Friday, February 26

Health Care and Ambulatory Care

Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures even when provided outside of hospitals.

According to Modern Healthcare magazine, there is a new trend toward building medical facilities that focus on treating and releasing patients on an ambulatory basis. One of the big drivers of the trend toward bedless hospitals is cost. Under pressure from insurers and consumers, hospital systems have been shifting to lower-cost outpatient care, from which they generally earn higher margins than inpatient care.

But a lot of this also is driven by consumer demand and the evolution of technology. Many health systems are forgoing traditional hospital expansions and building free-standing emergency centers away from main hospitals. More details about this topic are located at this site: http://www.modernhealthcare.com/article/20150912/MAGAZINE/309129973.

Patients do not stay overnight in the facility, according to the Virginia Department of Health. The term "ambulatory care" encompasses a large variety of healthcare settings that include but are not limited to physician offices, urgent care centers, dialysis facilities, ambulatory surgical centers, cancer clinics, imaging centers, endoscopy clinics, public health clinics, and other types of outpatient clinics. Information and studies are available at this website: http://www.vdh.virginia.gov/epidemiology/surveillance/hai/ambulatory.htm.

According to Healthcare Design, the prospect of this greatly expanded customer base, along with a focus on wellness and incentives to deliver care more efficiently, has U.S. hospitals and health systems looking at how and where they treat patients who will be more actively engaged in their own health and well-being.  Going to where the customer is—out in the community—is a primary strategy that has hospitals and health systems around the country busily forming networks of ambulatory care centers, physician practices, and urgent care centers.

To attract patients who will have a number of choices for where they receive their healthcare, providers are also upgrading facilities to support a new model of delivery that will rely heavily on technology and teamwork. Details on this topic are located at this site: http://www.healthcaredesignmagazine.com/article/ambulatory-care-centers-make-their-move.

A body of research dedicated to patient safety in ambulatory care has emerged over the past few years. These efforts have identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety, according to the Patient Safety Network.

Ensuring patient safety outside of the hospital setting poses unique challenges for both providers and patients. A new model for patient safety in chronic disease management, modified from the original Chronic Care Model. This model broadly encompasses three concepts that influence safety in ambulatory care:
·         The role of patient and caregiver behaviors
·         The role of provider–patient interactions
·         The role of the community and health system

Part of the overview of ambulatory care includes the quality of patient safety both during and after treatment. Improving outpatient safety will require both structural reform of office practice functions as well as engagement of patients in their own safety. While Electronic Health Records (EHRs) hold great promise for reducing medication errors and tracking test results, these systems have yet to reach their full potential.

Coordinating care between different physicians remains a significant challenge, especially if the doctors do not work in the same office or share the same medical record system. Efforts are being made to increase use of EHRs in ambulatory care, and physicians believe that use of EHRs leads to higher quality and improved safety. Tools to help track and improve patient quality of life and treatment options during and after release need continual review for efficacy and improvement.

Patient engagement in outpatient safety involves two related concepts: first, educatingpatients about their illnesses and medications, using methods that require patients to demonstrate understanding (such as "teach-back"); and second, empoweringpatients and caregivers to act as a safety "double-check" by providing access to advice and test results and encouraging patients to ask questions about their care. Success has been achieved in this area for patients taking high-risk medications, even in patients with low health literacy at baseline. More detailed info is located at this website: https://psnet.ahrq.gov/primers/primer/16/patient-safety-in-ambulatory-care.

According to the US Bureau of Labor Statistics, industries in the Ambulatory Health Care Services subsector provide health care services directly or indirectly to ambulatory patients and do not usually provide inpatient services. Health practitioners in this subsector provide outpatient services, with the facilities and equipment not usually being the most significant part of the production process. If  you are considering a career in ambulatory care, this site provides an in-depth overview of that trend in healthcare as well as the growth potential: http://www.bls.gov/iag/tgs/iag621.htm.

Additionally, the Accreditation Association for Ambulatory Health Care (AAAHC) was founded in 1979 to: "encourage and assist ambulatory health care organizations to provide the highest achievable level of care for recipients in the most efficient and economically sound manner. The AAAHC accomplishes this by the operation of a peer-based assessment, consultation, education and accreditation program." If you are a patient in an ambulatory medical facility, you’ll want to know if that location and its staff are part of this organization. More information on the AAAHC is found at this website: http://www.aaahc.org/about/history/.

