Convulsions / Seizures / Fits

A seizure or a convulsion is a result of abnormal electrical activity in the brain. It can affect an individual at any age. However, not all convulsions amount to epilepsy. The term ‘epilepsy’ is used when the person suffers from 2 or more apparently unprovoked seizures at an interval of at least 24 hours.

Repeated seizures can cause brain damage; hence it is necessary to diagnose the cause and treat it. In some cases, where the cause of seizures is not known, it is necessary to prevent seizures from recurring by taking daily medications.

Seizures may be focal (partial) or generalized. In partial seizures, jerking is observed in a limb or a part of the body. Such seizures are seen when a part of the brain is affected. On the other hand, generalized seizures affect the whole body. Generalized seizures occur when both sides of the brain are affected. The patient often loses consciousness.

Types of generalized seizures are:

 Tonic / Clonic Convulsions: The patient may experience a premonition just before the seizure. This is followed by the stiffening of limbs in the tonic phase. The tonic phase is followed by the clonic phase in which the person starts shaking and jerking. The patient may bite his /her tongue. This stage is followed by deep sleep. Loss of bladder and bowel control may be seen during the seizure.

 Absence Seizures: Absence seizures more commonly affect children. The child may show a temporary blackout that lasts for a short duration. 

 Atonic Seizures: During an atonic seizure, the tone of the muscles is lost and the person goes floppy and may fall down. 

 Myoclonic Seizures: In myoclonic seizures, the legs, arms, head or whole body will jerk up, often after the patient has just woken up. 

Types of partial seizures are: 

 Simple Partial Seizures: Simple partial seizures are when one part of the body like the face, arms or legs are affected but consciousness is not lost.

 Complex Partial Seizures: Complex partial seizures are localized seizures with impairment of consciousness.

Status Epilepticus: Status epilepticus is a condition where a patient suffers from repeated partial or generalized seizures without regaining consciousness between the seizures.

Tests used to diagnose the presence of epilepsy or the causes of seizures are:

 EEG Monitoring: An EEG (Electroencephalography) is a test used to record the electrical activity of the brain. It should ideally be performed within the first 24 hours of a patient suffering from a seizure. It may be abnormal in an epileptic patient, even while the patient is not suffering from the seizure.

 Brain Scans: Brain scans like CT and MRI can detect structural abnormalities of the brain like tumors and cysts. PET scan is used to monitor the brain’s activity. SPECT scan is sometimes used to localize the seizure focus in the brain.

 Blood Tests: Blood tests help to detect metabolic or genetic disease. They also help to detect conditions like infections, lead poisoning, anemia, and diabetes that may cause the seizure.

Causes 

In many cases, the cause of seizures cannot be detected despite all tests. In some other cases like genetic, the cause can be detected but cannot be completely eliminated. These patients are controlled using antiseizure drugs. In some other cases like brain tumor and low blood sugar levels, the seizures may stop after the cause is treated, provided there has been no damage to the brain. Some of the causes of seizures are listed below:

 Genetic Causes: Mutations in the genes may make a person more susceptible to seizures. Conditions like Lafora disease and myoclonus epilepsy are caused due to genetic abnormalities. More than themselves causing seizures, these genetic abnormalities may make a person more prone to seizures in the presence of another provoking factor like a head injury. Epilepsy of genetic origin sometimes runs in families, but this depends on a variety of factors including the type of epilepsy.

 Head Injury: Head injury may result in a single seizure or an epileptic syndrome within 2 years following the injury. In some cases, it can cause a bleed within the skull, resulting in seizures. A history of head injury can be elicited in these patients. Head injuries may occur during birth resulting in seizures that usually manifest in infancy or early childhood.

 Metabolic Disorders: Metabolic disorders can cause seizures in individuals of any age. Many of these seizures can be controlled by treating the metabolic disorder. For example, low or high blood sugar levels in diabeticscan cause seizures. Kidney failure can cause increased urea levels and electrolyte abnormalities, which can precipitate seizures. Phenylketonuria is an inherited condition where there is lack of an enzyme called phenylalanine hydroxylase. This results in accumulation of a substance called phenylalanine in the blood, which could result in seizures. Symptoms in patients with classical phenylketonuria usually manifest when the child is a few months old. Besides seizures, the child may develop behavioral problems and psychiatric disorders. The excess phenylketonuria may cause a musty or mouse-like odor. The skin and hair may be lighter and the children may also suffer from eczema.

 Drugs, Alcohol and Poisons: Sudden withdrawal from alcohol and drugs acting on the brain could precipitate generalized seizures. Seizures may follow lead or carbon monoxide poisoning, exposure to street drugs and medications like antidepressants.

 Brain Tumors: Tumors affecting the brain can result in seizures. Middle aged and older patients suffering from seizures should be particularly investigated using imaging studies like CT scan and MRI to rule out brain tumors. The seizures are usually focal in nature and symptoms depend on the location of the tumor.

