It's Come to This: Lottery for Health Insurance in Oregon

New risk factor identified for early death - lack of health insurance. In the US, 18,000 preventable deaths occur annually due to lack of health insurance coverage, costing the nation $65- 130 billion dollars. 600,000 people in Oregon are uninsured. Oregon decided to hold a lottery for the 3,000 spots that it can afford to cover and 80,000 people have applied. The winners will be randomly selected by computer.

The other 577,000 are out of luck.

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Heart Disease as an Interactive Drama - You Can Change the Outcome

A piece of writing from The Lancet this month is so beautiful and eloquent, I am just going to quote it here:

"Age can be deconstructed into time-related effects of disintegration that affect all of us versus time-related effects of exposure to the modifiable causal factors that affect some of us more than others. This crucial distinction is not taken into account by the methods we use to predict risk. The natural history of coronary disease can be likened to a three-act tragedy. The first act introduces and develops the main characters - namely, atherogenic dyslipoproteinaemia, high blood pressure, and smoking - that appear as we mature and unless something is done, persist during our lifetime. During the second act, which also takes place over decades, these villains incessantly attack and progressively deform the innocent arterial wall. Finally, the third act, which can be tragically brief: in an instant, the plaque ruptures, the artery thromboses, and the hero or heroine dies, all too frequently unaware of the drama that was enacted within their arteries. What is the difference, you ask? In the drama of coronary disease, the ending is not fixed; if some of the characters are edited out of the play as soon as they appear, the third act need never take place."

From: Age as a modifiable risk factor for cardiovascular disease
Allan D Sniderman, Curt D Furberg
The Lancet, March 4, 2008
DOI:10.1016/S0140-6736(08)60313-X

In other words, it's never too late to have a healthy heart.

Thank you Maapu for use of photo, Smile.

Labels: cardiovascular disease, health habits, healthy aging

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World TB Day: March 24 - 82% of US cases in ethnic minorities

Dr. Robert Koch announced the discovery of the bacteria that causes Tuberculosis on this day in 1882. Today, public health officials are calling for elimination of the disease. While some in our country want to act as if race is no longer an issue, as if 40 years of civil rights legislation have suddenly reversed 400 years of disparities, those of us who work in health care see, everyday, the hard evidence that as a nation, we have a long way to go.

Take tuberculosis - 82% of all reported US cases are in non-Hispanic whites, and 45% are in US born blacks. The northeast and southeast regions are where most of the cases are congregated, and the disease is compounded by substance abuse, HIV, homelessness and incarceration.

10 million people in the world are incarcerated and at risk for tuberculosis. Improved prison conditions - reduction of overcrowding, improved health services and improved nutrition and hygiene to prison populations will do a lot for prevention and control of TB. If the international goal is to eliminate TB by 2015, we must get real about access to health services for the poor and underserved in our communities. The US has the largest penal system in the world. In 2006, 7 million US citizens were incarcerated. 8% of black men, 1 % of white men and 2 % of Latino men are behind bars. Black women are jailed at 3 x the rate of white women.

Support of patients during treating, including direct observation of therapy (DOT) will need to be implemented on a broad scale - including prisons - to treat the 2 billion people infected. That's right - 1/3 of the world's population is infected with TB - most of them poor. $15 billion will be spent educating Californians and $15 billion will be spent incarcerating them. Male high school dropouts are incarcerated at 31 x the rate of young males with college degrees. For black males, the rate is double that - 60 x more likely to end up behind bars. Funding education is funding health prevention - by improving health literacy and access to care, by keeping people out of prison and in the work force - we can prevent communicable diseases like TB and reduce racial disparities in health care and health expenditures.

Thank you CDC for use of photo of overcrowded prison, US.

Labels: education, health disparities, prison expansion, TB

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Interview with Coach E of HBO's Autism: The Musical

I had the pleasure of interviewing Elaine Hall – Coach E – of the HBO documentary Autism: The Musical. The movie premieres Tuesday at 8 PM. Click here for the complete viewing schedule.

