COMPARISON OF COST OF MEDICAL TREATMENT IN NEUROLOGICAL ILLNESSES (INDIA versus USA)

COMPARISON OF COST OF MEDICAL TREATMENT IN NEUROLOGICAL ILLNESSES (INDIA versus USA) (in US dollars; 1 USD=70 INR)

	INDIA	USA
Neurologist consultation fees	10-20	500-600
CT scan charges	30-60	1,000-1,600
MRI scan charges	150	2,600
EEG (routine)	30-60	500-600
Long term EEG recording	150	3,000
NCS/EMG	50-150	1,000-5,000
Botox (One vial cost)	300	525
Hospitalization for acute STROKE treatment	1,500-7,000	14,000-30,000

The costs in India are that of private hospitals and diagnostic centers. Also, the discussion pertains to Neurology treatments in urban areas and metros of India.

Costs are exorbitantly high in USA

It is obvious that the treatment costs are several times higher in USA, as compared to India. I agree that insurance companies cover most of the cost in USA, but individuals still need to pay at least 10-20% of the bills. You can imagine the fate of those who do not have medical insurance (about 12% of Americans do not have insurance). In 2007, 62% of filers for bankruptcy in US claimed high medical expenses. US spends about 10,000 dollars per year per person on healthcare. About 20% of GDP is spent on healthcare. The medical treatment costs in the US are the highest in the world. 

                                          (Source: Washington Post)

Waiting periods to see specialists/get procedures are long

In USA, there are long waiting periods to see a Neurologist, as well as, to get the procedures (EMG, EEG, Botox, MRI, etc) done. In India, one can see a neurologist, get the MRI done and get it reported by a Radiologist in a few hours! On the other hand, the average wait time to see a Neurologist in USA is 30-35 days. Getting the MRI done and its report would take several more days. The situation in UK and Canada are worse, where one may have to wait for 2-3 months to see a specialist and get an MRI done. 

The charges are higher in several other countries too, including Singapore, Australia and Thailand.

Indian Neurologists are well trained and experienced

Regarding the expertise of Neurologists, training in premier Indian Institutes such as AIIMS, PGI Chandigarh, NIMHANS, CMC Vellore, Sree Chitra, Tiruvannathpuram, JIPMER Puducherry, etc are at par with the best in USA. The clinical experience of treating neurological illnesses is several times more among Indian Neurologists, simply because they see more number of patients. There are about 2000 neurologists to cater to 1.25 billion people (one Neurologist for every 6,25,000 people). In comparison, US have about 18,000 neurologists for a population of 320 million (one Neurologist every 18,000 people). On an average, Indian neurologists see 3-4 times more number of patients as compared to American or British Neurologists.

In summary, Neurological treatment costs are much lower in India as compared to US and many other countries. The access to Neurology care is easy, and has little or no waiting times. Neurologists in India are well trained in the subject and have a vast clinical experience. 

DR SUDHIR KUMAR MD (Internal Medicine) DM (Neurology)

Senior Consultant neurologist

Apollo Hospitals, Jubilee Hills, Hyderabad

Phone: 0091-40-23607777/60601066
Online Consultation:  http://bit.ly/Dr-Sudhir-kumar
Email: drsudhirkumar@yahoo.com

MANAGEMENT OF EPILEPSY IN PREGNANCY

MANAGING EPILEPSY IN PREGNANCY

Epilepsy is a common illness and therefore, we commonly encounter women with epilepsy (WWE), who are either pregnant or contemplating pregnancy. There are a lot of apprehensions and misconceptions regarding managing epilepsy in this group of WWE. Here, I wish to highlight some of the important aspects of managing epilepsy in women who are planning pregnancy or are currently pregnant.

1. If a woman is seizure-free for at least two years, she can consider withdrawing anti-epileptic drugs (AEDs) under the supervision of neurologist, and then plan for pregnancy.

2. If a woman has seizures, it is better to continue AEDs during pregnancy, as the risk to the baby is several times higher with seizures, as compared to that with AEDs.

3. Sodium valproate has the highest risk to the developing baby, and it should be avoided in pregnancy.

4. AEDs such as levetiracetam, lamotrigine, oxcarbazepine, topiramate, etc are safe and may be continued during pregnancy.

5. The lowest effective dose of AED should be used.

6. Try to use only a single anti-epileptic drug, if possible.

7. Folic acid vitamin supplements should be used in pregnancy.

8. The dose of anti-epileptic medication may have to be increased during the last three months of pregnancy.

9. CT scan of brain should be avoided, as far as possible, during pregnancy, as radiation exposure due to it may harm the baby.

10. MRI brain is reasonably safe for baby, especially after the first three months of pregnancy. So, if needed, it may be performed.

