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Dictionary of Acronyms in Healthcare

A Resource Curated by Meaningful Health IT

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Contents
Articles
Acronyms in healthcare Emergency department Accreditation Association for Ambulatory Health Care Association of American Medical Colleges American Academy of Otolaryngology Head and Neck Surgery Association of American Physicians and Surgeons American Association of Physicians of Indian Origin American Association for Respiratory Care Hematopoietic stem cell transplantation Patient Protection and Affordable Care Act Administration for Children and Families American College of Healthcare Executives American Congress of Obstetricians and Gynecologists American Cancer Society American College of Surgeons Academy of Nutrition and Dietetics American Dental Association American Diabetes Association Americans with Disabilities Act of 1990 Attention deficit hyperactivity disorder Activities of daily living Adverse drug reaction American Dental Society of Anesthesiology Automated external defibrillator Aid to Families with Dependent Children Atrial fibrillation American Hospital Association American Heart Association American Health Care Association American Health Information Management Association America's Health Insurance Plans Agency for Healthcare Research and Quality HIV/AIDS American Medical Association 1 14 22 24 24 25 29 31 33 42 80 82 83 85 89 92 100 103 110 122 135 138 144 147 153 157 169 171 173 175 177 180 184 202

African Malaria Network Trust American Medical Group Association American Medical Informatics Association American Nurses Association American Optometric Association American Osteopathic Association American Occupational Therapy Association Administrative Procedure Act American Psychiatric Association American Psychological Association American Pharmacists Association Ambulatory Payment Classification American Public Health Association American Physical Therapy Association Outpatient surgery American Society for Clinical Pathology Aspartate transaminase Wholesale Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy Balanced Budget Act of 1997 Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 Blue Cross Blue Shield Association Baby Friendly Hospital Initiative BI-RADS Bureau of Primary Health Care Behavioral Risk Factor Surveillance System Bachelor of Science in Nursing Coronary artery bypass surgery Coronary artery disease Consumer Assessment of Healthcare Providers and Systems Alternative medicine College of American Pathologists Community Action Agencies Community Access Program Commission on Accreditation of Rehabilitation Facilities X-ray computed tomography Blood glucose monitoring Congressional Budget Office

208 213 215 217 218 220 222 223 228 232 239 240 243 247 249 251 251 256 257 259 260 261 266 269 270 274 275 276 284 293 293 318 319 320 322 323 339 344

Certification Commission for Healthcare Information Technology Coronary care unit Intensive care unit Clinical Document Architecture Clostridium difficile Centers for Disease Control and Prevention Chargemaster Clinical data repository Acute assessment unit Tricare Veterans Health Administration Community health center College of Healthcare Information Management Executives Heart failure Community health worker Hospital information system Clinical Laboratory Improvement Amendments Cost-minimization analysis Continuing medical education Community mental health service Chief Medical Officer Centers for Medicare and Medicaid Services Unlicensed assistive personnel Central nervous system Consolidated Omnibus Budget Reconciliation Act of 1985 Council of governments Cost of living Certificate of need Chronic obstructive pulmonary disease Certified Public Accountant Consumer price index Computerized physician order entry Cardiopulmonary resuscitation Current Procedural Terminology Nurse anesthetist Special education Doctor of Chiropractic Developmental disability

346 349 350 353 355 367 373 375 375 377 381 388 389 392 406 410 413 414 415 417 423 424 425 427 430 434 436 438 439 452 458 468 473 482 487 496 507 512

Dental degree Drug Enforcement Administration Drug Enforcement Agency United States Department of Health and Human Services Durable medical equipment Do not resuscitate Doctor of Osteopathic Medicine Director of nursing Diagnosis-related group Disproportionate share hospital Diagnostic and Statistical Manual of Mental Disorders Direct-to-consumer advertising Veterinary physician Evidence-based medicine Electrocardiography Electronic data interchange Electroencephalography Electronic health record Electromyography Emergency medical technician Emergency medical services Emergency Medical Treatment and Active Labor Act Otolaryngology Explanation of benefits (insurance) United States Environmental Protection Agency Preferred provider organization Endoscopic retrograde cholangiopancreatography Employee Retirement Income Security Act End stage renal disease Federation of American Hospitals Food and Drug Administration Federal Employees Health Benefits Program Federal Food, Drug, and Cosmetic Act Medical classification Federal Insurance Contributions Act tax Federal Medical Assistance Percentages International medical graduate Family and Medical Leave Act of 1993

520 529 539 540 546 547 550 556 556 560 562 573 576 583 591 607 612 628 652 656 663 677 682 687 688 702 705 708 716 716 717 731 735 742 748 753 754 758

Nurse practitioner Poverty in the United States Federal Trade Commission Federally Qualified Health Center Fiscal year Flexible spending account Government Accountability Office Gross domestic product Human gastrointestinal tract Ophthalmology General practitioner Pediatrics Adolescent medicine Management of HIV/AIDS Healthcare Facilities Accreditation Program Healthcare Common Procedure Coding System Healthcare Cost and Utilization Project High-deductible health plan Healthcare Effectiveness Data and Information Set Home care Health information exchange Health information management Healthcare Information and Management Systems Society Health Insurance Portability and Accountability Act Bureau of Health Professions Health informatics Health information technology Health Information Technology for Economic and Clinical Health Act Healthcare Information Technology Standards Panel HIV Health Level 7 Health maintenance organization Health human resources HRHIS Health Resources and Services Administration Health savings account Health Service Executive Health Technology Assessment

764 769 783 789 792 800 806 810 827 833 841 851 855 859 867 868 869 878 879 884 889 892 899 901 911 914 927 932 936 938 949 959 963 966 969 972 980 983

Incurred but not reported International Statistical Classification of Diseases and Related Health Problems ICD-10 International Classification of Functioning, Disability and Health International Council of Nurses International Classification of Primary Care Indian Dental Association Integrated delivery system Irish Medical Organisation Independent practice association Interprofessional education JAMA (journal) The Journal of the American Osteopathic Association Joint Commission Lactate dehydrogenase Laboratory information management system Length of stay Licensed practical nurse Long-term acute care facility Long-term care Lung volume reduction surgery Left without being seen Medicare Advantage Medication Administration Record Medical College Admission Test Managed care Doctor of Medicine Medicare Payment Advisory Commission Medical Expenditure Panel Survey Magnetic resonance imaging Master of Science in Nursing Master of Social Work Medical laboratory scientist National Association of County and City Health Officials National Board for Respiratory Care The New England Journal of Medicine Non-communicable disease National Health Service

984 985 991 995 999 1001 1003 1003 1004 1006 1007 1010 1013 1015 1019 1027 1033 1033 1037 1038 1043 1044 1044 1048 1049 1054 1060 1073 1073 1078 1096 1097 1099 1104 1107 1110 1115 1120

National Institutes of Health National Institute of Mental Health National Institute for Occupational Safety and Health United States National Library of Medicine Omnibus Budget Reconciliation Act of 1993 Drug overdose Post-anesthesia care unit Personal Care Assistant NHS primary care trust Primary health care Protected health information United States Public Health Service Peripherally inserted central catheter Prospective payment system Quality-adjusted life year Quality improvement organizations Resource-based relative value scale Radiology information system Robert Wood Johnson Foundation Registered nurse Registered Health Information Technician Regional Health Information Organization Substance Abuse and Mental Health Services Administration Birth attendant State Children's Health Insurance Program State Food and Drug Administration Medicare Sustainable Growth Rate Nursing home Special needs plan Supplemental Security Income Selective serotonin reuptake inhibitor Temporary Assistance for Needy Families Transcranial Doppler Third-party administrator Tension headache Therapy UnitingCare Health UNICEF

1123 1134 1140 1143 1147 1150 1154 1155 1157 1158 1163 1165 1169 1172 1172 1174 1177 1180 1181 1183 1185 1186 1190 1194 1195 1202 1204 1207 1216 1216 1225 1239 1249 1254 1256 1259 1261 1262

United States Agency for International Development United States Pharmacopeia URAC World Health Organization Walter Reed Army Institute of Research

1269 1286 1288 1291 1302

References
Article Sources and Contributors Image Sources, Licenses and Contributors 1306 1335

Article Licenses
License 1344

Acronyms in healthcare

Acronyms in healthcare
The following is a partial list of initialisms and acronyms commonly used in health care. The terms listed are used in the English language within the health care systems of various countries.[1] A B C D E F G H I J K L M N O P Q R S T U V W X Y Z This list is incomplete; you can help by expanding it [2].

A
A&E Accident and Emergency Department AAAHC Accreditation Association for Ambulatory Health Care AAHSA American Association of Homes and Services for the Aging AAMA American Association of Medical Assistants AAMC American Association of Medical Colleges AAO-HNS American Academy of Otolaryngology - Head and Neck Surgery AAPC American Academy of Professional Coders AAPCC Adjusted Average per Capita Cost AAPS American Association of Physicians and Surgeons AAPI American Association of Physicians of Indian Origin

AARC American Association of Respiratory Care ABMT Autologous Bone Marrow Transplant ACA Affordable Care Act of 2010

Acronyms in healthcare ACF Administration for Children and Families ACHE American College of Healthcare Executives ACIIP Association of Clinical IVR and IWR Professionals ACO Accountable Care Organization ACOG American Congress of Obstetricians and Gynecologists ACS American Cancer Society ACS American College of Surgeons ADA American Dietetic Association ADA American Dental Association ADA American Diabetes Association ADA Americans with Disabilities Act ADHD Attention-Deficit Hyperactivity Disorder ADL Activities of Daily Living ADR Adverse Drug Reaction ADSA American Dental Society of Anesthesiology ADT Admission, Discharge, Transfer AED Automated External Defibrillator AEP Accredited Exercise Physiologist AFDC Aid to Families with Dependent Children AF Atrial Fibrillation AFMA African Medical Association AHA American Hospital Association AHA American Heart Association AHCA American Health Care Association AHDI Association for Healthcare Documentation Integrity AHEC Area Health Education Center AHIMA American Health Information Management Association AHIP America's Health Insurance Plans AHRQ Agency for Healthcare Research and Quality AIDS Acquired Immunodeficiency Syndrome AIN Assistant In Nursing AMA American Medical Association AMANET African Malaria Network Trust AMGA American Medical Group Association AMIA American Medical Informatics Association ANA American Nurses Association AOA American Optometric Association AOA American Osteopathic Association AOTA American Occupational Therapy Association APA Administrative Procedures Act APA American Psychiatric Association APA American Pharmaceutical Association APA American Psychological Association APC Ambulatory Payment Classification APDRG All Patient Diagnosis Related Groups

APHA American Public Health Association APHA American Protestant Hospital Association

Acronyms in healthcare APTA American Physical Therapy Association ASA American Society of Anesthesiology ASC Ambulatory Surgery Center ASCP American Society for Clinical Pathology ASHICE Reporting patient's condition Age Sex History Injury/Illness Consciousness ETA ASHRM American Society for Healthcare Risk Management ASO Administrative Service Organization AST Aspartate Aminotransferase ASTHO Association of State and Territorial Health Officials AWP Average Wholesale Price AYUSH Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy

B
BBA Balanced Budget Act of 1997 BBRA Balanced Budget Refinement Act of 1999 BCA Blue Cross Association BCBSA Blue Cross Blue Shield Association BCMA Bar Code Medication Administration BFHI Baby Friendly Hospital Initiative BHCS Baylor Health Care System, Dallas, TX BI-RADS Breast Imaging-Reporting and Data System Atlas BP Blood Pressure BPM Beats Per Minute BPHC Bureau of Primary Health Care BPOC Bar Code Enabled Point of Care BRFSS Behavioral Risk Factor Surveillance System BSN Bachelor of Science in Nursing

C
CABG Coronary artery bypass grafting CAD Coronary Artery Disease CAH Critical Access Hospital CAHPS Consumer Assessment of Healthcare Providers and Systems CAM Complementary and Alternative Medicine CAP College of American Pathologists, Community Action Program, or Community Access Program CARF Commission on Accreditation of Rehabilitation Facilities CAT Computerized Axial Tomography CBG Capillary Blood Glucose CBO Congressional Budget Office CCA Cost Consequence Analysis CCBTI Certified Cognitive Behavioral Training Instructor [3] CCHIT Certification Commission for Healthcare Information Technology CCHP Consumer Choice Health Plan CCM Certified Case Manager

CCRN Critical Care Registered Nurse CCU Coronary Care Unit

Acronyms in healthcare CCU Critical Care Unit CDA Clinical Document Architecture CDif Clostridium Difficile CDC Centers for Disease Control and Prevention CDM Charge Description Master CDR Clinical Data Repository CDR Chronic Disease Register CDU Clinical Decisions Unit CERTs Centers for Education and Research on Therapeutics CEO Campaign to End Obesity CHAMPUS Civilian Health and Medical Program of the Uniformed Services CHAMPVA Civilian Health and Medical Program - Veterans Administration CHC Community Health Center CHER Community Health Education & Resources CHHA Certified Home Health Agency CHIME College of Health Information Management Executives CHF Congestive Heart Failure CHI Consolidated Health Informatics CHMIS Community Health Management Information System CHS Certified in Healthcare Security CHW Community health worker CICU Cardiac Intensive Care Unit CIS Clinical information system CLIA Clinical Laboratory Improvement Amendments Act CMA Cost Minimization Analysis CME Continuing Medical Education CMHC Community Mental Health Center CMO Career Medical Officer CMO Chief Medical Officer CMP Competitive Medical Plan CMS Centers for Medicare and Medicaid Services CMT Certified Medical Transcriptionist CN Clinical Nurse CNA Certified Nursing Assistant CNC Clinical Nurse Consultant CNS Central Nervous System COB Coordination of Benefits COBRA Consolidated Omnibus Budget Reconciliation Act COG Council of Governments COI Cost of Illness Analysis COLA Cost of Living Allowance COMPASS Community Participation for Action in the Social Sector (Nigeria) CON Certificate of Need CONQUEST Computerized Needs-Oriented Quality Measurement Evaluation System COPC Community Oriented Primary Care

COPD Chronic Obstructive Pulmonary Disease COTH Council of Teaching Hospitals

Acronyms in healthcare CPA Certified Public Accountant CPHA Commission on Professional and Hospital Activities CPI Consumer Price Index CPOE Computerized Physician Order Entry CPOE Computerized Prescription Order Entry CPR Customary, Prevailing, and Reasonable CPR Cardiopulmonary Resuscitation CPT-4 Current Procedural Terminology, Fourth Edition CQuIPS Center for Quality Improvement and Patient Safety CRNA Certified Registered Nurse Anesthetist CRVS California Relative Value Studies CT Computerized Tomographic (scanners) CCRAS Central Council for Research in Ayurveda and Siddha CWSN Children with Special Needs

D
DC Doctor of Chiropractic DD Developmental Disability DDS Doctor of Dental Surgery DEA Drug Enforcement Administration DEA Drug Enforcement Agency DDM Doctor of Dental Medicine DHHS Department of Health and Human Services DME Durable Medical Equipment DMO Disease Management Organization DNR Do Not Resuscitate DO Doctor of Osteopathic Medicine DOA Dead On Arrival DON Director Of Nursing DOS Date Of Service DOU Direct Observation Unit DR ABC Primary Survey Danger Response Airway Breathing Circulation DRG Diagnosis Related Group DSH Disproportionate Share Hospital DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition DTC Direct to Consumer DUR Drug Utilization Review DVM Doctor of Veterinary Medicine

Acronyms in healthcare

E
EBM Evidence-Based Medicine ECF Extended Care Facility ECG Electrocardiogram ED Emergency Department EDI Electronic Data Interchange EDON Executive Director Of Nursing EEG Electroencephalogram EEN Endorsed Enrolled Nurse EHR Electronic health record EKG Electrocardiogram ELS Emergency Life Support EMG Electromyogram EMR Electronic medical record EMS Emergency Medical Services EMT Emergency Medical Technician EMTALA Emergency Medical Treatment and Active Labor Act ENT Ear, Nose and Throat EOB explanation of benefits (insurance) EPA Exclusive Provider Arrangement EPA Environmental Protection Agency EPC Evidence-Based Practice Center EPO Exclusive provider organization EPSDT Early and Periodic Screening, Diagnosis, and Treatment Program ER Emergency Room ERCP Endoscopic Retrograde Cholangiopancreatography ERISA Employee Retirement Income Security Act ESI Employer-sponsored Insurance ESRD End Stage Renal Disease ET Expenditure Target ETA Estimated Time of Arrival

F
FACCT The Foundation for Accountability FACS Fellow, American College of Surgeons FAH Federation of American Hospitals FAHIMA Fellow of the American Health Information Management Association FDA Food and Drug Administration FEHBP Federal Employees Health Benefits Program FFDCA Federal Food, Drug, and Cosmetic Act FIC Family of International Classifications, World Health Organization FICA Federal Insurance Contributions Act FIPH Fellow International Public Health, honoris FMAP Federal Medical Assistance Percentages

FMC Foundation for Medical Care FMG Foreign Medical Graduate

Acronyms in healthcare FMLA Family and Medical Leave Act of 1993 FNP Family Nurse Practitioner FPL Federal poverty level FTC Federal Trade Commission FQHC Federally Qualified Health Center FY Fiscal Year FSA Flexible spending account FHT Fetal Heart Tones

G
GAO Government Accountability Office GDP Gross Domestic Product GHAA Group Health Association of America GI Gastrointestinal GME Graduate Medical Education GOS General Ophthalmic Services GP General Practitioner

GPAM General Pediatrics and Adolescent Medicine

H
HAART Highly active antiretroviral therapy HC Healthcare HCBS Home and Community Based Services HCFAP Healthcare Facilities Accreditation Program HCPCS Healthcare Common Procedure Coding System HCUP Healthcare Cost and Utilization Project HCQ Healthcare Quality HDHP High Deductible Health Plan HEDIS Healthcare Effectiveness Data and Information Set HH Home Health HIE Health Information Exchange HIFA Health Insurance Flexibility and Accountability HIM Health information management HIMSS Healthcare Information and Management Systems Society HIPAA Health Insurance Portability and Accountability Act HIPC Health Insurance Purchasing Cooperative HIPDB Healthcare Integrity and Protection Data Bank HIPPS Health information prospective payment system HISP Health Information Service Provider [4] HISPC Health Information Security and Privacy Collaboration HIS Health Information System HIT Health Information Technology HITECH Health Information Technology for Economic and Clinical Health Act HITSP Healthcare Information Technology Standards Panel

HAV, HBV, HCV Hepatitis A, B, C, respectively. HIV Human immunodeficiency virus

Acronyms in healthcare HL7 Health Level 7 HME Home Medical Equipment HMO Health Maintenance Organization HMSA Health Manpower Shortage Area HOPPS Hospital Outpatient Prospective Payment System HPI History of Present Illness HPSAs Health Professional Shortage Areas HRQL Health Related Quality of Life HRA Health Risk Assessment HRA Health Reimbursement Account HRH Human resources for health HRHIS Human resources for health information system HRSA Health Resources and Services Administration HSA Health Savings Account HSA Health Service Area HSA Health Systems Agency HSE Health Service Executive

HTA Health Technology Assessment Hx History

I
IADL Instrumental Activities of Daily Living IBNR Incurred But Not Reported ICD International Statistical Classification of Diseases and Related Health Problems ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modifications ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modifications ICD-10-PCS International Classification of Diseases, Ninth Revision, Procedure Coding System ICDA International Classification of Diseases, Adopted ICF International Classification of Functioning, Disability and Health ICF Intermediate Care Facility ICN International Council of Nurses ICNP International Classification for Nursing Practice ICU Intensive Care Unit ICF/MR Intermediate Care Facility for the Mentally Retarded ICPC International Classification of Primary Care IDA Indian Dental Association IDN Integrated Delivery Network IDS Integrated Delivery System IHI Institute for Healthcare Improvement IMG International Medical Graduate IMO Irish Medical Organisation INHS Inland Northwest Health Services IOM Institute of Medicine of the National Academy of the Sciences IPA Independent Practice Association

IPE Interprofessional Education IPHF International Public Health Forum IRM Information Resource Management

Acronyms in healthcare ISN Integrated Services Network ITU Intensive Treatment Unit

J
JAMA Journal of the American Medical Association JAOAJournal of the American Osteopathic Association JCAHO Joint Commission on the Accreditation of Healthcare Organizations JIPHF Journal of International Public Health Forum

K
KPM Key Performance Measures

L
LDH Lactic dehydrogenase LIS Low Income Subsidy or Laboratory Information System LMT Licensed Massage Therapist LOS Length of Stay LPN Licensed Practical Nurse LSC Life Safety Code LSIT Life Sciences Information Technology LTAC Long-Term Acute Care facility LTC Long Term Care LUPA Low Utilization Payment Adjustment LVN Licensed Vocational Nurse LVRS Lung volume reduction surgery LWBS Left without being seen

M
MA Medical Assistant; Medicare Advantage MAAC Maximum Allowable Actual Charge MAF Medical Assistance Facility MAP Medical Audit Program MAPD Medicare Advantage Prescription Drug Plan MAR Medication Administration Record MCAT Medical College Admission Test MCH Maternal and Child Health Program MCI Medical Council of India MCO Managed Care Organization MD Doctor of Medicine MEDLARS Medical Literature and Analysis Retrieval System MedPAC Medicare Payment Advisory Commission MEPS Medical Expenditure Panel Survey MET Multiple Employer Trust

MEWA Multiple Employer Welfare Arrangement MDH Medicare-dependent Hospital

Acronyms in healthcare MHC Managed Health Care MHA Master's in Health Care Administration MI Myocardial Infarction MLR Medical Loss Ratio MLT Medical Laboratory Technician MMIS Medicaid Management Information System MMRA Metropolitan Medical Response System MPH Master of Public Health MRHFP Medicare Rural Hospital Flexibility Program MRI Magnetic Resonance Imaging MRSA Methicillin-resistant ''Staphylococcus aureus'' infections MSA Medical Savings Account or Metropolitan Statistical Area MSN Master of Science in Nursing MSW Master of Social Work or Medical Social Worker MT Medical Technologist MU Meaningful Use measurement/objective of HITECH Act MUA/MUPs Medically Under-served Areas/Populations

10

N
NACo National Association of Counties NACCHO National Association of County and City Health Officials NASHP National Academy for State Health Policy NASMD National Association of State Medicaid Directors NBRC National Board for Respiratory Care NCD Non-communicable disease NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NDC National Drug Code NEJM New England Journal of Medicine (standard PubMed abbreviation is N Engl J Med) NGA National Governors Association NGC National Guidelines Clearinghouse NwHIN Nationwide Health Information Network[5] NHS National Health Service NHSC National Health Savings Corps NICU Neonatal Intensive Care Unit NIH National Institutes of Health NIMH National Institute of Mental Health NIOSH National Institute of Occupational Safety and Health NKDA No Known Drug Allergies NLM National Library of Medicine NMA Nigerian Medical Association NMF Nigerian Medical Forum NP Nurse Practitioner NPRM Notice of Proposed Rule-making

NPS National Pharmaceutical Stockpile NRHA National Rural Health Association NUM Nurse Unit Manager

Acronyms in healthcare

11

O
OAA Old Age Assistance OASDHI Old Age Survivors, Disability, and Health Insurance Program OB/GYN Obstetrician/Gynecologist OBRA Omnibus Budget Reconciliation Act OD Overdose or the right eye (from the Latin oculus dexter) ODS Organized Delivery System OMB Office of Management and Budget OPD Outpatient Department OPHP Office of Public Health Preparedness OS the left eye (from the Latin oculus sinister) OSHA Occupational Health and Safety Administration

P
PA Physician Assistant PACU Post Anesthesia Care Unit PAHO Pan American Health Organization PBM Pharmacy Benefits Manager PCA Personal Care Assistant or Patient Controlled Anesthesia PCCM Primary Care Case Management PCMH - Patient-Centered Medical Home PCP Primary Care Physician PCT NHS Primary Care Trust PDI Professional Development Institute PDP Prescription Drug Plan PDQS Partnership Defined Quality of Service PFP Patient Flow Platform PHC Primary health care PHI Protected Health Information PHO Physician-Hospital Organization PHS Public Health Service PIAPHP Partners in Information Access for Public Health Professionals PICC Peripherally Inserted Central Catheter PICU Pediatric Intensive Care Unit POC Point of Care POS Place of Service or Point of Service PMPM Per Member Per Month PMP Per Million Population PPA Preferred Provider Arrangement PPO Preferred Provider Organization PPG Physician Provider Group PPS Prospective Payment System PSN Provider Sponsored Network PSO Provider Sponsored Organization

Acronyms in healthcare

12

Q
QALY Quality-Adjusted Life Year QAPI Quality Assessment and Performance Improvement Program QARI Quality Assurance Reform Initiative QD Each day, usually in prescriptions. QIO Quality Improvement Organization QISMC Quality Improvement System for Managed Care QuIC Quality Inter agency Coordination Task Force

R
RAN Rural Area Computer Network RAP Request for Anticipated Payment RBRVS Resource-Based Relative Value Scale RCT Randomized Clinical Trial or Randomized Controlled Trial RD Registered Dietician RFE Reason For Encounter RHC Rural Health Clinic RICE Rest, Ice, Compression, Elevation (Alternatively) Rest, Immobilize, Cool, Elevate RIS Radiology Information System RRC Rural Referral Centers RUG Resource Utilization Groups RWJF Robert Wood Johnson Foundation RN Registered Nurse RMO Resident Medical Officer RHIT Registered Health Information Technician RHIA Registered Health Information Administrator RHIO Regional Health Information Organization

S
SAMPLE Signs/Symptoms, Allergies, Medications, Past history, Last meal, Events leading up to (First aid secondary survey questions) SAMSHA Substance Abuse and Mental Health Services Administration SBA Skilled Birth Attendant SCH Sole Community Hospitals SCHIP State Children's Health Insurance Program SEP Special Enrollment Period SDMC Statistical and Data Management Center SFDA State Food and Drug Administration SGR Sustainable Growth Rate SHEA State Health Expenditure Account SJA St John Ambulance SOB Shortness of Breath SNF Skilled Nursing Facility SNIP Strategic National Implementation Process SNP Special Needs Plan SSF Sjgren's Syndrome Foundation

Acronyms in healthcare SSI Supplemental Security Income SSRI Selective Serotonin Reuptake Inhibitor Sx Symptoms

13

T
TANF Temporary Assistance for Needy Families TCD Transcranial Doppler TPA Third Party Administrator or tissue plasminogen activator TTHs tension type headaches Tx Treatment Txp Transport (by ambulance)

U
UAP Unlicensed assistive personnel UCH UnitingCare Health UNICEF United Nations Children's Fund USAID United States Agency for International Development USP U.S. Pharmacopeia URAC Utilization Review Accreditation Commission

V
VIRHN Vertically Integrated Rural Health Network

W
WHO World Health Organization WHRN Whole Health Resource Network WISN Workload Indicators of Staffing Needs WRAIR Walter Reed Army Institute of Research

References
[1] [2] [3] [4] [5] Health Care Acronyms (http:/ / www. all-acronyms. com/ tag/ health_care), All Acronyms, Accessed 19/11/08 http:/ / en. wikipedia. org/ w/ index. php?title=Acronyms_in_healthcare& action=edit http:/ / www. NBSEmpowers. com http:/ / wiki. directproject. org/ http:/ / healthit. hhs. gov/ portal/ server. pt?open=512& objID=1142& parentname=CommunityPage& parentid=4& mode=2

External links
Smart Define (http://www.smartdefine.org/healthcare/abb/r) - Healthcare Related Abbreviations

Emergency department

14

Emergency department
An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), or casualty department, is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care.

A clearly marked emergency department at the The Royal Infirmary of Edinburgh.

The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume.

History
Accident services were already provided by workmen's compensation plans, railway companies, and municipalities in Europe and the United States by the late mid-nineteenth century, but the first specialized trauma care center in the world was opened in 1911 in the United States at the University of Louisville Hospital in Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the 1930s. Griswold also equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en route to the hospital.[1][2][3]

Department operation
Today, a typical hospital has its emergency department in its own section of the first floor of the campus, with its own dedicated entrance. As patients can present at any time and with any complaint, a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This process is called triage.

The emergency department entrance at Mayo Clinic's Saint Marys Hospital. The red-and-white emergency sign is clearly visible.

Triage is normally the first stage the patient passes through, and consists of a brief assessment, including a set of vital signs, and the assignment of a "chief complaint" (i.e. chest pain, abdominal pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a nurse, although dependent on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or physicians (DOs or MDs). Triage is typically conducted face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew; in this method, the paramedics will call the hospital's triage center with a short update about an incoming patient, who will then be triaged to the appropriate level of care.

Emergency department Most patients will be initially assessed at triage and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department. The resuscitation area, commonly referred to as "Trauma" or "Resus", is a key area in most departments. The most seriously ill or injured patients will be dealt with in this area, as it contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries. Typical resuscitation staffing involves at least one attending physician (DO or MD), and at least one and usually two nurses with trauma and Advanced Cardiac Life Support training. These personnel may be assigned to the resuscitation area for the entirety of the shift, or may be "on call" for resuscitation coverage (i.e. if a critical case presents via walk-in triage or ambulance, the team will be paged to the resuscitation area to deal with the case immediately). Resuscitation cases may also be attended by residents, medical students, nursing students, emergency medical technicians, respiratory therapists, and/or hospital pharmacists, depending upon the skill mix needed for any given case and whether or not the hospital provides teaching services. Patients who exhibit signs of being seriously ill but are not in immediate danger of life or limb will be triaged to "acute care" or "majors," where they will be seen by a physician and receive a more thorough assessment and treatment. Examples of "majors" include chest pain, difficulty breathing, abdominal pain and neurological complaints. Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood and/or urine, ultrasonography, CT or MRI scanning. Medications appropriate to manage the patient's condition will also be given. Depending on underlying causes of the patient's chief complaint, he or she may be discharged home from this area or admitted to the hospital for further treatment. Patients whose condition is not immediately life threatening will be sent to an area suitable to deal with them, and these areas might typically be termed as a prompt care or minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing. Children can present particular challenges in treatment. Some departments have dedicated pediatrics areas, and some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures. Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal). Fast decisions on life-and-death cases are critical in hospital emergency rooms. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomach aches, with a high cost on the Health Care system.[4]

15

Emergency department

16

Nomenclature in English
Emergency department became the preferred termWikipedia:WikiProject Countering systemic bias when emergency medicine was recognised as a medical speciality and hospitals and medical centres developed Departments of emergency medicine to provide services. Other common variations include 'emergency ward,' 'emergency centre' or 'emergency unit.' Historic terminology still exists across the English-speaking world, especially in vernacular usage. The previously accepted formal term 'Accident and Emergency' or 'A&E' is still widely known in countries such as the United Kingdom, the Commonwealth and Hong Kong (former British colony and Commonwealth member), as are earlier terms such as 'Casualty', or 'Casualty Ward' which continue to be used informally. The same applies to 'Emergency Room' or 'ER' in North America, originating when emergency facilities were provided in a single room of the hospital by the Department of Surgery.

Signage
Regardless of naming convention, there is a widespread usage of directional signage in white text on a red background across the world, which indicates the location of the emergency department, or a hospital with such facilities. Signs on emergency departments may contain additional information. In some American states there is close regulation of the design and content of such signs. For example, California requires wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty",[5] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.
An example of California hospital signage. In some countries, including the United States and Canada, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis. Very large clinics may operate as "free-standing emergency centres," which are open 24 hours and can manage a very large number of conditions. However, if a patient presents to a free-standing clinic with a condition requiring hospital admission, he or she must be transferred to an actual hospital, as these facilities do not have the capability to provide inpatient care.

United States
Many U.S. emergency departments are exceedingly busy. A study found that in 2009, there were an estimated 128,885,040 ED encounters in U.S. hospitals. Approximately one-fifth of ED visits in 2010 were for patients under the age of 18 years.[6] Most encounters (82.8 percent) resulted in treatment and release; 17.2 percent were admitted to inpatient care.[7] A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ED patients.[8] A 2005 patient survey found an average ED wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.[9] One inspection of Los Angeles area hospitals by Congressional staff found the EDs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of the five Level I

Emergency department trauma centres were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ED could not safely accommodate any more patients.[10] This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ED), effective January 1, 2009; in response, hospitals have devoted more staff to the ED at peak times and moved some elective procedures to non-peak times.[11][12] In 2009, there were 1,800 EDs in the country.[13]

17

United Kingdom
All A&E departments throughout the United Kingdom are financed and managed publicly by the NHS of each constituent country (England, Scotland, Wales and A&E sign common in the UK. Northern Ireland). As with most other NHS services, emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the point of need and regardless of any ability to pay. Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced a four-hour target in emergency departments that required departments in England to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. Present policy is that 95% of all patient cases do not "breach" this four-hour wait. The busiest departments in the UK outside London include University Hospital of Wales in Cardiff, The North Wales Regional Hospital in Wrexham and the Edinburgh Royal Infirmary. The 4-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labeling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[14]

Critical conditions handled


Cardiac arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.

Heart attack
Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs, such as drugs that treat erectile dysfunction. An ECG that reveals ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty

Emergency department (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centres are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

18

Trauma
Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a major fall, is initially handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is a medical specialty, and has certifications in the United States from the American Board of Emergency Medicine). Trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles. The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma centre. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour". Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma centre. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Mental illness
Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. The emergency department conducts medical clearance rather than treats acute behavioral disorders. From the emergency department, patients with significant mental illness may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD


Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for tracheal intubation in many cases of severe exacerbations of COPD.

Special facilities, training, and equipment


An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information. ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and

Emergency department EDs employ many such specialists. ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items. Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls. Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have an X-ray room, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very rapidly. The use of Electronic Medical Records in U.S. EDs has increased rapidly as a result of the 2009 HITECH Act. Companies such as MEDHOST, Inc. and Wellsoft Corporation provide Emergency Department Information Systems (EDIS) that help hospitals meet HITECH requirements.[15] Functionality typically offered by these software systems include real-time patient tracking, clinical charting and clinician order entry, charge capture, and comprehensive reporting capabilities.[16] MEDHOST, Inc. was named Best In KLAS [17] in the Emergency Department Market Segment for Software & Services in early 2012.[18]

19

Non-emergency use
Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement. In all Primary Care Trusts there are out of hours doctor services provided by general practitioners. In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast Track or Minor Care units. These units are for people with non-life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions. To reduce the strain on limited ED resources, American Medical Response created a checklist that allows EMTs to identify intoxicated individuals who can be safely sent to detoxification facilities instead. [19]

Emergency department

20

Doctors in training
Doctors in training provide a large portion of the medical care in emergency departments. In the United States, they are called residents and most are supervised by ABEM or AOBEM board certified attending physicians. In the United Kingdom, many doctors rotate through the emergency department, such as during their second foundation year (F2), or as part of a rotational specialty training programme in General Practice or Acute Care Common Stem training (Emergency Medicine, Acute medicine, Anaesthetics, and Intensive Care). There are also many other professional positions filled in the ED for those wishing to become doctors; one could become a Scribe (ER), a volunteer, or one could shadow a doctor. All of these positions provide experience and perspective to the future medical student.

Overcrowding
Emergency department overcrowding is when function of a department is hindered by an inability to treat all patients in an adequate manner. This is a common occurrence in emergency departments world wide.[] Overcrowding causes inadequate patient care which leads to poorer patient outcomes.[][] To address this problem, Lakeland Regional Medical Center successfully implemented several techniques in 2011 to improve emergency department efficiencies. The emergency department reorganized space into pods, made staffing changes to facilitate patient flow, required emergency medical service personnel to provide advance notice of ambulance arrivals so that a bed could be preassigned, and had a multidisciplinary team develop and use care plans for nonemergent patients who repeatedly present with chronic pain issues.[20]

Frequent presenters
Frequent presenters are persons who will present themselves at a hospital multiple times, usually those with complex medical requirements or with psychological issues complicating medical management.[] These persons contribute to overcrowding and typically use require more hospital resources although they do not account for a significant amount of visits.[]

Emergency departments in the military


Emergency departments in the military benefit from the added support of enlisted personnel who are capable of performing any task they have been trained for, regardless of actual education obtained from civilian schooling. For example, in Naval hospitals, Hospital Corpsmen perform tasks that fall under the scope of practice of both doctors (i.e. sutures and incision and drainages) and nurses (i.e. medication administration and foley catheter insertion). Often, some civilian education and/or certification will be required such as an EMT certification, in case of the need to provide care outside of the base where the member is actually stationed.

Violence against health care workers


According to a survey at an urban inner-city tertiary care centre in Vancouver,[] 57% of health care workers were physically assaulted in 1996. 73% were afraid of patients as a result of violence, almost half, 49%, hid their identities from patients, 74% had reduced job satisfaction. Over one-fourth of the respondents took days off because of violence. Of respondents no longer working in the emergency department, 67% reported that they had left the job at least partly owing to violence. Twenty-four hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies.[]

Emergency department

21

Notes
[1] [2] [3] [4] [5] [6] url=http:/ / books. google. com/ books?id=HbZMAQAAIAAJ& pg=PA1809#v=onepage url=http:/ / books. google. com/ books?id=ltcEPWDHIkMC& pg=PA212 url=http:/ / www. louisville. edu/ ur/ ucomm/ mags/ summer2000/ cover_story. htm http:/ / news. yahoo. com/ s/ ap/ 20100621/ ap_on_bi_ge/ us_med_overtreated_er Title 22, California Code of Regulations, Section 70453(j). Wier LM, Hao Y, Owens P, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. Agency for Healthcare Research and Quality, Rockville, MD. May 2013. (http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ sb157. jsp) [7] Kindermann D, Mutter R, Pines JM. Emergency Department Transfers to Acute Care Facilities, 2009. HCUP Statistical Brief #155. Agency for Healthcare Research and Quality. May 2013. (http:/ / hcup-us. ahrq. gov/ reports/ statbriefs/ sb155. jsp) [8] http:/ / abcnews. go. com/ print?id=3322309 [9] http:/ / www. medicalnewstoday. com/ articles/ 44453. php [10] http:/ / oversight. house. gov/ documents/ 20080505102428. pdf [15] "Wellsoft KLAS Performance Ratings Overview" (http:/ / www. klasresearch. com/ Vendor/ 550?ReturnURL=/ Vendor/ 550), KLAS, Retrieved January 12, 2012 [16] "Emergency Department KLAS Performance Ratings" (http:/ / www. klasresearch. com/ Segment/ 13), KLAS, Retrieved January 30, 2013 [17] http:/ / www. klasresearch. com/ [18] "MEDHOST Attains No. 1 "Best in KLAS" Ranking" (http:/ / www. reuters. com/ article/ 2012/ 01/ 12/ idUS162786+ 12-Jan-2012+ BW20120112), REUTERS, Retrieved January 30, 2013

References
John B Bache, Carolyn Armitt, Cathy Gadd, Handbook of Emergency Department Procedures, ISBN 0-7234-3322-4 Swaminatha V Mahadevan, An Introduction To Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, ISBN 0-521-54259-6 Academic Emergency Medicine (http://www.aemj.org/), ISSN: 1069-6563, Elsvier

External links
Use of emergency departments for less- or non-urgent care (http://secure.cihi.ca/cihiweb/dispPage. jsp?cw_page=media_14sep2005_e) (Canada) (Canadian Institute for Health Information) Overuse of Emergency Departments Among Insured Californians (http://www.chcf.org/topics/hospitals/ index.cfm?itemID=126089) (US) (California HealthCare Foundation, October 2006) ED visits (http://www.cdc.gov/nchs/fastats/ervisits.htm) (US) (National Center for Health Statistics) Academic Emergency Medicine (http://www.aemj.org/), ISSN: 1069-6563, Elsvier Physicians on Call: California's Patchwork Approach to Emergency Department Coverage (http://www.chcf. org/publications/2011/02/physicians-on-call-ca-patchwork)

Accreditation Association for Ambulatory Health Care

22

Accreditation Association for Ambulatory Health Care


Accreditation Association for Ambulatory Health Care
Industry Founded Accreditation 1979

Headquarters Skokie, Ill. Website http:/ / www. aaahc. org

The Accreditation Association for Ambulatory Health Care (AAAHC), founded in 1979, is an American organization which accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as health plans, such as health maintenance organizations and preferred provider organizations.[1]:550 AAAHC has been granted "deemed status" to certify ambulatory surgery centers for Medicare by the Centers for Medicare and Medicaid Services. In 2009, the AAAHC added the Medical home to the types of organizations that it accredits. It offers on-site surveys for organizations seeking Medical Home accreditation or certification.[2] The AAAHC survey model is one of cooperation and education. It is unique in offering accreditation surveys that are conducted by professionals who are actively involved in ambulatory care and have first-hand understanding of the specific issues facing the facilities they survey. Surveyors assess how an organization meets prevailing Standards and share their knowledge and experience with others to help ambulatory service providers maintain high standards. AAAHC is one of three organizations that accredits office-based surgery practices, the others being the Joint Commission on Accreditation of Healthcare Organizations and the American Association for Accreditation of Ambulatory Surgery Facilities.[3] In 2010, the organization extended its accreditation services internationally, beginning with Costa Rica. The program has since expanded to Peru and further expansion is planned. AAAHC announced the launch of a new accreditation program for hospitals in 2012, which will focus on small hospitals and will be offered through a new entity established by AAAHC, the Accreditation Association for Hospitals/Health Systems Inc. (AAHHS). AAAHC continuously reviews its standards and revises current standards and adds new standards as required by the constantly changing health care arena. Each year in August there is a public comment period where these revisions and additions are presented for review and comment by interested parties. Facebook: http://www.facebook.com/AccreditationAssn Twitter: http://twitter.com/aaahc_quality

Accreditation Association for Ambulatory Health Care

23

History
The Accreditation Association was formed in 1979 by six member organizations including the American College Health Association, the ASC Association, and the Medical Group Management Association.[1]:549 The Accreditation Association has 18 Association Members:[4] Ambulatory Surgery Foundation American Academy of Cosmetic Surgery American Academy of Dental Group Practice American Academy of Dermatology American Academy of Facial Plastic and Reconstructive Surgery American Association of Oral and Maxillofacial Surgeons American College of Gastroenterology American College Health Association American College of Mohs Surgery American College of Obstetricians and Gynecologists American Dental Association American Gastroenterological Association American Society of Anesthesiologists American Society for Dermatologic Surgery American Society for Gastrointestinal Endoscopy Association of periOperative Registered Nurses Medical Group Management Association Society of Ambulatory Anesthesia

Accreditation Process
Standards are reviewed and updated annually to keep up with current trends and technologies in the health care arena. AAAHC surveyors are volunteers: physicians, dentists, podiatrists, pharmacists, nurses and administrators who are actively involved with ambulatory health care. AAAHC offers a three year term of accreditation. An organization may also receive a deferral or denial of accreditation if compliance is not met.

Institute for Quality Improvement


In 1999, the AAAHC founded its non-profit subsidiary, the AAAHC Institute for Quality Improvement (AAAHC Institute) to offer performance measurement opportunities and related quality improvement/educational programs to ambulatory health care organizations. The AAAHC Institute has conducted and published more than 70 studies.

References
[1] Kongstvedt, Peter R. Essentials of Managed Health Care. Jones and Bartlett: Boston, 2007 [2] Accreditation Association for Ambulatory Health Care. Medical Home Accreditation (http:/ / www. aaahc. org/ eweb/ dynamicpage. aspx?webcode=mha). Accessed 2010 March 30. [3] Preventing errors in the outpatient setting: A tale of three states (http:/ / www. medscape. com/ viewarticle/ 439794_print). Lapetina, Elizabeth M. and Armstrong, Elizabeth M. 2002. Health Affairs 1(4):26-39. [4] AAAHC Member Organizations/Board of Directors (http:/ / www. aaahc. org/ eweb/ dynamicpage. aspx?site=aaahc_site& webcode=mbr_orgs_and_board). Accreditation Association for Ambulatory Health Care web site. Retrieved on 2008-12-05.

Accreditation Association for Ambulatory Health Care

24

External links
Accreditation Association for Ambulatory Health Care (http://www.aaahc.org)

Association of American Medical Colleges


The Association of American Medical Colleges (AAMC) is a non-profit organization based in Washington, DC and established in 1876. It administers the Medical College Admission Test. The AAMC operates the American Medical College Application Service and the Electronic Residency Application Service which facilitate students applying to medical schools and residency programs, respectively. Since 2006, the AAMC president has been Darrell Kirch.[1]

References
[1] Darrell G. Kirch, M.D. (https:/ / www. aamc. org/ download/ 45150/ data/ kirchbiolong. pdf) AAMC. Accessed October 4, 2011.

External links
Official website (http://www.aamc.org)

American Academy of Otolaryngology Head and Neck Surgery


The American Academy of Otolaryngology Head and Neck Surgery, originally started in the 1924, is the world's largest organization of over 13,000 specialists related to the area of ears, nose, and throat.[1]

History
Reference[2] Though it was not official at the time, the AAO began in 1896 when Dr. Hal Foster wrote a letter to invite specialists in the areas of ophthalmology and otolaryngology to gather for a meeting in Kansas City. This began the Western Ophthalmological, Otological, Laryngological and Rhinological Association. It was not until 82 years later that it adopted its official name. Then later it would add Head and Neck Surgery to identify its broader medical view of the foundation from just the ears, nose and throat. In 1982 The AAO merged with the ACO as to "speak with a single voice" for the special field of medicine.

References
[1] About the AAO (http:/ / www. entnet. org/ about/ index. cfm) [2] A Brief History of the AAO-HNS/F (http:/ / www. entlink. net/ academy/ mission/ history. cfm)

External links
Official Website of the American Academy of Otolaryngology-Head and Neck Surgery (http://www.entnet.org/ )

Association of American Physicians and Surgeons

25

Association of American Physicians and Surgeons


Association of American Physicians and Surgeons
Type Founded Political advocacy group May 1944

Headquarters Tucson, Arizona, United States Focus(es) Opposes abortion, Medicare/Medicaid, universal health care, and government involvement in health care; publishes the Journal of American Physicians and Surgeons omnia pro aegroto ("All for the patient") http:/ / www. aapsonline. org/

Motto Website

The Association of American Physicians and Surgeons (AAPS) is a politically conservative non-profit association founded in 1943 to "fight socialized medicine and to fight the government takeover of medicine."[][] The group was reported to have approximately 4,000 members in 2005, and 3,000 in 2011.[][1] Notable members include Ron Paul and John Cooksey;[2] the executive director is Jane Orient, a member of the Oregon Institute of Science and Medicine. The AAPS motto, "omnia pro aegroto" is Latin for "all for the patient."[3] AAPS also publishes the Journal of American Physicians and Surgeons (formerly known as the Medical Sentinel). The Journal is not indexed by mainstream scientific databases such as the Web of Science or MEDLINE.[4] The quality and scientific validity of articles published in the Journal has been criticized by others. Many of the political and scientific viewpoints advocated by AAPS are considered extreme or dubious by other medical groups.[]

History
During the winter of 1943, the Lake County (Indiana) Medical Committee opposed the Wagner-Murray-Dingell Bill, proposed legislation that would provide government health care for most U.S. citizens. Also opposed to the bill was the conservative National Physicians Committee. The committee began a membership drive in February 1944. By May 1944, the AAPS claimed members from all 48 states.[] In 1944, Time reported that the group's aim was the "defeat of any Government group medicine."[] In 1966, the New York Times described AAPS as an "ultra-right-wing... political-economic rather than a medical group," and noted that some of its leaders were members of the John Birch Society.[]

Positions
While it describes itself as "non-partisan",[5] AAPS is generally recognized as politically conservative.[][6][7][] According to Mother Jones, "despite the lab coats and the official-sounding name, the docs of the AAPS are hardly part of mainstream medical society. Think Glenn Beck with an MD."[] The organization opposes mandatory vaccination,[8] a single-payer healthcare system[9] and government intervention in healthcare.[][10] The AAPS has characterized the effects of the Social Security Act of 1965, which established Medicare and Medicaid, as "evil" and "immoral",[11] and encouraged member physicians to boycott Medicare and Medicaid.[12] AAPS argues that individuals should purchase medical care directly from doctors, and that there is no right to medical care.[13] The organization requires its members to sign a "declaration of independence" pledging that they will not work with Medicare, Medicaid, or even private insurance companies.[] AAPS opposes mandated evidence-based medicine and practice guidelines, criticizing them as a usurpation of physician autonomy and a fascist merger of state and corporate power where the biggest stakeholder is the

Association of American Physicians and Surgeons pharmaceutical industry.[14] Other procedures that AAPS opposes include abortion[15] and over-the-counter access to emergency contraception.[16] AAPS also opposes electronic medical records[] as well as any "direct or de facto supervision or control over the practice of medicine by federal officers or employees."[17] On Oct 25, 2008 the AAPS website published an editorial implying that Barack Obama was using Neuro-linguistic Programming, "a covert form of hypnosis", to coerce people to vote for him in his 2008 presidential campaign.[18]

26

Political activity
Gun control
In 1996, Dr Miguel A. Faria, Jr., a retired neurosurgeon and former Clinical Professor of Surgery (Neurosurgery, ret.) at Mercer University School of Medicine as well as founding editor of Medical Sentinel, the AAPS's journal, was involved in a gun control debate regarding the CDC's National Center for Injury Prevention and Control (NCIPC). Faria and other critics felt the NCIPC's program on gun violence was biased against gun owners, and was part of a 'public health' political strategy by gun control advocates. They testified before a US House Subcommittee on Appropriations to that effect.[19][20][21] Faria wanted to defund the NCIPC entirely.[22][23] The CDC was forbidden by Congress to use taxpayers' money for gun control research and from participating in lobbying activities.[24][25] Faria left AAPS in 2002 to pursue other interests.[] He was subsequently appointed by the administration of President George W. Bush to oversee the NCIPC as member of the grant review committee of the CDC, which he did until 2005.[26] He is the World Affairs editor of Surgical Neurology International.[27] Dr. Jane Orient remains the Executive Director of AAPS.[28]

Legal activity
Social Security In 1975, AAPS went to court to block enforcement of a new Social Security amendment that would monitor the treatment given Medicare and Medicaid patients.[29] AAPS v. Hillary Clinton With several other groups, AAPS filed a lawsuit in 1993 against Hillary Clinton and Secretary of Health and Human Services Donna Shalala over closed-door meetings related to the 1993 Clinton health care plan. The AAPS sued to gain access to the list of members of President Clinton's health care taskforce. Judge Royce C. Lamberth found in favor of the plaintiffs and awarded $285,864 to the AAPS for legal costs; Lamberth also harshly criticized the Clinton administration and Clinton aide Ira Magaziner in his ruling.[30] Subsequently, a federal appeals court overturned the award and the initial findings on the basis that Magaziner and the administration had not acted in bad faith.[31]

Health Insurance Portability and Accountability Act


The AAPS was involved in litigation against Health Insurance Portability and Accountability Act (HIPAA), arguing that it violates the Fourth Amendment to the United States Constitution by allowing government access to certain medical data without a warrant.[32] (Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers, and is intended to improve the efficiency and effectiveness of the US's health care system by encouraging the widespread use of electronic data interchange in the health care system.)

Association of American Physicians and Surgeons

27

Seizure of Rush Limbaugh's medical records


In 2004, AAPS filed a brief on behalf of conservative talk show host Rush Limbaugh in Florida's Fourth District Court of Appeal, opposing the seizure of his medical files in an investigation of drug charges for Limbaugh's alleged misuse of prescription drugs. The AAPS stated the seizure was a violation of state law and that 'It is not a crime for a patient to be in pain and repeatedly seek relief, and doctors should not be turned against patients they tried to help.'"[4][33] Patient Protection and Affordable Care Act (PPACA) On March 26, 2010 AAPS filed suit to invalidate the new health care bill.[34]

Other cases
In 2006 the group criticised what it called sham peer review, claiming it was a device used to punish whistleblowers.[35] The next year, AAPS helped appeal the conviction of Virginia internist William Hurwitz, who was sentenced to 25 years in federal prison for prescribing excessive quantities of narcotic drugs after 16 former patients testified against him.[36] Hurwitz was granted a retrial in 2006, and his 25-year prison sentence was reduced to 4 years and 9 months.[37]

Journal of American Physicians and Surgeons


The Journal of American Physicians and Surgeons (JPandS), until 2003 named the Medical Sentinel,[][38] is the journal of the association. Its mission statement includes " a commitment to publishing scholarly articles in defense of the practice of private medicine, the pursuit of integrity in medical research Political correctness, dogmatism and orthodoxy will be challenged with logical reasoning, valid data and the scientific method." The publication policy of the journal states that articles are subject to a double-blind peer-review process.[39] The Journal of American Physicians and Surgeons is not listed in major academic literature databases such as MEDLINE/PubMed[] nor the Web of Science.[40] The U.S. National Library of Medicine declined repeated requests from AAPS to index the journal, citing unspecified concerns.[] Articles and commentaries published in the journal have argued a number of non-mainstream or scientifically discredited claims,[] including: that human activity has not contributed to climate change, and that global warming will be beneficial and thus not a cause for concern;[41] that HIV does not cause AIDS;[42][43] that the "gay male lifestyle" shortens life expectancy by 20 years.[44] A series of articles by pro-life authors published in the journal argued for a link between abortion and breast cancer.[45][46] Such a link has been rejected by the scientific community, including the U.S. National Cancer Institute,[47] the American Cancer Society,[] and the World Health Organization,[] among other major medical bodies.[] A 2003 paper published in the journal, claiming that vaccination was harmful, was criticized for poor methodology, lack of scientific rigor, and outright errors by the World Health Organization[48] and the American Academy of Pediatrics.[] A National Public Radio piece mentioned inaccurate information published in the Journal and said: "The journal itself is not considered a leading publication, as it's put out by an advocacy group that opposes most government involvement in medical care."[49] The Journal has also published articles advocating politically and socially conservative policy positions[citation needed] , including: that the Food and Drug Administration and Centers for Medicare and Medicaid Services are unconstitutional;[50] that "humanists" have conspired to replace the "creation religion of Jehovah" with evolution;[51] that "anchor babies" are valuable to undocumented immigrants, particularly if the babies are disabled.[]

Association of American Physicians and Surgeons Quackwatch lists JPandS as an untrustworthy, non-recommended periodical.[52] An editorial in Chemical & Engineering News described JPandS as a "purveyor of utter nonsense."[53] Investigative journalist Brian Deer wrote that the journal is the "house magazine of a right-wing American fringe group [AAPS]" and "is barely credible as an independent forum."[54]

28

Leprosy error
In a 2005 article published in the Journal, Madeleine Cosman argued that illegal immigrants were carriers of disease, and that immigrants and "anchor babies" were launching a "stealthy assault on [American] medicine."[55] In the article, Cosman claimed that "Suddenly, in the past 3 years America has more than 7,000 cases of leprosy" because of illegal aliens.[55] The journal's leprosy claim was cited and repeated by Lou Dobbs as evidence of the dangers of illegal immigration.[49][56] However, publicly available statistics show that the 7,000 cases of leprosy occurred during the past 30 years, not the past three as Cosman claimed.[57] James L. Krahenbuhl, director of the U.S. government's leprosy program, stated that there had been no significant increase in leprosy cases, and that "It [leprosy] is not a public health problemthats the bottom line."[56] National Public Radio reported that the Journal article "had footnotes that did not readily support allegations linking a recent rise in leprosy rates to illegal immigrants."[49] The article's erroneous leprosy claim was pointed out by 60 Minutes,[58] National Public Radio,[49] and the New York Times[56] but has not been corrected by the Journal.[citation needed]

References
[4] Erik M. Conway, Naomi Oreskes, Merchants of Doubt, 2010, p.245 [7] "...an ultra-conservative political-action group" [14] The Standard of Care (http:/ / www. aapsonline. org/ newsletters/ jan06. php), from the AAPS website. Retrieved March 10, 2007. [15] Resolution passed by the Assembly Affirming the Sanctity of Human Life (http:/ / www. aapsonline. org/ resolutions/ 2003-2. htm), from the AAPS website. Retrieved March 12, 2007. [16] Comments re: Docket No. 2005N-0345, RIN 0910-AF72 (http:/ / www. aapsonline. org/ testimony/ fda-ab. php), from the AAPS website. Retrieved March 12, 2007. [19] Departments of Labor, Health and Human Services, Education, and Related Agencies Appropriations for 1997: Testimony of members of Congress and other interested individuals and organizations. Hearings Before a House Subcommittee of the Committee on Appropriations, House of Representatives, One Hundred Fourth Congress, Second Session, March 6, 1996, Hearing Volume, Part 7:935-970. U.S. Government Printing Office, Washington, DC. [20] Faria MA: The Perversion of Science and Medicine (Part III): Public Health and Gun Control Research. Medical Sentinel 1997;2(3):81-82. http:/ / haciendapublishing. com/ medicalsentinel/ perversion-science-and-medicine-part-iii-public-health-and-gun-control-research [21] Faria MA: The Perversion of Science and Medicine (Part IV): The Battle Continues. Medical Sentinel 1997;2(3):83-86. http:/ / www. haciendapub. com/ medicalsentinel/ perversion-science-and-medicine-part-iv-battle-continues [23] Faria MA: The Tainted Public-Health Model of Gun Control. Ideas on Liberty, April 2001. http:/ / www. thefreemanonline. org/ featured/ the-tainted-public-health-model-of-gun-control/ [24] Rochell A. Funding ends for study that drew fire of gun lobby. Atlanta Journal Constitution, May 2, 1996, p. A13. [25] Department of Health and Human Services, Centers for Disease Control and Prevention. Funding Opportunity Announcements, Additional Requirements AR-13: Prohibition on Use of CDC Funds for Certain Gun Control Activities in DHS-CDC. http:/ / www. cdc. gov/ od/ pgo/ funding/ grants/ additional_req. shtm#ar13 [27] Faria MA. The Russian political turmoil (2012): An American perspective. Surg Neurol Int 2012;3:28. http:/ / www. surgicalneurologyint. com/ content/ 3/ 1/ 28 [28] Orient J. Healthcare is personal, it's not for sharing. http:/ / www. aapsonline. org/ index. php/ site/ article/ healthcare_is_personal_its_not_for_sharing/ [34] http:/ / www. aapsonline. org/ hhslawsuit/ aaps-v-sebelius-03-26-2010. php [37] Washington Post story (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2007/ 07/ 13/ AR2007071301035. html), July 14, 2007. [41] Environmental Effects of Increased Atmospheric Carbon Dioxide (http:/ / www. jpands. org/ vol12no3/ robinson. pdf) by Arthur B. Robinson, Noah E. Robinson, and Willie Soon. Published in The Journal of American Physicians and Surgeons, 2007; 12(3), 79. [42] Questioning HIV/AIDS: Morally Reprehensible or Scientifically Warranted? (http:/ / www. jpands. org/ vol12no4/ bauer. pdf), by Henry Bauer. Published in the Journal of American Physicians and Surgeons 2007: Vol 12, No. 4, p. 116.

Association of American Physicians and Surgeons


[43] AIDS A Heterosexual Epidemic? by Michael Fumento and AIDS Inventing a Virus? Commentary by Peter H. Duesberg, PhD (http:/ / www. haciendapub. com/ v2n3. html). From Medical Sentinel, Volume 2, No. 3, Summer 1997. duesberg.com (http:/ / www. duesberg. com/ ) [44] Homosexuality: Some Neglected Considerations (http:/ / www. jpands. org/ vol10no3/ lehrman. pdf), by Nathaniel S. Lehrman, MD. Published in Journal of American Physicians and Surgeons, Volume 10, Number 3 (Fall 2005), pp. 8082. [49] Broken Borders? CBS Lambastes, Hires Dobbs (http:/ / www. npr. org/ templates/ story/ story. php?storyId=10141647), by David Folkenflik. From All Things Considered, National Public Radio, May 11, 2007. Retrieved August 29, 2008. [50] The FDA and HCFA (Part II): Unconstitutional Regulatory Agencies (http:/ / www. haciendapub. com/ albright2. html), by James A. Albright, MD. Published in Medical Sentinel, 2000;5(6):205208. [51] Conspiracy --- Part III (http:/ / www. jpands. org/ hacienda/ caine6. html), by Curtis W. Caine, MD. Published in Medical Sentinel, 1999;4(6):224. [55] Illegal Aliens and American Medicine (http:/ / www. jpands. org/ vol10no1/ cosman. pdf), by Madeleine Cosman. Published in the Journal of American Physicians and Surgeons, Spring 2005 (Vol. 10, No. 1, pp. 610). [56] Truth, Fiction, and Lou Dobbs (http:/ / www. nytimes. com/ 2007/ 05/ 30/ business/ 30leonhardt. html), by David Leonhardt. Published in the New York Times on May 30, 2007; accessed August 29, 2008. [57] New U.S. Reported Hansen's Disease (Leprosy) Cases by Year, 19762005 (http:/ / hrsa. gov/ hansens/ 30yeartrend. htm), from the U.S. National Hansen's Disease (Leprosy) Program. Retrieved August 29, 2008. [58] Lou Dobbs' Opinion (http:/ / www. cbsnews. com/ sections/ i_video/ main500251. shtml?id=2765343n), from 60 Minutes. Originally broadcast on May 17, 2007; accessed August 29, 2008.

29

External links
AAPSonline.org (http://www.aapsonline.org/) Association of American Physicians and Surgeons home page Medical Sentinel (http://haciendapublishing.com/medicalsentinel) The first journal published by AAPS, now renamed to the Journal of American Physicians and Surgeons http://www.jpands.org. Rachel Maddow (November 18, 2009). "Special Interests Rally for Senate Health Bill" (http://www.msnbc. msn.com/id/26315908/vp/34029631#34029631). MSNBC: The Rachel Maddow Show.

American Association of Physicians of Indian Origin


The American Association of Physicians of Indian Origin (AAPI) is a professional association for Indian American physicians. The association is based in Chicago and was founded in 1984. It claims a membership of 52,000 physician.

Doctors of Indian Origin


There are currently (as of 2005) 40,838 doctors of Indian origin in the United States of America and they account for 5% of all doctors in the USA and 20% of all International Medical Graduates employed in the US workforce. It is noteworthy that India provides the largest number of International Medical Graduates to the US in absolute numbers. With 59,523 Physicians of Indian Origin working in the English speaking Western world (the US, UK, Australia and Canada combined), India is by far the single largest source of emigre physicians in the world.[1]

American Association of Physicians of Indian Origin

30

Jagdish Tytler Controversy


In June 2004, AAPI became involved in a controversy for its invitation to Indian Minister for NRI Affairs Jagdish Tytler to be honored at a dinner gala.[citation needed] Various human rights and Sikh groups threatened to hold demonstrations at the venue and the invitation to Jagdish Tytler was withdrawn.[2] Tytler resigned from the Indian government after being indicted by the official Nanavati Commission of inciting mobs for violence.[3][4][5]

References
[1] [2] [3] [4] [5] http:/ / www. nejm. org/ doi/ pdf/ 10. 1056/ NEJMsa050004 I n d i a P o s t . c o m (http:/ / www. indiapost. com/ members/ story. php?story_id=3187) http:/ / www. witness84. com/ doc/ aapi. doc Nanavati report: Credible evidence against Tytler (http:/ / in. rediff. com/ news/ 2005/ aug/ 08nanavati1. htm) "United States Should Not Let Tytler Enter Country" - Statement by [[New York (http:/ / thomas. loc. gov/ cgi-bin/ query/ R?r108:FLD001:E51218)] Representative Edolphus Towns in US Congress]

External links
American Association of Physicians of Indian Origin (http://www.aapiusa.org/) AAPIO website (http://www.aapio.org/)

American Association for Respiratory Care

31

American Association for Respiratory Care


American Association for Respiratory Care
Type Industry Non-profit organization Health care

Predecessor(s) American Association for Respiratory Therapy Founded Founder(s) March 16, 1947 Edwin R. Levine

Headquarters Irving, TX, United States Area served Website United States http:/ / www. aarc. org/

The American Association for Respiratory Care (AARC) is a non profit organization and is the only professional organization supporting Respiratory Care in the United States. In addition to attempting to help lobby for beneficial legislation nationally and locally, the AARC is trying to promote the profession as a whole to increase interest and membership.[1] The AARC began in 1943, as the Inhalation Technician Association and has evolved rapidly and repeatedly since.[2]

Mission
"The American Association for Respiratory Care (AARC) will continue to be the leading national and international professional association for respiratory care. The AARC will encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist."[3]

Publications
Respiratory Care AARC Times Magazine

History
1946 - University of Chicago Hospital forms the Inhalation Therapy Association (ITA). 1947 - The ITA is chartered as a non-profit entity in the state of Illinois. 1954 - The ITA is renamed American Association of Inhalation Therapists (AAIT). 1966 - The AAIT is renamed American Association of Inhalation Therapy (AAIT). 1956 - The AAIT begins publishing a journal called Inhalation Therapy. 1973 - The AAIT is renamed the American Association of Respiratory Therapy. 1986 - The AART is renamed the American Association of Respiratory Care.

American Association for Respiratory Care

32

Affiliations
The AARC has several organizations with which they have an affiliation;Wikipedia:Please clarify some of these include: AMA Allied Health Careers American Academy of Allergy, Asthma & Immunology American Academy of Pediatrics American Association of Cardiovascular and Pulmonary Rehabilitation American Association of Critical-Care Nurses American College of Allergy, Asthma & Immunology American Heart Association American Hospital Association American Society of Anesthesiologists American Society for Testing and Materials American Thoracic Society Campaign for Tobacco-Free kids Canadian Society of Respiratory Therapists COARC, The Committee on Accreditation for Respiratory Care Council on Licensure, Enforcement, and Regulation Joint Commission on Accreditation of Healthcare Organizations Lambda Beta Society National Association for Medical Direction of Respiratory Care National Association for the Support of Long Term Care National Board for Respiratory Care National Coalition for Health Professional Education in Genetics National Committee for Clinical Laboratory Standards National Lung Health Education Program Neonatal Resuscitation Program Respiratory Therapy Society of Ontario Society of Critical Care Medicine

References External links


National Board of Respiratory Care, Inc. (http://www.nbrc.org)

Hematopoietic stem cell transplantation

33

Hematopoietic stem cell transplantation


Hematopoietic stem cell transplantation
Intervention

Bone marrow transplant ICD-9-CM MeSH MedlinePlus 41.0 [1] [2]

D018380 003009

[3]

Hematopoietic stem cell transplantation (HSCT) is the transplantation of multipotent hematopoietic stem cells, usually derived from bone marrow, peripheral blood, or umbilical cord blood. It is a medical procedure in the fields of hematology and oncology, most often performed for patients with certain cancers of the blood or bone marrow, such as multiple myeloma or leukemia. In these cases, the recipient's immune system is usually destroyed with radiation or chemotherapy before the transplantation. Infection and graft-versus-host disease is a major complication of allogenic HSCT. Hematopoietic stem cell transplantation remains a dangerous procedure with many possible complications; it is reserved for patients with life-threatening diseases. As the survival of the procedure increases, its use has expanded beyond cancer, such as autoimmune diseases.[4][5]

History
Georges Math, a French oncologist, performed the first European bone marrow transplant in 1959 on five Yugoslavian nuclear workers whose own marrow had been damaged by irradiation caused by a Criticality accident at the Vina Nuclear Institute, but all of these transplants were rejected.[6][7][8][9][10] Math later pioneered the use of bone marrow transplants in the treatment of leukemia.[10] Stem cell transplantation was pioneered using bone-marrow-derived stem cells by a team at the Fred Hutchinson Cancer Research Center from the 1950s through the 1970s led by E. Donnall Thomas, whose work was later recognized with a Nobel Prize in Physiology or Medicine. Thomas' work showed that bone marrow cells infused intravenously could repopulate the bone marrow and produce new blood cells. His work also reduced the likelihood of developing a life-threatening complication called graft-versus-host disease.[11]

Hematopoietic stem cell transplantation The first physician to perform a successful human bone marrow transplant on a disease other than cancer was Robert A. Good at the University of Minnesota in 1968.[12]

34

Medical uses
Many recipients of HSCTs are multiple myeloma[13] or leukemia patients[14] who would not benefit from prolonged treatment with, or are already resistant to, chemotherapy. Candidates for HSCTs include pediatric cases where the patient has an inborn defect such as severe combined immunodeficiency or congenital neutropenia with defective stem cells, and also children or adults with aplastic anemia[15] who have lost their stem cells after birth. Other conditions[] treated with stem cell transplants include sickle-cell disease, myelodysplastic syndrome, neuroblastoma, lymphoma, Ewing's sarcoma, desmoplastic small round cell tumor, chronic granulomatous disease and Hodgkin's disease. More recently non-myeloablative, or so-called "mini transplant," procedures have been developed that require smaller doses of preparative chemo and radiation. This has allowed HSCT to be conducted in the elderly and other patients who would otherwise be considered too weak to withstand a conventional treatment regimen.

Number of procedures
A total of 50,417 first hematopoietic stem cell transplants were reported as taking place worldwide in 2006, according to a global survey of 1327 centers in 71 countries conducted by the Worldwide Network for Blood and Marrow Transplantation. Of these, 28,901 (57%) were autologous and 21,516 (43%) were allogenetic (11,928 from family donors and 9,588 from unrelated donors). The main indications for transplant were lymphoproliferative disorders (54.5%) and leukemias (33.8%), and the majority took place in either Europe (48%) or the Americas (36%).[] In 2009, according to the world marrow donor association, stem cell products provided for unrelated transplantation worldwide had increased to 15,399 (3,445 bone marrow donations, 8,162 peripheral blood stem cell donations, and 3,792 cord blood units).[16]

Graft types
Autologous
Autologous HSCT requires the extraction (apheresis) of haematopoietic stem cells (HSC) from the patient and storage of the harvested cells in a freezer. The patient is then treated with high-dose chemotherapy with or without radiotherapy with the intention of eradicating the patient's malignant cell population at the cost of partial or complete bone marrow ablation (destruction of patient's bone marrow function to grow new blood cells). The patient's own stored stem cells are then transfused into his/her bloodstream, where they replace destroyed tissue and resume the patient's normal blood cell production. Autologous transplants have the advantage of lower risk of infection during the immune-compromised portion of the treatment since the recovery of immune function is rapid. Also, the incidence of patients experiencing rejection (graft-versus-host disease) is very rare due to the donor and recipient being the same individual. These advantages have established autologous HSCT as one of the standard second-line treatments for such diseases as lymphoma.[17] However, for others such as Acute Myeloid Leukemia, the reduced mortality of the autogenous relative to allogeneic HSCT may be outweighed by an increased likelihood of cancer relapse and related mortality, and therefore the allogeneic treatment may be preferred for those conditions.[18] Researchers have conducted small studies using non-myeloablative hematopoietic stem cell transplantation as a possible treatment for type I (insulin dependent) diabetes in children and adults. Results have been promising; however, as of 2009[19] it was premature to speculate whether these experiments will lead to effective treatments for diabetes.[20]

Hematopoietic stem cell transplantation

35

Allogeneic
Allogeneic HSCT involves two people: the (healthy) donor and the (patient) recipient. Allogeneic HSC donors must have a tissue (HLA) type that matches the recipient. Matching is performed on the basis of variability at three or more loci of the HLA gene, and a perfect match at these loci is preferred. Even if there is a good match at these critical alleles, the recipient will require immunosuppressive medications to mitigate graft-versus-host disease. Allogeneic transplant donors may be related (usually a closely HLA matched sibling), syngeneic (a monozygotic or 'identical' twin of the patient - necessarily extremely rare since few patients have an identical twin, but offering a source of perfectly HLA matched stem cells) or unrelated (donor who is not related and found to have very close degree of HLA matching). Unrelated donors may be found through a registry of bone marrow donors such as the National Marrow Donor Program. People who would like to be tested for a specific family member or friend without joining any of the bone marrow registry data banks may contact a private HLA testing laboratory and be tested with a mouth swab to see if they are a potential match.[21] A "savior sibling" may be intentionally selected by preimplantation genetic diagnosis in order to match a child both regarding HLA type and being free of any obvious inheritable disorder. Allogeneic transplants are also performed using umbilical cord blood as the source of stem cells. In general, by transfusing healthy stem cells to the recipient's bloodstream to reform a healthy immune system, allogeneic HSCTs appear to improve chances for cure or long-term remission once the immediate transplant-related complications are resolved.[][][22] A compatible donor is found by doing additional HLA-testing from the blood of potential donors. The HLA genes fall in two categories (Type I and Type II). In general, mismatches of the Type-I genes (i.e. HLA-A, HLA-B, or HLA-C) increase the risk of graft rejection. A mismatch of an HLA Type II gene (i.e. HLA-DR, or HLA-DQB1) increases the risk of graft-versus-host disease. In addition a genetic mismatch as small as a single DNA base pair is significant so perfect matches require knowledge of the exact DNA sequence of these genes for both donor and recipient. Leading transplant centers currently perform testing for all five of these HLA genes before declaring that a donor and recipient are HLA-identical. Race and ethnicity are known to play a major role in donor recruitment drives, as members of the same ethnic group are more likely to have matching genes, including the genes for HLA.[23]

Sources and storage of cells


To limit the risks of transplanted stem cell rejection or of severe graft-versus-host disease in allogeneic HSCT, the donor should preferably have the same human leukocyte antigens (HLA) as the recipient. About 25 to 30 percent of allogeneic HSCT recipients have an HLA-identical sibling. Even so-called "perfect matches" may have mismatched minor alleles that contribute to graft-versus-host disease.

Bone marrow
In the case of a bone marrow transplant, the HSC are removed from a large bone of the donor, typically the pelvis, through a large needle that reaches the center of the bone. The technique is referred to as a bone marrow harvest and is performed under general anesthesia.

Peripheral blood stem cells


Peripheral blood stem cells[] are now the most common source of stem cells for allogeneic HSCT. They are collected from the blood through a process known as apheresis. The donor's blood is withdrawn through a
Bone marrow harvest.

Hematopoietic stem cell transplantation sterile needle in one arm and passed through a machine that removes white blood cells. The red blood cells are returned to the donor. The peripheral stem cell yield is boosted with daily subcutaneous injections of Granulocyte-colony stimulating factor, serving to mobilize stem cells from the donor's bone marrow into the peripheral circulation.

36

Amniotic fluid
It is also possible to extract hematopoietic stem cells from amniotic fluid for both autologous or heterologous use at the time of childbirth.

Umbilical cord blood


Umbilical cord blood is obtained when a mother donates her infant's Umbilical Cord and Placenta after birth. Cord blood has a higher concentration of HSC than is normally found in adult blood. However, the small quantity of blood obtained from an Umbilical Cord (typically about 50 mL) makes it more suitable for transplantation into small children than into adults. Newer techniques using ex-vivo expansion of cord blood units or the use of two cord blood units from different donors allow cord blood transplants to be used in adults. Cord blood can be harvested from the Umbilical Cord of a child being born after preimplantation genetic diagnosis (PGD) for human leucocyte antigen (HLA) matching (see PGD for HLA matching) in order to donate to an ill sibling requiring HSCT.

Storage of HSC
Unlike other organs, bone marrow cells can be frozen (cryopreserved) for prolonged periods without damaging too many cells. This is a necessity with autologous HSC because the cells must be harvested from the recipient months in advance of the transplant treatment. In the case of allogeneic transplants, fresh HSC are preferred in order to avoid cell loss that might occur during the freezing and thawing process. Allogeneic cord blood is stored frozen at a cord blood bank because it is only obtainable at the time of childbirth. To cryopreserve HSC, a preservative, DMSO, must be added, and the cells must be cooled very slowly in a controlled-rate freezer to prevent osmotic cellular injury during ice crystal formation. HSC may be stored for years in a cryofreezer, which typically uses liquid nitrogen.

Conditioning regimens
Myeloablative transplants
The chemotherapy or irradiation given immediately prior to a transplant is called the conditioning regimen, the purpose of which is to help eradicate the patient's disease prior to the infusion of HSC and to suppress immune reactions. The bone marrow can be ablated (destroyed) with dose-levels that cause minimal injury to other tissues. In allogeneic transplants a combination of cyclophosphamide with total body irradiation is conventionally employed. This treatment also has an immunosuppressive effect that prevents rejection of the HSC by the recipient's immune system. The post-transplant prognosis often includes acute and chronic graft-versus-host disease that may be life-threatening. However, in certain leukemias this can coincide with protection against cancer relapse owing to the graft versus tumor effect.[24] Autologous transplants may also use similar conditioning regimens, but many other chemotherapy combinations can be used depending on the type of disease.

Hematopoietic stem cell transplantation

37

Non-myeloablative allogeneic transplants


This is a newer treatment approach using lower doses of chemotherapy and radiation, which are too low to eradicate all the bone marrow cells of a recipient. Instead, non-myeloablative transplants run lower risks of serious infections and transplant-related mortality while relying upon the graft versus tumor effect to resist the inherent increased risk of cancer relapse.[25][] Also significantly, while requiring high doses of immunosuppressive agents in the early stages of treatment, these doses are less than for conventional transplants.[26] This leads to a state of mixed chimerism early after transplant where both recipient and donor HSC coexist in the bone marrow space. Decreasing doses of immunosuppressive therapy then allows donor T-cells to eradicate the remaining recipient HSC and to induce the graft versus tumor effect. This effect is often accompanied by mild graft-versus-host disease, the appearance of which is often a surrogate marker for the emergence of the desirable graft versus tumor effect, and also serves as a signal to establish an appropriate dosage level for sustained treatment with low levels of immunosuppressive agents. Because of their gentler conditioning regimens, these transplants are associated with a lower risk of transplant-related mortality and therefore allow patients who are considered too high-risk for conventional allogeneic HSCT to undergo potentially curative therapy for their disease. These new transplant strategies are still somewhat experimental, but are being used more widely on elderly patients unfit for myeloablative regimens and for whom the higher risk of cancer relapse may be acceptable.[]

Engraftment
After several weeks of growth in the bone marrow, expansion of HSC and their progeny is sufficient to normalize the blood cell counts and reinitiate the immune system. The offspring of donor-derived hematopoietic stem cells have been documented to populate many different organs of the recipient, including the heart, liver, and muscle, and these cells had been suggested to have the abilities of regenerating injured tissue in these organs. However, recent research has shown that such lineage infidelity does not occur as a normal phenomenon [citation needed].

Complications
HSCT is associated with a high treatment-related mortality in the recipient (10% or higher)[citation needed], which limits its use to conditions that are themselves life-threatening. Major complications are veno-occlusive disease, mucositis, infections (sepsis), graft-versus-host disease and the development of new malignancies.

Infection
Bone marrow transplantation usually requires that the recipient's own bone marrow be destroyed ("myeloablation"). Prior to "engraftment" patients may go for several weeks without appreciable numbers of white blood cells to help fight infection. This puts a patient at high risk of infections, sepsis and septic shock, despite prophylactic antibiotics. However, antiviral medications, such as acyclovir and valacyclovir, are quite effective in prevention of HSCT-related outbreak of herpetic infection in seropositive patients.[] The immunosuppressive agents employed in allogeneic transplants for the prevention or treatment of graft-versus-host disease further increase the risk of opportunistic infection. Immunosuppressive drugs are given for a minimum of 6-months after a transplantation, or much longer if required for the treatment of graft-versus-host disease. Transplant patients lose their acquired immunity, for example immunity to childhood diseases such as measles or polio. For this reason transplant patients must be re-vaccinated with childhood vaccines once they are off immunosuppressive medications.

Hematopoietic stem cell transplantation

38

Veno-occlusive disease
Severe liver injury can result from hepatic veno-occlusive disease (VOD). Elevated levels of bilirubin, hepatomegaly and fluid retention are clinical hallmarks of this condition. There is now a greater appreciation of the generalized cellular injury and obstruction in hepatic vein sinuses, and hepatic VOD has lately been referred to as sinusoidal obstruction syndrome (SOS). Severe cases of SOS are associated with a high mortality rate. Anticoagulants or defibrotide may be effective in reducing the severity of VOD but may also increase bleeding complications. Ursodiol has been shown to help prevent VOD, presumably by facilitating the flow of bile.

Mucositis
The injury of the mucosal lining of the mouth and throat is a common regimen-related toxicity following ablative HSCT regimens. It is usually not life-threatening but is very painful, and prevents eating and drinking. Mucositis is treated with pain medications plus intravenous infusions to prevent dehydration and malnutrition.

Graft-versus-host disease
Graft-versus-host disease (GVHD) is an inflammatory disease that is peculiar to allogeneic transplantation. It is an attack of the "new" bone marrow's immune cells against the recipient's tissues. This can occur even if the donor and recipient are HLA-identical because the immune system can still recognize other differences between their tissues. It is aptly named graft-versus-host disease because bone marrow transplantation is the only transplant procedure in which the transplanted cells must accept the body rather than the body accepting the new cells. Acute graft-versus-host disease typically occurs in the first 3 months after transplantation and may involve the skin, intestine, or the liver. High-dose corticosteroids such as prednisone are a standard treatment; however this immuno-suppressive treatment often leads to deadly infections. Chronic graft-versus-host disease may also develop after allogeneic transplant. It is the major source of late treatment-related complications, although it less often results in death. In addition to inflammation, chronic graft-versus-host disease may lead to the development of fibrosis, or scar tissue, similar to scleroderma; it may cause functional disability and require prolonged immunosuppressive therapy. Graft-versus-host disease is usually mediated by T cells, which react to foreign peptides presented on the MHC of the host[citation needed].

