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|NI FEATURE: CITADELS SCULPTING FUTURE - COMMENTARY
|Year : 2015 | Volume
| Issue : 4 | Page : 589-596
Neurosurgery at All India Institute of Medical Sciences, a center of excellence: A success story
Manmohan Singh, Dattaraj Sawarkar, Bhawani S Sharma
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Aug-2015|
Professor, Room No. 715, Department of Neurosurgery and Gamma Knife Center, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The department of neurosurgery at All India Institute of Medical Sciences (AIIMS) started its humble beginning in 1965. With the untiring and selfless hard work of Prof. P N Tandon and Prof. A K Banerji, the department progressed over time to become a center of excellence in the subcontinent. To establish a neurosciences center at AIIMS was an uphill task, which was accomplished with great efforts. The department has established itself as one of the highest centers of learning in the country with its vast infrastructure and diversity in all fields of neurosurgery. AIIMS, New Delhi was established by an act of the parliament in 1956. It was started with a grant from the Government of New Zealand under the "Colombo Plan." It was the vision of Rajkumari Amrita Kaur, the first Health Minister of India, that led to the establishment of a medical institute of international repute in India. AIIMS, New Delhi is an autonomous institute and is governed by the AIIMS Act, 1956. The department of neurosurgery at AIIMS was started in March 1965 with Prof. P.N. Tandon as the Head of the Department. Prof. A.K. Banerji joined him a few months later. The Department celebrated its golden jubilee in the year 2015, and has tremendously grown in stature from its humble beginnings to being a center of excellence with world-wide recognition.
Keywords: All India Institute of Medical Sciences; department; history; Neurosurgery
|How to cite this article:|
Singh M, Sawarkar D, Sharma BS. Neurosurgery at All India Institute of Medical Sciences, a center of excellence: A success story. Neurol India 2015;63:589-96
| » Introduction|| |
The departments of neurology and neurosurgery at All India Institute of Medical Sciences (AIIMS) were established in March 1965 with the appointment of Prof. Baldev Singh and Prof. P N Tandon as the first professors, respectively. Prof. P N Tandon, [Figure 1] after finishing his neurosurgery training from Oslo University, Norway and Montreal Neurological Institute, Canada joined King George's Medical College, Lucknow before starting his epic journey at AIIMS. Prof. A K Banerji [Figure 2] completed his neurosurgical training at Christian Medical College, Vellore and joined AIIMS in June 1965, 3 months after Prof. P N Tandon had joined. With a lot of painstaking efforts and hard work, Prof. P N Tandon and Prof. A K Banerji together built the department from scratch to being one of the finest institutes in the country. The warm spirit of cooperation between both of them was instrumental in the steady progress that the department of neurosurgery at AIIMS made. At the same time, Prof. Baldev Singh gave a new direction to neurology services, which were earlier started in the Department of Medicine by Prof. Jim Austin from USA and later on, by Prof. Vimla Virmani.
Since its inception, the department was fortunate to have a broad base of neuroscience. The first two professors in the Department of Physiology. Prof. B K Anand and Prof. A S Paintal were undisputed leaders of neurophysiology in the country. Prof. Keswani, the Chief of Anatomy, was primarily interested in neuroanatomy. Prof. G P Talwar was enthusiastically involved in research in neurochemistry. Dr. Sriramachari, Deputy Director of Indian Council of Medical Research (ICMR), though not on rolls of the institute, provided his services for all neuropathological work until Prof. Subimal Roy took over the responsibility several years later.  A close interaction existed among all these departments in those earlier years.
| » Genesis of the Neuroscience Centre|| |
The idea of establishing a "Brain Research Centre" at AIIMS had been envisaged by Prof. B K Anand (a neurophysiologist) even before the clinical departments had come into existence. He requested the Director in 1964 to initiate steps for developing a Brain Research Centre with the existing ICMR neurophysiology unit as its nucleus. In 1968, when the institute was to formulate its development plans for the fourth five-year plan of the Government of India, Prof. P N Tandon, Prof. B K Anand, and Prof. Baldev Singh had several informal discussions to revive the proposal for a Brain Research Centre. Although the department of neurosurgery was heavily constrained with clinical work due to limited diagnostic and operative facilities, Prof. P N Tandon along with Prof. B K Anand brought up the proposal for a Brain Research Centre to strengthen the patient care services through the development plan of the institute. The Development Committee approved the proposal in principle but owing to financial constraints, no concrete steps could be undertaken. 
