Globalization & Healthcare: Understanding Health & Medical Tourism

Global competition is evolving rapidly in the health industry. Rich patients from developing nations travel to developed countries for quality medical care. Now, large numbers of patients from developed countries are visiting third world countries for medical treatments. Most of these medical tourists who are not much wealthy are seeking quality medical care at affordable prices from Asian countries. To meet the rising demand, entrepreneurs are building advanced facilities using foreign and domestic capital. They are employing physicians, doctors, technicians and nurses who trained to American and European standards.

Medical tourism is the most modern global phenomenon in the healthcare industry, which is undeniably on a rapid growth with thousands of medical tourists worldwide. Reports show that it is a hundred billion dollar industry now and it is growing. Medical tourism imparts growth not only in the healthcare industry but also develops the travel and tourism sector. Hence more countries are getting transformed into top destination countries for medical tourists. Patients don’t find a flight journey for a medical procedure to be expensive when considering the cost of treatment in their own country.

In USA, a minor surgery can be very costly where the same surgery can cost very less in another country. Another major factor for health tourism to get popular is specialization. Some countries may be advanced in certain procedures while another country may be advanced in some other procedures. Time is another factor which is considered by patients when the operation is to be carried out immediately. There is a long wait for medical procedures in wealthy countries while most medical tourism countries can arrange for immediate operations. Since life is precious and patients can’t wait, they prefer to travel to other countries for treatment.

The medical tourism business is now worth about $40 billion a year with almost 7 million people travelling globally in search of affordable medical care. India is renowned for alternative system of medicine such as Ayurveda, Unani and Siddha which has proven to be very useful and developed interest in patients around the world. Besides the cost of medical procedures, the attainment of rare drugs is also available at less cost in countries offering medical tourism.

The high levels of skill with advanced facilities and small treatment costs in the Indian hospitals have made it one of the leading destinations for Healthcare in the world. Tourists from American and European countries visit Asian countries for cardiac surgery, joint replacement surgery and knee replacement surgery in India. Individuals from African and West Asian countries undergo Heart surgery in India. The cost of heart surgery in India is just about 1/10th of that of USA and Britain. Their are hundreds of advanced cardiac hospitals in India and it has now become the heart treatment hub of South East Asia.

MIMS (Malabar Institute of Medical Sciences) thrived to become quality healthcare provider in Kerala, India. MIMS, located in the heart of Calicut city has been the leader in medical technology and it is sustained by internationally trained and qualified physicians, who manage the best offered medical services across all departments of medicine and surgery.

Although there is a long travel time involved in visiting India, it is among the most popular destinations for medical tourists. It undoubtedly has the lowest cost and highest quality of all healthcare facilities, where English is widely spoken. MIMS is the first multispecialty hospital in India to get NABH accreditation for its quality service and patient safety.  

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Globalization & Healthcare: Understanding Health & Medical Tourism
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MIMS Witnessed one more Cadaver transplant Surgery

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MIMS Witnessed one more Cadaver transplant Surgery

The relatives of Mr. Rajeev Kumar (42) from Kottiyoor who was declared brain dead following a road accident have set an example donating his organs. They agreed to donate his kidneys and eyes to 4 persons respectively. Mr. Rajeev Kumar was brain dead at MIMS Calicut on 18^th Sunday at 11 PM.

When his wife Mrs. Pushpavally confirmed the willingness to donate his organs, we have informed the patients who are on waiting list for organs both in Medical College and MIMS as well as Comtrust Eye hospital, Calicut. 4 patients from MIMS and 2 patients from Calicut Medical College came for kidneys and we sent their blood to AIMS, Kochi for cross matching. Sevenseas Ambulance helped us in providing the fastest transport service. The result was received at 2.45 AM. One 21 year lady from panoor, Kannur district, (Dialysis Patient at MIMS Calicut for last 5 years) and 48 year male from Malapuram (Patient from Calicut Medical College) were selected for cadaver transplant as per the cross matching result.  

