Thursday, October 3, 2019

Risk Management In Health Care

Risk Management in Health Care

Otumdi Omekara, MD. MPAHA, Member of Society of Physician Entrepreneurs
Otumdi Omekara thumbnail.jpg
Risk management in the health care industry is not too different from other industries, since every industry basically manages money, men and material. Each of these three core management areas poses its own risks that ultimately affect any company's bottom line or net worth. Anything that takes away from a company's net worth is a risk that has the potential to put it out of business. Any company that fails to effectively manage its risks basically plans to fail. In the health care industry, the tendency is for only for profit health care organizations to pay serious attention to risk management. Social health care services funded by governments and not-for-profit organizations generally focus more on service delivery with little attention to risk management, counting on the funders to always provide the funds.
   
But the irony is that government funded agencies are managed by human beings who belong to the "men" category of the three main risk sources. Politicians dictate how much fund is allocated to the health care and other industries. If they are not managed well, they pose the risk of reduction in health care capital, which impacts the establishment and maintenance of health care infrastructure and professional manpower. This in turn impacts accessibility of health care services due to limited service points. Professional health care associations like the American Medical Association have learned to manage this risk by hiring the services of professional lobbyists in Washington DC to ensure that no laws are passed that are detrimental to health care funding and practice. Individual retired health care professionals have also contested for congressional and senatorial offices at state and national levels to ensure that the necessary protective health car laws are created and passed in a timely manner.
    
While the traditional emphasis in preventive medicine had been to break the vicious cycle of poverty, ignorance and disease, current preventive medicine now stretches to monetary loss prevention and material over-utilization and loss prevention. Poverty, ignorance and disease all focus mainly on patient related risks without addressing the money and material related risks. Money and material risk prevention have in the past been viewed as outside the area of responsibility of preventive medicine experts. But well informed patients earning average income are still constrained by affordability of adequate health insurance for  accessing the health care system to treat their diseases. The risk management need in this case is for an appropriate health insurance law like the current ACA passed by the Obama administration to accommodate individuals not covered by Medicare and Medicaid insurance laws. 

In general, health care management risks fall into two broad categories: revenue reducing and revenue wasting risks. The revenue reducing risks include inadequate budgetary allocation to government funded health care agencies, legally restrictive private provider insurance billing rates, inefficient revenue collection system from insurance payers and inefficient account receivable system for patient billing system. The revenue wasting risks include inefficient organizational budgeting, inefficient budgetary control system, inefficient audit system, inadequate electronic and physical financial security, inadequate organizational property security, inadequate loss prevention policies, inadequate employee injury prevention, inadequate regulatory compliance policies and inadequate law suite prevention policies. How each of these risk factors affects the net worth of a health care organization will now be further explored to create increased management sensitivity to their riskiness.  

The way politics affects budgetary allocation for health infrastructural and manpower development has already been touched on above. A US administration  or state government that does not believe in abortion will reduce allocation of funds to Planned Parenthood and prohibit insurance payment for abortion related patient care. Similarly an administration that does not believe in a large military establishment will reduce military budget, which in turn will reduce Veterans Administration's funding of physicians and nurses education. Less number of doctors ultimately reduces patient access to health serves. Thus the control of revenue reducing risks starts at the Federal government level with the employment of professional lobbyists.  
Private health institutions  have the option of accepting large volume of Medicare or Medicaid patients at a reduced fixed government rate or limited volume of direct pay and other insurance pay patients. Very few health organizations in US can function successfully without accepting Medicare and Medicaid patients. Again, to contain this revenue reducing risk, US health services managers lobby hard for more favorable Medicare and Medicaid laws.  They also lobby hard for the appointment of favorable candidates for the offices of Secretary of Health and Human Services and US Surgeon General.  

For individual health facilities, dealing with insurance payers is such a night mare with the complicated coding system. Inability to effectively submit patient bills to insurance payers can frustrate an organization out of business. Insurance payments can take weeks to months after a patient's visit. Providers can hardly count on current month's revenue to pay current month 's bills. A simple mistake or multiple payers for one patient can even further lengthen the payment time. Not being able to generate cash for payroll each month forces management to borrow money from the banks and further lose money on interest payment. The portion of patient bills not legally covered by insurance plans also needs to be aggressively collected by the accounts receivable teams. So, most health facilities now make sure to have very efficient case management and billing teams who are always on top of their games, as a way of managing these last two revenue reducing risk factors.  

Coming to the revenue wasting risks, the first is bad organizational budget, which fails to represent the ultimate working document for any organization's strategic plan. A good organizational budget should be addressing the vision, goals and action plans of the organization. A good budget makes it easy to compare financial projections with actual performance and apply necessary financial controls. When and where to apply financial control is usually determined by independent monthly or quarterly audits by the CEO or an internal auditor.  

The financial security of any organization has to do with where it stores its physical cash/checks and how it control access to its bank accounts. There should be clear policies on who should have access codes to company safe onsite and its online banking sites. At least two top level officers, like the CEO and CFO should have the ability to access the onsite safes and bank accounts. If the CEO alone signs the checks, the CFO alone should sign major purchase invoices. Both should receive alerts about every major transaction on the accounts. There should be an agreed limit to maximum daily or monthly withdrawals. The bank account pass words should be changed at least quarterly and never be saved on the bank website. A good IT unit helps to protect an organization’s website from hackers. Just one  major fraud by any company executive could easily cripple or bankrupt a health facility.  

Loss prevention in a health facility requires an in-house or contracted security service. Loss or damage of major equipment and installations prevention requires a skilled maintenance unit. The security service provides public safety, patient safety, provider safety, and prevents property theft and vandalism. Work site injury and falls are both major risk sources in any health facility. Workman compensation claims could add up to millions of dollars a year. Employee safety training and safety procedure enforcement have proved very effective in reducing workman compensation claims. Staying in compliance with the ADA laws by creating disability friendly facilities protects them against expensive law suits by fall victims. Very few health facilities can survive more than one or two major law suits.  