Meanwhile in 1971, Prof. Gopinath (Professor of Cardiac Surgery) submitted a proposal for a "Cardio-Thoracic Centre." To efficiently address the patient load in neurosurgery, and to promote clinical and research work, Prof. P N Tandon, persisted with his previous efforts to establish a comprehensive Neuroscience Centre that would promote the parallel development of basic neurosciences and the clinical disciplines. Prof. P N Tandon, in consultation with Prof. Sumedha Pathak (Professor and Head of Department of Neurology), and on the advice of Prof. Baldev Singh and Prof. A K Banerji, prepared a plan for establishing a clinical center dedicated to the development of neuroscience. A draft proposal was submitted on 16 th July 1971 to the Dean. Decision was taken to change its name from 'Brain Research Centre' to 'Neurosciences Centre.' Detailed and ambitious plans for its establishment were formulated. Although the plan was ready, there was no source of funding for it. Prof. P N Tandon could arrange a meeting with the personal secretary to the Hon'ble Minister of Health, Shri Uma Shanker Dixit. The result of meeting was encouraging and resulted in progress towards the establishment of the Neurosciences Centre. 
On 2 nd August 1972, the Director sent a copy of the formal proposal of "Neuroscience Center" to the then health secretary Shri K K Das. The proposal was discussed at the institute body meeting held on 12 th September 1972 [Figure 3],[Figure 4] and [Figure 5]. Recognizing the advantages of establishing a dedicated Neurosciences Centre, the institute body approved the proposal in principle to set up a center for neurological sciences at AIIMS and envisaged that not only should it be included in the proposal for the fifth five-year plan of AIIMS but the possibility of an advanced action in the fourth five-year plan itself should also be seriously explored. It was accordingly decided that the matter be considered by the finance committee in greater detail. However, the battle was not yet won as there were no funds. Due to financial constraints, Dr. Banwari Lal, Chief of Health Division, Planning Commission, rejected the idea of establishing a comprehensive center that included both clinical and basic neurosciences and came up with the proposal of including only the clinical services. For the pioneers attempting to establish this neuroscience centre, it was a big disappointment to abandon the dream of inclusion of basic neurosciences in the proposal.
|Figure 3: Archival document of proposal for the establishment of a comprehensive Neuroscience center, 1972|
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|Figure 4: Prof. P N Tandon accepting Padma Shri award from the President of India, Shri V V Giri in 1973|
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|Figure 5: Prof. Kristiansen from Oslo, Norway along with Prof. Baldev Singh inaugurating the "Prof. Baldev Singh library." Prof. Kristiansen donated his personal collection of books for this initiative|
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As the proposal for a separate cardiothoracic center had already been put forward by Prof. Gopinath, due to financial constraints, the Health Minister, Shri. Khadilkar asked the authorities in AIIMS to place a combined proposal for a combined Neuroscience and Cardiothoracic Centre. Thus, Prof. P N Tandon and Prof. Gopinath drafted yet another proposal, maintaining the basic character of two independent centers, and yet having some common areas and support laboratories. On 2 nd August 1973, a new combined draft proposal was forwarded to the Director.