JC: So what would you like to tell me about this project?

EH: It’s really about the ability within the disability. And we are so privileged to be part of HBO with this, that they picked this up…They are just amazing…

[We spend a moment gushing about HBO – both of us unabashed fans]

JC: The Miracle Project – you are the founder of it?

EH: Yes, I am. What happened was that 10 months after I brought my son Neal home from Russia – he was 2 years and 10 months old then – he was diagnosed with autism. Traditional therapies weren’t working and I got connected with Dr. Stanley Greenspan who was doing Relationship-based interventions. What I found was that I could get creative people – actors, artists, musicians to work with Neal more easily than therapists could. What we did was join Neal’s world – if he was spinning, we would spin and play ring-a-round the rosie.. If he sat under a table, an actor would sit under the table with him. We did this 10 hours a day, 7 days a week. Little by little, as we joined Neal’s world, Neal started to emerge into our world. Such that he was able to attend a regular school, full time, with an aide.

JC: So you kind of turned the model of using specially trained therapists – like Dance Therapists or Art Therapists or Drama therapists – on it’s head and tried something totally different?

EH: That’s right – because artists find it easy to relate to people who are different. They’re just like ‘OK, that’s interesting.’ Artists go into their own little world to create – so they can relate to these children who go into a different space… When Neal started going to school full time, it was time for me to go back into the work force. I started a theater program for children with autism and other special needs, and I trained actors and creative people to work with the kids. I called it The Miracle Project.Then this group of filmmakers with Trisha Regan saw what we were doing and wanted to film it…One thing I want to emphasize is that siblings and peers participate in the program. So we aren’t isolated and off doing this thing on our own…

JC: So the siblings and peers model interactive behavior?

EH: They model interactive behavior but the typical kids learn compassion and understanding from working with the special kids.

JC: One thing that struck me – maybe it’s just the way it came across in the film – is that while the children’s relationships improved, the mothers were having more trouble with their own relationships – with each other, with their partners. There was the one husband who referred to “…monomaniacal mothers...” and “crazed mom with disabled child”. How much of that is lack of a supportive society? What would society look like to change that?

EH: …providing support for families…taking the stigma away. It would be great if people – just regular neighbors in the community or schools – could reach out and call the family and offer to help. If the faith community could reach out more. Not looking at these kids as negatives and hiding them and telling them to be quiet. Raising these kids is challenging. I depleted all of my savings to get help for my son. Early intervention is essential, so in an ideal society, if the health insurance community could support preventive services, if in middle schools and high schools, working with kids with autism could be taught as a Peer Training Program…Autism is a sensory processing disorder. As a society we need to show that we value our children.

JC: You’re doing this in LA – have other communities started similar programs?

EH: We’ve gotten requests from all over the country and even China – we’ve created curriculum for the Miracle Project and our 1^st training program will be in July. One Miracle Project Workshop incorporates many of the protocols recommended for autism… For more information please go to our website at www.themiracleproject.com

JC: And are these requests coming from the therapeutic community or schools, parent groups?

EH: A.B.C. and D…they come from all of the above. I am writing a book and a CD is coming out with Lexi singing a solo and Wyatt singing with Stephen Sills…It’s very replicable – it’s all about love, acceptance and joy. We presented at the International Occupational Therapy Conference and the therapists were excited by what we were doing. We were doing what they had been learning about all day!

JC: Thank you for your time. It was a pleasure speaking with you today. Best of luck.

Thank you, HBO, for use of photo of Neal & Elaine from Autism: The Musical, available on HBO.