Ambulatory care is getting more traction in the medical community due to changes in the overall healthcare environment. Ease of access, quality of care, and cost are contributing factors to its growth in locations and popularity. Although not a complete answer to all medical needs, ambulatory care helps cut the expense of unnecessary inpatient medical care.  


Until next time.
Read more

Friday, February 19

Health Care and Rosacea

One of the most embarrassing health maladies is the skin rash that appears on your face and is known as Rosacea. Many people suffer from redness and the bumps that accompany it. This dermatologic condition is uncomfortable and irritating to deal with if you’ve ever had it or know someone who does. Because of its red-faced, acne-like effects on personal appearance, however, it can cause significant psychological, social and occupational problems if left untreated.

According to the National Rosacea Society (NRS), this common but poorly understood disorder of the facial skin that is estimated to affect well over 16 million Americans -- and most of them don't know it. In fact, while rosacea is becoming increasingly widespread as the populous baby boom generation enters the most susceptible ages, a NRS survey found that 95 percent of rosacea patients had known little or nothing about its signs and symptoms prior to their diagnosis. Much more information is located at this website: http://www.rosacea.org/ .

Rosacea often begins with a tendency to blush or flush more easily than other people, according to the American Academy of Dermatology (AAD). The redness can slowly spread beyond the nose and cheeks to the forehead and chin. Even the ears, chest, and back can be red all the time. With time, people who have rosacea often see permanent redness in the center of their face.

Rosacea can cause more than redness. There are so many signs and symptoms that rosacea has four subtypes:
·         Erythematotelangiectatic rosacea: Redness, flushing, visible blood vessels.
·         Papulopustular rosacea: Redness, swelling, and acne-like breakouts.
·         Phymatous rosacea: Skin thickens and has a bumpy texture.
·         Ocular rosacea: Eyes red and irritated, eyelids can be swollen, and person may have what looks like a sty.  
.
Most people, according to the AAD, who get rosacea are:
·         Between 30 and 50 years of age.
·         Fair-skinned, and often have blonde hair and blue eyes.
·         From Celtic or Scandinavian ancestry.
·         Likely to have someone in their family tree with rosacea or severe acne.
·         Likely to have had lots of acne — or acne cysts and/or nodules.

Women are a bit more likely than men to get rosacea, according to the AAD. Women, however, are not as likely as men to get severe rosacea. Some people are more likely to get rosacea, but anyone can get this skin disease. People of all colors get rosacea. Children get rosacea. Much more detailed material is located at this site: https://www.aad.org/public/diseases/acne-and-rosacea/rosacea.

Doctors do not know the exact cause of rosacea but believe that some people may inherit a tendency to develop the disorder. People who blush frequently may be more likely to develop rosacea. Some researchers believe that rosacea is a disorder where blood vessels dilate too easily, resulting in flushing and redness, according to the National Institutes for Health (NIH).

Factors that cause rosacea to flare up in one person may have no effect on another person. Although the following factors have not been well-researched, some people claim that one or more of them have aggravated their rosacea: heat (including hot baths), strenuous exercise, sunlight, wind, very cold temperatures, hot or spicy foods and drinks, alcohol consumption, menopause, emotional stress, long-term use of topical steroids on the face, and bacteria.

The NIH reports that although there is no cure for rosacea, it can be treated and controlled. A dermatologist (a medical doctor who specializes in diseases of the skin) usually treats rosacea. The goals of treatment are to control the condition and improve the appearance of the patient’s skin. It may take several weeks or months of treatment before a person notices an improvement of the skin.

Some doctors will prescribe a topical antibiotic, which is applied directly to the affected skin. For people with more severe cases, doctors often prescribe an oral (taken by mouth) antibiotic. The papules and pustules symptomatic of rosacea may respond quickly to treatment, but the redness and flushing are less likely to improve. Recently, a topical gel was approved that can ease the redness associated with rosacea. A significant amount of info on this malady is found at this website: http://www.niams.nih.gov/Health_Info/Rosacea/.

