“…(WHO) reports the next seven to 10 days are critical in controlling the spread of the Ebola virus in eastern Democratic Republic of Congo.”

“A doctor in the Democratic Republic of Congo (DRC) has been hospitalised with the deadly Ebola virus after coming into contact with nearly 100 people…
The World Health Organization (WHO) said on Friday investigating the infection and its possible spread to 97 people in contact with the physician would be difficult because the area was entirely surrounded by rebels.”
“It is the first time we have a confirmed case and contacts in an area of high insecurity,” said Dr Peter Salama, WHO’s deputy director-general for emergency preparedness and response.
“It is really the problem we were anticipating and at same time dreading,” he told a news briefing.” (A)

““Really, in two weeks, we’ve gone from 24 cases to 105 cases,” … mainly because many health workers at a hospital in the town of Mangina, where the outbreak began, became infected when they treated early patients without recognizing that they had Ebola and therefore did not take adequate precautions….
So far, Redfield said, it is not necessary to test travelers at U.S. ports of entry, in part because there are no direct flights to the United States from the affected region and screening of outgoing travelers is being conducted. Four years ago, debate raged about whether to cut off all travel from West Africa to the United States. President Trump, then a private citizen, was an outspoken advocate of that position, tweeting that the United States should not allow two infected American missionaries back into the country for treatment.” (B)

“Military escorts are helping health workers quell an Ebola outbreak in eastern Democratic of Congo that’s killed 63 people in three weeks…
World Health Organization and Health Ministry workers are using escorts from the Congolese army and the United Nations peacekeeping force in areas of insecurity, said Michael Yao, a WHO spokesman. Other key partners, such as Doctors Without Borders and the International Federation of Red Cross & Red Crescent Societies, eschew the assistance to maintain their neutrality.” (C)

“Uganda has opened two Ebola treatment units in the border districts with the Democratic Republic of Congo, a World Health Organisation official said.
Yonas Woldemariam, WHO Representative in Uganda, told Xinhua that the two treatment units have been established in the western border districts of Kasese and Bundibugyo to respond to any deadly Ebola hemorrhagic fever alert case or outbreak.
He said the units are fully equipped and ready to manage any Ebola case in the east African country.
“Ebola Treatment Units are where patients can get the best care possible – with access to rehydration methods and protection from infecting their family and community,” said Woldemariam.
Although there is no confirmed Ebola case in Uganda, the country remains on high alert following an outbreak of the hemorrhagic fever in neighbouring DRC. “ (D)

“Congo has approved the use of four more experimental treatments in the Ebola virus outbreak in its northeast, as health officials try to contain the spread amid the threat from armed groups in the region.
The treatments ZMapp, Remdesivir, Favipiravir and Regn3450 – 3471 – 3479 can now can be used on those suffering from Ebola, the health ministry said Wednesday. On Tuesday, health officials administered Remdesivir, which is produced by Gilead Sciences, to a patient in Beni, the ministry said.
Health officials began using the mAb114 treatment on Aug. 11 on 10 patients and the ministry said they were doing well.” (E)

“Congo’s health ministry says two of the first 10 people to receive an experimental treatment for the Ebola virus in the latest outbreak have recovered, and monitoring could show what role the treatment played.
The head of the World Health Organization on Saturday congratulated Congo’s government for making several experimental treatments available in this Ebola outbreak, calling it “a global first, and a ray of hope for people with the disease.”
The two people received the mAb114 treatment isolated from a survivor of an Ebola outbreak in 1995. It was the first of five experimental treatments Congo approved for use in the outbreak that was declared on Aug. 1. The others are ZMapp, Remdesivir, Favipiravir and Regn3450 – 3471 – 3479.” (F)

Interim Guidance for Preparing Ebola Treatment Centers
Who this is for: State and local health departments and acute care hospitals designated as Ebola treatment centers.
What this is for: Guidance to assist state and local health departments and acute care hospitals as they develop preparedness plans to serve as Ebola treatment centers.
Key Points
1. Ebola treatment centers are prepared to provide comprehensive care to people diagnosed with Ebola virus disease (EVD) for the duration of a patient’s illness.
2. Designation as an Ebola treatment center will be a decision made between state and local health authorities and the hospital administration, informed by the results of a CDC site visit conducted by an interdisciplinary team of subject matter experts.
3. Decisions to receive a patient with EVD should be informed by discussions with public health authorities and referring physicians, depending on the status of the patient. (G)

“The UN Children’s Fund said more than 82,500 children are being prepared for the new school year in Ebola-affected areas of the Eastern Democratic Republic of the Congo .
UNICEF said it was scaling up education, health and water, sanitation and hygiene programmes to assist the schools to provide a protective learning environment for children and their teachers.” (H)

“Days after the Democratic Republic of the Congo declared an end to a deadly Ebola outbreak in the western province of Équateur, a new one emerged in North Kivu province. With the number of cases and death toll rising rapidly, the country’s ministry of health, the World Health Organization, and partners are working to launch a rapid and effective response that includes the use of an experimental vaccine. But their decision not to vaccinate women who are pregnant or lactating unfairly deprives them of the protection they deserve against this deadly disease….
Some contacts, though, won’t get the vaccine. Pregnant women and those who are lactating are being excluded from this life-saving intervention. From a public health perspective and an ethical perspective, the decision to exclude pregnant and lactating women is utterly indefensible.
There’s no question that evidence about the safety of the Ebola vaccine in pregnancy is limited. But what we don’t know is dwarfed by what we do know. We know that in previous outbreaks, up to 90 percent of pregnant women infected with Ebola died from it. We know that nearly 100 percent of the pregnancies of Ebola-infected women end in miscarriage or neonatal death. And we also know that pregnant and lactating women are more likely than many others in the population to be caring for sick relatives, and thus are among those most likely to be infected. Indeed, the most recent WHO situation report on Ebola in the DRC shows that a large proportion of the cases are among women of childbearing potential.” (I)

“The World Health Organization (WHO) reports the next seven to 10 days are critical in controlling the spread of the Ebola virus in eastern Democratic Republic of Congo. Its latest update reported 111 cases of Ebola, with 83 confirmed and 28 probable, including 75 deaths.
The WHO reports it is continuing to rapidly scale-up its response to the Ebola outbreak in North Kivu and Ituri provinces, including in Oicha, a town difficult to reach because of security concerns.
More than 100 armed groups are operating in these areas, putting some places, known as Red Zones, off limits because of the dangers. But, WHO spokesman Christian Lindmeier told VOA health workers have had access to all places they need to go with the help of MONUSCO, U.N. peacekeepers acting as escorts…
Lindmeier said the next week is critical in efforts to prevent Ebola from spreading to areas that cannot be reached.
“The quicker we can respond and in which we can get to people, to talk to them about how to protect themselves, how to prevent infection, how to deal with infected family members and loved ones, the better it is for any future control,” he said. “So, the earlier we get to any place where this outbreak could possibly reach, the better.”” (J)

(A) DRC: Doctor stricken with Ebola in rebel stronghold, https://www.aljazeera.com/news/2018/08/drc-doctor-stricken-ebola-rebel-stronghold-180824095226217.html
(B) Ebola outbreak now at 105 cases, and bordering countries are on alert, by Lena H. Sun and Lenny Bernstein, https://www.washingtonpost.com/national/health-science/ebola-outbreak-now-at-105-cases-and-bordering-countries-are-on-alert/2018/08/24/3b7a58a2-a7c2-11e8-a656-943eefab5daf_story.html?noredirect=on&utm_term=.53c97b919f02
(C) Military Escorts Back Ebola Response in Restive Congo Region, by William Clowes and Ignatius Ssuuna, https://www.bloomberg.com/news/articles/2018-08-23/military-escorts-back-ebola-response-in-restive-congo-region
(D) Uganda opens Ebola treatment units at border with DRC, https://punchng.com/uganda-opens-ebola-treatment-units-at-border-with-drc/
(E) Congo approves 4 experimental Ebola treatments in outbreak, by CARLEY PETESCH, https://abcnews.go.com/Health/wireStory/congo-approves-experimental-ebola-treatments-outbreak-57328608
(F) Two of first 10 people recover from Ebola outbreak in Congo after receiving experimental treatment, officials say, by Saleh Mwanamilongo, https://nationalpost.com/news/congo-2-who-received-experimental-ebola-treatment-recover
(G) Interim Guidance for Preparing Ebola Treatment Centers, https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/treatment-centers.html
(H) UNICEF prepares DRC school children for Ebola response, https://punchng.com/unicef-prepares-drc-school-children-for-ebola-response/amp/
(I) Pregnant and lactating women should be vaccinated in an Ebola outbreak , by Ruth Faden, Ruth Karron, and Carleigh Krubiner, https://www.statnews.com/2018/08/27/ebola-vaccine-pregnant-lactating-women/?utm_source=STAT+Newsletters&utm_campaign=9fa414a249-MR_COPY_12&utm_medium=email&utm_term=0_8cab1d7961-9fa414a249-149527969
(J) WHO: Rapid Response Needed to Stem Ebola Outbreak in DR Congo, https://www.voanews.com/a/who-rapid-response-needed-to-stem-ebola-outbreak-in-dr-congo/4547478.html

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QUICK CASE. Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

Health care disruption has become so complex that there are few, if any, up-to-date case studies. So I have been developing a method of “raw” contemporaneous cases studies (CCS) each prepared by curating news articles into a coherent thread, after a topic has called out to me. Topics come from navigating the system news feeds, and friends and family.
As health care transformation takes place on an ever steeper and faster trajectory “real time” QUICK CASES can play an increasing “rapid response” role in the classroom. Each QUICK CASE CCS ends with a “challenge” for immediate discussion, debate, a group project, and/or homework assignment.