 Brain Infections: Brain infections can cause seizures. These infections may be due to bacteria like meningitis or brain abscess or virus like herpes encephalitis. A lumbar puncture is useful in diagnosing these infections. Patients with AIDS may suffer from seizures due to toxoplasmosis, cyptococcal meningitis, viral encephalitis or other infections. Neurocysticercosis is a parasitic infection that results in the formation of cysts in the brain. This condition affects pork eaters. The cyst can be diagnosed using imaging studies.

 Conditions Affecting Blood Supply to the Brain: Vascular disorders are the most common cause of seizures in individuals over the age of 60 years. Strokes and heart attacks reduce oxygen supply to the brain and can result in seizures. Bleeding within the skull can also reduce the blood supply and can occur at any age from infancy to adulthood.

 Congenital Abnormalities: Epilepsies due to congenital malformations in the brain usually manifest during infancy or childhood.

 Brain Degenerative Diseases: Brain degenerative diseases like Alzheimer’s disease can result in seizures in older individuals. Features of the underlying degenerative disease are usually obvious in these patients.

 Febrile Seizures: Febrile seizures are triggered by a fever and most commonly occur in children.. Most children with a febrile seizure usually do not suffer from a repeat seizure, unless they have some predisposing factors.

 Eclampsia: Eclampsia is a life-threatening condition that occurs in some pregnant women. The patient suffers from very high blood pressure and seizures during pregnancy. It usually does not result in additional seizures once the pregnancy is over.

 Psychogenic Seizures: Psychogenic non-epileptic seizures are seizures that are not associated with abnormal electrical activity of the brain. The condition may be precipitated by a need for attention, avoidance of stressful situations, or specific psychiatric conditions. This condition is treated by a psychiatrist.

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Nelson Mandela in Good Spirits, Says Presidency

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Nelson Mandela in Good Spirits, Says Presidency Mar 30th 2013, 06:22 "Mandela enjoyed a full breakfast this morning, and the doctor reported that he is making steady progress," Xinhua quoted a statement from the presidency as stating and adding that he "remains under the treatment and observation". The 94-year-old was admitted to hospital just before Wednesday midnight due to recurrence of his lung infection. Mandela has a history of lung problems after suffering from tuberculosis towards the end of his 27-year term for national liberation movement. He became the first democratically-elected president of South Africa in 1994 following the end of apartheid. Early this month, Mandela was admitted to a Pretoria hospital for a scheduled check-up after the long standing abdominal complaint. He was discharged the following day. Source-IANS

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Surgical Menopause may Up Risk of Stroke, Alzheimer's Disease

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Surgical Menopause may Up Risk of Stroke, Alzheimer's Disease Mar 30th 2013, 06:22 "This is what the clinical studies indicate and our animal studies looking at the underlying mechanisms back this up," said Brann, corresponding author of the study in the journal Brain. "We wanted to find out why that is occurring. We suspect it's due to the premature loss of estrogen." In an effort to mimic what occurs in women, Brann and his colleagues looked at rats 10 weeks after removal of their estrogen-producing ovaries that were either immediately started on low-dose estrogen therapy, started therapy 10 weeks later or never given estrogen. When the researchers caused a stroke-like event in the brain's hippocampus, a center of learning and memory, they found the rodents treated late or not at all experienced more brain damage, specifically to a region of the hippocampus called CA3 that is normally stroke-resistant. To make matters worse, untreated or late-treated rats also began an abnormal, robust production of Alzheimer's disease-related proteins in the CA3 region, even becoming hypersensitive to one of the most toxic of the beta amyloid proteins that are a hallmark of Alzheimer's. Both problems appear associated with the increased production of free radicals in the brain. In fact, when the researchers blocked the excessive production, heightened stroke sensitivity and brain cell death in the CA3 region were reduced. Interestingly the brain's increased sensitivity to stressors such as inadequate oxygen was gender specific, Brann said. Removing testes in male rats, didn't affect stroke size or damage. Although exactly how it works is unknown, estrogen appears to help protect younger females from problems such as stroke and heart attack. Their risks of the maladies increase after menopause to about the same as males. Follow up studies are needed to see if estrogen therapy also reduces sensitivity to the beta amyloid protein in the CA3 region, as they expect, Brann noted. Brann earlier showed that prolonged estrogen deprivation in aging rats dramatically reduces the number of brain receptors for the hormone as well as its ability to prevent strokes. Damage was forestalled if estrogen replacement was started shortly after hormone levels drop, according to the 2011 study in the journal Proceedings of the National Academy of Sciences. The surprising results of the much-publicized Women's Health Initiative - a 12-year study of 161,808 women ages 50-79 - found hormone therapy generally increased rather than decreased stroke risk as well as other health problems. Critics said one problem with the study was that many of the women, like Brann's aged rats, had gone years without hormone replacement, bolstering the case that timing is everything. Source-Eurekalert

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Pakistani Politicians to Increase Their Budget on Health and Education

