Internal Radiation Therapy (SIRT),

which combines embolisation

with radiation therapy, is an

endovascular treatment for

primary and secondary liver

tumours

Radioembolisation has

increasingly been considered as a

treatment modality in the West,

especially in Europe.

Data on the safety and

efficacy of this procedure for

the treatment of primary and

secondary liver tumours is

available.

In chemoembolsation,

chemotherapy along with

embolic agents are injected, in

combination, into the tumour.

Currently, the Cardiovascular

and Interventional Radiological

Society of Europe (CIRSE) is

conducting a Europe-wide,

prospective, observational study

to gather data on transarterial

chemoembolisation (TACE)

using LifePearl Microspheres

loaded with irinotecan (LP-IRI) in

colorectal cancer (CRC) patients

with liver metastatic disease.

Called CIREL (CIRSE Registry

for LifePearl Microspheres), it

is expected to provide more

data on the appropriate use of

drug-eluting beads (DEB-TACE)

loaded with the chemo agent

irinotecan (DEB-IRI), helping

avoid unnecessary standard

chemotherapy where possible.

Also, the study may bring in

evidence for applying TACE with

drug-eluting beads earlier in the

disease, besides giving some idea

about the potential indications to

treat patients with TACE.

Already, many clinicians in

the West have started to use

DEB-TACE with irinotecan to

treat metastatic liver tumours.

DEB-IRI is mainly considered as

a palliative option for patients

who have preserved liver function

and performance status with

unresectable chemotherapyresistant

lesions, liver metastases,

beyond second-line treatment.

IRs expect that DEB-TACE

has a substantial potential to

become a standard treatment

in metastatic colorectal cancer

(mCRC), as well.

JANUARY 2019 / FUTURE MEDICINE / 51


when catheters were the mainstay of

interventional procedures, IRs currently

employ a variety of devices and

techniques to tackle complex anatomies

like the brain. IR itself is getting further

diversified into subspecialties focusing

on areas like the brain or abdomen

exclusively.

IR, presently, allows procedures

including angioplasty, endovascular

aneurysm repair, embolisations,

ablations, biliary intervention,

placement of central venous catheters,

nephrostomy, pleural aspiration and

vertebroplasty. The list of indications

is likely to expand with advances in

technology.

In situations where a patient is

contraindicated for a surgical procedure

due to a highly complicated condition,

the intervention by an IR can often make

a dramatic difference.

Even though percutaneous

interventions usually represent a safer

approach compared with traditional

surgical alternatives, IR procedures

can lead to iatrogenic interventional

complications. Inadvertent injury to

blood vessels represents one of the

most common among them. Such

complications can range from minor to

catastrophic.

Biopsy to

diagnose cancer

• Angioplasty and stent

insertion

• Ascitic tap

• Biliary drainage

• Bursal injection

• Carotid stenting

• Carpal tunnel ultrasound

and injection

• Image-guided cervical

nerve root sleeve

corticosteroid injection

• Image-guided liver biopsy

• Image-guided lumbar

epidural corticosteroid

COMMON IR PROCEDURES

Treatment of

Primary Tumors

injection

• Image-guided lumbar

nerve root sleeve injection

• Nephrostomy

• Pleural aspiration

• Radiofrequency ablation

• Radioembolisation

• Cryoablation

• Joint injection

• Thyroid fine needle

aspiration (FNA)

• Inferior vena cava filters

• Uterine fibroid

embolisation

Treatment of

symptoms such as

pain, infection of

swelling caused from

spread of cancer

Placement of devices

such as catheters,

feeding tubes and

ports to deliver

medications

• Varicose vein ablation

• Vascular closure devices

• Venous access

• Vertebroplasty

• Subarachnoid

hemorrhage vasospasm

endovascular treatment

• Selective internal radiation

therapy (SIRT)

• Spinal cord embolisation

(AVM/DAVF)

• Transarterial

chemoembolisation (TACE)

ABLATING

UNRESECTABLE

TUMOURS

RFA is more effective than any

other modality for

unresectable liver cancer

Radio Frequency Ablation (RFA)

has been found highly useful in

liver tumours. With the help of this

outpatient procedure, clinicians can

change the inoperable status of a

patient to operable in many cases.

Its effectiveness, however, greatly

depends upon the size of the growth.

“The size of the liver tumour is an

important determining criterion as far

the outcome of RFA is concerned,’’

said Dr S Kalpana, Professor at Barnard

Institute of Radiology, Chennai, making

a presentation titled “RFA for Liver

Tumours” at the recent TNPY IRIA,

at Chennai. According to her, RFA is

a safe, cost-effective and promising

option for recurrent, unresectable

hepatocellular carcinoma (HCC). The

procedure is more effective than other

modalities in HCC.

Microwave tumour ablation

provides a potentially curative

treatment option for various

neoplasms. Tried and tested for over

15 years, the safety and efficacy of

colorectal liver metastasis (CRLM)

ablation has been demonstrated in

52 / FUTURE MEDICINE / JANUARY 2019


Lacking in awareness;

dearth of expertise

Radiology is not restricted to simple

diagnostic tests anymore. It has become

more complex. Today, a CT of the

abdomen can be done in a hundred

different ways, opines Dr Rajendran

Vilvendhan, Section Chief, Interventional

Radiology, University of Boston, USA.

In US hospitals, IR is an integral part

of healthcare delivery. “If IR is taken

out of the Boston hospital, the hospital

will collapse,” points out Dr Vilvendhan.

It is part of the “decision tree”. The

intervention of an IR expert helps make

a risky emergency surgery into elective

surgery. This happens only when there

is a multi-disciplinary approach. In India,

such practices are not common. There

is no protocol. Patients go to different

doctors and hospitals. There are so

many small hospitals and many scanning

centres. Scanning is a lot cheaper here.

The clinicians, on the other hand, are

also very “protective” of their patients.

They don’t want to lose patients and

revenue.

IR is also highly capital-intensive.

Most of the hospitals in India are not

equipped with IR departments because

of the high cost of the devices. Lack

of expertise is another impeding

If IR is taken out of

the Boston hospital,

the hospital will

collapse.

Dr Rajendran

Vilvendhan

Section Chief

Interventional Radiology

University of Boston, USA

factor. Currently, the country has only

a handful of well-trained IR experts. It

is not the technology, but the humans

that are doing the actual job. So,

there’s no point in having technology

without trained human resources to

make use of it. Human capital is more

important than technology, observes Dr

Vilvendhan.

It is a fact that India is lacking in

experts who can impart training in

IR, concurs Dr Gireesh Warawdekar,

Consultant Interventional Radiologist,

Mumbai. A lot of modalities are

available in bigger cities. However,

there’s a lacuna as far as smaller cities

are concerned. “IR is the way to go. The

more IR experts are available, the better

the results for the patients. It is not

going to replace any other specialty,”

he adds.

Despite the huge promise imageguided

treatment interventions hold,

the availability of such treatment

facilities poses an issue. The awareness

about IR is still relatively low in many

regions of the world. Not just the

public, but many family physicians and

specialist physicians do not know the

capabilities of IR and that there are

many IR procedures available to help

their respective patients.

randomised trials.

The use of microwave technology

can improve liver ablation outcomes. -

IR has minimally invasive solutions

to many of the conditions affecting

the kidneys, said Dr Mukuntharajan,

head, Department of Imaging and

Interventional Radiology, Meenakshi

Mission Hospital & Research Centre

at Madurai, deliberating on the topic

“Renal Interventions” at TNPY IRIA

meet.

Ablation treatment of lung

tumours as an alternative to surgery

and radiation treatment is growing in

acceptance.

Similarly, the treatment of

metastatic pulmonary disease has

demonstrated good treatment

outcomes. Oligometastatic treatment

is also a developing option for some

patients with metastatic renal cancer

and prostate cancer.

Advanced interventional MRbased

ablation is being tried on an

experimental basis for new indications,

including focally recurrent prostate

cancer and for vascular malformation

treatment, according to CIRSE.

In hepatic cell carcinoma (HCC), an

approach combining immunotherapy

with local ablative treatments is being

evaluated currently.

However, large-scale studies are

still needed to establish the safety of

microwave ablation therapy.

JANUARY 2019 / FUTURE MEDICINE / 53


slug

Creation of awareness about IR

becomes the top priority among

the practitioners of this emerging

subspecialty. “We want the radiologist

to take up interventional radiology

and spread the message that IR can

really be helpful in a lot of places that

people are not aware of,” says Dr Lijesh

Kumar. The need to create awareness

is especially greater in changing

disease scenarios. There has been an

exponential rise in liver diseases owing

to lifestyle changes.

Towards longitudinal care

Further, there is a need for a proper

referral system like multi-disciplinary

board meetings in hospitals. Experts

from various specialties should sit

together to decide what is the best

treatment course to be followed for a

patient, says Dr Amar Mukund. Multidisciplinary

decision making, which

is common in oncological settings, is

the need of the hour, because all the

specialists may not always know what is

happening in other fields. ”So, if we sit

together, we’ll be able to narrow down

on the best tailor-made approach to the

patient. Probably in difficult situations,

we may give options that surgical

therapy is better in a certain case, or we

What surgery,

laparoscopy and

endoscopy cannot

do, can be done by

interventional

radiology. The

problem we face

with IR is the lack of

big infrastructure

and more trained

personnel.

Dr T S Chandrashekar

Gastroenterologist and

Founder Chairman

Medindia Hospitals

Chennai

may feel that neither surgical nor IR is

needed, only medicinal therapy will do,”

he explains.

Indications are that things are

gradually moving toward that direction,

believe many IR experts. “There’s a

slow shift towards a group interactive

approach,” argues Dr Mukunthan, “and

we [radiologists] need to become

clinical radiologists rather than [imaging]

radiologists.”

As a safe, quick, cost-effective and

less invasive solution in many clinical

conditions, IR holds much promise for

the future. As awareness grows, IR

technology should be accepted as a part

of the clinical management workflow.

Furthermore, IRs are globally

becoming more clinical, providing a

longitudinal care model by seeing

patients in the clinic before and after

procedures to ensure that proper

treatment has occurred. This model

will provide more momentum to the

subspecialty to emerge as a leader in

the future.

IR clinicians feel that the technology

will grow faster in the future, and that its

presence should have more impact in the

practice of medicine going forward.

—With inputs from Divya Choyikutty, Kochi

54 / FUTURE MEDICINE / JANUARY 2019


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hospital news

Radiant Life buys majority stake in Max Healthcare

Radiant Life Care Private Limited, an

Indian hospital management company

promoted by Abhay Soi and backed by

global investment firm KKR, will acquire a

majority stake in Max Healthcare Institute

Limited.

The acquisition will be undertaken

through a series of transactions, including

Radiant’s purchase of a 49.7% stake in

Max Healthcare from South Africa-based

hospital operator Life Healthcare in an

all-cash deal, followed by the demerger

of Radiant’s healthcare assets into Max

Healthcare, the company said in a press

release.

The merged entity will operate over

3,200 beds throughout 16 hospitals

across India, including tertiary and

quaternary care facilities offering high end

critical and super specialty care supported

by local brands such as BLK Hospital,

Max Saket Hospital, Max Smart Hospital,

Max Patparganj Hospital, and Nanavati

Hospital.

“Radiant has achieved significant

growth and expansion during a time of

rapid industry consolidation, and the

proposed acquisition of a majority stake

in Max Healthcare marks an exciting

step forward in our strategy to increase

scale by merging with a leading and

complementary hospital network,” said

Abhay Soi, chairman and managing

director of Radiant. Soi will lead the

combined company as its chairman.

With an equity valuation of INR 7,242

crores, the combination of Radiant and

Max Healthcare is expected to create the

largest hospital network in North India,

which will become among the top three

hospital networks in India by revenue

and the fourth largest in India in terms of

operating beds, according to the release.

Portea to deliver critical care at home

Portea Medical, a home healthcare

firm, has expanded its services to

include a range of specialized home

care.

Called Portea Intensive &

Specialized Care, the offerings include

critical care at home, respiratory

services such as home ventilation,

sleep apnoea care, palliative care,

cancer support services, post-trauma/

accident care, and specialized rehab

services including pulmonary, neuro,

and cardiac rehabilitation and speech

therapy. The suite of services also

includes end of life care for terminally ill

patients.

Portea has currently introduced

these services in Delhi NCR, Mumbai,

Pune, Bengaluru, Kolkata, Hyderabad

and Chennai. All the services will be

backed by Portea’s connected care

platform, making remote monitoring

possible and driving availability of

hospital-like care at home.

