Care Institute of Medical Sciences Outcomes 2012

Green Hospital C I M S NABL A premier multi-super specialty GREEN hospital

What's Inside u Vision, Mission and Values ...... 2 u Spine Surgery ...... 69 u Chairman's Letter ...... 3 u Urosurgery ...... 72 u Board of Directors...... 5 u Onco Surgery ...... 74 u Accreditations ...... 6 u General Surgery ...... 77 u Abbreviations ...... 8 u Plastic Surgery ...... 78 u Mission 2013: Cancer and u Obstetrics and Gynecology ...... 80 Radiotherapy Centre ...... 12 u ENT Surgery ...... 82 u Departmental Overview ...... 13 u Pain Management ...... 83 u Cardiology ...... 14 u Dentistry...... 84 u Cardiac investigations ...... 26 u Pathology ...... 85 u Forefront in Cardiac Technology ...... 27 u Radiology ...... 88 u Cardiac Rhythm Disorders ...... 29 u Dialysis Center ...... 90 u Cardiac Surgery ...... 32 u Physiotherapy, Rehabilitation u Coronary Artery Bypass Grafting ...... 33 and Nutrition ...... 91 u Heart Failure ...... 35 u Code Blue...... 92 u Cardiac Valve Disorders ...... 37 u Quality Measures ...... 93 u Minimal Invasive Cardiac Surgery ...... 40 u Pharmacovigilance Unit...... 97 u Vascular and Endovascular Surgery ...... 41 u Ambulance and Transport Services ...... 98 u Thoracic Surgery ...... 45 u Patient Experience ...... 99 u Neonatal and Pediatric Critical Care ...... 46 u Guest Relationship ...... 100 u Pulmonary Medicine...... 50 u Patient's Say...... 101 u Critical Care ...... 52 u Ethics...... 104 u Orthopedic Surgery...... 56 u Research Projects ...... 105 u Trauma Centre ...... 60 u Education ...... 107 u Gastro-Intestinal Surgery ...... 63 u Medical Fraternity ...... 108 u Bariatric Surgery...... 64 u Publication List ...... 114 u Endoscopy...... 65 u JIC 2014 ...... 117 u Neurosurgery ...... 66

1 Vision, Mission and Values

Vision To be the best multi-super specialty hospital in India

Mission

C are I nnovation To provide superior quality health C are using I nnovation to Manage lives and S ave lives. M anage Lives S ave Lives

Values n Patient's well-being: It will be our topmost priority n Adopt and encourage ethical practices n Comply with all applicable laws and regulations n Provide a safe and comfortable working environment to employees and associates n Embrace technology and innovation in the delivery of healthcare n Provide socially responsible and safe healthcare

Care Institute of Medical Sciences (CIMS) is a 150-bed multi-super speciality eco friendly green hospital located in Ahmedabad, Gujarat, India on Science City Road with a 175-bed expansion plan in progress and an aim to be 300 plus bed hospital by 2016.

In its third year since inception, CIMS has established itself to be a centre of medical excellence in extremely spacious surroundings and state-of-the-art Green building supported by one of the best medical teams and backed with cutting-edge technology. Care, compassion and courtesy is the mantra underlying patient care at CIMS.

760 full-time and visiting consultants, over 1000 employee with a ratio of 5 employees per bed (one of the highest in India) devote their full energies to ensure that every patient has the best outcome and experience.

2 Chairman's Letter

Dear Colleague,

On behalf of the CIMS family, I am pleased to present the second edition of our annual scientific audit CIMS Outcomes 2012 for all our medical colleagues in India and abroad.

Since the first edition of the book a year ago, we are proud to have added two feathers in our cap; the NABH accreditation of our hospital and the NABL accreditation of our pathology laboratory. Entire quality assurance team, CIMS staff as well as pathology department needs to be congratulated.

After Outcomes 2010-2011 extending the frame work of process measures, volume measures and clinical outcomes, 2012 edition covers most of our invasive, interventional, critical care specialties, and departments such as CIMS KIDS, Endoscopy, ENT, Gastrointestinal, GI & Bariatric Surgery, General Surgery, Gynecology, Neonatal & Pediatric, Nephrology, Neurology, Oncology, Oncosurgery, Orthopedic, Pain Management, Pathology, Pediatric Surgery, Plastic Surgery, Radiology, Spine Surgery, Thoracic Surgery, Trauma, Urology, Vascular Surgery and various subspecialities of Internal Medicine and Surgery. It focuses on every category, every quality measure, and every aspect which improves patient care at CIMS, making it the best health care experience for the patient.

This year, we have focused on Appropriateness of Care. Of all the reasons for paying attention to patient satisfaction, only one that transcends correctness, accountability, or accreditation standards is — Appropriateness of Care. We, at CIMS, are proud to inform that we do some of the lowest % of our angiographies converted to angioplasties. Also, our approach to appropriateness between angioplasty & bypass surgery is one of the most balanced in the country with an equal number of our patients being offered the both, subsequently resulting in a higher number of open heart surgeries. We perform angioplasties on 20 % of our coronary angiographies, which is one of the lowest conversion rate in the country (compared to 30-40 % elsewhere), confirming our ethical standards. The outcomes and ethical appropriateness of care presented in this book are not our final destination; but is a continuous journey to provide the best and right care to each patients who walks into our care at CIMS.

3 Chairman's Letter

The success of CIMS lies with its magnificent doctors and associates. I would like to "deeply bow" to my associates and directors namely Dr. Milan Chag, Dr. Anish Chandarana,Dr. Ajay Naik, Dr. Satya Gupta, Dr. Urmil Shah, Dr. Hemang Baxi, and Dr. Dhiren Shah who have made CIMS become a success. If you see them around, do bow to them as I do, as it is they who have supported in establishing CIMS cardiovascular division as an outstanding monument of healthcare in such a short span of time. I also appreciate immensely Dr. Dhaval Naik, Dr. Gunvant Patel, Dr. Shaunak Shah, Dr. Kashyap Sheth, Dr. Dipesh Shah, Dr. Srujal Shah all of whom who have worked together as outstanding partners to me as well as to society for last many years. Newer doctors working in various department both visiting as well as full time also need to the admired.

While a number of specific case studies about techniques or strategies used to improve patient care have been included, we present only some outstanding cases as an example. This book is directed to all who wish to improve the patient's experience and evaluation of care and who are willing to put some sweat equity into the effort. I suspect that this passion of mine will be very apparent throughout the book!

It is again the hard work and the effort of our 'knowledge team' under the able guidance and leadership of Dr. Parloop Bhatt and Ms. Preeta Chag. I also appreciate the help of over 20 members of our various quality control and communication team especially Ms. Komal Shah and Mr. Sanjay Gohel who made this book possible.

On behalf of CIMS Family and Board of Directors Sincerely,

Dr. Keyur Parikh Chairman Care Institute of Medical Sciences Ahmedabad Email : [email protected]

4 Accreditations

5 Accreditations

6 Board of Directors

Dr. Milan Chag Dr. Anish Chandarana Dr. Hemang Baxi Managing Director Executive Director Director

Dr. Urmil Shah Dr. Ajay Naik Dr. Satya Gupta Dr. Dhiren Shah Director Director Director Director

Dr. Ashit Jain Mr. Kirti Patel Dr. Kamlesh Pandya Dr.(Prof.) Dilip Mavlankar Director, USA Director, UK Director, USA Director, India

7 Abbreviations

AAC Access, Assessment and Continuity of Care BLS Basic Life Support ABG Arterial Blood Gas BMI Body Mass Index ABI Ankle-Brachial Index BMS Bare Metal Stent ABP Ambulatory Blood Pressure BNP Brain Natriuretic Peptide ABP Arterial Blood Pressure BP Blood Pressure ACA Anterior Cerebral Artery BSI Blood Stream Infection ACC American College of Cardiology BVS Bioresorbable Vascular Scaffold ACE Angiotensin Converting Enzyme CABG Coronary Artery Bypass Grafting ACL Anterior Cruciate Ligament CAD Coronary Artery Disease ACR American College of Radiology CAG Coronary Angiography ACS Acute Coronary Syndrome CAMC Cardiac Arrhythmias Management Centre AED Automated External Defibrillator CCA Common Carotid Artery AF Atrial Fibrillation CCHD Cyanotic Congenital Heart Disease AFB Acid-Fast Bacilli CCU Critical Care Unit AHA American Heart Association CDT Catheter Directed Thrombolysis AICD Automatic Implantable Cardioverter CFA Common Femoral Artery Defibrillator CFM Cubic Foot Per Meter AIDP Acute Inflammatory Demyelinating CHD Congenital Heart Disease Polyneuropathy CIED Cardiac Implantable Electronic Device AIS Abbreviated Injury Scale CKD Chronic Kidney Disease ALCAPA Anomalous Origin of Left Coronary Artery COP Care of Patient from Pulmonary Artery COPD Chronic Obstuctive Pulmonary Disease AMA American Medical Association CPK-MB Creatine Phosphokinase-MB AMAN Acute Motor Axonal Neuropathy CPK-T Creatinine Phosphokinase-T AMI Acute Myocardial Infarction CPR Cardiac Pulmonary Resuscitation AMSAN Acute Motor Sensory Axonal Neuropathy CQI Continuous Quality Improvement ARB Angiotensin Receptor Blocker CR Computerized Radiography ARDS Acute Respiratory Distress Syndrome CRS Cardiac Resynchronization Society ASD Atrial Septal Defect CRT Cathode Ray Tube ATA Anterior Tibial Artery CRT Cardiac Resynchronization Therapy AV F Arterio Venous Fistula CRS-D Cardiac Resynchronization Defrillation AVM Anterio Venous Malformation CRT-D Cathode Ray Tube Defibrillator AVR Aortic Valve Replacement CSF Cerebrospinal Fluid BBE Bickerstaff's Brainstem Encephalitis CT Angiography Computed Tomography Angiography B/L Bilateral CTnT Cardiac Troponin-T

8 Abbreviations

CVC Central Venous Catheter GA General Anaesthesia CVP Central Venous Pressure GBS Guillain Barré Syndrome DC Differential Count GCS Glasgow Coma Scale D and C Dilatation and Curettage GERD Gastroesophageal Reflux Disease DC shock Direct Current Shock GI Gastrointestinal DDDR Dual Chamber Pacemaker H2H Hospital to Home DES Drug Eluting Stent HAI Hospital Acquired Infection DFI Diabetic Foot Infections HCV Hepatitis C Virus DLC Dialysis Catheter HD High Definition DLCO Diffusing Capacity of Lung Carbon Monoxide HEPA High Efficiency Particulate Air DM Diabetes Mellitus HF Heart Failure DSA Digital Subtraction Angiography HIC Hospital Infection Control DTA Descending Thoracic Aorta HOLEP Holmium Laser Encleation of Prostate DVD Double Vessel Disease HPC Health Professional Council DVR Double Valve Replacement HRM Human Resource Management DVT Deep Vein Thrombosis HTN Hypertension EBW Excess Body Weight IABP Intra Aortic Balloon Pump ECG Electrocardiogram ICA Internal Carotid Artery Echo Echocardiogram ICD Implantable Cardioverter Defibrillator ECP External Counter Pulsation ICISS International Classification Of Diseases - 9 ECMO Extracorporeal Membrane Oxygenation Injury Severity Score EF Ejection Fraction ICU Intensive Care Unit EMS Emergency Medical Services IEC International Electrotechnical Commission ENT Ear Nose Throat IHD Ischemic Heart Disease EPS Electrophysiology Studies IITV Image Intensifier Television ER Emergency Room IJV Internal Jugular Vein ERCP Endoscopic Retrograde IMS Information Management System Cholangiopancreatography INR International Normalized Ratio ET EndoTracheal IPD Inpatient Department EVAR Endovascular Aneurysm Repair ISO International Organization for Standardization FESS Functional Endoscopic Sinus Surgery ISQua International Society for Quality in HealthCare FFR Fractional Flow Reserve ISR In-Stent Restenosis FMC First Medical Contact ISS Injury Severity Score FMS Facility Management and Safety IUD Intrauterine Device G6PD Glucose-6-Phosphate Dehydrogenase IV Intravenous

9 Abbreviations

IV bolus Intravenous bolus NABL National Accreditation Board for Testing and IVC Inferior Vena Cava Calibration Laboratory IVU Intravenous Urography NCV Nerve Conduction Velocity IVUS Intravascular Ultrasound NHS National Health Society IWMI Inferior Wall Myocardial Infarction NRL Non Reacting to Light Lap. Laparoscopic NSTEMI Non ST-segment Elevated Myocardial Infarction LAD Left Anterior Descending NT Pro BNP N-terminal Pronatriuretic Peptide LBBB Left Bundle Branch Block NYHA New York Heart Association LCCA Left Common Carotid Artery OPD Outpatient Department LCX Left Circumflex Artery OSR Open Surgical Repair LDH Lactate Dehydrogenase ORIF Open Reduction and Internal Fixation LECA Left External Carotid Artery OT Holding Room Operation Theatre Holding Room LICA Left Internal Carotid Artery PA Pulmonary Artery LIJV Left Internal Jugular Vein PAH Paroxysmal Atrial Fibrillation LMCA Left Main Coronary Artery PAP Pulmonary Alveolar Proteinosis LQTS Long QT Syndrome PAS Periodic Acid Schiff LSCS Lower Segment Caesarean Section PCA Patient Controlled Analgesia LV Left Ventricle PCB Pharyngeal Cervical Brachial LVEF Left Ventricular Ejection Fraction PCI Percutaneous Coronary Intervention LVSD Left Ventricular Systolic Dysfunction PCN Percutaneous Nephrostomy MACE Major Adverse Cardiac Events PCNL Percutaneous Nephro Lithotomy MCA Middle Cerebral Artery PCR Polymerase Chain Reaction MFS Miller Fisher Syndrome PDA Patent Ductus Arteriosus MI Myocardial Infarction PE Pulmonary Embolism MICS Minimally Invasive Cardiac Surgery PEEP Positive End Expiratory Pressure MISS Minimally Invasive Spine Surgery PFT Pulmonary Function Test MOM Management Of Medication PGRO Patient and Guest Relation Officer MPA ligation Main Pulmonary Artery ligation POD Post Operative Day MR Mitral Regurgitation PPHN Persistence Pulmonary Hypertension MRI Magnetic Resonance Imaging PRE Patient Right and Education MRM Modified Radical Mastectomy PSA Prostate Specific Antigen MLC Multi Leaf Collimator PSV Pressure Support Ventilation MVD Micro Vascular Decompression PTA Percutaneous Transluminal Angioplasty MVR Mitral Valve Replacement PTA Posterior Tibial Artery NABH National Accreditation Board for Hospital and Healthcare Providers 10 Abbreviations

PTCA Percutaneous Transluminal Coronary SVD Single Vessel Disease Angioplasty SVR Systemic Vascular Resistance PTFE Polytetrafluoroethylene SYNTAX Synergy between Percutaneous Coronary PTPS Post Traumatic Psycho Shock Intervention with Taxus and Cardiac Surgery QCI Quality Council of India TAPVC Total Anomalous Pulmonary Venous Connection QoL Quality of Life TC Total Count RA Right Atrium TEE Transesophageal Echocardiogram RAAS Renin Angiotensin Aldosteron System TEVAR Thoracic EndoVascular Aortic Repair RCA Right Coronary Artery THR Total Hip Replacement RCT Root Canal Treatment TIBC Total Iron-Binding Capacity RF Ablation Radio Frequency Ablation TKR Total Knee Replacement ROM Responsibility of Management TLR Target Lesion Revascularization RPA Right Pulmonary Artery TMT Tread Mill Test RR Respiratory Rate TPI Temporary Pacemaker Implantation RT Ryle's Tube TR Tricuspid Regurgitation RTA Road Traffic Accident TURBT Trans-Urethral Resection of Bladder Tumour RTS Revised Trauma Score TURP Trans-Urethral Resection of Prostate RT-PCR Reverse Transcription Polymerase Chain TVD Triple Vessel Disease Reaction UA Unstable Angina RV Right Ventricle URS Ureteroscopic Lithotripsy RVOT Right Ventricular Outflow Tract USFDA United States Food and Drug Administration SAH Sub Arachnoid Hemorrhage USG Ultrasonography SBP Systolic Blood Pressure UTI Urinary Tract Infection SBRT Stereotactic Body Radiotherapy VAP Ventilator Associated Pneumonia SCA Sudden Cardiac Arrest VDRL Venereal Disease Research Laboratory SDH Sub Dural Hematoma VF Ventricular Failure SGOT Serum Glutamic-Oxaloacetic Transaminase VIU Visual Internal Urethrotomy SGPT Serum Glutamic Pyruvic Transaminase VMAT Volumetric Modulated Arc Therapy SICU Surgical Intensive Care Unit VP Shunt Ventriculo Peritoneal Shunt SLEHD Sustained Low Efficiency Hemo-Dialysis VSD Ventricular Septal Defect SMA Superior Mesenteric Artery VT Ventricular Tachycardia SRR Survival Risk Ratio VVD AV Dual Chamber Synchronous Pacemaker SRS Stereotactic Radiosurgery VVI Ventricular Demand Pacemaker SSI Surgical Site Infection VVIRDual Sensor Ventricular Demand Rate Responsive STEMI ST Segment Elevation Myocardial Infarction SVC Superior Vena Cava 11 Mission 2013 : CIMS Cancer and Radiotherapy Center

To complete its mission of a multi-super specialty hospital, CIMS is geared to introduce a new service, The Radiation Oncology Center by end of November 2013 launching a full fledged CIMS Cancer Center (CCC).

It will commission the latest model of Linear Accelerator, Versa HD, from Elekta, the first of its kind in Asia and one of the first in the World. Versa HD gives clinicians the flexibility to deliver conventional therapies to treat a wide range of tumors throughout the body, besides enabling treatment of highly complex cancers that require extreme targeting precision. u Integrated with Elekta's recently- Linear Accelerator, Versa HD launched Agility 160-leaf multileaf collimator (MLC) u Versa HD provides highly conformal beam shaping – a critical requirement for maximizing the dose to the target, preserving surrounding healthy tissues. u Importantly, this high targeting accuracy is available over a large field-of-view, permitting delivery of high-definition (HD) beams to a wide spectrum of complex targets. u Capable of delivering radiation doses three times faster as compared to generation Elekta linear accelerators u Versa HD harnesses the ultra-fast leaf speeds of Agility MLC. u With this groundbreaking combination, clinicians at CIMS, for the first time, will have full advantage of higher dose rate delivery with sophisticated therapies, including stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT) and volumetric modulated arc therapy (VMAT) u This state-of-the-art radiotherapy facility will also mean more effective targeting of tumors, less damage to surrounding tissue and less risk of complications. 12 Departmental Overview

Departmental Overview 2011* 2012 Departmental Overview 2011 2012 Patient visits 33824 39917 Electrophysiology (EP Study) 376 383 OPD 26371 30081 Electrophysiology Study 196 212 IPD (Admission) 7453 9836 Radio Frequency Ablation 180 171 Total Procedures and Surgeries 7472 9937 Device Implants 113 131 Cardiac Procedures and Surgeries 6644 7846 Pace Makers 79 85 Cardiovascular Thoracic Surgeries 944 1147 Defibrillators 7 23 Cardiac Surgeries 861 1025 CRT 16 15 CABG 505 661 CRT-D 11 8 Valvular 120 118 Non Cardiac Procedures and 828 2081 Septal Defect Repair 69 65 Surgeries Pediatric 100 110 Orthopedic 99 502 MICS – CABG 27 19 CABG + MV Repair 11 15 Gastrointestinal, Bariatric and 360 629 MICS - ASD/Valve 12 17 Endoscopic Procedures Bental 1 6 Trauma 44 214 CABG+VSD 3 4 Neurology - Neurosurgery 27 150 Pericardiactomy 5 3 Urology 88 135 CABG + Carotid Endarterectomy 3 2 Oncology - Onco Surgery 61 124 Myxoma 3 2 General 28 58 CABG+SVR 2 3 Pediatric - Pediatric Surgery 21 63 Vascular surgery 55 73 Plastic - Reconstructive 26 35 Cardio Thoracic surgery 28 49 Spine 19 80 Cardiovascular Procedures 5700 6709 Gynecology 31 29 Invasive Cardiology 5211 6195 Diagnostic Cardiac 3834 4554 ENT 15 37 Catheterization (CAG) Pain management 9 25 Interventional Cardiac 1298 1519 Pathology 46215 67662 Procedures (PTCA) Radiology 14373 23541 Pediatric Catheterization 79 122 Dental Procedures 1158 2223 Procedures Pulmonary Medicine 1277 1845 *Corrected figures since the publication of outcomes 2010-11 13 CIMS Cardiology

CIMS Cardiology is manned by a committed team of experienced cardiologists with one of the largest group practice in Asia providing comprehensive quality care. Backed by the collective experience and technical expertise, the department performs over

600-700 coronary procedures a month making it one of the leading cardiac centre of the world treating every kind of heart and blood vessel disorder, from common to complex conditions. Dr. Satya Gupta, Dr. Milan Chag and Dr. Anish Chandarana

Different Cardiac Procedures at CIMS Hospital Total Cardiac Procedures and Surgeries

79 7856 Pediatric Catheterization 8000 122 res

u 6644 Device Implants 113 131 6000 roced P 376 2011 f

Electrophysiology Study o

and RF Ablation 383 4000

2012 ber m PCI/PTCA 1298 Nu 1519 2000 3834 Coronary Angiography 4554 0 0 1000 2000 3000 4000 5000 2011 2012 Number of Procedures *Amongst the highest in private sector in Western India

14 CIMS Cardiology

Coronary Revascularization- Appropriateness of use From total inhouse CAG only 21.43 % The increasing prevalence of coronary artery disease patients underwent PTCA in 2012. (CAD), continued advances in surgical and Total CAG and PCI at CIMS in 2012 5000 percutaneous techniques for revascularization and 4554 4500 concomitant medical therapy for CAD, and the costs 4000 3500 edures

of revascularization have resulted in heightened oc 3000 2500 interest regarding the appropriate use of coronary of Pr 2000 1519 revascularization which improves patients clinical ber 1500 976 1022 1000 543 outcome. Num 500 0 Appropriate use criteria are based on current In-house In-house PCI Other Total Open CAG PCI from Hospital's Heart understanding of the technical capabilities and In-house CAG - PCI Suregries potential patient benefits of the procedures examined. angiographies Aim of these criteria is to allow assessment of Use of coronary revascularization for patients with utilization patterns for a test or procedure. ACS and/or ischemia is appropriate. In contrast, revascularisation of asymptomatic The indications for coronary revascularization were patients or patients with low-risk findings on non developed considering some common variables such invasive testing and minimal medical therapy are as: viewed less favorable. u The clinical presentation (e.g., acute coronary In particular, the updated criteria address the following syndrome, stable angina) two areas: u Severity of angina (asymptomatic, Canadian 1. Re-evaluation of the indications for the treatment Cardiovascular Society [CCS] Class I, II, III, or IV) of multivessel CAD with symptoms by u Extent of ischemia on noninvasive testing and the percutaneous coronary intervention (PCI) and presence or absence of other prognostic factors coronary artery bypass graft (CABG) as a result of such as congestive heart failure, depressed left data from the SYNTAX trial, which came out after the original AUC were published ventricular function, or diabetes 2. Coronary revascularization is appropriate when u Extent of medical therapy the expected benefits, in terms of survival or u Extent of anatomic disease (1, 2, 3 vessel disease, health outcomes (symptoms, functional status, with or without proximal LAD or left main coronary and/or quality of life) exceed the expected disease). negative consequences of the procedure The technical panel scored each indication on a scale from 1 to 9 as follows: u Median Score 7 to 9 : Appropriate procedure for specific indication (procedure is generally acceptable and is a reasonable approach for the indication). u Median Score 4 to 6 : Uncertain for specific indication (procedure may be generally acceptable and may be a reasonable approach for the indication). Uncertainty implies that more research and/or patient information is needed to classify the indication definitively. u Median Score 1 to 3 : Inappropriate procedure for that indication (procedure is not generally acceptable and is not a reasonable approach for the indication). 15 CIMS Cardiology

Appropriate use ratings for re vascularisation in Acute Coronary Syndromes

UA/NSTEMI Cardiogenic Shock STEMI A

Low-Risk Intermediate/ Primary Thrombolytic Features High-Risk Reperfusion Therapy Features U A

< 12 hrs > 12 hrs Asymptomatic: no HF, Asymptomatic: no HF, no recurrent ischemic no recurrent ischemic A symptoms and symptoms and unstable ventricular unstable ventricular arrhythmia arrhythmia Severe HF, persistent Asymptomatic: no A ischemia, hemodynamic hemodynamic or instability and electrical instability electrical present instability

A I Normal LVEF Depressed with 1 - vessel CAD LVEF with 3 - vessel CAD U A

Asymptomatic: no HF, no evidence of recurrent Revascularization of Index Hospitalization or provocable ischemia non culprit vessel(s) I or no unstable ventricular arrhythmia Successful reperfusion with Lytic or PCI

Symptoms of recurrent Post Index Hospitalization myocardial ischemia and/or high risk findings on noninvasive stress Revascularization of testing performed after non culprit vessel(s) A A index hospitalization A=Appropriate, U=Uncertain, I=Inappropriate 16 CIMS Cardiology

Method of revascularization of multi coronary artery disease CABG PCI Two-vessel CAD with proximal LAD stenosis A A Three vessel CAD with low CAD burden(i.e. three focal stenosis, low SYNTAX score) A A Three vessel CAD with intermediate to high CAD burden (i.e. multiple diffuse A U lesions, presence of CTO, or high SYNTAX score) Isolated left main stenosis A U Left main stenosis and additional CAD with low CAD burden A U (i.e. one to two vessel additional involvement, low SYNTAX score) Left main stenosis and additional CAD with intermediate to high CAD burden A I (i.e. three vessel involvement, presence of CTO, or high SYNTAX score)

Noninvasive Risk Stratification Intermediate-risk (1% to 3% annual mortality rate) High-risk (>3% annual mortality rate) 1. Mild/moderate resting left ventricular dysfunction 1. Severe resting left ventricular dysfunction (LVEF 35% to 49%) (LVEF<35%) 2. Intermediate-risk treadmill score (score between -11 2. High-risk treadmill score (score≤-11) and <5) 3. Severe exercise left ventricular dysfunction 3. Stress-induced moderate perfusion defect without (exercise LVEF<35%) LV dilation or increased lung intake (thallium-201) 4. Stress-induced large perfusion defect 4. Limited stress echocardiographic ischemia with a (particularly if anterior) wall motion abnormality only at higher doses of 5. Stress-induced multiple perfusion defects of dobutamine involving less than or equal to 2 moderate size segments 6. Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201) Low-risk (<1% annual mortality rate) 7. Stress-induced moderate perfusion defect 1. Low-risk treadmill score (score≥5) with LV dilation or increased lung uptake 2. Normal or small myocardial perfusion defect at rest (thallium-201) or with stress* 8. Echocardiographic wall motion abnormality 3. Normal stress echocardiographic wall motion or no (involving>2 segments) developing at low change of limited resting wall motion abnormalities dose of dobutamine (≤ 10 mg/kg/min) or at a during stress* low heart rate (<120 beats/min) *Patients with these findings will probably not be at low 9. Stress echocardiographic evidence of risk in the presence of either a high-risk treadmill score or extensive ischemia severe resting left ventricular dysfunction (LVEF<35%).

