Vol.5 Issue 1 OCTOBER - DECEMBER 2019

THE DIAGNOSTICS NEWS JOURNAL Published at Agappe Diagnostics Limited on October 01, 2019 | 62 Pages |` 20

AGAPPE MAKING AN INDELIBLE MARK IN THE PRE-ANALYTICAL DIAGNOSTIC REALM Mr. Thomas John

ASTHMA: AN OVERVIEW Prof. Dr. D M Vasudevan

EFFECTS OF SMOKING ON ASTHMA Dr. S K Jindal

CAUSES AND CONTROL MEASURES OF ASTHMATIC DISEASE Prof. Dr. P R Goyal

PATIENT EDUCATION PROGRAMME FOR ASTHMATICS : INDIAN PERSPECTIVE Dr. Rajinder Singh Bedi

IN THE ZENITH OF SERVING PEOPLE: RAJAGIRI HOSPITAL AND ITS NOBLE CAUSE Fr. Jose Alex CMI & Fr. Johnson CMI ASTHMATIC DISORDERS Discussing Common Asthmatic Disorders & Showcasing Tales Of Triumph HAVE YOU RECEIVED TECHAGAPPE (20th ) PAEDIATRIC EDITION ?

SCAN THE QR CODE TO CONNECT WITH US

02 TECHAGAPPE OCTOBER - DECEMBER 2019 SCAN QR CODE TO INSTALL AGAPPE CUSTOMER ENGAGEMENT PROGRAM

Privilege® SCAN OUR REAGENTS KITS TO EARN YOUR PRIVILEGE POINTS

EARN & REDEEM POINTS IN 5 STEPS 1 2 3 4 5

Purchase Our Welcome Scan the product Earn 1 Redeem QUALITY happy customers Barcode Using Point for Every points for & through AG PRIVILEGE’S 100 RUPEES AGAPPE INNOVATIVE QUALITY APP SCANNER Purchase REAGENTS Products REAGENTS

“Agappe Hills”, Pattimattom (PO), Dist. Ernakulam, Kerala - 683 562, . TEL: + 91 484 2867000 | [email protected] | www.agappe.com

TECHAGAPPE OCTOBER - DECEMBER 2019 03

Volume 5 | Issue 1 | October-December 2019 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS○○○○○○○○○○○○ 7 Breathe Easy 12-15 Asthma: An overview 20-23 In the zenith of serving people- Rajagiri Hospital and its noble cause 24-25 Offer- Mispa i2 Ayushman 26-29 Patient education programme for Asthmatics: Indian perspective

08-11 AGAPPE MAKING AN INDELIBLE MARK IN THE PRE-ANALYTICAL DIAGNOSTIC REALM 50-51 Unseen Facts - Sample Integrity 54-55 Engagements - Domestic & International 56-57 AGXplore - Kochi and Kolkata 16-19 58 CSR - Health Checkup FROM BREATHLESSNESS TO 60 Editorial Feedback BREATHTAKING TRIUMPHS 36-38 Causes and control measures of 30-33 asthmatic disease SCALING NEW 39-41 Conquering terrains with HEIGHTS unconquerable confidence CHALLENGING THE 42-45 Effects of smoking on asthma BOUTS OF ASTHMA 46-48 Asthma is not a disability!

Views and opinions expressed in this magazine are not necessarily those of Agappe Diagnostics Limited, its publisher, or editors. We do our best to verify the information published but do not take any responsibility for the absolute accuracy of the information. We do not take responsibility for returning unsolicited material sent without due postal stamps for return postage. No part of this magazine can be reproduced without the prior written permission of the publisher. Techagappe publishers reserve the right to use the information published herein in any manner whatsoever.

Caution: After going through the techniques, procedures, theories, and materials that are presented in Techagappe, you must make your own decisions about specific treatment for patients and exercise personal/professional judgment for further clinical testing or education and your own clinical expertise before trying to implement new procedures. Contact info: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. www.agappe.com Contact: Ph: + 91 484 2867065, Mob: +91 9349011309. Published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district , Kerala-683 562, India. Contact: Ph: + 91 484 2867000, Fax: + 91 484 2867222; Printed at Five Star Offset Printers, Nettoor, Cochin-40, for Agappe Diagnostics Limited Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.

4 TECHAGAPPE OCTOBER - DECEMBER 2019 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ From The Chief Editor’s Desk

THE DIAGNOSTICS NEWS JOURNAL

Volume 5 | Issue 1| October-December 2019 ○○○○○○○○○○ ○○○○○○○○○○○○○○○ ASTHMA, WITH A EDITORIAL BOARD DIFFERENT PERSPECTIVE... EDITOR Meena Thomas I am proud to bring out this 21st edition of TechAgappe. During the last 5 years of its existence, this magazine is being regularly published every 3 CHIEF EDITOR months. This edition covers various aspects of Asthma. Here we have Prof. Dr. D M Vasudevan tried to include the best stories and medical articles to make the reader more impressed. CONSULTING EDITOR Rarima N S The first article is from Agappe’s MD’s desk, where he explains our new commitments and innovations in the pre-analytical field. Recently EDITORIAL ADVISORY BOARD Agappe has launched Mispa Label for intelligent tube labeling and Mispa Rajesh M Patel View to be used while difficult venipuncture, the details of which is well Dr. C S Satheesh Kumar discussed in this session. Sudhir K Nair Varghese George In the medical article session, we have included three articles on Sanjaymon K R Asthma. The first one is an overview of clinical presentation of asthma John Mathayi from my desk. The second one is from Dr. S K Jindal, from PGIMER, Sankar T S Chandigarh, emphasizing the effect of smoking on Asthma. The third Bintu Lijo article is from Dr. Rajinder Singh Bedi, Bedi Clinic and Nursing Home, Patiala about the Indian perspective on Asthma. LEGAL ADVISOR Adv. Denu Joseph Further in the life story session, we have three stories about people who have succeeded in life even though they suffer from asthma. First PUBLISHING COORDINATOR one is on Mr. Parupalli Kashyap, who is an international player. Jayesh Kumar The second story is on Mr. Satyarup Siddhanta, who is a mountaineer with a Guinness record in his credit. The third story is on Ms. Sumedha DESIGN AND LAYOUT Mahajan, an athlete, who could achieve a lot by controlling the asthmatic

M T Gopalakrishnan ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Dezign Centre, Kochi.9947144570 attacks. In addition, we have included two interviews to share the experiences PHOTOGRAPHY of medical professionals. The first interview is with the management of Nelson Thomas Rajagiri Hospital, Kochi, to discuss the hospital’s public support initiative for the welfare of mankind and to emphasize their relationship with BOARD OF DIRECTORS Agappe. Second interview is with Padmashree Dr. P R Goyal, who was the CHAIRMAN physician to former president of India. To empower the knowledge of IVD Prof. M Y Yohannan technicians, we have a technical article on laboratory procedure, high- lighting unseen factors of IVD testing. To develop and support rural vil- MANAGING DIRECTOR lages of the country, Agappe has launched a new scheme “Ayushman” to Thomas John promote Mispa i2 - the patented Specific Protein Analyzer. We have placed an article on this to highlight the scheme. EXECUTIVE DIRECTORS Meena Thomas I am glad to state that we have received very good feedbacks and great Sangeeta Joseph appreciating letters for the previous issues, out of which some selected Mary Baby Meleth letters are published in this edition. We thank all the readers for their Prof. Dr.D M Vasudevan continued support. I am sure, this issue of the TechAgappe will give useful insights to the asthmatic problems, and different aspects of laboratory practices. Your constructive criticisms to improve the contents will be Subscription-For subscription queries, write to techagappe@ greatly appreciated. agappe.in or call us at +91 484 2867065. Permissions-For permis- sions to copy or reuse material from Techagappe, write to techagappe With warm personal regards and wishing a very happy reading. @agappe.in Letters to the editor-Email: [email protected] Postal address: The Manager-Corporate Communication, Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O., Ernakulam district, Kerala-683 562, India. Advertisement Queries- Email: [email protected] Dr. D.M. Vasudevan

TECHAGAPPE OCTOBER - DECEMBER 2019 5 VOICE OF READERS

TechAgappe continuously for a few years and am very proud to Salubrious Content in Lucid Language say that it is very informative Dear TechAgappe Team, Very happy to receive your maga- and useful to pathologists and zine. Since each edition is published with specific cover clinicians alike. Kindly provide stories, it is easy to order book in our library and con- your copies regularly and I shall cerned departments can easily use its content for educating their be grateful to you for your valu- students. Other articles like health tips and life stories are good able initiative in publishing such and excellent parts of the magazine. It pro- TechAgappe - a great magazine. vides a charming effect to the analysing Prof. Dr. A K Das, Cuttack habits of readers. Nicely presented and Imparting Knowledge lucid language is the essence of easy read- and Motivation Good Read on ing from an ordinary man’s view. The en- Laboratory Practices tire team deserves a sincere pat. Keep go- Dear Agappe Team, We are highly ing with this great effort. All the TechAgappe editions fol- thankful for the valuable informa- Dr. Kamlesh Kumar Tanwani, low a good ethics, nice approach tion imparted through Tech Aga- J L N Hospital, Ajmer and are very useful for the labo- ppe journal. Every issue contains ratories as well as the propri- significant and updated informa- etors and technicians. We ap- about their beloveds’ health and plete the entire reading and dis- tion, which is useful not only to preciate the quality articles welfare. The poem, ‘The Child is cerned the sweetness of knowl- the doctors but also to the pa- about good laboratory practices the Father of Man’ was expedi- edge sharing. I use this oppor- tients. Beside clinical advice, your session. ently written and placed. There- tunity to congratulate the entire journal inculcates motivation and fore, I am very happy to enjoy read- team who have come up with provides moral support to those Bhupesh Rajan, ing your magazine. Thank you and such a noble initiative in pub- suffering from various ailments. Delta Q Labs, Puducherry keep in touch. lishing such a beautiful maga- The language being lucid and in- Great and Beneficial Dr. Mayank Purohit, Jodhpur zine. I could find a few more formation being comprehensive, editions also from the same even a layman can easily under- Content! laboratory and now I am wait- Catchy and ing to get upcoming copies. stand the information you are Dear Agappe Team, Congratu- imparting. The life story sessions lations for achieving 25 Years of Commendable Content Dr. T Venkatesan, are very much impressive and Success. We are very happy to Dear Editor, Very luckily, I got a Government Hospital, Namakkal provide psychological boost to receive your new journal Tech- chance to read your magazine the depressed sufferers. I would Agappe. Last edition had a dis- TechAgappe in our laboratory. Impressive in like to hear your opinion whether tinctive advantage over past When I saw it for the first time, as this type of treatment is afford- editions because nowadays, usual, I just invested a single sight Content Quality able and accessible for the com- children are suffering from a lot to taste the overall feel for a fair as well as mon man. We will be anxiously of ailments and an overview view, but with its neat presenta- waiting for your valuable advice about such illnesses would help tion and meaningful content, with Presentation to minimize the trials between the parents to become more alert in a couple of hours, I could com- Dear Team, Warm greetings! I penury and treatment. am in receipt of your prestigious Bhaskar Reddy, Splendid Life Stories and magazine TechAgappe at regu- Bless College of Nursing, Tirupati lar intervals and found it quite Awesome Articles impressive and I am attracted to Very Informative and I am receiving your magazine regularly its fair presentation. Last edition, and I am very happy to inform you that based on Paediatric Illnesses, Useful the life story session is great and the provided a lot of helpful infor- Dear Team, I am serving as pro- medical articles are awesome. Many per- mation and as a reader, I am very fessor of Pathology at S.C.B Med- sons get support and ample motivation much honoured for having sub- ical College, Cuttack (Odisha) for from this journal. Hope you can continue scribed to such an informative the last three years. I am also with same spirit and quality. All the Best. magazine. Keep going ahead with practicing at Zenith Life Kare, the same spirit. Dr. S B Lal Mittal, Cuttack for the many years. I have Dr. Harish Shenoy, Lecturer in Ex-National Vice President (IMA) been reading your publication Pathology, Mangalore.

6 TECHAGAPPE OCTOBER - DECEMBER 2019 Cover Story Poem on Asthma

Breathing normal with ease is the real blessing When wind brings out pollen & allergens in plethora, Petting the dog, dusting the rooms bring allergies in bulk, Air squeeks through my tubes and breathing goes dissonant, And then am deeply choked , chest heaving and crushed inside. A puff of Inhaler is my panacea and sometimes with nebulising too. The palpable struggle in the crucible of existence, its horrendous dear, My woes and tribulations nobody to throw light upon, as long as it’s hard. Architect of all these mayhems, it’s you my comrade, Gross deforestation and extirpation of plants in masses, Clearing away the good Oxygen mask of the world in piles. The hydrocarbons your motor vehicles expectorate day night, Chemical pollution and suffocating air you bequeath every day, You leave innate air, persisting to Air conditioning round the clock, More you pull out from Mother Nature, breathing becomes a hassle. Polluted havens and reckless industries contaminating the Nature a lot. Buddy, practice breathing exercises & stress-free life, Courses of Pranayama & Yoga lending hands to freedom, Refreshing Life styles & natural environ, doors to betterment. Healthy food & stress-free life embrace you to melioration, sure. Abstain from allergens, pollen grains and stale dust and dirt possible, Or, in life, what’s yours is never wholly yours and you’ll lose the battle. Breathing in and out a zillion times a day, passing without any obstruction, Dr. C S Satheesh Kumar Thank God for this gift, there are thousands who, a losing battle have fought. Senior Vice President, AGAPPE

TECHAGAPPE OCTOBER - DECEMBER 2019 7 Agappe MD’s Desk AGAPPE MAKING AN INDELIBLE MARK IN THE PRE-ANALYTICAL DIAGNOSTIC REALM Thomas John, Managing Director, AGAPPE Agappe is known for Quality, Innovation & Affordability. With one of best in class R&D facility, we have introduced compact solutions in clinical chemistry and specific protein testing, which revolutionized the IVD testing globally. All our focus so far was into the analytical automation and now Agappe is entering the pre-analytical segment by introducing MISPA LABEL - the compact automated tube labelling platform and MISPA VIEW - The Vein Detector. Improving the quality and reducing errors are the major challenges in the diagnostic laboratories. Today, when we look at the innovation in IVD testing, there is an expo- nential growth in the analytical phase. From huge systems, which occupy large space with limited functions, now automations are transformed to desktop systems with more advanced features. From semi-auto- mated systems to fully-automated sys- tems, the segment is flooded with regional as well as multinational players. Today, standalone automated testing platforms are available from a throughput of <80 tests/ hour to <2000 tests/hour. The industry is also witnessing a steady growth in the Point of Care Testing (POCT) segment with the advancement in the electronics and infor- mation technology. AI (Artificial Intelligence) based data analytics is also gaining momen- tum recently. Since internet is becoming faster and cheaper, online home care ser- vices with the help of digital apps are also increasing. Medical awareness is growing faster in the developing counties and hence the im- portance of assuring quality results with Thomas John with Mispa Label at Medlab - Middle East 2019, Dubai. better turnaround time is becoming the key factor. There is an increase in the number of patients and the collecting, transporting and testing the samples, which is based on tests performed annually. The laboratories are now looking for the working style of the individual laboratories. automated platforms with positive sample identification to re- The major errors happening in the pre-analytical phase are illegible duce the error and have better sample traceability. When it comes patient name, sample collected in the wrong container, sample not to analytical methods, there are many statistical methods to collected in specific test tube etc. There are efforts made to minimize control the errors that may happen during the testing phase. the pre-analytical error with the help of barcoded labels. Still there are Studies show that 70% of the diagnostic error happens in other issues like consistency of the label quality and the consistency in the pre-analytical stage. One of the reasons behind this higher pasting the label on the sample container, which leads to re-labelling share is the fact that each laboratory is having a unique way of the sample container which in turn increases the turnaround time.

