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Health plans certainly have as much incentive to change their business model as any actor in the healthcare system 10mg hydroxyzine fast delivery anxiety 8 weeks postpartum. If physicians face the crippling inability to take collective action and hospitals struggle with an anarchic clash of professional interests and cultures proven 10 mg hydroxyzine anxiety uncertainty management theory, then health plans will struggle with a legacy of paternalism and insensitivity to the needs of the consumer and family purchase hydroxyzine 10 mg amex anxiety games. Humana not only has invested $1 billion in the last four years to renovate and computerize its back office, but it has also invested in a suite of consumer applications to bring “consumer directed” health plan options to its members. Blending web-enabled health plan customization with sharp increases in cost sharing for hospital services, Humana was able to reduce its own employees’ health benefits cost escalation from 19 percent per year to under 5 percent in the first two years of its new plan. Delivering promised improvements in service is the true test of good intentions by health plans. If, as it is said in architecture, God is in the details, in e-commerce, God is in the back end. Adminis- trative systems in health plans need to be completely renovated and digitized for any of the promising Internet tools discussed above to make any difference. Properly executed, Internet applications can help health Health Plans 141 plans rebuild their relationships with hospitals and physicians by reducing or eliminating paperwork and bureaucratic interference with medical practice. Information technology enabled by the Internet can, again if properly executed, bring tangible benefits to consumers that will help them make constructive use of the choice they have demanded. In addition, information systems strategies can help health plans offset a significant percentage of the present cost rise with improved productivity and efficiency and more responsible consumer choices. Connectivity makes all organizations more transparent and ac- countable to customers. Health plans that embrace the need for openness and responsiveness will find their position in the health system strengthened in future years. The health plans that succeed in the digital transformation will not only survive, but also prosper. How government responds to these political pressures and how it structures payment for health services under the Medicare and Medicaid programs will affect both the speed and universality of the changes discussed in this book. Changing healthcare payment methodology Each of these issues will be discussed below. Personal health informa- tion is the most intimate documentary information that exists in the 145 U. Someone with access to this information knows a person’s most carefully guarded secrets—personal medical and psy- chiatric history, sexual orientation and history, lifestyles and their risks, drug history, and a lot of things about relationships with others. Insurers who see the totality of someone’s healthcare use can use that information to estimate how good or bad an insurance risk he or she may be in the future and decide not only if they wish to provide coverage, but also how much to charge for it. That patients disclose this information to physicians is vital to ensuring optimal care. Physicians require it because making intel- ligent treatment decisions is based on understanding medical and personal history and the impact of those decisions on health. If physicians cannot be trusted with intimate personal knowledge, the opportu- nity for injury or death escalates alarmingly. Yet this intimate doctor-patient relationship is really a three-way relationship, in which only two of the parties are physically present. Despite its intimacy, medical information is also among the most widely distributed and poorly protected personal information in our society. Thanks to federal legislation passed in the wake of the highly publicized Congressional hearings of Supreme Court Justice Clarence Thomas, video rental records were actually safer from dis- closure than a patient’s medical records. The main reason is that health costs have grown to the point that they are no longer an affordable personal respon- sibility. As a direct consequence, third parties, typically employers and the health insurers they hire to manage their health costs, de- mand access to this information.

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In Hertfordshire buy 10 mg hydroxyzine with visa anxiety heart rate, sixteen thousand men and women born between 1911 and 1930 were traced buy 25mg hydroxyzine amex anxiety natural supplements. Death rates from coronary heart disease fell steadily across the birth weight distribution such that rates at the higher end of the distribution were roughly half those at the lower end [4] buy hydroxyzine 25 mg on line anxiety vs panic attack. Findings from the Swedish cohort study, which followed up 14,611 babies, also supported the inverse association between cardiovascular disease and birth weight [5]. The associations of birth weight with these diseases were independent of lifestyle risk factors, including smoking and alcohol intake, and of socio-economic status. The developmental origins model of disease pathogenesis is supported by biological evidence from animal experiments. These have shown that alteration of maternal diet during pregnancy can modify offspring physiological processes, and that these modifications are lasting rather than transient [6]. Such a phenomenon is an example of phenotypic plasticity where a genotype can give rise to different physiological or morphological states depending on the prevailing environmental conditions during development. Studies in experimental animals have made it clear that the long-term effects of early life nutrition act through developmental changes to organs and tissues such as the pancreas, liver, kidneys, skeletal muscle and adipose tissue. Newborn size (equivalent to birth weight in human studies) is frequently used as an indicator of the intra-uterine experience, because it is easy to measure, but can only be a crude proxy of these changes at tissue level. Animal experiments have shown that overfeeding mothers with high fat or high energy diets, leading to maternal diabetes and obesity, will increase insulin resistance, diabetes and cardiovascular changes in their offspring [7,8]. Recently, there has been accumulating evidence that paternal diet, body composition and health can also affect the health of the offspring [9]. Low birth weight, an indicator of poor nutrition in utero, is associated with higher infant mortality, poorer educational outcomes in childhood and poorer long term health [11]. Social, psychological and occupational exposures during infancy, childhood and adult life will modify risk of ill health and disease. Maternal Nutrition Observational evidence of a link between early life and later disease has led to an interest in maternal influences on the development of the fetus. A girl or woman’s nutritional status before and during pregnancy influences outcomes both for her pregnancy and for the developing fetus [12]. It also has a strong influence on risk of pre-term delivery and impaired growth and development in utero and after birth. Recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life. In India, for example, findings of the Pune maternal nutrition study suggest that micronutrient deficiencies (such as vitamin B12) can also lead to low birth weight and an increased risk of later diabetes [13]. Healthcare 2017, 5, 14 4 of 12 Maternal undernutrition is usually caused by food shortage or economic hardship which leads to food insecurity and result in inadequate intake of nutrients. Exposure to undernutrition in utero is associated with low birth weight and stunting in childhood, which are in turn associated with shorter adult height and reduced economic productivity [14,15]. Undernutrition in utero also has adverse effects on cognitive development and so is also associated with lower levels of educational attainment. Overnutrition occurs when the energy consumed outstrips energy expended and usually leads to overweight and obesity. For women during pregnancy, overnutrition leads to greater risk of gestational diabetes and hypertensive disorders of pregnancy. For the fetus, maternal gestational diabetes leads to an increased risk of macrosomia, high blood glucose and insulin and these are associated with neonatal hypoglycemia, congenital anomalies, preterm birth, stillbirth and neonatal death. There is also evidence that obese women accumulate more metabolites in their ovarian follicles and this has been associated with increased risk of cardiovascular disease and obesity in later life in their offspring [18]. Deficiencies of specific vitamin and minerals can be caused by insufficient intake due to poor or inadequate diet, or by an increased demand for nutrients, for example because of rapid growth or menstrual bleeding. Micronutrient deficiencies can occur even when there is overnutrition, and lifestyle factors such as alcohol intake and smoking can affect their absorption.