What causes one person’s rosacea to flare may not trigger a flare-up for another person. This is why dermatologists recommend that patients with rosacea learn what triggers their flare-ups. Avoiding these triggers can reduce flare-ups. Follow a rosacea skin-care plan. Skin care plays an important role in keeping rosacea under control. Many skin care products are too harsh. This can make rosacea worse. More information about treatment is found at this site: http://rosacea-treatment.org/what-is-rosacea/.

According to the Mayo Clinic, although there's no cure for rosacea, treatments can control and reduce the signs and symptoms. Most often this requires a combination of prescription treatments and certain lifestyle changes on your part. Prescription drugs used for rosacea may include:

·         Antibiotics. The antibiotics used for rosacea also have anti-inflammation effects. They may come in the form of creams, gels or lotions to spread on the affected skin or in pills that you swallow. Antibiotic pills are generally more effective in the short term, but they can also cause more side effects.

·         Acne drugs. If antibiotics don't work, your doctor might suggest trying isotretinoin (Amnesteem, Claravis, others). This powerful drug is most commonly used for severe cystic acne, but it also often helps clear up acne-like lesions of rosacea. Don't use this drug during pregnancy as it can cause serious birth defects.

The duration of your treatment depends on the type and severity of your symptoms, but typically you'll notice an improvement within one to two months. Because symptoms may recur if you stop taking medications, long-term regular treatment is often necessary. Enlarged blood vessels, some redness and changes due to rhinophyma often become permanent. In these cases, surgical methods, such as laser surgery and electrosurgery, may reduce the visibility of blood vessels, remove tissue buildup around your nose and generally improve your appearance. Much more information can be found at this site: http://www.mayoclinic.org/diseases-conditions/rosacea/basics/definition/con-20014478.

Rosacea can affect the eyes, according to the American Osteopathic College of Dermatology (AOCD). How severely rosacea affects the eye is not related to how severe the facial rosacea is. Symptoms that suggest ocular (eye) rosacea include a feeling of dryness and grittiness in the eyes and inflamed bumps (chalazions) on the lids. The eyelashes may develop scales and crusts, often misdiagnosed as seborrheic dermatitis. 

A persistent burning feeling, red eyes and light sensitivity suggest the more severe problem of rosacea keratitis. This rare complication can lead to with blindness without treatment. All patients with significant symptoms of ocular rosacea should be seen by an ophthalmologist for a thorough examination.

The most effective treatments are oral tetracycline and similar antibiotics and low-dose oral Accutane. Mild cases can be controlled by gels or creams such a Metrogel, Cleocin-T, Azelex, or sulfa. Often, full doses of pills are needed only for a short while. Maintenance treatment can be intermittent doses or just topical creams. For rosacea of the eyes warm compresses to lids (hot towel) for 5 minutes twice a day, liquefies the oil in the gland ducts-can be very helpful.

Makeup can be an effective aid in rosacea, will not make it worse, and even some male rosacea sufferers use a bit. A slightly more olive color than usual helps to hide the redness. For some women, hormone replacement pills may be given to reduce menopausal hot flashes. Many advances have been made in recent years. Regular visits are advised for most rosacea patients. More details on rosacea are located here: http://www.aocd.org/?page=Rosacea.

Rosacea is treatable. If you are symptomatic, see your doctor or a health care professional. Your care as well as your wellbeing are at stake. More severe cases can be dangerous to your overall health if left untreated. Although rosacea is embarrassing to most people, it can be managed.


Until next time. 
Read more

Tuesday, February 9

Health Care and Medical Bankruptcy

Medical bills can pile up quickly if you have a catastrophic health care event, such as a heart attack, stroke, major accident, or need an organ transplant. Even the costs for common procedures can add up fast, especially if you’re uninsured or underinsured. These days, due to the changes in the health insurance game, many people have switched to a high deductible plan that requires first dollar payment until you reach your deductible. If that amount is high, like $5,000 or $10,000 or higher, you may struggle to make those payments to the medical facility.

What if you’re diagnosed with a form of cancer or another debilitating disease? What if you’re in a car accident or get hurt in some type of major injury requiring a trip to the hospital emergency room. Those dollars escalate in a hurry, and you are left to deal with the financial burden of payment to the hospital and attending medical staff, and some of those may be out of network for your insurance plan if you have one in place.