As a result of vigorous pursuit and unshakeable determination of Prof. P N Tandon, Prof. A K Banerji and Prof. Gopinath, the Cardiothoracic and Neuroscience Centre (CNC) soon became a reality. The planning Commission ultimately decided to allocate separate funds for the development of super specialties. On 22 nd July 1975, a formal letter from the Ministry of Health and Family Welfare was communicated to the Institute regarding the allocation of rupees 188.37 lakhs for the super-specialties (including both centers) in the Fifth five-year plan. In July 1976, the estate committee formally appointed M/s. Pradhan Ghosh and associates as the architects. The President of India, Shri. Neelam Sanjiva Reddy laid the foundation stone of the Cardiothoracic and Neurosciences Centre on 14 th April 1978.  In his welcome address, Dr. Ramalingaswami (director of AIIMS) stated, "Our vision of the center will be both of public service and of higher learning at the same time." Quoting the famous economist Francis Delaisi, he said, "The purpose of an institution is to supply stability needed for long-term operations. At the same time, institutions must be able to adjust to the inevitable changes. It is our hope that stability, adjustability, and continuity will mix in the centers in appropriate balance."
Five years later, in March 1983, the outpatient clinics for Neurology, Neurosurgery (and also Cardiology, and Cardio-Thoracic Surgery) moved to the new building while the work to complete the rest of the building was continuing. It was only by 1988 that both the centers became fully functional in their new abode. At that time, Neurosciences Centre had a bed strength of 180, three fully equipped operation theaters, a 30 bedded Intensive Care Unit (ICU), intermediate care wards and fully functional departments of neuroradiology and neuroanesthesia within its complex. The neuropathology and neurochemistry units, however, decided to continue within their parent departments in the main building.
| » Growth of the Department|| |
The department was started with only two faculty members. It was only in 1971 that the department added one additional lecturer, Dr. Brahm Prakash, who was also the first neurosurgery resident of the department. The next person to join the department was Dr. Ravi Bhatia as a lecturer in 1974. The first faculty to join the department after the Neurosciences Centre came up was Dr V S Mehta, who joined as a Lecturer in 1981, followed by Dr. A K Mahapatra, who joined in 1983. Meanwhile, Dr. Brahm Prakash left the department to join G.B. Pant Hospital as head of the department of neurosurgery in 1980. After the center had become fully operational in 1988, the department had a total strength of 5 faculty members, who continued to share the ever-increasing service load [Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10] and [Figure 11]. Over the years, new faculty members successively joined the department. Currently, the department of neurosurgery is headed by Prof. B S Sharma and has 18 faculty members. There are two units with the second one led by Prof. S S Kale.
|Figure 6: Prof. Hans Pia conducted a laboratory microsurgery course in 1976, which provided a breakthrough in microneurosurgical training in India|
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|Figure 7: Prof. PN Tandon, Prof. A K Banerji, and Prof. Sneha Bhargava at an academic meet|
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|Figure 8: Prof. Dhavan, Prof. B Ramamurthi, Prof. B K Anand, and Prof. P N Tandon sharing a light moment|
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|Figure 9: Prof. P N Tandon and Prof. V S Mehta with Prof. John Jane at AIIMS in 1998|
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|Figure 10: Prof. P N Tandon with Prof. Brahm Prakash at the annual Delhi Neurosurgical Association meet in 2001|
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|Figure 11: Prof. P N Tandon along with Mrs. Tandon and Mrs. Kristiansen at the IXth International Congress of Neurological Surgery (WFNS) held in New Delhi in 1989|
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Starting with only one resident in 1967, the department of neurosurgery currently has a resident strength of 40 in two streams (the 3- and 6- year residency programs).
| » Infrastructure|| |
The neurosurgery department, literally started from scratch, in the space allotted on the first floor of the hospital by the side of the anatomy lecture theater. A separate outpatient clinic was started on the 4 th floor of Rajkumari Amrit Kaur out patient department (OPD) block after 2 years of its inception. The department started with vintage surgical equipment belonging to the World War II era. Initially the department had no beds. The medicine and pediatrics departments generously allowed sharing of their ward beds with neurosurgery. The department finally established its own ward in the OPD block (ward IX) in 1968.
