You Won't Find Black Friday Deals at the Hospital

Unlike going to get a haircut or a massage, you never really know how much you are going to be charged for services that are provided to you at a hospital. Sick or injured, visits to the ER are costly, even more so to the uninsured, and rates vary significantly between hospitals. For example, the Federal Centers for Medicare and Medicaid revealed that the same treatment at one hospital in New York cost $100,000, and at a hospital 30 miles away in the same metropolitan city cost $7,000 (Young & Kirkham, 2013). But who has time to comparison shop when your dying?

            Hospitals have what is called the chargemaster, or list of billable services and items to a patient or their health insurance provider. Unfortunately, the chargemaster rates have become hugely inflated, and hospitals can charge patients whatever they want. Hospital lobbyists spend more than the defense and oil industries combined to keep things this way (Brill, 2013). As these inflation rates continue to rise, the price of a single stitch can top $500 (Rosenthal, 2018). In addition, patients receiving treatment from an out-of-network hospital most times will receive adjusted cost-to-charge ratios. Hospitals see these patients as cash cows and charge them significantly more than in-network patients (Bai & Anderson, 2016). These high rates are potentially keeping patients from seeking necessary or life-threatening care, especially the uninsured. In my opinion, policies should be implemented to offer transparency in charges and to protect patients from these high charges. What actions do you think should be taken?

Bai, G., & Anderson, G. F. (2016). US Hospitals Are Still Using Chargemaster Markups To Maximize Revenues. Health Affairs, 35(9), 1658–1664. https://doi.org/10.1377/hlthaff.2016.0093

Brill, S. (2013, March 4). Bitter Pill: Why Medical Bills Are Killing Us. Time. Retrieved from http://content.time.com/time/subscriber/article/0,33009,2136864-1,00.html

Rosenthal, E. (2018, October 19). As Hospital Prices Soar, a Stitch Tops $500. The New York Times. Retrieved from https://www.nytimes.com/2013/12/03/health/as-hospital-costs-soar-single-stitch-tops-500.html

Young, J., & Kirkham, C. (2013, May 8). Hospital Prices No Longer Secret As New Data Reveals Bewildering System, Staggering Cost Differences. Huffington Post. Retrieved from https://www.huffingtonpost.com/2013/05/08/hospital-prices-cost-differences_n_3232678.html

Impact of Stress on Acne

With the approach of finals everyone’s stress levels are increasing. With this stress comes the negative impact that this prolonged stress can have. It is common to believe that stress increases the severity of acne. Many people, including myself, seem to notice an increase in the severity of their acne as stress increases. However, in the research world, support for this phenomenon is not very strong or concrete. Based on what we have talked about in class this semester, it makes sense that an increase in stress could lead to an increase in acne. When we are stressed our parasympathetic nervous system, or rest and digest response, is turned off. It makes sense that prevention of acne, by keeping the pores clear, would be a function of the parasympathetic nervous system. When we have increased sympathetic nervous system action and decreased parasympathetic nervous system action for a prolonged period of time, it is logical that acne will increase.

Bondade, Hosthota, and Basavaraju’s paper explores stress’s impact on acne and somewhat supports this idea (2018). Their results claim that stressful life events do appear to increase the severity of acne flares, but they do not cause new cases of acne to appear. In addition, increases in the release of hormones such as corticotropin-releasing hormone and glucocorticoids have been seen to decrease skin permeability, prevent skin lipid synthesis, decrease antimicrobial defense, and delay wound healing. All of these together could lead to increased acne and slowed healing of acne. Despite these findings, it is generally believed that the impact of stress on acne is not totally clear from a research standpoint. (Bondade, Hosthota, & Basavaraju, 2018) Though stress is widely believed to have an impact on acne, we will not be able to say for sure what the impact of stress on acne is until research with more mathematically significant results are obtained. Nevertheless, based on current available research, we can add this to the ever-growing list of reasons why decreasing chronic stress is important.

Resource:

Bondade, S., Hosthota, A., & Basavaraju, V. (2018). Stressful life events and psychiatric comorbidity

in acne-a case control study. Asia-Pacific Psychiatry: Official Journal Of The Pacific Rim College Of Psychiatrists, e12340. https://doi-org.dml.regis.edu/10.1111/appy.12340

The Physiology of Starvation

It is important to understand that the body will regulate metabolism differently depending on the macromolecules stores that are available. Important changes in metabolism occur in both skeletal muscle and the brain when the body is starving or fasting for a couple of days, compared to when this occurs for a couple weeks.

During the 1-2 day mark, the skeletal muscle will switch from glucose consumption to free fatty acid and ketone metabolism, while the brain will still try and use glucose whenever possible. The liver is also a major player during this phase, because it can activate the Cori cycle to store lactate from glucose and create a lactate reserve that can go through gluconeogenesis to form glucose once again for immediate energy needs (Sherwood, Parris, & Cahill, 1970). During this period of lower glucose levels, insulin levels are also decreased because of less of a need to put glucose into the cells. This will stimulate lipolysis and proteolysis and breakdown triglycerides and proteins. Although the skeletal muscle will use a variety of macromolecules during this initial starvation phase, the brain will continue to use glucose as its primary energy source.

As starvation continues into a week and then to two weeks the rate of proteolysis declines, and the skeletal muscle and brain begin to change their metabolism pattern. If starvation continues long enough the body will begin proteolysis once again but cannot sustain this for long before death. During this phase, the brain will switch from using glucose to using primarily ketone bodies as a source of fuel. At the same point protein breakdown is no longer as efficient because the brain is not in immediate need of glucose made by gluconeogenesis from amino acids.