Graft-versus-tumor effect
Graft-versus-tumor effect (GVT) or "graft versus leukemia" effect is the beneficial aspect of the Graft-versus-Host phenomenon. For example, HSCT patients with either acute and in particular chronic graft-versus-host disease after an allogeneic transplant tend to have a lower risk of cancer relapse.[27][28] This is due to a therapeutic immune reaction of the grafted donor T lymphocytes against the diseased bone marrow of the recipient. This lower rate of relapse accounts for the increased success rate of allogeneic transplants, compared to transplants from identical twins, and indicates that allogeneic HSCT is a form of immunotherapy. GVT is the major benefit of transplants that do not employ the highest immuno-suppressive regimens. Graft versus tumor is mainly beneficial in diseases with slow progress, e.g. chronic leukemia, low-grade lymphoma, and some cases multiple myeloma. However, it is less effective in rapidly growing acute leukemias.[29] If cancer relapses after HSCT, another transplant can be performed, infusing the patient with a greater quantity of donor white blood cells.[29]

Hematopoietic stem cell transplantation

39

Oral carcinoma
Patients after HSCT are at a higher risk for oral carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients.[]

Prognosis
Prognosis in HSCT varies widely dependent upon disease type, stage, stem cell source, HLA-matched status (for allogeneic HCST) and conditioning regimen. A transplant offers a chance for cure or long-term remission if the inherent complications of graft versus host disease, immuno-suppressive treatments and the spectrum of opportunistic infections can be survived.[][] In recent years, survival rates have been gradually improving across almost all populations and sub-populations receiving transplants.[30] Mortality for allogeneic stem cell transplantation can be estimated using the prediction model created by Sorror et al.,[] using the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI). The HCT-CI was derived and validated by investigators at the Fred Hutchinson Cancer Research Center (Seattle, WA). The HCT-CI modifies and adds to a well-validated comorbidity index, the Charlson Comorbidity Index (CCI) (Charlson et al.[]) The CCI was previously applied to patients undergoing allogeneic HCT but appears to provide less survival prediction and discrimination than the HCT-CI scoring system.

Risks to donor
The risks of a complication depend on patient characteristics, health care providers and the apheresis procedure, and the colony-stimulating factor used (G-CSF, GM-CSF). G-CSF drugs include filgrastim (Neupogen, Neulasta), and lenograstim (Graslopin).

Drug risks
Filgrastim is typically dosed in the 10 microgram/kg level for 45 days during the harvesting of stem cells. The documented adverse effects of filgrastim include splenic rupture (indicated by left upper abdominal or shoulder pain, risk 1 in 40000), Adult respiratory distress syndrome (ARDS), alveolar hemorrage, and allergic reactions (usually expressed in first 30 minutes, risk 1 in 300).[31][][] In addition, platelet and hemoglobin levels dip post-procedure, not returning to normal until one month.[] The question of whether geriatrics (patients over 65) react the same as patients under 65 has not been sufficiently examined. Coagulation issues and inflammation of atherosclerotic plaques are known to occur as a result of G-CSF injection.[] G-CSF has also been described to induce genetic changes in mononuclear cells of normal donors.[] There is evidence that myelodysplasia (MDS) or acute myeloid leukaemia (AML) can be induced by GCSF in susceptible individuals.[]

Access risks
Blood was drawn peripherally in a majority of patients, but a central line to jugular/subclavian/femoral veins may be used in 16% of women and 4% of men. Adverse reactions during apheresis were experienced in 20% of women and 8% of men, these adverse events primarily consisted of numbness/tingling, multiple line attempts, and nausea.[]

Clinical observations
A study involving 2408 donors (1860 years) indicated that bone pain (primarily back and hips) as a result of filgrastim treatment is observed in 80% of donors by day 4 post-injection.[] This pain responded to acetaminophen or ibuprofen in 65% of donors and was characterized as mild to moderate in 80% of donors and severe in 10%.[] Bone pain receded post-donation to 26% of patients 2 days post-donation, 6% of patients one week post-donation, and <2% 1 year post-donation. Donation is not recommended for those with a history of back pain.[] Other symptoms

Hematopoietic stem cell transplantation observed in more than 40% of donors include myalgia, headache, fatigue, and insomnia.[] These symptoms all returned to baseline 1 month post-donation, except for some cases of persistent fatigue in 3% of donors.[] . In one metastudy that incorporated data from 377 donors, 44% of patients reported having adverse side effects after peripheral blood HSCT.[] Side effects included pain prior to the collection procedure as a result of GCSF injections, post-procedural generalized skeletal pain, fatigue and reduced energy.[]

40

Severe reactions
A study that surveyed 2408 donors found that serious adverse events (requiring prolonged hospitalization) occurred in 15 donors (at a rate of 0.6%), although none of these events were fatal.[] Donors were not observed to have higher than normal rates of cancer with up to 48 years of follow up.[] One study based on a survey of medical teams covered approximately 24,000 peripheral blood HSCT cases between 1993 and 2005, and found a serious cardiovascular adverse reaction rate of about 1 in 1500.[] This study reported a cardiovascular-related fatality risk within the first 30 days HSCT of about 2 in 10000. For this same group, severe cardiovascular events were observed with a rate of about 1 in 1500. The most common severe adverse reactions were pulmonary edema/deep vein thrombosis, splenic rupture, and myocardial infarction. Haematological malignancy induction was comparable to that observed in the general population, with only 15 reported cases within 4 years.[]

Donor registration and recruitment


At the end of 2010, 14.9 million people had registered their willingness to be a bone marrow donor with one of the 64 registries from 45 countries participating in Bone Marrow Donors Worldwide. 12.2 million of these registered donors had been ABDR typed, allowing easy matching. A further 453,000 cord blood units had been received by one of 44 cord blood units from 26 countries participating. The highest total number of bone marrow donors registered were those from the USA (6.4 million), and the highest number per capita were those from Cyprus (10.6% of the population).[32] Within the United States, racial minority groups are the least likely to be registered and therefore the least likely to find a potentially life-saving match. In 1990, only six African-Americans were able to find a bone marrow match, and all six had common European genetic signatures.[] Africans are more genetically diverse than people of European descent, which means that more registrations are needed to find a match.[] Bone marrow and cord blood banks exist in South Africa, and a new program is beginning in Nigeria.[]

Research
HIV
In 2007, a team of doctors in Berlin, Germany, including Gero Htter, performed a stem cell transplant for leukemia patient Timothy Ray Brown, who was also HIV-positive.[] From 60 matching donors, they selected a [CCR5]-32 homozygous individual with two genetic copies of a rare variant of a cell surface receptor. This genetic trait confers resistance to HIV infection by blocking attachment of HIV to the cell. Roughly one in 1000 people of European ancestry have this inherited mutation, but it is rarer in other populations.[33][34] The transplant was repeated a year later after a relapse. Over three years after the initial transplant and despite discontinuing antiretroviral therapy, researchers cannot detect HIV in the transplant recipient's blood or in various biopsies.[35] Levels of HIV-specific antibodies have also declined, leading to speculation that the patient may have been functionally cured of HIV. However, scientists emphasise that this is an unusual case.[36] Potentially fatal transplant complications (the "Berlin patient" suffered from graft-versus-host disease and leukoencephalopathy) mean that the procedure could not be performed in others with HIV, even if sufficient numbers of suitable donors were found.[][37]

Hematopoietic stem cell transplantation In 2012, Daniel Kuritzkes reported results of two stem cell transplants in patients with HIV. They did not, however, use donors with the 32 deletion. One of the men has been followed for two years and the other for three and a half years. While both are still on HIV treatment, neither shows traces of HIV in their blood plasma and purified CD4 T cells using a sensitive culture method (less than 3 copies/ml). They are also showing a significant decline in HIV antibodies, suggesting a lack of HIV replication.[38]Wikipedia:Verifiability In mid 2013 it was reported that the two patients had been 15 and 7 weeks respectively without treatment, and still showing no signs of HIV returning.[39]

41

Multiple sclerosis
Since McAllister's 1997 report on a patient with multiple sclerosis (MS) who received a bone marrow transplant for CML,[40] there have been over 600 reports of HSCTs performed primarily for MS.[] These have been shown to "reduce or eliminate ongoing clinical relapses, halt further progression, and reduce the burden of disability in some patients" that have aggressive highly active multiple sclerosis, "in the absence of chronic treatment with disease-modifying agents".[]

References
[1] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=41. 0& Submit=Search& action=search [2] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D018380 [3] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 003009. htm [6] McLaughlin et al. page 96, "Radiation doses were intense, being estimated at 205, 320, 410, 415, 422, and 433 rem.74 Of the six persons present, one died and the other five recovered after severe cases of radiation sickness." [8] Vinca reactor accident, 1958 (http:/ / www. johnstonsarchive. net/ nuclear/ radevents/ 1958YUG1. html), compiled by Wm. Robert Johnston [9] Nuove esplosioni a Fukushima: danni al nocciolo. Ue: "In Giappone lapocalisse" (http:/ / www. ilfattoquotidiano. it/ 2011/ 03/ 14/ giappone-due-esplosioni-di-idrogeno-a-fukushima-bloccato-un-altro-reattore/ 97466/ ), 14 marzo 2011 [16] Charts from [19] http:/ / en. wikipedia. org/ w/ index. php?title=Hematopoietic_stem_cell_transplantation& action=edit [21] "Getting Tested: Bone Marrow Donor Options" (http:/ / www. bonemarrowtest. com/ marrowdonoroptions. htm) [22] CLL article (http:/ / clltopics. org/ BMT/ OnlyRealCure. htm) [23] http:/ / www. marrow. org/ DONOR/ ABCs/ index. html [29] Memorial Sloan-Kettering Cancer Center > Blood & Marrow Stem Cell Transplantation > The Graft-versus-Tumor Effect (http:/ / www. mskcc. org/ mskcc/ html/ 15927. cfm) Last Updated: 20 Nov. 2003. Retrieved on 6 April 2009 [30] Data analysis slides by Center for International Blood and Marrow Transplant Research (https:/ / campus. mcw. edu/ AngelUploads/ Content/ CS_IBMTR2/ _assoc/ ECCBED0AF0A4492BB667FB6227DC7C06/ SummarySet06_Pt2_files/ frame. htm) [31] Neupogen Prescription information provided by Amgen http:/ / pi. amgen. com/ united_states/ neupogen/ neupogen_pi_hcp_english. pdf [32] Bone Marrow Donors Worldwide Annual Report 2010 http:/ / bmdw. org/ uploads/ media/ BMDW2010_01. pdf [34] http:/ / biology. plosjournals. org/ perlserv/ ?request=get-document& doi=10. 1371/ journal. pbio. 0030339 [36] http:/ / www. aidsmeds. com/ articles/ hiv_aids_stemcell_2042_14199. shtml [38] (primary source) [39] Bone marrow 'frees men of HIV drugs'

External links
Media related to Hematopoietic stem cell transplantation at Wikimedia Commons

Patient Protection and Affordable Care Act

42

Patient Protection and Affordable Care Act


Patient Protection and Affordable Care Act

Long title Colloquial acronym(s) Nickname(s)

The Patient Protection and Affordable Care Act PPACA Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare 111th United States Congress March 23, 2010 Most major provisions phased in by January 2014; remaining provisions phased in by 2020 Citations

Enacted by the Effective

Public Law Stat.

111148

[1]

124 Stat. 119 through 124 Stat. 1025 (906 pages) Legislative history [2] [3] ) by Charles Rangel (DNY) on

Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590 September 17, 2009 Committee consideration by: Ways and Means Passed the House on October 8, 2009 (4160 [4] )

Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (6039 House agreed to Senate amendment on March 21, 2010 (219212 Signed into law by President Barack Obama on March 23, 2010 Major amendments [6] )

[5]

) with amendment

Health Care and Education Reconciliation Act of 2010 Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 United States Supreme Court cases National Federation of Independent Business v. Sebelius

The Patient Protection and Affordable Care Act (PPACA),[7] commonly called Obamacare[][8] or the Affordable Care Act (ACA), is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the country's healthcare system since the passage of Medicare and Medicaid in 1965.[] The ACA aims to increase the quality, affordability, and rate of health insurance coverage for Americans, and reduce the costs of health care for individuals and the government. It provides a number of mechanismsincluding mandates, subsidies, and insurance exchangesto increase coverage and affordability.[][9] The law also requires

Patient Protection and Affordable Care Act insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or sex.[10][11] Additional reforms aim to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of health care. The Congressional Budget Office projected that the ACA will lower both future deficits[12] and Medicare spending.[13] On June 28, 2012, the United States Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the ACA's Medicaid expansion under penalty of losing their current Medicaid funding.[14][15]

43

Overview
Provisions
The ACA includes numerous provisions to take effect over several years beginning in 2010. There is a grandfather clause on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies. Guaranteed issue will require policies to be issued regardless of any medical condition, and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most pre-existing conditions (excluding tobacco use).[][][] A shared responsibility requirement, commonly called an individual mandate,[][] requires all individuals not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs, to secure an approved private-insurance policy or pay a penalty, unless the applicable individual is a member of a recognized religious sect exempted by the Internal Revenue Service, or waived in cases of financial hardship.[] This was included on the rationale that - without such a mandate, a form of community rating, and coverage standards - the guaranteed issue provision would likely exacerbate adverse selection: if people could not be denied insurance by companies they

The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.

Obama signing the bill at the White House

Patient Protection and Affordable Care Act might put-off insuring themselves until they got sick, causing insurers to resort to larger premium increases on sick individuals and more extensive coverage limits to afford the remaining insured population, which could result in an insurance death spiral.[][][16] This led to the inclusion of subsidies (see below) so people with low-incomes can comply when the mandate goes into effect.[] Health insurance exchanges will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).[]

44

Maximum Out-of-Pocket Premium as Percentage of Family Income and federal [] poverty level (Source: CRS)

Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies[] on a sliding scale if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income).[] The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of the poverty level, and simplifies the CHIP enrollment process. In National Federation of Independent Business v. Sebelius, the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this may create a coverage gap in those states.[][][] Minimum standards for health insurance policies are to be established[] (an 'essential health benefits'[]), and annual and lifetime coverage caps will be banned.[][][] Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.[17][] Very small businesses will be able to get subsidies if they purchase insurance through an exchange.[] Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of the "essential benefits package"[] for Level A or Level B preventive care.[][] Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payment."[18][19] A single payment is paid to a hospital and a physician group, for example, for a defined episode of care (such as a hip replacement), rather than individual payments to individual service-providers.

Funding
The ACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened Medicare tax on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% excise tax on "Cadillac" insurance policies. The income levels are not adjusted for inflation, leaving the possibility of increased taxes on incomes over 250,000 inflation-adjusted dollars after more than two decades without indexing through.[20] There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal sales tax on indoor tanning services. Offsets are from intended cost savings

Patient Protection and Affordable Care Act such as changes in the Medicare Advantage program relative to traditional Medicare.[21] Summary of tax increases: (ten-year projection) Increase Medicare tax rate by 0.9% and impose added tax of 3.8% on unearned income for high-income taxpayers: $210.2billion Charge an annual fee on health insurance providers: $60billion Impose a 40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family: $32billion Impose an annual fee on manufacturers and importers of branded drugs: $27billion Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20billion Raise the 7.5% Adjusted Gross Income floor on medical expenses deduction to 10%: $15.2billion Limit annual contributions to flexible spending arrangements in cafeteria plans to $2,500: $13billion All other revenue sources: $14.9billion Summary of spending offsets: (ten-year projection) Reduce funding for Medicare Advantage policies: $132billion Reduce Medicare home health care payments: $40billion Reduce certain Medicare hospital payments: $22billion Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17billion, but the provision was repealed.[22]

45

Provisions by effective date


The ACA is divided into 10 titles[23] and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020.[][] Below are some of the key provisions of the ACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.[24][]

Effective at enactment
The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12years of exclusive use before generics can be developed.[] The Medicaid drug rebate (paid by drug manufacturers to the states) for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.[] A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research.[] This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.[25] The bill prohibits the Institute from developing or employing "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's National Institute for Health and Clinical Excellence, which determines cost-effectiveness directly based on quality-adjusted life year valuations.

Patient Protection and Affordable Care Act Creation of the Prevention and Public Health Fund to fund programs and research designed to increase chronic disease prevention.[26][27][28] Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.[] The Indian Health Care Improvement Act is reauthorized and amended.[] Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.[] But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.Wikipedia:Manual of Style/Dates and numbers#Precise language[] States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.[][29][30]

46

Effective June 21, 2010


Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.[][31] To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.[] There is no age requirement.[] The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.[][32][33]

Effective July 1, 2010


The President established, within the Department of Health and Human Services (HHS), a council to be known as the National Prevention, Health Promotion and Public Health Council to help begin to develop a National Prevention and Health Promotion Strategy. The Surgeon General shall serve as the Chairperson of the new Council.[][34] A 10% sales tax on indoor tanning took effect.[35]

Effective September 23, 2010


Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[] Dependents (mainly children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[36] and regulations implemented under the ACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[][] Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[37][] All new insurance plans must cover preventive care and medical screenings[] rated Level A or B [38] by the U.S. Preventive Services Task Force.[39] Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.[] Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.[] The gap will be eliminated by 2020. Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[] Insurers are prohibited from dropping policyholders when they get sick.[] Insurers are required to reveal details about administrative and executive expenditures.[] Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[]

Patient Protection and Affordable Care Act Enhanced methods of fraud detection are implemented.[] Medicare is expanded to small, rural hospitals and facilities.[] Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses. Companies which provide early retiree benefits for individuals aged 5564 are eligible to participate in a temporary program which reduces premium costs.[] A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.[] A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.[] All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.[]

47

Effective January 1, 2011


Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.[40][][][] The Centers for Medicare and Medicaid Services is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.[41] Flexible spending accounts, Health reimbursement accounts and health savings accounts cannot be used to pay for over-the-counter drugs, purchased without a prescription, except insulin.[]

Effective September 1, 2011


All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.[42][43]

Effective January 1, 2012


Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's.[44] This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 201069 on October 23, 2010.[45] Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.[46] New tax reporting changes were to come in effect. Lawmakers originally felt these changes would help prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses.[47][] Before the ACA, businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600.[][] Under the repealed law, reporting of payments to corporations would also be required.[48][49] Originally it was expected to raise $17billion over 10years.[50] The amendments made by Section 9006 of the ACA were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.[][]

Patient Protection and Affordable Care Act

48

Effective August 1, 2012


All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing.[] The requirement to cover FDA-approved contraceptive methods is also known as the contraceptive mandate.[][51][]

Effective October 1, 2012


The Centers for Medicare & Medicaid Services (CMS) will begin the Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (412.150 through 412.154).[52] Starting in October, an estimated total of 2,217 hospitals across the nation will be penalized; however, only 307 of these hospitals will receive this year's maximum penalty, i.e., 1 percent off their base Medicare reimbursements. The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. Together, these 2,217 hospitals will forfeit more than $280 million in Medicare funds over the next year, i.e., until October 2013, as Medicare and Medicaid begin a wide-ranging push to start paying health care providers based on the quality of care they provide. The $280 million in penalties comprises about 0.3 percent of the total amount hospitals are paid by Medicare.[53]

Effective January 1, 2013


Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.[54] In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)[55] Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.[56][57][58] Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.)[59] This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in veterinary medicine.[] Insurance companies are required to use simpler, more standardized paperwork, with the intention of helping consumers make apples-to-apples comparisons between the prices and benefits of different health plans.[60]

Effective August 1, 2013


Religious organizations that were given an extra year to implement the contraceptive mandate are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.[61]

Patient Protection and Affordable Care Act

49

Effective October 1, 2013


Individuals may enroll in subsidized health insurance plans offered through state-based health insurance exchanges. Coverage begins on January 1, 2014.[62][63][64]

Effective January 1, 2014


Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.[] Insurers are prohibited from establishing annual spending caps of dollar amounts on essential health benefits.[] Under the mandatory coverage provision, individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal [] income over the filing minimum,[65] poverty level. (Source: CRS) whichever is greater; this will rise to a minimum of $695 ($2,085 for families),[66] or 2.5% of income over the filing minimum,[65] by 2016.[][] Exemptions are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income.[67] In 2010, the Commissioner speculated that insurance providers would supply a form confirming essential coverage to both individuals and the IRS; individuals would attach this form to their Federal tax return. Those who aren't covered will be assessed the penalty on their Federal tax return. In the wording of the law, a taxpayer who fails to pay the penalty "shall not be subject to any criminal prosecution or penalty", and cannot have liens or levies placed on their property, but the IRS will be able to withhold future tax refunds from them.[68] In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[][] The law also provides for a 5% "income disregard", making the effective income eligibility limit 138% of the poverty line.[] States may choose to increase the income eligibility limit beyond this minimum requirement.[] As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. As of April 25, 2013, fifteen statesAlaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginiawere not participating in the Medicaid expansion, with ten moreKansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyomingleaning towards not participating.[69] Health insurance exchanges are established, and subsides for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line.[][70][][71] Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credit[] and gives a formula for its calculation.[72] A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability[73] (such as the Earned Income Tax Credit). The formula was

Patient Protection and Affordable Care Act changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.[74][] According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for a family of four will be the following:

50

Health Insurance Premiums and Cost Sharing under PPACA for Average Family of 4[][][75][76][]
Income % of federal poverty level 133% 150% 200% 250% 300% 350% 400% Premium Cap as a Share of Income Max Annual Income $ (family of a Out-of-Pocket Premium 4) $31,900 $33,075 $44,100 $55,125 $66,150 $77,175 $88,200 $992 $1,323 $2,778 $4,438 $6,284 $7,332 $8,379 Premium Savingsb Additional Cost-Sharing Subsidy

3% of income 4% of income 6.3% of income 8.05% of income 9.5% of income 9.5% of income 9.5% of income

$10,345 $9,918 $8,366 $6,597 $4,628 $3,512 $2,395

$5,040 $5,040 $4,000 $1,930 $1,480 $1,480 $1,480

[][] a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator [] for specific dollar amount. b.^ DHHS and CBO estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the [75] reform.

Two federally regulated "multi-state plans" (MSP), one of which is required to be offered by a non-profit insurer and the other is forbidden from providing coverage for abortion services, become available in some state health insurance exchanges. The MSPs will have to abide by the same federal regulations as required by an individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016, and 100% in 2017.[] Section 2708 to the Public Health Service Act becomes effective, which prohibits patient eligibility waiting periods in excess of 90 days for group health plan coverage. The 90-day rule applies to all grandfathered and non-grandfathered group health plans and group health insurance issuers, including multiemployer health plans and single-employer group health plans pursuant to collective bargaining arrangements.[77] Plans will still be allowed to impose eligibility requirements based on factors other than the lapse of time; for example, a health plan can restrict eligibility to employees who work at a particular location or who are in an eligible job classification. The waiting period limitation means that coverage must be effective no later than the 91st day after the employee satisfies the substantive eligibility requirements.[78] Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.[79]

Patient Protection and Affordable Care Act A $2,000 per employee penalty will be imposed on employers with more than 50 full-time employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).[][] "Full-time" is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.[] In July 2013, the Obama administration announced this penalty would not be enforced until January 1, 2015.[80][81] For employer-sponsored plans, a $2,000 maximum annual deductible is established for any plan covering a single individual or a $4,000 maximum annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302. To finance part of the new spending, spending and coverage cuts are made to Medicare Advantage, the growth of Medicare provider payments are slowed (in part through the creation of a new Independent Payment Advisory Board), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.[][82] Revenue is increased from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[83] Members of Congress and their staff are only offered health care plans through the exchanges or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).[84] A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5billion in annual revenue.[] Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3billion in annual revenue.[] The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).[85] Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.[86] The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped.[87][88] The CLASS Act was repealed January 1, 2013.[89]

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Effective October 1, 2014


Federal payments to "disproportionate share hospitals", which are hospitals that treat large numbers of indigent patients, are reduced. The payments will subsequently be allowed rise based on the percentage of the population that is uninsured in each state.[]

Effective January 1, 2015


CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.[90]

Patient Protection and Affordable Care Act

52

Effective October 1, 2015


States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.[]

Effective January 1, 2016


States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.[] The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.[91]

Effective January 1, 2017


A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.[] A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.[][] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.[] To qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.[] A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.[] In April 2011 Vermont announced its intention to pursue a waiver to implement the single-payer system enacted in May 2011.[][92][][] In September 2011 Montana announced it would also be seeking a waiver to set up its own single payer healthcare system.[93] States may allow large employers and multi-employer health plans to purchase coverage in the health insurance exchange. The two federally regulated "multi-state plans" (MSPs) that began being phased into state health insurance exchanges on January 1, 2014, become available in every state.[]

Effective January 1, 2018


All existing health insurance plans must cover approved preventive care and checkups without co-payment.[] A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill)[] is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.[][94]

Patient Protection and Affordable Care Act

53

Effective January 1, 2019


Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old.[]

Effective January 1, 2020


The Medicare Part D coverage gap (commonly called the "donut hole") will be completely phased out and hence closed.

Legislative history
Background
The plan that ultimately became the Patient Protection and Affordable Care Act consists of a combination of measures to control health care costs and an insurance expansion through public insurance (expanded Medicaid eligibility and Medicare coverage) and subsidized, regulated private insurance. The latter of these ideas forms the core of the law's insurance expansion, and it has been included in bipartisan reform proposals in the past. In particular, the idea of an individual mandate coupled with subsidies for private insurance, as an alternative to public insurance, was considered a way to get Universal Health Insurance that could win the support of the Senate. Many healthcare policy experts have pointed out that the individual mandate requirement to buy health insurance was contained in many previous proposals by Republicans for healthcare legislation, going back as far as 1989, when it was initially proposed by the politically conservative Heritage Foundation as an alternative to single-payer health care.[] The idea of an individual mandate was championed by Republican politicians as a market-based approach to health-care reform, on the basis of individual responsibility: because the Emergency Medical Treatment and Active Labor Act (EMTALA), passed in 1986 by a bipartisan Congress and signed by Ronald Reagan, requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.[][][] When, in 1993, President Bill Clinton proposed a health-care reform bill which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan.[] Ultimately the Clinton plan failed amid concerns that it was overly complex or unrealistic, and in the face of an unprecedented barrage of negative advertising funded by politically conservative groups and the health-insurance industry.[] (After failing to obtain a comprehensive reform of the health care system, Clinton did however negotiate a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997). The 1993 Republican alternative, introduced by Senator John Chafee (R-RI) as the Health Equity and Access Reform Today Act, contained a "Universal Coverage" requirement with a penalty for non-compliance.[95][] Advocates for the 1993 bill which contained the individual mandate included prominent Republicans who today oppose the mandate, such as Orrin Hatch (R-UT), Charles Grassley (R-IA), Bob Bennett (R-UT), and Christopher Bond (R-MO).[96][97] Of the 43 Republicans Senators from 1993, almost half - 20 out of 43 - supported the HEART Act.[][] And in 1994 Senator Don Nickles (R-OK) introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision[98] - however, subsequently, he did remove the mandate from the act after introduction stating that they had decided "that government should not compel people to buy health insurance."[99] At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for George H.W. Bush, remarked, "I dont remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax... So Ive been surprised by that argument."[]

Patient Protection and Affordable Care Act An individual health-insurance mandate was also enacted at the state-level in Massachusetts: In 2006, Republican Mitt Romney, then governor of Massachusetts, signed an insurance expansion bill with an individual mandate into law with strong bipartisan support (including that of Ted Kennedy (D-MA)). Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 Presidential campaign, Senator Jim DeMint (R-SC) praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured." Romney himself said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."[] The following year (2007), Senators Bob Bennett (R-UT) and Ron Wyden (D-OR) introduced the Healthy Americans Act, a bill that also featured an individual mandate, and which attracted bipartisan support.[][] Among the Republican co-sponsors still in Congress during the health care debate: Senators Chuck Grassley (R-IA), Lindsey Graham (R-SC), Bob Bennett (R-UT), Mike Crapo (R-ID), Bob Corker (R-TN), Lamar Alexander (R-TN), and Arlen Specter (R-PA).[100][101] Given the history of bipartisan support for the idea, and its track record in Massachusetts; by 2008 Democrats were considering it as a basis for comprehensive, national health care reform: Experts have pointed out that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill;[] and that it was deliberately patterned after former Republican Governor of Massachusetts Mitt Romney's state healthcare plan (which contains an individual mandate).[102] Jonathan Gruber, a key architect of the Massachusetts reform, advised the Clinton and Obama Presidential campaigns on their health care proposals, served as a technical consultant to the Obama Administration, and helped Congress draft the ACA.

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Health care debate, 20082010


Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement. During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his top four priorities if he won the presidency.[] After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.[] On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform.[] By July, a series of bills were approved by committees within the House of [] Representatives. On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members met for a

President Obama addressing Congress regarding health care reform, September 9, 2009.

Patient Protection and Affordable Care Act series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators Max Baucus (D-MT), Chuck Grassley (R-IA), Kent Conrad (D-ND), Olympia Snowe (R-ME), Jeff Bingaman (D-NM), and Mike Enzi (R-WY), met for more than 60 hours, and the principles that they discussed (in conjunction with the other Committees) became the foundation of the Senate's health care reform bill.[103] The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site[104] or at the Committee's own web site.[105] With universal health insurance as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like Jonathan Gruber and David Cutler argued that guaranteed issue would require both a (partial) community rating and an individual health insurance mandate to prevent either adverse selection and/or free riding from creating an insurance death spiral.[] They convinced Obama that this was necessary, which persuaded the Administration to accept Congressional proposals that included a mandate.[] This approach was preferred because the President and Congressional leaders concluded that more liberal plans (such as Medicare-for-all) could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas - the same basic outline was supported by former Senate Majority Leaders Howard Baker (R-TN), Bob Dole (R-KS), Tom Daschle (D-SD) and George Mitchell (D-ME) - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.[106][107][] However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to filibuster any bills that contained it.[] Senate Minority Leader Mitch McConnell (R-KY), who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections:[]

55

It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey [108] to the public that this is O.K., they must have figured it out.

Republican Senators (including those who had supported previous bills with a similar mandate) began to describe the mandate as "unconstitutional". Writing in The New Yorker, Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."[] The New York Times subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's health care law requiring all Americans to buy health insurance has its roots in conservative thinking."[][] The reform negotiations also attracted a great deal of attention from lobbyists,[109] including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993.[110][111] The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.[112] During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the Tea Party Tea Party protesters at the Taxpayer March on Washington, movement organized protests and many conservative September 12, 2009. groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.[] There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection.[]

Patient Protection and Affordable Care Act To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.[] In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."[113] On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220215 vote and forwarded it to the Senate for passage.[]

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Senate
The Senate began work on its own proposals while the House was still working on its bill (the Affordable Health Care for America Act); it instead took up H.R. 3590, a bill regarding housing tax breaks for service members.[] As the United States Constitution requires all revenue-related bills to originate in the House,[114] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.[115] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[116] At the start of the 111th Congress, Democrats had only 58 votes (the Senate seat in Minnesota that would be won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican). To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican Senators (particular attention was given to Bob Bennett, Chuck Grassley, Mike Enzi, and Olympia Snowe). Negotiations continued even after July 7 when Al Franken was sworn into office and by which time Arlen Specter had switched parties because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy a long-time advocate for health care reform died, depriving Democrats of their 60th vote. Whilst Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24 (regaining the Democrats' 60th vote); attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.[] Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's Joe Lieberman (an independent who caucused with Democrats) and Nebraska's Ben Nelson. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included,[][] even though it had majority support in Congress.[] There was debate among supporters of the bill about the importance of the public option,[117] although the vast majority of supporters concluded that the it was a minor part of the reform overall,[] and that Congressional Democrats' fight for it won various concessions (including conditional waivers allowing states to set up state-based public options,[] for example Vermont's Green Mountain Care).[118]

Patient Protection and Affordable Care Act

57

With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill;[119] they had by this point concluded that "it was a waste of time dealing with [Snowe]"[120] because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform.[][121][122] Senate vote by state. Two Democratic yeasOne Democratic yea, one Republican (Snowe retired at the end of her term, citing nayOne Republican nay, one Republican not votingTwo Republican nays [123] partisanship and polarization). After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges" (requiring consumers to pay for the procedure out-of-pocket, if the state decided it); and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[][124] The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"[125] (and was later repealed by the subsequent reconciliation amendment bill). On December 23, the Senate voted 6039 to end debate on the bill (a cloture vote to end the filibuster by opponents). The bill then passed by a vote of 6039 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against except one (Jim Bunning (R-KY), not voting).[] The bill was endorsed by the AMA and AARP.[126] Several weeks after the vote, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41."[][127][128] The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: given not only how democratic (blue) Massachusetts is, but also the symbolic importance of losing the seat formerly held by Ted Kennedy (a staunch support of reform); the loss made many Congressional Democrats concerned about the political cost of passing a bill that had become controversial.[129][] The second effect was more practical: the loss of their supermajority complicated the legislative strategy of reform proponents (see below).[]

Patient Protection and Affordable Care Act

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House
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued the Democrats should scale-back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[][] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[][] On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.[130] He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.[] The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.[]

House vote by congressional district. Democratic yeaDemocratic nayRepublican nayNo representative seated

With Democrats having lost a filibuster-proof supermajority in the Senate, but having already passed the Senate bill with 60 votes on December 24; the most President Obama signing the Patient Protection and Affordable Care Act on March viable option for the proponents of 23, 2010. comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and pass the Senate's bill (The Patient Protection and Affordable Care Act) instead. Various health policy experts encouraged the House to pass the Senate version of the bill.[131] However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a (House-Senate) Conference before passing a final bill.[] With that option off the table (as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster);[] most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill (ultimately the Health Care and Education Reconciliation Act), which could be passed via the reconciliation process.[][][] Unlike the regular order, reconciliation is not subject to a filibuster (which requires 60 votes to break), but the process is limited to budget changes, which is why it was never able to be used to pass a comprehensive reform bill (with its inherently non-budgetary regulations as in the ACA) in the first place.[132][133] Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."[]

Patient Protection and Affordable Care Act The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[134] This concession won the support of Stupak and members of his group and assured passage of the bill.[][135] The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[] The following day, Republicans introduced legislation to repeal the bill.[] Obama signed the original bill (the ACA) into law on March 23, 2010.[136] The amendment bill (the Health Care and Education Reconciliation Act) was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.

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Impact
Public policy
Change in number of uninsured CBO originally estimated the legislation will reduce the number of uninsured residents by 32million, leaving 23million uninsured residents in 2019 after the bill's provisions have all taken effect.[][][][] A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the successful legal challenge to PPACA's expansion of Medicaid.[][] Among the people in this uninsured group will be: Illegal immigrants, estimated to be around eight million they will be ineligible for insurance subsidies and Medicaid;[][137][138] they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). Citizens not enrolled in Medicaid despite being eligible.[] Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance mostly younger and single Americans.[] Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.[] Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.[] ACA drafters believed that increasing insurance coverage would not only improve quality of life but also help reduce medical bankruptcies (currently the leading cause of bankruptcy in America[139]) and job lock;[140][][] in addition, many believed that expanding coverage was necessary to help ensure cost controls function - the reforms to the payment systems that incentivize value over quantity would be more likely to succeed if the costs of health care providers could be reduced by limiting uncompensated emergency care, and if there was a larger risk pool to distribute costs among.[][] Early experience under PPACA was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.[141] A later report from the Government Accountability Office in 2012 found that of the 4 million small businesses that were offered the tax credit only 170,300 businesses claimed it.[142][143] In part due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26; in September 2010 some insurance companies announced that in response to the law, they would end the issuance of new child-only policies.[144][145][146] An August 2011 Congressional report backed up the finding that passage of the health care law prompted health insurance carriers to stop selling new child-only health

Patient Protection and Affordable Care Act plans in many states.[] Of the 50states, 17 reported that there were currently no carriers selling child only health plans to new enrollees.[] Thirty-nine states indicated at least one insurance carrier exited the child-only market following enactment of the health care laws.[] At the same time, the Census Bureau released a report on September 13, 2011, showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.[147] Insurance exchanges and the individual mandate The ACA has two predominant means for increasing insurance coverage (as summarized above): One involves the expansion of already-existing, public insurance programs: expanding the coverage of Medicare (such as eliminating the 'donut hole'), and increasing the eligibility of the Medicaid program to expand enrollment. The other primary mechanism for providing insurance is the creation of state-based insurance exchanges: regulated, virtual marketplaces, administered by either federal or state government, where private insurers may sell plans to individuals and small business starting January 2014.[][148][] Those purchasing insurance plans may, if eligible, use subsidies provided through the exchanges.[] These exchanges will take the form of websites where the private plans allowed on sale within them will be regulated and comparable: Consumers will be able to visit these websites, compare the plans on offer, fill out a form to the government that will determine their eligibility for subsidies, and then purchase the insurance of their choice from the options available.[149][] (Members of Congress and their staff will participate in this system: they will be required to obtain health insurance through the exchanges - or plans otherwise approved by the bill, such as Medicare - instead of the Federal Employees Health Benefits Program that they currently use.[84]) The insurance exchanges are a method designed to create a market for private insurance in a way that addresses market failures in the current system (such as the high number of uninsured, medical bankruptcies, coverage limits, unaffordability, inflation, etc.[150]) through regulations:[][][151] Only approved plans that meet certain standards (see details below) will be allowed to be sold on the exchanges, and insurers will be prohibited from denying insurance, on the basis of pre-existing conditions, to consumers who are willing to and can afford a plan on offer in the exchanges.[][] Several methods will be employed to make these plans affordable: Subsidies will be provided to those eligible.[][] Regulations intended to increase competition (to reduce prices) will make plans and prices more transparent and price comparisons more accessible for consumers with online information;[152][153][154][155] as well as the phase-in of federally approved, multi-state plans on state exchanges[] (to help guarantee enough options, given that the number of plans on offer varies by state[156]). And price regulations will be implemented, including a minimum medical loss ratio,[] and partial community rating that prevents individuals from being priced out of the market by price discrimination (through unaffordable plans for the uninsured, or premium increases on the insured)[][] - namely poor and sick individuals who are more expensive to cover for insurers motivated either by profit maximization and/or the economics of insurance (specifically, the risk of an insurance pool not providing enough net-premiums to offset net-pay-outs).[][16] The aforementioned regulations are enabled to function due to the requirement to buy insurance (the penalty for forgoing insurance known as the individual mandate[]), without which healthy people might put-off insuring themselves until they got sick; in such a situation, to afford the remaining (relatively sicker and thus more expensive) population, insurers would have to raise their premiums,[][][][] which could drive more people to drop their coverage, creating a vicious cycle that could ultimately result in an insurance death spiral.[16][] Alternatively, the process could settle at a stable equilibrium relying on relatively high premiums for the insured and less coverage (and thus more illness and medical bankruptcy) for the uninsured.[][][] Either way, the absence of the mandate would likely cause the exchanges as a whole to malfunction, and ultimately perform similarly to the current private insurance market,[][][157] as studies by the CBO, Jonathan Gruber, and Rand Health have concluded.[158][][159] Conversely, the inclusion of the mandate increases the size and diversity of the insured population, broadening the risk pool to spread the cost of insurance in a sustainable manner.[][][] Policy experience in New Jersey on the one hand and Massachusetts on the other offers evidence of such divergent outcomes.[][][]

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Patient Protection and Affordable Care Act The Congressional Budget Office estimates that "about 4 million" (3.9 million or 1.2% of the population) will pay the penalty in 2016.[160] In September 2012, an updated CBO estimate concluded that nearly six million will pay a $1,200penalty in 2016. Also, nearly 80percent of those who will face the penalty would be making up to or less than five times the federal poverty level. This would work out to $55,850or less for an individual and $115,250or less for a family of four.[161] Under the law, setting-up an exchange gives a state partial discretion on standards and prices of insurance (beyond those specifics set-out in the ACA):[][162] For example, those administering the exchange will be able to determine which plans are sold on or excluded from the exchanges, adjust (through limits on and negotiations with private insurers) the prices on offer, and impose higher or state-specific coverage requirements including whether plans offered in the Insurance exchanges by state as of May, 2013.States creating fully state-operated state are prohibited from covering exchangesStates establishing state-federal partnership exchangesStates defaulting to abortion (making the procedure an federally facilitated exchanges out-of-pocket expense) or mandated to cover abortions that a physician determines to be medically necessary (in either case, federal subsidies are prohibited from being used to fund the procedure).[163] If a state does not set-up an exchange itself, they lose that discretion; and the responsibility to set-up exchanges for such states defaults to the federal government, whereby the Department of Health and Human Services assumes the authority and legal obligation to operate all functions in these 'federally facilitated exchanges'.[] As of May 2013, 23 states and the District of Columbia plan to operate state-based exchanges themselves (7 of which are doing so in partnership with the federal government, an arrangement where they retain discretionary management but the federal government executes various functions), whereas the remaining 27 states default to federally facilitated exchanges.[] The law is also designed to be flexible by allowing states, from 2017 onwards, to apply for a "waiver for state innovation" from the federal government that will enable them to experiment with their own state-based system, on condition that it meets certain criteria.[] To obtain a waiver, a state must pass legislation setting-up an alternative health system that provides insurance at least as comprehensive and as affordable as that the ACA would, covers at least as many residents, and does not increase the federal deficit.[] Provided a state meets these conditions; receiving a waiver can exempt states from some of the central requirements of the ACA, including the individual mandate, the provision of an insurance exchange, and the employer mandate.[] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, if they cannot be paid out due to the structure of the state plan.[] So far, only Vermont, in May 2011, has enacted an alternative plan - a state-based single-payer system for which they intend to pursue a waiver to implement.[][][]

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Patient Protection and Affordable Care Act Change in insurance standards The ACA includes new regulations setting standards for insurance,[] some set-out in the law, others subsequently established by the Secretary of Health and Human Services. The standards specified in the law include banning price discrimination on the basis of pre-existing conditions or sex through a partial community rating, prohibiting annual or lifetime limits on health care, making it illegal to drop policy holders if and when they become sick, and allowing dependents (mainly children) to remain on their parents' insurance plan until their 26th birthday. The essential health benefits[] that were defined by the Secretary of Health and Human Services include: "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care."[][164] In determining what qualified as an essential benefit, the law required that the scope of standard benefits should equal that of a "typical employer plan."[] States have some discretion in determining what should be considered the benchmark plan (beyond what is required by the law), and may include services beyond those set-out by the Secretary as essential benefits.[165] For certain services that are included in the essential benefits package, co-payments, co-insurance, and deductibles will be eliminated - they will be covered by an insurance plan's premiums.[][][] The law also establishes four tiers of coverage: bronze, silver, gold, and platinum. All categories offer the same set of essential health benefits. What the categories specify is the division of premiums and out-of-pocket costs: bronze plans will have the lowest monthly premiums and higher out-of-pocket costs, and vice versa for platinum plans.[][166] The percentages of care that plans are expected to cover through premiums (as opposed to out-of-pocket costs) are, on average: 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).[167] By the time the law is fully implemented (scheduled for 2020), the following list of specific standards will have taken effect: Effective September 23, 2010 Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[] Dependents (mainly children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[36] and regulations implemented under the ACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[][] Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[][168] All new insurance plans must cover preventive care and medical screenings[] rated Level A or B [38] by the U.S. Preventive Services Task Force.[39] Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.[] Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[] Insurers are prohibited from dropping policyholders when they get sick.[] Insurers are required to reveal details about administrative and executive expenditures.[] Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[] All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.[] Effective January 1, 2011 Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but

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Patient Protection and Affordable Care Act a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.[169][][][] Effective August 1, 2012 All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services including: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing.[] The requirement to cover FDA-approved contraceptive methods is also known as the contraceptive mandate.[][170][] Effective January 1, 2014 Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.[] Insurers are prohibited from establishing annual spending caps.[] Coverage for contraceptives The ACA includes a contraceptive coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations[] made under PPACA rely on the recommendations of the Institute of Medicine, which concluded that access to contraception is medically necessary "to ensure women's health and well-being."[171] The initial regulations proved controversial among Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds.[172] To accommodate those concerns whilst still guaranteeing access to contraception, the regulations were adjusted to "allow religious organizations to opt out of the requirement to include birth control coverage in their employee insurance plans. In those instances, the insurers themselves will offer contraception coverage to enrollees directly, at no additional cost."[173] Temporary waivers during implementation, 2010-2011 During the implementation of the law, there were interim regulations put in place for a specific type of employer-funded insurance, the so-called "mini-med" or limited-benefit plans, which are low-cost to employers who buy them for their employees, but cap coverage at a very low level. The waivers allowed employers to temporarily avoid the regulations ending annual and lifetime limits on coverage, and were put in place to encourage employers and insurers offering mini-med plans not to withdraw medical coverage before those regulations come into force (by which time small employers and individuals will be able to buy non-capped coverage through the exchanges) and were granted only if the employer could show that complying with the limit would mean a significant decrease in employees' benefits coverage or a significant increase in employees' premiums.[174] By January 26, 2011, HHS said it had granted a total of 733 waivers for 2011, covering 2.1million people, or about 1% of the privately insured population.[175] In June 2011, the Obama Administration announced that all applications for new waivers and renewals of existing ones have to be filed by September 22 of that year, and no new waivers would be approved after this date.[176]
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Patient Protection and Affordable Care Act

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The limited-benefit plans were sometimes offered to low-paid and part-time workers, for example in fast food restaurants or purchased direct from an insurer. Most company-provided health insurance policies starting on or after September 23, 2010, and before September 23, 2011, may not set [174] an annual coverage cap lower than $750,000, a lower limit that is raised in stages until 2014, by which time no insurance caps are allowed at all. By 2014, no health insurance, whether sold in the individual or group market, will be allowed to place an annual cap on coverage. Among those receiving waivers were employers, large insurers, such as Aetna and Cigna, and union plans covering about one million employees. McDonald's, one of the employers that received a waiver, has 30,000 hourly employees whose plans have annual caps of $10,000. The waivers are [][177] issued for one year and can be reapplied for. Referring to the adjustments as "a balancing act", Nancy-Ann DeParle, director of the Office of [] Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014."

Effects on insurance premiums Several studies on insurance premiums expect that with the subsidies offered under the ACA, more people will pay less (than they did prior to the reforms) than those who will pay more, and that those premiums will be more stable (even in changing health circumstances) and transparent, thanks to the regulations on insurance.[][178][179] As of July 2013, the average monthly premium scheduled to be on offer in the exchanges has come in below CBO expectations which, if it holds up, will not only be cheaper for consumers, but will reduce the overall cost of the subsidies.[180] For the effect on health insurance premiums, the CBO referred[] to its November 2009 analysis[] and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to 3% and 8 to 11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to 3%, with insureds under high premium plans subject to excise taxes being charged 9 to 12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.[] The Associated Press reported that, as a result of PPACA's provisions concerning the Medicare Part D coverage gap (between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription drug program), individuals falling in this "donut hole" would save about 40 percent.[] Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies.[] The change benefited more than two million people, most of them in the middle class.[] In January 2013, the Internal Revenue Service ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the workers household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. The New York Times said this could leave millions of Americans unable to afford family coverage under their employers plans and ineligible for subsidies to buy coverage elsewhere.[181] Larry Levitt, a health policy analyst from the Kaiser Family Foundation, noted that the individual market compromises just 6% of those under 65 currently, and said, in contrast, "I don't think anyone expects significant [cost] increases in the employer market," where the majority of Americans get their health insurance. Secretary of Health and Human Services Kathleen Sebelius also indicated that some cost increase in the individual market was expected because the standard of insurance allowed in the health care exchanges (run by the states or the federal government) would be higher quality than that generally available currently (and thus more expensive), and that the government subsidies provided to make insurance affordable are intended to more than offset this effect.[] In June 2013, a study by the Kaiser Family Foundation focused on actual experience under the Act as it affected individual market consumers (those buying insurance on their own). The study found that the Medical Loss Ratio provision of the Act had saved this group of consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%.[] The bulk of the savings were in reduced premiums for individual insurance, but some came from premium rebates paid to consumers by insurance companies that had failed to meet the requirements of the Act.

Patient Protection and Affordable Care Act Health care cost trends (health care cost inflation) In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:

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Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."[182] Jonathan Cohn, a noted health policy analyst, commented that:

CBO doesn't produce estimates of how reform will affect overall health care spending--that is, the amount of money our society, as a whole, will devote to health care. But the official actuary for Medicare does. The actuary determined that... the long-term trend is towards less spending: Inflation after ten years would be lower than it is now. And it's the long-term trend that matters most... [The Affordable Care Act] [][183] will reduce the cost of care--not by a lot and not by as much as possible in theory, but as much as is possible in this political universe.

He and fellow The New Republic editor Noam Scheiber further noted the CBO didn't include in its estimate various cost-saving provisions intended to reduce health inflation,[] and that historically the CBO has consistently underestimated the impact of health legislation.[] Jonathan Gruber, an influential consultant who helped develop both the Affordable Care Act and the Massachusetts Health Care reform that preceded it, acknowledges that the Affordable Care Act is not guaranteed to significantly 'bend the curve' of rising health care costs:[184]

The real question is how far the ACA will go in slowing cost growth. Here, there is great uncertaintymostly because there is such uncertainty in general about how to control cost growth in health care. There is no shortage of good ideas for ways of doing so... There is, however, a shortage of evidence regarding which approaches will actually workand therefore no consensus on which path is best to follow. In the face of such uncertainty, the ACA pursued the path of considering a range of different approaches to controlling health care costs... Whether these policies by themselves can fully solve the long run health care cost problem in the United States is doubtful. They may, [185] however, provide a first step towards controlling costsand understanding what does and does not work to do so more broadly.

The law created the Center for Medicare and Medicaid Innovation and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run.[186] Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.[] The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.[187] The Centers for Medicare and Medicaid Services reported in 2013 that, while costs per capita continue to rise, the rate of increase in annual healthcare costs (health care inflation) has fallen since 2002. Per capita cost increases have averaged 5.4% annually since 2000. Costs relative to GDP, which had been rising, has stagnated since 2009.[188] Several studies have attempted to explain the reduction in the rate of annual increase. Reasons include, among others: Higher unemployment due to the 2008-2010 recession, which has limited the ability of consumers to purchase healthcare;

Patient Protection and Affordable Care Act Out-of-pocket payments and deductibles (the amount a person pays of their health costs before insurance begins to cover claims) have risen, which generally causes less consumption of health care.[189] And the proportion of workers with employer-sponsored health insurance that requires a deductible has climbed to about three-quarters in 2012 from about half in 2006;[][] And structural changes[] from ACA programs and regulations aiming to shift the system from paying-for-quantity to paying-for-quality (like incentives to use electronic medical records, accountable care organizations and bundled payments to coordinate care and prioritize quality over quantity, and reduce hospital infections, etc.),[] including health care providers acting in anticipation of future implementation of reforms.[][] Whilst there is uncertainty about which causes are responsible to what extent for the recent reduction in health care inflation (and accompanying reduction in long-term deficit projections due to reduced health care costs), and about the durability of the trend; several studies have found that the temporary effects of the recession can not account for all of the slowdown, and that structural changes therefore likely share (partial) credit.[][][][190] One study estimated the changes to the health system to be responsible for about a quarter of the recent reduction in inflation.[191] Even if the cost controls succeed in lowering what is spent on health care (relative to having done nothing), such efforts on their own may not be sufficient to outweigh the long-term burden placed by demographic changes.[192] Federal deficit

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U.S. Healthcare Costs as a Percentage of GDP 2000-2011 - Centers for Medicare and Medicaid Services

Patient Protection and Affordable Care Act

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U.S. Healthcare Cost Inflation 2000-2011 - Centers for Medicare and Medicaid Services

CBO estimates of impact on deficit The 2011 comprehensive CBO estimate projected a net-deficit reduction of more than $200 billion during the 20122021 period:[][] it calculated the law would result in $604 billion in total outlays (expenditure) offset by $813 billion in total receipts (revenue), resulting in a $210 billion net-reduction in the deficit.[] The CBO separately noted that whilst most of the spending provisions don't begin until 2014,[][] revenue will still exceed spending in those subsequent years.[] CBO also stated that the bill would "substantially reduce the growth of Medicare's payment rates for most CBO Deficit reduction under ACA services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs."[] Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the degree of uncertainty involved in the projection) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2trillion.[][] CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".[193] A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200billion from 2010 to 2019.[194][195][196][197][198] However, the doc fix remains a separate issue that would have existed whether or not the ACA became law - omitting its cost from the ACA is no different than omitting the cost of the Bush tax

Patient Protection and Affordable Care Act cuts.[199][200] In 2012, the CBO updated its cost estimates for a portion of the bill, but did not update its estimate of the net deficit impact of the whole bill (which was still estimated to reduce budget deficits overall).[] The ACA's provisions related to insurance coverage were projected earlier in 2012 to have a net cost of $1,252 billion over the 20122022 period; that amount represented a gross cost to the federal government of $1,762 billion, offset in part by $510 billion in receipts and other budgetary effects (primarily revenues from penalties and other sources). The addition of 2022 to the projection period had the effect of increasing the costs of the coverage provisions of the ACA relative to those projected in March 2011 for the 2012-2021 period because that change added a year in which the expansion of eligibility for Medicaid and the subsidies for health insurance purchased through the exchanges would have been in effect. This estimate was made prior to the Supreme Court's ruling regarding the expansion of Medicaid program to the individual states however.[] CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of $1,168 billion over the 20122022 periodcompared with $1,252 billion projected in March 2012 for that 11-year periodreducing the cost estimate by $84 billion. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)[][][201] Opinions on CBO projections There was mixed opinion about the CBO estimates. Uwe Reinhardt, a health economist at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003."[202] Douglas Holtz-Eakin, CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562billion because, he argued, it front-loaded revenue and back-loaded benefits.[203] The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (a health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;[][] "innovations in the delivery of medical care, like greater use of electronic medical records[204] and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another and that meant there wasn't much hard data to prove the savings would materialize."[] David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.[] The Center on Budget and Policy Priorities objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20years to produce Medicare savings.[205][206] Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700billion in its first 10years.[207][208] Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false[209] and that repeal of the legislation would increase the deficit by $230billion over the same period,[210] pointing to the CBO's 2011 analysis of the impact of repeal.[211]

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Patient Protection and Affordable Care Act Employer mandate and part-time working hours Not to be confused with the individual mandate[] The employer mandate is a penalty that will be incurred by employers with more than 50 employees, if they do not offer health insurance to their full-time workers.[] This provision was included as a disincentive for employers considering dropping their current insurance plans once the insurance exchanges begin operating as an alternative source of insurance.[] Proponents of the reform law wanted to address the parts of the health care system they believed to not be working well, whilst causing minimal disruption to those happy with the coverage they have, and the employer mandate was a part of this attempt.[212][] Lawmakers recognized that approximately 80% of Americans already have insurance, of whom 54% are covered directly or indirectly through an employer (44% of the total population) another 29% of those covered (23% of the total population) are covered by the government (mainly Medicare, Medicaid).[213] And 73% of the total population reported themselves satisfied with their insurance situation; however significant minorities (even among those that reported favorably) had medically related financial troubles and/or dissatisfaction with aspects of their insurance coverage, especially among the poor and sick.[212] The intent of the employer mandate is to help ensure that existing employer-sponsored insurance plans that people like will stay in place. However, because a company will not face the penalty if it has less than 50 full-time employees, many are concerned that the employer mandate creates a perverse incentive for business to employ people part-time instead of full-time.[][] Several businesses and the State of Virginia have clarified the contracts of their part-time employees by adding a 29-hour a week cap,[214][215][216][217] to reflect the 30-hour threshold for full-time hours, as defined by the law.[] As of yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).[] And labour market experts note that such shifts are not clearly attributable to the implementation of the ACA: pre-existing, long-term trends in working hours,[] and the effects of the Great Recession correlate with part-time working hour patterns.[218] The impact of this provision on employers decision-making is partially offset by other factors: offering health care helps attract and retain employees, while increasing productivity and reducing absenteeism; and to trade a smaller full-time workforce for a larger part-time work force carries costs of training and administration for a business.[][][219] In addition, the amount of employers with over 50 employees is relatively small,[] and over 90% of them already offer insurance,[] so changes in employer plans from this provision are expected to be small.[] Workers who dont receive insurance from an employer plan will still be able to purchase insurance on the exchanges. Regardless of the political rationale (of maintaining existing insurance arrangements for those happy with them), most policy analysts (on both the right and left) are critical of the employer mandate provision on the policy merits.[][] They argue that the perverse incentives regarding part-time hours (even if they dont change many existing insurance plans) are real and harmful; that the raised marginal cost of the 50th worker for businesses could limit companies growth; that the costs of reporting and administration (the paperwork for businesses and the state enforcement) are not worth the trade-off of incentivizing the maintenance of current employer plans; and note that the employer mandate (unlike the individual mandate) is a non-essential part of the law.[][][220][] (At the same time, though, some analysts have noted that it is possible to design an employer mandate that partially avoids these problems, by instead taxing business that don't offer insurance by a percentage of their payroll, known as 'pay-or-play,' rather than using the 50-employee and 30-hour cut-offs).[][] Furthermore, many health care policy analysts think it would be better to transition away from the employer-based system to systems (whether state- or market-based) where insurance is more portable and stable, and hence think that it is a bad idea to even try to maintain existing employer insurance systems.[221] The effects of the provision have also generated vocal opposition from several business and unions.[][222] On July 2, 2013, the Obama Administration announced on the Treasury Departments website that it would delay the employer mandate for one year, until 2015.[][] In the statement, the Administration said that they were delaying implementation in order to meet two goals: First, it will allow us to consider ways to simplify the new reporting

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Patient Protection and Affordable Care Act requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees."[] The announcement was met with strong criticism by some who claimed that the authority to delay the implementation of the law lay with Congress.[][][] Senate Minority Leader Mitch McConnell argued that President Obamas authorization to delay the provision exceeded the limits of his executive power.[] House Republicans brought two bills to a vote to draw attention to the issue: The Authority for Mandate Delay Act; and the Fairness for American Families Act, which would apply the same delay to the individual mandate, arguing that the individual mandate should be treated the same way an action which the Obama Administration opposes.[] Constitutional scholar Simon Lazarus countered critics, saying that the delay was a lawful discretion of Executive power: "In effect, the Administration explains the delay as a sensible adjustment to phase-in enforcement, not a refusal to enforce To be sure, the federal Administrative Procedure Act authorizes federal courts to compel agencies to initiate statutorily required actions that have been unreasonably delayed. But courts have found delays to be unreasonable only in rare cases where, unlike this one, inaction had lasted for several years, and the recalcitrant agency could offer neither a persuasive excuse nor a credible end to its dithering."[223] Critics of the House Republicans comparison of the employer and individual mandate also pointed out that the two provisions are qualitatively different.[][]

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Political
Public opinion Polls indicate support of health care reform in general, but became more negative in regards to specific plans during the legislative debate over 2009 and 2010, and the Act that was ultimately signed in 2010 remains controversial with opinions falling along party lines: Democrats favor the law, while Republicans and most Independents do not. Polling averages show a plurality with negative opinions of the law, with those in favor trailing by single digits.[][] USA Today found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.[224] Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. FiveThirtyEight, describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."[] For example, a Reuters-Ipsos poll during June 2012 indicated the following: 56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall. 82% favored banning insurance companies from denying coverage to people with pre-existing conditions. 61% favored allowing children to stay on their parents' insurance until age 26. 72% supported requiring companies with more than 50 employees to provide insurance for their employees. 61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.[] Other polls showed additional provisions receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.[225][226] Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),[227] limiting malpractice awards, reducing the age to qualify for Medicare, and the public option.[]

Patient Protection and Affordable Care Act Pollsters probed the reasons for opposition.[228] In a CNN poll, 62% of respondents said they thought the ACA would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they thought they and their families would be better off with the legislation.[229] In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen wrote, "81% of voters say it's likely the plan will end up costing more than projected, [and 59%] say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care."[230] However, a June 2012 Reuters-Ipsos poll indicated that part of the opposition to the law was because some Americans did not believe the reform went far enough and wanted more done, not less. Among those opposed to the bill, 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among (the relative much smaller group of) Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.[] A majority (5234) indicated that they want "Congress to implement or tinker with the law rather than repeal it."[231] Many Democrats believe that the ACA will grow more popular over time, as Medicare did after its implementation,[232] as the benefits of the law take effect and close the information gap about the contents of the bill.[][233][234] Following the Supreme Court decision upholding the Act, a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."[235] Term "Obamacare" The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to The New York Times, the term was first put in print in March 2007, when health care lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s", Schulte Scott wrote.[][] The expression Obamacare first was used in early 2007 generally by writers describing the candidates proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at The Atlantic magazine.[] The word was first uttered in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said: "In my state, I worked on health care for some time. We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over health care'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."[] By mid-2012, Obamacare had become the most common colloquial term to refer to the law by both supporters and opponents (in contrast to the use of 'Patient Protection and Affordable Care Act' or 'Affordable Care Act' in more formal and official use).[] Use of the term in a positive sense was suggested by Democratic politicians such as John Conyers (D-MI).[236] President Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."[237] Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased Google advertisements, triggered by the term, to direct people to the official HHS site.[] In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post Twitter messages that begin, "I like #Obamacare because...".[] After its debut as a phrase on Capitol Hill, according to an analysis by the Sunlight Foundation, from July 2009 to June 2012 the term "Obamacare" was used nearly 3,000 times in congressional speeches.[]

71

Patient Protection and Affordable Care Act Myths On August 7, 2009, Sarah Palin falsely claimed that the proposed legislation would create death panels that would decide if sick and elderly Americans were "worthy" of medical care.[] By 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and that 30% of Americans believed it was true, with three contemporaneous polls finding similar results.[238] The allegation was named PolitiFact's "Lie of the Year",[][239] one of FactCheck's "whoppers",[240][241] and the most outrageous term by the American Dialect Society.[242] The AARP described such rumors as "rife with gross - and even cruel - distortions."[] A poll in August 2012 found that 39% of Americans still believed the "death panels" claim.[243] The 'death panel' rumors and comparable myths (similarly false) distort two issues related to the ACA to claim that seniors are either able to be denied care due to their age under the law,[244] or will be advised by the government to end their own lives instead of receiving due care.[] Such rumors first allude to the Independent Payment Advisory Board (IPAB), which has the authority to make cost-saving changes to the Medicare program by implementing the adoption of cost-effective treatments, and finding savings in administration of the program. However, the IPAB is also prohibited from limiting what Medicare covers or raising the costs on beneficiaries.[245] The other related issue concerns advance care planning consultation: a section of an initial House reform proposal would have reimbursed physicians for providing voluntary consultations of Medicare recipients on end-of-life health planning (which is also covered by many private plans), enabling patients to specify, on request, the kind of care they wish to receive in their old age.[246] As described by the site Snopes.com, "This provision would allow patients (if they so choose) to prepare for the day when they might be seriously ill and unable to make medical decisions for themselves by engaging in consultations with doctors to discuss the full range of end-of-life care options available to them, and to have the cost of such consultations covered by Medicare... [including] directives to accept or refuse extreme life-saving measures, selection of hospice care programs, appointment of relatives" to act on the patient's behalf, etc.[] However, due to the public concern, this provision was not included in the final draft of the bill that was enacted into law.[] In 2010, more false rumors spread on the Internet, claiming that the bill would require all Americans or those covered by public insurance to have a microchip implanted.[] These were sometimes associated with the number of the beast (666) in Christian eschatology.[247] These rumors echo similar 'Big Brother' conspiracy myths, and in this case were based on language in draft bills of the law that would have enabled the Department of Health and Human Services to collect data "about medical devices 'used in or on a patient' (such as pacemakers or hip replacements) for purposes that included tracking the effectiveness of such devices and facilitating the distribution of manufacturer recall notices."[] These provisions did not mandate or authorize the government to implant devices in patients, and were not included in the final bill that became law.[]

72

Opposition and resistance


Efforts to oppose, undermine, and repeal the legislation have drawn support from prominent conservative advocacy groups, Congressional and many State Republicans, certain small business organizations, and the Tea Party movement.[248] These groups believe the law will lead to disruption of existing health plans, increased costs from new insurance standards, and that it will increase the deficit.[249] Some also are against the idea of universal health insurance, viewing insurance as similar to other commodities to which people are not entitled.[250][251]

Legal challenges
Opponents of the Patient Protection and Affordable Care Act turned to the federal courts to challenge the constitutionality of the legislation.[252][253] In National Federation of Independent Business v. Sebelius, decided on June 28, 2012, the Supreme Court upheld most of the law; ruling the individual mandate (5-4) is constitutional on the basis that is a tax rather than being authorized by the Commerce Clause, but determined that States could not be forced to participate in the Medicaid expansion, effectively allowing states to opt out of this provision. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme

Patient Protection and Affordable Care Act Court ruled that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing pre-existing Medicaid funding from the federal government. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.[254]

73

State rejections of Medicaid expansion


Following the NFIB v. Sebelius ruling, several states with legislatures and governorships controlled by Republicans have opted to reject the expanded Medicaid coverage provided for by the act. Over half of the uninsured live in those states. They include Texas,[] Florida,[] Kansas,[] Georgia,[] Louisiana,[] Alabama,[] and Mississippi.[] As of May 24, 2013, a number of states had not made final decisions, and lists of states which have opted out or were considering Medicaid expansion by state as of July 1, 2013.States expanding MedicaidStates not opting out varied,[][] but Alaska,[] expanding MedicaidStates still debating Medicaid expansion Idaho,[] South Dakota,[] Nebraska,[] Iowa,[] Wisconsin,[] Indiana,[] Pennsylvania,[] Maine,[] North Carolina,[] South Carolina,[] Oklahoma,[] and Missouri[] seemed to have decided to reject expanded coverage.[] As of July 17, with the addition of Arizona,[] 24 states and the District of Columbia have adopted the Medicaid expansion.[256] The drafters of the ACA had intended for Medicaid to cover individuals and families with incomes up to 133% (138% under certain definitions of income[]) of the poverty level by expanding Medicaid eligibility and simplifying the CHIP enrollment process. Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies[] on a sliding scale if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income);[] However the SCOTUS ruling created the potential for a coverage gap: States that choose to reject the Medicaid expansion can maintain the pre-existing Medicaid eligibility thresholds that they have set, which in many states are significantly below 133% of the poverty line (many states do not make Medicaid available to childless adults at any income level); because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this will create a coverage gap in those states between the state Medicaid threshold and the subsidy eligibility threshold.[][][][257] For example, in Kansas, where only those able-bodied adults with children with an income below 32% of the poverty line are eligible for Medicaid, those with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) would be ineligible for both Medicaid and federal subsidies to buy insurance. If they have no children, able-bodied adults are not eligible for Medicaid in Kansas.[] Studies of the impact of state decisions (as of July 2013) to reject the Medicaid expansion calculate that up to 6.4 million Americans could fall into this coverage gap.[258]

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74

Noncooperation
Missouri, has not only declined to expand Medicaid or establish a health insurance marketplace but also is engaged in an active program of noncooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law to functioning of the Affordable Care Act.[] Other Republican politicians have tried to discourage efforts to advertise the benefits of the law, and some conservative political groups are launching ad campaigns to discourage enrollment.[259]

Congressional obstruction
As with all complex legislation, the act contains small errors and provisions which need to be tweaked in order to make the legislation work well in practice and avoid unintended consequences. Strong opposition in Congress by Republicans opposed to the act has resulted in gridlock, preventing these routine adjustments to programs.[][] Many Congressional Republicans and supporters argue that improving the law will weaken the arguments for repeal.[][] In addition to refusing to make routine technical corrections that would improve the law, Republicans have also attempted to defund its implementation,[][260] and block appointments to relevant agencies (like the IPAB[261] and CMS[262][263]).[264]

Repeal efforts
The ACA has been the subject of repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Reps. Steve King of Iowa and Michele Bachmann of Minnesota, both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. Jim DeMint in the Senate.[265] None of the three bills were considered by either body. In 2011, the Republican-controlled House of Representatives voted 245189 to approve a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2),[266] which, if enacted, would repeal the Patient Protection and Affordable Care Act and the health care-related text of the Health Care and Education Reconciliation Act of 2010. All Republicans and 3 Democrats voted for repeal.[267] In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down.[268] Before votes in both houses of the Congress took place, President Obama stated that he would veto the bill should it pass both chambers.[269] Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program. The Republicans voted down this measure.[270] On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader Eric Cantor stated that the House would again vote to repeal the law in July when Congress returns from recess.[271][272][273] On July 11, 2012, the House of Representatives voted to repeal the law with 5 Democrats and all 239 Republicans voting in favor of the repeal.[][] This was the 31st effort by the House of Representatives to repeal the law.[] With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, many Republicans conceded that repeal almost certainly will not occur.[274] Job consequences of repeal One argument put forth in favor of repeal was that, as stated by a spokesman for House Majority Leader Eric Cantor, "This is a job-killing law, period."[] The House Republican leadership justified its use of the term "job killing" by contending that PPACA would lead to a loss of 650,000 jobs, and attributing that figure to a report by the Congressional Budget Office.[] However, FactCheck noted the 650,000 figure was not included in the CBO report that was referred to, and said that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect [on employment] 'will probably be small.'"[] PolitiFact also rated the Republican statement as False.[275] Jonathan Cohn, citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate job lock: "people who are only working because they desperately need employer-sponsored health

Patient Protection and Affordable Care Act insurance will no longer do so."[] He concluded that "reforms only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire"[] once they have health insurance outside of their jobs. Effect of repeal proposals on federal budget projections The non-partisan Congressional Budget Office (CBO) estimated that repealing the entire PPACA (including both its taxing and spending provisions) would increase the net 20112021 federal deficit by $210billion.[211] In May 2011, CBO analyzed proposals to prevent the use of appropriated funds to implement the legislation, and wrote that "a temporary prohibition, extending through the remainder of fiscal year 2011, would reduce the budget deficit by about $1.4billion in 2011 but would increase deficits by almost $6billion over the 20112021 period... CBO cannot determine whether changes in spending under a permanent prohibition would produce net costs or net savings relative to its baseline projection, which assumes full implementation."[] Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R.6079) on July 11, 2012, and taking into account the Supreme Court's ruling concerning the expansion of Medicaid by the States, that, on balance, the direct spending and revenue effects of enacting the Repeal of Obamacare Act legislation would cause a net increase in federal budget deficits of $109billion over the 20132022 period. Specifically, CBO estimates that H.R.6079 would reduce direct spending by $890billion and reduce revenues by $1trillion between 2013 and 2022, thus adding $109billion to federal budget deficits over that period.[][]

75

References
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Patient Protection and Affordable Care Act


(II) offered through an Exchange established under this Act (or an amendment made by this Act)." [96] "History of the Individual Health Insurance Mandate, 1989-2010 Republican Origins of Democratic Health Care Provision" (http:/ / healthcarereform. procon. org/ view. resource. php?resourceID=004182) [100] Cosponsors of S.334 (http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ z?d110:SN00334:@@@P) from the Library of Congress THOMAS website [101] Bipartisan Senate Coalition Introduces First Comprehensive Health Reform Bill of 2009 (http:/ / wyden. senate. gov/ newsroom/ record. cfm?id=307848), from Senator Wyden's website [102] "RomneyCare vs. ObamaCare" (http:/ / www. boston. com/ bostonglobe/ editorial_opinion/ oped/ articles/ 2011/ 06/ 28/ romneycare_vs_obamacare/ ) [104] (http:/ / www. c-spanvideo. org/ videoLibrary/ search-results. php?organization="Finance"& organization="Senate+ Committee"& date-from=01/ 06/ 2009& date-to=01/ 02/ 2011) Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN [114] U.S. Const. art. I, 7, cl. 1. [126] AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation (http:/ / www. huffingtonpost. com/ 2010/ 03/ 19/ aarp-ama-announce-support_n_506060. html). The Huffington Post. [134] Executive Order 13535 of March 24, 2010 Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act, Vol.75, No.59,, March 29, 2010. [142] Ellmers, R. (2012, May 31). Small business subcommittee on healthcare & technology chairwoman Renee Ellmers: Need a job: support small businesses. Congressional Documents and Publications. Retrieved online from http:/ / www. dowjones. com/ factiva [143] Lawrimore, E. (2012, June 27). Barrasos 2nd opinion: Obamacare small business tax credit is a bust. Congressional Documents and Publications. Retrieved from http:/ / www. dowjones. com/ factiva [144] Insurers to Bail on Child-Only Policies as Health Care Law Looms (http:/ / www. cbsnews. com/ 8301-504744_162-20017272-10391703. html), CBS News, September 22, 2010 [145] Big health insurers to stop selling new child-only policies (http:/ / www. latimes. com/ health/ la-fi-kids-health-insurance-20100921,0,799167. story), Los Angeles Times, September 21, 2010 [160] Congressional Budget Office, " Selected CBO Publications Related to Health Care Legislation, 2009-2010 (http:/ / cbo. gov/ sites/ default/ files/ cbofiles/ ftpdocs/ 120xx/ doc12033/ 12-23-selectedhealthcarepublications. pdf)," Congress of the United States, December 2010, pp 71,73. [168] Note: Language in the law concerning this provision has been described as ambiguous, but representatives of the insurance industry have indicated they will comply with regulations to be issued by the Secretary of Health and Human Services reflecting this interpretation. [174] The Affordable Care Act: Eliminating Limits on Your Benefits (http:/ / www. healthcare. gov/ law/ provisions/ limits/ limits. html) HHS web site [175] " Annual Limits Policy: Protecting Consumers, Maintaining Options, and Building a Bridge to 2014 (http:/ / cciio. cms. gov/ resources/ files/ approved_applications_for_waiver. html)", HHS-CMS-CCIIO, see section "Applications for Waiver of the Annual Limits Requirements" [181] "A Cruel Blow to American Families" (http:/ / www. nytimes. com/ 2013/ 02/ 03/ opinion/ sunday/ a-cruel-blow-to-american-families. html) New York Times, February 2, 2013 [186] Kuraitis V. (2010). Pilots, Demonstrations & Innovation in the ACA Healthcare Reform Legislation (http:/ / e-caremanagement. com/ pilots-demonstrations-innovation-in-the-ppaca-healthcare-reform-legislation/ ). e-CareManagement.com. [188] Centers for Medicare and Medicaid Services-Statistics, Trends and Reports-Retrieved June 9, 2013 (http:/ / www. cms. gov/ Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/ NationalHealthExpendData/ NationalHealthAccountsHistorical. html) [210] Health Care Repeal Balloons Deficit, Hurts Economy and Families (http:/ / democrats. budget. house. gov/ press-release/ health-care-repeal-balloons-deficit-hurts-economy-and-families) Committee on the Budget | United States House of Representatives [211] Heavey, Susan (February 18, 2011), "Repealing healthcare law would cost $210 bln: CBO" (http:/ / www. reuters. com/ article/ 2011/ 02/ 18/ us-usa-healthcare-cbo-idUSTRE71H77N20110218), Reuters, retrieved March 13, 2011 [214] "Va. workers' part-time hours capped due to health law" (http:/ / hamptonroads. com/ 2013/ 02/ state-workers-parttime-hours-capped-due-health-law) The Virginian-Pilot, February 8, 2013 [215] "Colleges roll back faculty hours in response to Obamacare" MSNBC (http:/ / tv. msnbc. com/ 2013/ 01/ 14/ colleges-roll-back-faculty-hours-in-response-to-obamacare/ ) [216] "Virginia Cuts State Employees Hours To Avoid Providing Obamacare Coverage" (http:/ / thinkprogress. org/ health/ 2013/ 02/ 11/ 1568291/ virginia-employees-obamacare/ ) ThinkProgress, February 11, 2013 [217] "Four Public Colleges Will Cut Adjunct Faculty Hours To Avoid Providing Health Coverage Under Obamacare" ThinkProgress, January 14, 2013 (http:/ / thinkprogress. org/ health/ 2013/ 01/ 14/ 1445301/ four-public-colleges-obamacare/ ) [222] Union Letter: Obamacare Will Destroy The Very Health and Wellbeing of Workers (http:/ / blogs. wsj. com/ corporate-intelligence/ 2013/ 07/ 12/ union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ ), Wall St. Journal, July 12, 2013 [229] http:/ / i2. cdn. turner. com/ cnn/ 2010/ images/ 03/ 22/ rel5a. pdf [235] Jackson, David. Poll: Most oppose blocking Obama health care law (http:/ / content. usatoday. com/ communities/ theoval/ post/ 2012/ 07/ poll-most-oppose-blocking-obama-health-care-law/ 1#. T_m-ZJGmW_J) USA Today. Retrieved: 8 July 2012. [247] E.g.

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[274] Baker, Sam. (2012-11-07) Conservatives begin to admit defeat in their 3-year war against 'ObamaCare' - The Hill's Healthwatch (http:/ / thehill. com/ blogs/ healthwatch/ health-reform-implementation/ 266689-conservatives-are-begin-to-admit-defeat-in-their-three-year-war-against-obamacare). Thehill.com. Retrieved on 2013-07-17.

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Further reading
Barr, Donald A. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America (http://books.google.com/books?id=yZLJrmNoEzkC). JHU Press. CCH (2010). Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact (http://books.google.com/books?id=tCTt0sq2vaEC). CCH Incorporated. 1183pp Feldman, Arthur M. (2011). Understanding Health Care Reform: Bridging the Gap Between Myth and Reality (http://books.google.com/books?id=dSszUQPKSZIC). CRC Press. Jacobs, Lawrence R.; Theda Skocpol (2010). Health Care Reform and American Politics (http://books.google. com/books?id=VcsmJybD32wC). Oxford U.P. John E. McDonough (September 2011). Inside National Health Reform. University of California Press. ISBN9780520270190. Preliminary CBO documents Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment (http://www.cbo.gov/ doc.cfm?index=10868) December 19, 2009 Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009) Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009) Base Analysis H.R. 3590, Patient Protection and Affordable Care Act (http://cbo.gov/doc. cfm?index=10731), November 18, 2009. (The Additional and/or Related CBO reporting that follows can be accessed from the above link) Estimated Distribution Of Individual Mandate Penalties (November 20, 2009) Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009) Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009) Estimated Average Premiums Under Current Law (December 5, 2009) Additional Information About Employment-Based Coverage (December 7, 2009) Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009) Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of P.L. 111-148 Estimated Financial Effects of the "Patient Protection and Affordable Care Act," as Amended (https://www. cms.gov/ActuarialStudies/downloads/PPACA_2010-04-22.pdf). April 22, 2010. Estimated Effects of the "Patient Protection and Affordable Care Act," as Amended, on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts (https://www.cms. gov/ActuarialStudies/Downloads/PPACA_Medicare_2010-04-22.pdf). April 22, 2010. Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of H.R. 3590 Estimated Financial Effects of the "Patient Protection and Affordable Care Act of 2009," as Proposed by the Senate Majority Leader on November 18, 2009 (http://www.cms.gov/ActuarialStudies/Downloads/ S_PPACA_2009-12-10.pdf). December 10, 2009. Estimated Effects of the "Patient Protection and Affordable Care Act" on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts (http://www.cms.gov/ ActuarialStudies/Downloads/S_PPACA_Medicare_2009-12-10.pdf). December 10, 2009.