DR SUDHIR KUMAR MD DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Jubilee Hills, Hyderabad-500096

Email: drsudhirkumar@yahoo.com

For appointments: 0091-40-23607777/60601066

DISC DISEASE OR SLIPPED DISC

CERVICAL AND LUMBAR DISC DISEASE

Introduction

Disc is the soft tissue located in between the vertebral bodies.

A picture showing different types of disc problems. 

Disc problems are common in cervical (neck) and lumbar (lower back) regions. Earlier, it was common in older people, due to more degeneration of discs in them. However, now-a-days, we see several younger people, even in their 20s and 30s, who come with disc problems. This is because of sedentary life style, lack of exercises, prolonged sitting (on account of job, computer use, etc), and sports injuries. 

What are the common symptoms of disc diseases?

Disc prolapse or slipped disc can present with several symptoms:

In cervical disc disease, following symptoms are common:

1. Neck pain,

2. Pain in the arm, which may increase on coughing,

3. Tingling or pins and needle sensations in the arm,

4. Numbness in arm,

5. Weakness in the arm.

In lumbar disc disease, the following symptoms may occur:

1. Lower back pain,

2. Pain in the leg, which may radiate from lower back to the leg, also referred to as sciatica,

3. Tingling or numbness in leg,

4. Weakness of leg,

5. Leg pain, numbness or weakness may increase on walking (referred to as claudication), and get relieved on resting. 

How is the diagnosis of disc disease confirmed?

1. Clinical history and examination by a neurologist are useful in suspecting the diagnosis.

2. MRI of spine (cervical or lumbar region, as the case may be) is the confirmatory test for disc disease. 

An MRI scan of lumbar spine showing a prolapsed disc at L5-S1 level

What are the treatment options for disc disease?

Conservative (without surgery): It is useful to note that surgery is not needed in about 90% of cases. 

Several measures are useful in relieving pain in patients with disc prolapse: 

1. Rest- in severe cases, bed rest may be advised. In less severe cases, limited mobility within the house (for toilet and dining purposes) may be permitted.

2. Use of analgesics (such as aceclofenac, etoricoxib) and muscle relaxants (such as mobizox and myospaz forte) may help in relieving pain.

3. Specific medications that help reduce the nerve pain are pregabalin, gabapentin, duloxetine, etc. 

4. Physiotherapy- measures such as IFT, ultrasound, traction, etc help reduce the pain in several people with disc prolapse. 

Surgical options

In 10% of patients, medical treatment fails, then, surgery may be needed. Following are the specific indications for surgery in a patient with slipped disc:

1. Failure of medical treatment to adequately control the pain,

2. Progressive neurological deterioration, such as worsening of weakness or numbness, or bladder/bowel involvement,

Various types of surgeries are:

1. Laminetomy,

2. Discectomy,

3. Spine stabilisation with instrumentation. 

The choice of surgery depends on patient's symptoms, MRI findings and age. 

General advice to patients with disc disease:

1. Avoid forward bending,

2. Avoid lifting heavy weights. 

3. Lose weight, if overweight or obese

What is the prognosis of patients with disc disease?

In general, the outcome of patients with disc prolapse is good and most patients return to normal life after proper treatment. They are able to do their activities of daily living and are gainfully employed.

Surgery is also safe, however, I come across many people who have wrong notions about surgery. They have been mis-informed that after surgery, people get paralysed. In practice, this does not happen. However, if the case for surgery is not correctly chosen, there may not be good relief from pain after surgery also, a condition referred to as "failed back syndrome". 

If you have any further queries, you may get back to me.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Hyderabad, India

Phone- 0091-40-23607777

Email: drsudhirkumar@yahoo.com

Online consultation: http://bit.ly/Dr-Sudhir-kumar

MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

1. What is multiple sclerosis?

Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.

The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  

Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

2. What is the meaning of demyelination or demyelinating illness?

Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.

A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.

·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),

·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.

·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

4. What are the common symptoms of multiple sclerosis?

Common symptoms of multiple sclerosis include:

• Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
• Numbness of arm or leg on one or both sides of body,
• Weakness of arm or leg on one or both sides of body,
• Imbalance while walking,
• Bladder symptoms,

Less common symptoms of multiple sclerosis include

·        Memory disturbances,

·        Seizures or fits,

·        Depression

It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

5. How is the diagnosis of multiple sclerosis confirmed?

A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.

After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

6. What are the important investigations for confirming a diagnosis of multiple sclerosis?

• MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.

• CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
• Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
• Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

7. What are the current treatment options for multiple sclerosis?

Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.

Treatment for acute episodes:

Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.

Treatment to prevent relapses of disease:

The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.

Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:

1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.

2. Fingolimod- oral capsule (0.5 mg) once daily

3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),

4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.

5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.

6. Teriflunomide (Aubagio)- once daily tablets. 

 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com