My first experience with clinical turf competition was in 1968 as administrator of the Department of Surgery at Wilford Hall U.S.A.F. Medical Center. The Chiefs of general surgery, E.N.T., and Oral Maxillofacial Surgery each needed Head & Neck surgical cases for their residents. Time and time again protocols were agreed upon to rotate the cases but they always broke down when residents in one specialty or another needed the required number of H&N cases before they graduated. Interestingly I never recall that any of the Chiefs thought the patients had a role in the decision-making.

Several months ago my GI physician ordered a “rule out” MRI. On my next visit my doctor clicked on the images and went over them with me; it was clear he had gone down to the radiology suite and gone over the “films” with the radiologist. In fact since the senior MRI radiologist was on vacation, he reviewed the images with him too when he returned.
While I did get copies of the MRI reports, I never spoke directly to the radiologist. No one usually does, perhaps with the exception of women talking to their breast radiologist.

Fast forward to another MRI and x-rays for chronic back pain. In each case I asked to meet the radiologist and in both cases the radiologist went over the images with me, before I went back to the referring physiatrist. WOW!!
Now the back MRI and x-rays were outpatient in a free-standing imaging center, and the radiologist was right there. Not so easy if you are in an ER, or a hospital bed, or if the images are read “off-site.”

Recently I met a physician who said he was an interventional gastroenterologist. I didn’t know what that meant.
Back in the day vascular procedures were the domain of vascular surgeons. So I started Googling and found that besides cardiology, stenting has expanded to GI, neurology, oncology, radiology, urology, nephrology, pulmonology, and pain management.
So now as an educated patient you should know more about interventional procedures and who is performing them on you. Some questions: Is the procedure evidence-based? Does the physician have special training in the procedure, and certification if this is the gold standard? Does the physician do enough of the procedure to ensure proficiency and good outcomes?

But first…
“A new study has found that while stents can be lifesaving in opening arteries in patients having a heart attack, the devices are ineffective in relieving chest pain.
A procedure used to relieve chest pain in hundreds of thousands of heart patients each year is useless for many of them, researchers reported on Wednesday.
Their study focused on the insertion of stents, tiny wire cages, to open blocked arteries. The devices are lifesaving when used to open arteries in patients in the throes of a heart attack….
When the researchers tested the patients six weeks later, both groups said they had less chest pain, and they did better than before on treadmill tests.
But there was no real difference between the patients, the researchers found. Those who got the sham procedure did just as well as those who got stents.
Clinical guidelines in the United States say stenting is appropriate for patients with a blocked artery and chest pain who have tried optimal medical therapy, meaning medications like those given to the study patients… “ (A)

Now let’s look at ever expanding interventional medicine.
“A vascular surgeon diagnoses, treats, and manages conditions in your arteries and veins, also called your blood vessels. These specialists treat a range of health problems, from spider and varicose veins to life-threatening aneurysms, and can help patients manage chronic conditions throughout their lives.
A vascular surgeon treats many conditions that affect the blood vessels in every part of your body except for your heart and brain. This can include: Aneurysm, a bulge or weak spot in an artery; Atherosclerosis, or hardening of the arteries, where plaque builds up on your artery walls; Carotid artery disease or peripheral artery disease (PAD), where the arteries that bring blood to your neck or limbs become narrow or blocked; Compression disorders like nutcracker syndrome and thoracic outlet syndrome; Dialysis access, or the placement of a graft or fistula that allows you to receive dialysis treatment for kidney disease; Deep vein thrombosis (DVT), a blood clot in a vein deep below your skin; Spider veins, or small webs of veins just below the surface of the skin; Trauma to arteries and veins caused by accidents or injuries; Varicose veins, or large, swollen, twisted veins that can cause pain or aching in your legs; Venous ulcers and arterial and diabetic (neuropathic) wounds, which are nonhealing wounds that result from poor blood flow, especially in the legs” (B)

“Interventional Cardiology represents advanced training in cardiovascular disease and focuses on the invasive (usually catheter-based) management of heart disease.
Clinical issues usually managed by interventional cardiologists include: Ischemic heart disease (percutaneous coronary intervention (angioplasty), stent placement, coronary thrombectomy; Valve disease (valvuloplasty, percutaneous valve repair or replacement); Congenital heart abnormalities (repair of atrial and ventricular septal defects, closure of patent ductus arteriosus, angioplasty of the great vessels).” (C)

“Interventional Radiology” (IR) refers to a range of techniques which rely on the use radiological image guidance (X-ray fluoroscopy, ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) to precisely target therapy. Most IR treatments are minimally invasive alternatives to open and laparoscopic (keyhole) surgery. As many IR procedures start with passing a needle through the skin to the target it is sometimes called pinhole surgery!
The essential skills of an interventional radiologist are in diagnostic image interpretation and the manipulation of needles and the use of fine catheter tubes and wires to navigate around the body under imaging control. Interventional radiologists are doctors who are trained in radiology and interventional therapy.” (D)

“Interventional Nephrology is a new and emerging subspecialty of Nephrology that mainly deals with ultrasonography of kidneys and ultrasound-guided renal biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters as a vascular access for patients undergoing hemodialysis as well as percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas or grafts in end stage renal disease patients.” (E)

“Interventional urology provides care for many urologic diseases in the most minimally invasive fashion possible. New approaches include state of the art prostate cancer screening technologies, focal therapies for prostate cancer, minimally invasive kidney cancer treatments, embolization for BPH, non-surgical approaches to treat varicoceles and erectile dysfunction.” (F)

“Interventional oncology uses image-guided technology to directly target solid tumors. It’s a complementary intervention that I hope will eventually be integrated into standard care algorithms. It gives clinicians another focused area of cancer care in which we can collaborate with other specialists. We perform targeted procedures that can be characterized as either arterial or ablative. Interventional oncology, and to some extent interventional radiology, also involves the use of biopsies for genomics analysis, in a similar way as other oncologic specialists use biopsies to help guide their biological therapies or systemic therapies.” (G)

“Interventional pulmonology is a relatively new field in pulmonary medicine. Interventional pulmonology uses endoscopy and other tools to diagnose and treat conditions in the lungs and chest.
These procedures may be offered by pulmonologists (lung specialists) who have undergone extra training. Cardiothoracic and other surgeons also routinely perform interventional pulmonology procedures.
Procedures for interventional pulmonolgy include: Flexible bronchoscopy. Biopsy of lung or lymph node.
Airway stent (bronchial stent). Rigid bronchoscopy. Foreign body removal. Pleuroscopy. Thoracentesis.
Pleurodesis. Indwelling pleural catheter. Bronchoscopic thermoplasty.
Interventional Pulmonary Diagnostics: Endobronchial ultrasound system (EBUS); Electromagnetic navigation bronchoscopy (superDimension) (H)

“Interventional (gastrointestinal) endoscopy is a minimally invasive procedure that involves the use of a thin, flexible tube (or scope) that is equipped with a camera and light at its tip. The endoscope is inserted either in the mouth or rectum and passed through the esophagus or intestines to make color images of the esophagus and intestinal tract. It also can be used to make images of surrounding organs such as the pancreas.
Interventional endoscopy can be used to screen, diagnose, manage, and treat: Colon and rectal bleeding, polyps, and cancer; Complete and colon polyp resection, including large polyps; Complications from bariatric surgery; Diseases of the esophagus; Gallbladder disease; Gastric stomach diseases; Pancreatic diseases; interventional endoscopy also is used to prevent cancer by removing growths (polyps) before they become cancerous.” (I)

“Endovascular neurosurgery is a subspecialty within neurosurgery. It uses catheters and radiology to diagnose and treat various conditions and diseases of the central nervous system. The central nervous system is made up of the brain and the spinal cord. This medical specialty is also called neurointerventional surgery.
Interventional neuroradiology is a subspecialty within radiology. It also involves catheters and radiology to diagnose and treat neurological conditions and diseases.
The term endovascular means “inside a blood vessel.” Endovascular neurosurgery uses tools that pass through the blood vessels to diagnose and treat diseases and conditions rather than using open surgery. The surgeon often uses radiology images to help him or her to see the part of the body involved in the procedure.” (J)

“A variety of interventional procedures can be used to treat a range of pain conditions, from chronic low back pain to migraine headaches. Many of these techniques are performed under X-Ray guidance, which helps the physician deliver the therapy—whether it’s a steroid injection or heat-based remedy—to the exact source of the pain.
The range of interventional pain management treatment options include: Epidural Steroid Injections;
Medial Branch Blocks / Facet Joint Injections; Radiofrequency Nerve Ablations; Major Joint Injections (Knee, Hip, Shoulder); Occipital Nerve Blocks; Kyphoplasty (Balloon kyphoplasty). (K)

