How could an undocumented MS patient get care?

The course that Ms. X’s case has taken is non-reassuring in that she has not regained any of her lost function and now receives IVIG a treatment that has not shown efficacy in SPMS, her presumptive diagnosis. However, what has further complicated her care is her citizenship status: she is undocumented, and currently receives care under emergency Medicaid. My understanding of Medicaid is quite limited so I wanted to expand on this subject and attempt a greater understanding of the legal complications to her care.

Medicaid, enacted in 1965, is a federally funded program that provides assistance to acquiring healthcare to those individuals with low incomes¹. The program assumes the cost of medical care by reimbursing on a state level certain medical expenses that fall within its sphere. The burden of cost shared by each state varies; those states with higher per capital incomes are less well reimbursed for the cost of the care they provide, and poorer states with less per capital income are federally reimbursed more substantially. Currently New York States federal medicaid match rate is 50%², shifting the burden of health care onto state coffers. Guidelines for states to administer entitlements vary, but most states do not offer benefits for adult men and non-pregnant women who are not disabled. In fact beneficiary populations are normally subdivided into categorically needy, medically needy, special groups, waiver populations, and children¹.

Categorically needy are pregnant women, women with children less than 6, income below 133% of poverty level ($29,326.50 for family of four)³, those living in medical institutions, and the impoverished elderly who are eligible for supplemental security income (SSI). The medically needy are individuals who may have limited financial resources and states may chose to expand and widely vary in what they cover. Certain individuals who variably qualify may nonetheless be unable to get care, and so Medicaid reserves the following special groups, those who lose Medicaid coverage because of work but are still below 200% of federal poverty line, those with TB, women with breast/cervical cancer not otherwise eligible for Medicaid but who have no insurance. Many states engage in cost experimentation and pilot studies and in these circumstances a “waiver” may be acquired to access care. Centers for Medicaid and Medicare Services (CMS) regularly reviews these waivers. Finally there is SCHIP, the state children’s health insurance program designed to provide care for children whose parents do not meet income criteria for Medicaid. Benefits provided by Medicaid include hospital services and long term nursing care. “The bulk of long term care is provided by medicaid⁴.”

However, what about Ms. X? How is she able to access care? Immigrants and undocumented individuals are generally ineligible for Medicaid, however Ms. X is eligible for emergency treatment under Emergency Medicaid and Emergency Medical Treatment and Labor Act (EMTALA)⁵. These laws require anyone who shows up on the doorstep of the emergency room the right to receive care and be stabilized. However what about Ms. X’s case, she is overall medically stable and being treated for a chronic neurodegenerative disease. How was her care able to be arranged? The New York City Health and Hospitals Corporation has a program called HHC Options which has the ability to provide care for everyone regardless of legal status and ability to pay⁶. This would include access to city hospitals, including her current residence where she is receiving long term care at the skilled nursing facility XYZ. Although it is not clear how her care is arranged I believe this program may in fact be her lifeline. As the social burden in New York and America continually increases, tax funded city programs like this will face mounting financial stressors. But it is critical that they be maintained so that the rare cases like Ms. X do not end in tragedy. Currently Ms. X is getting by with very little help and is not a great burden on taxpayes, and she has no good options. First she is unfortunately afflicted with a crippling and unremitting neurodegenerative disease. Second, she has little support from family members, only a sister that has been a regular caretaker. And third, she is undocumented, a status that severely limits her access to care, keeping her the institutionalized. But although the system where she subsides may at times be inefficient she is nevertheless receiving some standard of care (more than if she were in her home country).