Regardless of percentages and political leanings, some people are going to have to use up all their savings to pay off their medical bills. Many will be unable to pay for basic necessities like rent, food and utilities. Some of them have children. A lot of them even have medical insurance. To save money, some will cut corners with their treatments, not taking their prescription drugs as indicated, skipping doses, taking less medicine than prescribed or delaying a refill.

Here are a few interesting stats about medical bankrutpcy:
--“Medical Bills Are the Biggest Cause of U.S. Bankruptcies” – 2013 NerdWallet Health study.
-- “56M Americans under age 65 will have trouble paying medical bills [in 2013]” – 2013 NerdWallet Health study.
-- “The percentage of people under age 65 in families having problems paying medical bills decreased from 21.7 percent in the first six months of 2011 to 20.3 percent in the first six months of 2012” – 2013 Center for Disease Control study.

Although passage of the Affordable Care Act has shown that there is a slow decline in personal bankruptcies due to medical debt, many families are still struggling to afford to pay their bills from medical care. It’s understandable that so many Americans are being compelled to think about bankruptcy and medical bills as a potential answer to severe medical debt. But unfortunately, the downsides to bankruptcy are so severe and end up affecting individuals for years beyond making the decision to file.

According to USA Today, But the Affordable Care Act hasn't eliminated the problem. In 2013, medical debt was the largest cause of personal bankruptcy — 1.7 million people lived in households experiencing bankruptcy because of health costs. Many states haven't expanded Medicaid and even those with insurance can rack up big bills, a problem exacerbated by the growing number of plans with high deductibles.

The health law brought regulations that limited for the first time the cost-sharing in plans. An individual plan sold on an exchange can't include out-of-pocket costs greater than $6,600. In practice, the average deductible, or portion a consumer must pay before insurance kicks in, varies based on how expensive a plan is. But the regulation still only applies to providers and specialists specified by the plan as "in-network." The narrower the network, the more vulnerable consumers are to incurring medical debt by visiting unapproved doctors or hospitals.

Some numbers suggest a decline in people facing medical debt. About 64 million Americans struggled to pay medical bills in 2014, according to a survey by the Commonwealth Fund — that's a drop of about 10 million since 2012. Experts have celebrated the decline but cautioned that high-deductible insurance plans could put a damper on those gains.  Of the 64 million the authors said were struggling to pay for care, 38 million, or 59%, were insured the whole year.

There's been some improvement: The same report found 29% of the insured had medical debt or difficulty with medical bills, a drop from 33% in 2012 — while the pool of insured adults grows larger. But analysts caution that absent a significant change in industry or policy, even this group will likely continue to face the prospect of medical debt. More details can be found at this website:  http://www.usatoday.com/story/news/2015/02/01/consumers-still-struggling-with-medical-debt/22587749/#.

The New York Times reported earlier this year that among those who reported having problems paying their bills despite having insurance, 63 percent said they used up all or most of their savings; 42 percent took on an extra job or more work hours; 14 percent moved or took in roommates; and 11 percent turned to charity. In partnership with the Kaiser Family Foundation, the study found that roughly 20 percent of people under age 65 with health insurance reported having problems paying their medical bills over the last year. By comparison, 53 percent of people without insurance said the same.

Unlike other polls, which have focused on the ways that insurance affects health care, the new Times-Kaiser survey explored the effects of medical bills on people’s daily lives well beyond the medical system. We found that medical bills don’t just keep people from filling prescriptions and scheduling visits to the doctor. They can also prompt deep financial and personal sacrifices, affecting their housing, employment, credit and daily lives.

 People without health insurance, of course, are more vulnerable to medical bills than those with health coverage. The study found that the people most likely to report bill problems were uninsured, poor or disabled. However, the majority of people struggling with bills are insured. Of the people in the survey reporting difficulty with their medical bills, 34 percent lacked health insurance, 39 percent had insurance through work, 14 percent were covered through public programs and 7 percent had purchased their own health plans. More info is located at this website: http://www.nytimes.com/2016/01/06/upshot/lost-jobs-houses-savings-even-insured-often-face-crushing-medical-debt.html?_r=0.