The use of ketone bodies by the brain is a useful adaptation; however it is important to note that prolonged use of ketone bodies can cause ketoacidosis if the mechanisms to reduce this are not working. The kidney is a prime location where H+ ions can be excreted by converting an ammonia to an ammonium ion and thereby protect the pH balance in the body. Thus the body has useful methods for surviving through starvation, but like any organism there is a limit to how long survival is possible.

Ferrier, D. R. (2014). Biochemistry. Philadelphia: Wolters Kluwer Health/Lippincott Williams &                Wilkins.

Sherwood, L. M., Parris, E. E., & Cahill, G. F. (1970). Starvation in Man. New England Journal of Medicine, 282(12), 668–675. https://doi.org/10.1056/NEJM197003192821209

America’s Next Epidemic

While the American public has remained largely focused on the nation’s biggest drug crisis, the opioid epidemic, another pharmaceutical is quickly making strides towards that title. Benzodiazepines (BZDs) are a class of sedative medications used to treat anxiety and panic, seizures, alcohol withdrawal, and muscle tension. They increase the effects of an inhibitory neurotransmitter called GABA by allosterically binding to the GABA receptor, a ligand gated chloride channel, thereby causing an influx of chloride into the cell. This influx causes a membrane hyperpolarization, which makes it more difficult for subsequent action potentials to occur. Thus, you achieve the inhibitory/anxiolytic effects seen with benzodiazepines (Sankar, 2012).

Although BZDs are quite efficient, there is a growing body of research linking long term benzodiazepine use to cognitive impairments and dementia (Toombs et al., 2018). Similar to opioids, those taking BZDs are subject to increased dependence and withdrawal. Moreover, BZDs can cause fatal overdose when taken in abundance or in combination with other drugs. From 1996-2014, the rate of fatal overdoses involving benzodiazepines quadrupled (Bacchuber et al., 2016).

With this knowledge, why do we continue to prescribe them? The answer is easy, right? Just don’t do it. I would argue that it’s not always that easy. A study of 35 general practitioners investigated reasons why general practitioners decided to initiate benzodiazepine prescriptions. The study concluded that general practitioners tend to become overwhelmed by their patients’ psychosocial problems and perceive benzodiazepines as “the lesser evil” (Anthierens et al., 2007). One general practitioner stated, “I have to do a lot of “psycho”. Whether I want it or not but I haven't got the training for it. What do I do? I prescribe.…”.

From the outside looking in, it’s easy to make judgements, blaming this rising “epidemic” on physicians’ disregard of nonmaleficence. But consider what you would do in a similar situation—when a distressed patient is looking to you for answers. In the case of the practitioner just mentioned, this was likely an attempt to uphold beneficence, by giving a patient the relief he or she needed. Although there is evidence that BZDs are safe in short term, history shows us (i.e. our old pal the opioid crisis) that tapering/refusing to prescribe addictive medications is not particularly easy, especially when there is currently no better alternative. These are the difficult situations that we as future health providers will face.

References:

Anthierens, S., Habraken, H., Petrovic, M., & Christiaens, T. (2007). The lesser evil? Initiating a benzodiazepine prescription in general practice: A qualitative study on GPs’ perspectives. Scandinavian Journal of Primary Health Care, 25(4), 214–219. http://doi.org/10.1080/02813430701726335

Bachhuber, M. A., Hennessy, S., Cunningham, C. O., & Starrels, J. L. (2016). Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996–2013. American Journal of Public Health, 106(4), 686–688. http://doi.org/10.2105/AJPH.2016.303061

Sankar, R. (2012). GABAAreceptor physiology and its relationship to the mechanism of action of the 1,5-Benzodiazepine clobazam. CNS Drugs. https://doi.org/10.2165/11599020-000000000-00000

Toombs, A. R., Jung, J. Y., & White, N. D. (2018). Benzodiazepine Use and Cognition in the Elderly. American Journal of Lifestyle Medicine, 12(4), 295–297. https://doi.org/10.1177/1559827618767381

Our future immigrant colleagues

As future healthcare providers, our ethics discussions in class have largely focused on the patient population we will one day be serving. Recently, we had a discussion regarding immigration (remember the medical school candidate who made a mean comment about immigrants on her Facebook?) Although it is important to reflect on this, what about our future colleagues? Do you really think medical schools are only filled with US born students? I came across an article this afternoon, regarding the prevalence of immigrant healthcare workers. According to a research letter published in JAMA this month pertaining to a census surveying 164,000 US health professionals, 16.6% are immigrants and 4.6% are not US citizens. Professions included in the study ranged from dentists to pharmacists to home health aides to physicians. When it’s broken down, this accounts for nearly a third of physicians being born outside of the US and a quarter of dentists. Additionally, 18% of biomedical research run in the US is run by immigrant graduates. Those are a lot of numbers and percentages but hopefully, the point is clear: our healthcare system does not only serve a population of immigrants, it is also run by one. Part of the reason is because these individuals are willing to work in underserved communities, places where US-born medical school graduates often rather not serve. Do we often think about the prejudice the other way around? Would our medical school candidate have made the same comment about a physician? I have prediction about that, do you?

References:

Patel, Y. M., Ly, D. P., Hicks, T., & Jena, A. B. (2018). Proportion of Non–US-Born and Noncitizen Health Care Professionals in the United States in 2016. JAMA, 320(21), 2265–2267. https://doi.org/10.1001/jama.2018.14270

https://www.pbs.org/newshour/health/new-study-shows-1-in-6-u-s-health-care-workers-are-immigrants