“Pathologists use microscopic examination and supporting tests to study tissues taken from biopsies and make diagnosis. In conventional pathology, the samples are taken by a surgeon and then sent away to a pathologist for analysis.
Interventional pathology is a new, less invasive option that allows for preliminary sample testing to be done in-person by the pathologist. It enables the pathologist to directly communicate with the patient and helps the doctor put the biopsy samples in context with the patient as a whole. This achieves faster, more accurate, and more complete diagnoses. With interventional pathology, patients can receive a better diagnosis than is available with conventional pathology, and in fewer trips to the doctor’s office.” (L)

“Over the past decade or so, the trend has been toward less and less invasive treatment—laparoscopic surgery instead of open-body surgery. Now enter so-called interventional cardiologists, who perform angioplasty and deploy stents (small mesh tubes that act as scaffolds inside an artery) to treat coronary-artery disease, in place of cardiac surgeons scrubbing in for a bypass. Indeed, since 1994, such surgeries have fallen more than 20 percent, to fewer than 300,000 annually. And then there are interventional radiologists wielding catheters and stents to deal with, say, carotid-artery disease, in place of vascular surgeons reporting for duty, scalpel in hand.
“It’s like the Wild West, the turf wars with the vascular surgeons,” … “You’ve got interventional cardiologists, interventional neuroradiologists, interventional neurologists all wanting in.”…
The solution, many doctors say, is to develop criteria that carefully spell out which conditions call for which procedures and—this is key—to make certain that the practitioner who first sees a patient is knowledgeable about all treatment options: surgical, interventional, medication, lifestyle modification, the whole deal.” (M)

In summary be thorough when getting care from any interventionalist. One should know who is doing the procedure, and his or her training, experience and performance results.

THE CHALLENGE: More and more hospital based interventionalists serve on “on-call” panels (often in-house 24/7). This means that in “rapid response” situations the interventional procedure is performed by a pre-designated physician. What mechanisms can be put in place so the patient (or family members) more fully participate in interventional clinical decision-making?

“Capital Health Regional Medical Center has become the first hospital in New Jersey to employ the Embotrap II Revascularization Device for treatment of stroke, the Trenton-based facility said.
Neurosurgeons at Capital Health’s Capital Institute for Neuroscience use Embotrap II to remove a blood clot in the brain causing a stroke. The stent retriever features a fine, mesh-like end and is guided through a major artery to trap the clot.” (N)

(A) ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain, by GINA KOLATA, https://www.nytimes.com/2017/11/02/health/heart-disease-stents.html
(B) Learn About What Vascular Surgeons Do, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(C) Interventional Cardiology, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(D) What is Interventional Radiology?, by David Kessel, https://www.bsir.org/patients/what-is-interventional-radiology/
(E) Interventional Nephrology: a new subspecialty of Nephrology, by G Efstratiadis, I Platsas, P Koukoudis, and G Vergoulas, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464263/
(F) Interventional Urology, http://www.mountsinai.org/patient-care/service-areas/urological-conditions-and-surgery/areas-of-care/interventional-urology
(G) Burgeoning Field of Interventional Oncology Is Poised for Takeoff: A Q&A With Dan Brown, MD, by Andrew J. Roth, http://www.onclive.com/publications/obtn/2013/november-2013/burgeoning-field-of-interventional-oncology-is-poised-for-takeoff-a-qanda-with-dan-brown-md
(H) Interventional Pulmonology, https://www.webmd.com/lung/interventional-pulmonology-uses-effects#1
(I) WHAT IS INTERVENTIONAL ENDOSCOPY?, https://www.summitmedicalgroup.com/service/Interventional-GI-Endoscopy/
(J) Endovascular Neurosurgery and Interventional Neuroradiology, https://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/endovascular_neurosurgery_and_interventional_neuroradiology_135,39
(K) Interventional Pain Procedures Under X-Ray Guidance, http://www.mountsinai.org/patient-care/service-areas/pain-management/pain-management-services/interventional-spinal-procedures-under-x-ray-guidance
(L) Interventional Pathology, https://sites.google.com/site/pathdiag/upcoming-seminars/our-company
(M) The rise of low-invasion techniques—and the doctors who specialize in them—has made the competition for surgical patients, well, cutthroat, by Joanne Kaufman, http://nymag.com/nymetro/health/columns/strongmedicine/n_9311/
(N) Capital Health first in NJ to employ Embotrap II stroke treatment, by Jessica Perry, http://www.njbiz.com/article/20180822/NJBIZ01/180829948/capital-health-first-in-nj-to-employ-embotrap-ii-stroke-treatment

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At least 10 health-care workers have been infected with the deadly Ebola virus as they battle an outbreak in an eastern province of Congo

“We are on an epidemiological precipice. We have a critical, time-limited window of opportunity to prevent the #DRC #Ebola outbreak from taking hold in areas that are much more difficult to access because of insecurity. There is not a minute to lose.” Peter Salama, deputy director-general for emergency preparedness and response
Public health officials in the Democratic Republic of the Congo are scrambling to contain the Ebola outbreak, as neighboring countries of Burundi, Rwanda, South Sudan and Uganda bolster their readiness in case the hemorrhagic virus spreads past their border…
Concerns about conflict zones: One of the big concerns is that one of the affected areas is in a conflict region, which is dangerous for health care workers and is near the border of Uganda.
Peter Salama, a top World Health Organization official, told STAT News:
“That’s really the worst-case scenario: That we can’t get in quickly enough to an alert [of possible cases] or we just have a blind spot because of security. And then an outbreak really begins to take hold in those blind spots and becomes a multicountry regional outbreak.”..
Meanwhile, the DRC is continuing its vaccination, treatment and education program. The spokesperson tells Axios:

“ “The environment is really conducive for Ebola to transmit freely. This is a very dangerous outbreak.
“What makes the outbreak in eastern DRC or northern Kivu more dangerous is there is a security challenge – there is active conflict in that area.”
Because of the ongoing fighting, some areas have been designated “red zones”.
As a result health officials and aid agencies find it difficult to access these areas, making it hard to find, isolate and treat potential cases.
Such areas were potential “hiding places” for the disease, which WHO figures suggest has a mortality rate of about 50 percent.” “ (B)

“The possibility that the virus could spread unchecked in one of these areas raises prospects of an outbreak that could make this year’s earlier brush with Ebola seem like a training exercise.
“That’s really the worst-case scenario: That we can’t get in quickly enough to an alert [of possible cases] or we just have a blind spot because of security. And then an outbreak really begins to take hold in those blind spots and becomes a multicountry regional outbreak,’’ Dr. Peter Salama, the World Health Organization’s deputy director-general of emergency preparedness and response, told STAT.
“That’s what keeps me up at night.”
The outbreak was declared in North Kivu on Aug. 1, a week after the previous epidemic was deemed contained. Genetic analysis of viruses from the two show that while they are caused by the same species of ebolaviruses, Ebola Zaire, they are not linked..
North Kivu is in northeastern Congo, near the border with Uganda and Rwanda. It’s the country’s most populous province, with 8 million people. It is also its most dangerous.
Under a scoring system used by the U.N. to determine the level of risk for its personnel in conflict zones, North Kivu is at level 4. Level 5 means the U.N. must evacuate; it is simply too perilous to be present.” (C)

“”That environment is really conducive for Ebola … to transmit freely.
“We call on the warring parties for cessation of hostilities, because the virus is dangerous to all. It doesn’t choose between this group or that group,” he said.” (D)

“The U.N. refugee agency is working closely with DRC authorities and other agencies on actions to contain Ebola on the national and regional level. But, its main focus is to monitor possible Ebola infections among refugees fleeing across the border, mainly to Uganda, from conflict ridden North Kivu and Ituri.
UNHCR spokesman, William Spindler says the number of newly arriving refugees into Uganda from these two Ebola affected provinces increased during July from 170 a day to 250 a day. He says the majority currently is crossing at the Kisoro border point.
“So UNHCR is working with WHO, UNICEF and other partners and with the Ministry of Health of Uganda to intensify screening for Ebola at all border entry points. And, additional health workers have been deployed in the border districts to improve response capacity,” he said.
Spindler notes the World Health Organization is not recommending any restriction on the movement of people. Therefore, he says UNHCR is urging countries neighboring DRC to allow refugees in need of protection to enter their territory and to include them into preparedness and response plans and activities.
The UNHCR says refugees are at the same risk of contracting and transmitting the Ebola virus disease as local farmers, merchants, business people and others moving through the area. Therefore, it urges governments and local communities not to adopt measures that single out refugees. Those measures may not be scientifically sound and will only serve to stigmatize and restrict refugees’ freedom of movement.” (E)

