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It's Almost Thanksgiving Do You Know Where Your Next Job Is?

Sat, 21 Nov 2009 12:20:58 -0800

Can Linkedin Company Pages Help You Find Unadvertised Positions?

Sat, 21 Nov 2009 12:16:41 -0800

Have you Been Affected by the Holiday Effect?

Thu, 19 Nov 2009 18:19:10 -0800

Whos Hiring – Top employers week of 11-16-09

Tue, 17 Nov 2009 20:27:49 -0800

How to Care for Someone at Home Who Has Swine Flu

PRNewswire-USNewswire — Tue, 17 Nov 2009 11:19:00 -0800

If you are taking care of someone at home who has H1N1 (swine) flu, it is important for you to prevent other people in the house from getting sick, according to Gary Kalkut, MD, MPH, Senior Vice-President, Chief Medical Officer of Montefiore Medical Center. Dr. Kalkut and his colleagues at Montefiore offer the following information and advice on preventing illness during this flu season.

One of the easiest ways people can protect themselves, their family, and others from getting sick is to clean their hands.

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Use soap and water or an alcohol-based hand rub to prevent getting sick:

-Especially after coughing and sneezing.

-After every contact with the sick person.

-Even after handling the sick person's room or bathroom or their dirty
laundry.

Who can take care of someone with the flu?

-If possible, only one adult in the home should take care of anyone who
is sick. Try not to have people with the flu care for infants.

-People most at risk for flu (pregnant women, those with chronic
disease or immune issues) should not take care of people with the flu,
if possible.

Caring for someone with the flu:

-Try to keep the sick person from breathing, sneezing or coughing close
to your face. If close contact with a sick individual can't be helped,
think about wearing a mask to cover your nose and mouth.

-Try to keep the sick person in a separate room with the door closed.
Keep the sick person away from other people as much as possible,
especially others who are at high risk of getting sick from the flu.

-The sick person should not have visitors. A phone call, e-mail or text
message is safer than a visit.

-Do not eat food from dishes and glasses being used by someone who is
sick. Dishes and glasses used by a sick person can be washed with the
family's dishes.

-Use separate cloth towels for each person in the household for
bathing. Wash bed sheets and towels by using household laundry soap.
Dry clothes on a hot setting. Avoid putting laundry used by sick
family members against your body before washing it.

-Keep areas that can be covered by germs clean by wiping them down with
a household cleaner daily. These areas include:

-Bedside tables.

-The bathroom.

-Door knobs.

-Toys.

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Managing coughing and sneezing

-When holding small children who are sick, place their chin on your
shoulder so they will not cough in your face.

-Throw away tissues and other throw-away items used by the sick.

-If possible, maintain good air flow in shared areas of the home. Open
windows in the kitchen and bathroom for a short time to bring in fresh
air.

Using medications

If someone already has flu symptoms, over-the-counter cold and flu medications may help. These medications lessen some symptoms such as cough and congestion. Over-the-counter medications may help the sick person to feel better. A sick person can still make others sick up to 24 hours after their symptoms stop and they have stopped taking medication.

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-Children 5 years of age and older and teenagers with the flu can take
medicines without aspirin to ease symptoms. These include
acetaminophen (Tylenol(R)) and ibuprofen (Advil(R), Motrin(R),
Nuprin(R)).

-Do not give over-the-counter cold medicines to children 4 years old
and younger without first speaking with a health care provider. In
children 2 and younger, use a cool mist humidifier and a suction bulb
to help clear any mucus.

-Warning! Do not give aspirin (acetylsalicylic acid) to children or
teenagers who have flu-like illness. Aspirin can cause a rare but
serious illness called Reye's syndrome. Check ingredient labels on
over-the-counter cold and flu medicines to see if they have aspirin.
If they do, do not use these medicines.

-In adults, fevers and aches can be treated with acetaminophen
(Tylenol(R)) or ibuprofen (Advil(R), Motrin(R), Nuprin(R)), or
nonsteroidal anti-inflammatory drugs (NSAIDS). Adults with kidney
disease or stomach problems should check with their health care
provider before using these medications.

Antiviral medicines may help with flu symptoms, but you will need a prescription. Most people with the flu do not need these antiviral drugs to get better. Some people at higher risk for severe flu complications might benefit from antiviral medications.

Influenza infections can lead to, or occur with, bacterial infections. Some people may need to take an antibiotic. More severe illness or illness that seems to get better, but then gets worse again, may be a sign that a person has a bacterial infection. Check with your health care provider if you have concerns.

Lifestyle Could Reduce Cancer by Two-Thirds

United Press International — Tue, 17 Nov 2009 11:02:00 -0800

U.S. health experts say about two-thirds of cancers could be prevented via lifestyle changes.

The Mayo Clinic researchers explain in their Special Report on Cancer Prevention in the November issue of Mayo Clinic Women's HealthSource says maintaining proper weight by eating a healthy, low-fat diet and by stepping up moderate to vigorous physical activity to 45 to 60 minutes almost daily might reduce one-third of cancer deaths.

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Another one-third of the 560,000 yearly U.S. cancer deaths are related to tobacco exposure and they advise deciding to not smoke or if a smoker, to quit, the researchers says.

In addition, other ways to reduce cancer risk include limiting exposure to alcohol -- women should have no more than one alcoholic beverage a day and men, no more than two -- and ultraviolet radiation from the sun or tanning beds.

Everyone needs to get screening tests such as Pap tests, mammograms and colonoscopies -- to help find cancer early when successful treatment is most likely treated, the report says.

Infections caused by viruses are recognized as risk factors for several types of cancer. For example, human papillomavirus, a sexually transmitted disease, is the most common cause of cervical cancer and chronic hepatitis B and hepatitis C increase the risk of liver cancer.

Twins Joined at Head Successfully Separated

Associated Press/AP Online — Tue, 17 Nov 2009 10:50:00 -0800

MELBOURNE, Australia — A team of 16 surgeons and nurses successfully concluded 25 hours of delicate surgery Tuesday to separate twin Bangladeshi girls who had been joined at their heads, sharing blood vessels and brain tissue.

It is too early to know whether the two-year-old girls, Trishna and Krishna, suffered any brain damage during the marathon operation — an outcome doctors said had a 50-50 chance. The girls will remain in an induced coma for monitoring for several days after the completion of the surgery.

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The medical team began the work Monday morning on separating the girls, who were brought to Australia as infants by an aid organization.

"The teams managed to separate their brains and they are both very well," Royal Children's Hospital chief Leo Donnan told reporters. "Now we have the long task of the reconstructive surgery, which will go on for many hours."

