WASHINGTON - President Barack Obama declared the swine flu outbreak a national emergency, giving his health chief the power to let hospitals move emergency rooms offsite to speed treatment and protect noninfected patients.

The declaration, signed Friday night and announced Saturday, comes with the disease more prevalent than ever in the country and production delays undercutting the government’s initial, optimistic estimates that as many as 120 million doses of the vaccine could be available by mid-October.

Health authorities say more than 1,000 people in the United States, including almost 100 children, have died from the strain of flu known as H1N1, and 46 states have widespread flu activity. So far only 11 million doses have gone out to health departments, doctor’s offices and other providers, according to the Centers for Disease Control and Prevention officials.

Administration officials said the declaration was a pre-emptive move designed to make decisions easier when they need to be made. Officials said the move was not in response to any single development.

Health and Human Services Secretary Kathleen Sebelius now has authority to bypass federal rules when opening alternative care sites, such as offsite hospital centers at schools or community centers if hospitals seek permission.

Some hospitals have opened drive-thrus and drive-up tent clinics to screen and treat swine flu patients. The idea is to keep infectious people out of regular emergency rooms and away from other sick patients.

Hospitals could modify patient rules - for example, requiring them to give less information during a hectic time - to quicken access to treatment, with government approval, under the declaration.

It also addresses a financial question for hospitals - reimbursement for treating people at sites not typically approved. For instance, federal rules do not allow hospitals to put up treatment tents more than 250 yards away from the doors; if the tents are 300 yards or more away, typically federal dollars won’t go to pay for treatment.

Administration officials said those rules might not make sense while fighting the swine flu, especially if the best piece of pavement is in the middle of a parking lot and some medical centers already are putting in place parts of their emergency plans.

“I think the term emergency declaration sounds more dramatic than it really is,” said Dr. Peter Hotez, a research professor and chairman of the Department of Microbiology, Immunology and Tropical Medicine at George Washington University. “It’s largely an administrative move that’s more preemptive …” He said such a step would give emergency rooms and hospitals the flexibility they need.

The national emergency declaration was the second of two steps needed to give Sebelius extraordinary powers during a crisis.

On April 26, the administration declared swine flu a public health emergency, allowing the shipment of roughly 12 million doses of flu-fighting medications from a federal stockpile to states in case they eventually needed them. At the time, there were 20 confirmed cases in the U.S. of people recovering easily. There was no vaccine against swine flu, but the CDC had taken the initial step necessary for producing one.

“As a nation, we have prepared at all levels of government, and as individuals and communities, taking unprecedented steps to counter the emerging pandemic,” Obama wrote in Saturday’s declaration.

He said the pandemic keeps evolving, the rates of illness are rising rapidly in many areas and there’s a potential “to overburden health care resources.”

The government now hopes to have about 50 million doses of swine flu vaccine out by mid-November and 150 million in December. The flu virus has to be grown in chicken eggs, and the yield hasn’t been as high as was initially hoped, officials have said.

“Many millions” of Americans have had swine flu so far, according to an estimate that CDC Director Dr. Thomas Frieden gave Friday. The government doesn’t test everyone to confirm swine flu so it doesn’t have an exact count. He also said there have been more than 20,000 hospitalizations.

Swine influenza (also called swine flu, hog flu, pig flu and sometimes, the swine) is an infection by any one of several types of swine influenza virus. Swine influenza virus (SIV) is any strain of the Orthomyxoviridae that is endemic in pigs.[2] As of 2009, the known SIV strains include influenza C and the subtypes of Influenza A virus known as H1N1, H1N2, H3N1, H3N2, and H2N3.

Swine influenza virus is common throughout pig populations worldwide. Transmission of the virus from pigs to humans is not common and does not always lead to human influenza, often resulting only in the production of antibodies in the blood. If transmission does cause human influenza, it is called zoonotic swine flu. People with regular exposure to pigs are at increased risk of swine flu infection. The meat of an infected animal poses no risk of infection when properly cooked.

During the mid-20th century, identification of influenza subtypes became possible, allowing accurate diagnosis of transmission to humans. Since then, only 50 such transmissions have been confirmed. These strains of swine flu rarely pass from human to human. Symptoms of zoonotic swine flu in humans are similar to those of influenza and of influenza-like illness in general, namely chills, fever, sore throat, muscle pains, severe headache, coughing, weakness and general discomfort.

Classification

Of the three genera of influenza viruses that cause human flu, two also cause influenza in pigs, with influenza A being common in pigs and influenza C being rare.[3] Influenza B has not been reported in pigs. Within influenza A and influenza C, the strains found in pigs and humans are largely distinct, although due to reassortment there have been transfers of genes among strains crossing swine, avian, and human species boundaries.
Influenza C

Influenza C viruses infect both humans and pigs, but do not infect birds.[4] Transmission between pigs and humans have occurred in the past.[5] For example, influenza C caused small outbreaks of a mild form of influenza amongst children in Japan[6] and California.[6] Due to its limited host range and the lack of genetic diversity in influenza C, this form of influenza does not cause pandemics in humans.[7]
Influenza A

Swine influenza is known to be caused by influenza A subtypes H1N1,[8] H1N2,[8] H2N3,[9] H3N1,[10] and H3N2.[8] In pigs, three influenza A virus subtypes (H1N1, H1N2, and H3N2) are the most common strains worldwide.[11] In the United States, the H1N1 subtype was exclusively prevalent among swine populations before 1998; however, since late August 1998, H3N2 subtypes have been isolated from pigs. As of 2004, H3N2 virus isolates in US swine and turkey stocks were triple reassortants, containing genes from human (HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2 and PA) lineages.[12]
Surveillance

Although there is no formal national surveillance system in the United States to determine what viruses are circulating in pigs,[13] there is an informal surveillance network in the United States that is part of a world surveillance network.

Veterinary medical pathologist, Tracey McNamara, set up a national disease surveillance system in zoos because the zoos do active disease surveillance and many of the exotic animals housed there have broad susceptibilities. Many species fall below the radar of any federal agencies (including dogs, cats, pet prairie dogs, zoo animals, and urban wildlife), even though they may be important in the early detection of human disease outbreaks.[14] [15]
History

Swine influenza was first proposed to be a disease related to human influenza during the 1918 flu pandemic, when pigs became sick at the same time as humans.[16] The first identification of an influenza virus as a cause of disease in pigs occurred about ten years later, in 1930.[17] For the following 60 years, swine influenza strains were almost exclusively H1N1. Then, between 1997 and 2002, new strains of three different subtypes and five different genotypes emerged as causes of influenza among pigs in North America. In 1997-1998, H3N2 strains emerged. These strains, which include genes derived by reassortment from human, swine and avian viruses, have become a major cause of swine influenza in North America. Reassortment between H1N1 and H3N2 produced H1N2. In 1999 in Canada, a strain of H4N6 crossed the species barrier from birds to pigs, but was contained on a single farm.[17]

The H1N1 form of swine flu is one of the descendants of the strain that caused the 1918 flu pandemic.[18][19] As well as persisting in pigs, the descendants of the 1918 virus have also circulated in humans through the 20th century, contributing to the normal seasonal epidemics of influenza.[19] However, direct transmission from pigs to humans is rare, with only 12 cases in the U.S. since 2005.[20] Nevertheless, the retention of influenza strains in pigs after these strains have disappeared from the human population might make pigs a reservoir where influenza viruses could persist, later emerging to reinfect humans once human immunity to these strains has waned.

Swine flu has been reported numerous times as a zoonosis in humans, usually with limited distribution, rarely with a widespread distribution. Outbreaks in swine are common and cause significant economic losses in industry, primarily by causing stunting and extended time to market. For example, this disease costs the British meat industry about £65 million every year.[22]
1918 pandemic in humans

The 1918 flu pandemic in humans was associated with H1N1 and influenza appearing in pigs;[19] this may reflect a zoonosis either from swine to humans, or from humans to swine. Although it is not certain in which direction the virus was transferred, some evidence suggests that, in this case, pigs caught the disease from humans.[16] For instance, swine influenza was only noted as a new disease of pigs in 1918, after the first large outbreaks of influenza amongst people.[16] Although a recent phylogenetic analysis of more recent strains of influenza in humans, birds, and swine suggests that the 1918 outbreak in humans followed a reassortment event within a mammal,[23] the exact origin of the 1918 strain remains elusive. It is estimated that anywhere from 50 to 100 million people were killed worldwide.
1976 U.S. outbreak
Main article: 1976 swine flu outbreak

On February 5, 1976, in the United States an army recruit at Fort Dix said he felt tired and weak. He died the next day and four of his fellow soldiers were later hospitalized. Two weeks after his death, health officials announced that the cause of death was a new strain of swine flu. The strain, a variant of H1N1, is known as A/New Jersey/1976 (H1N1). It was detected only from January 19 to February 9 and did not spread beyond Fort Dix.[26]
President Ford receives swine flu vaccination

This new strain appeared to be closely related to the strain involved in the 1918 flu pandemic. Moreover, the ensuing increased surveillance uncovered another strain in circulation in the U.S.: A/Victoria/75 (H3N2) spread simultaneously, also caused illness, and persisted until March.[26] Alarmed public-health officials decided action must be taken to head off another major pandemic, and urged President Gerald Ford that every person in the U.S. be vaccinated for the disease.

The vaccination program was plagued by delays and public relations problems.[28] On October 1, 1976, immunizations began and three senior citizens died soon after receiving their injections. This resulted in a media outcry that linked these deaths to the immunizations, despite the lack of any proof that the vaccine was the cause. According to science writer Patrick Di Justo, however, by the time the truth was known-that the deaths were not proven to be related to the vaccine-it was too late. “The government had long feared mass panic about swine flu-now they feared mass panic about the swine flu vaccinations.” This became a strong setback to the program.