References:

1. Baldor R. Medicaid. http://www.uptodate.com/

2. Comparison of State Medicaid Costs. 2002. http://www.leg.state.vt.us

3. Human Health Services. 2009 Federal Poverty Guidelines http://aspe.hhs.gov/poverty/09poverty.shtml

4. Baldor, RA. Managed Care Made Simple, 2nd ed, Blackwell Science, Cambridge, MA 1998.

5. Kaiser Family Foundation: Kaiser Commission Medicaid and the Uninsured: Medicaid and SCHIP eligibility for immigrants. 2006

6. http://www.nyc.gov/html/hhc/downloads/pdf/hhc-options-06-2009-eng.pdf

Charles Bonnet b1720 Swiss naturalist

Charles Bonnet was a swiss lawyer turned naturalist. He was the first to describe the phenomenon of visual release hallucinations in his aging father in the 18th century. The tonic inhibition of the visual cortex by visual input from the environment when removed creates a denervation hypersensitivity that can occur anywhere along the visual pathway (from the granular layer to higher order integration areas), thus excessive cortical activity about the occipital lobe and beyond originally inhibited is now "released" and the patient experiences a wide ranging assemblage of visual hallucinations.

This above picture was a drawing by a patient described in this case report who also experienced these visual hallucinations.

Later in his life, Bonnet set out to the Swiss countryside to write. In my opinion his intuition regarding the nervous system as a modifiable feedback loop with the environment first, correctly identified the chief mechanism believed to underlie the development of memory in organisms, that repeated environmental stimuli create nerve approximations that are favored because that have less resistance (or could be said to be more likely to refire). And second, created the central dogma for approaching an understanding of how nervous tissue functions (much the way Newton reorganized bodies in motion) Genius!!!

The following excerpt is taken from his 1760 essay on the faculties of the heart Essai analytique sur les facultes de l'ame (i think).

"All knowledge originates in sensations; sensations follow vibrations in the nerves appropriate to each; the nerves are made to vibrate by external physical stimulus. A nerve once set in motion by a particular object tends to reproduce that motion; so that when it a second time receives an impression from the same object it vibrates with less resistance. The sensation accompanying this increased flexibility in the nerve is, the condition of moemory. That which puts [the mind] into activity is pleasure or pain. When the active element of the mind is applied to the acquisistion and combination of sensations, those abstract ideas are formed which, though generally distinguished from , are thus merely sensations in combination only."

cosmetic neurology

This is an interesting paper by Dr. Chaterjee, a very well respected neurologist. I find this subject matter endlessly fascinating, ultimately I do not think there is a difference between therapy and enhancement but in their use. I put my perspective/comments in green!

University of Pennsylvania

ScholarlyCommons

Neuroethics Publications Center for Cognitive Neuroscience

8-1-2004

Cosmetic Neurology: For Physicians the Future is Now

Anjan Chatterjee

University of Pennsylvania, anjan@mail.med.upenn.edu

Published in Virtual Mentor: Ethics Journal of the American Medical Association Volume 6, Number 8.

Publisher URL: http://www.ama-assn.org/ama/pub/category/12799.html

Basic neuroscience and neuropharmacology are beginning to yield therapies for cognitive disorders. While we can eagerly anticipate treatments for dementing illnesses, stroke, traumatic brain injury, and developmental abnormalities, these very treatments raise uncomfortable questions. If we can improve cognitive systems in disease, can we also do so in health? Should we practice cosmetic neurology?

I do not agree with the set up because it frames anything outside of treating an acute decrease in health, i.e. -disease, as "cosmetic". The word cosmetic is taken from the greek kosmetikos, meaning to adorn, that usage connotes a preoccupation with the exterior. I believe improving our cognitive systems is the same as "improving" our blood pressures, nutrition, or life spans.

The possibility of “better brains” has captured the imagination of the press, policy pundits, and ethicists [1-10]. With few exceptions, physicians have not contributed to these discussions, despite their central role in this unfolding drama [11,12]. Cosmetic neurology includes the use of botulinum toxin to brush away wrinkles.

I'll agree, using botox for wrinkles seems less "necessary" than using it for migraines or dystonias.

However, it also alters how we function and feel, rather than just how we look. Many interventions to improve cognitive and emotional systems are available now, and others are on the horizon. The risks and benefits of newer medications remain to be worked out. However, we can assume that some version of these medications will be relatively efficacious and safe. The accompanying article on neuroethics by Martha Farah reviews the anticipated pharmacopeia of cosmetic neurology and the deep ethical concerns raised for individuals and society (also see [12]). The focus here is on the role of the physician in managing the use of cosmetic neurologicinterventions.