Plastic surgeons finished reconstructing the girls' skulls using a combination of their own skin, bone grafts and artificial materials about five hours after the separation surgery ended.

"Their bodies have to recover from this, and we've got a lot of unknown territory we're moving into," Donnan said. "All I can say is that everything is in place for the best possible outcome. The main thing is that the girls are healthy."

Earlier Tuesday, Ian McKenzie, a member of the surgical team, said the girls were improving as their bodies began to work individually.

"The twins are actually in better condition because the degree of separation has increased and this problem we've had with their circulation affecting each other has actually gotten less," he said.

The girls shared parts of their skull, brain tissue and blood flow.

Before the surgery, doctors had said there was a 50 percent chance the girls could suffer brain damage and a 25 percent chance one of the sisters would die.

They were found in an orphanage in Bangladesh in 2007 by a representative from the Children First Foundation, who brought to them to Australia.

New Advice: Skip Mammograms in 40s, Start at 50

Associated Press/AP Online — Tue, 17 Nov 2009 10:32:00 -0800

NEW YORK - Most women don't need a mammogram in their 40s and should get one every two years starting at 50, a government task force said Monday. It's a major reversal that conflicts with the American Cancer Society's long-standing position.

Also, the task force said breast self-exams do no good and women shouldn't be taught to do them.

For most of the past two decades, the cancer society has been recommending annual mammograms beginning at 40.

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But the government panel of doctors and scientists concluded that getting screened for breast cancer so early and so often leads to too many false alarms and unneeded biopsies without substantially improving women's odds of survival.

"The benefits are less and the harms are greater when screening starts in the 40s," said Dr. Diana Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies.

But Susan Pisano, a spokeswoman for America's Health Insurance Plans, an industry group, said insurance coverage isn't likely to change because of the new guidelines. No changes are planned in Medicare coverage either, said Dori Salcido, spokeswoman for the Health and Human Services department.

Experts expect the task force revisions to be hotly debated, and to cause confusion for women and their doctors.

"Our concern is that as a result of that confusion, women may elect not to get screened at all. And that, to me, would be a serious problem," said Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer.

The guidelines are for the general population, not those at high risk of breast cancer because of family history or gene mutations that would justify having mammograms sooner or more often.

The new advice says:

-Most women in their 40s should not routinely get mammograms.

-Women 50 to 74 should get a mammogram every other year until they turn 75, after which the risks and benefits are unknown. (The task force's previous guidelines had no upper limit and called for exams every year or two.)

-The value of breast exams by doctors is unknown. And breast self-exams are of no value.

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Medical groups such as the cancer society have been backing off promoting breast self-exams in recent years because of scant evidence of their effectiveness. Decades ago, the practice was so heavily promoted that organizations distributed cards that could be hung in the shower demonstrating the circular motion women should use to feel for lumps in their breasts.

The guidelines and research supporting them were released Monday and are being published in Tuesday's issue of the Annals of Internal Medicine.

The new advice was sharply challenged by the cancer society.

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"This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over," the society's chief medical officer, Dr. Otis Brawley, said in a statement.

The task force advice is based on its conclusion that screening 1,300 women in their 50s to save one life is worth it, but that screening 1,900 women in their 40s to save a life is not, Brawley wrote.

That stance "is essentially telling women that mammography at age 40 to 49 saves lives, just not enough of them," he said. The cancer society feels the benefits outweigh the harms for women in both groups.

International guidelines also call for screening to start at age 50; the World Health Organization recommends the test every two years, Britain says every three years.

Breast cancer is the most common cancer and the second leading cause of cancer deaths in American women. More than 192,000 new cases and 40,000 deaths from the disease are expected in the U.S. this year.

Mammograms can find cancer early, and two-thirds of women over 40 report having had the test in the previous two years. But how much they cut the risk of dying of the disease, and at what cost in terms of unneeded biopsies, expense and worry, have been debated.

In most women, tumors are slow-growing, and that likelihood increases with age. So there is little risk by extending the time between mammograms, some researchers say. Even for the minority of women with aggressive, fast-growing tumors, annual screening will make little difference in survival odds.

The new guidelines balance these risks and benefits, scientists say.

The probability of dying of breast cancer after age 40 is 3 percent, they calculate. Getting a mammogram every other year from ages 50 to 69 lowers that risk by about 16 percent.

"It's an average of five lives saved per thousand women screened," said Georgetown University researcher Dr. Jeanne Mandelblatt.

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Starting at age 40 would prevent one additional death but also lead to 470 false alarms for every 1,000 women screened. Continuing mammograms through age 79 prevents three additional deaths but raises the number of women treated for breast cancers that would not threaten their lives.

"You save more lives because breast cancer is more common, but you diagnose tumors in women who were destined to die of something else. The overdiagnosis increases in older women," Mandelblatt said.

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She led six teams around the world who used federal data on cancer and mammography to develop mathematical models of what would happen if women were screened at different ages and time intervals. Their conclusions helped shape the new guidelines.

Several medical groups say they are sticking to their guidelines that call for routine screening starting at 40.

"Screening isn't perfect. But it's the best thing we have. And it works," said Dr. Carol Lee, a spokeswoman for the American College of Radiology. She suggested that cutting health care costs may have played a role in the decision, but Petitti said the task force does not consider cost or insurance in its review.

The American College of Obstetricians and Gynecologists also has qualms. The organization's Dr. Hal Lawrence said there is still significant benefit to women in their 40s, adding: "We think that women deserve that benefit."

But Dr. Amy Abernethy of the Duke Comprehensive Cancer Center agreed with the task force's changes.

"Overall, I think it really took courage for them to do this," she said. "It does ask us as doctors to change what we do and how we communicate with patients. That's no small undertaking."

Abernethy, who is 41, said she got her first mammogram the day after her 40th birthday, even though she wasn't convinced it was needed. Now she doesn't plan to have another mammogram until she is 50.

Barbara Brenner, executive director of the San Francisco-based Breast Cancer Action, said the group was "thrilled" with the revisions. The advocacy group doesn't support screening before menopause, and will be changing its suggested interval from yearly to every two years, she said.

Mammograms, like all medical interventions, have risks and benefits, she said.

"Women are entitled to know what they are and to make their best decisions," she said. "These guidelines will help that conversation."

Whos Firing - Layoffs week ended 11-13-09

Mon, 16 Nov 2009 10:40:31 -0800

Whos Hiring – Top employers week of 11-9-09

Sun, 15 Nov 2009 15:55:41 -0800

How Can Linkedin's New Features Help Job Seekers?

