Health for life

Researchers at the Linda Crnic Institute for Down Syndrome and the University of Colorado School of Medicine have found that a single mechanism may underlie the damaging effect of cholesterol on the brain and on blood vessels.

High levels of blood cholesterol increase the risk of both Alzheimers disease and heart disease, but it has been unclear exactly how cholesterol damages the brain to promote Alzheimers disease and blood vessels to promote atherosclerosis.

Using insights gained from studying two much rarer disorders, Down Syndrome and Niemann Pick-C disease, researchers at the Linda Crnic Institute for Down Syndrome and the Department of Neurology of the University of Colorado School of Medicine found that cholesterol wreaks havoc on the orderly process of cell division, leading to defective daughter cells throughout the body.

In the new study published this week in the on-line journal PLOS ONE, Antoneta Granic, PhD, and Huntington Potter, PhD, show that cholesterol, particularly in the LDL form, called bad cholesterol, causes cells in both humans and mice to divide incorrectly and distribute their already-duplicated chromosomes unequally to the next generation. The result is an accumulation of defective daughter cells with the wrong number of chromosomes and theore the wrong number of genes. Instead of the correct two copies of each chromosome, and thus two copies of each gene, some cells acquired three copies and some only one.

Granic and Potters study of the effects of cholesterol on cell division included a prominent finding of cells carrying three copies of the chromosome (#21 in humans and #16 in mice) that encodes the amyloid peptide that is the key component of the neurotoxic amyloid filaments that accumulate in the brains of Alzheimer patients.

Human trisomy 21 cells are significant because people with Down syndrome have trisomy 21 in all of their cells from the moment of conception, and they all develop the brain pathology and many develop the dementia of Alzheimers disease by age 50. Earlier studies by Granic, Potter and others have shown that as many as 10% of cells in an Alzheimer patient, including neurons in the brain, have three copies of chromosome 21 instead of the usual two. Thus, Alzheimers disease is, in some ways, a form of acquired Down syndrome. Furthermore, mutant genes that cause inherited Alzheimers disease cause the same defect in chromosome segregation as does cholesterol, thus indicating the presence of a common cell division problem in both familial and sporadic (non-familial) Alzheimers disease.

The new research also found trisomy 21 neurons in the brains of children with what, until now, was thought to be an unrelated neurodegenerative disease (Niemann Pick type C), caused by a mutation affecting cholesterol physiology. This result suggests that neurodegeneration itself might be linked to chromosome missegregation.

Such a model is supported by the finding of Thomas Arendt, MD, and colleagues at the University of Leipzig that 90% of the neuronal cell death observed at autopsy in Alzheimer patients is due to the creation and selective loss of neurons with the wrong number of chromosomes.

Identifying the specific problem caused by cholesterol will lead to completely new approaches to therapy for many human diseases, including Alzheimers disease, atherosclerosis and possibly cancer, all of which show signs of defective cell division. Granic and Potter already have found a potentially simple approach to preventing cholesterol from causing cells to distribute their chromosomes unequally into their new daughter cells. Specifically, when cells in culture were first treated with ethanol, the subsequent exposure to bad cholesterol was without effect on cell division: Each daughter cell received the correct number of chromosomes.

Researchers publishing in the journal Nutrition show that Omega-3 fatty acids found in fish and natural foods including nuts and seeds can lower levels of dangerous homocysteine, an amino acid linked with increased risk of cardiovascular disease and dementia. Reviewing data from eleven trials including more than 720 study participants, scientists found that introducing Omega-3 fats from dietary or supplemental sources were associated with significantly lowered levels of plasma homocysteine.

Consumption of whole walnuts or their extracted oil can reduce cardiovascular risk through a mechanism other than simply lowering cholesterol, according to a team of Penn State, Tufts University and University of Pennsylvania researchers.

"We already know that eating walnuts in a heart-healthy diet can lower blood cholesterol levels," said Penny Kris-Etherton, Distinguished Professor of Nutrition, Penn State. "But, until now, we did not know what component of the walnut was providing this benefit. Now we understand additional ways in which whole walnuts and their oil components can improve heart health."

