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 MIGRAINE HEADACHES

Management of Migraine Headaches

There are two steps involved in ensuring the best outcomes for a patient with migraine:

1. Correct diagnosis, and 
2. Correct treatment.

Diagnosis of Migraine Headaches

Migraine is a common condition, affecting about 15% of women and 5% of men. Often, no tests are required for diagnosing migraine. Despite this, there is a significant delay in diagnosis of migraine in many cases. The correct diagnosis depends on the clinical features. Therefore, a good history, as given by the patient, is often sufficient for the diagnosis of migraine. The details can be read on my earlier post in May 2011

http://bestneurodoctor.blogspot.in/2011/05/how-to-diagnose-migraine.html

Treatment of Migraine Headaches

Starting appropriate treatment is equally important.

Many patients come to me telling that there is no treatment available for migraine or it can not be cured or I have to suffer with these headaches whole life and so on. So, they never take any treatment. Obviously, it is totally incorrect. There are excellent treatments available for treating migraine, and more than 95% of patients get better with proper treatment. You can read about these treatments later on in this post.

There is another group of patients who take only pain-killers, as and when they get headaches. This approach is not correct and may be harmful too, on account of three reasons:

1. Taking a pain-killer may help in reducing one episode of headache, however, it does not prevent the recurrence of headaches in future.
2. Pain-killers may cause side effects such as gastric ulcers, acidity, liver damage and kidney damage, if used for long.
3. Taking more than 15 tablets of pain-killers per month may actually worsen the headaches, a condition called as analgesic-abuse or analgesic-overuse headaches.

On account of the above, it is advised to restrict the use of pain-killers to as low as as possible.

Medical treatment of Migraine

1. If a person has only one or two episodes of headaches per month, then, there is no need of any preventive medications. Use of analgesics may be justified in these cases, as and when they get headaches. Common drugs in this category include-

• Paracetamol,
• Disprin,
• Zandu balm or tiger balm (very popular in India)
• Ibuprofen,
• Diclofenac,
• Vasograin,
• Rizatriptan,
• Sumatriptan

Any of the above can be used at the time of severe headaches. Some people also have vomiting, then ondansetron or domperidone tablets may be used.

2. Preventive therapy of migraine-

If a patient gets more than two episodes of headaches per month, then, it is important to start preventive medications (on daily basis) so that the headache frequency and severity can be minimised (or stopped).
Common drugs in this category include:

• Flunarizine
• Beta blockers such as propranolol,
• Topiramate,
• Divalproex sodium

In some cases, a combination of two medicines may be required.

Patients, who do not show adequate improvement with above, can be treated with botox injections. More details on this can be read in my previous post (October 2012)

http://bestneurodoctor.blogspot.in/2012/10/botox-treatment-for-migraine.html

I hope this article provides a little help to those with migraine. If you have any further queries, please mail me.

Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
email: drsudhirkumar@yahoo.com

BOTOX TREATMENT FOR MIGRAINE

Botox Therapy for Chronic Migraine

What is migraine?

• Migraine is a condition, characterized by repeated episodes of headache.
• Headache can be on one side or both sides of head.
• Headache typically lasts for more than four hours, but usually resolves in less than 72 hours.
• Nausea (a sensation to vomit) or vomiting may be present during headache episodes.
• There may be photophobia (headache becomes more in bright light or sunlight) or phonophobia (headache becomes more in noise).

 What is chronic migraine?

A person, who has been suffering from migraine, for a period of more than six months, is said to be suffering from chronic migraine.

What is the impact of chronic migraine on the sufferer?

Chronic migraine leads to a number of problems in the sufferer:

• Recurrent headache interferes with job or studies, leading to poor performance at work or in studies.
• It leads to frequent absenteeism at workplace or in college.
• People suffering from chronic migraine can not enjoy social functions, as slight triggers such as music can trigger the headaches.
• They need to avoid road travel, as it can trigger headaches.
• Patients are frequently forced to take multiple analgesics (pain-killers) every month, leading to significant adverse effects.

What are the treatment options for patients with chronic migraine?

Patients with chronic migraine, who get three or more than three episodes of headache in a month, require preventive therapy (medications to prevent repeated episodes of headache).

What are the commonly used medications to prevent headaches in a migraine patient?

