On exam, the most striking feature was a slow, cautious gait with difficulty turning around.  Otherwise the exam was non-focal. 

First, an MRI of the brain showed signs that cerebrospinal fluid (CSF) was pushing into the adjacent brain (‘transependymal flow’).  In addition, when comparing the size of the ventricles (the chambers found in the center of the brain that house the CSF) to the size of the ventricles from a pre-accident MRI, it was clear that the ventricles were much larger.   This suggested that he had acquired hydrocephalus (‘water on the brain’). 

I then sent him for a lumbar puncture which revealed a normal pressure when performed – rather than an elevated pressure as one might expect.  I then performed a nuclear study called an Indium-111 cisternogram in which radioactive Indium-111 is injected into the CSF around the lumbar spinal cord.  In a normal person, this Indium-111 will not collect inside the ventricles but with patients who have a condition called Normal Pressure Hydrocephalus (NPH), the Indium-111 does end up inside the lateral ventricles.  This test was positive for this patient.

 He underwent placement of a ventriculoperitoneal (VP) shunt and immediately showed a return to his normal walking pattern and had resolution of his urinary urgency.  The confusion improved as well.  

DIAGNOSIS: NPH

Normal Pressure Hydrocephalus is thought to occur as a result of blockage of arachnoid granulations by degraded blood products.   Normally, the arachnoid granulations are responsible for resorption of the used CSF.  If an individual has experienced an intracranial bleed then they are theoretically at risk for developing NPH afterwards.  The classic clinical triad is ‘wild, wet and wobbly’ meaning worsening cognition, change in urinary habits and change in gait.  The treatment is placement of a VP shunt which will drain a small amount of the CSF continuously into the person’s gut.  

THEORY

The goal is to have as many healthy young individuals who previously were not insured go purchase health insurance.  In theory, they will underutilize services and the insurance companies will make money on them.  This will offset the money the insurance companies will lose caring for the older adults (age 55-65) who will be paying relatively low premiums but going to the doctor and hospital more frequently for care.   

Although there is close to 75 million US citizens between ages 18-65 without insurance, at this time only 6 million have signed up.  The government will encourage citizens to sign up by issuing a penalty for those that do not and will also pay the difference (subsidize) the high-cost of the premium for the older adults (age 55-65).  For example, I have a patient who is married and as a couple they earn $76,000 a year.  Prior to 2014, they chose to go without health insurance as their combined premium was $1400 a month.  However, they qualify for a subsidy (their family income is within four times the poverty level).  They now only pay $350 a month.  The government writes a check to Lifewise for $1050 each month to make up the difference.  Obviously, it’s unclear how long the government can continue to afford this generous program but they are likely hoping that once a critical number of younger adults obtain health insurance that they can stop this program.

MAJOR PROBLEM

This entire problem does not address the underlying problem which is escalating health care costs.  The two healthcare systems (Providence, UofW, Swedish) and the Insurance Companies (Lifewise, Blue Cross) only gain from this new arrangement.  There are now 76 million new insured customers added to the business of healthcare.  As I see it, at this time it doesn't appear that the insurance companies are losing any money on the premiums since the government simply subsidizes the difference. 

REALITY

Health care costs will continue to rise and premiums will go up.  We may have Universal Health Care but it will come at the cost of higher premiums which will be shared by employers, employees and now even the unemployed.

A GLINT OF HOPE

Maybe this only represents the bargaining and concessions necessary to improve the American healthcare system.  It’s possible the US government will get tough with the insurance companies and make them more transparent about their profit margins.  At the very least they could stop writing out the subsidy checks and just demand the insurance companies accept the older adult patients. This would motivate the insurance companies to help regulate the healthcare systems which continue to inflate healthcare costs. 

IN AN ALTERNATIVE UNIVERSE

How come we can’t just have a universal catastrophic health insurance program?  The government could even make that mandatory if they wanted.  Why can’t we remove the obligation for businesses to provide health insurance to their employees?   In this Shangri-La, people would just go to a health-provider and pay cash.  There wouldn't be any pre-approval, no preferred provider list, no in-network provider lists, no complicated billing.  It would mean the end of the health insurance industry (other than catastrophic insurance).  And … that’s why Shangri-La will never come to be.  So instead, an inefficient system grows even more complicated with the entry of the US government.