8 TECHAGAPPE OCTOBER - DECEMBER 2019 Proper specimen labelling practices are critical components of effective and accu- rate patient identification. Accurate and timely labelling of specimens is an integral MISPA VIEW- part of patient identification. It is critical The Vein Viewer because errors resulting from a failure in this step can, at best, provide results of no System is clinical value and, at worst, lead to the most developed under adverse outcomes to patients. When things technical tie-up go wrong in the pre-analytical phase, more expenses do occur, like the cost of redraw- with Sree Chitra ing the specimen where the phlebotomy Tirunal institute, labour and supplies are involved. Further, the cost of reanalysing the sample comes Trivandrum to into picture. Moreover, there would be ad- assist the ditional costs in the non-phlebotomy labour also, considering the additional nurs- phlebotomist to ing and physician time. When limited re- locate the vein sources become an issue, even the best- trained, experienced staff member may for a safe deviate from proper and generally accepted venipuncture. practices. The best way to minimize such pre-ana- lytical errors are using the help of automated labelling platforms revolutionized the IVD testing globally. All our focus so far was called tube labelling systems, automated sample transport sys- into the analytical automation and now Agappe is entering the tems and automated sample sorting systems. pre-analytical segment by introducing MISPA LABEL - the com- pact automated tube labelling platform. The system is designed At present, only a few systems are available in the market in considering the scenarios in countries like India and nearby pre-analytical segment and majority of these platforms are de- nations to suit the market requirements well. The hardware is signed based on the requirements in the developed countries and designed based on minimal robotic architecture for low mainte- hence involves huge investment and recurring cost. At present, nance and with highly flexible software to suit the industry very few players are present in the sample transport and sample demands. The compact design is made keeping in mind the sorting platforms, which is designed considering the few higher space constraints in the medium segment laboratories. The end customers. The scenario is same in case of post analytical tube loading mechanism design is so simple to allow the user platforms. When we look at countries like India, majority of the to load the tubes while running the system without interrupt- testing is performed in the Tier-II cities where space requirement ing the process. The product received wide acceptance in the for automation also plays a role. A highly compact system with market and we are sure that MISPA LABEL is going to change ease of use and better interconnectivity is the need of the day. the pre-analytical market. Agappe is known for Quality, Innovation & Affordability. With The other product launched by Agappe is MISPA VIEW, the one of best in class R&D facility, we have introduced compact vein viewer system, which is developed under technical tie-up solutions in clinical chemistry and specific protein testing, which with Sree Chitra Tirunal institute, Trivandrum. Mispa VIEW is used to assist the phlebotomist to locate the vein for a safe venipuncture. Virtually, this system is going to compliment Agappe is known for Quality, Innovation MISPA LABEL in a phlebotomy station. & Affordability. With one of best in class Agappe plans to introduce more automated platforms in the pre-analytical & Post analytical segment in the forms of R&D facility, we have introduced unique phlebotomy platforms, sample transport systems, compact solutions in clinical chemistry sample sorting systems and sample archive systems in com- ing years, which will be interconnected with a state-of-the art and specific protein testing, which intelligent software platform. revolutionized the IVD testing globally. Our aim is to provide affordable automation to the labora- tories in pre-analytical, analytical and post analytical phase to become “your best partner in diagnostics” globally.

TECHAGAPPE OCTOBER - DECEMBER 2019 9 Agappe Launching Products

ABCLIGNMENT | ARCODE LABEL | OLLECTION TUBE

Mispa Label ensures that you never go wrong with the A..B..C of Pre-Analytics

Mispa Label - The automated tube labeling system reduces human errors and increase throughput by eliminating need for manual printing /labeling with a convenient test tube loading mechanism, designed to deliver a high accuracy tube labeling with least turnaround time and low maintenance.

Label Intelligent Tube Labeling System

LABELING SAMPLE TUBES CORRECTLY

10 TECHAGAPPE OCTOBER - DECEMBER 2019 Agappe Launching Products

Know- How from Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.

4Non ionizing infra-red light source4Portable system with battery backup 4Three different colour modes46X optical zoom4Power saver function 4No patient contact or radiation issues4No pain suffering complications 4Reduced patient anxiety and stress4Improved puncture site selection 4Guaranteed safety by potentially reducing the risk of phlebitis complications 4Preserves vein options, especially in chronic conditions

VENIPUNCTURES MADE SIMPLER

TECHAGAPPE OCTOBER - DECEMBER 2019 11 Cover Story Asthmatic Disorders - An Overview ASTHMA AN OVERVIEW Asthma was recognized as early as ancient Egypt. The word ‘asthma’ is a Greek term, which means ‘panting’. It was officially named as a specific respiratory problem by Hippocrates circa 450 BC. Asthma Prof. Dr. D M Vasudevan, causes inflammation and narrowing of airways (bronchospasm), causing MBBS, MD (Biochem), FRCPath, Technical Director, AGAPPE blockage in the airflow. People with asthma often have other allergies.

Incidence Asthma is a common clinical condition. In India, more than10 million cases are reported per year. Worldwide, asthma affects 6 % of the people. Worldwide, 250,000 persons die every year as a result of asthma. It is often a leading cause for missed workdays. More- over, the prevalence of asthma ap- pears to be on the rise. Different Types of Asthma The ‘allergic’ or ‘eosinophilic’ asthma is also called a ‘T2 high’ type, which means the immune inflammation is associated with asthma. This form typically devel- ops in childhood and is associated with environmental allergies. Typically, there is a family his- tory of allergies such as food al- lergies or eczema. Allergic asthma often appears with elevated blood eosinophils. Sometimes, patients in this category also have nasal polyps, which are eosinophil-rich growths in the nasal lining.

12 TECHAGAPPE OCTOBER - DECEMBER 2019 The T2 low asthma is not associated with aller- gies or eosinophils. This type of asthma is some- times called ‘neutrophilic asthma’. Childhood asthma: Children are more likely to have intermittent severe attacks. There will be heightened sensitivity to substances that cause al- lergy. Mild asthma might resolve without treatment during childhood. How- ever, the condition might return later on, especially if symptoms are moder- ate or severe. Adult-onset asthma: Asthma in adults is often persistent and requires daily management. Obesity is a strong risk factor for adult- onset asthma and women are more likely to develop the condition after the age of 20 years. mostly from cat, dog or bird dander (fragments of fur or feath- Occupational asthma: It is estimated that 20% of asthma ers), mites, cockroaches, fungi, noxious fumes from house- cases in adults are work-related. Symptoms will become appar- hold cleaners and paints. Exposure to indoor volatile organic ent after attending a particular occupation such as baking, labora- compounds and formaldehyde exposure may also be a tory work, working with isocyanates, aldehydes, grain and wood trigger for asthma. Also, phthalates in certain types of PVC dust, soldering, contact with latex, animals or spray paint. are associated with asthma in both children and adults. Other Severe asthma: There will be consistent, debilitating breath- asthma triggers in the home and environment include sul- ing difficulties. Roughly 5 percent of people with asthma do not phur dioxide, nitrogen oxide, ozone, cold temperatures and see improvements after using the standard asthma medications. high humidity. Perfumes are a common cause of acute at- Seasonal asthma: This type occurs in response to allergens tacks in women and children. Cold air can lead to airway con- that are found only in the surrounding environment at certain gestion, constricted airway, extra secretions of mucus and a times of year such as cold air in the winter or pollen during certain reduced ability to clear that mucus. Tobacco smoke will in- seasons. crease the risk of asthma, wheezing and respiratory infec- Acute severe asthma: This is otherwise known as status tions. Smoking makes the effects of asthma on the airways asthmaticus and is an acute exacerbation of asthma that does not worse by adding coughing and breathlessness to its symp- respond to standard treatments. toms as well as increasing the risk of infections from the over- Non-allergic asthma: Also known as intrinsic or non-atopic production of mucus. asthma, it makes up to 30% of cases. There is negative skin test to Genetics play a significant role in asthma. If one parent has common inhalant allergens and serum concentration of immu- asthma, there is a 25 percent chance that a child will develop noglobulin (IgE) is normal. asthma. Having two parents with asthma increases the risk to Causes of Asthma 50%. If one identical twin is affected, the probability of the other having the disease is approximately 25%. More than 25 Asthma is caused by a combination of genetic and environ- genes have been associated with asthma. Many of these genes mental factors. Environmental factors include exposure to air are related to the immune system. pollution and allergens. Over 65% of adults with asthma over the age of 55 years also have an allergy. General triggering agents for Atopy is a general class of allergic hypersensitivity that the attacks are airborne pollutants, mold, mildew and cigarette leads to allergic reactions in different parts of the body that smoke. Common sources of indoor allergens include animal fur, do not come in contact with an allergen. A triad of atopic

TECHAGAPPE OCTOBER - DECEMBER 2019 13 Cover Story Asthmatic Disorders - An Overview

eczema, allergic rhinitis and asthma is called atopy. During atopy, the body produces more immunoglobin (IgE) antibodies in re- sponse to common allergens. Environmental allergens lead to overproduction of IgE antibodies and trigger asthmatic reac- tions. The strongest risk factor for developing asthma is a his- tory of atopy; with asthma occurring at a much greater rate in those who have eczema or urticaria. Hay fever or seasonal aller- gic rhinitis occurs when a person comes in contact with an aller- gen. Food allergies can cause a severe life-threatening reaction called anaphylaxis. The condition can lead to symptoms that include difficulty breathing, wheezing, rash and low blood pres- sure. The common foods associated with allergy are eggs, cow’s milk, peanuts, almonds, walnuts, wheat, fish and shrimp. Food preservatives such as sodium bisulfite, sodium metabisulfite, potassium metabisulfite and sodium sulfite may also trigger asthma. Even the slightest respiratory tract infection can trigger an matory drugs (NSAIDS) such as ibuprofen and naproxen. This is asthma attack. Approximately 10% to 20% of adults with called aspirin-exacerbated respiratory disease (AERD) or aspirin- asthma have sensitivity to aspirin or non-steroidal anti-inflam- induced asthma. Pathology Asthma is defined as ‘a chronic inflammatory disor- der of the airways in which many cells and cellular ele- ments play a role’. The chronic inflammation is associ- ated with airway hyper-responsiveness that leads to re- current episodes of wheezing and breathlessness. In asthma, the inside walls of the airways (bronchial tubes) become swollen or inflamed and the muscles around the airway tighten, making it difficult for air to move in and out of the lungs. There will be an overproduction of mucus too. At the start of an asthma attack, the airways allow enough air into the lungs, but it does not let the carbon dioxide leave the lungs at a fast enough rate. Carbon dioxide is filled in the lungs, which might further reduce the amount of oxygen entering the bloodstream. Nar- rowing of the airway causes the classic symptom of wheezing. Typical changes in the airways include an in- crease in eosinophils and thickening of the lining. The T lymphocytes, macrophages and neutrophils are also seen in the airways. The muscles surrounding the airway may increase in size along with an increase in the number of mucous glands. Chronic Obstructive Pulmonary Disease (COPD) can coexist with asthma and can occur as a complica- tion of chronic asthma. After age 65, most people with obstructive airway disease will have asthma and COPD. COPD can be differentiated by increased airway neutro- phils, abnormally increased wall thickness and increased smooth muscle in the bronchi. It closely resembles asthma in symptoms, is correlated with more exposure to cigarette smoke, an older age, less symptom reversibility after bronchodilator administration and de-

14 TECHAGAPPE OCTOBER - DECEMBER 2019 creased likelihood of family history of atopy. Onset before age 12 roids) that prevent symptoms. Severe cases may require is more likely due to genetic influence, while onset after age 12 is longer-acting inhalers that keep the airways open as well as more likely due to environmental influence. Asthma is character- inhalant steroids. Short-acting drug such as salbutamol are ized by reversible airway narrowing whereas COPD typically has the first-line treatment for asthma symptoms. Medications fixed airway narrowing. Severe asthma can evolve as COPD over are typically provided as metered dose inhalers (MDIs) in com- time. Sometimes, there may be an overlap of asthma/COPD that bination with a spacer. displays characteristics of both asthma and COPD. Corticosteroids (Fluticasone) are the most effective treat- Signs and Symptoms ment available for long-term control. Inhaled forms are usu- Wheezing is a characteristic symptom of asthma along with ally used once or twice daily. Leukotriene receptor antagonists shortness of breath. Chest pain or tightness can accompany an (Montelukast) may be used in addition to inhaled corticoster- asthma attack. Sputum may appear pus like due to high levels of oids. This reduces the risk of moderate and severe asthma white blood cells called eosinophils. Symptoms are usually worse at night and in the early morning or in response to cold air. The symptoms may oc- cur a few times a day or a few times per week and may flare up at any time. If children experience wheezing episodes during colds or respiratory infec- tions in early life, they are likely to develop asthma after 6 years of age. Laboratory Diagnosis Lung function tests are another component of asthma diagnosis. They measure how much air a person inhales and exhales and the speed with which a person can expel air from the lungs. Spirometry is a non-invasive test that exacerbations. In severe acute cases, intravenous adminis- requires deep breaths and forceful exhalation into a hose. Forced tration of aminophylline may be tried. Anti-IgE monoclonal Vital Capacity (FVC) is the measurement of the maximum amount antibody injections (Mepolizumab) may be useful in those of air a person can inhale and exhale. Forced Expiratory Volume with poorly controlled allergic asthma. Anti-IL5 treatment (FEV-1) is the maximum amount of air a person can exhale in one (Mepolizumab, Reslizumab) can be used in eosinophilic second. Measurements below normal indicate obstructed air- asthma. ways and probable asthma. If the FEV-1 measured by this tech- nique improves more than 12% and increases by at least 200 mil- Prevention liliters following administration of a salbutamol, this is supportive Smoking cessation and minimizing exposure to second- of the diagnosis. hand smoke are critical while treating asthma. Allergy testing will identify which allergen is the trigger. Small amounts of a Skin testing for common aeroallergens: The presence of sen- various allergens are injected under skin. A skin reaction could sitivities to environmental allergies increases the likelihood of identify the particular allergens which are responsible for asthma. Testing for food allergies is not indicated in the diagnosis asthma in that particular individual. Then by injecting very small of asthma. Blood tests for the allergic antibody (IgE) and eosino- amount of that particular allergen many times, the body is likely phils are done to establish the presence of T2 high asthma. Chest to develop a tolerance to it and the allergy will become much x-rays and ECG may be indicated to rule out other conditions. less severe. This is called immunotherapy (allergy shots) which Treatment may be helpful to reduce the attacks. Exercise is beneficial in Asthma can usually be managed with rescue inhalers people with stable asthma.Yoga could provide small improve- (Salbutamol) to treat symptoms and with controller inhalers (ste- ments in quality of life and symptoms in people with asthma.

TECHAGAPPE OCTOBER - DECEMBER 2019 15 Life Story P Kashyap (International Badminton Player) FROM BREATHLESSNESS TO BREATHTAKING TRIUMPHS “Asthma has never stopped me from achieving my dreams and goals!” Those words are from Parupalli Kashyap, the much famed P Kashyap, India’s star badminton player. Kashyap who made the country proud by winning the gold medal in men’s singles at the 2014 Glasgow Commonwealth Games had been suffering from asthma ever since he was a teenager. But the aliment was diagnosed only in 2005. “It was a big shock for me. Many thought that my career was over. But I was determined to fight back and put in a lot of hard work to overcome the disorder,” Kashyap recollects the hard times.