If a health facility survives the risks of heavy law suits, it could still be caught by the most dangerous of them all, regulatory non-compliance. In fact regulatory non-compliance in the areas of unreported patient negligence, physical abuse, financial abuse, sexual abuse, verbal abuse, rights violations, privacy violation or racial discrimination could lead to facility failure of re-certification surveys and suspension of facility operating license or outright closure of the facility. Most health facilities manage this dangerous risk by retaining the services of independent health care regulatory compliance consultants to continuously audit patient care and correct any non-compliant practices prior to re-certification surveys. 

What has been discussed so far should awaken or re-awaken a high sensitivity in health facility executives to the various risk factors plaguing the industry. Both the veteran executive and a new health facility  administrator will benefit from this discussion. Employees will, on their part probably begin to understand why their facility executives tend to be very touchy about seemingly unimportant events in their facilities. However we look at it, efficient risk management in health care remains at the core of successful management and facility survival.  

Dr. Otumdi Omekara is a preventive/business medicine specialist and medical publisher with over two decades of clinical practice experience and over a decade of provider management experience. His passion for patient education drives his medical content article writing and publishing. He was a health educator at Oregon DHS Center for Disease Control from 2001 to 2002. Since 2002 he has been the Medical Publisher at Drotumdio Health Publications (dHp). He lives in Portland Oregon and can be reached through his website at www.health-pub.com or by text at +1971-2085909.

Wednesday, October 18, 2017



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  • Treatment of Asthma Without Inhale


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                                                HEALTHCARE CONSULTANCY



Healthcare Organizational Development 


Setting up a medical practice or a long term care facility from the scratch can be very intimidating. But with the help of Droomekara.com
consultants, the whole process can be broken down into manageable
phases and stages. We first sit down with the investors or partners to
hear exactly what they have in mind regarding their proposed facility.
During strategic planning meetings, we ask about their goals and
expectations for the facility, how big or small they want to start and
where they see themselves in the next five to ten years. see all





 How the money market works


 The Future of Healthcare Real Estate Financing


Droomekara.com consultants will
help startup healthcare providers to find inexpensive or interest-free
start up capitals. For those already established, we help them manage
their money market investments or source expansion capitals.
 
We help healthcare providers to develop easily acceptable cash flow
plans that show a well thought out business proposal to funding
institutions. We also provide backup plans for addressing departures
from annual projections.

Call 971-208-5909 to speak with one our consultants.

HEALTHCARE CONSULTING


Healthcare Organizational Development 
Setting up a medical practice or a long term care facility from the scratch can be very intimidating. But with the help of Droomekara.com consultants, the whole process can be broken down into manageable phases and stages. We first sit down with the investors or partners to hear exactly what they have in mind regarding their proposed facility. During strategic planning meetings, we ask about their goals and expectations for the facility, how big or small they want to start and where they see themselves in the next five to ten years.
 
We also ask about who they perceive as their competitors and how much of the niche market to intend to dominate eventually. We find out how they intend to source their capital for the entire project, and the projected startup capital. We look into how they intend to manage the organization in terms of chain of command, we ask them about their profit sharing or investment plan as well as their tax payment plans. At the end of this brainstorming meeting, we schedule followup meetings to review the policy documents we present to them based on the strategic planning meetings.
 
We present them a mission statement or slogan, a vision, and a goal statement. Once they have edited and approved the policy document, we proceed to long-term budget production to be reviewed at our next meeting. We basically attach numbers to the goals, objectives, and action plans. Based of the projected startup capital and capital sourcing costs, we begin to sort expenses into operating, non-operating, and capital expenses. We make a projections of break-even operating revenues, and use that to determine appropriate fees for services.
 
We then go ahead to figure out how many employees can be employed to generate the break-even revenue with a little profit margin in the first three to five years. When the stakeholders accept the proposed balance sheet for the first three to five years, they then have to appoint a chief execute officer to start implementing the agreed phases and steps. We visit the chief execute and project manager on monthly basis to keep track of the actual expenses in comparison to the budget projections.

This is where we make sure that the chief executive is applying reasonable budgetary controls to minimize wastes and risks. Once the infrastructure has been developed and the organization takes off, we switch over to the provider management mode. Call us today at 971-208-5909 to schedule an onsite informational meeting.

Healthcare Capital Finance Development

Droomekara.com consultants will help startup healthcare providers to find inexpensive or interest-free start up capitals. For those already established, we help them manage their money market investments or source expansion capitals.
 
We help healthcare providers to develop easily acceptable cash flow plans that show a well thought out business proposal to funding institutions. We also provide backup plans for addressing departures from annual projections.

Call 971-208-5909 to speak with one our consultants.

Healthcare Human Resources Development and Management

 
While the management of money, men, and materials has never been easy, the toughest aspect of business management is human resources management. It is even worse so in the healthcare industry with its heavy regulatory constraints. Consultants at Droomekara.com have onsite experience in staffing healthcare facilities. We know firsthand, that it takes at least one month to properly replace a care provider even at the lowest level.
 
Even when a prospective employee is professionally qualified, the facility administrator or human resources manager, is required to do a state or nationwide background check in addition to DHS background check. To start training the new hire pending the result, of the background check, he/she has to be paired with another employee, at a time when the unit is already short-staffed. If the background check result is bad, the new hire is relieved of his/her duty on the spot, and search for replacement continues.
 
During this search period the marginally staffed facility remains out of regulatory compliance, and prays that nothing bad happens that make that a big issue. But Droomekara.com consultants will not encourage marginal staffing. We look at the facility balance sheet and advise the administrator on how many employees the budget can carry and still break even. Usually that allows for up to 25% backup staffing. The surplus employees in one unit are cross-trained to worked in related units like pediatrics and obs/gyn.
 

This makes it easy to pull in a fully qualified and trained staff at short notice to fill in for sick or injured employee. On the job injury claims rank second to legal losses in healthcare facilities. As such risk management is a huge part of human resources management. This means that employees must be properly trained in ergonomics, which is knowing how to perform their jobs without injury. Employees must also be monitored to ensure that they are not taking unnecessary risks at work.
 

