Individual plans are offered by third-party payers directly to individuals. About fifteen million Americans have individual plans; approximately ten million of them have individual plans with commercial companies, four million with Blue Cross/Blue Shield, and one million with HMOs. Individual plans offer four basic kinds of policies: major medical policies, hospital-surgical policies, hospital indemnity policies, and dread disease policies. The best coverage is under major medical policies: they typically pay for hospital care, physicians’ fees, laboratory tests, drugs, ambulance services, and skilled nursing facilities. Hospital-surgical policies pay for hospital and surgical services only. Hospital indemnity policies pay a fixed amount only while a person is hospitalized. Since a typical amount paid is $75 a day, and since the average hospital charge per day is ten times higher, hospital indemnity policies are regarded as a rip-off. Dread disease policies will generally not provide coverage for people who already have the dread disease. Individual plans have different requirements for eligibility, cover different services, and reimburse at different rates than group plans. Generally, an insurer will cover some percentage of your medical costs if you continue to meet certain conditions: if you pay your premiums; if you have not reached some (usually extremely high) upper limit or cap on expenses; if you ask the company to pay for only those items they contracted to pay for; and if you do not seem to pose to them an unacceptably high risk. For commercial insurance companies and Blue Cross/Blue Shield, risks are classified as (1) standard, for which the insurer will supply standard coverage at the usual rates; (2) substandard, for which the insurer will supply coverage at increased rates or will exclude coverage for some medical condition; and (3) denied, for which the insurer will supply no coverage. For HMOs, risks are either acceptable or unacceptable: that is, HMOs will either accept you at the usual rate or they will deny your application. For insurers, virtually all people with AIDS, cancer, coronary artery disease, and diabetes pose unacceptably high risks. To assess the risk you pose, all private, third-party payers (that is, all private insurers) use similar mechanisms. You must fill out an application, which includes a health questionnaire. Nearly all health questionnaires include questions about HIV infection: for example, Have you ever had AIDS, ARC, or tested positive for HIV infection? Other questions may ask whether you have or ever had symptoms of HIV infection. Still other questions may be about drug abuse, age, and occupation: these questions are triggers for the insurer to scrutinize the application further. Questions about sexual orientation are also triggers, despite the fact that such questions violate the guidelines of the National Association of Insurance Commissioners. When you apply for an individual plan, the insurer will request your medical records. Everyone applying for individual insurance must authorize the insurer to request medical records. The insurer might also request a statement, called an Attending Physician Statement, from your physician. Your medical records must be complete, including HIV status. Withholding or falsifying any information on a medical record is grounds for the insurer to deny payment and cancel the policy. Most insurers also require the applicant to take a medical examination. Whether an insurer can require you to take an HIV antibody test is still a matter of legal argument. Some insurers require HIV antibody tests for all applicants for individual plans; most will require the tests if the answers on your health questionnaire merit the test. California and Washington, D.C., have banned HIV antibody testing but allow insurers to use CD4 counts instead. What insurers want to rule out with all these questions and tests and checks is what they call a preexisting condition. A preexisting condition is defined by the National Association of Insurance Commissioners as “the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment,” or as “a condition for which medical advice or treatment was recommended by a physician or received from a physician within a five-year period preceding the effective date of coverage.” In short, a preexisting condition is a medical condition for which you have received advice or treatment (assuming you are an ordinarily prudent person) from a physician within the last five years. Some insurers will accept an applicant with certain preexisting conditions as a substandard risk; others will deny the application for the same condition. To be certain the applicant does not have a preexisting condition that has escaped everyone’s notice, insurers usually enforce a waiting period—usually a matter of months—between the time of application and the time coverage begins. If, during the waiting period, the applicant shows no evidence of a preexisting condition, the company will accept the application and will pay eligible medical benefits. If you develop AIDS well after you enrolled in an individual plan with the insurer, by law that company is not permitted to drop you. The bottom line: An asymptomatic person with a positive HIV blood test does not fit the definition of having a preexisting condition. Insurers nevertheless will often deny the applications for individual plans from people with HIV infection. Some of these denials are being contested in court. Note that the preexisting condition rule affects people who apply for individual plans with a new insurer. For this reason, people with HIV infection who have a long-time plan with an insurer are often advised to stay with that insurer. You can find out the details of individual plans by reading your policy or by talking to your insurance agent.*205\191\2*