Dr. Sajeesh Sahadevan, Dr. Rajesh Nambiar, Dr. Rohit Raveendran (Gastro Surgeons, MIMS) lead the surgery for harvesting the kidneys.  Dr. Nisha Sajeesh and Dr. Unnikrishnan from Comtrust Eye Hospital lead the surgery for harvesting the eyes.  Harvesting surgeries held between 12 AM to 2 AM. Dr. Harigovind, Dr. Ashish Jindal and Dr. Rahul (Urologists, MIMS) lead the transplant Surgery. Anaesthetists were Dr. Kishore and Dr. Padmaja and nephrologists were Dr. Sajith Narayanan & Dr. Benil Hafeeque. Transplant surgery at MIMS started at 5 AM and completed at 10 AM successfully.

The Transplant Physician Dr. Feroz Aziz with the support of Ms. Shahana, Mr. Sunil Kumar (Dialysis)  and many other staff backed with all support starting from informing the needy patients, sending recipients’ bloods to kochi for cross matching and completing all required legal formalities at midnight.

MIMS is honored to conduct one more Cadaver Transplant Surgery and helped four deserving patients to retrieve a new life. We thank our doctors and entire team of Multi organ Transplant Unit at MIMS in showing this social gesture and commitment.MIMS Hospital offers one of the best organ transplantation in Kerala.
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Well Known Singapore Cardiac Surgeon undergoes training in Beating Heart Surgery in MIMS Hospital

Dr Kang Gap Swieb , MRCS (Edinburgh), FRCS CTh (Edinburgh)from the famous National University Hospital Singapore was in the city recently to study the latest techniques employed by Dr Murali P Vettath, renowned Cardiac Surgeon at MIMS Hospital, who has been performing 100% CABG’s (Coronary Artery Bypass Grafting Surgery) without the Heart Lung Machine for the past 7-8 years. In the past, Cardiac surgeons from USA, Europe, Australia, China, Singapore and the Gulf had visited this International Center of Excellence in OPCAB (Beating heart surgery) to undergo training..

An expert in the field of cardiac surgery, Dr Kang was in the International Centre of Excellence in OPCAB for three months to gain his fellowship in beating heart surgery. Dr Kang said he had decided to choose MIMS Hospital because it is one of the well known hospitals in the world carrying out such surgeries. And he could observe first hand the intricate techniques from Dr. Murali Vettath, one of the pioneers in this field, who with his inventions and research had created a benchmark in beating heart surgery nationally and internationally. Dr Kang also added that he hoped to replicate the same techniques in his own institution once back home. 4 weeks after returning Singapore, Dr Kang performed the 1st beating heart surgery in his institution successfully. 
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Liver transplantation: – The need and the results