Portea also plans to include

home haemodialysis and home

chemotherapy; and remote

monitoring and management of

chronic diseases.

Portea’s Critical Care encompasses

customized care plans in consultation

with the treating physician; detailed

clinical assessment of the patient;

regular clinical audits; presence of

highly trained and expert ICU care

providers; remote patient support/

monitoring; and 24x7 clinical

supervision by ICU doctors.

Texila and Yashoda

to offer cardiology

programme

Texila American University (TAU), a

provider of medical education, has

joined hands with Yashoda Hospital &

Research Centre, Ghaziabad to launch a

fellowship programme in non-invasive

cardiology in India.

Non-invasive cardiology involves the

detection and treatment of heart disease,

using external tests.

Yashoda Hospital will introduce the

fellowship programme in non- invasive

cardiology. As a specialisation, noninvasive

cardiology is much in demand

across the globe as heart-related ailment

have increased many- folds.

According to recent statistics, on

an average, a non-invasive cardiologist

receives about 25-30 patients per day, said

Saju Bhaskar, founder and president, Texila

American University.

56 / FUTURE MEDICINE / JANUARY 2019


hospital news

WORST OVER FOR

HOSPITAL SECTOR: ICRA

Regulatory pressure impacted Indian hospitals in 2017,

but worst likely over, says rating agency

The hospital industry in the country

has seen its muted performance,

which started in 2017, continuing

through the quarter ended September

owing to pressure from regulatory

actions by both the centre and the

states, said a report by the credit rating

agency ICRA.

However, the impact of these

factors has likely peaked and conditions

can only improve going forward in

the absence of additional regulatory

setbacks.

ICRA’s sample set of hospital

operators - Apollo Hospitals Enterprise

Limited, Fortis Healthcare Limited,

Narayana Hrudayalaya Limited,

Healthcare Global Enterprises Limited,

Max India Limited and Shalby Limited -

reported a seven percent year-on-year

drop in its earnings before interest, tax,

depreciation and amortisation (EBITDA)

to Rs 516-crore in Q2 FY2019 from Rs

556-crore in Q2 FY2018. Operating

margin declined from 15% to 13.3%,

while aggregate revenue grew by 5%

to Rs 3,889 crore. This is in line with

the subdued performance in FY2018,

a year that witnessed the first fall in

aggregate EBITDA of the sample set

in over six years. The year also saw

operating profitability hitting a multiyear

low, dropping to 11.4% in FY2018

from a peak profitability of 15.7%

during the six-year period.

DECLINING MARGINS

Leading hospitals reported a seven

percent year-on-year drop in their

earnings

₹556

crore

₹516

crore

GST impact

The hospital sector has been

witnessing a decline in performance

since the beginning of 2017 due to

Q2 FY2018

Q2 FY2019

58 / FUTURE MEDICINE / JANUARY 2019


several factors that have adversely

affected profitability. These include

the implementation of the Goods and

Services Tax (GST), after which there

was a hike in the indirect tax rate on

services. GST on certain medical inputs

has adversely impacted the hospitals,

since hospitals could not claim input

credits because they are exempt

from GST. Also, they could not do

commensurate tariff increases to offset

the full impact of higher tax burden,

which impacted margins, as per ICRA

report.

Other factors that impacted the

sector include the cap on prices of

stents and knee implants by the

National Pharmaceutical Pricing

BEDS vs OCCUPANCY

The aggregate number of

operational beds has gone

up but occupancy level has

dropped.

20,665

21,551

Beds

65.6% 63.9%

Occupancy

Q2 FY2018

Q2 FY2019

GST ON CERTAIN MEDICAL

INPUTS HAS ADVERSELY

IMPACTED THE HOSPITALS,

SINCE HOSPITALS COULD

NOT CLAIM INPUT

CREDITS THEY ARE

EXEMPT FROM GST

Authority (NPPA) and stiff regulatory

action by certain states, including

restrictions on procedure rates and the

imposition of penalties and operational

limitations on erring hospitals. Owing

to these factors, the Average Revenue

Per Occupied Bed (ARPOB) of the

sample set of hospitals has grown by

a muted two per cent in the second

quarter of the financial year on a yearover-year

basis,well below the fiveyear

compounded annual growth rate

(CAGR) of around 7.2%. The intense

competition in some of the key markets

of operations of these players has also

resulted in sub-optimal operating and

financial parameters.

On account of the increase in debt,

the rise in financial expenses and the

pressure on operating margins, the

interest coverage ratio of the hospitals

under study has dropped from 2.79

times in the first half of financial year

2017-18 to 2.05 times in the same

period of year 2018-19. The net

debt/EBITDA of these hospitals

has jumped from 2.78 times as on

September 30, 2017 to 3.14 times

during the same quarter this year. The

aggregate debt coverage indicators of

these companies include the impact

of non-hospital businesses as well,

such as standalone pharmacies and

diagnostics services, which have fared

much better.

Outlook good in long run

The regulatory environment continues

to be a challenge for the hospital

sector, as wide-ranging regulatory

restrictions from multiple authorities

continue to suppress the ARPOB of

the players. This has had its impact

during the quarter, resulting in a subpar

growth in ARPOB and a drop in the

profit margin.

“The aggregate number of

operational beds has gone up by

4% from 20,665 beds in Q2 FY2018

to 21,551 beds in Q2 FY2019, but

the aggregate occupancy level has

dropped during this period, from

65.6% to 63.9%. This is due to capacity

expansion, the recalibration of the

payee-mix and the specialty-mix at

some of the facilities and a sharp drop

in occupancy rates at one of the largest

players due to internal challenges,

including corporate governance and

liquidity issues. Consequently, the

occupied bed nights grew by a modest

2%,” Shubham Jain, Group Head and

Vice President, ICRA said.

However, Jain added, the impact of

these factors has likely peaked and if

there are no additional measures, the

worst is behind for the sector. Besides,

the significant capex in the last four

years will start showing marked results

going forward and start-up costs of

new hospitals will be much lower.

Structurally, in the long term, underlying

fundamentals continue to favour the

sector, he added. This is because of

the significant shortage of beds in the

country, the increase in disease burden

and an ageing demographic profile. The

demand for quality healthcare will be

supported by rising per capita income,

increasing penetration of medical

insurance and double-digit growth in

medical tourism, ICRA added.

JANUARY 2019 / FUTURE MEDICINE / 59


orthopaedics

ADVANCED

ORTHO IMAGING

Newer imaging modalities are set to transform

the management of skeletal diseases

DR VINOD KUMAR B P

X-rays revolutionized orthopedic

management in fundamental

ways, especially in the diagnosis

of conditions and their management.

However, there are limitations to

X-rays that have paved the way for the

further advancements in this field.

An analysis of the limitations

reveals that X-rays cannot visualise

cartilages, occult fractures and stress

fractures. Also, early detection of

osteomyelitis, tumours with marrow

involvement and micrometastasis or

soft tissue component are not possible.

Many hospitals nowadays

utilise PACS (Picture Archival and

Communicating System). PACS is an

imaging technology which transmits

images and reports digitally in the

universal format DICOM (Digital

Imaging and Communications in

Medicine). The major components of

PACS include the imaging modalities

THE MAJOR COMPONENTS

OF PACS INCLUDE THE

IMAGING MODALITIES

A SECURED NETWORK

AND WORKSTATIONS FOR

INTERPRETING THE IMAGES

(like X-ray, CT, MRI), a secured network,

and workstations for interpreting the

images, and archives for the storage

and retrieval of images and reports.

The system offers some major benefits.

A soft copy of X-ray films replaces the

costlier hard copy film. In teleradiology

and telediagnosis, it facilitates the

effective and efficient management

of various medical conditions. It

also allows for electronic image

integration with Hospital Information

System, Radiology Information

System, Electronic Medical Record,

thus enabling a seamless flow of

information across the system.

MRIs for occult fractures

Since the development of MRI back

60 / FUTURE MEDICINE / JANUARY 2019


RECONSTRUCTION CT IN PREOPERATIVE PLANNING

A CT, particularly a 3D reconstruction CT, is helpful in determining the number

of fracture lines and their orientation, fragments, displacements, rotation,

impaction and incarcerated fragments, particularly in the hip joint. This

information makes the CT very helpful in pre-operative planning.

The advantages of reconstruction CT can be illustrated with the help of

a few case reports.

1

2

3

CASE 1: ELBOW INJURY TRIAD

A 64-year-old lady presented in our out-patient clinic with an unexplained left

elbow pain. She had a history of fall at her work place 5 years back. Now, she has

sustained another fall at her home. The case is referred from a local hospital. Note

that a proper diagnosis is clearly not possible from the ordinary X-ray (Pic 1 & 2).

The reconstruction CT (Pic 3) clearly shows a displaced fracture head of radius and

a small fracture of coronoid process of ulna, a terrible triad of elbow injury.

in the 1970s, it has become the

best choice for diagnostic medicine

and biomedical research. With

rapid advancements in this imaging

technique, it has become the 1st choice

in detecting occult fractures, stress

fractures, osteomyelitis, tumours with

marrow involvement, micrometastasis

or soft tissue component. MRI studies

are useful in evaluating the internal

structure and surface of the meniscus,

peripheral and inferior surface tears of

the meniscus and multiple tears. MRI

should be done in every patient of

suspected ligamentous injury posted

for arthroscopy to prevent unwanted

arthroscopies. Many anatomic variants

can erroneously look like tears on

MRI. MRIs are always advised before

1 2

3

CASE 2: TRANS SCAPHOID PERI LUNAR DISLOCATION

A case of trans-scaphoid peri lunar dislocation in a 32 years old man sustained

following fall from bike at home.

Pic 1: Digital X-ray. Pic 2 & 3: 3D CT where the fracture scaphoid and orientation

of kunate are clearly visualised. Pic 4: Open reduction and internal fixation with

K-wire.

JANUARY 2019 / FUTURE MEDICINE / 61


slug

CASE 3: SUBTALAR ARTHRITIS

Digitalised X-ray showing joints more accurately.

Ordinary X-ray showing joints around foot and ankle.

3D reconstruction CT showing the fracture orientation which helps the

surgeon to do subtalar arthrodesis.

Subtalar arthrodesis for subtalar arthritis when the person

presented with severe pain and not able to walk.

surgery or biopsy, because it reveals the

extent of a tumour better than X- ray.

For example, in enchondroma, X-rays

may not appreciate the involvement

of the shaft fully. Surgery based on

X-rays alone would not be adequate.

Contrast in MRI is used to identify

cystic or necrotic areas from where we

do not take a representative biopsy;

viable areas appear bright. Contrast

can also help to differentiate between

edema and a tumour, as the latter

takes contrast intensely. A dynamic

contrast MRI can also be used to assess

the response to treatment given. It

IN DICOM FORMAT, WE

CAN TAKE MEASUREMENTS

TO PLAN THE SURGERIES,

PARTICULARLY LIMB

SALVAGE PROCEDURES

is always advisable to get a scale for

measurement while doing CT. In DICOM

format, we can take measurements

to plan the surgeries, particularly limb

salvage procedures.

Orthopedicians experience great

challenge in interpreting the MRI of

people with implants in situ. With

newer MRI sequences with MARS

(Metal Artifact Reducing Sequences),

this traditional problem of imaging

can be overcome. MAVRIC (Multi

Acquisition Variable Resonance Image

Combination) and SEMAC (Slice

Encoding for Metal Artifact Correction)

and the use of materials that produce

less artifacts, like titanium, have

overcome the limitations of MRI to a

certain extent. Interventional radiology,

62 / FUTURE MEDICINE / JANUARY 2019


CASE 4: TEMPLATING BEFORE TOTAL

HIP REPLACEMENT

The complications that can arise while performing

total hip replacement are:

1. Femoral neck fracture 2. Limb length

discrepancies 3. Instability 4. Offset abnormalities 5.

Failure in bone in-growth.

These can be prevented by proper pre-operative

planning which include templating. The method of

templating involves combining the use of digital

radiographs and standard acetate templates.

CASE 5: ACETABULAR FRACTURES

Most of the acetabular fractures can be identified by AP and Judet view

X-rays (Pic 1). But the reconstruction views help a lot to get fracture

orientation beautifully.

Acetabular fracture direction, orientation and displacements are well

explained in reconstruction CT (Pic 2 & Pic 3). Treated with open reduction

and internal fixation with plates and screws (Pic 4).