ligence is only one of the critical factors in the child’s ability to learn. There can be other problems. For example, reading is a complex task. The child must first see the letters and the seeing must then be translated into electrical signals in the eye. These signals are then sent to the occipital lobe of the brain. From there the message goes to the association areas of the brain in the parietal lobe where the symbols are interpreted. Meaning comes from association with something that the child remembers, memories which must be retrieved from the frontal and temporal lobes.Thus problems with reading could occur at many levels. A child with visual problems who needs glasses may not be able to see the letters. A child with damage in the occipital lobes might have normal eyes but might not “see” the letters. One with damage in the association areas of the brain might be able to see the letters but might not be able to recognize them. Problems in other areas might keep him from being able to retrieve the memories that give the words meaning. These varied difficulties with reading often go under the heading of “dyslexia.” “Dys-” means not working properly, and “lexia” means having to do with words. In most children the basic cause of the dyslexia is not understood. There clearly is a higher incidence of this type of learning problem in children with epilepsy.242\208\8*
Sometime with thrombosis or thrombophlebitis of a deep vein, a portion of the thrombus becomes detached and travels through the veins to the right side of the heart and is then pumped into the lung circulation, where it blocks an artery in the lung. This is called pulmonary embolism.Symptoms of Pulmonary Embolism.Depending on the size of the pulmonary embolus, it can cause chest pain, shortness of breath, or cough (that may produce blood-streaked sputum). In extreme cases, loss of consciousness or even sudden death may occur.Pulmonary embolism may not be suspected, especially if the person has heart and lung disease already. Prompt diagnosis is critical, because about 10 percent of people with pulmonary embolism die within the first hour.Who Is Affected by Pulmonary Embolism? Your risk of having a pulmonary embolus increases if you are confined or immobile for prolonged periods, in other words, the same conditions that are likely to cause deep venous thrombosis or thrombophlebitis. The most likely times for pulmonary embolism to occur are after surgery, stroke, heart attack, hip or leg fracture, or prolonged bed rest or inactivity (such as sitting for a long time in a plane or car). Your risk is also higher if you are overweight or if your blood has an abnormally high tendency to clot.*208\252\8*
“The people who are my support,” said Alan Madison, “also upset me most. My partner, when I came home from work early, gave that look of, ‘Oh God, he’s sick, he’s probably dying.’ ” Their caregivers’ worry about them occasionally seems to be a request for reassurance, as though they want the sick person to say, “No, I’m not sick at all. Nothing to worry about.” When people are tired and not feeling well and a little worried themselves, reassuring others is trying. Steven’s caregiver is his cousin: “My cousin gets too doting. She gives me her entire schedule and wants to know mine. But I can’t feel accountable to her—we’re both full grown—in spite of her good intentions.” People with HIV infection are extremely aware that they are affecting the lives of their caregivers. They worry that they are causing trouble and suffering, and they feel responsible for that. Perhaps they also occasionally feel some guilt for inflicting trouble on their caregivers. As a result, people with HIV infection protect their caregivers. Sometimes they keep worrisome information to themselves, or they minimize symptoms and pains. They say they don’t want to make the caregivers’ burdens any heavier. They worry that the caregivers will burn out and be unable to help them in times of urgent need. They also worry that no one is caring for the caregivers: “My cousin hasn’t had an easy life,” says Steven. “She lost her father, and now she’s losing me. She’s having a hard time and somebody should be watching out for her.” People with HIV infection are sometimes bothered by reassuring caregivers because they want not to be reminded of sickness, but to concentrate on getting well. Too often, what the caregiver expresses as sympathy sounds to the receiver like pity. The sick person sometimes hears the caregiver saying, “It must be awful to be you.” “That kind of sympathy,” says Steven, “makes me very uneasy.”