They must also know to report on the job injuries to their supervisors as soon they occur. Unit managers must be quick to report on the job injuries reported to them to human resource department. HR understands how best to deal with SAIF on workman compensation issues. Dromekara.com consultants help onsite managers to properly manage this intricate area of their job.

Call us today at 971-208-5909 for a free informational meeting and onsite visit.

Healthcare IT Management

 
Managing IT in health facilities is a huge part of what we do to achieve regulatory compliance. Starting from secure telephone communication as appointments are made for provider visits to secure storage of the information gathered during the encounter and during treatment period, a lot of careful monitoring goes into making sure that the privacy of patients is not compromised.

Automatic systems are put in place to limit access to patient information to only specific providers who have professional need to know. Every possible effort is made to protect both personal and financial information of clients from being hacked through health facility websites. IT software and computers used in healthcare facilities are carefully disposed of to avoid inadvertent delivery of hard drives with vital patient information into the hands of cyber criminals.

We emphasize thorough IT training and retraining to ensure that professional staff who must use facility computers for their daily duties use them efficiently and securely.

Give us a call at 971-208-5909 to schedule an appointment for trouble shooting any IT problems plaguing your facility.

Provider Management

Dromekara.com consultatnts have decades of experience in both acute and long-term care management. We bring this experience to bear when helping ailing health facilities to turn things around for good, especially close to annual facility re-certification government surveys. We step in as interim administrators or program managers, and review the operations of the facility from vision development to program evaluation. 


We correct policy problems and performance issues and retrain employees to embrace a more efficient patient care processes. Over a two to three month period we inspect clinical and financial documentations to make sure they meet the government prescribed guidelines, drawing from our in-depth knowledge of US state and federal healthcare laws. We conduct mock surveys prior to government surveys, and correct any deficiencies.
 
We stick around and monitor the facilities activities until they successfully complete their annual surveys. Thereafter, we pay monthly visits and conduct random reviews of financial and clinical documents to make sure the facility is still in compliance.

Give us a call at 971-208-5909 to schedule an onsite visit.
 

Healthcare Marketing and Public Relations Management

 
We help our clients with proper identification of their market niche and the best marketing tools to reach that niche market. We help create good looking websites. We also create the most effective ads on high traffic search engines like Google.
 
We then generate attractive web contents for specific niche markets to keep their customers engaged and eager to return for more information, products or services. We do the same thing we do with electronic social medial with their community and public relations to ensure name recognition and good will in the communities they serve.
 
Call 971-208-5909 today for a free consult.

Healthcare Compliance Management and Monitorin

The healthcare industry is the second most heavily regulated in the US. Health services managers have had to go to jail for regulatory lapses not directly caused by them, but by employees under their supervision. Medical practices have had to fold because of overwhelming legal losses. 

Virtually evey aspect of healthcare provision has a legal component. Some healthcare facilities must have thier entry doors open for 24 hours a day. Others must have it locked and coded at all times. The inside tempearature must not exceed 70-72 degrees F. The current operating license of the facility must be displayed at the front lobby. The facilty manager's license must also be displayed at the front lobby. 

The food served to residents must be at a specified temperatures and prepared by cooks with specified qualifications. Employees must have specified qualifications and go through specified background checks. They must also have current CPR/FirstAid certification, and complete specified number of continuing education classes every month. The patient DATA form for each resident must be properly completed and returned to CMS every month.

Patients must be educated about thier rights, all heathcare workers are mandatory abuse reporters. Every shift in a long term care facility has a stipulated number of nurses and nurse aids that must be availale for any given number of residents. The facility infrastructure must be ADA compliant and food storage and preparation area must meet stipulated guidelines. Maintenance records must be up to date.

Helping healthcare administrators and managers monitor these endless list of requirements is what Dromekara.com consultants do. We have managemed facilities and we know where the shoe pinches most. We visit our clients' facilities monthly and independently monitor what is going on without drawing too much attention.
 
Employees usually tend to straighten up once they see the administrator coming. We do random sampliing of financial and clinical doments to ensure that they are in compliance with government guide lines. We even sample residents' meals sometimes, to investigate complaints about meal quality.

Give us a call today at 9712085909 and let's set a plan in motion to help you manage regulatory compliance in your facility.

Healthcare Program Evaluation

Droomekara.com consultants would normally establish concrete and measurable goals with time lines of where the organization should be at various points over a ten year period. Part of our compliance monitoring is to see that all the measurable goals are being reported and documented on a continuous basis. The chief executive should have an ongoing chart for tracking the numbers that come to his/her table.
 
Since facility census has a lot to do with meeting the revenue projections, most chief executive or chief finance officers will keep an ongoing chart of facility census in their offices, so as to get an early warning of a downtrend and investigate it. Risk management can also be a killer for any healthcare organization, from law suite payments to on the job injury claims. The CFO therefore keeps an eye how much is paid out monthly to legal fees and fines, as well as disability claims.
 
While monthly tracking of measurable goals and objectives, may be useful for financial and management controls, it is the yearly aggregates of the data that tells the stakeholders whether the vision of the organization is actually being followed. Significant disparities in projected vision and actual outcomes, usually call for strategic review and policy adjustments.

Where it becomes obvious that the existing infrastructure or the prevailing economic environment will not allow the organization to meet its vision and goals, the stakeholders, may decide to go into partnership with another organization for synergy or sell the company outright. Our consultants play a vital role in helping healthcare facilities take these crucial decision.

Call us today at 971-208-5909 for a free informational meeting.

Live Presentations

 
Droomekara.com consultants are available for live presentations on some of the medical content articles by popular demand. If we receive so many requests for an article on a particular health - related subject, we go beyond article writing to organize seminars in the area with the greatest number of requests. The area could be here in the US or abroad. Dr. Omekara has been speaking at medical and healthcare conferences since his penultimate year in medical school.
 
As Medical students' Association president he presented a paper at the IFMSA international convention in Vienna Austria , that attracted a multinational IFMSA funded international medical students' summer school to UNTH in Nigeria. As Imo State Resident Doctors' Association Vice President his presentation to the Imo State governor's office led to the appointment of the first physician Chief Executive to head the Health Services Management Board. It also led to the creation of the Civil Service Staff Clinic, which he pioneered, to decongest the Owerri General Hospital.
 
