Can Polio Come Back?


Dr KK Aggarwal    28 June 2018

Morning Medtalks with Dr KK Aggarwal 28th June 2018


Can the Govt. force hospitals & doctors to comply with the price capping under the Ayushman Bharat National Health Protection Scheme?


When we talk of affordable health care, we need to have value for money for both masses as well as classes. The economically weaker section of the society or BPL with more than 40 categories are today deprived of secondary and tertiary health care.


Without insurance, it is not possible for a citizen to afford secondary and/or tertiary health care. Workers drawing a salary of up to Rs 21,000/- a month are mandatorily covered under ESI. Those who have a salary of more than Rs 21,000/- should pay the private insurance premium on their own. Then there is a subgroup of people in this income bracket, the EWS and BPL, who cannot even afford any insurance premium.


The responsibility falls on the state to provide health care to all under Article 21, “No person shall be deprived of his life or personal liberty except according to procedure established by law”.


The Ayushman Bharat National Health Protection Scheme, therefore, can be a way to bridge this gap. The scheme principally targets the poorest and the vulnerable sections of the society. It will cover more than 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization with no restriction of family size. This coverage of Rs 5 lakh for the whole family for the economically backward patient may be sufficient in 80-90% cases.


The experience of the National insurance companies has been that reimbursement has been more than the total premium collected, so they were forced to bring in TPA to cap the prices of reimbursement which has been practically accepted by the medical establishment.


The Govt has fixed the pricing for 1,354 treatment packages under the Ayushman Bharat National Health Protection Scheme. More than 20 specialties like cardiology, cancer care, neurosurgery and neonatal care have been covered under the scheme depending on the type of therapeutic category and procedure. These package rates include all the costs associated with treatment i.e. the govt. has capped the total money required for the treatment.


Without invoking the Essential Commodities Act, the govt. cannot cap the prices but they can cap the prices for enrolling the medical establishment under their loop or at the most, the govt. can provide the list of hospitals as preferred hospitals as is the prevailing practice in third party reimbursements.


Participating in the scheme is voluntary; the hospital may or may not choose to join. Success of the scheme will depend on how many will enroll in the scheme. If the participation is poor, the govt. will be forced to revise the reimbursement charges. But, if the scheme gets off successfully, then the govt. may continue with the present reimbursement rates.


But everybody needs to work with the govt. and not compare the rates of the Ayushman Bharat National Health Protection Scheme with those of CGHS, PSUs, TPAs as they are not meant for the EWS/BPL patients but for rich patients.


Charity has to be at the cost of the rich. Therefore, the govt. may consider subsidizing the cost of poor by way of subsidizing package in Ayushman Bharat National Health Protection Scheme by revisiting the rates of package for non Ayushman Bharat subsidized people who are not in the income bracket of this scheme.



NLEM Implants



The Central Drug Standard Control Organisation (CDSCO), had issued a notification wherein it proposed to include all implantable medical devices and other high-end equipment under the purview of the Drugs and Cosmetics Act, 1940. The list includes all implantable devices, CT scan equipment, MRI equipment, defibrillators, PET equipment, dialysis machine, X-ray machine, bone marrow cell separator etc.


Once these equipments are brought under the new act, it will be able to regulate the licences to manufacture, sell and import them. The Central Drugs Standard Control Organisation (CDSCO), has notified the list of devices to be regulated under the D&C Act and asked stakeholders to submit their suggestions by July 15.



Medical Electronics are not drugs and may misfit under Drugs & Cosmetics Act, so the government should enact a separate medical equipment act.


Implants can be long term implants (> 30days) or short-term implants (< 30 days > one hour) or even transient implants (< one hour). Short term applies to such devices as temporary implants and surgical instruments that come in contact with skin, bodily fluids, bone and tissue.  The examples are joint replacement sizers and placeholders for implants, over-molded surgical blades, electrosurgical devices, catheters, shunts, diagnostic guidewires etc. Long term examples are tubing and drains, drug delivery systems, pacemakers, vaginal rings (IUD devices) and audiology applications.

Editors views: All medical equipment, reagents, drugs and devises should be sub classified in NLEM and non NLEM



Polio can come back any time

SYDNEY (AFP) - An outbreak of polio has been confirmed in Papua New Guinea as per WHO with the virus detected in a child, 18 years after the Pacific nation was declared free of the disease.

The WHO said there was one confirmed case - a six-year-old boy with lower limb weakness from Morobe province - with the disease detected in late April, and paralysis associated with the virus confirmed in May.

The US Centres for Disease Control and Prevention said the same virus was also isolated from stool specimens of two healthy children in the same community, "representing an outbreak".

According to the WHO, the number of polio cases worldwide has fallen by more than 99 per cent since 1988, from an estimated 350,000 cases then to 22 reported cases in 2017.

Only three countries - Afghanistan, Nigeria and Pakistan - were considered polio-endemic by the WHO in March.


Coke and Pepsi to reduce their sugar content in Australia: Will they follow it in India?


