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Nathan Wei asked:




A number of methods have been used to repair of cartilage damage. The first is osteochondral transplantation, which involves taking a plug of cartilage from a non-weight bearing area and placing it into a defect in a weight-bearing region. The second is microfracture. In this procedure, a surgeon will drill a number of small (2 mm diameter) holes into the cartilage until bleeding from the bone marrow occurs. The theory is that stem cells from the bone marrow will “leak out” and heal the cartilage damage. The final method is the use of autologous stem cell implantation with or without the assistance of a scaffold matrix to hold the cells.

The problem is that all these techniques have been used to treat focal cartilage lesions and not osteoarthritis. Also, recuperation from the first two procedures (chondral plug and microfracture) is exceedingly long.

Osteoarthritis lesions are generally large and unconfined and as a result may not hold onto chondrocytes (early cartilage cells) long enough for them to repair the damage.

Of the three methods described above, the one that seems to be garnering the most interest lately is autologous stem cells.

Results from a number of uncontrolled studies seem to show that stem cells can be harnessed to repair and possibly regenerate cartilage damage in OA.

There are three types of stem cells that have been used in research. The first type is embryonic stem cells. These have the advantage of being the cells that probably can grow the quickest. Unfortunately, there is the theoretical possibility that there might be unregulated growth, ie. cancer. Also, some have raised ethical concerns.

The second type is donor mesenchymal stem cells. These are cells that are obtained from a human volunteer, and then grown in a lab. They have the advantage of numbers. The concentration of stem cells can reach anywhere from 20-50 million stem cells. The disadvantage is the possibility of rejection reaction and also the possibility of transmission of infection.

The final type is autologous stem cells. These are cells harvested from the patient. A large amount of bone marrow is aspirated from the iliac crest of the hip. The bone marrow is then concentrated using a special technique in order to obtain the stem cells.

Duke researchers have recently reported on their findings that stem cells obtained from the fat pad behind the kneecap can be reprogrammed to become cartilage cells. This research is preliminary but is worth noting.

Other theoretical problems and questions regarding the use of autologous stem cells include the following:

• Inability to get enough stem cells from the host

• The relative weakness of older stem cells to multiply and divide

• The possible metabolic abnormality in stem cells taken from a patient with osteoarthritis that might make them more susceptible to degrading earlier

• The inability to stimulate the stem cells to grow

• The best type of matrix to use to “house” the stem cells so they have a place to grow

Recent technological advances have enabled us to address these questions. Through the use of special techniques, harvesting a significant volume of bone marrow aspirate, then concentrating it into a small volume containing anywhere from 1-5 million stem cells has been easily accomplished.

While older stem cells may not have the growth potential of younger ones, they do appear to function well enough to regenerate connective tissue. Still, it is probably wise, in the patient selection process, to exclude patients above a certain age.

There is no convincing evidence that the stem cells obtained from patients with osteoarthritis contain a metabolic defect that would render them ineffective. Nonetheless this area requires more research.

Stimulation of stem cell growth requires the use of growth factors that will bind to the tyrosine kinase receptors on the surface of stem cells. Once the receptors have been stimulated, a signal is sent to the nucleus of the stem cells leading to cell growth and proliferation.

The best “stimulant” appears to be platelet rich plasma which is easily obtained from a patient’s peripheral blood. Platelet-rich plasma (PRP) contains platelet-derived growth factor, transforming growth factor-B, fibrinogen, IL-1, epidermal growth factor, vascular endothelial growth factor, and adhesion molecules.

This is a potent soup of protein messengers that readily attach to stem cell surface receptors.

A number of different matrices have been used and this area is still being explored. The major logistical problem is creating a matrix that is biocompatible, biodegradable, and easily instilled.

At our center we use a mixture of calcium chloride and thrombin to create a gel that stem cells are bound to.

The joint is prepared using a specific approach designed to induce a local inflammatory response at the site to be healed. Autologous stem cells, PRP, and the matrix are then introduced carefully using ultrasound needle guidance.

To date, clinical response has been excellent.

Autologous stem cells provide an attractive option for both osteoarthritis patients and their physicians. Combining stem cells and PRP appears to be physiologically sound and more importantly, effective. This procedure holds much promise for Baby Boomers who wish to remain active.