He presented the welcome address as the pioneer Medical officer in charge of the clinic during the commissioning ceremony. At PCC Portland while on President`s List, he was nominated to give the "Thank you" speech at an annual scholarship donors` banquet. As a UPA Department Achievement Award recipient at Portland State University he also made "Thank you" comments. He is currently a member of the Association of Health Care Journalists with the ability to cover health and medical news events. Call him at 9712085909 with live presentation proposals.

 


How Asthma Can Be Avoided
There are more than enough individual and public health reasons to avoid asthma in the United States. For one thing,  it could be fatal if a patient having a severe asthmatic attack is not given rescue treatment fast enough at home or at the ER. It is also incapacitating to the patients, who are unable to perform their normal daily functions in support of the national economy.
Up to 34% of school absenteeism among US children is attributable to asthmatic attacks. About the same goes for work absenteeism among adults adult Americans. When lost work hours are combined with 47.8% of ER visits and 34% of hospitalizations per year, it adds up to 6.2 billion dollars per year in costs to the US economy.
Total avoidance of asthma is theoretically very possible given the fact that each attack needs a trigger, even where there is a genetic predisposition. In practice people still experience breakthrough asthmatic flares despite appropriate preventive measures. The good news is that with strict adherence to asthma prevention plans, patients only have occasional mild attacks that are not debilitating.
So, once a doctor has successfully diagnosed bronchial asthma and placed the patient on appropriate medical treatment, the next task is develop a prevention plan for the patient. The plan generally aims at: 1) Identification and control of triggers, 2) Anticipation and control of flares, 3) Adherence to a medication plan, 4) Acute flare Control, and 5)Patient self-education about asthma medications and treatment.
1) Trigger Identification and Control
a) Trigger Identification
Asthma triggers differ for different individuals, different ages and different seasons. But what they all have in common is that they irritate the cells lining the small air passages, causing broncheolar muscle constriction, excessive mucus secretion and narrowing of the small airways. A trigger can be a virus, an allergen, cold air, an irritant,, exercise, a mediation, or weather change. Among the common irritants are, smoke, fumes, auto exhaust, dust, and perfume odors
After the physician has identified the trigger through indepth history taking, the full list is documented in the patient's chart. A copy is sent home with the patient and copies sent the day care center, school, or church, where the patient spends some time. Domestic care providers and schools are also educated on the prevention and control of asthmatic attacks.
b1) Trigger Control - Indoor
§ Dust Mites control requires polyester pillows, mite-proof covers,  vacuuming and cleaning of mattresses, weekly washing of bed sheets with 137F water, no upholstery furniture, no fiber window blinds or rug carpets in patient's room, weekly dusting and vacuuming of bedroom furniture

  • Pollen control requires, keeping windows closed during pollen season, no humidifiers to avoid molds, only air conditioning, and no wall papers or carpets in bathrooms,

  • Irritant control requires no smoking indoors, no wood stove or fumes, and no strong odors from paints or perfumes

  • Animal dander control requires:, keeping pets outside, keeping pets away from patient's room, and bathing the pets weekly

  •  
2) How Asthma Can Be Avoided
There are more than enough individual and public health reasons to avoid asthma in the United States. For one thing,  it could be fatal if a patient having a severe asthmatic attack is not given rescue treatment fast enough at home or at the ER. It is also incapacitating to the patients, who are unable to perform their normal daily functions in support of the national economy.
Up to 34% of school absenteeism among US children is attributable to asthmatic attacks. About the same goes for work absenteeism among adults adult Americans. When lost work hours are combined with 47.8% of ER visits and 34% of hospitalizations per year, it adds up to 6.2 billion dollars per year in costs to the US economy.
Total avoidance of asthma is theoretically very possible given the fact that each attack needs a trigger, even where there is a genetic predisposition. In practice people still experience breakthrough asthmatic flares despite appropriate preventive measures. The good news is that with strict adherence to asthma prevention plans, patients only have occasional mild attacks that are not debilitating.
So, once a doctor has successfully diagnosed bronchial asthma and placed the patient on appropriate medical treatment, the next task is develop a prevention plan for the patient. The plan generally aims at: 1) Identification and control of triggers, 2) Anticipation and control of flares, 3) Adherence to a medication plan, 4) Acute flare Control, and 5)Patient self-education about asthma medications and treatment.
1) Trigger Identification and Control
a) Trigger Identification
Asthma triggers differ for different individuals, different ages and different seasons. But what they all have in common is that they irritate the cells lining the small air passages, causing broncheolar muscle constriction, excessive mucus secretion and narrowing of the small airways. A trigger can be a virus, an allergen, cold air, an irritant,, exercise, a mediation, or weather change. Among the common irritants are, smoke, fumes, auto exhaust, dust, and perfume odors.
After the physician has identified the trigger through indepth history taking, the full list is documented in the patient's chart. A copy is sent home with the patient and copies sent the day care center, school, or church, where the patient spends some time. Domestic care providers and schools are also educated on the prevention and control of asthmatic attacks.
b1) Trigger Control - Indoor

  • Dust Mites control requires polyester pillows, mite-proof covers,  vacuuming and cleaning of mattresses, weekly washing of bed sheets with 137F water, no upholstery furniture, no fiber window blinds or rug carpets in patient's room, weekly dusting and vacuuming of bedroom furniture

  • Pollen control requires, keeping windows closed during pollen season, no humidifiers to avoid molds, only air conditioning, and no wall papers or carpets in bathrooms,

  • Irritant control requires no smoking indoors, no wood stove or fumes, and no strong odors from paints or perfumes

  • Animal dander control requires:, keeping pets outside, keeping pets away from patient's room, and bathing the pets weekly.

  •  
b2) Trigger Control - Outdoors
Requires the use of prescription antihistamines during pollen season, bathing and changing clothes after outdoor activities, driving with rolled up car windows; no lawn mowing or leaves raking, Immunotherapy by doctor for severe allergic asthma
2) Flare Anticipation and Control
Requires the monitoring of lung functions with spirometers, and peak flow meters for negative changes in FEV1, FVC, and Q/V ratio, recognition of previous early  warning signs

  • Responding by making necessary medication adjustments as instructed in prevention plan

  • Calling the clinic for advice.