Can a debilitating breathing disorder push someone with towering spirits to the chasms of despair? When we meet Kashyap, we immediately get the answer - “No’. “Asthma has never stopped me from achieving my dreams and goals!” Those words are from Parupalli Kashyap, the much famed P Kashyap, India’s star bad- minton player. Kashyap who made the country proud by winning the gold medal in men’s singles at the 2014 Glasgow Commonwealth Games had been suffering from asthma ever since he was a teenager. But the aliment was diagnosed only in 2005. “It was a big shock for me. Many thought that my career was over. But I was determined to fight back and put in a lot of hard work to overcome the disorder,” Kashyap recollects the hard times. Born to Uday Shankar and Subhadra in , , Kashyap first started playing badminton recreationally in 1997. He was just a 11-year old child then and tried his hand at badminton during a summer camp. But the pastime soon turned to a consuming passion and eventually a dream. A dream, which made Kashyap dis- continue his engineering studies and pursue badminton as his only mission in life. Kashyap had first enrolled with Mohamad Arif’s camp in as a 11-year old and later joined the Padukone Academy in Bengaluru. Kashyap recalls how he was diag- nosed with asthma at the age of 16. By then, he had made a mark as a young, emerging badminton player and se- cured several national titles. For training, he was at Parupalli Kashyap Bengaluru. While his stay there, he began to notice that

16 TECHAGAPPE OCTOBER - DECEMBER 2019 every now and then, he kept on falling sick. Cough, cold and fe- ver became his constant com- panions. What astonished him was that it kept occurring every two to three weeks like a cycle. For a young emerging badmin- ton player like Kashyap, it was really a difficult situation as it had began to take up his valu- able time of training and daily routine. Since the situation didn’t change much, Kashyap thought to seek medical attention. He went to a general physician who prescribed some medicines for the cold and fever. Since Kashyap was clueless about the situation, he took the medicines and waited for the disease to subside. But after the initial re- covery, his health issues re- turned. Now, Kashyap thought it could be weather that was play- ing the spoilsport as the weather and air at Bengaluru were com- pletely different from that of Hyderabad, his native place. The polluted air at Bengaluru could have affected him badly. Soon, he shifted back to Hyderabad. Parupalli Kashyap At Hyderabad, things didn’t change much for Kashyap. “It chest physician. It was the chest physician at Hyderabad who used to be very, very bad. I used to be sick during every tourna- diagnosed me with asthma,” he points out. Kashyap’s mother ment. I had to keep taking antibiotics and I used to feel ill all the Subhadra recalls that it was chest specialist, Dr. K J R Murthy, time,” Kashyap remembers. He again sought medical consulta- who rightly diagnosed that he was asthmatic. They were really tion. This time, the general physician, whom he had approached, worried as he had been in the second stage of asthma. “The suggested him to consult a chest physician. “The general physi- doctor told me that I could continue to do what I was doing cian whom I had seen back at Bengaluru didn’t direct me to a until then. You can train harder. There are a lot of athletes who have won medals all the while suffering from asthma. Those words encouraged me a lot,” states Kashyap. By then, he had Kashyap was not ready to give up his dream joined the Gopichand Academy under , a former All England Open Badminton Champion. because of his disease. He believed that Kashyap was not ready to give up his dream because of his with proper medication and determination, disease. He believed that with proper medication and deter- he could control asthma. He was given an mination, he could control asthma. He was given an inhaler, which he credits to have brought an instant change in his inhaler, which he credits to have brought lifestyle after he was diagnosed with asthma. “I was suddenly an instant change in his lifestyle after he fitter, faster and healthier. Now, I can eat well and I became stable. I’m still asthmatic and I take medication once a day, but was diagnosed with asthma. I’m perfectly fine otherwise. The cycle of sickness stopped and within 6 months of the proper medication, I won the jun-

TECHAGAPPE OCTOBER - DECEMBER 2019 17 Life Story P Kashyap (International Badminton Player)

ior nationals and was selected to join the Indian Badminton team. The change really helped to improve my overall perfor- P Kashyap, who made the mance on the court,” Kashyap adds with a smile of pride. country proud by winning sev- “Basically, asthmatics have to keep on working on endur- eral medals at various interna- ance. You can’t build it up and stop working on it for a while, tional events for India, was like the others. My endurance goes down if I don’t work on it. recognised by Arjuna Award in So, I do endurance workouts even during tournaments, when 2012 given by the Ministry of Youth other players don’t,” Kashyap reveals his health mantra. Affairs and Sports, Government of India, to recognise outstanding achievements in sports. Personally, Kashyap believes that the inhaler is the best Apart from the Gold medal in Commonwealth Games 2014, way to treat asthma. “I wanted quick results as I had to train he had secured Bronze medal in Commonwealth Games harder each day. I believe Inhalation Therapy is the easiest 2010. He had reached the quarterfinals of the London Olym- pics in 2012 representing India. In Badminton World Federation (BWF) World Tour, 2019 Tournament, he became the runner up. He won the Tournament in 2018 after defeating Malaysia’s . In 2015, Kashyap was the champion in International Tournament, af- ter defeating India’s . Prior to it, in 2012 also, Kashyap defeated Thailand’s in Syed Modi International Tournament and became the champion. The highest world ranking in Badminton Kashyap has secured until now is Rank 6 in 2013. His current ranking is 31. Injuries had been there through-out his career which affected his ranking. In 2016, he recovered from a knee sur- gery and then had a calf-muscle tear. In early 2017, he had a complex shoulder injury. “There was a phase when a couple of times I thought it was all over given the pain coming back every time I started training after an injury break,” said him once after his constant injury breaks. Kashyap is married to , another prominent badminton player who has many international titles to her credit.

After returning to Hyderabad, he went to see his doctor again and then doctor explained him about the need to update his asthma medication. Due to the dust and conditions in Malaysia, P Kashyap with his wife Saina Nehwal his ongoing medication was not effective enough and it affected him badly. “This is just one story out of the many where asthma

way to treat asthma and it is a very good way to control it without any side effects,” he comments from experience. Yet, “Basically, asthmatics have to keep on he warns about the importance to update the meditation once in a while. Kashyap has a story to share about the need to do working on endurance. You can’t build so. He was in Malaysia for a tournament which was hosted in it up and stop working on it for a while, a small dusty village. He passed the first round of the tourna- ment. During his second round, he was winning comfortably like the others. My endurance goes down when suddenly he began to feel dizzy and disoriented. “It was if I don’t work on it. So, I do endurance hard for me to breath and I was really scared as to what was happening to me. My coaching team was also upset as they workouts even during tournaments, could not understand what was wrong and was unable to when other players don’t,” Kashyap assess the situation. I wanted to pull out of the match as I felt like I was about to faint. But somehow, I powered through but reveals his health mantra. ended up losing the game from a winning position.”

18 TECHAGAPPE OCTOBER - DECEMBER 2019 has affected my daily life and more importantly, my game. But I have overcome the situation eventually and moved on to do better. I, hereby, would like to call out to all of those young men and women who may have asthma and tell them that it is not a condition that stops you from living your life the way you want. It’s just a speed bump which can easily be surpassed if taken care of correctly,” he adds. Kashyap has some fond memories also associated with asthma. In the 2010 Commonwealth Games, where he secured the bronze medal in the men’s singles, he battled his breathing problems without some key medi- cines because of the stringent anti-doping rules in the Games. World Anti-Doping Agency, better known as WADA, has stringent code of conduct regarding the medicines or drugs used by the contestants. Every year Kashyap has to get the TUE (Therapeutic Use Exemp- tion) certificate from WADA. To renew the certificate, he has to undergo tests and produce medical certifi- cates each time, which is quite a tough job. In many ways, that “I feel really happy. I’ve achieved a lot. I would give 10/10 to bronze medal is very special for Kashyap as he battled asthma my career. The way I’ve endured asthma and the way I fought along with the opponent to secure the medal. and conquered it is a remarkable feat for me. I wanted to have a history-making accomplishment and I’ve achieved that with the CWG medal”. BRAND REACH When asked about his message to asthma patients who want to pursue a normal life, Kashyap’s words are as follows, Great products and after-sales service “I want to tell everyone that asthma is not a myth. When I was We are using the equipment Mispa Count of diagnosed with asthma for the first time, I was scared and I had Agappe Diagnostics since last 18 months and no prior knowledge about it. we are satisfied with the results. We also have Like any other disease, which has got a medication, asthma been using Agappe’s biochemistry reagents like has also got effective medication. I know many who want to Glucose, Cholesterol, HDL, Triglycerides etc. for hide it from their friends or relatives that they have asthma or the last three years. We would like to inform that they use an inhaler. But, I think it is not a disease which that the after-sales service of Mispa care is re- people need to hide from others,” his words are quite poignant. ally great. Atul Y Chaudhari, To all those who hide their asthmatic condition from oth- Shreeram Clinical Laboratory, Jamner ers, Kashyap says, “I still have headaches or sneezing associ- ated with asthma even during the international tournaments. But I overcome it with proper medication. I’m very regular with Guaranteed and satisfactory medication and I suggest everyone to be regular in following medication. Before diagnosed with the disease, I was guided performance of products wrongly and was taking many antibiotic medicines, which made We are using Agappe’s Mispa Nano-Fully auto me weak. With proper guidance, determination and medica- biochemistry Analyser, Mispa-i2 Specific Pro- tion, I have regained my strength”. tein Analyser and BC 3000 Plus - Hematology Kashyap has also associated with several campaigns about Analyzer from Agappe Diagnostics for the last asthma. He had associated with a leading pharmaceutical com- two years and are very satisfied with the per- pany twice in their campaigns named ‘Berok Zindagi’, which formance of the equipment. means Unstoppable Life and ‘Open up to Asthma’ campaigns. Dr. Asad Shaikh, “There are many widespread misconceptions about asthma, Maxim Clinical Laboratory & especially in the rural parts of the country. I’m doing my bit to Research Centre, Kalyan take the right message to those who suffer from asthma that a normal life is not a hard thing to achieve even for the asthmat- ics”, Kashyap is moving forward with a noble cause.

TECHAGAPPE OCTOBER - DECEMBER 2019 19 Interview Rajagiri Hospital Management, Kochi

IN THE ZENITH OF SERVING PEOPLE- RAJAGIRI HOSPITAL AND ITS NOBLE CAUSE Within a short span of time, Rajagiri Hospital located at Aluva, has turned out to be one of the leading multispeciality hospitals in the state. An initiative from the renowned Rajagiri (CMI) group of institutions, Rajagiri Hospital believes in offering quality and affordable medical care to the needy by the best healthcare professionals in the industry.

God’s grace and teamwork! Rajagiri Hospital Management tients’ safety and comfort. “There is a required space (like 36 sq. gives credit to these for the smooth functioning of the hospital m. for operation theatre) for ICU, wards, corridor of the hospital that excels in many ways than its peers. The decision to enter for it to be accredited with national and international standards. the healthcare sector was not a sudden decision for Rajagiri Many a time, my friends from aboard were astonished to find (CMI) group, which had its notable presence in the education more space here than the required space. They even had pointed sector of the state. “Apart from educating his followers, Christ out areas where we could have saved some space. But the man- has always found time to heal the masses. Healing was one of agement was very clear with the plan that there should be enough the prominent visions of Christ. That is why we got into this space for the patients to move freely. They never compromised noble sector. Our idea is to bring the highest standards of on providing the much required comfort to patients,” says expertise and skill into the treatment of patients, using the Dr. Major General M N Gopinathan Nair (Retd.), Medical Director, most advanced and sophisticated instrument and techniques Rajagiri Hospital. available, that too in the most affordable way to the laymen”, Rajagiri Hospital can be a case study on how to effectively says Fr. Johnson Vazhappilly CMI, Executive Director, Rajagiri intervene local population into employment. The management Hospital. thought how the local people could benefit apart from just being From the very beginning, starting from the construction of a hospital nearby. With the help of Rajagiri Institute of Social the hospital, the management had given top priority to pa- Science and two nearby panchayats, the management collected

20 TECHAGAPPE OCTOBER - DECEMBER 2019 Fr. Johnson Vazhappilly CMI-Executive Director (left) and Fr. Jose Alex Oruthayappilly CMI-Chief Finance Director (right) sharing their experiences with team AGAPPE data of the unemployed women in the vicinity. “We thought about from African countries, South East Asia and Central Asian coun- women empowerment of this region and for that, we carefully tries. planned a program. Interested women were given three months’ training and those who performed well were inducted into the Social commitment hospital as employees. More than 300 local women are now a part Being affirmed with a Christian missionary background, of the hospital as employees. social commitment is of prime importance in Raja- Within two years of time, giri Hospital. “We make Rajagiri Hospital achieved a lot sure that treatment is not of accreditations. “National denied to any patient be- accreditations like NABH and cause of lack of money. It international accreditations is not followed only in the like Joint Commission Inter- hospital but the same national, ISI certification, policy is followed in our Nursing Excellence award and educational institutions NABL for hospital labs! You also - money shouldn’t be name it, we have it,” states a problem for the educa- Fr. Johnson proudly. tion of a child,” says Apart from all these, Fr. Jose Alex Oruthayappilly Rajagiri Hospital was also able CMI, Chief Finance Direc- Fr. Jose Alex Oruthayappilly CMI Fr. Johnson Vazhappilly CMI to attract a large chunk of tor, Rajagiri Hospital. Chief Finance Director Executive Director medical value travellers from Fr. Jose points out that different countries for treatments and surgeries. In a short span of Rajagiri Hospital also has a dedicated doctor for Palliative Care. time, Rajagiri Hospital became a hot spot for patients from different “I think there is no other hospital which provides such service countries with its quality healthcare providing. While the lion’s share in a hospital environment. Our Palliative Home Care serves three of medical tourists come from Middle East, there are also many panchayats close to the hospital. We know that there are

TECHAGAPPE OCTOBER - DECEMBER 2019 21 Interview Rajagiri Hospital Management, Kochi

Rajagiri hospital, where adher- ence to international standards, recognition and patient safety is given prime importance, got a significant support from MISPA Label – Intelligent Tube labeling system in ensuring IPSG 1 and reducing pre analytical variables. We are very much impressed with the product quality and its performance.

Dr. Sunitha Thomas, M D Pathologist

government divisions for this service but what we feel that they tion, which will include medical school, nursing college, paramedi- aren’t effective enough,” comments Fr. Johnson. “Our Palliative cal institute and some amount of medical research too. Care is centred on the locality. There are bedridden people who are extremely poor and there is no one to take care of them. Our Maintaining quality and affordability team reaches their home, give them the required medical care In the global healthcare sector, maintaining quality and and we train the people, if there is someone at home, to take affordability is a challenge. If you take the Indian scenario, things care of the patients in the absence of the healthcare personnel,” are not much different. Fr. Johnson thinks that it will remain so in he adds on. the future also. “There are many reasons for that. One could be that we are completely dependent on MNCs and foreign compa- Talking about the immediate future plans, Fr. Johnson says, nies for medicines or devices. One solution is to develop indig- “We are moving into radiation oncology. We are actively looking enous R&D, technology and production,” he points out. forward to introduce nuclear medicine by December this year so as to provide a bit of comfort to patients who suffer from the “As we said, profit making is not our model. Sustainability is agony of the fatal disease.” He also pointed out that during the what we look into. We are also glad that Agappe is also following next phase, the management will enter into healthcare educa- the same path,” comments Fr. Jose. Recognising the contributions and investments made by Agappe in Indian IVD industry, Fr. Johnson said that it is the right model “Agappe has come out with solutions that should be developed. “Agappe has come out with solutions and those solutions are much and those solutions are much cheaper than many of the other products that we get from elsewhere. I think this kind of model cheaper than many of the other needs to be expanded and a lot more companies should come to products that we get from elsewhere. this field. We shouldn’t be unaware of the drastic changes that take place in the healthcare industry. You look at the developments that I think this kind of model needs to be come up in the field of artificial intelligence, big data analytics and expanded and a lot more companies machine learning. I believe, if all those are incorporated in the healthcare sector, it will bring about a change in the life of patients should come to this field" who undergo treatment,” he adds a valuable point here. Fr. Johnson comments. Fr. Johnson believes that the insurance system of the country should be developed. As the cost in healthcare sector is going up

22 TECHAGAPPE OCTOBER - DECEMBER 2019 with each day, he wonders how an ordinary man with a meagre recalls how as medical students they had to depend on sev- income can undergo treatment for a serious disease. “We need an eral medical equipments that time. He is amazed at the ad- insurance system where the government must also contribute. I vancement of technology now. “Back then, we had many pro- think the future lies in the expansion of insurance coverage. Those tocols to be followed. There were many tests and the results who are marginalised should have some help from the govern- always came late. It used to take a long time to get the correct ment. It is true that the Modi Government has brought it in the diagnosis. The need of the hour is the correct analysis in the national level but we have still a long way to go,” he states. shortest time with the minimal possible sample taken,” he points out. Another area which he believes that should undergo change is the approach of Keralites towards research and experiment. There He wants the innovations in the IVD industry to help and have been multiple incidents where people crowd the social media provide the point of care (POC) test results immediately to the with half truths or even fantasy versions when they happen to clinician. “The point of care test sample must not be trans- know about an ongoing medical experiment or a clinical trial ported to the central place or laboratory. Transportation be- conducted in a hospital - which the hospital would be performing comes an issue if it is not near to the hospital. Our concern abiding to all necessary laws. must be to provide the fastest diagnosis to them. Also, I feel that the equipment shouldn’t be huge in size as it could be “People who read such half-baked news might think that some another problem for labs and clinicians. A table-top model experiments are done by the doctors on a patient without the could save time and energy,” he adds. consent of the latter. In reality, no such programs can happen without the consent of the patient. I personally believe there should He is concerned about our country's over dependence on be a certain amount of experimentation or clinical trials or how imported medical equipment. “Many of our equipments are else could you find an ef- imported as we fail to fective cure,” he voices produce quality prod- forth his true concern in ucts. Take the case of this significant matter. ventilators. Every group vouch for im- Indian IVD ported ventilators as industry their quality is supe- rior. There is also the Talking about the case of pessimistic problems faced by the customers who Indian IVD industry, doubt the quality of Dr. Maj. Gen. M N Indian companies. But Gopinathan Nair (Retd.) the irony of it is that believes that the biggest the brain power of problem in India is the these major foreign lack of awareness and MNCs goes from our availability. “Awareness country,” he makes a is improving with the poignant note. spread of information technology. But there is He also believes a risk of knowledge and that 70% of errors wisdom. You may learn come in the pre- something from the analytics sector. The internet but only when fact that there aren’t you excel in the area, many companies in you will get the wisdom. the pre-analytics sec- Availability is good in the Dr. Maj. Gen. M N Gopinathan Nair tor shows a way of urban parts but still in Medical Director growth for the Indian the rural parts, it is a challenge. Accessibility to a technology is as IVD companies. important as availability. Affordability and quality are other fac- Another area which the Indian IVD companies can focus more tors which could influence the growth of IVD industry. I would say is the Point of Care (POC) equipment. “Convincing the mindset every district in the state must have a quality lab which should be of Indians about quality is the path for growth with respect to in public-private partnership,” he adds. Indian companies in the IVD industry. People are now more and As a person with a solid experience both as a healthcare per- more aware and cautious of their health,” he points out an im- sonnel and a teacher, Dr. Maj. Gen. M N Gopinathan Nair (Retd.) portant message for the Indian IVD segment here.