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Verapamil and digoxin are contraindicated as two pathways may form a re-entry circuit with the fast they accelerate anterograde conduction through the accessory pathway causing a retrograde stimulation of accessory pathway generic hydroxyzine 10mg on line anxiety symptoms weak legs. Clinical features Prognosis In sinus rhythm Wolff–Parkinson–White syndrome is With age the pathway may fibrose and so some patients asymptomatic order hydroxyzine 10mg mastercard anxiety 9 code. Definition Aventricular ectopic/extrasystole/premature beat is an extramyocardial depolarisation triggered by a focus in Prognosis the ventricle generic hydroxyzine 10mg fast delivery anxiety reddit. Ventricular ectopics worsen the prognosis in patients with underlying ischaemic heart disease but there is no evidence that anti-arrhythmic drugs improve this. Aetiology/pathophysiology Ventricular ectopics are not uncommon in normal indi- viduals and increase in incidence with advancing age. Common causes include ischaemic heart disease and Ventricular tachycardia hypertension. Ectopic beats may arise due to any of Definition the mechanisms of arrhythmias, such as a re-entry cir- Tachycardia of ventricular origin at a rate of 120–220 cuit or due to enhanced automaticity (which may occur bpm. When ventricular ectopic beats occur regularly Ventricular tachycardia is normally associated with un- after each sinus beat, it is termed bigeminy, which is fre- derlying coronary, ischaemic or hypertensive heart dis- quently due to digoxin. Clinical features Patients are usually asymptomatic but may feel uncom- Pathophysiology fortable or beaware of an irregular heart or missed beats. The underlying mechanism is thought to be enhanced On examination the pulse may be irregular if ectopics automaticity,leadingtore-entrycircuitasinothertachy- are frequent. In ventricular tachycardia there is a small (or sometimes large) group of ischaemic or electrically non- homogeneouscells,typicallyresultingfromanacutemy- Investigations r ocardial infarction. Clinical features r Echocardiography and exercise testing may be used The condition is episodic with attacks usually lasting to look for underlying structural or ischaemic heart minutes. Chapter 2: Cardiac arrhythmias 55 compromise of cardiac output overt cardiac failure or Torsades de pointes loss of consciousness may occur. The presenting pic- Definition ture is dependent on the rapidity of the tachycardia and Torsades de pointes or ‘twisting of the points’ is a con- the function of the left ventricle, as well as general con- dition in which there is episodic tachycardia and a pro- dition of the patient (e. Carotid sinus massage may help to to congenital cause, hypokalaemia, hypocalcaemia, anti- distinguish ventricular tachycardia, which does not re- arrhythmic drugs, tricyclic antidepressants or bradycar- spond, from supraventricular tachycardia with bundle dia from the sick sinus syndrome. Low serum potas- It is thought that the long Q–T interval allows adjacent sium or magnesium may predispose to arrhythmias, so cells, which are repolarising at slightly different rates, levels should be checked. The Q–T interval is prolonged by biochemical abnormalities and Complications drugs, and is also prolonged in bradycardic states. Cardiac arrest due to pulseless ventricular tachycardia or ventricular fibrillation. Clinical features It typically recurs in frequent short attacks, causing pre- syncope, syncope or heart failure. Management r Any underlying electrolyte disturbance should be identified and managed. It is now customary to use these in patients Definition known to have a high risk of sudden cardiac death. Chaoticelectromechanicalactivityoftheventriclescaus- ing a loss of cardiac output. Conduction disturbances Incidence The most common cause of sudden death and the most Atrioventricular block common primary arrhythmia in cardiac arrest. Atrioventricular or heart block describes an alteration in the normal pattern of transmission of action poten- Aetiology tials between the atria and the ventricles. Pathophysiology r complete failure of transmission (third-degree heart The underlying electrical activity consists of multiple ec- block). First degree atrioventricular block Definition Clinical features Atrioventricular block describes an alteration in the The clinical picture is of cardiac arrest with loss of ar- transmission of action potentials between the atria and terial pulsation, loss of consciousness and cessation of the ventricles. Management r Early defibrillation is the most important treatment, as the longer it is delayed the less likely reversion to Clinical features sinus rhythm is possible.