By the mid 70's, neurosurgery and neurology wards had been relocated to the main hospital's 4 th floor. The neurosurgery department had 22 beds. There was one operation theater but there was no specialized neurosurgical operation table and no ICU facilities had been established. The neuroradiology set up consisted of a skull table without automatic changer for angiography. There were neither facilities for tomography nor a dedicated unit for myelography. Isotope encephalometry, then a routine diagnostic investigation in the international arena, was not available. The department had an electroencephalography machine but no facilities for electromyogram or nerve conduction. The department was facing an increasing demand for patient care from all over the country and also from neighboring countries. The waiting list for admission and for surgery was a constant source of worry. With the start of a well-equipped Neurosciences Centre in 1983, the department progressed rapidly. By 1988, the cardiac and neuroscience centre (CNC) had OPDs, record rooms, an administrative wing, noninvasive laboratories, cardiac catheterization laboratories, a radiology wing, 8 operation theaters (neurosurgery 3, cardiac surgery 4, common 1) along with ICUs, postoperative wards, private wards, and office space (the latter on the 7 th floor).
The CNC had the new addition of the Cardiac and Neurosciences tower in 2007. This includes dedicated neurosciences and cardiac sciences private wards on the 6- floor. The 7 th floor has 4 dedicated modular neurosurgical operating rooms. This new addition has increased the operating room strength to 7. In the year 2011, an intraoperative magnetic resonance imaging (MRI) was installed for MRI-guided procedures. Furthermore, in the same year, to provide advanced research and clinical care in the field of epilepsy, a "Centre of Excellence for Epilepsy" project (DBT funded) came up with the persistent efforts of Prof. P S Chandra and Prof. Manjari Tripathy. Under the same project, an Epilepsy Research Lab was inaugurated in February 2015 and was named "Prof. P N Tandon Neurobiology of Epilepsy Laboratory."
Today, the department conducts more than 3500 surgeries annually at the neurosciences center and nearly 1500 cranio-spinal trauma surgeries at the trauma center. In addition to this, around 450 patients are treated annually with radiosurgery at the Gamma Knife Centre. At present, the Department of Neurosurgery runs the outpatient clinics 4 times a week at the neurosciences center, 3 times a week at the trauma center, and once in a week at the Gamma Knife Centre. Currently, the department of neurosurgery has a bed strength of 180 beds including 60 trauma beds at Jai Prakash Narayan Apex Trauma Center. There are 46 ICU beds including 20 at the trauma center, and 10 operating rooms including 3 at the trauma center [Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15] and [Figure 16].
|Figure 12: Suturing practice in microneurosurgery under a high magnification is being supervised by a national faculty at the Neurosurgery Skills Training and Experimental Laboratory|
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|Figure 13: Trainees improving their micro-drilling skills at the Neurosurgery Skills Training Facility and Experimental Laboratory using high-speed drills on sheep's head and scapula|
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|Figure 14: The intraoperative "Brain Suite." A magnetic resonance imaging guided surgery in progress|
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|Figure 15: Gamma Knife Perfexion unit with its "Extend Adapter" in place|
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| » Neurosurgery Skills Training Facility and Experimental Laboratory|| |
The Department of Neurosurgery started an "Experimental Microneurosurgery Laboratory" in 1971, which was modernized under the persistent efforts of Prof. A K Mahapatra and Prof. Ashish Suri in 2007. It was converted into a state-of-the- art training facility named as "Neurosurgery Skills Training Facility and Experimental Laboratory" with the support of Department of Science and Technology (Ministry of Science and Technology, Government of India), Department of Biotechnology Indo-German Collaboration (Ministry of Science and Technology, Government of India) and Department of Health Research (DHR-ICMR, Ministry of Health and Family Welfare, Government of India). The Neurosurgery Skills Training Facility and Experimental Laboratory is equipped with modern equipments such as the latest microscopes, endoscopes, pneumatic drills, image intensifiers, which simulate a modern neurosurgical operating room environment. Over the years, the neurosurgery laboratory has patented many modules that are dedicated towards neurosurgical training. The training imparted is aimed at enhancing neurosurgical skills and operating techniques of trainee neurosurgeons. The training imparted is in the form of quarterly workshops, hands-on practice on synthetic/semi-synthetic models, live anesthetized animals and cadavers using highly advanced equipment and technology [Figure 12] and [Figure 13]. This program has both short- and long-term fellowships for training young neurosurgeons.