17 CIMS Cardiology Appropriateness of Coronary Intervention and Angioplasty at CIMS

Use of radial artery for access Angioplasty (Percutaneous Coronary Intervention - PCI) predominates at CIMS. Though the Procedural Approach for Angioplasty procedure may take slightly longer and 1600 1388 (91.38 %) radiation exposure to the cardiologist 1400 1173 (90.37 %) 1200 is slightly higher, the radial access site edures 1000 2011 (N=1298) oc

has less vascular complications to the Pr 800 2012 (N=1519)

of 600 patient than the femoral approach. In 400 125 131 (9.63 %) (8.62 %) addition, it allows for earlier Number 200 0 ambulation and is particularly Radial Femoral efficacious in the obese. Various Risk Factors Among Patients Undergoing PCI (Angioplasty) 700

605586 600

ients 500 442 at 2011

P 401

of 400 2012 300 226 171 180 Number 150 200 122 90 51 77 76 100 22 0 Hypertension Diabetes MI Age > 75 Smoking Tobacco Alcohol Dr. Urmil Shah

18 CIMS Cardiology

Age Distribution in Years Among Patients Undergoing PCI (Angioplasty) 700 604 600

ients 500 449

at P 400 351 2011(N=1298) of 329 348 282 2012(N=1519) 300

200 Number 131141 83 100 70 15 14 0 ≤ 40 41-50 51-60 61-70 71-80 > 80 Age Distribution

As compared to 2011, in 2012 there was 34.53 % increase in PCI in the age group of 51-60.

Gender Distribution Among Patients Undergoing PCI (Angioplasty) Dr. Keyur Parikh and Dr. Ashit Jain 1400 1299 1200 1077

ients 1000 at P 2011 (N=1298) of 800 2012 (N=1519) 600

Number 400 221 220 200

0 Males Females

Proportion of male patients undergoing catheterization was higher as compared to females in 2012 as compared to 2011. Dr. Vineet Sankhla 19 CIMS Cardiology

Angiography at CIMS CIMS is a regional, national and 5000 4554 international referral centre for

3834 percutaneous coronary intervention. 4000 ients at P 3000 of

2000 Number 1000

0 2011 2012

Various Risk Factors Among Patients Undergoing Angiography 600 481 Dr. Gunvant Patel

ts 500 395 tien

a 400 P 317 2011 of 300 260 2012 Prevalence of hypertension and diabetes 239 197 187 200 154

Number 96 117 100 62 75 was higher among patients undergoing

0 Hypertension Diabetes Prior CABG Age > 75 Obesity Smoking angiography in 2012 as compared to 2011.

Age Distribution in Years Among Patients Undergoing Angiography in Year 2012 (N=4554) 1400 1273 1200

ients 1000

at 859 P 808 Males(N=3605)

of 800 Females(N=949)

600 Number 400 340 340 299 249 199 200 98 50 26 13 0 ≤ 40 41-50 51-60 61-70 71-80 > 80 Proportion of male patients in the age group of 51-60 years undergoing angiography was higher than Rotablator system for females in 2012. hard calcified lesions 20 CIMS Cardiology

Coronary Artery Disease

Percutaneous Intervention Door to Ballon Time 1550 1519 100 90 90 1500 90 s 1450 80

tient 70 a 1400 58** 2011 P 60 48.6* Of 1350 47 50 40 2012

1298 Minutes 1300 40 30 Number 1250 20

1200 10 1150 0 2011 2012 CIMS Hospital Indian National Average Cleveland Clinic ACC/AHA Goal CIMS does some of the largest number **Cleveland Clinic: http://my.clevelandclinic.org/Documents/outcomes/2011/ outcomes-hvi-2011.pdf of primary angioplasties amongst any *http://articles.timesofindia.indiatimes.com/2012-09-29/mumbai/34163390_1_angioplasties-cath-labs-cardiac-care centers in India. Door to Balloon Time

Widespread adoption of primary The ACC/AHA practice guidelines recommend PCI Percutaneous Coronary Intervention (Angioplasty) balloon inflation within 90 minutes of arrival in (PCI) at CIMS represents a major the emergency department for patients with ST-Elevation advance in the management of Acute Myocardial Infarction(AMI) resulting in a Myocardial Infarction (STEMI). Early reperfusion reduces the significant reduction in early and late risk of morbidity and mortality. At CIMS, we achieve this in mortality compared with pharmacologic less than 50 minutes on an average. reperfusion therapy.

Percutaneous Interventions Left Ventricular Ejection Fraction Among Patients Undergoing 1200 1119 Angioplasty

1040 450 1000 404 400 345 350 329 800 ients

at 281 P

ients 300 2011 (N=1298) 2011 at 600 of P

250 2012 (N=1519) of 2012 400 354 200

240 Number 150 200 Number 100 55 18 46 46 50 0 Single Vessel Double Vessel Triple Vessel 0 Disease Disease Disease 40-50% 30-40% < 30% (SVD) (DVD) (TVD) (Intermediate Risk) (High Risk) Coronary Artery Disease 21 CIMS Cardiology

Type of Intervention Restenosis after angioplasty and stent 1400 implantation has been historically considered 1200 1152 the most significant problem in coronary

ention 1000 interventional treatment. Drug Eluting Stent v 882 800 (DES) have dramatically reduced the rates of 2011 (1423) Inter r e s t e n o s i s a n d T a r g e t L e s i o n 600 521 498 2012 (1670) Revascularization (TLR) compared with Bare 400 Metal Stent (BMS). A low rate of In-Stent 200 Number of 20 20 Restenosis (ISR) exists after DES. 0 DES BMS Balloon Proportion of patients having zotarolimus Types of Drug Eluting Stents stent as well as everolimus was higher in 800

2012 as compared to 2011. Zotarolimus and 672 700 everolimus are second generation drug nts 600 548

tie eluting stents with anti-proliferative agent

a 500 2011(N=882) P

f which is released from a thin coating of a

o 400 2012(N=1152) r 300 255 225 biocompatible fluoro polymer on a flexible 184 mbe 150 u 200 cobalt–chromium stent frame with thin

N 100 struts. 3rd generation bioabsorbable stents 0 Zotarolimus Sirolimus Everolimus are widely used at CIMS in 2013 on regular Drugs basis.

Drugs Prescribed to Patients Undergoing Angioplasty

Aspirin Clopidogrel/Prasugrel/ Ticagrelor Statins

Beta Blocker

ACEI 2011

Isosorbide Dinitrate 2012

Nicorandil

CCB

ARB

0 20 40 60 80 100

Percentage Dr. Hemang Baxi and Dr. Ashit Jain 22 CIMS Cardiology

PCI Outcome at 6 months at CIMS (2011) Mortality Rate at One year Following PCI (2011)

5 4 4.5 3.89* 4 3.9

3.5 ges 3.8

tages 3 Males 3.7 2.5 Females ercenta P ercen 2 3.6 3.54 P 1.48

1 .5 3.5 0.89 1 3.4 0.5 0.29 0.15 0.2 0 3.3 Rehospitalization MACE Revascularization CIMS Hospital ACC *http://content.onlinejacc.org/article.aspx?articleid=1143854

IVUS Guided - A Case of Severe LAD Blockage Reverted with Bioresorbable Vascular Scaffold (BVS)

Case Presentation: A 62 year old male patient, was admitted to CIMS hospital with complaints of breathlessness for last three months. 80 % blockage Diagnosis and Management: After angiography report, intervention 90 % blockage was advised for total occluded distal Left Circumflex Artery (LCX), 90 % blockage critical multiple diffuse lesions in Left Anterior Descending (LAD), and 80% proximal Right Coronary Artery (RCA) lesion. Successful stenting with DES to RCA lesion was done in first stage. Since LAD Fig. 1 : LAD Blockages showed 3 sequential lesions (Figure 1) extending into distal part, latest technique of Bioresorbable Vascular Scafflold (BVS) was implanted. This prevented life long antiplatelet therapy, no metal 3 Overlapping 0 % blockage inside the artery, broader options available if any surgery or BVS 0 % blockage procedures to be required in future, and arterial remodeling to 0 % blockage natural status in that area. Successful PTCA with stenting of LAD was done using total 3 overlapping BVS. Outcome: Patient's post-operative hospital course was uneventful. Patient was haemodynamically stable at the time of discharge. Fig. 2 : LAD after Intervention with 3 overlapping BVS 23 CIMS Cardiology

Post Percutaneous Nephrolithotomy (PCNL) Massive Hematuria Treated Non-surgically with Coil Embolization

Case Presentation: A 18 year old male patient, operated for Percutaneous Nephrolithotomy (PCNL), had post PCNL recurrent hematuria.

Diagnosis and Management: CT-angiography revealed large perinephric hematoma with segmental branch of right renal artery having pseudoaneurysm with rupture. Patient's hemoglobin was 8.0 gm % Fig.-1: CT-Angiography revealing Fig.- 2: Colored Picture of Pseudoaneurysm Pseudoaneurysm on Right Kidney even after 2 packed cell volume (PCV) transfusions. In view of frank hematuria and rapidly dropping hemoglobin levels, emergency coil embolization of culprit segmented artery was done successfully. Aneurysm

Outcome: Coil Embolization Patient stabilized immediately and hematuria stopped totally.

Fig.-3 : Post PCNL Hematuria Fig.-4 : Embolization at the site Discussion: of Aneurysm The reported incidence of renal pseudo aneurysm following PCNL is 0.6 – 2.5%. Hemorrhage is one of the common complications and may occur at any point during the clinical course beginning with the nephrostomy puncture. Angiography with embolization is an effective modality for massive bleeding after PCNL. Many substances can be employed for embolization like Ethanol; gel foam particles; microcoil; detachable balloons; N-butyl-2- cyanoacrylate. We used microcoil for the treatment as it is easily available, cost-effective and has no long-term side effects. 24 CIMS Cardiology

A Young patient with Acquired Rheumatic Heart Disease and Congenital LongQT Syndrome

Case Presentation: A 30 year old female presented with complaints of Temporary Pacing breathlessness with dry cough, generalized weakness, on and off Implantation since 1 month. Patient was admitted to CIMS for Balloon Mitral Balloon Valvoplasty (BMV). Diagnosis and Management: Echo suggested severe mitral stenosis Remote DC Shock Patch with moderate Pulmonary Hypertension (PH). Resting ECG showed Fig.1 Balloon Mitral Fig.2 Defibrillator Leads long QT syndrome (Type-I), so patient was treated with IV MgSO4 and Valvoplasty temporary pacing was done. Balloon Mitral Valvoplasty was suggested. While patient was being prepared for BMV, she had Sudden Cardiac Arrest (SCA) which was revived with resuscitation. Patient had 3 episodes of Ventricular Tachycardia (VT, Torsade de Pointes) and two episodes of cardiac arrest which were reverted with DC shock and CPR. BMV was performed successfully thereafter (fig-1). Post operative echo suggested no significant Mitral Regurgitation (MR). During ICU stay, patient had multiple episodes of VT (Torsade de

Pointes). Hence AICD was planned, implanted successfully. Fig.3 Dual Chamber AICD Outcome: This is a very rare case of combination of Rheumatic Heart Disease (RHD) and LQTS which was successfully managed with BMV and dual chamber AICD (fig -2 and fig.-3).

IVUS Guided - PCI of Complicated Isolated Left Main Coronary Artery Disease with Low SYNTAX Score

Case Presentation: A 42 year old, male patient with smoking habit, presented with complaints of chest pain on exertion for last 2-3 months.

Diagnosis and Management: Exercise stress ECG showed ST depression in multiple leads with angina. Treatment was started with dual anti-platelet therapy, high dose of Fig.1 Significant Fig.2 IVUS statin besides other required treatment. CAG revealed Lesion in LMCA Assessment 60-70 % luminal narrowing of mid region of Left Main Coronary Artery (LMCA). PTCA followed by stenting was done under Intravascular Ultrasound (IVUS) guidance for this complicated isolated LMCA disease with low SYNTAX score. The patient was discharged after 48 hours. Outcome: He was prescribed antiplatelets, and statins on discharge as a measure Fig.3 Final Result of appropriateness of care at the time of discharge. after Stenting 25 CIMS Cardiac Investigations

OPD Cardiology Investigation Volume

18000 16681

16000 ts

14000 tien a 11609 11060 p 12000 2011(N=21959) of 10000 7556 8000 2012(N=33857) 6000 5059 Number 4000 2862 2000 0 ECG Echo TMT

OPD Cardiology Investigatio n Volume 300 260

250

ients 200 177 166 at

P 138 150 2011(N=21959)

of 114 100 82 2012(N=33857) 50 25 27 Number 0 Dobutamine Tilt Table Test Holter TEE Echo Stress Echo Monitering Test

Dr. Kashyap Sheth

26 CIMS Forefront in Cardiac Technology

Renal Denervation (Pending DCGI approval) The Symplicity™ renal denervation system uses a technique called Renal In 2013 CIMS will be one Denervation (RDN) to selectively calm hyperactive renal nerves. This causes a of the first centers to reduction in the kidneys' production of hormones that raises blood pressure implement Renal and protects the heart, kidneys and blood vessels from further damage. The Denervation Technology. Symplicity renal denervation system provides doctors an innovative treatment option for uncontrolled hypertension that offers several benefits including: u Significant reduction in blood pressure u Safe, short treatment that does not require general anesthesia u Fast recovery time with minimal complications

RDN therapy using the Symplicity renal denervation system accomplishes the same results as nonselective sympathectomy—effectively lowering blood pressure. However, it is performed with a safer, less invasive and more selective technique that carries a much lower incidence of potential complications and side effects. The Symplicity™ renal denervation system demonstrates promising results and has been featured at prominent medical conferences and in international medical journals. Clinical research shows that renal denervation with the Symplicity™ renal denervation system can provide safe, superior, and sustained reductions in blood pressure levels for patients with uncontrolled blood pressure with multiple antihypertensive medications. This research includes the Symplicity HTN-11 and Symplicity HTN-22 clinical trials.

The Symplicity renal denervation system has an unmatched safety record. In both the Symplicity HTN-1 and HTN-2 clinical trials, there have been: u No serious device or procedure-related events u No evidence of vascular injury/stenosis at the treatment site via imaging at 6 months u No orthostatic or electrolyte disturbances u Sustained renal function (eGFR and creatinine)

SUSTAINED REDUCTIONS IN BP THROUGH 3 YEARS Symplicity HTN-1 was a series of pilot studies involving 153 patients at 19 centers in Australia, Europe, and the US. In these studies, patients achieved a mean blood pressure change of -22/-10 mm Hg at 6 months, and a change of -31/-16 mm Hg for those patients that have reached their 3-year follow-up. Patients who have reached 3 year follow-up in the Symplicity HTN-1 study have shown a sustained reduction in blood pressure. Reference : 1. Symplicity HTN-1 Investigators; Hypertension.2011;57:911-917. 2. Symplicity HTN-2 Invegastitors. The Lancet. 2010:376:1903-1909. 27 CIMS Forefront in Cardiac Technology

Fractional Flow Reserve(FFR) u Fractional flow reserve (FFR) is a physiologic parameter Fractional Flow Reserve which can be measured easily during the intervention 12 10 procedure and can assess the functional significance of 10

ients 8

coronary stenosis. at P

u FFR-guided revascularization strategy is reported to be of 6 more effective than angiography-guided strategy in 4 Number patients with coronary artery disease. 2 1 u 0 Coronary stenosis with FFR ≤ 0.80 can be considered to 2011 2012 be “significant.” Benefits u FFR is a specific index for the epicardial stenosis and therefore better indicates as to what degree a patient can be helped by revascularization. u FFR is independent of changes in heart rate, blood pressure, and contractility. u FFR takes into account the contribution of the collateral flow. u FFR can be applied in multivessel disease and for serial lesions within one vessel. u FFR evaluates optimum stent deployment.

Rotablator At CIMS, Rotablator is used when: u The plaque is felt to be too difficult to flatten against the Since 1990 CIMS Cardiology has one of artery wall with just PTCA. u The plaque appears to have a large amount of calcium the highest experiences in using present in it and does not move easily. Rotablator in hundreds of cases. u The plaque is too long or starts where the artery begins. u The artery has too much plaque, which needs to be removed before another procedure. u The artery is felt to be small for other procedures. u A PTCA and/or stent has been done before and the lesion has reclosed.

Intravascular Ultrasound (IVUS) Cardiologists at CIMS observe images inside the heart and CIMS has been deploying the use coronary arteries to assist in diagnosis. IVUS offers a of IVUS since many years tomographic, 360-degree view of the arterial wall from the including virtual histology. inside, allowing a more complete and accurate assessment than is possible with angiography. 28 CIMS Cardiac Rhythm Disorders

CIMS has established a unique Cardiac Arrhythmia CIED Volumes Management Centre which provides customized catheter-based treatment that incorporates es 140 131 comprehensive state-of-the-art technology to edur 120 113

oc effectively cure arrthymias. 100 80 CIMS offers: 60 1) Electrophysiology Studies (EPS) 40 2) Radiofrequency Ablation (RFA) 20 Number of Pr 0 3) 3-Dimensional Mapping and Ablation 2011 2012 4) Pacemaker Therapy 5) Implantable Cardioverter Defibrillator (ICD) Pacemaker Implantation 90 85 6) Biventricular Pacing (CRT and CRT-D) 79

80

ants 70 Number of EP study and RF Ablation were higher in 2012 60 50 as compared to 2011. 2011 40 Goals of EP achieved at CIMS include: 30 2012 u A complete accurate diagnosis of an arrhythmia 20 Number of Impl (supraventricular or ventricular tachyarrhythmia or a 10 0 bradyarrhythmia) 2011 2012 u Establish the etiology for syncope (bradyarrhythmia Device Implantation or tachyarrhythmia) especially in patients with

structural heart disease 25 23 s t u Evaluate prognosis 20 ien 16 15 u at Stratification for risk of sudden cardiac death 15

f P 11 2011(N=34) u Acquire data regarding indications for therapy (e.g. 10 7 8 2012 (N=46) permanent pacemaker or defibrillator implantation) 5 u

Guide antiarrhythmic drug therapy Number o 0 u Evaluate the feasibility or outcome of CRT ICD CRT-D nonpharmacological therapy: (CRT-Cardiac Resynchronization therapy, e.g. transcatheter radiofrequency ablation, ICD- Implantable Cardioverter Defibrillators, antiarrhythmic surgery, or implantable CRT-D- Cardiac Resynchronization Therapy- cardioverter/defibrillator therapy) Defibrillator) 29 CIMS Cardiac Rhythm Disorders

At CIMS, patient with EF<35% were evaluated for risk of Pacemaker Implatation 2012 45 41 sudden cardiac death and a need for ICD. All patients 40

ients 35 implanted with defibrillators were followed up. These at P 30 27

of 25 patients have successfully survived sudden cardiac arrest 20 15 10 10 episodes due to VT/VF. Number 6 5 1 0 VVI DDDR VDD VVIR AAIR At CIMS, (VVI- Ventricular Demand Pacemaker, u Electrophysiologists and neurologists work DDDR-Dual Chamber Pacemaker, collaboratively to evaluate patients with unexplained loss VVD- AV Dual Chamber Synchronous Pacemaker, VVIR-Dual Sensor Ventricular of consiousness (syncope). Evaluation includes blood Demand Rate Responsive volume studies, tilt table testing, hemodynamic testing, AAIR - Artificial Pacemaker) heart rate variability and autonomic reflex testing. EP Study u CIMS is in the process of initiating an innovative 250 212 approach of remote monitoring to keep track of patients 196 200 ients 180 171 at

P

health regardless of their condition. Remote monitoring 150 2011(N=376) of of implanted patients is associated with increased 2012(N=383) 100

longevity and decreased need for in-person follow-up. Number 50

0 EP study RFA

CRT-D implantation Dr. Ajay Naik 30 CIMS Cardiac Rhythm Disorders

A Complex Case of Device Re-implantation

Case Presentation: A 68 year old gentleman, with procedural history of Aortic Valve Replacement (9 years ago), Coronary Artery Bypass Graft (7 years ago) and subdural hematoma (4 year ago) was admitted to CIMS. He had persistent Congestive Heart Failure, NYHA class III with repeated episodes of ventricular tachycardia, had undergone cardiac resynchronization therapy device (Biventricular Pacemaker + Fig. 1 Showing Leads of Defibrillator) implantation 6 months ago at another center. Fig. 2 Left Ventrical Temporary Pacing Leads of CRT-Device Diagnosis and Management: The patient was extremely sick, Electrodes in Jugalar Vein suffering from CAD, old anterior wall myocardial infarction, severe LV dysfunction LVEF about 25 %, ventricular tachycardia, CRT-Device pocket infection with pseudomonas. As the clinical profile suggests, the prognosis of the patient was quite poor. Dual chamber temporary pacing electrode was deployed via jugular vein. R2 defibrillator patches were attached to manage Fig.3 RA, RV and LV Fig. 4 CRT-Device ventricular tachyarrhythmias. Antibiotic therapy was initiated. Leads of CRT-Device Re-implantation Device re-implantation was performed on the right infraclaviuclar region. Implantation parameters for Right Atrial Lead were RA Threshold-0.5 V at 0.5 ms PW, Resistance-330 ohms, P wave- 2.2mV; Right Ventricular Lead RV Threshold- 0.3 mV@ 0.5 ms, Resistance-440 ohms at 5.0 V, R wave-11.7 mV; and Left Ventricular Lead LV Threshold-3.5 V at 0.5 ms, Resistance-730 ohms at 5.0 V, R wave-11.7 mV. The patient Fig. 5 : ECG on admission, showing Sinus Rhythm with t o l e r a t e d t h e Prolonged PR interval and Left Bundle Branch Block (LBBB) procedure well and t h e r e w e r e n o complications. Outcome: LVEF had improved to 35%. T h e r e w a s n o evidence of infective Fig. 7 : Post re-implantation ECG, showing a Fig. 6: Patient's ECG showing ventricular pacing during process. Ventricular Paced rhythm with LBBB temporary implanted pacemaker 31 CIMS Cardiac Surgery

CIMS Cardiac Surgery team comprises of skilled and experienced surgeons, anaesthetists and perfusionists who are highly committed to patient centered care.

Cardiac Surgeries at CIMS

505 CABG 661 Total Valvular Surgery… 120 118 100 Pediatric Cardiac Surgeries 110 69 Septal Repair Surgeries 65 Dr. Dhiren Shah MISC-CABG 27 19 11 CABG + MV Repair 15 12 2011 (N=861) MISC-ASD/Valve 17 2012 (N=1025) 1 Bental 6 3 CABG+VSD 4 5 Pericardioctomy 3 3 CABG + Carotid Enderectomy 2 3 Myxoma 2 2 CABG+SVR 3 0 200 400 600 800 Number of Procedures Dr. Dhaval Naik

Management Strategies for CABG Patients To Reduce Mortality and Morbidity: u At CIMS, in 95 % u Pre-operative complete evaluation of the patient isolated CABG's u To Continue aspirin till the date of Surgery patients internal memory artery is u Peri-operative trans-oesophageal evaluation of all patients grafted. u Doing maximum number of Off pump CABGs for better and faster recovery u In 18-20 % patients u To use maximum number of arterial grafts total arterial bypass u Continuous cardiac output and hemodynamic monitoring in the ICU graft were u Fast-tracking protocols in ICU for early mobilization and recovery succesfully u Post-operative physiotherapy and dietary counseling and advising performed - a high u Psychotherapy evaluation and management during post-operative period risk procedure. 32 CIMS Coronary Artery Bypass Grafting

Procedures 2011 2012 At CIMS clinic, mortality rates for patients, who Isolated CABG 505 661 had CABG plus other procedures with CABG was around 3 % which is lower than expected rate, despite the fact that nearly all patients were sick CABG + Other Procedures 34 29 and most of them had severe LV dysfunction. At CIMS, 661 isolated CABG procedures have been performed in 2012. LV Ejection Fraction Among Patients Undergoing CABG 400 350 At CIMS Hospital, bypass surgery may be 300

ients 250 performed in combination with other heart at P surgeries, when necessary, of 200 150 such as valve surgery, aortic 100 Number aneurysm surgery or surgery 50 0 to treat atrial fibrillation (an LVEF 40-50 % LVEF 30-40 % LVEF <30 % irregular heart beat). T h e g r e a t e s t r i s k i s Age Distribution in Years Among Patients Undergoing CABG correlated with the urgency 300 263 of operation, advanced age, 250 ients

LV ejection fraction, renal at 200 P

Dr. Dipesh Shah

of 149 dysfunction and peripheral 150 93 vascular disease. 100 84 Number 37 50 16 Variables that are related to mortality include: 0 ≤ 40 41-50 51-60 61-70 71-80 >80 u Coronary angioplasty during index Years admission Majority patients undergoing CABG surgery at CIMS u Recent Myocardial Infarction (MI) were in age group of 61-70 year. u History of severe and stable angina u Ventricular arrhythmias The observed (O) overall u Congestive heart failure or mitral mortality (1.8 %) was regurgitation u Comorbidities such as diabetes, lower than the expected hypertension, obesity, age>75, smoking. (E) mortality (2 %) Patients with LV systolic dysfunction resulting in low O/E (predominantly mild to moderate in severity) mortality ratio (0.9 %). had better survival with CABG than with Dr. Shaunak Shah medical therapy alone. 33 CIMS Coronary Artery Bypass Grafting

CABG in a Patient with Ruptured Pituitary Oedema

Case Presentation: A 68 year old male patient, known case of diabetes, hypothyroidism and pituitary macroadenoma, had complaints of chest pain on exertion.