For more information about stem cells and PRP, contact the Arthritis and Osteoporosis Center of Maryland at (301) 694-5800.



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Nathan Wei asked:




Tarsal tunnel syndrome is condition where the posterior tibial nerve in the ankle is compressed. In many ways, this condition is analogous to carpal tunnel syndrome in the hand where the median nerve is compressed.

With tarsal tunnel syndrome, compression of the tibial nerve occurs within a tunnel created by a floor consisting of the calcaneus (heel bone) and bounded by the medial malleolus- the bump on the inside part of the ankle- and the far corner of the heel bone. The roof of the tarsal tunnel is formed by a retinaculum- a tough piece of fibrous tissue.

Within the tarsal tunnel run a number of tendons (posterior tibial tendon flexor digitorum tendon, and flexor hallucis tendon) as well as the posterior tibial nerve, and the posterior tibial artery.

Many people with tarsal tunnel syndrome may have compression of nerves elsewhere. An example would be a patient who has a pinched nerve in the low back along with tarsal tunnel syndrome. This condition, where there is compression at least two locations, is termed “double-crush” syndrome.

Another problem is that many people who have tarsal tunnel syndrome may have peripheral neuropathy. This is a condition where there is damage to the small nerves in the feet. Numbness and tingling are common symptoms. Among the diseases associated with peripheral neuropathy are diabetes and hypothyroidism.

Medications can also cause a peripheral neuropathy. These include colchicine given for gout, nitrous oxide (an anesthetic), metronidazole (Flagyl- an antibiotic), phenytoin (Dilantin- an anti-seizure medicine), lithium (given for manic depression), disulfiram (Antabuse- given for alcohol addiction), cimetidine (Tagamet- given for peptic ulcer disease), hydroxychloroquine (Plaquenil- given for autoimmune disorders), amitriptyline (Elavil- an antidepressant), and various chemotherapy agents given for cancer.

Excessive alcohol and tobacco use as well as nutritional deficiencies can cause peripheral neuropathy as can exposure to heavy metals. Infectious diseases such as Lyme disease, leprosy, and HIV infection can also lead to peripheral neuropathy.

The most common symptom of tarsal tunnel syndrome is foot pain, which can also be accompanied by numbness and tingling.

Tapping on the tibial nerve at the tarsal tunnel may cause pain and tingling to occur. This is called a positive Tinel’s sign and is clinical evidence of tarsal tunnel syndrome.

The clinical impression can be confirmed with electrical testing (electromyography and nerve conduction). Electrical testing is important to evaluate the patient for other nerve entrapment problems such as a pinched nerve in the back. Peripheral neuropathy can also be diagnosed.

The posterior tibial nerve divides into three branches that include the calcaneal, medial plantar, and lateral plantar nerve branches, all of which innervate different parts of the foot and ankle.

Magnetic resonance imaging (MRI) and ultrasonography may be useful in evaluating a patient for underlying reasons for tarsal tunnel syndrome.

Medical therapy for tarsal tunnel syndrome may start with local injection of steroids into the tarsal tunnel. Physical therapy may be of some value in reducing soft-tissue edema which can ease pressure on the compartment.

Splints and braces may be helpful for patients who have anatomic abnormalities in the hindfoot and ankle.

When conservative therapy fails to help the patient’s symptoms, surgical intervention may be warranted.

More recently, the use of a percutaneous ultrasound guided needle release technique has been found to be effective. With this procedure, which is done using local anesthetic, the retinaculum is pierced several times with a small needle while injecting small amounts of fluid at the same time. In essence, the retinaculum is shredded to relieve pressure in the tarsal tunnel. Recovery time is limited to about one day compared with the weeks to months that can accompany open surgery.

When a patient doesn’t improve and has persistent pain, associated plantar fasciitis may be a cause of persistent pain in the medial heel region after surgery or percutaneous needle release.

Complete relief of symptoms may not be possible because tarsal tunnel syndrome has many causes and because the likelihood of irreversible nerve damage exists. An increase in pain after decompression either by needle release or by open surgery is extremely rare.



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Alok Prasad asked:




Does EMR increase revenues?

The economy has been in a recessionary trend for more than a year now. Whilst the economic conditions are challenging, the insurance companies are applying a squeeze on physicians to accept lower reimbursements. Funding by way of donations from private contributions is also reducing thereby adversely impacting availability of cash to implement an EMR / EHR system.