SYDNEY (REUTERS) - Australias biggest soft drink makers, including Coca-Cola and Pepsi, pledged on Monday (June 25) to cut industry-wide sugar use by a fifth over seven years to curb obesity in a country where nearly a third of the population is dangerously fat.

Companies will aim for a 10 per cent reduction in total sugar per 100 millilitres in their drinks by 2020 and a 20 per cent reduction by 2025, achieved via a combination of recipe modification and increasing sales of low-sugar beverages.

The WHO said last year drinking fewer sweet drinks was the best way to curb excessive weight and prevent chronic diseases such as diabetes, although fat and salt in processed foods were also to blame.


Canagliflozin  Safe

The drug was not associated with an increased risk for below-knee amputations in an observational study of more than 700,000 patients with type 2 diabetes in the OBSERVE-4D study (Canagliflozin vs Other Antihyperglycemic Agents on the Risk of Below-Knee Amputation for Patients with T2DM — A Real-World Analysis of >700,000 US Patients) presented as a late-breaking poster on June 25 here at the American Diabetes Association (ADA) 2018 Scientific Sessions by John B. Buse, MD, PhD, director of the Diabetes Center at the University of North Carolina School of Medicine in Chapel Hill.


Dog does CPR

MADRID (AP) - Can dogs perform CPR? Probably not, but a video posted by police in Madrid sure makes it seem so.

In a video posted on Facebook, Poncho the dog springs into action when his partner falls to the ground and pretends to be unresponsive. The dogs actions mimic CPR.

The dog pounds up and down on the officers chest and pauses to place its ear on the officers neck. Poncho continues until the officer stands up.

Police write that Poncho "did not hesitate for an instant" to save a life.



Ultrasound in acute appendicitis


Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure is considered a positive study. Non-visualization or indeterminate studies are considered negative. A new study has shown that a heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. (Western J Emerg Med. 2018;19(3):460-464)


Alpha blockers may not help expulsion of renal stones

Use of medical expulsive therapy for urinary stone disease in the setting of the emergency department is common, varying between about 15% and 55%


Andrew Meltzer, MD, associate professor of emergency medicine, George Washington University School of Medicine and Health Sciences, Washington, DC says "We found that compared with placebo, 28-day treatment with tamsulosin did not increase the overall stone passage rate or improve a wide range of secondary outcomes in patients who presented to the emergency department with symptomatic ureteral stones less than 9 mm in diameter,"

The study was published online June 18 in JAMA Internal Medicine.


Sometimes the relations only want an apology from the doctor

Dr GS, a general surgeon, was called in to place a central line in a 75-year-old man suffering from a gangrenous foot. The patients primary care physician wanted to administer a long-term course of IV antibiotics for this man with diabetes, hypertension, coronary artery disease, congestive heart failure, and arrhythmia.


The day following Dr GSs placement of the line, the patient engaged in his usual daily activities. The antibiotics arrived late that evening, so the patient and his wife decided to wait until the morning to begin the therapy.


The next morning, the patient awoke at 7:30 AM and had breakfast. After the meal, according to his wife, the patient looked "a little green." The patients temperature was 87.6° and he said that the left side of his upper chest—the area where the line had been placed—was burning. A bit later, while reclining, the patient said the burning sensation had returned. He took a deep breath and told his wife that he loved her. Shortly thereafter, the patients wife noticed bluish coloration rise from his neck to his face. When the paramedics arrived, they were unable to revive the patient, who was pronounced dead just after 10:00 that morning.


The patients wife sued Dr GS for the wrongful death of her husband.


As the case progressed, it became clear that the plaintiffs attorney could not get an expert to directly support his theory that an improper placement of the subclavian catheter caused an atrial fibrillation and myocardial infarction. The best he could get his expert to state in a signed declaration was that he "could not rule out" that Dr GSs placement of the catheter contributed to the patients death.


As the case moved toward trial, the patients widow finally agreed to dismiss the action if Dr GS would send her a letter of sympathy over the death of her husband.


The contents of Dr GSs letter will remain private, but the widows dismissal of her lawsuit showed that sometimes a simple human expression can mean more than a legal victory. (Medscape)


The Californias "Im Sorry Law" says that expressing sympathy to a patient or family for the pain, suffering, or death of a patient is inadmissible as evidence of an admission of liability in a civil action.


The intention of the bill was to allow parties greater leeway in expressing regret for their role in an accident, and for expressions of sympathy to become part of the resolution process.


Acute Cardiac Effects of Severe Pre-Eclampsia: All patients with pre-eclampsia should undergo cardiac evaluation with tissue doppler echocardiography. Timely detection of LV diastolic dysfunction, oncoming pulmonary edema and right heart failure will reduce mortality and morbidity.  Rising PA pressure and shift from grade 0 or 1 to grade 2 LV diastolic dysfunction may be the earlier markers. ((J Am Coll Cardiol 2018;72:1–11) © 2018 by the American College of Cardiology Foundation.)


Happy good Thursday


Dr KK Aggarwal

Padma Shri Awardee

President Heart Care Foundation of India

Vice President CMAAO

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