Diagnosis and Management: CAG and 2D Echo of patient revealed, CAD-TVD, mild inferior wall MI, mild MR, LVEF: 50-55 %. Pre operative examinations were normal except Serum cortisol level-0.4 μ gm (low). Neurologist and endocrinologist were referred and after their clearance, beating heart CABG was done. During surgery, patient started developing hypotension with normal ECG. Patient was shifted to ICU with slightly high inotropic support but inotropic support requirement went on increasing. Arterial Blood Gas (ABG) acidosis kept increasing and lactic acidosis went upto 14.2. Cardiac output and Systemic Vascular Resistance (SVR) were measured. Intra-aortic Balloon Pump (IABP) was inserted but no improvement was observed. Sugar levels were very high inspite of insulin infusion, hence loading dose of hydrocortisone and dexamethasone were given. Sustained Low

Efficiency Haemodialysis (SLEHD) was planned for lactic acidosis. After 6-8 hr Ruptured Pitutary of dialysis and Inj. Effocorlin IV TDS, patient gradually started improving; ABG became normal and overall haemodynamic condition improved. Inotropes were gradually tapered and IABP was removed. Patient was extubated and overall post operative recovery was uneventful. Only abnormal laboratory reports post operatively were high WBC counts.

Outcome: Repeat CBC showed Hb – 11.2, platelet - 124,000, TC – 21190, Fig.1 Pitutary Oedema DC – 92/06/01/01

Conclusion: Patient had pituitary apoplexy postoperative leading to severe vasodilatation and low cardiac output. A variety of clinical symptoms associated with pituitary apoplexy have been described including headache, lethargy, confusion, obtundation, Addisonian crisis, unilateral ptosis, myosis, hemiparesis, visual field deficits and ophthalmoplegia.

34 CIMS Heart Failure

At CIMS, a total number of 339 patients were Appropriateness of Care 2012 successfully treated for heart failure. Left Ventricular Systolic 92 Function Evaluated

AT CIMS, Process measures for "heart failure" ACE/ARB Given For LVSD 97.5 patients include: Discharge Instructions 100 Provided u LVEF assessment (outpatient setting) Adult Smoking Cessation 100 u Symptom and activity assessment Advice Provided u Symptom management 0 10 20 30 40 50 60 70 80 90 100 110 u Patient self-care education Percentage u Beta-blocker therapy for LVSD Age Distribution in Years Among Patient with Heart Failure

100 91 86 u ACE inhibitor or ARB therapy for LVSD 90 81 80 72

ts u 70 62 65 Counseling about ICD implantation for 56 tien 60 a 47 2011 50 Of P patients with LVSD receiving combination 40 32 35 2012

30 16 medical therapy 20

Number 10 2 u 0 Post discharge appointment for HF patients Less than 40 41 - 50 51-60 61-70 71-80 more than 80 u Patient education about lifestyle, physical Years activity, diet, and medications is an Heart failure was higher in age group of less than 40year followed by 51-60 year. important component of providing quality Gender Distribution Among Patients With Heart Failure care for patients with HF. 250 s 209 Different Surgeries for Heart Failure 200 ient 175

160 at 145 P

f 140 140 150 130 2011(N=315) so 2012(N=339) 120 100

edures 100 oc

80 2012 Number 50

of Pr 60

ber 0 40 Males Females Num 20 15 3 4 Male patients with heart failure were higher 0 CABG CABG+MV RepairCABG+SVR CABG+ VSD compared to females in 2012. 35 CIMS Heart Failure

Post Myocardial Infarction Ventricular Septal Disease (VSD) in Cardiogenic Shock

Case presentation: A 68-year old female patient, normotensive, non-diabetic, had complaints of breathlessness on mild exertion, orthopnea, since 15 days which had aggravated since few days. Patient was admitted at CIMS Hospital for further evaluation and coronary work up. Diagnosis and Management: On admission, patient was in cardiogenic shock and was managed conservatively. On pre CAG investigations she had altered renal function (Creatinine=3.5). CAG was done which was suggestive of CAD, Acute Inferior Wall Myocardial Infarction (IWMI), cardiogenic shock, acute renal dysfuction, post MI VSD. Patient was advised for CABG with VSD closure. 2D echo was done on 11/01/2013, which was suggestive of LVEF: 50%, large post muscular VSD with left to right shunt, severe Tricuspid Regurgitation (TR) and severe Pulmonary Artery Hypertension (PAH). IABP was inserted preoperatively and patient was stabilized. Patient's lab parameters were abnormal; serum creatinine 3.5, prothrombine 4.5 (INR), platelet counts - 90,000, serum KP - 5.6 mcq/lt. With this parameters patient was considered in high risk. Patient was operated in emergency for CABG with post MI VSD closure. CABG with VSD closer was done using PTFE patch.Intra-operative transesophageal echo was done. LV posterior wall near crux was thin friable & RV in Sandwitch Patch that area was friable. Inlet muscular VSD of 20mm size with L-> R Fig.1 Patch Closure of Ventricular Septal Disease shunt and sever PAH with normal LV systolic function. Aneurysmal post LV wall near base. There was infarct at crux region with thin myocardium there.VSD was as large as 2 cm size in sub-mitral region with serpiginous tract into RV. RV septal and inferior wall was very friable and inflamed and divided into two plane. Repair of the VSD was done by exclusion technique, with a double patch sandwich technique with glue in between. Post operative 2D Echo showed no leak. Outcome: Post operatively, patient was shifted to SICU with high inotropic support and on IABP support. She was extubated after 2 days and IABP was removed after 3 days of surgery. Patient was discharged on 28/01/2013. Discussion: Post infarction rupture of the interventricular septum is a potentially fatal complication of acute myocardial infarction. It occurs in only 1-2% of patients with acute MI, and it causes early death in about 5% of post-MI patients. The most frequent complications of acquired VSD are rapidly progressing: congestive heart failure, cardiogenic shock, hemorrhage, pulmonary edema, renal insufficiency and eventual multiple organ failure; with these complications, mortality approaches 50%. Despite intervention, operative mortality for post-MI VSD repair remains high (from 20% to 40% by several studies); however, patients that survive in the short-term usually have favorable long-term outcomes.

36 CIMS Cardiac Valve Disorders

Prevalence of Cardiac Valve Disorders (N=405) Cardiac Valve Disorders 250 235 treated at CIMS include: 200 u Mitral Valve Replacement and Repair ts

atien 150 (MVR) P of u Aortic Valve Replacement (AVR) 100

mber 60 45 52 u Double Valve Replacement (DVR) Nu 50 13 0 MS MR MS-MR AS AR (MS- Mitral Stenosis, MR- Mitral Repair, AS- Aortic Stenosis, AR- Aortic Repair)

Patient population with Valve Non Ischemic Mitral Valve Repairs(N=29) Disorders

Myxomatous and 10 degenerative mitral 200 205 Valve Males 19 Rheumatic mitral Females Valve

Gender Base Prevelance 160 148

140 120 100

87 ients Males (N=233) at 80 P Females (N=172) of 60 36 38 40 22 23 22 16 Number 20 9 4

Patients from USA, UK, Kenya, 0 MS MR MS-MR AS AR Tanzania, Uganda Tajikistan, Zimbabwe,

Nigeria, Bangladesh, etc. come for Prevalence of mitral stenosis and regurgitation were higher in females, while aortic stenosis and regurgitation were higher in Cardiac Surgery at CIMS hospital. males.

37 CIMS Cardiac Valve Disorders

Majority of valve replacement procedure at CIMS Septal Repair Surgeries at CIMS (ASD/VSD) involves bio prostheses (biology tissue valves). 50 Newer generation bioprostheses are preferred for 46 45 41 most aortic and mitral valve procedures because res 40 u they are durable and help most patients avoid life 35

roced 30 long anticoagulant therapy after surgery and its P f 23 24 2011 (N= 69) o

25 associated complications. 2012 (N=65)

ber 20 m 15 Nu Mitral Valve Repairs for LV dysfunction are done 10 on a regular basis. 5 0 Patient who had isolated valve replacement had ASD VSD fewer complications than expected. Cardiac Valve Replacement Surgeries In all mitral valve patients, left atrial electro 90 77 cautery maze and LA ligation is done. 80 70 60 Valve repair, rather than replacement, is edures 2011 (N=87) associated with better survival, improved life oc 50 42 40 34 2012 (N=132) style, better preservation of heart function and of Pr 31 lower risk of stroke and 30

ber 20 infection (endocarditis) 20 14 w i t h n o n e e d o f Num 10 1 anticoagulation therapy. 0 CV surgery Team at CIMS AVR MVR TVR DVR is a pioneer and does high v olume valve repair Different Valve Surgeries at CIMS 80 surgeries. Mitral annuloplasty 72 70 60

eries 60 g

ur 50

of S 40 2012 30 30 20 Number 10 0 Dr. Niren Bhavsar Dr. Hiren Dholakia Dr. Chintan Sheth Biological valve Mechanical Valve Mitral Valve Repair 38 CIMS Cardiac Valve Disorders

Complex Aortic-Arch Reconstruction for an Acute Aortic Dissection, De Bakey Type I, Presenting with Stroke Case Presentation: A 38 year old female developed a sudden onset of giddiness, multiple episodes of vomiting and slurring of speech at home which progressed rapidly to left hemiplegia and was admitted to CIMS. Diagnosis: 2D echocardiography revealed ascending aortic dissection with severe aortic regurgitation. Multiline CT angiography of aorta revealed dissection flap in aorta (Stanford type-A ;De Bakey type-I) arising from the aortic root extending up to the bifurcation of aorta. The dissection was extending into brachiocephalic artery, both subclavian arteries, right common carotid artery with complete occlusion of right Internal carotid artery. CT scan of brain revealed Lacunar infarct in right caudate nucleus. Surgical Management: There was an impending rupture of ascending aorta contained just within the adventitia. Ascending aorta and total aortic arch replacement was done using femoral cannulation and cardiopulmonary bypass with profound hypothermia. Brief period (38 min) of total A circulatory arrest with antegrade cerebral perfusion for an open ended Fig.1A distal anastomosis was used. Native aortic valve was spared after fixing the dissection flap in the aortic root. All the arch vessels were reimplanted as an island after stabilizing the dissection flap. Outcome: No significant postoperative bleeding developed. Patient followed commands on the first post-operative day but unfortunately the neurological condition deteriorated on second post-operative day. CT scan of brain revealed progression of stroke on the right side. Discussion: In Acute Type-A aortic dissection, 100% patients presenting with coma and 76.2% presenting with stroke will not survive with just B medical management. However the mortality with surgical management is Fig.1B 27% for patients with preoperative stroke and 44% for those with preoperative coma. Also successful surgical repair increases the chances of post-operative brain injury reversal very much C which in turn increases the chances of survival. Fig 2 - Pre Operative Fig 3 - Post Repair Fig.1C CT Angiography 39 CIMS Minimal Invasive Cardiac Surgery

CIMS is the first official centre to launch a fully Total MICS Surgery equipped MICS program in Ahmedabad and 39 Gujarat 40 36 es MICS Surgeries at CIMS 35 (1) ASD 30 (2) Mitral valve repair / replacement ocedur (3) Aortic valve replacement 25 20 2011 (5) Selected cases of CABG of Pr 15 (6) Hybrid CABG 2012 At CIMS, of the total 36 patients, majority of ber 10 5 patients underwent 'Off-pump' MICS surgery. Num 0 Age Distribution of MICS Patients 2011 2012 20 15 15 14 12 edures MICS Procedures 10 oc 9 2011 (N=39) 10 8 2012 (N=36) 19 of Pr 20 18 4 5 3 ber 15 Num 0

Less than 40 41-50 51-60 61-70 greater than edures

oc 2011 70 10 9 9 7 2012 Gender Distribution of MICS Patients of Pr 5 5 29 5 3 30 ber

25 21

Num 0 20 edures 15

oc 2011 (N=39) 15 MICS-Off Pump ASD Closure MICS Mitral Valve Aortic Valve 10 2012 (N-36) CABG Replacement Replacement of Pr 10

ber 5

Num 0 Males Females LVEF of Patients Undergoing CABG MICS in 2012 (N=19) In Hospital Morbidity Rate in 2012

20 10 9 16 ents 8

ati 15 8 edures P oc of 10 6 5 ber

3 of Pr 5 2 4 Num

0 ber 2 2 Re-operation for Re-procedure Stroke Dialysis

Bleeding Num 0 Inspite of high morbid patient load, only in 2 % patients Less or Equal to 35 % 35-45 % 50-55% deep sternal wound infection was observed. 40 CIMS Vascular and Endovascular Surgery u As compared to 2011 (n=55) more vascular The use of vascular surgery reduces surgeries were performed in 2012 (n=73) patient morbidity and mortality. treating peripheral arterial occlusion disease, Vascular Procedures aortic aneurysms, varicose veins, diabetic 80 foot infection, deep vein thrombosis and 73 res u pulmonary embolism. 60 55

u With state-of-the-art operating rooms, roced P

f 40 o cathlabs, ICUs and the latest technologies at

ber 20

CIMS, surgeons have been successful in m Nu achieving excellent outcomes in all the 0 avenues of vascular diseases. 2011 2012 u CIMS team of vascular surgeon and Vascular Procedures interventional cardiologists perform a variety Varicose Vein 1 17 of procedures to treat patients with Carotid Angioplasty 13 peripheral artery conditions. They are skilled 8 2011 (N=55) 2012 (N=73) Limb Vessel Angioplasty 18 at angioplasty, atherectomy, stenting, 23

Renal plasty 23 thrombectomy and thrombolysis. 25 u CIMS vascular surgeons strive to use 0 10 20 30 Number of Patients autologous vein grafts. Aortic Aneurysm At CIMS, we manage aortic aneurysm (thoracic and abdominal) using open surgical repair and minimally invasive endovascular repair (EVAR and TEVAR) with high success rate. Varicose Veins and Chronic Venous Diseases The most complex venous ulcers and varicose veins are managed at CIMS with most advanced RF ablation, foam sclerotherapy and compression treatment. We do CDT (thrombolysis) for acute massive DVT and venous stenting for PTS (Post Dr. Srujal Shah Thrombotic Syndrome).

41 CIMS Vascular and Endovascular Surgery

Diabetic Foot Clinic Age Distribution u Diabetic Foot Infections (DFI) 50 47 are quite common in Gujarat and 45 s 40 thousands of patients loose rie 35 ge 29 30 their limbs due to failure to Sur 2011 (N=55) 25 of 18 19 2012 (N=73)

er 20 revascularize or optimal Diabetic foot infection 15 podiatric care. umb 8 7

N 10 u Infra Genicular (Tibial) Angioplasties as well as 5 0 bypasses using saphenous vein upto ankle are < 30 30 - 60 > 60 performed. u CIMS is proud to salvage many limbs with focused Gender Distribution 60 treatment strategies. 51 53 50 s

rie 40 A-V Access Surgeries 2011 (N=55) Surge 30 u At CIMS, Arterio Venous Fistula (AV fistula) of 20 2012 (N=73)

er 20 creation for the CKD patients for permanent dialysis umb 10 is done. N 4 0 u CIMS Vascular team have done basilic vein Males Females transposition and A-V grafting successfully for Patient Outcomes Vascular Surgery (N=55) patients having failed fistulas or poor venous 100 92.6 (51) conduits. (N) 80 ts

u n CIMS follows fistula first initiative. 60 u atie Having the best nephrologists of Ahmedabad as a 40 of P part of CIMS team, scientific and high quality care is 20 cent 3.7 (2) 3.7 (2) er

given to the patients. P 0 Deep Vein Thrombosis (DVT) and Pulmonary Embolism(PE) No re-admission Rehospitalization Death With an excellent back up of Intensivists and Cardiologists, experts are geared up to manage and save lives of patients suffering from Pulmonary Embolism. u Experts believe in early Catheter Directed Thrombolysis (CDT) whenever suitable to prevent 'Post Thrombotic Syndrome' and its lifelong sequel. CIMS endovascular surgeons place IVC filters in highly selected patients having contraindications or complications with anticoagulation or free floating thrombus in IVC. u At CIMS, venous plasties and stenting for treatment of post thrombotic syndrome and non healing venous ulcers is conducted with good outcomes. 42 CIMS Vascular and Endovascular Surgery

A Case of Complicated Acute Type B Aortic Dissection Treated Successfully using Staged Hybrid Repair

Case Presentation: This is a case of acute type B dissection in a 62 year old smoker; complicated by severe Superior mesenteric artery (SMA) and a celiac artery mal perfusion with Michigan Static (S) type compromise. After initial stabilization, CT angiogram and DSA were performed which confirmed clinical diagnosis. Management: Patient was kept on “Whit and

Pulmar” regimen (IV B blocker plus SNP) for Fig. 1 Type B Aortic Dissection Entry Tear Fig.2Re-entry/Exit Tear in Thoracic Aorta initial three days and then taken up for final definitive staged hybrid repair. Stage-I - Carotid to Carotid Bypass using dacron graft, Stage-II - TEVAR using Medtronic Valiant Stentgraft [38mm×38mm×150mm] were performed. Having deployed the stent graft, check Fig.3 Celiac Artery Compromise 70 % Fig.4 SMA Compromise 95 % angiogram confirmed sealing of dissection tear and patient's innominate artery, totally expanded true lumen of aorta upto bifurcation and opened up celiac and superior mesenteric artey. CSF (Cerebrospinal fluid) drainage, steroids and neuro protective agents were used for brain and spinal cord protection. Right Fig.5 Renal Arteries Fig.6 Thoracic Stent Graft in ventricular pacing through femoral vein was situ in Arch and Upper DTA used for accurate deployment of the stent graft. Right CFA was suture repaired and patient was shifted for elective monitoring. Outcome: Patient made excellent recovery in form of relieved abdominal angina, controlled BP, relieved back pain without any neurological deficit. Patient needs follow up for aortic dimensions and blood pressure control. To our knowledge this is the first case of complicated acute type B Aortic dissection treated successfully using staged hybrid repair Fig7A Fig.7B Fig.8 PostOperative CT Angiogram Showing Carotid-Carotid Medtronic Valiant Stent (Carotid-carotid bypass followed by TEVAR Bypass and Thoracic Stentgraft with Collapsing False Lumen Graft Covering Dissection Tear thoracic endovascular aneurism repair). 43 CIMS Vascular and Endovascular Surgery

Below the Knee Intervention for Chronic Limb Ischemia (CLI) in Diabetics Case Presentation: A 65 year old gentleman having persistent left foot rest pain and a chronic non healing ulcer was evaluated at CIMS hospital. Diagnosis and Management: Angiography showed multiple calcified stenotic lesions in proximal ATA, distal PTA and a short segment occlusion in distal ATA. Ante Fig.1Angiography Fig.2 Posterior Tibial Fig.3 Anterior Tibial grade left femoral puncture was done. Artery (PTA) Angioplasty Artery (ATA) Angioplasty Lesions crossed with dedicated CTO wire Vin 18 and lesions were treated using 2 x100 mm tibial balloons with prolonged inflation time of 1 minute at 14 atm pressure. ATA lesions were also treated and planter arch circulation was completed. Outcome: Post procedure patient was kept on high dose lipid lowering medicines and dual antiplatelet therapy. Pain at rest was relieved and ulcer healed over 2 week's periods. Follow up is required. Successful Management of the Most Challenging Venous Ulcers at CIMS Vein Clinic

Case Presentation: We present a case of grade 6 venous disease in a 50 year old male having non healing ulcer over gaiters area. Despite consulting almost 30 doctors, wound remained unhealed.

Diagnosis and Management: Patient was evaluated and found to have leg perforator incompetency on venous Doppler. USG guided micro foam sclero therapy was performed and compression stockings were given. Fig.1 Before Sclerotherapy The ulcer healed within 1 month span with excellent patient satisfaction. At CIMS vascular surgery division, we have the latest RF ablation device and micro foam therapy technique. We have treated the most complex venous ulcers with a 100% success rate.

Outcome: The challenging venous ulcer was managed successfully.

Fig.2 One Month after Sclerotherapy 44

CIMS Thoracic Surgery

At CIMS, Cardiothoracic surgeons perform different Thoarcic Surgery types of surgeries which reveals their expertise and 49 skills. 50 res Guidelines followed for Thoracic Surgery u 40 u High antibiotic levels at the site of incision for the 28 roced 30 P

duration of the operation, are essential for effective f o prophylaxis. 20 u Antibiotic prophylaxis administered too early or too ber

m 10 late increases the risk of SSI. Studies suggest that Nu antibiotics are most effective when given ≤ 30 0 minutes before skin is incised. 2011 2012 u The pragmatic approach is to administer prophylaxis towards the end of induction and ensure that surgery Thoracic Procedures 4 starts within 30 minutes of this time wherever Lobectomy 6 possible. 1 Lung Decortication 5 u It is important that antibiotics are fully administered 6 prior to tourniquet inflation. Thoractomy 4 4 u Patient's who experience major blood loss (greater Embolectomy 4 2011 (N=28) than 1500ml) should have fluid resuscitation, Pneumoectomy 1 3 2012 (N=49) followed by re-dosing with the Sinus Related 2 recommended prophylaxis regimen 1 for that operation. Rib Excision 1 3 u For operations lasting > 4 hours, re- Pleuroscopy + ICD 1 8 dosing may be necessary. Others* 23 u F o r s u r g i c a l s i t e i n f e c t i o n 0 5 10 15 20 25 flucloxacillin, vancomycin IV and Number of Surgeries Dr. Pranav Modi PLUS IV are given. Gender Distribution of Thoracic Patients Age Distribution of Thoracic Patients 30 35 33 27 30 25 23 25 atients atients 20 2011 (N=28) 2011 (N=28) 20 14 of P

of P 16 13 15 2012 (N=49) 15 2012 (N=49) 11 ber ber 10 8 10 5 4 Num 5 Num 5 0 0 Males Females < 30 30 - 60 > 60 45 CIMS Neonatal and Pediatric Critical Care

Key features of Neonatal and Pediatric Critical Care Children Admitted for Medical illness ts 389 Unit 400

atien 322 u Highly qualified intensive care team to treat P of 300 2011 (N=419) 185 critical neonates and children 200 2012 (N=574) mber u Nu 97 State-of-the-art 12 bedded advanced 100

neonatology setup, well equipped with 0 NICU PICU conventional as well as high frequency Non Cardiac Pediatric Surgery oscillatory ventilation (HFOV-SLE 5000) with 70 63 60 50 ients 37 facility of Nitric Oxide(NO) delivery at 40

P 2011 (N=21)

of 30 21 2012 (N=63) u Multi-disciplinary intervention program with 20 12 14 12 10 4 4 1

Number 0 facilities like in-house pediatric surgery, Gestrointestinal Genito-Urinary Respiratory Head and Neck Total

pediatric cardiology and pediatric cardiac Age Distribution of Non Cardiac Pediatric Surgery 35 surgery, fibreoptic bronchoscopy, post trauma 33 30 care 25 ients 20 2011 (N=21) at P

14 u 15 12 2012 (N=63) 24x7 emergency support and pediatric of 10 10 6 5 5 transport team equipped with pediatric 5 Number 0 ventilators < 1 month 2-12 months 2-10 yr > 10 yr

Dr. Tejas Shah and Dr. Amit Chitaliya 46 CIMS Neonatal and Pediatric Critical Care

Pediatric Cardiac Catheterization Procedures(N=122)

RVOT device closure 1

Balloon atrial septostomy 2

Balloon aortic valvoplasty 4

VSD device closure 4

Coarctation dilation 11

Balloon pulmonary valvoplasty 13

Diagnostic studi es 17

ASD device closure 31

PDA device clousre 39 Pediatric Bronchoscopic Procedures 0 20 40 60 15 13 Number of Procedures

edures 12 oc Pediatric Cardiac Surgeries 2012 (N=110)

Pr 9

of 6 3 VSD closure 32 Tetrology repair 23 3 ASD closure 21

Number 0 PDA closure 7 2011 2012 TAPVC repair 4 Glenn 4 Coarctation repair 4 Arterial switch 3 Neonatal and Pediatric Cath Lab Procedures and Cardiac Surgeries PA band 2 BT shunt 2 140 122 Valve replacement 2 120 110 ients Supravalvar AS 1

at 100

P RV- PA conduit 1 79 80 71 of 2011 (N=150) Pericardiactomy 1 60 2012 (N=232) Subaortic Membrane Resection 1 40 Fontan 1 20 Senning's 1 Number 0 0 10 20 30 40 Cardaic Surgeries Cath Lab Procedures Number of Procedures