  •  
Implementation of medication plan
Requires:
  • Knowledge of the broad groups of asthmatic drugs

  • Using rescuers for acute flares; controllers for maintenance; and treatment drugs (antibiotics, NSAIDS, and mucolytics) for reduction of infection and swelling and mucus secretion

  •  
Flare Control

  • Is accomplished implementing prescribed rescue medication plan for home or rushing to the ER, or calling 911.

  • Mild to moderate attacks are usually controlled at home with rescue inhalers contain quick and short acting beta agonist drugs and steroids

  • Such medications that quickly relax the broncheoles include, albuterol and salmeterol

  • Faster acting corticosteroids, like hydrocortisone, as also given fast reduction of swelling in the air passages

  • When the attack subsides, longer acting beta agonists, steroids, mast cell stabilizers, leukothrane inhibitors, and IgE inhibitors are started for maintenance

  •  
Trigger Control - Outdoors
Requires the use of prescription antihistamines during pollen season, bathing and changing clothes after outdoor activities, driving with rolled up car windows; no lawn mowing or leaves raking, Immunotherapy by doctor for severe allergic asthma
b2) Flare Anticipation and Control
Requires the monitoring of lung functions with spirometers, and peak flow meters for negative changes in FEV1, FVC, and Q/V ratio, recognition of previous early  warning signs

  • Responding by making necessary medication adjustments as instructed in prevention plan

  • Calling the clinic for advice

  •  
Implementation of medication plan
Requires:
  • Knowledge of the broad groups of asthmatic drugs

  • Using rescuers for acute flares; controllers for maintenance; and treatment drugs (antibiotics, NSAIDS, and mucolytics) for reduction of infection and swelling and mucus secretion.

  •  
How Clinicians Make A Diagnosis of Chest Pain

The good thing about having many clinicians who know how to make a diagnosis of chest pain in the US is that it reduces the chances of misdiagnosis with disastrous consequences. Heart attack is a major cause of morbidity (illness) in the US and as such calls for increased ability of non-clinical members of society to differentiate chest pain of heart attack from other types of chest pain. 
Being aware of the peculiar symptoms of heart attack enables the layperson to recognize them in emergency situations, and dial 911 in good time. The chest and abdominal organs are so closely packed and cross-wired that it is often difficult to ascertain the cause of chest pain from clinical history alone. Pain from the abdomen could be referred to the chest while that from the chest could be referred to the abdomen following the distribution of nerves on the skin surface. Heart pain could be localized at the same spot as lung pain.
So, it takes the expertise of clinicians trained on how to a make a diagnosis of chest pain to figure out the cause of chest pain of any type and decide how quickly to intervene. Life-saving intervention time could be a little as minutes for heart attack and hours for pneumonia. Accurate diagnosis of chest pain can be a challenge sometimes for clinicians, especially without adequate patient history.

It usually requires a detailed history and a thorough physical exam focused on cardiovascular system, chest, abdomen and muscles. Laboratory tests are often needed to corroborate the physical signs or distinguish between very close differential diagnoses.
Cardiovascular Chest Pain
Cardiovascular chest pain can be a symptom of four main diseases: angina pectoris, myocardial infarction, pericarditis or aortic dissection. A clinician with basic knowledge of how to make a diagnosis of chest pain will sequentially examine the history and physical examination findings to narrow down the diagnosis.
Angina pectoris chest pain usually presents as a short-lasting (< 30 minutes) pressure sensation under the sternum (breast plate), extending to the jaw and arm. It shows nonspecific signs of ST segment elevation or depression on ECG, without any changes in blood level of heart muscle enzymes (troponin and CK-MB) normally released by damaged heart muscle tissue.
Myocardial Infarction (MI) chest pain usually starts out like angina pain, but lasts longer than 30 minutes. It is chest pain arising from heart muscle metabolic stress or damage. It goes beyond pressure sensation to present with dyspnea (breathlessness), tarchypnea (rapid heart beats), and diaphoresis (cold sweats or fainting sensation).

It also shows acute heart metabolic stress signs of ST segment elevation on ECG about a couple of hours after MI onset, due muscle tissue under-perfusion from acute severe narrowing or obstruction of the coronary arteries that supply the heart. The first couple of hours without ST segment elevation is referred to as NSTEMI or non-ST segment elevation myocardial infarction, while the later stage with ST segment elevation is called the STEMI
The blood level of CK-MB begins to rise about four hours after the onset of MI, followed by troponin four hours later.  While CK-MB blood level may return to normal in 24 – 48 hours, troponin level remains raised for up to ten days. This makes troponin the preferred biomarker for MI. The intervention of a clinician who knows how to make a diagnosis of chest pain at the NSTEMI stage can prevent extensive heart muscle damage. This is why the first 2-3 hours from the onset of heart attack (MI) are very critical for patient survival. Massive MI could l congestive heart falure
Pericarditis chest pain originates from the inflammation, irritation, or stretching of the heart envelope (pericardium). It usually presents as a sharp pain starting from the anterior chest wall and extending to the back. It is worsened by breathing and relieved by sitting forward. Chest auscultation reveals pericardial friction rub, and ECG shows signs of diffuse ST segment elevation in all precordial leads.
Aortic Dissection Chest Pain is the result of the accumulation of blood between the layers of the root of the aorta after it has given off the arterial supply to the right arm and right half of the head region. The accumulated blood leaks through a degenerated spot in the aortic endothelial layer (lining of inner aortic surface). It usually presents as a very sharp stabbing pain in mid front and back area of the chest.