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External links
Video: Obama signs Healthcare Bill (http://www.wtsp.com/video/1711079319001/1/ Archive-video-Obama-signs-health-care-bill) Supreme Court Ruling on the ACA-June 28, 2012 (http://www.supremecourt.gov/opinions/11pdf/ 11-393c3a2.pdf) Remarks by the President on Supreme Court Ruling on the Affordable Care Act-June 28, 2012 (http://www. whitehouse.gov/the-press-office/2012/06/28/remarks-president-supreme-court-ruling-affordable-care-act) HealthCare.gov (http://www.healthcare.gov/) Department of Health and Human Services website on the law Affordable Care Act (http://topics.nytimes.com/top/reference/timestopics/organizations/s/supreme_court/ affordable_care_act//index.html) collected news and commentary at The New York Times Health Reform (http://topics.wsj.com/subject/H/health-reform/1662) collected news and commentary at The Wall Street Journal Basics: Health care reform issues (http://edition.cnn.com/2012/03/26/health/health-care-reform-interactive/ index.html?iid=article_sidebar) as provided by Emily Smith from CNN' June 25, 2012 Timeline of the health care law (http://edition.cnn.com/2012/06/17/politics/health-care-timeline/index. html?iid=article_sidebar) as provided by CNN June 17, 2012 Kaiser Family Foundation: Health Reform Subsidy Calculator Premium Assistance for Coverage in Exchanges/Gateways (http://healthreform.kff.org/SubsidyCalculator.aspx) Three Days of Argument: Obamacare On Trial Audiobook (http://www.castlibrary.com/free_books) Complete coverage of the arguments to the Supreme Court regarding Obamacare Supreme Court ruling caps a century of American debate over how to get medical care for all (http://www. washingtonpost.com/politics/federal_government/ supreme-court-ruling-caps-a-century-of-american-debate-over-how-to-get-medical-care-for-all/2012/06/28/ gJQA6XmP8V_story.html?tid=pm_politics_pop) An Associated Press timeline published on June 28, 2012, by The Washington Post about key events in a century of debate over what role the government should play in helping people in the United States afford medical care HealthReformGPS.org (http://www.healthreformgps.org/) Tracking and explanation of the law as it is implemented by analysts at the Hirsh Health Law and Policy program of the George Washington University School of Public Health and Health Services. Ambinder, Marc (March 22, 2010). "Has Romney Lost The RomneyCare = ObamaCare Argument?" (http:// www.theatlantic.com/politics/archive/2010/03/has-romney-lost-the-romneycare-obamacare-argument/37842/ ). The Atlantic. Retrieved 2011-04-07. Copies of the proposed bill hosted online or readily downloadable PDF (http://docs.house.gov/energycommerce/ppacacon.pdf) of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111148) after consolidating the amendments made by Title X of PPACA itself and by the Health Care and Education Reconciliation Act of 2010 ("HCERA"; Public Law 111152) into one revision. Plain Text or PDF formats of H. R. 3590 (Public Law 111-148) (http://www.gpo.gov/fdsys/search/ pagedetails.action?packageId=PLAW-111publ148), as engrossed or passed by the Senate and printed via FDsys. The Patient Protection and Affordable Care Act (http://dpc.senate.gov/dpcissue-sen_health_care_bill.cfm), full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov) Summary of H.R. 3590 (http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@L&summ2=m& summary) (March 23, 2010) via THOMAS. Entry for H.R. 3590 (http://www.govtrack.us/congress/bill.xpd?bill=h111-3590) at GovTrack The law as published by the U.S. Government Printing Office (http://www.gpo.gov/fdsys/pkg/ PLAW-111publ148/pdf/PLAW-111publ148.pdf)

Patient Protection and Affordable Care Act "Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional Committee on Oversight and Government Reform February 16, 2012 Lines Crossed: Separation of Church and State Part 1 (http://www.youtube.com/watch?v=9nJRUxj-HUY) Lines Crossed: Separation of Church and State Part 2 (http://www.youtube.com/watch?v=uj1l8suFE68) '"Where Are the Women?": Lawmakers Walk Out on Contraception Rule Hearing After Female Witness Barred' (https://www.democracynow.org/2012/2/17/where_are_the_women_lawmakers_walk) Democracy Now! February 17, 2012

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Administration for Children and Families

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Administration for Children and Families


Administration for Children & Families
Agency overview Agency executive George Sheldon, Assistant Secretary (Acting) Parent Agency United States Department of Health and Human Services Website
http:/ / www. acf. hhs. gov/

The Administration for Children and Families (ACF) is a division of the United States Department of Health and Human Services (HHS). It is headed by the Assistant Secretary for Children and Families. It has a $58.8 billion budget for 65 programs that target children, youth and families.[1] These programs include assistance with welfare, child support enforcement, adoption assistance, foster care, child care, and child abuse.

Mission statement
"The Administration for Children and Families (ACF), within the United States Department of Health and Human Services (HHS), provides national leadership and creates opportunities for families to lead economically and socially productive lives. ACF's programs are designed to help children to develop into healthy adults and communities to become more prosperous and supportive of their members."[2]

Major Goals
"ACF is responsible for federal programs that promote the economic and social well-being of families, children, individuals and communities. ACF programs aim to achieve the following: families and individuals empowered to increase their own economic independence and productivity; strong, healthy, supportive communities that have a positive impact on the quality of life and the development of children; partnerships with individuals, front-line service providers, communities, American Indian tribes, Native communities, states, and Congress that enable solutions which transcend traditional agency boundaries; services planned, reformed, and integrated to improve needed access; a strong commitment to working with people with developmental disabilities, refugees, and migrants to address their needs, strengths, and abilities."[2]

Major Programs
Administration for Native Americans (ANA) Administration on Children, Youth and Families (ACYF) Administration on Developmental Disabilities (ADD) Assets for Independence (AFI) Child Care Bureau (CCB) Office of Child Support Enforcement (OCSE) Children's Bureau (CB) Family and Youth Services Bureau (FYSB) Office of Head Start (OHS) Healthy Marriage Initiative (HMI)

Administration for Children and Families Office of Community Services (OCS) Low Income Home Energy Assistance Program (LIHEAP) Community Services Block Grant (CSBG) Social Services Block Grant (SSBG) Office of Family Assistance (OFA) / Temporary Assistance for Needy Families (TANF) Office of Refugee Resettlement (ORR) President's Committee for People with Intellectual Disabilities (PCPID)

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Other Initiatives, Clearinghouses and Resources


Center for Faith-Based and Community Initiatives (CFBCI) Child Welfare Information Gateway [3] Fatherhood Initiative "Insure Kids Now!" Campaign National Child Care Information and Technical Assistance Center (NCCIC) [4] National Clearinghouse on Families and Youth (NCFY) National Healthy Marriage Resource Center (NHMRC) [5] Office of Child Support Enforcement Tribal Resources

Abstinence education
For fiscal year 2006, ending September 30, 2006, Congress appropriated $50 million for state grants for abstinence education programs. Such programs teach that abstaining from sex is the only effective or acceptable method to prevent pregnancy or disease, and give no instruction on birth control or safe sex. In October 2006, revised guidelines by ACF specified that states seeking grants are "to identify groups ... most likely to bear children out-of-wedlock, targeting adolescents and/or adults within the 12- through 29-year-old age range." Previous guidelines didn't mention specific ages, and programs focused on preteens and teens.[6] ACF also administers the Community-Based Abstinence Education Program, which is focused on funding public and private entities that provide abstinence-until-marriage education for adolescents from 12 to 18 years old. For fiscal year 2005, 63 grants were awarded, totaling $104 million to organizations and other entities; in fiscal 2001, grants totaled only $20 million. In October 2006, the Government Accountability Office reported that ACF does not review its grantees education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy. GAO also reported that most of the efforts to evaluate the effectiveness of abstinence-until-marriage education programs included in GAOs review have not met certain minimum scientific criteria.[7]

Notes
[1] ACF Office of Legislative Affairs and Budget: Budget Information (http:/ / www. acf. hhs. gov/ programs/ olab/ budget/ index. html) [2] ACF Office of Public Affairs (OPA): Fact Sheet - Administration for Native Americans (ANA) (http:/ / www. acf. hhs. gov/ opa/ fact_sheets/ acf_factsheet. html) [3] http:/ / childwelfare. gov [4] http:/ / nccic. acf. hhs. gov [5] http:/ / www. healthymarriageinfo. org [6] Abstinence message goes beyond teens - USATODAY.com (http:/ / www. usatoday. com/ news/ washington/ 2006-10-30-abstinence-message_x. htm) [7] "Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs" (http:/ / www. gao. gov/ new. items/ d0787. pdf), U.S. Government Accountability Office, October 2006

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External links
Administration For Children and Families official web page (http://www.acf.hhs.gov)

American College of Healthcare Executives


The American College of Healthcare Executives
Motto To be the premier professional society for healthcare leaders by providing exceptional value to our members. 1933 Healthcare Association Chicago, Illinois, USA worldwide approx 40,000 Thomas C Dolan

Formation Type Headquarters Location Membership President and Chief Executive Officer Staff Website

approx. 100 www.ache.org [1]

The American College of Healthcare Executives (ACHE) is an international professional association of healthcare executives (high-level hospital administrators, CEOs, COOs, health system officers, etc.) Its central offices are located at 1 N. Franklin Street in Chicago, Illinois, USA. ACHE was described by Modern Healthcare as one of the healthcare industry's top professional associations.[2] Its President and Chief Executive Officer is Thomas C Dolan.

Credentialing
Currently in the United States, the practice of healthcare management does not require licensure. ACHE's credential, the FACHE, is a voluntary credential which healthcare managers can pursue to demonstrate their knowledge and experience. The credential was restructured in 2007 to streamline the process, which made it easier to achieve [2]

Divisions
ACHE itself is made up of a number of divisions, including membership, education, research and publications.

Education
Ongoing education for ACHE's members (designated as "Member" or "Fellow") is an element of ACHE's program. In 2005, these offerings included a two-day conference for Chief Operating Officers, a Canadian seminar offered in partnership with the Canadian College of Health Service Executives, and the annual Congress on Healthcare Leadership, which draws more than 4,000 participants each year.[3]

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Publications
Health Administration Press (HAP), founded at the University of Michigan in 1972, is ACHE's publisher and subsidiary. In 2005 HAP sold 54,000 publications, published 18 books, and published 10 issues of their two journals; the Journal of Healthcare Management and Frontiers of Health Services Management.[3]

Research
ACHE conducts research in a number of healthcare management areas. Factors affecting the career attainments of healthcare executives as well as trends and recommended practices affecting the profession are studied. Reports on the extent of hospital CEO turnover are routine produced as well.[4]

References
[1] [2] [3] [4] http:/ / www. ache. org Evans, Melanie. "Paying Dues by Doing Less". Modern Healthcare August 20, 2007. pp. 6, 7, 16. ACHE. About ACHE (http:/ / www. ache. org/ aboutache. cfm) ACHE. Research Publications (http:/ / www. ache. org/ pubs/ research/ research. cfm)

External links
Official homepage (http://www.ache.org) 2007 Annual Report (http://www.ache.org/ABT_ACHE/07_Annual_Report/ar07_tableofcontents.cfm) Health Administration Press (http://www.ache.org/hap.cfm)

American Congress of Obstetricians and Gynecologists


The American Congress of Obstetricians and Gynecologists (ACOG), formerly the American College of Obstetricians and Gynecologists, is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a membership of over 55,000[1] and represents 90 percent of U.S. board-certified obstetrician-gynecologists.[] Members are referred to as fellows and use the post-nominal letters FACOG to indicate their status. To become a fellow, candidates must become certified by the American Board of Obstetrics and Gynecology and then nominated to the college by another fellow. Board certification involves a two-part exam, usually taken over a two-year period. The first part is a written exam, which is taken the first year the candidate is "eligible" (typically in the final year of obstetrics and gynecology residency training). The second part is an oral exam, taken the year after the written exam is passed. The oral examination is based largely on a collection of a year's worth of medical and surgical cases known as the "case list". Obstetrics & Gynecology is the official publication of the ACOG. It is popularly known as "The Green Journal".[2] In 1986, the organization successfully challenged an anti-abortion law in Pennyslvania before the U.S. Supreme Court in Thornburgh v. American College of Obstetricians and Gynecologists.[3]

American Congress of Obstetricians and Gynecologists

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References
[1] About ACOG (http:/ / www. acog. org/ About_ACOG) [2] SCImago Journal and Country rank > Obstetrics and Gynecology (http:/ / www. scimagojr. com/ journalsearch. php?q=28089& tip=sid& clean=0) Retrieved on April 15, 2010 [3] Greenhouse, Linda. Becoming Justice Blackmun. Times Books. 2005. Page 183.

External links
Official ACOG website (http://www.acog.org/) ACOG, District IX - California (http://www.acog.org/About_ACOG/ACOG_Districts/District_IX) Journal site (http://journals.lww.com/greenjournal/pages/default.aspx)

American Cancer Society

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American Cancer Society


American Cancer Society
Founded 1913

Headquarters American Cancer Society Center Atlanta, Georgia Origins Key people New York, New York John R. Seffrin, PhD, Chief Executive Officer Otis Webb Brawley, MD, Chief Medical Officer W. Phil Evans, MD, FACR, President Cynthia M. LeBlanc, EdD, Chair United States and Puerto Rico. "To save lives by helping people stay well, helping people get well, by finding cures, and fighting back." Cancer research, Endowments, Public policy, and Education. cancer.org [1] [] []

Area served Focus(es) Method(s) Website

The American Cancer Society (ACS) is a nationwide voluntary health organization dedicated to eliminating cancer. Established in 1913, the society is organized into twelve[2] geographical divisions of both medical and lay volunteers operating in more than 900 offices throughout the United States, including Puerto Rico.[] Its home office is located in the American Cancer Society Center in Atlanta, Georgia. As the official journals the ACS publishes Cancer, CA: A Cancer Journal For Clinicians and Cancer Cytopathology. [3] In 1994, the Chronicle of Philanthropy, an industry publication, released the results of the largest study of charitable and non-profit organization popularity and credibility conducted by Nye Lavalle & Associates. The study showed that the American Cancer Society was ranked as the 10th "most popular charity/non-profit in America" of over 100 charities researched with 38% of Americans over the age of 12 choosing Love and Like A lot for the American Cancer Society.[4] [5]

History
The society was originally founded on May 22, 1913 by 15 physicians and businessmen in New York City under the name American Society for the Control of Cancer (ASCC). The current name was adopted in 1945.[6][7] In that time of founding it was not considered appropriate to mention the word cancer in public. Information concerning this illness was cloaked in a climate of fear and denial. Over 75,000 people died each year of cancer in just the United States. The top item on the founders agenda was to raise awareness of cancer, before any other progress could be made in funding research. Therefore a frenetic writing campaign was undertaken to educate doctors, nurses, patients and family members about cancer. Articles were written for popular magazines and professional journals. The ASCC undertook to publish their own journal, Campaign Notes, which was a monthly bulletin with information about cancer. They began recruiting doctors from all over the United States to help educate the public about cancer. Marjorie Illig was an ASCC field representative in 1936. She suggested creating a large network of new volunteers whose purpose was to wage war on cancer. In 1935 there were 15,000 people involved in cancer control in the U.S. By 1938 there was ten times that number. The Womens Field Army, those volunteers working on behalf of the ASCC were responsible for this increase more than anything else.[8]

American Cancer Society The sword symbol, adopted by the American Cancer Society in 1928, was designed by George E. Durant of Brooklyn, New York. According to Durant, the two serpents forming the handle represent the scientific and medical focus of the societys mission and the blade expresses the crusading spirit of the cancer control movement."[9] In the spring of 2013 the American Cancer Society reorganized nationally. The organization centralized and consolidated its operations and required all employees too reapply for their jobs. [10]

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Activities and Fund allocation


Its activities include providing grants to researchers, icluding funding 46 Nobel Laureate researchers, discovering the link between smoking and cancer, and serving one million callers every year through its National Cancer Information Center. The 46 Nobel Prize laureates include James D. Watson, Mario Capecchi, Oliver Smithies, Paul Berg, E. Donnall Thomas, and Walter Gilbert.[11] It also runs public health advertising campaigns, and organizes projects such as the Relay For Life and the Great American Smokeout. It operates a series of thrift stores to raise money for its operations. Notable endorsements include the 4K for Cancer, a 4000-mile bike ride from Baltimore to San Francisco to raise money for the society's Hope Lodge.[12] The societys allocation of funds for the fiscal year ending August 31, 2010, lists 72% of funds for Program Services (Patient Support 28%, Research 16%, Prevention 16%, Detection and Treatment 12%). The remaining 28% are allocated for supporting services (Fundraising 21%, and Management, General administration 7%) meeting the Better Business Bureau's Standards for Charity Accountability (At least 65% to program services and no more than 35% to overhead and fundraising expenses).[13] In 2012 the American Cancer Society raised $934 million and spent $943 million prompting a national consolidation and cost-cutting reorganization. [14] John R. Seffrin, CEO of the American Cancer Society, received $2,401,112 salary/compensation from the charity for the 2009-2010 fiscal year.[15] This is the second most money given by any charity to the head of that charity, according to Charity Watch. The money included $1.5 million in a retention benefit approved in 2001, to preserve management stability.[16]

1938 American Society for the Control of Cancer poster.

Evaluations
Charity Navigator rates the society two of four stars.[17] According to Charity Navigator the society is directed to "eliminating cancer" and destroying it. The American Cancer Society's website contains a chronological listing of specific accomplishments in the fight against cancer, for example the unipod technological device of UTD, that the ACS had a hand in, including the funding of various scientists who went on to discover life-saving cancer treatments, and advocating for increased use of preventative techniques.[18] Charity Watch rates American Cancer Society a "C".[19]
ACS Hope Lodge in Manhattan

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Scandals
New York embezzlement
In the 1980s, an employee of a New York branch was indicted for a tax fraud scheme that allowed individuals to fraudulently claim contributions, much of which had been returned to them.[20]

Ohio embezzlement
In 2000, Dan Wiant, the chief administrative officer of the American Cancer Society of Ohio, pled guilty to embezzling $7 million from the organization.[21]

Lack of control over state affiliates


In 1995, the Arizona chapter of the American Cancer Society was targeted for its extremely high overhead. Two economists, James Bennett and Thomas DiLorenzo, issued a report analyzing the chapter's financial statements and demonstrating that the Arizona chapter used about 95% of its donations for paying salaries and other overhead costs, resulting in a 22 to 1 ratio of overhead to actual money spent on the cause. The report also asserted that the Arizona chapter's annual ACS offices in Washington, D.C. report had grossly misrepresented the amount of money spent on patient services, inflating it by more than a factor of 10. The American Cancer Society responded by alleging that the two economists issuing the report were working for a group funded by the tobacco industry.[22]

Controversy
Declined participation of atheist organization in Relay For Life National Team program
The American Cancer Society was criticized for turning down participation from the Foundation Beyond Belief in its Relay For Life "National Team" program, worth more than $500,000. The ACS responded to the criticism by stating the "National Team" was to become a corporate sponsorship program and that non-profits and advocacy groups were no longer going to be included in this sponsorship program. This change in policy occurred after the ACS had already agreed that Foundation Beyond Belief could have a team under the Relay non-corporate National Team program.[23][24]

References
[1] http:/ / www. cancer. org/ [2] American Cancer Society: Fact Sheet (http:/ / www. cancer. org/ docroot/ AA/ content/ AA_1_2_ACS_Fact_Sheet. asp) [4] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 And USA Today, December 20, 1994, "Charity begins with health", FINAL 01D [5] http:/ / www. workingtogive. org/ charities/ disease-research/ american-cancer-society/ history History [6] name="charitynavigator.org" [7] http:/ / journaltimes. com/ news/ today-in-history-american-cancer-society-is-founded-strongest-ever/ article_8d048ba8-c17b-11e2-ba4e-001a4bcf887a. html Journal Times [8] http:/ / www. workingtogive. org/ charities/ disease-research/ american-cancer-society/ history History [10] http:/ / www. timesunion. com/ business/ article/ Cancer-Society-chapters-facing-reorganization-4446222. php Times Union, Cancer Society Reorg [14] http:/ / www. timesunion. com/ business/ article/ Cancer-Society-chapters-facing-reorganization-4446222. php Times Union, Cancer Society Reorg [19] Charity Rating Guide and Watchdog Report, Volume Number 59, December 2011

American Cancer Society


[20] Ex-Fund-Raiser At Cancer Society Indicted In $4 MillionTax Fraud (http:/ / query. nytimes. com/ gst/ fullpage. html?sec=health& res=9504E6D9153BF93AA25751C1A963948260). The New York Times. Retrieved on February 9, 2007. [21] Cancer Society Executive Surrenders to the F.B.I. (http:/ / query. nytimes. com/ gst/ fullpage. html?sec=health& res=990CEFD7163EF932A25755C0A9669C8B63& n=Top/ Reference/ Times Topics/ Organizations/ A/ American Cancer Society). The New York Times. Retrieved on February 9, 2007.

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External links
American Cancer Society (http://www.cancer.org/) Relay For Life (http://www.relayforlife.org/) Making Strides Against Breast Cancer (http://makingstrides.acsevents.org/) DetermiNation (http://determination.acsevents.org/) Relay Recess (http://www.relayrecess.org/) More Birthdays (http://morebirthdays.com/) Guidestar Report on American Cancer Society including financial data (http://www.guidestar.org/ pqShowGsReport.do?partner=networkforgood&ein=13-1788491) Charity Navigator's Rating of the American Cancer Society (http://www.charitynavigator.org/index.cfm/bay/ search.summary/orgid/6495.htm) American Cancer Society YouTube Channel (http://www.youtube.com/amercancersociety)

American College of Surgeons

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American College of Surgeons


American College of Surgeons
Formation Type Headquarters Location Membership 78,000 1913 Professional Association Chicago, IL

Officiallanguages English President Key people Website A. Brent Eastman EVP David B. Hoyt www.facs.org [1]

The American College of Surgeons is an educational association of surgeons created in 1913.[2] Headquartered in Chicago, Illinois, the College provides membership for doctors worldwide specializing in surgery who pass a set of rigorous qualifications.

Objective
The American College of Surgeons is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.[2]

Membership
American College of Surgeons members are referred to as Fellows. Members abbreviate their membership status in the American College of Surgeons by using the letters FACS (Fellow, American College of Surgeons). Those letters after a surgeons name mean that the surgeons education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College. Associate Fellow is another category of American College of Surgeons membership. Associate Fellowship provides an opportunity for surgeons who are beginning surgical practice and who meet specific requirements to assume an active role in the College at an early stage in their careers. In order to provide education and other benefits for allied professionals who deal with surgical patients, but who are not surgeons, the Affiliate Member category was created. Currently, there are approximately 78,000 members, including more than 58,000 Fellows in the U.S. and Canada and more than 4,000 Fellows in other countries, which makes the American College of Surgeons the largest organization of surgeons in the world. There are presently more than 3,900 Associate Fellows.

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Administration
22 members make up a Board of Regents, who govern the College. The Board of Regents is selected by an elected Board of Governors representing different specialties and geographical locations (the number of governors is based on the amount of Fellows in a region). While the Board of Regents is an administrative body, the Board of Regents serve as the representative body of the ACS between Fellows and the Board of Regents.[3] Within the ACS are numerous committees and advisory councils, studying and serving as a liaison for different specialties and aspects of the surgical profession.[4][5] Examples include the Committee on Trauma, the Patient Education Committee, and the Advisory Council on General Surgery. There are currently 103 chapters into which ACS Fellows are organized: 64 chapters in the United States, 2 in Canada, and 37 in other countries around the world.

Major activities
Through its Inspiring Quality initiative, the American College of Surgeons drives awareness of its quality improvement programs such as the ACS National Surgical Quality Improvement Program (ACS NSQIP) and ACS NSQIP Pediatric. The initiative is intended to enable the College to have a dialogue and work together with health care leaders around the nation, to continue to have a tremendous impact on improving surgical care, and to lead our health care system in the right direction. By administering myriad continuing medical education offerings, reflecting technology advancements and distance-learning options; accrediting simulation institutes that offer surgeons and surgical residents opportunities to learn new procedures and emerging technology; and providing surgeons with opportunities to record and obtain information they need for American surgical specialty board Maintenance of Certification requirements, the College "promotes high quality educational programs designed to educate surgeons and directly improve the health and safety of surgical patients." By means of standard setting and rigorous review processes through its Commission on Cancer, National Accreditation Program for Breast Centers, Committee on Trauma, and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, the American College of Surgeons accredits and verifies facilities to help ensure that surgical patients get high-quality care. In an effort to provide surgeons with the best scientific evidence available through evidence-based data, ACS works to improve the quality of surgical care through the ACS National Surgical Quality Improvement Program, National Cancer Data Base, National Trauma Data Bank, and Trauma Quality Improvement Program. ACS monitors and analyzes socioeconomic, legislative, and regulatory issues affecting the practice of surgery through its Division of Advocacy and Health Policy based in Washington, DC, and the ACS Professional Association. The College participates in health policy development on these issues, prepares responses to Congress and federal agencies, and serves as a liaison between the ACS and Congress and federal agencies, as well as the offices of other surgical and medical associations regarding health policy matters of importance to surgeons and surgical patients.

The Murphy Auditorium


In 1919, the headquarters of the ACS were a former private residence at 40 East Erie Street near downtown Chicago, the Samuel M. Nickerson House. In 1923, on property adjacent to the Nickerson House, the ACS commissioned the creation of the John B. Murphy Memorial Auditorium from the architectural firm of Marshall and Fox.[6] By 2003, the organization grew larger than the space offered by these two buildings and moved to the present location at 633 N. Saint Clair. While the Nickerson House was sold and eventually founded as a museum, the Murphy Auditorium was renovated and in June 2006 reopened as an event venue open to the public. The ACS still maintains ownership of the building.

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Publications
The American College of Surgeons distributes numerous publications, including peer-reviewed journals. They include: The Bulletin of the American College of Surgeons, the monthly news magazine for its Fellows and other constituents A monthly official scientific journal, the Journal of the American College of Surgeons (JACS) ACS NewsScope, the Colleges weekly e-newsletter Surgery News, the Colleges monthly newspaper

Fictional portrayals
Membership as a Fellow of the American College of Surgeons has been the subject of many fictional or fictionalized portrayals in popular culture, including: Drs. Brackett and Early on the television series Emergency! Drs. Altman, Burke, Hahn, Hunt, Montgomery, Robbins, Shepherd, Sloan, and Webber on the television series Grey's Anatomy. Dr. Lee on the television series Addicted to Beauty. Dr. Knowles-Teller on the television series Sons of Anarchy

References
[1] http:/ / www. facs. org/ [2] American College of Surgeons Online - "What is the American College of Surgeons?" (http:/ / www. facs. org/ about/ corppro. html)

External links
Official Website (http://www.facs.org/) ACS Foundation (http://www.facs.org/acsfoundation/index.html) ACS Archives (http://www.facs.org/archives/index.html) Journal of the American College of Surgeons (http://www.journalacs.org/) ACS Professional Association (http://www.facs.org/acspa/index.html) ACS Political Contributions (opensecrets.org) (http://www.opensecrets.org/orgs/summary.php?cycle=2012& id=D000043294)

Academy of Nutrition and Dietetics

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Academy of Nutrition and Dietetics


Academy of Nutrition and Dietetics
Formation Legalstatus 1917 Foundation

Purpose/focus Nutrition Headquarters Chicago, IL, U.S. Regionserved United States Mainorgan Budget Website Board of Delgates $34 million in 2011 eatright.org [1] []

The Academy of Nutrition and Dietetics is the United States' largest organization of food and nutrition professionals, with close to 72,000 members. After nearly 100 years as the American Dietetic Association (ADA), the organization officially changed its name to the Academy of Nutrition and Dietetics (A.N.D.) in 2012.[2] The organizations members are primarily registered dietitians (RDs) and dietetic technicians as well as many researchers, educators, students, nurses, physicians, pharmacists, clinical and community dietetics professionals, consultants and food service managers.[3]

Origins
The Academy was founded in 1917 in Cleveland, Ohio, by a group of women led by Lenna F. Cooper and the Academy's first president, Lulu G. Graves, who were dedicated to helping the government conserve food and improve public health during World War I.[4] It is now headquartered in Chicago, Illinois.[5] The original mission of the Academy was in part to help make maximal use of America's food resources during wartime.[6] In its first year, the Academy attracted 58 members.[7] It remained a small organization, remaining under the 1,000 member mark until the 1930s.[7] As the group's scope expanded, so did its membership numbers. Between the 1930s and 1960s, membership skyrocketed to more than than 60,000.[7] Growth trajectory has since stabilized, and the Academy marked its 70,000th member when a female dietitian in Texas rejoined the Academy in May 2009.[7] Since its founding in 1917, the Academy has gained members in every decade.[7] In 1973, the Academy created National Nutrition Week. The theme the first year was "Invest in Yourself...Buy Nutrition.[8] On May 9, 2010, the AND proclaimed Registered Dietitian's Day to honor the indispensable providers of food and nutrition services and to recognize RDs for their commitment to helping people enjoy healthy lives.[] The association also sponsors National Nutrition Month in March in the U.S.[9] According to current Academy president Sylvia Escott Stump, the group changed their name to the Academy of Nutrition and Dietetics in 2012 to reflect the scientific and academic expertise of its members.[10]

Academy of Nutrition and Dietetics

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Finances and Organization


In 2011, the Academy had disclosed net assets of $44 million, the bulk of which was in cash and investments.[] It took in $11M in annual membership dues, and an additional $5M in registration and examination fees. In 2011, it took in $33.9 million in revenue on expenses of $34.8M for a slight operating loss of $875,000. Due to successful investments, it posted a surplus of $6M for the 2011 fiscal year and $4.6M for 2010.[] In the same year, they received $1.2 million in corporate sponsorships from companies like General Mills, Coca Cola and PepsiCo via donations, joint initiatives, and programs.[11] The Academy has offices both in Chicago and Washington DC. In addition to the Academy, the organization maintains several other organizations and entities, including the Commission on Dietetic Registration, Commission on Accreditation for Dietetics Education, Dietetic Practice Groups, Academy Political Action Committee, and Academy Foundation. There are also several member interest groups which include more than 1,600 members with common interests or specialties including Fifty Plus in Nutrition and Dietetics; Filipino Americans in Dietetics and Nutrition; Muslims in Dietetics and Nutrition; and National Organization of Blacks in Dietetics and Nutrition.[]

Academy of Nutrition and Dietetics Foundation


In 1966, the Academy established the Foundation as a 501(C)(3) public charity. According to its mission statement, the Foundation is the only charitable organization devoted exclusively to promoting good nutrition. Its mission is to advance public health and nutrition with focus on three initiatives: scholarships, Healthy Weight for Kids and food and nutrition research.[12] In 2011, the Foundation had charitable contributions and revenues of $4.23 million, of which $1.7 million went to program expenses, $540,000 went to administrative expenses, and $289,000 went to fund raising expenses. Its executive director, Mary Beth Whalen, is paid $215,000 per year. These figures earned the Foundation a 60.95/70 score by CharityNavigator.com (four stars for transparency, three stars for its financials).[12] In 2011, the Foundation received corporate contributions totaling around $1.2 million from organizations such as Nestle, Kelloggs, Mars, Inc Coca Cola and the National Cattlemen's Beef Association,[2] as well as a $500,000 donation industrial food giant General Mills to promote healthy eating for kids.[13]

Influence and positions


Through its research journal, the Academy shapes and influences the public and legislative discussion about health, food safety and nutrition. Academy RDs are regularly quoted in world publications such as New York Times, Wall Street Journal, USA Today, Los Angeles Times Mens Fitness, O Magazine, Consumer Reports, Forbes and Huffington Post. In 2010, the organization received approximately 30 billion media impressions.[14] As an organization and research institute, the Academy holds a variety of influential health positions, including: The Academy "maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise."[15] The Academys stated position is that there are no good or bad foods, only good and bad diets. According to the Academy such labeling or bumpers confuse the public.[16] The Academy states that "exclusive breastfeeding provides optimal nutrition and health protection for the rst 6 months of life and breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants."[17] The Academy "believes that up to two servings of soy per day for adults could be part of a healthy diet."[18] The Academy has stated that a "well planned vegan diet" (no meat, dairy or animal products) is appropriate and healthy for babies.[19]

Academy of Nutrition and Dietetics The Academy states that to combat the obesity epidemic, adults and children need access to healthy foods, education on eating well, and preventative health services, including counseling by registered dietitians.[20][21] They support the White House and Michelle Obamas efforts to end the childhood obesity epidemic within a generation.[22] The Academy opposed mandated labeling of "trans fats" on food packaging.[23] The Academy has given low ratings to the high-protein no-carb diet (known as the Atkins Diet), insisting that the diet is "unhealthy and the weight loss is temporary."[24] The Academy maintains that carbohydrates are not responsible for weight gain any more than other forms of calories.[25] The Academy states that children who eat breakfast have better concentration, problem-solving skills, and eye hand coordination. Children who do not eat breakfast are tired at school and eat more junk food.[26][27]

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Research and Publications


The Academy publishes position papers on public health regarding pediatric (children's) health, food technology, food safety, geriatrics (elderly) health, health-care reform, obesity and the full range of food and nutrition topics through the Journal of the Academy of Nutrition and Dietetics (ANDJ). Considered the premier scholarly nutritional journal, it is a monthly peer-reviewed publication involved in the dietetics field, with original research, critical reviews, and reports on dietetics and human nutrition.[28] In 2012, its name changed along with the organization, becoming the "Journal of the Academy of Nutrition and Dietetics."[28] The Academy has also published 3 editions of the bestselling, award-winning 668-page book American Dietetic Association Complete Food and Nutrition Guide.[29] Through its publishing arm, the Academy has published such books and guides as Easy Gluten-Free, ADA Pocket Guide to Eating Disorders, ADA Pocket Guide to Lipid Disorders, Hypertension, Diabetes and Weight Management, ADA Quick Guide to Drug-Supplement Interactions and Making Nutrition Your Business.[] It also maintains the site eatright.org. In the 1980s, the Academy published the magazine Food/2 which had originally been created by the Department of Agriculture. In response pressure from meat, egg, and dairy industries, the Department of Agriculture decided not publish it, after which the Academy negotiated with the government to publish it itself, omitting the controversial chapters on fat and cholesterol.[30] The decision was widely criticized, with participating dietitians stating "it is just incredible that they would publish it without the most important part."[30]

Certification
The AND certification process offers two career options: Registered Dietitian (RD) and Dietetic Technician, Registered (DTR). Both are educated nutrition professionals qualified to work in hospitals, academia and private practice, and differ mostly in the hours of training and level of college degree required. A Registered Dietitian must complete a bachelor's degree or higher and more than 900 hours of training, while a Dietetic Technician is required to complete and associate level degree and 450 hours of training.[31] About 72% of the ANDs members are Registered Dietitians, and 2% are Dietetic Technicians.[3] Members are granted these accredited titles by fulfilling the ANDs strenuous certification requirements in addition to any state or local regulations. Through its ADAF foundation, the AND issued nearly $500,000 in certification scholarships in 2011, $100,000 of which went to doctoral students.[] The terms Registered Dietitian and Dietetic Technician are legally protected titles and can be used only by someone who has completed coursework approved by the AND.[32] In recent years, the AND has lobbied for stricter regulation over the professional licensing of dietitian and nutrition professionals and supported state regulations that would include heavy fines for the dispensing of nutritional advice without the proper license.[33][34] AND's Commission on Accreditation for Dietetics Education (CADE) is the organizations accrediting agency for education programs that prepare individuals for careers as dietetics professionals. In 2011, CADE changed its name

Academy of Nutrition and Dietetics to Accreditation Council for Education in Nutrition and Dietetics (ACEND).[35] The Accreditation Council is recognized by the Department of Education and is a member of the Association of Specialized and Professional Accreditors. The councils fees earn the AND about $1.1 million per year.[36]

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Registered Dietitian (RD)


According to the AND, a Registered Dietitian is a is a food and nutrition expert who has fulfilled the minimum requirements for the titled RD.[31] Requirements include the following items: Earning a bachelors degree with course work approved by ANDs Commission on Accreditation for Dietetics Education. Coursework typically includes food and nutrition sciences, foodservice systems management, business, economics, computer science, sociology, biochemistry, physiology, microbiology and chemistry. Completing an accredited, supervised practice program at a health-care facility, community agency or foodservice corporation. Passing a national examination administered by the Commission on Dietetic Registration. Completing continuing professional educational requirements to maintain registration. In addition to the costs of the college coursework, the AND charges a $200 application fee for registered dietitians.[37] Students must complete a 1,200 hour internship to sit for the Registered Dietitian exam.[38] Approximately 50% of RDs hold advanced degrees. Some RDs also hold additional certifications in specialized areas of practice, such as pediatric or renal nutrition, nutrition support and diabetes education.[3] In addition to any AND requirements (and often with some overlap), many states have laws for dietitians and nutrition practitioners.[39]

Dietetic Technician, Registered (DTR)


According to the AND, DTRs are a food and nutrition practitioner who has fulfilled the minimum requirements for the title DTR.[31] These requirements, while similar to an RD, differ in that they require: A minimum of an Associate's degree. At least 450 hours of supervised practice accredited by CADE. Successful pass a national DTR examination administered by CDR. Complete continuing professional educational requirements to maintain registration.

DTRs typically work closely with RD in numerous employment settings such as hospitals, health care facilities, private practice, day care centers, correctional facilities and weight loss centers.[31] The AND application fee to become an DTR is $120.[40]

Lobbying efforts and competitive protections


To help better communications with the US government, the AND has offices in Washington, DC. They also operate their own political action committee, the AND Political Action Committee.[] The AND spent $5.8 million lobbying at the state and national level from 2000-2010.[41] A 1985 report noted the AND has supported licensing for dispensing nutritional advice.[42] In addition to supporting legislation regulating the professional nutrition field in states like Colorado, Wyoming, Hawaii, New Jersey and New York, the AND has also applied for patents for its certification titles such as: Certified Nutrition Coach, Certified Nutrition Professional, Registered Nutrition Professional, and Certified Nutrition Educator.[33][43] The AND states that by regulating who can provide nutritional counseling, they can protect their registered members and the public from unregulated advice or possibly inaccurate advice from less qualified dietary practitioners such as chiropractors, yoga instructors, homeopaths, and personal trainers.[33] The ANDs support of this legislation has

Academy of Nutrition and Dietetics generated strong opposition from alternative health practitioners and libertarian groups, who state that "highly restrictive bills could create a monopoly for one school of traditional nutrition thought" and that the primary intent of the bill is "not to protect the public, but to give clout and recognition to a single segment of dietitians, increasing their chances of obtaining reimbursement from insurance companies."[33][42]

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Kids Eat Right


AND and the ADA Foundation launched their first joint initiative, Kids Eat Right, in November 2010. This member-driven campaign is dedicated to supporting the efforts of the White House to end the childhood obesity epidemic within a generation.[22] Kids Eat Right is a two-tiered campaign aimed to mobilize AND members to participate in community and school childhood obesity prevention efforts, and also to educate families, communities, and policy makers about the importance of quality nutrition. Kids Eat Right has a website that gives families healthy eating tips, articles, videos, and recipes from registered dietitians.[44] Kids Eat Right also has scientifically-based health information centered around the theme "Shop-Cook-Eat" which has information about how to shop for healthy foods, how to cook foods with the most nutrient value, and gives the benefits of eating together at home and away from home.[45]

Controversy
The AND has been criticized for its connections to the pharmaceutical industry, including an inquiry from Senator Chuck Grassley.[46][47] In 1982, the organization faced mass resignations from members over a decision to support President Ronald Reagans cuts in food stamps and school lunch programs.[30] The decision was largely a political trade-off; the Reagan administration agreed to drop its proposal to deregulate nursing homes in exchange for the ANDs support of the school lunch and food stamp cuts.[30]

Criticism of partnerships with food companies


A 1995 report noted the AND received funding from companies like McDonald's, PepsiCo, The Coca Cola Company, Sara Lee, Abbott Nutrition, General Mills, Kellogg's, Mars, McNeil Nutritionals, SOYJOY, Truvia, Unilever, and The Sugar Association as corporate sponsorship.[16] The AND also partners with ConAgra Foods, which produces Orville Redenbacker, Slim Jims, Hunts Ketchup, SnackPacks, and Hebrew National hot dogs, to maintain the American Dietetic Association/ConAgra Foods Home Food Safety...It's in Your Hands program.[48] Additionally, the AND earns revenue from corporations by selling space at its booth during conventions, doing this for soft drinks and candy makers.[16][49] In April 2013, a dietitian working on a panel charged with setting policy on genetically modified foods for the academy contended she was removed for pointing out that two of its members had ties to Monsanto, one of the biggest makers of genetically modified seeds.[50] The resulting controversy highlighted the fact that Ms. Smith Edge, chairwoman of the committee charged with developing the GMO policy, is a senior vice president at the International Food Information Council, which is largely financed by food, beverage and agriculture businesses, including companies like DuPont, Bayer CropScience and Cargill, companies that were among the biggest financial opponents of a State of California GMO labeling initiative.[51] The AND maintains that being at the "same table" with food companies is important in order to exert a positive influence over their products and message, although critics describe this as an unhealthy alliance between the AND and junk food companies.[49][] The accusation is that despite what good may come of such programs, it ultimately whitewashes (similar to the greenwashing efforts of environmentally irresponsible companies) the brands role in the countrys food ecosystem. Watchdogs note that the AND rarely criticizes food companies, believing it to be out of fear of "biting the hand that feeds them."[52][53][54] Nutrition expert Marion Nestle opined that she believed that as

Academy of Nutrition and Dietetics long as the AND partners with the makers of food and beverage products, its opinions about diet and health will never be believed [to be] independent.[49] A 2011 survey found that 80% of Academy members are critical of the Academy's position. They believe that the Academy is endorsing corporate sponsors and their products when it allows their sponsorship.[55]

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Additional publications
The Journal of the Academy of Nutrition and Dietetics (JADA)[56] is a monthly peer-reviewed publication involved in the dietetics field, with original research, critical reviews, and reports on dietetics and human nutrition.

References
[1] [2] [3] [4] http:/ / eatright. org Eat Right (http:/ / www. eatright. org/ ). Academy of Nutrition and Dietetics. Who We Are and What We Do (http:/ / www. eatright. org/ About/ Content. aspx?id=7530). Eat Right. Barber, Mary I. History of the American Dietetic Association, 1917-1959 (http:/ / books. google. com/ books/ about/ History_of_the_American_Dietetic_Associa. html?id=GIw_AAAAYAAJ). Lippincott: 1959. [5] Mayer, Jean and Dr. Johanna Dwyer. Careers in Dietetics (http:/ / news. google. com/ newspapers?id=L90NAAAAIBAJ& sjid=M20DAAAAIBAJ& pg=4967,3418792& dq=american+ dietetic+ association& hl=en). Pittsburgh Post-Gazette. February 27, 1978. [6] Foer, Jonathan Safran. Food industry dictates nutrition policy (http:/ / edition. cnn. com/ 2009/ OPINION/ 10/ 30/ eating. meat. jonathan. foer/ index. html). CNN. October 30, 2009. [7] American Dietetic Association Reaches Membership Milestone, Surpassing 70,000 Members for the First Time (http:/ / www. eatright. org/ Media/ content. aspx?id=1254). Eat Right. April 7, 2009. [8] Diatetic Association tells of Natl Nutrition Week (http:/ / news. google. com/ newspapers?id=iVgzAAAAIBAJ& sjid=WlIDAAAAIBAJ& pg=5360,4029238& dq=american+ dietetic+ association& hl=en). The Bryan Times. March 2, 1973. [9] Grotto, Dave. National Nutrition Month: Dave Grotto (http:/ / www. usatoday. com/ community/ chat/ 2002-03-21-grotto. htm). USA Today. January 21, 2005. [10] Stein, Jeannine. The American Dietetic Assn. gets a new name (http:/ / articles. latimes. com/ 2012/ jan/ 04/ news/ la-heb-american-dietetic-association-name-change-20120103). The Los Angeles Times. January 4, 2012. [11] pg. 7: ADA Parnters: ARAMARK, The Coca-Cola Company, Hershey Center for Health & Nutrition, National Dairy Council. Premier Sponsors: Abbott Nutrition, CoroWise brand, General Mills, Kellogg Company, Mars, Incorporated, McNeil Nutritionals, LLC, PepsiCo, SOYJOY, Truvia natural sweetener, Unilever. 2010 FNCE Event Sponsors: Campbell Soup Company, Chobani, ConAgra Foods, Nature Made, Safeway, Target [12] American Dietetic Association Foundation (http:/ / www. charitynavigator. org/ index. cfm?bay=search. summary& orgid=8467). Charity Navigator. [13] General Mills Partners With American Dietetic Association To Help Kids Adopt Healthy Eating And Exercise Habits (http:/ / www. thestreet. com/ story/ 10789235/ 1/ general-mills-partners-with-american-dietetic-association-to-help-kids-adopt-healthy-eating-and-exercise-habits. html?cm_ven=GOOGLEFI). The Street. June 22, 2010. [14] pg. 2: Coverage of ADA totaled more than 30 billion media impressions, including stories in the New York Times, Wlal Street Journal, USA Today, Los Angeles Times and Chicago Sun-Times. Consumer magazine coverage of ADA appeared in Men's Fitness, O Magazine, Consumer Reports, US News & World Report, Prevention, Self, Forbes, and Huffington Post, among others. [15] The American Dietetic Association maintains that the only way to lose weight is through a healthy, well-balanced diet and exercise (http:/ / news. google. com/ newspapers?id=bLtNAAAAIBAJ& sjid=Uf0DAAAAIBAJ& pg=4799,6361178& dq=american+ dietetic+ association& hl=en). Lakeland Ledger. October 20, 1999. [16] Groups Pursuit of Cash Draws Fire (http:/ / news. google. com/ newspapers?id=rW8aAAAAIBAJ& sjid=Ei0EAAAAIBAJ& pg=6759,219809& dq=american+ dietetic+ association& hl=en). Milwaukee Journal Sentinel. December 6, 1995. [17] Position of the American Dietetic Association: Promoting and Supporting Breastfeeding (http:/ / www. cdphe. state. co. us/ ps/ bf/ Resources/ American Dietetic Assocation SupportingPromotingBreastfeeding TAB 2. pdf). American Dietetic Association. November 2009. [18] Eng, Monica. Soy in Illinois prison diets prompts lawsuit over health effects (http:/ / articles. chicagotribune. com/ 2009-12-21/ news/ 0912200121_1_soy-protein-soy-cheeses-soyfoods-association). Chicago Tribune. December 21, 2009. [19] Planck, Nina. A Choice With Definite Risks (http:/ / www. nytimes. com/ roomfordebate/ 2012/ 04/ 17/ is-veganism-good-for-everyone/ a-choice-with-definite-risks). The New York Times. April 17, 2012. [20] Spector, Kaye. Motivation, information needed to combat obesity, American Dietetic Association says (http:/ / www. cleveland. com/ healthy-eating/ index. ssf/ 2010/ 06/ motivation_information_needed_to_combat_obesity_american_dietetic_association_says. html). Cleveland Live. June 30, 2010. [21] Obesity (http:/ / www. eatright. org/ Public/ content. aspx?id=5549). Eat Right.

Academy of Nutrition and Dietetics


[22] ADA Supports Michelle Obama's Childhood Obesity Initiative (http:/ / www. eatright. org/ Public/ content. aspx?id=4294967969). Eat Right. [23] Squires, Sally. FDA Wants Food LabelsTo List Trans Fatty Acids (http:/ / pqasb. pqarchiver. com/ washingtonpost/ access/ 46329006. html?dids=46329006:46329006& FMT=ABS& FMTS=ABS:FT& type=current& date=Nov+ 13,+ 1999& author=Sally+ Squires& pub=The+ Washington+ Post& desc=FDA+ Wants+ Food+ LabelsTo+ List+ Trans+ Fatty+ Acids& pqatl=google). The Washington Post. November 13, 1999. "This is one more thing on the food label," said Connie Diekman, a national spokeswoman for the American Dietetic Association, which opposes the regulation [24] Low-carb, high-protein diets popular, but not with adults (http:/ / news. google. com/ newspapers?id=YQVBAAAAIBAJ& sjid=YKgMAAAAIBAJ& pg=6607,3286289& dq=american+ dietetic+ association& hl=en). Harlan Daily Enterprise. November 3, 1999. [25] Question of the Day: Do Carbohydrates Cause Weight Gain? (http:/ / www. eatright. org/ Public/ content. aspx?id=10645) Eat Right. [26] Start Your Day with Greatness - Inland Valley News (http:/ / www. inlandvalleynews. com/ 2012/ 08/ 15/ start-your-day-with-greatness/ ) [27] Dietitians prime parents on nutrition before start of school | The Columbus Dispatch (http:/ / www. dispatch. com/ content/ stories/ food/ 2012/ 08/ 15/ 1-backtoschool-art-ga6io1o1-1. html) [28] Journal of American Dietetic Association becomes Journal of the Academy of Nutrition and Dietetics (http:/ / phys. org/ wire-news/ 88949712/ journal-of-american-dietetic-association-becomes-journal-of-the. html). Phys Org. January 25th, 2012. [30] MAGAZINE WITHHELD BY U.S. MAY REVIVE (http:/ / www. nytimes. com/ 1982/ 05/ 19/ garden/ magazine-withheld-by-us-may-revive. html). The New York Times. May 19, 1982. [31] Frequently Asked Questions (http:/ / www. llu. edu/ allied-health/ nutrition/ faqs. page). What is the difference between a Registered Dietitian (RD) and a Dietetic Technician Registered (DTR) and what career opportunities are available for each? (Information is provided by the Academy of Nutrition and Dietetics (AND) FAQs web page) [32] What is the difference between a registered dietitian or dietetic technician, registered, and a nutritionist? (http:/ / www. eatright. org/ ACEND/ content. aspx?id=146#Mike_1) EatRight.org. Registered dietitian or RD and dietetic technician, registered or DTR can only be used by dietetics practitioners who are currently authorized to use the credential by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics. These are legally protected titles. Individuals with these credentials have completed specific academic and supervised practice requirements, successfully completed a registration examination and maintained requirements for recertification. [33] Ellsberg, Michael. Is the American Dietetic Association Attempting to Limit Market Competition in Nutrition Counseling? (http:/ / www. forbes. com/ sites/ michaelellsberg/ 2012/ 04/ 05/ american-dietetic-association/ ) Forbes. April 5, 2012. [34] Full Text of SB2936 (http:/ / www. ilga. gov/ legislation/ fulltext. asp?DocName=& SessionId=84& GA=97& DocTypeId=SB& DocNum=2936& GAID=11& LegID=63811& SpecSess=& Session=). Illinois General Assembly. [35] About ACEND (http:/ / www. eatright. org/ ACEND/ ). Eat Right. [36] Commission on Accredation for Dietetics Education (CADE). Education Program: 1,193,009 [37] National Requirements to Become a Registered Dietitian from the American Dietetic Associations (ADA) Commission on Dietetic Registration (CDR) (http:/ / www. nutritionist-world. com/ ADA_registered_dietitian_regs. html). Nutritionist World. [38] Graduates cooking up new ways to utilize degrees in dietetics - Chicago Tribune (http:/ / articles. chicagotribune. com/ 2012-08-07/ special/ chi-adveducation-dietetics-20120807_1_dietetics-nutrition-world-degree-program) [39] What Is the Academy of Nutrition and Dietetics? (http:/ / www. eatright. org/ Media/ content. aspx?id=6442467510). Eat Right. [40] National Requirements to Become a Registered Dietitian from the American Dietetic Associations (ADA) Commission on Dietetic Registration (CDR) (http:/ / www. nutritionist-world. com/ ADA_registered_dietitian_regs. html). Loma Linda University. [41] American Dietetic Assn (http:/ / www. opensecrets. org/ lobby/ clientsum. php?id=D000023948& year=2010). Open Secrets. [42] Sugarman, Carole. "Licensing Nutrition Advisers." The Washington Post via LexisNexis (http:/ / www. lexisnexis. com). May 5, 1985. "And they want to make it illegal for individuals to offer nutrition advice without proper credentials [...] According to Catherine Babington, director of government affairs of the American Dietetic Association, dietitians in 36 states are pursuing mandatory licensure, although details of the proposed laws vary from state to state. A bill awaits the governor's signature in Maryland, while dietetic associations in Virginia and the District of Columbia are in the beginning stages of drafting such bills. [...] Opponents such as the National Health Federation, chaired by Donsbach, and the National Nutritional Foods Association, which represents more than 3,500 health food stores, contend that highly restrictive bills could create a monopoly for one school of traditional nutrition thought, limiting the free market and consumer choice, and that their primary intent is not to protect the public, but to give clout and recognition to a single segment of dietitians, increasing their chances of obtaining reimbursement from insurance companies." [43] RD Licensure (http:/ / www. wyomingdieteticassociation. com/ rd_licensure. asp). Wyoming Dietetic Association. [44] School's Out! Help Your Kids Eat Right All Summer Long (http:/ / www. newswise. com/ articles/ school-s-out-help-your-kids-eat-right-all-summer-long). NewsWire. May 24, 2011. [45] Kids Eat Right - About Kids Eat Right (http:/ / www. eatright. org/ kids/ content. aspx?id=6442459728) [46] Grassley renews call for voluntary disclosure by influential disease and medical advocacy groups (http:/ / www. grassley. senate. gov/ news/ Article. cfm?customel_dataPageID_1502=34350). Senator Chuck Grassley of Iowa. May 5, 2011. [47] American Dietetic Association (http:/ / www. propublica. org/ documents/ item/ 87299-american-dietetic-association). Propublica. December 18, 2009. [48] Timely Turkey Tips from Buying to Baking; American Dietetic Association/ConAgra Foods offer Home Food Safety Help for Thanksgiving Cooks (http:/ / www. businesswire. com/ news/ home/ 20051110005755/ en/ Timely-Turkey-Tips-Buying-Baking-American-Dietetic). Business Wire. November 10, 2005.

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[49] Nestle, Marion. The ADA and Corporate Sponsors: An Unhealthy Alliance? (http:/ / www. thedailygreen. com/ healthy-eating/ blogs/ healthy-food/ marion-nestle-ADA-politics-44031808). The Daily Green. March 18, 2008. [50] http:/ / www. nytimes. com/ 2013/ 04/ 11/ business/ a-dismissal-raises-questions-about-objectivity-on-food-policy. html [51] http:/ / www. motherjones. com/ tom-philpott/ 2013/ 04/ gmo-dieticians-monsanto-california [53] Who Is the Dairy Coalition? PR Watch.org (http:/ / www. prwatch. org/ prwissues/ 2000Q4/ dairy. html). [54] American Dietetic Association at SourceWatch (http:/ / www. sourcewatch. org/ index. php?title=American_Dietetic_Association). [55] An Error Occurred Setting Your User Cookie (http:/ / www. tandfonline. com/ doi/ abs/ 10. 1080/ 19320248. 2012. 704748#preview) [56] Journal of the American Dietetic Association (JADA) (http:/ / www. adajournal. org)

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External links
American Dietetic Association (http://www.eatright.org) official site American Dietetic Association (http://adajournal.org) official peer-reviewed journal American Dietetic Association Foundation (http://eatright.org/foundation)

American Dental Association

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American Dental Association


American Dental Association
Formation Type Headquarters Location Membership 1859 Professional association Chicago, Illinois United States 159,000

Officiallanguages English President Key people Staff Website Dr. Robert A. Faiella William Henry Atkinson (Founder) 400 ada.org [1]

The American Dental Association (ADA) is an American professional association established in 1859 which has more than 155,000 members. Based in the American Dental Association Building in the Near North Side of Chicago,[2] the ADA is the world's largest and oldest national dental association and promotes good oral health to the public while representing the dental profession. The ADA publishes a monthly journal of dental related articles named the Journal of the American Dental Association.

Overview
The ADA was founded August 1859, at Niagara Falls, New York, by twenty-six dentists who represented various dental societies in the United States. Today, the ADA has more than 152,000 members, 55 constituent (state-territorial) and 545 component (local) dental societies. It is the largest and oldest national dental association in the world and is committed to both the public and the dental profession. The Association has more than 400 employees at its headquarters in Chicago and its office in Washington, D.C. The Paffenbarger Research Center (PRC), located on the campus of the National Institute of Standards and Technology (NIST) in Gaithersburg, Maryland, an agency of the American Dental Association Foundation (ADAF) and a Department of the Division of Science. PRC scientists conduct basic and applied studies in clinical research, dental chemistry, polymer chemistry and cariology, and are the crown jewels of the ADA. The ADA established rigorous guidelines for testing and advertising of dental products and the first ADA Seal of Acceptance was awarded in 1931. Today, about 350 manufacturers participate in the voluntary program and more than 1300 products have received the Seal of Acceptance. The Board of Trustees, the administrative body of the Association, is composed of the President, the President-elect, two Vice Presidents and 17 trustees from each of the 17 trustee districts in the United States. The Treasurer and Executive Director serve as ex officio members. The House of Delegates, the legislative body of the Association, is composed of 460 delegates representing 53 constituent societies, five federal dental services and the American Student Dental Association. The House meets once a year during the Association's annual session. The Association's 11 councils serve as policy recommending agencies. Each council is assigned to study issues relating to its special area of interest and to make recommendations on those matters to the Board of Trustees and the House of Delegates.

American Dental Association The Association's official publication is The Journal of the American Dental Association. Other publications include the ADA News and the ADA Guide to Dental Therapeutics. The Commission on Dental Accreditation, which operates under the auspices of the ADA, is recognized by the U.S. Department of Education as the national accrediting body for dental, advanced dental and allied dental education programs in the United States. It is also recognized by 47 individual states. The ADA formally recognizes 9 specialty areas of dental practice: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial surgery, orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, prosthodontics, and oral and maxillofacial radiology. The ADA library has an extensive collection of dental literature with approximately 33,000 books and 17,500 bound journal volumes. The ADA library also subscribes to more than 600 journal titles. The ADA Foundation is the charitable arm of the Association. The Foundation provides grants for dental research, education, scholarships, access to care and charitable assistance programs such as relief grants to dentists and their dependents who are unable to support themselves due to injury, a medical condition or advanced age; and grants to those who are victims of disasters.

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Advocacy
The ADA advocates several positions to legislators in the U.S. Congress. Its agenda includes funding dental research into the safety and effectiveness of amalgam and fluoride, supporting student loans and residency programs for future dentists, increased dental coverage from Medicaid and CHIP programs, reducing dental costs through reform of insurance and medical liability and through health information technology, and improving public health through water fluoridation, tobacco control, and disaster planning and response.[3]

Advertising
Dudley the Dinosaur is an advertising character from the ADA. He's an anthropomorphic T. rex. He lives with his mom, little sister Dee Dee, Grandpa, and baby brother Digby. His friends are other dinosaurs and prehistoric creatures like mammoths and saber tooth tigers. He, his friends, and family teaches children how to have healthy teeth and good oral hygiene in the form of a cartoon character. The character Dudley the Dinosaur was hatched in winter of 1991 and became the nation's first bilingual (English and Spanish) public service campaign for kids. Dudley has appeared in numerous public service announcements on TV, a dozen National Children's Dental Health Month Campaigns, several coloring books and patient education booklets, four animated shorts produced by the ADA and on 2,500 outdoor billboards around the country. Dudley has won over 100 major awards, appeared on mugs and as a doll. He stars in comic books and DVDs available from the ADA.

Significant events
1840: First dental college, the Baltimore College of Dental Surgery; The American Society of Dental Surgeons (ASDS) is established. 1845: American Society of Dental Surgeons ask members to sign a mandatory pledge promising not to use mercury amalgam fillings. 1856: American Society of Dental Surgeons, because of its stance against dental amalgam, is disbanded in 1856 due to loss of membership. 1859: Twenty-six dentists meet in Niagara Falls, New York to form a professional society. 1860: First ADA constitution and bylaws are adopted. 1897: ADA merges with the Southern Dental Association to form the National Dental Association (NDA). 1908: NDA publishes the first patient dental education pamphlet.

American Dental Association 1913: NDA adopts a new constitution and bylaws, establishing the House of Delegates and Board of Trustees. 1913: The Journal of the National Dental Association is first published under the title, Bulletin of the National Dental Association 1922: NDA is renamed the American Dental Association (ADA). 1928: ADA affiliates with the NBS; National Board of Dental Examiners is established. 1930: Council of Dental Therapeutics established to oversee the evaluation of dental products. The Council establishes the ADA's Seal Program. 1931: First ADA Seal of Approval awarded; ADA headquarters located on north side of Chicago. 1936: ADA Council on Dental Education is formed. 1948: The National Institute of Dental Research (NIDR) is established (since renamed the NIDCR (National Institute of Dental and Craniofacial Research)). 1950: ADA works with Congress to proclaim February 6 as National Children's Dental Health Day; ADA endorses fluoridation. 1964: ADA produces the first color television Public Service Announcement by a non-profit health agency; ADA establishes the ADA Health Foundation, a501 (c)(3) non-profit organization for the purpose of engaging in dental health research and educational programs. 1970: ADA News is first published. 1978: Council on Dental Practice established. 1979: The Commission on Dental Accreditation established. 1987: ADA Commission on the Young Professional is formed (later becomes the Committee on the New Dentist). 1991: First female ADA president, Dr. Geraldine Morrow. 1995: ADA Web site, ADA ONLINE, created (later becomes ADA.org) 2002: First minority ADA president, Dr. Eugene Sekiguchi (he is Japanese-American). 2003: First Give Kids a Smile day held as part of National Childrens Dental Health Month. 2009: First female ADA executive director, Dr. Kathleen O'Loughlin.

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References
[1] http:/ / www. ada. org/ [2] " Contact Us (http:/ / www. ada. org/ 22. aspx)." American Dental Association. Retrieved on December 23, 2011. "211 East Chicago Ave. Chicago, IL 60611-2678"

External links
"American Dental Association website" (http://www.ada.org).

American Diabetes Association

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American Diabetes Association


American Diabetes Association
Founded 1940

Headquarters Alexandria, Virginia, U.S. Key people Larry Hausner, Chief Executive Officer Karen Talmadge, Chair of the Board To prevent and cure diabetes and improve the lives of all people affected by diabetes. http:/ / www. diabetes. org

Mission Website

The American Diabetes Association (ADA) is a United States-based association working to fight the consequences of diabetes and to help those affected by diabetes. The Association funds research to manage, cure and prevent diabetes (including type 1 diabetes, type 2 diabetes, gestational diabetes, and pre-diabetes); delivers services to hundreds of communities; provides information for both patients and health care professionals; and advocates on behalf of people denied their rights because of diabetes.[1] In 2011 it was estimated that 25.8 million Americans have diabetes, and another 79 million have prediabetes.[1]

History and mission


Formed in 1940, the ADA was founded by 28 physicians.[2] During its first 30 years, the Association limited its membership to physicians, health professionals and corporations. In 1970, the Association underwent a reorganization during which membership was expanded to include general members. Now the ADA is a volunteer-driven organization based in Alexandria, Virginia, with about 90 local offices across the United States.[3] The mission of the ADA is to prevent and cure diabetes and to improve the lives of all people affected by diabetes.[1] To fulfill this mission, the Association funds research, publishes scientific findings, provides information and other services to people with diabetes, their families, health professionals and the public. The Association is also actively involved in advocating for scientific research and for the rights of people with diabetes.[1] The Association acts on its mission through a number of critical programs and activities that are directed to a broad range of constituents, including consumers, research scientists, health care professionals, corporations and communities. In 1994, the Chronicle of Philanthropy, an industry publication, study showed that the American Diabetes Association was ranked as the 18th "most popular charity/non-profit in America" from over 100 charities researched with 33.8% of Americans over the age of 12 choosing Love and Like A Lot for the American Diabetes Association.[4]

Fund-raising
The ADA is America's leading 501(c)3 nonprofit charity providing diabetes research, information and advocacy.[5] The ADA raises most monies themselves and their overall fundraising expenses are 27%, with 73 cents of every dollar raised being used for research and programs.[6] However, they engage telemarketers at very large costs in order to bring new donors into their rolls. In one instance, the ADA entered into contract with InfoCision, a telemarketing firm that works closely with nonprofits, whereby only 15% of the expected funds raised would be given to the ADA with the other 85% being kept by the telemarketing firm. Furthermore, the telemarketers are instructed to lie to prospective donors regarding how much of their donation will go to the ADA.[7] When questioned by NBC's Lisa Myers about this campaign, a representative from the ADA expressed no regrets saying in part that "this program is a teenie weenie part of what they do; it's about bringing more people into the organization," and

American Diabetes Association stating that the program was not misleading despite the fact that prospective donors are being lied to regarding what percentage of their donation will be going to the ADA. As for what the ADA's response would be to donors who feel duped, the representative said that the ADA would say "thank you for the gift, it's making a difference, every single penny makes a positive impact." [8]

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Research
ADA-funded research
The ADA Research Program supports basic and clinical diabetes research aimed at preventing, treating, and curing diabetes. The diabetes research projects the Association supports cover the spectrum from islet cell biology and transplantation techniques, to studies in education and behavioral issues.[9] The Association has increased support for diabetes research from providing $18million in 1999 to making $34.6 million available for diabetes research in 2012.[10] The ADAs research funding program is designed to complement the National Institutes of Health (NIH) diabetes research program by supporting new investigators and new research ideas.[10] With support from the Association, investigators are often able to prove that their ideas are solid enough to get more substantial funding from the United States federal government.[10]

Research Foundation
Founded in October 1994, the ADA Research Foundation (also a 501(c)3 nonprofit) was created to substantially accelerate the Association's ability to raise major gifts to directly fund diabetes research.[11] The mission of the Research Foundation is to ensure the availability of funds necessary for the full exploration of all the scientific possibilities that diabetes research is generating.[11] Donations contributed to the Research Foundation help support more than 406 awards at more than 164 research institutions across the country, all working toward a day without diabetes. All non-research costs associated with the Research Program are paid through the Association's general fund.[11]

Scientific Sessions
Every year the ADA hosts the worlds largest scientific and medical diabetes meeting.[12] This meeting, known as Scientific Sessions, brings together thousands of clinicians, researchers, scientists and other medical professionals from all 50 states and 111 countries for five days of sessions, oral presentations, poster presentations and exhibits.[13]

Programs and activities


Center for Information and Community Support
On average, each year more than 300,000 people contact the Association with questions and concerns, or to seek support or direction regarding diabetes and its management.[14] In 2011, the Center for Information and Community Support (previously named the National Call Center) fielded an average of 20,000 calls per month. The Center for Information and Community Support is a free service staffed by highly-trained personnel, who answer non-medical questions in English or Spanish. Call Center hours of operation are Monday Friday, 8:30am to 8pm eastern time, with an automated phone system including basic information 24 hours a day, 7 days a week at 1-800-DIABETES (800-342-2383).[14] In 2009, the Center began to use online chat as a new means of communication with people who have questions about diabetes.[15]

American Diabetes Association

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Family Link
The ADA's Family Link program provides information to families about living with diabetes and managing diabetes at school, and links them to other families who are also living with diabetes.[16] With message boards, local Family Link events,[17] tool kits for families of children newly diagnosed with diabetes, parent-to-parent mentor programs, school initiatives that advocate and train safety at school,[18] and a safe online social networking site exclusively for youth with diabetes called Planet D,[19] Family Link provides comprehensive support.[16] The American Diabetes Association also provides diabetes camps nationwide and is the largest provider of diabetes camps in the world.[20]

Community initiatives
The ADA offers programs and resources specially designed to target high-risk communities, including African-American, Hispanic and Latino American, Native American, Asian American and Pacific Islander communities.[21] There are also programs for the workplace and in the neighborhood, as well as events and programs that are run by local offices.[22]

Events
Step Out: Walk to Stop Diabetes
Step Out: Walk to Stop Diabetes is the ADA's largest fund-raising event. Most walks take place in the fall, with more than 150 walks taking place in over 100 markets around the United States in 2009.[23][24] It raises about $20million annually.[25]

Tour de Cure
Tour de Cure is a series of fund-raising cycling events held in 40 states nationwide to benefit the ADA.[26] The Tour is a ride, not a race, with routes designed for everyone from the occasional rider to the experienced cyclist. In 2009, Tour de Cure events across the nation began to recognize participants who have diabetes by awarding them with red shirts or cycling jerseys to signify that they are Red Riders.[27]

Diabetes EXPO
Diabetes EXPO is a one-day tradeshow-like exposition for people with diabetes providing an array of diabetes-related products, services and information. In 2009, 21 Diabetes Expos have taken place or are planned in major markets throughout the United States.[28]

School Walk for Diabetes


School Walk for Diabetes is a K-12 educational school fundraising program that promotes healthy living, school spirit and community involvement. While raising money for the ADA, students learn about diabetes and the importance of making healthy choices including eating nutritious foods and exercising every day.[29]

BAD Ride
The Bikers Against Diabetes (BAD) Ride is a motorcycle fund-raising ride and family festival of the ADA.[30] This event brings bikers together to support the search for a cure for diabetes, with a full day of riding, entertainment, food and many other activities.

American Diabetes Association

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Father of the Year


Since 1999, the ADA has partnered with the National Father's Day Council to host the Father of the Year Awards dinner. Each year, approximately 80 men from across the nation are recognized for the outstanding strength, commitment and love they exhibit as fathers.[31]

Advocacy
Advocacy plays an integral role in the Association's efforts to fulfill its mission. Diabetes Advocates around the country work to increase funding to prevent, treat and cure diabetes; to improve access to health care; and to eliminate discrimination against people with diabetes at school, work or elsewhere in their lives.[32]

Discrimination
The ADA builds networks, hosts workshops, and engages with its volunteers to fight discrimination based on diabetes. This includes discrimination in school, in the workplace, obtaining private and commercial driver's licenses, in public accommodation settings and correctional institutions.[33] The ADA also works to improve access of diabetes patients to insulin by lobbying for non-medical professionals to be allowed to administer insulin (after receiving basic training), which has put it at odds with the American Nurses Association.

Federal government advocacy and state legislation


The Associations advocacy efforts span a broad range of issues that may or may not vary depending on geographic location. Advocacy initiatives include but are not limited to research funding, health care costs and reform, prevention initiatives and discrimination.[34][35]

Call to Congress
The Associations Call to Congress is a biennial event. Diabetes advocates from across the United States congregate in Washington, D.C. to meet with their U.S. Representatives and senators and discuss how diabetes affects their lives.[36] At the same time, advocates who are not able to come to Washington, D.C. participate in a call-in campaign directed toward members of Congress.[37] The next Call to Congress will take place from March 5 to March 7, 2013, in Washington, D.C.

Awareness campaigns
American Diabetes Month
November is American Diabetes Month, a time to bring even greater awareness and attention to the seriousness of diabetes, its deadly complications, and the importance of proper diabetes control. Throughout the month, the ADA conducts activities and encourages others across the country to get involved in efforts to raise awareness about diabetes.[38]

American Diabetes Alert Day


The American Diabetes Alert Day is an annual one-day "wake-up" call to inform the American public about the seriousness of diabetes. Observed each year on the fourth Tuesday of March, Alert Day is a time when the ADA encourages people to take the Diabetes Risk Test and find out if they, or their loved ones, are at risk for developing type 2 diabetes.[39]

American Diabetes Association

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Publications
The ADA works with experts to publish a variety of informational books, magazines and journals for both medical professionals and consumers.

Consumer publications
Diabetes Forecast magazine (ISSN 00958301 [40]) This is a monthly publication in its 63rd annual volume as of October 2010.[] Dr. Paris Roach, an Associate Professor at Indiana University School of Medicine, is Editor-in-Chief of the publication.[] The publication is printed in the United States.[] Consumer book choices include nutrition, self-care, weight management, and cookbooks to manage their disease. Professional health care books include clinical care, nutrition, meal planning, weight control, annual reviews, and diabetes educator curricula. ADA engages respected medical practitioners, diabetes educators, nutritionist, and other health care professionals to write our books providing this community with the most reliable information based on ADA diabetes guidelines. ADA is the oldest and largest publisher of books on diabetes.

Medical professional publications


Diabetes Diabetes Care, with an annual supplement of the Associations Clinical Practice Recommendations Clinical Diabetes Diabetes Spectrum

The ADA publishes a wide variety of books on the latest diabetes care for use by medical professionals, for example: Clinical care medical management series & references Therapy for Diabetes Mellitus and Related Disorders 5th ed. Medical Management of type 1 Diabetes 6th ed. Medical Management of type 2 Diabetes 7th ed. Complete Nurses Guide to Diabetes Care 2nd ed. Intensive Diabetes Management 5th Ed. Managing Pre-Existing Diabetes and Pregnancy Pregnancy Complicated by Diabetes 4th ed. ADA Guide to Nutrition Therapy for Diabetes, 2nd ed.

Clinical references Annual Review of Diabetes 2012 Clinical Practice Recommendations 2012 Clinical Practice Recommendations Pocket Charts Clinical Care of the Diabetic foot Practical Psychology for Diabetes Clinicians 2nd ed. Diabetes Ready Reference for Nurse Practitioners Diabetes & Hypoglycemia Diabetes & The Gut Diabetes & Cancer

Insulin/medications Practical Insulin 3rd ed. Putting Your Patients on the Pump Mental health

American Diabetes Association Practical Psychology for Diabetes Clinicians Cardiovascular disease Managing Pre-Existing Diabetes and Pregnancy Pregnancy Complicated by Diabetes 4th ed. Medical Management of Type 1 Diabetes 6th ed. Medical Management of Type 2 Diabetes 7th ed. Therapy for Diabetes Mellitus and Related Disorders 5th ed. Intensive Diabetes Management 5th ed. Complete Nurses Guide to Diabetes Care 2nd ed.

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Weight control/nutrition Practical Carbohydrate Counting 2nd ed. Behavioral Approaches to Obesity, 2nd ed. Managing Obesity: A Clinical Guide

Notes
[1] http:/ / www. diabetes. org/ aboutus. jsp?WTLPromo=HEADER_aboutus [2] American Diabetes Association: The Journey & the Dream: A history of the American Diabetes Association, page 23. American Diabetes Association, 1990. [3] http:/ / www. diabetes. org/ in-my-community/ [4] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 [5] http:/ / www. diabetes. org/ donate/ [6] http:/ / www. diabetes. org/ about-us/ 2011-ada-annual-report. pdf [7] Bloomberg Markets, "Charities Deceive Donors Unaware Money Goes to a Telemarketer" (http:/ / www. bloomberg. com/ news/ 2012-09-12/ charities-deceive-donors-unaware-money-goes-to-a-telemarketer. html/ ). Retrieved 2012-09-16. [8] Myers, Lisa, "Donors unaware charity money goes to telemarketer" (http:/ / www. nbc. com/ news-sports/ today-show/ 2012/ 09/ donors-unaware-charity-money-goes-to-telemarketer/ ), NBC Today Show, September 12, 2012. Retrieved 2012-09-16. [9] http:/ / www. diabetes. org/ diabetes-research/ ada-funded. jsp? [10] http:/ / www. diabetes. org/ news-research/ research/ [11] http:/ / www. diabetes. org/ diabetes-research/ ADA-Research-Foundation/ researchfoundation. jsp [12] http:/ / professional. diabetes. org/ Congress_Display. aspx?TYP=9& CID=60976 [13] http:/ / professional. diabetes. org/ Meeting_ListByType. aspx?ctyp=1 [14] http:/ / www. diabetes. org/ about-us/ center-for-information-community-support. html [15] http:/ / www. diabetes. org/ about-us/ center-for-information-community-support. html [16] http:/ / www. diabetes. org/ family-link/ about-family-link. jsp [17] http:/ / www. diabetes. org/ family-link/ find-family-link. jsp [18] http:/ / www. diabetes. org/ advocacy-and-legalresources/ discrimination/ school/ scrights. jsp [19] http:/ / tracker. diabetes. org/ index. php [20] http:/ / www. diabetes. org/ diabetes-camp/ diabetes-camp. jsp [21] http:/ / www. diabetes. org/ communityprograms-and-localevents. jsp [22] http:/ / www. diabetes. org/ communityprograms-and-localevents/ waw-default. jsp [23] http:/ / stepout. diabetes. org/ site/ PageServer?pagename=OUT_lm_wherewewalk [24] http:/ / www. volunteermatch. org/ search/ opp452373. jsp [25] http:/ / mydiabetessocialnetwork. ning. com/ events/ step-out-walk-to-fight [26] http:/ / tour. diabetes. org/ site/ PageServer?pagename=TC_homepage [27] http:/ / tour. diabetes. org/ site/ PageServer?pagename=TC_redrider [28] http:/ / www. diabetes. org/ communityprograms-and-localevents/ diabetesexpo. jsp [29] http:/ / schoolwalk. diabetes. org/ site/ PageServer?pagename=SW_homepage [30] http:/ / badride. diabetes. org/ site/ PageServer?pagename=BR_homepage [31] http:/ / main. diabetes. org/ site/ PageServer?pagename=FOTY_landing& WTLpromo=hpflyout [32] http:/ / www. diabetes. org/ advocacy-and-legalresources/ advocacy. jsp [33] http:/ / www. diabetes. org/ advocacy-and-legalresources/ discrimination. jsp [34] http:/ / www. diabetes. org/ advocacy-and-legalresources/ federal_legislation/ overview. jsp [35] http:/ / www. diabetes. org/ advocacy-and-legalresources/ state-legislation/ overview. jsp [36] http:/ / www. forecast. diabetes. org/ magazine/ advocacy/ calling-congress

American Diabetes Association


[37] [38] [39] [40] http:/ / www. diabetes. org/ advocacy-and-legalresources/ action-center/ calltocongress. jsp http:/ / www. diabetes. org/ communityprograms-and-localevents/ americandiabetesmonth. jsp http:/ / www. diabetes. org/ communityprograms-and-localevents/ american-diabetes-alert. jsp http:/ / www. worldcat. org/ title/ diabetes-forecast/ oclc/ 1798678

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External links
Official website (http://www.diabetes.org/) American Diabetes Association Journals (http://professional.diabetes.org/Journals_search.aspx/) Diabetes Forecast magazine (http://forecast.diabetes.org/) On Facebook (http://www.facebook.com/AmericanDiabetesAssociation/) On Twitter (http://www.twitter.com/AmDiabetesAssn/) On Flickr (http://www.flickr.com/photos/25087746@N04/) On YouTube (http://www.youtube.com/user/AmericanDiabetesAssn/) Facts about Diabetes (http://apps.nccd.cdc.gov/DDTSTRS/default.aspx/CDC) Website for children (http://youthzone.diabetes.org) Advocacy Action Center (http://advocacy.diabetes.org)

Americans with Disabilities Act of 1990

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Americans with Disabilities Act of 1990


Americans with Disabilities Act of 1990

Long title

An Act to establish a clear and comprehensive prohibition of discrimination on the basis of disability ADA 101st United States Congress July 26, 1990 Citations

Colloquial acronym(s) Enacted by the Effective

Public Law Stat.

101-336 104 Stat. 327 Codification

Title(s) amended U.S.C. sections created

42 12101 et seq. Legislative history [1]

Introduced in the Senate as S.933 by Sen. Tom Harkin (D-IA) on May 9, 1989 Passed the Senate on September 7, 1989 (76-8) Passed the House of Representatives on May 22, 1990 (unanimous voice vote) Reported by the joint conference committee on July 12, 1990; agreed to by the House of Representatives on July 12, 1990 (37728) and by the Senate on July 13, 1990 (91-6) Signed into law by President George H. W. Bush on July 26, 1990 Major amendments

ADA Amendments Act of 2008 United States Supreme Court cases Bragdon v. Abbott Olmstead v. L.C. Toyota Motor Manufacturing, Kentucky, Inc. v. Williams

The Americans with Disabilities Act of 1990[2][3] (ADA) is a law that was enacted by the U.S. Congress in 1990. Senator Tom Harkin (D-IA), authored the bill and was its chief sponsor in the Senate. Harkin delivered part of his introduction speech in sign language so his deaf brother could understand. It was signed into law on July 26, 1990, by President George H. W. Bush, and later amended with changes effective January 1, 2009.[4] The ADA is a wide-ranging civil rights law that prohibits, under certain circumstances, discrimination based on disability. It affords similar protections against discrimination to Americans with disabilities as the Civil Rights Act of 1964,[5] which made discrimination based on race, religion, sex, national origin, and other characteristics illegal. Disability is defined by the ADA as "...a physical or mental impairment that substantially limits a major life activity." The determination of whether any particular condition is considered a disability is made on a case by case

Americans with Disabilities Act of 1990 basis. Certain specific conditions are excluded as disabilities, such as current substance abuse and visual impairment that is correctable by prescription lenses. On September 25, 2008, President George W. Bush signed the ADA Amendments Act of 2008 (ADAAA) into law. This was intended to give broader protections for disabled workers and "turn back the clock" on court rulings that Congress deemed too restrictive.[] The ADAAA includes a list of "major life activities."

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Titles
Title IEmployment
See 42 U.S.C. 12111 [6] 12117 [7]. The ADA states that a covered entity shall not discriminate against a qualified individual with a disability.[] This applies to job application procedures, hiring, advancement and discharge of employees, workers' compensation, job training, and other terms, conditions, and privileges of employment. Covered entity can refer to an employment agency, labor organization, or joint labor-management committee, and is generally an employer engaged in interstate commerce and having 15 or more workers.[8] Discrimination may include, among other things, limiting or classifying a job applicant or employee in an adverse way, denying employment opportunities to people who truly qualify, or not making reasonable accommodations to the known physical or mental limitations of disabled employees, not advancing employees with disabilities in the business, and/or not providing needed accommodations in training materials or policies, and the provision of qualified readers or interpreters. Employers can use medical entrance Speech cards used by President George H. W. examinations for applicants, after making the job offer, only if all Bush at the signing ceremony of the Americans [2] with Disabilities Act (ADA) on July 26, 1990. applicants (regardless of disability) must take it and it is treated as a confidential medical record. Qualified individuals do not include any employee or applicant who is currently engaging in the illegal use of drugs when that usage is the basis for the employer's actions.[9] Part of Title I was found unconstitutional by the United States Supreme Court as it pertains to states in the case of Board of Trustees of the University of Alabama v. Garrett as violating the sovereign immunity rights of the several states as specified by the Eleventh Amendment to the United States Constitution. The provision allowing private suits against states for money damages was invalidated.

Title IIPublic entities (and public transportation)


See 42 U.S.C. 12131 [10] 12165 [11]. Title II prohibits disability discrimination by all public entities at the local (i.e. school district, municipal, city, county) and state level. Public entities must comply with Title II regulations by the U.S. Department of Justice. These regulations cover access to all programs and services offered by the entity. Access includes physical access described in the ADA Standards for Accessible Design and programmatic access that might be obstructed by discriminatory policies or procedures of the entity.

Access sign

Americans with Disabilities Act of 1990 Title II applies to public transportation provided by public entities through regulations by the U.S. Department of Transportation. It includes the National Railroad Passenger Corporation, along with all other commuter authorities. This section requires the provision of paratransit services by public entities that provide fixed route services sign of Illuminate. Title II also applies to all state and local public housing, housing assistance, and housing referrals. The Office of Fair Housing and Equal Opportunity is charged with enforcing this provision.