Over 200,000 patients in India die annually from end stage liver disease and its complications. Liver transplantation is the treatment of choice for those suffering from end-stage liver disease (ESLD). This procedure is now applied world wide as treatment for a large number of irreversible acute liver failure and chronic liver diseases for which there were previously no other treatment Options. The primary goals of liver transplantation are to prolong life and to improve the quality of life. It is essential to optimize patient selection and ideally time the transplant procedure so as to gain the maximum benefit. The number of liver transplants happening in India is only around 750 per year which is nothing in support of the need. The outcomes of liver transplantation are currently excellent and much improved as compared to 20 years ago due to advances in operative technique, a better understanding of the course and prognosis of several liver diseases, and more effective postoperative care including immunosuppression.
                             Liver donors could be deceased donors and live donors. Donors should be blood group matching to recipient’s. Deceased donors in India are presently the brain dead donors maintained on ventilator and other supports for blood pressure and kidney. Despite the fact that non governmental organizations like Chennai based MOHAN (Multi Organ Harvesting Aid Network), Cochin based SORT (Society for Organ Retrieval and Transplantation) and Calicut based HOPE (Human Organ Procurement and Education) have done commendable thrusts, deceased organ donation has not come to its true potential in India and Kerala. Due to this large volume centres in India practice living donor liver transplantation. Living donation is based on the fact of enormous regenerative capacity of liver. A healthy person with no liver disease and co morbidities could donate up to 60-70% of his liver. The functional status of remnant liver is minimally or unaltered by this donation and is fully recovered by time of discharge which is by 10 days.
                                  The patients with ESLD are complicated by refractory ascites (fluid accumulation in abdomen), renal failure due to hepato renal Syndrome, hepatic encephalopathy (alteration in sensorium ranging from mild to comatose situation), recurrent variceal bleeding (presenting with vomiting of blood), pulmonary complications like Hepato pulmonary Syndrome and portopulmonary hypertension (presenting as respiratory difficulty) and liver malignancy like hepatocellular carcinoma. Transplantation should be considered in any patient with liver disease in whom the procedure would extend life expectancy beyond what the natural history of the underlying liver disease would predict or in whom transplantation is likely to improve quality of life. Timimg could not be delayed to the extent of patient having developed severe complications of ESLD like Portopulmonary hypertension, severe hepatopulmonary syndrome, severe hyponatremia as all these predicts mortality during procedure and are relative contraindications to procedure. On the other hand patients who are too well should not be transplanted. Since the goal of transplantation is to prolong survival, liver transplantation should be performed at the time point when the patient is expected to have greater survival with a liver transplant than without. A more scientific basis for this led to implementation of the MELD(Model for End Stage Liver disease ) scoring system, which is an objective, score depending on Prothrombin time, bilrubin and  S. Creatinine of the patient. Organs are allocated in deceased organ sharing based on higher  MELD score. In live donation scenario also same criteria for  indication are  used.
                             Usual stay of recipient in the hospital is 15-21 days and they need frequent monitoring by blood tests in first 2 weeks after discharge and after that the visits reduce to once in month to once in 3 month. Immunosuppression is with 3 drugs of which steroids are tapered and removed by 3 months and the dose of other two drugs could be reduced and kept at min levels. The complications that could occur include technical complications, primary nonfunction of liver, rejection  and infectious complications. The overall one and 5 year survival after this procedure has improved from 80% and 50% to 90 % and 80% respectively in last  two decades.

By,

Dr.Sajeesh Sahadevan MS MCh

Senior Consultant Surgical Gastroenterologist and Liver transplant Surgeon, MIMS Calicut
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PCO Publication

“I am 25 years old, a newlywed and recently got diagnosed with PCOS. Every time I see baby things, watch baby stories on tv and in movies I get very emotional. I am very excited to start a family soon and now I hit this road block. I get a lot of positive talk that it is something that can be fixed and there still is hope, but to me it is devastating. I was also told that a lot of worrying can effect things too, that isn't good because I worry about everything under the sun. I am trying to lose weight, I just lost 18kg in a year for myself, so losing more sounds hard to do right now, I am not morbidly obese just a little extra here and there. Although I here PCOS is highly hereditary and my mother tried for 8 years to have me although she had normal menstrual cycles. If anyone could share with me their positive stories that have PCOS that would do me a world of good”

This was a genuine concern from one among many women who was diagnosed with polycystic ovary syndrome. Let us have a look about this condition.

What is polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is a condition which can affect a woman’s menstrual cycle, fertility, hormones and aspects of appearance. It can also affect long-term health. 

What are polycystic ovaries?

Polycystic ovaries are slightly larger than normal ovaries and have twice the number of follicles (small cysts). Polycystic ovaries are very common affecting 20 in 100 (20%) of women. Having polycystic ovaries does not mean you have polycystic ovary syndrome. Around 6 or 7 in 100 (6-7%) of women with polycystic ovaries have PCOS. 

What are the symptoms of PCOS?