According to the American Journal of Medicine, out-of-pocket medical costs averaged $17,943 for all medically bankrupt families: $26,971 for uninsured patients, $17,749 for those with private insurance at the outset, $14,633 for those with Medicaid, $12,021 for those with Medicare, and $6545 for those with Veterans Affairs/military coverage. For patients who initially had private coverage but lost it, the family’s out-of-pocket expenses averaged $22,568.

Among common diagnoses, non-stroke neurologic illnesses such as multiple sclerosis were associated with the highest out-of-pocket expenditures (mean $34,167), followed by diabetes ($26,971), injuries ($25,096), stroke ($23,380), mental illnesses ($23,178), and heart disease ($21,955).

Hospital bills were the largest single out-of-pocket expense for 48.0% of patients, prescription drugs for 18.6%, doctors’ bills for 15.1%, and premiums for 4.1%. The remainder cited expenses such as medical equipment and nursing homes. While hospital costs loomed largest for all diagnostic groups, for about one third of patients with pulmonary, cardiac, or psychiatric illnesses, prescription drugs were the largest expense.

The AJM interviews indicated the severity of job problems caused by illness. In 37.9% of patients’ families, someone had lost or quit a job because of the medical event; 24.4% had been fired, and 37.1% subsequently regained employment. In 19.9% of families suffering a job loss, the job loser was a caregiver. More details are found here: http://amjmed.org/under-aca-medical-bankruptcy-continues/ 

Due to higher medical expenses and fluctuations in insurance coverage, many families are forced to max out credit cards and chip away at their savings or retirement accounts, and once these funds have been wiped out, the only option left may be bankruptcy. An illness or medical emergency shouldn’t have to become a financial nightmare or lead to so many financial sacrifices. 

With the right resources and information, there are ways you can deal with your medical bills effectively to prevent yourself from falling into medical bankruptcy, according to YouCaring.com. They offer some great tips how to deal with medical bankruptcy at their website: https://www.youcaring.com/blog/2016/how-to-avoid-medical-bankruptcy.

Bankruptcy was designed to resolve debt and get people that second chance they deserve. Ask a local bankruptcy lawyer if filing Chapter 7 or Chapter 13 bankruptcy could eliminate your debts. An attorney that is versed in bankruptcy laws would be able to provide counsel to you based on your personal situation. Be careful in your choice, and do your research before you choose a law firm that insists they can help alleviate your financial pain and suffering due to an overdose of medical bills. The quick fix may not always be the best answer for you. Everyone’s situation is different based on the amount they owe and their personal financial situation.


Until next time.
Read more

Thursday, February 4

Health Care and Zika

A new virus has reared its ugly head. Just when you think SARS, MERSA, Ebola, Chikengunya, Swine and Bird Flus, and a host of other recent critical diseases have been contained, a new bug goes rogue. Currently the World Health Organization and other agencies are tracking the movement of the disease with various mechanisms and reporting.  Zika is primarily a threat to pregnant women due to the potential harm to unborn children.

Zika virus is not new. Outbreaks have occurred in areas of Africa, Southeast Asia and the Pacific Islands. It is new in the Americas, however. Brazil reported the first case in May 2015, and since then, infections have occurred in at least 20 countries in the Americas. Puerto Rico reported the first locally transmitted infection in December 2015, and Zika cases are now being reported in the United States, all from returning travelers, reported CNN earlier last week. The first case of sexually transmitted Zika was reported in Dallas, Texas, this month from a traveler who returned from Venezuela.

Zika has been called a milder form of dengue fever. The most common symptoms of Zika virus disease are fever, rash, joint pain and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon, says the CDC.

It is spread to people through the bite of infected Aedes mosquitoes. Although it can also be transmitted from a pregnant mother to her baby during pregnancy, it is not otherwise transmitted person to person. People are contracting Zika in areas where those Aedes mosquitoes are present. This includes South America, Central America, the Caribbean and the U.S. mainland. For more information, visit this website: http://qz.com/601302/zika-what-is-it-and-should-you-be-worried-about-it/.

According to the CDC, there is no vaccine to prevent infection or medicine to treat Zika. CDC has issued a travel notice (Level 2-Practice Enhanced Precautions) for people traveling to regions and certain countries where Zika virus transmission is ongoing. This notice follows reports in Brazil of microcephaly(http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html)and other poor pregnancy outcomes in babies of mothers who were infected with Zika virus while pregnant. However, additional studies are needed to further characterize this relationship. More studies are planned to learn more about the risks of Zika virus infection during pregnancy.