Whether caused by a gunshot, a fall from a balcony, a car or motorcycle accident, or a dive into a shallow pool of water a spinal cord injury requires immediate emergency medical assistance. Care must be taken at the scene of the accident to preserve the integrity of the spinal cord. This means that the injured person should be moved only by a professional who is trained in the proper protocol. Stabilizing the neck and transferring the patient onto a backboard – a flat board or stretcher-are usually the first steps taken by the emergency medical technicians. The backboard is placed securely into an emergency vehicle, and a swift journey to a trauma center or hospital follows. Sometimes helicopters do the transporting. On reaching the hospital, the injured person is rapidly transferred to the Emergency Room (ER). Time is of the essence.Franklin remembers bits and pieces of his trip to the hospital, emergency treatment efforts, and the fears and feelings swirling through his mind. At this point, injured people often have an awareness of their surroundings but no real understanding of what has actually happened. You may be thinking, “What’s going on? What’s wrong with me? Where’s my family?” Questions may float through your mind but you maybe too stunned to ask. Events seem beyond you. You feel as if you’ve been transported into someone else’s life. There is pain. There is no pain. Your headache is like no other you’ve experienced. Time whizzes by. Time is in slow motion.If you remember the trip to the hospital, you may recall the board on which you arrived and the doctors and nurses examining you. You may remember chaos in the ER, and the sudden appearance of family members and how they reacted, whether with tears or with stiff upper lips. After a quick visit, your family was probably escorted to the waiting room, and you were on your own again with medical staff.
Certain symptoms are suspicious and should be given serious consideration. Not long ago a state cancer organization asked 158 people with cancer why they had delayed so long in seeking medical attention with their problem. One half of them said that they had not taken it seriously. Two had hesitated because they were afraid of cancer and two because they were afraid of doctors. Ten per cent said that they just had not bothered about it, and another 10 per cent were afraid that it would cost them something to see the doctor. This information is enlightening, since we know that hundreds of thousands of lives could be saved today if people would just bring their symptoms soon enough to the attention of competent physicians and surgeons.Whenever a lump appears underneath the surface of the body and does not go away the symptom must be considered suspicious. Whenever there is bleeding or a discharge, from any portion of the body, that is not easily explainable the symptom is a warning sign. Whenever a sore or rubbed area in the body does not heal promptly, investigation should be made immediately. Cancers that may be seen and felt easily are those on the skin, in the mouth, or in the breast. Women are much less likely to suffer cancers of the skin than are men, because women are much more careful about the appearance of the surface of the body. Men suffer more cancers of the mouth than do women. Cancers of the breast, however, are far more frequent in women than in men. The most frequent cancers which cannot be seen or felt but which warn of their presence by unusual symptoms such as bleeding and discharges are cancers of the urinary bladder, the kidney, or the organs concerned in childbirth.Pain is a relatively late symptom in cancer. Pain is likely to cause people to seek medical attention promptly; but other symptoms usually come before pain. Cancers which cannot be seen and which do not give any external signs of their presence are those of the stomach, the bowels, or the lungs. Hoarseness that persists more than a short time, and particularly hoarseness that does not go away after the voice has been rested, may be considered a danger signal. Many a man with serious symptoms affecting his stomach satisfies himself with a dose of baking soda. This is like pouring water on a fire bell when the fire is burning in the house.*2/318/5*
Sthe compulsions that crippled Howard Hughes, as well as those affecting his fellow OCD sufferers, can be divided into two groups’, behavioral (observable acts) and mental (thought rituals).Behavioral compulsions include all the classic and well-recognized OCD rituals. Hughes was troubled primarily by washing and checking, the two most common types of severe compulsions. Another widespread behavioral compulsion is asking for reassurance. Other common examples include hoarding, repeating, tapping, and ordering.
Washingmany experts think that washing is the single most prevalent type of behavioral compulsion. Judith Rapoport, M.D., of the National Institutes of Health, a top OCD researcher and author of the acclaimed book, The Boy Who Couldn’t Stop Washing, reports that more than 80 percent of the people who come to her clinic for treatment of OCD have been bothered at some time by washing rituals.At the root of washing compulsions, not surprisingly, is an obsession that a part of the body is unclean. Washing eases the feeling temporarily, but once the scrubbing is done, the thought returns. More scrubbing follows. Dermatologists are often the first to diagnose this disorder, as people frequently seek treatment for the skin damage caused by this excess.Handwashing compulsions are OCD’s most recognized symptom. They are, indeed, the hallmark of the disorder. A typical example is provided by a math teacher:
I get to thinking that my hands are unclean in some way. It’s not that they look dirty. And it’s not that I imagine germs on them, either. It’s just that I have this feeling they’re unclean. So I’ll lather them up good, wash them for a couple minutes, and dry them carefully. But pretty soon I’ll touch something and then I’ll get the feeling again. Some evenings after work I wash my hands every five minutes. They’re in bad shape. I have to put medication on them and wear gloves when I sleep.