In a randomized-controlled trial, the researchers gave 15 participants with elevated blood cholesterol one of four treatments -- either 85 grams of whole walnuts, 6 grams of skin, 34 grams of defatted nutmeat, or 51 grams of oil. The team evaluated biochemical and physiological responses in the participants before the treatments were administered and again 30 minutes, one hour, two hours, four hours and six hours after administering the treatments. The researchers repeated this process for each of the remaining three treatments.

Results -- which will appear in the June 1 issue of the Journal of Nutrition and are now online -- showed that a one-time consumption of the oil component in walnuts favorably affected vascular health. In addition, consumption of whole walnuts helped HDL -- good cholesterol -- perform more effectively in transporting and removing excess cholesterol from the body.

"Our study showed that the oil found in walnuts can maintain blood vessel function after a meal, which is very important given that blood vessel integrity is often compromised in individuals with cardiovascular disease," said Claire Berryman, graduate student in nutritional sciences, Penn State. "The walnut oil was particularly good at preserving the function of endothelial cells, which play an important role in cardiovascular health."

According to the researchers, walnuts contain alpha-linolenic acid, gamma-tocopherol and phytosterols, which may explain the positive effects of the walnut oil treatment.

"Implications of this finding could mean improved dietary strategies to fight heart disease," said Berryman. "The science around HDL functionality is very new, so to see improvements in this outcome with the consumption of whole walnuts is promising and worth investigating further."

Further studies are needed to determine the mechanisms that account for cardiovascular disease risk reduction with walnut consumption, according to Kris-Etherton.

"Our study indicates that simple dietary changes, such as incorporating walnuts and/or their oil in a heart healthy diet, may reduce the risk of heart disease," she said.

While the population health management service industry has a successful track record when it comes to chronic heart failure, diabetes and asthma, the Disease Management Care Blog thinks, after a quick scan of the literature, that there are fewer studies of its impact on hypertension.

 A recent Morbidity and Mortality Weekly Report (MMWR) reminds us that thats a problem.

The National Health and Nutrition Examination Survey(NHANES) performs interviews and physical examinations of a representative sample of U.S. households.  This particular report on the prevalence and treatment of high blood pressure was based on a sample of 20,811 individuals from four 2-year survey cycles that were performed from 2003 to 2010.

Extrapolating from the sample, 66.9 million persons or 30.4% of the U.S. populationn have high blood pressure. Of this population, just over half (54% or 35.8 million) have uncontrolled hypertension.  Of these persons, 31 million (or 88%) had been seen by a health care provider in the preceding year. The prevalence of uncontrolled hypertension among those hypertensives with Medicare was 52%. Not having health insurance or having seen a health care provider in the past year increased the risk of untreated and uncontrolled high blood pressure.

Whats more, the DMCB discovered control of hypertension doesnt appear to be getting better over time.

The good news is that the treatment of high blood pressure is not all that complicated and that team-based non-physicians can play an important role.  Patients should be engaged on weight control, a DASH diet, restricting salt, exercise and moderating alcohol intake. Medication therapy can be individualized and tailored to meet mutually agreed-upon goals and to minimize any barriers.  Check out this MMWR table and youll see erences to "lifestyle counseling," "self monitoring," "self-management education."

Given the looming shortage of primary care care settings and the coming influx of newly insured persons, the DMCB believes population health management will need to be part of the solution.  In addition to the established science, the industry 1) understands the importance of risk stratification, 2) can be bolted onto accountable care arrangements and 3) understands that optimal outcomes are somewhere between 46% and 100% control.

Hopefully, given the relative dearth of high quality studies, this opportunity will be accompanied by ongoing studies of outcomes.