Labels: autism, innovative therapies, mother's love

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AUTISM: The Musical Premieres on HBO March 25 at 8PM

HBO rocks. They keep bringing these crazy love stories to TV - and Autism: The Musical is yet another. The movie ends with Stevie Wonder's song As, fitting for this testament of love mothers have for their children. The fathers love their autistic children, too, but not with the passionate vehemence of the mothers. Autism: The Musical, directed by Tricia Regan tells the story of Elaine Hall, her autistic son Neal and the courageous and unconventional approach she took to unlock her son's world. Coach E, as Ms. Hall is called, engages other autistic children and their families in the production of a musical, written by the children themselves. Look for an interview with Coach E later this week.

Half a million children in the US today are diagnosed with an autism spectrum disorder (ASD). ASD's are developmental disabilities, marked by significant impairments in social interaction and communication. Autistic people are, well, different. Society isn't kind to people who are different. We all know autistic people and struggle with how to accommodate their odd behaviors into our world. Autism: The Musical offers new ideas and fresh approachs for people who seem to be locked into a world of their own.

Warning signs of ASD in adults or children:

• lack of "pretend" play
• not pointing at items that interest them
• not responding to their name
• repeating words over and over
• repetitive actions

Some children seem to develop normally until 18 - 24 months of age when they stop gaining new skills or losing skills they already have, like language or interaction with others. Watch HBO's Autism: The Musical and step into someone else's world.

Thank you, HBO, for use of Group photo from Autism: The Musical, available on HBO.

Labels: autism, autism spectrum disorders, Elaine Hall, HBO

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Thank You Scott at Polite Dissent for Grand Rounds 4.26

Polite Dissent: Comics, Medicine and Politics & Fun! hosted Grand Rounds this week and included my post Health Concerns of Prostitutes in a Western style round-up of a score of stories...Thanks Scott & great job of hosting!

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Racial Disparities in US Healthcare

The Commonwealth Fund, A Private Foundation Working Toward a High Performance Health Care System, has published a workbook - a resource to help policymakers understand the racial and ethnic disparities in our health care system. The hope is that dissecting the problem will obviate solutions. Here are some of the findings:

Current ethnic mix of the US population:

• 67% non-Hispanic white
• 8.6% of families have incomes below the Federal Poverty Level(FPL)
• 89% are high school graduates. 30% are college graduates
• 13% under age 65 are uninsured
  
• 14% Hispanic
• 22% of families have incomes below the (FPL)
• 57% are high school graduates. 11% are college graduates
• 35% under age 65 are uninsured
• 12% black
• 25% of of families have incomes below the (FPL)
• 80% are high school graduates. 17% are college graduates
• 17% under age 65 are uninsured
• 4% Asian
• 9.8% of families have incomes below the (FPL)
• 88% are high school graduates. 50% are college graduates
• 10% under age 65 are uninsured
• 1% Native American
• more information not available
  

Other findings of note:

• States with the highest population of non-Hispanic whites have the highest Medicare quality rankings
• Blacks suffer the highest rate of post-operative complications compared to other ethnic groups
• Black youths age 5 - 18 years of age are 2 x as likely to be restrained upon admission to a psychiatric facility as white youths
• Blacks with heart attacks endure longer door-to-balloon times than any other ethnic group -
  

We may lead the world in health care spending but that has not translated into leading the world in health care outcomes. Correcting disparities in care through improving access to care and responsiveness to ethnic minorities will help close that gap.

Thank you Voice of Eye for use of photo The Pulse of America.

Labels: disparities in health care US

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Health Concerns of Prostitutes

The legal status of prostitutes is complex - they work outside the law. Are they victims or are the activities they participate in so-called victimless crimes? When the prostitute is a consenting adult earning (at times substantial) compensation for participation in activities, is the prostitute being exploited?

If nothing else, the case of Governor Spitzer makes it clear there are willing workers in the prostitution trade. As such, should they be afforded the same benefits and protections as any other laborer? We need to remove the blinders from our eyes and evaluate prostitution differently in order to address the health care needs of these special groups. There are voluntary prostitutes who enter into prostitution by choice and those who are coerced and trafficked involuntarily, especially minors, are in particular need of human-rights protections.