Sun, 15 Nov 2009 15:51:04 -0800

5 Ways Social Media Gives Job Seekers an Advantage in a Recession

Sun, 15 Nov 2009 15:48:05 -0800

Experts: Placebo Power Behind Many Natural Cures

Associated Press | AP Online — Wed, 11 Nov 2009 13:59:00 -0800

People looking for natural cures will be happy to know there is one. Two words explain how it works: "I believe."

It's the placebo effect - the ability of a dummy pill or a faked treatment to make people feel better, just because they expect that it will. It's the mind's ability to alter physical symptoms, such as pain, anxiety and fatigue.

In just the past few weeks, the placebo effect has demonstrated its healing powers. In tests of a new drug to relieve lupus symptoms, about a third of patients felt better when they got dummy pills instead of the drug.

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The placebo effect looms large in alternative medicine, which has many therapies and herbal remedies based on beliefs versus science. Often the problems they seek to relieve, such as pain, are subjective.

"It has a pejorative implication - that it's not real, that it has no medicinal value," said Dr. Robert Ader, a psychologist at the University of Rochester in New York who has researched the phenomenon.

But placebos can have real and beneficial effects, he said.

"Much of the results of certain alternative procedures are largely placebo effects, unless you believe there are people who exert magical powers so they can hold their hands over your body and cure you of disease," Ader said. "Make you feel better? That's entirely possible, especially if you believe it."

The placebo effect accounts for about a third of the benefits of any treatment - even carefully tested medicines, scientists say. This dates to a landmark report in 1955 called The Powerful Placebo. Viewed as groundbreaking, the analysis of dozens of studies by H.K. Beecher found that 32 percent of patients responded to a placebo.

Later studies found that dummy pills could raise pulse rates, blood pressure and reaction speed when people were told they had taken a stimulant; the opposite occurred when people were told that a drug would make them drowsy.

How does it work? Scientists do not always know, but there are many possible ways. Brain imaging shows that beliefs ("I know these pills will help") can cause biological changes and affect levels of chemical messengers and stress hormones that signal pain or pleasure.

Emotions, too, can trigger physical changes. Take the case of a child with croup. Crying tightens the airways and makes it tougher to breathe. Many people believe that cool mist is helpful, but when it has been tested in hospital studies with croup tents, it has not been found to help, said Dr. Owen Hendley, a pediatrician at the University of Virginia.

Try it at home, though, and you may get a different result.

"The child sits in the lap of the mother and the mother holds the mist maker close to the child. The child settles down, the mother settles down. The setting, and the mother feeling that it is helping, makes everybody calmer," and the child actually is able to breathe better, Hendley explained.

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If it were not for the placebo effect, "physicians would not be nearly as successful as we are," said Dr. Thomas Schnitzer, a Northwestern University arthritis specialist. He helped lead a big study that found glucosamine and chondroitin supplements were no better than dummy pills for arthritic knee pain.

Doctors sometimes exploit the placebo effect to help patients. One survey found that many doctors admitted sometimes giving patients sugar pills or drugs or vitamins that would not really help their condition, in an effort to trigger a placebo effect.

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In Baltimore, the University of Maryland Medical Center's shock trauma center is offering some patients Reiki therapy, which claims to heal through invisible energy fields manipulated by a special "master." The hospital's anesthesia chief, Dr. Richard Dutton, says it is self-hypnosis and compares it to Lamaze classes that teach pregnant women breathing exercises to take their minds off the pain of labor.

Roy A. Armstrong's family agreed to it after he was injured in a motorcycle crash last year. The 39-year-old suffered cardiac arrest and had many broken bones. As he lay tethered to a breathing machine, nurse Donna Audia and a partner circled his bed, waving their arms through the air and touching his head while humming and making tunes by rubbing a crystal bowl with a wand.

Armstrong was too sedated to remember anything, but "I think in some way it helped him to get better," his wife said. He is still recovering through physical therapy.

Dutton said: "You can call it a placebo effect, you can call it a chicken soup effect. It's all about creating the right mental state in the person. The patients tell us they seem to like it. And in pain management, that's the whole goal. If 30 percent of your patients get better on placebo, why not give it to them?"

Swear-by-it stories and anecdotal reports of benefit are one thing. Proving a treatment helps is quite another. Many alternative medicine studies have not included a placebo group - people who unknowingly get a dummy treatment so its effect can be compared.

Acupuncture is especially hard to research. Positive studies tend to lack comparison groups that have been given a sham treatment. Or they are often done in China, where the treatment is an established part of health care.

One U.S. study found that true acupuncture relieved knee arthritis pain better than fake acupuncture, in which guide tubes were placed but no needles were inserted. But a European study involving twice as many patients and using a more realistic sham procedure found the fake treatment to be just as good. The conclusion: Pain relief was due to the placebo effect.

Advertisements and testimonials from product users can encourage a placebo effect. The Federal Trade Commission last summer reached a settlement over advertising claims for Airborne, a product "invented by a teacher" that was supposed to ward off germs spread through the air.

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"Products like Airborne are what we call `credence products.' That's a fancy word for saying it's difficult or impossible for consumers to determine if the product has done anything for them," said commission lawyer Rich Cleland. "Part of that is because of the placebo effect. Part of that is because people don't want to believe they've been ripped off."

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Barbara Domen, a former kindergarten teacher in Caswell Beach, N.C., said she was prone to colds and used Airborne six or seven times a year when she flew on planes.

"It worked for me," although it could be because since she retired, "I'm away from all the germs," she said. She skipped it on one flight and caught a terrible cold.

"Maybe it's psychological, but I think I'll continue to use it," she said.

Some placebo effects are due to conditioning, or ascribing benefits to something you did that may in fact have played no role in your improvement. Insomnia is an example, said Michael Perlis, a psychologist and neuroscientist at the University of Pennsylvania.

If you have trouble sleeping one night, your body's need for sleep makes it very likely you'll sleep well the next night. If you take a sleeping pill, you think you slept well because of the pill, he said.

Do any herbal remedies work for insomnia? "Not that I know of," Perlis said. "But all of them have potential to be useful with time. It has nothing to do with them - it has everything to do with conditioning."

Poll: Only One-Third Able to Get Swine Flu Vaccine

Associated Press | AP Online — Wed, 11 Nov 2009 13:45:00 -0800

ATLANTA - Only about a third of adults who have tried to get a swine flu vaccine have been able to get it, according to a new national poll released Friday.

That's true even for people who are at extra risk for severe complications and should be at the front of the line. The numbers are about the same for parents who tried to get the vaccine for their children, the Harvard School of Public Health poll found.