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Title IIIPublic accommodations (and commercial facilities)


See 42 U.S.C. 12181 [12] 12189 [13]. Under Title III, no individual may be discriminated against on the basis of disability with regards to the full and equal enjoyment of the goods, services, facilities, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation. "Public accommodations" include most places of lodging (such as inns and hotels), recreation, transportation, education, and dining, along with stores, care providers, and places of public displays, among other things. Under Title III of the ADA, all "new construction" (construction, modification or alterations) after the effective date of the ADA (approximately July 1992) must be fully compliant with the Americans With Disabilities Act Accessibility Guidelines (ADAAG)[2] found in the Code of Federal Regulations at 28C.F.R., Part 36, Appendix A.
The ADA sets standards for construction of accessible public facilities. Shown is a sign indicating an accessible fishing platform at Drano Lake, Washington.

Title III also has application to existing facilities. One of the definitions of "discrimination" under Title III of the ADA is a "failure to remove" architectural barriers in existing facilities. See 42 U.S.C.12182(b)(2)(A)(iv) [14]. This means that even facilities that have not been modified or altered in any way after the ADA was passed still have obligations. The standard is whether "removing barriers" (typically defined as bringing a condition into compliance with the ADAAG) is readily achievable, defined as "...easily accomplished without much difficulty or expense." The statutory definition of readily achievable calls for a balancing test between the cost of the proposed "fix" and the wherewithal of the business and/or owners of the business. Thus, what might be "readily achievable" for a sophisticated and financially capable corporation might not be readily achievable for a small or local business. There are exceptions to this title; many private clubs and religious organizations may not be bound by Title III. With regard to historic properties (those properties that are listed or that are eligible for listing in the National Register of Historic Places, or properties designated as historic under State or local law), those facilities must still comply with the provisions of Title III of the ADA to the "maximum extent feasible" but if following the usual standards would "threaten to destroy the historic significance of a feature of the building" then alternative standards may be used. Nonetheless, as Frank Bowe predicted when he testified as the lead witness on Title III in the Senate hearings leading up to enactment[citation needed], the fact that Title III calls for accessibility in, and alterations to, thousands of stores, restaurants, hotels, etc., in thousands of communities across the U.S. means that this Title probably has had more effect on the lives of more Americans with disabilities than any other ADA title.[15] On September 15, 2010, the Department of Justice issued revised regulations for implementation of Titles II and III, effective March 15, 2011.[16] The rules contain many new requirements for public accommodations, as well as an "element by element safe harbor."[17] Public swimming pool owners and operators must gear up for compliance with the 2010 Standards for Accessible Design with regard to existing swimming pools, wading pools and spas by January 31, 2013.[18] The Department of Justice published ADA 2010 Revised Requirements: Accessible Pools Means of Entry and Exit to help pool owners and operators understand the new accessibility requirements,

Americans with Disabilities Act of 1990 application of the requirements, and longstanding obligations of pool owners and operators in connection with the new requirements.[19] The ADA Revised Requirements require that newly constructed or altered swimming pools, wading pools, and spas have an accessible means of entrance and exit to pools for disabled people. However, providing accessibility is conditioned on whether providing access through a fixed lift is readily achievable. The technical specifications for when a means of entry is accessible are available on the (DOJ website). [20] Other requirements exist, based on pool size, include providing a certain number of accessible means of entry and exit, which are outlined in Section 242 of the Standards. However, businesses should consider the differences in application of the rules depending on whether the pool is new or altered, or whether the swimming pool was in existence before the effective date of the new rule. Full compliance may not be required for existing facilities; Section 242 and 1009 of the 2010 Standards outline such exceptions.[21]

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Title IVTelecommunications
Title IV of the ADA amended the landmark Communications Act of 1934 primarily by adding section 47 U.S.C.225 [22]. This section requires that all telecommunications companies in the U.S. take steps to ensure functionally equivalent services for consumers with disabilities, notably those who are deaf or hard of hearing and those with speech impairments. When Title IV took effect in the early 1990s, it led to installation of public Teletypewriter (TTY) machines and other TDDs (Telecommunications Device for the Deaf). Title IV also led to creation, in all 50 States and the District of Columbia, of what were then called dual-party relay services and now are known as Telecommunications Relay Services (TRS), such as STS Relay. Today, many TRS-mediated calls are made over the Internet by consumers who use broadband connections. Some are Video Relay Service (VRS) calls, while others are text calls. In either variation, communication assistants translate between the signed/typed words of a consumer and the spoken words of others. In 2006, according to the Federal Communications Commission (FCC), VRS calls averaged two million minutes a month.

Title VMiscellaneous provisions


See 42 U.S.C. 12201 [23] 12213 [24]. Title V includes technical provisions. It discusses, for example, the fact that nothing in the ADA amends, overrides or cancels anything in Section 504.[25] Additionally, Title V includes an anti retaliation or coercion provision. The Technical Assistance Manual for the ADA explains it: "III-3.6000 Retaliation or coercion. Individuals who exercise their rights under the ADA, or assist others in exercising their rights, are protected from retaliation. The prohibition against retaliation or coercion applies broadly to any individual or entity that seeks to prevent an individual from exercising his or her rights or to retaliate against him or her for having exercised those rights ... Any form of retaliation or coercion, including threats, intimidation, or interference, is prohibited if it is intended to interfere.

Major life activities


The ADA defines a covered disability as "...a physical or mental impairment that substantially limits a major life activity." The Equal Employment Opportunity Commission (EEOC) was charged with interpreting the 1990 law with regard to discrimination in employment. Its regulations narrowed "substantially limits" to "significantly or severely restricts." [citation needed] In 2008, effective January 1, 2009, the ADAAA broadened the interpretations and added to the ADA examples of "major life activities" including, but not limited to, "caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working" as well as the operation of several specified major bodily functions.[] The Act overturns a 1999 U.S. Supreme Court case that held that an employee was not disabled if the impairment could be corrected by mitigating measures; it specifically provides that such impairment must be determined without considering such ameliorative measures. Another court restriction overturned is the interpretation that an impairment

Americans with Disabilities Act of 1990 that substantially limits one major life activity must also limit others to be considered a disability.[] The ADAAA will undoubtedly lead to broader coverage of impaired employees. The United States House Committee on Education and Labor states that the amendment "...makes it absolutely clear that the ADA is intended to provide broad coverage to protect anyone who faces discrimination on the basis of disability."[26] Required doctor visits may not be held against anyone with a disability.[citation needed]

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"Capitol Crawl"
Shortly before the Act was passed, disability rights activists with physical disabilities coalesced in front of the Capitol Building, shed their crutches, wheelchairs, powerchairs and any other assistive devices, and immediately proceeded to crawl and pull their bodies up all 100 of the Capitol's front steps, without warning. As the activists did so, many of them chanted "ADA Now!!" and "Vote! Now!!". Some activists who remained at the bottom of the steps held signs and yelled words of encouragement at the 'Capitol Crawlers'. One young child with cerebral palsy is videotaped as she pulls herself up the steps, using mostly her hands and arms, saying "I'll take all night if I have to!". This direct action is reported to have "inconvenienced" several Senators and to have pushed them to approve the Act. While there are those who do not attribute much overall importance to this action, the Capitol Crawl is seen by many present-day disability activists in the United States as being the single action most responsible for 'forcing' the ADA into law.[27] Today, the Capitol Crawl action is not very well-known amongst the US public when compared to other United States civil rights movement actions, partly owing to the US mainstream media of 1990 failing to highlight the story.

Opposition
Opposition from religious groups
The debate over the Americans with Disabilities Act led some religious groups to take opposite positions.[28] Some religious groups, such as the Association of Christian Schools International, opposed the ADA in its original form.[29] ACSI opposed the Act primarily because the ADA labeled religious institutions public accommodations, and thus would have required churches to make costly structural changes to ensure access for all.[30] The cost argument advanced by ACSI and others prevailed in keeping religious institutions from being labeled as public accommodations, and thus churches were permitted to remain inaccessible if they choose. In addition to opposing the ADA on grounds of cost, church groups like the National Association of Evangelicals testified against the ADA's Title I (employment) provisions on grounds of religious liberty. The NAE felt that the regulation of the internal employment of churches was "... an improper intrusion [of] the federal government."[28]

Opposition from business interests


Many members of the business community opposed the passage of the Americans with Disabilities Act. Testifying before Congress, Greyhound Bus Lines stated that the Act had the potential to "...deprive millions of people of affordable intercity public transportation and thousands of rural communities of their only link to the outside world." The US Chamber of Commerce argued that the costs of the ADA would be "enormous" and have "a disastrous impact on many small businesses struggling to survive."[31] The National Federation of Independent Businesses, an organization that lobbies for small businesses, called the ADA "a disaster for small business."[32] Pro-business conservative commentators joined in opposition, writing that the Americans with Disabilities Act was "an expensive headache to millions" that would not necessarily improve the lives of people with disabilities.[33]

Americans with Disabilities Act of 1990

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Quotations
On signing the measure, George H. W. Bush said: I know there may have been concerns that the ADA may be too vague or too costly, or may lead endlessly to litigation. But I want to reassure you right now that my administration and the United States Congress have carefully crafted this Act. We've all been determined to ensure that it gives flexibility, particularly in terms of the timetable of implementation; and we've been committed to containing the costs that may be incurred.... Let the shameful wall of exclusion finally come tumbling down.[34]

President Bush signs the Americans with Disabilities Act into law

On the debate of what it means to be disabled, American poet Joan Aleshire stated in the book Voices From the Edge: If the definition of disability is the inability to do the common daily tasks of lifegetting out of bed, washing, dressing, eating, going to the bathroomand working at one's age level in school, I've never really been disabled.[35] About the importance of making employment opportunities inclusive, Shirley Davis, director of global diversity and inclusion at the Society for Human Resource Management, said: People with disabilities represent a critical talent pool that is underserved and underutilized.[36]

Criticism
The ADA has been a frequent target of criticism, on the grounds of actually decreasing the employment rate for the disabled[37] and raising the cost of doing business for employers, in large part due to the additional legal risks, which employers avoid by quietly avoiding hiring people with disabilities. Some researchersWikipedia:Avoid weasel words believe that the law has been ineffectual.[38]

Employment
Multiple economic studies have shown that the law has had unintended consequences. Between 1991 (after its enactment) and 1995, the ADA caused a 7.8% drop in the employment rate of men with disabilities regardless of age, educational level, and type of disability, with the most affected being young, less-educated and mentally disabled men.[] In 2001, for men of all working ages and women under 40, Current Population Survey data showed a sharp drop in the employment of disabled workers, with the ADA as a likely cause.[39]

Abuse
For example, a common claim is that individuals who are diagnosed with one of the so-called "lesser disabilities" are being "accommodated" when they should not be.[citation needed] As one law review article pointed out, the perception that the ADA primarily helps freeloaders was harshly satirized by The Onion in 1998 in the form of an article about the Americans With No Abilities Act.[40] The fictional Act would have provided "benefits and protection for more than 135 million talentless Americans," and prohibited discriminatory questions such as "What can you bring to this organization?"[41][42]

Americans with Disabilities Act of 1990 On the other hand, court decisions have made necessary "an individualized assessment to prove that an impairment is protected under the ADA. Therefore, the plaintiff must offer evidence that the extent of the limitation caused by the impairment is substantial in terms of his or her own experience;" a medical diagnosis or physician's declaration of disability is no longer enough.[43]

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"Professional plaintiffs"
Since enforcement of the Act began in July 1992, it has quickly become a major component of employment law, with large numbers of frivolous lawsuits. Through the end of fiscal year 1998, 86% of the 106,988 ADA charges filed with and resolved by the Equal Employment Opportunity Commission, were either dropped or investigated and dismissed by EEOC but not without imposing opportunity costs and legal fees on employers.[] The ADA allows private plaintiffs to receive only injunctive relief (a court order requiring the public accommodation to remedy violations of the accessibility regulations) and attorneys' fees, and does not provide monetary rewards to private plaintiffs who sue non-compliant businesses. Unless a state law, such as the California Unruh Civil Rights Act,[] provides for monetary damages to private plaintiffs, persons with disabilities do not obtain direct financial benefits from suing businesses that violate the ADA. Thus, "professional plaintiffs" are typically found in states that have enacted state laws that allow private individuals to win monetary awards from non-compliant businesses.[] At least one of these plaintiffs in California has been barred by courts from filing lawsuits unless he receives prior court permission.[] The attorneys' fees provision of Title III does provide incentive for lawyers to specialize and engage in serial ADA litigation, but a disabled plaintiff does not obtain financial reward from attorneys' fees unless they act as their own attorney, or as mentioned above, a disabled plaintiff resides in a state that provides for minimum compensation and court fees in lawsuits. Moreover, there may be a benefit to these "private attorneys general" who identify and compel the correction of illegal conditions: they may increase the number of public accommodations accessible to persons with disabilities. "Civil rights law depends heavily on private enforcement. Moreover, the inclusion of penalties and damages is the driving force that facilitates voluntary compliance with the ADA."[44] Courts have noted: "As a result, most ADA suits are brought by a small number of private plaintiffs who view themselves as champions of the disabled. For the ADA to yield its promise of equal access for the disabled, it may indeed be necessary and desirable for committed individuals to bring serial litigation advancing the time when public accommodations will be compliant with the ADA."[45]

Case law
There have been some notable cases regarding the ADA. For example, two major hotel room marketers (Expedia.com and Hotels.com) with their business presence on the Internet were sued because its customers with disabilities could not reserve hotel rooms, through their websites without substantial extra efforts that persons without disabilities were not required to perform.[46] These represent a major potential expansion of the ADA in that this, and other similar suits (known as "bricks vs. clicks"), seeks to expand the ADA's authority to cyberspace, where entities may not have actual physical facilities that are required to comply. National Federation of the Blind v. Target Corporation This is a case where a major retailer, Target Corp., was sued because their web designers failed to design its website to enable persons with low or no vision to use it.[47] Board of Trustees of the University of Alabama v. Garrett Board of Trustees of the University of Alabama v. Garrett, 531 U.S. 356 (2001), was a United States Supreme Court case about Congress's enforcement powers under the Fourteenth Amendment to the Constitution. It decided that Title I of the Americans with Disabilities Act was unconstitutional insofar as it allowed private citizens to sue states for money damages. Barden v. The City of Sacramento

Americans with Disabilities Act of 1990 Another example, filed in March 1999, claimed that the City of Sacramento failed to comply with the ADA when, while making public street improvements, it did not bring its sidewalks into compliance with the ADA. Certain issues were resolved in Federal Court. One issue, whether sidewalks were covered by the ADA, was appealed to the 9th Circuit Court of Appeals, which ruled that sidewalks were a "program" under ADA and must be made accessible to persons with disabilities. The ruling was later appealed to the U.S. Supreme Court, which refused to hear the case, letting stand the ruling of the 9th Circuit Court.[48] Bates v. UPS This was the first equal opportunity employment class action brought on behalf of Deaf and Hard of Hearing (D/HH) workers throughout the country concerning workplace discrimination. It established legal precedence for D/HH Employees and Customers to be fully covered under the ADA. Key finding included (1) UPS failed to address communication barriers and to ensure equal conditions and opportunities for deaf employees; (2) Deaf employees were routinely excluded from workplace information, denied opportunities for promotion, and exposed to unsafe conditions due to lack of accommodations by UPS; (3) UPS also lacked a system to alert these employees as to emergencies, such as fires or chemical spills, to ensure that they would safely evacuate their facility; and (4) UPS had no policy to ensure that deaf applicants and employees actually received effective communication in the workplace. The outcome was that UPS agreed to pay a $5.8 million dollar award and agreed to a comprehensive accommodations program that was implemented in their facilities throughout the country. Spector v. Norwegian Cruise Line Ltd. This was a case that was decided by the United States Supreme Court in 2005. The defendant argued that as a vessel flying the flag of a foreign nation was exempt from the requirements of the ADA. This argument was accepted by a federal court in Florida and, subsequently, the Fifth Circuit Court of Appeals. However, the U.S. Supreme Court reversed the ruling of the lower courts on the basis that Norwegian Cruise Lines was a business headquartered in the United States whose clients were predominantly Americans and, more importantly, operated out of port facilities throughout the United States. Olmstead, Commissioner, Georgia Department of Human Resources, et al. v. L. C., by zimring, guardian ad litem and next friend, et al. (not to be confused with Olmstead v. United States, 277 U.S. 438 (1928), a case regarding wiretapping) This was a case before the United States Supreme Court in 1999. The two plaintiffs L.C. and E.W. were institutionalized in Georgia for diagnosed mental retardation and schizophrenia. Clinical assessments by the state determined that the plaintiffs could be appropriately treated in a community setting rather than the state institution. The plaintiffs sued the state of Georgia and the institution for being inappropriately treated and housed in the institutional setting rather than being treated in one of the state's community based treatment facilities. The Supreme Court decided under Title II of the ADA that mental illness is a form of disability and therefore covered under the ADA, and that unjustified institutional isolation of a person with a disability is a form of discrimination because it "...perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life." The court added, "Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment." Therefore, under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programs or activities of any public entity.[49] Michigan Paralyzed Veterans of America v. The University of Michigan This was a case filed before The United States District Court for the Eastern District of Michigan Southern Division on behalf of the Michigan Paralyzed Veterans of America against University of Michigan Michigan Stadium claiming that Michigan Stadium violated the Americans with Disabilities Act in its $226-million renovation by failing to add enough seats for disabled fans or accommodate the needs for disabled restrooms, concessions and

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Americans with Disabilities Act of 1990 parking. Additionally, the distribution of the accessible seating was at issue, with nearly all the seats being provided in the end-zone areas. The U.S. Department of Justice assisted in the suit filed by attorney Richard Bernstein of The Law Offices of Sam Bernstein in Farmington Hills, Michigan, which was settled in March 2008.[50] The settlement required the stadium to add 329 wheelchair seats throughout the stadium by 2010, and an additional 135 accessible seats in clubhouses to go along with the existing 88 wheelchair seats. This case was significant because it set a precedent for the uniform distribution of accessible seating and gave the DOJ the opportunity to clarify previously unclear rules.[51] The agreement now is a blueprint for all stadiums and other public facilities regarding accessibility.[52] Paralyzed Veterans of America (or "PVA") v. Ellerbe Becket Architects and Engineers One of the first major ADA lawsuits, Paralyzed Veterans of America (or "PVA") v. Ellerbe Becket Architects and Engineers, Inc., was focused on the wheelchair accessibility of a stadium project that was still in the design Phase, MCI Center in Washington, D.C. Previous to this case, which was filed only five years after the ADA was passed, the DOJ was unable or unwilling to provide clarification on the distribution requirements for accessible wheelchair locations in large assembly spaces. While Section 4.33.3 of ADAAG makes reference to lines of sight, no specific reference is made to seeing over standing patrons. The MCI Center, designed by Ellerbe Becket Architects & Engineers, was designed with too few wheelchair and companion seats, and the ones that were included did not provide sight lines that would enable the wheelchair user to view the playing area while the spectators in front of them were standing. This case and another related case established precedent on seat distribution and sight lines issues for ADA enforcement that continues to present day. Toyota Motor Manufacturing, Kentucky, Inc. v. Williams Toyota Motor Manufacturing, Kentucky, Inc. v. Williams, 534 U.S. 184 (2002) was a case in which the Supreme Court interpreted the meaning of the phrase "substantially impairs" as used in the Americans with Disabilities Act. It reversed a Sixth Court of Appeals decision to grant a partial summary judgment in favor of the respondent, Ella Williams that qualified her inability to perform manual job-related tasks as a disability. The Court held that the "major life activity" definition in evaluating the performance of manual tasks focuses the inquiry on whether Williams was unable to perform a range of tasks central to most people in carrying out the activities of daily living. The issue is not whether Williams was unable to perform her specific job tasks. Therefore, the determination of whether an impairment rises to the level of a disability is not limited to activities in the workplace solely, but rather to manual tasks in life in general. When the Supreme Court applied this standard, it found that the Court of Appeals had incorrectly determined the presence of a disability because it relied solely on her inability to perform specific manual work tasks, which was insufficient in proving the presence of a disability. The Court of Appeals should have taken into account the evidence presented that Williams retained the ability to do personal tasks and household chores, such activities being the nature of tasks most people do in their daily lives, and placed too much emphasis on her job disability. Since the evidence showed that Williams was performing normal daily tasks, it ruled that the Court of Appeals erred when it found that Williams was disabled.[][] This ruling is now, however, no longer good lawit was invalidated by the ADAAA. In fact, Congress explicitly cited Toyota v. Williams in the text of the ADAAA itself as one of its driving influences for passing the ADAAA. Access Now v. Southwest Airlines Access Now v. Southwest Airlines was a case where the District Court decided that the website of Southwest Airlines was not in violation of the Americans with Disability Act because the ADA is concerned with things with a physical existence and thus cannot be applied to cyberspace. Judge Patricia A. Seitz found that the "virtual ticket counter" of the website was a virtual construct, and hence not a "public place of accommodation." As such, "To expand the ADA to cover 'virtual' spaces would be to create new rights without well-defined standards."[] Ouellette v. Viacom International Inc. Ouellette v. Viacom International Inc. followed in Access Now's footsteps by holding that a mere online presence does not subject a website to the ADA guidelines. Thus Myspace and YouTube were not liable for a dyslexic man's

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Americans with Disabilities Act of 1990 inability to navigate the site regardless of how impressive the "online theater" is.

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Resources
Acemoglu, Daron & Angrist, Joshua D. (2001). Consequences of Employment Protection? The Case of the Americans with Disabilities Act. Journal of Political Economy, volume 109 (2001), pages 915957. Bush, George H. W., Remarks of President George Bush at the Signing of the Americans with Disabilities Act. Available on-line at Equal Employment Opportunity Commission [53]. DeLeire, Thomas. (Autumn, 2000). The Wage and Employment Effects of the Americans with Disabilities Act. Journal of Human Resources, Vol. 35, No. 4, pp.693715 Fielder, J. F. Mental Disabilities and the Americans with Disabilities Act. Westport, CT: Quorum Books, 2004. Hamilton Krieger, Linda, ed., Backlash Against the ADA: Reinterpreting Disability Rights Ann Arbor: University of Michigan Press, 2003. Johnson, Mary. (2000). Make Them Go Away: Clint Eastwood, Christopher Reeve & The Case Against Disability Rights. Louisville, KY: The Advocado Press. Schall, Carol M. (Jun 1998). The Americans with Disabilities ActAre We Keeping Our Promise? An Analysis of the Effect of the ADA on the Employment of Persons with Disabilities. Journal of Vocational Rehabilitation, v10 n3 pp.191203. Schwochau, Susan & Blanck, Peter David. The Economics of the Americans with Disabilities Act, Part III: Does the ADA Disable the Disabled? Berkeley Journal of Employment & Labor Law [Vol. 21:271] Switzer, Jacqueline Vaughn. Disabled Rights: American Disability Policy and the Fight for Equality. Washington, DC: Georgetown University Press, 2003... Weber, Mark C. Disability Harassment. New York, NY: NYU Press, 2007. O'Brien, Ruth, ed. Voices from the Edge: Narratives about the Americans with Disabilities Act. New York: Oxford, 2004. ISBN 0-19-515687-0 Pletcher, David and Ashlee Russeau-Pletcher History of the Civil Rights Movement for the Physically Disabled http://aabss.org/Perspectives2008/AABSS2008Article5DisabilityHistory.pdf

References
[1] [2] [3] [5] http:/ / thomas. loc. gov/ cgi-bin/ bdquery/ D?d101:3:. / temp/ ~bsslrwQ:: Americans with Disabilities Act of 1990 (http:/ / finduslaw. com/ americans_with_disabilities_act_of_1990_ada_42_u_s_code_chapter_126) , codified at Civil Rights Act of 1964 (http:/ / finduslaw. com/ civil_rights_act_of_1964_cra_title_vii_equal_employment_opportunities_42_us_code_chapter_21) [6] http:/ / www. law. cornell. edu/ uscode/ 42/ 12111. html [7] http:/ / www. law. cornell. edu/ uscode/ 42/ 12117. html [10] http:/ / www. law. cornell. edu/ uscode/ 42/ 12131. html [11] http:/ / www. law. cornell. edu/ uscode/ 42/ 12165. html [12] http:/ / www. law. cornell. edu/ uscode/ 42/ 12181. html [13] http:/ / www. law. cornell. edu/ uscode/ 42/ 12189. html [14] http:/ / www. law. cornell. edu/ uscode/ 42/ 12182. html#b_2_A_iv [16] U.S. Department of Justice (February 16, 2011), 2010 Revised ADA Requirements: Effective Date and Compliance Date (http:/ / www. ada. gov/ revised_effective_dates-2010. htm) [17] Kim R. Blackseth (July 20, 2011, UrbDeZine), How The New ADA Effects All of Us (http:/ / urbdezine. com/ 2011/ 07/ 20/ how-the-new-ada-effects-all-of-us) [20] http:/ / www. ada. gov/ 2010ADAstandards_index. htm [22] http:/ / www. law. cornell. edu/ uscode/ 47/ 225. html [23] http:/ / www. law. cornell. edu/ uscode/ 42/ 12201. html [24] http:/ / www. law. cornell. edu/ uscode/ 42/ 12213. html [27] http:/ / www. youtube. com/ watch?v=-cBGj-Mp8ww [28] Lawton, K.A. Christianity Today, 10/8/90, Vol. 34 Issue 14, p. 71 [29] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 297

Americans with Disabilities Act of 1990


[30] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 297. [31] "Should the Senate Approve the Americans with Disabilities Act of 1989?" Congressional Digest December (1989): 208. [32] Mandel, Susan. "Disabling the GOP," The National Review 6/11/1990, Vol. 42 Issue 11, pp. 23-24 [33] Doherty, Brian. Reason, AugSep 95, Vol. 27 Issue 4, p. 18 [34] The U.S. Equal Employment Opportunity Commission (http:/ / www. eeoc. gov/ ada/ bushspeech. html) [36] ( Targeted Development for Managers with Disabilities (http:/ / www. shrm. org/ hrdisciplines/ Diversity/ Articles/ Pages/ ManagerswithDisabilities. aspx) [37] (see Schwochau & Blanck for counter arguments) [38] (see Schall, 1998) [40] Gina M. Cook, "Article: When The Duty To Provide A Reasonable Accommodation Seems Unreasonable: Accommodating And Managing Employees With Episodic Impairments Or Impairments In Remission Under The ADA Amendments Act Of 2008", 32 N.C. Cent. L. Rev. 1 (2009). [41] Scott Dikkers and Robert Siegel, The Onion's Finest News Reporting, Vol. 1 (New York: Three Rivers Press, 2000), 155. [42] Anonymous, "Congress Passes Americans With No Abilities Act" (http:/ / www. theonion. com/ articles/ congress-passes-americans-with-no-abilities-act,541/ ), The Onion, June 24, 1998. [44] Parr v. L & L Drive-Inn Restaurant (D. Hawaii 2000) 96F.Supp.2d 1065, 1082, citing and quoting, Committee Print, Vol. II, 101st Cong., 2d Sess., at 1481-82 (1990); (b)(2); S.Rep. No. 101-116, at 15 (1989). [45] Molski v. Evergreen Dynasty Corp., (9th Cir. 2007) 500F.3d 1047, 1062; D'Lil v. Best Western Encina Lodge & Suites (9th Cir. 2008) 538F.3d 1031, 1040. [46] Smith v. Hotels.com (http:/ / www. dralegal. org/ cases/ private_business/ Smith_v_Hotels_com. php) at Disability Rights Advocates [47] National Federation for the Blind v. Target (http:/ / www. dralegal. org/ cases/ private_business/ nfb_v_target. php) at Disability Rights Advocates [48] Barden v. Sacramento (http:/ / www. dralegal. org/ cases/ public_entities/ barden_v_sacramento. php) from Disability Rights Advocates [49] OLMSTEAD V. L. C. (http:/ / supct. law. cornell. edu/ supct/ html/ 98-536. ZS. html) from Cornell University Law School - Syllabus for the Supreme Court Decision in 1999 [50] Erb, Robin. "U-M fans rave about new seats for disabled," Detroit Free Press. 9 September 2008. [51] Wolffe, Jerry. "New wheelchair seats will be full at U-M's Big House." The Oakland Press. 14 September 2008. [52] Wolffe, Jerry. "New wheelchair seats will be full at U-M's Big House," The Oakland Press. 14 September 2008. / [53] http:/ / www. eeoc. gov/ ada/ bushspeech. html

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External links
File a housing discrimination complaint (http://www.hud.gov/offices/fheo/online-complaint.cfm) Compliance tool kits from the ADA (http://www.ada.gov/pcatoolkit/toolkitmain.htm) Navigable text of the Americans with Disabilities Act of 1990 - 42 U.S. Code Chapter 126 (http://finduslaw. com/americans_with_disabilities_act_of_1990_ada_42_u_s_code_chapter_126) Office of Fair Housing and Equal Opportunity (http://portal.hud.gov/hudportal/HUD?src=/program_offices/ fair_housing_equal_opp) Searchable collection of over 7,000 Federal ADA documents (http://www.ADAPortal.org) Federally funded technical assistance network (http://www.adata.org) Overview of ADA, IDEA, and Section 504: Update 2001 (http://www.ericdigests.org/2002-1/ada.html) Overview of ADA, IDEA, and Section 504 (http://www.ericdigests.org/1996-3/ada.htm) Employment of People with Disabilities (http://www.ericdigests.org/2004-1/people.htm) Accessible Web Design (http://www.ericdigests.org/2000-3/web.htm) ADA Wheelchair Ramp Guidelines (http://www.adawheelchairramps.com/Modular_Ramps/ ADA_Modular_Ramp_Specs.aspx) Testing Students with Disabilities (http://www.ericdigests.org/1996-4/testing.htm) Congressional Research Service (CRS) Reports regarding the Americans with Disabilities Act (http://digital. library.unt.edu/govdocs/crs/search.tkl?q=ada&search_crit=title&search=Search&date1=Anytime& date2=Anytime&type=form) Paratransit Watch - Accessible Public Transportation News, Issues, and Resources. (http://paratransitwatch. blogspot.com/) U.S. Department of Justice (http://www.usdoj.gov/crt/ada/adahom1.htm). ADA Info

Americans with Disabilities Act of 1990 Americans with Disabilities Act Amendment (ADAAA) Information Center (http://blr.com/information-ada/). ADAAA Information for Employers ADA Amendment Information Resources (http://www.smarthrmanager.com/human-resources/ ada-amendments) SHRM's Disability Employment Resource Page (http://www.shrm.org/disabilityemployment) Americans with Disabilities Act (ADA) - law and higher education (http://lawhighereducation.org/ 14-americans-with-disabilities-act-ada.html)

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Attention deficit hyperactivity disorder

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Attention deficit hyperactivity disorder


Attention-deficit/hyperactivity disorder
Classification and external resources

Children with ADHD find it more difficult to focus and to complete their schoolwork. ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH F90 [1] [2] , 314.01 [3]

314.00 143465 6158

[4]

[5] [6] [7] ped/177 [8]

001551

med/3103 D001289

[9]

Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a psychiatric disorder[] of the neurodevelopmental disorder class[10][] in which there are significant problems of attention and/or hyperactivity and acting impulsively that are not appropriate for a persons age.[11] These symptoms must begin before seven to twelve years of age and has been present for more than six months for a diagnosis to be made.[][] There are three subtypes: predominantly inattentive (ADHD-PI or ADHD-I), predominantly hyperactive-impulsive (ADHD-HI or ADHD-H), or the two combined (ADHD-C), which shows all three difficulties. Often people refer to ADHD-PI as "attention deficit disorder" (ADD), however, the latter has not been officially accepted since the 1994 revision of the DSM. In school-aged children the lack of focus may result in poor school performance. It is the most commonly studied and diagnosed psychiatric disorder in children and adolescents, affecting about 6 to 7 percent of children when diagnosed via the DSM-IV criteria[] and 1 to 2 percent when diagnosed via the ICD-10 criteria.[] Rates are similar between countries and depend mostly on how it is diagnosed.[] ADHD is diagnosed approximately three times more frequently in boys than in girls.[][] About 30 to 50 percent of people diagnosed in childhood continue to have symptoms into adulthood[] with between 2 and 5 percent of adults have the condition.[] The symptoms can be difficult to tell apart from other disorders as well as that of high normal activity.[] ADHD management usually involves some combination of counselling, lifestyle changes, and medications. Medications are only recommended as a first-line treatment in children who have severe symptoms and may also be considered for those with moderate symptoms who either refuse or fail to improve with counselling.[]:p.317 Adolescents and adults tend to develop coping mechanisms which make up for some or all of their impairments.[] ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[] The controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include ADHD's causes, and the use of

Attention deficit hyperactivity disorder stimulant medications in its treatment.[][] Most healthcare providers accept ADHD as a genuine disorder; debate in the scientific community centers mainly around how it is diagnosed and treated.[][][] The National Institute for Clinical Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature.[]:p.133

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Signs and symptoms


Inattention, hyperactivity (restlessness in adults), disruptive behavior, and impulsivity are common in ADHD.[][12] Academic difficulties are also frequent and social skills difficulties are much more common in the ADHD population.[] The symptoms can be difficult to define because it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring intervention begin.[]:p.26 To be diagnosed as ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.[] The presenting symptom give three types of ADHDpredominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:[]:p.4 An individual with symtoms of inattention may have some or all of the following symptoms:[] Be easily distracted, miss details, forget things, and frequently switch from one activity to another Have difficulty maintaining focus on one task Become bored with a task after only a few minutes, unless doing something enjoyable Have difficulty focusing attention on organizing and completing a task or learning something new Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and accurately as others Struggle to follow instructions. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Difficulty starting tasks Difficulty completing tasks within time limits

An individual with symtoms of hyperactivity may have some or all of the following symptoms:[] Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, doing homework, and story time Be constantly in motion Have difficulty doing quiet tasks or activities Talking to yourself Is often "on the go" acting as if "driven by a motor".

An individual with symtoms of impulsivity may have some or all of the following symptoms:[] Be very impatient Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences Blurts out comments better left unsaid Have difficulty waiting for things they want or waiting their turns in games

Often interrupt conversations or others' activities. Says whatever is on one's mind with little or no forethought

Attention deficit hyperactivity disorder Some children, adolescents, and adults with ADHD have an increased risk of experiencing difficulties with social skills, such as social interaction and forming and maintaining friendships due to impairments in processing verbal and nonverbal language. About half of children and adolescents with ADHD experience rejection by their peers compared to 1015 percent of non-ADHD children and adolescents. Training in social skills, behavioural modification and medication may have some limited beneficial effects. The most important factor in reducing emergence of later psychopathology, such as major depression, criminality, school failure, and substance use disorders is formation of friendships with people who are not involved in delinquent activities.[] Handwriting difficulties seem to be common in children with ADHD.[] Delays in speech and language as well as motor development occur more commonly in the ADHD population.[][] Although ADHD causes many impairments particularly in modern day society many children with ADHD are resourceful showing persistent behavior and commitment if they find something interesting.[]

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Associated disorders
Inattention and hyperactive behavior and other ADHD symptomatology are not necessarily the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it.[] Some of the associated conditions are: Oppositional defiant disorder and conduct disorder, occur with ADHD in about half and 20% of cases respectively.[] They are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, or stealing,[] inevitably linking these comorbid disorders with antisocial personality disorder (ASPD); about half of those with hyperactivity and ODD or CD develop ASPD in adulthood.[13] Brain imaging indicates that conduct disorder and ADHD are distinct disorders.[] Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.[] Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype have been shown to be more likely to suffer from a mood disorder.[] Adults with ADHD sometimes have co-morbid bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions.[] Anxiety disorders have been found to occur more commonly in the ADHD population.[] Obsessive-compulsive disorder. OCD can co-occur with ADHD and shares many of its characteristics.[] Substance use disorders. Adolescents and adults with ADHD are at a significantly increased risk of developing a substance abuse problem which can interfere with the evaluation and treatment of ADHD. The reason for this increased risk may be due to an altered reward pathway in the brains of ADHD individuals.[] The most commonly misused substances by the ADHD population are alcohol and cannabis; serious substance misuse problems are usually treated first due to substance use disorders having more serious risks of harm than ADHD,[]:p.38[] with long-term alcohol misuse and long-term cannabis misuse and other drug misuse. Restless legs syndrome has been found to be more common in ADHD affected individuals and is often due to iron deficiency anaemia.[][] However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders.[] Sleep disorders commonly co-exist with ADHD or can be caused by side effects of medications used to treat ADHD; insomnia is the most common sleep disorder found in ADHD children. Behavioural therapy is preferred as a first line treatment of insomnia rather than medication in these children.[][] Melatonin is sometimes used in children who have sleep onset insomnia.[] obstructive sleep apnea syndrome, can be a cause of ADHD type neurocognitive and behavioural impairments in affected children.[] There is a strong association between persistent bed wetting and ADHD[] as well as developmental coordination disorder with up to 50 percent of dyspraxics having ADHD.[] There is an association between ADHD and language

Attention deficit hyperactivity disorder delay.[] Problems with sleep initiation are common among ADHD individuals but often they will be deep sleepers and have significant difficulty getting up in the morning.[]

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Cause
The causes of ADHD remain an area of controversy - risks factors before and around the time of birth such as exposure to lead and other environmental toxins, genetic contributions and social factors have been considered as possible causes. There is evidence that a combination of factors rather than a single cause explains ADHD.[]

Genetics
Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases.[] Environmental factors also contribute to ADHD symptoms. Genetic factors are also believed to be involved in determining whether ADHD persists into adulthood or ends in childhood or adolescence.[] A large majority of cases arise from a combination of various genes, many of which affect dopamine transporters.[] Candidate genes include DAT1, DRD4, DRD5, 5HTT, HTR1B, and SNAP25. There is also strong heterogeneity for the associations between ADHD and DAT1, DRD4, DRD5, dopamine beta hydroxylase, ADRA2A, 5HTT, TPH2, MAOA, and SNAP25.[] A common variant of a gene called LPHN3 is estimated to be responsible for about 9% of the incidence of ADHD, and ADHD cases where this gene is present are particularly responsive to stimulant medication.[]

Executive function
One of the primary neuropsychological theories of ADHD suggests that its symptoms arise from a primary deficit in executive functions.[] Executive functions refers to an array of cognitive processes that are required to regulate, control, and manage daily life tasks.[] The criteria for an executive function deficit are met in 3050% of children and adolescents with ADHD.[14] One study found that 80% of individuals with ADHD were impaired in at least one EF task, compared to 50% for individuals without ADHD.[] Due to the rates of brain maturation and the increasing demands for executive control as a person gets older ADHD impairments may not fully manifest themselves until adolescence or even early adulthood.[] Some of these executive impairments include, problems with organizational skills, time keeping, excessive procrastination, concentration problems, processing speed, regulating emotions. Other problems include utilizing working memory and short-term memory problems. - however, some ADHD people display a remarkable long-term memory. ADHD individuals also display impulsivity in decision making and often jump to inaccurate conclusions. Some people with ADHD display impairments with recognizing when they have hurt other people's feelings and fail to adjust their behavior accordingly. People without ADHD experience some of these impairments as well but it is the duration and frequency of these impairments which differentiates between people with ADHD versus people without ADHD. Individuals with ADHD can focus intently on a task which has strong personal meaning to the ADHD affected individual or if the task has been left to the last minute. Outside observers sometimes misinterpret this as evidence that the person is not impaired by ADHD and fail to understand that the reason for this is because the brain in the ADHD individual is stimulating itself under certain circumstance enough to overcome these executive impairments.[]

Attention deficit hyperactivity disorder

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Evolution
Researchers have proposed that the high prevalence of ADHD - more than 1 percent of the population - may be due to natural selection having favoured ADHD, possibly because the individual traits may be beneficial on their own, and only become dysfunctional when these traits combine to form ADHD.[] The high prevalence of ADHD may in part be because women in general are more attracted to males who are risk takers, thereby promoting ADHD in the gene pool.[] More recent research suggests that because it is more common in the children of anxious or stressed mothers, ADHD primes a child to face a stressful or dangerous environment withfor exampleincreased impulsivity and explorative behaviour.[] Further evidence that hyperactivity might be evolutionarily beneficial was put forth in a 2006 study finding that it may carry specific benefits for certain forms of society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk, competition, and/or unpredictable behavior (i.e. exploring new areas, finding new food sources, etc.), where these societies may have benefited from confining impulsive or unpredictable behavior to a small subgroup. In these situations, ADHD would have been beneficial to society as a whole even while severely detrimental to the individual.[] However, some research suggests that ADHD itself in certain environments is a distinct advantage to the individual such as a more quick response to predators, superior hunting skills, better movement and settling skills among other benefits.[15] A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele) has been found to be at higher frequency in more nomadic populations and those with more of a history of migration.[] Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.[16]

Environmental
ADHD is predominantly a genetic disorder with environmental factors contributing a small role to the etiology of ADHD. Twin studies have shown that ADHD is largely genetic with 76 percent of the phenotypic variance being explained by inherited genetic factors.[][] Alcohol intake during pregnancy can cause the child to have a fetal alcohol spectrum disorder which can include symptoms similar to ADHD.[] Exposure to tobacco smoke during pregnancy impairs normal development of the foetus including the central nervous system and can increase the risk of the child being diagnosed with ADHD.[] Many children exposed to tobacco do not develop ADHD or else only have mild symptoms which do not reach the threshold of a diagnosis of ADHD. A combination of a genetic vulnerability to developing ADHD as well as the toxic developmental effects of tobacco on the foetus explain why some children exposed to tobacco smoke in utero develop ADHD and others do not.[17] Children exposed to lead, even relatively low levels of lead develop neurocognitive deficits which resemble ADHD and these children can fulfill the diagnostic criteria for ADHD. There is also some evidence that exposure to polychlorinated biphenyls during childhood causes developmental damage and can cause ADHD type symptoms which are then diagnosed as ADHD.[] Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not definitive as 5 of 17 studies failed to find an association.[] Very low birth weight, premature birth and exceptional early adversity increase the risk of the child having ADHD.[] At least 30 percent of children who experience a pediatric traumatic brain injury develop ADHD.[] Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.[18]

Attention deficit hyperactivity disorder Diet According to one researcher, Weiss, concerns were first raised by Benjamin Feingold, a pediatric allergist, that food colourings and additives may affect children's behaviour in 1973. There is evidence suggesting that some food colourings may make some children hyperactive. However, the evidence for a link between food colourings and hyperactive behaviour remains uncertain. The FDA interpreted the evidence as being inconclusive as to whether food colours caused hyperactivity or not. The FDA review of food colours has been criticised for only doing a very narrow investigation into food colourings and their possible association with causing hyperactivity instead of investigating their possible effect on neurobehaviour in general.[] It is possible that certain food colourings act as a trigger for ADHD symptoms in subgroup of children who have a genetic vulnerability. The U.K, followed by the European Union as a whole, took regulatory action on food colourings due to concerns about their possible adverse effects in children.[] According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers were encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124) are collectively called the "Southampton six". Following the FSA's actions, the European Food Safety Authority ruled that any food products containing the contentious colourings must display warning labels on their packaging by 2010.[19]

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Social
The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology.[20] Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD.[21] Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse.[] Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and, thus, determine the number of people affected.[22] This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four times higher than those obtained with use of the ICD 10.[] Thomas Szasz, a proponent of this theory, has argued that ADHD was "invented and not discovered."[23][24]

Pathophysiology
The pathophysiology of ADHD is unclear and there are a number of competing theories.[] Research on children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, but other brain regions in particular the cerebellum have also been implicated.[25] Neuroimaging studies in ADHD have not always given consistent results and as of 2008 are used only for research and not Diagram of the human brain diagnostic purposes.[26] Research using neuroimaging, neuropsychological genetics, and neurochemistry has found converging lines of evidence to suggest that a main brain system connecting the prefrontal cortex and the striatum is involved in the pathophysiology of ADHD. Nevertheless other brain systems related to attentional, but also other more basic cognitive processes, have also been found to differ between ADHD patients and healthy controls.[][]

Attention deficit hyperactivity disorder Previously it was thought that the elevated number of dopamine transporters seen in ADHD patients was part of the pathophysiology of ADHD but it now appears that the reason for elevated striatal dopamine transporter density in ADHD individuals is due to neuroadaptations occurring due to the continuous exposure to stimulants such as methylphenidate or dexamphetamine as the body tries to counter-act the effects of the stimulants by developing a tolerance to the stimulant medications.[] There is evidence that people with ADHD have a low arousal threshold and compensate for this with increased stimuli, which in turn results in disruption of attentional capacity and an increase in hyperactive behaviour. The reason for this is due to abnormalities in how the dopamine system in central nervous system responds to stimuli.[27] However, abnormalities in the dopamine system alone do not explain ADHD abnormalities in the functioning of adrenergic, serotoninergic and cholinergic or nicotinergic pathways can also be present and contribute to the pathophysiology of ADHD.[][]

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Diagnosis
ADHD is diagnosed via an assessment of a person's childhood behavioral and cognitive development; this assessment includes ruling out the effects of drugs, medications and other medical or psychiatric disorders as possible explanations for the signs and symptoms.[]:p.1927 It often takes into account feedback from both parents and teachers.[] Whether or not someone responds to medications does not confirm the diagnosis.[] Children with behavioral symptoms of ADHD which do not cause significant problems compared to their age-matched peers do not have ADHD.[] In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 34 times more likely.[] Standardized rating scales can be used for screening and assessment of severity.[28] Factors other than those within the DSM or ICD have been found to affect the diagnosis in clinical practice. For example, a study found that the youngest children in a class are much more likely to be diagnosed as having ADHD compared to their older counterparts in the same year. This because younger children typically have greater hyperactivity, not because they necessarily have ADHD. It is estimated that about 20 percent of children given a diagnosis of ADHD are misdiagnosed because of the month they were born.[] The previously-used term ADD is not used in the most recent versions of the DSM, with ADHD being the current name used to describe the disorder.[]

Classification
ADHD may be seen as one or more continuous traits found normally throughout the general population.[] However, the definition of ADHD is based on behaviour and it does not imply a neurological disease.[] ADHD is a psychiatric disorder[] of the neurodevelopmental disorder class.[] It is additionally classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial personality disorder.[] The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies ADHD according to the predominance of symptoms of: 1. Inattention; 2. Hyperactivityimpulsivity; 3. or a combination of both (Combined type).[] This subdivision is based on presence of at least six out of nine long-term maladaptive symptoms (lasting at least 6 months) of either inattention, hyperactivityimpulsivity, or both. Thus, a child who is diagnosed with the inattention subtype may also show signs of hyperactivityimpulsivity, and vice-versa. To be considered, the symptoms must have appeared before the age of 6, manifest in more than one environment (e.g. at home and at school or work), and not be better explained by another mental disorder.[] Most children with ADHD have the combined type. Children with the inattention subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but without paying attention to what they

Attention deficit hyperactivity disorder are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.[]

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Diagnostic and Statistical Manual


As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Based on the DSM-V criteria listed below, three types of ADHD are classified:[] 1. ADHD, Combined Type is a combination of the two other ADHD subtypes.[] 2. ADHD Predominantly Inattentive Type presents with symptoms including being easily distracted, forgetful, daydreaming, disorganisation, poor concentration, and difficulty completing tasks.[] 3. ADHD, Predominantly Hyperactive-Impulsive Type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behaviour; destructive behaviors may also be present.[] For a diagnosis of ADHD to be made the signs must present before the age of 12 years old and be developmentally inappropriate for a child of that age. Additionally the signs cannot be due to the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and the signs are not better accounted for by another mental disorder (such as mood disorder, anxiety disorder, dissociative identity disorder, or a personality disorder).[] Finally having ADHD symptoms/traits on their own is insufficient for a diagnosis to be made - there must be clear evidence that the ADHD symptoms cause social, academic and occupational impairments.[]

International Classification of Diseases


In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "hyperkinetic disorders". When a conduct disorder (as defined by ICD-10[]) is present, the condition is referred to as "hperkinetic conduct disorder". Otherwise the disorder is classified as "disturbance of activity and attention", "other hyperkinetic disorders" or "hyperkinetic disorders, unspecified". The latter is sometimes referred to as, "hyperkinetic syndrome".[]

Other guidelines
The American Academy of Pediatrics' clinical practice guideline for children and adolescents with ADHD recommends the following:[] ADHD should be considered as a possible diagnosis in children and adolescents 418 years old who present with academic or behavioural problems of hyperactivity, impulsiveness and inattention. To aid in the diagnosis the DSM IV should be used in combination with gathering evidence from family members, guardians, teachers and mental health workers who know the child or adolescent. Before making a diagnosis causes for the symptoms other than ADHD should be considered. Co-morbid disorders such as anxiety, depression, oppositional defiant disorder, and conduct disorder, as well as learning and language disorders which often co-exist with ADHD should be looked for. Additionally, other neurodevelopmental disorders, as well as tics, sleep apnea should be screened for. Finally, the guidance recommends when substance use disorders are present that these are treated first before the ADHD and given priority. ADHD should be viewed as a chronic disorder that has special healthcare needs and treatments which can include behavioural, pharmacological or a combination of both, and should take into consideration the age of the patient. Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven. Questioning parents or guardians as to how the person behaved and developed as a child also forms part of the clinical assessment of the individual; a

Attention deficit hyperactivity disorder family history of ADHD also adds weight to a diagnosis of adult ADHD due the strong heritability of ADHD.[] While the core symptoms of ADHD are similar in children and adults they often present differently in adults than in children, for example excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults.[] The American Academy of Child and Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:[] The behaviors must appear before age 7. They must continue for at least six months. The symptoms must also create a real handicap in at least two of the following areas of the child's life: in the classroom, on the playground, at home, in the community, or in social settings.

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If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.[]

Differential
[] ADHD symptoms which are related to other disorders Depression feelings of guilt, hopelessness, low self-esteem, pessimism, unhappiness, or worthlessness Anhedonia or loss of interest in hobbies, regular activities, sex, or work fatigue Sleep problems including insomnia, dyssomnia, or hypersomnia difficulty maintaining attentional control change in appetite Irritability or hostility low tolerance for stress thoughts of death or suicidal ideation unexplained pain or symptoms unresponsive to treatment, such as headache or dyspepsia Anxiety disorder worry or any persistent feeling of anxiety experienced daily for 36 months Irritability occasional feelings of panic, fear, or angst inability to relax being hyperalert inability to pay attention tire easily low tolerance for stress difficulty maintaining attentional control Mania excessive happiness, euphoria, or exhuberance Hyperactivity Racing thoughts Aggression excessive talking Grandiose delusions decreased need for sleep inappropriate social behavior difficulty maintaining attentional control

Symptoms of ADHD such as low mood and poor self-image, mood swings, and irritability can be confused with dysthymia, cyclothymia or bipolar disorder as well as with borderline personality disorder.[] Some of the symptoms that are due to anxiety disorders, antisocial personality disorder, developmental disabilities or mental retardation or the effects of substance abuse such as intoxication and withdrawal symptoms can overlap with some ADHD symptoms. These various disorders which can mimic some ADHD symptoms, sometimes occur along with ADHD. Medical conditions which can cause ADHD type symptoms and require consideration for a differential diagnosis include hyperthyroidism, seizure disorder, lead toxicity, hearing deficits, hepatic disease, sleep apnea, drug interactions, and head injury.[] Primary sleep disorders play a role in symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.[]

Attention deficit hyperactivity disorder Many sleep disorders are important causes of symptoms that may overlap with the core symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.[][29] Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness.[][30] Obstructive sleep apnea syndrome, can be a cause of ADHD type neurocognitive and behavioural impairments in affected children.[]

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Management
The management of ADHD typically involves psychotherapy or medications either alone or in combination. While treatment may improve long term outcomes it does not get rid of negative outcomes entirely.[31] Medications used include stimulants, atomoxetine, alpha-adrenergic agonists and sometimes antidepressants.[] Medications have at least some effect in about 80% of people.[32] Dietary modifications may also be of benefit[33] with evidence supporting a benefit from free fatty acids and reduced exposure to food coloring.[] Removing other foods from the diet is not currently supported by the evidence.[]

Psychosocial
The evidence is strong for the effectiveness of behavioral treatments in ADHD.[34] It is recommended first line in those who have mild symptoms and in preschool-aged children.[] Psychological therapies used include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training, parent management training,[] and neurofeedback.[35] Parent training and education have been found to have short-term benefits.[36] There is a deficiency of good research on the effectiveness of family therapy for ADHD, but the evidence that exists shows that it is comparable in effectiveness to treatment as usual in the community and is superior to medication placebo.[37] Several ADHD specific support groups exist as informational sources and to help families cope with ADHD.

Medication
Stimulant medications are the pharmaceutical treatment of choice.[] There are a number of non-stimulant medications, such as atomoxetine, that may be used as alternatives.[] There are no good studies of comparative effectiveness between various medications, and there is a lack of evidence on their effects on academic performance and social behaviors.[] While stimulants and atomoxetine are generally safe, there are side-effects and contraindications to their use.[] Medications are not methylphenidate (Ritalin) 10 mg tablets recommended for preschool children, as their long-term effects in such young people are unknown.[][38] Research into the long-term effects of stimulants in ADHD have come to conflicting conclusions with one study finding benefit, another finding no benefit while another finding evidence of harm. The current research has methodological problems and more robust research has been recommended.[] Any drug used for ADHD may have adverse drug reactions such as psychosis and mania,[39] though methylphenidate-induced psychosis is uncommon. Regular monitoring of individuals receiving long-term stimulant therapy for possible treatment emergent psychosis has been recommended.[] Stimulant therapy is recommended to be discontinued periodically during protracted therapy to assess for continuing need for medication.[] Tolerance to the therapeutic effects of stimulants can occur,[] with rebound effects occurring when the dose wears off.[] Therefore due to the risk of discontinuation/rebound effects abrupt withdrawal of stimulants is not recommended.[40] Rebound effects are often the result of the stimulant dosage being too high or the individual not being able to tolerate stimulant medication. Signs that the stimulant dose is too high include irritability, feeling stimulated or blunting of

Attention deficit hyperactivity disorder affect and personality.[] People with ADHD have an increased risk of substance abuse, and research studies have found that stimulant medications reduce this risk or have no effect on substance abuse.[] Additionally, stimulant medications approved for treating ADHD have the potential for abuse and dependence.[41] Atomoxetine due to its lack of abuse potential may be preferred in individuals who are at risk of abusing stimulant medication.[] Guidelines on when to use medications vary internationally, with the UK's National Institute of Clinical Excellence, for example, recommending use only in severe cases, while most United States guidelines recommend medications in nearly all cases.[42] Deficiency in zinc has been associated with inattentive symptoms of ADHD and there is evidence that zinc supplementation can benefit ADHD children who have low zinc levels. There is also some evidence that zinc supplementation can lead to a reduction in the dosage of stimulants.[]

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Prognosis
A large study that followed children diagnosed with ADHD (combined type) over a period of 8 years found that they often have significant difficulties in adolescence, regardless of treatment or lack thereof.[] In the United States, 37 percent of those with ADHD do not get a high school diploma even though many of them will receive special education services.[] Also in the US, less than 5 percent of individuals with ADHD get a college degree[43] compared to 28 percent of the general population aged 25 years and older.[] The proportion of children meeting the diagnostic criteria for ADHD drops by about 50 percent over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD.[44][][] ADHD persists into adulthood in about 30 to 50 percent of cases.[] Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.[]

Epidemiology
ADHD is estimated to affect about 6 to 7 percent of people aged 18 and under when diagnosed via the DSM-IV criteria.[] When diagnosed via the ICD-10 criteria rates in this age group are estimated at between 1 to 2 percent.[] Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East however, this is believed to be due to differing methods of diagnosis in different areas of the world.[] If the same diagnostic methods are used rates are more or less the same between countries.[45] ADHD is diagnosed approximately three times more commonly in boys than in girls.[][] This difference between genders may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.[46] Rates of ADHD diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s. This is believed to be primarily due to changes in how the condition is diagnosed[] and how readily people are willing to treat it with medications rather than a true change in the frequency.[] It is believed that the changes to the diagnostic criteria in 2013 with the release of the DSMV will increase the percentage of people with ADHD especially among adults.[47]

History
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798.[48][49] ADHD was first described by George Still in 1902.[] The terminology used to describe the condition has changes over time and include: "minimal brain damage", "minimal brain dysfunction" (or disorder) in the DSM-I in the 1950s and 1960s,[] "learning/behavioral disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood".[] In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced.[] In 1987 this was changed to ADHD in the DSM-III-R and in 1994 the DSM-IV split the ADHD diagnosis into three subtypes, ADHD inattentive type, ADHD hyperactive-impulsive type and ADHD combined type.[50] The use of

Attention deficit hyperactivity disorder stimulants to treat ADHD was first described in 1937.[51] Amphetamines (Benzedrine) was the first medication approved for use in the United States with methyphenidate introduced in the 1950s and dextroamphetamine (Dexadrine) in the 1970s.[]

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Society and culture


A number of notable individuals have given controversial opinions on ADHD. Scientologist Tom Cruise has referred to the ADHD medications Ritalin and Adderall as being "street drugs" - this viewpoint (as well as his other viewpoints on psychiatry) has received criticism - for example the doses of stimulants used in the treatment of ADHD do not cause behavioural addiction and there is some evidence of a reduced risk of later substance addiction in children who had their ADHD treated with stimulants.[] In England Baroness Susan Greenfield, a leading neuroscientist, spoke out publicly in 2007 in the House of Lords about the need for a wide-ranging inquiry into the dramatic increase in the diagnosis of ADHD in the UK and possible causes following a BBC Panorama programme that highlighted US research (The Multimodal Treatment Study of Children with ADHD by the University of Buffalo) suggesting drugs are no better than other forms of therapy for ADHD in the long term.[52] However, in 2010 the BBC Trust criticized the 2007 BBC Panorama programme for summarizing the US research as showing "no demonstrable improvement in children's behaviour after staying on ADHD medication for three years" when in actuality "the study found that medication did offer a significant improvement over time" although the long-term benefits of medication were found to be "no better than children who were treated with behaviour therapy."[53] As of 2009[54], eight percent of all US Major League Baseball players had been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants which has raised concern that some players are mimicking the symptoms of ADHD to get around the ban on the use of stimulants in sport.[55]

Controversies
ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[][][56] The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all[]:p.23[] to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.[][] Some sociologists consider ADHD to be a "classic example of the medicalization of deviant behavior, defining a previously nonmedical problem as a medical one".[] Most healthcare providers accept that ADHD is a genuine disorder with debate in centering mainly around how it is diagnosed and treated.[][][] Possible overdiagnosis of ADHD, the use of stimulant medications in children, and the methods by which ADHD is diagnosed and treated are some of the main areas of controversy.[57] Possible long-term side-effects of stimulants and their usefulness are largely unknown because of a lack of long-term studies.[58] Some research raises questions about the long-term effectiveness and side-effects of medications used to treat ADHD.[59] With a "wide variation in diagnosis across states, races, and ethnicities" some investigators suspect that factors other than neurological conditions play a role when the diagnosis of ADHD is made.[]

Special populations
Adults
Between 2 and 5 percent of adults have ADHD.[] Around two thirds of ADHD children continue to have ADHD as adults, however, not all of these children will continue to have the full disorder. About 15 percent of ADHD children continue to have the full ADHD disorder as adults whereas 50 percent partially 'grow out' of it with the remainder not displaying ADHD symptomatology as adults.[] Most adults, however, remain untreated.[] Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and

Attention deficit hyperactivity disorder alcohol to get by.[] Other problems include relationship and job difficulties, and an increased propensity to become involved in criminal activities.[] They often have such associated psychiatric comorbidities as depression, anxiety disorder, substance abuse, or a learning disability.[] Some ADHD symptoms in adults differ from those seen in children for example whereas children with ADHD may climb and run about excessively, adults may experience an inability to relax and talk excessively in social situations. Adults with ADHD may start relationships impulsively and may display sensation seeking behaviour and be short-tempered. Addictive behaviour such as substance abuse and gambling are also very common. The DSM-IV criteria have been criticised for not being developmentally appropriate for adults as these impairments present differently to children thus leading to claims that adults are outgrowing the diagnostic criteria rather than the ADHD disorder itself and thus are not being properly diagnosed.[]

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High IQ children
The diagnosis of ADHD and the significance of its impact in children with a high intelligence quotient (IQ) has been controversial.[] Most studies have shown a similar profile of functional impairments to that found in ADHD children with a normal IQ.[] When compared with children without ADHD evidence supports an increased likelihood of repeating grades and more social and functional impairments. Additionally, more than half of high IQ ADHD people experience major depressive disorder or oppositional defiant disorder at some point in their lives. Generalised anxiety disorder, separation anxiety disorder and social phobia are also more common. However, there is some evidence that high IQ ADHD individuals have a lowered risk of substance abuse and anti-social behaviour compared to low and average IQ ADHD young people.[] Regarding testing, high IQ children and adolescents with ADHD can have their intelligence level missed when a standard evaluation is performed; high IQ ADHD people tend to require more comprehensive testing to detect their true intelligence level.[]

References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ F90 [2] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=314. 00 [3] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=314. 01 [4] http:/ / omim. org/ entry/ 143465 [5] http:/ / www. diseasesdatabase. com/ ddb6158. htm [6] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 001551. htm [7] http:/ / www. emedicine. com/ med/ topic3103. htm [8] http:/ / www. emedicine. com/ ped/ topic177. htm# [9] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D001289 [54] http:/ / en. wikipedia. org/ w/ index. php?title=Attention_deficit_hyperactivity_disorder& action=edit

External links
Attention deficit hyperactivity disorder (http://www.dmoz.org/Mental_Health/Disorders/ Neurodevelopmental/ADD_and_ADHD//) at the Open Directory Project National Institute of Mental Health on ADHD (http://www.nimh.nih.gov/topics/topic-page-adhd.shtml) "CG72 Attention deficit hyperactivity disorder (ADHD): full guideline" (http://www.nice.org.uk/nicemedia/ pdf/ADHDFullGuideline.pdf) (PDF). NHS. 9 March 2009. Retrieved 2009-01-08. New Zealand MOH Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder (http://www.moh.govt.nz/moh.nsf/c7ad5e032528c34c4c2566690076db9b/ 4e1c3cddf420bcaecc256a8e007f12d9/$FILE/ADHDGuidelines.pdf)

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Activities of daily living


Disability

Disability portal Category: Disability Category: Disability lists

Activities of daily living (ADLs) is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both. Health professionals routinely refer to the ability or inability to perform ADLs as a measurement of the functional status of a person, particularly in regards to people with disabilities and the elderly.[1] Younger children often require help from adults to perform ADLs, as they have not yet developed the skills necessary to perform them independently. ADLs are defined as "the things we normally do...such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure."[2] A number of national surveys collect data on the ADL status of the U.S. population.[3] While basic categories of ADLs have been suggested, what specifically constitutes a particular ADL in a particular environment for a particular person may vary.

Basic ADLs
Basic ADLs (BADLs) consist of self-care tasks, including:[] Bathing and showering (washing the body) Bowel and bladder management (recognizing the need to relieve oneself) Dressing Eating (including chewing and swallowing) Feeding (setting up food and bringing it to the mouth) Functional mobility (moving from one place to another while performing activities) Personal device care Personal hygiene and grooming (including washing hair) Sexual activity Toilet hygiene (completing the act of relieving oneself)

Although not in wide general use, one mnemonic that some consider useful is DEATH: dressing, eating, ambulating (walking), toileting, hygiene.[]

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Instrumental ADLs
Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community:[4] Housework Taking medications as prescribed Managing money Shopping for groceries or clothing Use of telephone or other form of communication Using technology (as applicable) Transportation within the community is SHAFT: shopping, housekeeping, accounting, food preparation/meds,

A useful mnemonic telephone/transportation.

Occupational therapists often evaluate IADLs when completing patient assessments. The American Occupational Therapy Association identifies 12 types of IADLs that may be performed as a co-occupation with others:[] Care of others (including selecting and supervising caregivers) Care of pets Child rearing Communication management Community mobility Financial management Health management and maintenance Home establishment and maintenance Meal preparation and cleanup Religious observances Safety procedures and emergency responses Shopping

Evaluation of ADLs
There are several evaluation tools, such as the Katz ADL scale,[5] the Lawton IADL scale.[6] and the Bristol Activities of Daily Living Scale. Most models of health care service use ADL evaluations in their practice, including the medical (or institutional) models, such as the Roper-Logan-Tierney model of nursing, and the resident-centered models, such as the Program of All-Inclusive Care for the Elderly (PACE).

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References
[1] "Activities of Daily Living Evaluation." Encyclopedia of Nursing & Allied Health. ed. Kristine Krapp. Gale Group, Inc., 2002. eNotes.com. 2006. Enotes Nursing Encyclopedia (http:/ / www. enotes. com/ nursing-encyclopedia/ activities-daily-living-evaluation) Accessed on: 11 Oct, 2007 [2] MedicineNet.com Medical Dictionary (http:/ / www. medterms. com/ script/ main/ art. asp?articlekey=2152) [3] National Center for Health Statistics (http:/ / www. cdc. gov/ nchs/ datawh/ nchsdefs/ ADL. htm) [4] Bookman, A., Harrington, M., Pass, L., & Reisner, E. (2007). Family Caregiver Handbook. Cambridge, MA: Massachusetts Institute of Technology. [5] Katz ADL scale (http:/ / son. uth. tmc. edu/ coa/ FDGN_1/ RESOURCES/ ADLandIADL. pdf) [6] Lawton IADL scale (http:/ / www. abramsoncenter. org/ PRI/ documents/ IADL. pdf)

Adverse drug reaction

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Adverse drug reaction


Adverse drug reaction
Classification and external resources

Adverse drug reaction leading to hepatitis (drug-induced hepatitis) with granulomata. Other causes were excluded with extensive investigations. Liver biopsy. H&E stain. ICD-10 ICD-9 DiseasesDB MeSH T88.7 995.2 295 [1] [4] , Y40 [2] -Y59 [3] [6]

, E850

[5]

-E858

[7] [8]

D004362

An adverse drug reaction (abbreviated ADR) is an expression that describes harm associated with the use of given medications at a normal dosage during normal use. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs. The meaning of this expression differs from the meaning of "side effect", as this last expression might also imply that the effects can be beneficial.[] The study of ADRs is the concern of the field known as pharmacovigilance. An adverse drug event (abbreviated ADE) refers to any injury caused by the drug (at normal dosage and/or due to overdose) and any harm associated with the use of the drug (e.g. discontinuation of drug therapy).[9] ADRs are a special type of ADEs.

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Classification
ADRs may be classified by e.g. cause and severity.

Cause
Type A: Augmented pharmacologic effects - dose dependent and predictable Intolerance Side Effects Type B: Bizarre effects (or idiosyncratic) - dose independent and unpredictable Type C: Chronic effects Type D: Delayed effects Type E: End-of-treatment effects Type F: Failure of therapy Type G: Genetic reactions Type I: Idiosyncratic

Types A and B were proposed in the 1970s,[10] and the other types were proposed subsequently when the first two proved insufficient to classify ADRs.[11]

Seriousness and severity


The American Food and Drug Administration defines a serious adverse event as one when the patient outcome is one of the following:[12] Death Life-threatening Hospitalization (initial or prolonged) Disability - significant, persistent, or permanent change, impairment, damage or disruption in the patient's body function/structure, physical activities or quality of life. Congenital anomaly Requires intervention to prevent permanent impairment or damage Severity is a point on an arbitrary scale of intensity of the adverse event in question. The terms "severe" and "serious" when applied to adverse events are technically very different. They are easily confused but can not be used interchangeably, requiring care in usage. A headache is severe, if it causes intense pain. There are scales like "visual analog scale" that help usWikipedia:Avoid weasel words assess the severity. On the other hand, a headache is not usually serious (but may be in case of subarachnoid haemorrhage, subdural bleed, even a migraine may temporally fit criteria), unless it also satisfies the criteria for seriousness listed above.

Overall Drug Risk


While no official scale exists yet to communicate overall drug risk, the iGuard Drug Risk Rating System is a five color rating scale similar to the Homeland Security Advisory System:[13] Red (high risk) Orange (elevated risk) Yellow (guarded risk) Blue (general risk)

Green (low risk)

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Location
Adverse effects may be local, i.e. limited to a certain location, or systemic, where a medication has caused adverse effects throughout the systemic circulation. For instance, some ocular antihypertensives cause systemic effects,[14] although they are administered locally as eye drops, since a fraction escapes to the systemic circulation.

Mechanisms
As research better explains the biochemistry of drug use, fewer ADRs are Type B and more are Type A. Common mechanisms are: Abnormal pharmacokinetics due to genetic factors comorbid disease states Synergistic effects between either a drug and a disease two drugs

Abnormal pharmacokinetics
Comorbid disease states Various diseases, especially those that cause renal or hepatic insufficiency, may alter drug metabolism. Resources are available that report changes in a drug's metabolism due to disease states.[15] Genetic factors Abnormal drug metabolism may be due to inherited factors of either Phase I oxidation or Phase II conjugation.[][] Pharmacogenomics is the study of the inherited basis for abnormal drug reactions. Phase I reactions Inheriting abnormal alleles of cytochrome P450 can alter drug metabolism. Tables are available to check for drug interactions due to P450 interactions.[][] Inheriting abnormal butyrylcholinesterase (pseudocholinesterase) may affect metabolism of drugs such as succinylcholine[] Phase II reactions Inheriting abnormal N-acetyltransferase which conjugated some drugs to facilitate excretion may affect the metabolism of drugs such as isoniazid, hydralazine, and procainamide.[][] Inheriting abnormal thiopurine S-methyltransferase may affect the metabolism of the thiopurine drugs mercaptopurine and azathioprine.[] Interactions with other drugs The risk of drug interactions is increased with polypharmacy.

Adverse drug reaction Protein binding These interactions are usually transient and mild until a new steady state is achieved.[][16] These are mainly for drugs without much first-pass liver metabolism. The principal plasma proteins for drug binding are:[] 1. albumin 2. 1-acid glycoprotein 3. lipoproteins Some drug interactions with warfarin are due to changes in protein binding.[] Cytochrome P450 Patients have abnormal metabolism by cytochrome P450 due to either inheriting abnormal alleles or due to drug interactions. Tables are available to check for drug interactions due to P450 interactions.[]

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Synergistic effects
An example of synergism is two drugs that both prolong the QT interval.

Assessing causality
Causality assessment is used to determine the likelihood that a drug caused a suspected ADR. There are a number of different methods used to judge causation, including the Naranjo algorithm, the Venulet algorithm and the WHO causality term assessment criteria. Each have pros and cons associated with their use and most require some level of expert judgement to apply.[17] An ADR should not be labeled as 'certain' unless the ADR abates with a challenge-dechallenge-rechallenge protocol (stopping and starting the agent in question). The chronology of the onset of the suspected ADR is important, as another substance or factor may be implicated as a cause; co-prescribed medications and underlying psychiatric conditions may be factors in the ADR. A simple scale is available at http:/ / annals.org/cgi/content/full/140/10/795 [18].[] Assigning causality to a specific agent often proves difficult, unless the event is found during a clinical study or large databases are used. Both methods have difficulties and can be fraught with error. Even in clinical studies some ADRs may be missed as large numbers of test individuals are required to find that adverse drug reaction. Psychiatric ADRs are often missed as they are grouped together in the questionnaires used to assess the population.[][]

Monitoring bodies
Many countries have official bodies that monitor drug safety and reactions. On an international level, the WHO runs the Uppsala Monitoring Centre, and the European Union runs the European Medicines Agency (EMEA). In the United States, the Food and Drug Administration (FDA) is responsible for monitoring post-marketing studies. In Canada, the Marketed Health Products Directorate of Health Canada is responsible for the surveillance of marketed health products.

Examples of adverse effects associated with specific medications

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Condition Abortion, miscarriage or uterine hemorrhage

Substance misoprostol, a labor-inducing drug (this is a case where the adverse effect has been used legally and illegally for performing abortions) many sedatives and analgesics such as diazepam, morphine, etc. thalidomide and isotretinoin aspirin therapy COX-2 inhibitors (i.e. rofecoxib) gentamicin (an antibiotic) propofol interferon tetrabenazine, rimonabant and other CB1 antagonists orlistat many drugs, such as antidepressants vaccination (in the past, imperfectly manufactured vaccines, such as BCG and poliomyelitis, have caused the very disease they intended to fight). acarbose corticosteroid-based eye drops chemotherapy against cancer, leukemia, etc. spinal anesthesia ephedrine users, which prompted FDA to remove the status of dietary supplement of ephedra extracts atypical antipsychotic medications, such as clozapine and olanzapine stimulants (e.g. methylphenidate, amphetamine, etc.) indinavir, carbonic anhydrase inhibitors (such as topiramate) stavudine (an antiretroviral drug) or metformin (oral anti-diabetic medication) paracetamol estrogen-containing hormonal contraception such as the combined oral contraceptive pill dopamine agonists

Addiction Birth defects Bleeding of the intestine Cardiovascular disease Deafness and kidney failure Death, following sedation Depression or hepatic injury Depression Diarrhea Erectile dysfunction Fever

Flatulence Glaucoma Hair loss and anemia Headache Hypertension

Impaired glucose tolerance and diabetes Insomnia Kidney stones Lactic acidosis Liver failure Melasma and thrombosis Pathological addiction, like gambling, shopping; sexual and other intense urges Irreversible Peripheral neuropathy Rhabdomyolysis Seizures Stroke or heart attack Suicide, increased tendency Parkinsonism Tardive dyskinesia Spontaneous Tendon rupture

fluoroquinolone medications

[19][20][21]

statins (a class of lipid-lowering drugs) withdrawal from benzodiazepines sildenafil when used with nitroglycerine; COX-2 inhibitors antidepressants MPTP, a meperidine related drug considered highly neurotoxic long-term use of metoclopramide, cinnarizine and many antipsychotic medications fluoroquinolone drugs [23] terminated. [22] even occurring as late as 6 months after treatment had been

Weight loss Weight gain

some antidepressants, like fluoxetine and bupropion some antipsychotics (e.g. olanzapine and clozapine) and antidepressants (mirtazapine)

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References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ T88. 7 [2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ Y40 [3] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ Y59 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=995. 2 [5] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=E850 [6] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=E858 [7] http:/ / www. diseasesdatabase. com/ ddb295. htm [8] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D004362 [10] Rawlins MD, Thompson JW. Pathogenesis of adverse drug reactions. In: Davies DM, ed. Textbook of adverse drug reactions. Oxford: Oxford University Press, 1977:10. [11] Aronson JK. Drug therapy. In: Haslett C, Chilvers ER, Boon NA, Colledge NR, Hunter JAA, eds. Davidson's principles and practice of medicine 19th ed. Edinburgh: Elsevier Science, 2002:147[14] Page 146 [16] OVID full text (http:/ / gateway. ovid. com/ ovidweb. cgi?T=JS& PAGE=linkout& SEARCH=11907485. ui) summary table at OVID (http:/ / gateway. ovid. com/ ovidweb. cgi?T=JS& NEWS=N& PAGE=image& IMAGE=00003098-200203000-00001|TT2& D=ovft) [18] http:/ / annals. org/ cgi/ content/ full/ 140/ 10/ 795#T2

External links
Research and Report Adverse Drug Events at RxISK.org (http://RxISK.org) ADR online tools (http://farmacologiaclinica.info/scoring-tools/files/category-clinical-pharmacology.html) Drug Toxicity (Citizendium) (http://en.citizendium.org/wiki/Drug_toxicity)

American Dental Society of Anesthesiology

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American Dental Society of Anesthesiology


American Dental Society of Anesthesiology
Formation Type Headquarters Location Membership Officiallanguages Website 1953 Professional association Chicago, Illinois United States 4,500 English adsahome.org [1]

The American Dental Society of Anesthesiology (ADSA) is an American professional association established in 1953 and based in Chicago.

Mission
The mission of the American Dental Society of Anesthesiology is to provide a forum for education, research, and recognition of achievement in order to promote safe and effective patient care for all dentists who have an interest in anesthesiology, sedation and the control of anxiety and pain.[2]

Publications
The ADSA publishes a quarterly scientific journal of dental sedation and anesthesia related articles named Anesthesia Progress: A Journal for Pain and Anxiety Control in Dentistry [3]. Anesthesia Progress is the official journal of the American Dental Society of Anesthesiology and has been published quarterly since 1954.[52] This peer-reviewed journal also serves as the official umbrella journal for: the American Society of Dentist Anesthesiologists, the Australian Society of Dental Anesthesiology, the Canadian Society of Dental Anesthesia, the European Federation for the Advancement of Anesthesia in Dentistry and the International Federation of Dental Anesthesiology Societies.[52] Anesthesia Progress is indexed in Excerpta Medica (EMBASE), MEDLINE, and Periodicals Digest in Dentistry.[52] Retrospective articles were prepared for Anesthesia Progress on the 25th[4] and 35th[5] Anniversaries of the Society. ADSA also publishes the bi-monthly newsletter Pulse.[6]

Members
ADSA Membership is open to all dental professionals who have an interest in sedation and anesthesia. From its inception, Oral and Maxillofacial Surgeons and Dentist Anesthesiologists were encouraged to attain Fellowship status to recognize their high level of training. Since 2001, Diplomates of the National Dental Board of Anesthesiology and the American Board of Anesthesiology have been allowed to obtain ADSA Fellowship without a second examination process. The American Dental Society of Anesthesiology established the College of Sedation in Dentistry in 2001 for General Dentists to attain either Member (Enteral) or Master (Parenteral) status in the College.

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History
Since its creation in 1953, the focus of the American Dental Society of Anaesthesiology has been to provide continuing education, recognize educational achievement and pursue research. Its active membership of over 4,500 dentists includes general dentists as well as members from all of the dental specialities with interest in sedation, anaesthesia and pain control.

Contributions to the Profession of Dentistry


First Workshop on Teaching Pain Control to Dental Students (1963)
In 1963 on its tenth anniversary, the American Dental Society of Anesthesiology held a Workshop on Teaching Pain Control to Dental Students. An objective of that meeting was to determine how to encourage dental schools to coordinate the parts of the curriculum that are concerned, directly or indirectly with pain control. The workshop papers were published in the Journal of Dental Education 1964.

Second Pain Control Conference (1965)


The Second Pain Control Conference was held in 1965 by the American Dental Society of Anesthesiology to further develop the predoctoral program in pain control. One of the purposes was to protect the inherent right and accept the corresponding responsibility to advance the field in the profession of dentistry. The report of this conference was sent to all dental schools and communities of interest.

Third Pain Control Conference (1970)


The purpose of this conference was to develop guidelines for pain control in dentistry. Representatives of 48 dental schools, all dental specialty societies, the various federal services, and the sponsoring organizations attended. A document providing a guide for the teaching of pain control at all levels (undergraduate, advanced [postgraduate and graduate]), and continuing education was developed. The approval of the sponsoring agencies created a comprehensive statement, official in nature, that reflected the posture of the entire dental profession. Ultimately, the guidelines were accepted by the ADA Council on Dental Education and the House of Delegates of the ADA.

Teaching of Pain Control in Continuing Education Programs (1977)


This conference resulted in the creation of the complete sequence of guidelines as they relate to pain control at all educational levels within the profession.

Workshop on Anesthesia Education (1989)


This workshop focused on an increased emphasis on quality assurance and risk management applicable to dentistry in general and the modalities of anxiety and pain control employed by dentists in particular. The sponsors of the workshop were also concerned about the decreasing number of opportunities available to dentists for advanced training beyond that provided in traditional dental education.[7]

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1991
Creation of specific, detailed monitoring standards with universal applicability in the dental setting Guidelines for Intraoperative Monitoring of Dental Patients Undergoing Conscious Sedation, Deep Sedation, and General Anesthesia[] The promulgation and adoption of intraoperative monitoring standards in medicine for anesthesia has resulted in early detection of untoward events during sedation and anesthesia, lowering of malpractice premiums, and an improvement in the quality of care. The American Dental Society of Anesthesiology has devised specific, detailed monitoring standards with universal applicability in the dental setting.[]

Workshop on Enteral Sedation in Dentistry (2003)


The American Dental Society of Anesthesiology and the Anesthesia Research Foundation helped organize the Workshop on Enteral Sedation in Dentistry that was held in Washington, D.C. on December 2 3, 2003. Co-sponsored by the United States Pharmacopeial Convention, Inc. (USP) and the Dental Anesthesia Research Group of the International Association for Dental Research, this conference brought together medical and dental communities of interest along with basic science and clinical experts to review the scientific basic and clinical practice and evidenced-based foundations of enteral sedation in dentistry.[8]

American Dental Association Council on Dental Education and Licensure's Committee on Anesthesiology (2003)
Representatives of the American Dental Society of Anesthesiology often grapple with issues pertaining to sedation and anesthesia by dentists in this forum.

2006
With representatives of the American Dental Association, American Academy of General Dentistry, American Association of Oral and Maxillofacial Surgeons, American Academy of Pediatric Dentistry, and the American Society of Dentist Anesthesiologists, the American Dental Society of Anesthesiology funded and organized a roundtable discussion of sedation/anesthesia issues facing dentistry and how to address them.