A study in Australia found that the incidence of STD's was 80 times higher in illegal street walkers than their counterparts working in legal brothels. In legal brothels, the use of condoms is compulsory and periodic health evaluations are employee benefits. One aspect of the health care needs of prostitutes I would like to see addressed, though, is the psychological effect - long term and short term. Is it a high stress occupation? Are workers at risk for PTSD? Clearly, further study is needed.

Thank you Emily's mind for use of photo It's been the ruin of many a poor girl...

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Silent Enamel Eating Syndrome: Watch What You Eat

If it's eating away your tooth enamel, what is doing to the rest of you? Whatever it is, it can't be good. Dental erosion, the loss of the protective enamel coating on the teeth, is on the rise, according to Professor Amaechi at the University of Texas Health Science Center. The culprits are acids found in foods being consumed in ever increasing quantities - especially by the young. These acids are found in:

• soft drinks
• beer salts
• sports drinks
• herbal teas
• Lucas brand candy imported from Mexico
• aspirin
• the stomach acids in GERD

These acids are very corrosive but cause no signs or symptoms until the damage has been done. It is important for dental practitioners to be aware of the problem and screen for it. Without protective enamel, the teeth are brittle and more sensitive to pain.

Thank you Shira Golding for use of photo.

Labels: dental erosion, silent enamel eating syndrome

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Thank You Canadian Medicine for Grand Rounds 4.25

Canadian Medicine is a really great blog written by the editors of the National Review of Medicine. This week they hosted Grand Rounds and like my post about a medical mystery...Betadine, Dr. Roozrokh? and kindly included it in a very provocative round-up of entries. Now that HBO's The Wire has ended, do you have an excuse not to read it? And thanks, too, for the P.D. James reference. Any friend of Graham Greene's is a friend of mine...

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CDC Warnings & Updates: March 3-10, 2008

The Centers for Disease Control and Prevention (CDC) sends weekly updates to clinicians about public health issues. This past week has been particularly active, warranting public awareness.

Food Safety:

• Gourmet Boutique of N.Y. is voluntarily recalling almost 7000 lbs. of meat and poultry products that may be contaminated with Listeria monocytogenes. The products were released February 26 & 27, 2008 bearing the production code "GBD 08058" on the package. The products shipped to retail vendors in:
• Connecticut, Massachusetts
  
• Florida, South Carolina, Georgia
  
• New Jersey,New York, Pennsylvania
  
• Wisconsin, Minnesota
• Costco Wholesale (Issaquah, WA) is voluntarily recalling over 10,000 lbs. of frozen chicken entrees (4-pack 12 oz. packages of Discover Cuisine Red Curry Chicken and Jasmine Rice) that may be contaminated with Listeria monocytogenes. The food products were produced on October 18, 2007, bearing the item number "2880" on the UPC sticker and were shipped to retail vendors in:
• Alaska
• Idaho, Montana, Oregon, Washington State

Vaccinations
A shortage of Hib vaccine has been reported and clinicians are being asked to not give the vaccine booster to healthy children 12-15 months of age, while continuing regular vaccination schedule for children under 12 months of age and for high-risk children (HIV, asplenia, sickle cell disease, immune system syndromes or Alaskan and Native American children). Keep track of children who miss the vaccination and vaccinate them when the supply of the Hib vaccine improves.

Ricin
The Ricin incident in Las Vegas on 2/29/08 has prompted renewed concern about the substance and how to handle it. The CDC has a comprehensive website dedicated to Ricin. Most relevant for clinicians is an 88 page manual, Response to a Ricin Incident: Guidelines for Federal, State and Local Public Health and Medical Officials.

Seasonal Flu
The good news is that influenza activity is decreasing in the US. The bad news is that deaths attributed to pneumonia and influenza continues to be above the epidemic threshold for the eighth consecutive week.

