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July 7, 2015   Download print version

Complications of artery-hardening condition are no. 1 killer worldwide

CMS and AMA announce efforts to help providers get ready for ICD-10

Industry payments to nurses go unreported in Federal database

According to a new study, we are taller and smarter than our ancestors

HHS awards improve healthcare, public health preparedness

Is your supply chain ready for the congestion crisis?

Dermatologists say popular sunburn art can lead to cancer

The U.S. just recorded its first confirmed measles death in 12 years


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Self Study Series:
July 2015

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Complications of artery-hardening condition are no. 1 killer worldwide

Doctors’ efforts to battle the dangerous atherosclerotic plaques that build up in our arteries and cause heart attacks and strokes are built on several false beliefs about the fundamental composition and formation of the plaques, new research from the University of Virginia School of Medicine shows. These new discoveries will force researchers to reassess their approaches to developing treatments and discard some of their basic assumptions about atherosclerosis, commonly known as hardening of the arteries.

“The leading cause of death worldwide is complications of atherosclerosis, and the most common end-stage disease is when an atherosclerotic plaque ruptures. If this occurs in one of your large coronary arteries, it’s a catastrophic event,” said Gary K. Owens, PhD, of UVA’s Robert M. Berne Cardiovascular Research Center. “Once a plaque ruptures, it can induce formation of a large clot that can block blood flow to the downstream regions. This is what causes most heart attacks. The clot can also dislodge and cause a stroke if it lodges in a blood vessel in the brain. As such, understanding what controls the stability of plaques is extremely important.”

Until now, doctors have believed that smooth muscle cells – the cells that help blood vessels contract and dilate – were the good guys in the body’s battle against atherosclerotic plaque. They were thought to migrate from their normal location in the blood vessel wall into the developing atherosclerotic plaque, where they would attempt to wall off the accumulating fats, dying cells and other nasty components of the plaque. The dogma has been that the more smooth muscle cells there are in that wall, particularly in the innermost layer referred to as the “fibrous cap”, the more stable the plaque is and the less danger it poses.

UVA’s research reveals those notions are woefully incomplete at best. Scientists have grossly misjudged the number of smooth muscle cells inside the plaques, the work shows, suggesting the cells are not just involved in forming a barrier so much as contributing to the plaque itself. “We suspected there was a small number of smooth muscle cells we were failing to identify using the typical immunostaining detection methods. It wasn’t a small number. It was 82 percent,” Owens said.

Suddenly, the role of smooth muscle cells is much more complex, much less black-and-white. Are they good or bad? Should treatments try to encourage more? It’s no longer that simple, and the problem is made all the more complicated by the fact that some smooth muscle cells were being misidentified as immune cells called macrophages, while some macrophage-derived cells were masquerading as smooth muscle cells.

Researcher Laura S. Shankman, a PhD student in the Owens lab, was able to overcome the limitations of the traditional methods for detecting smooth muscle cells in the plaque. Further, Shankman identified a key gene, Klf4, that appears to regulate these transitions of smooth muscle cells.

Remarkably, when she genetically knocked out Klf4 selectively in smooth muscle cells, the atherosclerotic plaques shrank dramatically and exhibited features indicating they were more stable, the ideal therapeutic goal for treating the disease in people. Of major interest, loss of Klf4 in smooth muscle cells did not reduce the number of these cells in lesions but resulted in them undergoing transitions in their functional properties that appear to be beneficial in disease pathogenesis. That is, it switched them from being “bad” guys to “good” guys.

The discoveries have been outlined in a paper published online by the journal Nature Medicine.



CMS and AMA announce efforts to help providers get ready for ICD-10

With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1 deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.

Recognizing that healthcare providers need help with the transition, CMS and AMA are working to make sure physicians and other providers are ready ahead of the transition to ICD-10 that will happen on October 1. Reaching out to healthcare providers all across the country, CMS and AMA will in parallel be educating providers through webinars, on-site training, educational articles and national provider calls to help physicians and other healthcare providers learn about the updated codes and prepare for the transition.

The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms. The use of ICD-10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative payment models that drive quality of care.

CMS’ free help includes the “Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation.

The AMA also has a broad range of materials available to help physicians prepare for the October 1 deadline. To learn more and stay apprised on developments, visit AMA Wire.

In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes. Visit CMS for the release.



Industry payments to nurses go unreported in Federal database

A nurse practitioner in Connecticut pleaded guilty in June to taking $83,000 in kickbacks from a drug company in exchange for prescribing its high-priced drug to treat cancer pain. In some cases, she delivered promotional talks attended only by herself and a company sales representative.

But when the federal government released data on payments by drug and device companies to doctors and teaching hospitals, the payments to nurse practitioner were nowhere to be found.