| » Gamma Knife Centre|| |
To take neurosurgical services to the next level, a Gamma Knife Centre came up in May 1997 with the dedicated efforts of Prof. A K Banerji and the Elekta Gamma Knife Model B was established. In 2011, it was upgraded to the fully robotized Perfexion model. The new perfexion model is capable of performing hypofractionation using Gamma Knife Extend System [Figure 15], the first of its kind in South East Asia. The Gamma Knife Center also has an in-house 1.5-Tesla wide bore MRI machine dedicated to imaging patients attached to the Gamma Knife Centre. Till date, over 4200 cases have been treated.
| » Jai Prakash Narayan Apex Trauma Center|| |
After a long delay and discussions, in the year of 2007, considering the need to provide comprehensive care to patients who develop traumatic injury, a modern trauma center has been established and is known as Jai Prakash Narayan Apex Trauma Center (JPNATC). The neurotrauma services were shifted from the Neurosciences Centre to this center. The JPNATC has 60 beds under Neurosurgery (including 20 ICU beds) and 3 operation theaters. The department of neurosurgery at the trauma center has several state-of-the- art equipments including an O-arm, a Jackson frame operating table, a portable computed tomography machine installed both in the ICU and the ward, facilities for conducting cerebral microdialysis, etc., The center also has dedicated facilities to treat spinal injuries as well as peripheral nerve and brachial plexus injuries. The department of neurosurgery has a Cadaver Training and Research Facility (CTRF-http://www.ctrfaiims.in/) in JPNATC, which was started in 2014. This training laboratory provides a world-class cadaveric training facility for brain and spine surgery where cadaver workshops are held at quarterly intervals.
| » Center of Excellence in Epilepsy|| |
A National Center of Excellence for difficult-to-treat epilepsy patients was established at AIIMS in collaboration with the National Brain Research Centre in 2011. The Department of Biotechnology (DBT), Ministry of Science and Technology, Government of India funded this project. The objective of this national facility is to develop paradigms of epilepsy research and training in India. This center has all the modern gadgets for the treatment and research in epilepsy such as a magnetoencephalogram (the first of its kind in India), advanced human electrophysiology, brain-mapping, cellular electrophysiology, and molecular research facility. Prof. PN Tandon's Epilepsy Neurobiology laboratory [Figure 16] in this center has recruited several full- time faculty from the National Brain Research Center to conduct research in the basic sciences. The neurobiology laboratory is fundamentally structured to study the genesis of epileptogenic networks at a molecular and cellular level, by assessing the resected brain specimens. It has the first-of-its-kind facility in the country to conduct single neuronal in-vitro recordings. This center also has a fellowship program that helps to impart training to young neurosurgeons.
| » Patient Services|| |
The clinical services have tremendously expanded over the years. During 1966, the department admitted 140 patients, attended to 540 patients in the OPD and performed 111 major and 89 minor surgical procedures. In 2015, the department treated around 50,000 OPD patients at the Neuroscience center, 1600 patients at the gamma knife center, and 7000 patients at the trauma center. The department operates about 5000 cases/year. 
The department specializes in all fields of neurosurgery that include neuroendoscopy, neurovascular surgery, minimally invasive neurosurgery, spine surgery, stereotactic and functional neurosurgery, skull base surgery, pediatric neurosurgery, epilepsy surgery, radiosurgery, peripheral nerve and brachial plexus surgery, neuro-trauma, neuro-oncology, and surgery for pain and spasticity.
| » Awards and Recognitions|| |
The efforts of the faulty have been rewarded at national and international levels. To mention a few of them, Prof. P.N. Tandon received Padma Shree (1973) [Figure 4], Padma Bhushan (1989), Padma Vibhushan (2005), B C Roy Award (1982), ICMR Award, Hari Om Ashram Award, and Dhanwantri Award. He has also been appointed as the 'National Research Professor' in 2014. Prof. V S Mehta received Padma Shree (2005). Prof. A K Mahapatra received B C Roy award in (2007) and UP Ratan Award (2007). Dr. B S Sharma received Dr. Shurveer Singh best scientist award (2010).
| » Education|| |
The department is committed to the advancement and promotion of neurosciences in the country.