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Swine flu vaccine has been available in the United States for about a month, but supplies have been limited because of manufacturing delays. However, availability is picking up, said Dr. Anne Schuchat of the Centers for Disease Control and Prevention. About 38 million doses of swine flu are currently available, a one-week increase of about 11 million doses. Another 8 million doses are expected next week, she added.

Overall, the poll found about 80 percent of the adults in priority groups said they haven't tried to get it yet and 60 percent of parents haven't sought it out for their kids.

The Harvard telephone poll surveyed about 1,000 adults last weekend. The margin of error was plus or minus 3.8 percentage points.

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Many of the poll's findings seemed consistent with what the government has been hearing and seeing, said CDC officials. Nearly a third of Americans who tried and failed to get vaccine said they were very frustrated, the poll found, and that frustration has been evident at long lines at vaccination clinics.

But it was encouraging to see that nine in 10 people who couldn't get vaccine will try again, said Schuchat, who heads the CDC's National Center for Immunization and Respiratory Diseases.

The poll also found:

- About 5 percent of those surveyed said they'd been vaccinated.

- About 60 percent said there were swine flu vaccine shortages in their community.

- About half who tried couldn't find information about where to get the vaccine.

Because of limited supplies, there have been situations in which vaccine went to doctor's offices or clinics intended for children or other priority groups and it wasn't publicized, Schuchat said.

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"When you have limited supply, advertising is difficult. You don't want to frustrate the demand," Schuchat said at a Friday press conference in Atlanta.

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Swine flu is currently widespread in 48 states; Hawaii and Mississippi are the exceptions. Mississippi dropped off the list this week, reflecting that flu activity seems to be waning in some parts of the Southeast.

CDC officials said 129 children have died from swine flu complications since the virus was first identified in April. About two-thirds of them had other health conditions, like asthma or neurological problems like cerebral palsy or muscular dystrophy. The government does not keep a close count of all swine flu deaths, but estimates the number is above 1,000. Many millions of Americans have been infected with the virus, though most suffered only mild illness, health officials say.

Doctors Embrace Social Networking Technology

The Miami Herald — Wed, 11 Nov 2009 13:39:00 -0800

In the waiting room, the patient's family members circled a Blackberry. About every 15 minutes, Dr. Carlos Wolf of Miami Plastic Surgery gave them a few keystrokes of information about how the patient was doing.

"M is asleep," one of Wolf's nurses typed at 9:13 a.m. on June 3. "We will start surgery soon."

Less than an hour later, the nose job was complete.

"Beautiful," the nurse typed. "She's going to love it."

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Twitter, Facebook and YouTube aren't just for entertainment anymore. Wolf and doctors around South Florida and the rest of the country are using the social networking tools to bring patients' families and the general public into operating rooms, sometimes sharing step-by-step medical procedures. They favor the real-time updates and videos as a way to reduce the fear factor of surgeries and educate people about the realities of certain procedures, especially new ones.

Earlier this year, surgeons at a Detroit hospital used Twitter to report the blow-by-blow steps of an operation to remove a kidney tumor. In any given month at JFK Medical Center in Atlantis, Dr. Beth-Ann Lesnikoski likes to use Twitter as an educational tool during surgeries to treat breast cancer. Last month, anyone with Internet access could watch live as Dr. Harlan Selesnick repaired a knee ligament at Doctors Hospital in Coral Gables, courtesy of the Baptist Health South Florida website, which posts webcasts of surgeries on a regular basis.

Some physicians, such as Dr. Camil Sader, a South Florida surgeon, have gone so far as to create their own iPhone apps.

BEDSIDE MANNERS

Wolf says he masks patients' identities by using just one of their initials, and the posts are vague enough that strangers may have trouble figuring out what kind of operation is being performed.

"At this point, it's really to make those patients, family and friends feel comfortable," says Wolf, who has been practicing for more than 20 years. "We don't have a two-way conversation. The most important thing is for me to concentrate on what I'm doing."

And if something were to go wrong in surgery? Wolf says he or a nurse would step out to speak with the family -- just like in the past.

"People think of social media as being cold," says a South Florida mother whose teenage daughter lay on the table when Wolf performed his first surgical tweeting session. "Although I couldn't see it, I felt like I was close to my daughter. It's modern-day bedside manner."

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But not everyone is comfortable with physicians posting updates from the operating room -- especially when tweets and webcasts are available for public consumption.

"If it doesn't serve the patient, using it is unacceptable," says Dr. Erika Schwartz, an internist and medical director of the South Florida-based health insurance agency Cinergy Health. "Sometimes, we all get carried away with the novelty of something."

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Still, Schwartz has a Facebook page and encourages patients to communicate with her via e-mail. She says she has cut some of her patients' healthcare costs by answering questions electronically instead of requiring office visits.

"The Internet is a great opportunity to create a better connection between doctors and patients," Schwartz says. "I'm a big fan of social networking. It reaches people. There's a lot of information that can be shared. But it's got to be done with respect to the doctor-patient relationship."

When a patient sent her a medical question using Facebook, Schwartz says, she made a point not to answer it there.

At JFK Medical Center in Palm Beach County, Lesnikoski's inaugural tweets were designed to contrast the effect of breast cancer on a woman in her 40s and a woman in her 90s; she was operating on one of each that July day. The only information she revealed about the patients was their age.

Before the surgery, Lesnikoski prepared a series of facts about breast cancer that could be tweeted to her 70-plus followers, along with basic information about the surgery, from her account, drbethjfk.

Lesnikoski, who has a background as a medical educator, says every surgery is a highly prescribed process, so there are traditional stopping points that can be used to tweet without interrupting the operating team's concentration. She says the hospital is now looking into tweeting during surgery as a way to keep families informed about a patient's progress.

"Surgeries can last from 45 minutes to 2 1/2 hours," Lesnikoski says. "These families will get updates every 20 minutes. The patients we've done our focus groups with have loved this concept."

BRIEF IS BETTER

Dr. Donna Bilu Martin of South Beach Dermatology has been sharing skin facts and product information this year with her Twitter account followers. It's a compressed version of information she might send out in an e-mail -- but tweets don't clog up someone's inbox or get stuck in a spam filter.

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"We can do this without being annoying," says the dermatologist, who tweets under the user name drbilumartin.

"The risk of melanoma -- the most deadly form of skin cancer -- increased by 75 percent in people who started using sunbeds regularly before age 30," she tweeted last month.

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In another post, she shared information about a drug recently approved to hide wrinkles.

While Twitter identities are the latest tool in some doctors' medical bags, Dr. Camil Sader now considers his iPhone a medical necessity.

Sader, who specializes in laparoscopic surgery in Broward and Palm Beach counties, sometimes visits 180 patients at four hospitals in a single week. Tracking which patients he saw, their prognosis and other details about their care had become a paperwork nightmare.