47 CIMS Neonatal and Pediatric Critical Care

Case of A Life Threatening Right Ventricular Failure

Case Presentation: A 4 day old baby boy was brought from Bhavnagar with life threatening cyanosis (bluebaby) and right heart failure. Diagnosis and Management: 2D echo of patient was suggestive of Persistence Pulmonary Hypertension (PPHN), right ventricular hypertrophy with negligible forward flow per pulmonary valve to lungs. Child was unable to maintain his vitals Fig. 1 : Baby in NICU even on ventilator with 100% Fio2. Child showed symptoms of bradycardia and cardiac failure. Sildenafil citrate was given but there was no response. There were multiple episodes of cardiac compromise and child was in severe cardiogenic shock state. There was a team approach of managing the kid with life saving and novel Fig. 2 : Nitric Oxide gas tool-Nitric oxide therapy. The child started responding well gradually and nitric oxide was weaned off over next 3 days after coming to minimal dose of 5 ppm. Serial ECHO showed marked improvement and child was successfully weaned off from ventilator after 6 days. With 13 days of total hospital stay the child was discharged. Outcome: Nitric Oxide therapy was a life saving therapeutic tool. This exemplifies perfect multi disciplinary care of CIMS starting from safe Neonatal transport in ambulance from 200 km away from Ahmedabad to state-of-the-art unit offering life saving Nitric oxide therapy by a team of well experience expert; which is not available in more than 4 to 5 centres in entire Gujarat as per our information. Cases of Extremely Premature Babies Weighing merely 900 gm

During this academic year; we served the best of care to two premature delivered babies (newborn); Nature has made them new born at just 7 months of intrauterine age(premature births). They were placed on highly sophisticated neonatal ICU (NICU) for about 1.5 month preterm care including life support on ventilator due to their immature lungs and immature organ system. With premature delivery, child A at 7 months of delivery weighed 850 gm while child B weighed 890 gm. At 8-9 Fig-1A : Child B at the time of birth Fig-1B : Child B at 8 months months age, both are doing well. Figure-1 Child B weighing 890 gm at the time of birth 48 CIMS Neonatal and Pediatric Critical Care

Surgery of Anomalous Origin of Left Coronary Artery from Pulmonary Artery (ALCAPA) Case Presentation: A 3 month old baby girl, weighing 5 kg was referred to CIMS with history of repeated respiratory tract infections. Diagnosis and Management: X-ray of chest showed gross cardiomegaly (fig.1), 2- D Echo showed dilated left ventricle with severe LV dysfunction (EF 15%), severe mitral regurgitation and anomalous origin of left coronary artery from pulmonary artery (fig -2). Cardiomegaly: Patient underwent ALCAPA repair: The left coronary artery was explanted from pulmonary artery and was translocated to ascending aorta. The Fig.1 X-ray of chest showing defect was filled with autologous pericardial patch. Patient was weaned off cardiopulmonary bypass with left atrial pressure of 9 mm Hg. Peri operative Echo showed smooth flow in left coronary artery. After 48 hours, delayed sternal closure was done. The child was extubated on the sixth post operative day. Inotropes were gradually tapered. Outcome and Medication : At discharge Echo showed mild MR with LVEF of 25 % Fig.2 : 2-D Echocardiography and smooth flow into left coronary artery. The child was discharged with diuretics and ACE inhibitors. Discussion: ALCAPA is a rare congenital cardiac anomaly in which the left coronary originates from pulmonary artery instead of aorta. It carries a very high mortality if left untreated. Catheter Interventional Management of Post Operative Chylothorax in Complex Congenital Heart Disease

Case Presentation: A 5 year old boy, with Complex Congenital Heart Disease (CHD) Criss-cross AV connection, large ventricular septal defect, Fig.1Bidirectional Glenn Shunt :Glenn Procedure – Interim double outlet right ventricle and pulmonary stenosis underwent open heart palliative surgery in children with complex CHD – Single Ventricle surgery (Bidirectional Glenn Shunt (fig.1) + Atrial Septectomy + Physiology. Tricuspid valve repair) at CIMS. Three months later, patient presented with history of respiratory infection with onset of distress since few days. Diagnosis and Management: On investigation, he was found to have right pleural effusion. Intercostal drainage of pleural fluid revealed Chylothorax. Patient was initially managed with low fat diet, decongestives and Octreotide infusion and cardiac catheterization was planned. Cardiac catheterization revealed high Glenn pressures (mean 20-24 mmHg) due to Fig. 2 Device Closure of RVOT through IJV Approach high pulmonary artery pressures which by temporary obstruction with balloon catheter showed fall in mean pressure (14-15 mmHg) to normal. As high output of Chylothorax persisted despite above mentioned measures, Right Ventricular Outflow Tract (RVOT) device closure was done through internal jugular vein approach using 14 mm Amplatzer muscular VSD device. Outcome: The drain output reduced over few days and ICD was removed on 7th post procedure day. Discussion: Novel application of standard procedure works wonders at times. For this patient, CIMS team successfully avoided second surgery (MPA ligation)by occluding RVOT through percuteneous route. 49 CIMS Pulmonary Medicine

CIMS Pulmonary Medicine Department is managed by senior Pulmonary Medicine and eminent pulmonologists.They are well versed with all 2000 modern techniques in their field including Fiber Optic 1765

Bronchoscopy, Pulmonary Function Testing including DLCO 1600

ients 1208

at 1200 2011 (N=1277) Sleep study, fiberoptic pleuroscopy and allergy testing. P

of 2012 (N= 1845) 800 Following diseases are diagnosed and treated at CIMS 400 Number hospital : 18 17 51 63 u Bronchial asthma including difficult to treat asthma 0 Sleep study EEG PFT u COPD and advanced COPD u Interstitial lung diseases Number o f Patients in PFT Study u Respiratory allergic diseases 2000 1765 ts u Tuberculosis and drug resistant tuberculosis 1500 tien 1208 a u Lung tumors P

of 1000 u Snoring and sleep disorders (snoring is hazardous and 500

should not be ignored) Number u Non resolving and recurrent pleural effusion 0 2011 2012 u Critical care for critically ill pulmonary patients Number of Patients in Sleep Study Following facilities are available at CIMS hospital: 20 18 u Video fiber-optic bronchoscopy (diagnostic and 17 therapeutic procedure) 15 u Pulmonary Function Test (PFT) including Diffusing ts

tien 10 a P Capacity of Lung Carbon Monoxide (DLCO) of u Sleep laboratory (one of the best sleep lab with highly 5

trained sleep specialist and pulmonologist) Number 0 u Allergy Testing 2011 2012

Sleep Lab CIMS Sleep Laboratory fills the vacuum for a world class sleep disorder lab in Gujarat. It is the latest and most sophisticated sleep lab in Gujarat with dedicated suite room allocated in the hospital for comfort of patients. Dr. Amit Patel Dr. Nitesh Shah 50 CIMS Pulmonary Medicine

Who needs a sleep study? All individuals who snore at night and have one of the following symptoms u Excessive loud snoring u Disturbed night sleep u Daytime sleepiness u Choking in sleep u Lack of concentration u Loss of memory u Irritability u Depression u Sexual dysfunction u Breathlessness that wakes you from sleep u Patient with uncontrolled hypertension, heart diseases, CV stroke with loud snoring

Pulmonary Function Tests u Pulmonary function tests are a group of procedures that measure the function of the lungs, revealing problems in the way a patient breathes. u The tests can determine the cause of shortness of breath and help in differential diagnosis of lung diseases, such as asthma, COPD or interstitial lung disease. u The tests are also performed before any major lung surgery to make sure the person is not disabled by having a reduced lung capacity. u CIMS PFT lab has facility to conduct DLCO, which is an integral tool to measure extent of problem in interstitial lung disease.

Pulmonary Alveolar Proteinosis

Case Presentation: A 35 year old male non-smoker patient with no pre morbid condition came to CIMS with complaints of dry cough and breathlessness on exertion since 1 year. Patient was working in a warehouse. Diagnosis and Management: X-ray of chest showed bilateral fluffy opacities. HRCT thorax showed crazy paving pattern bilaterally (fig 1). Hematology was normal; previously was treated with antibiotics but showed no improvement. So pulmonary alveolar proteinosis was suspected. To confirm the diagnosis Fig. 1. CT Thorax showing bronchoscopy and transbronchial biopsy was done. Histopathological Crazy Paving Pattern examination showed deposition of periodic acid schiff (PAS) stain positive lipoproteineous material in alveoli, confirming pulmonary alveolar proteinosis (PAP). For treatment of PAP, both lungs were lavaged one after another with isotonic normal saline until remaining fluid was clear, requiring 20-50 litres of saline and 4-8 hours, while one lung being ventilated. Outcome: Patient's post operative hospital course was uneventful and post lavage CT scan and X-ray showed significant improvement. Fig.2. CT Thorax Showing Significant Improvement after lung lavage 51 CIMS Critical Care

CIMS Critical Care Unit u Equipped with state-of-the-art technology ICU, latest ICU/GICU Admission ventilators, infusion pumps, monitors, bed side 1000 918 900 warmers, defibrillators, bed side echo and availability of 800 dialysis facilities 700 653 u Offers a healing environment to the sick 600 ients 500 at u P Practices evidence based medicine to ensure good 400 outcomes of 300 u Experts manage an array of highly complex multisystem 200 100 Number medical and surgical condition. 0 u Our success rates are at par with the best institutions in 2011 2012 the world. Total admission rate increased by 40% in 2012. u Concept of Green ICU followed Admission in Medical ICU in 2012 (N=918) At CIMS, CCU Process Measures Include: 120 1. Avoid excessive use of antibiotics 105 100 92 ts 86 82 84 85 2. Judicious monitoring of fluid and inotrope therapy 76 80

atien 80 70

3. Avoid excess sedation P f 60

o 57 4. Avoid too liberal blood transfusion 60

ber 41 Responsibilities of CIMS Critical Care Physician/Director m 40 Nu 1. Creating guidance for granting of specific privilege in the 20

ICU 0 2. Developing ICU programs, policies, rules and regulations Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 3. Developing recommendations about the need for continuous educational programs that are consistent Bedside Procedures in Medical ICU

with the type of service offered by critical care and Intubation 150

developing performance improvement activities CVC 150 4. Managing physician staff members adherence to medical DLC and bedside Dialysis 100 laws and other hospital policies, sound principles of ICD 50 clinical practice regulation that promote patient safety Lumbar Puncture 40 A-line 30

Pericardiocentesis 20

Pleural Tap 12

IABP 10

Epidural Catheter 10

Ascitic Tap 8

0 50 100 150 200 Number of Procedures (CVC-Central Venous Catheter, ICD- Implantable Dr. Bhagyesh Shah, Dr. Vipul Thakkar, and Dr. Harshal Thaker Cardioverter Defibrillator, DLC- Dialysis Catheter, IABP- Intra Aortic Balloon Pump ) 52 CIMS Critical Care

Severe Acute Respiratory Distress Syndrome(ARDS): Nightmare for Critical Care Physician Case Presentation: A 56 year old gentleman, premorbidly healthy, except heavy smoking habit, was admitted at district level hospital with H/o fever and shivering 7 days before presentation. His fever improved with local treatment only to reappear with cough and expectoration, generalized weakness, tremulousness, got rapidly worsened in form of dyspnoea, desaturation with O2 support-requiring mechanical ventilator support within 12 hr of hospitalisation, planned for transfer with calculated risk considering limited further supportive facilities available at that center. Diagnosis and Management: Patient was shifted to CIMS hospital - on arrival he was unresponsive under effect of sedative and paralytic agents with Fig.1 On Admission

(100%fiO2, 14 PEEP) PaO2- 81.5 (100% fio2, 14 PEEP) with lung compliance of 30-32 ml/cm H2O, was hemodynamically stable. He was continued with sedation paralysis- controlled ventilation (Low Tidal Volume Ventilation Strategy-restricting Pplat to <= 30 cm H2O), antibiotics, antivirals, stress ulcer prophylaxis, DVT prophylaxis, pressure sore prophylaxis, enteral feeding through nasogastric tube. All possible sepsis screening culture was sent before antibiotics was initiated and invasive hemodynamic monitoring was done. X-ray of chest was s/o of B/L diffuse infiltrate s/o severe ARDS. His RT-PCR for H1N1 was negative. Next day, his PO2 69.5( on 70 % fiO2, 14 PEEP) pH 7.20,PCO2 73.2. Recruitment maneuver was done after hypovolemia correction, in view of Fig.2 On Discharge (3 lit O with nasal cannula) poor gas exchange/lung compliance 28ml/cmH2O. Over next 48 hours his FiO2 2 support came down to 55 %, PEEP - 10. After stopping sedation, he had vigorous coughing-biting of endotracheal tube - requiring intermittent sedation to facilitate oxygenation and ventilation. He was also continued with RT feeding, closed ET suctioning. He remained febrile but hemodynamically stable, could not be made fully conscious-needing sedation for intermittent agitation and difficult to ventilate state, hence early tracheostomy- on day 5- was done, antibiotics were escalated empirically and then administered a/c to sensitivity for Klebseilla and Acinetobacter pneumonia. As he was not in a normal conscious state (agitated delirium) with reduced both lower limb movement, CT brain and CSF study were done and were within normal limits. He was continued with antipsychotics (sedation- completely stopped), RT feeding and physical therapy. His febrile state, leucocytosis, radiological and oxygenation index improved over next one week. He was weaned from ventilator support by intermittent PSV mode ventilation and T piece. His conscious level gradually normalized and he was started on semisolids orally. His tracheostomy was decannulated on day 15 of arrival to CIMS hospital. He was transferred back to same hospital with minimal oxygen support. As per last telephonic discussion, he had recovered much better and had a good weight gain. 53 CIMS Critical Care

Severe Myocarditis due to Legionella Pneumonia Infection Case Presentation: A 23 year old female had complaints of high grade fever, abdominal discomfort since 2-3 days. Serum Widal test was done showed titre of 1:320. The patient was started on Inj.Ceftriaxone 2gm iv b.d. by the treating physician. Patient became afebrile on day 3 and discharged home on day 7.

After day 4 of discharge she started feeling breathless and taken back to physician who started her on oxygen support and CXR was done which showed bilateral fluffy infiltrates. Patient had tachypnea, tachycardia though afebrile. Her oxygen saturation was 85% on 8 litres . As the patient was getting worse with increasing breathing difficulty she was shifted to CIMS hospital. Fig.1 X-Ray chest Day-1 (On Admission) Diagnosis and Management: Patient was extremely breathless ,not able to speak, desaturating even on Non Re-Breather Mask (NRBM) with 15 ltrs; immediately put on Non-Invasive Ventilator (NIV) support with 100% Fio2. Samples were immediately sent for blood cultures, other laboratory parameters and for ABG. She was started on injectable azithromycin, vancomycin and cefepime in appropriate doses to cover atypical bacteria, resistent Pneumococcus and methicillin-resistant Staphylococcus aureus (MRSA) and salmonella respectively. We sent her Pneumoslide panel which is used to detect respiratory viruses and atypical bacterial infections.

Her first arrival ABG showed pH-7.56, PCO2-28, PO2-56, HCO3-21. Her Fig.2 X-ray Chest on Day-3 other laboratory parametes were Hb-9.7, TC-13290 with 81% neutrophils, On treatment PC-114000. Her QBC for Malarial parasites and DENGUE IgM antibody and NS-1 antigen were negative. Serum sodium-139, serum pottasium-3.34, serum urea16.45 and serum creatinine-0.75. SGPT-99.04, urine r/m and stool r/m were negative. She had NT-Pro BNP levels at 7723(very high). Her CXR showed bilateral extensive fluffy opacities. 2DEcho showed severe global 54 CIMS Critical Care hypokinesia, LVEF -25%, severe Triscuspid Regurgitation, mild Mitral Regurgitation and thickened myocardium along with moderate bilateral pleural infusion. Next day her legionella pneumonia titre came significantly Positive.

Oral digoxin, carvedilol, epleranone, perindopril and IV furosemide and dobutamine infusion according to cardiologist advice were started. Cefepime and Vancomycin were stopped when the blood c/s came sterile. We added Moxifloxacin for double coverage of Legionella. Patient slowly started improving and came off NIV support on day 4. She complained of epigastric discomfort on and off, her USG abdomen was non significant except mild ascites but her serum lipase levels were 1305(high). We managed her conservatively with modified diet.

Outcome: On day 7 she was discharged with oral antibiotics(azithromycin and moxifloxacin) and anti heart failure drugs. Her repeat 2D Echo showed significant improvement in terms of minimal hypokinesia, LVEF-45- 50%, No MR, TR. Her SGPT -70 and serum lipase was 113.

Patient came for follow up after 14 days of antibiotics and she was perfectly normal and had started working back .

Discussion: In conclusion, clinical findings and low sensitivity and specificity of tests like WIDAL can mislead the clinician if not followed with confirmatory tests like blood culture for typhoid. Again we would emphasize on using antibiotics judiciously covering all possible organisms at the same time deescalating and narrowing the spectrum once c/s reports are back. NIV still remains treatment of choice for cardiac dysfunction related respiratory failure to avoid invasive ventilation and thus avoiding its complications like VAP, VILI, Barotrauma etc. Atypical infections like legionella can cause multiorgan dysfunction with major organ involvement like heart, lung, pancreas and requires adequate therapy. This may misguide even an experienced doctor also.

55 CIMS Orthopedic Surgery

Orthopedic in house department

Joint Replacement Department 1. Orthopedic Procedures 502 Tertiary trauma care 510 2. es r u Pediatric Orthopedic 3. 340 oced

r P Arthroscopy f o

4. 170

ber 99

Spine m 5.

Nu 0 CIMS runs state-of-the-art joint replacement 2011 2012 department at the Orthopedic unit which takes care from admission to rehabilitation. CIMS Orthopedic Surgery Hospital had 5 fold rise in orthopedic Ankle Fixation 2 procedures from 2011 with predominantly 1 3 total knee replacements. Facial Bone Fracture 3 4 CIMS Orthopedic surgery team includes Shoulder Arthroscopy + Fixation 3 experienced Joint Replacement Surgeons, 4 Hip Joint Arthroscopy + DHS Fixation 10 Plastic Surgeons, Intensivist, Anaesthetologist Knee Arthroscopy + ACL Fixation 4 which conduct complicated procedures with 26 2011 (N=99) 5 2012 (N=502) excellent outcomes. Total Hip Replacement 36 The orthopedic surgeons of CIMS use 6 Amputation of Limbs and Digits 51 techniques like tendon sparing incision which Humerus and Radius Ulnar Naialing 6 aids in faster recovery. Patient walks on the 59 10 same day of surgery. Femur and Tibia Nailing 87 55 Knee is bend up to 90° without pain the next Total Knee Replacement 226 day. Patient is taught stairs climbing and toilet 0 50 100 150 200 250 training on second post operative day. Number of Patients Patient is discharged on 4th day. 56 CIMS Orthopedic Surgery

Guidelines for Total Knee Replacement Goals of Total Knee Replacement u Severe pain and disability with accompanying u Postoperative pain relief and wound radiological changes in the knee are almost always the care indications for the operation. u Early mobilisation from Day 1 u Orthopedic Assessment u Restoration of knee range of motion q A medical history, when the surgeon gathers u Functional muscular recovery information about general health u Maintain a healthy body weight to q Physical examination with assessment of knee reduce stress on the new joint movement, stability and strength, followed by an X-ray. u Discharge in 3-5 days q Occasionally blood tests and magnetic resonance imaging (MRI) may be required to clarify the Newer Procedures in 2012 at CIMS diagnosis q Smoking habit, if any 4 Elbow Fixation u Pre-Operative Evaluation is done by physiotherapist 12 4 Multiple Trauma u Knee replacement is performed under a general or epidural spinal anaesthesia, which numbs the lower Pelvic Girdle Surgery limbs. Carpel Tunnel Release u Careful tissue handling and attention to haemostasis 18 u Minimising post-operative pain, nausea and vomiting u Avoidance of fluid overload, hypothermia Gender Distribution of Orthopedic Patients u Use of multi-modal analgesia 350 303 u Limited use of tourniquets 300

atients 250 u Tranexamic acid to minimise blood loss 199 200 2011 (N=99) u of P For recovery, optional Physiotherapy and rehabilitation 150 2012 (N=502) ber therapy is given to patients, with many patients not 100 53 46 opting for the same. Num 50 0 Males Females

Age Distribution of Orthopedic Patients 250 227 190 200

atients 150 2011 (N=99) of P 85 2012 (N=502)

ber 100 54 50 33 Num 12 0 Dr. Amir Sanghvi and Dr. Chirag Patel Dr. Hemang Ambani Dr. Ateet Sharma < 30 30 - 60 > 60 57 CIMS Orthopedic Surgery

Unusual Case Presentation of Severe Arthritic Right Knee and Neglected Tendo Achilles Rupture

Case Presentation: A 63 year old male patient known case of hypertension, presented with complaints of pain in right knee for last 8 to 10 years with inability to walk without support and instability in left ankle area since 2 months.

Diagnosis and Management: Patient gave vague history of trauma in left ankle before 2 months and was treated by local doctor but investigation was not done. When patient came to CIMS Fig.1 Pre Operative Fig. 2 X-ray of Both hospital, he was not able to walk. Knee(AP View)

Complete tendo achilles rupture on left side and severe osteoarthritis of the right knee was confirmed by X-ray and sonographic investigations. This was an unusual case of Fig.3A Preoperative osteoarthritis and soft tissue injury together, in Fig.3B Post Operative X-Ray of Both Knee Lateral View Right Knee (AP Lateral view) different limbs. Simultaneous operation for total knee replacement (TKR) requiring supine position and tendo achilles reconstruction (interposition plantaris tendon graft with gastrosoleus turnover flap was done) which requires prone position were performed.

Outcome: Patient gradually improved after the operation. Patient's overall hospital course was Fig.4 IntraOperative Left Fig.5 IntraOperative uneventful. Ankle Showing Tendo Left Ankle showing Achilles Rupture Reconstructed Tendo Achilles 58 CIMS Orthopedic Surgery

Recurrent Osteoclastoma Operated for Limb Preserving Surgery

Case Presentation: A 59 year old female patient, known case of osteoclastoma, operated before 30 year, presented with complaints of pain while walking, redness and swelling at right knee.

Diagnosis and Management: Tumor excision was done and cement was placed before 30 years. Knee X-ray of patient showed osteoarthritis of knee and MRI did not Fig. 1 X-Ray of Tumour Fig.2 Pre Operative X-ray 30 years before show recurrence of tumor. Advised for TKR. On exploration of knee, it was found that articular cartilage breakage had been caused by the cement which led to osteoarthritis. Instead of simple Fig.3A Fig.3B Fig.3C During Procedure prosthesis, a novel approach of Custom Made

Prosthesis of lower end of femur was applied. TKR was performed successfully. Post operative X-ray of knee showed knee prosthesis with cementing normal knee joint space.

Outcome: At 3 months post surgery, patient is pain free and has a 00 range of movement from 00 to 1200. Fig.4APost Operative Fig.4B Post Operative X-ray(AP View) X-ray(Lateral view)' 59 CIMS Trauma Centre

Department No. of Patients Trauma due to RTA 200 179

2011 2012 ients at P

150

OPD Patients 9 26 of IPD Patients 44 214 100

Total 53 240 Number 50 36

0 CIMS Trauma center provides an organized and 2011 2012 systemic approach to the care of the injured patients. Main cause of trauma was road traffic accidents (RTA). Optimal trauma care requires system oriented approach that integrates field and hospital element Trauma Cases 15 which CIMS is already offering. 12 nts

tie 10 9

a 8 Goals achieved at CIMS Trauma Centre P 2011 (N=8) f o 4 4 u To assist in improving the care of the injured r 5 2012 (N=35) 2

1 1 1 1

patient by providing emergency consultation and mbe

u 0 comprehensive trauma care under one roof N Assaults Burn Fall Poisoning Others fromHeight according to Resources for Optimal Care of the *Others : Iron Rod Injury (1, 0); Chemical Explosion (0, 2); Snake Bite (0, 2) Injured Patient u To assist in the ongoing assessment of trauma Age Distribution patients for Optimal Care of the Injured Patient 70 65 for appropriateness, timeliness, and efficient management 60

50 45 Gender Distribution ients 40 2011(N=44) 200 at

181 P 40 180 2012(N=214)

of 29 160 30 21 140 ients 20 13 14 at 120

P 2011(N=44) 9 7 100 Number 10 6 4 5 of 2012(N=214) 80 0 60 ≤20 21-30 31-40 41-50 51-60 >60 35 40 33 Number 20 9 0 Young patients (21-30 age) were admitted to CIMS Males Females Trauma centre because of road traffic accidents. Proportions of males admitted at CIMS Trauma centre were higher as compared to females. 60 CIMS Trauma Centre

Injury Spectrum 90 83 80 70

nts 60 53

tie a

P 50

f 2011 (N=44) o

r 40 2012(N= 214) mbe

u 30 24 N 18 20 20 16 14 15

10 6 3 5 1 0 Maxillo-facial Pelvic injury Chest injury Abdomina l Limb Head injury injury Injury Fracture Dr. Sanjay Shah

To determine the line of treatment, the trauma 2011 (N=8) 15 severity scores include injury severity score and 11.86 e

l revised trauma score. ca

S 10 Post Discharge Care at CIMS: GCS 4.75 Occupational therapy : CIMS has state-of-the-art 5 age er

physiotherapy centre and team of expert v A physiotherapists who not only help in improving 0 functional status of the patients but also for his GCS at the Time of Admission GCS After Insulin Regulation improved Quality of Life(QoL). It aims at maximizing Proportions of patients treated at CIMS trauma centre the functional potential of an individual following a had highest percentage of head injury 2012 (N=27) disease/dysfunction after injury. 12 10.88

H2H care (Hospital to Home care) : CIMS provides e l 10 ca very efficient hospital to home care to patients. A S 8 5.88 doctor is sent to the residence of the patient for GCS 6 4 taking vitals and blood sugar in follow up after 1 age er

v 2 week to 10 days. Patient is asked for any complaints A 0 along with physical examination. He communicates GCS at the Time of Admission GCS After Insulin Regulation with treating consultant. 61 CIMS Trauma Centre

Case of Injury due to Iron Road Penetration over Left Side of Neck with Massive Hemorrhage Case Presentation: A 9 year old child fell down while playing, and had penetrating injury due to iron rod over left side of neck, had massive hemorrhage from wound. He was taken to local hospital where they tried to control the bleeding by applying multiple hemostatic forceps but could not do successfully and with prior intimation was shifted to CIMS accompanied with anaesthetic and surgeon. Our trauma team was ready for further treatment.