The MRI of the cervical spine demonstrates congenital narrowing of the spinal canal.  In addition, there are relatively small disc bulges and protrusions at several levels which in combination with the congenital spinal stenosis results in injury of the cervical spinal cord.  

DIAGNOSIS: Acute Cervical Cord Compression from Cervical Spondylosis 

DIAGNOSIS:  Progressive Supranuclear Palsy (PSP)

Progressive Supranuclear Palsy (PSP) is diagnosed in 30 of 100,000 individuals each year.  For every 100 patients with Parkinson’s Disease, there is 1 person with PSP. 

PSP typically first presents during the 6th decade of life with problems walking.  Individuals will complain of unexplainable falls or stiffness often falling backwards instead of forwards.  The individual with PSP often develops insomnia as a part of the disease.  A small percentage will develop a rest tremor and be misdiagnosed as having Parkinson’s disease.  Later in the disease, they will have difficulty moving their eyes upward or downward completely causing them to spill their food when they eat or having difficulty descending stairs.  They will tend to decrease the amount of blinking which will lead to dry eyes.  The speech will become slurred making it difficult to understand what they are saying.  Much later there will be problems with their thinking resulting in a change in their personality as they become more forgetful, possibly cantankerous and indifferent.

This disease is a result of neuronal loss throughout the midbrain of the brainstem.  Later in the disease there will be significant neuronal loss within the parietal lobes and the regions of the frontal lobes responsible for initiating movements of the limbs.  The neurons demonstrate an accumulation of tau within the cell body prior to dying.  There is no known treatment to stop the progression of the disease.  There are medications to help ameliorate some of the symptoms.  The median interval from onset of the initial symptom to confinement in a wheelchair is 8 years.   

DIAGNOSIS: Left ICA Aneurysm 

2) Young adults up to age 26 can remain on their parent’s health insurance plan.

REALITY

- Many parents won’t be able afford paying their child’s monthly premium (now that the premiums have increased for everyone because of the ACA) so will drop their coverage of the child anyway.  Currently, the percentage of 19 to 26 year olds without insurance has only fallen from 48% to 41%.

3) Companies with greater than 50 employees are required to provide health insurance for employees who work greater than 30 hours.

REALITY

- It is expected that in 2014, 44 percent of major US companies will only offer high-deductible health plans.  This shifts more of the health costs to the employee.

- Some employers will stop offering insurance and will instead provide what is called premium support, or funds that can be used for buying insurance.

- Some employers will decrease their employee's hours below the 30-hour per week threshold that relieves them from the mandate to provide insurance or pay a penalty.

4) Insurance Companies are forced to offer generous plans (cannot exclude specific patients on account of pre-existing health conditions, must cover medications).

REALITY

- Insurance companies are choosing to not offer plans on the healthcare exchange (anticipating that this is where ‘sick people’ might be enrolling) and sell plans mostly to businesses instead

- Insurance companies that do sell to the exchanges offer a ‘restricted network’.  This means they avoid hospitals that care for complicated patients and keep the number of doctors in their plans low, making it more likely that people will have to go out of network and pay more of the costs of care.

- Although insurance companies can't charge more to people with health problems as individuals, they can charge up to three times more based on age and can charge more in geographic areas where the population has more health problems or the costs of care are higher.

5) The healthcare exchange offers an easy to understand and fair alternative option for purchasing healthcare insurance.

REALITY

- On the new health insurance exchanges, plans are offered based on four tiers. The Platinum plans will pay for 90 percent of covered care, Gold (80%), Silver (70%) and Bronze plans, the lowest tier, will pay for 60 percent of covered services. It is important to distinguish that these levels are only for covered services because people don't usually understand that they will have to pay for uncovered services and out-of-network services. Unfortunately, the use of out-of-network services is often involuntary and occurs without being known at the time of care, especially in emergency situations.