1

2

4

3

like RFA (Radiofrequency ablation),

is used to treat osteoid osteoma,

metastasis etc.

PET choice

When F18 Fluro Deoxy Glucose is

injected into a patient, a PET (Positron

Emission Tomography) scanner can form

a 2D or 3D image of its distribution in

the whole body. Its uptake is analysed

by SUV (Standard Uptake Value). PET

can be utilized for diagnosing Hodgkin’s

disease, Non-Hodgkin’s lymphoma,

colorectal cancer, breast cancer,

melanoma, lung cancer and Alzheimer’s

disease. PET provides functional

information of tissue metabolism,

helping in initial evaluation and to

measure the response to treatment.

PET, CT/MRI combines functional

and spatial resolution. PET-CT is more

useful than a bone scan as it can

identify primary and is more specific

for tumour cells. But it has its own

limitations when it comes to osteoblastic

lesions, which have limited uptake on

PET, and a bone scan may be more

appropriate in such cases. A Tc-labelled

bone scan can pick up osteoblastic

activity; methylene diphosphonate is

taken up by osteoblasts on scanning

the whole skeleton. However, in multiple

metastases, a PET scan is the first choice.

Similarly, ultrasound-guided

biopsy and CT-guided biopsy have

revolutionized the ease of diagnosis

even in a routine set up.

The author is additional

professor in Orthopedics,

Govt. Medical College,

Kollam, India.

JANUARY 2019 / FUTURE MEDICINE / 63


diagnostics

METROPOLIS

LAUNCHES

HISTOXPERT TO

ADVANCE TISSUE

DIAGNOSTICS

A dedicated histopathology lab service for

providing tailor-made services to hospitals

India’s leading diagnostic chain

Metropolis Healthcare Ltd has

launched a unique subsidiary—

Metropolis HistoXpert Digital Services

(P) Ltd, to offer advanced tissue

investigation services in India. The

new unit, which will collaborate with

hospitals across the country to provide

integrated services with more subspecialties

and digital pathology,

was formed on the concept of reflex

testing. This helps avoiding the hassle

of having to order more tests to reach

a final diagnosis.

HistoXpert will leverage Metropolis’

existing capabilities of a highly skilled

team and a panel of sub-specialty

experts to provide these services

using latest technologies such as

pathology slide scanner, image

management system and a display.

This diagnostic solution is also

complemented by software tools

to manage the scanning, storage,

presentation, reviewing and sharing

of information to enable a complete

digital work flow.

The concept of a dedicated

PHOTO: UMESH GOSWAMI

“HistoXpert model will

make better commercial

sense for users”

AMEERA SHAH

Managing director, Metropolis Healthcare

What prompted you to come up with this concept?

Metropolis, as a company, has always believed in constantly

focusing on innovative models that can benefit both the

patients as well as the organisation. That has made us different

in an industry that has been stodgy and traditional. But now,

healthcare industry is witnessing vibrancy both in India and

internationally. While it is in terms of accessibility and

affordability in India, technology is the main driver

internationally. I am sure, in another five years’ time,

technology is going to change the full paradigm of

healthcare globally. So, our basic idea was to adopt

innovative business models to see how we can

combine these changes in medicine, science and

technology to meet the healthcare needs in India,

64 / FUTURE MEDICINE / JANUARY 2019


histopathology lab service for

providing tailor-made services to

hospitals is being introduced for the

first time in India. It helps even smaller

hospitals avail the whole series of

tests irrespective of the volume that

they get, without maintaining such

large infrastructure and huge panel of

experts.

“We at Metropolis understand that

running an in-house histopathology set

up is not a viable option for hospitals

with less than 500-600 samples

a month. Therefore, Metropolis

HistoXpert is our end to end

automated processing and digitization

solutions to all hospitals,” says Sanjeev

Nair, chief executive officer, Metropolis

HistoXpert, in an interview with Future

Medicine.

At the same time, it is necessary

for every hospital to maintain a

complete and accurate pathology

report for getting a precise diagnosis

and deciding on the best treatment

plan for the patient, he added.

“And the other major innovation

that we are going introduce with

Sanjeev Nair, CEO, Metropolis HistoXpert

PHOTO: SANJAY BORADE

METROPOLIS UNDERSTANDS

THAT RUNNING AN

IN-HOUSE HISTOPATHOLOGY

SET UP IS NOT A VIABLE

OPTION FOR HOSPITALS

WITH LESS THAN 500-600

SAMPLES A MONTH

the launch of HistoXpert is digital

pathology, which marks a key

milestone for innovation in pathology.

This will also increase accuracy and

efficiency in patient care,” Sanjeev Nair

said.

With 106 clinical laboratories and

1,130 patient touch points, Metropolis

is currently one of the leading

diagnostic chains in India. Founded

by Dr Sushil Kanubhai Shah in 1980,

it offers a broad range of some

3,480 clinical laboratory tests and

524 profiles. Its systems and services

broadly include clinical research,

laboratory in hospital, lab on lease,

home collection services, preventive

health check-ups and corporate and

wellness solutions.

During the financial year 2018,

Metropolis conducted approximately

16.0 million tests from approximately

7.7 million patient visits. The global

reference laboratory is accredited by

the National Accreditation Board for

Testing and Calibration Laboratories

(NABL) and the College of American

Pathologists (CAP).

so that everything doesn’t have to be done in a traditional

way anymore. That’s really the mindset with which we are

approaching our entire business and HistoXpert is an

example of that, taking the sub-specialties up. And the

other thing is that histopathology has been quite a generalised

space, though in reality, every pathologist has been specialised

in their respective areas like lung biopsy, skin biopsy etc.

Since every aspect in medicine is now being focused as

specialised areas, it is time to give credence to this sub-specialty

as well and create opportunities to put the best people for the

best job.

How is it going to make a real impact to the user, means,

hospitals in India?

Although histopathology has been traditionally followed

as a diagnostics segment in the industry, for any individual

player or individual hospital, it has been largely a fragmented

market. Every hospital, even the big ones, will have a maximum

of 10 to 15 samples a day. When it happens at such small scale,

they can never afford to have the best technologies and the

best set of people. Thus, mostly everything is done in a very

substandard way. That’s why we thought: Let’s find a way

that we will be able to use technology in a centralised

manner by which we will be able to provide the best personal

service and better quality of reports and also leverage the

best technology. We believe that it will not only make better

commercial sense for the users, we will also be able to

maintain better quality in the reports and also help them

aspire to and move toward higher technologies. Going forward,

digitisation in histopathology will take the service to a much

higher level wherein many more subspecialties and specialists

from different parts of the world can also get connected for

better analysis of results. Integrated with Al kind of processes,

this will also enable crowd sourcing and large-scale analysis of

big data.

What is the service model that you are going to follow in

this? Will you have centres in your partner hospitals or make it

centralised?

We will have both models and it will be different for different

partners according to their requirement. In some cases, we will

just pick up the samples and bring it to our central lab and for

some we will digitise it and send it. We will have direct labs in

some hospitals and will pick up samples from a few others. Also,

we will actually have wet labs in some hospitals plus digitisation

and interpretation. So, we have created broadly three models

to make it flexible for us to be able to serve the needs of every

partner.

JANUARY 2019 / FUTURE MEDICINE / 65


column

trialomics

Evidence-based herbal

medicines

The path of developing a modern drug from herbal therapy

is long and arduous

DR ARUN BHATT

Writer is a consultant

on clinical research &

development from

Mumbai

arun_dbhatt@hotmail.com

Globally, herbal medicine has become a

popular therapy. Many modern drugs,

e.g. aspirin or anticancer paclitaxel

and vinblastine, are derived from plants.

Nevertheless, the path of developing a modern

drug from herbal therapy is long and arduous.

The alternative of generating clinical evidence

through the conduct of randomized placebocontrolled

trials is also fraught with scientific

challenges, some of which are discussed here.

Selection of herbal medicine: In traditional

practice, many herbs are used for one

indication and each herb has multiple uses.

This is compounded by 2 plant species having

the same name e.g. Bacopa monnieri and

Centella asiatica are both called Brahmi. Many

herbal medicines in practice are a mixture of

multiple plants. Choosing such a polyherbal

medicine for a clinical trial will make design

and quality control complex and demanding.

Herbal medicines with long documentation of

safety in human use can undergo pilot clinical

trials in a small number of subjects, without

undergoing pre-clinical animal studies.

Preparation of herbal extract: Hot water

extracts of Artemisia annua – the plant

containing artemisinin – were ineffective

against mice infected with malarial parasite.

But cold ethereal extracts were active. Hence

preparation of the herbal formulation of an

active aqueous or ethanol extract is a must

before initiating a clinical trial.

Deciding dose: Traditional textbooks

recommend the use of the fresh plant in high

doses – grams. However, the herbal medicine

formulations are extracts of the whole plant.

The relationship between these doses may be

difficult to establish. Phase 2 proof-of-concept

studies using biomarker-based efficacy

endpoints would be useful in dose searching.

Placebo control: Some herbs have a distinct

taste, odour and appearance, which makes the

creation of matching placebo difficult. In such

situations, bias could be reduced by blinding

the assessor and having endpoints which are

objective.

Duration of treatment: A short-term trial for

a chronic indication e.g., rheumatoid arthritis,

cannot be conclusive for long-term benefits.

Duration of clinical trials in such conditions

could be 12-24 weeks, to obtain meaningful

conclusions.

Safety issues: Herbal medicines are usually

considered safer than synthetic drugs.

But there are reports of serious adverse

drug reactions e.g. hepatotoxicity of kava,

nephrotoxicity of plants containing aristolochic

acid and adverse drug interactions, e.g.

increase clotting time with garlic in patients

on warfarin. Hence the assessment of safety

by recording adverse events, frequent clinical

examination and laboratory tests should be

included in the clinical trial.

Quality control: For the safe and effective use

of herbal drugs, quality control is essential to

ensure consistency in composition and biologic

activity and the reduction of contamination

and adulteration with toxic metals,

microorganisms, microbial toxins, pesticides

and fumigation agents. Hence, before

initiating clinical trials, quality specifications

and tests should be available for raw herb,

the formulation process for extraction and

the subsequent fractionation and purification,

as well as the manufacturing process. The

formulation should be stable for the duration

of the clinical trial.

If herbal drugs have to compete and

complement modern drugs, the herbal

industry and medical experts should

collaborate to develop robust evidence, based

on randomized controlled clinical trials.

66 / FUTURE MEDICINE / JANUARY 2019


drug delivery

NEUROGLIA AS TARGETS

Non-neuronal cells can be targeted for effective drug delivery to the brain even

though reaching out to them remains a challenge

One of the major challenges in the

treatment of neuropathological

conditions is getting the drug

molecule to cross the blood-brain

barrier. The second challenge is getting

the drug to work only on the tissue/

cells that are affected. With the advent

of targeted drug delivery systems,

much attention has been given on the

subject of specifically targeting neurons.

Though targeting neurons is essential, it

is now becoming clear that therapeutic

targeting of the non-neuronal glial cells

(neuroglia) in the brain might also have

important clinical benefits. Neuroglia

encompass the non-neuronal cells in

the brain, and have been shown to

play major pathophysiological roles

in almost all neurological disorders. In

an article published in February 2017,

Madhusudanan et al. review the current

literature in “Neuroglia as targets

for drug delivery systems: A review”.

Nanomedicine. 2017 Feb;13(2):667-

679.

Why neuroglia?

Glial cells were thought to hold the

nervous system together, forming the

matrix that protects and facilitates

the functioning of neurons. The

word ‘glia’ means ‘glue’ in Greek and

thereby came the name ‘neuroglia’.

It was much later that different cell

types were identified within the neural

parenchyma. Considering their close

proximity to neurons, neuroglia are now

understood to be closely intertwined

with the functioning of neurons,

and consequently

involved in the

majority of neurological disorders.

Neuroglia include astrocytes,

oligodendrocytes, microglia, NG2-glia,

and ependymal cells in the central

nervous system, as well as Schwann

cells and satellite glial cells in the

peripheral nervous system.

Astrocytes are some of the most

studied neuroglial cells, and they

outnumber neurons 10 to 1. They are

NEUROGLIA HAVE

BEEN IMPLICATED IN

AMYOTROPHIC LATERAL

SCLEROSIS, ALZHEIMER’S

DISEASE, PARKINSON’S

DISEASE, STROKE AND

CEREBROVASCULAR

DISEASE

important for neurotransmitter reuptake

and recycling, and play a critical role

in mediating neuronal homeostasis.