There were reports of Guillain-Barré syndrome, a paralyzing neuromuscular disorder, affecting some people who had received swine flu immunizations. This syndrome is a rare side-effect of modern influenza vaccines, with an incidence of about one case per million vaccinations.[30] As a result, Di Justo writes that “the public refused to trust a government-operated health program that killed old people and crippled young people.” In total, 48,161,019 Americans, or just over 22% of the population, had been immunized by the time the National Influenza Immunization Program (NIIP) was effectively halted on December 16, 1976.

Overall, there were 1098 cases of Guillain-Barré Syndrome (GBS) recorded nationwide by CDC surveillance, 532 of which were linked to the NIIP vaccination, resulting in death from severe pulmonary complications for 25 people, which, according to Dr. P. Haber, were probably caused by an immunopathological reaction to the 1976 vaccine. Other influenza vaccines have not been linked to GBS, though caution is advised for certain individuals, particularly those with a history of GBS. Still, as observed by a participant in the immunization program, the vaccine killed more Americans than the disease did.[36]
1988 zoonosis

In September 1988, a swine flu virus killed one woman and infected others. 32-year old Barbara Ann Wieners was eight months pregnant when she and her husband, Ed, became ill after visiting the hog barn at a county fair in Walworth County, Wisconsin. Barbara died eight days later, after developing pneumonia.[37] The only pathogen identified was an H1N1 strain of swine influenza virus. Doctors were able to induce labor and deliver a healthy daughter before she died. Her husband recovered from his symptoms.

Influenza-like illness (ILI) was reportedly widespread among the pigs exhibited at the fair. 76% of 25 swine exhibitors aged 9 to 19 tested positive for antibody to SIV, but no serious illnesses were detected among this group. Additional studies suggested between one and three health care personnel who had contact with the patient developed mild influenza-like illnesses with antibody evidence of swine flu infection. However, there was no community outbreak.

In 1998, swine flu was found in pigs in four U.S. states. Within a year, it had spread through pig populations across the United States. Scientists found that this virus had originated in pigs as a recombinant form of flu strains from birds and humans. This outbreak confirmed that pigs can serve as a crucible where novel influenza viruses emerge as a result of the reassortment of genes from different strains.[41][42][43] Genetic components of these 1998 triple-hybrid stains would later form six out of the eight viral gene segment in the 2009 flu outbreak.

On August 20, 2007 Department of Agriculture officers investigated the outbreak (epizootic) of swine flu in Nueva Ecija and Central Luzon, Philippines. The mortality rate is less than 10% for swine flu, unless there are complications like hog cholera. On July 27, 2007, the Philippine National Meat Inspection Service (NMIS) raised a hog cholera “red alert” warning over Metro Manila and 5 regions of Luzon after the disease spread to backyard pig farms in Bulacan and Pampanga, even if these tested negative for the swine flu virus. ]
2009 outbreak in humans
Main article: 2009 flu pandemic

The H1N1 viral strain implicated in the 2009 flu pandemic among humans often is called “swine flu” because initial testing showed many of the genes in the virus were similar to influenza viruses normally occurring in North American swine.[51] Further research has shown that three-quarters or six out of the eight gene segments of the 2009 virus arose from the 1998 North American swine flu strains which emerged from the first-ever reported triple-hybrid virus of 1998.

In late April, Margaret Chan, the World Health Organization’s director-general, declared a “public health emergency of international concern” under the rules of the WHO’s new International Health Regulations when the first cases of the H1N1 virus were reported in the United States.[52][53] Following the outbreak, on May 2, 2009, it was reported in pigs at a farm in Alberta, Canada, with a link to the outbreak in Mexico. The pigs are suspected to have caught this new strain of virus from a farm worker who recently returned from Mexico, then showed symptoms of an influenza-like illness.[54] These are probable cases, pending confirmation by laboratory testing.

The new strain was initially described as an apparent reassortment of at least four strains of influenza A virus subtype H1N1, including one strain endemic in humans, one endemic in birds, and two endemic in swine. Subsequent analysis suggested it was a reassortment of just two strains, both found in swine. Although initial reports identified the new strain as swine influenza (i.e., a zoonosis originating in swine), its genetic origin was only later revealed to have been mostly a descendant of the triple-reassortment virus which emerged in factory farms in the United States in 1998. Several countries took precautionary measures to reduce the chances for a global pandemic of the disease.[56] The 2009 swine flu has been compared to other similar types of influenza virus in terms of mortality: “in the US it appears that for every 1000 people who get infected, about 40 people need admission to hospital and about one person dies.”[57] There are fears that swine flu will become a major global pandemic at the end of the year (coinciding with the Northern Hemisphere winter months), with many countries planning major vaccination campaigns.[58]
Transmission
Transmission between pigs

Influenza is quite common in pigs, with about half of breeding pigs having been exposed to the virus in the US. Antibodies to the virus are also common in pigs in other countries.

The main route of transmission is through direct contact between infected and uninfected animals.[11] These close contacts are particularly common during animal transport. Intensive farming may also increase the risk of transmission, as the pigs are raised in very close proximity to each other.[60][61] The direct transfer of the virus probably occurs either by pigs touching noses, or through dried mucus. Airborne transmission through the aerosols produced by pigs coughing or sneezing are also an important means of infection.[11] The virus usually spreads quickly through a herd, infecting all the pigs within just a few days.[2] Transmission may also occur through wild animals, such as wild boar, which can spread the disease between farms.
Transmission to humans

People who work with poultry and swine, especially people with intense exposures, are at increased risk of zoonotic infection with influenza virus endemic in these animals, and constitute a population of human hosts in which zoonosis and reassortment can co-occur. Vaccination of these workers against influenza and surveillance for new influenza strains among this population may therefore be an important public health measure Transmission of influenza from swine to humans who work with swine was documented in a small surveillance study performed in 2004 at the University of Iowa. This study among others forms the basis of a recommendation that people whose jobs involve handling poultry and swine be the focus of increased public health surveillance. Other professions at particular risk of infection are veterinarians and meat processing workers, although the risk of infection for both of these groups is lower than that of farm workers.
Interaction with avian H5N1 in pigs

Pigs are unusual as they can be infected with influenza strains that usually infect three different species: pigs, birds and humans.[67] This makes pigs a host where influenza viruses might exchange genes, producing new and dangerous strains.[67] Avian influenza virus H3N2 is endemic in pigs in China and has been detected in pigs in Vietnam, increasing fears of the emergence of new variant strains.[68] H3N2 evolved from H2N2 by antigenic shift.[69] In August 2004, researchers in China found H5N1 in pigs.

These H5N1 infections may be quite common: in a survey of 10 apparently healthy pigs housed near poultry farms in West Java, where avian flu had broken out, five of the pig samples contained the H5N1 virus. The Indonesian government has since found similar results in the same region. Additional tests of 150 pigs outside the area were negative.
Signs and symptoms
In swine

In pigs influenza infection produces fever, lethargy, sneezing, coughing, difficulty breathing and decreased appetite. In some cases the infection can cause abortion. Although mortality is usually low (around 1-4%), the virus can produce weight loss and poor growth, causing economic loss to farmers Infected pigs can lose up to 12 pounds of body weight over a 3 to 4 week period.
In humans
Main symptoms of swine flu in humans

Direct transmission of a swine flu virus from pigs to humans is occasionally possible (called zoonotic swine flu). In all, 50 cases are known to have occurred since the first report in medical literature in 1958, which have resulted in a total of six deaths.[74] Of these six people, one was pregnant, one had leukemia, one had Hodgkin disease and two were known to be previously healthy. Despite these apparently low numbers of infections, the true rate of infection may be higher, since most cases only cause a very mild disease, and will probably never be reported or diagnosed.

In this video, Dr. Joe Bresee, with CDC’s Influenza Division, describes the symptoms of swine flu and warning signs to look for that indicate the need for urgent medical attention.
See also: See this video with subtitles on YouTube

According to the Centers for Disease Control and Prevention (CDC), in humans the symptoms of the 2009 “swine flu” H1N1 virus are similar to those of influenza and of influenza-like illness in general. Symptoms include fever, cough, sore throat, body aches, headache, chills and fatigue. The 2009 outbreak has shown an increased percentage of patients reporting diarrhea and vomiting.[75] The 2009 H1N1 virus is not zoonotic swine flu, as it is not transmitted from pigs to humans, but from person to person.

Because these symptoms are not specific to swine flu, a differential diagnosis of probable swine flu requires not only symptoms but also a high likelihood of swine flu due to the person’s recent history. For example, during the 2009 swine flu outbreak in the United States, CDC advised physicians to “consider swine influenza infection in the differential diagnosis of patients with acute febrile respiratory illness who have either been in contact with persons with confirmed swine flu, or who were in one of the five U.S. states that have reported swine flu cases or in Mexico during the 7 days preceding their illness onset.” A diagnosis of confirmed swine flu requires laboratory testing of a respiratory sample (a simple nose and throat swab).

The most common cause of death is respiratory failure. Other causes of death are pneumonia (leading to sepsis)[77], high fever (leading to neurological problems), dehydration (from excessive vomiting and diarrhea) and electrolyte imbalance. Fatalities are more likely in young children and the elderly.
Diagnosis
Thermal scanning of passengers arriving at Singapore Changi airport.
Wiki letter w.svg This section requires expansion.

Different medical kits are available for diagnosis of swine flu.