TECHAGAPPE OCTOBER - DECEMBER 2019 23 Agappe Product Scheme

John Mathayi, Group Product Manager, AGAPPE As a part of our 25th year anniversary celebrations and with an aim to make healthcare diagnostics accessible to all, we at Agappe, have introduced our Rural India Healthcare Development Scheme, the ‘Mispa i2 Ayushman Project’, which is aimed at providing the best quality products with innovative features at the most affordable prices. We understand the need of methods with utmost accuracy in results and that too in a cost-effective way.

The Young India is on the advanced path of development a pivotal concern for rural India. Rural India faces and its rural population is a fundamental part of this a severe technology deficit especially in growth trajectory. As India gears up for an era of healthcare while there is shortage of basic increased digitalisation and technology revolu- healthcare amenities such as trained staff and tion, the issue of holistic and inclusive eco- paramedical personnel. Moreover, the avail- nomic growth and basic healthcare remains ability of In-vitro diagnostic solution in rural areas is marginal. The so-called health for all and digital divide is widely spoken and written about but the healthcare technology divide is hardly men- tioned. Yet, this disparity is arguably more important as it has a far greater impact. In Indian healthcare market, nephelometry has spread out its wings to urban India. Semi-automated nephelometry systems were introduced by Agappe in India in the last de- cade and it became a game changer initiative in specific pro- tein testing. We have approximately 5000 nephelometric analyser units installed in urban India. But in rural India, specific protein testing is still considered as one of the major challenges due to various reasons such as lack of product prescription, high cost of analysers, increased cost per re- portable test and less workload. We Agappe, one of the leading Indian conglomerates with a global footprint and a forerunner in digital innovation, aims to be an active contributor in transforming millions of In- dian lives, its services reaching far beyond citizens within city limits. Agappe, Asia Pacific’s largest reagent manufac- turing facility, is helming a socio-economic revolution with innovation and people as its core strength. Agappe is focus- ing to touch and change the lives of millions with its ‘Intelli- gent Breed- Mispa i2 Specific Protein Analyzer’ and is thus uniquely poised to assist in the radical social transforma- tion of children, men and women in need in the rural India. As a part of our 25th year anniversary celebrations and with an aim to make healthcare diagnostics accessible to all,

24 TECHAGAPPE OCTOBER - DECEMBER 2019 we at Agappe, have introduced our Ru- ral India Healthcare Development Sche- me, the ‘Mispa-i2 Ayushman Project’, which is aimed at providing the best quality products with innovative fea- tures at the most af- fordable prices. We understand the need of methods with utmost accu- racy in results and that too in a cost- effective way. Hence, our most innova- tive R&D team has introduced India’s first patented diag- nostics equipment, Mispa i2 - Semiautomated Specific Protein pressure. To give a socio-economic touch, we will be collect- Analyser, which makes quality an affordable parametre. ing an advance of Rs. 46, 467 and the remaining can be paid We are taking the first step for rural Indian Laboratory back in equal post dated cheques of Rs. 4,671. During the upliftment through our Mispa i2 Ayushman Scheme. Accordingly, realisation of each cheque, we will be giving a free kit of HbA1c the high cost nephelometry analyser, which ranges between Rs. 5 30 test pack as a gesture of goodwill to make the system more lakhs to 10 lakhs has been significantly brought down to Rs. 88,500. economical and friendly so that customer need not go through To make the Mispa i2 – Specific Protein Analyzer commercially the high cost pressure of the analyser. viable, we also have increased our payment period from 3 months The scheme is open for all labs in India and the only pre- to 9 months so that the rural customer can overcome the financial requisite is to have minimum one sample of HbA1c every 2 days as Mispa i2 comes with a small pack size of 15 test. Agappe also has introduced 1 + 2 year extended warranty so that the customer gets the breakdown free support for three years. With this novel gesture, we would like to see each and every lab performing specific protein testing at the most affordable rates which will make protein es- timation faster in the nooks and corners of rural India. This will enable the health- care professionals to support the faster turnaround of results and people in rustic areas also get benefitted by the 25 diagnos- tic specific protein parameters. We, at Agappe, wish to trans- form the lives of millions with our ‘Divine Love’ for humanity, literally.

TECHAGAPPE OCTOBER - DECEMBER 2019 25 Cover Story Asthma - Indian Perspective PATIENT EDUCATION PROGRAMME FOR ASTHMATICS : INDIAN PERSPECTIVE The management of bronchial asthma has undergone revolutionary changes during the last few decades. To streamline its management over forty guidelines, statements and position papers have been developed in different countries. Guidelines for asthma management at primary and secondary health care levels in India have also been published recently. All these guidelines are similar in broad outlines. Despite all this, the morbidity and mortality due to asthma is increasing worldwide. The problem with the delivery of asthma care is considered to be one of the important factors responsible for this paradoxical situation. Patient education, pulmonary function monitoring, environmental control and pharmacotherapy are four main pillars of asthma management. Global initiative for asthma (GINA) Dr. Rajinder Singh Bedi guidelines have also divided asthma management into six inter-related parts, M.D.,Bedi Clinic and Nursing Home, Patiala (Punjab), India. of which patient education is clearly an essential component.

Western Scenario health care system. Because of excellent medical facilities, socio- Asthma education programme (AEP), a common concept economic advantages, nearly 100% literacy and other factors, in western medical literature, is rarely discussed or practiced asthma management in the west is intimately associated with in our country. The western countries have a well-developed patient education. However, despite all these advantages, even the developed countries have not been able to achieve uniform success in the imple- mentation of their guidelines. Indian Scenario Due to poor medical infrastructure, over population, overcrowded hospitals, illiteracy, poverty and other social prob- lems, there is hardly any AEP in our coun- try. In view of all these factors, our AEP is likely to be different from what is being practiced in the west. Need for AEP Out of nearly 200 million asthmatics worldover, approximately 15 million are in India. Though prevalence rates vary in dif- ferent studies,4 the prevalence of bronchial asthma is over 2.5% in adults and over 5% in children in our country and the burden is constantly increasing. Out-patient ser-

26 TECHAGAPPE OCTOBER - DECEMBER 2019 vices in our hospitals are usually over- crowded and due to lack of time and man- power, it is virtually impossible to carry out any asthma education activity in such a scenario. Poorly controlled asthma is as- sociated with significant morbidity and socio-economic problems like absentee- ism from school or work, loss of produc- tivity and wages and a poor quality of life. Poorly controlled asthma can also be po- tentially fatal. Therefore, there is urgent need for an AEP for better asthma man- agement. ASTHMA EDUCATION PROGRAMME Aim Aim of AEP is to provide suitable infor- mation and training to patients and their families, so that patients can keep well and adjust their treatment according to a medi- cal plan developed in advance with the help of the treating physi- factors. The importance of regular treatment is not realised cian. The patient education should aim to increase understand- by our patients. A study from Jaipur showed that only 9% ing, skill satisfaction and confidence of the patients so that there is asthmatics take regular treatment according to the advice of better compliance to treatment and better self-management. the doctor while rest of the patients stop medicines either when they become asymoptomatic or when they can tolerate Efficacy symptoms. Patient’s knowledge about different types of treat- The usefulness of AEP has been reported from large number ment available and about inhalation therapy, its advantages of studies abroad. The Cochrane Airway Group recently reviewed and various devices is insufficient and often wrong. Knowl- 36 randomised trials comparing self-management education ver- edge about crisis management is almost non-existent. Vast sus usual care and reported reduced morbidity as well as de- majority of our patients are often confused about allergy test- creased use of health care services in the intervention group. The ing and desensitisation therapy. hospitalisations, emergency room (ER) visits, missed days of work and nocturnal awakenings were all reduced in the asthma educa- Parents tion groups as compared to the usual care groups. Few studies from India covering awareness about asthma The efficacy of asthma education and self-care manuals have amongst parents of asthmatic children are available, which show been reported in some Indian studies also. All these studies have same degree of inadequate knowledge and misconceptions shown better health status, better compliance to treatment and about various aspects of the disease amongst parents too. better peak expiratory flow rate (PEFR), symptom and emotion score in the asthma education groups. The hospitalisations, se- General practitioners vere attacks, ER visits and loss of productive days were all de- Before availing the specialised services, majority of our creased in patient education groups. patients first go to their family doctor, usually a general prac- titioner (GP), for treatment of asthma. The knowledge of the Indian Studies GP about asthma and the quality of services provided by them For planning an AEP which can fit into our scenario and fulfil is likely to have a direct impact on asthma scenario. A number our needs, it is essential to have information about knowledge, of Indian studies reveal that our GPs do not possess adequate attitude and practices (KAP) of our patients, parents, practitio- knowledge about various aspects of disease and its treatment ners and general public about various aspects of asthma so that and do not keep their knowledge upto- date. While treating we can plan and prune our AEP accordingly. Several Indian stud- these patients, the ephedrine preparations, short acting b2 ies are now available covering these aspects. inhalers, oral bronchodilators, oral steroids and supportive measures (expectorants, antibiotics, antihistaminics, etc) are Patients often overused. Desensitisation therapy too is overused and These studies have revealed the inadequate awareness among often wrongly prescribed. On the other hand, inhalation therapy Indian patients about various aspects of asthma, including its as a whole and inhaled corticosteroids in particular, peak flow aetiology, diagnosis, monitoring and about avoidance of trigger meter for monitoring and oxygen therapy for emergency treat-

TECHAGAPPE OCTOBER - DECEMBER 2019 27 Cover Story Asthma - Indian Perspective

ment are all grossly under-used and practice of patient education is almost non-existent in our country. Need to Educate All All these studies underline the im- portance of providing asthma edu- cation to one and all in our set-up. The patients and parents can be ide- ally educated in asthma clinics whereas awareness in general public can be created through media (news- papers, television and radio talks, etc.). General practitioners and para- medical staff can be involved by short-certificate courses and con- tinuing medical education programmes by medical colleges etc. Asthma Clinic An ideal asthma clinic is a well-knit effort requiring sufficient staff, fi- nances and lot of dedication. Our OPDs, being heavily overcrowded, are not an ideal place for onstration of device usage, for spirometry as well as for collecting imparting asthma education. To begin with, asthma clinics can information from the internet. be started in big hospitals and multispeciality nursing homes on special days in a week, though some degree of education to Asthma Self-management Plan patients should be imparted on each and every visit. Asthma self-management plan is an important goal of AEP. The treating physician will be ideal choice for imparting The concept for such plans arose when it was realised that delay asthma education. When doctors take out time to provide in recognising asthma exacerbations and initiating appropriate education, it sends a powerful message to the patients and therapy were important factors contributing to asthma morbid- families about the importance of asthma education. How- ity and mortality. Patients need to be educated about objective ever, a doctor alone is often not enough for this purpose. In a monitoring of asthma with peak flow meter, along with symp- study of over 1400 physicians, it was reported that only 2% of tom-assessment and take crisis medications when needed in the physicians were able to answer the queries of their asthma form of increasing dosages of inhaled short-acting b2-agonists patients in a convincing manner.29 We cannot expect a change and/or inhaled corticosteroids or a course of systemic oral corti- in the attitude of the patient, unless he/she is convinced fully. costeroids. Imparting proper asthma education is a teamwork requiring This crisis self-management by oral corticosteroids may ap- medical personnel, equipment and educational material. A pear little too premature for our set-up when there are deficien- computer can be utilised for record keeping, for video dem- cies in so many other aspects. This concept should be thoroughly discussed with patients and their relatives before implementa- tion. There is every possibility that patients may go on misusing The basic components of AEP remain the oral corticosteroids on their own and may ultimately develop fea- tures of steroid toxicity or dependence. same for pregnant women too. Here, Pregnancy the patient is motivated, and it is easier The basic components of AEP remain the same for to impart any education to her. Pregnant pregnant women too. Here, the patient is motivated, and it is women should be stressed the easier to impart any education to her. Pregnant women should be stressed the importance of regular treatment for the well- importance of regular treatment for the being of the mother and foetus. well-being of the mother and foetus. They should be assured that, broadly speaking, all antiasthma drugs are safe during pregnancy, but inhalation therapy is best and safest. Asthma is not a contraindication for breast feeding,

28 TECHAGAPPE OCTOBER - DECEMBER 2019 so it should be encouraged. Though more research is needed, patients should be informed that breast feeding, reducing infant’s exposure to indoor allergens, especially domestic mites and re- Education of parents of ducing exposure to maternal smoking can prevent the onset of asthma in newborn. asthmatic children is equally Children important for better control Education of parents of asthmatic children is equally impor- of asthma in children and tant for better control of asthma in children and parents should parents should be actively be actively involved in the process. Besides basic components of asthma education, parents should be motivated for acceptance of involved in the process. diagnosis so that there is better compliance to regular treatment. They should be politely informed that, as yet, no magic cure lies with other systems of medicine. This will also definitely lead to better compliance. Parents should be educated about limited role Impediments in the Indian scenario of food allergens, allergy testing and desensitisation therapy be- Asthma education programme is almost non-existent in our cause they are often obsessed and confused about these modali- country and is associated with formidable challenges. There are ties. In our scenario, home management plans should be handed certain impediments peculiar to our scenario which need to be out only after a few reliable visits and that tackled for making a start in this direction. Social stigma at- tached with the diagnosis of asthma, paucity of patient educa- Compliance to Treatment tion material, lack of time and manpower and language and com- Studies of adults and children have shown noncompliance munication barriers are some of the major obstacles. rates around 50% while taking regular preventive therapies. A num- Misconceptions about disease and its treatment (especially ber of drug and nondrug factors which may be responsible for inhalation therapy) are rampant and compliance to treatment is noncompliance are given in table 4. 5 All these factors are to be very poor. We have also to tackle the counter propaganda against analysed and tackled to ensure better compliance. A number of inhalation therapy by the doctors of the other systems of medi- studies point out that compliance to treatment is increased if cine. Financial support from government for asthma education patients accept the diagnosis of asthma and believe that their activity is nil. Lastly, patients and parents are often lured to- asthma can be dangerous too and that they are at risk. The com- wards the other systems of medicine because of their unau- pliance is also better if patients feel that the treatment, they are thenticated propaganda and false claims. taking is safe and is controlling their ailment effectively. Further, compliance is also likely to improve if there is good communica- Conclusions tion between the patient and the treating physician. Asthma education is an important but often most neglected aspect of asthma management in our country. Despite various guidelines and better understanding of the disease, the goals of asthma management are not met in the medical community all over the world at large but more so in devel- oping countries, including ours. We have our own peculiar impediments in plan- ning and implementing an AEP fulfilling our requirements. Currently, the pro- fessional and voluntary efforts on asthma education are only fragmented. There is an urgent need for close co- operation between health care provid- ers, voluntary organisations, government, pharmaceutical companies, media and Asthma education is an important but often most neglected aspect patients for planning a national level strat- of asthma management in our country. Despite various guidelines egy for asthma education. No doubt, the and better understanding of the disease, the goals of asthma task is formidable, but sincere and sus- management are not met in the medical community all over the tained efforts in a step-wise manner ap- world at large but more so in developing countries, including ours. pear to be the only answer to make a start and gradually achieve this goal.