Any investment in EMR is justified only if it can help in increasing revenues, decreasing costs or overheads, improving patient care or any combination of the above resulting in maximization of reimbursements, collections and customer goodwill.

How does EMR/EHR increase revenues?



1. Improves charge capture: When traditional paper charts are used, many services performed in a physician’s office are lost and never billed. The billing staff may either completely leave out an E&M Code or may erroneously enter fewer units, all resulting in lower billing and therefore lower reimbursements to a physician. EMR software can increase revenues by facilitating capturing of charges for all services provided by the physician thereby avoiding lost revenues. In a case study (Nick Fabrizio, July 2005, QIO Presentation quote), a family medicine physician while seeing same number of patients increased revenues by $3000 per month due to timely visit documentation and automated charge capture.

2. Maximizes Billing: When using paper charts, to be on the safe side of the law, many physicians down code (use a lower billing code), rather than use an appropriate level of code. Providers who use EMR software can increase revenues by using System recommended E&M billing codes that are based on the service accurately documented within the EMR, without the fear of an audit.  Medical Economics magazine has estimated that physicians, who routinely down-code to avoid audits, lose an average of $40,000 annually.

3. Optimizes reimbursement process: EMR software allows physicians to produce adequate supporting documentation that complies with CMS guidelines and supports the appropriate level of service to be billed. Accurate coding speeds up the reimbursement process and results in fewer rejected claims from insurance companies. Even better, an EMR helps produce clean claims the first time, significantly reducing the number of rejected claims!

4. Increases Physician productivity: When physicians do not use EMR, they have to spend several minutes per encounter, first dictating and then reviewing the transcript before signing the same. With an EMR, progress notes are automatically generated which can be signed electronically from home or work, with no pulling or filing of charts. The time saved can be used to see a few more patients each day. Further, the medical records storage space released as a result of implementing an EMR System can be used to add more consultation rooms. As a result, practices are able to generate more revenue with the same fixed costs in the same amount of time.



5. Increases Services with Health Maintenance Reminders: EMR Systems provide computerized checks and reminders which enable reminders to be sent to all patients who are overdue for recommended services, or who are coming up on their annual check-ups. This helps the physician to deliver enhanced patient care, while at the same time increasing service volume and revenue.

6. Increases sources of income: Electronic Medical Records (EMR) software can allow providers to apply for enhanced sources of revenue from various payers associated with higher quality of care, such as:

(i) DOQ-IT (Doctors’ Office Quality-Information Technology is one of the Physician-focused Quality Initiatives sponsored by the Centers for Medicare & Medicaid Services (CMS).

(ii) Healthcare Pay-for-Performance (P4P) programs like Medicare Care Management Performance (MCMP), which is a 3-year, pilot P4P program that encourages physicians to follow strict quality-control guidelines for treating chronically ill patients.  During the first year of treatment, physicians receive bonuses for reporting data on quality measures and in the second and third years, participating clinics receive an extra annual performance-based bonus of $10,000 per clinician plus, an additional 25% reward for using a CCHIT Certified EMR.

To participate in a P4P program, a physician will need to track and measure care, and monitor the efficiency of delivering quality care at an optimal cost. One must also document the patients’ experiences using post-exam surveys. Most EMR systems are capable of meeting these requirements while simplifying the process.

How does it decrease administrative costs / overhead?

A typical medical office employs a transcriptionist, billing and clerical staff such as appointment schedulers, medical billers, collectors, file clerks and others. As a Practice grows, EMRs significantly reduce the need for more personnel to provide these functions, while at the same time, reducing existing office staff time that will no longer be needed spending valuable time hunting down records or filing patient charts. EMR-enabled medical offices mean fewer bodies in the office, generating greater efficiencies and accomplishing more.

1. Reduces transcription cost: Many physicians pay hefty fees for transcription of their medical charts. EMRs ‘virtually’ eliminate transcription costs since medical charts are created electronically at the time of the patient’s visit itself.  According to Medical Economics (March 2002), physicians spend between $15,000 and $25,000 over the course of a year for transcription-related services. Implementation of an EMR eliminates the need to use in-house or outsourced transcriptionists.  Integration of voice recognition software with EMR Systems also plays an important role for the people who want to have free formatted notes or for some providers who are not comfortable using mouse and keyboard.