“The World Health Organization (WHO) said on Friday that at least 1,500 people had been potentially exposed to the deadly Ebola virus in the Democratic Republic of Congo’s North Kivu region, where insecurity prevents aid workers from reaching some areas.
But it expected more people to become infected and could not be sure that it had identified all chains by which the virus is spreading in the eastern part of the country beset by militia violence….
“We don’t know if we are having all transmission chains identified. We expect to see more cases as a result of earlier infections and these infections developing into illness,” WHO spokesman Tarik Jasarevic told a Geneva news briefing.
“We still don’t have a full epidemiological picture… The worst case scenario is that we have these security blindspots where the epidemic could take hold that we don’t know about,” he said.” (F)

“The ongoing deadly Ebola outbreak in the eastern part of the Democratic Republic of the Congo has particularly affected children, the United Nations Children’s Fund has said.
The outbreak in North Kivu Province was declared on August 1, and the UN children’s agency reported that more than 50 youngsters have lost their parents to Ebola.
UNICEF added that so far two children have died, while six others – who either are infected by the disease or suspected to be – are receiving treatment at two centres in the region.
Dr Gianfranco Rotigliano, UNICEF Representative in the DRC, said: “The children affected by the ongoing epidemic need special attention and care.
“Women are the primary caregivers for children, so if they are infected with the disease, there is a greater risk that children and families become vulnerable.”…
UNICEF and partners have trained nearly 90 psychosocial workers to assist and comfort children in Ebola treatment centres.
These professionals also support children who have been discharged, but who may be at risk of stigmatisation within their communities, and organised awareness-raising activities to facilitate their return. “ (G)

“The deadly Ebola outbreak in eastern DR Congo has now claimed 49 lives since the start of the month, the government has said, and the World Health Organization expects more cases.
The gradually increasing death toll, with a further 2,000 people feared to have come into contact with the virus, adds to the woes of a country already facing violence, displacement and political uncertainty.
First reported on August 1 in the North Kivu province, the current outbreak has killed 49 of the 90 cases reported, according to the latest health ministry bulletin on Saturday.” (H)

At least 10 health-care workers have been infected with the deadly Ebola virus as they battle an outbreak in an eastern province of Congo, officials said over the weekend, as concerns mount that the number of cases is growing faster than public health officials can respond…
The Health Ministry and the World Health Organization (WHO) expect more cases to emerge in the coming weeks. The Ebola virus disease carries an incubation period of up to 21 days, meaning it can take as long as three weeks for an infected person to show symptoms.
Tarik Jasarevic, a spokesman for the WHO in Geneva, told The Hill that health officials had identified more than 1,500 people who had come into contact with a possible or confirmed Ebola patient…
“Health-care workers are at the front line and extremely vulnerable to infection. They work in poor conditions, often without personal protective equipment, and thus [are] often exposed before an outbreak is detected,” Rimoin said. “The reason this is so important is because health-care workers can easily propagate disease given that they have contact with many sick people and their own families.”” (I)

(A) WHO official: Congo’s Ebola on “precipice” to spread further, by Eileen Drage O’Reilly, https://www.axios.com/who-warns-congo-ebola-outbreak-on-precipice-995ceba1-5d2a-4823-a796-f36cf57faa85.html
(B) Ebola latest: Dangerous outbreak can ‘spread rapidly’, warns WHO boss. by CIARAN MCGRATH, https://www.express.co.uk/news/world/1004172/Ebola-latest-news-dangerous-ebola-outbreak-rapidly-war-zone-who-vaccination
(C) Ebola outbreak shaping up as most dangerous test of world’s ability to respond since global crisis, by Helen Branswell, https://www.statnews.com/2018/08/16/ebola-outbreak-challenges/
(D) WHO says DRC conflict hindering push to stem Ebola outbreak https://www.aljazeera.com/news/2018/08/drc-conflict-hindering-push-stem-ebola-outbreak-180814172937317.html
(E) WHO says DRC conflict hindering push to stem Ebola outbreak, https://www.aljazeera.com/news/2018/08/drc-conflict-hindering-push-stem-ebola-outbreak-180814172937317.html
(F) WHO expects more Ebola cases in Congo, can’t reach no-go areas, by Stephanie Nebehay, https://www.reuters.com/article/us-health-ebola-who/who-expects-more-ebola-cases-in-congo-cant-reach-no-go-areas-idUSKBN1L20VB
(G) Child victims of Congo’s Ebola outbreak need ‘special care’ – UNICEF, https://punchng.com/child-victims-of-congos-ebola-outbreak-need-special-care-unicef/
(H) Ebola deaths in DR Congo rises to 49 with 2,000 feared ‘contacts’, https://punchng.com/ebola-deaths-in-dr-congo-rises-to-49-with-2000-feared-contacts/
(I) Ebola crisis worsens in Congo, health workers infected, by REID WILSON, http://thehill.com/policy/international/402553-ebola-crisis-worsens-in-congo-health-workers-infected

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“The U.S. is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply.” (I)

“When historians trace back the roots of today’s opioid epidemic, they often find themselves returning to the wave of addiction that swept the U.S. in the late 19th century. That was when physicians first got their hands on morphine: a truly effective treatment for pain, delivered first by tablet and then by the newly invented hypodermic syringe. With no criminal regulations on morphine, opium or heroin, many of these drugs became the “secret ingredient” in readily available, dubiously effective medicines.
In the 19th century, after all, there was no Food and Drug Administration (FDA) to regulate the advertising claims of health products. In such a climate, a popular so-called “patent medicine” market flourished. Manufacturers of these nostrums often made misleading claims and kept their full ingredients list and formulas proprietary, though we now know they often contained cocaine, opium, morphine, alcohol and other intoxicants or toxins.
Products like heroin cough drops and cocaine-laced toothache medicine were sold openly and freely over the counter, using colorful advertisements that can be downright shocking to modern eyes..
But more than that, widespread opiate use in Victorian America didn’t start with the patent medicines. It started with doctors.” (A)

“When I was in medical school, a professor instructed me to think of pain as the patient’s fifth vital sign. It was a radical, new idea, one that was quickly disseminating across the country, and it was supposed to alleviate suffering, improve outcomes and transform lives.
But as we discover in Beth Macy’s timely new book, “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America” (Little, Brown, 376 pp., ★★★½ out of four), that approach was wildly misguided. It led to thousands of unnecessary deaths and created an underclass of marginalized and debilitated drug addicts. How could we have gotten this so wrong?
You’ve probably heard pieces of this story before, but in “Dopesick” we get something original: a page-turning explanation.
We begin in Appalachia, the epicenter of the opioid crisis, where “few businesses dare to set up shop because it’s hard to find workers who can pass a drug test.” It’s a place that feels forgotten, where Americans are dying in the prime of their lives and those who hang on are known as “pillbillies.”..
From there, the narrative moves to Stamford, Connecticut, and Purdue Frederick, a family-owned pharmaceutical company. In 1952, Purdue was purchased by brothers Raymond, Mortimer and Arthur Sackler – who transformed the small operation into a massive conglomerate called Purdue Pharma, cornering the pain-relief market with MS Contin and OxyContin.” (B)

“The letters arrived from the San Diego County medical examiner’s office, informing clinicians that one of their patients had died from a prescription drug overdose.
These letters appear to have had an impact — prescriptions of addictive painkillers dropped.
In a small, randomized trial, researchers showed that this intervention — aimed at making the abstract issue of safe prescribing individually tangible — led to a slight reduction in the amount of opioids these clinicians prescribed. What’s more, prescribers who received the letters doled out fewer of the most powerful doses and appeared to start fewer patients on opioids compared with doctors who did not receive the letters.
Authors of the study published Thursday and experts not involved with the research urged other communities around the country to adopt the same strategy.
“Hearing about one person’s death can be really impactful,” said Jason Doctor, the lead author of the study and an expert in behavioral science and policy at the University of Southern California. “People often don’t change their behavior unless they have a really salient, personal experience.”” (C)

“The Food and Drug Administration on Monday announced a shift in the way it evaluates drugs to treat opioid addiction that the agency says will give it more flexibility to approve new treatments.
Now, rather than merely examining whether a potential treatment reduces opioid use, the agency will consider factors like whether a drug could reduce overdose rates or the transmission of infectious diseases.
“We must consider new ways to gauge success beyond simply whether a patient in recovery has stopped using opioids, such as reducing relapse overdoses and infectious disease transmission,” FDA Commissioner Scott Gottlieb said in a statement.
The announcement is the latest in a string of efforts to improve the federal government’s response to the growing opioid crisis, which also includes legislation on Capitol Hill that aims to ensure treatment is evidence-based and, separately, to ensure more federal programs will pay for methadone treatment.” (D)

“A fast-acting class of fentanyl drugs approved only for cancer patients with high opioid tolerance has been prescribed frequently to patients with back pain and migraines, putting them at high risk of accidental overdose and death, according to documents collected by the Food and Drug Administration.
The F.D.A. established a distribution oversight program in 2011 to curb inappropriate use of the dangerous medications, but entrusted enforcement to a group of pharmaceutical companies that make and sell the drugs.
Some of the companies have been sued for illegally promoting other uses for the medications and in one case even bribing doctors to prescribe higher doses.
About 5,000 pages of documents, obtained by researchers at the Johns Hopkins Bloomberg School of Public Health through the Freedom of Information Act and provided to The New York Times, show that the F.D.A. had data showing that so-called off-label prescribing was widespread. But officials did little to intervene.” (E)