Astrocytes also communicate with

the blood-brain barrier, releasing

various vasoactive mediators to

regulate cerebrovascular flow. They

have been implicated in amyotrophic

lateral sclerosis, Alzheimer’s disease,

Parkinson’s disease, stroke

and cerebrovascular

disease, as well as in epilepsy,

neuropathic pain and migraine.

Microglia are resident macrophages

that form the first line of defense

in the brain. They play critical

immunomodulatory roles in the CNS,

and are responsible for clearing

damaged cells and for active

communication between neurons and

surrounding glia. Activated microglia

are implicated in Alzheimer’s disease,

Parkinson’s disease, schizophrenia as

well as in neuroinflammation.

Oligodendrocytes are specialized

cells important for neuronal myelination

and production of trophic factors

important for neuronal function.

They are implicated in multiple

sclerosis, amyotrophic lateral sclerosis,

Alzheimer’s disease and Parkinson’s

disease. NG-2 cells, precursor cells for

oligodendrocytes, also share a close

relationship with neurons. They carry

Na+, K+ and Ca+ channels, in addition

to GABA and glutamate receptors.

However, they have not yet been fully

characterized and only a few studies

have been carried out for targeting

them.

In the peripheral nervous

system, the Schwann

Liposome

polymeric

nanoparticles

68 / FUTURE MEDICINE / JANUARY 2019


cells perform similar roles as the

CNS-resident oligodendrocytes. They

form the myelin sheath and provide

trophic support to the peripheral

axons. They have been implicated

in the onset and development of

peripheral nerve inflammatory diseases,

polyneuropathies and neuropathic pain

conditions.

Satellite glial cells wrap sensory

neurons present within the dorsal

root ganglion and become activated

upon injury. They have been implicated

in severe pain conditions. However,

their physiological roles are yet to be

completely elucidated.

Delivery approaches

Numerous drug delivery systems have

been studied extensively to deliver

different drugs targeting specific

affected areas in case of neurological

disorders. Drug delivery systems to

the brain present multiple challenges.

Such systems first need to cross the

blood-brain barrier. Strategies involving

modulation of vascular permeability,

increasing endothelial fenestration

and inducing selective uptake by brain

endothelial cells have been used.

The second challenge is selectively

delivering the drug in appropriate

concentrations and in a controlled

manner to the affected tissue or cells.

This is key to avoid adverse effects,

while enhancing drug effectiveness.

Microglia

NG-2 cells

Astrocytes

Oligodendrocytes

Schwann cell

Satellite cells

Metallic

nanoparticles

BLOOD-BRAIN

BARRIER

JANUARY 2019 / FUTURE MEDICINE / 69


Common strategies in this area involve

encapsulating the drug of interest in

slowly degrading polymeric matrices

and nanoparticles and attaching them

to specific proteins that will specifically

bind to certain cells. It is also key that

the drug delivery systems themselves

are not toxic to the cells. Several

systems have been shown to be taken

up by neuroglia and some can affect the

survival or functional capabilities of the

neuroglia. It is also known that microglia

sequester nanoparticles and prevent

them from reaching their target sites.

To understand the true benefits of drug

delivery systems, it is therefore essential

to perform extensive in vivo studies

in addition to starting with primary

in vitro studies. Polymeric systems,

nanoparticles and liposomes have been,

and continue to be, investigated in vitro

and in vivo as potential therapeutic

options for delivering proteins, drugs

and even siRNA.

Polymeric systems consisting of

polymeric matrices in the form of

microparticles and nanoparticles allow

for both encapsulating the drug as also

for their slow release. Biodegradable

matrices that can specifically target

non-neuronal cell types such as

astrocytes may offer a targeted

therapeutic option for neurological

disorders in which astrocytes have been

implicated. Polymers such as polylacticco-glycolic

acid (PLGA), poly(epsiloncaprolactone)

(PCL) and poly(L-lactic

acid) or PLLA have received regulatory

approval for use in humans, and are

being studied specifically for targeting

astrocytes. PLGA nanoparticles coated

with transferrin protein or bovine

serum albumin are shown to be nontoxic

to astrocytes. PCL and PLGA

microspheres can diminish astrocytic

response in acute traumatic brain

injury. Drugs such as tacrolimus FK506,

paclitaxel and resveratrol flavopiridol

have been attempted to be delivered to

astrocytes in this manner. Nimodipine,

along with PCL and polyethylene glycol

(PEG), has been delivered to microglial

cells to delay ischemic neurological

disorders. PEG and PCL polymersome

nanoparticles with an NGF-derived

peptide have been used to target

neurotrophin receptors on Schwann

cells and may be a potential therapeutic

option for schwannoma, which causes

deafness. Such biodegradable polymers

are likely to have fewer long-term

adverse effects. However, data is still

preliminary in this area.

Drugs can be bound to metallic

nanoparticles such as zinc oxide,

silver, gold or titanium nanoparticles

for creating effective drug delivery

systems. Zinc oxide nanoparticles have

been documented to be taken up

by astrocytes. They, however, cause

oxidative stress and dose-dependent

toxicity. On the other hand, silver

nanoparticles are better tolerated

POLYMERIC SYSTEMS,

NANOPARTICLES AND

LIPOSOMES HAVE BEEN

INVESTIGATED AS

POTENTIAL THERAPEUTIC

OPTIONS FOR DELIVERING

PROTEINS AND DRUGS

by astrocytes. Titanium dioxide

nanoparticles activate microglia to

become pro-inflammatory; silver, silicon

dioxide or iron oxide nanoparticles

have been reported to cause oxidative

stress and induce microglia to secrete

elevated pro-inflammatory cytokines like

TNF-α, IL-1β, and IL-6 that play a vital

role in inflammatory conditions leading

to neurological disorders. However, the

benefits of targeting microglia with

iron oxide nanoparticles have been

reported in imaging techniques for

detection by MRI, especially in case of

glioma. Likewise, they also accumulate

in Schwann cells and can be effectively

used for in vivo labeling and detected

via MRI. Iron oxide nanoparticles

conjugated to three neurotrophic

factors – β nerve growth factor (β NGF),

glial-cell derived factor (GDNF) and

basic fibroblast growth factor (FGF-2)

— have also been reported to promote

peripheral nerve regeneration as well as

myelination. Thus, metallic nanoparticles

have another beneficial role in imaging,

even though there are toxicity concerns

associated with using them as drug

delivery systems.

Liposomes are another category

of drug delivery systems that have

been used widely in attempts to

deliver therapeutic agents to nonneuronal

cells. They have been

used to downregulate certain

key functional pathways within

astrocytes. Liposomes made

ofdioleoylphosphatidylethanolamine/

cholesteryl hemisuccinate (DOPE/

CHEMS) have been used to deliver

antisense oligonucleotides against

sodium-myo-inositol co-transporter,

which is upregulated in bipolar diseases.

Liposomes containing sulfocerebroside,

a lipid derived from the myelin sheath,

have also shown promise for treating

demyelinating disorders, and those

made of phosphatidylserine and

phosphatidylcholine have been reported

to significantly decrease production

of amyloid β and IFN-γ-induced proinflammatory

cytokines and free radicals

in microglial cultures, with potential

to treat Alzheimer’s disease. Inhibiting

colony stimulating factor-1 receptor,

a surface protein found on microglia,

has been reported to reduce microglial

activation in an animal model of

Alzheimer’s disease.

Although promising in in vitro

experiments, a major challenge for

neuroglia-targeted therapy has been

crossing the blood-brain barrier in vivo,

and several of the above drug delivery

systems have not been successful in in

vivo studies and several strategies may

need to be combined for effectively

targeting cells within the central nervous

system. However, in vitro studies show

the proof of concept that neuroglia

can be specifically targeted, and once

targeted, may be used as an effective

treatment option for many neurological

disorders that cause inflammation and

oxidative stress to the local milieu.

70 / FUTURE MEDICINE / JANUARY 2019


guidelines

MAMMO NOT MUST FOR

WOMEN AGED 40-49 YEARS

There is a higher risk of potential harms, including over diagnosis,

says new Canadian guidline

72 / FUTURE MEDICINE / JANUARY 2019


The Canadian Task Force on

Preventive Health Care has released

an updated breast cancer screening

guideline placing emphasis on shared

decision-making between women and

their health care providers. This is meant

to support women to decide whether to

undergo screening or not based on their

own values and preferences.

In Canada, most women 50 years

and older who are not at elevated risk

are invited for mammography screening

for breast cancer and face a decision

about whether to participate, according

to Dr Ainsley Moore Vice-Chair of the

Task Force.

“A review conducted for this

guideline on women’s values and

preferences about breast cancer

screening suggests that many women

aged 40 to 49 years would choose not

to be screened if they were aware of

outcomes for their age group,” said Dr

Moore in a press release.

On the other hand, many women

aged 50 years and older would choose

BREAST CANCER SCREENING

USING MAMMOGRAMS MAY

ALSO LEADS TO KNOWN

HARMS INCLUDING

FALSE-POSITIVE RESULTS

to screen given the more favourable

balance of benefits and harms. Some

women of this age may choose not to be

screened based on their individual values

and preferences around the benefits and

harms of screening.

Breast cancer screening using

mammograms identifies breast cancer

earlier and leads to a reduction in the

risk of breast cancer mortality; however,

it also leads to known harms including

false-positive results, further testing

and possible breast biopsy, as well as

overdiagnosis resulting in unnecessary

treatment and potential associated

complications.

CANADIAN TASK FORCE GUIDELINES ON BREAST CANCER

RECOMMENDATIONS

While the Task Force has not changed

the direction of its recommendations

from its 2011 guideline, the new

guideline clarifies recommendations

as being conditional upon a woman’s

personal priorities around harms and

benefits of screening.

The most important harm of screening

is overdiagnosis which occurs when

a woman is diagnosed with ‘breast

cancer’ but cancer would not have

resulted in symptoms or harm in the

woman’s lifetime. However, since

doctors can’t tell which cancers will

progress and which will not, the

tendency is to treat them all. All cancer

treatments (e.g., chemotherapy,

radiation therapy, surgery) come with

serious harms.

The Task Force recommends against

screening women aged 40 to 49 years

old; the recommendation is conditional

on the relative value a woman places

on possible benefits and harms from

screening. In situations where women of

this age wish to be screened, they are

encouraged to discuss options with their

health care provider.

It recommends in favour of screening

women aged 50 to 74 years with

mammography every 2-3 years. The

decision to undergo screening is

conditional on the relative value that

a woman places on possible benefits

and harms from screening. Clinicians

are encouraged to engage in shared

decision-making to support women to

make an informed decision aligned with

their priorities.

EVIDENCE

Current evidence continues to show

a close balance between potential

benefits and harms of breast cancer

screening; this balance appears to be

less favourable for women under 50

years of age. Individual women may

differ in how they value these harms

and benefits.

For women aged 40 to 49 years who

are not at increased risk of breast

cancer, low-certainty evidence seems

to suggest a small reduction in the risk

of breast cancer death. On the other

hand, these women have a higher risk

of potential harms, including falsepositive

results, leading to further

testing, possible breast biopsy as well as

overdiagnosis resulting in unnecessary

treatment and associated complications.

For women aged 50 to 74 years who

are not at increased risk of breast

cancer, very low-certainty evidence

suggests a modest reduction in the risk

of breast cancer death. While potential

harms of screening are lower for

younger women, they remain a concern.

JANUARY 2019 / FUTURE MEDICINE / 73


The most recent evidence examined

by the Task Force continues to show a

close balance between these potential

benefits and harms.

The Guideline reflects the growing

importance of shared decision-making

between patients and physicians in

preventive health screening, especially

in situations like this where the balance

between potential benefits and harms is

not certain.

Meanwhile, screening is

recommended in women aged 50-74.

The Guideline, developed by the

Task Force, an independent body of

primary care and prevention experts, has

been published in the Canadian Medical

Association Journal (CMAJ).

Other screening modalities

The Task Force recommends not using

magnetic resonance imaging (MRI),

tomosynthesis or ultrasound to screen

for breast cancer in women not at

increased risk. (Strong recommendation;

no evidence)

THERE IS EVIDENCE THAT

PERFORMING BREAST

SELF-EXAMINATION HAS

NO IMPACT ON BREAST

CANCER MORTALITY

We recommend not performing

clinical breast examinations to

screen for breast cancer. (Conditional

recommendation; no evidence)

It recommends not advising women

to practice breast self-examination to

screen for breast cancer. (Conditional

recommendation; low-certainty

evidence)

There was an absence of evidence

on clinical outcomes of screening by

magnetic resonance imaging, ultrasound,

digital breast tomosynthesis or clinical

breast examination, and there was

evidence that performing breast selfexamination

has no impact on breast

cancer mortality.