Assuming an average of 25 visits per day and a conservative average of $2 per chart, an EMR brings instant savings of $50 per day per physician. Assuming that a physician works for 240 days in a year, this translates into potential savings of $12,000 per physician. Even if some or all of a practice’s physicians continue to use transcription, there is no doubt that these costs can be reduced significantly.

2. Reduces costs associated with storing paper charts: Once a medical office successfully converts to electronic medical records, all costs associated with purchasing, copying, management, storing or destroying paper charts can be eliminated. Additionally, the space typically used for storing patient charts can be utilized to create additional patient exam rooms, or increased office space, resulting in a more profitable use of resources. It is estimated that the total cost associated with maintaining a paper record average $3 per medical chart.

A case study revealed that a 12-physician practice saved $5,000 a year in storage space after converting to EMR. In another study, a major medical center in Boston seeing 750,000 patients a year, estimated they will save $6 million annually by reducing their dependence on paper records. At this saving rate, a practice seeing 5,000 patients annually could potentially save $40,000. In another case study, EMR implementation resulted in a reduction in office supplies expense by 50% with the elimination of paper charts.

3. Reduces liability and malpractice insurance premiums: Improved documentation, audit trails, and accuracy not only reduce incidents of medical errors, but also improve the chances of physicians receiving discounts from insurers. The cost of malpractice insurance has been showing a constant upward trend. A good EMR system leads to reduction in costs associated with poor documentation that otherwise generally means higher malpractice premiums.

a.    In a 2005 survey by the Medical Liability Monitor, a four-state average of the highest liability rates for OB/GYN was $230,919. With a two to five percent credit from malpractice insurance companies, clinics would save $4,600 to $11,500 per provider, per year, if they implemented an EMR.

b.    In another example, the Midwest Medical Insurance Company (MMIC) is offered a two to five percent credit to physician groups that used an EMR in 2008.

4. Self-service by Patients lowers data entry costs: The Patient Portal module of an EMR allows patients to enter much of their own demographics, even before they arrive to the Physicians office, including health insurance information, medical, family, and social history, and other pertinent data and this can save office staff a lot of data entry time. It can even allow patients to view certain information from their medical electronic file, and schedule appointments.

5. Saves time and increases efficiency: Staff and physician time is often ill spent due to:

i. Waiting: If a pharmacy calls while the chart is being used, or waiting to be filed, the staff receiving the call cannot access the information in a timely manner. EMR Systems allow multi-use access that enables staff to access and update patient records simultaneously – this saves time that would otherwise be spent in waiting for access to patient records.

ii. Time spent in pulling Medical Records: It is estimated that the cost of pulling and handling paper charts averages $5 to $12. In an EMR deployed Practice, Medical Records are accessible 24 x 7 from any web-enabled device or web access point, and this is done, securely.

iii. Data entry for billing purposes: When the EMR System interfaces or integrates with the Practice Management or Billing System, data entry workload reduces significantly while maintaining billing accuracy.

In a recent case study, a Practice reduced labor costs by 10% in the first year after implementing an EMR solution due to more efficient workflow and, the reduction of filing, coding, and data entry staff, while reducing time spent to complete clinical tasks such as Rx refills, referrals, lab, and diagnostic orders.

Revenue Acceleration and Denial Management

EMR implementation can help increase revenues but a physician practice must not forget to look at two other important and often neglected aspects:

1.    How can revenues be accelerated by proactive AR Follow-ups?

2.    How can we manage denials efficiently and expeditiously?

Revenue Acceleration

Experts believe that effective Account Receivables (AR) Follow up and AR Management are the most important areas requiring attention to ensure optimum revenue recovery. The average profit margin of US hospitals is less than 2% of Net Revenue while lost revenue due to denials accounts for an average of 6% to10% of net revenue, nationwide.  In fact, take a look at these powerful facts:

•    14% of all claims submitted to payers are denied and have to be resubmitted, appealed, or written off by Providers.

•    50% of denied claims are never re-filed.

•    90% of denials are preventable.

•    50-70% of denied claims are recoverable.