The two major tests that are being used are the nasopharyngeal (or back of the throat) swab for viral culture, the gold standard, and the indirect evidence test by detection of antibodies to novel H1N1 with PCR studies.
Prevention

Prevention of swine influenza has three components: prevention in swine, prevention of transmission to humans, and prevention of its spread among humans.
In swine

Methods of preventing the spread of influenza among swine include facility management, herd management, and vaccination (ATCvet code: QI09AA03). Because much of the illness and death associated with swine flu involves secondary infection by other pathogens, control strategies that rely on vaccination may be insufficient.

Control of swine influenza by vaccination has become more difficult in recent decades, as the evolution of the virus has resulted in inconsistent responses to traditional vaccines. Standard commercial swine flu vaccines are effective in controlling the infection when the virus strains match enough to have significant cross-protection, and custom (autogenous) vaccines made from the specific viruses isolated are created and used in the more difficult cases. Present vaccination strategies for SIV control and prevention in swine farms typically include the use of one of several bivalent SIV vaccines commercially available in the United States. Of the 97 recent H3N2 isolates examined, only 41 isolates had strong serologic cross-reactions with antiserum to three commercial SIV vaccines. Since the protective ability of influenza vaccines depends primarily on the closeness of the match between the vaccine virus and the epidemic virus, the presence of nonreactive H3N2 SIV variants suggests that current commercial vaccines might not effectively protect pigs from infection with a majority of H3N2 viruses.[81][82] The United States Department of Agriculture researchers say that while pig vaccination keeps pigs from getting sick, it does not block infection or shedding of the virus.

Facility management includes using disinfectants and ambient temperature to control virus in the environment. The virus is unlikely to survive outside living cells for more than two weeks, except in cold (but above freezing) conditions, and it is readily inactivated by disinfectants.[2] Herd management includes not adding pigs carrying influenza to herds that have not been exposed to the virus. The virus survives in healthy carrier pigs for up to 3 months and can be recovered from them between outbreaks. Carrier pigs are usually responsible for the introduction of SIV into previously uninfected herds and countries, so new animals should be quarantined.[59] After an outbreak, as immunity in exposed pigs wanes, new outbreaks of the same strain can occur.
In humans

Swine can be infected by both avian and human influenza strains of influenza, and therefore are hosts where the antigenic shifts can occur that create new influenza strains.

The transmission from swine to human is believed to occur mainly in swine farms where farmers are in close contact with live pigs. Although strains of swine influenza are usually not able to infect humans this may occasionally happen, so farmers and veterinarians are encouraged to use a face mask when dealing with infected animals. The use of vaccines on swine to prevent their infection is a major method of limiting swine to human transmission. Risk factors that may contribute to swine-to-human transmission include smoking and not wearing gloves when working with sick animals.

Prevention of human to human transmission

Influenza spreads between humans through coughing or sneezing and people touching something with the virus on it and then touching their own nose or mouth.[85] Swine flu cannot be spread by pork products, since the virus is not transmitted through food.[85] The swine flu in humans is most contagious during the first five days of the illness although some people, most commonly children, can remain contagious for up to ten days. Diagnosis can be made by sending a specimen, collected during the first five days for analysis.[86]
Thermal imaging camera & screen, photographed in an airport terminal in Greece. Thermal imaging can detect elevated body temperature, one of the signs of the virus N1H1 (Swine influenza).

Recommendations to prevent spread of the virus among humans include using standard infection control against influenza. This includes frequent washing of hands with soap and water or with alcohol-based hand sanitizers, especially after being out in public.[87] Chance of transmission is also reduced by disinfecting household surfaces, which can be done effectively with a diluted chlorine bleach solution.[88]

Experts agree that hand-washing can help prevent viral infections, including ordinary influenza and the swine flu virus. Also avoiding touching eyes, nose and mouth with hands prevents flu.[89] Influenza can spread in coughs or sneezes, but an increasing body of evidence shows small droplets containing the virus can linger on tabletops, telephones and other surfaces and be transferred via the fingers to the mouth, nose or eyes. Alcohol-based gel or foam hand sanitizers work well to destroy viruses and bacteria. Anyone with flu-like symptoms such as a sudden fever, cough or muscle aches should stay away from work or public transportation and should contact a doctor for advice.

Social distancing is another tactic. It means staying away from other people who might be infected and can include avoiding large gatherings, spreading out a little at work, or perhaps staying home and lying low if an infection is spreading in a community. Public health and other responsible authorities have action plans which may request or require social distancing actions depending on the severity of the outbreak.

Vaccination

Vaccines are available for different kinds of swine flu. The Food and Drug Administration (FDA) approved the new swine flu vaccine on September 15, 2009.[91] Studies by the National Institutes of Health (NIH), show that a single dose creates enough antibodies to protect against the virus within about 10 days.
Treatment
In swine

As swine influenza is rarely fatal to pigs, little treatment beyond rest and supportive care is required.[59] Instead veterinary efforts are focused on preventing the spread of the virus throughout the farm, or to other farms.[11] Vaccination and animal management techniques are most important in these efforts. Antibiotics are also used to treat this disease, which although they have no effect against the influenza virus, do help prevent bacterial pneumonia and other secondary infections in influenza-weakened herds.[59]
In humans

If a person becomes sick with swine flu, antiviral drugs can make the illness milder and make the patient feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms). Beside antivirals, supportive care at home or in hospital, focuses on controlling fevers, relieving pain and maintaining fluid balance, as well as identifying and treating any secondary infections or other medical problems. The U.S. Centers for Disease Control and Prevention recommends the use of Tamiflu (oseltamivir) or Relenza (zanamivir) for the treatment and/or prevention of infection with swine influenza viruses; however, the majority of people infected with the virus make a full recovery without requiring medical attention or antiviral drugs.[93] The virus isolates in the 2009 outbreak have been found resistant to amantadine and rimantadine.

In the U.S., on April 27, 2009, the Food and Drug Administration (FDA) issued Emergency Use Authorizations to make available Relenza and Tamiflu antiviral drugs to treat the swine influenza virus in cases for which they are currently unapproved. The agency issued these EUAs to allow treatment of patients younger than the current approval allows and to allow the widespread distribution of the drugs, including by non-licensed volunteers.

I sent my 11-year-old son to school today with a stuffy nose and mild cough, as I’ve done countless times in the past. Now, though, I’m wondering whether I should have kept him home. How do I know it’s really a garden-variety cold and not the swine flu?

“That’s a great question,” says Richard Wenzel, a swine flu expert and former president of the Infectious Diseases Society of America. “You really have no way of knowing if it’s the flu or just a cold.” Given that we’re in the middle of an H1N1 epidemic, he estimates that my son’s chances of having this flu are considerable, since some of his friends have had confirmed cases–maybe even as high as 50/50. Even though he doesn’t have fever? I press. “At the beginning of the outbreak in Mexico, only 30 percent of patients hospitalized with the infection had fever initially,” he tells me, “and 15 percent of patients never developed a fever at all.” What usually sent them to the hospital was shortness of breath or chest pain. In Chile, he adds, about half of those with confirmed H1N1 had no fever; many just had a headache and runny nose.

To truly contain the spread of this virus, he says, it would have been smart for me to keep my son home from school. While I can work effectively from home, many working parents can’t. I wonder if this is why the government isn’t recommending that we keep ourselves or our kids home at the first sign of a sniffle. The Centers for Disease Control and Prevention says: “Those with flulike illness should stay home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines.” That implies that hacking coughs and runny noses shouldn’t keep us away from others.

“The CDC is stuck. They’ve defined flu as having a fever, which means they’re going to miss a lot of cases,” Wenzel says. To be fair, the CDC does list the following as symptoms of H1N1: cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, and, in some people, diarrhea and vomiting. But fever seems to be the determining factor in whether we should isolate ourselves.

Since most doctors aren’t testing for H1N1, we must use our own judgment to decide if that mild cold warrants taking sick days and keeping our kids home from school for up to a week. We might be helping prevent the spread of a potentially deadly virus. Then again, it might be pointless if others are going about their usual day coughing and sneezing around others. (Hopefully, they’re washing their hands frequently and coughing into their elbows.) After speaking with Wenzel, I might keep my son home tomorrow–especially if his symptoms get worse.

“This flu seems to spread more easily than a cold virus or seasonal flu,” says Wenzel, “most likely because so few people have been exposed to it in the past.” Kids are slated to be among the first to get the H1N1 vaccine when it becomes available in early October–a nasal spray vaccine called FluMist will the first on the market. But many will probably already have been infected before they can get immunized; Wenzel predicts the outbreak will last another four to eight weeks before tapering off. Unfortunately, that’s just around the time when the vaccine will be available in large quantities. It seems that despite the government’s best efforts to get the vaccine out quickly, it missed the boat on this one.

Yes, the CDC will still stick with its recommendation to get any children over the age of 6 months vaccinated–and pregnant women too–unless a previous infection was confirmed via a lab test. But Wenzel says parents may decide on their own to pass up the immunization if their child recently had a respiratory infection that appeared to be swine flu. “These kids probably don’t need the vaccine,” he adds, “but there’s a level of uncertainty, and parents may still be wise to choose immunization just to be on the safe side.”

While most cases of H1N1 are mild, this virus has the potential to cause severe complications, including death. The CDC says warning signs in children that warrant immediate medical attention include fast breathing or trouble breathing; bluish or gray skin color; not drinking enough fluids; severe or persistent vomiting; not waking up or interacting; a child so irritable that he does not want to be held; and flulike symptoms that improve but then return with fever and a worse cough. Warning signs in adults include difficulty breathing or chest pain, purple or blue discoloration of the lips, vomiting and inability to keep liquids down, and signs of dehydration, such as feeling dizzy when standing or being unable to urinate.

WASHINGTON (AFP) - Eating heart-healthy, low-calorie foods and exercising is the key to losing weight regardless of levels of protein, fat or carbohydrates, a new study has found.

