1/31/2017

Trump will have a hard time pushing drug prices down

Here’s the template for President Donald Trump’s tussles with manufacturers: First, he declares something about their operations outrageous and demands change on behalf of the American people. Then he threatens to punish the manufacturers. A meeting with prominent CEOs ensues, followed by assurances that everybody got along great. The final act is some kind of concession by the manufacturers that allows Trump to declare victory and move on to the next target.
This is how it went with the appliance manufacturer Carrier (UTX), and then with automakers including Ford (F) and General Motors (GM). Trump threatened to punish such firms for moving jobs outside the country, and the firms responded with pledges to save or create more American jobs.
But the template may not hold for Trump’s latest target, the nation’s biggest drugmakers. Trump has called drug prices “astronomical” and said drug companies are “getting away with murder.” Many Americans undoubtedly agree, since drug prices have been rising by much more than inflation for years. After a meeting with CEOs of drug firms including Merck (MRK), Johnson & Johnson (JNJ), Eli Lilly (LLY) and Amgen (AMGN), Trump followed the script, striking a friendly tone while insisting, “We have to get drug prices down. We have no choice.” He promised to do his part by cutting regulations on drugmakers and fostering a more favorable business climate.
But Trump has limited ability to force drug prices down, and drugmakers have considerable leverage in Washington and in state capitals. Whatever victory Trump declares is likely to be shallow and fleeting.
The surest way to clamp down on drug prices would be to allow Medicare, the nation’s single-biggest purchaser of drugs, to negotiate prices with providers. But federal law prevents that and prospects of Congress changing that with new legislation seem remote. Vermont Democratic Sen. Bernie Sanders says he’ll introduce legislation this year that would allow just that, but such efforts have gone nowhere before. Neither have efforts to allow the importation of cheap drugs from Canada or other countries where prices are far lower. Big Pharma has powerful lobbyists in Washington, with campaign cash spread among hundreds of lawmakers of both parties to make sure its interests and profits are protected.
Some states are considering price caps, which would mainly apply to drugs purchased through Medicaid, which is funded by state and federal money. But that wouldn’t affect people covered on private-sector plans, and might even push up prices for drugs not subject to price caps, to compensate for lost revenue.
More competition usually helps lower prices, and this is one thing Trump points to as a cure for soaring healthcare costs in general. Maybe. But there’s little or no competition for some patent-protected drugs, which are usually the most expensive. And even some generic or off-patent drugs soar in price when drugmakers find clever ways to corner a market. That’s what led to big controversies recently involving Mylan’s Epipen and two heart drugs sold by Valeant. And if more drugs are made in the United States, at higher US labor costs, it will put upward pressure on prices as well, just as it would with electronics or automobiles.
Pharmaceutical executives say reforms involving faster approval for new drugs and better pricing models would help control prices. Bob Hugin, executive chairman at Celgene (CELG), recently told Yahoo Finance that “value-based pricing” based on a drug’s actual effectiveness—rather than a list price—would serve patients better. Some such reforms might be included in whatever Trump has in mind to replace the Affordable Care Act, which Congress is likely to repeal this year. But Big Pharma enjoys tremendous pricing advantages that aren’t likely to disappear. On this one, Trump has chosen an imposing adversary.
Newman tip line: rickjnewman@yahoo.com

Post Polio Litaff, Association A.C _APPLAC Mexico

The Polio Crusade

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

video

movie

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A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here