“Opioid addiction is an epidemic gripping the nation, leading to thousands of overdose deaths annually. But Dr. Kevin Zacharoff, an anesthesiologist with more than 25 years of experience in pain medicine, says opioids can also provide much-needed relief to many patients.
There are tens of thousands of people for whom opioids are the best form of treatment, Zacharoff told medical professionals and Long Islanders at a symposium at Stony Brook Medicine on Friday.
Rather than not prescribe opioids at all, Zacharoff believes there needs to be more discussion among health professionals and in medical schools about the risks and benefits of opioids as pain treatment. Currently, only about 4 percent of all medical schools in the country have curriculums dedicated to pain management and addiction, he said. Stony Brook is in the process of developing a curriculum for fourth-year medical students to be implemented next year on those topics, he said.
“The only thing that really concerns me is that we don’t throw the baby away with the bath water,” he said. “Opioids have been around for 4,000 years.”” (F)

“Addiction to prescription opioids like oxycodone has risen so rapidly in the last decade that now an average of 40 people die of overdoses in the U.S. each day, according to the Centers for Disease Control and Prevention (CDC). President Donald Trump declared opioid addiction a public health emergency last year, helping bring more attention to the crisis.
But newly published research led by the Mayo Clinic is raising serious questions about whether awareness of the dangers of opioid prescriptions is translating to fewer prescriptions and a reduction in use of the powerful painkillers.
Opioid prescription rates have remained flat for insured patients over the last 10 years, according to data published today in the BMJ. And even though prescriptions doled out to Medicare patients have recently shown signs of leveling, prescribing rates for some of those older people are actually higher than they were a decade ago.” (G)

“The New York State Department of Health recently began urging doctors prescribing opioids for patients with severe pain to consider medical marijuana as an alternative. The guidance was part of an emergency regulation that went into effect July 12.
The national opioid crisis on average causes 115 U.S. overdose deaths a day in the United States. New York has been focused on reducing its share of that toll. In 2016, opioids killed 18 of every 100,000 New Yorkers, according to the Centers for Disease Control and Prevention. New York’s State Health Commissioner Howard Zucker in June explained why the state is making this welcome move. “Medical marijuana has been shown to be an effective treatment for pain that may also reduce the chance of opioid dependence.”” (H)

“The new goal is pain elimination, which I believe is one factor that has fueled the overconsumption of opioids although there are other factors present…
But patients’ rising expectations of eliminating pain and the medical professions’ willingness to join in this mission has exacted a great societal cost. I am not blaming anyone here. Of course, patients want pain to go away. Of course, physicians want to relieve suffering. Isn’t a doctor’s mission to make his patient feel better?
Could this really result from a doctor’s prescription?
The consequences of this approach have exploded. Narcotics and opioids are addictive agents. Any individual who takes these medicines over time risks addiction, which is a new disease. In fact, the addiction may very well be a more severe illness than the original medical condition…
Consider this sobering statistic: The U.S. is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply…
The medical profession and the scientific community need to triple down on research to develop new drugs and techniques that attack pain but leave patients protected from the ravages and misery of drug addiction.” “ (I)

(A) How Advertising Shaped the First Opioid Epidemic, by By Jon Kelvey, cdn.com/uUasjiYUx7Ife2mLvzZD61wklig=/800×600/filters:no_upscale()/https://public-media.smithsonianmag.com/filer/d7/d7/d7d7f166-3063-45f8-bf0c-d0bbf18e2362/vintage-advert-for-medicine.jpg
(B) ‘Dopesick’ is a page-turning look at the nation’s opioid crisis and big Pharma, by Matt McCarthy, https://www.usatoday.com/story/life/books/2018/08/06/dopesick-page-turning-look-nations-opioid-crisis-beth-macy-big-pharma-book-review/882892002/
(C) Clinicians were told their patient had died of an overdose. Then opioid prescribing dropped, by ANDREW JOSEPH, https://www.statnews.com/2018/08/09/opioid-prescribing-medical-examiner-letters-overdose/
(D) FDA will broaden how it evaluates new addiction treatment drugs, by LEV FACHER, https://www.statnews.com/2018/08/06/fda-expands-medication-assisted-treatment/?utm_source=STAT+Newsletters&utm_campaign=7daa54108e-DC_Diagnosis&utm_medium=email&utm_term=0_8cab1d7961-7daa54108e-149527969
(E) F.D.A. Did Not Intervene to Curb Risky Fentanyl Prescriptions, by Emily Baumgaertner, https://www.nytimes.com/2018/08/02/health/fda-fentanyl-opioid-epidemic-overdose-cancer.html
(F) Despite epidemic, doctor says opioids also help patients, by Janelle Griffith, https://www.newsday.com/news/health/stony-brook-medicine-symposium-opioids-1.20278189
(G) Opioid Prescribing Hasn’t Declined In The Last Decade Despite Addiction Crisis, by Arlene Weintraub, https://www.forbes.com/sites/arleneweintraub/2018/08/01/opioid-use-hasnt-declined-in-the-last-decade-despite-addiction-crisis/#430bb8945dec
(H) New York Points The Way In Dealing With Opioid Crisis, by Kevin Murphy, https://www.forbes.com/sites/kevinmurphy/2018/08/02/new-york-points-the-way-in-dealing-with-opioid-crisis/#5e1407f38f62
(I) The Misguided Expectation of Eliminating Pain, by Michael Kirsch, https://www.forbes.com/sites/kevinmurphy/2018/08/02/new-york-points-the-way-in-dealing-with-opioid-crisis/#5e1407f38f62

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After Ebola scare, Denver Health wishes it notified public of potential deadly virus sooner

“The World Health Organisation (WHO) has raised the alarm that cases from the resurgent Ebola outbreak in the Democratic Republic of the Congo (DRC) are expected to rise in the coming days.
WHO’s Deputy Director General of Emergency Preparedness and Response, Peter Salama, said in Geneva that there had been around 20 deaths as a result of the Ebola virus.
Mr Salama also said protecting vulnerable people in eastern DRC from the latest Ebola Virus outbreak was going to be “very, very complex”, given the huge logistical challenges and ongoing conflict there.
The WHO emergency preparedness and response chief said: “We know for example that there have been around 20 deaths. We can’t at this stage confirm whether they are all confirmed or probable Ebola cases.
“We expect however that the overall case count will rise in coming days to weeks, based on the trajectory of epidemics at this stage in their development.”
Salama said that WHO was unaware of the public health emergency in North Kivu province when the UN agency a week ago declared the last Ebola episode over…
“It’s going to be a very, very complex operation,” he said, noting that the vast country is home to the UN’s largest peacekeeping operation, the UN Stabilisation Mission in the DRC.
One million of the province’s eight million inhabitants are displaced and getting access to some of those in danger of coming into contact with Ebola, will require an armed escort in some cases, the WHO official explained.
There is also the additional threat that those fleeing violence may also head into nearby Uganda, Tanzania and Burundi, taking the infection with them, Salama said, noting that additional surveillance measures are being implemented at crossing points.
“On the scale of difficulty, trying to extinguish a deadly outbreak pathogen in a war zone is at the top of the scale,” he added.” (A)

“In the outbreak earlier this year in DRC, health officials used a ring vaccination program, in which they tracked down the contacts of cases and the contacts of those contacts, and offered them all vaccine in a bid to halt spread. That approach might not be viable in North Kivu.
“The ring vaccination strategy is highly dependent on access, and really strong access to the population that’s being targeted,” Salama told STAT. “The ring vaccination is really the big question mark [here].”
Salama said consideration is being given to an “out-in strategy,” which would create a ring around an area where there had been cases, rather than trying to find and vaccinate specific individuals. The idea would be to start “with a protective buffer around a whole geographical zone,” and then moving inward, offering vaccine to everyone in the area.
A lot will depend on how freely the vaccine teams can travel. And that will be determined in negotiations with the United Nations peacekeeping operation in the region…
The fact that the Ebola Zaire virus is the cause of the outbreak also opens up the most options for experimental drugs to treat patients. In addition to the Merck vaccines, supplies of five potential therapeutics are already in the country, having been sent during the Bikoro outbreak.
None of the drugs was used during the previous outbreak. By the time DRC’s scientific and ethical committees reviewed the available scientific data and authorized the drugs for compassionate use, there were no more Ebola patients in care.” (B)

“Health workers are in the process of setting up a so-called cold chain, the series of measures needed to keep the vaccine well below zero in a tropical climate without reliable power supplies, the ministry said.” (C)