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Pakistani Politicians to Increase Their Budget on Health and Education Mar 30th 2013, 06:22 The 2013 report ranked Pakistan 146 out of 187 countries on a human development index, equal to Bangladesh and just ahead of Angola and Myanmar. "Pakistan has one of the lowest investments in terms of education and health -- it spends 0.8 percent of its GDP on health and 1.8 percent on education," the United Nations said in a statement. It said 49 percent of the population live in poverty. Senator Razina Alam of the opposition Pakistan Muslim League-N (PML-N), considered the frontrunner in May elections which will mark the country's first democratic transition, pledged to transform the education system. "We will increase resources for education and at least four percent of GDP would be allocated by the year 2018," she said. "In the health sector we will make a threefold increase in the budget by 2018," she added. Shafqat Mehmood, information secretary for ex-cricketer Imran Khan's Pakistan Tehreek-e-Insaf, said his party would triple spending on education and raise spending on health five times. "The challenge of governance is a serious challenge in Pakistan as there is a lack of attention towards responding to peoples' problems," said Mehmood. The party is contesting elections for the first time, seeking to oust the feudal and industrial elites grouped in the PML-N and the outgoing Pakistan People's Party (PPP), which have dominated governments for decades. "If voted into power, we will increase both the health and education budget which will be five percent of GDP for each sector," said Farooq Sattar, a senior member of the Muttahida Qaumi Movement (MQM), which rules Karachi. Sattar told AFP his party would tax feudal chiefs, curb corruption and improve public-sector departments to raise money for social development. The PPP did not attend the launch of the report with other politicians, diplomats and aid workers. Organisers said its representative cancelled at the last minute. According to its manifesto, the PPP increased the education budget by 196 percent to $78 million for 2012-13. "In our next term we will propose an increase in state spending on health to five percent of consolidated government spending by the end of our next term," it said. The powerful military is Pakistan's wealthiest institution. Last June's $31 billion federal budget increased defence spending by 6.8 percent.

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Another 250 Hotels in Rio by 2016

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Another 250 Hotels in Rio by 2016 Mar 30th 2013, 06:22 By 2016, Rio is expected to have an additional 250 hotels totalling upto 20,000 rooms, when it hosts the summer Olympics. "For the 2016 Olympics, we need an extra 12,000 rooms in Rio," ABIH-RJ President Alfredo Lopes told a press conference. Thanks to tax incentives provided by City Hall, the sector "has invested $1.5 billion in construction of new hotels," he noted. "We'll jump from 30,000 rooms today to 50,000 in 2016." For next year's football World Cup, he said occupation of all hotels was already 74 percent guaranteed. Lopes said the industry has set up a watchdog group to prevent price gouging and to ensure that prices are in line with services offered. But he rejected any government role in fixing prices. He said the role of government was to promote Rio, the gateway for Brazilian tourism, by ensuring greater security, notably with police control of major slums once under the sway of narcotraffickers. Source-AFP

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Road Accident Victims Now Benefit Cashless Treatment

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Road Accident Victims Now Benefit Cashless Treatment Mar 30th 2013, 05:22 According to the plan, the ministry has signed an MoU with the insurance company to launch a pilot project for cashless treatment of road accident victims on the Gurgaon-Jaipur stretch of National Highway (NH) 8. "The idea is that no one may be deprived of immediate treatment for want of money for paying hospital bills. The panel of hospitals will include government and private hospitals," said the statement. While the ministry has created a corpus of Rs.20 crore for providing cashless treatment to road accident victims for the first 48 hours subject to a ceiling of Rs.30,000, ICICI Lombard will spend Rs.30 lakh as part of Corporate Social Responsibility. The pilot project is being launched to gain data and experience for rolling out a pan-India scheme aimed at providing immediate medical attention to accident victims, said officials. About 1.4 lakh people die in road accidents every year in India. The ministry will enroll a large number of volunteers on the identified stretch of NH-8, who will be trained to act as "first responders". The governments of Haryana and Rajasthan will be closely associated with the project.

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EEG Identifies Seizures in Hospital Patients