However, the Task Force noted that

better-quality evidence is needed on the

impact of breast cancer screening for

women of all ages. Additional studies

on Canadian women’s values and

preferences for screening that are based

on accurate estimates of both benefits

and harms, conducted in a transparent

and easily comparable manner, would

help guide future recommendations.

This clinical practice guideline

has been endorsed by the Nurse

Practitioners’ Association of Canada

(NPAC).

The Canadian Task Force on

Preventive Health Care was established

to develop clinical practice guidelines

that support primary care providers

in delivering preventive health care.

The mandate of the Task Force is to

develop and disseminate clinical practice

guidelines for primary and preventive

care, based on a systematic analysis of

scientific evidence.

74 / FUTURE MEDICINE / JANUARY 2019


devices&gadgets

Sapien 3 Ultra for TAVR

gets US FDA nod

The latest generation Sapien 3 device

for transcatheter aortic valve

replacement (TAVR), Ultra, got clearance

from the US FDA, Edwards Lifesciences

announced.

The Ultra model comes in 20, 23

and 26 mm sizes. New features include

a heightened outer skirt to reduce

paravalvular leak as well as a new

delivery system and 14-French Axela

expandable sheath with an “on balloon”

design that makes valve alignment

unnecessary.

The device was cleared for use in

Europe in November last year for severe,

symptomatic aortic stenosis patients.

However, a patent dispute with CoreValve

maker Boston Scientific has prevented a

launch in Germany.

The prior generation of Sapien 3 device

was approved in 2015. The original Sapien

valve was first approved in 2011.

Hologic launches

TempSure

Surgical RF tech

in North America

Hologic, Inc has launched

TempSure Surgical RF

technology in North America.

The TempSure

radiofrequency (RF) platform

provides clinicians the ability

to perform both surgical

and non-surgical aesthetic

procedures across a variety of

specialties, on a single device.

TempSure Surgical

RF technology harnesses

a 300-watt and 4-MHz

radiofrequency platform that

enables precise incisions

with minimal lateral thermal

damage to the surrounding

tissues. The resulting highquality

coagulation lessens

sparking and charring during

procedures, which promotes

quicker recovery and better

healing for patients.

TempSure Surgical RF

technology includes a variety

of electrodes that integrate

seamlessly with the main

TempSure unit. In January

2018, Cynosure, a Hologic

arm, launched the TempSure

radiofrequency platform

with TempSure Envi, a device

for treating facial fine lines

and wrinkles, tightening

the skin through soft tissue

coagulation, and temporarily

reducing the appearance of

cellulite.

FFRangio for PCI

assessment gets

US FDA clearance

FFRangio System, a noninvasive

device for use

during percutaneous

coronary intervention (PCI)

assessment, received approval

in the US.

The FFRangio system

demonstrated accuracy versus

the invasive FFR wire in a

blinded comparative study,

FAST-FFR. The results of the

FAST-FFR pivotal study were

used to establish substantial

equivalence of the FFRangio

system.

The CathWorks FFRangio

System quickly and precisely

delivers the objective FFR

guidance needed to

optimize PCI therapy

decisions, said Cathworks in

a press release.

FFRangio is derived

from routine X-rays acquired

during a diagnostic angiogram

procedure, is non-invasive

and performed intraprocedurally

during coronary

76 / FUTURE MEDICINE / JANUARY 2019


angiography, eliminating

additional clinical risk, time

and cost associated with

invasive FFR.

FFRangio provides a 3D

reconstruction of the entire

coronary tree with FFR values

along each vessel.

LaparoGuard

to navigate

surgeries

Mariner Endosurgery’s

LaparoGuard Augmented

Surgical Navigation system

has been approved for use in

U.S. operating rooms.

LaparoGuard is an

augmented surgical navigation

system that enables surgeons

to annotate areas of 3D

safety zones during minimally

invasive procedures.

Similar to the headsup

display of a fighter jet,

LaparoGuard allows surgeons

to annotate areas of risk, and

then see 3D renderings of

surgeon-defined safety zones

as a heads-up, real-time

image overlay.

This information from

LaparoGuard is integrated

into the operating room’s

conventional visualization

equipment, and

LaparoGuard’s functionality

provides surgeons with

additional spatial awareness

information.

The navigation system

also provides continuous

tracking of multiple tools

throughout a procedure for

real-time location updates

within the abdominal cavity.

Siemens

launches mobile

C-arm for OR

Siemens Healthineers

has introduced Cios Fit,

a mobile C-arm designed

for operation room and

demanding multidisciplinary

environment, in India.

Cios Fit is designed to

help in improving quality

of care, achieve efficient

workflows, and profit from

high uptime, thereby reducing

avoidable costs, according to

a company release.

It is built for the tough

job in the operation room

(OR) where the equipment

needs to deliver high-quality

imaging, be simplified in its

Exablate Neuro receives CE mark

Exablate Neuro compatible

with Magnetom Skyra

and Prisma Fit scanners

from Siemens Healthineers

received CE mark. Exablate

Neuro uses focused ultrasound

for treatments deep within

the brain with no surgical

incisions. MR imaging provides

a complete anatomical

survey of the treatment area,

patient-specific planning and

real-time outcome monitoring

throughout the treatment.

The CE mark includes

approval for treatment

of medication-refractory

essential tremor, tremordominant

Parkinson’s

disease and neuropathic

pain. FDA approval for the

Exablate Neuro compatibility

with MRI scanners from

usage, and robust to last for

long.

With Cios Fit-powerful

imaging technology, the

surgeons are able to

maintain consistency with

crystal clear images of

anatomical structures,

implants, screws and

devices resulting in accurate

treatment.

Smart radiation dose

Siemens Healthineers to treat

medication-refractory essential

tremor was received on

October 1, 2018.

Clínica Universidad de

Navarra (CUN) in Pamplona,

Spain is the first institution in

Europe to successfully treat

management with dedicated

paediatric mode and

smart power management

for patients with diverse

needs ensure safety in

the OR.

Free movements with

380° C-arm angulation with

no need to lock it after each

movement simplifies the

entire process for the OR

team. Moreover, its small

footprint and lightweight

design ease the Door-to-Door

transfer for the OR staff.

Breakthrough

designation for

Hemopurifier

Aethlon Hemopurifier

for the treatment of

cancer has been granted

breakthrough device

designation from the US FDA.

The Hemopurifier is a first-inclass

technology designed for

the rapid depletion of cancerpromoting

exosomes and lifethreatening

viruses.

FDA’s Breakthrough

patients with Exablate Neuro

compatible with MRI scanners

from Siemens Healthineers.

CUN is a renowned academic

institution with a history of

innovative research and clinical

treatment for neurological

movement disorders.

78 / FUTURE MEDICINE / JANUARY 2019 JANUARY 2019 / FUTURE MEDICINE / 78


Device programme was

established under the 21st

Century Cures Act to facilitate

more rapid patient access to

breakthrough technologies

with the potential to

address life-threatening

disease conditions for which

no approved or cleared

treatment alternatives exist.

Aethlon has recently

demonstrated the ability of

the Hemopurifier to capture

exosomes underlying several

forms of cancer, including

breast, ovarian and metastatic

melanoma.

The Hemopurifier is a

single-use device indicated for

the treatment of individuals

with advanced or metastatic

cancer who are either

unresponsive to or intolerant

of the standard of care

therapy and with cancer types

in which exosomes have been

shown to participate in the

development or severity of

the disease, according to the

company.

Philips V60 Plus ventilator

receives CE mark

Philips V60 Plus

ventilator has received

CE mark approval, Royal

Philips announced.

The device integrates

non-invasive ventilation

(NIV) with high flow

therapy (HFT) in a single

device. Clinicians can

rapidly adjust therapies

around constantly

changing patient

conditions without having

to switch devices.

Designed for early

intervention in respiratory

failure, the V60 Plus

enables clinicians to

further enhance patient

outcomes with less invasive

respiratory care therapies,

while improving clinician

workflow and maximizing

equipment investments.

The complementary

modes in one device can

simplify both workflow and

device availability.

The V60 Plus has

received CE mark and is

available for sale in Europe,

and the US FDA 510k has

been submitted, according

to Philips.

India’s drug

regulator clears

Meril’s Myval

The Central Drugs Standard

Control Organization

(CDSCO), India’s top drug

regulator, has granted

approval for Myval-

Transcatheter Aortic Heart

Valve Replacement (TAVR)

technology from Meril Life

Sciences.

The device is the first

indigenously developed

and manufactured TAVR

technology.

Headquartered in Vapi,

Gujarat, the company received

approval for the Myval TAVR

technology on the basis of

successful results from clinical

study done in India.

With the launch, Meril Life

will become the first Indian

company to commercially

make this therapy available

in the country. The company

will soon bring the next

generation treatment modality

to thousands of patients

across the country and

globally, Meril said in a press

release.

Spiration valve to

treat emphysema

gets US nod

The US FDA approved

Spiration Valve System

(SVS) for the treatment

of severe emphysema, a

progressive form of Chronic

Obstructive Pulmonary

Disease (COPD), Olympus said.

Placed in targeted airways

of the lung during a short

bronchoscopic procedure, the

Spiration Valve is an umbrellashaped

device that improves

breathing by blocking airflow

to the diseased portion of

the lung. SVS therapy leads

to volume reduction in the

treated part of the lung,

allowing the healthier tissue in

the remaining portion of the

lung to function better.

FDA approval of the

SVS is based on results

of the EMPROVE clinical

trial demonstrating that

patients treated with the SVS

benefited from statistically

80 / FUTURE MEDICINE / JANUARY 2019


Baxter introduces buttressing patch

Baxter has come out with

Peri-Strips Dry with Veritas

(PSDV) Circular Staple Line

Reinforcement with Secure

Grip technology for surgical

buttressing and soft tissue

repair.

PSDV Circular, with the

included cartridge cone, is

designed to allow a circular

surgical stapler to advance

across the incision site with

minimal tissue injury while

protecting the buttress. PSDV

Circular also features Baxter’s

Secure Grip technology, which

provides secure placement of

PSDV onto a circular surgical

stapler. PSDV Circular is easyto-load

through a peel-andstick

configuration and can

be used in a range of surgical

procedures.

During bariatric

procedures, surgeons use

a variety of techniques

to reduce the risk of

significant complications

such as staple line leaks and

bleeds. To reduce this risk, many

surgeons choose to buttress, or

reinforce, the staple line with

biologic buttressing patches like

Baxter’s PSDV Circular product.

significant and clinically

meaningful improvements in

lung function and quality of

life compared to standard of

care medical management.

Further, the results

showed that the SVS offers a

favourable risk-benefit profile,

with a short procedure time,

which may reduce the risk of

adverse events.

Prominent guidelines now

recommend minimally invasive

bronchoscopic lung volume

reduction using endobronchial

valves as an alternative

treatment option for severe

emphysema to more invasive

options, such as open surgery.

The SVS is now approved

for use in emphysema in the

US, EU, Australia and New

Zealand.

Breakthrough

status for CTEPH

device

T

he US FDA granted

breakthrough device

designation to the artificial

intelligence software for

chronic thromboembolic

pulmonary hypertension

(CTEPH) pattern recognition,

which Bayer is currently

developing jointly with MSD.

Development of the

software will rely on using

deep learning methodology

to support radiologists by

identifying signs of CTEPH

in CTPA scans. The software

processes image findings of

cardiovascular, lung perfusion

and pulmonary vessel

analyses in combination

with the patient’s history of

pulmonary embolism.

If successful, the software

could be deployed via Bayer’s

Radimetrics, an informatics

technology platform that

connects contrast medium

with injector and scan

information to provide

important insights.

A rare form of pulmonary

hypertension, CTEPH affects

an estimated 8 to 40 people

per million globally. CTEPH

can be difficult to diagnose

because its symptoms are

similar to those of other lung

diseases.

Tissue Genesis

launches stem

cell isolator

Tissue Genesis LLC has

launched Icellator X, an

advanced system for isolating

stem cells in adipose tissue.

