Medicare Reimbursement During the Gonvernment Shutdown.

According to this article, it is unlikely that medicare reimbursement checks will stop going out to physicians.  This did not occur during the last shut-down either.  New medicare applicant's applications will likely be delayed.  However, government contractors will not be paid, which means for those of us going to the VA as a contractor may be affected.


"A program like Medicare involves a variety of services, many of which would be considered essential to the public. For example, a federal government shutdown would not prevent Medicare recipients from receiving health care. During the last shutdown, Medicare even continued to pay physicians and hospitals. However, due to some of the staff being furloughed, there were about 400,000 new Medicare applicants who were delayed.  With a government shutdown potentially around the corner, a program covering such a large population is bound to draw attention. Not to mention the program costs almost $700 billion per year, making up almost a

 quarter of federal spending and covering about 43 million people, 7 million being under-65 disabled people. Additionally, almost half of those covered by Medicare are considered from low-income households. Therefore, a large number of Americans would be impacted if portions of Medicare were shut down, and a large number of them would be unlikely to have the resources to cover their own medical care if there were some hold up.

Fortunately, Medicare recipients were largely unaffected during the last federal government shutdown, and would likely be unaffected if the government shuts down on April 8. However, if there is some effect, even a relatively small one, it would be drastic considering the breadth of the program and circumstances of those relying on it."



Full link here:  http://www.associatedcontent.com/article/7906973/who_will_be_affected_by_a_federal_government.html?cat=62

REPOST: Medicare Panel Recommends 1% Physician Pay Boost in 2012

Washington -- Lawmakers should increase Medicare payment rates to physicians and prevent a massive across-the-board cut set for 2012, the Medicare Payment Advisory Commission recommended in its annual March report to Congress.

 The commission suggested a 1% increase in doctor pay in place of the scheduled reduction. [DY: As if the 1% raise is at all realistic while the SGR cut is still dangling over our heads.]  The report was released March 15, days after the Centers for Medicare & Medicaid Services projected that doctor pay faces a 29.5% cut next year under the sustainable growth rate formula.
The MedPAC recommendation is not binding on Congress, although lawmakers sometimes use the advice as a starting point for congressional negotiations on preventing upcoming pay cuts. The 2012 reduction is the largest that physicians have faced to date.

"The AMA concurs with MedPAC's conclusion that the nearly 30% cut built into Medicare's payment system for 2012 would jeopardize access to physician services for many patients and should be replaced with a positive update to help offset increases in practice costs," said American Medical Association President Cecil B. Wilson, MD.

"The current Medicare physician payment formula is broken, and the AMA will work with MedPAC and policymakers on both sides of the aisle to replace it with a system that better reflects the costs and practice of 21st century medical care and provides stability for physicians and their Medicare patients."
....

Full article here:  http://www.ama-assn.org/amednews/2011/03/21/gvl10321.htm

Does Latisse Pose a Risk in Patients with Undiagnosed Blepharitis?

A patient was seen in our practice recently for hypotrichosis. She had asked for Latisse(brimatoprost 0.03%, Allergan) but was turned down by previous ophthalmolgoist. We in turn had the same opinion, as she had severe blepharitis, which resulted in thin brittle lashes that were in different stages of growth, and empty follicles. We placed her on Restasis(cyclosporin 0.05%, Allergan) instead, and after 3 months, she now has full healthy lashes and is very pleased. Another patient of mine returned to me recently after she was prescribed Latisse at a spa. She was a long-time patient of mine and had extensive history of blepharitis. While there was no flare-up of her blepharitis, I was disquieted that another clinician prescribed an eye medicine without consulting the ophthalmologist, especially a medicine that in my opinion may be contraindicated in her case. Nor did that clinician arrange any followup.

Further research into Latisse's relationship to blepharitis revealed several areas for concern. First it is so far not well-studied. While prostaglandin analogs' effect on lash growth is wellknown in the ophthalmic community, actual publications on brimatoprost and hypotrichosis treament is surprisingly sparce. the most commonly cited source is a single case-report by Tosti in 2004. Many ophthalmologists have opined that blepharitis is a contraindication for brimatoprost use for lash growth, but few have offered evidence. Allergan's own package insert describes a "multicenter, doublemasked, randomized, vehicle-controlled, parallel study including 278 adult patients for four months of treatment" Inclusion criteria was not described, nor is the study available to the public. Therefore it is not known if blepharitis was an exclusion criteria. However, an ongoing study registered by allergan, titled "Safety and Efficacy Study of Bimatoprost to Treat Hypotrichosis of the Eyelashes After Application to the Eyelid Margin" does list preexisting blepharitis as an exclusion criteria. This Phase III tri-armed study (NCT00907426) was listed as received in May 2009 and "recruiting" as of Feb 6th, 2010. It is not clear the relationship between this study and the safety study listed in Latisse pocket insert. While it is reasonable to exclude blepharitis, which is a known cause of hypotrichosis, from an efficacy study, it calls into question its applicability to the general population, where blepharitis is a extremely common condition.

This leads to the second concern, which is that a common medical condition that is a known cause of hypotrichosis is not addressed in the promotion of this product. Blepharitis is listed as number six under "adverse reactions" in the package insert, and not listed under "Contraindication". Furthermore the adverse reactions section was quoted from previous studies involving brimatoprost in the IOP-lowering role, which used the same concentration, but a different vehicle. Therefore one is hard-pressed to accept Allergan's exclusion of blepharitis from the list of contraindications.

