A.A hiatal hernia is an abnormality in which the upper part of the stomach (which is connected to the esophagus) herniates (protrudes) up through the diaphragm and into the chest. Normally, the junction between the esophagus and stomach is right at the diaphragm, and the diaphragm actually helps to support the gastroesophageal sphincter, which separates these organs and keeps stomach contents from flowing up into the esophagus. As a result of the upward bulging of the stomach, the sphincter may lose its ability to prevent reflux of stomach contents back into the esophagus, causing heartburn.

A.Although a hiatal hernia is very common, most patients with it do not suffer any symptoms. Those who do experience gastroesophageal reflux disease (GERD) are typically managed with acid-suppressive medications. A subset of patients are referred for surgical therapy, most often because of GERD-related complications or due to the desire to avoid taking acid-suppressive medications indefinitely.

The surgical procedure, known as fundoplication, involves wrapping the upper portion of the stomach (the fundus) around the lower esophagus in order to strengthen the gastroesophageal sphincter. If a hiatal hernia is present, it is pulled back into its place in the abdomen before the fundoplication.

The most common long-term complication of fundoplication is difficulty swallowing, known as dysphagia. This occurs when the fundal wrap around the lower esophagus is too tight and prevents swallowed food from easily traveling down the lower esophagus into the stomach. Although up to 30 percent of patients experience dysphagia shortly after fundoplication, only about 4 percent of patients report long-term swallowing problems. In these cases, it is managed with dilation of the esophagus.

According to the lawsuit, Thomas Morris, Jr., 55, was treated for cold symptoms and advised to take Tylenol even though he told the doctor he thought he had inhaled anthrax spores at Washington’s Brentwood mail processing center, the newspaper reported.

An anthrax-contaminated letter mailed to Senate Majority Leader Tom Daschle passed through the Brentwood center and is suspected in the deaths of Morris and another postal worker at the facility. They were among four people who have died of inhalation anthrax since early October.

There have been 17 confirmed cases of anthrax in the United States. Victims were infected by contaminated letters mailed following the September 11 hijacking attacks that killed more than 4,500 people in New York, Washington and Pennsylvania.

The lawsuit, filed by Morris’s son, Thomas Morris III, also accuses Kaiser Permanente of negligence for failing to prescribe the antibiotic Cipro even though Morris was in a known risk group for anthrax, the Post said.

Morris died on October 21, three days after he sought medical care at a Kaiser Permanente facility in Marlow Heights, Maryland, the report said.

Morris complained in the office visit about trouble breathing, muscle pain, headaches and tightness in the chest, the plaintiff’s attorney, Jimmy Bell, told the Post.

“He informed his physician right up front that he was exposed to anthrax,” Bell said. “He believed his doctor.”

Kaiser officials told the newspaper that the lawsuit was riddled with errors and that the HMO’s staff meticulously followed the guidance they had at the time from health officials.

“We will defend their allegations quite vigorously and with great passion,” Kaiser spokeswoman Susan Whyte Simon was quoted as saying.

With manufacturers going direct and changing their terms and conditions, resellers are facing another round of channel chaos. This will require a different perspective and approach to your business. If changes are not made promptly, you may find yourself out of business. Changes and improvements of performance such as cost, quality, service, support and speed are critical in reengineering. By outsourcing non-core functions to world class providers, you may increase efficiencies, reduce costs, increase quality and speed and be able to make quick and accurate business decisions about your core business.

Reduce or shared risk

Through outsourcing you may be able to spread your risk, or potentially even eliminate it. For example payroll processing providers make significant investments in staying on top of all the laws and regulations of federal, state and local agencies. A good payroll service should keep your company abreast of changes in laws and regulations concerning payroll. These changes, if not implemented in accordance with the law, can have serious ramifications and cause the company to incur substantial penalties. The time it takes to stay on top of all regulations in the area of payroll generally is far more “costly” than the total fee for payroll processing.

Free resources for other purposes.

With skinny margins and the changes in the channel, the resources available are limited. Outsourcing allows you to redirect resources such as positions from non-revenue producing positions such as accounts receivable collections clerk to a revenue-producing technician. Thus redirecting your internal focus externally to the customer.

Conclusion

Just as outsourcing is benefit to your customer, in that you provide the outsourcing service, your business can take advantage of this growing trend. With the increased pressures and competition, your focus be on your customer and your core-competencies.

There are different levels of operating costs that can be reduced, controlled or even eliminated with outsourcing. First and foremost is direct cost. For example, the direct cost would be the employee’s salary, taxes and benefits. Second would be indirect cost such as office supplies, telephone, desk, computer, chair and other overhead expenses associated with having that employee. Third would be the operational costs. For instance someone had to hire the employee, cut their paycheck, train them, take care of personnel issues, etc. used by that employee.