The enhanced enzymederived

stem cell isolation

system offers a greater overall

impact and efficiency in the

field of regenerative medicine

The Icellator X offers

greater cell yields, ease of use,

and a user interface available

in multiple languages.

Capabilities of the Icellator

X include: Input Lipoaspirate

Volume up to 100 mL,

Consistent isolation of high

stromal vascular fraction

(SVF) cell yields, typical 50

million SVF cell recovery per

100 mL of adipose tissue,

cell suspension safe for IV

delivery, approximate 1 hour

run time, touchscreen user

interface available in multiple

languages, sterile, singleuse

disposable cartridge

treatment kit, IEC 60601

compliant, UL listed to IEC

61010.

JANUARY 2019 / FUTURE MEDICINE / 81


ADVERTORIAL

VisuMax femtosecond

laser - P150040/S003

Zeiss VisuMax Femtosecond Laser is an

ophthalmic surgical laser indicated for use

in the small-incision lenticule extraction

(SMILE) procedure for the reduction or

elimination of nearsightedness (myopia)

with or without astigmatism. It is designed

to create small incisions in the transparent

layer on the front of the eye (the cornea).

The VisuMax Femtosecond Laser

developed by Carl Zeiss Meditec, Inc. has

received its FDA approval on 4th October

2018.

With its outstanding cutting precision,

unsurpassed speed and gentle treatment

technique VisuMax provides an ideal

platform for therapeutic and refractive

applications of cutting-edge corneal

surgery, including:

Flap - for precise flap cutting for Femto-

LASIK and PRESBYOND Laser Blended

Vision

Keratoplasty - for a broad spectrum of

corneal transplant procedures

Incision for ICR - for tailor-made

intracorneal tunnel segments

ReLEx SMILE - the step towards minimally

invasive laser vision correction

The surgical laser allows the eye surgeon

to cut a disc-shaped piece of corneal tissue

(lenticule), which is thicker in the center

and thinner at the edge. The surgeon

can then remove the tissue with surgical

instruments which flattens the center

of the cornea resulting in the reduction

or elimination of nearsightedness and

astigmatism.

Shaping the world of refractive surgery

VisuMax heralds a paradigm shift in

refractive surgery: minimally invasive laser

vision correction.

The VisuMax Femtosecond Laser

System consists of the following major

components:

Laser Console:

The Laser Console houses the

femtosecond laser source, the scanning

delivery system, the computer and

software-hardware control system, an

uninterruptible electrical power supply,

the power supply distribution electronics,

a visualization system and surgical

microscope, two slit illumination units, the

interface hardware for the Treatment Pack,

user controls and user interface.

The Patient Supporting System (PSS)

Used to support the patient in a supine

position during corneal surgery with the

VisuMax Femtosecond Laser. The PSS is

also used to properly position the patient

with respect to the Treatment Pack affixed

to the treatment objective lens in the Laser

Console. The joystick control on the PSS

is manipulated by the user to position

the patient with respect to the Treatment

Pack, and to applanate and immobilize the

eye of the patient in preparation for laser

treatment.

Accessories - Treatment Pack

The VisuMax Treatment Pack is a

commercially available, pre-sterilized,

single-use disposable accessory to the

VisuMax Femtosecond Laser. It consists

of disposable elements that allow for the

laser beam to be properly coupled onto a

patient’s cornea in a precise and controlled

manner. No cleaning, disinfection or

re-sterilization by the user is required or

permitted.

Features : Maximum cutting precision

High-precision optics provide an

extremely focused laser beam creating

desired depth in the cornea, even with

three-dimensional, curved incisions.

Brilliant visual control

The integrated, high-quality surgical

microscope, includes digital video camera

for live recording of the surgical procedure

ensuring precise and complete control of

each treatment step.

Patient Supporting System

The ergonomically pivoting patient

supporting system ensures maximum

comfort. The patient's position is

continuously monitored during treatment

and the sturdy yet comfortable patient

supporting system is automatically

adjusted during surgery.

This is a sponsored article. FM editorial holds no responsibility for the information therein.

82 / FUTURE MEDICINE / JANUARY 2019


D Y PATIL

UNIVERSITY

MEDICAL

SIMULATION LAB

India’s first comprehensive

medical simulation facility

to soon get modern

medical simulation

modules such as

augmented reality

Lucina is in the labour room.

Though admitted with normal

pain, the doctors later notice

signs of premature rupture of the

membranes in the patient. Lucina

also developed slight complications,

including symptoms of preeclampsia

84 / FUTURE MEDICINE / JANUARY 2019


INFRASTRUCTURE

There is a total of eight high

fidelity simulators that come

together to form this immersive

learning experience.

The simulation uses one of the

world’s most advanced physiological

modelling system. Built for

anaesthesia, respiratory, emergency

and critical care, it has a true oxygen

and CO2 gas exchange to exhibit the

high-end sophistication in validated

physiology.

It connects to a real patient

monitor and supports mechanical

ventilation to deliver more realism

for immersive learning. Hence, it

enables workshops and modules to

learn, relearn and unlearn the skills

of medical students and practicing

clinicians.

The courses and workshops

at the DY Patil human patient

simulation centre include advanced

cardiac life support and advanced

life support, cardiopulmonary critical

conditions, airway emergencies

and management, disaster medical

readiness, emergency medical

services, foundations of nursing

practice, intensive care emergencies,

preoperative management and rapid

assessment and management.

PHOTOS: UMESH GOSWAMI

and high blood pressure with protein

in the urine. A medical team — doctors,

para medics and a group of medical

students, are keenly observing her

fluctuating BP and other parameters.

Although the doctors suspect abnormal

position and presentation of the foetus,

labour is in progress. Lucia moans

and groans, and the baby’s head is

about to be out. But there is a further

complication with a suspected shoulder

dystocia.

“The labour progressed slower than

expected,” said the trainer and asked

the team to do what is required as

emergency.

Ah... the baby is finally out with a

right 90-degree rotation of its head to

the occipito-anterior position.

The team record every second of

the labor progress meticulously. They

keep monitoring the variation in BP and

the CSE effect. Finally, the trainer takes

the baby out, which makes its first cry,

and puts it over the lactating nipples of

Lucia.

Lucina is a high-fidelity female

mannequin used in various obstetric &

gynaecological workshops in Medical

Simulation Laboratory at D Y Patil

University, Navi Mumbai.

India’s first comprehensive medical

simulation lab is now embarking on

another pioneering project to make it

the most unique medical simulation

lab in the country. Established in 2013,

medical simulation laboratory at DY

Patil University is being expanded to the

country’s largest and the first to have

the most modern medical simulation

modules such as augmented reality and

Microsoft HoloLens platforms.

The Pioneer

The medical simulation laboratory at

the Navi Mumbai campus of DY Patil

University, which has at least half a

dozen high fidelity mannequins to train

JANUARY 2019 / FUTURE MEDICINE / 85


medical students and doctors before

they try their hands-on real patients,

was billed as the only such facility in

South East Asia when it was launched

six years ago.

“This facility was started when none

in this part of the world even thought

of having such a comprehensive human

patient simulation lab,” claims Dr

N.Sippy, Associate Professor, DY Patil

University.

A 5,000 sq ft lab is equipped with

high-fidelity mannequins covering most

of the medical specialities , a debriefing

room and a conference room.

“We are now expanding this lab to

a 15,000 sq. ft. facility with the latest

technologies in simulator platforms,

including augmented and mixed reality

studios — again, for first time in India,”

Sippy said.

As part of this innovation, it has

already launched the Microsoft HoloLens

module with CAE just two months

ago. With this, it wants to enhance the

training with the latest technologies

that can interfere in medical simulation,

especially in areas like ultrasound and

gynec procedures among others.

The Beginning

“Since we didn’t have any models

in India to follow, we took time

to understand and analyse the

requirement,” Dr Sippy quipped.

For this lab, mannequins were

supplied by UK’s CAE, one of the best

providers of high-fidelity mannequins

for human patient simulation. Such

mannequins are not available in

India and are imported for the lab,

as there are only three companies

worldwide that have the expertise to

manufacture them.CAE develops end

to end spectrum of simulation solutions

that includes patient ,interventional &

imaging simulation.

“Though the Indian regulatory

system typically mandates the very

minimum modules or programmes,

we wanted to introduce full- fledged

simulation infrastructure and invested

heavily on these high-end mannequins,”

Dr Sippy added.

“We have so far trained at least

25,000 consultants from various

In a medical

simulation lab, it is

not the investment

that is important,

though it is highly

capital intensive. The

most critical aspect

is the utilisation and

training efficiency.

Dr Vijay Patil

President

DY Patil University

86 / FUTURE MEDICINE / JANUARY 2019


hospitals from across India. This

excludes our own UG and PG students,”

says Dr Amit Nagpal, senior trainer at

the Centre.

“India currently lags far behind in the

utilisation of human patient simulation in

medical education as the curriculum in

the country is still based on trials on real

patients,” he added.

Medical students, nurses and doctors

are not allowed touch the real patients

in developed countries before they

complete a specific number of hours of

training in a simulation lab, as human

life is treated differently there.

The concept of simulation labs is

still very nascent in India, though it is

at least 20 years old in the Europe and

US. Medical simulation in India was, till

recently, focussed only on basic things

such as a chest compression test. Even

large government medical colleges,

which do have simulation labs, use them

suboptimally as their importance hasn’t

been fully understood here.

The main reason for this was a

lack of good trainers who can conduct

effective workshops and the absence of

regulation that makes it mandatory.

“In the advanced countries, there

are large patient simulation labs. For

instance, there are labs with much

bigger infrastructure, very high-fidelity

mannequins, simulator ambulances etc.,

to train the students, para medics and

doctors on each and every aspect of the

curriculum, including casualty, ICU and

OT.”

“In a medical simulation lab, it is not

the investment that is important, though

it is highly capital intensive. The most

critical aspect is the utilisation. Achieving

the optimum level of utilisation by

focusing on the efficiency of training

modules and providing the best trainers

are the most important factors,” says Dr

Vijay Patil, President, DY Patil University.

The concept is also not fully

established in India because there is

no standardised way of training that

has been stipulated as per the medical

curriculum.

“There is no standardisation of

training that has been introduced yet

in the country as far as this branch of

medical education is concerned. So, the

student can easily go wrong in assessing

the cause and treatment options or

even get misguided in the way the

procedures are done if he or she is not

being trained the right way.”

“So, we have signed MoUs with at

various universities from the West where

there is a competent and very robust

system in developing the standards for

patient simulation training, for setting

our standard of procedures,” Dr Patil

added.

The world renowned HPS expert

Guisappe Marraro, an Italian clinician

with specialisation in anaesthesia,

intensive care, neonatology and

paediatrics, was instrumental in setting

up the comprehensive human patient

simulation lab at DY Patil University.

Currently Professor Emeritus at the

University, Marraro is still involved in

the development and improvement of

training modules and the standard of

procedures of the lab.

70-year-old Marraro had also

contributed immensely in setting up

medical simulator labs and development

of training standards in several

advanced countries, where this part of

medical education is seriously pursued

and adopted.

The DY Patil centre has also

collaborated with several medical

associations and pharmaceutical

companies in India to conduct

workshops for their members and

consultants. The lab customises the

modules as per the learners of the users

while conducting the workshops.

“These customisations are with an

aim to enhance the training programme

for each set of students as we do not

want to offer a one-fits-all course just

for the sake of giving a certificate.

This is also the reason for not opting

for accreditations that often limit the

possibilities of enhancement in the

quality of workshops,” Dr Sippi added.

The other two medical colleges that

run similar labs in the country are the

Mangalore-based Father Muller Medical

College and Yenepoya Medical College.

But these labs were established much

later.

According to Sippy, the lab at DY

Patil University has been an inspiration

for these later entrants and could also

help them in many ways by sharing the

experience and the learning.

This is part of a series that features India’s

First & Most Unique institutions, facilities,

technologies, products etc in the medical

and healthcare space.

JANUARY 2019 / FUTURE MEDICINE / 87


events

TNPY IRIA 2018 calls for constant

practice to stay competitive

Radiology experts from various imaging modalities congregate at the three-day

event of Tamil Nadu and Pondicherry Chapter of IRIA

The 71st Annual Conference of

the Tamil Nadu and Pondicherry

Chapter of the Indian Radiological

and Imaging Association (TNPY IRIA)

called for constant updating and

continuous practice by resident and

practicing radiologists to keep pace with

fast-emerging advances in the field of

medical imaging.