People with heart disease have special needs when it comes to dental care. Here are some tips to consider before going to the dentist if you suffer from one of the following heart conditions.
Dental Care After Heart Attack

Wait a minimum of six months after a heart attack before undergoing any dental treatments. Tell your dentist if you are taking anticoagulants (blood-thinning drugs). These medications could result in excessive bleeding during some oral surgery procedures. Ask your dentist if oxygen and nitroglycerin are available in case a medical emergency should arise during your office visit.
High Blood Pressure (Hypertension)

Some high blood pressure drugs can cause dry mouth or alter your sense of taste. Calcium channel blockers in particular can cause the gum tissue to swell and overgrow, resulting in chewing difficulties. If you do experience gum overgrowth, your dentist will give you detailed oral hygiene instructions and may ask you to make more frequent dental visits for cleanings. In some cases, gum surgery may be required. (A gingivectomy is the name of the surgical procedure performed to remove excess gum tissue).

If your dental procedure requires the use of anesthesia, ask your dentist if the anesthesia contains epinephrine. Epinephrine is a common additive in local anesthesia products. Use of epinephrine in some patients with high blood pressure may result in cardiovascular changes - including the rapid development of dangerously high blood pressure, angina, heart attack, and arrhythmias - and theore should be used with caution.
Chest Pain (Angina)

Patients with angina treated with calcium cannel blockers may experience gum overgrowth. In some cases, gum surgery may be required.

Like patients with a previous heart attack, patients with angina may want to ask their dentist if oxygen and nitroglycerin are available in case a medical emergency should arise.

While patients with stable angina (chest pain that occurs in a predictable pattern) can undergo any dental procedure, patients with unstable angina (new chest pain or unpredictable chest pain) should not undergo elective (nonessential) dental procedures, and emergency dental care should be performed in a hospital or office equipped with cardiac monitoring capability.
Stroke

If you’ve had a stroke in the past, tell your dentist if you are taking anticoagulants (blood-thinning drugs). These medications could result in excessive bleeding during some oral surgery procedures.

If your stroke has impaired your ability to produce an adequate amount of saliva, your dentist may recommend the use of artificial saliva. If your stroke has affected your face, tongue, or dominant hand and arm, your dentist may also recommend use of fluoride gels, modified brushing or flossing techniques, and strategies others can use to assist you in maintaining good oral hygiene.
Oral Health and Heart Failure

Some medications used to treat heart failure (such as diuretics, or water pills) can also cause dry mouth. Ask your dentist about dry mouth treatments, including the use of artificial saliva.

Points to Remember About Dental Care and Heart Disease

    Give your dentist a complete list of the names and dosages of all the drugs you are taking for your heart condition (as well as any other prescription or nonprescription drugs that you may be taking). This will help your dentist decide on the best treatment course for you including medication selection for dental procedures.
    Give your dentist the name and phone number of your doctor(s) in case your dentist needs to speak to him or her about your care.
    If you are particularly nervous about undergoing a dental procedure as a result of your heart condition, talk with your dentist and heart doctor. Your doctors can provide you with information and work with you on strategies for controlling dental pain and easing your fears.


Is There a Link Between Periodontal Disease and Heart Disease?

Various researchers and government agencies continue to investigate the possible relationship between gum (periodontal) disease and heart disease. Some researchers speculate that bacteria in the mouth that are involved in the development of gum disease move into the bloodstream and cause inflammation in the blood vessels - changes that in turn contribute to heart disease and stroke.

Numerous studies are being conducted that both support and ute the possible link between these two diseases. One study, published in Stroke: Journal of the American Heart Association, found that people who had fewer than 25 teeth at the start of the 12-year trial (teeth loss is the ultimate end result of untreated gum disease) had a 57% greater risk of stroke compared with patients who had 25 or more teeth.

Another study involving over 4,000 patients and 17 years of follow up showed no evidence of a decreased risk of coronary heart disease if chronic gum disease was eliminated. Based on these results, these researchers speculate that the relationship between gum disease and an increase in cardiovascular risk is coincidental and not causal (that is to say that gum disease does not cause coronary heart disease).

The true role, if there is one, between gum disease and heart disease remains to be determined.