TECHAGAPPE OCTOBER - DECEMBER 2019 29 Life Story Satyarup Siddhanta (Mountaineer) SCALING NEW HEIGHTS, CHALLENGING THE BOUTS OF ASTHMA Born in Haridevpur in South Kolkata and presently based at Bengaluru, Satyarup’s father was a doctor. His first memory of asthma, which he remembers vividly, is that of an episode when he was in second grade. He had just returned to class after the lunch break and was struggling to breathe. His teachers soon took him home which was just opposite to the school. Being a child, he had no idea what the situation was and was happy that he could skip classes that after noon. But soon, it had its repercussions - he couldn’t play any of the outdoor games as his friends did.

At 8800 m on top of the mighty Everest, Satyarup Siddhanta’s 10 minutes. You people call this home and I’m quite sure you oxygen mask froze. For half an hour, he used up one third of could last more than me. If you could give me your mask for 10 the supplementary oxygen he had. His fingers had begun to minutes, I could complete the expedition and return. In case, if I turn numb. Satyarup approached his Sherpa and negotiated hesitate to give back your mask after returning, you can take it for his oxygen tank. One Sherpa declined the offer. Another from me forcefully”. With the acquired oxygen mask, Satyarup one, agreed to share his oxygen mask so that he could com- went ahead and conquered the . Returning to his plete the feat. But before that, they wanted to check his oxygen friends, he saw the Sherpa using his oxygen mask. As he was mask as it was quite common for climbers to start hallucinat- wondering how it happened, the Sherpa pointed his fingers at the ing in high altitudes. He allowed them to check it and they found rising sun. The frozen pipe began to function normally with the it to be true. Satyarup then told the Sherpa, “Look, I’m from the heat of the sun. Delighted, Satyarup and his friends began their plains and I was sustaining myself without oxygen for the last descent. For mountaineers and climb- ers, such stories are quite com- mon. In fact, many of the expedi- tion attempts fail and often there would be severe casualties. Satyarup’s three friends, who were part of another expedition team, died as their oxygen tanks turned empty while they were on their descent. Avalanches also posed a big threat to the moun- taineers. In this context, Satyarup Siddhanta’s attempt is not a rare achievement but it gains signifi- cance because of the fact that he had braved his severe asthmatic condition to complete this daring endeavour. The real depth of the attempt is revealed when we know that he hadn’t even taken his in- haler along (which is a constant companion for asthmatic pa- Satyarup Siddhanta tients) for his Mount Everest ex- pedition. Returning to the base

30 TECHAGAPPE OCTOBER - DECEMBER 2019 camp, everyone con gratulated Satyarup and wondered how he could stay calm during such a ter- rible situation. Sat- yarup, who once carried his inhaler as if it’s an organ, realised that what he faced there on top of the Everest was nothing new to him as he had been fighting asthma or breathing difficul- ties until then. Satyarup Siddh- anta is the world’s youngest person to climb the seven high est peaks and the seven highest volca- nic summits across the seven continen- ts of the world in Satyarup Siddhanta at Mount Everest seven years. He is also the first person in India to conquer the seven mountain peaks couldn’t play any of the outdoor games as his friends did. “It and seven volcanic summits. He is also credited as the fifth Indian was like an ‘early retirement’ from the games which required citizen to have climbed the tallest peaks in each continent. running and chasing. But I was still continuing my adventures like climbing or jumping off from the trees,” says Satyarup From being an asthmatic kid to conquering mountains with a smile. The hidden problem was that as he stopped Born in Haridevpur in South Kolkata and presently based at games altogether which involved running, the capacity of his Bengaluru, Satyarup’s father was a doctor. His first memory of lungs also came down. There were occasions when he had to asthma, which he remembers vividly, is that of an episode when wake up during midnight being not able to breathe. His father, he was in second grade. He had just returned to class after the being a doctor himself, used to give him a few medicines. lunch break and was struggling to breathe. His teachers soon took Later, the inhaler was introduced to his regime and he re- him home which was just opposite to the school. Being a child, he members it helped him a lot. In Eighth grade, he went for an had no idea what the situation was and was happy that he could allergy test in Kolkata. They gave him a list of things which he skip classes that after noon. But soon, it had its repercussions - he shouldn’t consume due to his allergic reactions like prawns, crab etc. They also asked him to do some running so as to regain his lung capacity. Eventually, he began to run to a cer- Satyarup Siddhanta is the world’s tain distance and also started swimming as a way of exercise. youngest person to climb the seven Later, he went to Sikkim to pursue his engineering at highest peaks and the seven highest Manipal Engineering Institute. Since the campus was located close to the mountains, the class rooms were spread across volcanic summits across the seven several levels. He had to use the inhaler several times as he continents of the world in seven years. had to take more effort to walk the distance. “I had an inferior- ity complex of using the inhaler. Hence, I made sure that no He is also the first person in India to one saw me with the inhaler,” he recollects. His brother, who conquer the seven mountain peaks and was also his roommate, used to understand when he needed seven volcanic summits. the inhaler as his breathing sounded different while climbing stairs. Satyarup’s brother believed that it was not something to be shy off.

TECHAGAPPE OCTOBER - DECEMBER 2019 31 Life Story Satyarup Siddhanta (Mountaineer)

The turning point Once during his stay in Sikkim, Satyarup got a bad cold. He needed to go to the nearest town to get some medicines which was 5 km away from his institute. So he started alone as he was confident enough to con- front any of the breathing difficulties with his inhaler. On the way, he became short of breath and he reached for his inhaler which he usually keeps in his pants pocket. That was when he realised that he had forgot- ten to take the inhaler for the first time. Running back to his room was quite impossible as it might take more than seven or eight minutes even if he tried so. Within two minutes, he had fallen to the road unable to breathe. He tried everything - inhaling fast, slow, normally and hard. Nothing worked. Eventually, he was in a state of giving up. But gradually, his breathing returned to nor- malcy. Satyarup sat up and reflected the whole thing in his mind. “I was very much frustrated. An array of emotions passed through me. I understood that I can’t go on like this forever. I have to cut down my depen- dency on inhaler somehow. I decided not to carry the inhaler with me from that day on,” remembers Satyarup. He made this daring decision in 2001. For the next few days, the breathing difficulties were more often and stronger. The efforts to calm the body were also more. Some days, he had to run to the hostel room from the class, on the pretext of going to toilet, to use the inhaler. But he was determined not to carry it with him. Meanwhile, he also tried food items which were prohibited to him owing to his allergic re- Sunita Kapur during chemotherapy actions. He wanted to know whether his body will cope with the situation. Earlier, he took the medication to the hotel so as to take it if something goes out of hand. He wanted to push the limits to see how far he can go with it. Finally, with exercises, discipline, diet and de- termination, he fine-tuned and conditioned his body and the disease. After completing his engineering, Satyarup went to Bengaluru. By then, he had also been doing a part- time job with an IT company. In 2008, he accidentally

saw the picture of his team leader on the top of a mountain called Parvathamalai in Tamil Nadu. Satyarup badly wanted to do some- The efforts to calm the body were thing like that. He was careful not to reveal his asthma problems to anyone. Later, he went on to climb that hill equipped with inhal- also more. Some days, he had to ers, in case of any emergency. “The terrain of hills made me for- run to the hostel room from the get the fact that I had asthma or breathing difficulties. Moreover, it had such scenic views. During the whole journey to the top of class, on the pretext of going to the hill, I never reached for my inhaler even once. I understood toilet, to use the inhaler. But he was that all my efforts from 2001 to 2008, to reduce the use of inhaler, had eventually worked. Standing there, I realised that I could do determined not to carry it with him. anything and everything I wanted to do just like normal guys. I was filled with confidence,” says Satyarup with his eyes shining with delightful pride.

32 TECHAGAPPE OCTOBER - DECEMBER 2019 Satyarup’s achievements of the are as fol- lows: in 2012, Mt. Elbrus in 2013, Mt. in 2014, Mt. in 2014, Mt. Kosciuszko in 2015, Mt. Everest in To complete the seven volcanic 2016, Carstensz Pyramid in 2017 and in the same summits, Satyarup was short of year end itself. The seven volcanic summits are Mt. Kilimanjaro (twice in 2012 & 2018), Mt. Elbrus in 2013, Mt. Ojos Del Salado, Mt. money. Though he had sponsorship Damavand, Mt. Giluwe and Mt. Pico De Orizaba (all in 2018) and from two groups, it was not sufficient. Mt. Sidley in 2019. He decided to auction several things Satyarup also undertook Last Degree South Pole Skiing and from his past expeditions so as to raise completed it successfully. It involves skiing 111 km over 6 days at a temperature of -40 degree. The backpack was close to 50 kg as he the fund for it. But his friends discoura had to complete the 6 days expedition. He is also looking to com- ged him and campaigned for him widely plete Last Degree North Pole Skiing along with the Greenland cross- ing from West to East (around 400 km and 36 days long) next year. and thus they were able to raise the The temperature is -40 degree. required funds for his amazing feat. The high expense factor To complete the seven volcanic summits, Satyarup was short award money is so meagre. But in a way, awards help me to get of money. Though he had sponsorship from two groups, it was recognised easily when I approach Corporates or MNCs for not sufficient. He decided to auction several things from his past help”, states Satyarup. expeditions so as to raise the fund for it. But his friends discour- For asthma patients who think that it is the end of their aged him and campaigned for him widely and thus they were able normal life, Satyarup’s message is to stay active! “For the first to raise the required funds for his amazing feat. 2 months, it could be very uncomfortable. But unless and until “Currently, I have a debt of Rs. 45 lakhs. I got a few awards - we utilise our lungs, it is going to cause more problem. It is fine state and national - which helped me to fund some of the expedi- to use an inhaler in case of a difficult sit-uation. My suggestion tions. But considering the huge expenses for each expedition, the is not to use inhaler to prevent a possible breathing difficulty attack. Slowly build on your stamina to withstand the breathing difficulty without the inhaler. I suppose, then you can pursue even mountain climbing or swimming so as to build a resistance. Eat fruits or veg- etables with Vita- min C to build im- munity. Having asthma is not the end of the world. A friend of mine from Canada who had been with me for several ex- peditions, still use inhaler during his expeditions,” Saty- arup adds to high- light that nothing can stop the true human spirit to move on in life.

TECHAGAPPE OCTOBER - DECEMBER 2019 33 Agappe Biochemistry Equipment

270 T/H) AGAPPE'S FULLY-AUTO BIOCHEMISTRY ANALYZERS 240 T/H)

140 T/H

Launchingsoon 120 T/H)

34 TECHAGAPPE OCTOBER - DECEMBER 2019 360 T/H) PERFECT INSTRUMENT PRODUCES PERFECT RESULTS 400 T/H)

Plus New Launch

1600 T/H)

2000 T/H)

TBA-120FR (Pearl Edition)

Tailor Made System Reagents TBA-2000FR

TECHAGAPPE OCTOBER - DECEMBER 2019 35 Interview Prof. Dr. P R Goyal (Pulmonologist) CAUSES AND CONTROL MEASURES ASTHMATIC DISEASE Prof. Dr. P R Goyal Padmashree Prof. Dr. P R Goyal MBBS, MRSH (London), FICA (USA), FSAS (MS), Dc RM was the physician to the former President of India Pranab Mukherjee. An eminent medical practitioner in the field of allergy, immunology and chest diseases, he is well recognised in India as well as abroad. Honoured with the Medical Excellence Award from Harvard Medical School, USA, Dr. Goyal is a renowned figure with his unparalleled achievements in medicine across various international professional societies. He is also a Professor Emeritus, Department of Chest & Pulmonary Medicine, SRM Medical College Hospital, Chairman and Managing Director PRG Medicare’s & Researches (P) Ltd. and Director, QRG Medicare Ltd. (QRG Super Speciality Hospital), Faridabad.

TechAgappe: Is asthma, a chronic respiratory disease? area. From my experience, I would say that the allergy those people get from pollens is much worse than what we people get from Dr. P R Goyal: I won’t use the word chronic. We have even dust and pollution. Many patients from US often come to us for small children having asthma. There are children who are born allergic tests and often we find that these people are allergic to with asthma. There are people who get it much in the later stage of their life. There are various reasons and causes. It can be genetic for some while allergy could be the reason for some. But the most common cause of asthma we nor- mally see is allergy. Predominantly, it is the cause of asthma in many cases. Many factors like atmosphere, pollu- tion and dust are all add-on factors for allergy. When a person has allergy, his immunity goes down. TechAgappe: What are the major triggers for asthma? Dr. P R Goyal: It varies from country to country, place to place! For example, in India, the basic trigger is caused by the dust, whether it be house dust or any kind of outdoor dust. In a place which is green and there is no dust, pollens could trigger asthma. Take the case of California. I have seen every second person from California having Dr. Barnali Das Prof. Dr. P R Goyal a bad asthma and they live on steroids. The reason is that place is in the Bay

36 TECHAGAPPE OCTOBER - DECEMBER 2019 most of the plants, trees, grass and they are in severe allergic conditions. TechAgappe: What are the different types of asthma? Dr. P R Goyal: The first asthma we could talk about is childhood asthma. Here, a child is born with asthma. The second category is the asthma which comes as the child grows up. It is exer- cise-induced asthma as the child goes to school or while he plays and so! After that, when they grow up further, they are introduced to more allergies in their workplace and atmosphere. Smokers for example! Many could land up in such scenario. It is a small smoke-induced asthma. Most important, in all of them is allergic asthma, which gets to people who keep pets at home. Food allergy is another common condition. They get various attacks. I still get many people from abroad who are allergic to peanuts in food allergic conditions. TechAgappe: Is it curable? Dr. P R Goyal: The cure of asthma de- pends upon the state at which we start taking treatment- the earlier the patient comes up, the more triggers are taken care of, the more comfortable the pa- Prof. Dr. P R Goyal receiving Padmashree Award from tient is. They need to modify their former President of India Shri. Pranav Mukherjee lifestyle and such patients can live bet- ter. There are also people who can’t adjust to different recom- Dr. P R Goyal: The first test we do is a lung function test. Every mendations made for asthma patients. They keep on getting bad time we monitor a patient by his lung function. That is the basic to worse each day. My point is that it varies from one person to and primary test. There are kits available in the market which we another, from place to place. The more you delay to start the recommend the patients to keep at home for checking the vol- treatment, the obstacles increases. After a point, you can only ume of inhaling and exhaling air. On an advanced level, we do control it, not cure it. Diffusion Studies. But the base for all this is Pulmonary Function Tests (PFTs). TechAgappe: Is it true that the number of asthmatic patients is on the rise now compared to the past? TechAgappe: Why is asthma getting worse at night? Dr. P R Goyal: Yes, the number of asthmatic patients is on the Dr. P R Goyal: That is an interesting question. But it is not rise. The basic reason is the living conditions - there is nothing at related to asthma alone. It is related to most diseases. If you present which could be very friendly to asthmatic patients. The notice most attacks happen between 2 am-4 am. Asthma attacks change of season will induce it - the spring, the fall, the rains, the also happen at that time. The basic reason for that is when our winter, the dust, harvest; everything will induce it. Even the food body goes to sleep, the organs inside our body also go to a state will induce it. We are far from organic foods and what we now get which we call as a ‘sleep state’. That is the time when they are is all toxic. But there are also surprises. I had a patient who was repairing themselves. So the defences are minimal. Your im- not responding well to the medicines. I asked him to shift to a new mune system will be half powerless in this state when compared place which was more hygienic, clean and affected by less pollu- to any other time. If you check the number of heart attacks and tion. He shifted to the outskirts of Shimla from Delhi and is now strokes happening at this time, it will be very high. much better. The air quality is much better there. TechAgappe: Is there a relation between stress and asthma? TechAgappe: What are the kind of tests do we need to monitor Dr. P R Goyal: Yes, there is a relation between stress and asthma? asthma and it is very important. Under high stress, the amount

TECHAGAPPE OCTOBER - DECEMBER 2019 37 Interview Prof. Dr. P R Goyal (Pulmonologist)

of stress hormones it secretes will make lungs unable to function normally. Not just lungs, but with stress almost all organs find it hard to func- tion. Now, many doctors and institutes all over "Exercise is a very the world look at psychological measures in a serious way for the treatment of asthma or al- important compon- lergy. Once the patient is relived of stress, the ent to improve the condition is much better. vital capacity of TechAgappe: Is exercise important for asthma patients? lungs. But, it is up to Dr. P R Goyal: Exercise is a very important com- the doctor to advise ponent to improve the vital capacity of lungs. the patient accord- But, it is up to the doctor to advise the patient ing to their condition according to their condition and I won’t recom- mend a patient to take his own decisions on this and I won’t recom- matter. There have been situations where my mend a patient to patients showed no improvement even after pro- viding the best medicine and expert advices. take his own decisi- Upon asking them, what they were doing, many ons on this matter". of them told us that they had been doing Pranayama (Yoga for breath control exercise). If you have a fracture in your hand, first you need

to heal it and then only you do physiotherapy. It is same in the case of asthma also. Once asthma patients improve their condition, exercise is a must. But the decision should be taken by the doctor. TechAgappe: What are the therapies to manage asthma? Dr. P R Goyal: Sudden death rarely happens in respira- tory diseases. It’s not the same with cardiac or cerebral diseases. We are so advanced in the treatment of diseases that we can now replace the total tissues in the damaged part of a lung. It is called thermoplasty. Even for allergies, immunotherapy is the latest measure. Immune system gets back to the normal state through immunotherapy. Many patients could go back to their normal state with immuno- therapy for their allergies. TechAgappe: How does smoking affect asthma patients? Dr. P R Goyal: Smoking affects terribly. Ultimately, lungs are just small spongy filters and the tar from cigar will affect the diffusion happening in lungs and day by day, it will reduce the capacity of lungs to diffuse. TechAgappe: What could be your health tips to asthma patients? Dr. P R Goyal: First and foremost is being aware of the problem which people aren’t normally aware of. Then recognising the trigger factors and modifying their life ac- Prof. Dr. P R Goyal with Indian film actor cording to the trigger factors. Leading a healthy lifestyle, tak- Amitabh Bachchan during a conference. ing medication regularly and awareness are factors which should be taken care of.