Framing the Issue: the Purpose of Medicine

Ethical discussions of cosmetic neurology often frame the issue as one of therapy versus enhancement [6,13]. Therapy treats disease and enhancement improves normal abilities. Most people consider therapy desirable. By contrast, many pause at enhancement. Francis Fukayama, for example, opines, “the original purpose of medicine is to heal the sick, not turn healthy people into gods” [14].

So I'll take issue with Fukayama's quote, which in my opinion is hyperbole. I believe the underlying assumption that guides an ethical pursuit of enhancement is that mankind is mortal and can never be "gods" moreover that is not the purpose of improving "normal" function. The purpose for improving normal function is create opportunity for the growth, development, and evolution of our existence. Also, "normal" is a statistical measure of central tendency, it is descriptive- think how the "normal" human lifespan has improved over the last millennia, no one argues against pursuing this similar "enhancement". Again "healthy" people are defined by their state of health, derived from heilen, meaning "whole", but that definition does not indicate what the whole is.

He suggests that public policy should restrict research for enhancement.

...and as a consequence risk falling behind those that do.

For 2 reasons, the distinction between therapy and enhancement is less useful than one might hope. First, notions of disease often lack clear boundaries. For example, if individuals of short stature can be “treated” with growth hormone [15], does it matter whether they are short because of a growth hormone deficiency or because of other reasons [13]?

I agree, in most cases no- it would not matter.

Second, promoting research for therapy and restricting it for enhancement ignores the simple fact that research in one often applies to the other. The therapy versus enhancement distinction also obscures what for physicians may be the critical question:

What is the purpose of medicine? The strength of allopathic medicine has been its scrutiny of disease mechanisms. Understanding the biology of malfunction provides insight into how to fix that malfunction. Despite its undoubted successes, this approach has limits. Most notably, the quality of patients' lives does not always correspond well to biomarkers and symptoms of disease. The symptoms of Parkinson's disease that are most responsive to dopamine agonists are not those that bother patients most [16]. Measures of disease activity may not be the best indicator of the impact of multiple sclerosis on patients [17]. Recognizing the limits of clinical and pathological indices, assessing patients' quality of life is now a routine practice in therapeutic trials. Such assessments seem eminently reasonable. After all, the point of treating a disease is to improve patients' quality of life. However, if a purpose of medicine is to improve quality of life

for people who happen to be sick, then why not apply medical knowledge to improve the quality of life of those who happen to be healthy?

Inevitability

Cosmetic neurology raises several serious ethical concerns. These interventions challenge fundamental notions of character and individuality; it is likely that they will be used coercively, and cosmetic neurology will not lessen the burden of distributive justice in a country in which the quality of health care is polarized by economic class. It is improbable, however, that cosmetic neurology will be restrained significantly by journalistic consternation, religious admonition, and government regulation. More likely, such restraints will be overwhelmed by free markets and military innovations.

Excellent paragraph, issues of coercion and distributive justice must be addressed but are not grounds for restricting the investigation into the field. I think what has come from

the field of reproductive endocrinology can inform how we implement advances in this field.

The market.

Pharmaceutical companies stand to make substantial profits and will probably support social pressures that encourage wide use of cosmetic neurology. According to Carl Elliott, in 2001 GlaxoSmithKline spent $91 million dollars in direct advertising to consumers for its medication Paxil [8], more than Nike spends on its top shoes. Advertisements for better brains would undoubtedly prey on an insecure public. Gingko Biloba, despite underwhelming effects on cognition [18], is a billion dollar industry. Pharmaceutical companies are not oblivious to the marketing possibilities of new “interventions” that could apply to the entire population [19, 20]. Sadly, the academy is unlikely to restrain Industry.

But I don't think this is the academy's role.

Scientific leaders who discover new therapeutic possibilities are quick to stake biotech claims [20]. Joint ventures between universities and pharmaceutical companies are increasingly common.