Irregular periods or no periods at all

Difficulty becoming pregnant (reduced fertility)

Having more facial or body hair than is usual for you (hirsutism)

Being overweight, rapid increase in weight, difficulty losing weight

Oily skin, acne

Depression and mood swings

The symptoms may vary from woman to woman. Being overweight increases the risk of developing symptoms.

What causes PCOS?

The cause of PCOS is not yet known. PCOS sometimes runs in families

The symptoms of PCOS are related to abnormal hormone levels. Testosterone is a hormone which is produced by the ovaries. Women with PCOS have slightly higher than normal levels of testosterone and this is associated with many of the symptoms of the condition.

Hormone Insulin also has a role. If you have PCOS, your body may not respond to the hormone insulin (known as insulin resistance), so the level of glucose is higher. To prevent the glucose levels becoming higher, your body produces more insulin. High levels of insulin can lead to weight gain, irregular periods, infertility and higher levels of testosterone.

This disorder affects the function of the ovaries, which produce eggs and the hormones oestrogen and progesterone. Other imbalances affect hormones produced by the brain and include elevated levels of luteinising hormone (LH) and a relative deficiency of follicle-stimulating hormone (FSH), both of which control the release of eggs from the ovaries. As the ovaries aren’t working properly, eggs may not be released in a regular monthly cycle. 

How is PCOS diagnosed?

PCOS is a syndrome where at least two of the following occur:

At least 12 follicles (tiny cysts measuring 2 to 9 mm) develop in your ovaries. (Polycystic means 'many cysts'.)

Ovulation may not occur regularly. Some women with PCOS do not ovulate at all. If you do not ovulate then you may not have a period.

The balance of hormones that are made in the ovaries is altered. In particular, the ovaries make more testosterone than normal.

How is it treated?

Unfortunately there is no cure for PCOS. However, symptoms can be treated, and the health risks can be reduced.

The cysts in polycystic ovaries are not harmful and do not need surgical removal.

If overweight, losing a few pounds may be enough to get the ovaries working properly again, as the more fat is carried, the higher the insulin levels are likely to be. Unfortunately, a lot of women with PCOS struggle for years to lose weight and have little success, so hormone treatment may be needed to restore the hormonal balance. 

Some women, who have no periods, or infrequent periods, do not want any treatment for this. However, the risk of developing cancer of the uterus (womb) may be increased if you have no periods for a long time or have less than four periods a year. Regular periods will prevent this increased risk to the uterus.

Possible treatments include the oral contraceptive pill , progestogen tablets taken to induce regular withdrawal bleeds or a progestogen releasing coil. 

An oral contraceptive Pill called Dianette is often used as it helps suppress testosterone levels and control acne and body hair growth

A promising new treatment currently being researched is a drug called Metformin, which makes tissues in the body more sensitive to insulin, helping bring insulin levels back to normal. However the current evidence is not enough to suggest that Metformin can improve fertility as well as the metabolic function in PCOS.

Finally, physical treatments such as electrolysis and laser hair removal are also helpful. 

Is infertility inevitable?

Not at all. Regular periods usually mean there isn’t a problem.  Irregular periods indicate irregular ovulation and about half of those with symptoms suffer from infertility as a result of not ovulating. The first treatment that’s usually tried is stimulation of the ovary with the tablet Clomiphene. This induces ovulation in about 70 per cent of women, and about half of these women will become pregnant within six months. If this fails, injections of FSH may be tried and this triggers ovulation in around 80 per cent of  women treated, of which about 60 per cent will conceive within six months. It’s vital, however, that ovarian stimulation is monitored by ultrasound in a fertility unit as women with PCOS have a tendency to develop a high number of eggs. This not only raises their risk of a multiple birth, but also of a potentially serious condition known as ovarian hyperstimulation syndrome (OHSS). 

Is laparoscopy has any role?

If drug treatment doesn’t work, laparoscopic surgery that involves cauterising the ovary(making few punctures)  is very successful in triggering ovulation without the risk of hyperstimulation. Laparoscopy can also can identify and treat the other causes of infertility if present.