38 TECHAGAPPE OCTOBER - DECEMBER 2019 Life Story Sumedha Mahajan (Marathon Athlete) CONQUERING TERRAINS WITH UNCONQUERABLE CONFIDENCE What sets marathoners on the run? For some, it is the prize money! For some, it’s the fame and name involved! But it’s not the same for all. A study on female marathoners revealed that it wasn’t winning races and setting course records, but it’s also really a sense of pushing themselves beyond their preconceived limits. What sets marathoners on the run? For some, it is the prize low her dreams. A Limca Book of Records holder, for completing money! For some, it’s the fame and name involved! But it’s not 1500 km-long run as the only woman in the six member team the same for all. A study on female marathoners revealed that from Delhi to Mumbai within a span of 30 days, she also proved it wasn’t winning races and setting course records, but it’s also her mettle with a first prize in Bengaluru Ultra Marathon of over really a sense of pushing themselves beyond their preconceived 75 km in 2011 and 15th position in Mumbai Marathon and the 6th limits. For Mumbai based Sumedha Mahajan, who is in her mid position in the Borneo Marathon in Malaysia. What sets her apart 30s, running marathon helped her to break the mould and fol- from all other marathoners is the fact that Sumedha Mahajan suffers from chronic asthma. Though now settled in Mumbai, Sumedha Mahajan hails from Amritsar, Punjab and had lived and worked in major metros like Hyderabad, Bengaluru, Chandigarh and Delhi. For her enduring spirit, she credits her Punjabi roots. “Punjabis never back down,” she beams with pride. However, the harvest season in Amritsar usually triggers severe asthma attacks to the ones prone to the disease. “My health has never been kind to me. Ever since I can remember, asthma restricted me indoors. The inhaler was my constant companion,” she recalls. “They called me a defective piece”, she writes in her own book ‘Miles to Run Before I Sleep.’ But her father Dr. Vishav and mother Dr. Kamlesh introduced her to sports quite early in her life. She took to tennis in her childhood days. She played tennis with her father and siblings. It was the best thing that occurred to her as she had turned to de- pression being confined by her condition. But pro- fessional tennis wasn’t sustainable in the middle class family and she had to gradually let it go. As she started her graduation, she ditched exercise alto- gether. After her marriage, she was relocated to Delhi. Her asthmatic condition increased without any ex- ercise. She recalls that she spent more time in the hospital than with her husband in those days. She Sumedha Mahajan decided that this was not the way to go ahead. She looked at opportunities to improve her lung capac-

TECHAGAPPE OCTOBER - DECEMBER 2019 39 Life Story Sumedha Mahajan (Marathon Athlete)

ity. Pursuing tennis looked impossible with her job and new responsibilities. She found the solution in the neighbourhood park where the residents jogged in the morning and evening. While usual participants of marathons An old pair of tennis shoes turned to be her running shoes and she started running. “After just one lap, my lungs were undergo training, Sumedha had none. bursting. But as I kept going, the changes were visible. Even She enrolled her name following a running 50 m proved to be a challenge at first. It took me 45 days to complete 2-3 km. To reach the 10 km mark, I practiced whim. Moreover, her doctors were for more than three months improving my endurance. For against her decision to run. Her mother the first time in years, that too in the Delhi winter, I wasn’t stuck with a nebuliser. The more I ran, the better I breathed. It and sister also held the same opinion. was a huge revelation for me,” she recalls happily.

The way to marathon Once she reached the venue, she realised how inadequate her The year 2011 has a special place in Sumedha Mahajan’s running gear was. Many of them were equipped with diet supple- heart. It was in the same year, she took to competitive run- ments, fancy watches that display different parameters about ning, her first debut in a marathon- Mumbai Marathon. By their runs, foot gels and special water bottles. Despite the odds, then, Sumedha and her husband had moved on to Mumbai she finished 15th in the Open Women’s Category. That day trans- from Delhi. Everywhere she saw young men and women and formed her whole existence. even old people jogging not just in the morning and evening but even at night. “I even connected with strangers who ran Later the same year, in December, she ran for 24 hours in every night along Carter Road,” says Sumedha. When she grew Gurgaon on a six-kilometre loop hosted by Running And Living, confident, she wanted to take it to the next level. As said ear- stopping only to relieve herself. Running And Living organises lier, she wanted to push her limits farther than she had imag- runs across India and links runners nationwide. She went on se- ined. This set Sumedha into motion. curing the national record for running 151 km in 24 hours. While usual participants of marathons undergo training, In 2012, she made her record performance. Her invitation to Sumedha had none. She enrolled her name following a whim. Greenathon came through Milind Soman, who was also the brand Moreover, her doctors were against her decision to run. Her ambassador of the same. “Covering 1500 km in record time is not mother and sister also held the same opinion. They even ad- easy, especially when it’s physically and mentally demanding,” vised her to focus on family than running on the racetracks. she comments from experience. Besides, she was the only girl in However, her husband was supportive. the team. “Participating in the run was a big decision for me as I had just recovered from an accident in- jury two weeks prior to the run that had me bedridden. I suffered a severe asthma attack during the run but I was up for the challenge mentally,” says an iron-willed Sumedha. They ran along highways, vil- lages, hills and deserts of Gurgaon, Rajasthan, Gujarat and Maharashtra. Dust and pollution along with the fumes from the vehicles exacerbated her asthma. Apart from these, bleeding skin lesions, acute dehydration, stomach in- fection, blackouts due to cramping and minor muscle and bone injuries were also there. Yet, she was determined to complete the challenge. Innings as an author After completing Greenathon, she went ahead with several other mara- thons. But all the while, she began to dream about a new turn altogether- as an author. She wanted to tell the world Sumedha Mahajan with parents how she achieved these rare feet. In 2013,

40 TECHAGAPPE OCTOBER - DECEMBER 2019 she took her draft to an agent and together they approach- ed several pub- lishing houses. Around 14 pub- lishing houses rejected her book and later, Rupa Publications agreed to pub- lish her book. It marked her in- nings as an au- thor. ‘Miles to Run Before I Sleep’ is her own story. “I’ve sha- red my experi- ence of running on the highways of India through a woman’s eyes and how the run chang- ed my life. The book was listed in Forbes try. I hope the government and my countrymen understand what Top 5 Fresh Books and also in Amazon’s Top 10 Self Help Books a developing infrastructure actually entails, especially for women”, in 2015,” she adds with a proud gleam in her eyes. she points out one of the major setbacks in India when it comes to basic necessities for women. Running a marathon is not an easy task especially when you are asthmatic. “At a certain point, your body will give up Living with Asthma and you have to play mind games to push it ahead. When even “Asthma is not something you can cure. And even after taking your mind gives up, you have to run with your heart. When so many precautions – eating healthy, working out, I am prone to heart also gives up, you still force yourself to run somehow. attacks,” she says admitting that she suffered an attack just a Every run is different. Every day is different. In my book, I have couple of months ago. “The effects linger on for weeks or months shared how I pushed myself and the strategies I used to achieve – dry cough, breathlessness or wheezy breathing, sleepless nights, my goals,” comments Sumedha. runny nose and so on,” she points out. Apart from that, her book also details the other challenges She advises asthmatic patients not to give up easily to the dis- she faced during the Greenathon. “There was not a single toilet ease. She also notes that many of the asthma patients she has met along the highways for the 1500 km that I ran and relieving are fat because they don’t exercise. “Challenge your condition with oneself was a huge challenge. There were eyes following me exercise. First you do it slowly and increase your endurance. Don’t everywhere. In my book, I have shared shamelessly the dis- think it is the end of your lives. You should be determined to change comforts and insecurities that I experienced in my own coun- your life,” she breathes hope to the other asthma patients. What she hates most is people’s sympathy. “Sometimes, I want to scream out to people about how much I have run. I’ve “Asthma is not something you can been able to cover distances in spite of weak lungs and a low cure. And even after taking so many immunity system. But I’ve realised my achievements are only my _ own,” Sumedha says. precautions eating healthy, work- Sumedha Mahajan proves that a normal life with asthma is ing out, I am prone to attacks,” she not something unachievable. From an ordinary asthmatic girl, she now has many laurels up her sleeve including that of an en- says admitting that she suffered an durance runner, motivational speaker, author and an entrepre- attack just a couple of months ago. neur. Sumedha presents before us as a ray of sunshine that ef- fortlessly glides through different terrains offering the same warmth and blissful cheer to all watching her.

TECHAGAPPE OCTOBER - DECEMBER 2019 41 Cover Story Asthma and Smoking EFFECTS OF SMOKING ON ASTHMA Tobacco smoking has several adverse associations with asthma. The odds ratios for prevalence of asthma are high for both active smoking and ETS exposures. In-utero exposure of foetus from maternal smoking, as well as its tertiary exposure from maternal passive-smoking are also known to be responsible for development of asthma in childhood. Smoking adversely affects the health and treatment-outcomes of asthma. There are increased requirements of drugs for smoker and ETS exposed asthmatics. Smoking is also an important factor in the development of airway remodelling, fixed airway obstruction and an exaggerated lung function decline. Dr. S K Jindal, M.D., Ex-Professor & Head, Department of Pulmonary Medicine & WHO Collaborating Center for Research & Capacity Building in Chronic Respiratory Diseases, PGIMER, Chandigarh.

Tobacco smoking is the most common cause of chronic airway not directly responsible as a cause of asthma in most of these diseases such as chronic bronchitis (CB) and chronic obstructive patients. There however is enough of evidence which point to- pulmonary disease (COPD). On the other hand, asthma is an air- wards the adverse effects of smoking on asth- ma. Both active way disorder which commonly starts in childhood. Smoking is smoking and exposure to environmental tobacco smoke (ETS) i.e. passive smoking are known to influence asthma in one or the other way. 1. Smoking as a risk factor The absence of a demon- strable relationship of smoking with asthma in some earlier studies can be possibly ex- plained because of its irritant effects on the airways triggering acute episodes, for which an asthmatic would tend to avoid smoking. While epidemiological rela- tionship of smoking with asthma in children is known for about two decades, the recent studies from India done on large popu- lations have strongly supported the smoking association of asthma in adults.

42 TECHAGAPPE OCTOBER - DECEMBER 2019 For example, the Indian study on Epidemiology of Asthma, Respiratory symp- toms and chronic bronchitis (INSEARCH) demonstrated odds ratios of 1.82 for cigarette and 2.87 for bidi smoking in a sample population of 169575 adults of over 15 years of age. The other study which used data on self-reported asthma from the India’s third National Family Health Sur- vey (NFHS) reported odds ra- tios of 1.72 and 1.35 for women and men respec- tively. In a study which used the data of Korean Youth Risk Behaviour Survey on asso- ciation of asthma symptoms with smoking and drinking, 21.7% of 3432 adolescent asth- matics were current smokers compared to 10.9% in the as- ymptomatic group. The epidemiological relationship of ETS-exposure with asthma respiratory symptoms, acute respiratory infections and bronchial in children, though variable from different countries, is significantly hyper-responsiveness amongst nonsmoker individuals exposed high in most of the recent studies. The ISAAC Phase Three to smoking of parents, sibs and friends. ETS exposure from par- programme examined the influence of parental smoking in chil- ents is also related to the severity of asthma and emergency de- dren of 6-7 years and 13-14 years age-groups employing a study- partment visits of asthmatic children. In our own study on 200 questionnaire. Both maternal and paternal smoking were associ- never-smoker patients of asthma of 15 to 50 years of age, the ated with an increased risk of asthma in children of both age groups control was poor and morbidity greater amongst patients ex- though the odds ratios were higher for maternal smoke exposure. posed to ETS at home and/or at work. There was also a clear dose relationship of number of asthma The poor asthma control amongst ETS exposed individuals is symptoms with number of cigarettes smoked. ETS exposure was further supported by the findings of a recent study which demon- also shown to increase the risk of respiratory symptoms in 1718 strated a significant reduction in episodes of poor asthma control never-smoker Chinese schoolchildren. There was also a dose re- after a decrease in ETS exposure in children. There were fewer sponse relationship of number of cigarettes with impairment of hospitalisation and emergency department visits after the caregivers lung function assessed by spirometry performed at baseline and at were provided with no-smoking cessation counselling or ETS-ex- 18-month follow-up. Similarly, prevalence of wheeze and asthma posure education. In a similar study, smoking of caregivers was was shown among ETS exposed Japanese children of 6 to 15 years strongly associated with child exposure to ETS amongst inner-city of age. There was an increased prevalence of wheeze and asthma in asthmatic children in Chicago. Measures for smoking cessation children of 6 to 10 years of age who were exposed to heavy passive amongst the caregivers are therefore important for adequate con- smoking of 7 or more pack years in the households. trol of asthma. In another study among 3761 children of below 12 These results are quite consistent with the findings of earlier years of age, household ETS exposure was shown to predict asthma studies which had pointed to the smoking exposure as an impor- attacks for girls (OR: 3.11, 95% C.I. = 1.24 – 1.76). tant risk factor of prevalence of asthma. Maternal smoking was shown to have strong and significant association as was concluded 3. Development of asthma in a meta-analysis of longitudinal studies on incidence of asthma In-utero exposure Maternal smoking during pregnancy con- and wheezing; this relationship was particularly significant for the stitutes an important source of ETS-exposure for the foetus in- first 5-7 years of life than for the incidence in the school years. utero. The foetus may also be exposed to paternal smoking from the father or other family members in the company of the preg- 2. Effects on asthma-control nant mother, sometimes referred to as “tertiary smoking”. The Smoking exposure is known to adversely impact the control in-utero smoking exposure is shown to be associated with lung of asthma in both children and adults. There is aggravation of immaturity, poor lung function and development of asthma in