The military. Imagine a soldier who is stronger, faster, more enduring, learns more quickly, needs less sleep, and is not hampered by disturbing combat memories. The military's deep interests in cognitive enhancements date back to “go-pills” (amphetamines) for World War II soldiers [20], and continue to the present [20, 21]. For example, military investigators found that modafinil [a wakefulness-promoting agent] has its greatest effects in helicopter simulation performances at the combined nadir of sleep deprivation and circadian troughs [22]. Relevant findings from military research are likely to trickle down to civilians. Over-fed Hummer vehicles maneuver through the cobbled streets of Philadelphia. Perhaps Hummer brains are around the corner.

Seems a bit glib, lots of great technologies had their roots in the military, the internet -for one. Hummers were originally popularized by a movie actor and civilian, Arnold Schwarzenegger, and this was long before the masses used these vehicles as a proxy for their manhood.

The Role of Physicians

Americans believe that the pursuit of happiness is an inalienable right. This pursuit assumes we know what constitutes happiness [23]. Fame and fortune have been standard proxies for happiness in American culture. Better brains may very well join the list, either as a means to fame and fortune or as a direct source of happiness [24]. Scientific, economic, marketing, and regulatory forces are likely to shape the role physicians will play. The details are difficult to predict, but what is certain is that physicians will engage in cosmetic neurology.

Again, I take issue with calling this practice "cosmetic neurology", these issues are much deeper than that!

This practice will be complicated by the fact that physicians will not be able to rely on the conventions of traditional practice. Neurologists may have special understanding of the potential risks and benefits of quality of life interventions that work through the nervous system, but they have no special insight into the underpinnings of happiness. One plausible scenario is that physicians will become quality-of-life consultants.

But I would posit that the physician as quality of life consultant is already the case in many specialties. In past eras physicians once even had moral authority to say what is right and wrong. For these reasons I do not believe that we will be able to rely on conventions of practice.

Physicians might offer a menu of options, with the likely outcomes and the incumbent risks stated in generalities. The role would be to provide information while abrogating final responsibility for decisions to patients.

This reminds me of a lecture during 2nd year of medical school discussing the new paradigm in American healthcare writ large. The demise of paternalistic medicine gave rise to the autonomous patient and the "provider" (read technician, not physician) role being as stated above. The meat of Dr. Chatterjee's statement I believe is the physician abrogation of final responsibility. This is akin to "buck passing" and its a phenomenon in the new era of medicine that I believe is creating major identity problems for physicians. When I was and when I will again be the patient, I want a physician who takes final responsibility for my health, it is the physician opinion that I want. So when a patient asks, "do you think i should take this pill to make me smarter?", in addition to informing risks/benefits I would take a stance, "I think you should/should not... because...xyz, and that is my medical opinion."

Abrogation of such responsibility is promoted by current practice norms. Financial incentives in medicine are now driven by paper trails and diagnostic studies, rather than by personal engagement with patients.

Sad but true and hopefully unsustainable in the long run.

A comfortable stance would be to let people decide for themselves. After all, isn't autonomy what patients want? It turns out that the degree of autonomy patients want is not so clear, especially when they are sick (as reviewed in [25]). Furthermore, the bewildering array of choices available to American consumers in almost every domain of life is a source of considerable anxiety [26 ]. A practice of medicine that encourages patients to be consumers is in danger of compounding these anxieties. I am not advocating that physicians become disengaged purveyors of quality-of-life elixirs. I am suggesting that this role is a distinct possibility given current trajectories of medical practice. In a litigious society, many physicians would gladly shed the irksome traditional mantle of beneficence.

Where do you stand?

Since 1997, the FDA has permitted direct marketing to consumers. Physicians can anticipate facing questions from “patients” and advocacy groups in which distilling principle from prejudice is not easy. To make these issues concrete, I invite readers to consider the following questions.

1. Would you take a medication with minimal side-effects half an hour before Italian lessons if it allowed you to learn the language more quickly?

Market cap $25billion.