Lastly, the insert places a very limited role in physician consultation and follow-up. The patient is asked to see a physician prior to starting Latisse only if they are already on a prostglandin-analog for IOP-lowering purpose. Physician evaluation is recommended only if the patient:

develops a new ocular condition (e.g., trauma or infection), experience a sudden decrease in visual acuity, have ocular surgery, or develop any ocular reactions, particularly conjunctivitis and eyelid reactions.

This places the burden on the patients to seek medical help after their pre-existing condition has been made worse by the product, when it could have been prevented by prior screening.

As an aesthetic surgeon, I do believe that Latisse is a valuable addition to our practice. However I also feeel that without proper screening by ophthalmologists, a large portion of the general public will experience undue adverse reactions to this product, and will ultimately hinder the product's gevity, as well as the public's trust. The AAO in its San Francisco meeting in 2009, has issued it's position. First among it's recommendations is to "see a doctor before starting Latisse." While broader than Allergan's own recommendation, it should go a step further and recommend seeing an ophthalmologist specifically. A family physician or a dermatologist simply do not have the instruments to evaluate for the cause of hypotrichosis appropriately. As Eye MD's, we are the one with the tools and know-how to protect the public against this potential epidemic. In addition, clinical studies of brimatoprost's effect on blepharitis are sorely needed. Potentially, a new paradigm for the treatment of hypotrichosis may involve anti-inflammatory therapy in some, and growth-promotion in others. Incidently both modalities are now available through Allergan, as Latisse and Restasis.

P-3 vs. TG100-8

Myasthenia Gravis and Local Anesthetics

I have come across a second patient now with MG that exhibited poor analgesia from local anesthetic. A middle-aged female with MG and Hep C underwent external levator repair yesterday. Pain control was poor despite generous amount of subcutaenous infiltration. Paralytic effect was also poor, as orbicular muscle contracted vigorously during unipolar incision. Extra amount of local anesthetic was required, resulting in eventual paralysis of the levator muscle and inablity to assess function of repair on the table. Patient was also exquisitely sensitive to stretching of the levator muscle, even though already immune from pain when muscle pinched by forceps. She is complicated by (1) her hepatic disease which may alter metabolism of lidocaine, and (2) a hyperacute personality which may be equating tactile sensation to pain.

A year ago I performed a cataract phacoemulsification of a 80 year of female with MG. A retrobulbar anesthesia was given due to unsteady eye position pre-op and squeezing of lids. Despite a good RBB, patient regained movement of eye shortly after beginning of case, making rest of procedure more challenging. The procedure was otherwise uncomplicated.

I wonder if MG somehow hinders the efficacy of local anesthetic. A brief PubMed search under "MG and local anesthetic", "MG and lidocaine", and "MG and analgesia" has not turned out report of similiar cases or mechanisms proposed. MG affects the neuromusclar junction via antibody against the nitoctinic ACH receptor. ACh receptor activation normally leads to dipolarization of the muscle cell, involving Voltage-gated Na channels. Lidocaine works by blocking this channels. Therefore one mechanisms of poor akinesia by lidocaine in MG may be a subsequent up-regulation of these Na channels due to chronic ACh receptor suppression. Literature search found only one paper on the subject, which reported DECREASE of Ach and Na channels at the endplate. Marx A, Siara J, Rüdel R Sodium and potassium channels in epithelial cells from thymus glands and thymomas of myasthenia gravis patients.

Association may be complicated as MG comes with other autoimmune conditions. Also, a second type of the MG has been identified that affects MuSK (muscle specific kinnase).

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Gravitational Lensing, Gravitational "Streaking"?

An interesting phenomenon called "gravitation lensing" is caused by a massive object such as a star or a black hole, that intervenes between a distance light source and an observer. This is caused by the bending of light near the gravitational well. Unlike a classical lens which bends light the greatest at the periphery, the gravitation lens bends the light greatest at the center, and weakest at the periphery.





















Thus, instead of a focal point, it has a focal line. And instead of a point image, it produces a ring of light, called the Einstein ring.



























This phenomenon has been used to estimate the size of the intervening object, the "lens", which otherwise cannot be oberved due to lack of native luminance. Here is an animation of the effect of a beam of light moving behind a black hole.


As an ophthalmologist, one would immediately notice the "against" motion of the lens arc, ie, while the light is moving down and to the left, the arc moves in the opposite direction. Imagine the light streaking across comes from a retinoscope, and us the observers are sitting at the back to the retina, i.e. earth, we could conclude that the grativational lens is of plus-power.

While there is no giant hand streaking the distant light source back and forth, the angular motion of the source light relative the lens may be induced either by the motion of the earth, "parallex motion", or of the sun "proper motion". Therefore, it is reasonable to hypothesize that the speed by which the arc migrates may be related to the mass and the relative distances of the lens system. Currently the mass is already able to be calculated by the lens effect, and distance is estimated by red-shift. But this "gravitational streaking" may be useful in aiding their calculations.

PET scan and Sexual Orientation

An article in the July 8th, 08's Proceeding of National Academy of Science boasted this grabbing title: "PET and MRI show differences in cerebral asymmetry and functional connectivity between homo- and heterosexual subjects"

Here's a telling image: Area activated is the amygdalae, the center for pheramon sensing and emotional learning. The study suggests heteralsexual men exhibit unilateral activation, while heteralsexual women exhibit bilateral activation, which is reverved in homosexual men and women.