TECHAGAPPE OCTOBER - DECEMBER 2019 43 Cover Story Asthma and Smoking early childhood. There was higher incidence of asthma in children Besides development of asthma, maternal smoking while in of mothers who smoked. utero has been shown to be associated with poor control of asthma. A case analysis of 2 multicentre case control studies on There is strong evidence in favour of foetal programming and 2481 Latino and black subjects with asthma was done to study the very early life events such as ETS exposure and use of chemical clinical effect and relative contribution of passive smoking. An domestic products in the development of asthma. The intrauter- odds ratio of 1.5 (95 CI 1.1 – 2.0) of in-utero exposure was seen ine insult from several such exposures could be blamed for early with poor asthma control among children of 8 to 17 years of age, sensitisation and at least for some of the phenotypes of asthma. implying the later effects of in-utero exposure. There were also Similar association of foetal exposure to maternal active and pas- other secondary outcomes such as the occurrence of early-onset sive smoking has been shown with occurrence of wheeze, child- asthma, daytime symptoms and asthma-related limitation of ac- hood asthma and atopic illnesses in Hong Kong Chinese children. tivities within utero smoking in this study. The maternal smoking and childhood asthma relationship was examined in babies born in Japan in 2001 during two specified 4. Development of fixed airway obstruction and weeks. The 4-year cumulative incidence among 36888 subjects lung function decline increased to 14.4% from 11.7% with a risk ratio of 1.24 for mater- Persistent inflammation in asthma causes structural changes nal smoking. The authors have therefore concluded strongly on in the airways responsible for thickness of bronchial walls, re- the necessity to stop or discourage maternal smoking especially duction of the airway lumen, decline in lung function and fixed during pregnancy. airway obstruction. Smoking modifies the inflammatory re- The interaction between maternal smoking during pregnancy sponses of asthmatic patients in causing squamous cell metapla- and prematurity was examined in an urban cohort of 1448 chil- sia and increased expression of inflammatory cytokines. The mor- phological and functional changes which occur due to The maternal smoking and childhood asthma relationship was examined remodelling result in severer in babies born in Japan in 2001 during two specified weeks. The 4-year forms of asthma and relative non-responsiveness to anti- cumulative incidence among 36888 subjects increased to 14.4% from asthma therapy. 11.7% with a risk ratio of 1.24 for maternal smoking. Continued smoking expo- sure, airway hyperrespo- nsiveness and eosinophilic inflammatory are important factors which lead to the de- velopment of chronic airway obstruction due to airway re- modelling. Such patients be- have like those of chronic ob- structive pulmonary disease. This is in consistence with the Dutch hypothesis, first pos- tulated in 1961 that COPD de- veloped due to exaggerated air- ways damage from smoking ex- posure of patients with under- lying atopic diagnosis. The ef- fect of smoking studied in 793 asthma patients aged 14 to 44 years clearly demonstrated an early lung function decline com- pared with non-smokers. dren in Boston; maternal smoke exposure and prematurity to- There was also a dose-response relationship of spirometric gether had odds ratio of 3.8 (95% C.I. 1.8 – 8.0) for recurrent wheez- measures with smoking. Another population-based study (Tas- ing. In this study, the in-utero maternal smoking alone was not manian Longitudinal Health Study) on a cohort born in 1961 re- shown to increase the risk of wheezing. Both maternal asthma ports the development of fixed airway obstruction in middle age and cigarette smoking were shown to increase the risk of preterm contributed by active smoking and current clinical asthma. The birth and other adverse perinatal outcomes in a retrospective authors of the study concluded that the association of fixed air- analysis of 172305 singleton pregnancies in South Australia. way obstruction was equivalent to a 33 pack-year history of smok-

44 TECHAGAPPE OCTOBER - DECEMBER 2019 ing for late onset current clini- cal asthma compared to 24 pack-year history for late on- set clinical asthma. There are also experimen- tal data in mice to suggest that airway remodelling may occur even from in-utero exposure to maternal smoking. Off- springs of mice exposed to cigarette smoke during preg- nancy had increased airway smooth muscle layer, collagen deposition and other changes seen in airway remodelling. Interestingly, a recent re- view cites the dangerous rela- tionship of asthma with sub- Smoking is one of the most modifiable risk factors for adverse outcomes stance abuse (cocaine, mari- of asthma such as increased severity, asthma related quality of life, juana, cigarette, heroin and al- generic mental health status and longitudinal risk of hospitalisation. cohol) in causing lung function decline, increase in number of Smoking cessation as well as control of ETS-exposure should therefore life-threatening asthma at- constitute important and essential components of asthma therapy. tacks and high asthma mor- tality. 5. Smoking, allergic sensitisation and airway nese women, a significant interaction was reported between some of the single nucleotide polymorphisms (SNPs) and smoking. inflammation However, there is limited information on the subject. No associa- There are a few reports on smoking relationship with different tion of ETS exposure and the studied polymorphism was seen in forms of atopy and asthma. Both active smoking and ETS expo- another study from Mexico. sure are shown to be associated with increased odds of develop- ing aspirin-exacerbated respiratory disease. 6. Effects on asthma-therapy and outcomes There were odds ratios of 1.54, 3.46 and 5.09 for active smok- There is relatively less information on the effects of smoking ing, childhood ETS exposure and both childhood and adulthood on pharmacotherapy of asthma. Smoking modifies the dosages ETS exposure. Foetal exposure to maternal active and passive and effects of drugs, especially of those administered through smoking were also shown to relate to other atopic illnesses such inhalational route. Further, the response to therapy is poor in the as allergic rhinitis and eczema. presence of airway remodeling. Smoking may also affect the association of asthma with gene Smoking is one of the most modifiable risk factors for ad- expression. In a study on ADAM33 gene polymorphism in Japa- verse outcomes of asthma such as increased severity, asthma related quality of life, generic mental health status and longitudi- nal risk of hospitalisation. Smoking cessation as well as control of ETS-exposure should therefore constitute important and essen- Smoking may also affect the asso- tial components of asthma therapy. Conclusion ciation of asthma with gene expre- In conclusion, smoking exposure is known to influence the ssion. In a study on ADAM33 gene development of allergic sensitisation and asthma as an important risk-factor. It also impacts the various asthma outcomes and treat- polymorphism in Japanese women, a ment modalities. significant interaction was reported Smoking cessation as well as adoption of measures to avoid between some of the single nucleotide ETS-exposure are essential steps for the comprehensive and ef- fective management of asthma. A probabilistic model of biologi- polymorphisms (SNPs) and smoking. cal ageing of the lungs convincingly demonstrates that the combi- nation of smoking with asthma (or COPD) is more harmful than asthma (or COPD) alone.

TECHAGAPPE OCTOBER - DECEMBER 2019 45 Health Tips ASTHMA IS NOT A DISABILITY ! Asthma is one of the most common and very significant disease burdens worldwide, costing billions of dollars. Anti-asthmatic drugs that are available in the market are expensive and have adverse effects. Thus, it is wise to look for better means to alleviate or minimise these problems. Asthma can be genetic also, where one should be more careful from the beginning. Normally, stress and allergens like dust, pollen grains; chillness, anxiety etc. make a major chunk of reasons, as evidently discussed.

Dr. C S Satheesh Kumar, Sr. Vice President-Supply Chain Management, AGAPPE (Retd. Drugs Controller, Kerala)

The American Academy of Allergy, Asthma and Immunol- A recent review analysis of 15 epidemiological studies showed ogy (AAAAI) estimated that 300 million people worldwide suf- that the mean prevalence of asthma among children was 7.24%. fer from asthma, with 250,000 annual deaths attributed to the The prevalence of childhood asthma has continued to increase in disease. One tenth of the patients live in India. According to the last 10 years in the Indian subcontinent. The five countries, the Centres for Disease Control and Prevention (CDC), one in with the highest prevalence of clinical asthma, are Australia (21.5%), almost 13 people has asthma in general. Sweden (20.2%), UK (18.2%), Netherlands (15.3%), and Brazil (13.0%). Smoking, very little exercise and the wrong food can all be ma- jor asthma causes. Control of asthma can be achieved with yoga, meditation, deep breathing techniques, healthier life style etc. Smoking - The single most important environmental factor that can make asthma worse is tobacco smoke and passive smoking. So, abstain from smoking. Obesity - Exercise regularly to control asthma with more aerobic exercises if obesity is a reason for asthma. Don’t exercise outside when other asthma causes, such as ozone or pollen levels are high in the atmosphere. Do find an indoor exercise pro- gram when the weather prevents any outdoor activity. Indulge in at least 30 minutes of moderately intense physical activity everyday or most days. Moderately in- tense physical activity means any activity that makes you breath noticeably faster and deeper than usual but does not make you puff and pant. Asthma symptoms should not stop you from participating in sports or physical activities. Many of our Olympic athletes have asthma and this need not necessarily be a hurdle for an athlete. Food Preservatives - Sulphites, which are used to keep food fresh and stop the growth of molds, can trigger temporary asthma symptoms in a few people. Sulphites can give off sulphur dioxide that can irritate the lungs. Sulphites are still used in many processed foods, and may also be in condiments,

46 TECHAGAPPE OCTOBER - DECEMBER 2019 dried fruits, canned vegetables, wine and other foods. Avoid food pre- There’s evidence servatives to the maximum. that people who Food Allergies - In modern times, we tend to eat fewer fruits and veg- eat diets higher in etables and consume more pro- vitamin C and cessed foods. This could contrib- ute to the risk of developing vitamin E, asthma. About 2% of adults with beta-carotene, asthma have food allergies to milk, flavanoids, eggs, shellfish, peanuts and other foods. magnesium, There’s evidence that people selenium and who eat diets higher in vitamin C omega-3 fatty acids and vitamin E, beta-carotene, flavanoids, magnesium, selenium have lower rates and omega-3 fatty acids have lower of asthma. rates of asthma. Many of these substances are antioxidants, which protect cells from damage. A 2007 study showed that children tassium, zinc, iron, calcium and magnesium. Magnesium defi- who grew up eating a Mediterranean diet — high in nuts and fruits ciency in asthmatic patients is quite common. like grapes, apples, and tomatoes - were less likely to have asthma- 6. Apple – Apple might prevent asthma and wheezing in new- like symptoms. Some researchers think that it might be the inter- borns. action of different vitamins, minerals and other antioxidants that naturally occur in foods that have the health benefits. Eat foods 7. Banana-One banana a day reduces asthmatic symptoms. with omega-3 fatty acids, as found in fish like salmon, tuna and Most likely because bananas, rich is potassium and fibre, helps sardines and some plant sources, like flaxseed. These are be- in lowering blood pressure and fighting cancer, as it prevents lieved to have a number of health benefits. Although the evidence the formation of free radicals. that they help with asthma is not clear, it’s still a good idea to include them in your diet. 8. Garlic - Garlic obliterates lung congestion and reduces air- way inflammation. This is largely due to the vitamin C, which 1. Avocado - With its high levels of L-glutathione, it acts as a neutralises the molecules causing airway constriction. master antioxidant. 9. Water- Not having enough water vapour in the lungs causes 2. Honey - Mixing 1 tsp. of honey in a cup of warm water (3 x a day) airways to constrict. This provides mucus, which (in conjunc- removes phlegm from your throat and treats asthma symptoms. tion with constriction) form asthma attacks and symptoms. 3. Kale – With more vitamin C per cup than a whole orange, kale reduces muscle contraction in our airway passages. 10. Ginger - It helps in boosting immune systems and helps treat asthma. It keeps respiratory tracts in check. Along with 4. Coffee - Coffee immediately treats asthma attacks or symp- airway-muscle relaxation, calcium uptake levels are regulated toms as they happen. Since caffeine expands our airwaves making (responsible for lessening the asthma attack). it easier for us to breathe. Gastroesophageal Reflux Disorder (GERD) - Up to 70% of 5. Spinach – This is largely considered the ‘king of super foods’ all the people with asthma also have GERD (reflux of stom- because it is stuffed with vitamin C, beta-carotene, vitamin E, po- ach acid), which can make asthma more difficult to control. Sometimes, you should also try eating smaller meals and cut- ting down on alcohol, caffeine and any foods that trigger GERD Smoking-The single most important symptoms. Avoid eating just before bedtime. environmental factor that can make Some Valuable Tips - Try to breathe through your nose (not your mouth) when you exercise. This makes the air warm and asthma worse is tobacco smoke moist when it reaches your lungs as cold dry air can make and passive smoking. So, abstain symptoms worse. Make sure you do a proper warm-up be- fore exercising. If you have asthma symptoms after your warm- from smoking. up but taking your reliever helps settle them, then you may be able to carry on without getting symptoms again during your

TECHAGAPPETECHAGAPPE OCTOBER OCTOBER - -DECEMBER DECEMBER 2019 2019 47 47 Health Tips

session, even if you exercise hard. After you exercise, do cool- tion and is highly recommended for people with asthma. ing down exercises while breathing through your nose and 7. AdhoMukhaSvanasana (Downward-Facing Dog Pose): covering your mouth (especially if the air is cold and dry). This asana calms the mind and relieves stress and is suitable for Lighten the load on your lungs - Losing just a bit of weight people suffering from asthma and sinusitis. could make you feel better and breathe more easily. Being over- weight may make asthma harder to manage, as carrying extra 8. Badhakonasana (Butterfly Pose): weight puts extra strain on your lungs and might also worsen The Butterfly Pose stimulates and improves the blood circulation, asthma. relieves fatigue, and has a therapeutic effect on asthma. Plan a healthy pregnancy with asthma - If you can’t breathe, neither can your baby. If you are pregnant or planning for The Bridge Pose opens up the chest and lungs and reduces thyroid a pregnancy, you need to know some problem. It also improves digestion and is very useful for asthma patients. asthma facts. Untreated asthma, poorly controlled asthma or serious flare-ups during pregnancy put mothers and ba- bies at risk. Parents should stop smok- ing before the woman becomes pregnant to protect the unborn baby. Ask about which medicines you should keep taking during pregnancy and whether there are any safer options. If you are pregnant and have asthma or have had asthma at any time in your life, make sure your obste- trician and midwife is aware of it. Relieve asthma with yoga - Here’s a list of few pranayama and yoga postures to help you counter asthma more effec- tively: 1. NadiShodhan Pranayama (Alternate Nostril Breathing technique): 9. Poorvottanasana (Upward Plank Pose): Begin with this pranayama to calm your mind and relieving the body of accumulated stress. This breathing technique has a The Upward Plank Pose improves the respiratory system, stimu- healing effect on many respiratory and circulatory problems. lates the thyroid gland, and also strengthens wrists, arms, back and spine. 2. KapalBhati Pranayama (Skull Shining Breathing technique): 10. Shavasana (Corpse Pose): This breathing technique relaxes the mind and energizes the nervous system. It also clears all the nadis (energy channels) End your yoga practice by lying down for a few minutes in the and improves blood circulation. Corpse Pose. This asana brings the body in a meditative state, rejuvenates you and also helps reduce anxiety and pressure. A 3. ArdhaMatsyendrasana (Sitting Half Spinal Twist): calm and relaxed body and mindset can tackle asthma. The Sitting Half Spinal Twist opens the chest and improves the A daily practice of these postures and breathing techniques supply of oxygen to the lungs, thereby reducing the probability for 30-45 minutes will considerably reduce your chances of an of asthma restricting you. asthma attack and may even help you get rid of it. Sri Sri Ravi 4. Pavanamuktasana (Wind-Relieving pose): Shankar’s ‘The Art of Living’ Foundation has very good yoga com- This pose is good for people with asthma as it massages the bined with Pranayama courses to combat asthma. A few minutes abdominal organs and helps in digestion and release of gas. spent meditating will also enhance your experience and help calm your mind. 5. SetuBandhasana (Bridge Pose): The Bridge Pose opens up the chest and lungs and reduces Your control over asthma will let you choose how much you thyroid problem. It also improves digestion and is very useful enjoy your life. With a strong shield like yoga and pranayama, you can for asthma patients. experience life in its totality and be carefree. Yoga enables you to expand your capabilities and live life to its fullest. You will never know 6. Bhujangasana (Cobra Pose): just how much you value your breath until you can’t breathe! So take The Cobra pose expands the chest, improves blood circula- care of your lungs and live your life the best way possible.

48 TECHAGAPPE OCTOBER - DECEMBER 2019 Toll 1800 425 7151 Free 1800 270 7151

NATIONAL AWARD FOR ‘INNOVATION’ - OUR FOCUS FOR “INDIGENOUS DEVELOPMENT OF TECHNOLOGY & COMMERCIALISATION” OF MISPA-i3

Please keep the card in a clean surface

18344842 : : LOTLOT : 18344842 EXPEXP :

Please keep the card in a clean surface

For easy & accurate determination of various kind of panels like Diabetic, Cardiac, Automated Cartridge Based Specific Protein Analyzer Infectious & Allergic Etc..

ASO CRP RF HbA1c Microalbumin Ferritin Cystatin C

hsCRP IgM IgE IgG IgA Lp(a) Apo A1

New New New Apo B C3 C4 D Dimer Ceruloplasmin Haptoglobulin many more...