It also shows a higher blood pressure with stronger pulse in the right arm than in the left arm, due to severe narrowing of the aortic lumen before it gives off the branches that supply the left arm and left half of the head region. Chest X-ray shows a widened central chest area (mediastinum). MRI shows a false lumen.
THORACIC CHEST PAIN
This is the chest pain arising from the lungs and rib cage. Clinical experts, who know how to make a diagnosis of chest pain, have associated this type of chest pain with pneumonia, pleuritis, pneumonthorax, pulmonary embolism, and pulmonary hypertension.
Pleuritic chest pain originates from inflamed surface lining tissue of the chest cavity and the lungs. (pleura). It usually presents with pain on inspiration (pleurisy).
Pneumonic chest pain is the pain from air sacs and smallest air passages that have become filled with fluid and cellular inflammatory infiltrates.  See similar more of similar articles and product recommendations.

Teatment of Asthma Without Inhaler
Once the diagnosis of bronchial asthma has been made, the physician then has to decide on the most appropriate treatment option based on the specific cause(s). There are at least nine treatment options for bronchial asthma without inhaler:1) IV/IM short-acting beta agonist for quick rescue of mild intermittent attacks; 2) IV/IM low-dose synthetic steroids for quick rescue; 3) IV/IM long-acting beta agonists; 4) mast cell stabilizers;
5) anti-leukotriene or IV low dose long-acting steroids for moderate persistent attacks; 6) IV/IM low to moderate dose long-acting steroids and long-acting beta agonists for moderate persistent attacks; 7) IV/IM high dose long acting steroids with long-acting beta agonists for severe persistent attacks; 8) Trigger identification and elimination through behavior therapy and allergic desensitization through immunotherapy; 9) Antibiotic or antifungal or antiviral therapy to control trigger infections.
 Under certain circumstances, it may not be possible for an asthmatic patient to use an inhaler: for instance in a patient with throat cancer or a semi-conscious patient. The choice of medication route under such conditions will be intravenous (IV), intramuscular (IM) or subcutaneous (SC) injection. The second consideration will be which component of the airway targeted. Most inhalers used to rescue patients from acute exacerbation of asthma, usually target the constricted bronchial muscles to relax them in a matter of minutes. The third consideration will be the classification of the asthmatic attack, whether it is mild intermittent, mild persistent, moderate persistent or severe persistent.
 Mild intermittent asthmatic attacks occurring less than twice a week, with less than two night attacks a month, will be treated with IV quick-acting rescuer beta agonist drugs like salmeterol, pirbuterol, or terbutaline. Instead of the usually ipratropium inhaler used to improve the delivery of beta agonist drugs, intravenous anticholinergics like atropine could be administered. IV low dose steroids like hydrocortisone will then complete the quick rescue treatment.
 Mild persistent asthmatic attacks occurring more than two to six times a week, with less than two night attacks per month, will be treated with IM low dose steroids like prednisolone, or mast cell stabilizers like cromolyn sodium or, anti-leukotrienes like montelukast and zafirlukast.
 Moderate persistent asthma occurring daily with more than one night attack per week will need low to medium dose IM steroids like prednisolone, plus long acting beta agonist drugs like salmeterol and theophylline
 For the severe persistent asthma with flares and frequent nighttime symptoms per week, long-acting beta agonist drugs like salmeterol or theophylline is given. IV or IM to keep the bronchi dilated. IV/IM long-acting steroids like prednisolone, to control airway swelling, follow the beta agonist treatment.
 For the asthma treatment to be effective, the triggers must be identified and avoided through behavior modification. Aspirin or exercise or cold or dust or smoke sensitive asthmatics must avoid those triggers in their homes of work sites.
 Allergic desensitization through immunotherapy is needed in allergic asthma. Antibiotics or anti-fungal treatments are added if the trigger is infection.
 Author Otumdi Omekara, MD
The Benefits of Adopting An Anti-depressive Mindset

The average person in the United States has a one in seven chance of suffering a major depression during his or her lifetime (NIMH). Anybody can come down with mood depression with or without warning at any time. All it takes is a sudden major personal loss of something valuable, be it a spouse, a child, a sibling, a close friend, job, business, or property. About 33 per cent of bereaved people may also be depressed one month after the loss, and up to 15 per cent may remain depressed one year after the loss. 


The immediate reaction to such acute loss, disappointment, or traumatic stress is called a normal acute grief reaction. According to Elizabeth Kubler-Ross, stage one of this reaction is denial; stage two is anger; stage three is bargaining; stage four is depression; while stage 5 is acceptance. The most critical stage of acute grief reaction is the depression stage. If one gets stagnated at this stage, a major depression could set in without being noticed.
 

The normal adaptive behavior of a bereaved person, for instance, is to be sad, sob at length, lose appetite, lose sleep, and still be willing to talk about the circumstances surrounding the loss of his/her spouse. When the person becomes too preoccupied with guilt feelings about the sad event to move on to the acceptance stage that is the first indication that a major depression might be setting in. But by definition a diagnosis of major depression can only be made after two weeks following the trigger event.
 

There must be depressed mood or severely diminished interest in or pleasure from previously pleasurable activities. In addition, there has to be at least four out of the following seven symptoms: 1) 5% change in body weight in one month or significant appetite change with weight loss, 2) lack of sleep or excessive sleep, 3) fatigue or loss of energy, 4) Reduced or excessive physical activity, 5) Impaired thinking, concentration, or decision-making, 6) diminished self-esteem with feeling of worthlessness and undue guilt, and 7) repeated thoughts of death and suicide.
 

Moderate exercise, supportive relationships, and positive life experiences are all useful in depression as in other illnesses, if only the depressed person can muster the courage to get them started. This is why the proactive anti-depressive lifestyle is preferable. It targets the core symptoms of major depression. It prepares the individual to see that self worth does not have to depend entirely on any single aspect of life.
 

It exposes the person to similar occurrences in that past despite adequate provisions, which takes away the guilt feelings. It enables the person to understand the normal time frame of four to six weeks for normal grief. It also teaches the person to make advance decisions should they find they become grief-stricken. It restores hope by exposing people to survivors of catastrophic events.
 

The first benefit of an anti-depressive mindset is that it takes out the surprise element from the sad events that trigger acute grief reactions. In essence it puts a person in the mindset of always being prepared for the unexpected or for the worst. To develop this mindset the person will deliberately flood his/her mind with thoughts of very ugly events that could happen to anyone, and figure out what he/she might do under those circumstances.
 