Following medicines (with their brand names) are available for use in chronic migraine:

Tablets

·        Amitryptiline (Tryptomer)

·        Flunarizine (Sibelium)

·        Propranolol (Betacap TR, Ciplar LA)

·        Divalproex (Divaa OD, Dicorate ER)

·        Topiramate (Topamac)

Injections

·        Botulinum toxin (Botox) injections

What are the disadvantages of oral medications?

1.      Lack of efficacy- many people do not adequately respond to these medications. They continue to get recurrent headaches despite taking them for long periods.

2.      Adverse effects- Significant adverse effects are noted with oral medications.

·        Amitryptiline- drowsiness

·        Flunarizine- drowsiness, weight gain

·        Propranolol- aggravation of asthma, depression

·        Divalproex- weight gain, tremors of hands, hair loss, pregnancy-related complications,

·        Topiramate- tingling of feet, weight loss, glaucoma in rare cases, renal stones in rare cases.

 3.      Need to take them on a daily basis

What are the advantages of Botox injections over oral medications in migraine treatment?

1.      Efficacy of botox in migraine has been proven in research and clinical practice.

2.      Botox is fairly safe and the side effects are negligible.

3.      Botox injections need to be repeated once in 3-6 months, so, the patient compliance is better and they can get rid of daily tablets.

Facts regarding Botox injections in a patient with migraine

·        There are fixed points over the scalp, where the injections are given (irrespective of the site of head pain).

·        These locations include front of head, over eyebrows, temple region, back of head and neck muscles.

·        Injections are given by a neurologist, who is trained in the botox procedure.

·        It is given by insulin syringe and needle, and is given in the superficial tissues (scalp muscles, which are hardly a few mm beneath the skin).

·        Topical (surface anesthetic) creams are used, so, the injection does not hurt much and is almost painless.

·        The whole procedure can be completed in an office (Outpatient) set up and is completed in 15-20 minutes.

·        Patient can leave for office or home immediately after the botox procedure.

·        A total dose of 155 units of botox is used in chronic migraine.

Are there any side effects of botox injections?

·        This is the same botox that is used in cosmetic procedures and several million patients have received botox for neurological problems as well (such as writer’s cramp, dystonia, blepharospasm, post-stroke spasticity, hyperhidrosis, etc).

·        It is among the safest injections, and has no serious side effects.

·        Mild pain at the injection site may be felt (just as is felt with any injections).

·        Mild bruising (and redness) and swelling may occur at the injection site.

·        Mild eyelid droop may occur, which improves in a few days on its own.

My experience with Botox in migraine

• I see about 15-20 new cases of migraine per month, and have seen thousands of patients in the past 18 years of my medical practice.
• About 20-30% of them either do not improve with oral preventive tablets or they have side effects with them. Some people find it difficult to take tablets on a daily basis for a long period of time.
• For this group of patients, botox injection therapy is the most ideal. I see 2-3 patients per month, who are eligible to receive botox therapy in chronic migraine. About 1-2 per month receive them. In the past two years, I have given botox to about 40 patients with chronic migraine.
• About 95% patients report benefit after botox therapy and in most cases, oral tablets are not required after botox.
• None of them reported any adverse or side effects with botox.

I would like to share an interesting experience with one of the patients. Mrs Nazia (name changed) from Dubai came in June 2012 for botox therapy in migraine. I gave her the injections on OP basis on the usual sites, including forehead. She had no side effects with botox. She came back for review three months later and reported that she was totally headache-free. However, she wanted a repeat botox injection. I was surprised. I asked her if she has no headache, then why does she want botox! She said, after botox, her husband has started to give her more attention and love, as her face has also improved (then, I realized that she wanted it for cosmetic effects). She also told me that three of her colleagues at her office want the botox to be given by me (but only for cosmetic reasons). I had a tough time, referring them to a cosmetic surgeon for the same.

If you want any further information regarding botox therapy in migraine, please email me at drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Medicine) DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Jubilee Hills, Hyderabad

Email: drsudhirkumar@yahoo.com

Phone-0091-40-23607777/60601066

ROLE OF BOTOX IN NEUROLOGICAL DISORDERS

BOTULINUM TOXIN (BOTOX) INJECTIONS IN NEUROLOGY

Botulinum toxin (popularly sold in the brand name Botox by Allergan company) is one of the commonly used treatment methods in cosmetology. Many actors and models take botox therapy to look young and hide away all facial and forehead wrinkles. Very few people know that Botox has wide applications in the field of neurology and patients with several neurological disorders can benefit from botox therapy. In this post, I would list out all the conditions where I give botox injections and would share my experiences in treating them.