• Tamiflu: Roche and the FDA have informed of neuropsychiatric events associated with the use of Tamiflu in patients with influenza. These events were noted primarily in pediatric patients and had an abrupt onset with rapid resolution. Monitor flu patients receiving Tamiflu carefully for signs of abnormal behavior. There have been some reports of delirium and death, but the relationship to Tamiflu is unclear.

Avian Flu
Egypt reported a new case of an 11 year old with H5N1 virus infection. In 2008, 3 cases have been confirmed in Egypt resulting in 1 death. Indonesia has reported 12 cases in 2008 with 10 deaths, and Vietnam has had 4 reported cases, with 4 deaths.

Travelers' Health

• Paraguay: Yellow fever vaccination is now recommended for all travelers older than 9 months who travel to Paraguay, due to a resurgence identified yellow fever outbreak. A total of 22 cases resulting in 6 deaths have been confirmed by the Paraguay Ministry of Health.
  
• Brazil: the Brazilian Ministry of Health has issued a yellow fever disease alert due to 35 confirmed cases resulting in 19 deaths. Most of Brazil is considered an area of risk and a vaccination is recommended. See the CDC website for further guidance.
• Argentina: has reported the first human case of yellow fever. One of 17 monkeys found to be infected with the virus. Argentinian health officials are increasing yellow fever vaccination in humans living in the area.
  
• The CDC reminds all travelers to these areas to use mosquito repellent with DEET and to wear long sleeved shirts and pants when out of doors.
  

Labels: CDC, flu, travelers health, vaccines

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Public Health Crisis Due to Negligence at Endoscopy Center

The Centers for Disease Control and Prevention (CDC) reports that a campaign to notify 40,000 patients of the Endoscopy Center of Southern Nevada in Las Vegas that they may have been exposed to Hepatitis B, C and HIV is the largest ever in US history. Nurse anesthetists reused syringes when administering anesthesia to patients, contaminating the vials containing the medications used in procedures. The vials are intended for single use. The standard of care for decades has been to use a new syringe for each patient. So far, five of the nurses have voluntarily surrendered their licenses, being cited with dangerous and irresponsible practices. Health officials claim that reuse of syringes and vials was common practice and that endoscopic equipment was not cleaned properly between procedures. The turn around time between patients has been reported to be as low as 15 minutes - not nearly enough time to clean instruments to code.

Six people have been diagnosed with acute Hepatitis C and hospitalized. Hepatitis C is a potentially fatal blood-borne virus that can result in liver failure and cancer. The incubation period for Hepatitis C is 6-8 weeks but for HIV it can be years. Exposed patients are being advised to practice safe sex and use condoms. Health care workers are reporting that in addition to testing, people need counseling because they are understandably upset and afraid.

HOW TO CONTACT THE HEALTH DISTRICT
If you or someone you know has received medical services at the Endoscopy Center of Southern Nevada between March 2004 and Jan. 11, 2008, call the Southern Nevada Health District's hot line at 702-759-4636 or visit southernnevada healthdistrict.org.

Dr. Dipak Desai, 65% owner in the center, allegedly ordered them to reuse the vials on multiple patients to cut costs. Dr. Desai is also part owner of Spanish Hills Surgical Center in southwest Las Vegas and Gastroenterology Center of Nevada, which has multiple locations. The clinics remain open and the public is calling for the clinics to foot the bill for the testing. The Nevada State Board of Medical Examiners is investigating the doctors involved in the case. Las Vegas police and county prosecutors opened criminal investigations into the case. It is a broad based investigation, looking into every possibility of criminal negligence and wrong-doing. The attorney general's office and the Medicaid office are reviewing the case for insurance fraud.

As of March 5, 2008 multiple clinic offices were closed, citing a public health emergency and what Senator Townsend called "...the largest breach of public trust in the history of the state..."
This follows on the heels of an FBI probe into insurance fraud in Southern California doctor owned surgery centers. Blue Cross and Blue Shield assisted in the investigation - a case in which thousands of patients from 47 states were sent to California for unnecessary surgeries and diagnostic procedures, resulting in more the $1 billion in fraudulent claims. 21 doctors and 9 clinics are involved. Recruiters located patients in places like Boston, determined that they had insurance coverage, and arranged transportation to California for them to have colonoscopies and other procedures. Millennium Outpatient Surgery Center is named in the criminal case filed by the US attorney in Los Angeles.