When Sader couldn't find a simple and secure database program, he created one. It's an iPhone app called "Dr. Rounds" and it debuted in July. The information now stored in it can be formatted into an e-mail and be sent to his office manager for billing. Or it can be sent to other physicians watching over Sader's patients.

"It makes all the difference. At the end of the week, I press a few buttons and I get a report of what I did rather than shuffle through seven to 12 pieces of paper to see 'How many times did I see Mr. Smith?" " Sader says.

Health Care Bill Reignites Abortion Debate

Carolyn Lochhead | San Francisco Chronicle — Tue, 10 Nov 2009 15:22:00 -0800

Anti-abortion Democrats have reignited the national abortion wars with their victory Saturday on an amendment to House health care legislation that would prevent women from obtaining abortions through government-sponsored insurance or any plan that receives government subsidies.

Pro-choice and anti-abortion forces, each promising to mobilize the public, are girding for battle in the Senate, which aims to begin debate soon on its health care bill.

The amendment by Bart Stupak, D-Mich., passed 240 to 194, with backing from 64 Democrats, including Dennis Cardoza and Jim Costa from the Central Valley, and most Republicans. It expands an existing ban, known as the Hyde Amendment, on public funding for abortion.

The amendment would bar abortion coverage for women obtaining insurance through the "public option" of government-sponsored insurance. In addition, private companies that sell policies on the new exchanges envisioned in the bill could not offer abortion services if they accept federally subsidized policyholders.

Women with coverage through such exchanges could not use it for abortions even if they receive no federal subsidies. They would be allowed to purchase separate abortion policies, known as "riders," with their own money.

That option drew immediate fire from liberal pro-choice Democrats.

Rep. Jan Schakowsky, D-Ill., said it is "ridiculous" to expect women to buy separate policies for abortion coverage. "No one plans an unplanned pregnancy," she said.

Anti-abortion Democrats extracted a heavy price from ardently pro-choice House Speaker Nancy Pelosi, holding the mammoth $1.1 trillion health care legislation - a lifelong dream of party liberals - hostage to restrictions insisted upon by the National Conference of Catholic Bishops.

The bishops had sent word to local priests to mobilize their congregations and threatened to withhold their support from the larger bill, and punish anti-abortion Democrats, unless the amendment got a vote.

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Talks break down

Days of tense negotiations in Pelosi's office over an alternative by Rep. Lois Capps, D-Santa Barbara, and Brad Ellsworth, D-Ind., that would have codified existing law broke down in bitterness and recriminations.

"Pro-choice supporters in this country are going to be outraged that the anti-choice movement used this important debate over health care to expand anti-choice policies into the private employment sector," said Nancy Northup, president of the Center for Reproductive Rights, which will begin running advertisements next week.

On the other side, Charmaine Yoest, president of the anti-abortion Americans United for Life, promised "a tough fight in the Senate, and we're ready to engage on it."

"The bottom line is that Speaker Pelosi would not have allowed the vote unless she had to, and the reason she had to is that she heard from pro-life Americans all across this country who melted down the phones on the House side," Yoest said.

The vote on the amendment, she added, was bigger than the 220-215 passage of the bill itself, which she called evidence of "a bipartisan national consensus on not seeing abortion subsidized with federal dollars."

Lee's losing battle

But Rep. Barbara Lee, D-Oakland, who waged a losing battle to defeat the amendment, said "no religion should drive public policy. We're a democracy, not a theocracy. We cannot cross that line. No religious group should dictate what a law should be."

Yoest said religion has nothing to do with it. "Seventy percent of the American people don't want federal dollars going to abortion," she said. "That's not a religious question."

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Pro-choice lawmakers, including nearly every female liberal in the House, were furious but voted for the overall legislation in the hope that the language can be removed in the Senate or in a conference committee that would meld House and Senate bills.

"It was a very difficult thing to see the Stupak amendment get in," Lee said. "But the entire bill would have gone down."

Abortion had lurked for months underneath efforts by Democratic leaders to put together the complex moving parts of the health care bill. Stupak had insisted from the outset that he be allowed a vote on his amendment.

The amendment marred what otherwise was a giddy late-night celebration by House leaders who had pushed health care legislation further than any Congress before.

Common ground

Asked about the amendment, Pelosi replied, "We have sought in the course of the development of this bill common ground in many areas, this being one of those. We did not reach the common ground yet that we hope to achieve. Therefore, we had an amendment on the floor. We will continue to seek common ground."

Another social issue, immigration, has also been simmering in the health care debate. The Senate Finance Committee approved a provision in its bill that would ban illegal immigrants from using their money to purchase insurance policies on the exchanges.

TRACKBACK: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/11/10/MNQ81AHHRA.DTL

Shortage of Military Therapists Creates Strain

Associated Press | AP Online — Mon, 09 Nov 2009 11:31:00 -0800

WASHINGTON - Amputations. Combat stress. Divorce. Suicide. For troubled service members, military therapists are at their sides.

But with the U.S. fighting two wars, an acute shortage of trained personnel has left these therapists emotional drained and overworked, with limited time to prepare for their own war deployments.

An Army psychiatrist is suspected in the shootings at Fort Hood, Texas, and the rampage is raising questions about whether there's enough help for the helpers, even though it's unclear whether that stress or fear of his pending service in Afghanistan might be to blame.

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An uncle of Army Maj. Nidal Malik Hasan said Saturday that Hasan was deeply affected by his work treating soldiers returning from war zones. "I think I saw him with tears in his eyes when he was talking about some of patients, when they came overseas from the battlefield," Rafik Hamad told The Associated Press from his home near the West Bank town of Ramallah.

Rep. Tim Murphy, R-Pa., a psychologist in the Navy Reserves, said the toll is sometimes described as "compassion fatigue" or "vicarious trauma."

"They may not see combat themselves ... but they see the outcome of it and they hear the stories of it day in and day out," Murphy said. "It can be very real when you are dealing with people's difficulties every day."

A military mental health task force in 2007 expressed concerned about the stress on nondeployed mental health personnel because of the shortage, which it said was leading to high attrition rates. "A vicious cycle has formed that will probably continue to worsen before it improves," the report said.

Dr. Layton McCurdy, a psychiatrist and dean emeritus at the Medical University of South Carolina who served on the task force, said the shortage continues with the thousands of troops needing help because of combat-related stress.

"The psychiatrists are working with more people than they have time to work with," McCurdy said. "They are pressured in terms of the numbers."