41% of users found this article helpful.
[AFP/File/Frederic J. Brown] Overweight patients cast a shadow at a weight reduction clinic. A new study has found that eating heart-healthy, low-calorie foods and exercising is the key to losing weight regardless of levels of protein, fat or carbohydrates.(AFP/File/Frederic J. Brown)

The research, funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, seems to argue against blanket use of diets that do not necessarily limit calories but call for eating certain foods such as vegetables or proteins, at the expense of others.

The NIH study of 811 volunteers, 38 percent of them men and 62 percent women, aged 30-70 and either overweight or obese, looked at diets that have been popular in the United States in recent years, even as the number of obese Americans has soared.

The “Preventing Overweight Using Novel Dietary Strategies (POUNDS LOST) study found similar weight loss after six months and two years among participants assigned to four diets that differed in their proportions of these three major nutrients,” said researchers.

“The diets were low or high in total fat (20 or 40 percent of calories) with average or high protein (15 or 25 percent of calories). Carbohydrate content ranged from 35 to 65 percent of calories.

“The diets all used the same calorie reduction goals and were heart-healthy low in saturated fat and cholesterol while high in dietary fibre,” said researchers, whose study is published Thursday in the New England Journal of Medicine.

Participants lost an average 13 pounds (5.9 kilos) at six months and maintained a nine-pound (four-kilo) loss at two years.

“These results show that, as long as people follow a heart-healthy, reduced-calorie diet, there is more than one nutritional approach to achieving and maintaining a healthy weight,” said Dr. Elizabeth Nabel, director at NHLBI.

“This provides people who need to lose weight with the flexibility to choose an approach that they’re most likely to sustain: one that is most suited to their personal preferences and health needs,” she stressed.

Sixty-six percent of US adults are overweight and of those, 32 percent are obese, Centers for Disease Control and Prevention data show.

FRIDAY, Feb. 27 (HealthDay News) — You might look like you’re not paying attention when you doodle, but science says otherwise.

Researchers in the United Kingdom found that test subjects who doodled while listening to a recorded message had a 29 percent better recall of the message’s details than those who didn’t doodle. The findings were published in Applied Cognitive Psychology.

“If someone is doing a boring task, like listening to a dull telephone conversation, they may start to daydream,” study researcher Professor Jackie Andrade, of the School of Psychology at the University of Plymouth, said in a news release issued by the journal’s publisher. “Daydreaming distracts them from the task, resulting in poorer performance. A simple task, like doodling, may be sufficient to stop daydreaming without affecting performance on the main task.”

For the experiment, a two-and-a-half minute listing of several people’s names and places was played for test subjects, who were charged with writing down only the names of the people said to be attending a party. During the recording, half the participants were asked to simultaneously shade in shapes on a piece of paper without attention to neatness. Participants were not told they were taking part in a memory test.

When the recording ended, all were asked for the eight names of those attending the party as well as eight place names mentioned in the audio. Those asked to doodle wrote down, on average, 7.5 names and places, while those who didn’t doodle listed only 5.8.

“In psychology, tests of memory or attention will often use a second task to selectively block a particular mental process,” Andrade said. “If that process is important for the main cognitive task, then performance will be impaired. My research shows that beneficial effects of secondary tasks, such as doodling, on concentration may offset the effects of selective blockade.”

In everyday life, Andrade said, doodling “may be something we do because it helps to keep us on track with a boring task, rather than being an unnecessary distraction that we should try to resist doing.”

LOS ANGELES - Low-fat, low-carb or high-protein? The kind of diet doesn’t matter, scientists say. All that really counts is cutting calories and sticking with it, according to a federal study that followed people for two years. However, participants had trouble staying with a single approach that long and the weight loss was modest for most.

As the world grapples with rising obesity, millions have turned to popular diets like Atkins, Zone and Ornish that tout the benefits of one nutrient over another.

Some previous studies have found that low carbohydrate diets like Atkins work better than a traditional low-fat diet. But the new research found that the key to losing weight boiled down to a basic rule - calories in, calories out.

“The hidden secret is it doesn’t matter if you focus on low-fat or low-carb,” said Dr. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute, which funded the research.

Limiting the calories you consume and burning off more calories with exercise is key, she said.

The study, which appears in Thursday’s New England Journal of Medicine, was led by Harvard School of Public Health and Pennington Biomedical Research Center in Louisiana.

Researchers randomly assigned 811 overweight adults to one of four diets, each of which contained different levels of fat, protein and carbohydrates.

Though the diets were twists on commercial plans, the study did not directly compare popular diets. The four diets contained healthy fats, were high in whole grains, fruits and vegetables and were low in cholesterol.

Nearly two-thirds of the participants were women. Each dieter was encouraged to slash 750 calories a day from their diet, exercise 90 minutes a week, keep an online food diary and meet regularly with diet counselors to chart their progress.

There was no winner among the different diets; reduction in weight and waist size were similar in all groups.

People lost 13 pounds on average at six months, but all groups saw their weight creep back up after a year. At two years, the average weight loss was about 9 pounds while waistlines shrank an average of 2 inches. Only 15 percent of dieters achieved a weight-loss reduction of 10 percent or more of their starting weight.

Dieters who got regular counseling saw better results. Those who attended most meetings shed more pounds than those who did not - 22 pounds compared with the average 9 pound loss.

Lead researcher Dr. Frank Sacks of Harvard said a restricted calorie diet gives people greater food choices, making the diet less monotonous.

“They just need to focus on how much they’re eating,” he said.

Sacks said the trick is finding a healthy diet that is tasty and that people will stick with over time.

Before Debbie Mayer, 52, enrolled in the study, she was a “stress eater” who would snack all day and had no sense of portion control. Mayer used to run marathons in her 30s, but health problems prevented her from doing much exercise in recent years.

Mayer tinkered with different diets - Weight Watchers, Atkins, South Beach - with little success.

“I’ve been battling my weight all my life. I just needed more structure,” said Mayer, of Brockton, Mass., who works with the elderly.

Mayer was assigned to a low-fat, high-protein diet with 1,400 calories a day. She started measuring her food and went back to the gym. The 5-foot Mayer started at 179 pounds and dropped 50 pounds to 129 pounds by the end of the study. She now weighs 132 and wants to shed a few more pounds.

Another study volunteer, Rudy Termini, a 69-year-old retiree from Cambridge, Mass., credits keeping a food diary for his 22-pound success. Termini said before participating in the study he would wolf down 2,500 calories a day. But sticking to an 1,800-calorie high-fat, average protein diet meant no longer eating an entire T-bone steak for dinner. Instead, he now eats only a 4-ounce steak.

“I was just oblivious to how many calories I was having,” said the 5-foot-11-inch Termini, who dropped from 195 to 173 pounds. “I really used to just eat everything and anything in sight.”

Dr. David Katz of the Yale Prevention Research Center and author of several weight control books, said the results should not be viewed as an endorsement of fad diets that promote one nutrient over another.

The study compared high quality, heart healthy diets and “not the gimmicky popular versions,” said Katz, who had no role in the study. Some popular low-carb diets tend to be low in fiber and have a relatively high intake of saturated fat, he said.

Other experts were bothered that the dieters couldn’t keep the weight off even with close monitoring and a support system.

“Even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic,” Martijn Katan of Amsterdam’s Free University wrote in an accompanying editorial.

The term health insurance is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government.Synonyms for this usage include “health coverage,” “health care coverage” and “health benefits.” In a more technical sense, the term is used to describe any form of insurance that provides protection against injury or illness. This usage includes private insurance and social insurance programs such as Medicare, but excludes social welfare programs such as Medicaid. In addition to medical expense insurance, it also includes insurance covering disability or long-term nursing or custodial care needs.

The US market-based health care system relies heavily on private and not-for-profit health insurance, which is the primary source of coverage for most Americans. According to the United States Census Bureau, approximately 85% of Americans have health insurance; nearly 60% obtain it through an employer, while about 9% purchase it directly.Various government agencies provide coverage to about 28% of Americans (there is some overlap in these figures).

In 2007, there were nearly 46 million people in the US (over 15% of the population) who were without health insurance for at least part of that year.The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000.[3] There is considerable debate in the US on the causes of and possible remedies for this level of uninsurance as well as the impact it has on the overall US health care system.

History

Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the US by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the US effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case.

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations.The predecessors of today’s health maintenance organizations (HMOs) originated in 1929, through the 1930s and on during World War II.

Public health care coverage

Public programs provide the primary source of coverage for most seniors and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals; Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families; and SCHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.

Medicare

In the United States, Medicare is a federal social insurance program that provides health insurance to elderly workers and their dependents, individuals who become totally and permanently disabled, and end stage renal disease (ESRD) patients. Some health care economists (Uwe Reinhardt of Princeton and Stuart Butler among others) assert that the third-party payment feature of this program has had the unintended consequence of distorting the price of medical procedures. As a result, the Health Care Financing Administration has set up a list of procedures and corresponding prices under the Resource-Based Relative Value Scale. Recent research has found that the health trends of previously uninsured adults, especially those with chronic health problems, improves once they enter the Medicare program.

Medicare Advantage

Medicare Advantage plans expand the health care options for Medicare beneficiaries. The option for Medicare Advantage plans is a result of the Balanced Budget Act of 1997, with the intent to better control the rapid growth in Medicare spending, as well as to provide Medicare beneficiaries more choices.

Medicare Part D (Prescription Drugs)

Medicare Part D provides a private insurance option to allow Medicare beneficiaries to purchase subsidized coverage for the costs of prescription drugs. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.

Medicaid

Medicaid was instituted for the very poor in 1965. Despite its establishment, the percentage of US residents who lack any form of health insurance has increased since 1994.It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements. Medicaid is a social welfare or social protection program rather than a social insurance program.