Diagnosis and management: During transfer he had cardiac arrest before 10 minutes of arrival and was given CPR. On presentation, he was unconscious, GCS-E1M4VT, pupil dilate + 4mm and NRL(non reacting to light) as CPR was given. After CPR, P=160/min SBP: 60 mm Hg, on ionotropic support of dopamine and noradrenaline. Central and arterial line were inserted and normal Fig. 1: Multiple Hemostatis sinus rhythm regained, with ventilator support. X-ray of chest was suggestive Forceps applied to of no hemothorax or pneumothorax. The child was operated immediately. Left Control Bleeding common carotid artery and left intra jugular vein were dissected; avulsion of left superior thyroid artery at its origin, transaction of left facial artery rent in left internal jugular vein was repaired primarily. Patient was given multiple blood component (12 products), IV fluids, Inj.vit.K, Inj. Tranexemic acid and other supportive care. He was kept on ventilator support. Ionotropic support was tapered and stopped. Blood parameters came to normal levels. He regained consciousness after 14 hours and was extubated. Patient was not having any neurological deficit inspite of long CPR in ambulance and in ER of CIMS trauma centre along with torrential external bleeding. He was mobilized independently. Post operative colour doppler suggested normal flow in LCCA, LECA, LICA and Fig.2 Recovery left IJV. after Procedure Outcome: Patient came with poor haemodynamics and in cardiac arrest with extuberent external bleeding. An effective CPR along with aggressive resuscitation and invasive monitoring was done in ER. Timely intimation before transferring such patient allowed us to activate whole trauma team, ER department, operation theatre staff and blood bank. This event was managed successfully because of team work and the bold decision to go ahead by trauma surgeon inspite of very poor prognosis. Discharge medications included antibiotics, antacids and analgesics.

62 CIMS Gastro-Intestinal Surgery

Minimal Invasive Surgery Hernia Repair GI Procedures Under this surgery laparoscope with television monitor is used to push back hernia at its place with the help of a 300 259 surgical mesh. Recovery is faster with minimally-invasive res u hernia repair than with open hernia repair. The technique 200 leaves only small scars, and may cause less pain than roced P f o open hernia repair. 94 100 ber

Advantages of Minimal Invasive Surgery Hernia Repair m Nu u Causes less pain than an open hernia repair 0 u Allow the patient to return to work and to a normal 2011 2012 lifestyle more quickly u Allows easier repair of double (bilateral) inguinal GI Surgery 9 hernias Hernia Related Surgeries 39 20 u Reduce the chances of a ventral hernia re-occurring, Cholecystectomy 38 13 and possible complications Intestinal Surgery 17 3 Analrectal Surgery 9 Age Distribution of GI Surgery Patients Appendectomy 7 8 2011 (N=94) 2 2012 (N=259) 140 126 Spleen Related 2 120 Liver Related 6 1 atients 100 3 Whipples Surgery 1 80 72 2011 (N=94) of P 17 61 Laparotomy and Minor Surgery 75 2012 (N=259) 60 47 14 ber 34 Debridement and Suturing 69 40 0 20 40 60 80

Num 13 20 Number of Surgeries 0 Dr. Chirag Thakkar < 30 30 - 60 > 60 Patient Outcomes Gastrointestinal Surgery at 1 year (N = 94) Gender Distribution of GI Surgery Patients 100 91.5 (86)

250 (N) 213 80 200 atients 60 P atients

150 2011 (N=94) of e of P 40 2012 (N=259)

ber 100 69

centag 20 46 5.3 (5) er 3.2 (3) 50 25 P Num 0 0 No Re-admission Re-admission Death Males Females 63 CIMS Gastro-Intestinal Surgery - Bariatric Surgery

Bariatric Surgery Patient Outcomes Bariatric Surgery at 1 year

30 28 100 94.5 (17) 90

ts 25 80 (N)

20 18 s 70 60 f Patien

tient o

15 a 50 2011 (N=18) P 40 10 30

Number 5 20 5.5 (1)

ercent of 10

P 0 0 2011 2012 Death Re-admission No Re-admission Dr. Digvijaysingh Bedi Bariatric surgeries: Sleeve Surgery u Gastric By-pass u Bands u Intragastric balloon

Gender Distribution of Bariatric Patients Age Distribution of Bariatric Patients

20 19 20 18 18 18 16 16 14

14 atients atients

P 11 f

P 12

f 12 2011 (N=18) 2011 (N=18) o

o 10 10 9 10 9 2012 (N=28) 8 2012 (N=28) ber ber 8 8 m m

Nu 6 Nu 6 4 3 4 4 1 2 2 0 0 < 30 30 - 60 > 60 Males Females Dr. Jayant Jhala Bariatric Gastric Sleeve Surgery in a Morbid Obese Patient with Associated Complications

Case presentation: A 34 year old male patient, non diabetic, known case of hypertension since 5 years, on regular medication, having history of severe weight gain in last 6-7 months (117 kg pre-operative) was admitted for treatment at CIMS. Diagnosis and management: Following consultation was advised for gastric Fig-1A Before Surgery Fig-1B Before Surgery sleeve bariatric surgery. Patient was admitted to CIMS hospital for further management. Ultrasonography of pelvis and abdomen showed diffused fatty infiltrative liver. Patient was operated for Sleeve gastrectomy. Outcome: Patient's post operative hospital stay was uneventful. At the time of discharge, patient was haemodynamically stable. Now, patient's weight is 89 kg after 4 months of procedure. Fig-2A After Surgery Fig-2B After Surgery 64 CIMS Endoscopy

Endoscopy Services at CIMS: Endoscopy Procedures u Olympus Colonoscope is used to examine Large Bowel i.e. Colon, 400 342 res

Rectum (large intestine). u 300 248 u Ultramodern endoscopy from Olympus–Gastro scope for Upper GI roced P

f 200

tract i.e. Oesophagoscopy o

u Gastroscopy and Duodenoscopy ber 100 m

u Colonoscopy Nu 0 u ERCP to evaluate bile duct and pancreatic ducts 2011 2012 u Capsule Endoscopy for small intestinal diseases u Removal of tumors like polyps from stomach, duodenum, large intestine Fiberoptic Bronchoscopy 100 u Removal of stones from bile duct 89 80 u Stent placement in food pipe, bile duct and pancreatic duct 60 55 u Management of acute upper and lower GI hemorrhage (bleeding) 40

20 Number of Procedures Endoscopy at CIMS 0 CIMS Endoscopy is a state-of-the-art facility equipped with the latest 2011 2012 endoscopic, monitoring, and infection control equipment. Staffed by experienced Different Endoscopic Procedures 176 G a s t r o e n t e r o l o g i s t s , S u r g e o n s , 180 160 136 Respirologists, and endoscopy nurses 140 s CIMS is committed to deliver expert rie 120 100 89

Surge 2011 (N=248)

endoscopic care in a timely, safe, and of 80 60 2012 (N=342) er 60 55 patient friendly manner. We provide acute 38 umb 40 N 11 care 24 hours a day, 7 days a week, to 20 5 7 6 5 2 manage life threatening illnesses as well as 0 GI Scopy Bronchoscopy Coloscopy Nasal Direct Rigid Naso Endoscopy Laryngoscopy Bronchoscopy Pharango screening procedures for diagnostic and Laryngoscopy preventive purposes. Endoscopy Includes u Investigate causes of digestive pathologies like abdominal pain and gastrointestinal bleeding u Diagnose digestive diseases and conditions such as anemia, bleeding, inflammation, diarrhea or cancers of the digestive system u Treat certain digestive system problems such as difficulty in swallowing caused by a narrow esophagus, or to remove polyps; to remove foreign objects, etc.

Dr. Yatin Patel 65 CIMS Neurosurgery

At CIMS, state-of-the-art surgical and microsurgical techniques are employed to diagnose, treat and alleviate pain and disability caused by neurological problems. Procedures like Spine Trauma, Head Injuries, Polytrauma, Spine Surgery, Brain tumour surgery, Disk replacement surgery, Endovascular Neurosurgery are routinely performed.

Technological Excellence at CIMS u Moller Wedel operating microscope with stereo co-observer and Number of Patients in EEG Study 70 63 camera system 60 51 u Craniotome ts 50 atien 40 u of P LED OT light 30 u Inbuilt OT cameras for direct relay and transmission of cases in 20 Number 10

auditorium 0 CIMS Neurosrugery Principle 2011 2012 “Minimally invasive surgery for a focused exposure in the region of Shunt Surgery for Hydrocephalus brain brain, spine or skull base resulting in limited manipulations and Preoperative Post Operative disturbance to surrounding normal neural tissues along with accelerated recovery time.” - CIMS

Paediatric Neurosurgery u Hydrocephalus: Endoscopic ventriculostomy, shunt surgery u Pediatric brain and spine tumor surgery u Spinal dysraphism and tethered cord surgery u Craniosynostosis correction u Occipito cervical decompression for chiari malformation MRI scan brain

At CIMS, highly qualified and skilled team of neurosurgeons along with an efficient team of anaesthesiologists, nurses and medical staff perform different surgeries of neurology. Dr. Purav Patel Hydrocephalus baby 66 CIMS Neurosurgery

Brain Surgery Services Neurosurgeries u Cranial trauma 160 150 u Brain tumor surgery res u u Microscopic/ endoscopic transnasal pituitary 120 tumor excision u roced Neuro Vascular lesions: Aneurysm, AVM P

f 80 o u Stroke surgery: brain hemorrhage, carotid

endartrectomy ber 40 27 u Stereotactic surgery m Nu u Cranioplasty 0 u Epilepsy surgery 2011 2012

Skull Base Surgery Services Neurosurgeries 80 u Skull base tumor excision : acoustic neuromas, s 70 62 rie 60

chordomasu ge 2011 (N=27) u Cerebro spinal fluid leaks Sur 40 2012 (N=150) of 20 15 u er 11 Craniofacial deformallities 5 5 6 1 2 0 u Cranial base osteomyelitis umb N Spine Craniotomy + EVD VP Shunt Vascular Cranioplasty u Decompression + Excision of Malformation Micro vascular decompression for trigeminal and Fixation Tumor Excision neuralgia, hemifacial spasm Gender Distribution of Neurosurgery Patients Death rate and re-admission rates in patients 120 102 after neurosurgery were not more than 5.69% 100 atients and 7.32% respectively. 80 2011 (N=27) of P 60 48 2012 (N=150) ber 40 18

Patient Outcomes Neurology at 1 Year (N=27) Num 20 9 0 100 88.9 (24) Males Females (N) 80 Age Distribution of Neurosurgery Patients atients 60 P 90 77 of 80 e 40 70 atients 60 2011 (N=27)

of P 50

centag 38 20 35 2012 (N=150) 7.4 (2) er 40 er

3.7 (1) b

P 30 0 20 15 Num 5 7 No Re-admission Re-admission Death 10 0 < 30 30 - 60 > 60 67

CIMS Neurosurgery

Brain Abscess in Patient with Tetralogy of Fallot Case Presentation: A 27 year old male patient was admitted at CIMS hospital with complaints of left upper and lower limb hemiplegia, persistent headache, vomiting since last 20 days. Patient was initially evaluated elsewhere and diagnosed to have right parietal brain abscess for which burr hole and tapping of brain abscess was done before 4 weeks and patient was on continuous antibiotics since then. Diagnosis and Management: MRI brain (fig.1) revealed large right temporo-parietal abscess with thick capsule enhancement. Echocardiogram revealed feature suggestive of tetralogy of fallot. In view of known cardiac pathology responsible Fig. 1Brain Abscess Pre Operative for brain abscess and no response to tapping and antibiotic medication it was decided to do craniotomy and abscess evacuation with removal of total abscess wall to give maximum possible neurological recovery. The same was done after 3 days of admission with the team of neurosurgeon, neuroanaesthetist and cardiologist. Outcome: Post operative CT brain (Fig.2) showed total evacuation of abscess without any mass effect and midline shift. Left hemiplegia started improving and the patient was discharge in stable condition. Fig. 2 Post Operative Discussion: Cerebral abscess is a serious infection of the brain parenchyma. Un- operated cyanotic congenital heart disease (CCHD) is an important predisposing factor for brain abscess, accounting for 25-46% of cases . Brain Aneurysm Clipping Case Presentation: A 50 year old male patient presented with complaints of severe headache since last 10 days with vomiting and giddiness.

Diagnosis and Management: CT scan of the brain angio was suggestive of fusiform aneurysm (fig. 1) arising from terminal ICA at the part of origin of right middle cerebral artery (MCA) and anterior cerebral artery (ACA). Patient was Fig.1 CT scan of Brain Angio operated for right pterional craniotomy and clipping of right ICA bifurcation aneurysm under general anesthesia. Post operative CT brain (fig. 2) revealed resolution of SAH with clipping in situ.

Medication at Discharge: At the time of discharge patient was prescribed with anticonvulsant, antihypertensives and analgesics.

Fig.2 Postoperative CT of Brain 68 CIMS Spine Surgery

Spine Surgery Minimally Invasive Spine Surgery (MISS) 80 Out of total 80 spine surgeries performed on 80 res u patients, 41 were males and 39 were females. In 60

addition, majority of patients were of 30-60 age roced P

f 40 o group. Lumbar spine surgeries outnumbered cervical 19 and dorsal surgeries. ber 20 m Nu 0 2011 2012 Advantages of MISS u Less invasive than conventional discectomy Different Surgeries of Spine

procedures 40 38 37 u Causes less muscle damage than open s rie 30 discectomy ge Sur u Results in less back pain 20 2011 (N=19) of 14 2012 (N=80) u Has less operative blood loss er u 10 5 Shortens the hospital stay umb 3 2 N u Can also be used in recurrent disc herniations 0 Lumber Cervical Dorsal Common techniques for decompression u Discectomy-Microscopic Age Distribution of Patients of Spine Surgery u Spinal decompression 60 53 u Laminotomy or laminectomy 50 u atients Foraminotomy or foraminectomy 40 2011 (N=19) u of P Osteophyte removal 30 24 2012 (N=80)

u ber Corpectomy 20 11 u Spinal pedical fixation 6 Num 10 u Bone grafting 2 3 0 u Inter body fixation < 30 30 - 60 > 60 u Support by rods and cage Dr. Purav Patel Outcomes of Spine Surgery 2011 (N=19) Gender Distribution of Patients of Spine Surgery 120 45 41

(N) 100 (19) 39 100 40 35

80 atients atients 30 2011 (N=19) P

of P 25

of 60 2012 (N=80) e 20

ber 13 40 15 10 6 centag 20 Num

er 5 P 0 0 No Re-admission Re-admission Death Males Females 69 CIMS Spine Surgery

Anterior Cervical Microforaminotomy for Cervical Radiculopathy (Jho's Procedure)

Minimally invasive surgery aims to provide equivalent or better results than conventional surgery, with the advantage of reduced morbidity due to less invasive exposure. Anterior cervical microforaminotomy is one such procedure. It also aims to preserve motion at the operated level and hopefully avoid disc degeneration at the adjacent levels secondary to reduced movement after fusion Procedure: Skin marking of the appropriate level was performed after induction of anesthesia. A standard anterolateral cervical skin crease incision and approach to the spine were used. However the incision was made on the side of the lesion for unilateral pathology. The longer colli was retracted as far as possible. A 5-mm hole was then made using a round burr on the high speed drill (fig. - 1a and 1b). This began at the superior part of the unco-vertebral joint and Fig. 1a the trajectomy of drilling is shown in fig. - 2. The posterior longitudinal ligament was opened and the decompression was completed with the bones. Haematosis from the foraminotomy was obtained using gelatin sponge. The wound was closed with subcuticular monocryl with wound drainage. A surgical collar was not used and the patients were mobilized the day after surgery and discharged on the post operative day. Postoperatively radiating pain subsided completely and patient was mobilized after 3 hours of surgery and discharged on 2nd day. Case Presentation: 32 year old male presented with severe left upper limb L6 radiculopathy since 4 to 6 weeks. Treatment with analgesics, steroids and physiotherapy showed no improvement. MRI cervical spine (fig. 3a and 3b) showed L5-6 left side foramina disc with compression of exiting nerve root. L5-6 left side anterior cervical microforaminotomy was conducted. Fig. 1b

Fig. 2 Fig. 3a Fig. 3b Fig. 4 70 CIMS Spine Surgery

Balloon Kyphoplasty for Osteoporotic Compression Fractures Fractures : Balloon Kyphoplasty is a minimally invasive surgery for utilization of vertebral compression fractures. The incidence of osteoporotic fractures is increasing due to rising life span and osteoporotic and/or panic individuals in the population. Indications: 1. Osteoporotic vertebral compression fractures not responding to standard conservative treatment for more than 4-6 weeks duration 2. Progressive increase in pain, disability and radiologically documented worsening on follow-up 3. A vascular necrosis of vertebral body (cleft phenomenon) Investigations: X-ray of the spine, standing lateral view in flexion Fig.1 Balloon Kyphoplasty and extension should be taken. CT scan with 3D, saggital and coronal reconstructions is helpful in assessing the complex vertebral fracture. Thin reconstructed sections showed the fracture and integrity of the posterior vertebral wall. MRI can show positive prognostic sign with bone marrow edema or endplate edema. Procedure: 'C' arm fluoroscopic guidance is used throughout the procedure. Fig.1 is showing Balloon kyphoplasty in a thoracolumbar vertebral compression fracture (A). The instruments are inserted through a transpedicular bilateral approach following meticulous placement of (B) the K- (guide)-wires. The balloon is inflated and the applied pressure reduces the compression fracture, and forms (C) a cavity that is filled with (D) bone cement. Following injection and hardening of cement, the instruments are removed and the previous end plate angulations and kyphosis are restored. In well selected cases kyphoplasty can produce excellent pain relief and is one of Fig.2 MRI of L1 Decompression fracture the most gratifying procedures. It prevents progressive deformity in the spine and improves the quality of life in the elderly patients with compromised health due to other medical problems. Case Presentation: 24 year male patient had a fall from height. X-ray and MRI revealed L1 decompression fracture (fig. - 2). Patient underwent balloon kyphoplasty. Intra operative lateral 'C ' arm (fig. - 3a and 3b) shows cement concentrated in anterior column to give good support. Post –operative , the patient was discharged after 2 days. Fig.3a Fig.3b Intra Operative Lateral 'C ' Arm 71 CIMS Urosurgery

CIMS has a dedicated treatment program for Total Urology Surgery prostate cancer skills and facilities to carry out laparoscopic (keyhole) surgery. CIMS urologists 150 135 res perform minimally invasive surgical procedures u 120 resulting in shorter hospital stays, less discomfort 88

roced 90 and bleeding, and a shorter recovery period including P f o regular activities and less time away from work. 60 ber

m 30

New Urological Surgeries Performed in 2012 Nu 0 Name of Surgery Total No. 2011 2012 of Surgery Lap. + Micro Varicocelectomy 5 Urological Procedures 4 HOLEP 1 Lap. Radical Prostactomy 2 PCN insertion 1 4 Hydrocelctomy 2 Technological Excellence at CIMS 3 Prostate Biopsy 3 5 u Storz HD Laparoscopy and urology instrument Orchidectomy 6

Bladder Surgery 2 u LED OT lights 7 2011 (N=88) 3 2012 (N=135) u Nephroctomy 7 4th generation Harmonic and tissue sealing 3 Urethral Dilation + VIU 9 14 system for precise advanced laparoscopic Stent Related 11 14 surgery with minimal blood loss and tissue Cystoscopy 13 15 trauma Prostate TURP 29 Stone Surgery (PCNL + URS) 19 u Inbuilt OT cameras for direct relay and 47 0 10 20 30 40 50 transmission of cases in auditorium Number of Surgeries u Laser availability Outcomes of Urology Surgery 2011 (N=88) u Round-the-clock availability of experienced 100 94.3 (83)

surgeons to manage abdominal emergencies (N) 80 such as acute abdominal pain, GI bleeding or

atients 60 trauma P of u Experienced nursing staff, medical officers and e 40 infrastructure, high tech ICU set-ups for high

centag 20 5.7 (5) er

risk and major operative procedures P 0 u Reliable back-up of good surgical ICU facilities No Re-admission Re-admission Death

72 CIMS Urosurgery

Gender Distribution of Urology Surgery Patients Age Distribution of Urology Surgery Patients 80 120 114 70 70 100 60 52 75 atients 47 atients 80 2011 (N=88) 50 2011 (N=88) of P

of P 40 60 2012 (N=135) 2012 (N=135)

ber 30 ber 22 40 18 21 20 14 13 Num Num 20 10 0 0 Males Females < 30 30 - 60 > 60

Retro-Peritoneal Abscess Treated Laproscopically

Case Presentation: A 65 year old non-diabetic, female, presented with complaints of high grade fever (continuous) with rigor, anorexia, nausea, diffuse abdominal pain, breathlessness and burning micturation since last 15 days.

Diagnosis and Management: Patient was diagnosed as a case of septicemia. CT scan of abdomen was done which showed retro-peritoneal abscess with left pyelonephrosis due to upper uretaric stricture with stone. Laboratory Fig.1 Laproscopic Pus Drainage investigations showed she was having high total leucocyte count, with hypoprotienemia and high serum creatinine level. She was treated with antibiotics and referred to urologist.

Patient was posted for emergency surgery and laproscopic drainage of retro- peritoneal abscess and percutaneous drainage of pyelonephrosis was done and approximately 1 liter of pus was drained. Patient was in ICCU on ventilator for 7 days and she recovered fully. Post operative hospital course of patient Fig.2 PCN Insertion for Pyonephrosis was uneventful and patient's symptoms improved with supportive treatment. Patient was discharged on 15th post operative day with antibiotics and readmitted after 15 days for planned elective Nephrectomy for nonfunctioning left kidney. Post operative period was uneventful.

Outcome: On follow-up patient was asymptomatic with normal serum creatinine levels. Fig.3 Abscess Cavity after Pus Drainage 73 CIMS Onco Surgery

Combined (a number of body parts) Oncology Surgeries 150 Oral (mouth) 124 Mandible (jaw) and 120 res

And u Neck 90 roced

P 61 Dissection (cutting) f o Operation (surgical procedure) 60 ber COMANDO surgeries are performed at CIMS. m 30 Nu At CIMS, a significant reduction in recurrence 0 and mortality is seen in various oncology 2011 2012 patients. 2011 (N=61) Different Oncology Procedures 2012 (N=124) 70 63 Tests that examine the mouth s 60 rie and throat are used to detect, 50 ge diagnose, and stage lip and oral 40 Sur 30 25 25 of 19 20 cavity cancer. 20 er 9 7 u Physical exam of the lips 10 3 6 3 5

umb 0

and oral cavity N Head and Neck Digestive Breast Cancer Genitourinary Lung Others* u Endoscopy (MRM) (thoractomy) u X-rays of the head, neck, Oncology Patient Outcomes (N=61) and chest 100 86.9 (53) u Biopsy (N) 80 u MRI (magnetic resonance

atients 60 imaging) P u of CT scan (CAT scan) e 40 u Exfoliative cytology 20 u Barium swallow centag 8.2 (5) 4.9 (3) er u PET scan (positron emission tomography P 0 scan) No Re-admission Re-admission Death

Dr. Ashok Patel Dr. Dhaval Rajde Dr. Chaitanya Shroff Dr. J. D. Patel Dr. Natu Patel Dr. Jayesh Patel Dr. Laxmidhar Murtuza 74 CIMS Onco Surgery

CIMS follows Guidelines for Breast Cancer Age Distribution of Oncology Patients u Women of age 40 and 90 82 older should have a 80 mammogram every 70 atients 60 2011 (N=61) y e a r a n d s h o u l d 50 continue to do so for as of P 37 35 2012 (N=124)

er 40 long as they are in good b 30 24 Dr. Anjana Chauhan 20

health. Num 7 10 u Non-operative breast cancer diagnosis 0 is achieved by triple assessment, < 30 30 - 60 > 60 (clinical and radiological assessment followed by core biopsy and/or fine Gender Distribution of Oncology Patients needle aspiration). Whilst core biopsy is 80 70 preferable due to the additional 70 information it can provide, there may be 60 54 atients circumstances where only a fine needle 50 2011 (N=61)

of P 35 aspiration is possible. 40 2012 (N=124) 26 u Neoadjuvant chemotherapy is used for ber 30 the treatment of primary breast cancer. 20 Num u Surgical treatment of patients with 10 breast cancer is carried out by surgeons 0 with special interest and training in Males Females breast disease. Distribution According to Blood Group of Patient u Follow up is stratified according to 45 40

disease risk. Patients are given ts 40 35 information regarding their personal tien 30 a 30 27 follow up programme (clinical and P 2011 (N=58)

of 25 imaging). 20 15 2012 (N=98) 15 13 u High risk patients are followed up more 10 Number 5 5 5 4 4 closely with joint care by surgeons and 5 2 2 1 1 1 1 0 oncologists according to agreed local O +ve B +ve A +ve AB +ve A -ve O -ve B -ve AB -ve protocols. 75 CIMS Onco Surgery

A case of Male Breast Cancer

Background: When we talk about breast cancer we mean it is female breast cancer. But cancer of breast can occur to male also. The incidence of male breast cancer is 1 in 1000.