1. POST-STROKE SPASTICITY

Stroke is a common disease leading to paralysis of muscles on one side of the body, due to reduced blood flow to the brain. Patients who survive stroke are left with severe disabilities. Spasticity- increased stiffness and tone of weak muscles- is a common cause of disability in stroke survivors. There are several medications (oral tablets) available for reducing the spasticity, but they have limited efficacy and significant side effects such as drowsiness. Botox injection therapy is a very effective method of treating post-stroke spasticity. Botox is injected in the spastic muscles. In the past 10 years, I have treated more than 100 patients with this condition and most of them do well. One of my recent patients was an ex-army person from Baghdad (Iraq), who was wheel-chair bound for five years due to a stroke. I gave him botox treatment, and referred him for physiotherapy. After a week, he came walking to my office. Patient and his wife were so thrilled! Reduction in spasticity also helps in doing better physiotherapy.

2. CHRONIC MIGRAINE

Migraine is the commonest cause of headache, affecting about 10-15% of women and 5-8% of men. In many cases, migraine becomes chronic and leads to frequent headaches. Frequent, severe headaches adversely affects the patients' quality of life, studies, employment and family life. Oral preventive therapies for migraine are available, but are ineffective in some and lead to adverse events in others. In these patients, botox therapy has a great role to play.

Botox is injected in scalp and neck muscles (frontalis, temporalis, occipitalis, cervical, trapezius, etc) using a very thin needle. The procedure can be done in the office, with little discomfort to the patient, and is completed within 15-20 minutes. In the past two years, I have treated about 30 patients with chronic migraine with botox. 29 of them showed good improvement in pain and quality of life. One patient who did not improve had various stressors in personal and professional life, leading to super-added tension headache. One patient, who I distinctly remember was a 35-year-old woman from Dubai, who came to me with 5 year duration of chronic migraine (20 headache days per month). She returned 3 months after botox injection therapy for review, and reported almost complete improvement in pain. However, she requested me for one more botox shot. I was surprised, as she was pain-free. Then she disclosed to me that her husband had started showing more interest in her now that she looked much younger and prettier (after botox shot to frontalis muscles) and she wanted to maintain the youthfulness of her face. I suggested to her that she consult a cosmetologist, but she insisted on me doing it. So, I along with my cosmetologist, gave her the second botox shot!

3. WRITER'S CRAMP

It is a condition, where patients find it difficult to write. They are able to perform all other activities normally, including lifting heavy weights with hands. Handwriting becomes poorer and illegible. Cheques signed by the patients start bouncing, as the signature on the cheque does not match that of bank records. Another feature of the disease is that writing becomes worse in front of others and when tensed.

Botox is very effective for treating writer's cramp. Injection is given in forearm muscles. Most patients improve very well.

4. SPASTICITY OF LIMBS IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy (CP) is a condition affecting children, characterized by developmental delay (delayed motor and speech milestones). Other features may include fits, deafness, squint, learning disability, etc. Cerebral palsy results due to a lack of oxygen or blood supply to the brain during peri-natal period (immediately before, during or immediately after birth). Many children with CP have spasticity of legs and hands. Spasticity of legs hamper in their standing and walking. Botox injections given in adducor and hamstring muscles of thighs reduce the spasticity, and improve walking. Today, I treated a 5-year old child from Bidar (Karnataka) with this condition.

5. Other dystonias- such as hemi-facial spasm, blepharospasm, cervical dystonia- are also very well treated with botox injections.

6. Hyperhidrosis- increased sweating over palms and feet, which can be embarrassing and cumbersome- responds well to botox treatment.

In general, all botox injection therapies are done on an out-patient basis. Patients can come after eating (fasting is not necessary). It is done without any anaesthesia, in the office setting. The entire procedure is completed in less than 30 minutes and patients are free to return home immediately after the procedure. No leave from work is required and they can join work the next day. Depending on the condition, 100 to 200 units (1-2 vials) of botox is required for the procedure, and the approximate cost could be Rs 25, 000- 50, 000 (USD 1000-2000). Botox treatment is safe and I have not seen any complication in more than 250 botox procedures that I have done in the past 10 years.


DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)
CONSULTANT NEUROLOGIST
APOLLO HOSPITALS, JUBILEE HILLS
HYDERABAD, INDIA.
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com