The most famous description of excessive handwashing is found in Shakespeare’s Macbeth:
doctor: Look how she rubs her hands.gentlewoman: It is an accustomed action. … I have knownher to continue in this a quarter of an hour. lady Macbeth: Yet here’s a spot. . . . Out, damned spot! Out,I say! . . . will these hands never be clean? . . . Here’s thesmell of blood still: All the perfumes of Arabia will notsweeten this little hand.
Although this would seem to be a good description of compulsive washing, in the context of Shakespeare’s play it probably does not represent true OCD. Lady Macbeth’s handwashing occurs during sleepwalking, and her ritual is driven not by clinical obsessions but rather by depressive delusions or preoccuptations fueled by her guilt over Duncan’s murder.
Checkingchecking compulsions is also very common. A recent study of 250 consecutive patients from Harvard’s outpatient OCD clinic found that 63 percent complained of checking rituals.With this type of compulsion, a person must examine a situation over and over to make sure that no harm will come of it. Obsessions such as, “Is the gas shut off?” and “Are the doors locked?” drive the checking. A young wife described the torment and disruption that these rituals can cause:I stand there and turn the light switch off and on, off and on, off and on, off and on. I can’t make myself stop. It’s crazy. What happens is that I have the thought that maybe I didn’t completely turn it all the way off. Maybe the switch is somewhere inbetween the off and on position and a fire will stat because of a short circuit. I know that this does not make sense. Still, I have to keep on switching back and forth until I get it just right. I might stay there for ten or fifteen minutes. One time the light switch started smoking. Now my husband swears at me and yells, “Leave the light switch alone of you really will start a fire!”
Requesting Reassurancethis type of compulsion tests the patience of family members more than any other. Here, a sufferer becomes obsessed that something terrible has happened and is compelled to coax a pledge from another person that everything is okay. “I didn’t hit anybody with the car, did I?” “That lump doesn’t mean I have AIDS, does it?” The OCDer asks over and over, unable to stop, knowing the answer she’ll get, but needing to ask again anyway. Reassurance must be endlessly provided. A newlywed explained how her marriage was almost on the rocks due to her reassurance compulsions:1 love my husband more than anything. But I get the crazy thought that I might be interested in other men. I’ll be walking in the mall and I’ll notice a handsome guy, and afterward I’ll get to wondering ifI looked at him too long, if maybe that means I’m interested in him. I’ll worry all day; I can’t stop myself from thinking that I might have had thoughts of unfaithfulness. Then, because I feel so guilty, I’m driven to tell my husband. I know it makes him feel bad, but I have to. He says that it’s okay, that he knows I’m not interested in anyone else. Then I feel better. But I’ve been doing this every day, and it’s driving him nuts.Hoardinghere, the natural tendency to save things is stretched to a pathological degree. A young man whose apartment was more than half filled, floor to ceiling, with magazines and newspapers explained that he was afraid to throw an article away because he might later remember that there was something critically important in it. Then, if he couldn’t find it, he might get so upset that he would have a nervous breakdown.Repeatingwhen a routine action is repeated compulsively, and when— unlike in washing, checking, reassurance, and hoarding rituals—it bears no logical relationship to the obsession preceding it, this is called a repeating compulsion. One student, when struck by a harm obsession, compulsively repeated the action he was engaged in; this could be combing his hair, crossing his legs, or writing his name. Several quick repetitions usually sufficed to chase away the obsession. Repeating compulsions often must be performed a certain specific number of times. A young woman, in response to “a feeling of dread,” scratched her head, brushed her teeth, or chewed on Life-savers four times, no more no less.Rubbing, Touching, and Tappingthese common compulsions also defy logical analysis. A student with harm obsessions needed to tap her fingers ten times to prevent her tormenting thought from coming true.Orderinghere, items must be arranged so that they are “just so.” These rituals differ a bit from all others: They occur frequently in young boys, and their corresponding obsessions are often hard to identify.It has been hypothesized that ordering compulsions bear some resemblance to another kind of abnormal, repetitive action, the jerky movements referred to as “tics.” Ordering compulsions may represent a hybrid symptom between OCD and the related neurological disorder of tics, Tourette’s syndrome.*13/338/2*
Cost-EffectivenessCost-effectiveness studies have suggested benefit from antibiotic prophylaxis, but the assumptions inherent to these studies were inappropriate, limiting the usefulness of their conclusions. Two recent analyses were performed – one in the general population and one in patients with mitral valve prolapse. The study in the general population assumed that antibiotic prophylaxis is 100% effective, which is unlikely, and that 15% of IE (Infective Endocarditis) cases are related to dental procedures, although this number has been estimated to be closer to 4% to 10% in other studies. The mitral valve prolapse analysis also assumed 80% efficacy. Further study in this area is needed, with application of more accurate estimates of patient and physician adherence to recommendations, effectiveness of prophylaxis, and updated costs of complications of endocarditis and costs of antibiotic use.