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EEG Identifies Seizures in Hospital Patients Mar 30th 2013, 05:22 The research, which focused on patients who had been given an EEG after being admitted to the hospital for symptoms such as AMS and spells, appears on March 27 in Mayo Clinic Proceedings. "We have demonstrated a surprisingly high frequency of seizures - more than 7 percent - in a general inpatient population," said senior investigator John Betjemann, MD, a UCSF assistant professor of neurology. "This tells us that EEG is an underutilized diagnostic tool, and that seizures may be an underappreciated cause of spells and AMS." The results are important, he said, because EEG can identify treatable causes of AMS or spells, and because "it can prompt the physician to look for an underlying reason for seizures in persons who did previously have them." Seizures are treatable with a number of FDA-approved anticonvulsants, he said, "so patients who are quickly diagnosed can be treated more rapidly and effectively. This may translate to shorter lengths of stay and improved patient outcomes." In one of the first studies of its kind, Betjemann and his team analyzed the medical records of 1,048 adults who were admitted to a regular inpatient unit of a tertiary care hospital and who underwent an EEG. They found that 7.4 percent of the patients had a seizure of some kind while being monitored. "As I tell my patients, seizures come in all different flavors, from a dramatic convulsion to a subtle twitching of the face or hand or finger," said Betjemann. "There might be no outward manifestation at all, other than that the person seems a little spacey. It's easily missed by family members and physicians alike, but can be picked up by EEG." Another 13.4 percent of patients had epileptiform discharges, which are abnormal patterns that indicate patients are at an increased risk of seizures. Almost 65 percent of patients had their first seizure within one hour of EEG recording, and 89 percent within six hours. "This is good news for smaller hospitals that don't have 24 hour EEG coverage, but that do have a technician on duty during the day," Betjemann said. He speculated that lack of 24-hour coverage is a major reason that EEG is not used as an inpatient diagnostic tool as often as it might be. "This paper shows that, fortunately, it's not necessary. Almost two thirds of patients with seizures can be identified in the first hour, and almost 90 percent in the course of a shift." EEGs are easy to obtain, painless and noninvasive, said Betjemann. "The technician applies some paste and electrodes and hooks up the machine. All the patient has to do is rest in bed." Betjemann said that the next logical research step would be a prospective study. "We have to start at the beginning, see if patients are altered when they are admitted, and do an EEG in a formal standardized setting. Then we'd want to see how often EEG is changing the management of patients - either starting or stopping medications," he said. "A patient may be having spells, and an EEG might tell you this is not a seizure, and that it's important not to treat it with anti-epileptic medications." Source-Eurekalert

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Monounsaturated Fats Cut Risk of Metabolic Syndrome

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Monounsaturated Fats Cut Risk of Metabolic Syndrome Mar 30th 2013, 05:22 "The monounsaturated fats in these vegetable oils appear to reduce abdominal fat, which in turn may decrease metabolic syndrome risk factors," said Penny Kris-Etherton, Distinguished Professor of Nutrition, Penn State. In the randomized, controlled trial, 121 participants at risk for metabolic syndrome received a daily smoothie containing 40 grams (1.42 ounces) of one of five oils as part of a weight maintenance, heart-healthy, 2000-calorie per day diet. Members of the group had five risk factors characterized by increased belly fat, low "good" hdl cholesterol and above average blood sugar, blood pressure and triglycerides that increase the risk of heart disease, stroke and type 2 diabetes. The researchers repeated this process for the remaining four oils. The results were presented at the American Heart Association's EPI/NPAM 2013 Scientific Sessions in New Orleans. Results showed that those who consumed canola or high-oleic canola oils on a daily basis for four weeks lowered their belly fat by 1.6 percent compared to those who consumed a flax/safflower oil blend. Abdominal fat was unchanged by the other two oils, which included a corn/safflower oil blend and high-oleic canola oil enriched with an algal source of the omega-3 DHA. Both the flax/safflower and corn/safflower oil blends were low in monounsaturated fat. According to the American Heart Association, many of the factors that contribute to metabolic syndrome can be addressed by a healthy diet, exercise and weight loss, which can significantly reduce health risks of this condition."It is evident that further studies are needed to determine the mechanisms that account for belly fat loss on a diet high in monounsaturated fatty acids," said Kris-Etherton. "Our study indicates that simple dietary changes, such as using vegetable oils high in monounsaturated fatty acids, may reduce the risk of metabolic syndrome and therefore heart disease, stroke and type 2 diabetes." Source-Eurekalert

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South Africa to Follow India, China to Make Life-Saving Medications Affordable

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South Africa to Follow India, China to Make Life-Saving Medications Affordable Mar 30th 2013, 05:22 Speaking in Johannesburg, MSF South Africa media liaison officer Kate Ribet said other BRICS countries have fulfilled the commitments they made in July 2011 to enact public health safeguards spelled out in World Trade Organization (WTO) agreements. "Decisive moves by Brazil, India and China have saved hundreds of millions of taxpayer dollars and dramatically increased access to medicine by bringing down prices," Xinhua quoted Ribet as saying. "South Africa lags far behind because it still grants and protects patent monopolies of pharmaceutical companies, at the expense of South Africans' health," she added. MSF said South Africa's patent system currently allows for patent protection of pharmaceuticals additional to WTO 20-year requirements, and does not take advantage of flexibilities for protecting health, like overriding patents with a compulsory license (CL) when drugs are priced out of reach for those in need. In India, a CL on cancer drug sorafenib was upheld earlier this month, making generic sorafenib available in India for $1 per 200 mg tablet, 97 percent less than the brand name product. "In South Africa, where no generic versions of this medicine are available, patients must pay 203.50 rands (about $2.2) for the same tablet," Ribet said. MSF said when Brazil issued a CL on the widely-used antiretroviral efavirenz in 2007, the switch to a generic saved the Brazilian government an estimated $103.5 million in treating HIV/AIDS from 2007-2011. According to the group, Pretoria has never issued a CL, despite being a major purchaser of antiretroviral drugs and TB treatment. This is partly due to outdated laws. By protecting poor-quality patent monopolies of pharmaceutical companies, South Africa cannot obtain more affordable generic medications available from BRICS countries like India, nor develop substantial local pharmaceutical production capacity. MSF and the Treatment Action Campaign (TAC) are jointly campaigning for the amendment of South Africa's patent laws, to put the country on par with its BRICS peers in protecting public health.