Where do you get your protein? If its from red meat (steak and pork), processed meat (bacon and salami), and high-fat dairy foods, it may be increasing your risk of fatal and non-fatal heart attack.

That was the finding of a recent assessment of the very large Nurses Health Study which followed over 84,000 women for 26 years.¹

It found:

• Higher intakes of red meat, red meat excluding processed meat, and high-fat dairy were significantly associated with elevated risk of coronary heart disease (CHD).
  
  
• Higher intakes of poultry, fish, and nuts were significantly associated with lower risk.

And concluded:

"These data suggest that high red meat intake increases risk of CHD."

The study was unique in that it investigated how substituting one source of protein for another, e.g. nuts, fish, or poultry for red meat, affects heart disease risk. It found, for example, that substituting one serving of nuts for one serving of red meat reduced CHD risk by 30%; substituting a serving of fish for red meat reduced it by 24%.

Although the study was conducted on women, the researchers say men are likely to benefit from the findings as well.

Lead author of the study, Adam Bernstein:

"Our research adds to the growing and convincing body of evidence that red meat intake should be minimized or excluded from the diet in order to maintain cardiovascular health."

________
¹Major Dietary Protein Sources And Risk Of Coronary Heart Disease In Women, Circulation, August 2010

Shifting Protein Sources Away From Red Meats May Reduce Risk Of Heart Disease In Women, Harvard School of Public Health, Press Release, August 2010

Now that 2011 is gone, this is a good time for the Disease Management Care Blog pause and take stock. How is it doing?

It likes to think of itself as a unique ongoing journal club on the organization, delivery and financing of health care.  If the DMCB was soup, thered be three ingredients:

1) reliance, whenever possible, on peer-reviewed and published evidence,

2) a physicians "real world" experience and

3) a ready dash of skeptical humor.

The DMCB must be doing something right.  Despite a narrow mix of medical science, economics, effectiveness and policy, the DMCB has attracted a relatively large and elite readership.  If youre reading this, that means you. 

Sophistication

When it looks at the ISPs of its many return visitors, the DMCB sees dozens of academic institutions, big and small name news media outlets, publishing houses, trade associations, information technology businesses, Congress, CMS, the White House, state government, foundations, commercial insurers, hospitals, health care consulting organizations and population management service providers. Many are household names.

It doesnt stop there. The DMCB has been contacted by and gotten to know folks from all levels in the health care industry.  Based on those conversations, it knows this a smart group.  The author of this blog is a better person for it.

The DMCB knows each regular visitor, twitter follower and Google subscriber has been earned one person at a time. It knows its elite readers are knowledgeable, active or interested in health policy, population health management, the patient centered medical home or primary care. These are not casual readers.

And you have a lot of company:

According to Google Analytics mix of ISP addresses and cookies, DMCB Ver. 2011 had 29,000 unique visitors with 42,000 visits. A third were repeat (defined as more than one) visits.  While there is no definition of a "regular" reader, the number of visitors with more than 50 DMCB "hits" in 2011 numbered 5153. There were 786 visitors with more than 200 hits. 

The DMCB also has 416 Twitter followers.  According to TweetReach, the DMCB regularly reaches almost 1500 persons with its tweets.  Depending on re-Tweets, that number can exceed 7000. 

There are also 466 Google RSS subscribers. 

These 2011 numbers suggest there are thousands of persons that regularly read the DMCB.  Every individual visitor, follower and subscriber returned or opted-in based on the DMCB content and only the DMCB content. There is no marketing, emailing or use of any services to promote the DMCB. It doesnt have the advantage of a sponsoring institution or explicit link to a big-name business. And its readership continues to slowly grow.

The DMCB Web Juggernaut

The DMCB is regularly lected and linked in many prestigious web outlets, include HealthHombre, Health Affairs, KevinMD, Forbes, and many sister blogs. Its also appeared in the web sites of USAToday, Wall Street Journal, the Washington Post, Dartmouth Atlas, Business Week and the National Review. Its also been linked in the intranet web sites of many insurers, provider organizations, and health information tech companies.