Until more is known, CDC recommends special precautions for pregnant women and women trying to become pregnant: Pregnant women in any trimester should consider postponing travel to the areas where Zika virus transmission is ongoing. Pregnant women who do travel to one of these areas should talk to their doctor or other healthcare provider first and strictly follow steps to avoid mosquito bites during the trip. Women trying to become pregnant should consult with their healthcare provider before traveling to these areas and strictly follow those same steps.

Because specific areas where Zika virus transmission is ongoing are difficult to determine and likely to change over time, CDC will update this travel notice as information becomes available. Check CDC's Zika Travel Information website frequently for the most up-to-date recommendations. More info is located at this site: http://www.cdc.gov/zika/pregnancy/question-answers.html.

The NY Times reports that health officials in the United States, however, say the risk of a major homegrown outbreak is low because mosquito control programs are systematic and effective. They cite a related virus, dengue, which is also transmitted by mosquitoes but has not spread very much since first appearing locally a few years ago.

The current outbreak of Zika has taken the world by surprise. The virus was first identified in 1947 in Uganda, and for years lived mostly in monkeys. But last May in Brazil, cases began increasing drastically. The W.H.O. has estimated that four million people could be infected by the end of the year. The rapid spread is because people in the Americas have not developed immunity, public health experts say. More info is available at this site: http://www.nytimes.com/2016/02/02/health/zika-virus-world-health-organization.html.

CNN has reported an update about the current view of the potential threat of Zika. See their report here: http://www.cnn.com/2016/02/02/health/zika-virus-sexual-contact-texas/index.html. In addition, the CDC said there have been documented cases of virus transmission during labor, blood transfusion, and laboratory exposure. While Zika has been found in breast milk, it's not yet confirmed it can be passed to a baby through nursing.

According to PAHO, the Pan American Health Organization, In most people, diagnosis is based on clinical symptoms and epidemiological circumstances (such as Zika outbreak in the patient’s area or trips to areas where the virus is circulating). Blood tests can help to confirm the diagnosis. Some (virological PCR tests) are useful in the first 3-5 days after the onset of symptoms, while others (serological tests) detect the presence of antibodies but are useful only after five days. 

Once it has been demonstrated that the virus is present in a given area or territory, confirmation of all cases is not necessary, and laboratory testing will be adjusted to routine virological surveillance of the disease. Prevention involves reducing mosquito populations and avoiding bites, which occur mainly during the day. Eliminating and controlling Aedes aegypti mosquito breeding sites reduces the chances that Zika, chikungunya, and dengue will be transmitted.

An integrated response is required, involving action in several areas, including health, education, and the environment. To eliminate and control the mosquito, it is recommended to:
·         Avoid allowing standing water in outdoor containers (flower pots, bottles, and containers that collect water) so that they do not become mosquito breeding sites. 
·         Cover domestic water tanks so that mosquitoes cannot get in. 
·         Avoid accumulating garbage: Put it in closed plastic bags and keep it in closed containers. 
·         Unblock drains that could accumulate standing water. 
·         Use screens and mosquito nets in windows and doors to reduce contact between mosquitoes and people. 

To prevent mosquito bites, it is recommended that people who live in areas where there are cases of the disease, as well as travelers and, especially, pregnant women should:  
  • Cover exposed skin with long-sleeved shirts, trousers, and hats.
  • Use repellents recommended by the health authorities (and apply them as indicated on the label).
  • Sleep under mosquito nets. 

People with symptoms of Zika, dengue, or chikungunya should visit a health center. More information is available at this site: http://www.paho.org/hq/index.php?option=com_content&view=article&id=9183%3A2015-preguntas-frecuentes-virus-fiebre-zika&catid=3986%3Azika-virus-infection&Itemid=41463&lang=en

The Zika virus is no doubt a major health problem, and steps are being taken globally to help prevent and reduce the potential outbreak. For your own sake, practice common sense solutions to this health care issue. If you or someone you know may be symptomatic, see a doctor right away.

Until next time.  

Read more