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Plant Based Foods Contain DNA Damaging Toxins

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Plant Based Foods Contain DNA Damaging Toxins Mar 30th 2013, 05:22 The p53 gene becomes activated when DNA is damaged. Its gene product makes repair proteins that mend DNA. The higher the level of DNA damage, the more p53 becomes activated. "We don't know much about the foods we eat and how they affect cells in our bodies," says Scott Kern, M.D., the Kovler Professor of Oncology and Pathology at the Johns Hopkins University School of Medicine. "But it's clear that plants contain many compounds that are meant to deter humans and animals from eating them, like cellulose in stems and bitter-tasting tannins in leaves and beans we use to make teas and coffees, and their impact needs to be assessed."Kern cautioned that his studies do not suggest people should stop using tea, coffee or flavorings, but do suggest the need for further research. The Johns Hopkins study began a year ago when graduate student Samuel Gilbert, working in Kern's laboratory, noted that a test Kern had developed to detect p53 activity had never been used to identify DNA-damaging substances in food. For the study, published online February 8 in Food and Chemical Toxicology, Kern and his team sought advice from scientists at the U.S. Department of Agriculture about food products and flavorings. "To do this study well, we had to think like food chemists to extract chemicals from food and dilute food products to levels that occur in a normal diet," he says. Using Kern's test for p53 activity, which makes a fluorescent compound that "glows" when p53 is activated, the scientists mixed dilutions of the food products and flavorings with human cells and grew them in laboratory dishes for 18 hours. Measuring and comparing p53 activity with baseline levels, the scientists found that liquid smoke flavoring, black and green teas and coffee showed up to nearly 30-fold increases in p53 activity, which was on par with their tests of p53 activity caused by a chemotherapy drug called etoposide. Previous studies have shown that liquid smoke flavoring damages DNA in animal models, so Kern's team analyzed p53 activity triggered by the chemicals found in liquid smoke. Postdoctoral fellow Zulfiquer Hossain tracked down the chemicals responsible for the p53 activity. The strongest p53 activity was found in two chemicals: pyrogallol and gallic acid. Pyrogallol, commonly found in smoked foods, is also found in cigarette smoke, hair dye, tea, coffee, bread crust, roasted malt and cocoa powder, according to Kern. Gallic acid, a variant of pyrogallol, is found in teas and coffees. Kern says that more studies are needed to examine the type of DNA damage caused by pyrogallol and gallic acid, but there could be ways to remove the two chemicals from foods and flavorings. "We found that Scotch whiskey, which has a smoky flavor and could be a substitute for liquid smoke, had minimal effect on p53 activity in our tests," says Kern. Liquid smoke, produced from the distilled condensation of natural smoke, is often used to add smoky flavor to sausages, other meats and vegan meat substitutes. It gained popularity when sausage manufacturers switched from natural casings to smoke-blocking artificial casings. Other flavorings like fish and oyster sauces, tabasco and soy sauces, and black bean sauces showed minimal p53 effects in Kern's tests, as did soybean paste, kim chee, wasabi powder, hickory smoke powders and smoked paprika.

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New Insights into Alcohol Addiction

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New Insights into Alcohol Addiction Mar 30th 2013, 05:22 Jeff Weiner, who directs the Translational Studies on Early-Life Stress and Vulnerability to Alcohol Addiction project at Wake Forest Baptist, and colleagues used an animal model to look at the early stages of the addiction process and focused on how individual animals responded towards alcohol. Weiner said that their findings may lead not only to a better understanding of addiction, but to the development of better drugs to treat it as well. Weiner said that the study protocol was developed by the first author of the paper, Karina Abrahao, a graduate student visiting from the collaborative lab of Sougza-Formigoni, Ph.D, of the Department of Psychobiology at the Federal University of Sao Paulo, Brazil. "In high doses, alcohol is a depressant, but in low doses, it can have a mellowing effect that results in greater activity," Weiner said. "Those low dose effects tend to increase over time and this increase in activity in response to repeated alcohol exposure is called locomotor sensitization. "We found large variations in the development of locomotor sensitization to alcohol in these mice, with some showing robust sensitization and others showing no more of a change in locomotor activity than control mice given daily saline injections," he asserted. "Surprisingly, when all of the alcohol-exposed mice were given an opportunity to voluntarily drink alcohol, those that had developed sensitization drank more than those that did not. In fact, the alcohol-treated mice that failed to develop sensitization drank no more alcohol than the saline-treated control group," he added. The findings have been published in the Journal of Neuroscience. Source-ANI