Doctors seeing a constant stream of troops with symptoms of post-traumatic stress disorder can start to have problems of their own - an issue that has not gotten enough attention, said Dr. Allen Taylor, a cardiologist at Walter Reed Army Medical Center for 20 years before recently moving to Washington Hospital Center.

"It's time for some introspection: Who cares for the caregivers?" he said.

The military has used bonuses, scholarships, and allowed the hiring of legal nonresidents as part of its effort to bolster the number of therapists. It's even trying a pilot program that allows older health care providers to enter the Army for two years.

With the efforts, Defense Secretary Robert Gates said recently at a mental health conference that in the past two years, the Army has added nearly 900 behavior health providers - a 50 percent increase.

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But he said that still leaves the service with a shortfall of more than 330 specialists, which is a gap that will grow to more than 500 if the Army follows through on recommendations to put uniformed providers in every brigade.

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Barbara Cohoon, deputy director of government relations at the National Military Family Association, said while some therapists are embedding with units in the war zones, others are in more isolated areas at war where they might not be in the company of other therapists. She said the association has grown increasingly concerned about whether therapists are getting enough support in the war zones and on the home front.

"Who do they go to if they are feeling stressed?" Cohoon said.

Part of medical training - for psychiatrists, too - is learning when to seek help, Dr. Robert Ursano, psychiatry chief at the Uniformed Services University of the Health Sciences, told a meeting between military and civilian medical researchers Friday.

While it may be difficult, those providing support to troops must be willing to seek it themselves, said Capt. James Joppy Jr., a social worker in the Pennsylvania Army National Guard who is preparing to deploy to Iraq.

"We experience the same things everyone else does. It just happens we're helping everyone," Joppy said.

Brig. Gen. Terry "Max" Haston, the assistant adjutant general of the Tennessee Army National Guard, reminded about 100 mental health and substance abuse counselors meeting at a Guard center in Smyrna, Tenn., on Friday that combat affects more than just soldiers who went to war.

"This soldier had never deployed, but he listened to soldiers who had come back from theater and it had that large effect on him," Haston said. "What I am doing is cautioning you to take care of yourself. We are at war right here and you are on the front lines each and every day and you're dealing with a real hidden enemy."

In Europe, Most Swine Flu Shots by Invitation Only

Associated Press | AP Online — Mon, 09 Nov 2009 11:15:00 -0800

LONDON - In Britain, there are no long lines of people seeking swine flu vaccine. Doctor's offices aren't swamped with desperate calls. And there are no cries of injustice that the vaccine is going to wealthy corporations or healthy people who don't really need it.

Here, and across most of Europe, vaccine to protect against the pandemic flu is mostly given by invitation only to those at highest risk for flu complications.

"That is one of the great advantages of the British health system," said Dr. Steve Field, president of the Royal College of General Physicians. "We have a list of all the names of patients who qualify to be vaccinated."

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When Britain unrolled its pandemic vaccination program last month, it designed its campaign to ensure that priority groups - including pregnant women, health workers and those with chronic health problems like diabetes, cancer and AIDS - get the shots first.

Instead of advertising that vaccine had arrived and waiting for the lines to form, Britain's National Health Service sent letters, inviting all those who qualify to make an appointment and get the shots first.

Field said Britain's socialized health care system allows the country to target people who need to be vaccinated quickly: "It's not like the U.S., where it's the survival of the fittest and the richest."

Just this week, Americans learned that Wall Street giants Goldman Sachs and Citigroup got swine flu vaccine, even as many doctor's offices and community clinics still had none. The companies obtained the vaccine through standard procedures, and it was targeted to employees who met criteria for vaccination. But the perception of unfairness set off an outcry.

In the United Kingdom, the general population will be offered the shot after priority groups have been taken care of, probably in about two months. For now, only children with health problems are a priority; healthy children are not.

Similar programs are being carried out in other European countries, all of which have socialized medicine:

- In Germany, doctors have also been contacting high-priority patients to come in for their swine flu shot, though other people who have asked for one have not been turned away.

- In Sweden, Denmark and Finland, some local governments are sending invitations to people in high-risk groups or posting information about vaccine availability on their Web sites.

- So far, France is only vaccinating health care workers. Its health minister said 6 million people in priority groups would start getting invitations to be vaccinated next week.

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In North America, swine flu vaccination has largely been a free-for-all, although some U.S. states have recently beefed up their screening process to ensure pregnant women, children and people with health problems get shots before healthy older people.

In Canada, which has a form of socialized medicine, health officials began an investigation this week after professional hockey and basketball players got the vaccine ahead of thousands of children.

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Another trend has also affected the trans-Atlantic vaccination picture: While Americans and Canadians appear to be clamoring for the vaccine, many Europeans appear indifferent.

Verona Hall, a London-based midwife, said that among her dozens of pregnant patients none has accepted the invitation to take the shot. The reluctance among pregnant women stems in part from fears the vaccine could hurt their babies, but other priority groups have also shown little interest in the flu shot.

Hall herself recently received a text message asking her to book an appointment to get the vaccine. She declined. "It just doesn't seem that serious here," she said. "Maybe if there are a lot more cases, more people will consider having it. But right now it isn't a priority."

British officials estimate there have been more than 600,000 swine flu cases since the virus was identified in April. In the U.S., experts say there have been millions.

In the U.S., the federal government is paying for the vaccine and rationing supplies to each state. Then state and local health departments decide where it goes next - from schools to doctor's offices to community health clinics and even some large companies with health directors.

On Thursday, the director of the federal Centers for Disease Control and Prevention wrote to local health departments, asking them to ensure the vaccine is getting to high-risk groups first. Dr. Thomas Frieden warned that decisions that appear to send vaccine beyond high-priority groups "have the potential to undermine the credibility of the program."

Lenny Marcus, a public health expert at Harvard University, said the anxiety among Americans about vaccine shortages may have a snowball effect.

Early on, U.S. officials predicted there would be 120 million vaccine doses available by October. They later slashed that estimate, and as of this week there were only about 38 million doses in the country.

"When people believe there's a shortage, that increases demand," Marcus said. "The images of people lining up for hours to get the vaccine, which is in short supply, has a big impact. ... Parents with kids may suddenly be desperate to get them immunized."

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In contrast, there are no pictures in the British tabloids of crowded clinics. And the Department of Health won't reveal how many doses are available, saying only that enough vaccine to cover the entire population - 60 million people - had been ordered.

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For now, the biggest problem confronting Britain's vaccination effort is not a shortage or public demand. In recent weeks, postal strikes have delayed delivery of about 35 million letters. Health officials worry that high-risk patients waiting for their swine flu vaccine invitation letters might never get them.