- The United States is the only industrialized nation that uses a market-based health system and it has clearly failed. The US spends the most by far on health care and has average life expectancies to show for it.  As economists have shown, we will continue to pay high prices for medications and medical devices. Although there are proven methods to control health care costs such as simplified administration, global budgets and negotiating bulk prices, none of them were included in the ACA. In fact, the ACA increases our already enormous administrative costs by adding new levels of administration to our health system as outlined above. 

While I agree with the model of a National Health System, I have reservations simply expanding Medicare for all adults over age 18.  As a physician who has a small corporation and has personal experience dealing with this organization, I already understand its many weaknesses.  Any physician who has been practicing over the past 4 years while Medicare struggles unfolding other programs such as Meaningful Use (part of the ACA) and Physician Quality Reporting Initiative (PQRI) can attest to the frequent, bewildering changes that come year after year.  These changes come in response to what’s happening in the private market.  When one tries to get answers, either from the CMS support or local paid consulting services, it quickly becomes apparent that there’s a great deal of confusion and disorganization coming from DC.  Quite simply – the federal government moves far too slowly to be able to actively manage a beast like the healthcare sector.    

I would advocate expanding the Medicaid programs with greater policy oversight from CMS in Washington DC.  I think the US could provide a basic insurance health plan for adults above 18.  The federal government could set certain expectations for each state to meet or else they would not get a portion of their federal tax dollars the next year.  If the program does well then perhaps Medicare could be eliminated eventually to avoid redundancy.  Employers would no longer be required or asked to provide health insurance.  There would still be private health insurance for those individuals who wanted to be prepared for a catastrophe (cancer, heart attack).  After all, isn’t this how insurance is supposed to work?  There would be ‘boutique doctors’ who wouldn’t accept Medicaid and only see cash-paying patients.  There might even be private health insurance for those who wanted to see these ‘boutique doctors’. 

I’d love to hear any views or thoughts from readers on this matter.

Clinical Exam (07/10): no longer symptomatic 

He was referred to an oncologist who treated him with systemic chemotherapy and he has been in remission for the past 6 years.  All of his facial symptoms resolved completely with treatment of the underlying lymphoma. 

DIAGNOSIS: Lymphoma 

B) Alzheimer Brain

- Alzheimer disease is given to those individuals who have an inability to tolerate the neuronal damage of the cholinergic neurons within the brain.  This thought to be due to faulty repair mechanisms (e.g. familial defects, no HRT in post-menopausal women, Down’s Syndrome, etc). 

1.  There is a high density of cholinergic neurons in the low limbic region of the brain.  This is the location of the initial neuronal loss for Alzheimer’s disease.  This is the beginning of loss of smell and personality change.        

     a) entororhinal cortex

     b) amygdala

2.  With time, the damage progresses to the high limbic region.  This marks the beginning of amnestic Mild Cognitive Impairment. 

     a) association cortex of occipital-parietal lobe

     b) hippocampus

3.  Finally, it will spread to the high neocortex.   This is the beginning of Severe Dementia.

     a) frontal, parietal, anterior temporal neocortex

- At any point in time, if a person were to die from natural causes and undergo an autopsy, there would be a high concentration of neurofibrillary tangles found in the respective regions of the brain the correlate with the stage of their Alzheimer’s Disease.  Likewise, certain neuroimaging studies can also be used to confirm the diagnosis; specifically the SPECT study. 

C) Amyloid Neuritic Plaques

- Finally, in areas of the neuronal injury (of any sort) peptide structures called amyloid plaques can develop.  An amyloid plaque is made from protein and is found outside of any neurons.  In the normal population, these are found in increasing amounts as we age.  What has been observed is that in the brain of a patient with Alzheimer’s disease, these amyloid plaques surround the neuronal axons that are filled with the tau repair proteins.  There is a new neuroimaging test recently available called an Amyvid study which allows physicians to scan for higher than normal amount of amyloid plaques within the brain.  If present, in the right clinical scenario, it could support the diagnosis of Alzheimer’s disease.