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Practice Redesign Isn’t Going To Erase The Primary Care Shortage

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Practice Redesign Isn't Going To Erase The Primary Care Shortage Mar 29th 2013, 22:35 By Jeff Goldsmith Most experts agree that primary care needs to be re-invented.  There are a lot of promising ingredients of practice redesign:  better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing.  Linda Green's intriguing article in the January Health Affairs simulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage. Even if we make much more effective use of clinical time and energy, however, Green's formula isn't going to get us far enough fast enough.  The baby boom generation of physicians is fast nearing its "sell by" date.  In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older.  One in six general internists left their practices in mid-career.  Many more hardworking clinicians delayed retirement due to the 2008 financial collapse. Few manpower specialists have noted the cohort effect likely to manifest itself shortly.  A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years.  We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks.  During this same period, we'll be adding 1.5-1.7 million net new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform.  "Train wreck" is the right descriptor of the emerging primary care supply situation. Green suggests that this demand pressure could be accommodated with a much smaller replacement cohort of primary care docs if we:  increased each physician's patient visits slots to 28 per day; enabled more same-day scheduling; had physicians practice in pods of 3-8 docs where any doc in the pod could see one anyone else's patients; leveraged patient portals to substitute electronic visits for in-person ones; and plugged in physician "extenders."  Implementing all these innovations across the entire health system has the effect of doubling physicians' patient panels to more than 5,000 and, voila, no physician shortage. Real-World Problems With The Model Green Lays Out Several of these redesign elements aren't going to be well received either by physicians or their patients.  I've visited real-world group practices organized this way.  They reminded me of nothing so much as "I Love Lucy's" famous chocolate factory assembly line.  It was exhausting simply watching the physicians sprint through their days. You wanted to install oxygen carrels for them to catch their breath.  Gen Y docs aren't going to practice 28-slot days, with intensive "break times" to answer their emails and make phone calls.  Neither are Gen Y nurse practitioners. And without the sustaining influence of genuine relationships with their patients, the new generation of primary care physicians are likely to burn out even faster than their boomer elders did.  Moreover, aging patients will need relationships with physicians who understand the context for their chronic disease risks and can motivate them to manage those risks.  Even though they will like on-demand scheduling and e-visits, baby boomer patients, in particular, aren't going to embrace a "bullpen" approach to their primary care coverage.  Twenty-eight-slot physician work days staffed by physician pods is an inferior primary care product. In Group Health's Factoria medical home practices, panel sizes went the other way, shrinking to 1,800 rather than growing to 5,400.  Visit times were doubled, to about 30 minutes, not halved.  Previous Group Health primary care practice redesigns improved physician productivity, but at a terrible price:  increased turnover and markedly reduced professional satisfaction. The Factoria redesign leveraged Group Health's successful patient portal, physician extenders, and better scheduling and resulted in improved clinician morale and patient satisfaction.  And, most importantly for Group Health's business model, the redesign markedly reduced emergency visits and hospital costs per-member per-month.  Similarly, the widely cited ProvenCare Navigator model developed at Geisinger Clinic achieved panel sizes of about 2,500, less than half of Green's 5400 panel target. The Limitations Of Potential Strategies To Increase Productivity Better use of nurse practitioners.  Leveraging physician extenders is a key to making more "medical homes" work properly.  Here too, however, there are cohort problems.  The current nurse practitioner population is even more "boomer intensive" than the physician population is.  In 2008, 63 percent of nurse practitioners in the US were over the age of 45, and 15 percent over the age of 60. While Green suggests that nurse practitioners have been growing faster than population (e.g. faster than 0.8 percent a year), that growth won't be anywhere near enough to offset the impending retirement of the baby boom NP cadre, many of whom work a lot of unpaid overtime completing their documentation tasks.  And many of the new NP's are being snarfed up by the expansion of federally qualified health centers and by non-traditional care providers like the Minute Clinics.  There won't be many left over for redesigned primary care practices. Electronic health records.  Green's optimism about the potential productivity improvements from electronic health records might also be misplaced.  Despite, or perhaps because of, the pressure from meaningful use to automate office practices, physician offices added 162,000 workers from 2007 to 2011, even with a 10 percent shrinkage of visit volume.  Many of these new hires were medical secretaries, physician assistants, and the like. If there are productivity offsets for practicing physicians from automating medical records, they are hard to detect.  Most physicians I've talked to about their EMR conversions are spending less time with patients and more time feeding their EMRs coding information and complying with new Medicare documentation requirements.   The result:  richer coding and more dollars from fewer patients.   Unless documentation requirements are reduced, it is not clear that the EMR will actually make it easier for physicians, or other clinicians for that matter, to see more patients. A Potential Way Forward There are potential solutions in addition to the ones Green identified.  They include payment models that markedly consolidate payment transactions (bundling or partial capitation), and more targeted documentation requirements focusing more tightly on patient safety and outcomes.  We can also, per Green, reduce "unnecessary" visits by markedly improving patient communication and leveraging texting, email and social media linkages. Green does not address the market barriers to adequate primary care physician supply.  Presently, primary care physicians earn about 55 percent of the income of their procedure oriented colleagues, a number that will be barely dented by the Affordable Care Act's nominal increase in Medicare's evaluation and management payments.  Unless you're a trust funder, or someone with no medical school debt, selecting primary care as a specialty doesn't make a lot of economic sense.  Primary care docs will still be paying off loans in their sixties. To surmount this problem, we must markedly increase per-hour compensation for primary care physicians, or they will continue selecting life-style friendly subspecialties instead.  We'll all have great skin, but we'll be waiting three months to see a primary care physician. This problem isn't going to wait for Commissions, Blue Ribbon panels and learned pontification.  And it isn't going to be wished away by clever economic modeling.  Despite Green's optimism, we are going to experience a horrendous shortfall of front-line caregivers in the next decade.  Medicare beneficiaries whose physicians retire in the next ten years are going to have great difficulty replacing them.  Making more intelligent use of caregiver time is an urgent priority, but it is not going to be enough to meet the rising demand for primary care services in the next 20 years. Jeff Goldsmith is president of Health Futures Inc, which specializes in corporate strategic planning and forecasting future health care trends. He is also the author of "The Long Baby Boom: An Optimistic Vision for a Graying Generation." This post originally appeared on March 28, 2013 in the Health Affairs Blog.