“”So, not only do you have the problem of tracking that internal displacement, but then you have the potential exportation of infection across borders,” Salama said. “And, that is why we are already working with the government of Uganda particularly, but also Rwanda, which shares a border as well with northern Kivu to be fully prepared for any eventualities across the border.”
The U.N. refugee agency is lending its expertise to this situation. It is preparing shelters for at least 1,000 vulnerable Internally Displaced Persons and other extremely vulnerable people in the Ebola-affected Beni area. It also is undertaking protection and monitoring activities.
UNHCR spokesman Andrej Mahecic says his agency’s staff in Uganda, Rwanda and Tanzania are on Ebola alert.
“Specifically, in Uganda, we have a continuous influx from the DRC. Our operation has intensified the awareness-raising among the refugee and host communities. We have also increased the infection control and outbreak preparedness measures,” Mahecic said. “And, we also are preparing for entry screening, that could be the temperature checks for arriving Congolese refugees at the borders.”
Mahecic says around 92,000 Congolese refugees have fled to Uganda so far this year. He says they are continuing to arrive at an average rate of between 100 and 200 a day.” (D)

“John F. Kennedy Memorial Hospital, Liberia’s biggest referral hospital, has denied reports of having on its ward a confirmed Ebola case…
The Hospital assured the public that any confirmed cases of Ebola at the Medical Center would be immediately communicated to the relevant authority.
In an interview with FPA last week, the head of the National Public Health Institute (NPHIL), Mr. Tolbert Nyenswah, said should be “no cause for alarm” despite the discovery of a new strain of the Ebola virus in neighboring Sierra Leone
The new strain of Ebola named ‘Bombali virus’ was discovered in fruits eating bats and has the potential to infect humans, researchers say.
So far, according to health officials in Freetown, there is no evidence that the new virus strain has infected any human.
“There is no need to panic about this situation; researchers are in control. It is not a new outbreak as it is being considered by people,” says Tolbert Nyenswah, NPHIL’s Director General.
Nyenswah, an expert health practitioner who worked successfully through the 2014 Ebola outbreak in Liberia, says more research is needed in order to establish the characteristics of the new strain found in Sierra Leone.
“The facts are, it can be transferred to human cells but what is not known is whether or not it can cause the [Ebola] disease as in the case of previous outbreaks,” he told FrontPage Africa on Wednesday.
There has been no human-to-human transfer of the new strain as in the case of the ‘Zaire strain’ which infected thousands of people leading to the deaths over 11,300 people in Liberia, Guinea and Sierra Leone.
Nyenswah, however, added that what is unknown about the new strain is whether it is virulent like the Zaire strain; adding, “This is why scientists are working overnight to determine”.
Experts have disclosed that it is difficult to put a timeline to gathering sufficient information about the new strain to determine if the virus can cause an outbreak.
“So, what we need to be caution about is playing with fruits bats or eating them. These kinds of things are very much warned against especially in the region of Sierra Leone that we are talking about,” he said.” (E)

“At least 34 people are reported to have died in a fresh outbreak of Ebola in the Democratic Republic of Congo, including one healthcare worker, the World Health Organization says, as officials scramble to contain the deadly virus in the restive eastern part of the country.
As of August 6, 43 Ebola cases have been reported primarily in North Kivu province, an area that has been beleaguered by decades of violence, with an additional 33 suspected cases currently undergoing laboratory tests.” (F)

“Colorado health officials scrambled to determine whether a man who recently worked with sick people in eastern Congo and became ill Sunday in Denver had contracted the deadly Ebola virus — and doctors also isolated an ambulance crew for testing and were looking for another person in metro Denver who may have had contact with the man.
Denver Health and Hospitals officials Sunday night were waiting for test results from a state health lab but said that, based on an initial test in a special isolated unit, they do not believe the man has Ebola. A Colorado Department of Public Health and Environment (CDPHE) bulletin late Sunday said testing “is negative for Ebola.”
The man had been working with sick and dead people in an area of eastern Congo where a recent outbreak of Ebola had largely dissipated with no new Ebola cases reported over the past 45 days. On Sunday morning, he reported sudden severe symptoms at his residence in Denver, Denver Health chief medical officer Connie Price said.
“We felt that, if he had Ebola, then he could be very communicable … We had no wiggle room to be wrong,” Price said.
The man “became ill very suddenly this morning,” she said, declining to specify his exact symptoms but saying they could mimic illnesses including flu and appendicitis. “He is getting better, so that is good.”
Three members of the ambulance crew that picked up the man — two of them paramedics, one a student — also were being held in isolation, and Denver public health officials were looking for a “significant other” who may have had contact with the man warranting testing as a precaution…
Hospital officials said they were “on normal operations” and that “there is no threat or concern for patient, staff or visitor safety.” Denver Department of Public Health and Environment officials couldn’t be reached late Sunday…
Denver Health staffers are trained and equipped to deal with situations involving infectious diseases. And the CDC has designated Denver’s hospital as one of 10 around the nation prepared to treat patients with Ebola.” (G)

“A man who fell ill after a recent trip to eastern Congo has been removed from isolation after tests came back negative for the deadly Ebola virus, health officials said on Monday.” (H)

“Denver Health officials’ ability to respond to potential public health threats was thrown into the spotlight late last month when a man’s illness spurred fears that he may have contracted the deadly Ebola virus.
And while officials say they followed protocols, there is one aspect of their response they would like to improve on: the amount of time it took Denver Health to inform the public.
It took about seven hours to get out the word that they were handling a case potentially involving an infectious disease…
“If I had to look back on it now, I would have liked to have sent the press release out a little earlier,” she said…
“We followed our established protocols and all Denver Health staff responded efficiently and effectively; however, we use every opportunity we can to learn and improve,” she said in a later statement. “We will have several debriefings to review every aspect of our response, and will certainly be open to finding new ways to refine it.” “ (I)

(A) Ebola cases in DR Congo ‘will rise in coming days’ – WHO, https://www.premiumtimesng.com/news/top-news/278867-ebola-cases-in-dr-congo-will-rise-in-coming-days-who.html
(B) Ebola outbreak in DRC sets up another test for experimental treatments, by Helen Branswell, https://www.statnews.com/2018/08/03/ebola-outbreak-in-drc-sets-up-another-test-for-experimental-treatments/?utm_source=STAT+Newsletters&utm_campaign=de1a372488-Daily_Recap&utm_medium=email&utm_term=0_8cab1d7961-de1a372488-149527969
(C) Ebola vaccinations in eastern Congo due to begin on Wednesday, https://www.reuters.com/article/us-health-ebola-congo-vaccine/ebola-vaccinations-in-eastern-congo-due-to-begin-on-wednesday-idUSKBN1KQ0N0
(D) Can Ebola Spread From DRC to Neighboring Countries?, https://www.voanews.com/a/congolese-refugees-risk-infecting-neighboring-countries-with-ebola/4513607.html
(E) Liberia: John F. Kennedy Memorial Hospital Denies Having Confirmed Ebola Case on Ward, https://frontpageafricaonline.com/health/liberia-john-f-kennedy-memorial-hospital-denies-having-confirmed-ebola-case/
(F) Ebola death toll climbs to 34 as health workers struggle to contain latest outbreak in Congo, by Krista Mahr, https://www.telegraph.co.uk/news/2018/08/07/ebola-death-toll-climbs-34-health-workers-struggle-contain-latest/
(G) Denver man just back from Congo isolated for possible Ebola; CDPHE said testing “is negative”, by Bruce Finley, https://www.denverpost.com/2018/07/29/denver-health-ebola-virus-isolation/
(H) Denver man removed from isolation after tests prove negative for Ebola, by Kathryn Scott, https://www.denverpost.com/2018/07/30/denver-ebola-tests-negative/
(I) After Ebola scare, Denver Health wishes it notified public of potential deadly virus sooner, by Jessica Seaman, https://www.denverpost.com/2018/08/05/denver-health-ebola-scare-public-notice/

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“…of the 1.5 million Americans who develop sepsis each year, nearly 260,000 die from it.” (A)

“Sepsis is the body’s overwhelming response to an infection. It can occur in virtually anyone with an infection, though it’s more likely to appear among elderly individuals and those who have undergone surgery. While health care providers are broadly aware of the condition and its symptoms, it can be difficult to identify early.
Sepsis can start off with a fever and increased heart rate, but can quickly become more serious as it causes difficulty breathing, changes in skin color, and organ failure. The initial treatment for sepsis, antibiotics and intravenous fluids, is deceptively simple and widely accepted among health professionals. The big treatment challenge is time, because with every hour that passes during which the patient isn’t treated, the prognosis worsens significantly.
To help ensure timely, consistent, and high-quality care for sepsis patients, the Centers for Medicare and Medicaid Services adopted in 2015 the Sepsis National Hospital Inpatient Quality Measure (SEP-1) that had been developed by the National Quality Forum. This metric assesses hospitals’ timely treatment of sepsis, which costs more than $27 billion annually. Going a step further, the Centers for Medicare and Medicaid Services on Wednesday began publishing sepsis treatment statistics for all hospitals across the country. This is the first time that this information is being made publicly available.
To find your hospital’s score, visit Medicare’s Hospital Compare website. Type in your ZIP code, then the hospital’s name. On the hospital’s page, click the “Timely & effective care” tab and then click the “Sepsis care” drop-down menu. You can then see the hospital’s score and compare it to state and national averages.
A high score shows that a hospital has been following sepsis treatment protocols and that, when patients develop sepsis, they are generally treated properly. A low score indicates poor sepsis care.
Hospital Compare currently includes SEP-1 scores for the first nine months of 2017. The first full year of data will follow in October…. (A)