And, by the way, according to YouTube, the DMCBs videos to date have had 33,486 views.

As testimony to its growing web presence, the DMCB is on the first page when the term "disease management" is Googled.  The DMCBs growing web traffic has ironically made its "Comments" section a target by spammers with links to its dubious medical web sites.  With only one unobtrusive Google "Ad" that generates pennies per click, it still got a check for $100 (prompting the derision of the DMCB spouse, but thats another post).  The DMCB has also been offered - and used - cash to provide link backs.  It also had one complaint lodged over copyright infringement over an image (the post has since been removed, with apologies).  Simply put, folks are paying attention.

Last but not least, the DMCB is proud of its four 2011 peer reviewed publications in Population Health Management, Self Care and the Journal of Comparative Effectiveness Research.

And a thank you....

... to the readers who have commented or emailed with feedback, comments and insights.  To the readers who use their precious time and keep coming back.

Measuring ROI

In yesterdays posting on Al Lewis book Why No One Believes the Numbers, the Disease Management Care Blog pointed out that the measurement of population health management (PHM) outcomes remains an inexact and still evolving science. While that can be a source of endless fascination for the DMCB, the inability of the industry to rustle up credible "return on investment" numbers has prompted some observers to condemn PHM as a waste of money.

The search for simple answers explains much of the appeal of this book.

According to author, one important solution is the "dummy year analysis" (DYA). This relies on repeated year-over-year measurements of utilization that use multiple comparison pairings of all patients with the condition of interest. When thats combined with a "plausibility" check list, Mr. Lewis says purchasers of the Patient Centered Medical Home (PCMH), disease management or wellness programs should be able to get a better fix on whether they saved any money. You can a sense of that perspective here.

The DMCB isnt too sure about that because a) other factors that have nothing to do with population health management can also impact utilization during and after the dummy years, making it difficult to assign an attributable ROI and b) entire health plan populations can likewise regress toward a regional or national mean.

The DMCB also sees three additional reasons why there may be less to this books methodology than meets the eye:

1. When employers, health plans, accountable care organizations or other buyers have a list of names that have been through a care program, they typically want to understand the outcomes for the individuals on that list. If thats the case, the challenge is to find an adequate comparator that portrays what would have happened in the absence of the care program. Multiple options for identifying a parallel comparator have been used in published science for decades. Thats difficult, imperfect, but not broken.  It remains an option.

2. While the book is replete with examples of "actuaries behaving badly," it is impossible to underestimate the influence of actuarial science and trending on premium rate setting, statutory accounting, and the regulation of insurance. As a result, if the actuaries say money is - or is not - being saved, health system leaders ignore their insights at their peril.

3. Isolating the impact of PCMH, disease management or wellness program out of all the other "noise" of a changing economy, evolving consumerism, benefit changes, electronic health record databases, medical advances, inflation and the news media is a function of an increasingly sophisticated and changing statistical sciences and computational technology. Its ironic, but one outcome has been a better description and measurement of the uncertainty surrounding a result.
 
To the authors credit, Why No One Believes the Numbers is not being promoted as the single best methodology that will lead PCMH, disease management and wellness programs to outcomes certainty. Rather, it is one option among many in asking whether a program had any financial impact.

Ultimately, theore, thats why the DMCB advises that measuring outcomes in PHM - absent an ironclad methodology - comes down to using multiple approaches to triangulate on the truth. After reading Why No One Believes the Numbers, some readers may choose it as one of those approaches.

Changing opinion from right to left

Has marriage made the Disease Management Care Blog a better person?