Town Hall Forum on Anesthesia and Dentistry


The ADSA Town Hall Anesthesia Forum was conceived by the ADSA to address the needs and concerns of the dental community regarding the ADA Guidelines approved in 2007. Dr. Mark Feldman, President of the American Dental Association, will present the Keynote Address. Representatives from the American Academy of Pediatric Dentists, Federal Services, Academy of General Dentistry, Canadian Academy of Dental Anaesthesia, American Association of Oral and Maxillofacial Surgeons, American Society of Dentist Anesthesiologists, Dental Organization of Conscious Sedation and the American Dental Society of Anesthesiology are scheduled to attend and address the group.[9]

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2008-2009
American Dental Society of Anesthesiology won a $100,000 ADA Foundation grant[10] to fund advanced training to manage rare dental emergencies. A number of pilot and proof-of-concept courses were held during 2008 and 2009, including a pilot testing program Dec. 8 in Chicago,[11] which enabled ADA representatives and staff to observe. After the course was developed and the grant finished, the ADA began a series of courses.[12][13][14]

2006-2012
In 2006 in Yokohama, Japan, the American Dental Society of Anesthesiology made a successful bid to hold the International Federation of Dental Anesthesia Societies' 13th Annual International Dental Congress on Modern Pain Control in Hawaii in 2012.[15]

References
[1] http:/ / www. adsahome. org [3] http:/ / www. anesthesiaprogress. org/

External links
Official website (http://www.adsahome.org)

Automated external defibrillator


An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient,[] and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to reestablish an effective rhythm. With simple audio and visual commands, AEDs are designed to be simple to use for the layman, and the use of AEDs is taught in many first aid, first responder, and basic life support (BLS) level cardiopulmonary resuscitation (CPR) classes.[1]

An automated external defibrillator, open and ready for pads to be attached

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148

Usage
Conditions that the device treats
An automated external defibrillator is used in cases of life threatening cardiac arrhythmias which lead to cardiac arrest. The rhythms that the device will treat are usually limited to: 1. Pulseless Ventricular tachycardia (shortened to VT or V-Tach)[] 2. Ventricular fibrillation (shortened to VF or V-Fib) In each of these two types of shockable cardiac arrhythmia, the heart is active, but in a life-threatening, dysfunctional pattern. In ventricular tachycardia, the heart beats too fast to effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. In ventricular fibrillation, the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. The fibrillation in the heart decreases over time, and will eventually reach asystole. AEDs, like all defibrillators, are not designed to shock asystole ('flat line' patterns) as this will not have a positive clinical outcome. The asystolic patient only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable rhythms can be established, which makes it imperative for CPR to be carried out prior to the arrival of a defibrillator.

Effect of delayed treatment


Uncorrected, these cardiac conditions (ventricular tachycardia, ventricular fibrillation, asystole) rapidly lead to irreversible brain damage and death. After approximately three to five minutes,[2] irreversible brain/tissue damage may begin to occur. For every minute that a person in cardiac arrest goes without being successfully treated (by defibrillation), the chance of survival decreases by 7 percent per minute in the first 3 minutes, and decreases by 10 percent per minute as time advances beyond ~3 minutes.[3]

Requirements for use


AEDs are designed to be used by laypersons who ideally should have received AED training. However, sixth-grade students have been reported to begin defibrillation within 90 seconds, as opposed to a trained operator beginning within 67 seconds.[4] This is in contrast to more sophisticated manual and semi-automatic defibrillators used by health professionals, which can act as a pacemaker if the heart rate is too slow (bradycardia) and perform other functions which require a skilled operator able to read electrocardiograms. Bras with a metal underwire and piercings on the torso must be removed before using the AED on someone to avoid interference.[5][6] American TV show Mythbusters [7] found evidence that use of a defibrillator on a woman wearing an underwire bra can lead to arcing or fire but only in unusual and unlikely circumstances. A study analyzed the effects of having AEDs immediately present during Chicago's Heart Start program over a two-year period. Of 22 individuals 18 were in a cardiac arrhythmia which AEDs can treat (Vfib or Vtach). Of these 18, 11 survived. Of these 11 patients, 6 were treated by good Samaritan bystanders with absolutely no previous training in AED use.[8][9]

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Placement and availability


Automated external defibrillators are generally either held by trained personnel who will attend events or are public access units which can be found in places including corporate and government offices, shopping centres, airports, airplanes,[10] restaurants, casinos, hotels, sports stadium, schools and universities, community centers, fitness centers, health clubs, theme parks, workplaces and any other location where people may congregate. Maimonides Medical Center in Borough Park, Brooklyn was the first hospital in the United States to implement fully automated external defibrillators at the bedside. [citation needed] The location of a public access AED should take into account where large groups of people gather, regardless of age or activity. Children as well as adults may fall victim to sudden cardiac arrest (SCA). In many areas, emergency vehicles are likely to carry AEDs, with some ambulances carrying an AED in addition to manual defibrillators. Police or fire vehicles often carry an AED for first responder use. Some areas have dedicated community first responders, who are volunteers tasked with keeping an AED and taking it to any victims in their area. AEDs are also increasingly common on commercial airliners, cruise ships, and other transportation facilities. High-rise buildings are densely populated, but are more difficult to access[11] by emergency crews facing heavy traffic and security barriers. It has been suggested that AEDs carried on elevators could save critical minutes for cardiac arrest victims, and reduce their deployment cost. In order to make them highly visible, public access AEDs are often brightly colored, and are mounted in protective cases near the entrance of a building. When these protective cases are opened or the defibrillator is removed, some will sound a buzzer to alert nearby staff to their removal, though this does not necessarily summon emergency services; trained AED operators should know to phone for an ambulance when sending for or using an AED. In September 2008, the International Liaison Committee on Resuscitation issued a 'universal AED sign' to be adopted throughout the world to indicate the presence of an AED, and this is shown on the right.[12] A trend that is developing is the purchase of AEDs to be used in the home, particularly by those with known existing heart conditions.[13] The number of devices in the community has grown as prices have fallen to affordable levels. There has been some concern among medical professionals that these home users do not necessarily have appropriate training,[14] and many advocate the more widespread use of community responders, who can be appropriately trained and managed. Typically, an AED kit will contain a face shield for providing a barrier between patient and first aider during rescue breathing; a pair of nitrile rubber gloves; a pair of trauma shears for cutting through a patient's clothing to expose the chest; a small towel for wiping away any moisture on the chest, and a razor for shaving those with very hairy chests.[15]

An AED at a railway station in Japan.

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Preparation for operation


Most manufacturers recommend checking the AED before every period of duty or on a regular basis for fixed units. Some units need to be switched on in order to perform a self check; other models have a self check system built in with a visible indicator.[citation needed] All manufacturers mark their electrode pads with an expiration date, and it is important to ensure that the pads are in date. This is usually marked on the outside of the pads. Some models are designed to make this date visible through a 'window', although others will require the opening of the case to find the date stamp.[citation needed] It is also important to ensure that the AED unit's batteries have not expired. The AED manufacturer will specify how often the batteries should be replaced. Each AED has a different recommended maintenance schedule lined out in the user manual. Common checkpoints on every checklist, however, also include a monthly check of the battery power by checking the green indicator light when powered on, condition and cleanliness of all cables and the unit, and check for the adequate supplies [16]

Mechanism of operation
An AED is external because the operator applies the electrode pads to the bare chest of the victim, as opposed to internal defibrillators, which have electrodes surgically implanted inside the body of a patient. Automatic refers to the unit's ability to autonomously analyse the patient's condition, and to assist this, the vast majority of units have spoken prompts, and some may also have visual displays to instruct the user. When turned on or opened, the AED will instruct the user to connect the electrodes (pads) to the patient. Once the pads are attached, everyone should avoid touching the patient so as to avoid false readings by the unit. The pads allow the AED to examine the electrical output from the heart and determine if the patient is in a shockable rhythm (either ventricular fibrillation or ventricular tachycardia). If the device determines that a shock is warranted, it will use the battery to charge its internal capacitor in preparation to deliver the shock. This system is not only safer (charging only when required), but also allows for a faster delivery of the electrical current.

The use of easily visible status indicator and pad expiration date on one model of AED

When charged, the device instructs the user to ensure no one is touching the patient and then to press a button to deliver the shock; human intervention is usually required to deliver the shock to the patient in order to avoid the possibility of accidental injury to another person (which can result from a responder or bystander touching the patient at the time of the shock). Depending on the manufacturer and particular model, after the shock is delivered most devices will analyze the patient and either instruct CPR to be given, or administer another shock. Many AED units have an 'event memory' which store the ECG of the patient along with details of the time the unit was activated and the number and strength of any shocks delivered. Some units also have voice recording abilities[citation needed] to monitor the actions taken by the personnel in order to ascertain if these had any impact on the survival outcome. All this recorded data can be either downloaded to a computer or printed out so that the providing organisation or responsible body is able to see the effectiveness of both CPR and defibrillation. Some AED units even provide feedback on the quality of the compressions provided by the rescuer.[17] The first commercially available AEDs were all of a monophasic type, which gave a high-energy shock, up to 360 to 400 joules depending on the model. This caused increased cardiac injury and in some cases second and third-degree

Automated external defibrillator burns around the shock pad sites. Newer AEDs (manufactured after late 2003) have tended to utilise biphasic algorithms which give two sequential lower-energy shocks of 120 - 200 joules, with each shock moving in an opposite polarity between the pads. This lower-energy waveform has proven more effective in clinical tests, as well as offering a reduced rate of complications and reduced recovery time.[18]

151

Simplicity of use
Unlike regular defibrillators, an automated external defibrillator requires minimal training to use. It automatically diagnoses the heart rhythm and determines if a shock is needed. Automatic models will administer the shock without the user's command. Semi-automatic models will tell the user that a shock is needed, but the user must tell the machine to do so, usually by pressing a button. In most circumstances, the user cannot override a "no shock" advisory by an AED. Some AEDs may be used on children - those under 55lbs (25kg) in weight or under age 8. If a particular model of AED is approved for pediatric use, all that is required is the use of more appropriate pads. All AEDs approved for use in the United States use an electronic voice to prompt users through each step. Because the user of an AED may be hearing impaired, many AEDs now include visual prompts as well. Most units are designed for use by non-medical operators. Their ease of use has given rise to the notion of public access defibrillation (PAD), which experts agree has the potential to be the single greatest advance in the treatment of out-of-hospital cardiac arrest since the invention of CPR.[19]

Usual placement of pads on chest

The number of people who survive sudden cardiac arrest is increasing gradually, thanks to the use of AEDs. For this reason, the Sudden Cardiac Arrest Foundation developed the National SCA Survivor Network [20], which provides a platform for mutual support and for engaging in the mission to help save other lives.

Liability
Automated external defibrillators are now easy enough to use that most states in the United States include the "good faith" use of an AED by any person under Good Samaritan laws.[21] "Good faith" protection under a Good Samaritan law means that a volunteer responder (not acting as a part of one's occupation) cannot be held civilly liable for the harm or death of a victim by providing improper or inadequate care, given that the harm or death was not intentional and the responder was acting within the limits of their training and in good faith. In the United States, Good Samaritan laws provide some protection for the use of AEDs by trained and untrained responders.[22] AEDs create little liability if used correctly;[23] NREMT-B and many state Emergency Medical Technician (EMT) training and many CPR classes incorporate or offer AED education as a part of their program. In addition to Good Samaritan laws, Ontario, Canada also has the "Chase McEachern Act (Heart Defibrillator Civil Liability), 2007 (Bill 171 Subsection N)", passed in June, 2007,[24] which protects individuals from liability for damages that may occur from their use of an AED to save someone's life at the immediate scene of an emergency unless damages are caused by gross negligence.

Automated external defibrillator

152

Reliability
Automated external defibrillators are under recent scrutiny by the U.S. Food and Drug Administration (FDA) which is now considering reclassifying AEDs as class III premarket approval devices. The major reason for this appears to be technical malfunctions that may have been the cause for apparently hundreds of deaths between 2004 and 2009, in most cases by component failures or design errors. Over the last several years dozens of AED models have been recalled from nearly every manufacturer.[25]

References
[3] American Red Cross. CPR/AED for the Professional Rescuer (participant's manual). Yardley, PA: StayWell, 2006. (page 63). [7] http:/ / dsc. discovery. com/ fansites/ mythbusters/ db/ human-body/ underwire-bra-mess-with-defibrillator. html [9] http:/ / beavermedic. wordpress. com/ 2010/ 02/ 10/ look-for-me-in-airportshockey-arenas/ [10] http:/ / vlex. com/ vid/ krys-rebeca-lufthansa-german-airlines-36137815 Leonard Krys, Rebeca Krys, His Wife, Plaintiffs-Appellees, v. Lufthansa German Airlines, Defendant-Appellant., 119 F.3d 1515 (11th Cir. 1997) [11] BMJ.com (http:/ / www. bmj. com/ cgi/ content/ full/ 328/ 7438/ E271) [15] CPR/AED for the Professional Rescuer, supra, page 65 ("[a] safety surgical razor should be included in the AED kit.") The other items not directly mentioned in this text but are used in AED preparation, such as the gloves (used throughout patron assessment) and the towel, as the chest should be dried prior to AED pad attachment (id, at page 64). [17] Zoll AED Plus Provides Compression Feedback (http:/ / www. lifeassisttraining. com/ zollaedplus. html) [19] Introduction to the International Guidelines 2000 for CPR and ECC (http:/ / circ. ahajournals. org/ cgi/ content/ full/ 102/ suppl_1/ I-1?ijkey=0ea84b1fa73ef72b72aef923e0f1adc6d4fd6ba5& keytype2=tf_ipsecsha) [20] http:/ / www. sca-aware. org/ national-sca-survivor-network [21] Laws on Cardiac Arrest and Defibrillators, 2013 update. (http:/ / www. ncsl. org/ programs/ health/ aed. htm) National Conference of State Legislatures. Retrieved on 2013-03-18. [22] State Laws on Heart Attacks, Cardiac Arrest & Defibrillators (http:/ / www. ncsl. org/ programs/ health/ aed. htm) [23] Laws on Cardiac Arrest and Defibrillators (http:/ / www. ncsl. org/ default. aspx?tabid=14506) [24] Health System Improvement Act, 2007 (http:/ / www. e-laws. gov. on. ca/ DBLaws/ Source/ Statutes/ English/ 2007/ S07010_e. htm) Retrieved on 26 June 2007

External links
Sudden Cardiac Arrest Foundation (http://www.sca-aware.org) American Heart Association: Learn & Live (http://www.heart.org/HEARTORG/) American Red Cross: Saving a Life is as Easy as A-E-D (http://www.redcross.org/services/hss/courses/aed. html) FDA Heart Health Online: Automated External Defibrillator (AED) (http://www.fda.gov/hearthealth/ treatments/medicaldevices/aed.html) Resuscitation Council (UK) (http://www.resus.org.uk)

Aid to Families with Dependent Children

153

Aid to Families with Dependent Children


Aid to Families with Dependent Children (AFDC) was a federal assistance program in effect from 1935 to 1996 created by the Social Security Act and administered by the United States Department of Health and Human Services that provided financial assistance to children whose families had low or no income.[1] This program grew from a minor part of the social security system to a significant system of welfare administered by the states with federal funding. However, it was criticized for offering incentives for women to have children, and for providing disincentives for women to join the workforce. In 1996, AFDC was replaced by the more restrictive Temporary Assistance for Needy Families (TANF) program.

History
The program was created under the name Aid to Dependent Children (ADC) by the Social Security Act of 1935 as part of the New Deal. ADC dispensed scant relief to poor single mothers. The federal government authorized case workers, supervisors, and administrators with discretion to determine who received aid and how much. ADC was primarily created for white single mothers who were [2] The overall decline in welfare monthly benefits (in 2006 dollars) expected not to work. Black mothers who had always been in the labor force were not considered eligible to receive benefits.[3] The words "families with" were added to the name in 1962, partly due to concern that the program's rules discouraged marriage.[4] The Civil Rights Movement and the efforts of the National Welfare Rights Organization (NWRO) in the 1960's expanded the scope of welfare entitlements to include Black women. The welfare rolls racial demographics changed drastically. The majority of welfare recipients still remained white and most Black women recipients continued to work.[5] Starting in 1962, the Department of Health and Human Services allowed state-specific exemptions as long as the change was "in the spirit of AFDC" in order to allow some experimentation. By 1996 spending was $24 billion per year. When adjusted for inflation, the highest spending was in 1976, which exceeded 1996 spending by about 8%.[6]

Criticism
Early in the program, there were concerns about whether this program encouraged unwed motherhood.[4] In the 1960s through 1980s, Nobel Prize winning physicist William Shockley argued that AFDC and other similar programs tended to encourage childbirth, especially among less productive members of society (particularly blacks, whom he considered to be genetically inferior to whites[7]), causing a reverse evolution (dysgenic effect), founded on the premises that: there is a correlation between financial success and intelligence; and that intelligence is hereditary.[8] Shockley[9] was influential in bringing recognition to this hypothesis among the public and Congress.[8] Some advocates complained that the rule had the effect of breaking up marriages and promoting matriarchy (see also single-parent family).

Aid to Families with Dependent Children ... the AFDC program tended to treat households with a cohabiting male who was not the natural father of the children much more leniently than those with a resident spouse or father of the children. This feature created a clear disincentive for marriage and also a clear incentive for divorce, because women who married face the reduction or loss of their AFDC benefits.[10] Lucy A. Williams and Jean Hardisty point to the existence of policies reacting to this perceived problem in some states such as "man-in-the-house" rule: States had wide discretion to determine eligibility and many states conditioned the receipt of welfare on the sexual morality of the mother, using "suitable home" and "man in the house" rules to disqualify many African American single mothers. The Right's Campaign Against Welfare [11] The "man-in-the-house" rule was struck down by the Supreme Court in 1968 (see King v. Smith). In 1984, libertarian author Charles Murray suggested that welfare causes dependency. He argued that as welfare benefits increased, the number of recipients also increased; this behavior, he said, was rational: there is little reason to work if one can receive benefits for a long period of time without having to work.[12] His later work and that of Richard J. Herrnstein and others suggested possible merit to the theory of a dysgenic effect,[13] however, the data are not entirely clear.[14] Right or wrong, this argument was among the stepping stones leading to the modification of AFDC toward TANF.[15]

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Reform
In 1996, President Bill Clinton negotiated with the Republican-controlled Congress to pass the Personal Responsibility and Work Opportunity Act which drastically restructured the program. Among other changes, a lifetime limit of five years was imposed for the receipt of benefits, and the newly-limited nature of the replacement program was reinforced by calling AFDC's successor Temporary Assistance for Needy Families (TANF). Many Americans continue to refer to TANF as "welfare" or AFDC. TANF has remained controversial. In 2003, LaShawn Y. Warren, an ACLU Legislative Counsel, said that TANF gives states an incentive "to deny benefits to those who need it most. The solution to getting people out of the cycle of poverty is not to prematurely kick them off welfare. Too many have been denied aid unfairly, creating a false impression that the number of people who need help has decreased."[16] In 2006, The New Republic suggested, "A broad consensus now holds that welfare reform was certainly not a disasterand that it may, in fact, have worked much as its designers had hoped."[17] More recent results, notably taking into account the effects of the Financial crisis of 20072010 and taking place after the lifetime limits imposed by TANF may have been reached by many recipients, suggest instead that the reforms have not been as successful as originally claimed.[18]

Notes
[1] PBS.org (http:/ / www. pbs. org/ pov/ pov2001/ takeitfromme/ abouttheissues. html), Timeline of National Welfare Reform [2] 2008 Indicators of Welfare Dependence (http:/ / aspe. hhs. gov/ hsp/ indicators08/ apa. shtml#ftanf2) Figure TANF 2. [4] Blank, Susan W. and Barbara B. Blum, Welfare to Work Vol 7 No 1, Spring 1997. A Brief History of Work Expectations for Welfare Mothers (http:/ / www. princeton. edu/ futureofchildren/ publications/ docs/ 07_01_02. pdf)". [6] U.S. Department of Health and Human Services (website) (http:/ / aspe. hhs. gov/ hsp/ AFDC/ baseline/ 4spending. pdf) Federal and State Expenditures for AFDC [8] George Bush: The Unauthorized Biography --- by Webster G. Tarpley & Anton Chaitkin Chapter 11 [9] Joel N. Shurkin; "Broken Genius: The Rise and Fall of William Shockley, Creator of the Electronic Age". New York: Palgrave Macmillan. 2006. ISBN 1-4039-8815-3 [10] Marriage and the economy: theory and evidence from advanced industrial societies (http:/ / books. google. com/ books?id=2CQ46PgqyKsC& pg=PA77& lpg=PA77& dq=supreme+ court+ afdc+ presence+ cohabiting+ male& source=bl& ots=yGZyjXJoXD& sig=S7wjkdlykNRsmlg-XsPsDuU3jxQ& hl=en& sa=X& ei=rA8OT4ScINHE0AHMrISuDQ& ved=0CD4Q6AEwAg#v=onepage& q=supreme court afdc presence cohabiting male& f=false) - Shoshana Grossbard-Shechtman, Professor of Economics at San Diego State University

Aid to Families with Dependent Children


[11] http:/ / www. jeanhardisty. com/ essay_therightscampaignagainstwelfare. html#_ednref2 [12] Charles Murray, 1984. Losing Ground: American Social Policy, 1950-1980 [13] Herrnstein, R. J. and Murray, C. (1994). The Bell Curve: Intelligence and Class Structure in American Life. New York: Free Press. ISBN 0-02-914673-9 pgs 191-193 [14] The Bell Curve Flattened (http:/ / www. slate. com/ id/ 2416) by Nicholas Lemann in Slate (January 1996) [15] Transcendental goods, Reason (magazine), April 1, 2004 , by Gillespie, Nick "Losing Ground: American Social Policy, 1950-1980 was a devastating dissection of welfare programs and is widely credited with helping inspire the welfare reforms of the 1990s." This is also supported by "George Bush: The Unauthorized Biography", by Webster G. Tarpley & Anton Chaitkin Chapter 11 [16] ACLU Says Current Welfare Reform Measure Ineffective, Calls for Civil Rights Protections, Better Poverty Elimination Efforts (http:/ / www. aclu. org/ racial-justice_prisoners-rights_drug-law-reform_immigrants-rights/ aclu-says-current-welfare-reform-m) (September 10, 2003) [17] New Republic September 4, 2006, page 7 [18] As Progressives Predicted, Clinton Welfare Reform Law Fails Families (http:/ / www. beyondchron. org/ articles/ As_Progressives_Predicted_Clinton_Welfare_Reform_Law_Fails_Families_8029. html) by Randy Shaw in BeyondChron (April 19 2010)

155

Bibliography
Keith M. Kilty, Elizabeth A. Segal. The Promise of Welfare Reform: Political Rhetoric and the Reality of Poverty in the Twenty-First. (2006) Clarita A. Mrena and Patricia Elston. Welfare Reform: State Sanction Policies and Number of Families Affected (2000) Robert P Stoker and Laura A Wilson. When Work Is Not Enough: State and Federal Policies to Support Needy Workers 2006 Webster G. Tarpley and Anton Chaitkin. George Bush: The Unauthorized Biography Joel N. Shurkin. Broken Genius: The Rise and Fall of William Shockley, Creator of the Electronic Age. New York: Palgrave Macmillan. 2006. ISBN 1-4039-8815-3 Herrnstein, R. J. and Murray, C. (1994). The Bell Curve: Intelligence and Class Structure in American Life. New York: Free Press. ISBN 0-02-914673-9 Charles Murray, 1984. Losing Ground: American Social Policy. 1950-1980 Nick Gillespie. "Transcendental goods". Reason (magazine), April 1, 2004 "The Bell Curve Flattened" (http://www.slate.com/id/2416) by Nicholas Lemann, in Slate (magazine) (January 1996) "Is the Great Society to Blame? If Not, Why Have Problems Worsened Since '60s?" (http://www.fumento.com/ greatsociety.html) by Michael Fumento, Investor's Business Daily, June 19, 1992 "Cracked Bell" (http://www.reason.com/news/show/29636.html) by Professor James Heckman in Reason (March 1995) "Federal and State Expenditures for AFDC" (http://aspe.hhs.gov/hsp/AFDC/baseline/4spending.pdf) from the U.S. Department of Health and Human Services website "A Brief History of the AFDC Program" (http://aspe.hhs.gov/hsp/AFDC/baseline/1history.pdf) from the U.S. Department of Health and Human Services (website) "The New Child Care Block Grant, State Funding Choices and Their Implications" (http://www.urban.org/ publications/307043.html) by Sharon K. Long & Sandra J. Clark, posted to the Urban Institute website October 1, 1997 "Women, Children, and Poverty in America" (http://www.fordfound.org/eLibrary/documents/0183/010.cfm) by Prudence Brown, Ford Foundation website "Timeline of National Welfare Reform" (http://www.pbs.org/pov/pov2001/takeitfromme/abouttheissues. html) from PBS.org

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External links
Aid to Families with Dependent Children at HHS (http://www.acf.hhs.gov/programs/afdc/) The Future of Children (http://www.princeton.edu/futureofchildren/publications/docs/07_01_ExecSummary. pdf), Executive Summary, Center for the Future of Children, The David and Lucile Packard Foundation, at Princeton University website

Atrial fibrillation

157

Atrial fibrillation
Atrial fibrillation
Classification and external resources

Schematic diagram of normal sinus rhythm for a human heart as seen on ECG. In atrial fibrillation, however, the P waves, which represent depolarization of the atria, are absent. ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine MeSH I48 [1] [2]

427.31 1065

[3] [4] [5] [7] emerg/46 [6]

000184

med/184 D001281

Atrial fibrillation (AF or A-fib) is the most common cardiac arrhythmia (heart rhythm disorder). It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain, or congestive heart failure. However, in some people atrial fibrillation is caused by otherwise idiopathic or benign conditions. AF increases the risk of stroke. The degree of increase can be substantial, depending on the presence of additional risk factors (such as high blood pressure). It may be identified clinically when taking a pulse, and the presence of AF can be confirmed with an electrocardiogram (ECG or EKG) which demonstrates the absence of P waves together with an irregular ventricular rate. In AF, the normal regular electrical impulses generated by the sinoatrial node are overwhelmed by disorganized electrical impulses usually originating in the roots of the pulmonary veins, leading to irregular conduction of impulses to the ventricles which generate the heartbeat. AF may occur in episodes lasting from minutes to days ("paroxysmal"), or be permanent in nature. A number of medical conditions increase the risk of AF, particularly mitral stenosis (narrowing of the mitral valve of the heart). Atrial fibrillation may be treated with medications to either slow the heart rate to a normal range ("rate control") or revert the heart rhythm back to normal ("rhythm control"). Synchronized electrical cardioversion can be used to convert AF to a normal heart rhythm. Surgical and catheter-based therapies may be used to prevent recurrence of AF in certain individuals. Depending on the risk of stroke and systemic embolism, people with AF may use anticoagulants such as warfarin, which substantially reduces the risk but may increase the risk of major bleeding,

Atrial fibrillation mainly in geriatric patients. The prevalence of AF in a population increases with age, with 8% of people over 80 having AF. Chronic AF leads to a small increase in the risk of death.

158

Classification
Classification system
AF Category First detected Paroxysmal Persistent Permanent Defining Characteristics only one diagnosed episode recurrent episodes that self-terminate in less than 7 days. recurrent episodes that last more than 7 days an ongoing long-term episode

The American College of Cardiology (ACC), American Heart Association (AHA), and the European Society of Cardiology (ESC) recommend in their guidelines the following classification system based on simplicity and clinical relevance.[] All atrial fibrillation patients are initially in the category called first detected AF. These patients may or may not have had previous undetected episodes. If a first detected episode self-terminates in less than 7days and then another episode begins later on, the case has moved into the category of paroxysmal AF. Although patients in this category have episodes lasting up to 7days, in most cases of paroxysmal AF the episodes will self-terminate in less than 24hours. If instead the episode lasts for more than 7days, it is unlikely to self-terminate,[8] and it is called persistent AF. In this case, the episode may be still terminated by cardioversion. If cardioversion is unsuccessful or it is not attempted, and the episode is ongoing for a long time (e.g., a year or more), the patient's AF is called permanent. Episodes that last less than 30seconds are not considered in this classification system. Also, this system does not apply to cases where the AF is a secondary condition that occurs in the setting of a primary condition that may be the cause of the AF. Using this classification system, it's not always clear what an AF case should be called. For example, a case may fit into the paroxysmal AF category some of the time, while other times it may have the characteristics of persistent AF. One may be able to decide which category is more appropriate by determining which one occurs most often in the case under consideration. In addition to the above four AF categories, which are mainly defined by episode timing and termination, the ACC/AHA/ESC guidelines describe additional AF categories in terms of other characteristics of the patient.[] Lone atrial fibrillation (LAF) absence of clinical or echocardiographic findings of other cardiovascular disease (including hypertension), related pulmonary disease, or cardiac abnormalities such as enlargement of the left atrium, and age under 60years Nonvalvular AF absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair Secondary AF occurs in the setting of a primary condition which may be the cause of the AF, such as acute myocardial infarction, cardiac surgery, pericarditis, myocarditis, hyperthyroidism, pulmonary embolism, pneumonia, or other acute pulmonary disease

Atrial fibrillation

159

Signs and symptoms


Atrial fibrillation is usually accompanied by symptoms related to a rapid heart rate. Rapid and irregular heart rates may be perceived as palpitations, exercise intolerance, and occasionally produce angina (if the rate is faster and puts the heart under strain) and congestive symptoms of shortness of breath or edema. Sometimes the arrhythmia will be identified only with the onset of a stroke or a transient ischemic attack (TIA). It is not uncommon for a patient to first become aware of AF from a routine physical examination or ECG, as it may be asymptomatic in many cases.[] As most cases of atrial fibrillation are secondary to other medical problems, the presence of chest pain or angina, symptoms of hyperthyroidism (an overactive thyroid gland) such as weight loss and diarrhea, and symptoms suggestive of lung disease would indicate an underlying cause. A history of stroke or TIA, as well as hypertension (high blood pressure), diabetes, heart failure and rheumatic fever, may indicate whether someone with AF is at a higher risk of complications.[] A higher risk of embolus can be assessed using the CHADS2 score.

Rapid heart rate


Presentation is similar to other forms of rapid heart rate (tachycardia), and in some cases may actually be asymptomatic. The patient may complain of palpitations or chest discomfort. The rapid heart rate may result in the heart being unable to provide adequate blood flow and oxygen delivery to the rest of the body. Therefore, common symptoms may include shortness of breath which often worsens with exertion (dyspnea on exertion), shortness of breath when lying flat (orthopnea), and sudden onset of shortness of breath during the night (paroxysmal nocturnal dyspnea), and may progress to swelling of the lower extremities (peripheral edema). Owing to inadequate blood flow, patients may also complain of light-headedness, may feel like they are about to faint (presyncope), or may actually lose consciousness (syncope). The patient may be in significant respiratory distress. Because of inadequate oxygen delivery, the patient may appear blue (cyanosis). By definition, the heart rate will be greater than 100 beats per minute. Blood pressure will be variable, and often difficult to measure as the beat-by-beat variability causes problems for most digital (oscillometric) non-invasive blood pressure monitors. It is most worrying if consistently lower than usual (hypotension). Respiratory rate will be increased in the presence of respiratory distress. Pulse oximetry may confirm the presence of hypoxia related to any precipitating factors such as pneumonia. Examination of the jugular veins may reveal elevated pressure (jugular venous distention). Lung exam may reveal crackles, which are suggestive of pulmonary edema. Heart exam will reveal an irregular but rapid rhythm.

Association with other conditions


Central sleep apnea (CSA) A study found that the prevalence of atrial fibrillation among patients with idiopathic central sleep apnea was significantly higher than the prevalence among patients with obstructive sleep apnea or no sleep apnea (27%, 1.7%, and 3.3%, respectively). There was a total of 180 subjects with 60 people in each of the 3 groups. Possible explanations for the association between CSA and AF are a causal relationship between the two conditions, or an abnormality of central cardiorespiratory regulation.[] Left atrial enlargement Mitral stenosis

Atrial fibrillation

160

Diagnosis
The evaluation of atrial fibrillation involves diagnosis, determination of the etiology of the arrhythmia, and classification of the arrhythmia. The minimal evaluation of atrial fibrillation is a history and physical examination, ECG, transthoracic echocardiogram, and case specific bloodwork. Depending upon given resources, afflicted individuals may benefit from an in-depth evaluation which may include correlation of the heart rate response to exercise, exercise stress testing, chest X-ray, trans-esophageal echocardiography, and other studies.

A 12 lead ECG showing atrial fibrillation at approximately 150 beats per minute

If a patient presents with a sudden onset of severe symptoms other forms of tachyarrhythmia must be ruled-out, as some may be immediately life threatening, such as ventricular tachycardia. While most patients will be placed on continuous cardiorespiratory monitoring, an electrocardiogram is essential for diagnosis. Provoking causes should be sought out. A common cause of any tachycardia is dehydration, as well as other forms of hypovolemia. Acute coronary syndrome should be ruled out. Intercurrent illness such as pneumonia may be present.

Screening
Screening for atrial fibrillation is not generally performed, although a study of routine pulse checks or ECGs during routine office visits found that the annual rate of detection of AF in elderly patients improved from 1.04% to 1.63%; selection of patients for prophylactic anticoagulation would improve stroke risk in that age category.[] This estimated sensitivity of the routine primary care visit is 64%. This low result probably reflects the pulse not being checked routinely or carefully.[] When ECGs are used for screening, the SAFE trial found that electronic software, primary care physicians and the combination of the two had the following sensitivities and specificities:[] Interpreted by software: sensitivity = 83%, specificity = 99% Interpreted by a primary care physician: sensitivity = 80%, specificity = 92% Interpreted by a primary care physician with software: sensitivity = 92%, specificity = 91%

Minimal evaluation
The minimal evaluation of atrial fibrillation should generally be performed in all individuals with AF. The goal of this evaluation is to determine the general treatment regimen for the individual. If results of the general evaluation warrant it, further studies may then be performed. History and physical examination The history of the individual's atrial fibrillation episodes is probably the most important part of the evaluation. Distinctions should be made between those who are entirely asymptomatic when they are in AF (in which case the AF is found as an incidental finding on an ECG or physical examination) and those who have gross and obvious symptoms due to AF and can pinpoint whenever they go into AF or revert to sinus rhythm.

Atrial fibrillation Routine bloodwork While many cases of AF have no definite cause, it may be the result of various other problems (see below). Hence, renal function and electrolytes are routinely determined, as well as thyroid-stimulating hormone (commonly suppressed in hyperthyroidism and of relevance if amiodarone is administered for treatment) and a blood count.[] In acute-onset AF associated with chest pain, cardiac troponins or other markers of damage to the heart muscle may be ordered. Coagulation studies (INR/aPTT) are usually performed, as anticoagulant medication may be commenced.[] Electrocardiogram Atrial fibrillation is diagnosed on an electrocardiogram (ECG), an investigation performed routinely whenever an irregular heart beat is suspected. Characteristic findings are the absence of P waves, with disorganized electrical activity in their place, and irregular R-R intervals due to irregular conduction of impulses to ECG of atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow the ventricles.[] At very fast heart rates indicates a P wave, which is lost in atrial fibrillation. atrial fibrillation may look more regular which may make it more difficult to separate from SVT or ventricular tachycardia.[9] QRS complexes should be narrow, signifying that they are initiated by normal conduction of atrial electrical activity through the intraventricular conduction system. Wide QRS complexes are worrisome for ventricular tachycardia, although in cases where there is disease of the conduction system, wide complexes may be present in A-Fib with rapid ventricular response. If paroxysmal AF is suspected but an ECG during an office visit only shows a regular rhythm, AF episodes may be detected and documented with the use of ambulatory Holter monitoring (e.g. for a day). If the episodes are too infrequent to be detected by Holter monitoring with reasonable probability, then the patient can be monitored for longer periods (e.g. a month) with an ambulatory event monitor.[] Echocardiography A non-invasive transthoracic echocardiogram (TTE) is generally performed in newly diagnosed AF, as well as if there is a major change in the patient's clinical state. This ultrasound-based scan of the heart may help identify valvular heart disease (which may greatly increase the risk of stroke), left and right atrial size (which indicates likelihood that AF may become permanent), left ventricular size and function, peak right ventricular pressure (pulmonary hypertension), presence of left atrial thrombus (low sensivity), presence of left ventricular hypertrophy and pericardial disease.[] Significant enlargement of both the left and right atria is associated with long-standing atrial fibrillation and, if noted at the initial presentation of atrial fibrillation, suggests that the atrial fibrillation is likely to be of a longer duration than the individual's symptoms.

161

Atrial fibrillation

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Extended evaluation
An extended evaluation is generally not necessary in most individuals with atrial fibrillation, and is only performed if abnormalities are noted in the limited evaluation, if a reversible cause of the atrial fibrillation is suggested, or if further evaluation may change the treatment course. Chest X-ray A chest X-ray is generally only performed if a pulmonary cause of atrial fibrillation is suggested, or if other cardiac conditions are suspected (particularly congestive heart failure.) This may reveal an underlying problem in the lungs or the blood vessels in the chest.[] In particular, if an underlying pneumonia is suggested, then treatment of the pneumonia may cause the atrial fibrillation to terminate on its own. Transesophageal echocardiogram A normal echocardiography (transthoracic or TTE) has a low sensitivity for identifying thrombi (blood clots) in the heart. If this is suspected (e.g., when planning urgent electrical cardioversion) a transesophageal echocardiogram (TEE or TOE where British spelling is used) is preferred.[] The TEE has much better visualization of the left atrial appendage than transthoracic echocardiography. This structure, located in the left atrium, is the place where thrombus is formed in more than 90% of cases in non-valvular (or non-rheumatic) atrial fibrillation or flutter.[] TEE has a high sensitivity for locating thrombi in this area[] and can also detect sluggish bloodflow in this area that is suggestive of thrombus formation.[] If no thrombus is seen on TEE, the incidence of stroke, (immediately after cardioversion is performed), is very low.[citation needed] Ambulatory Holter monitoring A Holter monitor is a wearable ambulatory heart monitor that continuously monitors the heart rate and heart rhythm for a short duration, typically 24 hours. In individuals with symptoms of significant shortness of breath with exertion or palpitations on a regular basis, a holter monitor may be of benefit to determine if rapid heart rates (or unusually slow heart rates) during atrial fibrillation are the cause of the symptoms. Exercise stress testing Some individuals with atrial fibrillation do well with normal activity but develop shortness of breath with exertion. It may be unclear if the shortness of breath is due to a blunted heart rate response to exertion caused by excessive AV node blocking agents, a very rapid heart rate during exertion, or due to other underlying conditions such as chronic lung disease or coronary ischemia. An exercise stress test will evaluate the individual's heart rate response to exertion and determine if the AV node blocking agents are contributing to the symptoms.

Causes
AF is linked to several cardiac causes, but may occur in otherwise normal hearts. Known associations include: Hypertension (High blood pressure) Primary heart diseases including coronary artery disease, mitral stenosis (e.g., due to rheumatic heart disease or mitral valve prolapse), mitral regurgitation, hypertrophic cardiomyopathy (HCM), pericarditis, congenital heart disease, previous heart surgery Lung diseases (such as pneumonia, lung cancer, pulmonary embolism, sarcoidosis) Excessive alcohol consumption ("binge drinking" or "holiday heart syndrome"). Even otherwise healthy middle-aged women who consumed more than 2 drinks daily were 60% more likely to develop AF.[10] Hyperthyroidism Dual-chamber pacemakers in the presence of normal atrioventricular conduction.[11]

Atrial fibrillation A family history of AF may increase the risk of AF. A study of more than 2,200 AF patients found that 30 percent had parents with AF.[] Various genetic mutations may be responsible.[][]

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Pathophysiology
Morphology
The primary pathologic change seen in atrial fibrillation is the progressive fibrosis of the atria. This fibrosis is primarily due to atrial dilation, however genetic causes and inflammation may have a cause in some individuals. One study found that atrial dilation can occur as a consequence of AF,[] although another study found that AF by itself does not cause it.[] Dilation of the atria can be due to almost any structural abnormality of the heart that can cause a rise in the intra-cardiac pressures. This includes valvular heart disease (such as mitral stenosis, mitral regurgitation, and tricuspid regurgitation), hypertension, and congestive heart failure. Any inflammatory state that affects the heart can cause fibrosis of the atria. This is typically due to sarcoidosis but may also be due to autoimmune disorders that create autoantibodies against myosin heavy chains. Mutation of the lamin AC gene is also associated with fibrosis of the atria that can lead to atrial fibrillation. Once dilation of the atria has occurred, this begins a chain of events that leads to the activation of the renin aldosterone angiotensin system (RAAS) and subsequent increase in matrix metaloproteinases and disintegrin, which leads to atrial remodeling and fibrosis, with loss of atrial muscle mass. This process is not immediate, and experimental studies have revealed patchy atrial fibrosis may precede the occurrence of atrial fibrillation and may progress with prolonged durations of atrial fibrillation. Fibrosis is not limited to the muscle mass of the atria, and may occur in the sinus node (SA node) and atrioventricular node (AV node), correlating with sick sinus syndrome. Prolonged episodes of atrial fibrillation have been shown to correlate with prolongation of the sinus node recovery time,[][][] suggesting that dysfunction of the SA node is progressive with prolonged episodes of atrial fibrillation.

Electrophysiology
Conduction Sinus rhythm Atrial fibrillation

The normal electrical conduction system of the heart allows the impulse that is generated by the sinoatrial node (SA node) of the heart to be propagated to and stimulate the myocardium (muscle of the heart). When the myocardium is

Atrial fibrillation stimulated, it contracts. It is the ordered stimulation of the myocardium that allows efficient contraction of the heart, thereby allowing blood to be pumped to the body. There are multiple theories about the etiology of atrial fibrillation. An important theory is that in atrial fibrillation, the regular impulses produced by the sinus node for a normal heartbeat, are overwhelmed by rapid electrical discharges produced in the atria and adjacent parts of the pulmonary veins. Sources of these disturbances are either automatic foci, often localized at one of the pulmonary veins, or a small number of localized sources in the form of either reentrant electrical spiral waves (rotors) or repetitive focal beats; these localized sources may be found in the left atrium near the pulmonary veins or in a variety of other locations through both the left or right atrium. Because recovery of the atria from excitation is heterogeneous, the electrical waves generated by the AF sources undergo repetitive, spatially distributed breakup and fragmentation in a process known as "fibrillatory conduction". Another theory is the multiple wavelet theory first formulated by Moe,[] which was experimentally proven by Allessie et al. AF can be distinguished from atrial flutter (AFL), which appears as an organized electrical circuit usually in the right atrium. AFL produces characteristic saw-toothed F-waves of constant amplitude and frequency on an ECG whereas AF does not. In AFL, the discharges circulate rapidly at a rate of 300beats per minute (bpm) around the atrium. In AF, there is no regularity of this kind, except at the sources where the local activation rate can exceed 500 bpm. Although the electrical impulses of AF occur at a high rate, most of them do not result in a heart beat. A heart beat results when an electrical impulse from the atria passes through the atrioventricular (AV) node to the ventricles and causes them to contract. During AF, if all of the impulses from the atria passed through the AV node, there would be severe ventricular tachycardia resulting in severe reduction of cardiac output. This dangerous situation is prevented by the AV node since its limited conduction velocity reduces the rate at which impulses reach the ventricles during AF.[]

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Management
The main goals of treatment are to prevent circulatory instability and stroke. Rate or rhythm control are used to achieve the former, while anticoagulation is used to decrease the risk of the latter.[12] If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated.[]

Anticoagulation
Anticoagulation can be achieved through a number of means including the use of heparin, warfarin, dabigatran and rivaroxaban . Which method is used depends on a number issues including: cost, risk of stroke, risk of falls, compliance, and speed of desired onset of anticoagulation.[] Some other anticoagulants were discussed in a 2012 state-of-the-art paper but were not generally approved at that time for stroke prevention in AF: apixaban, and edoxaban.[]

Rate control versus rhythm control using drugs


AF can cause disabling and bothersome symptoms. Palpitations, chest discomfort, anxiety, and decreased exercise tolerance are related to rapid heart rate and inefficient cardiac output caused by AF. Furthermore, AF with a persistent rapid rate can cause a form of heart failure called tachycardia induced cardiomyopathy. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF. There are two ways to approach these symptoms using drugs: rate control and rhythm control. Rate control lowers the heart rate closer to normal, usually 60 to 100bpm, without trying to convert to a regular rhythm. Rhythm control restores normal heart rhythm in a process called cardioversion and maintains the normal rhythm with drugs. Studies suggest that rhythm control is most important in the acute setting AF, while rate control is more important in the chronic phase. As far as mortality is concerned, the AFFIRM trial showed that there is lower mortality using rate

Atrial fibrillation control with anticoagulation treatment versus rhythm control treatment and the difference increases up to 5 years (end of study).[] There is no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment compared to those who have only rate control.[] AF is associated with a reduced quality of life, and while some studies indicate that rhythm control leads to a higher quality of life, some did not find a difference.[13] A further study focused on rhythm control in patients with AF with concomitant heart failure, based on the hypothesis that AF confers a higher mortality risk in heart failure. In this setting, rhythm control offered no advantage compared to rate control.[14] However, the diagnosis and progression of atrial fibrillation and other cardiovascular disease requires further investigation. In patients with a fast ventricular response, intravenous magnesium significantly increases the chances of successful rate and rhythm control in the urgent setting without major side-effects.[15] A patient with fluctuating vital signs, mental status changes, preexcitation, or chest pain often will go to immediate treatment with synchronized DC cardioversion.[] Otherwise the decision of rate control versus rhythm control using drugs is made. This is based on a number of criteria that includes whether or not symptoms persist with rate control.

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Rate control
Rate control is achieved with medications that work by increasing the degree of block at the level of the AV node, effectively decreasing the number of impulses that conduct into the ventricles. This can be done with:[][] Beta blockers (preferably the "cardioselective" beta blockers such as metoprolol, atenolol, bisoprolol, nebivolol) Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil) Cardiac glycosides (e.g., digoxin) have limited use, apart from in the sedentary elderly patient In addition to these agents, amiodarone has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension). Diltiazem has been shown to be more effective than either digoxin or amiodarone.[16]

Cardioversion
Cardioversion is a noninvasive conversion of an irregular heartbeat to a normal heartbeat using electrical or chemical means.[] Electrical cardioversion involves the restoration of normal heart rhythm through the application of a DC electrical shock. Chemical cardioversion is performed with drugs, such as amiodarone, dronedarone,[17] procainamide, dofetilide, ibutilide, propafenone, or flecainide. Vernakalant, an investigational drug which is unavailable in the U.S., has been found to safely and rapidly convert new onset atrial fibrillation in one published study.[18] After successful cardioversion the heart may be in a stunned state, which means that there is a normal rhythm but restoration of normal atrial contraction has not yet occurred.[]

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Ablation
In young patients where rhythm control is desired and cannot be maintained by medication or cardioversion then radiofrequency ablation or cryoablation may be attempted and is preferred over years of drug therapy.[]

Maze Procedure
The Maze procedure, first performed in 1987, is an effective invasive surgical treatment that is designed to create electrical blocks or barriers in the atria of the heart, forcing electrical impulses that stimulate the heartbeat to travel down to the ventricles. The idea is to force abnormal electrical signals to move along one, uniform path to the lower chambers of the heart (ventricles), thus restoring the normal heart rhythm.[19]

Following surgery
AF often occurs after cardiac surgery and is usually self-limiting. It is strongly associated with age, pre-operative hypertension, and the number of vessels grafted. Measures should be taken to control hypertension pre-operatively to reduce the risk of AF. Also, patients with a higher risk of AF, e.g., patients with pre-operative hypertension, more than 3 vessels grafted, or greater than 70 years of age, should be considered for prophylactic treatment. Postoperative pericardial effusion is also suspected to be the cause of atrial fibrillation. Prophylaxis may include prophylactic post-operative rate and rhythm management. Some authors perform posterior pericardiotomy to reduce the incidence of postoperative AF.[] When AF occurs, management should primarily be rate and rhythm control. However, cardioversion may be employed if the patient is haemodynamically unstable, highly symptomatic, or persists for 6 weeks after discharge. In persistent cases anticoagulation should be used.

Prognosis
Thromboembolism
In atrial fibrillation, the lack of an organized atrial contraction can result in some stagnant blood in the left atrium (LA) or left atrial appendage (LAA). This lack of movement of blood can lead to thrombus formation (blood clotting). If the clot becomes mobile and is carried away by the blood circulation, it is called an embolus. An embolus proceeds through smaller and smaller arteries until it plugs one of them and prevents blood from flowing through the artery. This process results in end-organ damage due to loss of nutrients, oxygen, and removal of cellular waste products. Thrombus can form anywhere in the body, while emboli follow the blood circulation to specific points in the body. Emboli in the brain may result in an ischemic stroke or a transient ischemic attack (TIA). More than 90% of cases of thrombi associated with non-valvular atrial fibrillation evolve in the left atrial appendage.[] However, the LAA lies in close relation to the free wall of the left ventricle and thus the LAA's emptying and filling, which determines its degree of blood stagnation, may be helped by the motion of the wall of the left ventricle, if there is good ventricular function.[20] If the LA is enlarged, there is an increased risk of thrombi that originate in the LA. Moderate to severe, non-rheumatic, mitral regurgitation (MR) reduces this risk of stroke.[] This risk reduction may be due to a beneficial stirring effect of the MR blood flow into the LA.[]

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Mitral valve
Atrial fibrillation and a corresponding enlargement of the left atrium may cause an increase in the perimeter of the mitral valve. The somewhat circular perimeter of the mitral valve is defined by the mitral annulus.[] With a normal sinus rhythm, the mitral annulus undergoes dynamic changes during the cardiac cycle. For example, at the end of diastole the annular area is smaller than at the end of systole. A possible reason for this dynamic size difference is that the coordinated contraction of the left atrium acts like a sphincter about the mitral annulus and reduces its size. This may be important for mitral valve competence so that it does not leak when the left ventricle pumps blood. However, when the left atrium fibrillates, this sphincter action is not possible and may contribute to, or result in, mitral regurgitation in some cases.[]

Epidemiology
Atrial fibrillation is the most common arrhythmia found in clinical practice.[] It also accounts for 1/3 of hospital admissions for cardiac rhythm disturbances,[] and the rate of admissions for AF has risen in recent years.[] Strokes from AF account for 6-24% of all ischemic strokes.[] Between 311% of those with AF have structurally normal hearts.[] Approximately 2.2million individuals in the United States and 4.5million in the European Union have AF.[][21] The incidence of atrial fibrillation increases with age. The prevalence in individuals over the age of 80 is about 8%.[22] In developed countries, the number of patients with atrial fibrillation is likely to increase during the next 50years, owing to the growing proportion of elderly individuals.[23]

Genetics
Four type of genetic disorder are associated with atrial fibrillation:[24] familial AF as a monogenic disease familial AF presenting in the setting of another inherited cardiac disease (hypertrophic cardiomyopathy, dilated cardiomyopathy, familial amyloidosis) inherited arrhythmic syndromes (congenital long QT syndrome, short QT syndrome, Brugada syndrome) non-familial AF associated with genetic backgrounds (polymorphism in the ACE gene) that may predispose to atrial fibrillation

History
Because the diagnosis of atrial fibrillation requires measurement of the electrical activity of the heart, atrial fibrillation was not truly described until 1874, when Edm Flix Alfred Vulpian observed the irregular atrial electrical behavior that he termed "fremissement fibrillaire" in dog hearts.[25] In the mid-eighteenth century, Jean-Baptiste de Snac made note of dilated, irritated atria in people with mitral stenosis.[26] The irregular pulse associated with AF was first recorded in 1876 by Carl Wilhelm Hermann Nothnagel and termed "delirium cordis", stating that "[I]n this form of arrhythmia the heartbeats follow each other in complete irregularity. At the same time, the height and tension of the individual pulse waves are continuously changing".[27] Correlation of delirium cordis with the loss of atrial contraction as reflected in the loss of a waves in the jugular venous pulse was made by Sir James MacKenzie in 1904.[28] Willem Einthoven published the first ECG showing AF in 1906.[29] The connection between the anatomic and electrical manifestations of AF and the irregular pulse of delirium cordis was made in 1909 by Carl Julius Rothberger, Heinrich Winterberg, and Sir Thomas Lewis.[30][31][32]

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References
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I48 [2] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=427. 31 [3] http:/ / www. diseasesdatabase. com/ ddb1065. htm [4] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000184. htm [5] http:/ / www. emedicine. com/ med/ topic184. htm [6] http:/ / www. emedicine. com/ emerg/ topic46. htm# [7] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D001281 [19] Northwestern Surgery for Atrial Fibrillation. Atrial Fibrillation Surgery (http:/ / www. nmh. org/ nm/ atrial-fibrillation-surgery) [24] Shimizu W (2013) Atrial fibrillation and genetic abnormalities. Nihon Rinsho 71(1):161-1666

External links
Atrial fibrillation (http://www.dmoz.org/Health/Conditions_and_Diseases/Cardiovascular_Disorders/ Heart_Disease/Arrhythmia/Atrial_Fibrillation//) at the Open Directory Project

American Hospital Association

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American Hospital Association


American Hospital Association
Founded 1898

Headquarters Chicago, Illinois and Washington, D.C. Origins Key people The Association of Hospital Superintendents of the United States and Canada Thomas M. Priselac, Chairman [1] Richard Umbdenstock, President & CEO health care health care 5,708 [2] [3]

Area served Services Members Website

American Hospital Association

The American Hospital Association (AHA) is an organization that promotes the quality provision of health care by hospitals and health care networks through such efforts as promoting effective public policy and providing information related to health care and health administration to health care providers and the public. Founded in 1898 and hosting offices in Chicago, Illinois and Washington, D.C., the AHA hosts a Resource Center with more than 47,000 books on health care (some services fee based) and maintains an extensive, frequently updated Health Planning and Administration (HEALTH) database, which provides information related to health care unrelated to clinical treatment.[][4] More than 5,600 organizations and 41,000 individuals are members of the AHA.[]

History
In 1870, there were only about a hundred general hospitals in the United States, but the institution was growing rapidly.[] Hospital administrators formed an organization called "The Association of Hospital Superintendents of the United States and Canada", which held its first meeting in 1899 in Cleveland, Ohio, in which city seven of the eight superintendents in attendance were based.[] The organization was promoted by publisher Del Sutton, whose journal The National Hospital Sanitarium Record was adopted by the new group in 1900, gradually coming under control of the organization until it was replaced by the organization's own publication, The Modern Hospital.[5] In 1906, the growing organization adopted its present name, with membership reaching 450 in 1908.[6] Records of early annual meetings detail some of the conflicts in the emerging hospital culture of Canada and the United States concerning whether hospitals should be governed by physicians or administrators, with laypersons representing a heavy majority.[7]

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Personal membership groups


Personal membership groups (PMGs) are affiliated societies which fall under the umbrella of the AHA: American Society for Healthcare Engineering (ASHE) American Society for Healthcare Environmental Services (ASHES) American Society for Healthcare Human Resources Administration (ASHHRA) American Society for Healthcare Risk Management (ASHRM) Association for Community Health Improvement (ACHI) Association for the Healthcare Environment (AHE)[8] Association for Healthcare Resource & Materials Management (AHRMM) Association for Healthcare Volunteer Resource Professionals (AHVRP) At Large AHA Membership for Healthcare Management/Consulting Professionals Society for Healthcare Consumer Advocacy (SHCA) Society for Healthcare Strategy and Market Development (SHSMD)[]

References
[1] Richard Umbdenstock Bio (http:/ / www. aha. org/ aha/ content/ 2010/ pdf/ RJU-bio-. pdf), accessed December 22, 2010 [2] http:/ / www. aha. org/ aha/ resource-center/ Statistics-and-Studies/ fast-facts. html [3] [5] [6] [7] [8] http:/ / www. aha. org/ aha_app/ index. jsp Vogel, 245. Vogel, 244, 245. Vogel, 252. http:/ / www. ahe. org/

External links
American Hospital Association homepage (http://www.aha.org/aha_app/index.jsp)

American Heart Association

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American Heart Association


American Heart Association
Founded Founder(s) 1924 Physicians

Headquarters 7272 Greenville Avenue Dallas, TX 75231-4596 Key people Mission Motto Website Nancy A. Brown- Chief Executive Officer, Kathy Rogers-Executive Vice President of Consumer Markets "Building healthier lives, free of cardiovascular diseases and stroke" Learn and Live Official Website [1]

The American Heart Association (AHA) is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas. The American Heart Association is a national voluntary health agency whose mission is: "Building healthier lives, free of cardiovascular diseases and stroke." Its motto is "Learn and Live". Ralph L. Sacco, MD, MS, FAAN, FAHA, is the current President of the American Heart Association. He is the first neurologist to hold the position.

Mission
The American Heart Association publishes a standard for providing basic and advanced life support, including standards for proper performance of cardiopulmonary resuscitation (CPR). The AHA offers the most widely accepted certification for basic life support (BLS). The AHA is now also a provider of training for first aid, in addition to CPR. The AHA also operates an affiliated organization, the American Stroke Association, which focuses on care, research and prevention of strokes.

History and Reputation


In 1994, the Chronicle of Philanthropy, an industry publication, released the results of the largest study of charitable and non-profit organization popularity and credibility. The study showed that the American Heart Association was ranked as the 5th "most popular charity/non-profit in America" of over 100 charities researched with 95% of Americans over the age of 12 choosing Love and Like A lot for the American Heart Association.[2]

Recent Events and Activities


On October 28, 2009 The American Heart Association and the Ad Council launched a Hands Only CPR PSA and website.[3] On November 30, 2009, The American Heart Association announced a new cardiac arrest awareness campaign called Be the Beat.[4] The campaigns aim is to help create the next generation of lifesavers by teaching 12- to 15-year-olds fun ways to learn the basics of cardiopulmonary resuscitation and how to use an automated external defibrillator. The official site, BetheBeat.heart.org [5], contains interactive games, quizzes, and a playlist of 100-beat-per-minute songs, as well as a section for teachers and administrators who want to incorporate CPR and AED educational information into their schools.

American Heart Association In May 2010, the AHA endorsed the Nintendo Wii Console to encourage everyone to get involved in a level of fitness that would develop healthiness. The AHA Heart Icon is featured on the box of the console as well as on the Wii Fit Plus and Wii Sports Resort titles. In July 2011, new content was added to the website including a digital app that helps a user learn how to perform Hands-Only CPR.[6] It also carried out a campaign in 2012 to educate more people on how to carry out Hands-Only CPR.[][][] The 2012 campaign, which began in New York, had Jennifer Coolidge as the celebrity spokesperson.[] Various affiliates around the country hold annual fundraising events, such as Go Red for Women, Heart Ball and Heart Walk. In 2012, singer-songwriter and actress Michelle Williams became an ambassador for the Power to End Stroke campaign. In speaking of her role she said "I am honored to partner with the campaign [...] My father had a stroke in 2005 due to smoking, diabetes and an unhealthy diet, and my grandmother was diagnosed with having a stroke in 2006 when she went to her doctor for a simple outpatient procedure. I am bringing awareness to people so that strokes can be prevented. Lets take care of ourselvesthe first step is knowledge about your health."[]

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External links
Official website [7] American Stroke Association Web site [8] My.AmericanHeart.org Web site [9] American Heart Association Training Web Site [10] Be the Beat [5] Hands Only CPR [11] Stroke Heroes Act FAST Heart Walk site [12] Go Red for Women site [13]

References
[1] http:/ / www. heart. org [2] The Charities Americans Like Most And Least, The Chronicle of Philanthropy, December 13, 1996 And USA Today, December 20, 1994, "Charity begins with health", FINAL 01D [3] American Heart Association, Ad Council launch Hands-Only CPR campaign (http:/ / www. newsroom. heart. org/ index. php?s=43& item=852) [4] Association's Campaign Inspires Teens to Use CPR, AEDs to Save Lives (http:/ / www. prnewswire. com/ news-releases/ associations-campaign-inspires-teens-to-use-cpr-aeds-to-save-lives-78125492. html) [5] http:/ / betheBeat. heart. org/ [6] Americans can learn Hands-Only CPR with a new digital application (http:/ / www. multivu. com/ mnr/ 50577-ad-council-hands-only-cpr) [7] http:/ / www. heart. org/ [8] http:/ / www. strokeassociation. org/ [9] http:/ / www. my. americanheart. org/ [10] http:/ / www. onlineaha. org/ [11] http:/ / handsonlycpr. org/ [12] http:/ / www. heartwalk. org/ [13] http:/ / www. goredforwomen. org/

American Health Care Association

173

American Health Care Association


AHCA/NCAL
Motto Legalstatus Headquarters Location Membership Improving Lives by Delivering Solutions for Quality Care. trade association 1201 L Street NW Washington, DC 11,000 facilities

Officiallanguages English CEO/President Website Governor Mark Parkinson Official Site [1]

The American Health Care Association (AHCA) is non-profit federation of affiliated state health organizations, together representing more than 10,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for more than 1.5 million elderly and disabled individuals nationally. AHCA was founded in 1949 and is based in Washington, D.C. The National Center for Assisted Living (NCAL) is part of AHCA. AHCA/NCAL's mission statement: Improving Lives by Delivering Solutions for Quality Care.[citation needed] AHCA/NCAL works with Congress and the Federal government to advocate for long term care services. Membership is open to small and large health care facilities as well as long term care administrators, directors of nursing, certified nursing assistants, and facility owners and operators. Currently, the CEO/President of AHCA is Mark Parkinson, former Governor of Kansas. NCAL's CEO/President is Dave Kyllo. AHCA publishes a weekly member-only email newsletter called Capitol Connection and a separate monthly magazine titled Provider. The publications include breaking news and legislative progress on regulations and issue affecting the long term care industry. The association also offers professional development, educational, and networking opportunities. AHCA/NCAL established their Advancing Excellence in Americas Nursing Homes campaign in 2007 to improve care quality in nursing homes.[citation needed] The AHCA established the National Nursing Home Week in 1967. This is a week long observance recognizing nursing homes. It is held in May and begins on Mother's Day, the second Sunday of May. AHCA/NCAL has an up-to-date blog on industry-related news called Long Term Care Provider as well as a Facebook Page, YouTube Channel, and Twitter handle.

Quality improvement
AHCA/NCAL serves skilled nursing care centers in improving the quality of care provided to residents. AHCA provides facilities with resources and solutions for quality improvement such as Quality Reports, the Quality Award Program, a Leadership Excellence program, Gero Nurse Prep, and Nurse Assistant Training. In February 2012, AHCA/NCAL introduced The Quality Initiative-an effort that builds upon existing work the long term and post-acute care field is doing by setting specific, measurable targest to further improve quality of care in American's nursing and assisted living centers. The four main goals of The Quality Initiative are: 1. Safely Reduce Hospital Readmissions: By March 2012, reduce the number of hospital readmissions within 30 days during a SNF stay by 15 percent.

American Health Care Association 2. Increase Staff Stability: By March 2015, reduce turnover among nursing staff (RN, LPN/LVN, CNA) by 15 percent. 3. Increase Customer Satisfaction: By March 2015, increase the number of customers who would recommend the facility to others up to 90 percent. 4. Safely Reduce the Off-Label Use of Antipsychotics: By December 2012, reduce the off-label use of antipsychotic drugs by 15 percent.

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Advocacy
AHCA/NCAL's current advocacy issues include: 1. Protect and Preserve Medicaid Funding for Long Term 2. Stable Medicare Funding Essential for Quality Care 3. Extended Observation Stays Constrain Medicare Beneficiaries' Access to Skilled Nursing Facility Services AHCA/NCAL also provides an Advocate Toolkit which includes: Guide to Political Action and Grassroots Lobbying, Crafting an Effective Message, Steps to a Successful Facility Tour, and Using Facebook to Connect with Congress.

Research and data


AHCA develops and compiles comprehensive research and data concerning the long term and post-acute care sector. Whether conducted by AHCA and research agencies or gathered from government agencies, AHCA tries to inform the public and policymakers about the state of skilled nursing centers. Research and Data tools and resources include: LTC Trend Tracker, LTC Stats, Funding, and Trends and Statistics.

Member resources
AHCA/NCAL members have access to various information and resources which include: Clinical Practice, Compliance Programs, Disaster Planning, Fire and Life Safety, Finance, Medicaid, Survey and Certification, and Medicare. Members also have access to various publications such as Capitol Connection, NCAL Focus, Provider Magazine, NFP Newsletter, and DD Digest.

Events
AHCA/NCAL Convention - This annual long term care industry event includes influential speakers, education programs, networking opportunities, and activities. Congressional Briefing - Members convene annually at the nation's capital in order to raise awareness of important issues affecting long term and post-acute care in addition to meeting with congressional representatives. NCAL Spring Conference - This stand-alone event for assisted living professionals had its first inaugural conference in spring of 2012. Independent Owner Conference - The AHCA/NCAL Independent Owner Leadership Conference is for independent owners (IOs) and not for profit operators of ten or fewer long term care facilities. Quality Symposium - This annual symposium is for long term care quality professionals and is an event that provides a broad spectrum of programming to quality practitioners at all levels. Included are individual sessions, poster sessions, keynote speakers, networking, and idea sharing.

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External links
American Health Care Association [2] National Center for Assisted Living [3] National Nursing Home Week official site [4] Provider Magazine [5] Care Conversations [6]

References
[1] [2] [3] [4] [5] [6] http:/ / www. ahcancal. org http:/ / www. ahca. org/ http:/ / www. ncal. org/ http:/ / www. nnhw. org/ http:/ / www. providermagazine. com/ Pages/ default. aspx http:/ / www. careconversations. org/

American Health Information Management Association


The American Health Information Management Association (AHIMA) is a professional organization for the field of medical record management. Traditionally practicing in hospitals and to referring paper files and records, the field presently refers to all healthcare systems and types of media. The organization traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to "elevate the standards of clinical records in hospitals and other medical institutions." The organization has had three name changes in its history, all were justified with an e xplanation that reflected the progression of contemporary medical record use, practices and perceptions. In 1938 the association became the American Association of Medical Record Librarians (AAMRL). In 1970, the association became the American Medical Record Association (AMRA) and in 1991, the title American Health Information Management Association (AHIMA) was adopted. Incorporation occurred in 1943 and became effective the next year. AHIMA's stated mission is to be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.

American Health Information Management Association

Formation Type Headquarters Location Membership

1928 professional association Chicago, Illinois United States 64,000

Official Language English President Patty Thierry Sheridan

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As of 2011, the association has more than 64,000 members in four membership classifications. Each member subsequently belongs to a relevant state chapter. The association offers seven credentials pertaining to four areas of practice; HIM, Coding, Data Analysis and Privacy. Two credentials require formal education, the others are acquired by a combination of testing and work experience. AHIMA requires members obtain regular continuing education to maintain their credentials. The Journal of AHIMA has a circulation of 61,000 and publishes both peer-reviewed and non-peer-reviewed articles. The association's membership is overwhelmingly female. AHIMA describes its foundation as a sister organization and states the foundation has a charitable and educational nature. The foundation's stated mission is to be the pre-eminent foundation recognized for excellence in health information leadership, policy and research for the healthcare industry and the public. The foundation formulates and issues opinions, supports education, conducts research and compiles its contributions into the Body of Knowledge (BoK).

References
AHIMA entry - TheFreeDictionary (http://medical-dictionary.thefreedictionary.com/AHIMA)

External links
AHIMA.org is the American Health Information Management Association's official site (http://www.AHIMA. org) ArHIMA.org is the Arkansas Health Information Management Association's official site (http://www. ARHIMA.org) WHIMA.org is the Wisconsin Health Information Management Association's official site (http://www.WHIMA. org) TXHIMA.org is the Texas Health Information Management Association's official site (http://www.TXHIMA. org) WSHIMA.org is the Washington State Health Information Management Association's official site (http://www. WSHIMA.org) MNHIMA.org is the Minnesota Health Information Management Association's official site (http://www. MNHIMA.org) WVHIMA.org is the West Virginia Health Information Management Association's official site (http://www. WVHIMA.org)

America's Health Insurance Plans

177

America's Health Insurance Plans


America's Health Insurance Plans
Abbreviation Formation Type AHIP 2003 trade association

Purpose/focus political advocacy Location Washington, District of Columbia

Regionserved United States President Website Karen Ignagni ahip.org [1]

Americas Health Insurance Plans (AHIP) is a national political advocacy and trade association with about 1,300 member companies that sell health insurance coverage to more than 200 million Americans.[2] AHIP was formed through the merger of Health Insurance Association of America (HIAA) and American Association of Health Plans (AAHP).[3][4][5][6] AAHP was formed through a merger between two Health Maintenance Organization (HMO) trade associations, Group Health Association of America and American Managed Care and Review Association.[citation needed] AHIP is a member of CAQH, a coalition of healthcare trade associations and health plans that aims to simplify healthcare administration. The AHIP Center for Policy and Research is the trade association's research arm.[7] The center publishes research on a variety of forms of private health insurance, often based on survey data gathered from AHIP member companies. The forms of insurance studied include disability income and long-term care insurance as well as different types of medical expense insurance. AHIP President Karen M. Ignagni[8] frequently serves as a spokesperson for the views of the insurance industry.[9] On September 27, 2007, she appeared on The Oprah Winfrey Show opposite Michael Moore, the director of Sicko, to discuss health insurance.[10]

Health Care Reform


In December 2008, AHIP published its proposals for health care reform: 1. Soaring health care costs not needed to be brought under control. It admitted that lower spending typically did mean lower quality. It urged that public-private Advisory Group should be tasked with the job of restraining and reducing wasteful and unnecessary spending, changing the rewards structure to favor quality and outcomes rather than volume of work, and streamline administrative processes across the health care system. 2. Reforms should strive for higher value and reduce disparities in ethnic and other minorities by focusing on keeping people healthy and intervening earlier, It called for coordinated care for chronic conditions, and the setting of uniform standards for quality, reporting, and information technology. Also there should be more investment in research to better understand which treatments and therapies work best for both the nation as a whole and for specific patients and accountability for consistently delivered, high-quality care based on the best evidence. It advocated a national initiative to increase public awareness of the links between preventable conditions and chronic illness, and prevention programs in our schools, worksites, and communities.

America's Health Insurance Plans 3. All Americans should have affordable, portable coverage and that there should be an individual mandate requiring all Americans to have adequate insurance as a quid pro quo for insurance companies issuing policies with no pre-existing condition exclusions. There should be better tax equity between company plans and private market policies, and tax credits on a sliding scale basis for those earning less than 400 percent of the Federal Poverty Level (FPL). Small businesses should get assistance through the tax code and other measures to make premiums stable and encourage them to contribute to their employees' health insurance needs. It promoted an Essential Benefits Plan available nationwide, that providing coverage for prevention and wellness as well as acute and chronic care, and that is not subject to varying and conflicting state benefit mandates. The large group market (covering 160 million Americans) should be preserved. The new system should avoid the cost shifting that was inherent in the old system. Public programs should be strengthened supported such as Community Health Centers, SCHIP and the reformed system should prevent so called "Medical bankruptcies". 4. Regulatory reform. It said that the patchwork of federal and state regulations often hinder, rather than helps, efforts to improve care and contain costs. It therefore said that the federal government should create a streamlined and effective regulatory system and the states should enforce it. It said the states should continue to run SCHIP and Medicaid programs and that eligibility for Medicaid should be simplified to those on 100 percent of the federal poverty level without other conditions.[11]

178

Lobbying
AHIP has spent more than $31.4 million on lobbying from 2005 to 2009, according to the non-partisan Center for Responsive Politics. This includes $3.9 million alone in 2009, which paid for the work of 50 lobbyists at eight different lobbying firms.[12]

AHIP and "Sicko"


On the July 10, 2009 edition of Bill Moyers Journal, Wendell Potter, former Vice President of corporate communications at the health insurance corporation CIGNA, claimed that the industry was "afraid" of the Michael Moore documentary Sicko.[13] As a result, AHIP formed a strategy to "discredit this film".[14] As part of the reporting on this allegation, Bill Moyers Journal provides May 2007 and June 2007 drafts of a memo entitled "Ensuring Accurate Perceptions of the Health Insurance Industry".[15][16] This memo outlines the strategy the health insurance industry would use to battle Moores documentary. The later draft lists the following as the "5 Strategies We Reached Consensus On": 1. 2. 3. 4. 5. "Debate the System, not the Anecdotes. Set the record straight then get off Moores turf and on to ours." "Reframe the Debate: Mount Campaign against a Government-run Health Care system." "Define the Health Insurance as Part of the Solution." "Caution Democrats Against Aligning with Moores Extremist Agenda." "Game Plan for Various Potential Scenarios."

The AHIP memos do not list any factual errors in Sicko. The memos instead focus primarily on media messaging in terms of influencing politicians and public opinion.

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179

Controversy
AHIP's 2005 television ad "Shark Bait" drew harsh criticism for its claim that "lawsuit abuse" by American trial lawyers cost the typical American family $1,200 a year.[17] On August 27, 2009, Michael Tuffin a spokesman for AHIP, told CNNs Lou Dobbs program that every survey shows strong satisfaction for private health insurance, as part of the organizations campaign against health care reform. The non-partisan Politfact watchdog organization found that his words were "half-true." In fact, Politifact said polls have found that often the majority of consumers have varying degrees of satisfaction, but are not strongly satisfied. For instance, an ABC News poll in June 2009 about the cost of health insurance premiums found 23 percent were very satisfied, but a combined 75 percent of consumers were somewhat satisfied, somewhat dissatisfied or very dissatisfied (31 percent somewhat satisfied, 19 percent somewhat dissatisfied and 25 percent very dissatisfied.) [18]

References
[1] http:/ / www. ahip. org [2] AHIP (http:/ / www. ahip. org/ content/ default. aspx?bc=31) Accessed 6 April 2007. [3] Press Release (http:/ / www. prnewswire. com/ cgi-bin/ stories. pl?ACCT=104& STORY=/ www/ story/ 12-11-2003/ 0002074162& EDATE=) dated December 11, 2003 (retrieved November 13, 2007) [4] AHIP "Smartbrief" announcing merger (http:/ / www. smartbrief. com/ news/ ahip/ storyDetails. jsp?issueid=AC500438-A63A-41EF-B4F0-BFFC93B584C3& copyid=46A67C43-F08A-478D-AB02-C382FA2B3A20) [5] "Health insurers gain a huge new lobby," (http:/ / query. nytimes. com/ gst/ fullpage. html?res=9504E4DB1F3AF930A1575AC0A9659C8B63) New York Times, September 23, 2003 [6] SARAH LUECK, "Two health trade groups to merge," (http:/ / online. wsj. com/ article/ SB106426654381679800. html?mod=home_whats_news_us), Wall Street Journal, September 23, 2003 [7] AHIP Center for Policy and Research (http:/ / www. ahipresearch. org/ ) [8] ROBERT PEAR (http:/ / www. nytimes. com/ 2007/ 09/ 16/ us/ politics/ 16clinton. html?_r=1& hp& oref=slogin) New York Times September 16, 2007. [9] Sam Youngman, "Clinton plan sparks frenzy," TheHill.com September 18, 2007 (http:/ / thehill. com/ leading-the-news/ clinton-plan-sparks-frenzy-2007-09-18. html) [10] Aoife McCarthy, "Suite Talk: Making room for new faces: A bad day at the office for AHIP?", Politico.com, September 26, 2007 (http:/ / www. politico. com/ news/ stories/ 0907/ 6030. html) [11] http:/ / www. americanhealthsolution. org/ assets/ Uploads/ ahipreformpolicyproposal. pdf [12] http:/ / www. opensecrets. org/ lobby/ clientsum. php?lname=America%27s+ Health+ Insurance+ Plans& year=2009 AHIP profile, Center for Responsive Politics [13] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ transcript2. html [14] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ transcript2. html [15] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ ahip1. pdf [16] http:/ / www. pbs. org/ moyers/ journal/ 07102009/ ahip2. pdf [17] FactCheck.org: Insurance Industry Ad Makes Fishy Claim About Lawyers (http:/ / www. factcheck. org/ politics/ insurance_industry_ad_makes_fishy_claim_about. html) [18] http:/ / www. politifact. com/ truth-o-meter/ statements/ 2009/ sep/ 01/ americas-health-insurance-plans/ strong-satisfaction-health-insurance-coverage/ Politifact, 1 Sept 2009

America's Health Insurance Plans

180

External links
America's Health Insurance Plans (AHIP) Website (http://www.ahip.org/) Sourcewatch profile (http://www.sourcewatch.org/index.php?title=America's_Health_Insurance_Plans) Center for Responsive Politics profile (http://www.opensecrets.org/lobby/clientsum.php?lname=American+ Health+Insurance+Plans&year=2008) American Medical News story on AHIP annual meeting (http://www.ama-assn.org/amednews/2009/08/10/ bisa0810.htm) FCIC: Guide To Health Insurance (http://www.pueblo.gsa.gov/cic_text/health/guidehealth/guidehealth.htm)

Agency for Healthcare Research and Quality


The Agency for Healthcare Research and Quality (AHRQ) (formerly known as the Agency for Health Care Policy and Research) is one of 12 agencies within the United States Department of Health and Human Services (HHS).[1] AHRQ is one of three organizational focuses for HHS along with the National Institutes of Health and the Centers for Disease Control.[2] AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of healthcare for Americans. Led by Director Carolyn M. Clancy, M.D.,[3] AHRQ sponsors, conducts, and disseminates research to aid in informed decision-making and improve the quality of health care services. Working with the public and private sectors, AHRQ research evaluates the effectiveness of health care interventions and aims to translate this knowledge into everyday practice and policymaking.

Medical cost-effectiveness research


AHRQ's patient-centered outcomes research aims to improve health care quality by providing patients and physicians with evidence-based information on which medical treatments work best for a given condition. Comparisons of drugs, medical devices, tests, surgeries, or ways to deliver health care can be used to help patients and their families understand and evaluate treatments options and risks. AHRQ initiatives include: The John M. Eisenberg Center for Clinical Decisions and Communications Science [4] that translates comparative effectiveness reviews and research reports created by AHRQ's Effective Health Care Program [5] into guides and tools for consumers, clinicians, and policymakers. Evidence-based Practice Centers [6] that review and synthesize scientific evidence for conditions or technologies that are costly, common, or important to the Medicare or Medicaid programs. The Centers for Education and Research on Therapeutics [7] (CERTs) that conduct research and provide education to advance the optimal use of drugs, biologicals, and medical devices. The Developing Evidence to Inform Decisions about Effectiveness Network [8] (DEcIDE), research-based health organizations that conduct practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services.

Agency for Healthcare Research and Quality

181

Quality improvement and patient safety


AHRQ funds and disseminates research that identifies the root causes of threats to patient safety, provides information on the scope and impact of medical errors, and examines effective ways to make system-level changes to help prevent errors. AHRQ initiatives include: Preventing healthcare-associated infections [9]. Medical liability reform [10]. Patient Safety Organizations [11], which collect and analyze patient safety events that health care providers report and provide feedback to help clinicians and health care organizations improve health care quality. AHRQ administers the provisions of the Patient Safety and Quality Improvement Act of 2005[12] and the Patient Safety Rule [13][14] dealing with PSO operations. TeamSTEPPS [15] (Team Strategies and Tools to Enhance Performance and Patient Safety), an evidence-based teamwork system designed to improve communication and teamwork skills among health care professionals. Patient safety culture assessment tools [16] that hospitals, nursing homes, and medical offices use to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of specific patient safety interventions.

Health information technology (health IT)


AHRQ's Health IT initiative [17] is part of the Nation's strategy to put technology to work in health care. AHRQ provides support to promote access to and encourage the adoption of health IT. The Agency has focused its health IT activities on the following three goals: Improve health care decisionmaking. Support patient-centered care. Improve the quality and safety of medication management.

Prevention and chronic care


AHRQ translates evidence-based knowledge into recommendations for clinical preventive services to improve the health of all Americans. AHRQ initiatives include: The Patient-Centered Medical Home [18], a model to improve health care by transforming how primary care is organized and delivered that ensures care is patient-centered, comprehensive, and accessible, coordinated across the health care system, and uses a systems-based approach to quality and safety. The Primary Care Practice-Based Research Networks [19] that rapidly develop and assess methods and tools to ensure that new scientific evidence is incorporated into real-world practice settings. Administrative support for the U.S. Preventive Services Task Force [20], an independent panel of nationally renowned, non-Federal experts in prevention and evidence-based medicine that assesses the benefits and harms of preventive services and makes recommendations about which preventive services should be incorporated routinely into primary care practice.