2. Would you give your children a medication with minimal side-effects half an hour before piano lessons if it allowed them to learn better?

Not until long term data came out about safety and adverse events with respect to their growth and development. e.g. - stimulants used as treatment for ADHD were found to make kids physically smaller (height and weight) at 10/20 yr follow up. Second, the child can decide for themselves when they are no longer a minor. It could be argued that having a beer or beta blocker before recital may make them perform better, but no one is credibly supporting that idea in a child either.

3. Would you pay more for flights whose pilots were taking a medication that made them react better in emergencies?

I would be happy to if it was shown to reduce the risk of death.

4. Would you want residents to take medications after call nights that would make them less likely to make mistakes in caring for patients because of sleep-deprivation?

Planning on at least trying this, but I believe (anecdotally) that one will eventually need to pay the sleep debt. I think that would be a great investigation, whether or not these medications reduce errors resulting from sleep deprivation. But I think another question in this debate is whether we should treat sleep deprivation, or prevent it!

5. Would you take a medicine that selectively dampened disturbing memories?

Great question!! Maybe...

This article has put forward legitimate concerns regarding the ethical practice of medicine where it relates to improving the healthy. For me, there have yet to be any convincing arguments against

the use and development of enhancing agents save for adverse events. Maybe one question worth asking is, given that these agents are not good or bad except for how they are used, would it be

right to use them knowing that most use could be "bad"?

This is such an exciting topic,

References

1. Groopman J. Eyes wide open. The New Yorker. December 3, 2001. 52-57.

2. Marcus S. Neuroethics: Mapping the Field. New York: Dana Press; 2002.

3. Rose S. Smart drugs: do they work, will they be legal? Nature Reviews Neuroscience. 2002;3:975-979.

4. The ethics of brain science: open your mind. The Economist. May 25, 2002; 77-79.

5. Farah MJ. Emerging ethical issues in neuroscience. Nature Neuroscience. 2002;5:1123-1129.

6. Wolpe P. Treatment, enhancement, and the ethics of neurotherapeutics. Brain and Cognition. 2002;50:387-305.

7. Plotz D. The ethics of enhancement. Slate. March 12, 2003. Accessed July 27, 2004.

8. Elliot C. American bioscience meets the American dream. The American Prospect. 2003;14:38-42.

9. President's Council on Bioethics. Beyond Therapy: Biotechnology and the Pursuit of Happiness. Washington, DC; President's Council on Bioethics. 2003. Accessed July 27, 2004.

10. Baily R. The battle for your brain. Reasononline. February 2003. Accessed July 26, 2004.

11. Whitehouse P, Juengst E, Mehlman M, Murray T. Enhancing cognition in the intellectually intact. Hastings Center Report. 1997;27 (May-June):14-22.

12. Chatterjee A. Cosmetic neurology: the controversy over enhancing movement, mentation and mood. Neurology. 2004 (in press).

13. Daniels N. Normal functioning and the treatment-enhancement distinction. Cambridge Quart Healthcare Ethics. 2000;9:309-322.

14. Fukayama F. Our Posthuman Future. New York: Farrar, Straus & Giroux, 2002.

15. Cuttler L, Silvers J, Singh J, et al. Short stature and growth hormone therapy: a national study of physician recommendation patterns. JAMA. 1996;276: 531-537.

16. Harris Interactive. Inc. The impact of Parkinson's disease on quality of life. Online Survey. 2003.

17. Nortvedt M, Riise T. The use of quality of life measures in multiple sclerosis research. Multiple Sclerosis.

2003;9:63-72.

18. Solomon P, Adams F, Silver A, Zimmer J, DeVeaux R. Ginkgo for memory enhancement: a randomized controlled trial. JAMA. 2002;288:835-840.

19. Langreth R. Viagra for the brain. Forbes. February 4, 2002: 46-52.

20. Hall S. The quest for a smart pill. Scientific American. 2003;289:54-65.

21. George M. Stimulating the brain. Scientific American. 2003;289:67-77.

22. Caldwell JJ, Caldwell J, Smythe NR, Hall K. A double-blind, placebo-controlled investigation of the efficacy of modafinil for sustaining the alertness and performance of aviators: a helicopter simulator study. Psychopharmacology. 2000;150:272-282.