That's because the federal Physician Payment Sunshine Act doesn't require companies to publicly report payments to nurse practitioners or physician assistants, even though they are allowed to write prescriptions in most states.

Nurse practitioners and physician assistants are playing an ever-larger role in the healthcare system. While registered and licensed practice nurses are not authorized to write prescriptions, those with additional training and advanced degrees often can.

A ProPublica analysis of prescribing patterns in Medicare's prescription drug program, known as Part D, shows that these two groups of providers wrote about 10 percent of the nearly 1.4 billion prescriptions in the program in 2013. They wrote 15 percent of all prescriptions nationwide (not only Medicare) in the first five months of the year, according to IMS Health, a health information company.

For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are among the top prescribers.

Asked whether payments to these providers should be reported, a spokesman for the Centers for Medicare and Medicaid Services, which manages the disclosure system, said: "Nurse practitioners and physician assistants are currently not covered recipients under the statute for Open Payments."

Visit NPR for the story.



According to a new study, we are taller and smarter than our ancestors

New studies of the global population have given a report that we are apparently taller and even smarter than our ancestors. Even though part of that statement might seem kind of obvious, the new studies of global populations was analyzed by a team of researchers at the University of Edinburgh and came to a conclusion that, indeed, we have picked up some adaptations.

This collective study followed at least 100 total studies over many years, discussing the details of 350,000 people from both rural and urban communities.

Dr. Peter Joshi, who is from the University of Edinburgh’s Usher Institute said in a statement that their research answered questions first posed by Darwin as to the benefits of genetic diversity.

He goes on to say that their next step will be to hone in on the specific parts of the genome that most benefit from diversity. He also added that what they didn’t measure is what’s happening in this generation. He said factors that affected people’s lives years ago are very different today. This was after looking back over evolutionary times.

Joshi also said in a statement that if you inherit two identical defective genes from the mother and father you’re going to reduce brain size and function. Why evolution has favored bigger brain size and higher cognitive function they could not say. He also said there were several further avenues they want to go down. They want to hone in on the genes genetic diversity affects the most. Visit the Dispatch Times for the story.



HHS awards improve healthcare, public health preparedness

Health departments across the country will receive more than $840 million in cooperative agreements from the U.S. Department of Health and Human Services to improve and sustain emergency preparedness of state and local public health and healthcare systems.

The cooperative agreement funds are distributed through two federal preparedness programs: the Hospital Preparedness Program (HPP) and the Public Health Emergency Preparedness (PHEP) programs. Nationwide, HHS awarded a total of $228.5 million for HPP and $611 million for PHEP in fiscal year 2015.

These programs represent critical sources of funding and support for the nation’s health care and public health systems. The programs provide resources needed to ensure that local communities can respond effectively to infectious disease outbreaks, natural disasters, or chemical, biological, or radiological nuclear events.

Approximately 24,000 organizations across the country form nearly 500 healthcare coalitions. Coalition members include hospitals, emergency medical service providers, emergency management associations, long-term care facilities, behavioral health organizations, public health agencies, and other public and private sector partners. Visit HHS for the release.



Is your supply chain ready for the congestion crisis?

Longer commute times are just one sign that congestion is creeping into our lives. Highways and bridges are in desperate need of repair, making travel slower—and more dangerous. Our overburdened air-traffic-control system struggles to deal with increasingly crowded skies. Port congestion is a growing problem, exacerbated by the new super-size container ships that take far longer to unload than older, smaller ships. “Expect delays” has become the recurring theme of our transportation system.

With growing congestion a global megatrend, companies have a choice. Either accept it (and its higher costs and lower profits) or take control of your fate with strategic, game-changing actions that cut time and costs from the supply chain.

First, it’s important to understand the magnitude of the coming congestion crisis and its underlying drivers. These include the following:

Not enough port container capacity. Until the summer of 2008, container ports on both the west and east coasts of North America were nearing capacity as imports and exports soared. Then the recession hit, and the problem receded as port traffic slowed. But now the problem is back with a vengeance. Shipment volumes through North American ports, which fell 20% in 2009 from a record peak in 2007, are now higher than they were in 2007, and port-expansion plans from Vancouver to Los Angeles/Long Beach are bogged down by political wrangling.

Railway systems are near capacity. For instance, the average transit times to move containers from the ports of Los Angeles and Long Beach to Chicago grew from 84 hours at the end of 2004 to 120 hours by early 2015.

Highways can’t keep up with demand. The highway systems in North America and Western Europe are also feeling the strain. The United States greatly expanded “lane miles”—one measure of capacity—in the 1950s, 1960s, and 1970s but not much since then. Meanwhile, the load factor on the system has been doubling every 30 years. Today, the load factor (total vehicle miles traveled divided by lane miles) is growing more than 10 times faster than capacity is.