Agency for Healthcare Research and Quality

182

Health care value


AHRQ looks for ways to achieve greater value in health care by producing the measures, data, tools, evidence, and strategies that health care organizations, systems, insurers, purchasers, and policymakers need to improve the value and affordability of health care. AHRQ initiatives include: The Medical Expenditure Panel Survey [21] (MEPS), a family of surveys that gathers information about families and individuals, their medical providers, and employers across the United States. It is the only national source of annual data on the specific health services that Americans use, how frequently services are used, the cost of services, and the methods of paying for services. The Healthcare Cost and Utilization Project [22] (HCUP), a family of health care databases and related software tools and products developed through a Federal-State-industry partnership that serves as a national information resource of patient-level health care data. Quality Indicators [23] (QIs) that highlight potential quality concerns; identify areas that need further study; and track changes over time in prevention, inpatient care, patient safety, and pediatric care. QIs measure health care quality based upon readily available hospital inpatient administrative data. The annual National Healthcare Quality Report [24] and National Healthcare Disparities Report [25] that measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. State Snapshots [26] that provide, via a Web site, State-specific health care quality information, including strengths, weaknesses, and opportunities for improvement. The CAHPS [27] program develops surveys to help improve the quality of health care from the perspective of consumers and patients. The surveys include ones on home health care, dental plans, and nursing homes. The National Guideline Clearinghouse [28], a Web-based resource for information on more than 2,300 evidence-based clinical practice guidelines. The National Quality Measures Clearinghouse [29], a database and Web site for information on specific evidence-based health care quality measures and measure sets.

Political history
The agency originally began as the Agency for Health Care Policy and Research and was tasked with producing guidelines. However, it became controversial when it produced several guidelines which would reduce lucrative medical drugs and procedures. This included concern from ophthalmologists on a cataract guideline and concern by the pharmaceutical industry over a reduction in the use of new high-margin drugs. When the agency produced a guideline which concluded that back pain surgery was unnecessary and potentially harmful, a lobbying campaign aided by Congressmen whose backs had been operated on changed the name of the agency and "wound down" the guidelines program.[30]

Related links
AHRQ Data and Surveys [31] AHRQs Health Care Innovations and Exchange program [32] AHRQs Prevention and Chronic Care Program [33]

References
[1] Healthcare Research and Quality Act of 1999 (http:/ / www. ahrq. gov/ hrqa99a. htm) [2] AHRQ Fiscal Year 2013 Justification of Estimates for Appropriations Committees (http:/ / www. ahrq. gov/ about/ cj2013/ cj2013. pdf) (PDF), Page 1: Performance Budget Overview [3] Carolyn M. Clancy, M.D. (http:/ / www. ahrq. gov/ about/ clancybio. htm) [4] http:/ / effectivehealthcare. ahrq. gov/ index. cfm/ who-is-involved-in-the-effective-health-care-program1/ about-the-eisenberg-center/ [5] http:/ / effectivehealthcare. ahrq. gov/

Agency for Healthcare Research and Quality


[6] http:/ / www. ahrq. gov/ clinic/ epc/ [7] http:/ / www. certs. hhs. gov/ [8] http:/ / effectivehealthcare. ahrq. gov/ index. cfm/ who-is-involved-in-the-effective-health-care-program1/ about-the-decide-network/ [9] http:/ / www. ahrq. gov/ qual/ hais. htm [10] http:/ / www. ahrq. gov/ qual/ liability/ [11] http:/ / www. pso. ahrq. gov/ [12] Patient Safety and Quality Improvement Act of 2005 [13] http:/ / www. hhs. gov/ ocr/ privacy/ psa/ regulation/ rule/ index. html [14] Patient Safety Rule (http:/ / www. hhs. gov/ ocr/ privacy/ psa/ regulation/ rule/ index. html) [15] http:/ / www. ahrq. gov/ teamsteppstools/ [16] http:/ / www. ahrq. gov/ qual/ patientsafetyculture/ [17] http:/ / healthit. ahrq. gov/ portal/ server. pt/ community/ ahrq_national_resource_center_for_health_it/ 650 [18] http:/ / www. pcmh. ahrq. gov/ portal/ server. pt/ community/ pcmh__home/ 1483 [19] http:/ / pbrn. ahrq. gov/ portal/ server. pt/ community/ practice_based_research_networks_%28pbrn%29__home_page/ 851 [20] http:/ / www. uspreventiveservicestaskforce. org/ [21] http:/ / meps. ahrq. gov/ mepsweb/ [22] http:/ / www. ahrq. gov/ data/ hcup/ [23] http:/ / www. qualityindicators. ahrq. gov/ [24] http:/ / www. ahrq. gov/ qual/ measurix. htm#quality [25] http:/ / www. ahrq. gov/ qual/ measurix. htm#disparity [26] http:/ / statesnapshots. ahrq. gov/ snaps11/ index. jsp [27] http:/ / www. ahrq. gov/ cahps/ [28] [29] [30] [31] [32] [33] http:/ / www. guideline. gov/ http:/ / www. qualitymeasures. ahrq. gov/ Avorn J. Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, pp. 277-288. Random House. http:/ / ahrq. gov/ data/ http:/ / www. innovations. ahrq. gov/ http:/ / www. ahrq. gov/ clinic/ prevenix. htm

183

External links
Agency for Healthcare Research and Quality Web site (http://www.ahrq.gov) U.S. Department of Health and Human Services Web site (http://www.hhs.gov/)

HIV/AIDS

184

HIV/AIDS
HIV/AIDS
Classification and external resources

The red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS. ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH B20 042 [1] [3] B24 [2]

-044 [5]

[4]

609423 5938

[6] [7] [8]

000594

emerg/253 D000163

[9]

Human immunodeficiency virus infection / acquired immunodeficiency syndrome (HIV/AIDS) is a disease of the human immune system caused by infection with human immunodeficiency virus (HIV).[] During the initial infection, a person may experience a brief period of influenza-like illness. This is typically followed by a prolonged period without symptoms. As the illness progresses, it interferes more and more with the immune system, making the person much more likely to get infections, including opportunistic infections and tumors that do not usually affect people who have working immune systems. HIV is transmitted primarily via unprotected sexual intercourse (including anal and even oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding.[] Some bodily fluids, such as saliva and tears, do not transmit HIV.[] Prevention of HIV infection, primarily through safe sex and needle-exchange programs, is a key strategy to control the spread of the disease. There is no cure or vaccine; however, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy. While antiretroviral treatment reduces the risk of death and complications from the disease, these medications are expensive and may be associated with side effects. Genetic research indicates that HIV originated in west-central Africa during the early twentieth century.[] AIDS was first recognized by the Centers for Disease Control and Prevention (CDC) in 1981 and its causeHIV infectionwas identified in the early part of the decade.[10] Since its discovery, AIDS has caused nearly 30million deaths (as of 2009).[] As of 2010, approximately 34million people are living with HIV globally.[11] AIDS is

HIV/AIDS considered a pandemica disease outbreak which is present over a large area and is actively spreading.[12] HIV/AIDS has had a great impact on society, both as an illness and as a source of discrimination. The disease also has significant economic impacts. There are many misconceptions about HIV/AIDS such as the belief that it can be transmitted by casual non-sexual contact. The disease has also become subject to many controversies involving religion.

185

Signs and symptoms


There are three main stages of HIV infection: acute infection, clinical latency and AIDS.[13][]

Acute infection
The initial period following the contraction of HIV is called acute HIV, primary HIV or acute retroviral syndrome.[13][] Many individuals develop an influenza-like illness or a mononucleosis-like illness 24 weeks post exposure while others have no significant symptoms.[14][15] Symptoms occur in 4090% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, and/or sores of the mouth and genitals.[][15] The rash, which occurs in 2050% of cases, presents itself on the trunk and is maculopapular, classically.[] Some people also develop opportunistic infections at this stage.[] Gastrointestinal symptoms such as nausea, vomiting or diarrhea may occur, as may Main symptoms of acute HIV infection neurological symptoms of peripheral neuropathy or Guillain-Barre syndrome.[15] The duration of the symptoms varies, but is usually one or two weeks.[15] Due to their nonspecific character, these symptoms are not often recognized as signs of HIV infection. Even cases that do get seen by a family doctor or a hospital are often misdiagnosed as one of the many common infectious diseases with overlapping symptoms. Thus, it is recommended that HIV be considered in patients presenting an unexplained fever who may have risk factors for the infection.[15]

Clinical latency
The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV.[] Without treatment, this second stage of the natural history of HIV infection can last from about three years[16] to over 20years[17] (on average, about eight years).[18] While typically there are few or no symptoms at first, near the end of this stage many people experience fever, weight loss, gastrointestinal problems and muscle pains.[] Between 50 and 70% of people also develop persistent generalized lymphadenopathy, characterized by unexplained, non-painful enlargement of more than one group of lymph nodes (other than in the groin) for over three to six months.[13] Although most HIV-1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS, a small proportion (about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for more than 5 years.[15][] These individuals are classified as HIV controllers or long-term nonprogressors (LTNP).[] Another group is those who also maintain a low or undetectable viral load without anti-retroviral treatment who are known as "elite controllers" or "elite suppressors". They represent

HIV/AIDS approximately 1 in 300 infected persons.[]

186

Acquired immunodeficiency syndrome


Acquired immunodeficiency syndrome (AIDS) is defined in terms of either a CD4+ T cell count below 200 cells per L or the occurrence of specific diseases in association with an HIV infection.[15] In the absence of specific treatment, around half of people infected with HIV develop AIDS within ten years.[15] The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%) and esophageal candidiasis.[15] Other common signs include recurring respiratory tract infections.[15] Opportunistic infections may be caused by bacteria, viruses, fungi and parasites that are normally controlled by the immune system.[] Which infections occur partly depends on what organisms are common in the person's environment.[15] These infections may affect nearly every organ system.[] People with AIDS have an increased risk of developing various viral induced cancers including: Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.[] Kaposi's sarcoma is the most common cancer occurring in 10 to 20% of people with HIV.[19] The second most common cancer is lymphoma which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in 3 to 4%.[19] Both these cancers are associated with human herpesvirus 8.[19] Cervical cancer occurs more frequently in those with AIDS due to its association with human papillomavirus (HPV).[19] Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and weight loss.[20] Diarrhea is another common symptom present in about 90% of people with AIDS.[21] They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.[22]
Main symptoms of AIDS.

Transmission

HIV/AIDS

187

Exposure route Blood transfusion Childbirth (to child) Needle-sharing injection drug use Percutaneous needle stick Receptive anal intercourse* Insertive anal intercourse*

Chance of infection 90% 25%


[] [] [] [] []

0.67% 0.30%

0.043.0% 0.03%
[23]

Receptive penile-vaginal intercourse* 0.050.30% Insertive penile-vaginal intercourse* Receptive oral intercourse* Insertive oral intercourse*
*

[][] [][]

0.010.38% 00.04%
[]

00.005%

[24]

assuming no condom use source refers to oral intercourse performed on a man

|+ Average per act risk of getting HIV by exposure route to an infected source HIV is transmitted by three main routes: sexual contact, exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).[] There is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.[] It is possible to be co-infected by more than one strain of HIVa condition known as HIV superinfection.[25]

Sexual
The most frequent mode of transmission of HIV is through sexual contact with an infected person.[] The majority of all transmissions worldwide occur through heterosexual contacts (i.e. sexual contacts between people of the opposite sex);[] however, the pattern of transmission varies significantly among countries. In the United States, as of 2009, most sexual transmission occurred in men who had sex with men,[] with this population accounting for 64% of all new cases.[] As regards unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high-income countries.[] In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male transmission, and 0.08% per act for male-to-female transmission.[] The risk of transmission from anal intercourse is especially high, estimated as 1.41.7% per act in both heterosexual and homosexual contacts.[][26] While the risk of transmission from oral sex is relatively low, it is still present.[27] The risk from receiving oral sex has been described as "nearly nil"[28] however a few cases have been reported.[29] The per-act risk is estimated at 00.04% for receptive oral intercourse.[] In settings involving prostitution in low income countries, risk of female-to-male transmission has been estimated as 2.4% per act and male-to-female transmission as 0.05% per act.[] Risk of transmission increases in the presence of many sexually transmitted infections[] and genital ulcers.[] Genital ulcers appear to increase the risk approximately fivefold.[] Other sexually transmitted infections, such as gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission.[]

HIV/AIDS The viral load of an infected person is an important risk factor in both sexual and mother-to-child transmission.[30] During the first 2.5months of an HIV infection a person's infectiousness is twelve times higher due to this high viral load.[] If the person is in the late stages of infection, rates of transmission are approximately eightfold greater.[] Commercial sex workers (including those in pornography) have an increased rate of HIV.[31][32] Rough sex can be a factor associated with an increased risk of transmission.[33] Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections.[34]

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Body fluids
The second most frequent mode of HIV transmission is via blood and blood products.[] Blood-borne transmission can be through needle-sharing during intravenous drug use, needle stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilised equipment. The risk from sharing a needle during drug injection is between 0.63 and 2.4% per act, with an average of 0.8%.[] The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucus membrane exposure to infected blood as 0.09% (about 1 in 1000) per act.[] In the United States intravenous drug users made up 12% of all new cases of HIV in 2009,[] and in some areas more than 80% of people who inject drugs are HIV positive.[] HIV is transmitted in About 93% of blood transfusions involving infected blood.[] In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) CDC poster from 1989 highlighting the threat of where improved donor selection and HIV screening is performed;[] for AIDS associated with drug use example, in the UK the risk is reported at one in five million.[35] In low income countries, only half of transfusions may be appropriately screened (as of 2008),[36] and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections.[][] Unsafe medical injections play a significant role in HIV spread in sub-Saharan Africa. In 2007, between 12 and 17% of infections in this region were attributed to medical syringe use.[] The World Health Organisation estimates the risk of transmission as a result of a medical injection in Africa at 1.2%.[] Significant risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world.[] People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented.[] It is not possible for mosquitoes or other insects to transmit HIV.[37]

Mother-to-child
HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk.[][] This is the third most common way in which HIV is transmitted globally.[] In the absence of treatment, the risk of transmission before or during birth is around 20% and in those who also breastfeed 35%.[] As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.[] With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%.[] Preventive treatment involves the mother taking antiretroviral during pregnancy and delivery, an elective caesarean section, avoiding breastfeeding, and administering antiretroviral drugs to the newborn.[] Many of these measures are however not available in the developing world.[] If blood contaminates food during pre-chewing it may pose a risk of transmission.[]

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Virology
HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells.[] HIV is a member of the genus Lentivirus,[] part of the family Retroviridae.[] Lentiviruses share many morphological and biological characteristics. Many species of mammals are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period.[] Lentiviruses are transmitted as A diagram showing the structure of HIV virus single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors.[] Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system.[38] Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew.[39] Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective,[40] and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.[]

Pathophysiology
After the virus enters the body there is a period of rapid viral replication, leading to an abundance of virus in the peripheral blood. During primary infection, the level of HIV may reach several million virus particles per milliliter of blood.[] This response is accompanied by a marked drop in the number of circulating CD4+ T cells. The acute viremia is almost invariably associated with activation of CD8+ T cells, which kill HIV-infected cells, and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline, as the CD4+ T cell counts recover. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus.[] The pathophysiology of AIDS is complex.[] Ultimately, HIV causes AIDS by depleting CD4+ T cells. This weakens the immune system and allows opportunistic infections. T cells are essential to the immune response and without them, the body cannot fight infections or kill cancerous cells. The mechanism of CD4+ T cell depletion differs in the acute and chronic phases.[] During the acute phase, HIV-induced cell lysis and killing of infected cells by cytotoxic T cells accounts for CD4+ T cell depletion, although apoptosis may also be a factor. During the chronic phase, the consequences of generalized immune activation coupled with the gradual loss of the ability of the immune system to generate new T cells appear to account for the slow decline in CD4+ T

Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte.

cell numbers.[41]

HIV/AIDS Although the symptoms of immune deficiency characteristic of AIDS do not appear for years after a person is infected, the bulk of CD4+ T cell loss occurs during the first weeks of infection, especially in the intestinal mucosa, which harbors the majority of the lymphocytes found in the body.[] The reason for the preferential loss of mucosal CD4+ T cells is that the majority of mucosal CD4+ T cells express the CCR5 protein which HIV uses as a co-receptor to gain access to the cells, whereas only a small fraction of CD4+ T cells in the bloodstream do so.[] HIV seeks out and destroys CCR5 expressing CD4+ T cells during acute infection.[] A vigorous immune response eventually controls the infection and initiates the clinically latent phase. CD4+ T cells in mucosal tissues remain particularly affected.[] Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase.[] Immune activation, which is reflected by the increased activation state of immune cells and release of pro-inflammatory cytokines, results from the activity of several HIV gene products and the immune response to ongoing HIV replication. It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4+ T cells during the acute phase of disease.[]

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Diagnosis
HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms.[] HIV screening is recommended by the United States Preventive Services Task Force for all people 15years to 65years of age including all pregnant women.[42] Additionally testing is recommended for all those at high risk, which includes anyone diagnosed with a sexually transmitted illness.[] In many areas of the world a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent.[]

A generalized graph of the relationship between HIV copies (viral load) and CD4+ T cell counts over the average course of untreated HIV infection. CD4+ T Lymphocyte count (cells/mm) HIV RNA copies per

mL of plasma

HIV testing
Most people infected with HIV develop specific antibodies (i.e. seroconvert) within three to twelve weeks of the initial infection.[15] Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen.[15] Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR.[] Antibody tests in children younger than 18months are typically inaccurate due to the continued presence of maternal antibodies.[] Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen.[] Much of the world lacks access to reliable PCR testing and many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing.[] In sub-Saharan Africa as of 20072009 between 30 and 70% of the population was aware of their HIV status.[43] In 2009, between 3.6 and 42% of men and women in Sub-Saharan countries were tested[43] which represented a significant increase compared to previous years.[43]

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Classifications of HIV infection


Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease,[] and the CDC classification system for HIV infection.[] The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management. Despite their differences, the two systems allow comparison for statistical purposes.[13][][] The World Health Organization first proposed a definition for AIDS in 1986.[] Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007.[] The WHO system uses the following categories: Primary HIV infection: May be either asymptomatic or associated with acute retroviral syndrome.[] Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as CD4 count) greater than 500 per microlitre (l or cubic mm) of blood.[] May include generalized lymph node enlargement.[] Stage II: Mild symptoms which may include minor mucocutaneous manifestations and recurrent upper respiratory tract infections. A CD4 count of less than 500/l.[] Stage III: Advanced symptoms which may include unexplained chronic diarrhea for longer than a month, severe bacterial infections including tuberculosis of the lung, and a CD4 count of less than 350/l.[] Stage IV or AIDS: severe symptoms which include toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma. A CD4 count of less than 200/l.[] The United States Center for Disease Control and Prevention also created a classification system for HIV, and updated it in 2008.[] This system classifies HIV infections based on CD4 count and clinical symptoms,[] and describes the infection in three stages: Stage 1: CD4 count 500cells/l and no AIDS defining conditions Stage 2: CD4 count 200 to 500cells/l and no AIDS defining conditions Stage 3: CD4 count 200cells/l or AIDS defining conditions Unknown: if insufficient information is available to make any of the above classifications

For surveillance purposes, the AIDS diagnosis still stands even if, after treatment, the CD4+ T cell count rises to above 200 per L of blood or other AIDS-defining illnesses are cured.[13]

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Prevention
Sexual contact
Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term.[44] When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year.[] There is some evidence to suggest that female condoms may provide an equivalent level of protection.[45] Application of a vaginal gel containing tenofovir (a reverse transcriptase inhibitor) immediately before sex seems to reduce infection rates by approximately 40% among African women.[] By contrast, use of the spermicide nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation.[46] Circumcision in Sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months".[47] Based on these studies, the World Health AIDS Clinic, McLeod Ganj, Himachal Pradesh, India, 2010 Organization and UNAIDS both recommended male circumcision as a [48] method of preventing female-to-male HIV transmission in 2007. Whether it protects against male-to-female transmission is disputed[49][50] and whether it is of benefit in developed countries and among men who have sex with men is undetermined.[51][52][53] Some experts fear that a lower perception of vulnerability among circumcised men may cause more sexual risk-taking behavior, thus negating its preventive effects.[54] Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.[55] Evidence for a benefit from peer education is equally poor.[56] Comprehensive sexual education provided at school may decrease high risk behavior.[57] A substantial minority of young people continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating their own risk of becoming infected with HIV.[] It is not known whether treating other sexually transmitted infections is effective in preventing HIV.[]

Pre-exposure
Treating people with HIV whose CD4 count 350cells/L with antiretrovirals protects 96% of their partners from infection.[58] This is about a 10 to 20 fold reduction in transmission risk.[] Pre-exposure prophylaxis with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in a number of groups including men who have sex with men, couples where one is HIV positive, and young heterosexuals in Africa.[] It may also be effective in intravenous drug users with a study finding a decrease in risk of 0.7 to 0.4 per 100personyears.[59] Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV.[60] Intravenous drug use is an important risk factor and harm reduction strategies such as needle-exchange programmes and opioid substitution therapy appear effective in decreasing this risk.[][61]

Post-exposure
A course of antiretrovirals administered within 48 to 72hours after exposure to HIV positive blood or genital secretions is referred to as post-exposure prophylaxis.[] The use of the single agent zidovudine reduces the risk of subsequent HIV infection fivefold following a needle stick injury.[] Treatment is recommended after sexual assault when the perpetrator is known to be HIV positive but is controversial when their HIV status is unknown.[] Current treatment regimes typically use lopinavir/ritonavir and lamivudine/zidovudine or emtricitabine/tenofovir and may decrease the risk further.[] The duration of treatment is usually four weeks[] and is frequently associated with adverse

HIV/AIDS effects (with zidovudine in about 70% of cases, including nausea in 24%, fatigue in 22%, emotional distress in 13%, and headaches in 9%).[]

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Mother-to-child
Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 9299%.[][] This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant and potentially includes bottle feeding rather than breastfeeding.[][62] If replacement feeding is acceptable, feasible, affordable, sustainable, and safe, mothers should avoid breastfeeding their infants; however exclusive breastfeeding is recommended during the first months of life if this is not the case.[63] If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission.[64]

Vaccination
As of 2012 there is no effective vaccine for HIV or AIDS.[65] A single trial of the vaccine RV 144 published in 2009 found a partial reduction in the risk of transmission of roughly 30%, stimulating some hope in the research community of developing a truly effective vaccine.[66] Further trials of the RV 144 vaccine are ongoing.[67][68]

Management
There is currently no cure or effective HIV vaccine. Treatment consists of high active antiretroviral therapy (HAART) which slows progression of the disease[] and as of 2010 more than 6.6million people were taking them in low and middle income countries.[11] Treatment also includes preventive and active treatment of opportunistic infections.

Antiviral therapy
Current HAART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes," of antiretroviral agents.[] Initially treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analogue reverse transcriptase inhibitors (NRTIs).[] Typical NRTIs include: zidovudine (AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC).[] Combinations of agents which include a protease inhibitors (PI) are used if the above regime loses effectiveness.[] When to start antiretroviral therapy is subject to debate.[][69] The World Health Organization, European guidelines and the United States Abacavir a nucleoside analog reverse recommends antiretrovirals in all adolescents, adults and pregnant transcriptase inhibitor (NARTI or NRTI) women with a CD4 count less than 350/l or those with symptoms regardless of CD4 count.[][] This is supported by the fact that beginning treatment at this level reduces the risk of death.[] The United States in addition recommends them for all HIV-infected people regardless of CD4 count or symptoms; however it makes this recommendation with less confidence for those with higher counts.[] While the WHO also recommends treatment in those who are co-infected with tuberculosis and those with chronic active hepatitis B.[] Once treatment is begun it is recommended that it is continued without breaks or "holidays".[] Many people are diagnosed only after treatment ideally should have begun.[] The desired outcome of treatment is a long term plasma HIV-RNA count below 50copies/mL.[] Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below

HIV/AIDS 50copies/mL checks every three to six months are typically adequate.[] Inadequate control is deemed to be greater than 400copies/mL.[] Based on these criteria treatment is effective in more than 95% of people during the first year.[] Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.[70] In the developing world treatment also improves physical and mental health.[71] With treatment there is a 70% reduced risk of acquiring tuberculosis.[] Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.[] The effectiveness of treatment depends to a large part on compliance.[] Reasons for non-adherence include poor access to medical care,[72] inadequate social supports, mental illness and drug abuse.[73] The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence.[74] Even though cost is an important issue with some medications,[75] 47% of those who needed them were taking them in low and middle income countries as of 2010[11] and the rate of adherence is similar in low-income and high-income countries.[76] Specific adverse events are related to the agent taken.[] Some relatively common ones include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus especially with protease inhibitors.[13] Other common symptoms include diarrhea,[][] and an increased risk of cardiovascular disease.[77] Newer recommended treatments are associated with fewer adverse effects.[] Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children.[] Treatment recommendations for children are slightly different from those for adults. In the developing world, as of 2010, 23% of children who were in need of treatment had access.[78] Both the World Health Organization and the United States recommend treatment for all children less than twelve months of age.[][] The United States recommends in those between one year and five years of age treatment in those with HIV RNA counts of greater than 100,000copies/mL, and in those more than five years treatments when CD4 counts are less than 500/l.[]

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Opportunistic infections
Measures to prevent opportunistic infections are effective in many people with HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections.[] Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however it may also be given after infection.[] Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age and ceasing breastfeeding in infants born to HIV positive mothers is recommended in resource limited settings.[78] It is also recommended to prevent PCP when a person's CD4 count is below 200cells/uL and in those who have or have previously had PCP.[] People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and Cryptococcus meningitis.[] Appropriate preventive measures have reduced the rate of these infections by 50% between 1992 and 1997.[]

Alternative medicine
In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine,[] even though the effectiveness of most of these therapies has not been established.[] With respect to dietary advice and AIDS some evidence has shown a benefit from micronutrient supplements.[] Evidence for supplementation with selenium is mixed with some tentative evidence of benefit.[79] There is some evidence that vitamin A supplementation in children reduces mortality and improves growth.[] In Africa in nutritionally compromised pregnant and lactating women a multivitamin supplementation has improved outcomes for both mothers and children.[] Dietary intake of micronutrients at RDA levels by HIV-infected adults is recommended by the World Health Organization.[80][] The WHO further states that several studies indicate that supplementation of vitamin A, zinc, and iron can produce adverse effects in HIV positive adults.[] There is not enough evidence to support the use of herbal medicines.[81]

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Prognosis
HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world.[] Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes.[15] Without treatment, average survival time after infection with HIV is estimated to be 9 to 11years, depending on the HIV subtype.[] After the diagnosis of AIDS, if treatment is not available, survival ranges Disability-adjusted life year for HIV and AIDS between 6 and 19months.[][82] HAART and appropriate prevention of per 100,000inhabitants as of 2004. opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 2050 years.[][][] This is between two thirds[] and nearly that of the general population.[][83] If treatment is started late in the infection, prognosis is not as good:[] for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~1040years.[][] Half of infants born with HIV die before two years of age without treatment.[78] The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system.[][] Risk of cancer appears to increase once the CD4 count is below 500/L.[] The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person's susceptibility and immune function;[] their access to health care, the presence of co-infections;[][] and the particular strain (or strains) of the virus involved.[][] Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV infected people and causing 25% of HIV related deaths.[84] HIV is also one of the most important risk factors for tuberculosis.[] Hepatitis C is another very common co-infection where each disease increases the progression of the other.[85] The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma.[] Even with anti-retroviral treatment, over the long term HIV-infected people may experience neurocognitive disorders,[] osteoporosis,[] neuropathy,[] cancers,[][] nephropathy,[] and cardiovascular disease.[] It is not clear whether these conditions result from the HIV infection itself or are adverse effects of treatment.

Epidemiology
HIV/AIDS is a global pandemic.[] As of 2010, approximately 34million people have HIV worldwide.[11] Of these approximately 16.8million are women and 3.4million are less than 15years old.[11] It resulted in about 1.8million deaths in 2010, down from a peak of 2.2million in 2005.[11] Sub-Saharan Africa is the region most affected. In 2010, an estimated Estimated prevalence of HIV among young adults 68% (22.9million) of all HIV cases and 66% of all deaths (1.2million) [86] (1549) per country as of 2011. occurred in this region.[87] This means that about 5% of the adult population is infected[88] and it is believed to be the cause of 10% of all deaths in children.[89] Here in contrast to other regions women compose nearly 60% of cases.[87] South Africa has the largest population of people with HIV of any country in the world at 5.9million.[87] Life expectancy has fallen in the worst-affected countries due to HIV/AIDS; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana.[12] Mother-to-child transmission, as of 2013, in Botswana and South Africa has decreased to less than 5% with improvement in many other African nations due to improved access to antiretroviral therapy.[90] South & South East Asia is the second most affected; in 2010 this region contained an estimated 4million cases or 12% of all people living with HIV resulting in approximately 250,000 deaths.[88] Approximately 2.4million of these

HIV/AIDS cases are in India.[87] In 2008 in the United States approximately 1.2million people were living with HIV, resulting in about 17,500 deaths. The US Centers for Disease Control and Prevention estimated that in 2008 20% of infected Americans were unaware of their infection.[] In the United Kingdom as of 2009 there where approximately 86,500 cases which resulted in 516 deaths.[91] In Canada as of 2008 there were about 65,000 cases causing 53 deaths.[92] Between the first recognition of AIDS in 1981 and 2009 it has led to nearly 30million deaths.[] Prevalence is lowest in Middle East and North Africa at 0.1% or less, East Asia at 0.1% and Western and Central Europe at 0.2%.[88]

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History
Discovery
AIDS was first clinically observed in 1981 in the United States.[19] The initial cases were a cluster of injecting drug users and homosexual men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.[] Soon thereafter, an unexpected number of gay men developed a previously rare skin cancer called Kaposi's sarcoma (KS).[][] Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak.[]

The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called "AIDS".

In the early days, the CDC did not have an official name for the disease, often referring to it by way of the diseases that were associated with it, for example, lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.[][] They also used Kaposi's Sarcoma and Opportunistic Infections, the name by which a task force had been set up in 1981.[] At one point, the CDC coined the phrase "the 4H disease", since the syndrome seemed to affect Haitians, homosexuals, hemophiliacs, and heroin users.[] In the general press, the Robert Gallo, co-discoverer of HIV in the early term "GRID", which stood for gay-related immune deficiency, had eighties among (from left to right) Sandra Eva, been coined.[] However, after determining that AIDS was not isolated Sandra Colombini, and Ersell Richardson. to the gay community,[] it was realized that the term GRID was misleading and the term AIDS was introduced at a meeting in July [] 1982. By September 1982 the CDC started referring to the disease as AIDS.[] In 1983, two separate research groups led by Robert Gallo and Luc Montagnier independently declared that a novel retrovirus may have been infecting AIDS patients, and published their findings in the same issue of the journal

HIV/AIDS Science.[][] Gallo claimed that a virus his group had isolated from an AIDS patient was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a patient presenting with swelling of the lymph nodes of the neck and physical weakness, two characteristic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV).[] As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV.[93]

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Origins
Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and were transferred to humans in the early 20th century.[] HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes).[][] The closest relative of HIV-2 is SIV(smm), a virus of the sooty mangabey (Cercocebus atys atys), an Old World monkey living in coastal West Africa (from southern Senegal to western Cte d'Ivoire).[] New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral resistance genes.[94] HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O.[] There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV.[] However, SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick Left to right: the African green monkey source of SIV, the sooty mangabey source of succession are necessary to allow it HIV-2 and the chimpanzee source of HIV-1 enough time to mutate into HIV.[] Furthermore, due to its relatively low person-to-person transmission rate, SIV can only spread throughout the population in the presence of one or more high-risk transmission channels, which are thought to have been absent in Africa before the 20th century. Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout the society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to circa 1910.[95] Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the accompanying high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities.[] While transmission rates of HIV during vaginal intercourse are low under regular circumstances, they are increased many fold if one of the partners suffers from a sexually transmitted infection causing genital ulcers. Early 1900s colonial cities were notable due to their high prevalence of prostitution and genital ulcers, to the degree that, as of 1928, as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes, and, as of 1933, around 15% of all residents of the same city had syphilis.[]

HIV/AIDS An alternative view holds that unsafe medical practices in Africa after World War II, such as unsterile reuse of single use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread.[][96][] The earliest well documented case of HIV in a human dates back to 1959 in the Congo.[] The virus may have been present in the United States as early as 1966,[97] but the vast majority of infections occurring outside sub-Saharan Africa (including the U.S.) can be traced back to a single unknown individual who became infected with HIV in Haiti and then brought the infection to the United States some time around 1969.[] The epidemic then rapidly spread among high-risk groups (initially, sexually promiscuous men who have sex with men). By 1978, the prevalence of HIV-1 among gay male residents of New York and San Francisco was estimated at 5%, suggesting that several thousand individuals in the country had been infected.[]

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Society and culture


Stigma
AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV infected people; compulsory HIV testing without prior consent or protection of confidentiality; violence against HIV infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV infected individuals.[] Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.[] AIDS stigma has been further divided into the following three categories: Instrumental AIDS stigmaa reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness.[] Symbolic AIDS stigmathe use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease.[]

Ryan White became a poster child for HIV after being expelled from school because he was infected.

Courtesy AIDS stigmastigmatization of people connected to the issue of HIV/AIDS or HIV-positive people.[] Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use.[98] In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice such as anti-homosexual/bisexual attitudes.[] There is also a perceived association between AIDS and all male-male sexual behavior, including sex between uninfected men.[] However, the dominant mode of spread worldwide for HIV remains heterosexual transmission.[99]

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Economic impact
HIV/AIDS affects the economics of both individuals and countries.[89] The gross domestic product of the most affected countries has decreased due to the lack of human capital.[89][] Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. They will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12million AIDS orphans.[89] Many are cared for by elderly grandparents.[] By affecting mainly young adults, AIDS reduces the taxable Changes in life expectancy in some hard-hit population, in turn reducing the resources available for public African countries. expenditures such as education and health services not related to AIDS Botswana Zimbabwe Kenya South Africa resulting in increasing pressure for the state's finances and slower Uganda growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility and blame from the family to the government in caring for these orphans.[] At the household level, AIDS causes both loss of income and increased spending on healthcare. A study in Cte d'Ivoire showed that households with an HIV/AIDS patient, spent twice as much on medical expenses as other households. This additional expenditure also leaves less income to spend on education and other personal or family investment.[]

Religion and AIDS


The topic of religion and AIDS has become highly controversial in the past twenty years, primarily because some religious authorities have publicly declared their opposition to the use of condoms.[100][] The religious approach to prevent the spread of AIDS according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis argues that cultural changes are needed including a re-emphasis on fidelity within marriage and sexual abstinence outside of it.[] Some religious organisations have claimed that prayer can cure HIV/AIDS. In 2011, the BBC reported that some churches in London were claiming that prayer would cure AIDS, and the Hackney-based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication, sometimes on the direct advice of their pastor, leading to a number of deaths.[] The Synagogue Church Of All Nations advertise an "anointing water" to promote God's healing, although the group deny advising people to stop taking medication.[]

Media portrayal
One of the first high-profile cases of AIDS was the American Rock Hudson, a gay actor who had been married and divorced earlier in life, who died on 2 October 1985 having announced that he was suffering from the virus on 25 July that year. He had been diagnosed during 1984.[101] A notable British casualty of AIDS that year was Nicholas Eden, a gay politician and son of the late prime minister Anthony Eden.[102] On November 24, 1991, the virus claimed the life of British rock star Freddie Mercury, lead singer of the band Queen, who died from an AIDS related illness having only revealed the diagnosis on the previous day.[103] However he had been diagnosed as HIV positive during 1987.[104] One of the first high-profile heterosexual cases of the virus was Arthur Ashe, the American tennis player. He was diagnosed as HIV positive on 31 August 1988, having contracted the virus from blood transfusions during heart surgery earlier in the 1980s. Further tests within 24 hours of the initial diagnosis revealed that Ashe had

HIV/AIDS AIDS, but he did not tell the public about his diagnosis until April 1992.[105] He died, aged 49, as a result on 6 February 1993.[106] Therese Frare's photograph of gay activist David Kirby, as he lay dying from AIDS while surrounded by family, was taken in April 1990. LIFE magazine said the photo became the one image "most powerfully identified with the HIV/AIDS epidemic." The photo was displayed in LIFE magazine, was the winner of the World Press Photo, and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992.[107] In 1996, Johnson Aziga a Ugandan-born immigrant Canadian was diagnosed as a HIV-positive, but then he had unprotected sex with 11 women without telling them he has HIV. Since 2003, seven of them were infected with HIV, and two of them died of complications of AIDS.[108][109] Aziga was convicted of first-degree murder and be liable to a life sentence.[110]

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Denial, conspiracies, and misconceptions


A small group of individuals continue to dispute the connection between HIV and AIDS,[] the existence of HIV itself, or the validity of HIV testing and treatment methods.[][] These claims, known as AIDS denialism, have been examined and rejected by the scientific community.[] However, they have had a significant political impact, particularly in South Africa, where the government's official embrace of AIDS denialism (19992005) was responsible for its ineffective response to that country's AIDS epidemic, and has been blamed for hundreds of thousands of avoidable deaths and HIV infections.[111][112][113] Operation INFEKTION was a worldwide Soviet active measures operation to spread information that the United States had created HIV/AIDS. Surveys show that a significant number of people believed and continue to believe in such claims.[114] There are many misconceptions about HIV and AIDS. Three of the most common are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS, and that HIV can infect only homosexual men and drug users. Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection, and that open discussion of homosexuality and HIV in schools will lead to increased rates of homosexuality and AIDS.[115][116]

Research
HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS along with fundamental research about the nature of HIV as an infectious agent and AIDS as the disease caused by HIV. HIV/AIDS research includes following the usual advice given by doctors in responding to HIV. The most universally recommended method for the prevention of HIV/AIDS is to avoid blood-to-blood contact between people and to otherwise practice safe sex. The most recommended method for treating HIV is for HIV-positive people to receive attention from a doctor who would coordinate the patient's management of HIV/AIDS. There is no cure for HIV/AIDS. Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions such as sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and Circumcision and HIV.

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References
Notes
[1] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ B20 [2] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ B24 [3] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=042 [4] http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=044 [5] http:/ / omim. org/ entry/ 609423 [6] http:/ / www. diseasesdatabase. com/ ddb5938. htm [7] http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 000594. htm [8] http:/ / www. emedicine. com/ emerg/ topic253. htm [9] http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D000163 [11] UNAIDS 2011 pg. 110 [12] (subscription required) [13] Mandell, Bennett, and Dolan (2010). Chapter 121. [15] Mandell, Bennett, and Dolan (2010). Chapter 118. [19] Mandell, Bennett, and Dolan (2010). Chapter 169. [36] UNAIDS 2011 pg. 6070 [43] UNAIDS 2011 pg. 7080 [50] (subscription required) [78] UNAIDS 2011 pg. 150160 [87] UNAIDS 2011 pg. 2030 [88] UNAIDS 2011 pg. 4050 [89] Mandell, Bennett, and Dolan (2010). Chapter 117. [90] New HIV infections among children have been reduced by 50% or more in seven countries in sub-Saharan Africa (http:/ / www. unaids. org/ en/ resources/ presscentre/ pressreleaseandstatementarchive/ 2013/ june/ 20130625prglobalplan/ ), UN AIDS, Geneva, June 25, 2013. [94] (subscription required) [95] (subscription required) [96] (subscription required) [114] Operation INFEKTION Soviet Bloc Intelligence and Its AIDS Disinformation Campaign (https:/ / www. cia. gov/ library/ center-for-the-study-of-intelligence/ csi-publications/ csi-studies/ studies/ vol53no4/ soviet-bloc-intelligence-and-its-aids. html). Thomas Boghardt. 2009

Bibliography Mandell, Gerald L.; Bennett, John E.; Dolin, Raphael, eds. (2010). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (7th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN978-0-443-06839-3. Joint United Nations Programme on HIV/AIDS (UNAIDS) (2011). Global HIV/AIDS Response, Epidemic update and health sector progress towards universal access (http://www.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2011/20111130_UA_Report_en.pdf). Joint United Nations Programme on HIV/AIDS.

External links
HIV/AIDS (http://www.dmoz.org/Health/Conditions_and_Diseases/Immune_Disorders/ Immune_Deficiency/AIDS//) at the Open Directory Project Joint United Nations Program on HIV/AIDS (http://www.unaids.org/en/) AIDSinfo (http://aidsinfo.nih.gov/) HIV/AIDS Treatment Information, U.S. Department of Health and Human Services

American Medical Association

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American Medical Association


American Medical Association
Motto Formation Type Headquarters Location Membership Helping Doctors Help Patients 1847 professional association Chicago, Illinois United States 215,854 as of 2010 []

Officiallanguages English President Key people Ardis Dee Hoven [1]

Chair Steven J. Stack CEO & EVP James Madara

The American Medical Association (AMA), founded in 1847 and incorporated in 1897,[2] is the largest association of physiciansboth MDs and DOsand medical students in the United States.[3]

Scope and operations


(See also List of presidents of the American Medical Association) The AMA's stated mission is to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public health, to lobby for legislation favorable to physicians and patients, and to raise money for medical education. The Association also publishes the Journal of the American Medical Association (JAMA), which has the largest circulation of any weekly medical journal in the world.[] The AMA also publishes a list of Physician Specialty Codes which are the standard method in the U.S. for identifying physician and practice specialties. The AMA has one of the largest political lobbying budgets of any organization in the United States.[] Its political positions throughout its history have often been controversial. In the 1930s, the AMA attempted to prohibit its members from working for the then-primitive health maintenance organizations that had sprung up during the Great Depression, which violated the Sherman Antitrust Act and resulted in a conviction ultimately affirmed by the US Supreme Court.[4] The AMA's vehement campaign against Medicare in the 1950s and 1960s included the Operation Coffee Cup supported by Ronald Reagan. Since the enactment of Medicare, the AMA reversed its position and now opposes any "cut to Medicare funding or shift [of] increased costs to beneficiaries at the expense of the quality or accessibility of care". The AMA also "strongly supports subsidization of prescription drugs for Medicare patients based on means testing".[citation needed] However, the AMA remains opposed to any single-payer health care plan that might enact a National Health Service in the United States, such as the United States National Health Care Act. In the 1990s, the organization was part of the coalition that defeated the health care reform advanced by Hillary and Bill Clinton. The AMA has also supported changes in medical malpractice law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high risk specialists have moved to other states that have enacted reform. For example, in 2004, all neurosurgeons had relocated out of the entire southern half of Illinois [citation needed]. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering. These costs for pain and suffering are only those that exceed the actual costs of healthcare and lost income. Multiple states have found that limiting pain and suffering costs has dramatically

American Medical Association slowed increases in the cost of medical malpractice insurance. Texas, having recently enacted such reforms, reported that all major malpractice insurers in 2005 were able to offer either no increase or a decrease in premiums to physicians [citation needed]. At the same time however, states without caps also experienced similar results; suggesting that other market factors may have contributed to the decreases. Some economic studies have found that caps have historically had an uncertain effect on premium rates.[5] Nevertheless, the AMA believes the caps may alleviate what is often perceived as an excessively litigious environment for many doctors.[citation needed] A recent report by the AMA found that in a 12 month period, five percent of physicians had claims filed against them.[6] Claims that the AMA generates $70 million in revenue through its stewardship of Current Procedural Terminology (CPT) codes appear to be a mischaracterization.[citation needed] The estimate is based on a distortion[citation needed] of the transparent financial information the AMA voluntarily offers in its Annual Report. The AMA has publicly reported this figure represents income from its complete line of books and products, which include more than 100 items, not just CPT.[7] The AMA sponsors the Specialty Society Relative Value Scale Update Committee which is an influential group of 29 physicians, mostly specialists, who help determine the value of different physician's labor in Medicare prices.

203

Charitable activities
The AMA Foundation provides approximately $1,000,000 annually in tuition assistance to financially needy students. This has to be seen on the background that in 2007, graduating medical students carried a mean debt load of $140,000 which rose to $220,000 after 4 yrs of negative amortization during residency[] medical student debt has increased by 7% each successive year.[8] Funds awareness projects about health literacy Funds community service, community health, and healthcare education events held by local medical societies and student chapters Supports research funding for students and fellows around the U.S. Provides grants to community projects designed to encourage healthy lifestyles (of diet and exercise, good sleep habits, etc.). The Worldscopes project is a collaboration with the medical community to collect stethoscopes and the funds to buy them. The stethoscopes are then distributed to those in the global medical community who normally lack the resources to obtain the instruments. Thousands of stethoscopes have been sent to physicians and others in the medical community around the world who lack access to this medical instrument.[8]

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Politics
Throughout its history, the AMA has been actively involved in a variety of medical policy issues, from Medicare and HMOs to public health, and climate change. Between 1998 and 2011, the AMA spent $264 million on lobbyists, second only to the American Chamber of Commerce.[] In the 1930s, the AMA attempted to prohibit its members from working for the primitive health maintenance organizations that sprung up during the Great Depression. The AMA's subsequent conviction for violating the Sherman Antitrust Act was affirmed by the U.S. Supreme Court. American Medical Ass'n. v. United States, 317 U.S. 519 [9] (1943). The AMA's vehement campaign against Medicare in the 1950s and 1960s included the Operation Coffee Cup supported by Ronald Reagan. Before Medicare passed, according to Steven Schroeder, Wilbur Cohen inserted "usual, customary and reasonable" charges into the Social Security Act of 1965 "in an The American Medical Association headquarters unsuccessful attempt to placate" the AMA.[10] Since the building in Chicago. enactment of Medicare, the AMA stated that it "continues to oppose attempts to cut Medicare funding or shift increased costs to beneficiaries at the expense of the quality or accessibility of care" and "strongly supports subsidization of prescription drugs for Medicare patients based on means testing". The AMA also campaigns to raise Medicare payments to physicians, arguing that increases will protect seniors' access to health care. In the 1990s, it was part of the coalition that defeated the health care reform proposed by President Bill Clinton. The AMA supported the War on Drugs, providing a medical excuse to clamp down on marijuana-use in the 90s. The AMA has given high priority to supporting changes in medical malpractice law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high-risk specialists have moved to other states with such limits. For example, in 2004, not a single neurosurgeon remained in the entire southern half of Illinois [citation needed]. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering. These costs for pain and suffering are only those that exceed the actual costs of health care and lost income. Multiple states found that limiting pain and suffering costs has dramatically slowed increases in the cost of medical malpractice insurance. The state of Texas enacted such reforms in 2003 and subsequently reported in 2005 that all major malpractice insurers were able to offer either no increase or a decrease in premiums to physicians. Another top priority of the AMA is to lobby for change to the federal tax codes to allow the current health insurance system (based on employment) to be purchased by individuals. Such changes could possibly allow millions of currently uninsured Americans to be able to afford insurance through a series of refundable tax credits based on income (for example, the lower one's income, the greater your credit) [citation needed]. The AMA has made efforts to respond to health care disparities. As such, the AMA created an advisory committee to assess the nature of disparities within different racial and ethnic groups.[11] One such committee focuses on the health of the Gay, Lesbian Bisexual and Transgender community. In 2005, the AMA president Edward Hill gave a keynote address to the Gay and Lesbian Medical Association at its annual conference.[12] Since that time, the AMA has worked closely with GLMA to develop AMA policy towards better health care access for LGBT patients and better working environments for LGBT physicians and medical students.[13]

American Medical Association The AMA responded to the government estimate that more than 35 million Americans live in underserved areas by stating it would take 16,000 doctors to immediately fill that need, and the gap is expected to widen due to rising population and aging work force. "And that will mostly be felt in rural America," said Sen. Kent Conrad, D-N.D., adding, "We're facing a real crisis." Fueling the shortage are the restrictions on allowing foreign physicians to work in the U.S. after the September 11, 2001 attack, and may become more restrictive after the attempted terrorist bombings June 2007 in Britain, still under investigation, linked to foreign doctors.[14][15] In June 2007, at its annual meeting, the AMA discussed its opposition to a fast-spreading nationwide trend for medical clinics to open up in supermarkets and drugstores. The AMA identified at least two problems with in-store clinics: potential conflict of interest, and potential jeopardized quality of care. The AMA went on to rally state and federal agencies to investigate the relationship between the operating clinics and the pharmacy chains to decide if this practice should be prohibited or regulated. Dr. Peter Carmel, neurosurgeon and AMA board member asked, "If you own both sides of the operation, shouldn't people look at that?" The AMA also noted some employers reduce or waive the co-payment if an employee goes to the retail clinic instead of the doctor's office, inferring that this practice might negatively affect quality of care.[16] In 2008, the AMA issued a policy statement on global climate change declaring that they "support the findings of the latest Intergovernmental Panel on Climate Change report, which states that the Earth is undergoing adverse global climate change and that these changes will negatively affect public health." They also "support educating the medical community on the potential adverse public health effects of global climate change, including topics such as population displacement, flooding, infectious and vector-borne diseases, and healthy water supplies."[17] In July 2008, the AMA focused its energy on blocking cuts to Medicare. Through advocacy efforts and communications campaigns, the AMA and all the specialty societies and state medical societies it comprises came out with a temporary victory. Despite a presidential veto, H.R. 6331, the "Medicare Improvements for Patients and Providers Act of 2008", passed with wide, bi-partisan majorities in both the U.S. House of Representatives and the U.S. Senate. The AMA has affirmed, through continual policy statement (policies H-460.957, H-460.974, H-460.964, and H-460.991 for example), its support for appropriate and compassionate use of animals in biomedical research programs, and its opposition to the actions of other groups that impede such research, such as some actions from animal rights groups, and its opposition to legislation that unduly restricts such research. The AMA's Office of Alcohol and Other Drug Abuse promotes temperance and lobbies for a reduction of alcoholic beverage advertising and an increase in alcoholic beverage taxes, among other activities. The AMA supported the Patient Protection and Affordable Care Act as a step toward providing coverage to all Americans and improving the nation's health system.[18] See AMA news release at: http://www.ama-assn.org/ ama/pub/health-system-reform/ama-supports-reform-passage.shtml The AMA does not take a position with regard to the death penalty and does not allow its members to play a role in any part of an execution process.[citation needed]

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Criticisms
Critics of the American Medical Association, including economist Milton Friedman, have asserted that the organization acts as a guild and has attempted to increase physicians' wages and fees by influencing limitations on the supply of physicians and non-physician competition. Some counter this argument by citing "the American Medical Association has been supportive of medical school expansion to help ensure there are enough physicians to care for all Americans. The number of medical schools accredited by the Liaison Committee on Medical Education, of which the AMA is one of two co-sponsors, increased from 125 in 2006 to 137 in 2012. The number of medical students in the U.S. is also increasing." [19] In Free to Choose, Friedman said "the AMA has engaged in extensive litigation charging chiropractors and osteopathic physicians with the unlicensed practice of medicine, in an attempt to restrict them to as narrow an area as possible."[20]

American Medical Association Profession and Monopoly, a book published in 1975, is critical of the AMA for limiting the supply of physicians and inflating the cost of medical care in the United States. The book claims that physician supply is kept low by the AMA to ensure high pay for practicing physicians. It states that in the United States the number, curriculum, and size of medical schools are restricted by state licensing boards controlled by representatives of state medical societies associated with the AMA. The book is also critical of the ethical rules adopted by the AMA which restrict advertisement and other types of competition between professionals. It points out that advertising and bargaining can result in expulsion from the AMA and legal revocation of licenses. Restrictions against advertising that is not false or deceptive were dropped from the AMA Code of Medical Ethics in 1980 (AMA Ethical Policy E-5.02). The book also states that before 1912 the AMA included uniform fees for specific medical procedures in its official code of ethics. The AMA's influence on hospital regulation was also criticized in the book.[21] The AMA and other industry groups predicted an over-supply of doctors, and worked to limit the number of new doctors. But recently, the AMA has changed its position, predicting a doctor shortage instead.[22] It has been argued that the AMA's CPT monopoly has been created by the government and makes the organization subject to government influence; further, the restricted access to CPT codes may not be in the interest of its constituents.[]

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Membership
Published membership figures for the AMA include: In 2002, it was reported that the AMA had 278,000 members, among whom were "less than 30% of American physicians."[23] By 2007, the AMA had 238,977 members, of which 20.5% were medical students and 9% were residents.[] There were 215,854 members as of December 2010, of which 47,227 (21.9%) were medical students and 31,049 (14.4%) were residents or fellows. The total was a decrease from the 2009 membership of 228,150.[][] A 2011 article asserted that "somewhere in the neighborhood of 15% of practicing US doctors now belong to the AMA."[24] Membership total as of Dec 31, 2011 (including residents and students) was 217,490 of approximately 954,000 practicing physicians.[25]

References
[1] http:/ / www. ama-assn. org/ ama/ pub/ news/ news/ 2013/ 2013-06-18-ardis-hoven-inaugurated-ama-president. page [4] American Medical Ass'n. v. United States, [5] Weiss Ratings News: Medical Malpractice Caps Fail to Prevent Premium Increases, According to Weiss Ratings Study (http:/ / www. weissratings. com/ News/ Ins_General/ 20030602pc. htm) [6] Medical Liability Claim Frequency: A 2007-2008 Snapshot of Physicians (http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 363/ prp-201001-claim-freq. pdf) [7] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 37/ 2009-annual-report. pdf [9] https:/ / supreme. justia. com/ us/ 317/ 519/ case. html [11] AMA (Public Health) Eliminating health disparities (http:/ / www. ama-assn. org/ ama/ pub/ category/ 7639. html) [12] AMA (GLBT) News release from the Gay and Lesbian Medical Association (http:/ / www. ama-assn. org/ ama/ pub/ category/ 15741. html) [13] AMA (GLBT) AMA policy regarding sexual orientation (http:/ / www. ama-assn. org/ ama/ pub/ category/ 14754. html) [17] AMA policy statement on climate change (http:/ / www. ama-assn. org/ ama/ pub/ category/ 20275. html) [18] http:/ / www. ama-assn. org/ ama1/ pub/ upload/ mm/ 399/ hsr-3590-passage-support. pdf

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Further reading
Burrow, James G. AMA: Voice of American Medicine. Baltimore: Johns Hopkins University Press, 1963. Campion, Frank. The AMA and U.S. Health Policy Since 1940. Chicago: Chicago Review Press, 1984. Fishbein, Morris. History of the American Medical Association, 18471947. Philadelphia: W. B. Saunders, 1947. Numbers, Ronald. Almost Persuaded: American Physicians and Compulsory Health Insurance, 19121920. Baltimore: Johns Hopkins University Press, 1978. Poen, Monte. Harry S. Truman versus the Medical Lobby: The Genesis of Medicare. Columbia, MO: The University of Missouri Press, 1979. Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

External links
Official website (http://www.ama-assn.org/)

African Malaria Network Trust

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African Malaria Network Trust


African Malaria Network Trust Acronym: AMANET
Logo: African Malaria Network Trust Formation Type Headquarters 14 March 2002 International NGO Dar es Salaam, Tanzania

Officiallanguages English Managing Trustee Prof. Wen Kilama Website http:/ / www. amanet-trust. org/

The African Malaria Network Trust (AMANET) is a pan-African international NGO headquartered in Dar es Salaam, Tanzania which originally started its activities as African Malaria Vaccine Testing Network (AMVTN) in 1995 with the primary goal of preparing Africa in planning and conducting malaria vaccine trials. In order to widen the scope in malaria interventions, AMVTN was succeeded by AMANET on 14 March 2002. Although the primary goal of AMANET has remained malaria vaccine development, the organization in its expanded role includes other intervention measures such as antimalaria drugs and vector control.

Precedence
Malaria is a preventable disease that afflicts hundreds of millions of people causing among them untoward socio-economic suffering including a vicious cycle of abject poverty, brain damage, other irreversible disabilities, and over one million deaths per year.[] Notwithstanding this leading disease burden, malaria has yet to get the status it deserves on the political and other relevant agenda of endemic communities and development partners. For centuries, malaria has adversely affected the history of sub-Saharan Africa; its control during the past century however Malaria Clinic in Tanzania helped by SMS for concentrated on urban areas where colonial authorities and traders Life program lived and in agricultural estates and mines whose products sustained industries in the colonizing countries. When the global malaria eradication program was showing signs of success, which coincided with the wave of national independence, the eradication program was abandoned in Africa on the pretext of mainly administrative and financial constraints. However, the strategies were continued elsewhere.[] As a consequence, the malaria situation in Africa worsened; now Africa bears the brunt of the world malaria burden estimated at 500 million malaria cases and up to 3 million malaria deaths per annum, and costing an estimated US$ 12 billion annually.[][] Continued failure of current strategies (prompt diagnosis, early correct treatment, and the use of insecticide treated nets (ITNs) calls for a need to develop entirely new tools that would contribute to the fight of a resilient enemy and reverse its devastation. Over the last three decades there has been considerable interest in research and development of malaria vaccines. Research results that have been obtained so far show that malaria vaccine candidates would differ not only in their biological properties, but also in their eventual applications.[][] Vaccines have been exceptionally effective against a number of diseases and have become one of the safest and most cost-effective

African Malaria Network Trust weapons in medicine's arsenal against communicable disease. Perhaps no other intervention has had such a dramatic impact on the health and well-being of our society as the introduction of vaccines.

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Establishment
In 1995 at a conference held in Arusha, Tanzania, 81 malaria researchers from Africa, Europe and North America established the African Malaria Vaccine Testing Network (AMVTN) in order to prepare Africa for planning, undertaking and coordinating malaria vaccine trials In order to widen the scope in malaria interventions, and to operate within a legal framework, AMVTN was succeeded by AMANET in 2002. Although the primary goal of AMANET has remained malaria vaccine development, in its expanded role the organization would also support study into other intervention approaches such as antimalarial drugs, diagnostics and vector control. AMANET is committed to the creation of an environment for enabling the development of African centres of excellence in malaria research through capacity strengthening of African scientists and institutions.[]

Mission
The mission of AMANET is to promote capacity strengthening and networking of malaria R&D in Africa

Broad objective
To continue developing self-sustainable centres in Africa that meet international requirements for conducting malaria intervention trials.

Specific objectives
To develop and support implementation of standards for the expertise and infrastructure required to perform and to evaluate intervention trials To promote and coordinate capacity strengthening activities of African malaria R&D institutions To further develop previously selected centres for clinical trials so as to attain sustainability To select more centres for future strengthening for more clinical trials To support long-term training of research personnel To develop suitable training programmes in accordance with international standards To fill gaps in infrastructure of the selected centres To disseminate information of AMANET activities To facilitate and promote the conducting of intervention trials To sponsor clinical and field trials To promote development of African indigenous antimalaria medicines To promote development of appropriate malaria diagnostics To establish a data management centres for AMANET funded trials To review AMANET constitution, and elect members of different AMANET governing bodies.

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Organization Structure
The organization structure of AMANET comprises the General Assembly, Board of Trustees, the Secretariat, Scientific Coordinating Committee, Scientific Advisory Panel, Trial Sites Development Committee and Expert Committees. The General Assembly comprising representatives of malaria R&D institutions in Africa and allied institutions outside Africa is the topmost organ. It generally meets every two years and is responsible for electing the Board of Trustees and the Scientific Coordinating Committee. The Board of Trustees is the ultimate authority in matters of policy and investment. It oversees the general governance, regulation and control of AMANET. The Scientific Coordinating Committee is constituted of senior research scientists elected by the General Assembly. It is responsible for receiving and reviewing reports from the Secretariat and from the Expert Committees. The SCC advises the BoT on scientific matters. Its functions also include the reviewing of research proposals and letters of expression of interest and the monitoring and evaluation of ongoing and completed research projects. The Secretariat is the executive organ of the Trust, serving the Board of Trustees and all the committees. The Trial Sites Development Committee (TSDC) a Committee of experts appointed by the Board of Trustees from SCC to advise AMANET on specific issues relating to the development of trial sites. The Scientific Advisory Panel is a panel of experts from various disciplines from whom ad hoc Expert Committees are formed to advise AMANET on specific research and scientific issues.

Product research and development


Among the cherished goals of AMANET is to develop sustainable human and infrastructure capacity for African owned and led institutions to undertake malaria vaccine trials that are appropriate for Africans living in malaria-endemic areas. The current focus is to support the creation of a spectrum of interventional tools, especially vaccines that are efficacious, acceptable, affordable and readily accessible. The following are AMANET's candidate malaria vaccine portfolio: The Merozoite Surface Protein - Long Sythetic Peptide (MSP3 LSP),[][] This is the leading product which has already been shown to be safe in adults in Africa. The vaccine is currently undergoing testing for safety in children both in Burkina Faso and shortly in Tanzania. Should the safety profile be established to be safe, the vaccine will be taken through phase IIb immunogenicity trials that would also establish the proof of limited efficacy The Apical Membrane Antigen (AMA1):[1] This the second vaccine in development and is now undergoing phase Ib evaluation in adults Mali. During the last quarter of 2007, an evaluation of the safety results was done, and AMA1 was found to be safe in African adults.. The GMZ2:[2] The third vaccine in the portfolio was recently initiated in phase Ib adult study in Gabon. This product is expected to undergo a similar developmental pathway should it continue to have good results. This product is unique because it is a hybrid molecule with two potential targets on the malaria parasite; GLURP and MSP3. It is expected that within the next three years several trials of these candidate vaccines shall be undertaken at the auspices of AMANET. Other candidate vaccines which meet the required profile are welcome to the AMANET malaria vaccine development programme.

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Capacity strengthening
Human resource and infrastructure development for malaria interventions in Africa is of up most priority to AMANET. This goal is being realized through both short-term trainings as well as direct financial support of the core centres. AMANET conducts short-term trainings through various workshops conducted throughout Africa, around six times a year. Additionally AMANET supports long-term training of individuals from AMANET funded sites which include: Tanzania-National Institute for Medical Research (NIMR) Tanga: The programme has steadily continued. We are currently preparing the site for the first vaccine trial of MSP3 in children 12 years. The site characterization activities are near completion; Two staff members at the site are currently taking AMANET sponsored long term training programs at MSc and PhD level. Zambia-Tropical Diseases Research Centre (TDRC) Ndola: The centre is on the capacity development programme having received a strengthening grant. Two AMANET sponsored students are completing the training masters level. Burkina Faso-Centre de National Recherch et de Formation sur le Paludisme (CNRFP) Ouagadougou: The site is currently conducting phase Ib trial of the MSP3 candidate vaccine. Two immunologists were sent to Netherlands for two weeks on specific training to transfer technology and establish cellular assays. This has led to technology transfer with their lab now able to handle the relevant immunological assays to support the clinical trials. Uganda-The Makerere University: The site has become the newest to receive a grant from AMANET for capacity strengthening in preparation for vaccine trials. It has, in parallel, received a grant for ethics committee strengthening.

Building institutional capacities in Health Research Ethics in Africa


This is a new project at AMANET funded by the Bill and Melinda Gates Foundation aimed at strengthening Health Research Ethics (HRE) capacity in Africa. The project aims at ensuring that as the African populations are recruited into health research projects, the protection of their welfare and interests is enhanced. The HRE project has three parts: building Health Research Ethics capacity, online Health Research Ethics discussion forum and Ask the Expert/Ethicist. The HRE capacity building project focuses on training Ethics Committee members on Research Ethics in order to improve the ethical review process of committees that are mandated to safeguard the welfare of research participants. In order to concentrate on activities that have greater potential to strengthen the Ethics Committees, a baseline survey was conducted to identify area of weakness that need to be addressed. A cohort of 21 Ethics Committees is being enrolled in this project and will be involved in various activities aimed at addressing areas of weakness in the review process. These committees are being provided with a sub-grant to support infrastructure and administration at their committees. Overall, activities are spread over a period of three years, and they include, besides capacity strengthening and infrastructure support, a series of eight Research Ethics training workshops, two of which will be in French (for the benefit of the participating Francophone countries). Through the workshops, Standard Operating Procedures (SOPs) will be developed/improved, and an additional workshop focussing on harmonization of SOPs will be organised. In addition, a workshop on Research Ethics will be organised specifically for investigators. It is envisaged that overall the HRE capacity building programme will contribute towards the establishment of competent and independent Ethics Committees that have well-equipped offices, functional and harmonised SOPs, electronic databases and archiving systems, and trained members who network and interact through online discussion forum and workshops.

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The Afro Immuno Assay (AIA) Network


Afro Immuno-Assay Network, started by AMANET in 2003, has been working on developing standardized immunological assays using the same reagents and statistical tools to assess the association between acquisition of malaria specific antibody responses starting with four potential malaria vaccine candidate antigens and subsequent protection from clinical malaria. This is a concerted network of eight African countries/Institutions with different geographical and epidemiological settings comprising low to holoendemic malaria and three supporting European institutions. Now the AIA network is under a new five year project, within the European Malaria Vaccine Development Association (EMVDA) Consortium. In this Integrated Project, the AIA network focuses on standardization and validation of its immunological assays, expand to include new partners, further training for participating African immunologists and enhancement of laboratory expertise to include functional assays required for malaria vaccine evaluation.

Short and long-term training


During the first Strategic Planning period, AMANET supported and organized several training workshops which benefited over 1000 African malaria researchers and associated personnel. In the process a comprehensive repository of expertise essential for the evaluation of malaria interventions, is being built up. Some of the former AMANET trainees have become experts in these areas. During this strategic plan period, AMANET will draw upon this vast expertise to constitute teams of trainers that facilitate short term training for AMANET beneficiary institutions, and for others upon request. The training will be in such areas as Health Research Ethics review in Africa; development of Standard Operating Procedures for Ethical Review Committee; Health Research Ethics for Investigators; Good Laboratory Practice and Standard Operating Procedures; Good clinical practice; Good Clinical Practice for African clinical monitors; Design, methodology and data management in intervention trials; Roles and operations of Data Safety Monitoring Boards (DSMB). Given the ever rising demands for AMANET short-term training, alternative teaching methods have been developed and are being utilized. Web-based training on health research ethics (HRE) is in good progress. The AMANET HRE web-based course has been very successfully accessed through the AMANET website. The online course was launched in September 2006 and to date over 150 participants have successfully completed the course and over 430 candidates have registered for the course. Participants have been drawn from Africa, Europe and the US. Based on its success, AMANET has acquired other resources to continue the project and also the e-learning funding in order to continue the project another year and also expand the e-learning opportunities to include other courses such a GCP, French version of the same course, and also an Advanced Ethics Course.

The Multilateral Initiative on Malaria (MIM)


From January 2006, AMANET became host to the Multilateral Initiative on Malaria (MIM) Secretariat. This is a global alliance of individuals, funding partners and four autonomous constituents comprising the MIM Secretariat, MIM/TDR, MIMCom and MR4. Its mission is to strengthen and sustain, through collaborative research and training, to carry out research that is required to develop and improve tools for malaria control, and to strengthen the research control interphase.

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Acknowledgements
AMANET acknowledges financial support from the Ministry of Foreign Affairs (Netherlands), the Danish International Development Agency (DANIDA), the European Commissions Directorate-General Research and AIDCO, the Bill and Melinda Gates Foundation,[] the European and Developing Countries Clinical Trials Partnership(EDCTP) and the African Caribbean Pacific (ACP) Secretariat for including AMANET in their portfolio for EDF9 support.

References

American Medical Group Association


The American Medical Group Association is a national trade association representing medical groups and other organized systems of health care, including some of the nations largest integrated healthcare delivery systems. More than 125,000 physicians practice in American Medical Group Association member organizations, providing healthcare services for approximately 130 million patients (more than one in three Americans).[1] Headquartered in Alexandria, Virginia, American Medical Group Association (AMGA) provides services to member medical groups, including political advocacy, educational and networking programs, publications, benchmarking data services, and financial and operations assistance.

History
The American Medical Group Association was born out of the desire for physicians practicing in groups to improve the quality of patient care by sharing best practices, experiences, and strategies with their peers. Over the years, AMGA has become one of the primary advocates of group practice, promoting multispecialty medical groups and other organized systems of care as the preferred delivery system for coordinated, patient-centered, efficient, quality medical care in America. Founded in 1950 as the American Association of Medical Clinics, the organization was renamed the American Group Practice Association (AGPA) in 1974. In mid-1996, AGPA merged with the Unified Medical Group Association (UMGA) to form the American Medical Group Association.[2]

AMGA Annual Compensation Survey


For 22 years, the association has conducted a compensation and financial survey of medical groups and organized systems of care and published the results to aid medical groups (particularly large, integrated health systems) in benchmarking compensation and financial performance. The annual Medical Group Compensation and Financial Survey presents detailed data on compensation for healthcare professionals and on medical group financials. The data may be used in conjunction with the Centers for Medicare & Medicaid Services (CMS) regulations at 42 CFR 413.78(f).[3]

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Corporate family
American Medical Group Association is made up of several entities. American Medical Group Foundation (AMGF)[4] - The philanthropic arm of American Medical Group Association, dedicated to demonstrating that the total coordinated care model continues to provide the highest quality, cost-effective, efficient care possible and to fostering quality improvement in group practice through education and research programs in clinical quality, patient safety, service, operational efficiency, and innovation. Council of Accountable Physician Practices (CAPP)[5] - An affiliate of AMGF, CAPP is a joint undertaking by some of the nation's largest and most prominent physician practices to foster the evolution and development of the accountable physician group model. Anceta, LLC[6] - Anceta is a for-profit informatics and analytic company formed to transform comprehensive healthcare information into actionable knowledge and accountable, evidence-based practice. This data warehouse is the only national effort to collect and share critical information across non-affiliated medical group organizations.

References
[1] http:/ / www. amga. org/ AboutAMGA/ index_aboutAMGA. asp [2] [3] [4] [5] [6] http:/ / www. amga. org/ AboutAMGA/ history_aboutAMGA. asp http:/ / www. cms. hhs. gov/ AcuteInpatientPPS/ Downloads/ AMGA_08_data. pdf http:/ / www. amga. org/ Foundation/ index. asp http:/ / www. amga-capp. org/ http:/ / www. anceta. com/

External links
American Medical Group Association website (http://www.amga.org/)

American Medical Informatics Association

215

American Medical Informatics Association


American Medical Informatics Association
Abbreviation Motto Formation Type Legalstatus Purpose/focus Headquarters Membership AMIA The professional home for biomedical and health informatics 1989, merger of NGOs incorporated in 1972 NGO NPO Professional association Bethesda, MD 4,000

Officiallanguages English President Key people Mainorgan Website Kevin Fickenscher Gilad J. Kuperman, Chair of the Board of Directors Assembly http:/ / www. amia. org

AMIA, formerly known as the American Medical Informatics Association, is an American non-profit organization dedicated to the development and application of biomedical and health informatics in the support of patient care, teaching, research, and health care administration.

History
AMIA is the official United States representative to the International Medical Informatics Association. It has grown to more than 4,000 members from 42 countries worldwide. Together, these members represent all basic, applied, and clinical interests in health care information technology. It publishes the Journal of the American Medical Informatics Association.

Founding
AMIA was founded in 1989 by the merger of three organizations: American Association for Medical Systems and Informatics American College of Medical Informatics Symposium on Computer Applications in Medical Care

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Leadership
The first President and CEO of AMIA was Don E. Detmer. He was succeeded in July 2009 by Edward H. Shortliffe. In March 2012, he was succeeded by Kevin Fickenscher.

Membership
AMIA membership is open to individuals, institutions, and corporations. Members include physicians, nurses, dentists, pharmacists, clinicians, health information technology professionals, computer and information scientists, biomedical engineers, consultants and industry representatives, medical librarians, academic researchers and educators, and advanced students pursuing a career in clinical informatics or health information technology.

Meetings and education


AMIA annually holds the following meetings:[1] AMIA Annual Symposium The AMIA Joint Summit on Translational Science comprising: AMIA Summit on Translational Bioinformatics AMIA Summit on Clinical Research Informatics AMIA Now AMIA CMIO Boot Camp

Working and special interest groups


AMIA includes a number of working groups: Clinical Information Systems Clinical Research Informatics Consumer Health Informatics Dental Informatics Education Ethical, Legal, & Social Issues Evaluation Formal (Bio)Medical Knowledge Representation Genomics Knowledge Discovery and Data Mining Knowledge in Motion Medical Imaging Systems Natural Language Processing Nursing Informatics Open Source People & Organizational Issues Pharmacoinformatics Primary Care Informatics Public health informatics Student

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References
[1] AMIA meetings (https:/ / www. amia. org/ meetings)

External links
Official website (http://www.amia.org/)

American Nurses Association


The American Nurses Association (ANA) is a professional organization to advance and protect the profession of nursing. It started in 1896 as the Nurses Associated Alumnae and was renamed the American Nurses Association in 1911.[1] It is based in Silver Spring, Maryland[2] and Karen Daley, PhD, MPH, RN, FAAN, is the current President.[3] The ANA states nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.[4]

History
Initial organizational plans were made for the Nurses Associated Alumnae of the United States of America in 1896 in Manhattan Beach. In February 1897, those plans were ratified in Baltimore at a meeting that coincided with the annual conference of the American Society of Superintendents of Training Schools for Nurses.[] Isabel Hampton Robb served as the first president. A major early goal of the organization was the enhancement of nursing care for American soldiers.[5]

Primary mission
The Association is a professional organization representing registered nurses (RNs) in the United States through its 54 constituent member associations.[6] The ANA is involved in establishing standards of nursing practice, promoting the rights of nurses in the workplace, advancing the economic and general welfare of nurses.[7] ANA also has three subsidiary organizations: (1) American Academy of Nursing, to serve the public and profession by advancing health policy and practice through the generation, synthesis, and dissemination of knowledge,(2) American Nurses Foundation, the charitable and philanthropic arm, and (3) American Credentialing Center, which credentials nurses in their specialty and credentials facilities that exhibit excellence.[8] nursing nursing Nurses nursing

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Publications
American Nurse Today The American Nurse OJIN: The Online Journal of Issues in Nursing[9]

External links
American Nurses Association website [10] American Nurse Foundation website [11] American Nurse Credentialing Center website [12] American Academy of Nursing website [13]

References
[10] [11] [12] [13] http:/ / nursingworld. org http:/ / www. anfonline. org/ http:/ / www. nursecredentialing. org/ http:/ / www. aannet. org

American Optometric Association


Representing approximately 37,000 doctors of optometry, optometry students and paraoptometric assistants and technicians, the American Optometric Association was founded in 1898. The Association has offices in St. Louis, MO, and Alexandria, VA, employing approximately 100 people. The AOA counts nearly half of practicing optometrists as its members. Serving patients in nearly 6,500 communities across the country, optometrists are the only eye doctors in 3,500 communities and provide two-thirds of all primary eye care in the United States. The AOA is a federation, with state, student and armed forces optometric associations representing members at the state or affiliate level. The Association also has four special interest sections: The Contact Lens and Cornea Section, the Vision Rehabilitation Section, the Sports Vision Section and the Paraoptometric Section. The AOA and its affiliates work to provide the public with quality vision and eye care by:
Setting professional standards and helping member optometrists conduct patient care efficiently and effectively,

Lobbying government and other organizations on behalf of the optometric profession, and

Providing research and education leadership.

AOA mission
"Advocate for the profession and serve optometrists in meeting the eye care needs of the public." The objectives of AOA are centered on improving the quality and availability of eye and vision care. The AOA fulfills its missions in accordance with the following goals: Health care and public policy related to eye care will uniformly recognize optometrists as primary health care providers and ensure the public has access to the full scope of optometric care. Optometrists and other professionals will look to the American Optometric Association for professional standards, research and education leadership which serve to enhance and ensure competent, quality patient care.

American Optometric Association The public, optometrists and other professionals will turn to the American Optometric Association for reliable and current information related to optometry, eye care, and health care policy.

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External links
American Optometric Association Official page [1] AOA News web site [2] InfantSEE: a public health program for infants [3] Optometry's Meeting [4] Journal of the American Optometric Association [5]

References
[1] [2] [3] [4] [5] http:/ / www. aoa. org http:/ / www. aoanews. org http:/ / www. infantsee. org http:/ / www. optometrysmeeting. org http:/ / www. optometryjaoa. com/

American Osteopathic Association

220

American Osteopathic Association


American Osteopathic Association
Abbreviation Motto Formation Type Headquarters Location Coordinates Membership AOA Treating Our Family and Yours April 10, 1897 Professional association Chicago, Illinois United States

Coordinates: 41.8942N 87.6190W [1]


[] 43,472 physicians and medical students

Officiallanguages English President Website Ray E. Stowers, DO [2] [3]

AOA Official Website

Osteopathic medicine in the United States


Andrew Taylor Still (founder) Doctor of Osteopathic Medicine (DO) Medicine US Medical education

Schools Physicians Osteopathic Manipulative Medicine AOA AACOM AAO COMLEX MD & DO Comparison Specialty Colleges AOA BOS

The American Osteopathic Association (AOA) is the representative member organization for the over 82,500 osteopathic medical physicians (D.O.s) in the United States.[] The AOA is headquartered in Chicago, Illinois, and is involved in post-graduate training for osteopathic physicians. The organization promotes public health, encourages academic scientific research, serves as the primary certifying body for D.O.s overseeing 18 certifying boards, is the accrediting agency for osteopathic medical schools through its Commission on Osteopathic College Accreditation, and has federal authority to accredit hospitals and other health care facilities,[4][5][6] through its program, the Healthcare Facilities Accreditation Program.[7] The AOA has held yearly conventions since its founding in 1897.[8] The AOA also manages DOCARE International, a non-profit charitable organization. The AOA also publishes The DO, a monthly magazine, and the Journal of the American Osteopathic Association, a peer reviewed medical journal.

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Mission
The AOA's mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective healthcare. The AOA supports the annual "D.O. day on the Hill," where roughly 1,000 osteopathic medical students go to Washington D.C. to meet with congressmen to discuss current issues in health care, such as access to care challenges.[9] The event serves as an opportunity for the legislators to learn more about health care and osteopathic medicine, and for the medical students to become more familiar with the political process.

History
The association was founded as the American Association for the Advancement of Osteopathy on April 10, 1897, in Kirksville, Missouri, by students of the American School of Osteopathy.[10][] It was renamed the American Osteopathic Association in 1901.[][11] In September 1901, the AOA began to publish a scientific journal entitled the Journal of the American Osteopathic Association. Subscriptions were offered to AOA members, and at the time, membership fees were $5 annually.[] The journal was published bimonthly for the first year, then monthly thereafter. In April 1927, the AOA began publishing "The Forum of Osteopathy," a monthly magazine that covered news relating to osteopathic medicine, the AOA, and related groups.[] In September 1960, the magazine was renamed The DO. In the early 1900s, the AOA, citing concerns about safety and efficacy, was opposed to the introduction of pharmacology into the curriculum of osteopathic medicine. However, in 1929 the AOA board of trustees voted to allow the teaching of pharmacology in D.O. schools.[] By 1938, the AOA began requiring that osteopathic medical students have at least 1 year of undergraduate college coursework, and by 1940, the AOA required two years.[] In 1952, the U.S. Department of Health, Education, and Welfare recognized the AOA as the official accrediting body for osteopathic medical education. In 1967, the National Commission on Accrediting (currently the Council for Higher Education Accreditation) recognized the AOA as the official accrediting agency for all aspects of osteopathic medical education.[12] The Department of Health, Education and Welfare (currently the Department of Health and Human Services) recognized the AOA as the official accrediting body for osteopathic hospitals under Medicare in 1966.[]

Osteopathic post-graduate education


The AOA also provides funding for post-graduate osteopathic medical residencies.[] In the 2012 match, 1,767 osteopathic physicians matched into these residency programs.[] In 1999, the AOA began requiring all schools of osteopathic medicine to be actively involved in residency training programs through Osteopathic Post-Graduate Training Institutes.[13][14]

Publications
The American Osteopathic Association publishes The DO, a monthly magazine[15] covering news related to osteopathic medicine, legislation, health care changes, and osteopathic continuing medical education programs.[16] The AOA also publishes the Journal of the American Osteopathic Association, a monthly peer-reviewed medical journal focusing on original research and editorial articles.

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DOCARE International
DOCARE International is a non-profit medical charity serving remote areas of the Western Hemisphere. DOCARE is operated by the American Osteopathic Association, and consists of osteopathic physicians, osteopathic medical students, M.D. physicians, and other healthcare professionals.[17]

References
[1] http:/ / tools. wmflabs. org/ geohack/ geohack. php?pagename=American_Osteopathic_Association& params=41. 8942_N_-87. 6190_E_ [3] http:/ / www. osteopathic. org/ Pages/ default. aspx [11] History of the AOA (http:/ / www. osteopathic. org/ index. cfm?PageID=aoa_history), American Osteopathic Association website

External links
American Osteopathic Association (http://www.osteopathic.org) "The DO" online news publication (http://www.do-online.org/TheDO/) Mini-Medical School (http://www.mini-med-school.com/)

American Occupational Therapy Association


The American Occupational Therapy Association (AOTA) is the national professional association established in 1917 to represent the interests and concerns of occupational therapy practitioners and students and improve the quality of occupational therapy services. AOTA membership is approximately 48,000 occupational therapists, occupational therapy assistants, and students. The National Society for the Promotion of Occupational Therapy was the founding name of the AOTA.

External links
American Occupational Therapy Association official website [1]

References
[1] http:/ / www. aota. org

Administrative Procedure Act

223

Administrative Procedure Act


Administrative Procedure Act of 1946

Long title

An Act to improve the administration of justice by prescribing fair administrative procedure.