From its inception, the Department has been actively engaged in continuing medical education programs. Short-term training programs are organized regularly. Prof P N Tandon organized an annual course on neurobiology for clinicians in the 1980's for 5 consecutive years. Operative Workshops have been organized from time to time with the participation of several international invited faculty members since the inception of the department [Figure 7],[Figure 8],[Figure 9],[Figure 10] and [Figure 11]. A major breakthrough achieved in enhancing the clinical services occurred in 1976 with the arrival of Prof. H W Pia [Figure 6], who conducted a course in laboratory microsurgery. Thereafter, the microsurgical work of the department took a new direction. In the year 1989, the Department of Neurosurgery organized the IXth International Congress of Neurological Surgery under the aeges of the World Federation of Neurosurgical Societies (WFNS). Subsequently, live operative demonstrations and cadaveric dissections were held in 1992, 1995, 1996, and 1997 with the participation of several international faculty members. These workshops served as important milestones in the history of microneurosurgery in India. Since 1999, the department organizes the 'Annual Microneurosurgery Workshops' in the month of February. Each year, a renowned international neurosurgeon participates in the workshop. Till date, 'giants' in the field of neurosurgery, such as Prof. Alan Crockard, Prof. Arnold Menezes, Prof. Roberto Heroes, Prof. T Kawase, Prof. Juha Hernesniemi, Prof. Madjid Sami, and Prof. William Couldwell have participated in the workshop. The visiting international faculty during the Annual Microneurosurgery workshop also delivers the prestigious "Sarveshwari Memorial Oration." Since the year 2015, the department has also started "Prof. P N Tandon Oration" and "Prof. A K Banerji Oration" to be delivered during alternate years in the Annual Micro-neurosurgery Workshop. Apart from the microneurosurgery workshops, the department also organizes the AIIMS complex spine operative workshop in May, and, the AIIMS annual spine workshop and the AIIMS neurotrauma conference in October.
The department has produced over 700 publications in the last 50 years and many neurosurgical text-books. The department has created a forum (http://www.aiimsnets.org/neurosurgeryeducation.asp) to support, coordinate, and enhance the efforts to generate an online forum for disseminating scientific information useful to neurosurgical trainees and specialists.
| » Training and Courses|| |
A three-year MCh training program was started in 1967. The MCh course eventually had two streams of neurosurgery courses in the department, a 3-year course and a 6-year course. Residents have an extensive training program, which includes regular clinical case presentations, journal clubs, morbidity and mortality meetings, seminars, neuro-radiology conferences, neuropathology conferences, and teaching ward rounds. The department of neurosurgery has trained more than 170 neurosurgeons. Many of them have become chairmen of their respective departments at various national neurosurgical centres, thus fulfilling an important objective for which the department was created. The department also provides short- and long-term training to national and international candidates.
| » Views of Founders of the Department|| |
In the true spirit of Gita, the sole concern of the founding fathers of the department was the duty and not the reward. No sacrifice was great enough durng the efforts made for the establishment of a center of excellence. Posterity will judge whether they succeeded or not but no one can deny that they put forth their utmost efforts. Even after the departure of those who initiated it, the Centre continues its journey to greater heights, as will be obvious in the future from the description that will be given by those of the succeeding generations. Let us hope and pray that the Centre will continuously strive to live up to its tenets engraved in its foundation stone, "In the ultimate analysis, it is not the budget, nor the number of staff positions that makes a truly great center of public service and higher learning. It is the presence of thoughtful, imaginative, humanistic, loyal and devoted faculty and students that is vital."
| » References|| |
Personal communication with Prof. P N Tandon and his official letters to the administration and ministry of health and family welfare for the establishment of neurosciences centre.
Annual Report of AIIMS; 2013-2014.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]