"The timing isn't great," said Field, adding doctors would also be telephoning or sending patients text messages if they qualified to get a swine flu vaccine. "So far we have not had a lot of terribly anxious people here."

The House, Senate Health Care Bills in Detail

Associated Press | AP Online — Mon, 09 Nov 2009 10:54:00 -0800

WASHINGTON - A comparison of the health care bills before Congress.

The Democratic-controlled House passed its legislation on a 220-215 vote Saturday night. Republican opposition was nearly unanimous.

In the Senate, Majority Leader Harry Reid, D-Nev., is finalizing legislation merging the work of two committees and making other changes. The Senate Democrats' bill has not yet been made public, so some specifics are unknown.

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The House Bill (Affordable Health Care for America Act):

WHO'S COVERED: About 96 percent of legal residents under age 65 - compared with 83 percent now. About one-third of the remaining 18 million people under age 65 left uninsured would be illegal immigrants.

COST: The Congressional Budget Office says the bill's cost of expanding insurance coverage over 10 years is $1.055 trillion. The net cost is $894 billion, factoring in penalties on individuals and employers who don't comply with new requirements. That's under President Barack Obama's $900 billion goal. However, those figures leave out a variety of new costs in the bill, including increased prescription drug coverage for seniors under Medicare, so the measure may be around $1.2 trillion.

HOW IT'S PAID FOR: $460 billion over the next decade from new income taxes on single people making more than $500,000 a year and couples making more than $1 million. The original House bill taxed individuals making $280,000 a year and couples making more than $350,000, but the threshold was increased in response to lawmakers' concerns that the taxes would hit too many people and small businesses.

>>> Sound Off! What do you think about the health care bill that passed? <<<

There are also more than $400 billion in cuts to Medicare and Medicaid; a new $20 billion fee on medical device makers; $13 billion from limiting contributions to flexible spending accounts; sizable penalties paid by individuals and employers who don't obtain coverage; and a mix of other corporate taxes and fees.

REQUIREMENTS FOR INDIVIDUALS: Individuals must have insurance, enforced through a tax penalty of 2.5 percent of income. People can apply for hardship waivers if coverage is unaffordable.

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REQUIREMENTS FOR EMPLOYERS: Employers must provide insurance to their employees or pay a penalty of 8 percent of payroll. Companies with payrolls under $500,000 annually are exempt - a change from the original $250,000 level to accommodate concerns of moderate Democrats - and the penalty is phased in for companies with payrolls between $500,000 and $750,000.

Small businesses - those with 10 or fewer workers - get tax credits to help them provide coverage.

SUBSIDIES: Individuals and families with annual income up to 400 percent of poverty level, or $88,000 for a family of four, would get sliding-scale subsidies to help them buy coverage. The subsidies would begin in 2013.

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HOW YOU CHOOSE YOUR HEALTH INSURANCE: Beginning in 2013 through a new Health Insurance Exchange open to individuals and, initially, small employers. It could be expanded to large employers over time. States could opt to operate their own exchanges in place of the national exchange if they follow federal rules.

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BENEFITS PACKAGE: A committee would recommend a so-called essential benefits package including preventive services. Out-of pocket costs would be capped. The new benefit package would be the basic benefit package offered in the exchange.

INSURANCE INDUSTRY RESTRICTIONS: No denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age.

GOVERNMENT-RUN PLAN: A new public plan available through the insurance exchanges would be set up and run by the secretary of Health and Human Services. Democrats originally designed the plan to pay Medicare rates plus 5 percent to doctors. But the final version - preferred by moderate lawmakers - would let the HHS secretary negotiate rates with providers.

CHANGES TO MEDICAID: The federal-state insurance program for the poor would be expanded to cover all individuals under age 65 with incomes up to 150 percent of the federal poverty level, which is $33,075 per year for a family of four. The federal government would pick up the full cost of the expansion in 2013 and 2014; thereafter the federal government would pay 91 percent and states would pay 9 percent.

DRUGS: Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson's and other deadly diseases. Phases out the gap in Medicare prescription drug coverage by 2019. Requires the HHS secretary to negotiate drug prices on behalf of Medicare beneficiaries.

>>> Sound Off! What do you think about the health care bill that passed? <<<

ANTITRUST: Would strip the health insurance industry of a long-standing exemption from antitrust laws covering market allocation, price fixing and bid rigging. The bill also would give the Federal Trade Commission authority to look into the health insurance industry at its own initiative.

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The Senate Democratic Bill:

WHO'S COVERED: The Senate Finance version covered an estimated 94 percent of Americans. Illegal immigrants would not receive government benefits.

COST: Senate leaders aim to keep it under $900 billion over 10 years.

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HOW IT'S PAID FOR: Fees on insurance companies, drug makers, medical device manufacturers. Tax levied on insurance companies, equal to 40 percent of total premiums paid on insurance plans costing more than $8,000 annually for individuals and $21,000 for families. But that number may rise to $23,000. Retirees over age 55 and people in high-risk professions may be allowed to have somewhat more valuable plans before they're taxed. Cuts to Medicare and Medicaid. A fee on employers whose workers receive government subsidies to help them pay premiums. Fines on people who fail to purchase coverage.

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REQUIREMENTS FOR INDIVIDUALS:Almost everyone must get coverage through an employer, on their own or through a government plan. Exemptions for economic hardship. The Senate Finance Committee version required individuals and families to buy coverage as long as it cost no more than 8 percent of their income. Those who are obligated to buy coverage and refuse would face a fine of perhaps $100 in the first year of the program, likely to increase over time.

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REQUIREMENTS FOR EMPLOYERS: Not required to offer coverage, but companies with more than 50 full-time workers would pay a fee as high as $750 multiplied by the total size of the work force if the government ends up subsidizing employees' coverage.

SUBSIDIES: Tax credits for individuals and families likely making up to 400 percent of the federal poverty level, which computes to $88,200 for a family of four. Tax credits for small employers.

BENEFITS PACKAGE: All plans sold to individuals and small businesses would have to cover basic benefits. The government would set four levels of coverage: Under legislation passed by the Senate Finance Committee the least generous would pay an estimated 65 percent of health care costs per year; the most generous would cover an estimated 90 percent. Those numbers could change.

INSURANCE INDUSTRY RESTRICTIONS: No denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age and family size.

GOVERNMENT-RUN PLAN: Reid proposed a new federal insurance plan this week with payment rates to providers negotiated by the health and human services secretary. Unlike the House bill, states could opt out of the plan. It's not clear the proposal commands enough votes to survive, and it could be replaced by a standby system pushed by moderates that would not go into effect until it was clear individual states were experiencing a lack of competition among private companies. The bill also would create nonprofit, member-owned co-ops to compete with private insurers.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Self-employed people, uninsured individuals and small businesses could pick a plan offered through new state-based purchasing pools. Employees would be generally encouraged to keep their work-provided coverage.