23. Elliot C. Better than Well: American Medicine Meets the American Dream. New York: WW Norton & Company; 2003.

24. Kass L. The pursuit of biohappiness. Washington Post. October 16, 2003: A25.

25. Schneider C. The Practice of Autonomy: Patients, Doctors and Medical Decisions. New York: Oxford Press; 1998.

26. Schwartz B. The Paradox of Choice: Why Less Is More. New York: Ecco, 2004.

Anjan Chatterjee, MD, is associate professor in the Department of Neurology and a faculty member of the Center for Cognitive Neuroscience at the University of Pennsylvania, Philadelphia, Pa.

medicine rotation reflection...

i couldn't figure out why i was so tired at the end of every day. then the answer was given to me one evening when my sig. other said to me when i was staring blankly off into the distance, "dude you are out to lunch right now, you look emotionally exhausted" thats exactly it- people in milstein are going through so much it just takes its toll after a while.

-als patient who has to use eye movements to communicate every last thing, "itch her, thirsty, cramping, done..."

-guy who had traumatic brain injury, and is brain dead but kept alive

-guy with pulmonary issue who yells "i wanna die, i wanna die i wanna die" over and over and over (especially when we round) -he died

-woman who took previous guy's room w/CHF who can't recline past 45degrees or suffocates, "do you know what its like to want to die?", "please let me die" -she dies too

-undocumented woman w/no known family from mexico who is unresponsive and sits in mckeen for 100+ days and counting..."

-guy out of prison after 10 year stint w/drug problem and a-fib who doesn't take meds and elopes in the middle of one night despite not being able to walk >200ft without hacking

-woman w/MS with one functioning (but paretic) distal upper limb.

-woman stuck in nursing home with (choose at least one) pneumonia/sepsis/altered mental status/dementia/infected wound/vomit x10

-women w/cirrhosis and renal failure refusing dialysis for reason, "god will save me if its not my time, you doctor's don't care about anythings except money"

-women w/ severe mental retardation who is medically ok but all care is done by aging mother...

-woman (age 65, young!) w/cancer x2 and renal failure who is deaf and shivering literally falling apart

-alcoholic guy (with wife kids and other girlfriend) who drinks himself into acute pancreatitis and is demanding and entitled

the patients on our particular service average 80+ years old and are chronically sick. many of there health problems exist because of poor social situations.

i get the sense that the physician-patient relationship in inpatient medicine differs greatly compared to the outpatient setting. i put myself "in the patient's bed", like this one woman was visited by so many people one day (~20) its hard to keep track of who is doing what. consider the fact that the attendings dont spend as much time with the patients (like a few minutes in the morning x10 patients per service= less than an hour a day at best), the resident's have to rotate and cross cover so the patient never knows who's who and where's what, plus there is the cast consulting physicians, nurses, pt, ot, respiratory, speech and swallow, social worker. its a real production. this rotation has shown me that inpatient medicine is a lot like general contracting, and much of the day's work consists in lining things up for a client's project (in this case the patient's health). my conception as physician as a moral authority who sits at the bedside and chats w/patients about their children or swaps recipes and smiles and is generally happy emotionally available etc etc has been greatly challenged- a lot of "physicians" are specialty technicians, and the patient can see many "doctors" in one day. its probably because milstein is an incredibly busy place, i can't wait to try out another hospital and see how the physician/patient relationship differs.

renal clinical notes

renal notes

immune complex GN

post strep/infectious

SLE (full house)

MPGN (HCV)

IgA nephropathy

anti-GBM (very fast onset)

affects renal, lung or both (goodpastures)

pauci immune

vasculitis

sore throat + GN same day = IgA (no time lag)

sore throat + GN later = post strep

microscopic polyangiitis - lungs are whited out

wegener's - lung nodules

systemic disease (nodules, purpura, ulcers, sinusitis)