Air freight isn’t the answer. Airports in North America are slowed by outdated traffic-control systems, limited runway capacity, and a shortage of fuel-efficient air freighters. In the last 40 years, only three major new airports have been built in North America: Dallas-Fort Worth, Montreal’s Mirabel, and Denver International. All of them replaced existing airports. Expansion of runway capacity in the United States also has been limited. Since 1975, just 41 new runways were planned, and only 25 were actually built, each with an average construction time of about 11 years! Lobbying by special interest groups got in the way.

The shortage of transport capacity relative to demand will have a profound effect on businesses. For instance, Procter & Gamble’s logistics costs already exceed such key value-adding costs as manufacturing, even though the company mainly ships by land. Longer supply chains also increase inventory levels and carrying costs related to financing and warehousing.

These are just the first-order costs of congestion. The second-order costs are even greater. Companies can easily match supply and demand if demand is steady over time with no change in volume or mix. But as soon as demand changes, supply levels at each step of the chain must adjust.

Given the lag time before changes in demand are actually felt by different players along the chain, their effects are amplified when they hit, leading to inventory shortages or pile-ups. Then, companies tend to overcompensate by stopping or increasing production lines, and inventory levels can fluctuate wildly. This is the “whipsaw” effect, and congestion can exacerbate it.

The associated costs can be significant: Lost profits from a stockout equal the gross margin of a product—generally in the range of 20% to 50%. Product overstocks result in discounted prices, which are usually about half to two-thirds of the gross margin. Congestion-driven losses from stockouts and overstocks are overwhelmingly greater than the direct costs of congestion but often remain hidden because they may not be measured or called out.

The bottom line: Companies must redesign their supply chains or become victims of the direct and indirect costs of increasing congestion.

The longer your supply chain is, the greater the risk of variability. But much supply-chain variability is self-inflicted, the result of inadequately informed planning and needless complexity in processes, products, and portfolios. Companies should also look for ways to shorten and simplify their supply chains by shifting away from high-volume, world-scale plants that make just a few products to smaller plants that make a wider range of products closer to local markets. Increases in unit-production costs are often offset by lower logistics costs, faster replenishment cycles and fewer stockouts and overstocks. The same logic can apply to distribution logistics when global distribution centers are replaced by regional warehouses. Visit Harvard Business Review for the report.



Dermatologists say popular sunburn art can lead to cancer

There is a warning by dermatologists to the public against a new trend in skin decoration known as sunburn art. Report from doctors says that this new trend is dangerous because as a form of sunburn it increases the risk of melanoma which is the most common kind of skin cancer in the United States.

This new sunburn art is created through the decorative use and placement of sunscreen on the skin, this is to create a specific symbol or design while exposing the rest of their skin to direct sunlight. They intentionally get extreme sunburns in order to highlight the design or mark of choice.

According to physicians, this activity can increase the risk of melanoma by as much as 50 percent. They also said that it causes the skin to prematurely age.

Reports from dermatologists states that extreme exposure to the sun’s rays can cause “fragmentation of collagen”. Collagen is what makes humans look fresh and young. Ergo, if fragmentation occurs it can cause the skin to look old and dull.

Recommendation from experts has it that before venturing out into the sun, people should apply a sunblock with a minimum of SPF 30. They further suggest that people reapply the sunblock once every three or four hours according to the manufacturer’s directions. They also note that people should use cream rather than spray as spray does not cover the skin entirely which renders it less effective. Visit the Dispatch Times for the article.



The U.S. just recorded its first confirmed measles death in 12 years

Health officials confirmed the country's first measles death since 2003, and they believe the victim was most likely exposed to the virus in a health facility in Washington state during an outbreak there.

The woman died in the spring; a later autopsy confirmed that she had an undetected measles infection, the Washington State Department of Health said in a statement. The official cause of death was announced as "pneumonia due to measles."

The woman was at a Clallam County health facility "at the same time as a person who later developed a rash and was contagious for measles," the health department statement read. "The woman had several other health conditions and was on medications that contributed to a suppressed immune system. She didn’t have some of the common symptoms of measles such as a rash, so the infection wasn’t discovered until after her death."

According to the U.S. Centers for Disease Control and Prevention, 178 people from 24 states and the District were reported to have measles from Jan. 1 through June 26 of this year. Two-thirds of the cases, the CDC noted, were "part of a large multi-state outbreak linked to an amusement park in California."

This newly confirmed case marks Washington's 11th reported instance of measles this year, and state health officials urged people to vaccinate against the virus. Visit the Washington Post for the article.