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DRUGS: Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson's and other deadly diseases. Drug companies contribute $80 billion over 10 years with the majority of the money used to limit the prescription coverage gap in Medicare.

CHANGES TO MEDICAID: Income eligibility levels likely to be standardized to 133 percent of poverty, which is $29,327 a year for a family of four, for all parents, children and pregnant women. States could negotiate with insurers to arrange coverage for people with incomes slightly higher than the cutoff for Medicaid.

ANTITRUST: Amendment expected to be offered on the Senate floor to strip the health insurance industry of its antitrust exemption.

>>> Sound Off! What do you think about the health care bill that passed? <<<

House Passes Landmark Health Care Bill on Close Vote

Associated Press | AP Online — Mon, 09 Nov 2009 10:41:00 -0800

WASHINGTON - In a victory for President Barack Obama, the Democratic-controlled House narrowly passed landmark health care legislation Saturday night to expand coverage to tens of millions who lack it and place tough new restrictions on the insurance industry. Republican opposition was nearly unanimous.

The 220-215 vote cleared the way for the Senate to begin a long-delayed debate on the issue that has come to overshadow all others in Congress.

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A triumphant Speaker Nancy Pelosi likened the legislation to the passage of Social Security in 1935 and Medicare 30 years later - and Obama issued a statement saying, "I look forward to signing it into law by the end of the year."

"It provides coverage for 96 percent of Americans. It offers everyone, regardless of health or income, the peace of mind that comes from knowing they will have access to affordable health care when they need it," said Rep. John Dingell, the 83-year-old Michigan lawmaker who has introduced national health insurance in every Congress since succeeding his father in 1955.

In the run-up to a final vote, conservatives from the two political parties joined forces to impose tough new restrictions on abortion coverage in insurance policies to be sold to many individuals and small groups. They prevailed on a roll call of 240-194.

Ironically, that only solidified support for the legislation, clearing the way for conservative Democrats to vote for it.

The legislation would require most Americans to carry insurance and provide federal subsidies to those who otherwise could not afford it. Large companies would have to offer coverage to their employees. Both consumers and companies would be slapped with penalties if they defied the government's mandates.

>>> Sound Off! What do you think about the health care bill that passed? <<<

Insurance industry practices such as denying coverage because of pre-existing medical conditions would be banned, and insurers would no longer be able to charge higher premiums on the basis of gender or medical history. In a further slap, the industry would lose its exemption from federal antitrust restrictions on price fixing and market allocation.

At its core, the measure would create a federally regulated marketplace where consumers could shop for coverage. In the bill's most controversial provision, the government would sell insurance, although the Congressional Budget Office forecasts that premiums for it would be more expensive than for policies sold by private firms.

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A cheer went up from the Democratic side of the House when the bill gained 218 votes, a majority. Moments later, Democrats counted down the final seconds of the voting period in unison, and let loose an even louder roar when Pelosi grabbed the gavel and declared, "the bill is passed."

The bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed were 176 Republicans and 39 Democrats.

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From the Senate, Majority Leader Harry Reid of Nevada issued a statement saying, "We realize the strong will for reform that exists, and we are energized that we stand closer than ever to reforming our broken health insurance system."

In his written statement, Obama praised the House's action and said, "now the United State Senate must follow suit and pass its version of the legislation. I am absolutely confident it will."

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Minority Republicans cataloged their objections across hours of debate on the 1,990-page, $1.2 trillion legislation.

"We are going to have a complete government takeover of our health care system faster than you can say, `this is making me sick,'" jabbed Rep. Candice Miller, R-Mich., adding that Democrats were intent on passing "a jobs-killing, tax-hiking, deficit-exploding" bill.

But with little doubt about the outcome, the rhetoric lacked the fire of last summer's town hall meetings, when some critics accused Democrats of plotting "death panels" to hasten the demise of senior citizens.

The bill is projected to expand coverage to 36 million uninsured, resulting in 96 percent of the nation's eligible population having insurance.

To pay for the expansion of coverage, the bill cuts Medicare's projected spending by more than $400 billion over a decade. It also imposes a tax surcharge of 5.4 percent on income over $500,000 in the case of individuals and $1 million for families.

>>> Sound Off! What do you think about the health care bill that passed? <<<

The bill was estimated to reduce federal deficits by about $104 billion over a decade, although it lacked two of the key cost-cutting provisions under consideration in the Senate, and its longer-term impact on government red ink was far from clear.

Democrats lined up a range of outside groups behind their legislation, none more important than the AARP, whose support promises political cover against the cuts to Medicare in next year's congressional elections.

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The nation's drug companies generally support health care overhaul. And while the powerful insurance industry opposed the legislation, it did so quietly, and the result was that Republicans could not count on the type of advertising campaign that might have peeled away skittish Democrats in swing districts.

Over all, the bill envisioned the most sweeping set of changes to the health care system in more than a generation, and Democrats said it marked the culmination of a campaign that Harry Truman began when he sat in the White House 60 years ago.

Debate on the House floor had already begun when Obama strode into a closed-door meeting of the Democratic rank and file across the street from the Capitol to make a final personal appeal to them to pass his top domestic priority.

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Later, in an appearance at the White House, he said he had told lawmakers, "to rise to this moment. Answer the call of history, and vote yes for health insurance reform for America."

It appeared that a compromise brokered Friday night on the volatile issue of abortion had finally secured the votes needed to pass the legislation.

As drafted, the measure denied the use of federal subsidies to purchase abortion coverage in policies sold by private insurers in the new insurance exchange, except in cases of incest, rape or when the life of the mother was in danger.

But abortion foes won far stronger restrictions that would rule out abortion coverage except in those three categories in any government-sold plan. It would also ban abortion coverage in any private plan purchased by consumers receiving federal subsidies.

Disappointed Democratic abortion rights supporters grumbled about the turn of events, but pulled back quickly from any thought of opposing the health care bill in protest.

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One, Rep. Jan Schakowsky, D-Ill., detailed numerous other benefits for women in the bill, including free medical preventive services and better prescription drug coverage under Medicare. "Women need health care reform," she concluded in remarks on the House floor.

A Republican alternative was rejected on a near party line vote of 258-176.

It relied heavily on loosening regulations on private insurers to reduce costs for those who currently have insurance, in some cases by as much as 10 percent. But congressional budget analysts said the plan would make no dent in the ranks of the uninsured, an assessment that highlighted the difference in priorities between the two political parties.