The natural approach to this “what if” style of thinking is to try to empathize with people close to us when they experience the never expected losses or disappointments that put them into grief.
 

 The second benefit of this mindset is that it encourages an individual to talk openly about similar sad events and how they were resolved with grieving people. It might just be a matter of sharing one’s knowledge of some the symptoms of depression manifested by other bereaved people in the past and how quickly they got resolved..
 

The third benefit is that it encourages people to research the available resources for treating depression in the community even when they are not depressed.  An easy place to start would be during a visit to a primary care physician for routine medical examination. Where possible, a visit to a psychotherapist just to see exactly what they do for depressed patients and what symptoms would warrant a consult, could be very helpful. This is particularly important because a chronically moody people hardly knows when to talk to a friend, a doctor or a therapist about it.
 

The fourth benefit is that it gives people reason to stay socially connected with people who share similar concerns or interest, know them by their first names, and are ready to telephone them or knock on their doors when they go off the radar. It is very easy nowadays to go online or page through church directories and find a group that shares the same concern about how to prepare for unexpected personal losses of life.
 

It might not be totally out of place to attend group meetings for the unemployed, divorced, handicapped, cancer survivors, blind, etc. Seeing how members of these different groups are coping with their circumstances, quietly prepares an individual to face similar situations should they come their way.
 

The fifth benefit of ant-depressive mindset is that it gets people interested in the various medications advertised in the electronic and print media for the treatment of depression. The share number of brand name drugs alone begins to suggest that depression is a treatable disease. Once a depressed person comes to term with the fact that depression is a treatable illness, seeking help for it becomes a lot easier. Most cases of major depression that present early for diagnosis and treatment usually get resolved in about six months. See more of similar articles and product recommendations .
 

 Author: Dr. O. Omekara
 

Is This Autism or What?
 

Friday, October 10, 2014
 

7:34 PM
 

The ability of parents to suspect that their baby may have autism is very critical to early diagnosis and intervention. This article is aimed at getting parents to the point where they are able to ask: Is this autism or what? How early this question is answered in a child's life, goes a long way to determine whether he/she will live a dependent or independent life.
 

A high index of suspicion is so important because having had previous normal children does not exclude the possibility of having an autistic baby. The risk of having autism is highest (90%) for a concordant twin of a known autistic kid.  Other siblings have only 35% risk of being diagnosed with autism.
 

Autism usually presents enough symptoms and signs for accurate diagnosis by the age of two.  As such many federal and state government programs for supporting autistic children require that it is diagnosed before his/her second birth day for them to qualify.
 

In response to the growth of autism as a source of disability in the US, Congress passed the Children's Health Act in 2000, mandating several activities that included the establishment of a new autism research network.
 

This legislation led to the birth of five NIH institutes charged with the responsibility of researching into the causes, diagnosis, early detection, prevention and treatment of autism. Yet a CDC autism survey in 2009 showed that 1 in 110 US kids wss at risk of developing autism, with boys being four to five time more likely to be affected than girls.
 

 A significant number of high-functioning autistic kids diagnosed in 2000 are now in their early twenties and need vocational employments as people with liability. There are many federal, state and county programs currently available to assist higher functioning autistic adults with independent living, job procurement, community inclusion, speech therapy and mental health care.
 

Since 2000 a lot has been learned about autism neurobiology, diagnosis, intervention, genetics, and services. The number of autism support resources have also grown dramatically. One key knowledge that has emerged from the various research efforts is that autism is a broad spectrum disorder including several members of a group of disorder known as pervasive developmental disorders (PDDs).
 

Autism is therefore presently classified in the Diagnostic and Statistical Manual of Mental Disorders , 4th Edition. (DSMV--IV-TR)  as  Autism Spectrum Disorder (ASD). The DSMV-IV describes ASD as a group of five pervasive brain. disorders (AD, AS, PDD-NOS, RD, and PCDD) which variably impair a child's ability to communicate, socialize, behave normally.  and reason at age-appropriate levels.
 

AD is the classic autism disorder. AS is Asperger's Syndrome. PDD-NOS is Pervasive Developmental disorders Not Otherwise Specified. RS IS Rett Syndrome while CDD is Childhood Disintegrative Disorder.
 

The classic ASD is a neuro-psychiatric developmental  disorder affecting the brain in such a way that an individual's communication, socialization,  behavioral, cognitive (reasoning) abilities are compromised to various extents.
 

 It is the extent to which these adaptive skills are compromised that differentiates one PDD from the other.  It also accounts for the spectral nature of autism. In severe ASD the IQ is substantially reduced adding the fourth component, cognitive (reasoning) impairment to the picture. It also accounts for the highly variable levels of disability observed among individuals diagnosed with ASD.
 

Some autism patients are so minimally affected as in Rett disorder that they live independently without supervision. Others are so severely affected, as in classic ASD, that they need 24/7 residential care, as well as assistance with activities of daily living (ADL).  The rest of the PDDs then fit in at various levels between these two extremes.
 

How ASD selectively targets and alters the areas of the brain responsible for emotions, speech, behavior and reasoning is still being actively researched. These target areas include the the limbic system (amygdala and nucleus accombens), and the ventromedial prefrontal cortex and the frontal lobe.  How these areas have been genetically altered by other disordered affecting them and observations in traumatic/surgical lobotmy are providing some insight into the possible risk factors for autism.
 

What is known so far is that ASD is triggered by multiple and random gene alterations (frame shift mutation, gene duplication, or deletion) on chromosomes 15 and 16. Gene depletion or duplication could lead to a frame shift mutations.  In most frame shifts mutations, the codon changes could lead to the production of a neutral protein, a destructive protein, or an enhancing protein in the target areas areas of the brain.
 

When neutral proteins are produced, mild ASD will occur due to inadequate production of  synaptic adhesion proteins (neuroligin, neurexin, MDGA1 and MDGA2) needed for normal mood, speech and behavior.   When a toxic protein results it would destroy the target sites, and impaIr their functions. On rare occasions, a mutant synaptic adhesion protein may have an enhancing protein may lead to a super-functioning ASD patient.
 

