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editor’s note 

Dear Doctor, 

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

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 

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FUTUREMEDICINEINDIA.COM 

THE BRAVE 

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A NEW ERA OF MEDICAL IMAGING 

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RADIOLOGY 

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REGULAR FEATURES 

06 Letters 

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64 Diagnostics 

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76 Devices&gadgets 

88 Events 

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97 Book review 

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Columns 

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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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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 


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. 


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 


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. 


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 


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. 


cover story 

THE 

BRAVE 

NEW 

WORLD 

OF MEDICAL 

IMAGING 

Application of artificial intelligence and big data accelerates 

medical imaging technology at an unprecedented pace 


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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 


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 


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. 


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 


“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. 


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 


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 


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, 


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 


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. 


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 



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. 


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 


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 


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 


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, 


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. 


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 


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. 


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 


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 


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 



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’. 


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 


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 


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 


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 


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 


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 


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. 


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 


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. 


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 


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. 


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 


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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. 


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 


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. 


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 


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. 


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, 


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. 


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 


“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, 


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. 


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. 


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 


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 


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. 


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 


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. 


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. 


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 


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 


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. 


ADVERTORIAL 

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The VisuMax Femtosecond Laser 

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Accessories - Treatment Pack 

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


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 


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 


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 


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. 


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 


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. 


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. 



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. 


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 


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. 


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 


Cancer Rehabilitation (CAN- 

REHAB) 

Mumbai 

CRITICAL CARE 


Indian Society of Critical Care 

Medicine (CRITICARE) 

Mumbai 

PSYCHIATRY 


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 



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 


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 


India Live Conference 

Mumbai 

MARCH 


ISAR Conference 

Mumbai 

2-3 GASTROENTEROLOGY 

ISTH–ILBS Symposium on 

Coagulopathy in Liver Disease 

2019 

New Delhi 

8-10 NEUROLOGY 

ISAR Conference 

New Delhi 


India Fertility Show-2019 

Bangalore 


ICCA Stroke 2019 - Acute Stroke 

Interventions and Carotid 

Stenting 

New Delhi 


Indo Japan Neurosurgical 

Meeting (IJNM) 

Secunderabad 

The announced dates of the conferences may change 


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. 


“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 


A New Dawn... A New Hope 

With Passion and Expertise 

After redefining the healthcare scenario in Middle East Asia, 

Visionary Leader & Padmashri, Dr B R Shetty is now focusing on the Indian subcontinent with 

his healthcare enterprise 

“ 

With a mission of creating a healthier world by encompassing the values of care, compassion 

and clinical excellence, BR Life intends to become the numero uno network of hospitals across 

India and the Indian subcontinent. 

“ 

We deliver 

Evidence based clinical practice for best patient outcomes 

Ergonomically designed state-of-the-art infrastructure 

Worldclass affordable healthcare backed with cutting 

edge medical technologies 

The BR Life Group of Hospitals 

BR Life SUT Hospital, Pattom, 

Thiruvananthapuram, Kerala 

BR Life SSNMC Superspecialty Hospital, R R Nagar, 

Bengaluru, Karnataka 

BR Life Mother & Child Hospital, Udupi 

Karnataka. 

BR Life Kalinga Superspecialty Hospital, Gautamnagar 

Bhubaneswar, Odisha 

 

No. 8, Ideal Homes HBCS Layout, Rajarajeshwari Nagar, Bengaluru - 560 098, Karnataka, India. Tel: +91 80 6766 6766

RNI Number KERENG/2012/44529

FM JANUARY 2019 - digital edition

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