“Agappe Hills”, Pattimattom (PO), Dist. Ernakulam, Kerala - 683 562, India. TEL: + 91 484 2867000 | [email protected] | www.agappe.com

TECHAGAPPE OCTOBER - DECEMBER 2019 49 Cover Story Good Laboratory Practices UNSEEN FACTS- SAMPLE INTEGRITY Studies show that pre-analytical error accounts for 70% errors in an invitro diagnostic laboratory. When we look deep into this, majority of the errors happen due to improper sampling. Let us discuss some events to get better clarity. Sanjaymon K R, General Manager, Business Development, AGAPPE

Case - I results were not getting in a proper way in the ISE based sys- One of the automated diagnostic centres received the sample of a tem and even after diluting the sample in multiple dilutions, male patient in two different containers, one in EDTA for the Com- the sodium was going on the higher side. The same sample plete Blood Count and Serum in a plain tube for performing the was retested in another system and got concordant values. biochemical tests and also sodium & potassium from a nearby Since there is no correlation with the renal function results hospital. and the sodium values, the technical in-charge of the diagnos- While testing for the Complete Blood Count in the automated tic centre made a call to the hospital to know the medical con- hematology analyzer, the result came with flags leucopoenia and dition of the patient and the non-correlating values they are mild variation in the red cell indices whereas in the case of bio- getting for the sample received. Hospital person conveyed that chemistry test results - except glucose - all other parameters the patient is a male in his 30s who came with dehydration were in the lower range. The biochemistry result appeared in nor- because of vomiting and diarrhea and is now stabilizing and mal ranges and the technical staff validated the report accord- on IV fluids. ingly. Alarmingly for the same patient, the sodium & potassium The word ‘on IV fluids’ gave a spark in the mind of the laboratory person and after discussing with the hospital team, it was further found that the blood was drawn through the same IV If there was no sodium or canula by a new staff for testing. Both teams identified the error and immediately a new potassium testing, the sample is collected from the patient and re- laboratory might have given tested where the values were found corre- a wrong report of the patient. lating. If there was no sodium or potassium It is always better to ask for testing, the laboratory might have given a the clinical condition when wrong report of the patient. It is always bet- ter to ask for the clinical condition when such such dubious values occur. dubious values occur. The best practice for The best practice for the the laboratory is to validate the report after correlating the complete reports so that laboratory is to validate the events like above can be identified. report after correlating the Case - II complete reports so that A laboratory received a sample from out- side hospital for doing 24-hour Urine Pro- events like above can be tein in a small urine culture bottle with pa- identified. tient details and a 24-hour urine volume. After testing, the values came on the higher side and based on the demographics received,

50 TECHAGAPPE OCTOBER - DECEMBER 2019 the laboratory gave the report. After a while, the laboratory re- ceived a call from the consult- ing doctor saying that the urine protein report was on the higher side and is not correlating with his findings and requested for a retest. Sample during retest gave concordant values and the same is communicated to the doctor. Later, it came to know that the sample was not collected with a proper stabilizing agent and hence the sample was contaminated giving higher protein values. Case - III A reference laboratory re- ceived two separate sample vi- als from a nearby hospital for biochemistry testing and INR testing. The sample came with labels for renal function tests and electrolytes. written as citrated plasma and serum. Since the report was ur- Surprisingly, except for the sodium, potassium and cal- gent, the laboratory started the testing immediately. cium values, the other biochemistry values came within the While testing PT, result came as inconclusive from the auto- expected range along with hemoglobin. Sodium and potassium mated system showing the time greater that the detection limit showed a higher value whereas the calcium was very low. While whereas from the biochemistry department, the result came with validating the reports, the technical head of the laboratory was slight lower values and non-correlating liver function test results. suspicious about the result and requested for a repeat sample Since the results were not correlating, the reference laboratory and a phlebotomist is assigned to draw the sample from the requested for a repeat sample in the primary tube. Within 30 min- patient. Interestingly, the new sample collected shown correlat- utes, a new sample was received from the hospital in the primary ing values with the clinical condition. Upon analyzing the case, it tube, which is separated at the reference laboratory and the test came to light that the person who collected the sample for the values showed correlation to the clinical condition. first time forgot to collect the sample in the plain tube for bio- Later, they came to know that there was an error in labelling chemistry and on realizing the mistake ‘transferred’ some the sample at the hospital, where the serum and citrate label inter- amount of the blood from EDTA into the plain tube and labelled changed while being pasted on the sample vials. for biochemistry. Case - IV When we look at the above incidents, it is evident that the The central diagnosis laboratory in a hospital received an in- errors happening at the pre-analytical phase is the major cul- patient sample for hemoglobin, renal function test with Ca and prit creating chaos in clinical laboratory. In order to eliminate electrolytes. The sample was received in EDTA and plain tube where the errors in pre-analytical phase, the laboratories should have the sample volume was very low in both the tubes. EDTA tube was pre-analytical automation systems based on the workload and sent to the hematology department and the plain tube was taken workflow of the laboratory. The best way to eliminate pre-ana- lytical error is by using automated pre-analytical systems like tube labeling system, tube transport systems and tube sorting In order to eliminate the errors in pre- systems. Tube labeling system will help the laboratory for bet- ter sample traceability with primary tubes and barcodes; trans- analytical phase, the laboratories port systems will assure that critical samples are sent to the should have pre-analytical automation central laboratory in a short time and tube sorting system will help the laboratories to decrease the turnaround time for tests. systems based on the workload and Moreover, laboratories should also make sure that the con- workflow of the laboratory. cerned technical person is aware of the sample collection, es- pecially the specific procedure to collect the sample and to always collect sample after ensuring the patient identity.

TECHAGAPPE OCTOBER - DECEMBER 2019 51 Brand Reach Customer Speaks

11 Amazing Product Range and Excellent Service from Agappe In our laboratory, almost 80% of ma- we have already done AMC for 2 years chines are from Agappe Diagnostics. Out with Agappe. Engineers and Applica- Dr. Vaishali Deshmukh of two cell counters we have, one is BS tion personnel from Agappe have set Pathologist, 3000 Plus and we have a specific protein the machines in a perfect way and all Bhakthi Laboratory, analyzer Mispa-i2 and Mispa Clog for Co- the parameters of biochemistry are Jalgaon. agulation. I am very much satisfied with working well on that machine and re- the performances of the products and sults are quite good. Agappe’s sales- the after-sales service part from Agappe. persons and engineers are soft-spo- Apart from this, we have a fully auto- ken and skilled. Engineer service team- mated biochemistry analyzer BS 220 and work is more appreciable.

22 Great association with Agappe

"We share long and fulfilling associa- tomatic systems integrated to other soft- tion with Agappe Diagnostics Ltd. We ware and the training of vendors for other started our association with the Reagents accessories are equally appreciable. We and then with Mispai2. With each day our Dr. Yugam Chopra have really experienced much better ac- confidence on the products and service Director & Quality curacy, precision and dependability than Manager, has gained immensely and we tried with many MNC and we strongly recommend KOS Diagnostic Lab, Fully Automatic system of Biolis 24I. In- Agappe Products and Services." Ambala. deed it was a great eye opener on the Quality and Service that can be provided by any Indian Company and for us there was no looking back and we are using TBA25FR and TBA120FR Fully Automatic Biochemistry Analyzers from Agappe for quite long years. The company not only provides excel- lent after sales ser- vice but the re- sponse to issues is extremely high, the support to make the Fully Au-

52 TECHAGAPPE OCTOBER - DECEMBER 2019 Brand Reach Customer Speaks

33 Excellent Quality Products and Services

Dr. Mahfuzul Anowar, "I am Dr. Mahfuzul Anowar, MBBS, FCPS (Medicine) Rangpur, Medical College practicing as a consultant of & Hospital, Rangpur, medicine in Metrolab Imag- Bangladesh. ing & Diagnostic centre. This centre is using Agappe’s Mispa CCXL-Fully automated biochemistry analyser & Re- agents which give accurate and precise results. I would like to say that the quality of Agappe products is excel- lent.

44 Our Journey so far with Agappe Diagnostics Ltd. Myanmar, also known as Dubai, and we started our association with Agappe in Burma, is a developing 2014 with open type biochemistry reagents. With time, parliamentary republic Agappe has developed Mispa series and we grew to- country, which currently gether & we could be able to bring state-of-the-art Mr. Darren Lee, is going through a quick technology of nephelometric & photometric Mispa-i2 Managing Director, developmental phase in & Mispa-i3 to Myanmar with the support of Agappe Uni Diagnostics Co. Ltd healthcare sector. Uni Di- team. We have installed more than hundreds of Mispa- Myanmar. agnostics Company was i2, Mispa-i3 & Mispa Viva within a short time span. We founded in 2013. Over the time, we were able to ex- are transforming to fully automation series & Agappe pand & widen our coverage across Myanmar through brings the latest products Mispa CXL for small to quality products, timely service & affordable price. We middle-sized laboratory, which is indeed most neces- mainly focus on in-vitro diagnostic products trading sary for our country whose healthcare sector is im- & achieve private market share of more than 40% within proving in both public & private sectors. five years. We are the main distributor of some well- Agappe products are well-accepted in Myanmar be- known manufacturers like Agappe, Mindray, Acon etc. cause of their good quality & affordable price. Thanks Our mission is to provide quality products with af- to Agappe team for their fantastic innovations, com- fordable price & achieve customer satisfaction through prehensive technical support & quick response. We proficient service. wish Agappe more prosperity on new innovations & We met Agappe Diagnostics in 2014 at Arab Health, more success in the future.

TECHAGAPPE OCTOBER - DECEMBER 2019 53 Engagements Exhibitions

MORE PLACES TO KNOW ABOUT US

TEAM AGAPPE AT PRODUCT LAUNCH, MYANMAR

ACBICON & APFCB 2019

17th-20th November 2019 at JECC, Jaipur. Agappe’s Stall Nos. P3 PLATINUM SPONSORSHIP TEAM AGAPPE AT AACC 2019, CALIFORNIA MEDICA 2019 18th to 21th November 2019 at Exhibition Centre, Dusseldorf, Germany. Agappe’s stall at Hall No. 1, Stand No. B04

TEAM AGAPPE AT EGYHEALTH EXPO 2019, EGYPT

54 TECHAGAPPE OCTOBER - DECEMBER 2019 Engagements Exhibitions

MORE PLACES TO KNOW ABOUT US

TEAM AGAPPE AT BUSINESS WORLD DIAGNOSTICS SUMMIT, DELHI

AMBICON 2019 12th -15th December 2019, Dayanand Medical College & Hospital, Ludhiana

TEAM AGAPPE AT MEDICAL FAIR THAILAND 2019, BANGKOK

APCON 2019 5th – 8th December 2019 (PGIMER), Chandigarh.

TEAM AGAPPE AT MEDICAL TECHNOLOGIST ASSOCIATION 2019, MYANMAR

TECHAGAPPE OCTOBER - DECEMBER 2019 55 AGXplore Kochi

AGAPPE’s CME programme on “Nephelometry & Its Clinical Applications" by Dr. D M Vasudevan (Technical Director - R&D, AGAPPE) & “Good Clinical Laboratory Practices in Haematology" by Dr. Vijay Parekh (Scientific Advisor, AGAPPE) on 18th September 2019 at The Renai Cochin, Kochi.

56 TECHAGAPPE OCTOBER - DECEMBER 2019 AGXplore Kolkata

AGAPPE’s CME programme on “Nephelometry & Its Clinical Applications" by Dr. D M Vasudevan (Technical Director - R&D, AGAPPE) on 21st September 2019 at Hindustan International, Kolkata, West Bengal.

TECHAGAPPE OCTOBER - DECEMBER 2019 57 CSR Health Checkup

HEALTH CHECKUP FOR ERNAKULAM RURAL DISTRICT POLICE IN ASSOCIATION WITH AGAPPE DIAGNOSTICS LTD.

58 TECHAGAPPE OCTOBER - DECEMBER 2019 Reward Programme

By signing this form, I confirm that the information provided above is true and that I am fully familiar with and accept the General Business Terms for Privilege Account. I agree that the authorized personnel of Agappe Company may collect and process my personal information, the information about received privileges, collected points, information regarding the privileges used and other Information acquired during my visit to AG privilge website and ACEP mobile application. Also in absence of me I authorize my staff Mr / Mrs. / Miss / …………………………...... to avail benefits of AG Privilege and redeem Reward point's benefits using the registered mobile……………………………..... Number, through AG Privilege Website / AG Privilege mobile application. Also Agappe Diagnostics Ltd undertakes to handle the information in line with the requirements of the Personal Data Protection Act and that it will use them only for marketing reasons. Proprietor Name:......

CONSENT Address...... Scan QR code to download AG Date: Sign & Seal of the owner / proprietor / director Privilege app

Disclaimer submitting the signed copy of the disclaimer. • AG Privilege points are subjected to offer made to Agappe Loyal customers who are either • Agappe diagnostics/Agappe employee will not be in any manner responsible for any claim on purchasing or using existing Agappe reagent as products.AG Privilege offers are not valid on account of claim/Point redeemed or point burnt by lab technicians/distributors, distributor instrument purchase. staff or any other personnel who is not a part of lab or hold any organizational position. Any • Lab must claim points accrued through the program through the redemption process to such act, if it comes to the notice, will be considered as malpractice and the concern exchange the points for reagents. laboratory owner/director or any other official will be informed. • Lab must claim points or rewards only after reaching the redemption level. • Delivery of reagents will be done after conducting and possible due diligence. • Points can be claimed and used for rewards available in the then current program only and by • Agappe require verification of lab identity and account prior to processing your order. authorized personnel of Laboratory. • Government/Semi Government undertakings will not be covered under this program. • Point requirements assigned to any reward are subject to change from time to time without • The Privilege program is not meant for any Agappe staff. notice, and rewards may be substituted at any time. • Jurisdiction: Any dispute arising out of this program shall be subject to the exclusive • The loyalty points can be claimed by the Legal owner of the program and will be done only after jurisdiction of the Courts at Ernakulam, Kerala, India. Kindly fill the form carefully and hand over to Agappe’s staff or post to The Manager-Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562. For more details, contact +91 9349011309.

TECHAGAPPE OCTOBER - DECEMBER 2019 59 Editorial Feedback

Scan QR code and participate in the lucky draw contest. Amazing prizes are waiting Mr Prasun T M, Aroha Clinic, Pantheerankavu, Calicut receives gift as the winner of lucky draw contest for the winners. (TechAgappe July - September 2019 edition) from Azif K M , Senior Diagnostic Specialist, AGAPPE. Conditions apply*

What do you think of this edition of TechAgappe? Are you happy with the overall look and feel of the magazine? Do you recommend any change of style with regard to presentation of articles? You can share your views with us in the space given below. All you have to do is to post this sheet of paper to the address given below. The best letter shall be featured in the next edition’s letters to the editor section.

......

......

......

......

......

......

Name...... Address......

Pin...... Mobile...... Email ...... Postal address: The Manager - Corporate Communication, Agappe Diagnostics Limited, Agappe Hills, Pattimattom PO, Ernakulam district, Kerala-683562. Email: [email protected] Mob: +91 9349011309 Kindly let us know which section of the magazine you like more... Poem Life Stories Health Tips Cover Stories Good Laboratory Practices Interviews

60 TECHAGAPPE OCTOBER - DECEMBER 2019 Healthcare Solutions Worldwide...

th

1995 * 2020 SURGING INNOVATION SERVING MANKIND

CLINICAL CHEMISTRY | IMMUNO CHEMISTRY | HEMATOLOGY | COAGULATION | SEROLOGY | URINALYSIS BLOOD GROUPING | ELECTROLYTE | POINT OF CARE | CONTROLS | CALIBRATORS | RAPIDS | PRE-ANALYTICS

BRANCHES: MUMBAI | DELHI | KOLKATA | www.agappe.com | www.agappeswiss.com ISO 9001 : 2015 & EN ISO 13485 : 2016

CORPORATE OFFICE REGISTERED OFFICE INTERNATIONAL OFFICE Agappe Hills, Pattimattom P.O, Dist. Ernakulam, Jaisingh Business Centre, 119, Sahar Road, AGAPPE DIAGNOSTICS SWITZERLAND GmbH, Kerala - 683 562, India. Parsiwada, Andheri (East), Mumbai, India. Knonauerstrasse 54 - 6330, Cham - Switzerland Tel: +91 484 2867000. Tel : 022-4300 8000. Tel: +41 41 780 60 10 [email protected] [email protected] [email protected]

TECHAGAPPE OCTOBER - DECEMBER 2019 61 RNI No.: KERENG/2015/62113 www.agappe.com Toll 1800 425 7151 Free 1800 270 7151

Our Motto Quality & Affordable Healthcare Worldwide...

Printed and Published by Ms. Meena Thomas on behalf of Agappe Diagnostics Limited and Printed at Five Star Offset Printers, Nettoor, Cochin-40 and published from Agappe Diagnostics Limited, “Agappe Hills”, Pattimattom P.O, Ernakulam district, Kerala-683 562. Editor is Ms. Meena Thomas.

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