Most people would stop there. However there are other costs that need to be taken into consideration such as lost opportunity costs and the cost of bad decisions or judgements. By focusing energies on internal operations resellers can lose touch with customers and lose the vision of the future. However, without a good grasp on the internal operations of your company, you cannot make good business decisions thus adding another cost.An outsourcing provider’s lower cost structure, which is the result of efficiencies in systems, greater economies of scale or other advantages based on specialization, centralization, expertise, etc allows them to offer their services at a fraction of what it would cost internally. Which result in reducing your operating costs and increasing your bottom line.

Cash infusions

In some situations it is possible that the outsourcing firm may “buy” your current function, including staff and assets. For example, you may wish to outsource your accounting function. The outsource firm would hire your accounting personnel and purchase desks, computers, accounting software package, etc. Essentially, the result is the outsourcing company gives the operating company a loan to be paid back over time in the form of outsourcing fees charged.

Functional Areas For Outsourcing

Improve company focus

Outsourcing lets resellers focus on their core business competencies and improve overall competitiveness by allowing outside expertise to perform non-core business functions. By doing this, it frees you to concentrate on more important things, such as your customer, building sales revenue and increasing overall profitability.

Expertise

Most outsourcing providers make huge investments in technology, systems, procedures, and people. Their expertise is acquired by working with many customers with comparable issues to yours. By outsourcing, you can take advantage of their specialization and expertise without all the costs.

For example, Ingram Micro’s distribution model is much more sophisticated than that of most computer resellers. Drop shipments, custom configuring, custom labeling and reserved inventory are some of the outsourcing services that most distributors provide. These services are their core competencies and using their services allows you to reduce your costs and focus on your core competencies

Outsourcing of human resources accounts for 16% of all outsourcing dollars, while marketing/sales make up 14% and finance/accounting totals 11%. Human resource functions typically outsourced consist of payroll processing, staff leasing, outplacement and job searches, 401K administration, etc. In the marketing/sales area it is common to outsource direct mail, advertising, telemarketing, sales operations and even field sales. Financial administration, purchasing, accounts payable, accounts receivable, general accounting, taxes, internal audit are some of the financial areas that can be outsourced.

The following are some of the more common reasons that outsourcing has grown so dramatically over the last decade:

1. Resources are not readily available
2. Cost savings
3. Cash infusions
4. Improve company focus
5. Expertise
6. Corporate restructuring
7. Reduce or shared risk
8. Free resources for other purposes.

Resources Are Not Available Internally

The fact is most resellers run lean operations. Few have the luxury of being “overstaffed” and most have cross-functional organizational charts that require almost all of the employees to wear multiple hats. Most employees are simply spread too thin. So, how does a reseller accomplish the “extra” job that needs to be done? Outsourcing is an ideal solution; the resources can be efficiently acquired to fill in any gaps.

For example, most resellers could benefit from the expertise and knowledge of a qualified Chief Financial Officer, but unfortunately, many can not afford the high salary needed to hire a truly qualified individual. There are also many others areas of your business that you could use help and expertise and most do not require full time personnel. These are perfect for outsourcing by a professional service provider.

Currently, Sharon McLoser, MD, of the Centers for Disease Control and Prevention in Atlanta, is spearheading a project to evaluate the potential for screening all adults. The call for such screenings has not been formally accepted. In the meantime, if you recognize some of the symptoms described in the accompanying article or have a family history of IOD, by all means go for a checkup.

At the present time, the tests we recommend you ask for are the transferrin saturation blood test and the serum iron test, says Barry Green, MD, PhD, hemochromatosis expert in Ottumwa, IA.

A genetic test is also available. But because it’s still not clear that all people with hemochromatosis have the same defective gene, a negative test doesn’t guarantee you don’t have the disease. “Until it’s put through its paces,” says Dr. McLoser, “it’s probably less expensive and easier to test first with the other tests. Then, depending on these two test results, you may want to follow up with the DNA test.”

Do you need iron supplements?
The quick answer: probably not. “No one, unless he or she has been diagnosed as iron-deficient or belongs to a high-risk group, should routinely take iron in supplements,” warns Jerard R. Matlon, MD, an iron specialist at the University of Kansas Medical Center, along with nearly every other expert consulted for this article. Prevention has already advised women over 50 and all men to avoid iron in supplements. For premenopausal women, Dr. Matlons statement is stronger than anything we have previously published. To find a multivitamin that isn’t iron-fortified, look for a brand aimed at men or seniors; then check the contents list to make sure it’s iron-free.