Sign and Symptoms: Usually patient presents with swelling and pain in breast. In cases of male breast cancer, clinically it present as gynaecomastia and lump in breast. Figure - 1: Intraoperative Scar Diagnosis and Management: Routine investigation like Chest X-ray, mamography and sonography are done. Fine needle aspiration cytology gives us diagnosis in most cases. If cytology is negative then either lumpectomy and/or frozen section of breast evaluation should be done. After confirmation of diagnosis, surgery is planned. Modified radical mastectomy is recommended. After final histopathological report patient is advised chemo-radiotherapy.

Discussion: In comparison to female breast cancer, male breast cancer has poor prognosis. Early diagnosis, awareness about disease and proper complete treatment gives excellent results. Photo shows intraoperative scar which is not ideal as somebody has done Figure - 2: Specimen lumpectomy instead of final needle aspiration cytology (FNAC). Second after surgery photo shows specimen after surgery of MRM.

76 CIMS General Surgery

General Surgeries General Procedures 58 60 16 Biopsy res 16 u 40 Excision of Mass 4 roced 28 P

16 f o

20 2 ber Tracheostomy 11 m Nu 0 1 Tendon Repair 4 2011 2012

2 2011 (N=28) Patient Outcomes General Surgery at 1 year (N=28) Removal of Foreign Body 2 2012 (N=58) 100 92.8 (26) 1 (N) Haemorrhoidectomy 80

atients 60 Wire Removal 7 P of

e 40 Feeding 2 1 3.6 (1)

centag 20 er

ICD insertion P 1 0 No Re-admission Re-admission Death 0 5 10 15 20 Number of Surgeries Age Distribution of General Surgery Patients 35 30 30 25 Gender Distribution of General Surgery Patients atients 2011 (N=28) 20 18

of P 16 15 2012 (N=58) 60 ber 10 10 7 48 5 50 Num 5 0

atients 40 2011 (N=28) < 30 30 - 60 > 60

of P Number of patients of age(30-60) years undergoing general 30 2012 (N=58) 21 surgery were higher in 2012. ber 20 10 7

Num 10 0

Males Females

Proportion of male patients undergoing general surgery was higher as compared to females in 2012.

77 CIMS Plastic Surgery

CIMS follows WHO Plastic Surgeries 40 35 res

guidelines for Burns Care u 30 26 roced P

f 20 o A total number of 35 plastic surgeries were performed at

ber 10 CIMS in 2012. m Nu At CIMS, out of total 35 plastic surgeries performed, 28 0 patients were males and 7 were females. In addition, 22 2011 2012 patients were of age of 60 year or less, which was higher as Different Surgical Procedures of Plastic Surgery 24 compared to 2011. 25

20 15 15 Criteria for hospitalization; 2011 (N=26) of Surgeries 10 8 2012 (N=35) 6 5 u Greater than 15% burns in an adult 5 3 Number 0 u Greater than 10% burns in a child Upper & Lower Extremities Head & Neck Surgery Thorax & Abdomen surgery u Any burn in the very young, the elderly or the infirm Number of patients undergoing burn surgery was higher in 2012. u Any full thickness burn Age Distribution of Plastic Surgery Patients u Burns of special regions: face, hands, feet, perineum 25 22 u Circumferential burns 20 18 u Inhalation injury atients 15 2011 (N=26) u Associated trauma or significant pre-burn illness: e.g. of P 2012 (N=35) 10 8 ber diabetes 6 5 5 Num 2 Outcomes of Plastic Surgery at 1 year (N=26) 0 100 < 30 30 - 60 > 60 84.6 (22) (N) Gender Distribut ion of Plastic Surgery Patient 80 30 28

atients 60 25 P atients

of 20 17 2011 (N=26) e

40 of P 15 2012 (N=35)

ber 9 15.4 (4) 10 7

centag 20 er Num 5 P 0 0 No Re-admission Re-admission Death Males Females 78 CIMS Plastic Surgery

Complex Reconstruction Surgery of Right Upper Limb of an Accident Patient

Case Presentation: A 28 year old female patient, presented with alleged history of RTA, having reverse side swap injury . Patient had crush injury of right upper limb with open elbow joint with right brachial artery avulsed, along with avulsion of biceps and brachialis muscle at its insertion with proximal forearm flexor muscle avulsion with open elbow joint and capsular tear with active bleeding, no sensation, pulsation and movement in distal forearm. She had injury over right dorsum of right Fig.1 Crush Injury to wrist and hand with less of skin and soft tissues, comminuted fractures Right Upper Limb of metacarpals and tendon injury.

Diagnosis and Management: CT angiography of right upper limb suggested complete block with no flow in distal brachial artery. Reconstructive surgery for limb salvage was done. Debridement of devitalized muscles, repair of capsule of elbow joint and fixation with ST pin, interposition great saphenous vein graft and anostomosis for right Fig. 2 Injury over Right brachial artery with muscle repair were done and raw area was covered Dorsum of Right Wrist and Hand with less of Skin with primary skin grafting by the team of trauma surgeon, plastic and and Soft Tissue reconstructive surgeon, and orthopedic surgeon. Once right forearm and upper limb regained complete vascularity, groin flap was done to cover dorsum of right wrist after 6 days of initial surgery to preserve exposed tendons and bones. Groin flap was detached after 3 weeks and gradually started regaining sensation and movement of all fingers, wrist and partial movement of right elbow joint.

Fig. 3 Recovery after Surgery 79 CIMS Obstetrics and Gynaecology

CIMS Gynaecology and Obstetrics Gynaecology Surgeries provides multidisciplinary services for women's health. Our team of experienced 40 es

r 31 gynecologists along with round-the-clock u 29 medical and paramedical staff provide 30

oced tender care to pregnant females and r P gynaec patients. Most importantly, f 20 o patient receives personalized, state of- ber 10

the-art care in a confidential setting m

comfortably discuss the needs. Nu Gynecology services include: 0 u High-risk pregnancy 2011 2012 u Infertility u Urogynecology Gynaecology and Obstetrics Surgeries u Gynecologic cancer screening and Tightening of Cervical 1 treatment Encircalage u Pelvic pain u Menopause counselling Vaccum Delivery 1 u Women's mental health needs Burn with IUD 1 u Women's wellness and exercise 1 u Wellness exams Myomectomy 1 u Pap smear 4 2011 (N=31) Normal Delivery 3 u Preventive gynecology 2012 (N=29) u 3 Contraceptive choices Ovarian Tumor Excision 1 u Management of birth control options 4 u Chronic pelvic pain D and C 3 u Pre and post menopause 8 LCSC 9 u Fetal Echocardiography 10 u A d v a n c e d L a p r o s c o p i c a n d Hysterectomy 10 Hysteroscopic surgery 0 2 4 6 8 10 12 u Menorrhagia Number of Surgeries u 3-D USG and color doppler

80 CIMS Obstetrics and Gynaecology

Age Distribution of Gynaecology Patients Patient Outcomes of Gynaecology at 1 Year (N=31) 25 120 21 100 (31) (N) 20 18 100

atients 80

15 2011 (N=31) atients P of P 60 9 2012 (N=29) of 10 e ber 7 40 4 5 centag Num 1 20 er P 0 0 < 30 30 - 60 > 60 No Re-admission Re-admission Death

Pregnant Woman with Hemiplegia Developed Breathlessness and Anasarca in Early Third Trimester Operated for Lower Segment Caesarian Section on 36th week of Pregnancy Case Presentation: A 36 year old hemiplegic, pregnant woman had eventless ,normal pregnancy till 7th month. At 7th month, the patient developed anasarca and severe breathlessness. Cardiac, pulmonary, physician and neurophysician evaluations were normal. At 36 weeks of foetal maturity, the mother developed orthopnea and severe cough suggestive of an infective pathology or cardiac overload and was brought to CIMS hospital for further management. Diagnosis and Management: Colour Doppler and USG to evaluate the foetal maturity, showed 37 weeks maturity. With worsening respiration in the mother at 37 weeks maturity LSCS was done. In transverse incision the baby was delivered while the mother was continuously wheezing and on oxygen. The baby's immediate Apgar was 9 but somehow within an hour went into cyanosis and tachypnea. Bilateral lung pathology was diagnosed and lung surfactant was given while the infant was on ventilator. The mother developed severe distension of abdomen and respiratory embarrassment within 24 hours and was nebulised and treated for paralytic ileus. Problems were resolved in 36 hours. Outcome: The mother started handling the child on the 5th day.

81 CIMS ENT Surgery

CIMS goals: ENT Surgeries u To discover new insights into the 40 37 res

pathophysiology of otalaryngological diseases u u To invent new technological application 30 roced P designed to optimize therapy of challenging f 20 15 o clinical problems as well as to overcome ber 10 disabilities brought on by illness m Nu 0 Micro Laryngeal Surgery for Vocal Cord Polyps 2011 2012 These are benign lesions of the larynx, usually Patient Outcomes ENT 100 located on the edge of the vocal cords, which 86.7 (13) prevent the vocal cords from meeting in the midline. (N) 80 ts 60 Polyps can interfere with voice production and may tien a P 40 produce a hoarse, breathy voice that tires easily. of 2011 (N=15) 20 These may respond to conservative medical therapy 6.7 (1) 6.7 (1) ercent and intensive speech therapy. If the lesion fails to P 0 respond, meticulous microsurgery may be indicated. Death Re-admission No Re-admission Causes of Vocal Cord Polyps: This surgery is endoscopic in nature as no skin u Laryngitis sicca incision is made. Work is done through special u Malignant lesions endoscopes introduced via the mouth. An operating u Presbylarynx microscope with high power magnification, video u Laryngeal dystonia, or spasmodic dysphonia (SD) recording is used for the actual surgery.The same u Microlaryngeal surgery aims in precision removal technique is used in tissue augmentation of vocal of these growths and restores the original voice. cords, excision of early T1 cancers.

Different Surgical Procedures of ENT 15 12 11 s

rie 10 ge

Sur 2011 (N=15) 5 5 5 of 5 3 3 3 2012 (N=37) er 2 1 1 1 umb

N 0 Nasal Endoscopy Nasal Surgery ( Tonsil and Surgery of Ear Surgery Others* FESS + Adenoidectomy Larynx (Tympanoplasty Septoplasty) + Mastoidectomy) 82 CIMS Pain Management

CIMS approach is to free the patients from every painful sensation in the most painless manner. CIMS Pain management team specialise in the evaluation, diagnosis, and treatment of persistent pain by eliminating the pain at its origin.

CIMS now focuses on new approaches to the management of acute perioperative pain, on ways to improve the risk/benefit profile of various agents, enhance the consistency of pain control, address the individual variability in responses to pain and analgesics, and avoid periods of ineffective pain relief (analgesic gaps). For acute Pain Management, CIMS uses: Dr. Dipak Desai u Pre emptive analgesia u Patient controlled analgesia with PCA pump Pain Management u Continuous epidural analgesia 30 u Transdermal fentanyl patch + Transdermal 25 buphrenorphine patch 25

u ients Multi modal analgesia (Combination of regional 20 at P analgesia) 15 of

At CIMS we are also looking for chronic pain 10 9 management (without surgery) for patients suffering from chronic conditions like back pain, neck pain, Number 5 sciatica, trigeminal neuralgia, post herpetic neuralgia, 0 post spine surgery pain syndrome and many chronic 2011 2012 pain conditions. CIMS pain management team approach these conditions with various new methods. At CIMS, we do very high end procedures like: u Selective nerve root blocks u Radio frequency ablation u Facet joint block u Trigeminal RF ablation u Cervical procedure u Disk procedures (Nucleoplasty, IDET) u Spinal cord stimulator u Intra-thecal drug delivery system u Vertebroplasty and khyphoplasty u Cancer Pain, Acupuncture, Low level laser therapy 83 CIMS Dentistry

We excel in providing dental treatment to CIMS Dentistry patients with serious cardiac disease like: u Preventive Dentistry u Valvular Heart Disease u Periodontics u (with ACC/AHA Guidelines ) Orthodontics u u Heart failure Maxillofacial Surgery u u Arrhythmias and Implanted Pacemaker Fillings u Root Canal Treatment (RCT) u Implanted Coronary Stents and on u Pedodontics Antiplatelet/ Anticoagulant treatment u Implants u Cosmetic Dentistry u Procedures to these patients are done under u Prosthodontics Dr. Parvin Chandarana continuous cardiac/ NIBP and SPO2 monitoring on dental chair only. Dental Surgeries 2500 u Backup support of Cardiologist / Intensivist/ 2223 Physician 2000 u ocedures Pr

Day care / Indoor facilities for medically 1500 compromised and seriously ill patients of 1158 1000 u Facility of general anaesthesia on dental chair Number only 500 u Comprehensive care (24 X 7) to Trauma 0 patients 2011 2012 u Total care for NRI and overseas patients by Dental Procedures

special International Patient's Department 530 Cleaning of Teeth 707

242 We improve the quality of life Composite Filling 500 125 with Dental IMPLANTS Extraction 301 113 u Improved aesthetics Crown & Bridge 458 96 u Preserve facial structure RCT 168 14 Impacted Wisdom Tooth 13 u Improved chewing function 2011 (N=1158) 10 Pediatric Procedure 25 and confidence 2012 (N=2223) 10 u Improved dental hygiene Cometic Dental Treatment 6 9 u Replace a whole missing Implants 26 4 tooth (root) Dentures 8 3 u Avoid the need to prepare Orthodontics Occlusion 4 2 adjacent teeth, since a Apicectomy 5 Gum Surgery conventional bridge is not 2 used 0 200 400 600 800 Number of Procedures 84 CIMS Pathology

The recently NABL accredited Pathology Department at CIMS is well-equipped to carry out the latest tests on patients and assist clinicians in evaluation and diagnosis of diseases. The tests carried out within the department aid in the evaluation and treatment of virtually every patient admitted within the hospital or outpatients who form a very integral part of our hospital. Aided by state-of-the-art fully automated instruments and highly skilled HPC registered biomedical Dr. Manisha Shah Dr. Jitendra Nayak scientists under constant supervision of consultant pathologist with a high quality assurance, CIMS Pathology provides near-perfect pathology services to all patients.

The Pathology Department provides a range of services including: u Biochemistry, Immunoassay and General Haematology and Clinical Pathology Hormonal assay, Hematology and 80000 67662 Clinical Pathology, Histopathology 70000

tions 60000 and Cytology a

ig 46215 u Along with highly specialized tests, all 50000 vest 40000 In

the routine tests like hemoglobin, al 30000 ot complete blood count, blood group, T 20000 blood sugar, cholesterol, lipid profile, 10000 0 thyroid function tests, liver function 2011 2012 tests, renal function tests, test for malaria, dengue, urine, stool, pap smear, PSA, etc. are also available in different packages. u Services are available for indoor as well as outdoor patients. u Facilities for home visit available round the clock for all.

Microbiology The Department is well equipped for conducting clinical trials and research projects for all consultants. Experienced Microbiologists are available for regular patient interactions. With services available round the clock, CIMS microbiology stands strong to support the clinician. CIMS Microbiology also offers state-of-the-art molecular microbiology with the high end fully automated gene sequencer. 85 CIMS Pathology

Pathology Investigation Volumes Pathology Investigation Volumes 2011 2012 2011 2012 Cardiac Markers Liver Function Tests u Troponin - T 1220 1162 u SGPT 10555 13893 u CPK-T 395 281 u SGOT 2671 3780 u CPK-MB 380 691 u Alkaline Phospate 1576 2449 u NT Pro BNP 107 176 u Billirubin 2531 3690 u LDH 139 194 u Proteins 2425 3560 Diabetic Markers Renal Function Tests u Sugar Investigations 27259 20929 u Urea 10107 14015 u Insulin Investigations 12 18 u Creatinine 18077 24970 u HbA1c 2406 3410 u Sodium 11910 14601 u Microalbuminurea 710 855 u Potassium 26264 33743 u Serum Acetone 201 337 u Chloride 7936 10313 Coagulation Markers Endocrine Investigations u D-Dimer 106 152 u T3 578 755 u Fibrinogen 78 110 u T4 577 764 u Fibrin Degradation 23 13 u TSH 3489 5284 Production u Free T3 156 241 u Prothrombin Time 3717 5005 u Free T4 172 269 u Activated Partial 1042 1614 u PTH 66 109 Thromboplastin Time u Cortisol 36 64

86 CIMS Pathology

Pathology Investigation Volumes Pathology Investigation Volumes 2011 2012 2011 2012 Collagen Markers Markers for Disease u Antinuclear Antibody 98 123 u HIV 1 & 2 (ECLIA) 7251 9518 u Antinuclear Antibody Profile 13 12 u HBsAg 7281 9258 u VDRL 199 371 u Malaria 153 337 Septicemic Markers u HCV 98 159 u Procalcitonine 177 277 u Dengue 77 137 u C-reactive Protein 1157 1735 u AFB Stain 95 91 u AFB Culture 26 68 Tumour Markers u Pneumoslide 18 54 u Prostate Specific Antigen 413 1022 Anemia Profile (PSA) u CBC 20807 28849 u Carcinoembryonic Antigen 54 78 u Hb Electrophoresis 15 29 u CA125 19 30 u G6PD 22 61 u CA19.9 12 26 u TIBC 62 109 u u CA15.3 2 6 Retic 68 102 u Ferritin 72 134 u Iron 66 141 Bone Markers u Vitamin B12 680 1354 u Rheumatoid Arthritis 82 189 Allergy Profile u Uric Acid 901 1258 u Absolute Eosinophil Count 32 68 u Vitamin D3 (250H) 77 339 u Immunoglobulin E (IgE) 26 86 u Calcium 1340 1603 u Test of Allergens 14 27

87 CIMS Radiology

Investigation 2011 2012 USG and Doppler Study - I CT Scan 1177 2536 2500 X-Ray 10079 16062 2217 tions

a 2000 Ultrasound 1390 2561 ig 1625

vest 1500 2011

In 1143 1089 Doppler 1727 2382

of 2012 1000 Total Number 14373 23541 425 500 375 Number Radiology and imaging plays a vital role in 0 determining diagnosis and subsequent planning of USG Abdomen Carotid Doppler Renal Doppler treatment. Radiology and imaging help surgeons immensely to plan all aspect of surgery in advance. USG and Doppler Study - II 140 126 116 tions 120 111

iga 97 96 97 Department of Radiology and Imaging at CIMS 100 89 vest 80 68 In 60 52 2011 hospital offers services of: of 37 40 28 28 2012 u Digital X-ray 19 20 7 1 6 u Number 0 IITV Both USG Chest USG Both USG Pelvis USG Brain USG Aorta u Lower Abdomen Lower Thyroid Doppler Ultrasonography Limb with Renal Limb u Venous Doppler Arterial Colour Doppler Doppler Doppler u Mammography u Computerized Tomography Scan (CT Scan) CT Scan: u Interventional procedures like tapping, biopsy, Before any contrast CT Scan, patient is aspirations advised to refrain from consuming solids and X-Ray liquids for at least 3-4 hours, preferably. Computerized Radiography (CR) gives excellent X-ray images of various parts of body. Various X-ray procedures e.g. barium studies, I.V.U. (Intravenous CT-Scan Investigations

Urography), ascending urethrogram, micturating 3000 urethrogram, sinogram, etc. help in diagnosis. 2536 2500 tions a ig 2000 vest In 1500 1177 of 1000

Number 500 0 2011 2012 Dr. Jaimin Shah, Dr. Kirtan Shah, Dr. Rupal Doshi and Dr. Kunjal Patel 88 CIMS Radiology

Mammography Current guidelines of American Cancer Society (ACS), American Medical Association (AMA) and American College of Radiology (ACR) recommend screening mammography every year for women above 40 year of age. u http://www.acr.org/~/media/ACR/ Documents/AppCriteria/ Diagnostic/BreastCancer Screening.pdf

Ultra Sonography and Doppler USG helps in identifying various pathologies inside body. Trans vaginal USG and Trans rectal USG helps in diagnosis and detailed evaluation of pathology. Doppler study is useful for detecting blockages in blood vessels.

Computerised Tomography Scan (16 slice CT scan) u CT angiography studies offer non-invasive, Out Patient (OPD) angiographic procedure. u Identifying internal injuries such as liver, spleen contusion/ laceration etc. CT scan can also be used for guiding biopsy. u 3D CT scan is very helpful in evaluation of fractures in different parts of body, e.g. fracture in pelvic bone, acetabulum.

CT Coronary Calcium Scoring CT coronary calcium scan is a non-invasive way to detect presence, location and extent of calcified plaque in the coronary arteries—the vessels that supply oxygen containing blood to the heart muscle. CT coronary calcium scoring gives the following important information: 1. The presence or absence of calcium in coronary arteries. This indirectly suggests presence or absence of cholesterol and fat deposition in arteries. 2. The degree of the calcium in coronary arteries. Higher the amount of calcium, more severe is the disease. 3. The probability of a heart attack in future.

89 CIMS Dialysis Centre

Total Number of Hemodialysis Year 2011 (N=1860) 2012 (N=2381) Hemodialysis 1842 2368 Plasma 18 13

Total Number of Hemodialysis

2500 2368 sis y 2000 1842

1500

of Hemodial 1000

500 Number 0 2011 2012

Total Number of Dialysis 1800 1571 1600 1511

sis 1400 y 1200 Dial 2011 (N=1860) Plasma Exchanges 1000 of 810 20 2012 (N=2381) 18

800 changes

15 13 600

Number 349 10

400 Plasma Ex

of 200 5 0

Number 0 OPD IPD 2011 2012

90 CIMS Physiotherapy, Rehabilitation and Nutrition

CIMS Physiotherapy and Rehabilitation centre is equipped with latest Total Physiotherapy IPD equipments and has qualified physical therapist team to give higher and OPD Patients of 2012 standards of services. 18000 16425 16000 14000

Services: CIMS Hospital provides comprehensive IPD and OPD 12000 ients

at 10000 P Physiotherapy and Rehabilitative services as: 7300

of 8000 REHABILITATION 6000 4000

u Number Cardiac and Pulmonary Rehabilitation 2000 u Orthopedic / Musculoskeletal Rehabilitation 0 IPD OPD u Neurological Rehabilitation u Post Surgery Rehabilitation Cardiac Rehabilitation Prescription 14000 12775 PHYSIOTHERAPY 12000 u Physiotherapy in Geriatrics (Above 60 years) 10000

atients 8000 2011 (N=5198) u P Physiotherapy in Obstetrics and Gynecology 5475 of

6000 2012 (N=18250) u 4418 Physiotherapy for Sports Injuries ber 4000 u Physiotherapy for Pediatrics Num 2000 780 u 0 Obesity Management IPD OPD u Pain Management u Nutritional Counseling u Yoga Sessions MANUAL THERAPY AND ELECTROTHERAPY u Manipulations and Mobilization Techniques u Biomechanical Assessments u Orthotic Prosthetic Exercises u Electrotherapy Modalities like Short wave diathermy, Ultrasound, Interferential therapy, Electrical stimulation, TENS, Wax therapy, Tractions, Moist Pack, etc. NUTRITION CIMS dietician takes care of patient's condition and tailor it according to pathological conditions prescribed by doctors. At CIMS, diets are classified into basically four types: a) Clear liquid diet in which milk, thick soups and thick juices are avoided; b) Full liquid diet in which all types of juices, milk and milk products, soups are included; c) Soft diet which contains very soft food and is easily digestible for the patient; d) Full diet which consists of balancing nutrients consisting of cereals, pulses, fruits, green vegetables and limited amount of sugar and oil. Over all, CIMS provides low fat low cholesterol diet for all patients which changes from time to time as per requirement. 91 Code Blue

Code Blue is the term for a medical Code Blue emergency, meaning a person is 60 possibly in danger of immediate dying. 54 50 Dial 222 for immediate assistance of a life threatning medical emergency or 40 cardio pulmonary (cerebral) arrest ients

at 2011 (N=26) P occurring anywhere in CIMS. 30

of 2012 (N=71)

CIMS Crash Cart is a special cart kept 20 16 17 on all wards and in the ER which 10 houses life saving equipments. Number 10

0 Calling criteria for our MET service are Male Female based on acute changes in 1. Heart rate (<40 or >130 beats/min), Outcome of Code Blue 2. Systolic blood pressure (<90 100 mmHg), 90 3. Respiratory rate (<8 or >30 77.46 (55) breaths/min), 80 4. Conscious state, urine output 70 61.54 (16) (N)

(<50 ml over 4 hours), and , 60 2011 5. Oxygen saturation derived from 50 2012 pulse oximetry (<90%, despite 38.46 (10)

entage 40 oxygen administration). c

er 30 22.54 (16) P 20 In addition, the calling criteria contains 10 a 'staff member is worried' category to allow staff to summon senior 0 Alive Death assistance to manage any possible emergency situation.

92 CIMS Quality Measures

Appropriateness of Care: Appropriateness in healthcare is a complex Quality improvement is not just about standard- parameter with various dimensions and definitions setting and benchmarking with the best: there which differ with pathologies and regions. However, principally they address - are analytical, counseling and self-improvement A) Clinically effective evidence based care B) Cost effective care dimensions to the process. Through self- C) Consistent ethical care assessment at CIMS, we strive to assess our The priorities of these dimensions vary in different populations. level of performance in relation to established

Based on above principles Appropriateness of Care standards and implement ways to continuously can be measured using below indicators which improve. directly and/or indirectly relate to patient wellbeing. These indicators include- I) Patient care indicators Length of stay (LOS) is a term used to measure the II) Guideline driven indicators III) Clinical outcome indicators duration of a single episode of hospitalization. IV) System specific indicators V) Cost-effective indicators Inpatient days are calculated by subtracting day of VI) Structural indicators. admission from day of discharge. At CIMS Appropriateness of Care is the followed ideology.