State Children’s Health Insurance Program (SCHIP)

The State Children’s Health Insurance Program (SCHIP) is a joint state/federal program to provide health insurance to children in families who earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance. The statutory authority for SCHIP is under title XXI of the Social Security Act. SCHIP programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services, and may be structured as independent programs separate from Medicaid (separate child health programs), as expansions of their Medicaid programs (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP combination programs). States receive enhanced federal funds for their SCHIP programs at a rate above the regular Medicaid match.

Military health benefits

Health benefits are provided to active duty service members, retired service members and their dependents by the Department of Defense Military Health System (MHS). The MHS consists of a direct care network of Military Treatment Facilities and a purchased care network known as TRICARE. Additionally, veterans may also be eligible for benefits through the Veterans Health Administration.

Indian health service

The Indian Health Service (IHS) provides medical assistance to eligible American Indians at IHS facilities, and helps pay the cost of some services provided by non-IHS health care providers.

State risk pools

In 1976, some states began providing guaranteed-issuance risk pools, which enable individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan; 34 states now offer them. Plans vary greatly from state to state, both in their costs and benefits to consumers and in their methods of funding and operations. They serve a very small portion of the uninsurable market—about 182,000 people in the US as of 2004.In best cases, they allow people with pre-existing conditions such as cancer, diabetes, heart disease or other chronic illnesses to be able to switch jobs or seek self-employment without fear of being without health care benefits.However, the plans are expensive, with premiums that can be double the average policy, and the pools currently cover only 1 in 25 of the so-called “uninsurable” population.[14] Efforts to pass a national pool have as yet been unsuccessful, but some federal tax money has been awarded to states to innovate and improve their plans.

Private health care coverage

Private health insurance may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. Most Americans with private health insurance receive it through an employer-sponsored program. According to the United States Census Bureau, some 60% of Americans are covered through an employer, while about 9% purchase health insurance directly.Private health insurers have a significant economic impact in the US as employers—in 2004 they directly employed almost 470,000 people at an average salary of $61,409.

The US has a joint federal/state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers.State mandates generally do not apply to the health plans offered by large employers, due to the preemption clause of the Employee Retirement Income Security Act.

Employer-sponsored

Employer-sponsored health insurance is paid for by businesses on behalf of their employees as part of an employee benefit package. Most private health coverage in the US is employment based. According to the Centers for Medicare and Medicaid Services, nearly 100% of large firms offer health insurance to their employees.The employer typically makes a substantial contribution towards the cost of coverage.In 2008 the average employee contribution was 16% of the cost of single coverage and 27% of the cost of family coverage. These percentages have been stable since 1999.Health benefits provided by employers are also tax favored. Employee contributions can be made on a pre-tax basis if the employer offers the benefits through a section 125 cafeteria plan.

Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.Employer costs have risen significantly per hour worked, and vary significantly. In particular, average employer costs for health benefits vary by firm size and occupation. The cost per hour of health benefits is generally higher for workers in higher-wage occupations, but represent a smaller percentage of payroll.The percentage of total compensation devoted to health benefits has been rising since the 1960s.Average premiums, including both the employer and employee portions, were $4,704 for single coverage and $12,680 for family coverage in 2008.

However, in a 2007 analysis, the Employee Benefit Research Institute concluded that the availability of employment-based health benefits for active workers in the US is stable. The “take-up rate,” or percentage of eligible workers participating in employer-sponsored plans, is falling. The percentage of workers actually covered has fallen somewhat, but not sharply. EBRI interviewed employers for the study, and found that others might follow if a major employer discontinued health benefits. Public policy changes could also result in a reduction in employer support for employment-based health benefits.

Although much more likely to offer retiree health benefits than small firms, the percentage of large firms offering these benefits fell from 66% in 1988 to 34% in 2002.

Small employer group coverage

According to a 2007 study, about 59% of employers at small firms (3-199 workers) in the US provide employee health insurance. The percentage of small firms offering coverage has been dropping steadily since 1999. The study notes that cost remains the main reason cited by small firms who do not offer health benefits.Small firms that are new are less likely to offer coverage than ones that have been in existence for a number of years. For example, using 2005 data for firms with fewer than 10 employees, 43% of those that had been in existence at least 20 years offered coverage, but only 24% of those that had been in existence less than 5 years did. The volatility of offer rates from year to year also appears to be higher for newer small businesses.

The types of coverage available to small employers are similar to those offered by large firms, but small businesses do not have the same options for financing their benefit plans. In particular, self-insuring the benefits (see Self-funded health care) is not a practical option for most small employers.A RAND Corporation study published in April 2008 found that the cost of health care coverage places a greater burden on small firms, as a percentage of payroll, than on larger firms.A study published by the American Enterprise Institute in August of 2008 examined the effect of state benefit mandates on self-employed individuals, and found that “the larger the number of mandates in a state, the lower the probability that a self-employed person will be a significant employment generator.”

States regulate small group premium rates, typically by placing limits on the premium variation allowable between groups (rate bands). Insurers price to recover their costs over their entire book of small group business while abiding by state rating rules.Over time, the effect of initial underwriting “wears off” as the cost of a group regresses towards the mean. Recent claim experience - whether better or worse than average - is a strong predictor of future costs in the near term. But the average health status of a particular small employer group tends to regress over time towards that of an average group.The process used to price small group coverage changes when a state enacts small group reform laws.

Insurance brokers play a significant role in helping small employers find health insurance, particularly in more competitive markets. Average small group commissions range from 2 percent to 8 percent of premiums. Brokers provide services beyond insurance sales, such as assisting with employee enrollment and helping to resolve benefits issues.

Federal employees health benefit plan (FEHBP)

In addition to such public plans as Medicare and Medicaid, the federal government also sponsors a health benefit plan for federal employees—the Federal Employees Health Benefits Program (FEHBP). FEHBP provides health benefits to full-time civilian employees. Active-duty service members, retired service members and their dependents are covered through the Department of Defense Military Health System (MHS). FEHBP is managed by the federal Office of Personnel Management.

“Portability” of group coverage

Two federal laws address the ability of individuals with employment-based health insurance coverage to maintain coverage.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) enables certain individuals with employer-sponsored coverage to extend their coverage if certain “qualifying events” would otherwise cause them to lose it. Employers may require COBRA-qualified individuals to pay the full cost of coverage, and coverage cannot be extended indefinitely. COBRA only applies to firms with 20 or more employees, although some states also have “mini-COBRA” laws that apply to small employers.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides for forms of both “group-to-group” and “group-to-individual” portability. When an individual moves from one employer’s benefit plan to another’s, the new plan must count coverage under the old plan against any waiting period for pre-existing conditions, as long as there is not a break in coverage of more than 63 days between the two plans. When certain qualified individuals lose group coverage altogether, they must be guaranteed access to some form of individual coverage. To qualify, they must have at least 18 months of prior continuous coverage. The details of access and the price of coverage are determined on a state-by-state basis.

Individually purchased

Policies of health insurance obtained by individuals not otherwise covered under policies or programs elsewhere classified. Generally major medical, short-term medical, and student policies. According to the US Census Bureau, about 9% of Americans are covered under health insurance purchased directly. The range of products available is similar to those provided through employers. However, average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions.Major medical is the most commonly purchased form of individual health insurance.

In the individual market, the consumer pays the entire premium without benefit of an employer contribution.While self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit.

Premiums vary significantly by age.In states that allow individual medical plan underwriting, premiums also vary by health status.[36] For individuals who pass individual medical plan underwriting where it is used, the average premiums they pay are lower than the average paid for employer-sponsored coverage (this comparison is based on the entire premium for employer-sponsored coverage, including both the employee and employer contributions).Factors that may be contributing to this include: differences in age; less generous coverage in the individual market (higher beneficiary cost sharing); and a tendency for individual consumers to only buy benefits that they expect to need and use while group coverage may provide some benefits that most beneficiaries do not use.Individual policyholders are also more likely to report being in excellent health than are people covered by employer-sponsored health insurance, which may be a contributing factor.Premiums in the individual market rose less rapidly over the period 2002 through 2005 than did out-of-pocket premiums in the employer-sponsored market (17.8% versus 34.4%). The increase was larger for family policies than for single policies (25.3% for family policies; the increase for single policies was not statistically significant). Note that these comparisons did not adjust for changes in benefit levels.

Research confirms that consumers in the individual health insurance market are sensitive to price. Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals.One study found that among individuals who lack other sources of health coverage, the percentage purchasing individual insurance increases steadily with income. However, even among those with incomes four times the federal poverty level, only about a fourth buy individual coverage. The self-employed, who can tax-deduct their premiums, are more likely to purchase than other individuals. The researchers concluded that affordability appears to be a key barrier to coverage in this market, and that any premium subsidies would likely have to be substantial to be effective. The researchers note that other factors such as health status and the complexity of the market can also affect the purchase of individual health insurance, but conclude that they are unlikely to be the primary drivers of low coverage rates.

Many states allow medical underwriting of applicants for individually purchased health insurance. An estimated 5 million of those without health insurance are considered “uninsurable” because of pre-existing conditions.[14] A number of proposals have been advanced to limit the effect of underwriting on consumers and improve access to coverage. Each has its own advantages and limitations.[46] One study published in 2008 found that people of average health are least likely to become uninsured if they have large group health coverage, more likely to become uninsured if they have small group coverage, and most likely to become uninsured if they have individual health insurance. But, “for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance.” The authors attribute these results to the combination in the individual market of high costs and guaranteed renewability of coverage. Individual coverage costs more if it is purchased after a person becomes unhealthy, but “provides better protection (compared to group insurance) against high premiums for already individually insured people who become high risk.” Healthy individuals are more likely to drop individual coverage than less-expensive, subsidized employment-based coverage, but group coverage leaves them “more vulnerable to dropping or losing any and all coverage than does individual insurance” if they become seriously ill.