“More than half of hospitals on average fail to comply with the CMS’ sepsis treatment requirements, new data from the agency reveals.
The data, publicly released Wednesday on Hospital Compare for the first time, show that the national average compliance rate for the CMS’ sepsis treatment measure was 49%. But patient safety experts say the generally low compliance rate for the measure doesn’t necessarily mean sepsis treatment is poor at hospitals. The measure is a process measure, so it doesn’t directly reflect outcomes for patients with sepsis. Additionally, clinical nuance and trouble reporting the measure must be taken into account when looking at the data.
The measure—called the Severe Sepsis and Septic Shock Early Management Bundle—was adopted by the CMS in July 2015 to improve hospitals’ identification and treatment of sepsis, a serious and life-threatening condition. More than 200,000 people die each year from sepsis, according to the agency. A study last year also found the mortality rate from the condition has worsened in recent years.
The measure requires hospitals to follow multiple, time-sensitive steps to comply. Physicians and researchers say that early dedication and intervention is critical to prevent death from sepsis…
“What CMS has done with sepsis has elevated everyone’s game and made us all aware of the importance of compliance but I take these numbers with a grain of salt,” he said.
The CMS data set includes performance of 3,005 hospitals for the first nine months of 2017.” (B)

Not all clinicians agree…

“Guidelines that go beyond guidance and move to regimented, time-based prescriptions of care must be based on unassailable evidence. Even then, the clinician’s assessment of the individual patient should allow a diversion from the guideline directed care.
The current iteration of the Surviving Sepsis Campaign Guidelines (2018) fails on all counts:
The recommendations are based on low to moderate quality evidence. Even this level of evidence lumps into one group various severities of illness.
Despite this, the recommendations are made at a Strong level without conditionals
No consideration is made for the judgment of clinician as to whether the individual patient in front of them will be helped or harmed by the recommendations
No consideration has been made for the downstream effects these guidelines will have on other non-septic patients being cared for simultaneously.” (C)

More than one in 10 children hospitalized with sepsis die, but when a series of clinical treatments and tests is completed within an hour of its detection, the chances of survival increase considerably, according to a new analysis led by the University of Pittsburgh School of Medicine.
The results, published today in the Journal of the American Medical Association, support an initially controversial New York mandate established after 12-year-old Rory Staunton died from undiagnosed sepsis in 2012 following an infection from a scrape. These results will likely encourage the mandate’s expansion to other states…
Rory’s Regulations require New York hospitals to follow protocols regarding sepsis treatment and submit data on compliance and outcomes. The hospitals can tailor how they implement the protocols, but must include a blood culture to test for infection, and administration of antibiotics and fluids within an hour to any child suspected of sepsis.
Seymour and his team analyzed the outcomes of 1,179 children with sepsis reported at 54 New York hospitals. The children had an average age of just over 7 years, and 44.5 percent were healthy before developing sepsis. A total of 139 patients died.
Completion of the sepsis protocol within one hour decreased the odds of death by 40 percent. When only parts of the protocol were completed within an hour – for example, giving fluids but not testing for infection or giving antibiotics – the patients did not fare better. The finding held only if the entire protocol was completed in an hour.
“It’s clear that completing the entire sepsis protocol within an hour is associated with lower mortality,” said lead author Idris V.R. Evans, M.D., assistant professor in Pitt’s Department of Critical Care Medicine. “But the mechanism of benefit still requires more study. Does each element of the protocol contribute to specific biologic or physiologic changes that, when combined, improve outcomes? Or is it that completion within an hour may simply be an indication of greater awareness by doctors and nurses caring for the child? Or could it be something else entirely?”
The researchers note that testing the sepsis protocol in a future randomized clinical trial will be very difficult. Such work would require leaving off some protocol elements for some septic children but not others in a random fashion – a design which would not currently align with the standard of care. But if more states adopt rules and regulations similar to New York’s, and also mandate data reporting, future work could expand on these results.” (D)

“The prognosis of patients with sepsis is related to the severity or stage of sepsis as well as to the underlying health status of the patient. For example, patients with sepsis and no ongoing sign of organ failure at the time of diagnosis have about a 15%-30% chance of death. Patients with severe sepsis or septic shock have a mortality (death) rate of about 40%-60%, with the elderly having the highest mortality rates. Newborns and pediatric patients with sepsis have about a 9%-36% mortality rate.” (E)

“Patients today tend to have options when seeking hospital care. Those aware of the dangers of sepsis may well look for hospitals with more favorable sepsis ratings. This isn’t a Yelp review or blog post; it’s an official report from the Centers for Medicare and Medicaid Services. Since hospitals no longer have the option to conceal this information, it pushes the issues of transparency and accountability to the surface, which are absolute necessities to drive change.
Hospitals are working to combat sepsis: employing special training to educate staff on the warning signs of sepsis; mandating the use of protocols; and deploying electronic surveillance and alerting systems. Many such systems frequently fire false alerts. Over time, staff members tend to ignore these alerts, due to what is known as alert fatigue. A highly accurate and effective alerting system can be a game-changer in saving lives.
Institutions need to look closely at their sepsis performance and it will be a sobering moment for some. But this new trove of data has the potential to be historic in combating the deadliest condition in U.S. hospitals. July 2018 could be the dawn of a new era of sepsis treatment, one in which more patients will be as fortunate as the young hunter I cared for and make full recoveries from this deadly and fast-moving condition.” (A)

(A) Hospital Compare lifts the veil on sepsis care. Check your hospital’s score, by Steve Claypool, https://www.statnews.com/2018/07/26/hospital-compare-lifts-veil-on-sepsis/
(B) Just 49% of hospitals follow CMS’ sepsis treatment protocols, By Maria Castellucci, https://www.knoxnews.com/story/news/health/2018/07/27/sepsis-treatment-how-do-east-tennessee-hospitals-score/844117002/
(C) Surviving Sepsis Campaign: Retract the SSC 2018 Guidelines, by: Emcrit P, https://www.thepetitionsite.com/772/830/097/surviving-sepsis-campaign-sccm-esicm/
(D) Pediatric sepsis care within an hour increases chances of survival, shows study, https://www.news-medical.net/news/20180725/Pediatric-sepsis-care-within-an-hour-increases-chances-of-survival-shows-study.aspx
(E) Sepsis (Blood Poisoning), by Charles Patrick Davis, https://www.medicinenet.com/sepsis/article.htm#what_causes_sepsis

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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write in AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital admission documents accepting financial responsibility for your care

“No Surprise Charges” is one of the key Lessons Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS (Penguin Press, 2017). “Hospitals in your network should also be required to guarantee that all doctors who treat you are in your insurance network.”
We have all harshly experienced or heard about under-the counter out-of-network hospital charges:
“A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.”(A)
A study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an “out-of-network” doctor — and thus exposed to additional charges not covered by their insurance plan.” (B)

Here is a brief case study:
“When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma. Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.” (C)

So what can you do to avoid out-of-network charges?
– Speak with a practice representative before being seen to understand the costs of seeing your doctor on an out-of-network or a cash basis. (DOCTOR note: maybe you need to leave and go to an in-network physician instead)
– If you need additional services, such as surgery, imaging or physical therapy, ask your doctor to refer you to an in-network facility to keep your costs down. (D)

A New York law is a great start toward transparency to reduce out-of-network surprises.
Under a recent New York law, Hold Harmless Protections for Insured Patients, “… patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.
A bill is considered a surprise if consumers receive services without their knowledge from an out-of-network doctor at an in-network hospital or ambulatory surgical center, among other things. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out of network and may result in higher out-of-pocket costs, it’s considered a surprise bill.” (E)

“Advocates for patients, senior citizens, labor unions, and businesses hailed Gov. Phil Murphy’s signing of a complex and controversial measure designed to curb the impact of costly “surprise” medical bills in New Jersey. Supporters said the law, nearly 10 years in the making, is the strongest of its kind nationwide…
The Democratic governor, who pledged his support for the bill in March, said the law closed a loophole to protect patients and make healthcare more affordable; sponsors called it the right thing to do to protect vulnerable residents. “We have put patients first. We have made clear that New Jersey stands for transparency when it comes to health care,” …
The reform is designed to protect patients, businesses, and others who pay for medical care from the high-cost bills associated with emergency or unintentional care from doctors or other providers who are not part of their insurance network. The law requires greater disclosure from both insurance companies and providers — so patients are clear on what their plan covers — ensures patients aren’t responsible for excess costs, and establishes an arbitration process to resolve payment disputes between providers and insurers, a mechanism intended to better control costs…
“It’s a solution that is fair to healthcare providers and consumers alike because it strikes a balance between providing reasonable compensation to facility-based providers, while protecting consumers from unexpected, nonnegotiable bills that drive health insurance premiums higher,” said NJBIA president and CEO Michele Siekerka. “This was an extremely difficult and complicated issue, and NJBIA commends the governor and the bill sponsors who worked hard to address the concerns of all stakeholders.”” (F)