Synaptic protein abnormalities have been associate with autism and schizophrenia.
 

In order to easily recognize an abnormal pattern of child development, one needs to have a sense of what is normal.  After having two normal kids a mom might get a sense of what is normal.in child development. But a new mom will need help knowing what to expect.
 

She needs to know that at birth, a newborn baby will have a grabbing and reaching behavior or the startle reflex. The newborn is also able to initiate facial grimace, as well as cry and cling for attachment. As early as 1 week a newborn can distinguish mom's smell from dad's smell.  A normal new born, in the first couple of months is attracted to bright, colorful, moving objects, and can distinguish voice sound from ordinary noise.
 

Prior to the 8th week, the baby exhibits reflex (endogenous) smile. But by week 8, the baby responds to faces with a smile (exogenous or social smile). By week 12, the smile becomes selective for familiar faces only (preferential social smile).
 

The new born quickly learns to draw attention to personal needs by crying aloud. The loud cry usually builds up from unhappy face to grunting to sobbing to cry outburst with tear stream. As the child grows older he/she learns to kick off bed covers in protest and roll into ready to crawl position with head lifted up and eyes scanning for parents.
 

In general the manifestations of autism are related to the child's tendency to be disinterested in the environment, to be inflexible with habits and mannerisms, and to be emotionally numb.
 

Two early sign of inflexibility often overlooked in a newborn are the selective feeding on only one breast and selective sleeping in only one position.  The autistic newborn may also only fall asleep when the room is pitch dark or clutching a specific part of his/her body. Some may insist on having their thumb in their mouth before they can fall asleep.
 

One of the earliest obvious suggestions that something may be wrong is the absence social smile between three to four months after birth. There may also be absence of eye contacts or tracking eye movements. It becomes more obvious that something is wrong between ages 6 and 12, when a child fails to develop normal emotional, speech and play patterns, and makes only repetitive sounds and hand movements.
 

Synaptic failures between primary cortical sensory areas (visual, auditory, and somatosennsory) and association cortex, prevents learning and memory formation that occurs through the association of particular emotions with specific stimuli, place and objects.  Normally,  the smiley face of a mom breastfeeding her baby stimulates increased dopamine release in the pleasure center (nucleus accumbens), and causes the baby to return a smile whenever a physiologic need is met.



The pleasure of social interaction by itself may directly create a positive memory in a normal child through the hippocampus without nuerotransmitter surge in nucleus accombens. The sript recorded in the hyppocampus is played over and over by the autistic kid for every emotional situation, until there occurs a strong intrusive override by way of teaching. This accounts for the repetitive and non-interactive, domineering style of communication exhibited by autistic individuals.
 

A negative emotion creates a diminished desire for the stimulus, by reducing the level of dopamine, which normally causes a craving for the stimulus. This association of negative emotion with withdrawal occurs in the amygdala, the limbic nucleus for harm avoidance. Dopamine reduction is produced by a surge of serotonin into the synapses, which creates the feeling of satisfaction and switches off the stimulus.



Two other neurotransmitters, mGluR2 and mGluR3,  inhibit the opening of dopamine receptors, thereby further reducing its craving effect and increasing the harm avoidance response. The craving response and harm avoidance response are modulated by the ventromedial prefrontal cortical association area, which is the center for problem solving reward.with a strong kink to the limbic system.



Cancer Overview: Types, Causes, Diagnosis and Treatment

Cancer is the name given to a cell that has lost its normal physiological or natural growth control and multiplies very rapidly to produce a large new growth called a tumor or neoplasm (swelling). This new growth or neoplasm could be confined to the local region or directly invade the surrounding tissues. It may also break out with tumor particles carried by blood to distant parts of the body. This is what determines the stage of the tumor.
 

Such cancers that invade neighboring tissues or spread to distant organs as said to be malignant. Those confined to the original tissue type are said to be benign. The level of disorganization of the tissue architecture also gives a sense of whether the tumor is benign or malignant. Benign cancers are not as dangerous as malignant cancers, although large ones depending on their locations could produce dangerous pressure effects as happens with FIBROIDS causing abortions.
 

Cancers can arise from virtually any tissue of the body, in the presence of the right stimulus and genetic predisposition. The stimuli that initiate cancer could be radiations (x-ray, solar, etc), chemicals like carbon tetrachloride or asbestos or cigarette smoke, drugs used in early pregnancy, biochemicals like VEGF, etc. The stimuli generally alter the genetic code of the individual cells to disable the tumor suppressor genes that prevent uncontrolled cell growth or ensure PROGRAMMED cell death (apoptosis)
 

Different tissues are sensitive to different stimuli, but those cells that naturally grow rapidly are most sensitive to cancer stimuli. Such tissues include the skin, testis, ovaries, breast, uterus, liver, spleen, gastro-intestinal tract, growing bones, blood cell, lungs, lymph nodes etc. The commonest cancers therefore involve the lungs (carcinoma), blood (leukemia), lymphoid tissues (lymphoma), bones (osteoma or steosarcoma), skin (carcinoma), liver (hepatoma), ovaries (cystadenoma or cystadenocarcinoma).
 

The destructive potential of a particular cancer depends on the type and location. Lung and breast cancers are known to be the two leading causes of death among women in the US. Colon cancer kills a lot of men and women. Leukemia kills a lot children in America by destroying their bone marrows and making them very anemic. PROSTATE CANCER kills a lot men each year in the US. Sun exposure causes a lot of skin cancer in States like Florida. Tumors affecting blood vessels cause them to be fragile and bleed easily. This can be a huge problem in the eyes and brain.
 

The general approach to treatment of cancers is to detect them early when they are still very local and ablate them surgically, thermally (diathermy) or cryoscopically (freezing). Surgical biopsy is used to obtain some of the cancer tissue for laboratory examination and classification. Early stage cancers are generally cured by surgical excision.
 

Mid stage cancers, involve both wide surgical dissection, as in breast cancer, and radiation therapy to kill off residual cancer cells. Late stage cancer is mostly treated with CHEMOTHERAPY AND RADIATION.  Leukemias, often involve the wiping out of patients' bone marrow cells and replacing them with donor cells.