Morning Medtalks with Dr KK Aggarwal 12th June 2018


Dr KK Aggarwal    12 June 2018

Dear Colleague

Minds Vision

Decide while others are delaying, time is the main factor that ensures success.

Should we remove tonsils in children?

And now it has been shown in June 7 issue of JAMA Otolaryngology–Head & Neck Surgery that children who have their tonsils or adenoids removed before age 9 years are at higher risk for respiratory, infectious, and allergic diseases up to the age of 30 years. Tonsillectomy was associated with a nearly tripled risk of upper respiratory tract diseases, and that adenoidectomy was associated with doubled risk of [chronic obstructive pulmonary disease] and upper respiratory tract diseases and nearly doubled risk of conjunctivitis. Doctors often remove adenoids and tonsils to treat recurrent tonsillitis or middle ear infections. Adenoids and tonsils are parts of the immune system, have known roles in pathogen detection and defence, and are usually removed at ages when the development of the immune system is sensitive.

Now an ultra-thin stent

Often doctors are blamed for putting a costly stent. The government does not differentiate between different stents.  The smallest-sized DES currently available is 2.25 mm. Patients with CAD in vessels <2.25 mm are currently managed with bare-metal stents, oversizing with a 2.25-mm DES, or plain old balloon angioplasty, as drug-eluting balloons are not yet available.

Now the first prospective study of a 2.0-mm drug-eluting stent (DES) met its primary end point and was associated with a reassuringly low rate of clinical events in patients with CAD in very small coronary vessels. The 12-month target lesion failure rate was 5%. In addition, there was zero stent thrombosis with the investigational 2.0-mm zotarolimus-eluting stent (Resolute Onyx, Medtronic). This dedicated size of Resolute Onyx allows for the successful treatment of lesions involving extremely small vessels, thereby fulfilling an important unmet clinical need. The mean reference vessel diameter (RVD) in the RESOLUTE ONYX 2.0 mm Clinical Study was 1.91 mm.

Now with all stents in NLEM will the companies introduce the 2.0 stent in India market and if so will they be able to match the current Indian capped prise?

Lightening injury and cricket

Sorry for 21-year-old aspiring cricketer who died on the spot after he was struck by lightning coupled with thundershowers during practice at the Calcutta Cricket Academy here. The club members did CPR but after seeing no response, took him to Ramakrishna Mission Seva Pratishthan where he was declared dead. I hope CPR was continued on the way.

Lightning injuries are responsible for an average of 300 injuries and 100 deaths per year in the United States. 30 percent of those struck by lightning die and up to 74 percent of survivors may have permanent disabilities. Two-thirds of lightning-associated deaths occur within one hour of injury and are generally due to a fatal arrhythmia or respiratory failure.

Prolonged CPR should be undertaken following electrical injury regardless of the initial rhythm, since most victims are young and good outcomes have been noted even among patients with asystole. Usual triage priorities are reversed if multiple victims are present: patients without signs of life are treated first.

Lightning injury (asystole, DC current) can result in clinical signs typically associated with severe brain injury (fixed and dilated pupils) but which may not accurately reflect the patients neurologic status. Therefore, prolonged CPR is indicated.

Bone Banks

In Delhi we have now two government bone banks, at AIIMS and GTB hospital. Bone banks collect grafts from cadaver donors. These are used for reconstruction of large bone defects. Unlike the heart and the kidneys that must harvested within 6-8 hours of brain death, bones can be removed within 24 hours, and preserved for more than 20 years at -80 degrees Celsius. One bone graft can be used to treat more than 15 persons.

At Ganga Ram hospital another bank is currently using well processed and gamma irradiated cortico cancellous bone allografts from tibial slices and femoral heads, bones from amputated stumps in various clinical conditions. The grafts are screened for HIV, HCV, HBV and syphilis to eliminate risk of disease transmission. Unlike other transplants, bone graft recipients do not have to take any immunosuppressant or other drugs. They preserve the graft for a year.  


A “biosimilar” is defined by the World Health Organization as a “biotherapeutic product which is similar in terms of quality, safety and efficacy to an already licensed reference biotherapeutic product” and the “similarity” is defined as the “absence of a relevant difference in the parameter of interest.” The biosimilar agents are expected to be marketed at a lower cost than the original biologic medications. 