This can cost a clinic or practice thousands of dollars every year. Aside from the direct impact from the loss of revenue, there’s an additional impact on resources because of the expense associated with reprocessing denied claims. A judicious combination of process, technology and people skills must be effectively used to follow up with the payers to identify, address and rectify the identified problem and accelerate your revenues so that you can get money in your bank – faster.

Denials Processing

Accurate coding speeds up the reimbursement process and results in fewer rejected claims from insurance companies. Sophisticated denial processing solutions can captures claims, payments, and denials and addresses your denial management issues with an effective denial management plan.

Here are some of the tools used to achieve high rates of denial reversals:

•    Continuously update denials database

•    Immediate identification of the root causes of denials, and use the experience and knowledge to address each denial trend

•    Utilize denial data to generate custom reports

•    Better feedback to the coding and billing team

Conclusion

The many benefits enumerated in this article can be experienced by all Physicians, however, the payback period (ROI) will vary from Practice to Practice. In most cases, Practices experience increased cost in Year 1, and then, begin seeing increased revenues and, decreased administrative costs and overhead from the second year onward.  The key ingredient for success lies in the willingness of the Practice to critically examine their existing workflow and make recommended adjustments to optimize workflow efficiency. If these efforts can be supplemented with other revenue acceleration and denial management techniques, the Practice can see significant improvements in each and every revenue cycle Key Performance Indicator (KPI).



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Jatin asked:




Lamictal is an anti-seizure medication available at your local pharmacist. Lamictal medication cannot completely stop the occurrence of seizures but helps to control some types of seizures. Epilepsy is a neurological condition, which affects your nervous system. Epilepsy is also known as seizure disorder.

Lamotrigine also known as Lamictal is a drug of the class phenyltriazine which is chemically unrelated to existing antiepileptic drug. It has been clinically proved that Lamictal when used with existing antiepileptic drug is very effective in reducing seizure and also frequency of seizures. As earlier mentioned, Lamictal alone cannot cure epilepsy completely, but it helps by controlling seizures as long as you continue to take it.

A person suffering from epilepsy can only be treated if he has had two seizures which were formed by any of the known medical conditions. Some of the known medical conditions which can cause seizures are alcohol withdrawal and low blood sugar level. It is not possible to catch the actual cause of seizures. It can also be a heredity problem or can be caused by any brain injury.

Important Lamictal Information:-

It is advisable that you visit your doctor regularly during the initial few months of your treatment with Lamictal. Regular visits will keep your doctor updated about your condition. It will enable him to make decisions regarding your dosage, if you experience in any kind side effects. He might ask you to reduce your dosage or check for other related causes of side effects.

It has been observed that Lamictal can increase the effects of alcohol and other central nervous system (CNS) depressants. Therefore, if you consume the same amount of alcohol as you usually do, don’t be surprised if you feel drowsier this time. If you consume alcohol or CNS depressants, consult your doctor before taking lamictal. Some people have also complained of experiencing blurred or double vision, clumsiness, unsteadiness, dizziness while they are taking Lamictal.

Hence, it becomes very important to understand the effect this medicine can have on you. until you are aware of the possible effects of this medicine, it is recommended that you should not drive or use any machinery that can cause accident. If the above mentioned reactions persist for long, check with your doctor as soon as possible.

Are you planning to quit lamictal? If yes, check with your doctor and follow his instructions. Sudden withdrawal of lamictal can have some serious side effects. You doctor might advice you to reduce your dosage and gradually quit the medication than stopping it suddenly. If you do stop this medication suddenly, your seizures might return or occur more often.



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Jhon Murphy asked:




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It is your right as a patient to have your details of pain taken seriously. Be as organized and specific as possible. Write out your concerns ahead of time and go over them with your physician. Keep a file of all your medical information. It’s often hard to concentrate when you are in pain, bring a trusted friend with you to help take notes and ask questions. You can Buy Muscle pain medicine online from Discount Medication pharmacy without prescription.

There are many alternative treatments available as well. Research options, talk with others, contact the health association for your diagnosis and talk to your doctor. Different people find different treatments helpful. Try what you believe is best for you, whether it’s herbs, chiropractic, acupuncture or traditional medicine; it’s a very personal process. Now you can buy CARISOPRODOL Muscle Pain Relaxers online from Discount Medication pharmacy without prescription. This medication relaxes muscles and relieves pain and discomfort associated with strains, sprains, spasms or other muscle injuries.

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