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Pandora’s Pillbox

The Health Care Blog The Health Care Blog

Pandora's Pillbox Mar 29th 2013, 18:51 By J.D. KLEINKE WASHINGTON — Oral contraceptives may be small, but they are proving to be tough pills for a vast number of Americans to swallow. Last week, the Sunlight Foundation reported that the contraception provisions of President Obama’s health reform law garnered 147,000 comments from the public — more than on any other regulatory ruling, on any subject, in the history of the nation. Really. The unprecedented flood of comments came from a wide range of organizations and individuals who support or oppose mandated contraception coverage as part of Obamacare. Supporters, in general, want to extend coverage for this cornerstone of women’s health; oral contraceptives are used not just for birth control, but also for the treatment of pelvic pain, irregular periods, fibroid tumors, ovarian cysts, endometriosis, severe acne, mood disorders, and excessive menstrual bleeding that could lead to anemia. Opponents, in general, want to block this extension based on religious, moral or personal objections to women using pooled insurance resources to pay for pills that enable sex-for-fun — and that can be used, as it happens, for early termination of an unwanted pregnancy. Such are the gray areas of medicine, the mechanics of health insurance, and the culture wars at the heart of Obamacare. When President Obama set out to fix a broken health insurance system and find a pathway to coverage for all Americans, he could not help but open Pandora’s Pillbox — focusing and intensifying nearly every one of our culture wars. This has less to do with the actual details of Obamacare than with the hard realities of how the health insurance system invades, pervades, and connects us all — as almost anyone involved in prior health reform debates, or in trying to manage health care for an insured population, would attest. As evidenced by those 147,000 comments, the Obama administration is simply confronting, en masse, what everyone in myriad private health insurance administrations has been facing for decades: our health care system is the dumping ground for all of our worst, unresolved arguments as a society. It is a long, messy list, and runs from the ovary to the grave: access to reproductive technology for the infertile, access to abortion for unwanted pregnancy, childhood vaccination, domestic violence, mental illness, personal responsibility for self-destructive behavior, generational economic conflict, the value of heroic medical treatment, the denial of death. Name a subject that inflames people and drives them into warring camps of irreconcilable, passionately held beliefs, and the keepers of the U.S. health care system (and now the architects and implementers of Obamacare) get to deal with it. Extend our current health insurance system to everyone outside its walls — the essence of Obamacare — and you spark every remaining culture war: health care as an earned good versus human right, access to care by illegal immigrants, social justice and the cycle of poverty, compassion versus stigmatization of substance abuse, and pesky little issues like using the tax code for re-distribution of wealth and the role of government in our private lives. Abortion jumps out of Pandora’s pillbox first because the country has been engaged in a civil war over it — and not always just a cold civil war — for half a century. But contraception? One of the best ways to reduce abortion rates?? 147,000 comments??? By contrast and for some odd reason, there has been almost no public discussion of Obamacare’s coverage of vasectomy, the single most effective form of birth control. Which leads one to believe that this particular debate is less about abortion — or even sex-for-fun, as enabled by vasectomy — than about something else that apparently belongs on the list of unresolved cultural arguments: female sexual autonomy. Yes, it may seem odd or appalling that we are even having this discussion in the current century — until you take a quick glance at some of those 147,000 comments, posted by people nonetheless sufficiently modern to access the Internet. Perhaps I’ve been over-conditioned by decades of HBO and Showtime, but I’d assumed that sex-for-fun was like fluoride: it’s in the water, and people can’t really still be arguing about it, right? Apparently they are — and The Scarlet Letter is one of the most durable works of American literature for good reason. In the current century, we can no longer run Hester Prynne out of town — but we can try to run her out of the insurance pool. This would be the core rationale for much of the opposition to the contraception rule, and shows a perfect misunderstanding of how our health insurance system works today and will work when extended under Obamacare. The National Republican Congressional Committee sponsors a menacing-sounding website, “Living Under Obamacare,” that serves as an online bunker for potshots against health reform. A testimonial at the top of the site’s section dedicated to “Women Living Under Obamacare” is a perfect example of the public’s uninformed whining about Obamacare on its face, but is actually