Remember, you are much less likely to become pregnant if you are obese. If you are obese or overweight then losing weight is advised in addition to other fertility treatments. 

What are the long term health risks?

Diabetes – 10-20% women with PCOS go on to develop diabetes

High blood pressure

Heart disease

Cancer of the uterus

What can be done to reduce long-term health risks?

Healthy life style:

Healthy diet, regular exercise and weight reduction should help to reduce the long-term health risks.

You should aim to keep your weight to a level which is normal (a BMI between 19 and 25)

Regular health checks:

Women with PCOS over the age of 40 should be offered a blood sugar test once a year to check for signs of diabetes.

After the menopause it would be wise to have regular cholesterol and blood pressure checks so early signs of disease can be treated.
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Urinary Incontinence in Female

Urinary incontinence is an embarrassing little problem, and lots of women -- regardless of age -- are secretly dealing with it.

What is urinary incontinence?

Urinary incontinence is the accidental release of urine. It can happen when you cough, laugh, sneeze, or jog. Or you may have a sudden need to go to the bathroom but can't get there in time. Bladder control problems are very common, especially among older adults. They usually don't cause major health problems, but they can be embarrassing.

Incontinence can be a short-term problem caused by a urinary tract infection, a medicine, or constipation. It gets better when you treat the problem that is causing it. But in majority, it is an ongoing problem

There are two main kinds of urinary incontinence. Some women-especially older women-have both.

Stress incontinence occurs when you sneeze, cough, laugh, jog, or do other things that put pressure on the bladder. It is the most common type of bladder control problem in women.

Urge incontinence happens when they have a strong need to urinate but can't reach the toilet in time. This can happen even when the bladder is holding only a small amount of urine. Some women may have no warning before they accidentally leak urine. Other women may leak urine when they drink water or when they hear or touch running water.

What causes urinary incontinence?

Bladder control problems may be caused by:

Weak muscles in the lower urinary tract.

Problems or damage either in the urinary tract or in the nerves that control urination.

Stress incontinence can be caused by childbirth, weight gain, or other conditions that stretch the pelvic floor muscles. When these muscles can't support your bladder properly, the bladder drops down and pushes against the vagina. You can't tighten the muscles that close off the urethra. So urine may leak because of the extra pressure on the bladder when you cough, sneeze, laugh, exercise, or do other activities

Urge incontinence is caused by an overactive bladder muscle that pushes urine out of the bladder. It may be caused by irritation of the bladder, emotional stress, or brain conditions such as Parkinson's disease or stroke. Many times doctors don't know what causes it.

Investigations

Your doctor will examine you and may do some simple tests to look for the cause of your bladder control problem. Some of the commonly used tests are:

·  Bladder diary Keep track of your symptoms and any leaking of urine with a bladder diary. This can help you and your doctor find the best treatment for you.

    Urinalysis. A sample of urine is sent to a laboratory, where it's checked for signs of infection, traces of blood or other abnormalities.

    Ultrasound also may be used to view other parts of the urinary tract or genitals to check for abnormalities.

    Urodynamic testing. These tests measure pressure in the bladder when it's at rest and when it's filling. A catheter is introduced into your urethra and bladder to fill the bladder with water. Meanwhile, a pressure monitor measures and records the pressure within the bladder. This test helps measure the bladder strength and urinary sphincter health, and it's an important tool for distinguishing the type of incontinence

How is it treated?

Treatments are different for each person. They depend on the type of incontinence you have and how much it affects your life. The treatment may include exercises, bladder training, medicines or a combination of these. Some women may need surgery.

There are also some things you can do at home. In many cases, these lifestyle changes can be enough to control incontinence.

· Cut back on caffeine drinks, such as coffee and tea.

· Eat foods high in fiber to help avoid constipation

· Stay at a healthy weight.

· Try simple pelvic-floor exercises like Kegel exercises.