Biosimilars are not the same as generics. A generic drug is an identical copy of a currently licenced pharmaceutical product that has an expired patent protection and must contain the ‘same active ingredients as the original formulation’. A biosimilar is a different product with a similar, but not identical, structure that elicits a similar clinical response.  As a result, biosimilars medicines have the potential to cause an unwanted immune response. Whereas generics are interchangeable, biosimilars are not.

The potentially lower cost of biosimilars raises the risk that insurers may favor them over the original reference medicine, even when they may not be appropriate for an individual patient. India must cultivate national guidance on safety of biosimilars.

India (CDSCO) Definition: Similar biologics- A biological product/ drug produced by genetic engineering techniques and claimed to be “similar” in terms of safety, efficacy and quality to a reference biologic, which has been granted a marketing authorization in India by DCGI based on a complete dossier, and with a history of safe use in India. In 2012, India has issued the Similar Biologics Guideline by Central Drugs Standard Control Organization nd the Department of Biotechnology.

Affordable Health Care

This is how a consultation will be charged and reimbursed in the US by the Medicare (equivalent of Mediclaim in India)

Level 1 Established Office Visit: This is the lowest level of care for established patients in the office and accounts for only 3.21% of consults. Usually the presenting problems are minimal.  It is the only one which does NOT REQUIRE THE PRESENCE OF THE PHYSICIAN.  There are no specific documentation requirements, but the purpose of the visit should be recorded. ( Us Medicare allowable reimbursement for this level of care is $20.05)

Level 2 Established Office Visit: This is the second lowest level of care for an established patient being seen in the office and is used for 3.1% of patients. Usually the presenting problems are self-limited or minor.  The Medicare allowable reimbursement for this code is $43.68. Documentation requires TWO out of THREE of the following:  Problem Focused History, Problem Focused Exam, Straightforward Medical Decision-Making or 10 minutes spent face-to-face with the patient if coding based on time. 

Level 3 Established Office Visit: This level of care is located “in the middle’ of the coding spectrum for office visits with established patients.  It involves 41.78% of patients. Usually the presenting problems are of low to moderate severity.  The reimbursement for this level of care is $73.40. The documentation for this encounter requires TWO out of THREE of the following:  Expanded Problem Focused History, Expanded Problem Focused Exam or Low Complexity Medical Decision-Making or 15 minutes spent face-to-face with the patient

Level 4 Established Office Visit: This code represents the second highest level of care for established office patients. This is the most frequently used code in 47.41% of established office patients. The Medicare allowable reimbursement for this service is $108.13. Usually the presenting problems are of moderate to high severity.

The documentation for this encounter requires TWO out of THREE of the following:  Detailed History, Detailed Exam, Moderate Complexity Medical Decision-Making 0r 25 minutes spent face-to-face with the patient if coding based on time.

Level 5 Office Visit: The highest level of care for established patients being seen in the office.  It involves 9% of established office patient visits. The Medicare allowable reimbursement for this level of care is $145.72. The documentation for this encounter requires TWO out of THREE of the following:  Comprehensive History, Comprehensive Exam, High Complexity Medical Decision-Making Or 40 minutes spent face-to-face with the patient if coding based on time.

Plastic Pollution

Hon’ble Delhi High Court Acting Chief Justice Ms. Gita Mittal stated that immediate steps need to be taken to minimise plastic utilisation, especially single-use of the plastic items including the pens and the other stationery items, in Courts. She issued an administrative order, directing High Court and all district courts in the capital to take immediate steps to replace plastic items. She added that, “Global concerns of environment degradation, as well as those of pollution and the waste management in Delhi, render it imperative that immediate steps are taken to reduce the carbon footprints of all our actions and reduce contribution to waste generation in Delhi and the courts”.

Hon’ble Delhi HC has constituted a Committee which will be headed by its Registrar General Dinesh Kumar Sharma to examine the working branches and courts and identify sources of waste generation (including liquid and solid waste) as well as pollution. (Latestlaws.com)

Happy Tuesday

With Regards

Dr K K Aggarwal

Padma Shri Awardee

Vice President CMAAO

President HCFI

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