Thank you tikker for use of photo Colonoscopy.

Labels: Hepatitis C outbreak, Las Vegas endoscopy clinic, unsafe practice

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Music and the Brain

Researchers at Helsinki Brain Research Centre have reported cognitive recovery in stroke victims who listen to music during rehabilitation. Stroke patients who listened to music a couple of hours a day were happier, more focused and had improved verbal memory compared to those who did not listen to music.

Scientists at National Institute on Deafness and Other Communication Disorders (NIDCD) found that improvisation and creativity in music is in full swing when the part of the brain that monitors the self - the dorsolateral prefrontal cortex - shuts down and the medial prefrontal cortex becomes extremely active. The scientists speculate that the kind of beauty created by jazz musicians like Coltrane and Miles Davis results when the inhibitory, self-monitoring frontal brain activities are suppressed, allowing creativity to flow. Increased neural activity is seen in sensorimotor processing as well as the systems which regulate emotions, so creativity is not generated from one specific area of the brain.

The brains of musicians are different from nonmusicians - they have more grey matter in the auditory cortex of the right hemisphere. Musician and neuroscientist Daniel J. Levitin says that music activates every region of the brain and effects almost every body function. Music is a universal source of pleasure to humans and we use it to modulate our moods. Teens use music as a distraction from their troubles and as a means to bond with their tribe. Whether we are conscious of it or not, we have all become more or less addicted to altering our brain chemistry through the use of music.

Thank you notorious d.a.v. for use of image Music Tames even the Wildest of Beasts.

Labels: brain, music, music therapy

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Google's PHR: HIPAA? What HIPAA?

Google has entered the PHR business. This we all know. Some thousands of Cleveland Clinic patients have volunteered to allow Google to store their personal health records (PHR) on-line. Access to the records will be through use of the same ID and password the patients use to get their Google email or calendar. Privacy concerns at the HIMMS conference were dismissed - Google is not a provider of health care services therefore they are not required to be HIPAA compliant.

Healthcare Insurance Portability and Acountability Act (HIPAA) is a civil rights law enacted by Congress in 1996. The Privacy Rule went into effect in 2003, giving patients the right to control who has access to their health and medical information. All health care providers and insurers are bound by law to protect your privacy. Should anyone violate your privacy, they face stiff penalties.

Guess what? Patients lie to their doctors. Doctors lie about their patients. Why? Because by now most patients know that if they don't want to get dinged on their health insurance, they shouldn't talk about the depression they suffered twenty years ago. Some will ask their doctors to keep information that they were former cocaine users out of their medical records. Some will seek care for certain conditions out of pocket so it is not reported to their insurer.

What's the answer? Universal healthcare, where nobody gets dropped and nobody gets dinged. And EMR's managed by health care professionals which are not accessible by anyone except the patient, provider and payor. The electronic medical record (EMR) is an objective, accurate health history. A patient may write in his PHR that he suffers from migraines because he has a bad headache. The EMR may state the patient suffers from severe headaches. Only a doctor can diagnose migraines. Not every bad headache is a migraine - so a PHR is bound to have some subjective inaccuracies in it.

Why the need for privacy? Prospective employers, jilted lovers, your mother-in-law, your children, your parents, coworkers, neighbors all may have an unhealthy curiosity about you. The last thing they need to be reading is your health history. Then there is the identity theft crisis... Predatory people preying on the vulnerable. Umm, sorry Mr. Schmidt, but these are real problems we little people face everyday...

Thanks striatic for use of portrait Privacy is Dead.

Labels: EMR, PHR, universal health care

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