While it and the spouse heartily agree on the ultimate answer, using hard numbers to prove it to a skeptical mother-in-law is a different matter. To definitively answer the question, the affable DMCB came up with some proposed measurement approaches, such as:

1. Pre vs. Post: comparing past beer guzzling to present-day chardonnay sipping;

2. Actuarial: actual vs. projected appreciation for the leather-clad vampire vixens of Underworld;

3. Comparison to a Control: the DMCBs willingness to take direction on shrubbery trimming, versus that of more docile hubbies;

4. Randomized and Prospective: (the DMCB has wisely opted to not go there).

While the DMCB continues to work on the complex methodology of marital outcomes, it is reminded of a key paradox: while we live in an "Information Age," other pressing questions - such as the extent of the Eurozones influence on GDP, the merits of vouchers in public education and the link between the Presidents approval rating and his governing by remote memo - likewise defy conclusive measurement.

Whats more, frustrated by our worlds complexity, we ironically want fewer answers. The DMCB suggests this search for simplicity partially explains the luster of a balanced budget amendment, laws on minimum medical loss ratios, Newts bombast, Obamas rhetoric, blanket coverage of birth control and, last but not least, single approaches to assessment of population-based programs.

Which brings the DMCB to Al Lewis $10,000 challenge, in which he dares anyone to come up with a more accurate approach to measuring disease management return on investment. 

Al is a luminary in the disease management firmament who leads the Disease Management Purchasing Consortium. He was there at the founding of the Disease Management Association of America, led the attack on the vendors past lazy outcomes reporting and has been instrumental in questioning the conclusions about North Carolinas Medical Home Program. He now claims to offer the only approach to accurately measuring the financial impact of disease and population health management.

Maybe, but the DMCB would like to humbly offer up an alternate perspective.

Check out this DMCB paper that simultaneously deployed three uncomplicated methodologies to assess the claims expense impact of a chronic heart failure disease management program. While all three gave different answers, they all pointed in the same direction.

That was enough for the DMCB boss to continue the programs funding.

This same overlapping and multi-layed approach also underlies the Care Continuum Alliances Outcomes Guidelines Reports, which recommend a suite of measurement approaches that pivot on important determinants such as population characteristics, the influence of confounders as well as bias and the resources available to answer the question.

None of this should be any surprise to seasoned and prudent health administrators, physician leaders, clinical program architects or DMCB readers. They know that good actuaries use complimentary and overlapping approaches to come up with the right premium. They understand that good medical researchers demand caution, skepticism and multiple research studies before reaching any conclusions.

In other words, there is no one-time and one-size fits all approach in outcomes assessment.

All this adds up to the fact that optimum outcomes measurement triangulates on the truth. The measurement approaches advocated by the DMCB, Care Continuum Alliance members and health system leaders have been around for years, are within the reach of standard statistical software, are familiar to researchers and are highly adaptable to the circumstances of 99.99% of disease management programs, not to mention the medical home and accountable care organizations.

The DMCB says that when multiple, competing, overlapping, repeated and adaptable measurement methodologies point in the same direction, thats when regulators, consumers, purchasers, buyers, providers and patients and mothers-in-law can be really confident that they have the answer they need.

Image from Wikipedia

The Disease Management Care Blog is reconsidering the wisdom of agreeing to host the Cavalcade of Risk #140. The links below are a unpleasant reminder that disasters are lurking everywhere and that there is no escape.  Being a contrarian physician-blog that dwells on health care and insurance, your DMCB was confident that it could intellectually digest the topics below.  After writing this Cav of ubiquitous hazards, however, the DMCB now wants to digest some Xanax and PeptoBismol.

Who knew that so much could go so wrong out there?

Ever heard of the "Terrorism Risk Insurance Act" (TRIA) of 2002?  Neither has the DMCB, but readers can learn more about it at the Insurance Regulatory Law Blogs post on Quantifying the Unquantifiable: Some Perspective on Terrorism Risk.  It turns out the U.S. government is providing "reinsurance" (insurers can buy their own insurance) for a host of commercial companies that have to deal with a threat that is hugely expensive, quite rare and non-random, which is the very antithesis what the usual market needs to function well.  And by the way, TRIA is set to expire 2014 and it looks like it may not be renewed.  Seems some sort of budget issue has come up.