In August 2008 the Hartford Courant reported that competition was increasing in the individual health insurance market, with more insurers entering the market, an increased variety of products, and a broader spread of prices.

Individual health insurance is primarily regulated at the state level, consistent with the McCarran-Ferguson Act. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change. The primary NAIC models affecting the individual health insurance market are:

* The Uniform Individual Accident and Sickness Policy Provision Law (UPPL);
* The Accident and Sickness Insurance Minimum Standards Model Act;
* The Advertisements of Accident and Sickness Insurance Model Regulation; and
* The Unfair Trade Practices Act.

All of these models have been implemented in one form or another by most states.

Federal laws affecting individual health insurance include:

* The Health Insurance Portability and Accountability Act (HIPAA);
* The Newborns’ and Mothers’ Health Protection Act;
* The Women’s Health and Cancer Rights Act;
* The Fair Credit Reporting Act; and
* Federal rules governing Medicare supplement policies.

Types of medical insurance

Traditional indemnity or fee-for-service

Commercial insurance companies began offering accident and sickness insurance (disability insurance) as early as the mid-1800s.Hospital and medical expense policies were introduced during the first half of the 20th century. The first group medical plan was purchased from The Equitable Life Assurance Society of the United States by the General Tire & Rubber Company in 1934.

Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider’s fee. The relationship between the patient and the medical provider was not changed. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract (”reimbursement benefits”). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.

Blue Cross & Blue Shield plans

During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis. The first group pre-payment plan was created at the Baylor University Hospital in Dallas, Texas.This concept became popular among hospitals during the Depression, when they were facing declining revenues. The Baylor plan was a forerunner of later Blue Cross plans. Physician associations began offering pre-paid surgical/medical benefits in the late 1930s Blue Shield plans. Blue Cross and Blue Shield plans were non-profit organizations sponsored by local hospitals (Blue Cross) or physician groups (Blue Shield). As originally structured, Blue Cross and Blue Shield plans provided benefits in the form of services rendered by participating hospitals and physicians (”service benefits”) rather than reimbursements or payments to the policyholder.

Health Maintenance Organizations

The Ross-Loos Clinic, founded in Los Angeles in 1929, is generally considered to have been the first health maintenance organization (HMO).[5] Henry J. Kaiser organized hospitals and clinics to provide pre-paid health benefits to his shipyard workers during World War II. This became the basis for Kaiser Permanente HMO. Most early HMOs were non-profit organizations. The development of HMOs was encouraged by the passage of the Health Maintenance Organization Act of 1973. Benefits are provided through a network of providers. Providers may be employees of the HMO (”staff model”), employees of a provider group that has contracted with the HMO (”group model”), or members of an independent practice association (”IPA model”). HMOs may also use a combination of these approaches (”network model”).

Managed care

The term managed care is used to describe a variety of techniques intended to reduce the cost of health benefits and improve the quality of care. It is also used to describe organizations that use these techniques (”managed care organization”).Many of these techniques were pioneered by HMOs, but they are now used in a wide variety of private health insurance programs. Through the 1990s, managed care grew from about 25% US employees with employer-sponsored coverage to the vast majority.Rise of managed care in the US

Year     Conventional plans     HMOs     PPOs    POS plans HDHP/SOs

1998     14%             27%     35%     24%        ~
1999     10%             28%     39%     24%        ~
2000     8%             29%     42%     21%        ~
2001     7%             24%     46%     23%        ~
2002     4%             27%     52%     18%        ~
2003     5%             24%     54%     17%        ~
2004     5%             25%     55%     15%        ~
2005     3%             21%     61%     15%        ~
2006     3%             20%     60%     13%        4%
2007     3%             21%     57%     15%        5%

Network-based managed care

Many managed care programs are based on a panel or network of contracted health care providers. Such programs typically include:

* A set of selected providers that furnish a comprehensive array of health care services to enrollees;
* Explicit standards for selecting providers;
* Formal utilization review and quality improvement programs;
* An emphasis on preventive care; and
* Financial incentives to encourage enrollees to use care efficiently.

Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently.

Network-based plans may be either closed or open. With a closed network, enrollees’ expenses are generally only covered when they go to network providers. Only limited services are covered outside the network—typically only emergency and out-of-area care. Most traditional HMOs were closed network plans. Open network plans provide some coverage when an enrollee uses non-network provider, generally at a lower benefit level to encourage the use of network providers. Most preferred provider organization plans are open-network (those that are not are often described as exclusive provider organizations, or EPOs), as are point of service (POS) plans.

The terms “open panel” and “closed panel” are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. In a “closed panel” HMO, the network providers are either HMO employees (staff model) or members of large group practices with which the HMO has a contract. In an “open panel” plan the HMO or PPO contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan’s credential requirements and is willing to accept the terms of the plan’s contract.

Other managed care techniques

Other managed care techniques include such elements as disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as “managed indemnity.”

Blurring lines

Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies.However, some Blue Cross and Blue Shield plans continue to serve as insurers of last resort.Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects due to market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company).At one time the distinctions between traditional indemnity insurance, HMOs and PPOs were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market.

The blurring of distinctions between the different types of health care coverage can be seen in the history of the industry’s trade associations. The two primary HMO trade associations were the Group Health Association of America and the American Managed Care and Review Association. After merging, they were known as American Association of Health Plans (AAHP). The primary trade association for commercial health insurers was the Health Insurance Association of America (HIAA). These two have now merged, and are known as America’s Health Insurance Plans (AHIP).

New types of medical plans

One approach to addressing increasing premiums, dubbed “consumer driven health care,” received a boost in 2003, when President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act. The law created tax-deductible Health Savings Accounts (HSAs). An HSA is an untaxed private bank account; withdrawals are only penalized if the money is spent on non-medical items or services. Consumers wishing to deposit pre-tax funds in an HSA must be enrolled in a high-deductible insurance plan with a number of restrictions on benefit design; in 2007, qualifying plans must have a minimum deductible of US$1,050. HSAs enable healthier individuals to pay less for insurance and bank money for their own future health care expenses.HSAs are one form of tax-preferenced health care spending account. Others include Archer Medical Savings Accounts (MSAs), which have been superseded by the new HSAs (although existing MSAs are grandfathered), Flexible Spending Arrangements (FSAs) and Health Reimbursement Accounts (HRAs). HSAs, FSAs and HRAs are most commonly used as part of an employee health benefit package.

Limited Medical Benefit Plans pay for routine care and do not pay for catastrophic care. As such, they do not provide equivalent financial security to a major medical plan. Annual benefit limits can be as low as $2,000. Lifetime maximums can be very low as well.

One option that is becoming more popular is the discount medical card. These cards are not insurance policies, but provide access to discounts from participating health care providers. While some offer a degree of value, there are serious potential drawbacks for the consumer.

Other types of health insurance (non-medical)

While the term “health insurance” is most commonly used by the public to describe coverage for medical expenses, the insurance industry uses the term more broadly to include other related forms of coverage, such as disability income and long-term care insurance.

Disability income insurance

Disability income (DI) insurance pays benefits to individuals who lose their ability to work due to injury or illness. DI insurance replaces income lost while the policyholder is unable to work during a period of disability (in contrast to medical expense insurance, which pays for the cost of medical care). For most working age adults, the risk of disability is greater than the risk of premature death, and the resulting reduction in lifetime earnings can be significant. Private disability insurance is sold on both a group and an individual basis. Policies may be designed to cover long-term disabilities (LTD coverage) or short-term disabilities (STD coverage).Business owners can also purchase disability overhead insurance to cover the overhead expenses of their business while they are unable to work.

A basic level of disability income protection is provided through the Social Security Disability Insurance (SSDI) program for qualified workers who are totally and permanently disabled (the worker is incapable of engaging in any “substantial gainful work” and the disability is expected to last at least 12 months or result in death).

Long-term care insurance

Long-term care (LTC) insurance reimburses the policyholder for the cost of long-term or custodial care services designed to minimize or compensate for the loss of functioning due to age, disability or chronic illness.LTC has many surface similarities to long-term disability insurance. There are at least two fundamental differences, however. LTC policies cover the cost of certain types of chronic care, while long-term-disability policies replace income lost while the policyholder is unable to work. For LTC, the event triggering benefits is the need for chronic care, while the triggering event for disability insurance is the inability to work.

Private LTC insurance is growing in popularity in the US. Premiums have remained relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to purchase it. The average age of new purchasers was 61 in 2005, and has been dropping.
Supplemental coverage

Private insurers offer a variety of supplemental coverages in both the group and individual markets. These are not designed to provide the primary source of medical or disability protection for an individual, but can assist with unexpected expenses and provide additional peace of mind for insureds. Supplemental coverages include Medicare supplement insurance, hospital indemnity insurance, dental insurance, vision insurance, accidental death and dismemberment insurance and specified disease insurance.

Supplemental coverages are intended to:

* Supplement a primary medical expense plan by paying for expenses that are excluded or subject to the primary plan’s cost-sharing requirements (e.g., co-payments, deductibles, etc.);
* Cover related expenses such as dental or vision care;
* Assist with additional expenses that may be associated with a serious illness or injury.

Medicare Supplement Coverage (Medigap)

Medicare Supplement policies are designed to cover expenses not covered (or only partially covered) by the “original Medicare” (Parts A & B) fee-for-service benefits. They are only available to individuals enrolled in Medicare Parts A & B. Medigap plans may be purchased on a guaranteed issue basis (no health questions asked) during a six-month open enrollment period when an individual first becomes eligible for Medicare. The benefits offered by Medigap plans are standardized.