Pulmonary and Renal

lung vasculitis - lupus, henoch schonlein purpura, wegeners, microscopic polyangiitis

pneumonia/sepsis major cause of ATN

ANCA is to RPGN as antiDNA is to lupus

tx of vasculitis - cytoxan + steroids + plasmapharesis

IgA nephropathy -renal

HSP - systemic

IgA nephropathy treatment - ACEi

if > 1gm protein in urine 50% loss of renal function in ten years

Lupus - endocaopillary proliferation

Serum complement is low with

MPGN

Lupus

Post infectious

Complement is normal with

IgA neph

anti-GBM

ANCA-RPGN/Wegeners

Anemia + decrease plts? could be thrombotic microangiopathy

when doing a kidney biopsy a drop in Hgb of 1.0g/dL is no problem

radiology lecture

dont need chest ct for pneumonia should be able to use cxr, persistent pneumonia is indication for chest ct

indications

known interstitial lung disease

f/u to therapy

lung ca staging

immunocompromised

for pulmonary embolism test is CTA

aneurysm ask for contrast and noncontrast, noncontrast first to see acute blood

ascending aorta is surgical management, descending is medical management

anterior mediasinal mass differ

Teratoma

Terrible lymphoma

Thymoma

Thyroid tumors

Thoracic aorta

air bronchograms are airways traversing through consolidated lung - alveoli are filled

clinical notes

80% of all GI bleeds UGIB - dx includes PUD, varices, AVM, GAVE, gastritis

fecal antigen test for H. pylori ~100% sensitive

pepto bismo makes stool look melanic

mycobacterial infections increased in north carolina because greater numbers of them in the soil

anti dsDNA antibodies used to monitor lupus

doing an LP? send for VZV, EBV, HSV, AFB, bacterial, india ink, toxo, jc and lyme

"cant correlate response to tx of crypto meningitis by using titers, use clinical symptoms, you can follow serum titers"

tx amphotericin and fluconazole

ICP>25cm should be drained

HCV Ab takes ~12wks to seroconvert but when do are 98% sensitive

acute HAV big rise in ALT ~2months,

dont be fooled- hep B surface antibody can go away (become undetected) patient still has immunity

HBV mainly sexually transmitted disease

tx - IFNalpha2b nucleotide/side inhibitors,

pros - 1 year treatment, increased clearance

cons - subq injection, depression/psych side fx

15-40% will clear acute HCV infxn

normally transmitted parenterally (blood to blood)

test is elisa if + then look for RNA,

HCV elisa false negative w/early test and immunosuppressed

normal ALT does not rule out HCV

HCV tx PEG-IFNalpha

random fact - dysgeusia - an alteration in taste

c. diff colitis can occur 6months after abx

mammography guidelines - 40-50 nada (would need to expose 3000 women to ten years of radiation to pick one cancer)

50-60 every two years, 60+ yearly

mammography not a great screen for young denser breast tissue anyway

Mollaret's meningitis - recurrent HSV-2 mediated

"gastric ulcer bleeding is arterial- not venous"

"an ulcer in the antrum is almost never cancerous"

ulcer healing while on PPI ~90%, while on ranitidine/famotidine -85%

when you get ulcers in the antrum the problem is pyloric stenosis

risk of PUD - bleeding and perforation

Obstruction? differential - malignancy, crohn's, pancreatitis, gastric polyp, tb, gastric bezoars (foreign body)

IgG4 deficiency predisposes to atelectasis

heard on the wards-

"patient complains of losing hearing? check the ear for cockroaches"

senna/docusate - softens bowel movements

dulcolax/miralax/enema -heavy duty

"don't give epi/terbutaline for asthma exacerbation to patient w/htn and h/o cad or other risk factors, iatrogenic MI well described"

pulmonary

contraindications to permissive hypercapnia

1. pregnancy

2. increased ICP

heliox - 70/30 blend of helium and o2 allows for more laminar flow, have to reset ventilator settings

inhaled anesthetics are great bronchodilators