· Go to the bathroom at several set times each day, and wear clothes that you can remove easily. Make your path to the bathroom as clear and quick as you can.

If you have symptoms of urinary incontinence, don't be embarrassed to tell your doctor. Most people can be helped or cured.

How can you prevent urinary incontinence?

Strengthening your pelvic muscles with Kegel exercises may lower your risk for incontinence.

Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter and pelvic floor muscles — the muscles that help control urination. Your doctor may recommend that you do these exercises frequently. They are especially effective for stress incontinence, but may also help urge incontinence.

To do pelvic floor muscle exercises (Kegel exercises), imagine that you're trying to stop your urine flow. Squeeze the muscles you would use to stop urinating and hold for a count of three and repeat.

Medications

Often, medications are used in conjunction with behavioral techniques. Drugs commonly used to treat incontinence include:

Duloxetine  is sometimes used to treat stress incontinence.

Drugs like Tolteradine and Oxybutinine are used. Possible side effects of these medications include dry  mouth, constipation and blurred vision .Estrogen vaginal  creams or patch may help to improve the tone and rejuvenate tissues in the urethra and vaginal areas.

Surgery
If other treatments aren't working, several surgical procedures have been developed to fix problems that cause urinary incontinence.

Some of the commonly used procedures include:

Sling procedures. 

A sling procedure uses strips of synthetic material or mesh to create a pelvic sling or hammock around your bladder neck and urethra. The sling helps keep the urethra closed, especially when you cough or sneeze.  Tension-free vaginal tape (TVT) is a commonly used sling surgery. More than 85% of the persons get cured by this procedure.

    Bladder neck suspension. This procedure is designed to provide support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra. It involves an abdominal incision, so it's done using general or spinal anesthesia.
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Palliative care at MIMS

What is palliative care? Is it synonymous to hospice? Does it mean terminal care alone ?

     

            Palliative care is an approach that improves the quality of life of patients and their families facing the problem  associated with life threatening  illness, through the prevention and  relief of  suffering by means of early identification  and impeccable assessment and  treatment of pain and other problems physical, psychosocial and spiritual. 

            Palliative care is a patient  centered approach . It is  death accepting but also life enhancing,  and offers a support system to the patient to live as actively as possible until death. 54 lakhs of people in India require palliative care. Palliative care comprises of co-ordinated services in home and hospital, as day care  and specialized centers extending till bereavement. Malabar area has  set a role model for community based,  palliative service in the world.

            At MIMS MOC, we opened a pain and  palliative clinic on 07-07-12. Palliative services are extended on a OP and IP basis. Extended support is provided to patients  even  at the point when active cancer treatment ceases. Thus active  medical care continue to palliate the patient  from his symptoms.

Collaborative Clinics

✗     Pain clinic -In associate with  Anesthesiology and Radiation Oncology Departments.

✗     Counseling Clinic - Psychiatric social worker

✗     Lymphoedema Clinic  - In association with  the physiotherapy Department

✗     Rehab Clinic - In association with the physiotherapy Department & rehabilitation.

Services

1. Symptom management in advanced cancer[Aiming for highest measure of patient comfort.

2. Pain management

3. Op /IP/Day care services

4. Terminal care/Sedation for terminally distressed patient

5. Abdominal paracentesis/Thoracentesis/Wound care.

6. Counseling sessions /Breaking bad new sessions

           

            We strive to bring quality care to cancer and beyond at, MOC, palliative clinic. Home care services will be our upcoming facility in the near future.

By  
Dr.Vineetha Rijju (MBBS, BCCPM, FPM) has specialization in Palliative Oncology.

About MIMS Hospital:The Malabar institute of Medical sciences Ltd (MIMS), the first NABH Accredited multi specialty Hospital in India, is situated in the heart of Calicut (Kozhikode), Kerala, India. It is a pioneer hospital in India renowned for its excellent medical expertise, nursing care and quality of diagnostic services. For more details : Visit http://www.mimsindia.com
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