Hospital indemnity insurance

Hospital indemnity insurance provides a fixed daily, weekly or monthly benefit while the insured is confined in a hospital. The payment is not dependent on actual hospital charges, and is most commonly expressed as a flat dollar amount. Hospital indemnity benefits are paid in addition to any other benefits that may be available, and are typically used to pay out-of-pocket and non-covered expenses associated with the primary medical plan, and to help with additional expenses (e.g., child care) incurred while in the hospital.

Scheduled health insurance plans

Scheduled health insurance plans are an expanded form of Hospital Indemnity plans. In recent years, these plans have taken the name mini-med plans or association plans. These plans may provide benefits for hospitalization, surgical, and physician services however, they are not meant to replace a traditional comprehensive health insurance plan. Scheduled health insurance plans are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug; but these benefits will be limited and are not meant to be effective for catastrophic events. Payments are based upon the plan’s “schedule of benefits” and are usually paid directly to the service provider. These plans cost much less then comprehensive health insurance. Annual benefit maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.

Dental insurance

Dental insurance helps pay for the cost of necessary dental care. Many medical expense plans include coverage for dental expenses, and stand-alone dental insurance is also available. Discount dental programs are also available. These do not constitute insurance, but provide participants with access to discounted fees for dental work.

Vision care insurance

Vision care insurance provides coverage for routine eye care and is typically written to complement other medical benefits. Vision benefits are designed to encourage routine eye examinations and ensure that appropriate treatment is provided.

Specified disease

Specified disease provides benefits for one or more specifically identified conditions. Benefits can be used to fill gaps in a primary medical plan, such as co-payments and deductibles, or to assist with additional expenses such as transportation and child care costs.

Accidental Death and Dismemberment (AD&D) insurance

AD&D insurance is offered by group insurers and provides benefits in the event of accidental death. It also provides benefits for certain specified types of bodily injuries (e.g., loss of a limb or loss of sight) when they are the direct result of an accident.

Status of the uninsured

In 2007, more than 45 million people in the US (15.3% of the population) were without health insurance for at least part of the year. The percentage of the non-elderly population who are uninsured has been generally increasing since the year 2000.Among the uninsured population, some 37 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 38% of the uninsured live in households with incomes over $50,000.According to the Census Bureau, nearly 36 million of the uninsured are legal US citizens. Another 9.7 million are non-citizens, but the Census Bureau does not distinguish in its estimate between legal non-citizens and illegal immigrants.It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans). An estimated 5 million of those without health insurance are considered “uninsurable” because of pre-existing conditions.

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.

A report published by the Kaiser Family Foundation in April 2008 found that economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur at the same time state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.

Infectious mononucleosis, also known as Pfeiffer’s disease, mono (in the United States of America) and more commonly known as glandular fever in other English-speaking countries, is an infectious disease. It occurs most commonly in adolescents and young adults, where it is characterized by fever, sore throat, muscle soreness, and fatigue. Infectious mononucleosis typically produces a mild illness and is often asymptomatic. Mononucleosis is predominantly caused by the Epstein-Barr virus (EBV), which infects B cells (B-lymphocytes), producing a reactive lymphocytosis predominantly consisting of atypical lymphocytes, a specific type of T-cell that gives the disease its name.

The name “kissing disease” is often applied to mono in casual speech, as in developed countries it is most common at the same age when adolescents and young adults are initiating romantic behaviour. This co-occurrence is not apparent in undeveloped countries, where poor sanitation and close living arrangements cause the causative virus to be spread at a much earlier age, when the disease is mild and seldom diagnosed. Both males and females are susceptible to mononucleosis.

Symptoms

* Fever—this varies, but is seen in nearly all cases.
* Enlarged and tender lymph nodes—particularly the posterior cervical lymph nodes.
* Sore throat—White patches on the tonsils and back of the throat are often seen
* Muscle weakness and Mental fatigue (sometimes extreme)

Additional symptoms include:

* Enlarged spleen (splenomegaly, which may lead to rupture) and/or liver (hepatomegaly)
* Petechial hemorrhage
* Abdominal pain - a possible symptom of a potentially fatal rupture of the spleen.
* Aching muscles
* Headache
* Loss of appetite
* Depression
* Diarrhea
* Dizziness or disorientation
* Inability to swallow, due to enlarged tonsils
* Dry cough
* Supra-orbital edema—the eyes become puffy and swollen—may occur in the early stages of infection

After an initial prodrome of 1-2 weeks, the fatigue of infectious mononucleosis often lasts from 1-2 months. The virus can remain dormant in the B cells indefinitely after symptoms have disappeared, and resurface at a later date. Many people exposed to the Epstein-Barr virus do not show symptoms of the disease, but carry the virus. This is especially true in children, in whom infection seldom causes more than a very mild cold which often goes undiagnosed. Children are typically just carriers of the disease. This feature, along with mono’s long (4 to 6 week) incubation period, makes epidemiological control of the disease impractical. About 6% of people who have had infectious mononucleosis will relapse.[citation needed]

Mononucleosis can cause the spleen to swell. Rupture may occur without trauma,[citation needed] but impact to the spleen is also a factor. Other complications include hepatitis (inflammation of the liver) causing elevation of serum bilirubin (in approximately 40% of patients), jaundice (approximately 5% of cases), and anemia (a deficiency of red blood cells). In rare cases, death may result from severe hepatitis or splenic rupture.

Although most cases of mononucleosis are caused by the E.B. virus, the condition is defined by the clinical presentation and laboratory findings. Cytomegalovirus can produce a similar illness, usually with less throat pain, and also generate atypical lymphocyte proliferation. In recent years, as precise virological and serological studies are more commonly done to identify the actual causative virus, some clinicians have taken to use “mononucleosis” to refer only to the E.B. virus cases. Symptoms similar to those of mononucleosis can also be caused by adenovirus, acute HIV infection and the protozoan Toxoplasma gondii

Diagnosis
Please help improve this section by expanding it. Further information might be found on the talk page or at requests for expansion. (June 2008)
Peripheral blood smear (low power) showing lymphocytosis from a 16-year-old male with pharyngitis and positive monospot test.
Peripheral blood smear (low power) showing lymphocytosis from a 16-year-old male with pharyngitis and positive monospot test.

Laboratory findings usually include an elevated white blood cell count and abnormal liver function tests. The white cell count elevation is predominantly in the lymphocyte portion, and of those the majority is often of the atypical form characteristic of the disease.

Specific tests for EBV include:

* A monospot test (positive for infectious mononucleosis)
* Epstein-Barr virus antigen by immunofluorescence (positive for EBV)
* Epstein-Barr virus antibody titers to help distinguish acute infection from past infection with EBV

Transmission

Mononucleosis is typically transmitted from asymptomatic individuals through saliva, earning it the name “the kissing disease”, or by sharing a drink, or sharing eating utensils. As with many viral infections, such as chickenpox, antibodies are developed by individuals who become infected with the disease and recover. In most individuals, these antibodies remain in their system, creating lifelong immunity to further infections.

Atypical presentations of mononucleosis/EBV infection

In small children, the course of the disease is frequently asymptomatic. Some adult patients suffer fever, tiredness, lassitude (abnormal fatigue), depression, lethargy, and chronic lymph node swelling, for months or years. This variant of mononucleosis has been referred to as chronic EBV syndrome or chronic fatigue syndrome (CFS), although CFS is a distinct condition from IM. Still, current studies suggest there is an association between infectious mononucleosis and CFS.[3] In case of a weakening of the immune system, a reactivation of the Epstein-Barr virus is possible; in CFS there is evidence of immune activation also. “Chronic fatigue states” as defined by the CDC criteria for CFS, appear to occur in 10% of those who contract mononucleosis.Chronic fatigue may then be a rather common side effect of infectious mononucleosis. On the other hand, studies conducted by the CDC[citation needed] and others[who?] have discounted a link between EBV and CFS.

Perhaps a majority of chronic post infectious “fatigue states” appear not to be caused by a chronic viral infection, but are triggered by the acute infection.[citation needed] Direct and indirect evidence of persistent viral infection has been found in CFS, for example in muscle and via detection of an unusually low molecular weight RNase L enzyme, although the commonality and significance of such findings is disputed. Hickie et al contend that mononucleosis appears to cause a hit and run injury to the brain in the early stages of the acute phase, thereby causing the chronic fatigue state. This would explain why in mononucleosis, fatigue very often lingers for months after the Epstein Barr virus has been controlled by the immune system. Just how infectious mononucleosis changes the brain and causes fatigue (or lack thereof) in certain individuals remains to be seen. Such a mechanism may include activation of microglia in the brain of some individuals during the acute infection. Microglia may remain activated or “damaged” for months following infection, thereby causing a slowly dissipating fatigue. Secondary infections can occur. Such infections include mild swelling of the cartilage between the sternum and ribs occurring approximately one month after initial diagnosis.

Treatment

Infectious mononucleosis is generally self-limiting and only symptomatic and/or supportive treatments are used.Rest is recommended during the acute phase of the infection, but activity should be resumed once acute symptoms have resolved. Nevertheless heavy physical activity and contact sports should be avoided to abrogate the risk of splenic rupture, for at least one month following initial infection and until splenomegaly has resolved, as determined by ultrasound scan.

In terms of pharmacotherapies, acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) may be used to reduce fever and pain.

Intravenous corticosteroids, usually hydrocortisone or dexamethasone, are not recommended for routine use but may be useful if there is a risk of airway obstruction, severe thrombocytopenia, or hemolytic anemia.