Considering ReferralThe current recommendations for antibiotic prophylaxis of IE are designed to facilitate widespread application by primary care physicians. Some possible reasons for referral would include the work-up of an undiagnosed murmur, clarification of a congenital heart defect, or suspected penicillin allergy.*51/348/5*
Because the skin forms the covering of the body we do not associate it directly with the digestive processes. Yet if we are to understand the true function of the skin, and be in a position to take care of it so that it remains in a healthy condition, we must appreciate the fact that is intimately associated with the nutrition of the whole body. As we have already pointed out, all the cells of the body live in a fluid medium; from this medium they get their nutriment, and into this medium they return the waste products of their own activity. It is therefore true to say that it is in this intercellular fluid that the final digestive process is carried out.There is a direct connection between the alimentary tract and this fluid medium, and in the normal state of affairs a perfect balance is maintained. But this balance can be upset by indiscretions in eating, because if the stomach and the bowels are disturbed by overloading the end-results of the pressure will be felt in the inter-cellular fluid. This will mean that the fluid will be under stress of having to deal with too much nutriment and, at the same time, unable to stem the rising tide of increased cell activity. This is probably the first step in the making of congestion, which in turn is the first stage of what we call disease.Such congested tissues lead to disorders of the circulation, because, as we have already shown, the “sea-water” of the body depends for its movement on the circulation of the blood and the lymph, and the thickened inter-cellular fluid will not circulate so freely through the small vessels. We shall not get very far if we merely try to increase the circulation by mechanical and other means, because, as we have explained, the pressure from the overloaded digestive organs is at the bottom of most of the trouble.The skin is very much involved in such conditions, because the great network of connective tissues lying in and under it, are great reservoirs of inter-cellular fluid. When the congestion occurs in this area the skin begins to show the effects of it, and if we draw the fingers with pressure over it, large red weal will follow the course of the fingers. That is a very sure sign of congestion in the tissues of the skin, and out of this condition a great many troubles will develop. It is the basis of many acute skin complaints, especially those that have their roots in digestive disorders; for we shall find that at the back of the congestion lie the errors of nutrition that are so easily overlooked.It is clear, therefore, that a healthy skin is directly dependent on the dietetic habits of the individual, and that it can be affected more quickly through this medium than in any other way. The habit of overeating, especially of heavy starchy and sugary foods, will affect the health of the skin much more quickly than many people imagine, and a diet deficient in mineral salts and vitamins will produce typical disorders in the skin. If the diet is lop-sided and contains too much of one kind of food, the alkaline balance of the fluids of the body may be disturbed and the connective tissue in and under the skin will become swollen with fluid. All these conditions are end-results and need no direct treatment. They need tackling at their source, i.e. in the disorders of the digestive tract.From these observations it is clear that the health of the skin must be considered in direct relationship to the food that is eaten, and it follows that the diet must be evenly and properly balanced. In spite of, or perhaps because of, the increased knowledge we have of the vitamin content of foods, the need for balancing the diet still remains.
Stress is so important in PMS that it warrants this whole chapter of its own. The research just emerging shows mat PMS and stress go hand-in-hand. If you have a lot of stress in your life you are more likely to develop PMS. Women with PMS often have more stress in their lives than women without the condition, according to Dr Jane Chihal from Texas, USA.”Perhaps stress predisposes the patient to PMS or perhaps the syndrome can be perceived as a type of inner stress. If a patient also experiences external stress, the total stress “load” may exacerbate the severity of her symptoms,” she says.Typical signs of built-up stress:• inability to sleep properly• unexplained aches and pains• indigestion• feeling tired all the time• a reefing of having too much to do and loo little time to Soft• uncontrolled eating• chain smoking• drinking too much alcohol• lack of Interest In sex• crying for no reason• outbursts of temper• sweating/palpitations• shortness of breath and/or dizziness• feeling tired as soon as you wake up• twitching muscles, especially the eyesIf you recognize several of these signs in yourself then the alarm bells should be ringing. You could be under too much stress.*39\120\4*