Percentage of Errors in Report Generation in Average Length of Stay of Patients Radiology and Pathology 10 7 6.65 10 8.1 s 6 2011 7.4 2011 8 5 Error

s

y of

2012 4 2012 6 Da

age

2.8 of 4 3 Standard 3.8 cent 1.96 4 Standard er Benchmark 2.7 P 2 Be nchmark 1 0.98 1

1 Number 2

0 Percentage of Error s in Percentage of Errors in 0 Report Generation in Report Generation in Surgical Patients Medical Patients Radiology Pathology 93 CIMS Quality Measures

Quality Measures

1.94 Mortality 1.98

1.57 Re-admission 1.22

Re-Scheduling 8.74 2

2.81 2011 Re-Exploration 2.51 3 2012

Pathology Waiting Time 18.4 Standard 15 Benchmark

Radiology Waiting Time 20.55 15

99.25 Pathology Safety Adherance 99.93 100

100 Radiation Safety Adherance 100 100

0 10 20 30 40 50 60 70 80 90 100 Percentage u Mortality: Total number of deaths, during hospital stay to the total number of deaths and discharges is termed as mortality rate. u Re-admission: Total number of patients readmitted to hospital for the same complain or further management of same complain within 48 hours of discharge, to number of total admission is termed as re-admission rate. u Re-scheduling of patients includes cancellation and postponement (beyond 4 hours) of the surgery. u Re-exploration: If after surgery, due to demand of circumstances the re-opening or procedure is repeated in the same patient it is defined as re-exploration. u Waiting time: It is the time starting right from patient had presented requisition form till the time that the test is initiated. u Safety adherence: Staff's adherence, in the respective laboratory, to the pre-defined safety measures. 94 CIMS Quality Measures

Quality Measures

0.0004 Blood Transfusion Reaction 0

Adverse Anaesthetic Events 0.0004 0

0.5 Medication Errors 1.25 2011 1

1 .25 2012 ADR Incidences 0.5 2 Standard Benchmark

0.83 Incidence of Bed Sore 0.64 1

1 Incidence of Fall 1 1

0 1 2 3 4 5 Percentage

A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient (US-FDA). Examples include, but are not limited to: u Errors in the prescribing, transcribing, dispensing, administering, and monitoring of medications u Wrong drug, wrong strength, or wrong dose errors u Wrong patient, wrong route of drug administration and Calculation or preparation errors

ADR is any untoward medical occurrence that may present during treatment but which does not necessarily have a causal relationship with the treatment.

95 CIMS Quality Measures

Infection Control Standard Benchmark 6 set according to 5 5

on 5 International

ecti 4 Nasocomial Infection

Inf 4 2011 Control Consortium. tage 3

2.252 2012 cen 2 2 Benchmark for er 2 Standard Benchmark P Infection Control age

1 0.658 HAI <5 0.533 er 0.461 0.36 0.047 0.003 0.128 Av 0.022 UTI <5 0 HAI UTI VAP BSI SSI VAP <4 HAI - Hospital Acquired Infection; VAP - Ventilator Associated Pneumonia; BSI - Blood Stream BSI <2 Infection; UTI - Urinary Tract Infection; SSI - Surgical Site Infection SSI <2

Patient satisfaction is defined in In Patient Satisfaction

95 terms of the degree to which the 100 91.51 87.69 90 patient's expectations are fulfilled. 80

ction 70 At CIMS, quality measures 60 tisfa

a 50 are assessed by monitoring S 2011

ge 40 2012 a wide range of parameters 30 Standard Benchmark enta 20 monthly and comparing erc P 10 them to established certified 0 2011 2012 Standard Benchmark benchmarks.

96 CIMS Pharmacovigilance Unit

CIMS Pharmacovigilance Outcomes

At CIMS, Naranjo's scale was used for causality assessment of detected ADRs. It revealed that in an OPD setting, 67%

ADRs were probable followed by 16% as definitely related,

13% as possible and 4% as doubtful; while in IPD incidence rate of probable and possible were found to be same as Causality Assessment of ADRs 43%, followed by 11% as Definitely and 3% as doubtful.

At CIMS, severity assessment was done with the help of

Modified Hartwig and Siegel scale. Out door patient reported same number of mild and moderate reaction to drug which is

47% followed by 6% severe reaction. In case of indoor Severity aseessment of ADRs patient, 50 % of reactions were found to be mild followed by

39% of moderate and 11% of severe reaction.

At CIMS, analysis by Schumock and Thornton scale for preventability showed that in both department most of the

ADRs were probably preventable as in case of OPD it was

53 % while in IPD it was 44% followed by definitely preventable 33% and 30% in OPD and IPD respectively and Preventability Assessment of ADRs not preventable 14% and 26% in OPD and IPD respectively.

97 CIMS Ambulance and Transport Services

Emergency Medical Services (EMS) is an essential part of the CIMS healthcare system as it saves lives by providing comprehensive, speedy, reliable and quality care Rajasthan immediately. Gujarat Madhya Pradesh

Maharasthra

CIMS has 5 ambulances including 1 trauma ambulance with fixed ventilator, 1 CIMS kids ambulance (neonatology and pediatric), 2 ICU on Wheels and 1 General ambulance. Ambulance Services 100 94 Our services are very effective and they are 90 84 82 80 73 74 made available to the customers in a very 66 ices 70 61 63 60 57 60 54 52 prompt manner and at very reasonable rates. serv

of 50 40 The ambulance comprises of medical staff to mber 30

Nu 20 give temporary relief or first aid to the patient 10 on the way to the hospital efficiently. 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec u 24 x 7 services are provided for all patient transport needs Other state pick up and drop services in u Transfers from home to hospital and Rajasthan, Madhya Pradesh and Maharashtra from hospital to hospital u Highly trained medical personnel u Our ambulances carry oxygen therapy equipment with defibrillator to provide aid in the event of any deterioration of patients whilst in our care. 98 Patient Experience

“Patient Care” is the guiding principle of CIMS hospital.

CIMS values the patient most. Patient care comes first and our commitment to them goes beyond providing the best care.

We aim to make their stay in the hospital pleasant and make continuous endeavors to create a highly comfortable ambience for them.

Patient experience is of prime importance in Hospital's strategic plan to improve clinical outcomes, quality, and safety.

Patient Experience at CIMS

Process Explanation

Rx Explanation

Taste and Quality of Food

Room Rating and Cleanliness 2011 Doctor Communication 2012

Efficient Problem Solving

Quick Care

Polite and Helpful

70 75 80 85 90 95 100 Percentage

99 CIMS Guest Relationships

We endeavor to celebrate birthday and anniversary of patients and birth of new born with cake cutting and room decoration so that patient's relatives don't miss the chance of celebrating their own or beloved's birthday or anniversary.

Festival Celebration: Christmas, Holi, Uttrayan, Republic Day, Independence day and Diwali are celebrated at CIMS by creating a festive look. Community Health Awareness: Various camp and awareness programs like World Heart Day, Swasthya Mela, CIMS health fair are held. Kem Cho Round: This round taken by PGRO (Patient and Guest Relation Officer) helps cross cultural bridges between hospital and patient to create a better interaction and smoother flow of services. Pediatrics: Toys and games are provided to pediatric patients to make their stay in the hospital a more pleasant one. Movie CD/DVD: Lists of DVD/CD are available for patients which include comics, kid's specials, devotional, English movies, various other Hindi old and new movies for Pediatric Ward, Single and Suite Rooms. Others: 1. Get well soon cards given to all patients after admission 2. Thank you/ Apology letter sent to all patients for their feedback. 3. After discharge, patients are given call to inquire for their health. If any complaints, forwarded to concerned person. 100 Patient's Say

J Bhailal Patel I had been admitted at CIMS hospital for angiography and further management under care of Dr. KP. I have really good experience here. Hospital has all the facilities with most ultra modern and latest technology. He is very supportive and helpful by nature and has given me personal care. In-house doctors, nursing staff and other managerial staff also are well-skilled and caring. Over all, I am well-impressed with CIMS, as regards to medical treatment and care taken during my admission here. I would highly recommend it to anyone.

J Ramnik Makwana This was a nice experience of staff work, it's good work of service to patient. We are happy with hospital facility. Doctor's staff, Nursing staff and all other staff special thanks to Dr. MC and Dr. VT. "Also special thanks for Birthday Celebration".

J Nimish H. Vaishav Treatment done by Dr. MC and Dr. DS. I am very satisfied with the facilities provided by the hospital. The food provided by the hospital was very hygienic. I am going to refer CIMS hospital to all my known ones and family members.

J C.A. Ravani Got admitted my father for angiography today morning! Thank God! Nothing to worry! Generally people face the issue of extended cardiac treatments such as angioplasty or bypass surgery. But Dr. AC was too good! He informed us about the non requirement of any further treatment. We were relaxed! Dr. AC is a gem of a person! Infact the whole team and their team members are very good doctors and more importantly very good human beings! The hospital staff is also very good! Though they are hospital staff they know the " hospitality " much better ! They take very good care of the patient and their relatives. Ultimately, when a patient is hospitalised what matters is not the medical treatments but " healing " and the same is very well known to CIMS ! Congrats! And go ahead! Thanks for every things.

J Vijay Sarda I Mr.VijaySarda had Angiography under Dr. SG at CIMS Hospital. Hospital is best. Environment is very good. Staff is excellent and also very cooperative as well as helpful."Thanks."

J Tararam Prajapati Treatment done by Dr. HB. With the grace of God and hard work of Dr HB, my relative got the treatment in a good hospital with the very good doctor, with awesome hospitality. Keep it up.

J Baby Tanvi Dharmesh Pansuriya CIMS: Saved my daughter BABY TANVI DHARMESH PANSURIYA for high risk heart surgery (Dr. SS, Dr. AC and Dr. KS) Excellent doctor and good guide lines, good care by nursing and ICU staffs Thanks..

101 Patient's Say

J Jimit Barot My Son Mr. Jimit U. Barot was suffering from dengue fever on Sunday. We got him admitted at CIMS Hospital under Dr. BS for the treatment. The services of the Hospital is best. The atmosphere is very good. Treatment was good of doctors. "Thanks."

J Pinakin Gajjar My relative Mrs. Sushilaben Doshi was operated for TOTAL KNEE REPLACEMENT by Joint Replacement Team, We were very happy with the services of the doctors and the hospital. World class facilities at very reasonable rates at CIMS HOSPITAL.

J Revat Sanger Thank you, Thank you, Thank you! The treatment my son Yudhvir Sanger has received is beyond words. Dr. AC and his team at the NICU stand as an example for outstanding treatment. In one word for me they have been" life savers ". I cannot thank enough for the entire hospital. Please keep doing this noble deed and bring smile on people's face as you did for me and my family. One word of advice for current and future patient is during time of crisis please let the medical team and your doctor perform their duties because they are the best judge while we can wait for the results and trust me it will be positive as it did in our case. Last but not the least I want to thank the entire CIMS hospital for being so nice to us and humble, keep up the good work and god bless.

J Nishant Thakkar "Thank You Dr. KP for gifting my father a new Life. Now my father is very happy and fine. My father's words to Dr. KP: "You came as God to me and gifted me a new life. And now I believe in God. I am really grateful to you. And this is not only text message, but it is message from my heart for my belief". THIS HOSPITAL IS WORLD CLASS HOSPITAL IN INDIA.

J Adit Patel Excellent hospitality at CIMS Hospital, excellent medical facilities and services, which I have "NEVER SEEN BEFORE" in any hospital, while myself a well established physician, practicing in North Gujarat, India from last 30 year. World class treatment, I have seen here, where I feel like HOME or HEAVEN.

J Jay Singh It was a very comfortable and a caring stay at CIMS. At CIMS they really care. Doctors, nursing staff, attendants and the whole hospital staff was very good. It was a value for money for medical facility provided by CIMS to people of all categories irrespective of cost, colour and creed. "I Thank all CIMS staff for that treatment other than medical facilities like canteen, dormitory, parking, security and HRD which were more than expectation."

102 Patient's Say

J Seva Shah My dad underwent bypass surgery at CIMS. The team of doctors and surgeons handling my dad's case were excellent. All the doctors were very humble and always available to answer any questions. Everyone from the receptionist, the nurses, and nutritionist as well as other hospital staff; this place is stellar in terms of performance, patient satisfaction, cleanliness and care. After the surgery, my dad was provided excellent care. Hospital staff was available 24 hours ensuring speedy and precise recovery by providing him vital care he required. The family waiting area was very comfortable and extremely organized. It is already agonizing enough to have to wait for the outcome of loved ones, but CIMS staff made sure to make family and friends feel relaxed and cared for. Lots of magazines and newspapers are available; tea service for family and friends, on site canteen plus very knowledgeable and approachable staff. I was very impressed with the orderliness of this place and friendliness of the staff. Thanks to CIMS staff for making surgery experience much better for my dad and my family.

J Richard Frederick Operation was very good and patient automatically cure from what he is suffering because of good co-operation from all staff. Food, nurses, all staff and doctors team is excellent. The atmosphere of hospital is homely. "Thanks a lot to all."

J Pramod Sisodia My husband Mr. Pramodkumar had a Health Check up at CIMS Hospital. Hospital and services are excellent. I wish all success to CIMS and will certainly suggest other to friends and relatives to visit CIMS hospital.

J Narendra Sawant I was admitted to CIMS before one year for my heart treatment after a heart attack in Chittorgarh, Rajasthan. I was treated very promptly. I felt very homely in hospital. Consultants, doctors and all staff are very caring and lovely. We were guided very nicely. All were helpful right from entry to exit. We never felt it like a hospital. The atmosphere and setup is very friendly. During our stay, we were stress free. After my discharge , I recommended CIMS to many patients of Rajasthan and all are happy with the treatment and behavior of everybody at CIMS. We wish all the success to the hospital.

J Pawan Sharma I am very much satisfied from all the activities of the CIMS. I am very proud that this type of hospitals are in India (Ahmedabad). From the very beginning i.e cleanliness, behaviour of all the staff persons and doctors are so beautiful that patient will get cured before the treatment. At last, dispensing of medicines is good. Each medicines has a particular slip for how to take and when to take the medicines. "I will appreciate all the activities of the CIMS.” and many many others... 103 CIMS Ethics

CIMS Hospital Dictates its Ethical Standards Through

Independent Ethics Committee of Care Institute of Medical Sciences

The Ethics Committee is an independent body whose responsibility is to protect the rights, safety and well being of human subjects involved in a clinical trial and to provide public assurance of that protection.

Ethics Committee of CIMS registered by DCGI and Registration No.: ECR/206/Inst/GJ/2013

Number of Protocols Evaluated and Approved

45 41 40

35 ocols 30 27 25

of Prot 20

ber 15

Num 10 5 0 2011 2012

CIMS Hospital Ethics Committee

In house Hospital Ethics Committee monitors requirements and responsibilities of physician towards patient care besides checking overall hospital performance.

Scope of Hospital Ethics Committee u Monitoring hospital practice as per code of medical ethics, 2002 u To resolve potential conflict of ethical issues and practice u Provide opinion on hospital related ethical matters

104 CIMS Research Projects

Orbital Atherectomy System in Treating Calcified Coronary Lesions: First in Man Assessment- 3 Year Follow Up 3 year follow up orbit trial was conducted at CIMS to evaluate the safety and performance of the Diamondback 360 Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc., St. Paul, MN, USA) for the treatment of calcified coronary lesions. Of the 33 patients,

90.90% (n=30/33) were males with an average age of 54.9 years. Saline Tubing Crown The ACC/AHA lesion class was: Type A 6.06% (n=2/33); Type B1

Optical 33.33% (n=11/33); Type B2 60.60% (n=20/33). The % diameter Tachometer Fiber

Turbine stenosis was 85.75%; lesion length was 15.90 mm. The procedural Gas Intake Hose success was 97% (32/33) with one case where IVUS/device was Crown Control Knob Sheath cove ring the Shaft not able to cross the lesion due to severe calcification. This case Control Handle series demonstrates that OAS safely and effectively modified calcified lesions and facilitated stent delivery in this difficult-to-treat plaque morphology, which continues up to three years post- procedure. OAS Device Published in JACC : Cardiovascular Intervention CRT 2013 Supplement : Volume-6, No. 2S.

Correlation between Coronary Heart Disease and Depression and its Influence on Quality of Life and Clinical Outcomes A total of 1648 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) at CIMS were enrolled in the study. Of this, 39.8% patients were depressed (MARDS score > 6). Prevalence of depression was higher in males as compared to females. Of these patients with MARDS score>6, 62.04% were hypertensive, 35.77% were diabetic. Socioeconomic data of 1648 patients revealed that depression was higher in males, uneducated, unemployed and rural subjects. Prevalence of depression was higher in males as compared to females. Presented at Journal of American College of Cardiology in March 2013.

105 CIMS Research Projects

A Study to Evaluate the Trends of Accidental Trauma and Significance of Random Blood Sugar in Traumatic Brain Injury A total of 258 records of injured patients attended the Accident and Emergency (A&E) at CIMS were analyzed. Injuries to the head occurred in 98 patients, Limb fracture 67, Revised Trauma Score Abdomen injury 30, Chest injury 25, and Pelvic injury 19, and maxilla-facial 160 150 injury 19 patients. Cause of trauma was due to the road traffic accidents in 140 120 92 ents 100 217, poisoning 13, fall in 14 while burns and assaults cause injuries in 11 i 80 Pat f and 3 patients respectively. 150 patients with revised trauma score came 60 47

No O 40 under the priority 1, 92 patients came under priority 2 while 36 patients 20 0 under priority 3.Among them 35 patients with severe head injury were Priority 1 Priority 2 Priority 3 treated with insulin for their hyperglycemic condition which improved the level of consciousness(GCS scale).At the time of admission the average GCS was 5.62 and after giving insulin it averaged to 11.

To study the comparative effect of Ivabradine and Metoprolol for Postoperative Inappropriate Sinus Tachycardia (IST) after Coronary Artery Bypass Graft Surgery IST may be induced due to catecholamine infusion during CABG. At CIMS, patients were divided in to three different groups. First group received only Ivabradine (5 mg/twice a day), second group received only Metoprolol (25 mg/twice a day) and third group received both. The heart rate and blood pressure were measured at different time interval after drug administration. Follow up of patients were taken after 5 days from hospital discharge for assessment of quality of life, drug adherence, complications, adverse drug reactions and prescription compliance. Combination therapy showed 5 percent fall of heart rate at 12 hrs and better blood pressure control after drug infusion as compared to single drug treatment group.

Correlation between Gastrointestinal Distress with Depression and Quality of Life in Cardiovascular Disease Patients In this prospective study a total of 644 CVD patients with either effort angina, unstable angina, myocardial infarction and left ventricular dysfunction were enrolled at CIMS. Gastric distress was assessed with complains such as abdominal pain, vomiting, constipation, gas, abdominal tenderness and others. GI distress was depicted in 58.97% patients. Most common GI distress symptoms reported were abdominal pain (32.81%), constipation (33.12%) and gas (34.07%). Mean MADRS score (7.3±5.12 v/s 3.38±5.36) and HADS score (7.48±3.24 v/s 3.94±3.34) were significantly higher in patients with GI complains. QoL as assessed by Physical Component Summary scores (68.42±26.23 v/s 75.68±26.17) and Mental Component Summary scores (71.04±23.62 v/s 79.82±23.54) were significantly lower in patients with GI distress as compared to subjects without GI distress. Presented at Cardiology Society of India Conference held in Dec.2012 106 CIMS Education

There are no full stops in education. Conducted CME and Camp 9 8 8 Education for Innovation 7

Camp 7 6 6 6 6 6 CME ENCE and

(N=49) 5 We are firmly committed to the 4 4 4 Camp 4 (N=22) application of newer and innovative 3 3 of CME 3 ONFER 2 2 2 2 2 2 2

medical techniques for improved patient C 2 care. 1 1 1 1 1 3C Number 0 CIMS regularly organizes CMEs, Jan Feb Mar Apr May Jun Jul Aug sep Oct Nov Dec workshops, etc. to acquaint its doctors with the latest technology and techniques in the field of medicine and surgery.

At CIMS, critical care unit holds weekly scientific and educational meetings open to all physicians. These discussions range from guidelines to patient management and latest medical updates with case studies supported by interactive audio-visual discussions.

As a part and process of education, we are proud of our annual mega educational event (www.cimsre.org), an annual conference targeted at physicians showcasing advances in medicine and surgery. Addressed by leading international and national medical luminaries, the conference is a result of an unwavering passion to educate all. 107 Operating / Assisting / Consulting doctors at CIMS since August, 2010 Medical Fraternity

Cardiology Cardiac Anaesthesiology *u Dr. Rajiv Bathla u Dr. Ajay Naik u Dr. Niren Bhavsar u Dr. Minol Amin u Dr. Satya Gupta u Dr. Hiren Dholakia u Dr. Vinod Chaudhari u Dr. Vineet Sankhla u Dr. Chintan Sheth u Dr. Viral Gandhi u u Dr. Gunvant Patel Dr. Vivek Iyer u Dr. Mitesh Kakkad u Dr. Keyur Parikh Vascular & Endovascular Surgery u Dr. Jalini Mehta u Dr. Milan Chag u Dr. Srujal Shah u Dr. Shirish Parikh u Dr. Urmil Shah u Dr. Ankit Patel u Dr. Hemang Baxi u Dr. Chandraveer Singh u Dr. Anish Chandarana Pediatric Cardiology u Dr. Jayant Shah u Dr. Kashyap Sheth u Dr. Kiran Shah Cardiac Electrophysiology u u Dr. Milan Chag Dr. Parag Thaker & Pacing u Dr. Vivek Uppal u Dr. Ajay Naik Neonatology and Pediatric Critical Care Intensive Care u Dr. Bhagyesh Shah Cardiothoracic & u Dr. Amit Chitaliya u Dr. Harshal Thaker Vascular Surgery u Dr. Tejas N Shah u Dr. Vipul Thakkar u Dr. Dhiren Shah #u Dr. Eva Bhagat u Dr. Dhanashri Atre Singh u Dr. Dhaval Naik u Dr. Urmish Chudgar u Dr. Dipesh Shah u Dr. Sanjiv Mehta Trauma u Dr. Harshuti Shah u Dr. Sanjay Shah Pediatric & Structural u Dr. Siddharth Shah u Dr. Nilam Thaker Heart Surgery Anaesthesiology u Dr. Varsha Tripathi u Dr. Shaunak Shah u Dr. Dipak Desai

We have been unable to include the names of physician / internist/paeditrician due to space constraints. We acknowledge their contribution to the success of CIMS *Visiting Consultant(s)/ We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. Surgeon(s) (alphabetically) We would appreciate if any missed name is brought to our notice. # Pediatric Superspecialty 108 Medical Fraternity Operating / Assisting / Consulting doctors at CIMS since August, 2010

Orthopaedic u Dr. Kartik Patel u Dr. Laxmidhar Murtuza u Dr. Chirag Patel u Dr. Satish Patel u Dr. Shakuntala Shah u u Dr. Amir Sanghavi Dr. Maulik Patwa u Dr. Manish Gandhi (GI Onco) u Dr. Ateet Sharma u Dr. Viren Rajyaguru *u Dr. Somesh Chandra u Dr. Hemang Ambani u Dr. Dhaval Sagala u Dr. Lalit B. Choksi *u Dr. Amit Agrawal u Dr. Ashvin Sardhara u Dr. Sagar Agrawal u Dr. Ajay Shah u Dr. Darshil Dalal u Dr. Prakash Amin u Dr. Alap B. Shah u Dr. Ashish Dave u Dr. Harshad Bhalodiya u Dr. Darshan Shah u Dr. Sonali Garg (Gynec Onco) u Dr. Jitendra Chaudhary u Dr. Harshal Shah u Dr. Natwar Gupta u Dr. Ritesh Davada u Dr. Jaymin Shah u u Dr. Deepak Dave u Dr. Jigar Shah Dr. Anila Kapadia (Gynec Onco) u Dr. Ronak Desai u Dr. Manish Shah u Dr. Kalpna Kothari u Dr. Arvind Gosai u Dr. Mukesh Shah u Dr. Kiran Kothari u Dr. Saurabh Goyal u Dr. Nishith Shah (Arthroscopy) u Dr. Meeta Makand u Dr. Yogesh Kapadia u Dr. Pranav A. Shah u Dr. Roopesh Modi u Dr. Ajay Krishnan u Dr. Rikin Shah u Dr. Arti Patel u Dr. Hasmukh Kubavat u Dr. Saurabh Shah u Dr. Sunil Maheshwari u Dr. Daria Singh u Dr. Brijesh Patel u Dr. Mehul Maskariya u Dr. Ketan Thaker u Dr. Mahesh Patel u Dr. Jayprakash V Modi u Dr. Navin Thakkar u Dr. Shailesh Patel u u Dr. Jyotindra Pandit Dr. Sanjay Trivedi (Arthroscopy) u Dr. Tarang Patel u Dr. Dimple Parekh u Dr. Jayesh Prajapati u Dr. Yogesh R Parikh Oncosurgery u Dr. Falguni Shah u Dr. Biren Parikh u Dr. Ashok Patel u u Dr. Jitendra Parmar u Dr. Dhaval Rajde Dr. Pinakin Shah u Dr. Mahipatsingh Parmar u Dr. Chaitanya Shroff u Dr. Viren Shah u Dr. Bharat H. Patel u Dr. Jayesh (J.D) Patel u Dr. Hemant Shukla u Dr. Bhavin Patel u Dr. Anjana Chauhan u Dr. Rajan Tankshali u Dr. Hitendra Patel u Dr. Natubhai Patel u u Dr. Jyotish Patel Dr. Mukund Trivedi u u Dr. Kamlesh Patel Dr. Jayesh V Patel u Dr. Jasmin Vasavada *Visiting Consultant(s)/Surgeon(s) (alphabetically) We also welcome new We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. doctors to affiliate with CIMS. We would appreciate if any missed name is brought to our notice. 109 Operating / Assisting / Consulting doctors at CIMS since August, 2010 Medical Fraternity