There is little evidence to support the use of aciclovir, although it may reduce initial viral shedding.However, the antiviral drug valacyclovir has recently been shown to lower or eliminate the presence of the Epstein-Barr virus in subjects afflicted with acute mononucleosis, leading to a significant decrease in the severity of symptoms.Antibiotics are not used as they are ineffective against viral infections. The antibiotics amoxicillin and ampicillin are contraindicated in the case of any coinciding bacterial infections during mononucleosis because their use can frequently precipitate a non-allergic rash. In a small percentage of cases, mononucleosis infection is complicated by co-infection with streptococcal infection in the throat and tonsils (strep throat). Penicillin or other antibiotics (with the exception of the two mentioned above) should be administered to treat the strep throat. Opioid analgesics are also contraindicated due to risk of respiratory depression.

Morbidity and mortality

Fatalities from mononucleosis are nearly impossible in developed nations. Uncommon, nonfatal complications exist, including various forms of CNS and hematological affection:

* CNS: Meningitis, encephalitis, hemiplegia and transverse myelitis. EBV infection has also been proposed as a risk factor for the development of multiple sclerosis (MS), but this has not been affirmed.
* Hematologic: EBV can cause autoimmune hemolytic anemia (direct Coombs test is positive) and various cytopenias.

It’s the best medical news in ages.

Studies in two prestigious scientific journals say dark chocolate — but not white chocolate or milk chocolate — is good for you.

What is it about dark chocolate?

The answer is plant phenols — cocoa phenols, to be exact. These compounds are known to lower blood pressure.

Chocolates made in Europe are generally richer in cocoa phenols than those made in the U.S. So if you’re going to try this at home, remember: Darker is better.

What are flavonoids?

Flavonoids are naturally-occurring compounds found in plant-based foods recognized as exuding certain health benefits.

Flavonoids are naturally-occurring compounds found in plant-based foods recognized as exuding certain health benefits.

Flavonoids are found in a wide array of foods and beverages, such as cranberries, apples, peanuts, chocolate, onions, tea and red wine. There are more than 4,000 flavonoid compounds; flavonoids are a subgroup of a large class called polyphenols.

Have you had your flavonoids today?

While not a question normally asked at a social gathering, flavonoids have become quite a hot topic in the media and in scientific journals.

Flavonoids provide important protective benefits to plants, such as in repairing damage and shielding from environmental toxins. When we consume plant-based foods rich in flavonoids, it appears that we also benefit from this “antioxidant” power. Antioxidants are believed to help the body’s cells resist damage caused by free radicals, formed by normal bodily processes such as breathing or environmental contaminants like cigarette smoke. When the body lacks adequate levels of antioxidants, free radical damage ensues, leading to increases in LDL-cholesterol oxidation and plaque formation on arterial walls.

In addition to their antioxidant capabilities, flavonoids also:

* Are thought to help reduce platelet activation
* May affect the relaxation capabilities of blood vessels
* May positively affect the balance of certain hormone-like compounds called eicosanoids, which are thought to play a role in cardiovascular health.

Dark Chocolate Is Healthy Chocolate
Dark Chocolate Has Health Benefits Not Seen in Other Varieties
By Daniel DeNoon

Dark chocolate — not white chocolate — lowers high blood pressure, say Dirk Taubert, MD, PhD, and colleagues at the University of Cologne, Germany. Their report appears in the Aug. 27 issue of The Journal of the American Medical Association.
But that’s no license to go on a chocolate binge. Eating more dark chocolate can help lower blood pressure — if you’ve reached a certain age and have mild high blood pressure, say the researchers. But you have to balance the extra calories by eating less of other things.

Antioxidants in Dark Chocolate

Dark chocolate — but not milk chocolate or dark chocolate eaten with milk — is a potent antioxidant, report Mauro Serafini, PhD, of Italy’s National Institute for Food and Nutrition Research in Rome, and colleagues. Their report appears in the Aug. 28 issue of Nature. Antioxidants gobble up free radicals, destructive molecules that are implicated in heart disease and other ailments.

“Our findings indicate that milk may interfere with the absorption of antioxidants from chocolate … and may therefore negate the potential health benefits that can be derived from eating moderate amounts of dark chocolate.”

Translation: Say “Dark, please,” when ordering at the chocolate counter. Don’t even think of washing it down with milk. And if health is your excuse for eating chocolate, remember the word “moderate” as you nibble.

Quotes from Cleveland Clinic Heart Center

It is not secret that fruits, vegetables and grains convey health benefits - we’ve been told that for years. But did you know that chocolate could result in health benefits, more specifically heart-health benefits?

The Heart-Health Benefits of Chocolate Unveiled
It is not secret that fruits, vegetables and grains convey health benefits - we’ve been told that for years. But did you know that chocolate could result in health benefits, more specifically heart-health benefits?

Forms of Chocolate

Before you grab a chocolate candy bar or slice of chocolate cake, let’s look at what forms of chocolate would be ideal over others:

When cocoa is processed into your favorite chocolate products, it goes through several steps to reduce its naturally pungent taste. Flavonoids (polyphenols) provide this pungent taste. The more chocolate is processed (such as fermentation, alkalizing, roasting), the more flavonoids are lost.

To date, dark chocolate appears to retain the highest level of flavonoids. So your best bet is to choose dark chocolate over milk chocolate.

Some chocolate manufacturers are studying ways to retain the highest level of flavonoids while still providing acceptable taste. Stay tuned for more information in this area.

What about all of the fat in chocolate?

You may be surprised to find out that chocolate isn’t as bad as once perceived. The fat in chocolate, from cocoa butter, is comprised of equal amounts of oleic acid (a heart-healthy monounsaturated fat also found in olive oil), stearic and palmitic acids. Stearic and palmitic acids are forms of saturated fat. Saturated fats are linked to increases in LDL-cholesterol and risk for heart disease.

Research indicates that stearic acid appears to have a neutral effect on cholesterol, neither raising nor lowering LDL-cholesterol levels. Palmitic acid on the other hand, does affect cholesterol levels but only comprises one-third of the fat calories in chocolate.

This great news does not give us a license to consume as much dark chocolate as we’d like.

First, be cautious as to the type of dark chocolate you choose: chewy caramel-marshmallow-nut-covered dark chocolate is by no means a heart-healthy food option. What wreaks havoc on most chocolate products is the additional fat and calories added from other ingredients.

Second, there is currently no established serving of chocolate to reap the touted cardiovascular benefits. However, what we do know is you no longer need to feel guilty if you enjoy a small piece of dark chocolate once in awhile.

Source:stuffedchocolate

In testicular torsion the spermatic cord that provides the blood supply to a testicle is twisted, cutting off the blood supply, often causing orchalgia. Prolonged testicular torsion will result in the death of the testicle and surrounding tissues.

It is also believed that torsion occurring during fetal development can lead to the so-called neonatal torsion or vanishing testis, and is one of the causes of an infant being born with monorchism
Risk factors
In most males, the testes are attached posteriorly to the inner lining of the scrotum by the mesorchium. When the mesorchium terminates early and does not attach the testis, this is called a bell clapper deformity as the testis is free floating in the tunica vaginalis, only attached to the spermatic cord, like a bell clapper. A bell clapper deformity is a predisposing factor for testicular torsion in non-neonates. Currently there is no recommended clinical examination for a bell clapper deformity.

Torsions are sometimes called “winter syndrome”. This is because they often happen in winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is twisted while the scrotum is loose, the sudden contraction that results from the abrupt temperature change can trap the testicle in that position. The result is a testicular torsion.

Prevalence

While torsion is more frequent among adolescents, it should be considered in all cases where there is testicular pain. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection. Two risk factors are trauma and strenuous physical activity.

Diagnosis

Emergency testing for torsion may be indicated when the onset of pain is sudden and/or severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made. A doppler ultrasound scan of the scrotum, if available, is of help in the diagnosis by showing the presence or absence of blood flow to the testicle. However, if suspicion is high, immediate untwisting is advised in order to prevent infarction and subsequent testicular loss with or without sterility(i.e. incidental and unfortunate testiculectomy). Dizziness and nausea are often present when there is an absence of blood supply to the testicle, as well as a tremendous amount of pain. If the diagnosis is questionable, an expert should be consulted immediately, because testicular viability may be compromised. If physical examination suggests a compromised blood supply and the patient has had such symptoms for a significant period of time, medical personnel may choose to bring the patient directly to surgery without an ultrasound since the time required for ultrasound testing could affect testicular viability.

Color Doppler sonography is used to identify the absence of blood flow typically found in a twisted testicle, which distinguishes the condition from epididymitis.

Urinalysis (analyzing chemical composition of urine) can be used to rule out bacterial infections.

Surgical exploration may be necessary if diagnosis cannot be made using other methods. If there is the slightest hint of a torsion of the testicle, then doctors will perform surgery; even if the testicle turns out not to have twisted, they will still protect it by attaching the testicle to the scrotum wall.

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of cases.

Testicular torsion is a medical emergency that needs immediate treatment. If treated within 6 hours, there is nearly a 100% chance of saving the testicle. Within 12 hours this rate decreases to 70%, within 24 hours is 20%, and after 24 hours the rate approaches 0. (eMedicineHealth) Once the testicle is dead it must be removed to prevent gangrenous infection.

A simple and minimally invasive surgery pioneered in Dallas by Dr. Dean Moheet in 1952 effectively corrects and further prevents future testicular torsion. It can be done in an emergency situation after determination that the testicle is cut off from blood supply or as an outpatient procedure for patients who have experienced frequent episodes with testicular torsion. If necessary, the surgeon will first untwist the testicle(s). The surgeon will then permanently suture the testicles to the inner lining of the scrotum. If only one testicle has been problematic, the surgeon may suture both testicles as a preventative effort.