Doctors may not have caught up to new thinking about the dangers of excess iron. Too many physicians still think hemochromatosis is a rare disease of middle-age men, says Sharon McLoser, MD, at the Centers for Disease Control and Prevention in Atlanta.

So everyone needs to know the facts about iron and iron supplementation. Here’s what’s what, iron-wise:
Most adults already get from 10 to 12 milligrams (mg) of iron without sup-plements. Since the current Recommended Dietary Allowance (RDA) is up to 10 mg/day for men and postmeno-pausal women, this group in particular does not need supplementation.

The RDA for premenopausal women is up to 15 mg/day. At least one expert hinted that this level may be revised downward. In the meantime, if your diet includes some meat, fish, eggs, beans, white bread or pasta, fortified cereals, or nuts, chances are you’re already meeting your RDA. Unless, that is, you’re someone described in the paragraph below.

The only people who need iron from a supplement are those whose blood-iron status has been diagnosed as low — that’s diagnosed as in, “you had your blood properly tested.” In the United States, low-iron types are most likely to be rapidly growing young children, adolescents, pregnant women, women who experience heavy menstrual bleeding, strict vegetarians, extreme low-calorie dieters, and people who exercise very heavily — like elite runners. To put this in perspective: “Only 6% of Americans have iron-deficiency anemia. Twice that number, 12%, have hemochromatosis-related iron overload,” says Victor Herbert, MD, chief of Mount Sinai’s hematology and nutrition research lab in the Bronx.

Well, how about thinking of it as not being self centered, but being “self caring”. Don’t feel that you are feeling sorry for yourself. A friend I have recently met, with a chronic illness herself, expresses this as “entitlement to grief”. I love that, because they are our feelings, and even ones that are born of sadness and grief, we are entitled to them. It is important to feel these emotions. Feelings of anger, hurt, fear, frustration, and even just simply sadness, get buried deep within us, because we feel they are inappropriate to talk about or share with others. This issue comes up from time to time at our support group here, as well as at an online MS support group I facilitate.

Well, I can tell you from experience, and have been told by others far wiser than I, that the feelings you keep inside and never deal with, or even acknowledge, are the feelings that will end up causing you and others more trouble than you can imagine.

Now I’m not saying every negative thing we think or feel can be validated. I’m just saying that these feelings can’t be kept inside. You have to bring them out, really examine them from all angles and deal with them as needed. Work through them, discard the ones that are a waste of energy to harbour, and then really feel the ones that are born of real issues and problems that aren’t going to go away. Understand the way you feel, the reason you feel that way, and if at the end of the day, these are real legitimate feelings that can’t be dismissed, understand there is a place in your heart and soul for them. But don’t just leave them there, unattended, to fester and take over. Share them, vent, and get them out in the open. That is the only way to keep your spirit healthy. It would be naive to think we can cope with everything in our lives, adding a chronic illness like MS to the mix, and not be legitimately “down” and angry, from time to time, about the heavy load we carry.

Find the right people and places to open up. Of course, we can’t go around talking to everyone we see about these things. If we aren’t constructively dealing with our negative feelings, then I guess it does come down to just complaining. But if you talk to the right people, you are dealing in a positive way. You are exercising your “entitlement to grief” and you are doing it in a “self caring”, not a self-centered way. There is no better place, than in a support group setting, or with close and understanding people in your life.

Quite often it seems that unless people have experienced the challenges you face, that they can’t really understand, and sometimes that is true. It’s not their fault in any way. It’s just the way it can be. That is why support groups are so effective. Everyone there can relate to having the same feelings at one time or another. Everyone there wants to hear about your fears, your problems, because maybe they can help, and they probably share those very same thoughts! Talking with people who experience the same things can be great, because, other than the fact that misery loves company, just maybe they can offer suggestions on how to fix the wrong or if not fix it, offer ways to cope. And, there’s a very good chance that if you share with someone now, down the road, someone else will need a shoulder, and you’ll be there with yours.

So, I guess what I am saying, at great length, is to “own” your feelings. Bring them out, don’t bury them. Cry when you need to. Mourn your losses as freely as you celebrate your accomplishments.
I used to think that the person who let their problems rise to the surface, was the person who would let these things get the better of them. Again, a very wise professional in the field told me it is exactly the opposite. Only by acknowledging and really feeling what is inside, can you understand and make room for these very real and legitimate feelings that are a part of you. Feelings you have to learn to live with. Only when you do that, can you find a place inside for them, where they can be a part of you, without overshadowing the great feelings you are also entitled to. The positive and happy feelings, that make life so worth living!