Transformational technologies

are re-drawing the way radiology is

practised with break-neck speed. Older

technologies are getting outdated and

replaced with newer ones faster than

ever, participants pointed out. Keeping

abreast of the latest in each domain

is the only way to be successful in the

profession, they said.

“Today, the practice of radiology

has become a race. And the only way

to win the race is practice, practice,

practice,” said Dr T Mukuntharajan,

president-elect, TNPY IRIA, delivering

the keynote address at the inaugural

ceremony of the three-day conference

at Chennai, which commenced on 14th

of December 2018.If they fail to update

themselves, radiologists are likely to lose

out their turf to others.

Radiologists are the masters of

medicine as they deal with each and

every specialty in their day-to-day

practice, unlike other specialists whose

exposure is usually limited to their

respective areas. In this sense, radiology

is a highly rewarding profession and

every radiologist can be proud of it, he

commented.

The three-year education

programme of post-graduates pursuing

radiology may provide an overview of

radio-imaging, but not necessarily the

kind of exposure required across the

In this conference, we’ve

adopted two approachesregion-specific

and modality

specific, so that participating

doctors get exposure to both

simultaneously.

Dr R Ravi

Organising Chairman

TNPY IRIA 2018

domains. The idea behind organising

the summit was to share the relevant

knowledge and the practical tips to

residents, according to Dr R Ravi,

organising chairman of TNPY IRIA 2018.

“In this conference, we’ve

adopted two approaches- regionspecific

and modality specific, so that

participating doctors get exposure to

both simultaneously. We have experts

specialised in different modalities,”

said Dr Ravi, who is also the director

and professor of Barnard Institute of

Radiology, Chennai, which conducted

the meet under of the auspices of the

Chennai Subchapter of IRIA.

The scientific programme featured

musculoskeletal session, rectal cancer

imaging, geriatric imaging etc.

A customary preconference

workshop was held at the venue on

day one, featuring, for the first time, a

hands-on workstation in select fields

such as advanced neuroimaging, cardiac

CT/MRI, mammography. The secondand

third-day programmes focused on

PHOTOS: RAVI KUMAR

88 / FUTURE MEDICINE / JANUARY 2019


interactive sessions in topics including

the Pearls and Pitfalls in Head and Neck

Imaging; Paediatric Sonography; Pitfalls

in Abdominal Imaging; Post Laparotomy

Complications and USG Assessment of

Abnormal Uterine Bleeding.

Case-based discussions covered

paediatric radiology, commonly missed

musculoskeletal conditions, MRCP, skullbase

lesions, gynaecologic imaging,

interventional radiology and mesentery,

among others.

The 71st state conference had

`Inspiring Minds — Novice to Expert’ as

the theme. Explaining the reason behind

choosing the theme, Dr S Shanmugam,

president, TNPY IRIA said the objective

is to impart the knowledge and

experience to both the residents as well

as the practicing radiologists.

“The whole idea of the CME

sessions was to inspire the young and

experienced radiologists alike by getting

them exposed to the advancements in

medical imaging. There are definitive

takeaways from learning from the

horse’s mouth,” he explained.

Even though the fundamentals

remain the same, the conference

aims to be different every year with

the addition of newer practices and

modalities. This year, for example, it

had a session on elastography. The

technique was earlier limited to breast

imaging. Now elastography’s application

is expanding to various other imaging

modalities such cirrhotic liver etc, Dr

Shanmugan pointed out.

Despite considerable scope in the

profession, Indian radiologists are faced

Today, the practice of

radiology has become a race.

And the only way to win the

race is practice, practice,

practice.

Dr T Mukuntharajan

President-Elect, TNPY IRIA

with challenges like the cost of the

equipment. The machines get outdated

very soon with the advancement of

technology. This necessitates radiologists

to change their imaging systems within

three years. That poses a huge financial

strain to radiologists, especially for those

practising in rural parts of the country.

Any physician, who can afford to buy

an ultrasound device, can start imaging

patients in India. In certain specialties,

such as in gynaecology, the use of

ultrasound is crucial. But it is not always

the case and many others, including

GPs, use them extensively. Now, with the

introduction of the new PNDT Act, the

The whole idea of the CME

sessions was to inspire the

young and experienced

radiologists alike by getting

them exposed to the

advancements in medical

imaging.

Dr S Shanmugam

President, TNPY IRIA

scenario is changing. In fact, the Act is

a blessing in disguise, Dr Shanmugam

added.

Around 500 delegates, including

international faculty, attended the

meet. The conference also featured two

orations. Dr Arthur Daniel Oration by Dr

Krishnakumar on the topic Endovascular

Neurointerventional Surgery and Dr Ida

Scudder Oration by Dr D Karthikeyan on

Cardiac Computed Tomography.

Quantitation CT with Spectral

Imaging, a quiz with audience response

pads, a piano recital by Anil Srinivasan, a

contemporary music festival etc. were the

other highlights of the programme.

JANUARY 2019 / FUTURE MEDICINE / 89


events

ISGCON 2018 highlights

transformational GI endoscopy

The four-day session takes a peek into the future of gastroenterology

DIVYA CHOYIKUTTY

The 59th edition of the annual

conference, ISGCON, was held

at Kochi on 28th November

2018. The conference discussed

the latest advances in the field of

gastroenterology, hepatology and

gastrointestinal endoscopy.

The four-day event, organized by

the Kerala chapter of Indian Society

of Gastroenterology, saw participation

from over 2,500 delegates from across

the globe.

“The meet is aimed at educating

young gastroenterologists and to give

an update on new technologies and

research happening around the world

through the experts in the field,” said

organizing secretary Dr Mathew Philip,

director of PVS Institute of Digestive

Diseases, Ernakulam, Kerala.

The conference stressed the need

to take up effective strategies to tackle

the gastrointestinal disease burden of

the country, growing by the day.

“The future of gastroenterology

is going to be more interesting,”

mentioned Dr T S Chandrasekhar,

gastroenterologist & founder chairman

of Medindia Hospitals, Chennai.

According to him, capsule

endoscopy, currently used in diagnosis,

can be used for treatment and

screening in near future.

THE FIELD OF

INTERVENTIONAL ENDOSCOPY

IS SLOWLY ENTERING INTO

A NEW ERA OF FLEXIBLE

ENDOSCOPIC SURGERY

“Endoscopy is rapidly changing

from diagnostic to therapeutic,” said

Dr Amit Maydeo, director of Baldota

Institute of Digestive Sciences, Global

Hospital, Mumbai, participating in a

session on third space endoscopy.

“The field of interventional endoscopy

is slowly entering into a new era of

flexible endoscopic surgery.”

Third space endoscopy, commonly

referred to as submucosal endoscopy,

helps assess deeper layers of the

gastrointestinal (GI) tract by tunneling

in the submucosal space without

compromising the integrity of the

overlying mucosa.

Discussing the role of

personalized genomic medicine

in gastroenterology, Dr Douglas

A. Corley, a gastroenterologist at

Kaiser Permanente, San Francisco

Medical Center, said it was possible,

to a limited extent, to predict the

genetic susceptibility of a person

to a particular disease. He said that

the development of chronic diseases

should be viewed as a continuum of

interactions between the individual’s

genetic make-up and environmental

factors such as diet, physical activity

and emotions.

The sessions also emphasized the

lack of gastroenterologists in India.

Parallel sessions by an Asian-EUS

group, giving importance to endoscopic

ultrasound and hands-on workshops on

animal models, were conducted as part

of the event.

90 / FUTURE MEDICINE / JANUARY 2019


AUGUST 2018/ FUTURE MEDICINE / 85


events

Increased medical awareness on MDR

infection need of the hour: HDR Summit

Experts debate critical healthcare issues that pose bigger medical challenges

One of the most critical health

issues that India currently needs

to address by putting its act

together is the increasing risk of drugresistant

infection. MDR — caused by

various factors ranging from community

infected diseases, uncontrolled usage

of antibiotics in the healthcare and

non-healthcare setups and the growthpromotional

use of antibiotics in animals

and plants — is going to be one of

the biggest medical challenges in the

country soon. While non-communicable

diseases such cardiac and hypertension

problems and diabetes and renal

disorders have already created a huge

healthcare burden in the country, it is

soon going to witness an even bigger

crisis caused by bacterial resistance to

a large spectrum of known antibiotics,

cautioned HDR Summit 2018, the multispecialty

medical conference focusing

on hypertension, diabetes and renal

diseases held during December 8 to 9 in

Bengaluru.

Medical experts who spoke at the

conference alerted the community that

it is time to bring in rapid measures

to check the spread of drug-resistant

bacterial infection.

“Besides precautions like strong

implementation of anti-infection

protocols at medical setups, there is

also an urgent need for controlling

overcrowding of population, improving

hygiene and sanitary systems,

vaccination for high-risk people including

immunodeficient patients, discouraging

growth-promotional use of antibiotics

etc.,” said Dr Adbdul Ghafur, an infectious

diseases expert from Chennai, while

making a presentation on the topic of

how to bring down community-acquired

serious infections.

The summit did serve its purpose

of updating the community on

newer challenges and solutions

in the chosen subjects.

Dr Dinesh Kamath

Organising Secretary, HDR Summit 2018

“Colistin resistance in bacteria causes

80% of infection-related deaths in India

and at least 6% of adult population in

the country already carry carbapenemresistant

bacteria in their gut,” he said

referring to recent health surveys.

The conference, which had 18

scientific sessions, also discussed

challenges and the need for new

approaches in disease management in

various disease segments. Presenting

a paper on implications of obesity on

health and its management, senior

endocrinologist Dr Supratik Bhattacharya

from Kolkata said new findings have

proved that there are other factors

such as environmental, lifestyle and

psychological conditions that contribute

significantly to obesity, besides genetic

and food-related causes.

According to Dr Dinesh Kamath,

organising secretary of the Summit,

the topics at the scientific sessions

were chosen on the basis of current

day challenges in the Indian healthcare

scenario and for the purpose of updating

the medical fraternity on several

commonly faced issues.

“The speakers were selected

considering their exposure to such key

issues and their own research work

in the respective areas. I feel that the

conference could fully serve its purpose

of updating the community about newer

challenges and solutions in the chosen

subjects,” Dr Kamath said.

“With 4,200 registered delegates,

this was one of the best conferences in

South India in recent times in terms of

participant response. One of the reasons

for such a positive response from the

fraternity was the selection of current

and topical subjects,” said organising

committee chairman Dr V Shankar.

92 / FUTURE MEDICINE / JANUARY 2019


events

Nanotech-2018 showcases exciting

world of nanomedicine

Seminar focuses on biological applications of various types of nanoparticles

Nanotechnology offers exciting

possibilities in medicine and

medical applications for the

near future. While some of the unique

applications using these possibilities

are still in the conceptual stage, many

are already in trials or being applied in

treatment and disease management.

These promising technologies, involving

applications of nanoparticles or nanorobots

to make repairs at the cellular

level, are predicted to revolutionize the

way the medical world detects and

treats diseases.

Nanotech-2018, the one-day annual

nanotechnology seminar, was jointly

organised by Center for Nanoscience

and Technology, Anna University,

Chennai with Slovak Academy of

Sciences, Slovakia, and MagGenome

Technologies Pvt. Ltd on 7 December in

Chennai. It showcased some of these

techniques, which were only imagined a

few years ago, as they are making their

The seminar mainly

focused on biological

applications of various

types of nanoparticles and

the major emphasis was

given to the development

of novel technologies which

are technically superior and

commercially viable.

Dr C N Ramchand

CEO, MagGenome Technologies

Convenor of Nanotech-2018

way into the market.

Explaining the novel concept of

developing iron oxide nanoparticles

as solid support for affinity and

hydrophobic ligands, Dr Tessy Iype,

scientist at MagGenome Technologies,

said that a novel method of

immobilizing affinity ligands developed

by MagGenome will potentially open

up a whole new avenue for purification

of proteins, especially monoclonal

antibodies using a magnetic system.

“This will provide researchers

a quick and cost-effective method

in reagent or therapeutic antibody

purification, compared to the existing

column-based technology. Our longterm

goal is to provide a unique and

robust automated magnetic system

for effective purification of therapeutic

antibodies,” she added.

While many Indian scientists from

promising research start-ups and

scientific organisations have already

94 / FUTURE MEDICINE / JANUARY 2019


displayed significant breakthroughs in

this field, there are promising large-scale

projects also underway in the world.