If being reminded about terrorism isnt enough to rattle you, how about cyberwar?  Thats tackled by the Risk Management Monitor Blog in this post on how UK Infrastructure Providers Accept an Unexpectedly High Level of Risk of Cyber-Threats, and the National Response Is Fractured and Incoherent.  It appears, lacking a coordinated response by their government, that the Brits businesses and banks have decided to deal with this risk on their own.  Unfortunately, theyre not dealing with it very well.  Not only have some companies been slow off the mark, others have decided to accept the inevitability of an intrusion and plan on simply dealing with it then.  How many other key industries worldwide have adopted the same cavalier attitude, asks the DMCB?

Terrorism, cyber attacks.... its enough to make the DMCB flee to the country and seek sanctuary on a farm and live simply off the land.  But wait, even that isnt safe, because Lynch Ryans Workers Comp Insider Blog points out that the risk of getting trapped, suffocated or crushed in a grain bin is increasing.  In response, the National Grain and Feed Association has a video on one more reason why our nations farmers deserve a lot of respect.  The DMCB thinks it deserves to flee back to the suburbs.

So it might be best to stay safe and stay at home, right?  Well, if you have a mortgage on that home, the canadianfinanceblog warns that your sneaky bank may try to to sell you "mortgage life insurance."  It turns out this may be a lousy deal, since the premium may not change even as the balance on the mortgage declines.  Better to get standard term life policy.  And when youve done that, you can scrutinize the rest of that small print in the mortgage documents that you signed for some other unpleasant surprises.

After you read all that fine print and discover what youve unwittingly agreed to, you may want to think about property losses from hurricanes, floods, tornadoes and earthquakes. Yes, you can buy a specific insurance policy for each of those possibilities, says the Free From Broke Blog.  On the other hand, given how uncommon hurricanes, tornadoes and earthquakes are, it may make more sense to invest in a sump pump and simply stash away an emergency fund.  The DMCB followed that game plan during the recent flooding from Tropical Storm Lee and now needs a basement mold mitigation fund and a get-rid-of-wet-carpets fund.

Plus, you may want to get "home insurance" against the possibility of a loss from a robbery.  Unfortunately, says the My Personal Finance Journal Blog, the cousins across The Pond are grappling with a daily toll of more than $3.5 million in home insurance fraud.  As a result, the DMCB calculates that honest home owners there are unnecessarily having to add a hidden tax of $1 for every $3 in insurance.

While youre putting bars on your home windows and barricading the doors, it may be smart to take that money out from under that mattress and seek some investment income, right?  If thats your plan, you may want to check out this "101" posting on the fundamentals of investment risks posted at The Financial Literates Blog.  How many things can go wrong, you ask?  "Fifteen" says the FLB!

Or if you want to avoid those 15 dreaded errors, how about an "annuity?"  This lengthy post by the Free Money Finance Blog on Why Do We All Hate Annuities explains that the fine print is perplexing, the sellers are a shady lot, their fees are high, the company (like AIG) could go belly-up, you lose control of your money and theyre still a big gamble.  One option is "laddering."  Another option, says the DMCB, is digging a hole and stashing away some precious metals.

While being attacked, hacked, crushed, ripped off or making a bad investment bet is a possibility, at least we Americans have an enlightened government that is helping us buy health insurance, right?  Think again, says Louise of the Colorado Health Insurance Insider.  She points out the feds online "healthcaredotgov" web site can be misleading.  It appears that the site reports blunt pricing underwriting statistics that fail to capture what is really going on.  While Louise makes the point that brokers can help customers navigate this complicated marketplace, the DMCB thinks that the healthcaredotgov website is a telling lection of the unsophistication of Washington DCs health insurance bureaucrats.  Good grief, and these amateurs actually want to be in charge.

Maybe you should take charge, then, and confront the risk that you may come down with a debilitating, crippling and non-curable condition and need long term insurance.  The curiously named High Yield Savings Accounts Blog  offers up a check list of what to look for in such a policy, such as excluded services, maximum lifetime benefit terms, riders and renewable guarantees.