Neurosurgery Pediatric Uro Surgery *u Dr. Abhilash Choksi u Dr. Purav Patel u Dr. Raj Shah u Dr. Anand Desai u Dr. Chirag Desai u Dr. Parimal Tripathi *u Dr. Mitul Parikh u Dr. Jitendra R. Desai u Dr. Y.C. Shah u Dr. Nemi Goriwal Thoracic & Vascular Surgery u Dr. Mukesh Patel u Dr. Praful Jarmarwala u u Dr. Navin Patel Dr. Pranav Modi u Dr. Bijal Kadia u Dr. Harshil Shah *u Dr. Rajesh Hydrabadi u Dr. Didar Kapadia u u Dr. Dipak Patel Dr. Kiran Dave u Dr. Manoj Kapoor u u Dr. Somesh Desai Dr. Sadiq Kazi Gastrointestinal Surgery u Dr. Raju Lakhani *u Dr. Vipul Amin u Dr. Jayant Jhala u Dr. Tushar Lakhiya u Dr. Nagesh Bhandari u Dr. Bhaumin Maniar u Dr. Chirag Thakkar u Dr. Ramil Diwanji u Dr. Pankaj Modi u Dr. Rashmi Thakkar u Dr. Sandip Modh u Dr. Nayan Panchotra u Dr. Rajesh Shukla u Dr. Manish A. Rathi u Dr. Ketu Parekh u u u Dr. Sandeep Shah Dr. Hitesh Chavda Dr. Dewal Parikh u u Dr. Apoorva R. Patel u Dr. Manish Gandhi Dr. Ashok Somani u u Dr. Mahendra Bhavsar Dr. Apoorva S. Patel u Dr. Mahesh Trivedi u Dr. Hitesh N. Patel u Dr. Premal Desai u Dr. Krishnakant Patel u Pediatric Surgery Dr. Bhavin Patel u Dr. Pritesh Patel *u u Dr. Keyur Bhalawat Dr. Kaushal Anand u Dr. Rajesh S. Patel u u u Dr. Jayul Kamdar Dr. Vismit Joshipura Dr. Manish N. Raval u Dr. Shail Sanghavi u Dr. Parthiv Shah u Dr. Anish Nagpal u Dr. Amit Shah u Dr. K.S. Purohit u Dr. Raj Shah u Dr. Bharat Shah *u Dr. Nikhilesh Bhattacharji u Dr. Kartik D. Shah u Dr. Hitesh Gandhi General Surgery u Dr. Piyush Shah u Dr. Vasant Valu u Dr. Mitul Parikh u Dr. Viral D. Shah u Dr. Deval Shah u Dr. Kirit Sheth u Dr. Dhiren Patel u Dr. Alpesh Patel u Dr. Paresh Somani u Dr. Amar Shah u Dr. Vikram Patel u Dr. Balkrishna Tanna u Dr. Maulin Shah u Dr. Ajay Gadhavi u Dr. Niranjan Trivedi u Dr. Krunal Sheth u Dr. Sanjay Vyas *Visiting Consultant(s)/Surgeon(s) (alphabetically) We also welcome new We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. doctors to affiliate with CIMS. We would appreciate if any missed name is brought to our notice. 110 Medical Fraternity Operating / Assisting / Consulting doctors at CIMS since August, 2010

Endoscopy & ERCP u Dr. Rohit Joshi u Dr. Parul Kotdawala u Dr. Yatin Patel u Dr. Gaurang Kadam u Dr. Dipak Limbachiya u Dr. Nagendra Mishra u Dr. Ashish Nanavati Gastroenterology & Endoscopy u Dr. Pathik Parghi u Dr. Priti Parikh u *u Dr. Rajiv Bansal u Dr. Kandarp Parikh Dr. Arunkumar Patel u Dr. Dipak B. Patel u Dr. Manish Bhatnagar u Dr. Himanshu Patel u Dr. Falguni Patel u Dr. Jay Bhatt u Dr. Kamlesh Patel u Dr. Kalpana Patel u Dr. Manoj Ghoda u Dr. Pankaj Patel u Dr. Sanjay Patel u u Dr. Nilay Mehta Dr. Pragnesh Patel u Dr. Rajesh Punjabi u Dr. Sudhanshu Patwari u Dr. Ketan Rajyaguru u Dr. Akshay C. Shah u Dr. Sanjay Rajput u Dr. Chandresh Shah u Dr. Dipti A. Shah u Dr. Umang Rathi u Dr. Darshan Shah u Dr. Pragnesh Shah u Dr. Kaushal Vyas u Dr. Shrenik Shah u Dr. Parul Shah u Dr. Tejanshu Shah u Dr. Jayshree Sheth Bariatric and GI Surgery u Dr. Ketan Shukla u Dr. Riddhi Shukla u Dr. Digvijaysingh Bedi u Dr. Amit Trivedi u Dr. Chirag Thakkar u Dr. Kirtipal Visana Spine Surgery u Dr. Purav Patel *u Dr. Manoj Agrawal u Dr. Hitesh Modi Obstetric and Gynecology u Dr. Subir Jhaveri Urology u Dr. Nita Thakre u Dr. Tarak Patel u u Dr. Pinky Naik Dr. Himanshu Shah u Dr. Jayprakash V. Modi *u Dr. Ashini Acharya u Dr. Sharad Dodia *u Dr. Jigar Anandjiwala u Dr. Prashant Acharya *u Dr. Hemang M. Baxi u Dr. Bharat Dave u Dr. Rajni Asthana u Dr. Hemen Das u Dr. Bharat Patel u Dr. Kashmira Chhatrapati u Dr. Janak Desai u Dr. Biren Shah u Dr. Yogendra Jhala u u Dr. Mayur Vala Dr. Deepak Joshi u Dr. Parul Kapoor

*Visiting Consultant(s)/Surgeon(s) (alphabetically) We also welcome new We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. doctors to affiliate with CIMS. We would appreciate if any missed name is brought to our notice. 111 Operating / Assisting / Consulting doctors at CIMS since August, 2010 Medical Fraternity

Plastic Surgery u Dr. Mehul Pujara *u Dr. Subhramanyam Iyar u Dr. Ashwin Lakhani u Dr. Bharat S. Shah u Dr. Rajkumar Mandot u Dr. Himanshu Vora u Dr. Monark Shah u Dr. Shailendra Singh u Dr. Vinod Shah Pulmonology *u Dr. Hemen Jaju u Dr. Nitesh Shah u Dr. Nischal Naik Pain Management u Dr. Amit Patel u Dr. Bijal Parikh u Dr. Hitesh Patel *u Dr. Harjitsingh Dumra u Dr. Chintan Patel u Dr. Dipak Desai u Dr. Ajay Jain u Dr. Vishal Patel u Dr. Hemaxi Ambani u Dr. Deepali Kamdar u Dr. Nitin D. Shah u Dr. Kamlesh Patel u Dr. Parthiv Mehta u Dr. Shishir Shah u Dr. Pravin Patel u Dr. Amrish Patel u Dr. Dilip Trivedi u Dr. Mukesh Patel Nephrology u Dr. Tushar Patel ENT Surgery u Dr. Manthan Kansara u Dr. Varun Patel u Dr. Shaishav Sakhidas u Dr. Apurva Parekh u Dr. Gopal Raval u Dr. Manish Ninama u Dr. Javed Vakil u Dr. Hitendra Thaker u Dr. Mihir Mehta u Dr. Bhavin Mehtalia u Dr. Navin K. Patel u Dr. Himanshu Patel Critical Care (Visiting) u Dr. Niti Pankaj Patel u Dr. Prakash Darji *u Dr. Pratibha Dileep *u Dr. Manish N. Goyal u Dr. Sonal Dalal u Dr. Rajesh Mishra u Dr. Rahul Gupta u Dr. Devang Patwari u Dr. Tejas Padodra u Dr. Rajiv Jha u Dr. Jagdeep Shah u Dr. Suresh B Patel u Dr. Nilam H Thaker (Paed.)

*Visiting Consultant(s)/Surgeon(s) (alphabetically) We also welcome new We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. doctors to affiliate with CIMS. We would appreciate if any missed name is brought to our notice. 112 Medical Fraternity Operating / Assisting / Consulting doctors at CIMS since August, 2010

Radiology u Dr. Kalpesh Panchal Ortho-Oncosurgery u Dr. Kirtan Shah u Dr. Chintan Parekh u Dr. Jaimin Shah u Dr. Mandip C Shah u Dr. Jaimin Shah u Dr. Rutul Parikh * u Dr. Rupal Doshi u Dr. Kiran Patel Pediatric Orthopedic Surgery u Dr. Kunjal Patel u Dr. Mayank Patel *u Dr. Premal Naik u Dr. Pravin M. Patel u Dr. Maulin Shah Dentistry u Dr. Amitkumar Prajapati Ophthalmology u Dr. Parvin Chandarana u Dr. Pranav R. Shah u Dr. Alpesh Shah u Dr. Alka Banker u Dr. Deepak Sharma u * * Dr. Nandani R. Shah u Dr. Rohan Bhatt u Dr. Pranav Shukla Interventional Radiology u Dr. Soham Dave u Dr. Kunal Soni *u Dr. Ajay Desai u Dr. Meet Ramatri u Dr. Pinal Soni u Dr. Milan Jolapara u Dr. Anish Tiwari We congratulate & appreciate the efforts of the following: Medical Officers Hospitalists Pathology u Dr. Vinay Agrawal u Dr. Himanshu Parmar u Dr. Manisha Shah u Dr. Jyoti Bhatia u Dr. Sachin Patel u Dr. Jitendra Nayak u Dr. Mehul Darji Physician Assistants u *u Dr. Payal Kamdar Dr. Harish Lohana u Dr. Sonal Pandya u Dr. Chetan Maheshwari u Dr. Varsha Parmar u Dr. Ghansham Das Maheshwari u Dr. Falu Patel Microbiology u Dr. Kishorilal Maheshwari u Dr. Vipul Patel *u Dr. Bhavini S. Shah u Dr. Rano Mal Maheshwari u Dr. Mitesh Prajapati u Dr. Bhargav Patel u Dr. Devankshi Shah u Dr. Narendra Rathi u Dr. Hemali Shah Anesthesiology u Dr. Kaumil Shah u Dr. Krunal K. Shah *u Dr. Manish Bhatt u Dr. Om Shukla u Dr. Prachi Shah u Dr. Dipak Desai Physiotherapists u Dr. Jayesh Solanki u Dr. Shubhi Gautam u Dr. Kalpesh Goklani Pediatricians u Dr. Siddharth Joshi u u Dr. Rajesh Maheshwari Dr. Sandeep Makani u Dr. Sagar Kundaliya u u Dr. Arun Panchal Dr. Ankita Topiwala *Visiting Consultant(s)/Surgeon(s) (alphabetically) We also welcome new We apologise for any inadvertent omission of visiting consultant(s)/surgeon(s) names. doctors to affiliate with CIMS. We would appreciate if any missed name is brought to our notice. 113 2010 onwards CIMS Publication List

1. Keyur Parikh: Three year Follow Up Data Demonstrates Safe And Effective Treatment Of De Novo Calcified Coronary Lesions By Orbital Atherectomy. Presented at CRT 2013. 2. Sergio Leonardi, MD, MHS, Amanda Stebbins, Meredith Todd, Deepak L. Bhatt, MD, Gregg W. Stone, MD,A. Michael Lincoff, MD, Harold L. Dauerman,MD, C. Michael Gibson,MD,Harvey D. White, DSc, Keyur H. Parikh, MD. “Quantification of Clopidogrel Effect on Enzymatic Infarct Size Related to Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes: Insights from the CHAMPION PCI Trial.” accepted for publication in Coronary Artery Disease. 3. Parikh K et al. – The ORBIT I trial evaluated the safety and performance of an orbital atherectomy system (OAS) for the treatment of de novo calcified coronary lesions. 4. Three year Follow Up Data Demonstrate Safe And Effective Treatment Of De Novo Calcified Coronary Lesions By OrbitalAtherectomy System.Keyur Parikh; Roosha Parikh; Apurva Patel; Milan Chag.Published in JACC: Published in Cardiovascular Interventions CRT 2013 Supplement: Volume 6, Number 2 S. 5. Jawahar L. Mehta , Parloop Bhatt ,Bhavesh Vagehla, Keyur Parikh , A Prospective Study to Evaluate Correlation between Coronary Heart Disease and Depression and Its Influence on Quality of Life and Clinical Outcomes, JACC March 12, 2013 Volume 61, Issue 10, E1478 . 6. Parloop Amit Bhatt, Jay Naik, Roosha Parikh, Parth Parikh, Jawahar L. Mehta, Keyur Parikh. Gender Related Disparity in Cardiovascular Risk Factors and Treatment Options. J Am Coll Cardiol 2012;60(17_S).doi:10.1016/jack.2012.08.391. 7. Parloop Amit Bhatt, Jay Naik, Parth Parikh, Keyur Parikh, Jawahar L. Mehta. Gender Related Disparity in Cardiovascular Risk Factors and Treatment Options: An Indian Scenario. J Am Coll Cardiol 2012;59(13 Suppl):E1459. 8. Bhatt Parloop, Parikh Keyur, Suthar Varun, Naik Jay, Mehta JL. Coronary Heart Disease and Risk Factors in Women of Western India. Clinical Cardiology (In Press). 9. Keyur Parikh. The Year in Cardiology: An Update for Physician (How Doctors Should Change). Abstract Book; CIMSCON 2012; 6-8 January 2012, Ahmedabad. 10. Keyur Parikh, Apurva Patel, Roosha Parikh, Shivam Parikh, Parth Parikh "Cloud Computing" - We all should learn. Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad. 11. Keyur Parikh. Arterial Hypertension-Diabetes-Heart Failure-Renal Nerves and Renal Denervation. Abstract Book; CIMSCON 2012; 6-8 January 2012, Ahmedabad. 12. Keyur Parikh. An Innovative confluence: Hypertension, Diabetes, Heart failure: What to do? Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad. 13. Keyur Parikh. The Year in Interventional Cardiology. Abstract Book; CIMSCON 2012; 6-8 January 2012, Ahmedabad. 14. Keyur Parikh, Samin Sharma. Clinical Case-1: A 68-year-old Man with left main undergoes PCI of the unprotected left main coronary artery. Abstract Book; CIMSCON 2012; 6-8 January 2012, Ahmedabad. 15. Keyur Parikh, C. Thomas Peter How to live life? Lessons to learn (Inspirational Oration for All). Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad 16. Keyur Parikh, Guy Heyndrickx Robert. Selection of guiding catheters, guide wires and balloons. Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad. 17. Keyur Parikh, Samin Sharma. Approach to Bifurcations. Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad. 18. Keyur Parikh. Clinical Care: ACS. Presented at CIMSCON 2012; 6-8 January 2012, Ahmedabad. 19. Naik A.et.al, Apixaban in Patients with Atrial Fibrillation. N Engl J Med. 2011 Mar 3;364(9):806-17. Epub 2011 Feb 10.

114 CIMS Publication List 2010 onwards

20. Satya Gupta, Ajay Naik, Hemang Baxi, Urmil Shah, Anish Chandarana, Keyur Parikh, et al. Third Heart Sounds Measured at CRT Device Implant Sites are Correlated to Echocardiographic Filling Parameters in Ambulatory Heart Failure Patient. 2011 HRS Abstract On TRAC HF Study. 21. Satya Gupta, Ajay Naik, Hemang Baxi, Urmil Shah, Anish Chandarana, Keyur Parikh, et al. Transient Heart Rate Responses to Transitions in Posture in Ambulatory Heart Failure Patients are Correlated to BNP. Heart Failure Society of America 2011 HFSA Abstract Number – 150398. 22. Parikh K, et al. FREEDOM-M: Efficacy and Safety of Oral Treprostinil Diethanolamine as Monotherapy in Patients with Pulmonary Arterial Hypertension. Chest Meeting, 26 Oct 2011. 23. Parikh K, et al. Maintenance Therapy with Thienopyridines May Reduce Enzymatic Infarct Size in Patients with Acute Coronary Syndrome Undergoing PCI: Insights from the CHAMPION PCI Trial. Circulation: In Process. 24. Keyur Parikh, et al. Baseline characteristics, intervention modalities and utilization of evidence based medications among ACS patients: does presence of diabetes affect the presentation as well as management scenario for ACS? – results from single centric cross-sectional study from India.Poster Presentation at ISPOR 14th Annual European Congress, 7th November, 2011. 25. Keyur Parikh, Apurva Patel, Milan Chag, et al. Six Month Follow Up Data of Orbital Atherectomy System for the Treatment of De Novo Calcified Coronary Lesions (ORBIT I Trial). J Am Coll Cardiol 2011;58;B172-B173. 26. Keyur Parikh, Roosha Parikh, Apurva Patel, Milan Chag. Two Year Follow Up Data of Orbital Atherectomy System for the Treatment of De Novo Calcified Coronary Lesions - A Single Centre Experience. J Am Coll Cardiol 2011;58;B174. 27. Keyur Parikh. Promise of Newer Antiplatelet Agents in PCI. Abstract Book of ICI Meeting, 5th December 2011, Israel. 28. Keyur Parikh. Regulatory Aspects in India. Abstract Book of ICI Meeting, 5th December 2011, Israel. 29. Keyur Parikh, Roosha Parikh, Apurva Patel, Milan Chag. Orbital Atherectomy System in Treating Calcified Coronary Lesion: First in Man Assessment- 3 Year Follow Up. Abstract Book of ICI Meeting (Technology Parade), 5th December 2011, Israel. 30. Keyur Parikh. Use of Extraction Devices in Acute Myocardial Infarction-Are we there or do we need More Trials? Abstract Book of ICI Meeting, 6th December 2011, Israel. 31. Keyur Parikh, Parloop Bhatt. Correlation between Insulin Resistance and Altered Thyroid State. Presented; CSI, 8-11 December 2011,Mumbai, India. 32. Keyur Parikh. Parloop Bhatt, JL Mehta, Abhishek Deshmukh. Correlation between Depression and Cardiovascular Disease. Presented CSI, 8-11 December 2011, Mumbai, India. 33. Naik A. Beta blockers in arrhythmias: when and where to use? Indian Heart J. 2010 Mar-Apr;62(2):136-8. 34. Keyur Parikh, et al. Exercise Improvement and Plasma Biomarker Changes with Intravenous Treprostinil Therapy for Pulmonary Arterial Hypertension: A Placebo-Controlled Trial (TRUST – 2) The Journal of Heart and Lung Transplantation 2010;29(2):137-149. 35. Parloop Bhatt, Keyur Parikh, et al. Reinventing the Phases of Clinical Trial. Pharmaceutical Reviews 2010;8(1). 36. Parikh K, et al. Baseline Clinical and Angiographic Characteristics of the Patient Related Outcomes with Endeavor Versus Cypher STenting (PROTECT) Trial. J Am Coll Cardiol 2010;56;B64. 37. Keyur H Parikh, et al. Long Term Follow-Up to Evaluate the Safety of the Neovasc Reducer A Device-Based Therapy for Chronic Refractory Angina. J Am Coll Cardiol 2010;55;A98.E927. 38. Keyur Parikh, Parloop Bhatt, et al. Pharmacoeconomical Comparison of Bare Metal Stent and Drug Eluting Stent. Journal of Chemical and Pharmaceutical Research 2010;2(2):73-81.

115 2010 onwards CIMS Publication List

39. Keyur Parikh, Parloop Bhatt, et al. Pharmacoeconomic Analysis, Clinical Outcomes between Medication Therapy and Drug Eluting Stent in Single Vessel Blockade Patients. Deccan Journal of Pharmacology 2010; (1):2942. 40. Keyur Parikh, Parloop Bhatt, et al. A Study to Compare Clinical Outcomes of Bare Metal Stent and Zotarolimus Eluting Stent. Journal of Global Pharma Technology 2010;2(3):146-153. 41. Parloop Bhatt, Keyur Parikh, et al. The Comparative Efficacy of Angiotensin Receptor Blockers in Acute Coronary Syndrome Patients Following Medicated and Non-medicated Stent Implantation. Journal of Global Pharma Technology 2010;2(3):98–106. 42. Keyur Parikh, Parloop Bhatt, et al. Triple Versus Dual Antiplatelet Therapy Following Coronary Stenting: Impact on Lipid Profile. Deccan Journal of Pharmacaology 2010;1(1):4359. 43. Keyur Parikh. Editorial: A Quarter Century of Direction- Femoral Approach Towards Extinction,Indian Heart Journal 2010;62(3):191. 44. Keyur Parikh. Guest Editorial. Gujarat Medical Journal 2010;5(7):13. 45. Parikh Keyur, Parikh Roosha. Guidelines (and Advisory) for Doctors and surgeons) to Manage Anti-thrombotic Agents in Patients with Drug Eluting and Bare Metal Stents Undergoing Non Cardiac Surgery. Gujarat Medical Journal 2010;5(7): 49-53. 46. Parikh Keyur, Naik Ajay, Gupta Satya, Baxi Hemang, Chandarana Anish, Shah Urmil, Chag Milan. RemonCHF: Better Care for Congestive Heart Failure Patients. Gujarat Medical Journal 2010 Jul;5(7):109-110. 47. Naik Ajay, Chandarana Anish, Chag Milan, Gupta Satya, Baxi Hemang, Shah Urmil, Parikh Keyur. Neovasc Coronary Sinus Reducer: The Time Tested Option for “No Option” Patients. Gujarat Medical Journal 2010;5(7):111-113. 48. Parikh Keyur, Pandya Nilesh, Baxi Hemang, Chag Milan, Gupta Satya, Chandarana Anish, Naik Ajay, Shah Urmil. The Principal Investigator of ORBIT I Trial Discusses Safety and Performance of Diamondback 360° TM Orbital Atherectomy System in Treating de novo Calcified Coronary Lesions.Gujarat Medical Journal 2010;5(7):114-116. 49. Chag Milan, Panchal Kanaiya, Baxi Hemang, Chandarana Anish, Naik Ajay, Shah Urmil, Parikh Keyur. Initial Experience with CiTop™ ExPander™ Guidewire in Chronic Coronary Total Occlusion. Gujarat Medical Journal 2010;5(7):117-120. 50. Chag Milan, Gupta Satya, Chandarana Anish, Shah Urmil, Baxi Hemang, Parikh Keyur. Transradial Interventions: Our Experience. Gujarat Medical Journal 2010;5(7):127-130. 51. Parikh Keyur, et al. Blood transfusion: Benefit or Harm? Allogenic Blood Transfusion related Mortality in the Cardiovascular Patient. Gujarat Medical Journal 2010;5(7):131-133. 52. Keyur Parikh. Perspective. Gujarat Medical Journal 2010;5(7):138-140. 53. Keyur Parikh, et al. Ticagrelor Versus Clopidogrel in Acute Coronary Syndromes in Relation to Renal Function: Results From the Platelet Inhibition and Patient Outcomes (PLATO) Trial. Circulation 2010;122:1056-1067. 54. Parikh K, et al. Pre-Treatment with Thienopyridines Reduces The Amount of Myonecrosis in Acute Coronary Syndrome Patients Invasively Managed: Insights from the CHAMPION trials. Circulation, 2010;122:A14813. 55. Keyur Parikh. Orbital Atherectomy Device: Two Year Follow-up Experience. Presented at ICI Meeting, 2010, Israel. 56. Keyur Parikh. A Three Year's Clinical Experience Evaluating the Safety of Neovasc Reducer for No Option Patients. Presented at ICI Meeting, 2010, Israel. 57. Gupta S. Trans-radial Interventions: Our Experience. Indian Heart J 2010;62:264-266. 58. Gupta S. Tips and Tricks for Radial Interventions. Indian Heart J 2010;62:275-276.

116 JIC 2014

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117 JIC 2014

Venue Gujarat University Convention Centre, Ahmedabd

2014 TRACKS - DAY-1 (January 10, 2014) JICJoint International Conference CARDIOLOGY TRACK Satellite Sessions u Introduction Session (Time : 8.00 pm - 10.00 pm) u Coronary Artery Disease / Acute Coronary Syndromes u Pharmacology & Therapeutics - 1 & 2 u Plenary Lectures by International Speakers u Hypertension / Lipids & Cardiovascular Risk Management u Cardiology Guidelines u Medical Devices in Cardiology / Interventional Cardiology u Peripheral/ Endovascular /Diabetic Foot u Debates u u Special Topics Stroke 2014 TRACKS - DAY-2 (January 11, 2014) JICJoint International Conference CARDIOLOGY TRACK u Interactive ECGs/Arrhythmia u Atrial Fibrillation/ Arrhythmia u Plenary Lectures u JIC-Oration u Structural / Congenital Heart Disease u Heart Failure u Live Case Session CARDIOVASCULAR THORACIC SURGERY (CVTS) TRACK NEONATAL & PEDIATRIC CRITICAL CARE TRACK CRITICAL CARE & PULMONARY TRACK TOTAL KNEE REPLACEMENT (TKR) TRACK

2014 TRACKS - DAY-3 (January 12, 2014) JICJoint International Conference CLINICAL CARDIOLOGY TRACK CARDIOVASCULAR THORACIC SURGERY (CVTS) TRACK NEONATAL & PEDIATRIC CRITICAL CARE TRACK CRITICAL CARE & PULMONARY TRACK TOTAL KNEE REPLACEMENT (TKR) TRACK INTERNAL MEDICINE TRACK TRAUMA CARE TRACK

118 JIC 2014

World Best International Faculty at JIC 2014

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