A price transparency RFI released by the agency this week asks for input on how CMS might develop consumer-friendly policy. In a request for information announced Thursday, the Centers for Medicare & Medicaid Services asked whether providers and suppliers should be required to tell patients, in advance, how much a given healthcare service will cost out-of-pocket. If the agency were to move forward with a price transparency requirement on physician practices, it could prove controversial. Many doctors say they themselves lack the training they would need to have effective conversations about how much the healthcare services they provide will ultimately cost patients.
But CMS has repeatedly indicated that it aims to get more pricing information to consumers one way or another. “We are concerned that challenges continue to exist for patients due to insufficient price transparency,” the agency wrote in its RFI, which is included in proposed revisions to the Physician Fee Schedule, Quality Payment Program, and other policies for 2019…

In order to determine what additional actions may be appropriate to connect consumers with accessible price information, the CMS price transparency RFI includes a variety of questions, including the following:How should the phrase “standard charges” be defined in various provider and supplier settings?
Which information types would be most useful to beneficiaries, and how can providers and suppliers empower consumers to engage in price-conscious decision-making?
Should providers and suppliers have to tell patients how high their out-of-pocket costs are expected to be before providing a service?” (G)

“Patients are at a higher risk of receiving surprise medical bills on Affordable Care Act exchanges, according to a new report.
In 2018, more than 73% of plans available in the exchange marketplace offered restrictive networks, compared with 48% in 2014, according to the report (PDF) commissioned by Physicians for Fair Coverage. PFC is a nonprofit alliance of physician groups which advocates for ending surprise insurance gaps and improving patient protections…
“This research confirms what patients and physicians across the country have known for some time,” said PFC President and CEO Michele Kimball in a statement. “Insurers have been systematically narrowing their networks and increasing premiums, creating surprise insurance gaps that patients don’t realize exist until it’s too late. While insurers are making record profits, patients are paying more for less.”
The coalition, which includes tens of thousands of emergency physicians, anesthesiologists and radiologists from across the country, is pressing for more states to adopt legislation to solve the problem of surprise medical bills. The problem often occurs when a patient seeks care at an in-network hospital but is then surprised the doctor treating them is out of their insurance company’s network—a fact they usually find out when they get the doctor’s bill.
“When it comes to health care, nobody likes a surprise. This study confirms what we’ve been hearing from patients for years: there is no real way for patients to avoid a ‘surprise’ medical bill, even when they’re insured and try to stay in-network. We need a transparent healthcare system designed for patients, not profits,” Rebecca Kirch, executive vice president of healthcare quality and value at the National Patient Advocate Foundation, said in a statement…
The best estimates indicate that 1 out of 7 times someone goes to the emergency department, they are going to be stuck with a surprise bill.” (H)

A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.
So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.
The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.
How should we respond? (I)

“In the absence of laws barring balance bills and surprise bills, there are steps hospitals and health plans can take to protect consumers from medical debt. The Healthcare Financial Management Association urges hospitals to inform patients that they may be eligible for financial assistance provided directly by the hospital and make clear to patients what services are and are not included in their price estimates. Hospitals also need to communicate better with uninsured patients about medical costs and options for sharing costs..
Health plan best practices include helping members estimate expected out-of-pocket costs and sharing price information for providers in a given region.
Beyond that, hospitals need to double down to ensure they have contracts with as many in-network providers as possible. “It requires the physicians, hospitals, health plans all working together to make sure that everybody’s in-network or, if they’re not, the patient knows that clearly up front,” says Rick Gundling, HFMA’s senior vice president for healthcare financial practices. “It’s kind of a three-legged stool.”
Consumers also need to become savvier when it comes to costs of medical care. Most people do see providers in their network, says Gupta. However, “because of their high-deductible health plan, they often don’t recognize until they get hit with a bill that the same MRI might be $3,000 after the deductible at a local hospital that is convenient for them versus $1,000 a mile down the street at an imaging center,” he adds.” (J)

“Cooper works as a physician assistant and hears about medical billing problems all the time.
So when she initially found out she was pregnant, this health care provider did everything she could to make sure anyone associated with her pregnancy would be considered what’s referred to as “in-network.”
She contacted her insurance company, Aetna, and she also contacted Banner Gateway Hospital, the hospital where she planned to give birth. The hospital then sent her written confirmation that she had nothing to worry about.
“She said, ‘Send me a picture of your insurance card front and back and I’ll double check that you’re covered.’ And, she sent me back an hour later saying, ‘Yes, you are in network,'” Cooper said.
Cooper eventually delivered her little girl at Banner Gateway Hospital. But, not long after, Cooper started getting a number of large “out-of-network” medical bills.
“Aetna then sent me back something that said, ‘No you are out-of-network’ and that’s how everything started to trickle through,” she said.
“Out-of-network.” How could that happen? Remember, she got written confirmation from Banner Gateway Hospital indicating she was “in-network.”…
When she added them all up, her medical bills came to around $18,000, money she shouldn’t have been responsible for. Still, she says she wasn’t getting any resolution…
We asked them to review Cooper’s case and after they did, they acknowledged there was a mistake.
As a result, Aetna reprocessed all of Heather’s bills as “in-network.”..
That means Cooper will now only have to pay just $750 out of pocket, the cost of her deductible rather than $18,000. Cooper said she couldn’t be happier and says it all happened with the help of 3 On Your Side.” (K)

“On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.
There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital.
The doctors at the hospital quickly determined that baby Jeong-whan was fine — just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.
Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” which sometimes is known as “a trauma response fee.”
Update: After this story was published on June 28, Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma response fee charged for Park Jeong-whan’s visit to the hospital. In a letter, the hospital’s patient experience manager said the hospital did a clinical review and offered “a sincere apology for any distress the family experienced over this bill.” Further, the hospital manager wrote that the case “offered us an opportunity to review our system and consider changes.” (L)

“The health insurer Anthem is coming under intense criticism for denying claims for emergency room visits it has deemed unwarranted…
The insurer initially rolled out the policy in three states, sending letters to its members warning them that, if their emergency room visits were for minor ailments, they might not be covered. Last year, Anthem denied more than 12,000 claims on the grounds that the visits were “avoidable,” according to data the insurer provided to Senator Claire McCaskill, a Democrat from Missouri, one of the affected states.
But when patients challenged their denials, Anthem reversed itself most of the time, according to data the company gave Ms. McCaskill. The report concludes that the high rate of reversals suggests that Anthem did not do a good initial job of identifying improper claims, meaning some patients who did not challenge their denials may have been stuck paying big bills they should not have been responsible for.” (M)

(A) Surprise Medical Bills by Karen Pollitz, kkf.org, http://kff.org/private-insurance/issue-brief/surprise-medical-bills/
(B) Many get hit with surprise ‘out-of-network’ bill after emergency rooms: Study” by Dan Mangan, CNBC, http://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-out-of-network-bill-after-emergency-rooms-study.html
(C) When Out-Of-Network Charges Pop Up, Try An Appeal, by Michelle Andrews, NPR, http://www.npr.org/sections/health-shots/2011/06/21/137304710/when-out-of-network-charges-pop-up-try-an-appeal
(D) (D) What It Means If Your Doctor is Out of Network, by Sergio Viroslav, Angie’s list, https://www.angieslist.com/articles/what-it-means-if-your-doctor-out-network.htm
(E) (E) N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges by Michelle Andrews, KHN http://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(F) Governor Signs Nation’s Strongest Law on ‘Surprise’ Medical Bills, by Lilo H. Stainton, https://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(G) SURPRISE MEDICAL BILLS: SHOULD CMS MAKE DOCTORS GIVE PRICE INFO UP FRONT?, by STEVEN PORTER, https://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
(H) Patients on ACA plans at higher risk for surprise bills, physician coalition says, by Joanne Finnegan, https://www.fiercehealthcare.com/practices/aca-exchanges-restrictive-networks-surprise-bills-physicians-for-fair-coverage
(I) Let’s tell the truth about what’s going on, by Michael Kirsch, https://www.medpagetoday.com/blogs/kevinmd/74070?xid=nl_mpt_hemoncvideo_2018-07-20&eun=g1223211d0r&pos=9&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-07-20&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days
(J) Some patients fight back against surprise medical bills, by Meg Bryant, https://www.healthcaredive.com/news/some-patients-fight-back-against-surprise-medical-bills/526576/
(K) Gilbert mom fighting medical bills she says she shouldn’t owe, by LiAna Enriquez, http://www.azfamily.com/story/38722098/gilbert-mom-fighting-medical-bills-she-says-she-shouldnt-owe
(L) A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill, by Jenny Gol and Sarah Kliff, https://www.vox.com/2018/6/28/17506232/emergency-room-bill-fees-health-insurance-baby
(M) A Health Insurer Tells Patients It Won’t Pay Their E.R. Bills, but Then Pays Them Anyway, https://www.nytimes.com/2018/07/19/upshot/anthem-emergency-room-bills.html?utm_source=STAT+Newsletters&utm_campaign=24e499fa7a-MR_COPY_09&utm_medium=email&utm_term=0_8cab1d7961-24e499fa7a-149527969


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