While were struggling with hazards, perils, dangers, disasters, terrorism and disease, Hank Stern over at the Insure Blog suggests there is a way out from all this danger, at least for the fairer sex. Women may want to have a mid-day tipple because another observational study has shown that there is an association between imbibing and well being.  To that, the DMCB says "Cheers!" and points out if you end up in the hospital anyway, your physicians will know what to do.

"Gulp!" says the DMCB.  While it likes the idea of imbibing to support the DMCB spouses continuing good health, it thinks it should also look into buying an electric generator, firearms and a years stash of fresh water and vacuum-packed ready-to-eat meals.  While its doing that, itll be looking forward to Jay Norris of Insurance Shoppers hosting the next edition of the Cav.

But wheres the money?

The Disease Management Care Blog has always been leery of the "return on investment" (ROI) metric in health care. It knows that there are precious few health care interventions that actually "save" money. Many prevention, wellness and disease management programs     - depending on the analysis -  can cost money since they a) add additional resources to a system with already high fixed costs with b) a short one-year time horizon.

Yet, the good news is even if a program isnt successful in slowing the rate of cost inflation (or "bending the curve," which represents the savings), it can still represent a great value.  Thats because the additional benefit represents significant benefit for each additional dollar of spending.

Thats the message in this recent JAMA Viewpoint editorial Assessing Value in Health Care Programs authored by Kevin Volpp, George Loewenstein and David Asch. They offer up a thought experiment. Consider, they say, a state-of-the-art medication compliance campaign for heart attack victims that avoids a number of costly hospitalizations.  The price tag at $2000 has a positive "ROI" because the investment is less than the avoided cost of the hospitalizations.  However, if the price tag is $3000 and the investment is now greater than the cost of the hospitalizations, the ROI is "negative" even though the same number of patients didnt have to be hospitalized.

The DMCB recommends readers keep this manuscript/link handy the next time some Finance weenie demands an "ROI calculation."

Speaking of readers, the DMCB is happy to announce that it just hit 500 Twitter followers.  Thats in addition to more than 500 "RSS" subscribers, 461 Google Reader subscribers and thousands of return visitors per month.  The DMCB knows each was earned one person at a time.

Study Highlights:

*Visible signs of aging may predict your risk of heart disease.

*A receding hairline, baldness, earlobe crease and yellow fatty deposits on the eyelids were among signs of aging associated with an increased risk of heart disease.


If you look old, your heart may feel old, according to research presented at the American Heart Association’s Scientific Sessions 2012.

In a new study, those who had three to four aging signs — receding hairline at the temples, baldness at the head’s crown, earlobe crease, or yellow fatty deposits around the eyelid (xanthelasmata) — had a 57 percent increased risk for heart attack and a 39 percent increased risk for heart disease .

“The visible signs of aging lect physiologic or biological age, not chronological age, and are independent of chronological age,” said Anne Tybjaerg-Hansen, M.D., the study’s senior author and professor of clinical biochemistry at the University of Copenhagen in Denmark.

Researchers analyzed 10,885 participants 40 years and older (45 percent women) in the Copenhagen Heart Study. Of these, 7,537 had frontoparietal baldness (receding hairline at the temples), 3,938 had crown top baldness, 3,405 had earlobe crease, and 678 had fatty deposits around the eye.

In 35 years of follow-up, 3,401 participants developed heart disease and 1,708 had a heart attack.

Individually and combined, these signs predicted heart attack and heart disease independent of traditional risk factors. Fatty deposits around the eye were the strongest individual predictor of both heart attack and heart disease.

Heart attack and heart disease risk increased with each additional sign of aging in all age groups and among men and women. The highest risk was for those in their 70s and those with multiple signs of aging.

In the study, nurses and laboratory technicians noted the quantity of gray hair, prominence of wrinkles, the type and extent of baldness, the presence of earlobe crease and eyelid deposits.

“Checking these visible aging signs should be a routine part of every doctor’s physical examination,” Tybjaerg-Hansen said.

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