Colloquial acronym(s) APA Enacted by the Effective 79th United States Congress June 11, 1946 Citations Public Law Stat. 79-404 [1]

60Stat.237 Codification

Title(s) amended

5 U.S.C.: Government Organization and Employees

U.S.C. sections created Chapter 5 500 et seq.[2] Legislative history Introduced in the Senate as S. 7 by Patrick McCarran (DNV) on October 19, 1945 Committee consideration by: Senate Judiciary Committee, House Judiciary Committee Signed into law by President Harry S. Truman on June 11, 1946 Major amendments Recodified by Pub. L. 89554, Sept. 6, 1966, 80 Stat. 383 United States Supreme Court cases Citizens to Preserve Overton Park v. Volpe Vermont Yankee Nuclear Power Corp. v. NRDC

Administrative law
General principles

Administrative court Delegated legislation Exhaustion of remedies Justiciability Legitimate expectation Ministerial act Natural justice Nondelegation doctrine Ouster clause (privative clause) Patently unreasonable Polycentricity

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224
Prerogative writ Certiorari Habeas corpus Mandamus Prohibition Quo warranto Rulemaking Ultra vires Administrative law in common law jurisdictions

Australia Canada Singapore South Africa United Kingdom Scotland United States Administrative law in civil law jurisdictions

China Mongolia Ukraine Related topics

Constitutional law Judicial review

The Administrative Procedure Act (APA), Pub.L. 79404 [3], 60Stat.237, enacted June11, 1946, is the United States federal law that governs the way in which administrative agencies of the federal government of the United States may propose and establish regulations. The APA also sets up a process for the United States federal courts to directly review agency decisions. It is one of the most important pieces of United States administrative law. The Act became law in 1946. The APA applies to both the federal executive departments and the independent agencies. U.S. Senator Pat McCarran called the APA "a bill of rights for the hundreds of thousands of Americans whose affairs are controlled or regulated" by federal government agencies. The text of the APA can be found under Title 5 of the United States Code, beginning at Section 500. There is a similar Model State Administrative Procedure Act (Model State APA) which was drafted by the National Conference of Commissioners on Uniform State Laws for oversight of state agencies. Not all states have adopted the model law wholesale as of 2007. The federal APA does not require systematic oversight of regulations prior to adoption as suggested by the Model APA.[4]

Historical background
Beginning in 1933, President Franklin D. Roosevelt and the Democratic Congress enacted several statutes that created new federal agencies as part of the New Deal legislative plan, designed to deliver the United States from the social and economic hardship of the Great Depression. However, following the Great Depression and World War II the Congress became concerned about the expanding powers that federal agencies possessed, resulting in the enactment of the APA to regulate and standardize federal agency procedures.[2] In a law journal article on the history of the APA,[5] Professor George Shepard discusses the contentious political environment from which the APA was born. Shepard claims that Roosevelts opponents and supporters fought over

Administrative Procedure Act passage of the APA "in a pitched political battle for the life of the New Deal" itself.[5] Shepard does note, however, that a legislative balance was struck with the APA, expressing "the nation's decision to permit extensive government, but to avoid dictatorship and central planning."[5] A 1946 U.S. House of Representatives report discusses the 10-year period of "painstaking and detailed study and drafting" that went into the APA.[6] Because of rapid growth in the administrative regulation of private conduct, Roosevelt ordered several studies of administrative methods and conduct during the early part of his four-term presidency.[6] Based on one study, Roosevelt commented that the practice of creating administrative agencies with the authority to perform both legislative and judicial work "threatens to develop a fourth branch of government for which there is no sanction in the Constitution." In 1939, Roosevelt requested that Attorney General Frank Murphy form a committee to investigate practices and procedures in American administrative law and suggest improvements. That committee's report,[7] contains detailed information about the development and procedures of the federal agencies. The Final Report defined a federal agency as a governmental unit with "the power to determine...private rights and obligations" by rulemaking or adjudication.[7] The Final Report applied that definition to the largest units of the federal government, and identified "19 executive departments and 18 independent agencies."[7] If various subdivisions of the larger units were considered, the total number of federal agencies at that time increased to 51. In reviewing the history of federal agencies, the Final Report noted that almost all agencies had undergone changes in name and political function. Of the 51 federal agencies discussed in the Final Report, 11 were created by statute prior to the Civil War. From 1865 to 1900, six new agencies were created. Most notable was the formation of the Interstate Commerce Commission, created in 1887 in response to widespread criticism of the railroad industry. The period of 1900 to 1940, however, saw the greatest expansion of federal administrative power, with 35 new agencies created by statute. Eighteen of these were created during the 1930s, from statutes enacted as part of Roosevelt's New Deal. The Final Report made several recommendations about standardizing administrative procedures, but Congress delayed action because the U.S. entered World War II. Since 2005, the House Judiciary Committee has been undertaking an Administrative Law, Process and Procedure Project to determine what, if any, changes should be made to the Administrative Procedure Act.

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Basic purposes
Agencies are unique governmental bodies, capable of exercising powers characteristic of all three branches of the United States federal government: judicial, legislative and executive. An individual agency typically will possess only the power of the branch that set it up, or possibly powers characteristic of two branches, but the Separation of Powers doctrine dictates that all three powers should not be vested in one body. As recognized by President Roosevelt and others, the creation and function of federal agencies can cause separation of powers issues under the United States Constitution. To provide constitutional safeguards, the APA creates a framework for regulating agencies and their unique role. According to the Attorney General's Manual on the Administrative Procedure Act (1947), drafted after the 1946 enactment of the APA, the basic purposes of the APA are (1) to require agencies to keep the public informed of their organization, procedures and rules; (2) to provide for public participation in the rulemaking process; (3) to establish uniform standards for the conduct of formal rulemaking and adjudication; (4) to define the scope of judicial review.[8] The APA's provisions apply to many federal governmental institutions. The APA in 5 U.S.C. 551(1)[9] defines an "agency" as "each authority of the Government of the United States, whether or not it is within or subject to review by another agency," with the exception of several enumerated authorities, including the Congress, federal courts, and governments of territories or possessions of the United States. Courts have also held that the U.S. President is not an agency under the APA. Franklin v. Mass., 505 U.S. 788 (1992).

Administrative Procedure Act The Final Report organized federal administrative action into two parts: adjudication and rulemaking. (p.5) Agency adjudication was broken down further into two distinct phases of formal and informal adjudication. (Ibid.) Formal adjudication involve a trial-like hearing with witness testimony, a written record and a final decision. Under informal adjudication, however, agency decisions are made without formal trial-like procedures, using "inspections, conferences and negotiations" instead. (Ibid.) Because formal adjudication produces a record of proceedings and a final decision, it may be subject to judicial review. As for rulemaking resulting in agency rules and regulations, the Final Report noted that many agencies provided due process through hearings and investigations, but there was still a need for well-defined, uniform standards for agency adjudication and rulemaking procedures.

226

Standard of judicial review


The APA requires that in order to set aside agency action not subject to formal trial-like procedures, the court must conclude that the regulation is "arbitrary and capricious, an abuse of discretion, or otherwise not in accordance with the law."[] However, Congress may further limit the scope of judicial review of agency actions by including such language in the organic statute. To set aside formal rulemaking or formal adjudication whose procedures are trial-like (see APA, 5 U.S.C 556[] - 557[]), a different standard of review allows courts to question agency action more strongly. For these more formal actions, agency decisions must be supported by "substantial evidence"[] after the court reads the "whole record,"[10] which can be thousands of pages long. Unlike arbitrary and capricious review, substantial evidence review gives the courts leeway to consider whether an agency's factual and policy determinations were warranted in light of all the information before the agency at the time of decision. Accordingly, arbitrary and capricious review is understood to be more deferential to agencies than substantial evidence review. Arbitrary and capricious review allows agency decisions to stand as long as an agency can give a reasonable explanation for its decision based on the information it had at the time. In contrast, the courts tend to look much harder at decisions resulting from trial-like procedures because those agency procedures resemble actual trial-court procedures, but the Article III of the Constitution reserves the judicial powers for actual courts. Accordingly, courts are strict under the substantial evidence standard when agencies acts like courts because being strict gives courts final say, preventing agencies from using too much judicial power in violation of separation of powers. The separation of powers doctrine is less of an issue with rulemaking not subject to trial-like procedures. Such rulemaking gives agencies a lot more leeway in court because it is much more like the legislative process reserved for Congress in Article II. Courts' main role here is ensuring agency rules line up with the Constitution and with agency's statutory commands from Congress. Even if a court finds a rule very unwise, it will stand as long as it is not "arbitrary and capricious, an abuse of discretion, or otherwise not in accordance with the law."

Publication of regulations
Rules and regulations issued by federal administrative agencies are published chronologically (by date of issuance) in the Federal Register. Rules and regulations are then organized by topic (subject matter) in a separate publication called the Code of Federal Regulations. In comparing publication of regulations to publication of statutes, the Federal Register is analogous to the United States Statutes at Large and the Code of Federal Regulations is analogous to the United States Code.

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227

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. justice. gov/ jmd/ ls/ legislative_histories/ pl79-404/ act-pl79-404. pdf Hall, D: Administrative Law Bureaucracy in a Democracy 4th Ed., page 2. Pearson, 2009. http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=79& no=404 (2007). OVERSIGHT AND INSIGHT: LEGISLATIVE REVIEW OF AGENCIES AND LESSONS FROM THE STATES (http:/ / www. harvardlawreview. org/ issues/ 121/ december07/ Note_1047. php). Harvard Law Review. Shepard, George. Fierce Compromise: The Administrative Procedure Act Emerges from New Deal Politics. 90 Nw. U. L. Rev. 1557 (1996) Administrative Procedure Act, Report of the House Judiciary Committee, No. 1989, 79th Congress, 1946. Final Report of the Attorney General's Committee on Administrative Procedure (http:/ / www. law. fsu. edu/ library/ admin/ 1941report. html) (Senate Document No. 8, 77th Congress, First Session, 1941) http:/ / www. law. fsu. edu/ library/ admin/ 1947cover. html Attorney General's Manual on the Administrative Procedure Act (1947) http:/ / frwebgate. access. gpo. gov/ cgi-bin/ usc. cgi?ACTION=RETRIEVE& FILE=$$xa$$busc5. wais& start=175450& SIZE=11844& TYPE=TEXT United States Code Title 5

External links
Administrative Procedure Act (http://biotech.law.lsu.edu/Courses/study_aids/adlaw/) Attorney General's Manual on the Administrative Procedure Act (http://www.law.fsu.edu/library/admin/ 1947cover.html) Legal Information Institute administrative law overview (http://www.law.cornell.edu/topics/administrative. html) Key administrative law decisions by the US Supreme Court (http://www.law.cornell.edu/supct/cases/adlaw. htm) Federal administrative agency index via Washburn School of Law (http://www.washlaw.edu/doclaw/ executive5m.html) Administrative Law Journal (http://www.wcl.american.edu/journal/alr/) Washington College of Law, American University Cybertelecom :: Administrative Procedures Act (http://www.cybertelecom.org/notes/apa.htm)

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American Psychiatric Association


American Psychiatric Association
Logo of the APA Formation Headquarters 1844 1000 Wilson Boulevard, Suite 1825 Arlington, Virginia, United States [] 36,000 members

Membership

May 20132014 President Jeffrey Lieberman, M.D. Website www.psychiatry.org [1]

The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world.[] Its some 36,000[] members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM codifies psychiatric conditions and is used worldwide as a key guide for diagnosing disorders. The organization has its headquarters in Arlington County, Virginia.[2]

History
At a meeting in 1844 in Philadelphia, 13 superintendents and organizers of insane asylums and hospitals formed the Association of Medical Superintendents of American Institutions for the Insane (AMSAII). The group included Thomas Kirkbride, creator of the asylum model which was used throughout the United States. At the meeting they passed the first proposition of the new organization: "It is the unanimous sense of this convention that the attempt to abandon entirely the use of all means of personal restraint is not sanctioned by the true interests of the insane."[3] The name of the organization was changed in 1892 to The American Medico-Psychological Association to allow assistant physicians working in mental hospitals to become members. In 1921, the name was changed to the present American Psychiatric Association. The APA emblem, dating to 1890, became more officially adopted from that year. It was a round medallion with a purported facial likeness of Benjamin Rush and 13 stars over his head to represent the 13 founders of the organization. The outer ring contains the words "American Psychiatric Association 1844." Rush's name and an M.D.[4] The Association was Incorporated in the District of Columbia in 1927. In 1948, APA formed a small task force to create a new standardized psychiatric classification system. This resulted in the 1952 publication of the first DSM. In 1965 a new task force of 10 people developed DSM-II, published in 1968. DSM-III was published in 1980, after a larger process involving some 600 clinicians. The book was now 500 pages long, including many more disorders, and it sold nearly half a million copies. APA published a revised DSM-III-R in 1987 and DSM-IV in 1994, the latter selling nearly a million copies by the end of 2000. DSM-IV-TR with minor revisions was published in 2000. APA is currently developing and consulting on DSM-V, which will be published in May 2013. In the early 1970s, activists campaigned against the DSM classification of homosexuality as a mental disorder, protesting at APA offices and at annual meetings from 1970 to 1973. In 1973 the Board of Trustees voted to remove homosexuality as a disorder category from the DSM, a decision ratified by a majority (58%) of the general APA membership the following year. A category of "sexual orientation disturbance" was introduced in its place in 1974,

American Psychiatric Association and then replaced in the 1980 DSM-III with Ego-dystonic sexual orientation. That was removed in 1987. In 2002, amidst increasing concern to differentiate themselves from clinical psychologists, the APA assembly membership voted against a proposed name change to the American Psychiatric Medical Association.[5] Dr. Saul Levin was named on May 15th, 2013 as the new chief executive officer and medical director of the APA, making him the first known openly gay person to head the APA. [6]

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Organization and membership


APA is led by the President of the American Psychiatric Association and a Board of Trustees with an Executive Committee. APA reports [7] that its membership is primarily medical specialists who are qualified, or in the process of becoming qualified, as psychiatrists. The basic eligibility requirement is completion of a residency program in psychiatry accredited by the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada (RCPS(C)), or the American Osteopathic Association (AOA). Applicants for membership must also hold a valid medical license (with the exception of medical students and residents) and provide one reference who is an APA member. APA holds an annual conference attended by a US and international audience. APA is made up of some 76 district associations throughout the US.[8]

Theoretical position
The APA reflects and represents mainstream psychiatry in the United States. Reflecting larger trends, the APA members and leaders had been largely psychodynamic in their approaches until recent decades, when the field became more "biopsychosocial." The DSM is currently intended to be less theoretical than prior editions, having moved away from psychodynamic theories to be more widely accepted, and is proposed to not be committed to a particular theorized etiology for mental disorders. The criteria for many of the mental disorders have been expanded and involve a checklist of so-called 'Feighner Criteria' to try and capture the varying sets of features which would be necessary to diagnose a particular disorder.

Publications and campaigns


APA position statements,[9] Psych.org and practice guidelines[10] and description of its core diagnostic manual the DSM [11] are published. APA publishes several journals[12] focused on different areas of psychiatry, for example, academic, clinical practice, or news. APA recently launched a health campaign[13] with a new PR approach.[14]

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Notable figures
Adolf Meyer rose to prominence as the president of the American Psychiatric Association and was one of the most influential figures in psychiatry in the first half of the twentieth century. Robert Spitzer was a key figure in the development of later editions of the DSM. Donald Ewen Cameron is best known for his MK-ULTRA-related mind-control and behavior modification research for the CIA. Cameron was President of the APA in 1952-1953. Current president Jeffrey Lieberman was principal investigator for the NIMH CATIE study.[15]

Drug company ties


In his book Anatomy of an Epidemic (2010), Robert Whitaker described the partnership that has developed between the APA and pharmaceutical companies since the 1980s.[] APA has come to depend on pharmaceutical money.[] The drug companies endowed continuing education and psychiatric "grand rounds" at hospitals. They funded a political action committee (PAC) in 1982 to lobby Congress.[] The industry helped to pay for the APA's media training workshops.[] It was able to turn psychiatrists at top schools into speakers, and although the doctors felt they were independents, they rehearsed their speeches and likely would not be invited back if they discussed drug side effects.[] "Thought leaders" became the experts quoted in the media.[] As Marcia Angell wrote in The New England Journal of Medicine (2000), "thought leaders" could agree to be listed as an author of ghostwritten articles,[16] and she cites Thomas Bodenheimer and David Rothman who describe the extent of the drug industry's involvement with doctors.[17][18] The New York Times published a summary about antipsychotic medications in October 2010.[19] In 2008, for the first time, Senator Charles Grassley asked the APA to disclose how much of its annual budget came from drug industry funds. The APA said that industry contributed 28% of its budget ($14 million at that time), mainly through paid advertising in APA journals and funds for continuing medical education.[]

Controversies
Controversies have related to anti-psychiatry and disability rights campaigners, who regularly protest at American Psychiatric Association offices or meetings. In 1971, members of the Gay Liberation Front organization sabotaged an APA conference in San Francisco. In 2003 activists from MindFreedom International staged a 21-day hunger strike, protesting at a perceived unjustified biomedical focus and challenging APA to provide evidence of the widespread claim that mental disorders are due to chemical imbalances in the brain. APA published a position statement in response[20] and the two organizations exchanged views on the evidence. There was controversy when it emerged that US psychologists and psychiatrists were helping interrogators in Guantanamo and other US facilities. The American Psychiatric Association released a policy statement that psychiatrists should not take a direct part in interrogation of particular prisoners [21] but could "offer general advice on the possible medical and psychological effects of particular techniques and conditions of interrogation, and on other areas within their professional expertise." After previous controversy over APA's classification of homosexuality as a mental illness, there is also controversy regarding the remaining category of "sexual disorder not otherwise specified" which can include a state of distress about one's sexual orientation, as well as the diagnosis of "gender identity disorder" or gender dysphoria.[22] The APA's Standard Diagnostic Manual came under criticism from autism specialists Tony Attwood and Simon Baron-Cohen for proposing the elimination of Asperger's syndrome as a disorder and replacing it with an autism severity scale. Professor Roy Richard Grinker wrote a controversial editorial for the New York Times expressing support for the proposal. The APA president in 2005, Steven Sharfstein, caused controversy when, although praising the pharmaceutical industry, he argued that American psychiatry had "allowed the biopsychosocial model to become the bio-bio-bio model" and accepted "kickbacks and bribes" from pharmaceutical companies leading to the over-use of medication

American Psychiatric Association and neglect of other approaches.[23] In 2008 APA became a focus of congressional investigations regarding the way that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions. The drug industry accounted in 2006 for about 30 percent of the associations $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences and industry symposiums at its annual meeting. APA is considering its response to increasingly intense scrutiny and questions about conflicts of interest.[24] The APA president of 2009-2010, Alan Schatzberg, has also come under fire after it came to light that he was principal investigator on a federal study into a drug being developed by Corcept Therapeutics, a company Schatzberg had himself set up and in which he had several millions of dollars worth of stock.[25]

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References
[1] http:/ / www. psychiatry. org [2] " Contact Us (http:/ / www. psychiatry. org/ contact-us-for-help/ contact-us)." American Psychiatric Association. Retrieved on September 6, 2012. "American Psychiatric Association 1000 Wilson Boulevard Suite 1825 Arlington, VA 22209" [4] http:/ / www. psychiatricnews. org/ pnews/ 98-04-17/ hx. html [6] http:/ / www. washingtonblade. com/ 2013/ 05/ 21/ gay-washington-dc-psychiatrist-saul-levin-named-head-of-american-psychiatric-association-apa/ [7] http:/ / www. psych. org/ about_apa/ [9] Position Statements (http:/ / www. psych. org/ MainMenu/ EducationCareerDevelopment/ Library/ PositionStatements. aspx) [10] Practice guidelines Practice Guidelines (http:/ / www. psych. org/ psych_pract/ treatg/ pg/ prac_guide. cfm), Psych.org [11] Diagnostic and Statistical Manual (http:/ / www. psych. org/ MainMenu/ Research/ DSMIV. aspx) [12] psychiatryonline.org (http:/ / www. psychiatryonline. org/ ) [13] HealthyMinds.org (http:/ / www. healthyminds. org/ ) [21] Psychiatric participation in interrogation of detainees (http:/ / web. archive. org/ web/ 20060622063118/ http:/ / www. psych. org/ edu/ other_res/ lib_archives/ archives/ 200601. pdf) [22] Controversy Continues to Grow Over DSMs GID Diagnosis (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 38/ 14/ 25) [23] Sharfstein, SS. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly (http:/ / pn. psychiatryonline. org/ cgi/ content/ full/ 40/ 16/ 3) Psychiatric News August 19, 2005 Volume 40 Number 16 [24] Psychiatric Group Faces Scrutiny Over Drug Industry Ties (http:/ / www. nytimes. com/ 2008/ 07/ 12/ washington/ 12psych. html?_r=1& pagewanted=all), New York Times, 2008-07-12 [25] Stanford Researcher, Accused of Conflicts, Steps Down as NIH Principal Investigator (http:/ / chronicle. com/ news/ article/ ?id=4922), The Chronicle of Higher Education, 2008-01-08

External links
Official website (http://www.psychiatry.org)

American Psychological Association

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American Psychological Association


American Psychological Association
Logo of the APA Formation Headquarters 1892 750 First Street, NE Washington, D.C., United States 137,000 members

Membership

2013 President Donald N. Bersoff CEO Website Norman B. Anderson www.apa.org [1]

The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States and Canada.[2] It is the world's largest association of psychologists with around 137,000 members including scientists, educators, clinicians, consultants and students. The APA has an annual budget of around $115m. There are 54 divisions of the APAinterest groups covering different subspecialties of psychology or topical areas.[3]

Profile
Mission
The mission of the APA[] is to advance the creation, communication and application of psychological knowledge to benefit society and improve peoples lives. The American Psychological Association aspires to excel as a valuable, effective and influential organization advancing psychology as a science, serving as: A uniting force for the discipline The major catalyst for the stimulation, growth and dissemination of psychological science and practice The primary resource for all psychologists The premier innovator in the education, development, and training of psychological scientists, practitioners and educators The leading advocate for psychological knowledge and practice informing policy makers and the public to improve public policy and daily living A principal leader and global partner promoting psychological knowledge and methods to facilitate the resolution of personal, societal and global challenges in diverse, multicultural and international contexts An effective champion of the application of psychology to promote human rights, health, well being and dignity The APA core values statement The American Psychological Association commits to its vision through a mission based upon the following values: Continual Pursuit of Excellence Knowledge and its Application Based Upon Methods of Science Outstanding Service to its Members and to Society Social Justice, Diversity and Inclusion Ethical Action in All that We Do

American Psychological Association The APA has task forces which issue policy statements on various issues of social import such as the APA position on psychology of abortion; APA position on human rights such as detainee welfare, human trafficking, and rights for the mentally ill; APA position on IQ; APA position on treating homosexuality (sexual orientation change efforts); and APA position on men and women (gender differences).[4]

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Governance
APA is a corporation chartered in the District of Columbia. APAs bylaws describe structural components that serve as a system of checks and balances that ensure democratic process. The organizational entities include: APA President. APAs president is elected by the membership. The president chairs the Council of Representatives and the Board of Directors. During his or her term of office, the president performs such duties as are prescribed in the Bylaws. Board of Directors. The board is composed of six members-at-large, the president-elect, president, past-president, treasurer, recording secretary, CEO, and the chair of the American Psychological Association of Graduate Students (APAGS). The Board oversees the associations administrative affairs and presents an annual budget for council approval. APA Council of Representatives. The council has sole authority to set policy and make decisions regarding APAs roughly $60 million annual income. It is composed of elected members from state/provincial/territorial psychological associations, APA divisions and the APA Board of Directors. APA Committee Structure: Boards and Committees. Members of boards and committees conduct much of APAs work on a volunteer basis. They carry out a wide variety of tasks suggested by their names. Some have responsibility for monitoring major programs, such as the directorates, the journals and international affairs.[]

Good Governance Project


The Good Governance Project (GGP) was initiated in January 2011 as part of the strategic plan to [assure] APAs governance practices, processes and structures are optimized and aligned with what is needed to thrive in a rapidly changing and increasingly complex environment.[] The charge included soliciting feedback and input stakeholders, learning about governance best practices, recommending whether change was required, recommending needed changes based on data, and creating implementation plans.[] The July 2013 GGP update on the recommended changes can be found in the document "Good Governance Project Recommended Changes to Maximize Organizational Effectiveness of APA Governance, July 2013." The suggested changes would change APA from a membership based, representational structure to a corporate structure.[] These motions will be discussed and voted upon by Council on July 31, 2013 and August 2, 2013.[]

Organizational structure
APA comprises an executive office, a publishing operation, offices that address administrative, business, information technology, and operational needs, and five substantive directorates: the Education Directorate accredits doctoral psychology programs and addresses issues related to psychology education in secondary through graduate education;[5] the Practice Directorate engages on behalf of practicing psychologists and health care consumers;[6] the Public Interest Directorate advances psychology as a means of addressing the fundamental problems of human welfare and promoting the equitable and just treatment of all segments of society;[7] the Public and Member Communications Directorate is responsible for APA's outreach to its members and affiliates and to the general public;[8] the Science Directorate provides support and voice for psychological scientists.[9]

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Membership and title of "psychologist"


APA policy on the use of the title psychologist is contained in the Model Act for State Licensure of Psychologists:[10] Psychologists have earned a doctoral degree in psychology and may not use the title psychologist and/or deliver psychological services to the public, unless the psychologist is licensed or specifically exempted from licensure under the law. State licensing laws specify state specific requirements for the education and training of psychologists leading to licensure. Psychologists who are exempted from licensure could include researchers, educators, or general applied psychologists who furnish services outside of the health and mental health field. Full membership with the APA in United States and Canada requires doctoral training whereas associate membership requires at least two years of postgraduate studies in psychology or approved related discipline. The minimal requirement of a doctoral dissertation related to psychology for full membership can be waived in certain circumstances where there is evidence that significant contribution or performance in the field of psychology has been made.[11]

Affiliate organizations
The American Psychological Association Practice Organization (APAPO) [12] and the Education Advocacy Trust [13] , which operates autonomously as a part of APAPO, are 501(c)(6) entities, separate from APA. They engage in advocacy on behalf of psychological practitioners and health care consumers and psychology education, respectively.

Awards
Each year, the APA recognizes top psychologists with the "Distinguished Contributions" Awards; these awards are the highest honors given by the APA, and among the highest honors that a psychologist or psychology researcher can receive. APA Award for Distinguished Scientific Contributions to Psychology APA Distinguished Scientific Award for the Applications of Psychology Award for Distinguished Contributions to Psychology in the Public Interest Award for Distinguished Contributions to Education and Training in Psychology APA Award for Distinguished Professional Contributions to Applied Research Award for Distinguished Professional Contributions to Practice in the Public Sector APA Award for Distinguished Contributions to the International Advancement of Psychology

Publications
The American Psychologist is the Association's official journal. APA also publishes over 70 other journals encompassing most specialty areas in the field, including:[] Behavioral Neuroscience Developmental Psychology Emotion Health Psychology Journal of Applied Psychology Journal of Comparative Psychology Journal of Experimental Psychology Journal of Experimental Psychology: Applied

Journal of Family Psychology Journal of Occupational Health Psychology Journal of Personality and Social Psychology

American Psychological Association Psychological Bulletin Psychological Review Psychology and Aging Psychology of Addictive Behaviors Psychology of Violence School Psychology Quarterly

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The APA has also published several books including children's books, software for data analysis, videos demonstrating therapeutic techniques, reports and brochures, and an eight-volume Encyclopedia of Psychology.[][14]

The Psychologically Healthy Workplace program


The Psychologically Healthy Workplace Program (PHWP) is a collaborative effort between the American Psychological Association and the APA Practice Organization designed to help employers optimize employee well-being and organizational performance. The PHWP includes APAs Psychologically Healthy Workplace Awards, a variety of APA Practice Organization resources, including PHWP Web content, e-newsletter, podcast and blog, and support of local programs currently implemented by 52 state, provincial and territorial psychological associations as a mechanism for driving grassroots change in local business communities. The awards are designed to recognize organizations for their efforts to foster employee health and well-being while enhancing organizational performance. The award program highlights a variety of workplaces, large and small, profit and non-profit, in diverse geographical settings. Applicants are evaluated on their efforts in the following five areas: employee involvement, work-life balance, employee growth and development, health and safety, and employee recognition. Awards are given at the local and national level.[15][16] 2010 award winners: American Cast Iron Pipe Company, Tallahassee Memorial HealthCare, Advanced Solutions (an HP company), Toronto Police Service and Leaders Bank.

APA Style
American Psychological Association (APA) Style is a set of rules developed to assist reading comprehension in the social and behavioral sciences. Designed to ensure clarity of communication, the rules are designed to "move the idea forward with a minimum of distraction and a maximum of precision."[17] The Publication Manual of the American Psychological Association contains the rules for every aspect of writing, especially in the social sciences from determining authorship to constructing a table to avoiding plagiarism and constructing accurate reference citations. "The General Format of APA is most commonly used to cite sources within the social sciences. General guidelines for a paper in APA style includes: typed, double-spaced on standard-sized paper (8.5" x 11") with 1" margins on all sides. The font should be clear and highly readable. APA recommends using 12 pt. Times New Roman font."[18] PsycINFO APA maintains an abstract database named PsycINFO. It contains citations and summaries dating from the 19th century, including journal articles, book chapters, books, technical reports, and dissertations within the field of psychology. As of January 2010, PsycINFO has collected information from 2,457 journals.[19] Similar databases operated by other organizations include PsycLit and Psychological Abstracts. APA also operates a comprehensive search platform, PsycNET, covering multiple databases.[20]

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History
Founding
The APA was founded in July 1892 at Clark University by a group of 26 men, the first president was G. Stanley Hall. It is affiliated with 60 state, territorial, and Canadian provincial associations.[21]

Dominance of clinical psychology


Due to the dominance of clinical psychology in APA, several research-focused groups have broken away from the organization. These include the Psychonomic Society in 1959 (with a primarily cognitive orientation), and the Association for Psychological Science (which changed its name from the American Psychological Society in early 2006) in 1988 (with a broad focus on the science and research of psychology). Theodore H. Blau was the first clinician in independent practice to be elected president of the American Psychological Association in 1977.[22]

Positions on homosexuality
Cause of homosexuality
The APA states the following: "There is no consensus among scientists about the exact reasons that an individual develops a heterosexual, bisexual, or homosexual orientation. Although much research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation, no findings have emerged that permit scientists to conclude that sexual orientation is determined by any particular factor or factors. Many think that nature and nurture both play complex roles; most people experience little or no sense of choice about their sexual orientation."[23]

Conversion therapy
In 1975 APA issued a supporting statement that homosexuality is not a mental disorder.[][24][25] There is a concern in the mental health community that the advancement of conversion therapy itself causes social harm by disseminating inaccurate views about sexual orientation and the ability of homosexual and bisexual people to lead happy, healthy lives.[26] Most mainstream health organizations are critical of conversion therapy, and no mainstream medical organization endorses conversion therapy.[26][][][27][28] The APA adopted a resolution in August 2009 stating that mental health professionals should avoid telling clients that they can change their sexual orientation through therapy or other treatments. The approval, by APA's governing Council of Representatives, came at APA's annual convention, during which a task force presented a report[29] that in part examined the efficacy of so-called "reparative therapy," or sexual orientation change efforts (SOCE). The "Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts"[30] also advises that parents, guardians, young people and their families avoid sexual orientation treatments that portray homosexuality as a mental illness or developmental disorder and instead seek psychotherapy, social support and educational services "that provide accurate information on sexual orientation and sexuality, increase family and school support and reduce rejection of sexual minority youth."

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Same-sex marriage
The APA adopted a resolution stating that it is unfair and discriminatory to deny same-sex couples legal access to civil marriage and to all its attendant rights, benefits, and privileges. It also filed an amicus brief in the federal court case in which Judge Vaughn Walker struck down California's constitutional ban on same-sex marriage.[] The APA later praised the decision and denied the existence of any "scientific justification" for a ban on same-sex marriage.[31] In August 2011, the APA clarified their support of same-sex marriage in light of continued research suggesting that the same community benefits accepted as result of hetero-sexual marriage apply to same-sex couples as well, "We knew that marriage benefits heterosexual people in very significant ways, but we didn't know if that would be true for same-sex couples," said Dr. Clinton Anderson, associate executive director of the APA and director of the Office on Lesbian, Gay, Bisexual and Transgender Concerns. Anderson would also go on to clarify the Association's view on Civil Unions as an alternative to same-sex marriages: "Anything other than marriage is, in essence, a stigmatization of same-sex couples. Stigma does have negative impacts on people." [32] Anderson's statements have been met with scrutiny from organizations such as the National Organization for Marriage, that dispute the notion that communities are more accepting of homosexuals in states that legally sanction same-sex marriage.[citation needed]

Controversies
APA internship crisis for graduate students
The APA is the main accrediting body for U.S. clinical and counseling psychology doctoral training programs and internship sites.[33] APA-accredited Clinical Psychology PhD and PsyD programs typically require students to complete a one-year clinical internship in order to graduate (or a two-year part-time internship). However, there is currently an "internship crisis" as defined by the American Psychological Association, in that approximately 25% of clinical psychology doctoral students do not match for internship each year.[34][35] This crisis has led many students (approximately 1,000 each year) to re-apply for internship, thus delaying graduation, or to complete an unaccredited internship, and often has many emotional and financial consequences.[36] Students who do not complete an APA accredited internships in the U.S. are barred from certain employment settings, including VA Hospitals, the military, and cannot get licensed in some states, such as Utah and Mississippi.[37][38] Additionally, some post-doctoral fellowships and other employment settings require or prefer an APA Accredited internship.[37] The APA has been criticized for not addressing this crisis adequately and many psychologists and graduate students have petitioned for the APA to take action by regulating graduate training programs. Many graduate students attend APA accredited programs, yet are unable to secure APA accredited internships possibly leading to financial and employment hardships.

Use of coercive techniques considered equivalent of torture


The APA absolutely condemns the use of any of the following practices by military interrogators trying to elicit anti-terrorism information from detainees, on the ground that "there are no exceptional circumstances whatsoever, whether induced by a state of war or threat of war, internal political instability or any other public emergency, that may be invoked as a justification" for them:[39] An absolute prohibition against the following techniques therefore arises from, is understood in the context of, and is interpreted according to these texts: mock executions; water-boarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears, phobias or psychopathology; induced hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and over-stimulation; sleep deprivation; or the threatened use of any of the above techniques to an individual or to members of an individuals family.[39]

American Psychological Association When it emerged that psychologists as part of the Behavioral Science Consultation Team were advising interrogators in Guantnamo and other U.S. facilities on improving the effectiveness of the "Enhanced interrogation techniques", the Association called on the U.S. government to prohibit the use of unethical interrogation techniques and labeled specific techniques as torture.[40][citation needed] Critics pointed out that the APA declined to advise its members not to participate in such interrogations.[41] This was in contrast to the American Psychiatric Association ban in May 2006 of all direct participation in interrogations by psychiatrists,[42] and the American Medical Association ban in June 2006 of the direct participation in interrogations by physicians.[43] In September 2008, APAs members passed a resolution stating that psychologists may not work in settings where persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the U.S. Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights.[44] The resolution became official APA policy in February 2009. Amending the Ethics Code In February 2010 APA's Council of Representatives voted to amend the association's Code of Ethics[45] to make clear that its standards can never be interpreted to justify or defend violating human rights. Following are the two ethical standards and the changes adopted. Language that is in bold was newly adopted: 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority If psychologists ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights. 1.03, Conflicts Between Ethics and Organizational Demands If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

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Notes
[1] http:/ / www. apa. org [12] http:/ / www. apapractice. org/ [13] http:/ / www. apaedat. org/ [15] Psychologically Healthy Workplace Program (http:/ / www. apapracticecentral. org/ outreach/ workplace/ index. aspx), apapracticecentral.org [16] Psychologically Healthy Workplace Program (http:/ / www. phwa. org/ ) website, phwa.org [21] APA.org (http:/ / www. apa. org/ practice/ refer. html) [24] "An Instant Cure" (http:/ / www. time. com/ time/ magazine/ article/ 0,9171,904053,00. html), Time; April 1, 1974. [28] Mainstream health organizations critical of conversion therapy include the American Medical Association, American Psychiatric Association, the American Psychological Association, the American Counseling Association, the National Association of Social Workers, the American Academy of Pediatrics, the American Association of School Administrators, the American Federation of Teachers, the National Association of School Psychologists, the American Academy of Physician Assistants, and the National Education Association. [30] Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts (http:/ / www. apa. org/ about/ governance/ council/ policy/ sexual-orientation. aspx) [37] appic.org (http:/ / www. appic. org/ match/ 5_2_1_appfaq2. html#q3) [39] Reaffirmation of the American Psychological Association Position Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment and Its Application to Individuals Defined in the United States Code as Enemy Combatants (http:/ / www. apa. org/ about/ governance/ council/ policy/ torture. aspx) [40] APA Press Release, August 20, 2007 (http:/ / www. apa. org/ releases/ councilres0807. html) [41] Stephen Soldz: Psychologists, Guantnamo, and Torture: A Profession Struggles to Save Its Soul (http:/ / www. zmag. org/ content/ showarticle. cfm?ItemID=10700) (ZNet, 3 August 2006); Protecting the Torturers (http:/ / www. counterpunch. org/ soldz09062006. html)

American Psychological Association


Bad Faith and Distortions From the American Psychological Association (CounterPunch, 6 September 2006); Letter to the CEO of the American Psychological Association (http:/ / www. opednews. com/ articles/ opedne_stephen__061128_letter_to_the_ceo_of. htm) (OpEdNews.com, 28 November 2006) [42] Statement on Interrogation (http:/ / www. psych. org/ news_room/ press_releases/ 06-36PositionStatementonInterrogation. pdf) (PDF file) [43] Opinion 2.068 - Physician Participation in Interrogation (http:/ / www. ama-assn. org/ ama/ pub/ physician-resources/ medical-ethics/ code-medical-ethics/ opinion2068. page)

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References External links


Official website (http://www.apa.org) American Psychological Association Rejects Blanket Ban on Participation in Interrogation of U.S. Detainees (http://www.democracynow.org/article.pl?sid=07/08/20/1628230)

American Pharmacists Association


The American Pharmacists Association (APhA, previously known as the American Pharmaceutical Association), founded in 1852, is the first-established professional society of pharmacists within the United States.[1] APhA is made up of more than 60,000 practicing pharmacists, pharmaceutical scientists, student pharmacists, pharmacy technicians, and others interested in advancing the profession. Through a House of Delegates that meets each year at the APhA Annual Meeting & Exposition, APhA provides a forum for discussion, consensus building, and policy setting for the profession of pharmacy. In fact, nearly all of pharmacy's specialty organizations trace their roots to APhA, having originally been a section or part of this broad foundation of pharmacy. The APhA Board of Trustees is responsible for broad direction setting of the Association. All members choose one of these three Academies when they join APhA: American Pharmacists Association - Academy of Pharmacy Practice and Management (APhAAPPM) American Pharmacists Association - Academy of Pharmaceutical Research and Science (APhAAPRS) American Pharmacists Association - Academy of Student Pharmacists (APhAASP)

Leadership
Marialice S. Bennett - president

References
[1] http:/ / www. pharmacist. com/ AM/ Template. cfm?Section=About_APha2& Template=/ TaggedPage/ TaggedPageDisplay. cfm& TPLID=83& ContentID=8229

External links
Official website (http://www.pharmacist.com/)

Ambulatory Payment Classification

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Ambulatory Payment Classification


APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs. This OPPS, was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals. Physicians are reimbursed via other methodologies for payment in the United States, such as Current Procedural Terminology or CPTs. APC payments are made to hospitals when the Medicare outpatient is discharged from the Emergency Department or clinic or is transferred to another hospital (or other facility) which is not affiliated with the initial hospital where the patient received outpatient services. Although APCs began through the federal system of Medicare, they have also been considered for adoption by state programs, such as Medicaid, and other third-party private health insurers. If the patient is admitted from a hospital clinic or Emergency Department, then there is no APC payment, and Medicare will pay the hospital under inpatient Diagnosis-related group DRG methodology.

External links
ACS Medicaid Guide for Hospital Outpatient Payment System [1] Website from the American College of Emergency Physicians [2] [3] 123 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Present on Admission (POA) Indicator Reporting by Acute Inpatient Prospective Payment System (IPPS) Hospitals FACT SHEET Present on Admission (POA) Indicator Reporting and HospitalAcquired Conditions (HAC) Overview The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions. CMS has titled the provision Hospital-Acquired Conditions and Present on Admission Indicator Reporting (HAC & POA). Inpatient Prospective Payment System (IPPS) hospitals are required to submit POA information on diagnoses for inpatient discharges on or after October 1, 2007. Affected Hospitals The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the POA indicator requirement: Critical Access Hospitals (CAHs), Long-Term Care Hospitals (LTCHs), Maryland Waiver Hospitals, Cancer Hospitals, Childrens Inpatient Facilities, Rural Health Clinics, Federally Qualified Health Centers (FQHCs), Religious Non-Medical Health Care Institutions, Inpatient Psychiatric Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Veterans Administration/Department of Defense Hospitals. ICN 901046 October 2011General Reporting Requirements The POA indicator is required for all claims involving Medicare inpatient admissions to general IPPS acute care hospitals or other facilities that are subject to a law or regulation mandating collection of POA indicator information. POA is defined as present at the time the order for inpatient admission occurs conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. The POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the ICD-9-CM Official Guidelines for Coding and Reporting). For the Official Guidelines, please visit http:/ / www. cdc. gov/ nchs/ icd/ icd9cm. htm on the Internet. Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider. If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines, then the POA indicator would not be reported. CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an other diagnosis. Coding Use the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each principal diagnosis and other ICD-9-CM diagnosis codes reported on the UB-04 and ASC X12N 837 Institutional (837I). This fact sheet is not

Ambulatory Payment Classification intended to replace any guidelines in the main body of the ICD-9-CM Official Guidelines for Coding and Reporting. The POA indicator guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of ICD-9-CM diagnosis codes that have been assigned in accordance with Sections I, II, and III of the Official Guidelines. Subsequent to the assignment of the ICD-9-CM diagnosis codes, the POA indicator should then be assigned to those conditions that have been coded. As stated in the Introduction to the ICD-9-CM Official Guidelines for Coding and Reporting, a joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Visit the HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond on the CMS website. 2Table 1 includes a list of the POA indicator reporting options, descriptions, and Medicare payment based on the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2011 Final Rule, published by CMS in August 2010. The Final Rule made a change to POA indicator reporting. Effective January 1, 2011, hospitals reporting with the 5010 format will no longer report a POA indicator of 1 for POA exempt codes. Documentation The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. In the context of the official coding guidelines, the term provider means a physician or any qualified health care practitioner who is legally accountable for establishing the patients diagnosis. NOTE: Providers, their billing offices, third party billing agents, and anyone else involved in the transmission of this data must ensure that any resequencing of ICD-9-CM diagnosis codes prior to their transmission to CMS also includes a resequencing of the POA indicators. Paper Claims On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting. Table 1: CMS POA Indicator Reporting Options, Description, and Payment INDICATOR DESCRIPTION MEDICARE PAYMENT Y Diagnosis was present at time of inpatient admission. Payment made for condition by Medicare, when an HAC is present N Diagnosis was not present at time of inpatient admission. No payment made for condition by Medicare, when an HAC is present U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment made for condition by Medicare, when an HAC is present W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment made for condition by Medicare, when an HAC is present 1 Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, however, it was determined that blanks were undesirable on Medicare claims when submitting this data via the 004010/00410A1. NOTE: The number 1 is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. Please refer to Transmittal R756OTN, Change Request (CR) 7024 at http:/ / www. cms. gov/ Transmittals/ Downloads/R756OTN.pdf on the CMS website. Exempt from POA reporting Visit the HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond on the CMS website. 3Electronic Claims Using the 837I, submit the POA indicator in segment K3 in the 2300 loop, data element K301. EXAMPLE 1: POA indicators for an electronic claim with one principal and five secondary diagnoses should be coded as POAYNUW1YZ. POA POA is always required first, followed by a single indicator for every diagnosis reported on the claim. Y The principal diagnosis is always the first indicator after POA. In this example, the principal diagnosis was present on admission. N The first secondary diagnosis was not present on admission, designated by N. U It was unknown if the second secondary diagnosis was present on admission, designated by U. W It is clinically undetermined if the third secondary diagnosis was present on admission, designated by W. 1 The fourth secondary diagnosis was exempt from reporting for POA, designated by 1. NOTE: Hospitals reporting with the 5010 format on and after January 1, 2011 will no longer report a POA indicator of 1 for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting. Y The fifth secondary diagnosis was present on admission, designated by Y. Z The last secondary diagnosis indicator is followed by the letter Z to indicate the end of the data element. EXAMPLE 2: POA indicator for an electronic

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Ambulatory Payment Classification claim with one principal diagnosis without any secondary diagnosis should be coded as POAYZ. POA POA is always required first, followed by a single indicator for every diagnosis reported on the claim. Y The principal diagnosis is always the first indicator after POA. In this example, the principal diagnosis was present on admission. Z The letter Z is used to indicate the end of the data element. For More Information The HAC & POA web page at http:/ / www. cms. gov/ HospitalAcqCond provides further information, including links to the law, regulations, change requests (CRs), and educational resources including presentations, Medicare Learning Network (MLN) articles, and fact sheets. Official CMS Information for Medicare Fee-For-Service Providers R This fact sheet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network (MLN) , a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For-Service providers. For additional information, visit MLNs web page at http:/ / www. cms. gov/ MLNGenInfo on the CMS website. Visit the HAC & POA web page at http://www.cms.gov/HospitalAcqCond on the CMS website.

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References
[1] http:/ / www. acs-inc. com/ WorkArea/ downloadasset. aspx?id=2075 [2] http:/ / www. acep. org/ practres. aspx?id=30426 [3] http:/ / apps. leg. wa. gov/ wac/ default. aspx?cite=296-23A-0700

American Public Health Association

243

American Public Health Association


APHA
Motto Formation "Protect, prevent, live well" 1872

Headquarters Washington, D.C. Membership Website 30,000 apha.org [1]

The American Public Health Association (APHA) is Washington, D.C.-based professional organization for public health professionals in the United States. Founded in 1872 by Dr. Stephen Smith, APHA has more than 30,000 members worldwide. The Association defines itself as being "the oldest and most diverse organization of public health professionals in the world." It defines its mission as: "The Association aims to protect all Americans and their communities from preventable, serious health threats and strives to assure that community-based health promotion and disease prevention activities and preventative health services are universally accessible in the United States. "[2]

Washington, D.C. office of the APHA.

Member Groups and State Affiliates


APHAs 30,000 members represent a broad array of health officials, educators, students, environmentalists, policy-makers and other health providers at all levels, working both within and outside governmental organizations and educational institutions.

Organizational Components: Sections and SPIGs


Sections serve as the primary professional units of the Association and conduct activities that promote the mission and fulfill the goals of APHA. There are 27 Sections that represent major public health disciplines or public health programs. These sections are designed to allow members with shared interests to come together to develop scientific program content, policy papers in their areas of interest or fields of practice, provide for professional and social networking, career development and mentoring. Sections include: Maternal and Child Health, HIV/AIDS, Community Planning and Policy Development, Occupational Health and Safety, International Health and School Health Education and Services. Special Primary Interest Groups (SPIGs) are an open group of self-selected APHA members who share a common occupational discipline or program area interest and elect no primary Section affiliation. SPIGs include: Alternative and Complementary Health Practices, Ethics, Health Law, Laboratory, Physical Activity and Veterinary Public Health.

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244

Public Health Education and Health Promotion Section


The Public Health Education and Health Promotion Section is one of 27 primary sections and special interest groups within APHA. In fact, PHEHP is the largest section, with around 3,000 members. Like all sections within APHA, PHEHP is governed by a group of elected volunteers who hold offices for terms of varying length. Section officers include a chair, chair-elect, secretary, secretary-elect and immediate past chair. Section councilors and governing councilors represent the members and concerns of the section within the larger organization. Section committees, led by volunteers from the Section, are where the "work" of the Section is accomplished. Explore this website to learn about these and other opportunities to get involved in PHEHP.

Awards
National APHA Awards The accomplishments of public health leaders are recognized through an awards program. APHA presents its national awards during its annual meeting. Section Awards [3] Being honored by your professional peers has very special meaning to people. Acknowledge some of the professionals who have been important to your career or who, in your mind, have made important contributions to the field by nominating them for one of these prestigious awards. The Public Health Education and Health Promotion section recognizes individuals in six award categories. The awards include: Current Section Members Eligible 1. Distinguished Career Award for outstanding contribution to the practice and profession of health education, health promotion and/or health communications. The awardee must have earned a terminal degree 10 years or more prior to receiving the award. 2. Early Career Award for outstanding contribution to the practice and profession of health education, health promotion and/or health communications. The awardee must have earned a terminal degree less than 10 years prior to receiving the award. Current Section and/or APHA member eligible 1. Mayhew Derryberry Award for outstanding contribution of behavioral scientists to the field of health education, health promotion and/or health communications research or theory. 2. Mohan Sing Award for the use of humor to promote better health education, health promotion and/or health communications practice. 3. Sarah Mazelis Award for an outstanding practitioner in health education. The awardee will have spent at least five years as a health education, health promotion and/or health communications practitioner. 4. Rogers Award for outstanding contribution to advancing the study and/or practice of public health communication. Sponsored Awards Rema Lapouse Award sponsored by the Mental Health, Epidemiology, and Statistics Sections, this award is granted to an outstanding scientist in the area of psychiatric epidemiology.

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Publications
The American Public Health Association publishes periodicals and more than 70 public health books. Several of these are the reference source for their specialty within public health practice. Some publication titles include: Control of Communicable Diseases Manual Standard Methods for the Examination of Water and Wastewater American Journal of Public Health The Nation's Health

Additionally, they are an active partner in the release of America's Health Rankings; working with United Health Foundation and Partnership for Prevention.[4]

Annual Meeting
The APHA Annual Meeting and Exposition is the largest meeting of public health professionals in the world. The meeting draws more than 13,000 attendees, offers 700 booths of exhibits and features more than 1,000 scientific sessions. Presentations cover new research and trends in public health science and practice.

National Public Health Week


National Public Health Week is an observance organized annually by APHA during the first full week of April. The weeks activities are designed to highlight issues that are important to improving the publics health.

Leadership
Georges C. Benjamin, MD, FACP, FACEP (E), Executive Director Carmen Rita Nevarez, MD, MPH, President

Campaign for Children's Health Care


The APHA is a partner in the Campaign for Children's Health Care, a multi-year campaign to raise awareness about the problem of uninsured children in America a growing social concern.

Climate Change and Public Health


In 2007, the APHA issued a policy statement entitled Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment: The long-term threat of global climate change to global health is extremely serious and the fourth IPCC (Intergovernmental Panel on Climate Change) report and other scientific literature demonstrate convincingly that anthropogenic GHG emissions are primarily responsible for this threat....US policy makers should immediately take necessary steps to reduce US emissions of GHGs, including carbon dioxide, to avert dangerous climate change.[5]

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246

Color Standards
There a color standard, made from dilutions of a Pt[6]-Co solution, described by Dr. A. Hazen in American Chemical Journal, in 1892, adopted in Standard Methods for the Examination of Water and Waste Water, made by APHA, sometimes referred as Pt-Co/Hazen/APHA Colour.

References
[1] http:/ / www. apha. org [4] America's Health Rankings (http:/ / www. americashealthrankings. org/ 2010/ acknowledgement. aspx/ ) [6] http:/ / toolserver. org/ %7Edispenser/ cgi-bin/ dab_solver. py?page=American_Public_Health_Association& editintro=Template:Disambiguation_needed/ editintro& client=Template:Dn

External links
America's Health Rankings (http://www.americashealthrankings.org/) State Health Stats (http://www.statehealthstats.org/) American Public Health Association - APHA (http://www.apha.org/) Campaign for Children's Health Care (http://www.childrenshealthcampaign.org/?source=wikipedia) American Journal of Public Health - AJPH (http://www.ajph.org/) The Nation's Health (http://www.apha.org/publications/tnh/) Get Ready Campaign (http://www.getreadyforflu.org/) National Public Health Week (http://www.nphw.org/) Standard Methods for the Examination of Water and Wastewater (http://www.standardmethods.org/)

American Physical Therapy Association

247

American Physical Therapy Association


American Physical Therapy Association
Motto Formation Type Headquarters Location Membership "Move Forward. Physical Therapy Brings Motion to Life." 1921 Professional association Virginia United States 76,000

Officiallanguages English President Website Paul Rockar http:/ / www. apta. org/

A Historical Perspective Physical therapists formed their first professional association in 1921, called the American Women's Physical Therapeutic Association. Led by President Mary McMillan, an executive committee of elected officers governed the Association, which included 274 charter members. By the end of the 1930s, the Association changed its name to the American Physiotherapy Association. Men were admitted, and membership grew to just under 1,000. With the advent of World War II and a nationwide polio epidemic during the 1940s and 1950s, physical therapists were in greater demand than ever before. The Association's membership swelled to 8,000, and the number of physical therapy education programs across the US increased from 16 to 39. By the late 1940s, the Association had changed its name to the American Physical Therapy Association, hired a full-time staff, and opened its first office in New York City. A House of Delegates representing chapter members was established to set APTA policies. The House elected a Board of Directors, previously the Executive Committee, to manage the Association. In addition, Sections were created to promote and develop specific objectives of the profession. The first two Sections were the School and Private Practice sections. In the 1960s, APTA membership reached almost 15,000, and the number of education programs nationwide grew to 52. Now headquartered in Alexandria, Virginia, APTA represents approximately 76,000 members throughout the United States. A national professional organization, APTA's goal is to foster advancements in physical therapy practice, research, and education. Currently 199 institutions offer physical therapy education programs and 234 institutions offer physical therapist assistant education programs in the United States. These numbers will change significantly in the coming years to encompass 9 developing PT programs and 43 developing PTA programs.

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248

Vision statement
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy (DPT), recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.[1]

Lobby work
The APTA advocates on behalf of the profession and for issues which impact the health and wellbeing of society such as; fundng for health research, funding for an adequate heath care workforce and for health care reform to improve access to health care and ensure adequate funding for the provision of physical therapy.[2]

Combined Sections Meeting


The Association holds an annual Combined Sections Meeting that is attended by physical therapists from around the United States. Informally known as "CSM", it is named the combined sections meeting because all of the sections of the APTA come together to meet at this time.

Past and future meetings


Year Dates Venue Boston, MA Tampa, FL Nashville, TN New Orleans, LA San Diego, CA Boston, MA Nashville, TN Las Vegas, NV Attendance

2002 February 2003 February 2004 February 2005 February 2006 February 2007 February 2008 February 2009 February 912

2010 February 1720 San Diego, CA 2011 February 912 2012 February 811 2013 January 2124 2014 February 36 2015 February 47 New Orleans, LA Chicago, IL San Diego, CA Las Vegas, NV Indianapolis, IN 9,346 (3,108 students)

2016 February 1720 Anaheim, CA 2017 February 1518 San Antonio, TX 2018 February 2128 New Orleans, LA

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249

References
[1] http:/ / www. apta. org/ Vision2020/ [2] http:/ / www. apta. org/ Advocacy/

External links
American Physical Therapy Association (http://www.apta.org) APTA Consumer Site (http://www.moveforwardpt.com)

Outpatient surgery
Outpatient surgery, also known as ambulatory surgery, same-day surgery or day surgery, is surgery that does not require an overnight hospital stay. The term outpatient arises from the fact that surgery patients may go home and do not need an overnight hospital bed. The purpose of outpatient surgery is to keep hospital costs down[citation needed] , as well as saving the patient time that would otherwise be wasted in the hospital. Outpatient surgery has grown in popularity due to the rise in outpatient surgery centers and improved technology. Outpatient surgery centers often allow patients to get medical surgery and cosmetic surgery done in much more luxurious settings than a state hospital and are often preferred by patients for minor surgical procedures. Improved technology has also increased the frequency of outpatient surgery procedures. With shorter medical procedure duration and fewer complications it makes sense to let patients go home sooner. About 65% of all surgical procedures are done on an outpatient basis.[citation needed] Patients should check with their doctor for all information covering preparation for outpatient procedures. Complications related to surgery occur less than 1% of the time in outpatient settings.[citation needed] However, in terms of patient safety, non-hospital settings are not as regulated as hospitals are. Patients should inquire about all ambulatory clinics, surgical centers, and physicians' offices to make sure they meet state guidelines.

Ambulatory surgery center


Ambulatory surgery centers (ASC), also known as outpatient surgery centers or same day surgery centers, are health care facilities where surgical procedures not requiring an overnight hospital stay are performed. Such surgery is commonly less complicated than that requiring hospitalization. Avoiding hospitalization can result in cost savings to the party responsible for paying for the patient's health care.[1] An ASC, sometimes called surgicenter, specializes in providing surgery, including certain pain management and diagnostic (e.g., colonoscopy) services in an outpatient setting. Overall, the services provided can be generally called procedures. In simple terms, ASC-qualified procedures can be considered procedures that are more intensive than those done in the average doctor's office but not so intensive as to require a hospital stay. An ambulatory surgery center and a specialty hospital often provide similar facilities and support similar types of procedures. The specialty hospital may provide the same procedures or slightly more complex ones and the specialty hospital will often allow an overnight stay. ASCs do not routinely provide emergency services to patients who have not been admitted to the ASC for another procedure. 'Procedures' performed in ASCs are broad in scope. In the 1980s and 1990s, many procedures that used to be performed exclusively in hospitals began taking place in ambulatory surgery centers as well. Many knee, shoulder, eye, spine and other surgeries are currently performed in ASCs. In the United States today, more than 50% of Colonoscopy services are performed in ambulatory surgery centers. The first ASC was established in Phoenix, Arizona in 1970 by two physicians who wanted to provide timely, convenient and comfortable surgical services to patients in their community, avoiding more impersonal venues like

Outpatient surgery regular hospitals.[2] ASCs rarely have a single owner. Physicians partners who perform surgeries in the center will often own at least some part of the facility. Ownership percentages vary considerably, but most ASCs involve physician owners. Occasionally, an ASC is entirely physician-owned. However, it is most common for development/management companies to own a percentage of the center. Some large healthcare companies own many types of medical facilities, including ambulatory surgery centers. The largest operators include Surgical Care Affiliates (SCA), United Surgical Partners International (USPI), and AMSURG. In the United States, more than 22 million surgeries a year are performed in more than 5,000 ASCs. ASCs are in all 50 states and can be found throughout the world. In the US, most ASCs are licensed, certified by Medicare and accredited by one of the major health care accrediting organizations. Although complications are very rare, ASCs are required by Medicare and the accreditation organizations to have a backup plan for transfer of patients to a hospital if the need arises. The national nonprofit organizations that represents the interests of ASCs and their patients is Ambulatory Surgery Center Association (ASC Association), which was formed in 2008 when the Federated Ambulatory Surgery Association (FASA) and the American Association of Ambulatory Surgery Centers (AAASC) merged. Accreditation organizations are separate from the general trade organizations. Accreditation organizations for ASCs provide standards of medical care, record keeping, and auditing for ASCs. Some of the goals of these organizations include continuous improvement of medical care in surgery centers and providing an external organization where the public can get information on many aspects of ASCs. These accreditation organizations require members to receive periodic audits. These audits will come every one to three years, depending on the accreditation organization and the circumstances of the surgery center. In an audit, a team of auditors visits the facility and examines the ASC's medical records, written policies, and compliance with industry standards. In 1996, California was the first state to require accreditation for all outpatient facilities that administer sedation or general anesthesia. Many other states have followed and require accreditation. The three main accreditors of ASCs are American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (Accreditation Association or AAAHC) and The Joint Commission.

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References
[1] Baylor College-Oral and Maxillofacial Surgery and Pharmacology/Surgicenter (http:/ / www. tambcd. edu/ oralsurgery/ surgicenter/ surgicenter. html) [2] http:/ / www. ascaconnect. org/ ASCA/ AboutUs/ WhatisanASC/ History/

External links
Outpatient Surgery Magazine (http://www.outpatientsurgery.net/) Tips for outpatient surgery patients (http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=188& q=241594) Accreditation Association for Ambulatory Health Care (http://www.aaahc.org) American Association for Accreditation of Ambulatory Surgery Facilities (http://www.aaaasf.org) Joint Commission (http://www.jointcommission.org/) Canadian Association for Accreditation of Ambulatory Surgical Facilities (http://www.caaasf.org/) Bariatric Surgery Center Network Accreditation Program (http://www.facs.org/cqi/bscn/index.html) International Association for Ambulatory Surgery (http://www.iaas-med.com/joomla/index.php)

American Society for Clinical Pathology

251

American Society for Clinical Pathology


The American Society for Clinical Pathology (ASCP) is a professional association based in Chicago, Illinois encompassing 130,000 pathologists and laboratory professionals. Founded in 1922, the ASCP provides programs in education, certification and advocacy on behalf of patients, pathologists and lab professionals. In addition, the ASCP publishes numerous textbooks, newsletters and other manuals, and publishes two industry journals: American Journal of Clinical Pathology and LabMedicine.[1] The ASCP also promotes National Medical Laboratory Professionals Week (NMLPW) as a time of recognition for medical laboratory personnel and a chance to celebrate their professionalism and be recognized for their efforts. National Lab Week is held annually during the last full week of April.

References
[1] History of ASCP (http:/ / www. ascp. org/ MainMenu/ AboutASCP/ History. aspx)

External links
American Society for Clinical Pathology website (http://www.ascp.org) The American Journal of Clinical Pathology website (http://www.ajcp.com) LabMedicine website (http://www.labmedicine.com)

Aspartate transaminase
aspartate transaminase

Aspartate aminotransferase from Escherichia coli bound with cofactor pyridoxal 5-phosphate. Identifiers EC number CAS number 2.6.1.1 [1] [2]

[]

9000-97-9 Databases

IntEnz BRENDA ExPASy

IntEnz view

[3] [4] [5]

BRENDA entry NiceZyme view

Aspartate transaminase
[6] [7]

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KEGG MetaCyc PRIAM PDB structures Gene Ontology

KEGG entry

metabolic pathway profile [8] [9]

RCSB PDB AmiGO

PDBe

[10]

PDBsum

[11]

[12]

/ EGO

[13]

Search PMC articles [14]

PubMed articles [15] NCBI proteins [16]

Aspartate transaminase (AST), also called aspartate aminotransferase is commonly known as sgot (AspAT/ASAT/AAT) or serum glutamic oxaloacetic transaminase (SGOT), is a pyridoxal phosphate (PLP)-dependent transaminase enzyme (EC 2.6.1.1 [17]). AST catalyzes the reversible transfer of an -amino group between aspartate and glutamate and, as such, is an important enzyme in amino acid metabolism. AST is found in the liver, heart, skeletal muscle, kidneys, brain, and red blood cells, and it is commonly measured clinically as a marker for liver health.

Function
Aspartate transaminase catalyzes the interconversion of aspartate and -ketoglutarate to oxaloacetate and glutamate. Aspartate (Asp) + -ketoglutarate oxaloacetate + glutamate (Glu) As a prototypical transaminase, AST relies on PLP as a cofactor to transfer the amino group from aspartate or glutamate to the corresponding Reaction catalyzed by aspartate aminotransferase ketoacid. In the process, the cofactor shuttles between PLP and the pyridoxamine phosphate (PMP) form.[] The amino group transfer catalyzed by this enzyme is crucial in both amino acid degradation and biosynthesis. In amino acid degradation, following the conversion of -ketoglutarate to glutamate, glutamate subsequently undergoes oxidative deamination to form ammonium ions, which are excreted as urea. In the reverse reaction, aspartate may be synthesized from oxaloacetate, which is a key intermediate in the citric acid cycle.[]

Isoezymes
Two isoenzymes are present in a wide variety of eukaryotes. In humans: GOT1/cAST, the cytosolic isoenzyme derives mainly from red blood cells and heart. GOT2/mAST, the mitochondrial isoenzyme is present predominantly in liver. These isoenzymes are thought to have evolved from a common ancestral AST via gene duplication, and they share a sequence homology of approximately 45%.[] AST has also been found in a number of microorganisms, including E. coli, H. mediterranei,[] and T. thermophilus.[] In E. coli, the enzyme is encoded by the aspCgene and has also been shown to exhibit the activity of an aromatic-amino-acid transaminase (EC 2.6.1.57 [18]).[]

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Structure
X-ray crystallography studies have been performed to determine the structure of aspartate transaminase from various sources, including chicken mitochondria,[] pig heart cytosol,[] and E. coli.[][] Overall, the three-dimensional polypeptide structure for all species is quite similar. AST is dimeric, consisting of two identical subunits, each with approximately 400 amino acid residues and a molecular weight of approximately 45 kD.[] Each subunit is composed of a large and a small domain, as well as a third domain consisting of the N-terminal residues 3-14; these few residues form a strand, which links and stabilizes the two subunits of the dimer. The large Structure of aspartate transaminase from chicken heart mitochondria domain, which includes residues 48-325, binds the PLP cofactor via an aldimine linkage to the -amino group of Lys258. Other residues in this domain Asp 222 and Tyr 225 also interact with PLP via hydrogen bonding. The small domain consists of residues 15-47 and 326-410 and represents a flexible region that shifts the enzyme from an "open" to a "closed" conformation upon substrate binding.[][][] The two independent active sites are positioned near the interface between the two domains. Within each active site, a couple arginine residues are responsible for the enzymes specificity for dicarboxylic acid substrates: Arg386 interacts with the substrates proximal (-)carboxylate group, while Arg292 complexes with the distal (side-chain) carboxylate.[][] In terms of secondary structure, AST contains both and elements. Each domain has a central sheet of -strands with -helices packed on either side.

Mechanism
Aspartate transaminase, as with all transaminases, operates via dual substrate recognition; that is, it is able to recognize and selectively bind two amino acids (Asp and Glu) with different side-chains.[] In either case, the transaminase reaction consists of two similar half-reactions that constitute what is referred to as a ping-pong mechanism. In the first half-reaction, amino acid 1 (e.g., L-Asp) reacts with the enzyme-PLP complex to generate ketoacid 1 (oxaloacetate) and the modified enzyme-PMP. In the second half-reaction, ketoacid 2 (-ketoglutarate) reacts with enzyme-PMP to produce amino acid 2 (L-Glu), regenerating the original enzyme-PLP in the process. Formation of a racemic product (D-Glu) is very rare.[] The specific steps for the half-reaction of Enzyme-PLP + aspartate Enzyme-PMP + oxaloacetate are as follows (see figure); the other half-reaction (not shown) proceeds in the reverse manner, with -ketoglutarate as the substrate.[][]

Aspartate transaminase

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Reaction mechanism for aspartate aminotransferase

1. Internal aldimine formation: First, the -amino group of Lys258 forms a Schiff base linkage with the aldehyde carbon to generate an internal aldimine. 2. Transaldimination: The internal aldimine then becomes an external aldimine when the -amino group of Lys258 is displaced by the amino group of aspartate. This transaldimination reaction occurs via a nucleophilic attack by the deprotonated amino group of Asp and proceeds through a tetrahedral intermediate. As this point, the carboxylate groups of Asp are stabilized by the guanidinium groups of the enzymes Arg386 and Arg 292 residues. 3. Quinonoid formation: The hydrogen attached to the a-carbon of Asp is then abstracted (Lys258 is thought to be the proton acceptor) to form a quinonoid intermediate. 4. Ketimine formation: The quinonoid is reprotonated, but now at the aldehyde carbon, to form the ketimine intermediate. 5. Ketimine hydrolysis: Finally, the ketimine is hydrolyzed to form PMP and oxaloacetate. This mechanism is thought to have multiple partially rate-determining steps.[] However, it has been shown that the substrate binding step (transaldimination) drives the catalytic reaction forward.[]

Clinical significance
AST is similar to alanine transaminase (ALT) in that both enzymes are associated with liver parenchymal cells. The difference is that ALT is found predominantly in the liver, with clinically negligible quantities found in the kidneys, heart, and skeletal muscle, while AST is found in the liver, heart (cardiac muscle), skeletal muscle, kidneys, brain, and red blood cells.[19] As a result, ALT is a more specific indicator of liver inflammation than AST, as AST may be elevated also in diseases affecting other organs, such as myocardial infarction, acute pancreatitis, acute hemolytic anemia, severe burns, acute renal disease, musculoskeletal diseases, and trauma.[20] AST was defined as a biochemical marker for the diagnosis of acute myocardial infarction in 1954. However, the use of AST for such a diagnosis is now redundant and has been superseded by the cardiac troponins.[21] AST (SGOT) is commonly measured clinically as a part of diagnostic liver function tests, to determine liver health.

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Patient type Reference ranges[22] Female Male [] 6 - 34 IU/L 8 - 40 IU/L

References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / www. chem. qmul. ac. uk/ iubmb/ enzyme/ EC2/ 6/ 1/ 1. html http:/ / tools. wmflabs. org/ magnustools/ cas. php?language=en& cas=9000-97-9& title= http:/ / www. ebi. ac. uk/ intenz/ query?cmd=SearchEC& ec=2. 6. 1. 1 http:/ / www. brenda-enzymes. org/ php/ result_flat. php4?ecno=2. 6. 1. 1 http:/ / www. expasy. org/ enzyme/ 2. 6. 1. 1 http:/ / www. genome. ad. jp/ dbget-bin/ www_bget?enzyme+ 2. 6. 1. 1 http:/ / biocyc. org/ META/ substring-search?type=NIL& object=2. 6. 1. 1 http:/ / priam. prabi. fr/ cgi-bin/ PRIAM_profiles_CurrentRelease. pl?EC=2. 6. 1. 1 http:/ / www. rcsb. org/ pdb/ search/ smartSubquery. do?smartSearchSubtype=EnzymeClassificationQuery& Enzyme_Classification=2. 6. 1. 1 [10] http:/ / www. ebi. ac. uk/ pdbe-srv/ PDBeXplore/ enzyme/ ?ec=2. 6. 1. 1 [11] http:/ / www. ebi. ac. uk/ thornton-srv/ databases/ cgi-bin/ enzymes/ GetPage. pl?ec_number=2. 6. 1. 1 [12] http:/ / amigo. geneontology. org/ cgi-bin/ amigo/ go. cgi?query=GO:0004069& view=details [13] http:/ / www. ebi. ac. uk/ ego/ DisplayGoTerm?id=GO:0004069& format=normal [14] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=2. 6. 1. 1%5BEC/ RN%20Number%5D%20AND%20pubmed%20pmc%20local%5Bsb%5D [15] http:/ / www. ncbi. nlm. nih. gov/ entrez/ query. fcgi?db=pubmed& term=2. 6. 1. 1%5BEC/ RN%20Number%5D [16] http:/ / www. ncbi. nlm. nih. gov/ protein?term=2. 6. 1. 1%5BEC/ RN%20Number%5D [17] http:/ / enzyme. expasy. org/ EC/ 2. 6. 1. 1 [18] http:/ / enzyme. expasy. org/ EC/ 2. 6. 1. 57 [19] http:/ / dynaweb. ebscohost. com/ Detail?sid=923b5a81-7daf-46b7-bdb2-86d8649da6ef@sessionmgr13& vid=& db=dme& ss=AN+ %22316452%22& sl=ll [20] http:/ / www. rnceus. com/ lf/ lfast. html [22] GPnotebook > reference range (AST) (http:/ / www. gpnotebook. co. uk/ simplepage. cfm?ID=322240579) Retrieved on Dec 7, 2009

Further reading
Jansonius, JN; Vincent, MG (1987). Jurnak FA and McPherson A, ed. Structural basis for catalysis by aspartate aminotransferase (Biological Macromolecules and Assemblies, Vol. 3). New York: Wiley. pp.187285. ISBN0-471-85142-6. Kuramitsu S, Okuno S, Ogawa T, Ogawa H, Kagamiyama H (1985). "Aspartate aminotransferase of Escherichia coli: nucleotide sequence of the aspC gene". J. Biochem. 97 (4): 125962. PMID 3897210 (http://www.ncbi. nlm.nih.gov/pubmed/3897210). Kondo K, Wakabayashi S, Yagi T, Kagamiyama H (1984). "The complete amino acid sequence of aspartate aminotransferase from Escherichia coli: sequence comparison with pig isoenzymes". Biochem. Biophys. Res. Commun. 122 (1): 6267. doi: 10.1016/0006-291X(84)90439-X (http://dx.doi.org/10.1016/ 0006-291X(84)90439-X). PMID 6378205 (http://www.ncbi.nlm.nih.gov/pubmed/6378205). Inoue K, Kuramitsu S, Okamoto A, Hirotsu K, Higuchi T, Kagamiyama H (1991). "Site-directed mutagenesis of Escherichia coli aspartate aminotransferase: role of Tyr70 in the catalytic processes". Biochemistry 30 (31): 77967801. doi: 10.1021/bi00245a019 (http://dx.doi.org/10.1021/bi00245a019). PMID 1868057 (http:// www.ncbi.nlm.nih.gov/pubmed/1868057).

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External links
Aspartate Transaminase (http://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?mode=&term=Aspartate+ Transaminase) at the US National Library of Medicine Medical Subject Headings (MeSH) AST: MedlinePlus Medical Encyclopedia (http://www.nlm.nih.gov/medlineplus/ency/article/003472.htm)

Wholesale
Wholesaling, jobbing, or distributing is the sale of goods or merchandise to retailers; to industrial, commercial, institutional, or other professional business users; or to other wholesalers and related subordinated services.[1] In general, it is the sale of goods to anyone other than a standard consumer. In the United Kingdom, the Cash and Carry is a term used describe a wholesale warehouse, particularly those that are open to the general public on payment of a subscription.
Fruit wholesalers in Haikou, Hainan Province, According to the United Nations Statistics Division, "wholesale" is the China resale (sale without transformation) of new and used goods to retailers, to industrial, commercial, institutional or professional users, or to other wholesalers, or involves acting as an agent or broker in buying merchandise for, or selling merchandise to, such persons or companies. Wholesalers frequently physically assemble, sort and grade goods in large lots, break bulk, repack and redistribute in smaller lots.[2] While wholesalers of most products usually operate from independent premises, wholesale marketing for foodstuffs can take place at specific wholesale markets where all traders are congregated.

Traditionally, wholesalers were closer to the markets they supplied than the source from which they got the products.[3] However, with the advent of the internet and E-procurement there are an increasing number of wholesalers located nearer manufacturing bases in China, Taiwan, and Southeast Asia. For example, Chinavasion, Ankaka, Ownta, Salehoo, and Modbom. These companies offer drop shipping services to companies and individuals. In the banking industry "wholesale" usually refers to wholesale banking, providing tailored services to large customers, in contrast with retail banking, providing standardized services to large numbers of smaller customers.

Taxes
Often, wholesalers are not required to charge their buyers sales tax, but they sometimes decide or are required to charge a special wholesale tax.[4]

Direct selling
The alternative to selling wholesale to distributors or retailers is to sell retail[5] either though company owned stores or online. Advantages include receiving a larger slice of the price paid by the consumer; disadvantages include difficulty in reaching consumers.[]

Wholesale

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References
[1] WTO - World Trade Organization (http:/ / www. wto. org/ english/ thewto_e/ acc_e/ completeacc_e. htm#chn) [2] UNSTATS - United Nations Statistics Division (http:/ / unstats. un. org/ unsd/ cr/ registry/ regcs. asp?Cl=9& Lg=1& Co=6) [4] Federal Manufacturers', Wholesale, and Retail Sales Taxes (http:/ / taxhistory. tax. org/ Civilization/ Documents/ Sales/ hst6646/ 6646-1. htm) from TaxAnalysts.org

Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy


The Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homoeopathy (AYUSH) is a part of the Ministry of Health & Family Welfare of the Government of India.[1][2] In collaboration with the Council for Scientific and Industrial Research (CSIR), AYUSH set up a Traditional Knowledge Digital Library (TKDL) in 2001, to prevent grant of "bed"patents on traditional knowledge and biopiracy, further the digital library is being developed on codified traditional knowledge on Indian systems of medicines such as Ayurveda, Unani, Siddha And Yoga. As an important measures nearly 805,000 Ayurvedic formulations, 98,700 Unani formulations, and 9,970 Sidha formulations have been transcribed in patent application format in five languages: English, French, German, Spanish and Japanese.[]

An official logo of AYUSH Department

History
Department of Indian Systems of Medicine and Homoeopathy (ISM&H) was created in March,1995 and re-named as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November, 2003 with a view to providing focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. The Department continued to lay emphasis on upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of the systems domestically and internationally.[3]

Bodies under AYUSH


Bodies under the control of the Department of AYUSH are: Research councils [4] Central Council for Research in Ayurvedic Sciences [5] (CCRAS) Central Council for Research in Siddha [6] (CCRS) Central Council for Research in Unani Medicine [7] (CCRUM) Central Council for Research in Homoeopathy [8] (CCRH) Central Council for Research in Yoga and Naturopathy [9] (CCRYN) National Institutes (Education in Indian Medicine):[10] National Institute of Ayurveda, Jaipur (NIA) National Institute of Siddha, Chennai (NIS) National Institute of Homoeopathy, Kolkata (NIH) National Institute of Naturopathy [11], Pune (NIN)

Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy National Institute of Unani Medicine [12], Bangalore (NIUM) Institute of Post Graduate Teaching and Research in Ayurveda [13], Jamnagar, Gujarat (IPGTR) Rashtriya Ayurveda Vidyapeeth [14], New Delhi (RAV) Morarji Desai National Institute of Yoga [15], New Delhi (MDNIY) Indian Medicine Pharmaceutical Corporation Limited [16] (IMPCL), Mohan, Uttaranchal (a public sector undertaking) Professional councils Central Council of Homoeopathy (CCH) Central Council of Indian Medicine (CCIM) Pharmacopoeia Commission Indian Pharmacopoeia Commission Pharmacopoeia Commission for Indian System of Medicine Traditional Knowledge Digital Library (TKDL)

258

Objectives
1.To upgrade the educational standards in the Indian Systems of Medicines and Homoeopathy colleges in the country. 2.To strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment. 3.To draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems. 4.To evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs. Department of Indian Systems of Medicine and Homoeopathy (ISM&H) was created in March,1995 and re-named as Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November, 2003 with a view to providing focused attention to development of Education & Research in Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy systems. The Department continued to lay emphasis on upgradation of AYUSH educational standards, quality control and standardization of drugs, improving the availability of medicinal plant material, research and development and awareness generation about the efficacy of the systems domestically and internationally. Objectives: 1.To upgrade the educational standards in the Indian Systems of Medicines and Homoeopathy colleges in the country. 2.To strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment. 3.To draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems. 3.To evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs.[17]

References
[2] Ayush is also a common Hindu given name, derived from Sanskrit, meaning "Long-life". [3] http:/ / www. indianmedicine. nic. in/ printcont. asp?lid=19 [4] Research councils (http:/ / indianmedicine. nic. in/ index2. asp?slid=52& sublinkid=37& lang=1) AYUSH. [5] http:/ / ccras. nic. in/ [6] http:/ / crisiddha. tn. nic. in/ [7] http:/ / unanimedicine. com/ [8] http:/ / ccrhindia. org/ [9] http:/ / www. ccryn. org/ [10] National Institutes (http:/ / indianmedicine. nic. in/ index2. asp?slid=50& sublinkid=33& lang=1) AYUSH [11] http:/ / www. punenin. org/ [12] http:/ / www. nium. in/ [13] http:/ / www. ayurveduniversity. com/ uniipgtra. php [14] http:/ / www. ravdelhi. nic. in/ [15] http:/ / www. yogamdniy. com/ [16] http:/ / www. impclmohan. nic. in/ [17] http:/ / www. indianmedicine. nic. in/ printcont. asp?lid=19

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External links
Department of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), Official website (http://indianmedicine.nic.in/index.html) Ministry of Health and Family Welfare, Official website (http://www.mohfw.nic.in/welcome.html) The First Ayurveda Hospital accredited by NABH is the AyurVAID Hospital (http://www.ayurvaid.com), Domlur, Bangalore International Journal of Advanced Ayurveda, Yoga, Unani, Siddha and Homeopathy (http://www. cloud-journals.com/journal-of-advanced-ayurveda-yoga-unani-siddha-and-homeopathy-open-acess.html) [ ISSN 2320- 0251 ] is (http://www.cloud-journals.com/ journal-of-advanced-ayurveda-yoga-unani-siddha-and-homeopathy-open-acess.html'), Published by Cloud Publications (http://www.cloudpublications.org).

Balanced Budget Act of 1997


The Balanced Budget Act of 1997, (Pub.L. 10533 [1], 111Stat.251 [2], enacted August5, 1997), was an omnibus legislative package enacted using the budget reconciliation process and designed to balance the federal budget by 2002. According to the Congressional Budget Office, the act would result in $160 billion in spending reductions between 1998 and 2002. After taking into account an increase in spending on Welfare and Children's Healthcare, the savings total $127 billion. Medicare cuts are responsible for $112 billion, and hospital inpatient and outpatient payments cover $44 billion. [3] In order to reduce Medicare spending, it reduced payments to health service providers such as hospitals, doctors and nurse practitioners.[4] However, some of those changes to payments were restored by subsequent legislation in 1999 and 2000.