A recent study performed by

Institute of Experimental Physics,

Slovak Academy of Sciences showed its

high-potential use of magneto ferritin

in various biomedical applications,

including targeted transport, MRI and

nanocatalytic chemistry.

Ferritin, which is a naturally occurring

iron-storage protein, is essential for iron

homeostasis and is involved in a wide

range of physiologic and pathologic

processes in our body. The magnetic

properties of ferritin nanoparticles play

an important role in nanoengineering

and biomedical applications.

Magnetoferritin biomacromolecule

consist of an apoferritin shell that

surrounds an inorganic core of magnetic

iron oxides, varying in the size according

to the amount of iron ions.

“We have proved that

magnetoferritin plays a significant

biomedical role with its potential

anti-amyloid activity and it helps in

the diagnosis of neurodegenerative

diseases using magneto-optical method.

Magnetoferritin and reconstructed

ferritin is also able to destruct

lysozyme amyloid fibrils, helping

reverse the process of aggregation.

H2O2 accumulation causes oxidative

stress, leading to physiological

conditions of cardiovascular, cancer,

We have proved that

magnetoferritin plays a

significant biomedical

role with its potential

anti-amyloid activity and

it helps in the diagnosis of

neurodegenerative diseases

using magneto-optical

method.

Dr Peter Kopcansky

Director, Institute of Experimental

Science, Slovak Academy of Science

neurodegenerative diseases.

The peroxidase-like activity of

magnetoferritin can provide a model

system of pathological ferritin effect on

H2O2 in vitro,” said Dr Peter Kopcansky,

Director, Institute of Experimental

Science at Slovak Academy of Science, in

his keynote address.

According to Milan Timko, head,

Department of Magnetism at the

PHOTOS: RAVI KUMAR

Institute of Experimental Physics, Slovak

Academy of Sciences, another promising

study has revealed the possibility of

a new innovative thermal-method

coupling magnetic and ultrasonic

hyperthermia as a promising heat

therapy for cancer treatment.

Hyperthermia is a biomedical

application of magnetic nanoparticles.

Mechanical oscillation of magnetic

nanoparticles using ultrasonic waves can

be converted into thermal energy which

increasing temperature in the treatment

of tumour affected zone.

“In Vivo Testing of Magnetic

Hyperthermia showed remarkable

regression of tumours with magnetic

hyperthermia in mice models in previous

studies. This study focussed on the

effect of simultaneous interaction of

ultrasounds and alternate current

(AC) magnetic field with magnetic

nanoparticles (MNPs) with a rise in

temperature in agar phantoms doped

with MNP,” Dr Timko said.

Using magnetic nanoparticles as

a tool for extracting DNA, total protein

and bioanalytical extraction of drugs

was another path-breaking technology

that was discussed at the Seminar. This

research proposed by MagGenome

Technologies offers an alternate method

for bioanalytical extraction of drugs

from human plasma samples using bare

magnetic nanoparticles.

“The seminar mainly focused

on biological applications of various

types of nanoparticles and the major

emphasis was given to the development

of novel technologies which are

technically superior and commercially

viable,” said Dr C N Ramchand,

chief executive officer, MagGenome

Technologies, and convenor of

Nanotech-2018

The other key speakers at the

Seminar included Dr Sailaja Elchuri of

Sankara Nethralaya, Dr Narayana Kalkura

of Anna University, Dr Anima Nanda of

Satyabhama University, Dr P Balakrishna

Murthy of Hiroshima University, Dr

Aniruddha Bhati of MagGenome

Technologies and Dr C. Gopalakrishnan

of SRM University.

JANUARY 2019 / FUTURE MEDICINE / 95


calendar

Upcoming conferences

JANUARY

3-6 PSYCHOTHERAPY

International Conference On

Counselling, Psychotherapy And

Wellness (ICCP)

Bengaluru

PAEDIATRIC

ORTHOPAEDICS

PosiCon

Mumbai

4-6 CLINICAL RESEARCH

Joint International Conference

Ahmedabad

NEUROLOGY

Neuro Updates Conference

Chennai

8-12 OBSTETRICS AND

GYNECOLOGY

62nd All India Congress of

Obstetrics and Gynaecology

(AICOG)

Bengaluru

9-11 MENTAL HEALTH

DYUTI International Symposium

on Evidences in Global Mental

Health

Kakkanad

17-19

VENOUS DISEASES

Vaicon

Hyderabad

17-20 DERMATOLOGY

National Conference of Indian

Association of Dermatologists,

Venereologists & Leprologists

Bengaluru

RADIOLOGY

Annual Conference of the

Indian Radiological and Imaging

Association (IRIA)

Chandigarh

19 GASTROENTEROLOGY

India Fertility Conference and

Awards 2019

New Delhi

23-26 UROLOGY

Annual National Conference of

The Urological Society of India

Bhubaneswar

24-26 GASTRO-ENTEROLOGY

National Conference on Obesity

and Metabolic Surgery Society

of India

Kolkata

24-27 SURGERY

Annual Conference of The

Asociation of Spine Surgeons of

India (ASSICON)

Ahmedabad

25-27 NEUROSURGERY

International Conference on

Complications in Neurosurgery

(ICCN)

Mumbai

30-31

31-

Feb2

ONCOLOGY

International Conference on

Cancer Rehabilitation (CAN-

REHAB)

Mumbai

CRITICAL CARE

Annual National Conference of

Indian Society of Critical Care

Medicine (CRITICARE)

Mumbai

PSYCHIATRY

Annual National Conference of

Indian Psychiatric Society

Lucknow

FEBRUARY

5-9 GYNECOLOGY

All India Congress of Obstetrics

and Gynaecology (AICOG) 2020

Lucknow

6-10 PAEDIATRICS

Illness to Wellness Pedicone

Mumbai

7-9 GASTRO-ENTEROLOGY

Annual Congress of Indian

Association of Gastrointestinal

Endosurgeons (IAGES)

Bhubaneswar

8-9 CLINICAL ANATOMISTS

Society of Clinical Anatomists

Chennai

8-10 PLASTIC SURGERY

Annual Meeting of Indian

Society of Cleft Lip Palate

and Craniofacial Anomalies

(Indocleftcon)

Varanasi

ONCOLOGY

Conference of Society of

Oncologic Imaging India

New Delhi

14-15 NEUROSURGERY

International Conference on

Conjoined Twins (ICCT)

New Delhi

15-17 PHYSIOTHERAPY

Society of Indian Physiotherapist

Annual Conference (Society of

Indian Physiotherapist Annual

Conference)

New Delhi

15-17 NEUROLOGY

Annual Conference of the Indian

Society of Neuroanaesthesiology

and Critical Care (ISNACC)

Gurgaon

HEPATOLOGY

Advanced Institute of Liver

& Biliary Science (AILBS)

International Conference 2019

New Delhi

21-24 CARDIOLOGY

ASCVTS & IACTSCON

Chennai

22-24 CARDIOLOGY

World Congress on Cardiac

Imaging Clinical Cardiology

(WCCICC)

Mumbai

ANAESTHESIOLOGY

Conference of the Indian

Association of Cardiovascular

Thoracic Anaesthesiologists

(IACTACON)

Kolkata

NEUROLOGY AND

PSYCHIATRY

MDSICON

New Delhi

28-3 CARDIOLOGY

India Live Conference

Mumbai

MARCH

1-3 GYNECOLOGY

ISAR Conference

Mumbai

2-3 GASTROENTEROLOGY

ISTH–ILBS Symposium on

Coagulopathy in Liver Disease

2019

New Delhi

8-10 NEUROLOGY

ISAR Conference

New Delhi

9-10 GYNECOLOGY

India Fertility Show-2019

Bangalore

11-12 CARDIOLOGY

ICCA Stroke 2019 - Acute Stroke

Interventions and Carotid

Stenting

New Delhi

16-17 NEUROSURGERY

Indo Japan Neurosurgical

Meeting (IJNM)

Secunderabad

The announced dates of the conferences may change

96 / FUTURE MEDICINE / JANUARY 2019


ook review

ON BEHALF OF

SCIENCE

VACCINES DID NOT

CAUSE RACHEL’S

AUTISM:

MY JOURNEY AS A

VACCINE SCIENTIST,

PEDIATRICIAN, AND

AUTISM DAD

By Peter J Hotez

pp 240

JHU Press, 2018

Why should Dr Peter J Hotez be

concerned when anti-vaxxers

portray vaccines as the cause of

autism? Why should he bother about the

vampires who live in the darkest corners

of the Internet, making false claims about

vaccine safety with abstract statistics?

Why should he keep an eye on Dr Andrew

Wakefield, who promulgated the lie about

vaccine link with autism?

Because he is the father of an autistic

girl.

It is also because he is a paediatrician.

Above all, Dr Hotez is a leading vaccine

scientist battling tropical diseases, some of

which is being stalled through vaccines.

In his book: Vaccines Did Not Cause

Rachel›s Autism: My Journey as a Vaccine

Scientist, Pediatrician and Autism Dad, Dr

Hotez takes us through a guided trip through

his own life, his family. He shows you his

daughter Rachel’s life as an autistic child.

After listening to Rachel speaking her

mind about her autism and after knowing

the science of vaccine from the first-hand

experience of Dr Hotez, you will come to

realise why anti-vaccinators are against

this book. Rachel’s autism is not rooted in

vaccines. There is no evidence from current

science that a child is autistic as a result of

vaccination.

Vaccine is a life-saving technology.

Vaccines have prevented the comeback of

many deadly contagions. And they still do.

In the process, they still do maim or kill

some of the children. But vaccine is no

way a cause of autism spectrum disorders.

There is no plausible link between vaccine

and autism. This is what the clinician wants

to convey from his insights and the parent

from his experience.

As the anti-vaccine sentiment spreads

throughout the world without encountering

resistance, a return of measles and other

childhood infections remains a grim

possibility, reversing the declining trend in

child mortality rates seen over the past years,

thanks to UN’s Millennium Development

Goals 2000. This would be nothing less than

a catastrophe, since measles is one of the

most deadly childhood infections, reminds

VACCINE IS NO WAY A CAUSE OF

AUTISM SPECTRUM DISORDERS.

THERE IS NO PLAUSIBLE LINK

BETWEEN VACCINE AND AUTISM

the author.

Some of the best-educated people still

harbour reservations against the safety

of vaccines. Thousands of parents choose

to exempt their kids from vaccination,

potentially contributing to outbreaks

imperilling the lives of many children. What

surprises the author the most is the silence

of the government and authorities that allow

the movement to proceed unopposed.

With the evidence of robust science, the

book provides a counter-narrative against the

growing anti-vaccine movement.

Dr Hotez hopes the book will prove a

clarion call for scientists and clinicians “to

speak out on behalf of science” and against

the false claims and public statements by the

modern vaccine movement which mostly go

unchallenged.

JANUARY 2019 / FUTURE MEDICINE / 97


“BE PASSIONATE ABOUT THE

PROFESSION IF YOU WANT TO

SERVE THE PATIENT”

PROF LISELOTTE METTLER M.D, PHD

Consultant of Obstetrics & Gynaecology, Infertility, and Gynaecologic Endoscopic Surgery, Kiel, Germany

Complete involvement in work typically comes

from one’s own interest and not from anyone

else’s compulsion. This has a lot to do with

the profession of a doctor, as every decision that

he or she makes at work can be life-changing in its

impact.

In this profession, there is always an important

element that can never be taught in the classroom

or read in the textbook. That is nothing but your

dedication, which forces you to go the extra mile to

ensure that the patient actually benefits from your

action.

But this dedication won’t come easily unless you

start believing in it from the time you choose the

profession. In other words, it is more important that

one should select his education of medicine out of

his or her passion to serve the patient community

and not as a part of choosing a career option.

I had the opportunity to work as a senior

consultant in several hospitals not only in Germany

but also in other countries, including India. I also

have many students trained under me in all these

places and was fortunate to work with many of

them later when they became senior consultants or

surgeons in many of these big hospitals. At all these

occasions, I could clearly observe how strongly their

attitudinal differences reflected in their performance.

There were students who were forced to choose this

profession and there were others who genuinely

pursued their aspiration to be in it. Here, one can

really make out how that element of passion in the

latter group helps them excel in their work and how

impactful their actions are in the ultimate benefit of

the patients.

So, let your passion choose your profession. It is

the intuition that you get from your soul that often

plays the most crucial role in your performance, and

in turn benefits your community the most.

— As told to CH Unnikrishnan

98 / FUTURE MEDICINE / JANUARY 2019


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