about health insurance in general. “I had a hysterectomy, I have no need for maternity coverage, but I have to now pay for it. I have to pay not only my own premium but I have to subsidize everybody else.” One little technical detail about this 49-year-old woman’s complaint: there is no way that whatever insurance premiums she or her employer paid in relevant accounting years covered the cost of her hysterectomy, combined with all the medical care leading up to it and the medications to follow. Her surgery was “subsidized” by tens of thousands of the same young healthy women in her insurance pool she now finds so burdensome — women who will be getting pregnant and having babies on her dime, along with all those Hester Prynnes who just wanna have fun. This is why premiums will be going up for those same women, and most likely for all younger people under Obamacare — to subsidize the greater medical costs incurred by older people. This is Insurance Economics 101. The inter-generational conflict elicited by trying to fix the broken health insurance market is corollary to the oddest cultural phenomenon of all in Pandora’s Pillbox: our exquisitely self-serving self-deception when it comes how health insurance works. It goes something like this: I’m paying for health insurance, so all my medical care should be covered, but to hell with any of your medical care I find morally objectionable. If I don’t approve of it, or just don’t feel like paying for it, then I shouldn’t have to. Sex-for-fun? For me, sure. Viagra good, but birth control pills bad — because I might not like what you do with them. Luckily, most physicians in the U.S. do know how health insurance works. And as they did with managed care, they will find ways around the final version of the contraception rule, however contorted by the Obama administration to accommodate the birth control scolds. The Administration’s work-around right now is to designate separate new accounting entities for contraception coverage — because our health insurance system needs a little more complexity and paperwork. This work-around may or may not ultimately appease opposition to this element of Obamacare by religious employers, but it will not matter in the trenches of medicine. Accounting entities deal in the black-and-whites of political accommodations and coverage rules; medicine deals in the gray areas of anxiety, need, fear, perception, deception, and what is or isn’t written down somewhere for submission as an insurance claim. Pelvic pain, irregular periods, fibroid tumors, ovarian cysts, endometriosis, severe acne, mood disorders, and excessive menstrual bleeding are real, and they all have diagnosis codes. For the past two decades. managed care has been training prescribers to shadow box with the system on behalf of what their patients really need. At the height of health care’s hyper-administrative madness in the late 1990s, more than half of physicians surveyed said they would falsify documentation to enable their patients’ access to medical care they believed they needed but insurers would not pay for. In a related study, more than a quarter of the public surveyed said they approved of such deliberate deception. Those numbers cannot have gone anywhere but up, as insurance coverage has gone down. As Obamacare extends the current health insurance system to cover the previously uninsurable, so too will physicians and patients extend their current ability to cope with administrative complexity and intrusive rules. “Birth control” pills, like so many others, may be named and used for one medical purpose, but are mobilized for a multitude of medical reasons. The FDA approves them, patients want them, doctors prescribe them, and insurers (and Obamacare) will cover them, one way or another. Even if the birth control scolds were able to prevail on contraception coverage and block Obamacare from allowing women to have access to pills for reasons that do not meet with their moral approval, it would not matter. Physicians will medicalize those patients, document other reasons for the prescriptions, and patients will get access. Once again, our doctors will serve as our last line of defense in the fight against medical tyranny — tyranny committed by the very people who, when they are not crusading against reproductive medicine in its many forms, like to accuse Obamacare of imposing its values on the rest of us. Rush Limbaugh, who probably knows a thing or two about gaming the nation’s prescribing systems, may think of women who use birth control as “sluts.” No doubt the same misogyny is driving — consciously or not — a large percentage of the 147,000 organizations and people who took time out from their busy day to comment in opposition to the contraception mandate. Most doctors, by contrast, think of them simply as women who have health insurance and either want or need oral contraceptives. As far as the rest of us should be concerned, yes, it is our money but their business – a courtesy we hope they show us when it is our turn to visit the doctor. J.D. Kleinke is a pioneering health care information entrepreneur, medical economist, author, policy expert, and business strategist.

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