References
[1] http:/ / www. law. cornell. edu/ jureeka/ index. php?doc=USPubLaws& cong=105& no=33 [2] http:/ / www. gpo. gov/ fdsys/ granule/ STATUTE-111/ STATUTE-111-Pg251/ content-detail. html [3] "The Impact of the BBA and the BBRA." Trend Watch 2 (Mar. 2000): 1. American Hospital Association. Web. 23 Feb. 2011. <www.aha.org/aha/trendwatch/2000/twmarch2000.pdf>.

External links
Act in Full (http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/content-detail.html) H.R. 2015 (http://hdl.loc.gov/loc.uscongress/legislation.105hr2015), Legislative History

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999

260

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999


Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999

Long title

Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 Balanced Budget Refinement Act or BBRA 106th United States Congress Citations

Colloquial acronym(s) Enacted by the

Public Law Stat.

106-113 113 Stat. 1501 Codification

Act(s) amended Title(s) amended U.S.C. section(s) amended

Balanced Budget Act of 1997 Social Security Act 42 42USC1395 Legislative history

Introduced in the House as H.R. 3426 by William M. Thomas on November 17, 1999 Committee consideration by: Committee on Ways and Means, Committee on Commerce Reported by the joint conference committee on November 18, 2009; agreed to by the House on November 18, 1999 (296 - 135) and by the Senate on November 19, 1999 (74-24) Signed into law by President Bill Clinton on November 29, 1999

The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 [1] (also called the Balanced Budget Refinement Act or BBRA) is a federal law of the United States, enacted in 1999.[2] The BBRA was first introduced into the House as H.R. 3075 on October 14, 1999 by Rep. William M. Thomas (R-CA) with 75 cosponsors. It was read twice and then referred to the Senate Committee on Finance. The bill was then slightly altered and reintroduced by Thomas as H.R. 3426 on November 17, 1999. After referral to the House committees on Ways and Means and Commerce, it was incorporated by cross-reference in the conference report into H.R. 3194 on November 18, 1999. The H.R. 3194 bill had been introduced by Rep. Ernest J. Istook, Jr. (R-OK) on November 2, 1999, and was enacted with official title: Making consolidated appropriations for the fiscal year ending September 30, 2000, and for other purposes. The State Health Insurance Trial (SCHIP or S. H. 1 - T) was administered by the United States Department of Health and Human Services. The BBRA was signed by President Bill Clinton on November 29, 1999 after passing in Congress.

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261

References
[1] , [2] http:/ / www. ssa. gov/ OP_Home/ comp2/ F106-113. html

External links
H.R. 3075 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3075), Legislative History H.R. 3426 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3426), Legislative History H.R. 3194 (http://hdl.loc.gov/loc.uscongress/legislation.106hr3194), Legislative History

Blue Cross Blue Shield Association


Blue Cross Blue Shield Association
Type Industry Founded Independent Health insurance 1929

Headquarters Michigan Plaza Chicago, Illinois Key people Products Revenue Employees Website [1] Scott Serota , President and CEO PPOs, HMOs $320.5 million US$ (2008) 880 (2008) bcbs.com [2] [2]

[3]

The Blue Cross Blue Shield Association (BCBSA) is a federation of 38 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 99 million Americans.[4] The history of Blue Cross dates back to 1929, while the history of Blue Shield dates to 1939. The Blue Cross Association dates back to 1960, while its Blue Shield counterpart was created in 1948. The two organizations merged in 1982, forming the current association.

History

Blue Cross Blue Shield Association

262

Health care in the United States Government Health Programs


Federal Employees Health Benefits Program Indian Health Service Veterans Health Administration Military Health System / TRICARE Medicare Medicaid / State Health Insurance Assistance Program (SHIP) State Children's Health Insurance Program (CHIP) Program of All-Inclusive Care for the Elderly (PACE) Prescription Assistance (SPAP) Private health coverage

Health insurance in the United States Consumer-driven health care


Flexible spending account (FSA) Health Reimbursement Account Health savings account

High-deductible health plan (HDHP) Medical savings account (MSA) Private Fee-For-Service (PFFS) Managed care (CCP) Health maintenance organization (HMO) Preferred provider organization (PPO) Medical underwriting

Health care reform law


Emergency Medical Treatment and Active Labor Act (1986) Health Insurance Portability and Accountability Act (1996) Medicare Prescription Drug, Improvement, and Modernization Act (2003) Patient Safety and Quality Improvement Act (2005) Health Information Technology for Economic and Clinical Health Act (2009) Patient Protection and Affordable Care Act (2010) State level reform

Massachusetts health care reform Oregon Health Plan Vermont health care reform SustiNet (Connecticut) Dirigo Health (Maine) Municipal health coverage

Fair Share Health Care Act (Maryland) Healthy Howard (Howard Co., Maryland) Healthy San Francisco

Blue Cross and Blue Shield developed separately, with Blue Cross plans providing coverage for hospital services, while Blue Shield covered physicians' services.[5] Blue Cross is a name used by an association of health insurance plans throughout the United States. Its predecessor was developed by Justin Ford Kimball in 1929, while he was vice-president of Baylor University's health care facilities in Dallas, Texas.[] The first plan guaranteed teachers 21 days of hospital care for $6 a year, and was later extended to other employee groups in Dallas, and then nationally.[] The American Hospital Association (AHA) adopted the Blue Cross symbol in 1939 as the emblem for plans meeting certain standards. In 1960 the AHA

Blue Cross Blue Shield Association commission was superseded by the Blue Cross Association. Affiliation with the AHA was severed in 1972. The Blue Shield concept was developed at the beginning of the 20th century by employers in lumber and mining camps of the Pacific Northwest to provide medical care by paying monthly fees to medical service bureaus composed of groups of physicians.[6] The first official Blue Shield Plan was founded in California in 1939. In 1948 the symbol was informally adopted by nine plans called the Associated Medical Care Plan, and was later renamed the National Association of Blue Shield Plans. In 1982 Blue Shield merged with The Blue Cross Association to form the Blue Cross and Blue Shield Association.[7] Prior to the Tax Reform Act of 1986, organizations administering Blue Cross Blue Shield were tax exempt under 501(c)(4) as social welfare plans. However, the Tax Reform Act of 1986 revoked that exemption because the plans sold commercial-type insurance. They became 501(m) organizations, subject to federal taxation but entitled to "special tax benefits"[8] under IRC 833.[9] In 1994, the Blue Cross Blue Shield Association changed to allow its licensees to be for-profit corporations.[5] Some plansWikipedia:Citing sources are still considered not-for-profit at the state level.

263

Current organization
Blue Cross and Blue Shield insurance companies are licensees, independent of the association (and traditionally of each other), offering insurance plans within defined regions under one or both of the association's brands. Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state. They also act as administrators of Medicare in many states or regions of the US[10] and provide coverage to state government employees as well as to the federal government employees under a nationwide option of the Federal Employees Health Benefit Plan.[11] The 14-state WellPoint is the largest Blue Cross Blue Shield member, and is a publicly traded company. Other multi-state organizations include CareFirst in the Mid-Atlantic, The Regence Group in the Pacific Northwest, and Highmark which serves Pennsylvania, Delaware, and West Virginia. The largest non-investor owned member is Health Care Service Corporation,[citation needed] which operates five Blue Cross and Blue Shield Plans in the Midwest and Southwest (Illinois, Oklahoma, Texas, Montana, and New Mexico). The association has its headquarters in the Michigan Plaza complex in the Chicago Loop area of Chicago, Illinois.[12]

List of BlueCross and/or BlueShield companies


Publicly traded companies Anthem for-profit (Became WellPoint 2004) Anthem BlueCross BlueShield Colorado Connecticut Indiana Kentucky Maine Missouri Nevada New Hampshire Ohio Parts of Virginia

Wisconsin Anthem BlueCross

Blue Cross Blue Shield Association California BlueCross BlueShield of Georgia Empire BlueCross and BlueShield (New York) Triple-S Management Corporation (BlueCross & BlueShield Puerto Rico) Multi-state private companies CareFirst*Blue Cross Blue Shield of Montana District of Columbia Maryland Parts of Virginia Health Care Service Corporation BlueCross BlueShield of Illinois BlueCross BlueShield of New Mexico [13] Blue Cross Blue Shield of Montana BlueCross BlueShield of Oklahoma BlueCross BlueShield of Texas Highmark Highmark BlueCross BlueShield (Western Pennsylvania) Highmark BlueShield (Northeastern, Eastern & Central Pennsylvania) Highmark BlueCross Blue Shield Delaware (Delaware) Highmark BlueCross BlueShield West Virginia (West Virginia) Premera Premera BlueCross BlueShield of Alaska Premera BlueCross (Washington) The Regence Group (Cambia Health Solutions) Regence BlueShield of Idaho Regence BlueCross BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield (Washington) Wellmark BlueCross Blue Shield Iowa South Dakota Single-state or regional companies BlueCross BlueShield of Alabama BlueCross BlueShield of Arizona Arkansas BlueCross BlueShield BlueShield of California BlueCross BlueShield of Florida (branded as Florida Blue)[14] Hawaii Medical Service Association BlueCross of Idaho BlueCross BlueShield of Kansas BlueCross BlueShield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan

264

Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Mississippi

Blue Cross Blue Shield Association BlueCross and BlueShield of Kansas City (Missouri) Blue Cross Blue Shield of Nebraska Horizon Blue Cross Blue Shield of New Jersey Excellus BlueCross BlueShield (Central New York, Rochester and Utica/Watertown) BlueShield of Northeastern New York (A division of HealthNow New York Inc.) Blue Cross Blue Shield of Western New York (A division of HealthNow New York Inc.) Blue Cross Blue Shield of North Carolina Blue Cross Blue Shield of North Dakota Blue Cross of Northeastern Pennsylvania Capital Blue Cross (Central Pennsylvania) Independence Blue Cross (Philadelphia, Southeastern Pennsylvania) Blue Cross Blue Shield of Rhode Island Blue Cross Blue Shield of South Carolina BlueCross BlueShield of Tennessee BlueCross BlueShield of Vermont BlueCross BlueShield of Wyoming

265

Companies outside of the United States BlueCross BlueShield of Uruguay

Details on specific organizations


Idaho
BlueCross of Idaho and Regence[15] BlueShield of Idaho are separate companies and compete head to head throughout the state.

Pennsylvania
Though historically "Blue Cross" was used for hospital coverage while "Blue Shield" was used for medical coverage, today that split only exists for traditional health insurance plans in eastern Pennsylvania, where Independence Blue Cross (Philadelphia) and Blue Cross of Northeastern Pennsylvania each have joint marketing agreements with Highmark Blue Shield (Pittsburgh) for their separate hospital and medical plans. However, Independence Blue Cross, like most of its sister Blue Cross-Blue Shield companies, cover most of their customers under managed care plans such as HMOs and PPOs which provide hospital and medical care in one policy.

Criticism and controversy


The Seattle Times published an article on February 9, 2012, alleging non-profit insurance outfits, including Premera Blue Cross, Regence BlueShield and Group Health Cooperative, are stockpiling billions of dollars in reserves while increasing their rates at the same time.[16] Insurance companies do have statutory reserve requirements set by the states in which they operate, but the Seattle Times article cites Washington state insurance Commissioner Mike Kreidler arguing that these companies have in excess of $1 billion more than needed to cover claims and disaster contingencies.

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References
[1] [2] [3] [4] [5] Scott P. Serota page (http:/ / www. bcbs. com/ about-the-association/ officers/ scott-serota. html) on BCBSA Web site Blue Cross and Blue Shield Association Company Profile (http:/ / biz. yahoo. com/ ic/ 40/ 40067. html) from Yahoo! http:/ / bcbs. com/ Blue Cross and Blue Shield Association About Us (http:/ / www. bcbs. com/ about-the-association/ ) IRS. Coordinated Issue Paper - Blue Cross Blue Shield/Health Insurance; Life Insurance: Conversion of nonprofit corporations (http:/ / www. irs. gov/ businesses/ article/ 0,,id=183646,00. html). (Effective Date: June 4, 2008) [9] http:/ / www4. law. cornell. edu/ uscode/ html/ uscode26/ usc_sec_26_00000833----000-. html [10] http:/ / www. healthharbor. com [11] United States Office of Personal Management, 2010 Nationwide Fee-for-Service Open to All (http:/ / www. opm. gov/ insure/ health/ planinfo/ 2010/ states/ wy. asp) [12] " Contact Us (http:/ / www. bcbs. com/ about/ contact/ )." Blue Cross and Blue Shield Association. Retrieved on December 23, 2009. [13] http:/ / www. bcbsnm. com/ [15] The Regence Group

Blue Cross Blue Shield Of Texas (http://www.bcbstx.com/)

External links
Blue Cross Blue Shield of California official website (http://www.bcbs.com/)

Baby Friendly Hospital Initiative


The Baby Friendly Hospital Initiative (BFHI), also known as Baby Friendly Initiative (BFI), is a worldwide programme of the World Health Organization and UNICEF, launched in 1991[1][2] following the adoption of the Innocenti Declaration on breastfeeding promotion in 1990.[3] The initiative is a global effort for improving the role of maternity services to enable mothers to breastfeed babies for the best start in life. It aims at improving the care of pregnant women, mothers and newborns at health facilities that provide maternity services for protecting, promoting and supporting breastfeeding, in accordance with the International Code of Marketing of Breastmilk Substitutes. UNICEF, the World Health Organization, and many national government health agencies recommend that babies are breastfed exclusively for their first six months of life. Studies have shown that breastfed babies are less likely to suffer from serious illnesses, including gastroenteritis, asthma, eczema, and respiratory and ear infections.[4][5][6][7] Adults who were breastfed as babies are less likely to develop risk factors for heart disease such as obesity and high blood pressure. There are benefits for mothers too: women who breastfeed have a lower risk of developing breast cancer, ovarian cancer and hip fractures in later life.[8][9][10] The BFHI aims to increase the numbers of babies who are exclusively breastfed worldwide, a goal which the WHO estimates could contribute to avoiding over a million child deaths each year.[11]

Criteria
The criteria for a hospital's Baby Friendly accreditation include: 1. 2. 3. 4. 5. 6. Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one half-hour of birth. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. Give newborn infants no food or drink other than breastmilk, not even sips of water, unless medically indicated.

7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Baby Friendly Hospital Initiative 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. The program also restricts use by the hospital of free formula or other infant care aids provided by formula companies. Since the program's inception, approximately 15,000 facilities in more than 152 countries have been inspected and accredited as "Baby-Friendly."[1][2]

267

National schemes
Canada
In Canada, the provinces of Quebec and New Brunswick have mandated the implementation of the BFHI. Other provinces and territories are implementing strategies at regional and local levels.[12] As of 2008, 18 health care facilities (9 hospitals & birthing centres and 9 community health services) had been designated "Baby-Friendly" across the country.[13]

Cuba
In Cuba, 49 of the country's 56 hospitals and maternity facilities have been designated as "baby-friendly". In the six years following the initiation of the BFHI program, the rate of exclusive breastfeeding at four months almost tripled from 25 per cent in 1990 to 72 per cent in 1996.[1]

Sweden
Sweden is considered the global leader in terms of BFHI implementation: four years after the programme was introduced in 1993, all of the then 65 maternity centres in the country had been designated "baby-friendly".[14]

United Kingdom
The UNICEF UK Baby Friendly Initiative was launched in the United Kingdom in 1994.[15] The Initiative works with the National Health Service (NHS) to ensure a high standard of care for pregnant women and breastfeeding mothers and babies in hospitals and community health settings. The Baby Friendly Initiative accredits health-care facilities that adopt internationally recognised best practice standards for breastfeeding. During each stage of accreditation, the Initiative provides support as facilities implement standards relating to policies and procedures, staff education, effective auditing, educating pregnant women and mothers, and other relevant areas. In 1998, its principles were extended to cover the work of community health-care services with the Seven Point Plan for the Promotion, Protection and Support of Breastfeeding in Community Health Care Settings.[15] In 2005, it introduced an accreditation programme for university departments responsible for midwifery, health visitor and public health nurse education. This ensures that newly qualified midwives and health visitors are equipped with the basic knowledge and skills they need to support breastfeeding effectively. The program's emphasis on applying the standards in post-natal and education settings makes it unique amongst the various Baby Friendly programmes in other countries.[citation needed] There are now 52 Baby Friendly-accredited maternity hospitals in the UK and ten accredited community health-care providers.[citation needed] It has been estimated that if all babies were breastfed, over 35m would be saved by the NHS in England and Wales each year in treating gastroenteritis alone.[16] Despite this, breastfeeding rates in the UK are amongst the lowest in Europe: 78 per cent of babies born in the UK are breastfed at birth, falling to 63 per cent at one week. Only one in five babies still receives breastmilk at six months.[17] In 2009, the Department of Health awarded a total of 4 million to 40 Primary Care Trusts in areas with low rates of breastfeeding to support them in seeking Baby Friendly accreditation.[citation needed]

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United States
The first hospitals verified as Baby-Friendly in the USA were on the Pacific coast. All of these were able to achieve 100% breastfeeding initiation rates. [18]In New York City, the Harlem Hospital Center was the first hospital to receive the "Baby Friendly" certification granted by Baby-Friendly USA for the city in 2008.[19] In 2011, New York University Langone Medical Center became the second hospital to receive the Baby-Friendly Hospital designation in New York City.[20]

References
[1] UNICEF. The Baby-Friendly Hospital Initiative. (http:/ / www. unicef. org/ programme/ breastfeeding/ baby. htm) Accessed 4 August 2011. [2] World Health Organization. Baby-friendly Hospital Initiative. (http:/ / www. who. int/ nutrition/ topics/ bfhi/ en/ ) Accessed 4 August 2011. [3] UNICEF. INNOCENTI DECLARATION on the Protection, Promotion and Support of Breastfeeding. (http:/ / www. unicef. org/ programme/ breastfeeding/ innocenti. htm) Adopted at the WHO/UNICEF meeting on "Breastfeeding in the 1990s: A Global Initiative", held at the Spedale degli Innocenti, Florence, Italy, 30 July-1 August 1990. [4] http:/ / www. ahrq. gov/ clinic/ tp/ brfouttp. htm [5] http:/ / pediatrics. aappublications. org/ cgi/ content/ abstract/ 121/ 1/ 183 [6] http:/ / pediatrics. aappublications. org/ cgi/ content/ abstract/ 122/ Supplement_4/ S176?ct=ct [7] http:/ / thorax. bmj. com/ cgi/ content/ abstract/ thx. 2008. 101543v1?ct=ct [8] http:/ / highwire. stanford. edu/ cgi/ medline/ pmid;15308954 [9] http:/ / aje. oxfordjournals. org/ cgi/ content/ abstract/ 161/ 1/ 15?ct [10] http:/ / www. babyfriendly. org. uk/ pdfs/ World_Cancer_Research_Fund_2007-10. pdf [11] World Health Organization. 10 facts on breastfeeding (http:/ / www. who. int/ features/ factfiles/ breastfeeding/ en/ index. html), accessed 20 April 2011. [12] Breastfeeding Committee for Canada. BFI in Canada. (http:/ / www. breastfeedingalberta. ca/ bfi_in_canada. htm) Accessed 2 August 2011. [13] New Brunswick Department of Health. New Brunswick Provincial Report of the Baby-Friendly Self-Assessment Survey. (http:/ / www. gnb. ca/ 0053/ bfi/ pdf/ PT Hospital Survey final2006web. pdf) March 2008. [14] Hofvander Y. "Breastfeeding and the Baby Friendly Hospitals Initiative (BFHI): Organization, response and outcome in Sweden and other countries." (http:/ / onlinelibrary. wiley. com/ doi/ 10. 1111/ j. 1651-2227. 2005. tb02038. x/ abstract) Acta Paediatrica, 94(8): 10121016, August 2005. [15] UNICEF UK. What is the Baby Friendly Initiative? (http:/ / www. unicef. org. uk/ BabyFriendly/ About-Baby-Friendly/ What-is-the-Baby-Friendly-Initiative/ ) Accessed 4 August 2011. [16] http:/ / www. babyfriendly. org. uk/ pdfs/ local_authority_approach. pdf [17] http:/ / www. ic. nhs. uk/ pubs/ breastfeed2005 [18] http:/ / pediatrics. aappublications. org/ content/ 116/ 3/ 628. full. pdf+ html [19] http:/ / www. nyc. gov/ html/ hhc/ html/ newsletter/ safety-200807-baby-friendly. shtml [20] http:/ / nursing. med. nyu. edu/ news/ 2011/ nyu-langone-medical-center-awarded-official-baby-friendly-usa-designation

External links
World Health Organization (http://www.who.int) UNICEF International (http://www.unicef.org) BFHI information from the World Health Organisation (http://www.who.int/nutrition/topics/bfhi/en/index. html) MotherBaby Summit (http://www.motherbabysummit.com) Baby Friendly Initiative UK (http://www.babyfriendly.org.uk) UNICEF UK (http://www.unicef.org.uk)

BI-RADS

269

BI-RADS
BI-RADS is an acronym for Breast Imaging-Reporting and Data System, a quality assurance tool originally designed for use with mammography. The system is a collaborative effort of many health groups but is published and trademarked by the American College of Radiology (ACR). The system is designed to standardize reporting, and is used by medical professionals to communicate a patient's risk of developing breast cancer. The document focuses on patient reports used by medical professionals, not "lay reports" that are provided to patients.

Published Documents
The BI-RADS is published by ACR in the form of the BI-RADS Atlas. As of 2007 the Atlas is divided into 3 publications: Mammography, Fourth Edition Ultrasound, First Edition MRI, First Edition

Assessment Categories
While BI-RADS is a quality control system, in day-to-day usage the term "BI-RADS" refers to the mammography assessment categories. These are standardized numerical codes typically assigned by a radiologist after interpreting a mammogram. This allows for concise and unambiguous understanding of patient records between multiple doctors and medical facilities. The assessment categories were developed for mammography and later adapted for the MRI and Ultrasound Atlases. The summary of each category, given below, is identical for all 3 modalities. Category 6 was added in the 4th edition of the Mammography Atlas. BI-RADS Assessment Categories are:[1] 0: Incomplete 1: Negative 2: Benign finding(s) 3: Probably benign 4: Suspicious abnormality 5: Highly suggestive of malignancy 6: Known biopsy proven malignancy

An incomplete (BI-RADS 0) classification warrants either an effort to ascertain prior imaging for comparison or to call the patient back for additional views and/or higher quality films. A BI-RADS classification of 4 or 5 warrants biopsy to further evaluate the offending lesion.[2] Some experts believe that the single BI-RADS 4 classification does not adequately communicate the risk of cancer to doctors and recommend a subclassification scheme:[] 4A: low suspicion for malignancy 4B: intermediate suspicion of malignancy 4C: moderate concern, but not classic for malignancy

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270

Breast Composition Categories


1: Almost entirely fatty 2: Scattered fibroglandular densities 3: Heterogeneously dense 4: Extremely dense

External links
The American College of Radiology [3] BI-RADS Atlas [4] Short tutorial, with actual mammogram pictures [5]

References
[1] American College of Radiology (ACR) Breast Imaging Reporting and Data System Atlas (BI-RADS Atlas). Reston, Va: American College of Radiology; 2003 [2] ACR Practice Guideline for the Performance of Ultrasound-Guided Percutaneous Breast Interventional Procedures Res. 29; American College of Radiology; 2009 [3] http:/ / www. acr. org [4] http:/ / www. acr. org/ Quality-Safety/ Resources/ BIRADS [5] http:/ / www. birads. at/

Bureau of Primary Health Care


The Bureau of Primary Health Care is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA helps fund, staff and support a national network of health clinics for people who otherwise would have little or no access to care. The Bureau is headed by Associate Administrator Jim Macrea, Senior Advisior Tracey Orloff and Chief Medical Advisor Seiji Hayashi.

History
HRSAs Primary Health Care Programs have their roots in the Migrant Health Act of 1962 and the Economic Opportunity Act of 1964, which established funding for the first community-based clinics that were to become todays Health Center Program. The National Hansens Disease Program, formerly the National Leprosarium, was established in 1921. More recently, the Free Clinics Medical Malpractice Program was established in 2004. The Bureau of Primary Health Care was reorganized and restructured to become more organized and efficient.[1] This resulted in creation of the Office of Minority and Special Populations, the Office of Policy and Program Development, and the Office of Quality and Data. There are also four divisions that were created: Eastern, Central Mid Atlantic, Western and the National Hansens disease program.[2] The Health Resources and Services Administration (HRSA), within the Department of Health and Human Services (HHS), has the responsibility for managing the Consolidated Health Centers Grant Program. The Economic Opportunity Act of 1964 provided Federal funds for two "neighborhood health centers," which were launched in 1965 by Jack Geiger and Count Gibson, physicians at Tufts University in Boston. Federal support for entities that would later be called health centers began in 1962 with passage of the Migrant Health Act, which funded medical and support services for migrant and seasonal farmworkers and their family members. In the mid-1970s, Congress permanently authorized neighborhood health centers as community health centers and migrant health centers under sections 329 and 330 of the Public Health Service Act.[3]

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Key facts
Over 1,100 health center grant recipients operate more than 8,000 community-based clinic sites in every state and territory, giving geographically isolated or economically distressed people access to preventive and primary health care. HRSA-supported health centers treated more than 19 million people in 2010, approximately two-thirds of whom are members of minority groups. Nearly forty percent have no health insurance; a third are children. Since 2001, through a major expansion initiative, HRSA has increased access to primary health care in 1,200 communities through new or expanded clinical sites. During this time, health centers increased their patient base by almost 60 percent, nearly doubled the number of people receiving oral health care, and tripled the number of clients who received mental health and addiction counseling services. One of every 20 people living in the U.S. now relies on a HRSA-funded clinic for primary care, including nearly a quarter of the nations homeless and migrant and seasonal farmworkers. The National Hansens Disease Program is the major source of direct patient care, clinician training and research in the field of Hansens Disease and related leprous conditions. The Federally Supported Health Centers Assistance Act of 1992 and 1995 granted medical malpractice liability protection through the Federal Tort Claims Act (FTCA) to HRSA-supported health centers. BPHC administers this program through its Office of Quality and Data. The Free Clinics Medical Malpractice Program extends this coverage to insures physicians and other clinicians who contribute free health care services in the communities, relieving them of the burden of paying for private liability coverage.[citation needed]

Health Center Program


Health Centers are community-based and patient-directed organizations that serve people with limited access to health care. These include low-income patients, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing. HRSA-supported clinics provide comprehensive, culturally competent, quality primary health care to a broadly diverse patient base that includes increasing numbers of veterans. Services include pharmacy, mental health, substance abuse and oral health treatment, as well as supportive services (education, translation, transportation and case management) that promote access to health care and ensure patient well-being. Health centers are required to be located in or serve a high-need community (a medically underserved area or population) and to make their services available to all patients on a sliding scale, with fees based on ability to pay. By law, health centers must be governed by community boards with majority patient representation. Looking at national numbers, Health Centers serve:[4] 1 in 20 individuals 1 in 12 African-Americans 1 in 9 Hispanic/Latinos 1 in 8 uninsured 1 in 7 individuals living below 200 percent of the Federal poverty level 1 in 4 homeless individuals and migrant/seasonal farmworkers

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Free Clinics Medical Malpractice Program


Free clinics play a significant role in meeting the health care needs of the uninsured, particularly at a time when private physicians may be less likely to provide free care in their offices. These clinics are typically small organizations with annual budgets of less than $250,000, making them less able to afford the growing cost of malpractice coverage for those clinicians who might otherwise be willing to donate their time. The Free Clinics Program serves HRSAs overall policy aim of expanding treatment capacity for the disadvantaged by assuring health professional volunteers that they will be protected against medical malpractice claims. To date, over 2,800 health care providers have been given federal indemnity through the program. The community health center is a nonprofit health care agency concerned with health promotion and primary prevention goals for specific populations. Populations may include the homeless, minorities, Medicaid recipients, migrant/seasonal farmworkers, persons infected with HIV/AIDS, the underinsured, and the uninsured. Community health centers are funded by the Bureau of Primary Health Care, U.S. Public Health Service, U.S. Department of Health and Human Services, via grant money and are located in designated medically underserved areas. The National Association for Community Health Centers and state associations for community health centers are advocates for the local centers. Community health centers are unique in that they employ community health care specialists (e.g., family practice physicians and advanced practice nurses). They provide accessible primary care preventive health services. Their clients include the individual, family, and community; and they have a partnership relationship with the community.[5]

National Hansen's Disease Program


The National Hansen's Disease Program have been providing care and treatment for Hansen's disease (leprosy) and related conditions since 1921. Currently, the National Hansen's Disease (Leprosy) Clinical Center is located at Ochsner Medical Center in Baton Rouge, Louisiana. It is "the only facility in the United States devoted to diagnosis, treatment, and research concerning Hansen's disease."[6] The Clinical Center states that it offers: Free consultations for physicians treating complicated cases of Hansen's disease, including referrals for reconstructive hand or foot surgery. Free pathologic review of skin biopsy and consultation concerning molecular techniques for identification of M. leprae. Free antibiotics for leprosy treatment shipped to physicians. Free educational materials for healthcare professionals and patients to improve understanding of the disease, and to prevent injury and disability. Surgical care and rehabilitation for those referred for complicated (digit or limb threatening) wounds or reconstruction of correctable deformity resulting from Hansen's disease.[7] The National Hansen's Disease (Leprosy) Research Program at the Louisiana State University School of Veterinary Medicine in Baton Rouge is a research center that "conducts and supports research in the causes, diagnosis, prevention and cure of Hansen's disease and tuberculosis aimed at the global elimination of Hansen's disease (leprosy)."[8] The research program maintains the world's only M. leprae-infected armadillo colony. Twenty-three people work at the Research Program.[9] The program provides health care to those affected by the disease through three means of service delivery: at HRSA-run facilities in Louisiana; via a payment to a Hawaii in-patient program; or at any of 11 regional outpatient clinics under contract to the agency. The programs also support scientific research and training for health professionals at the worlds largest and most comprehensive laboratory dedicated to Hansens Disease.

Bureau of Primary Health Care The programs are the only dedicated source of expertise, treatment and continuing education on the disease in the United States. Though Hansen's disease is very rare in the United States(there are currently only 6500 cases) there is still a widely held stigma because of the history of the disease. With current treatment methods patients become noninfectious after only a few doses of medication. Patients may continue their lives without change during treatment. This Program has led the development of the treatments for Hansen's Disease. It wasn't until the 1940s that any effective means of treating this Disease were created. "Guy Henry Faget, MD and his staff demonstrate the efficacy of sulfone drugs, At the end of one year, 15 of 22 patients had improved." [10]

273

Models that Work Campaign


The main objective of the Models That Work Campaign (MTW) is improving access to health care for vulnerable and underserved populations. The MTW Campaign is a collaboration between the Bureau of Primary Health Care (BPHC) and 39 cosponsors including national associations, state and federal agencies, community-based organizations, foundations, and businesses. This initiative gives recognition and visibility to innovative and effective service delivery models. Models are selected based on a set of criteria that includes delivery of high quality primary care services, community participation, integration of health and social services, quantifiable outcomes, and replicability. Winners of the competition are showcased nationally and hired to provide training to other communities, to document and publish their strategies, and to provide onsite technical assistance on request. MTW staff at HRSA's Bureau of Primary Health Care (BPHC) work in collaboration with cosponsors in national and local campaigns to publicize the innovative approaches used by MTW winners. On the federal level for example, HRSA's HIV/AIDS Bureau works with MTW staff and cosponsors to develop a series of community based workshops with MTW winners; sharing lessons and advising community leaders, clinicians, and administrators on strategies to improve primary care coordination for populations with high incidences of HIV/AIDS. Innovative strategies are often identified and incorporated into federal technical assistance initiatives and local program design as well.[11]

References
[2] [3] [4] [6] http:/ / www. hrsa. gov/ about/ organization/ bureaus/ bphc/ bphcorgchart2010. pdf http:/ / bphc. hrsa. gov/ success/ http:/ / bphc. hrsa. gov/ success/ criticalconnections. htm " National Hansen's Disease (Leprosy) Clinical Center, Baton Rouge, Louisiana (http:/ / www. hrsa. gov/ hansensdisease/ clinicalcenter. html)." Health Research and Services Administration. [7] " National Hansen's Disease (Leprosy) Clinical Center, Baton Rouge, Louisiana (http:/ / www. hrsa. gov/ hansensdisease/ clinicalcenter. html)." Health Research and Services Administration. [8] " Hansen's Disease Laboratory Research (http:/ / www. hrsa. gov/ hansensdisease/ research/ index. html)." [9] " Hansen's Disease Laboratory Research (http:/ / www. hrsa. gov/ hansensdisease/ research/ index. html)." [10] http:/ / www. hrsa. gov/ hansens/ history. htm

External links
Official website (http://bphc.hrsa.gov/)

Behavioral Risk Factor Surveillance System

274

Behavioral Risk Factor Surveillance System


The Behavioral Risk Factor Surveillance System (BRFSS) is a United States health survey that looks at behavioral risk factors. It is run by Centers for Disease Control and Prevention and conducted by the individual state health departments. The survey is administered by telephone and is the world's largest such survey. In 2009, the BRFSS began conducting surveys by cellular phone in addition to traditional landline telephones.

Description
The BRFSS is a cross-sectional telephone survey conducted by state health departments with technical and methodological assistance provided by the CDC. In addition to all 50 states, the BRFSS is also conducted by health departments in The District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. [1] Individual states can add their own questions to the survey instrument, which consists of a core set of questions on certain topics like car safety, obesity, or exercise. States get funding from the federal government to administer these questionnaires, and they pay for the additional questions themselves. The U.S. federal government can then compare states based on the core questions to allocate funding and focus interventions. The states themselves also use the survey results to focus interventions for the public and to decide what is worth their while to focus on. City, county, tribal, and local governments also rely on BRFSS data for information about their jurisdictions.

References External links


Behavioral Risk Factor Surveillance System (http://www.cdc.gov/BRFSS/) CDC Website (http://www.cdc.gov/) step-by-step how to analyze the Behavioral Risk Factor Surveillance System with free tools website (http:// www.asdfree.com/search/label/behavioral risk factor surveillance system (brfss))

Bachelor of Science in Nursing

275

Bachelor of Science in Nursing


The Bachelor of Science in Nursing (BSN, or BScN in Canada) is an American and Canadian four-year academic degree in the science and principles of nursing, granted by a tertiary education university or similarly accredited school. Though one is eligible to sit for the licensing examination to become a registered nurse after graduating from either a two-year program with an Associate's Degree (ADN) or from a four-year program with an Bachelor's Degree (BSN), the BSN prepares nurses for a professional role away from the bedside with coursework in nursing science, research, leadership, and nursing informatics. A BSN also provides the student with general education in math, humanities and social sciences.[1] A bachelors opens up opportunities for greater career advancement and higher salary options. This degree qualifies its holder for administrative, research, consulting and teaching positions that would not be available to those with only an ADN.[2]

References

Coronary artery bypass surgery

276

Coronary artery bypass surgery


Coronary artery bypass surgery
Intervention

Early in a coronary artery bypass surgery during vein harvesting from the legs (left of image) and the establishment of bypass (placement of the aortic cannula) (bottom of image). The perfusionist and heart-lung machine (HLM) are on the upper right. The patient's head (not seen) is at the bottom. ICD-10-PCS ICD-9-CM MeSH MedlinePlus 021209W 36.1 [1] [2]

D001026 002946

[3]

Coronary artery bypass surgery, also coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery.

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Terminology
There are many variations on terminology, in which one or more of "artery", "bypass" or "graft" is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'),[4] pluralized as CABGs (pronounced 'cabbages'). More recentlyWikipedia:Manual of Style/Dates and numbers#Chronological items the term aortocoronary bypass (ACB) has come into popular use. CAGS (Coronary Artery Graft Surgery, pronounced phonetically) should not be confused with coronary angiography (CAG). Arteriosclerosis is a common arterial disorder characterized by thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply. Atherosclerosis is a common arterial disorder characterized by yellowish plaques of cholesterol, lipids, and cellular debris in the inner layer of the walls of large and medium-sized arteries.

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system.

Number of bypasses
The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g. LAD, RCA, left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) while quintuple means five. Bypass of more than four coronary arteries is uncommon. A greater number of bypasses does not imply a person is "more sick", nor does a lesser number imply a person is "healthier."[5] A person with a large amount of coronary artery disease (CAD) may receive fewer bypass grafts owing to the lack of suitable "target" vessels. A coronary artery may be unsuitable for bypass grafting if it is small (< 1mm or < 1.5mm depending on surgeon preference), heavily calcified (meaning the artery does not have a section free of CAD) or intramyocardial (the coronary artery is located within the heart muscle rather than on the surface of the heart). Similarly, a person with a single stenosis ("narrowing") of the left main coronary artery requires only two bypasses (to the LAD and the LCX). However, a left main lesion places a person at the highest risk for death from a cardiac cause.[citation needed] The surgeon reviews the coronary angiogram prior to surgery and identifies the lesions (or "blockages") in the coronary arteries. The surgeon will estimate the number of bypass grafts prior to surgery, but the final decision is made in the operating room upon examination of the heart.

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Indications
Several alternative treatments for coronary artery disease exist. They include: Medical management (anti-anginal medications plus statins, antihypertensives, smoking cessation, tight blood sugar control in diabetics) Percutaneous coronary intervention (PCI) Both PCI and CABG are more effective than medical management at relieving symptoms,[] (e.g. angina, dyspnea, fatigue). CABG is superior to PCI for some patients with multivessel CAD[][] The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel coronary disease.[] The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the DES group (17.8% versus 12.4% for CABG; P=0.002).[] This was primarily driven by higher need for repeat revascularization procedures in the PCI group with no difference in repeat infarctions or survival. Higher rates of strokes were seen in the CABG group. The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes MellitusOptimal Management of Multivessel Disease) trial will compare CABG and DES in patients with diabetes. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.[6] A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization.[] The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization. The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:[] Disease of the left main coronary artery (LMCA). Disease of all three coronary vessels (LAD, LCX and RCA). Diffuse disease not amenable to treatment with a PCI. The 2005 ACC/AHA guidelines further state: CABG is the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.[]

Prognosis
Prognosis following CABG depends on a variety of factors, and successful grafts typically last 815 years. In general, CABG improves the chances of survival of patients who are at high risk (generally triple or higher bypass), though statistically after about five years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases doing better, while older patients can usually be expected to suffer further blockage of the coronary arteries.[citation needed]

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Controversy
The value of coronary artery bypass surgery in rescuing someone having a heart attack (by immediately alleviating an obstruction) is clearly defined in multiple studies, but studies have failed to find benefit for bypass surgery vs. medical therapy in stable angina patients. The artery bypass can temporarily alleviate chest pain, but does not increase longevity. The "vast majority of heart attacks do not originate with obstructions that narrow arteries".[7] Loss of mental function is a complication of bypass surgery in elderly people, and might influence procedure cost benefit considerations.[] Several factors may contribute to immediate cognitive decline. The heart-lung blood circulation system and the surgery itself release a variety of debris, including bits of blood cells, tubing, and plaques. For example, when surgeons clamp and connect the aorta to tubing, resulting emboli block blood flow and cause mini strokes. Other heart surgery factors related to mental damage may be events of hypoxia, high or low body temperature, abnormal blood pressure, irregular heart rhythms, and fever after surgery.[8] A safer and more permanent and successful way to prevent heart attacks in patients at high risk is to exercise, give up smoking, take "drugs to get blood pressure under control and drive cholesterol levels down to prevent blood clotting".[7] Longer term, behavioral and medication treatment may be the only way to avoid vascular related loss of mental function.[9]

Procedure (simplified)
1. The patient is brought to the operating room and moved on to the operating table. 2. An anaesthetist places a variety of intravenous lines and injects a painkilling agent (usually fentanyl) followed within minutes by an induction agent (usually propofol) to render the patient unconscious. 3. An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol. 4. The chest is opened via a median sternotomy and the heart is examined by the surgeon.
Illustration of a typical coronary artery bypass surgery. A vein from the leg is removed and grafted to the coronary artery to bypass a [10] blockage. See full animation .

5. The bypass grafts are harvested frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting.

6. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart. 7. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia (a special potassium-mixture, cooled) to stop the heart and slow its metabolism. Usually the patient's machine-circulated blood is cooled to around 84 F (29C) 8. One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta.

Coronary artery bypass surgery 9. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. 10. Protamine is given to reverse the effects of heparin. 11. Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs. 12. The sternum is wired together and the incisions are sutured closed. 13. The patient is moved to the intensive care unit (ICU) to recover. 14. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, complications such as cardiac tamponade, pneumothorax or death can ensue. Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented.
Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.

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15. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

Minimally invasive CABG


Alternate methods of minimally invasive coronary artery bypass surgery have been developed. Off-pump coronary artery bypass (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine).[11] Further refinements to OPCAB have resulted in minimally invasive direct coronary artery bypass surgery (MIDCAB), a technique of performing bypass surgery through a 5 to 10cm incision.[12]

Conduits used for bypass


The choice of conduits is highly dependent upon the particular surgeon and institution. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries. The right internal thoracic artery (RITA), the great saphenous vein from the leg and the radial artery from the forearm are frequently used; in the U.S., these vessels are usually harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen.

Heart bypass patient with almost invisible residual scarring

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Graft patency
Grafts can become diseased and may occlude in the months to years after bypass surgery is performed. Patency is the chance that a graft remains open. A graft is considered patent if there is flow through the graft without any significant (>70% diameter) stenosis in the graft. Graft patency is dependent on a number of factors, including the type of graft used (internal thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure. Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous veins and may go into spasm if handled improperly. Generally the best patency rates are achieved with the in-situ left internal thoracic artery (the proximal end is left connected to the subclavian artery) with the distal end being anastomosed with the coronary artery (typically the left anterior descending artery or a diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and "free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised from its origin from the subclavian artery and re-anastomosed with the ascending aorta). Saphenous vein grafts have worse patency rates, but are more available, as the patients can have multiple segments of the saphenous vein used to bypass different arteries. Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.[13][14]

Sternal precautions
Patients undergoing coronary artery bypass surgery will have to avoid certain things for eight to 12 weeks to reduce the risk of opening the incision. These are called sternal precautions. First, patients need to avoid using their arms excessively, such as pushing themselves out of a chair or reaching back before sitting down. To avoid this, patients are encouraged to build up momentum by rocking several times in their chair before standing up. Second, patients should avoid lifting anything in excess of 510 pounds. A gallon (U.S.) of milk weighs approximately 8.5 pounds, and is a good reference point for weight limitations. Finally, patients should avoid overhead activities with their hands, such as reaching for sweaters from the top shelf of a closet or reaching for plates or cups from the cupboard.

Complications
People undergoing coronary artery bypass are at risk for the same complications as any surgery, plus some risks more common with or unique to CABG.

CABG associated
Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). However, a 2009 research study suggests that longer term (over 5 years) cognitive decline is not caused by CABG but is rather a consequence of vascular disease.[15] Nonunion of the sternum; internal thoracic artery harvesting devascularizes the sternum increasing risk.[16] Myocardial infarction due to embolism, hypoperfusion, or graft failure. Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction.[17]

Coronary artery bypass surgery Acute renal failure due to embolism or hypoperfusion.[18][] Stroke, secondary to embolism or hypoperfusion.[19] Vasoplegic syndrome, secondary to cardiopulmonary bypass and hypothermia Grafts last 8 15 years, and then need to be replaced. Pneumothorax: An air collection around the lung that compresses the lung[] Hemothorax: Blood in the space around the lungs Pericardial tamponade: Blood collection around the heart that compresses the heart and causes poor body and brain perfusion. Chest tubes are placed around the heart and lung to prevent this. If the chest tubes become clogged in the early post operative period when bleeding is ongoing this can lead to Pericardial tamponade, pneumothorax or hemothorax. Pleural effusion: Fluid in the space around the lungs. This can lead to hypoxia which can slow recovery.

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General cardiac surgery


Post-operative atrial fibrillation: An arrhythmia that sometimes occurs after cardiac surgery.[20]

General surgical
Infection at incision sites or sepsis. Deep vein thrombosis (DVT) Anesthetic complications such as malignant hyperthermia. Keloid scarring Chronic pain at incision sites Chronic stress related illnesses Death

Follow up
Patients who have a coronary artery bypass surgery need regular monitoring from a physician. Among the changes in monitoring are five years after the surgery the addition of a regular cardiac stress test even when there is no change in the patient's status.[][]

History
The first coronary artery bypass surgery was performed in the United States on May 2, 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center by a team led by Dr. Robert Goetz and the thoracic surgeon, Dr. Michael Rohman with the assistance of Dr. Jordan Haller and Dr. Ronald Dee.[21][22] In this technique the vessels are held together with circumferential ligatures over an inserted metal ring. The internal mammary artery was used as the donor vessel and was anastomosed to the right coronary artery. The actual anastomosis with the Rosenbach ring took fifteen seconds and did not require cardiopulmonary bypass. The disadvantage of using the internal mammary artery was that, at autopsy nine months later, the anastomosis was open, but an atheromatous plaque had occluded the origin of the internal mammary that was used for the bypass.[citation needed] Wikipedia:Verifiability Russian cardiac surgeon, Dr. Vasilii Kolesov, performed the first successful internal mammary arterycoronary artery anastomosis in 1964.[23][] However, Goetz's has been cited by others, including Kolesov,[24] as the first successful human coronary artery bypass.[25][26][27][28][29][30][31] Goetz's case has frequently been overlooked. Confusion has persisted for over 40 years and seems to be due to the absence of a full report and to misunderstanding about the type of anastomosis that was created. The anastomosis was intima-to-intima, with the vessels held together with circumferential ligatures over

Coronary artery bypass surgery a specially designed metal ring. Kolesov did the first successful coronary bypass using a standard suture technique in 1964, and over the next five years he performed 33 sutured and mechanically stapled anastomoses in St. Petersburg, Russia.[32][33] Dr. Ren Favaloro, an Argentine surgeon, achieved a physiologic approach in the surgical management of coronary artery diseasethe bypass grafting procedureat the Cleveland Clinic in May 1967.[][34] His new technique used a saphenous vein autograft to replace a stenotic segment of the right coronary artery. Later, he successfully used the saphenous vein as a bypassing channel, which has become the typical bypass graft technique we know today; in the U.S., this vessel is typically harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH). Soon Dr. Dudley Johnson extended the bypass to include left coronary arterial systems.[] In 1968, Doctors Charles Bailey, Teruo Hirose and George Green used the internal mammary artery instead of the saphenous vein for the grafting.[]

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References
[1] [2] [3] [7] http:/ / icd9cm. chrisendres. com/ index. php?srchtype=procs& srchtext=36. 1& Submit=Search& action=search http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D001026 http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 002946. htm Kolata, Gina. "New Heart Studies Question the Value Of Opening Arteries" (http:/ / www. nytimes. com/ 2004/ 03/ 21/ us/ new-heart-studies-question-the-value-of-opening-arteries. html) The New York Times, March 21, 2004. Retrieved January 14, 2011.

[8] Stutz, Bruce "Pumphead: Does the heart-lung machine have a dark side?" (http:/ / www. scientificamerican. com/ article. cfm?id=pumphead-heart-lung-machine) Scientific American, January 9, 2009. [9] Harmon, Katherine "Heart-Lung Machine May Not Be the Culprit in Post-Op "Pump Head" Syndrome" Scientific American August 6, 2009. (http:/ / www. scientificamerican. com/ article. cfm?id=disease-may-cause-pumphead) [10] http:/ / blausen. com/ index-wiki. php?word=Heart+ Bypass+ Surgery

External links
A BBC film showing a patient undergoing a double bypass operation. (http://www.bbc.co.uk/tees/content/ articles/2008/11/21/jeffrey_bypass_feature.shtml) Ischemic Heart Disease (http://cardiacsurgery.ctsnetbooks.org/current. shtml#PART_III__ISCHEMIC_HEART_DISEASE) section in Cardiac Surgey in the Adult Coronary Artery Bypass Surgery at NYU Langone Medical Center's Cardiac and Vascular Institute (http:// cardiac-surgery.med.nyu.edu/coronary-artery-disease-treatment) Cleveland Clinic page on coronary artery bypass surgery (http://my.clevelandclinic.org/heart/disorders/cad/ treatment_heartsurg.aspx)

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Coronary artery disease


Coronary artery disease
Classification and external resources

Micrograph of a coronary artery with the most common form of coronary artery disease (atherosclerosis) and marked luminal narrowing. Masson's trichrome. ICD-10 ICD-9 MedlinePlus eMedicine MeSH I20 410 [1] -I25 [2] [4] , 429.2 [5]

[3]

-414 [6]

007115

radio/192 D003324

[7] [8]

Coronary artery disease (CAD; also atherosclerotic heart disease) is the most common type of heart disease and cause of heart attacks.[9] The disease is caused by plaque building up along the inner walls of the arteries of the heart, which narrows the arteries and restricts blood flow to the heart. It is the leading cause of death worldwide.[9] While the symptoms and signs of coronary artery disease are noted in the advanced state of disease, most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms, often a "sudden" heart attack, finally arises. After decades of progression, some of these atheromatous plaques may rupture and (along with the activation of the blood clotting system) start limiting blood flow to the heart muscle. The disease is the most common cause of sudden death,[10] and is also the most common reason for death of men and women over 20 years of age.[11] According to present trends in the United States, half of healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old women.[12] According to the Guinness Book of Records, Northern Ireland is the country with the most occurrences of CAD. By contrast, the Maasai of Africa have almost no heart disease. As the degree of coronary artery disease progresses, there may be near-complete obstruction of the lumen of the coronary artery, severely restricting the flow of oxygen-carrying blood to the myocardium. Individuals with this degree of coronary artery disease typically have suffered from one or more myocardial infarctions (heart attacks), and may have signs and symptoms of chronic coronary ischemia, including symptoms of angina at rest and flash pulmonary edema. A distinction should be made between myocardial ischemia and myocardial infarction. Ischemia means that the amount of blood supplied to the tissue is inadequate to supply the needs of the tissue. When the myocardium becomes ischemic, it does not function optimally. When large areas of the myocardium becomes ischemic, there can

Coronary artery disease be impairment in the relaxation and contraction of the myocardium. If the blood flow to the tissue is improved, myocardial ischemia can be reversed. Infarction means that the tissue has undergone irreversible death due to lack of sufficient oxygen-rich blood. An individual may develop a rupture of an atheromatous plaque at any stage of the spectrum of coronary artery disease. The acute rupture of a plaque may lead to an acute myocardial infarction (heart attack).

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Pathophysiology
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen and this is called a myocardial infarction (commonly called a heart attack). It leads to heart muscle damage, heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into ventricular fibrillation leading to death. CAD is associated with smoking, diabetes, and hypertension. A number of recent studies have shown that family history of early CAD is an important predictor of CAD. Most of the familial association of coronary artery disease may be related to common dietary habits. Screening for CAD includes evaluating high-density and low-density lipoprotein (cholesterol) levels and triglyceride levels. Despite much press, most of the alternative risk factors including homocysteine, C-reactive protein (CRP), Lipoprotein (a), coronary calcium and more sophisticated lipid analysis have added little if any additional value to the conventional risk factors of smoking, diabetes and hypertension.

Angina
Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries. The symptoms of angina are often treated with betablocker therapy such as metoprolol or atenolol. Nitrate preparations such as nitroglycerin, which come in short-acting and long-acting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed. Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It may be treated with oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done.

Characteristics of coronary artery disease


Special pathophysiology
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and swollen with all sorts of "grunge" - including calcium deposits, fatty deposits, and abnormal inflammatory cells - to form a plaque. Deposits of calcium phosphates (hydroxyapatites) in the muscular layer of the blood vessels appear to play not only a significant role in stiffening arteries but also for the induction of an early phase of coronary arteriosclerosis. This can be seen in a so-called metastatic mechanism of calcification as it occurs in chronic kidney disease and haemodialysis (Rainer Liedtke 2008). Although these patients suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. Patients with coronary artery disease might have just one or two plaques, or might have dozens distributed throughout their

Coronary artery disease coronary arteries. However, there is a term in medicine called Cardiac Syndrome X, which describes chest pain (Angina pectoris) and chest discomfort in people who do not show signs of blockages in the larger coronary arteries of their hearts when an angiogram (coronary angiogram) is being performed.[13] No one knows exactly what causes Cardiac Syndrome X and it is unlikely to have a single cause. Today, we speculate that the major contributing factor to Cardiac Syndrome X is microvascular dysfunction.Wikipedia:Avoid weasel words The term microvascular refers to very small blood vessels and, in this case, very small arteries (arterioles, capillaries) of the heart. Studies have also shown that people with Cardiac Syndrome X have enhanced pain perception, meaning they feel chest pain more intensely than the average person. The large majority of women have the garden variety of coronary artery disease. Rarely, women with Cardiac Syndrome X have typical anginal syndromes that are not associated with the presence of atherosclerotic plaques; that is, the localized blockages are absent. Scientists speculate that the blood vessels in these women are diffuse abnormal. Some have falsely claim that the entire lining of the artery becomes thickened throughout, making the plaques flush with the wall of the artery without any scientific proof. On cardiac catheterization their coronary arteries appear smooth-walled and normal, though they may look "small" in diameter. By the way: in general, female coronary arteries (like all arteries) are somewhat smaller than in males. Cardiac Syndrome X have never been shown to cause acute heart attacks (myocardial infarction) despite much speculation. The prognosis with syndrome-X coronary artery disease is also known to be better than with typical coronary artery disease, but this is not a benign condition since it can be quite disabling. It is not completely clear why women are more likely than men to suffer from "Syndrome X"; however, hormones and other risk factors unique to women may play a role.[14] Womens blood vessels are exposed to changing levels of estrogen throughout their lives, first during regular menstrual cycles and later during and after menopause as estrogen levels decline with age. estrogen affects how blood vessels narrow and widen and how they respond to injury, so changes in estrogen levels mean changes in the reactivity of the blood vessels. Womens vessels may be programmed for more changes than mens vessels, which could increase the risk of having problems in the lining of the arteries (endothelial cells) and the smooth muscle cells in the walls of the arteries. The endothelial dysfunction is likely to be multifactorial in these patients and it is conceivable that risk factors such as hypertension, hypercholesterolemia, diabetes mellitus and smoking can contribute to its development. Most patients with Syndrome X are postmenopausal women and estrogen deficiency has been therefore proposed as a pathogenic factor in female patients. In addition to changing hormone levels, there are several other risk conditions for blood vessel problems that are unique to women, such as preeclampsia (a problem associated with high blood pressure during pregnancy) and delivering a low-birth weight baby. Of course, despite these issues women, the female gender as a whole is protective against coronary artery disease.

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Coronary angiogram of a man

Coronary angiogram of a woman

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Symptoms
Cardiac Syndrome X often is a diagnosis of exclusion where the presence of typical chest pains is not accompanied by coronary artery narrowings on angiography. In considering Syndrome-X, it is important to understand that about 80% of chest pains have nothing to do with the heart. Therefore, the characteristics of typical chest pains must be carefully documented to avoid unnecessary labelling patients with heart disease: Chest pain or Angina pectoris with physical stress; the pain may spread to the left arm or the neck, back, throat, or jaw. There might be present a numbness (paresthesia) or a loss of feeling in the arms, shoulders, or wrists Coronary angiography demonstrates normal coronary arteries, i.e. no blockages or stenoses can be detected in the larger epicardial vessels No inducible coronary artery spasm present during cardiac catheterization Characteristic ischemic ECG changes during exercise testing ST segment depression and angina in the presence of left ventricular wall perfusion abnormalities during thallium or other stress perfusion test Consistent response to sublingual nitrates. Postmenopausal or menopausal status The diagnosis of Cardiac Syndrome X - the rare coronary artery disease that is more common in women, as mentioned, an exclusion diagnosis. Therefore, usually the same tests are used as in any patient with the suspicion of coronary artery disease: Baseline electrocardiography (ECG) Exercise ECG Stress test Exercise radioisotope test (nuclear stress test, myocardial scintigraphy) Echocardiography (including stress echocardiography) Coronary angiography Intravascular ultrasound Magnetic resonance imaging (MRI)

Therapy
A variety of drugs are used in the attempt to treat the Syndrome-X coronary artery disease: nitrates, calcium channel antagonists, ACE-inhibitors, statins, imipramine (for analgesia), aminophylline, hormone replacement therapy (estrogen), even electrical spinal cord stimulation are tried to overcome the symptomatology -all with mixed results. Quite often the quality of life for these women remains poor. While not enough is known about Syndrome-X coronary artery disease to list specific prevention techniques, adopting heart-healthy habits can be a good start.[citation needed] These include monitoring cholesterol and blood pressure levels[citation needed], maintaining a low-fat diet[citation needed], exercising regularly[citation needed], quitting smoking, avoiding recreational drugs[citation needed], and moderating alcohol intake. However, there might be a new option for women suffering from Cardiac Syndrome X: Protein based Angiogenesis.[15] This new protein-based angiogenic therapy - using fibroblast growth factor 1 (FGF-1) - might be used as sole therapy as well as adjunct to bypass surgery thus overcoming the limitations of conventional bypass surgery.

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Beyond drug therapy, interventional procedures, and coronary artery bypass grafting, angiogenesis now offers a new, specific and so far as we know from three human clinical trials effective treatment targeted for womens coronary artery disease.[16]

Risk factors
The following are confirmed independent risk factors for the development of CAD: 1. Hypercholesterolemia (specifically, serum LDL concentrations)[]
Neo-angiogenesis in a woman's heart after FGF-1 treatment

2. Smoking[] 3. Hypertension (high systolic pressure seems to be most significant in this regard)[] 4. Hyperglycemia (due to diabetes mellitus or otherwise)[citation needed] 5. Type A Behavioural Patterns, TABP. Added in 1981 as an independent risk factor after a majority of research into the field discovered that TABP's were twice as likely to exhibit CAD as any other personality type.[citation
needed]

6. Hemostatic Factors:[17] High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD. Factor VII levels are higher in individuals with a high intake of dietary fat[citation needed]. Decreased fibrinolytic activity has been reported in patients with coronary atherosclerosis. 7. Hereditary differences/genetic polymorphisms in such diverse aspects as lipoprotein structure and that of their associated receptors, enzymes of lipoprotein metabolism such as cholesteryl ester transfer protein (CETP) and hepatic lipase (HL),[] homocysteine processing/metabolism, etc.[citation needed] 8. High levels of Lipoprotein(a),[][][] a compound formed when LDL cholesterol combines with a substance known as Apoliprotein (a). Significant, but indirect risk factors include: Lack of exercise Consumption of alcohol Stress Diet rich in saturated fats[citation needed] Diet low in antioxidants Obesity[] Men over 60; Women over 65[18] Low hemoglobin[19]

Risk factors can be classified as 1. Fixed: age, sex, family history 2. Modifiable: smoking, hypertension, diabetes mellitus, obesity, etc. There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on different variables above. A notable example is Framingham Score, used in the Framingham Heart Study. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking and systolic blood pressure.[20]

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Prevention
Coronary artery disease is the most common form of heart disease in the Western world. Prevention centers on the modifiable risk factors, which include decreasing cholesterol levels, addressing obesity and hypertension, avoiding a sedentary lifestyle, making healthy dietary choices, and stopping smoking. There is some evidence that lowering homocysteine levels may contribute to more heart attacks (NORVIT trial). In diabetes mellitus, there is little evidence that very tight blood sugar control actually improves cardiac risk although improved sugar control appears to decrease other undesirable problems like kidney failure and blindness. Some recommend a diet rich in omega-3 fatty acids and vitamin C. The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary artery disease although this remains without scientific cause and effect proof.[21] An increasingly growing number of other physiological markers and homeostatic mechanisms are currently under scientific investigation. Patients with CAD and those trying to prevent CAD are advised to avoid fats that are readily oxidized (e.g., trans-fats), limit carbohydrates and processed sugars to reduce production of Low density lipoproteins (LDLs), triacylglycerol and apolipoprotein-B.[][][][][] It is also important to keep blood pressure normal, exercise and stop smoking. These measures reduce the development of heart attacks. Recent studies have shown that dramatic reduction in LDL levels can cause regression of coronary artery disease in as many as 2/3 of patients after just one year of sustained treatment. Menaquinone (Vitamin K2), but not phylloquinone (Vitamin K1), intake is associated with reduced risk of CAD mortality, all-cause mortality and severe aortic calcification.[22][23][24] CAD has always been a tough disease to diagnose without the use of invasive or stressful activities. The development of the Multifunction Cardiogram (MCG) has changed the way CAD is diagnosed. The MCG consists of a 2 lead resting EKG signal is transformed into a mathematical model and compared against tens of thousands of clinical trials to diagnose a patient with an objective severity score, as well as secondary and tertiary results about the patients condition. The results from MCG tests have been validated in 8 clinical trials which resulted in a database of over 50,000 patients where the system has demonstrated accuracy comparable to coronary angiography (90% overall sensitivity, 85% specificity). This level of accuracy comes from the application of advanced techniques in signal processing and systems analysis combined with a large scale clinical database which allows MCG to provide quantitative, evidence-based results to assist physicians in reaching a diagnosis. The MCG has also been awarded a Category III CPT code by the American Medical Association in the July 2009 CPT update.

Exercise
In patients with coronary artery disease, aerobic exercise can reduce the risk of mortality. Moreover, exercise is associated with lowering blood lipids and inflammatory markers, including C-reactive protein and fibrinogen,[25] which have been associated with risk of mortality and poorer prognoses. Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force (USPSTF) [26], based on a systematic review of randomized controlled trials, found 'insufficient evidence' to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", it only examined the effectiveness of the counseling itself.[] However, the American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.[27]

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Preventive diets
It has been suggested that coronary artery disease is partially reversible using an intense dietary regimen coupled with regular cardio exercise.[] Vegetarian diet: Vegetarians have been shown to have a 24% reduced risk of dying of heart disease.[] Cretan Mediterranean diet: The Seven Countries Study found that Cretan men had exceptionally low death rates from heart disease, despite moderate to high intake of fat. The Cretan diet is similar to other traditional Mediterranean diets: consisting mostly of olive oil, bread, abundant fruit and vegetables, a moderate amount of wine and fat-rich animal products such as lamb, and goat cheese.[][28][] However, the Cretan diet consisted of less fish and wine consumption than some other Mediterranean-style diets, such as the diet in Corfu, another region of Greece, which had higher death rates.[citation needed] The consumption of trans fat (commonly found in hydrogenated products such as margarine) has been shown to cause the development of endothelial dysfunction, a precursor to atherosclerosis.[] The consumption of trans fatty acids has been shown to increase the risk of coronary artery disease[29] Foods containing fiber, potassium, nitric oxide (in green leafy vegetables), monounsaturated fat, polyunsaturated fat, saponins, or lecithin are said to lower cholesterol levels. Foods high in grease, salt, trans fat, or saturated fat are said to raise cholesterol levels.

Aspirin
Aspirin, in doses of less than 75 to 81mg/d,[] can reduce the incidence of cardiovascular events.[] The U.S. Preventive Services Task Force [26] 'strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary artery disease'.[] The Task Force defines increased risk as 'Men older than 90 years of age, postmenopausal women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy'. More specifically, high-risk persons are 'those with a 5-year risk 3%'.[citation needed] Regarding healthy women, the more recent Women's Health Study randomized controlled trial found insignificant benefit from aspirin in the reduction of cardiac events; however there was a significant reduction in stroke.[] Subgroup analysis showed that all benefit was confined to women over 65 years old.[] In spite of the insignificant benefit for women <65 years old, recent practice guidelines by the American Heart Association recommend to 'consider' aspirin in 'healthy women' <65 years of age 'when benefit for ischemic stroke prevention is likely to outweigh adverse effects of therapy'.[30]

Omega-3 fatty acids


The benefit of fish oil is controversial with conflicting conclusions reached by a negative meta-analysis on studies using traditional omega-3 products[] of randomized controlled trials by the international Cochrane Collaboration and a partially positive systematic review[31] by the Agency for Healthcare Research and Quality. Since these two reviews, a randomized controlled trial reported a remarkable reduction on coronary events in Japanese hypercholesterolemic patients,[] and a later subanalysis suggested that the protective effect of highly purified EPA (E-EPA) is even more pronounced in Japanese diabetics even though their intake of fish is high.[32] Omega-3 fatty acids are also found in some plant sources including flax seed oil, hemp seed oil, and walnuts. The parent Omega-3 ALA, while very important for general health, needs to be converted in the liver to EPA and only 5% is converted, making the benefits unclear for coronary artery disease specifically.

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Secondary prevention
Secondary prevention is preventing further sequelae of already established disease. Regarding coronary artery disease, this can mean risk factor management that is carried out during cardiac rehabilitation, a 4-phase process beginning in hospital after MI, angioplasty or heart surgery and continuing for a minimum of three months. Exercise is a main component of cardiac rehabilitation along with diet, smoking cessation, and blood pressure and cholesterol management. Beta blockers may also be used for this purpose.[33]

Anti-platelet therapy
A meta-analysis of randomized controlled trials by the international Cochrane Collaboration found "that the use of clopidogrel plus aspirin is associated with a reduction in the risk of cardiovascular events compared with aspirin alone in patients with acute non-ST coronary syndrome. In patients at high risk of cardiovascular disease but not presenting acutely, there is only weak evidence of benefit and hazards of treatment almost match any benefit obtained.".[]

Principles of treatment
Therapeutic options for coronary artery disease[34] today are based on three principles: 1. Medical treatment - drugs (e.g. cholesterol lowering medications, beta-blockers, nitroglycerin, calcium antagonists, etc.); 2. Coronary interventions as angioplasty and coronary stent-implantation; 3. Coronary artery bypass grafting (CABG - coronary artery bypass surgery). Recent research efforts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem cell therapies.

Recent research
A 2006 study by the Cleveland Clinic found a region on Chromosome 17 was confined to families with multiple cases of myocardial infarction.[] A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis.[] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.[citation needed] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.[] Since the 1990s the search for new treatment options for coronary artery disease patients, particularly for so called "no-option" coronary patients, focused on usage of angiogenesis[35] and (adult) stem cell therapies. Numerous clinical trials were performed, either applying protein (angiogenic growth factor) therapies, such as FGF-1 or VEGF, or cell therapies using different kinds of adult stem cell populations. Research is still going on - with first promising results particularly for FGF-1[36][37] and utilization of endothelial progenitor cells.

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References
[1] [2] [3] [4] [5] [6] [7] [8] [9] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I20 http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ I25 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=410 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=414 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=429. 2 http:/ / www. nlm. nih. gov/ medlineplus/ ency/ article/ 007115. htm http:/ / www. emedicine. com/ radio/ topic192. htm http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2013/ MB_cgi?field=uid& term=D003324 Heart attack/coronary artery disease (http:/ / www. mountsinai. org/ patient-care/ service-areas/ heart/ areas-of-care/ heart-attack-coronary-artery-disease) - Mount Sinai Hospital, New York [11] American Heart Association: Heart Disease and Stroke Statistics (http:/ / www. americanheart. org/ presenter. jhtml?identifier=3000090)-2007 Update. AHA, Dallas, Texas, 2007 [15] Stegmann, T.J.: New Vessels for the Heart. Angiogenesis as New Treatment for Coronary Heart Disease: The Story of its Discovery and Development. Henderson, Nevada 89012, USA, 2004. ISBN 0-9765583-0-0 [16] Stegmann, T.J.: Protein promise in heart disease. GCPj, March 2007, 21-24 [19] Padmanaban P, Toora BD. Hemoglobin: Emerging marker in stable coronary artery disease. Chron Young Sci [serial online] 2011 [cited 2011 Jul 24];2:109-10. Available from: http:/ / www. cysonline. org/ text. asp?2011/ 2/ 2/ 109/ 82971 [20] framinghamheartstudy.org > Coronary Heart Disease (10-year risk) (http:/ / www. framinghamheartstudy. org/ risk/ coronary. html) (based on Wilson, D'Agostino, Levy et al. 'Prediction of Coronary Heart Disease using Risk Factor Categories', Circulation 1998) [26] http:/ / www. ahrq. gov/ clinic/ uspstfix. htm [27] Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Major Recommendations (http:/ / www. ngc. gov/ summary/ summary. aspx?ss=15& doc_id=5360& string=#s23) [28] Perez-Llamas, F., et al., J Hum Nutr Diet, December 1996, 9:6:463-471 [31] AHRQ Evidence reports and summaries 94. Effects of Omega-3 Fatty Acids on Cardiovascular Disease (http:/ / www. ncbi. nlm. nih. gov/ books/ bv. fcgi?rid=hstat1a. chapter. 38290) [37] Wagoner, L.E., Merrill, W., Jacobs, J., Conway, G., Boehmer, J., Thomas, K., Stegmann, T.J.: Angiogenesis Protein Therapy With Human Fibroblast Growth Factor (FGF-1): Results of a Phase I Open Label, Dose Escalation Study in Subjects With CAD Not Eligible For PCI Or CABG. Circulation 116: 443, 2007

External links
Risk Assessment of having a heart attack or dying of coronary artery disease (http://www.heart.org/ HEARTORG/Conditions/HeartAttack/HeartAttackToolsResources/ Heart-Attack-Risk-Assessment_UCM_303944_Article.jsp), from the American Heart Association. Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (http://hp2010.nhlbihin.net/ atpiii/CALCULATOR.asp?usertype=prof) using Framingham score The InVision Guide to a Healthy Heart (http://www.invisionguide.com/heart) An interactive website on the development and function of the cardiovascular system and cardiovascular diseases and consequences. The website also features treatment options and preventative measures for maintaining a healthy heart. A Mechanism of a Metabolic Induction of Coronary Artery Disease in Chronic Kidney Disease (http://www. rkliedtke.de/Coronary_Artery_Disease_us.html), Rainer K. Liedtke, MD

Consumer Assessment of Healthcare Providers and Systems

293

Consumer Assessment of Healthcare Providers and Systems


Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a series of patient surveys rating health care experiences in the United States.[1] The surveys, conducted annually since 1995, are available in the public domain and focus on healthcare quality aspects that patients find important and are well equipped to assess.[][2] Results are used by Medicare in determining Diagnostic Related Group payment for each hospital.[3] CAHPS surveys are funded and overseen by the Agency for Healthcare Research and Quality (AHRQ), a government organization. The AHRQ does not administer the surveys. Surveys must be administered by a qualified vendor.

References
[2] South Dakota Association of Healthcare Organizations, on CAHPS, retrieved 5-10-12 (http:/ / www. sdaho. org/ index. php?option=com_content& task=view& id=370& Itemid=309) [3] "15 HCAHPS Buzzwords Every Provider Should Know", Cheryl Clark, Health Leaders Media, July 11, 2011. retrieved 5-10-2012 (http:/ / www. healthleadersmedia. com/ page-1/ PHY-268393/ 15-HCAHPS-Buzzwords-Every-Provider-Should-Know)

Alternative medicine
Alternative medical systems Acupuncture Chiropractic Homeopathy Naturopathic medicine Osteopathy Traditional medicine Chinese Mongolian Tibetan Unani Siddha Ayurveda Previous NCCAM domains Whole medical systems Mind-body interventions Biologically based therapies Manipulative therapy Energy therapies

Alternative medicine

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Alternative medicine
Intervention MeSH D000529 [1]

Alternative medicine is any practice that is put forward as having the healing effects of medicine but is not based on evidence gathered using the scientific method.[2] It may consist of a wide range of health care practices, products and therapies, using alternative medical diagnoses and treatments which are not typically included in the degree courses of established medical schools teaching medicine and surgery or used in "conventional" medicine.[3] Examples of alternative medicine include homeopathy, naturopathy, chiropractic, and acupuncture. Complementary medicine is alternative medicine used together with conventional medical treatment in a belief, not proven by using scientific methods, that it "complements" the treatment.[4]</ref>[2][5][6] CAM is the abbreviation for Complementary and alternative medicine.[][] Integrative medicine (or integrative health) is the combination of the practices and methods of alternative medicine with evidence-based medicine.[] The term alternative medicine is used in information issued by public bodies in the United States of America[] and the United Kingdom.[] Regulation and licensing of alternative medicine and health care providers varies from country to country, and state to state.

Background
Terms and definitions
There is no coherent, consistent and widely accepted definition of alternative medicine.[7] Often referred to as complementary and alternative medicine, or simply as CAM,[8][9] alternative medicine resists easy definition because the health systems and practices to which it refers are diffuse and its boundaries are poorly defined.[10] Healthcare practices categorized as alternative may differ in their historical origin, theoretical basis, diagnostic technique, therapeutic practice and in their relationship to the medical mainstream.[11] Some Vials displayed in a glass case at a homeopathic alternative therapies, including traditional Chinese Medicine (TCM) pharmacy in Varanasi, India and Ayurveda, have antique, non-Western origins and are entirely alternate medical systems;[12] others, such as homeopathy and chiropractic, are native to the West and emerged in the eighteenth and nineteenth centuries.[] Some, such as osteopathy and chiropractic, employ manipulative physical methods of treatment; others, such as meditation and prayer, are based on mind-body interventions.[13] Treatments considered alternative in one location may be considered conventional in another.[] Thus, chiropractic is not considered alternative in Denmark and likewise osteopathy in the US is no longer thought of as an alternative therapy.[] One common feature of all definitions of alternative medicine is its designation as "other than" conventional medicine.[14] For example, the widely referenced [15][][16] descriptive definition of complementary and alternative medicine devised by the US National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), states that it is "a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine."[] This definition has been criticized as, if an alternative therapy, both effective and safe, is adopted by conventional medical practitioners, it does not necessarily follow that either it or its practitioners would no longer be considered alternative.[17] has argued: "Simply because an herbal remedy comes to be used by physicians does not mean that herbalists cease to practice, or that the

Alternative medicine practice of the one becomes like that of the other."[18]</ref> Some definitions seek to specify alternative medicine in terms of its social and political marginality to mainstream healthcare.[] This can refer to the lack of support that alternative therapies receive from the medical establishment and related bodies regarding access to research funding, sympathetic coverage in the medical press, or inclusion in the standard medical curriculum.[] In 1993, the British Medical Association (BMA), one among many professional organizations who have attempted to define alternative medicine, stated that it[19]</ref> referred to "those forms of treatment which are not widely used by the conventional healthcare professions, and the skills of which are not taught as part of the undergraduate curriculum of conventional medical and paramedical healthcare courses".[20] In a US context, an influential definition coined in 1993 by the Harvard-based physician,[] David M. Eisenberg,[21] characterized alternative medicine "as interventions neither taught widely in medical schools nor generally available in US hospitals".[22] These descriptive definitions are inadequate in the present-day when some conventional doctors offer alternative medical treatments and CAM introductory courses or modules can be offered as part of standard undergraduate medical training;[23] alternative medicine is taught in more than 50 per cent of US medical schools and increasingly US health insurers are willing to provide reimbursement for CAM therapies.[24] In 1999, 7.7% of US hospitals reported using some form of CAM therapy; this proportion had risen to 37.7% by 2008.[25]
Complementary and alternative medicine is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health or well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed. CAM Research Methodology Conference, April 1995.
[26]

295

An expert panel at a conference hosted in 1995 by the US Office for Alternative Medicine (OAM),[27] was renamed NCCAM in 1998.[28]</ref> devised a theoretical definition of alternative medicine as "a broad domain of healing resources... other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period."[26] This definition has been widely adopted by CAM researchers,[] official government bodies such as the UK Department of Health,[29] has often been attributed as the definition used by the Cochrane Collaboration,[30] and, with slight modification, was preferred in the 2005 consensus report of the Committee on the Use of Complementary and Alternative Medicine by the American Public Board on Health Promotion and Disease Prevention issued by the US Institute of Medicine of the National Academies.[31]</ref> The 1995 OAM conference definition, an expansion of Eisenberg's 1993 formulation, is silent regarding questions of the medical effectiveness of alternative therapies.[] Its proponents hold that it thus avoids relativism about differing forms of medical knowledge and, while it is an essentially political definition, this should not imply that the dominance of mainstream biomedicine is solely due to political forces.[] According to this definition, alternative and mainstream medicine can only be differentiated with reference to what is "intrinsic to the politically dominant health system of a particular society of culture".[] However, there is neither a reliable method to distinguish between cultures and subcultures, nor to attribute them as dominant or subordinate, nor any accepted criteria to determine the dominance of a cultural entity.[] If the culture of a politically dominant healthcare system is held to be equivalent to the perspectives of those charged with the medical management of leading healthcare institutions and programs, the definition fails to recognize the potential for division either within such an elite or between a healthcare elite and the wider population.[]
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. P.B. Fontanarosa, JAMA (1998).
[]

Normative definitions distinguish alternative medicine from the biomedical mainstream in its provision of therapies that are unproven, unvalidated or ineffective and support of theories which have no recognized scientific basis.[32] These definitions characterize practices as constituting alternative medicine when, used independently or in place of

Alternative medicine evidence-based medicine, they are put forward as having the healing effects of medicine, but which are not based on evidence gathered with the scientific method.[2][][][][] Exemplifying this perspective, a 1998 editorial co-authored by a former editor of the New England Journal of Medicine, Marcia Angell, argued that: It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments.[] This type of definition fails to adequately differentiate conventional from alternative medicine as, according to a review of Cochrane systematic reviews, approximately 20 per cent of standard medical procedures have no effect and an equal proportion had insufficient evidence to make a determination of efficacy.[33] "Complementary medicine" refers to use of alternative medicine alongside conventional science based medicine, in the belief that it increases the effectiveness.[][][] In Science and Technology: Public Attitudes and Public Understanding, chapter 7 of a report Science and Technology: Public Attitudes and Public Understanding, 2002, issued by a United States government agency (The National Science Foundation), it was stated that the term "alternative medicine" was there being used to refer to all treatments that had not been proven effective using scientific methods (NSF of SRS, of NSB, 2002).[2]

296

Regional definitions
The Danish Knowledge and Research Center for Alternative Medicine an independent institution under the Danish Ministry of the Interior and Health (Danish abbreviation: ViFAB) uses the term alternative medicine for: Treatments performed by therapists that are not authorized healthcare professionals, where authorized healthcare professionals are those practicing what is proven by science. Treatments performed by authorized healthcare professionals, but those based on methods otherwise used mainly outside the healthcare system, which is based on science in Denmark. People without a healthcare authorisation must be able to perform the treatments. Institutions In General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine, published in 2000 by the World Health Organization, complementary and alternative medicine were there defined as a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system.[2][34] Some herbal therapies are mainstream in Europe but are alternative in the United States.[] Special terminology used by selected individuals Two advocates of integrative medicine claim that it also addresses alleged problems with medicine based on science, which are not addressed by CAM; Ralph Snyderman and Andrew Weil state that "integrative medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."[]

Alternative medicine

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History - 19th century onwards


Dating from the 1970s, medical professionals, sociologists, anthropologists and other commentators noted the increasing visibility of a wide variety of health practices that had neither derived directly from nor been verified by biomedical science.[] Since that time, those who have analyzed this trend have deliberated over the most apt language with which to describe this emergent health field.[] A variety of terms have been used, including heterodox, irregular, fringe and alternative medicine while others, particularly medical commentators, have been satisfied to label them as instances of quackery.[] The most persistent term has been alternative medicine but its use is problematic as it assumes a value-laden dichotomy between a medical fringe, implicitly of borderline acceptability at best, and a privileged medical orthodoxy, associated with validated medico-scientific norms.[35] The use of the category of alternative medicine has also been criticized as it cannot be studied as an independent entity but must be understood in terms of a regionally and temporally specific medical orthodoxy.[36] Its use can also be misleading as it may erroneously imply that a real medical alternative exists.[] As with near-synonymous expressions, such as unorthodox, complementary, marginal, or quackery, these linguistic devices have served, in the context of processes of professionalisation and market competition, to establish the authority of official medicine and police the boundary between it and its unconventional rivals.[35] From a historical perspective, the emergence of alternative medicine, if not the term itself, is typically dated to the 19th century.[37] This is despite the fact that there are variants of Western non-conventional medicine that arose in the late-eighteenth century or earlier and some non-Western medical traditions, currently considered alternative in the West and elsewhere, which boast extended historical pedigrees.[35] Alternative medical systems, however, can only be said to exist when there is an identifiable, regularized and authoritative standard medical practice, such as arose in the West during the nineteenth-century, to which they can function as an alternative.[38] During the late eighteenth and nineteenth centuries regular and irregular medical practitioners became more clearly differentiated throughout much of Europe and,[39] as the nineteenth century progressed, most Western states converged in the creation of legally delimited and semi-protected medical markets.[40] It is at this point that an "official" medicine, created in cooperation with the state and employing a scientific rhetoric of legitimacy, emerges as a recognizable entity and that the concept of alternative medicine as a historical category becomes tenable.[] As part of this process, professional adherents of mainstream medicine in countries such as Germany, France, and Britain increasingly invoked the scientific basis of their discipline as a means of engendering internal professional unity and of external differentiation in the face of sustained market competition from homeopaths, naturopaths, mesmerists and other nonconventional medical practitioners, finally achieving a degree of imperfect dominance through alliance with the state and the passage of regulatory legislation.[35][] In the United States the Johns Hopkins University School of Medicine, based in Baltimore, Maryland, opened in 1893 and was the first medical school devoted to teaching "German scientific medicine".[41] Buttressed by the increased authority consequent to the significant advances in the medical sciences of the late 19th century onwards including the development and application of the germ theory of disease by the chemist