Home / Healthcare Updates

Healthcare Updates

Updates 180x100Healthcare Updates is something I created to aggregate healthcare-related news from around the web. I’ll usually throw in some snarky commentary and possibly some tired old cliches to try to make things more interesting.
If you’ve seen an interesting medically-related story, I’d be interested in reading it. E-mail a link to me at whitecoatrants [at] g mail dot com with the words “Healthcare Update Link” in the title. The words “Healthcare Update Link” MUST be in the title of the e-mail because I have set up filters on my e-mail account to help streamline the posting process.

Healthcare Update -- 09-12-2014

PMT Logo

Need certification or recertification in BLS, ACLS or PALS? Don’t wait for the next course to be offered at your hospital. You can get same-day certification with an entirely ONLINE course NOW at Pacific Medical Training. If you sign up for training through this link, you’ll get a 15% discount on the cost of the course at checkout and you’ll be able to download your certificate of completion as soon as you pass the online test.

————————

40 year old father/husband went to emergency department two days after feeling nauseous when he ate breakfast. Reportedly had cardiac symptoms, including chest pain. Was in the emergency department 4-5 hours, during which time no cardiac enzymes were ever ordered, and then released. Two days later, clutches his chest and dies from heart attack. Jury awards family $4 million.

Good news: Chinese researchers discover new way to kill cancer cells by injecting the metal gallium into the arteries supplying the tumors.
Bad news: In rabbit studies, the metal somehow finds its way into the heart and lungs and forms deposits there.

$62 million medical malpractice award to patient who goes to Winthrop University Hospital for endoscopic removal of an ectopic pregnancy, developed complications from an unnoticed bowel perforation, then developed sepsis that eventually required amputation of both legs. In addition, the high doses of antibiotics she was receiving caused her to lose her hearing.
When a front page story about the patient ran in the newspapers during trial, the hospital’s attorneys requested a mistrial, stating that the plaintiff “should be thankful the doctors were able to save her life.” Not really a good argument to use.
In the end, the plaintiff and her attorney were happy that “justice was served” and someone in the comment section to the article suggests that everyone “remember this case the next time you find yourself asking why a Tylenol in the ER costs you 30 bucks.”

Ohio jury awards patient and husband $1.2 million when patient had persistent pain after undergoing partial hysterectomy and physician didn’t order CT scan to diagnose perforated bowel until the patient was “critically ill.” By the time the complication had been diagnosed, she had developed respiratory distress syndrome and now requires a walker to help her walk.

Remember how the government is making elderly patients pay for more care when they’re admitted as “observation” versus fully admitted? Then they came up with the “two midnight” rule, where providers had to predict whether a patient would need to stay in the hospital for two midnights – and then sign an attestation to that effect. The government won’t give “prior authorizations” for admissions, so providers are left to guess whether the government will retrospectively consider an admission appropriate, and anything deemed as “unnecessary” care is considered fraudulent when the government is billed for it. End result? Community Hospital Systems pays $98 million to settle false claims allegations.
“The United States alleged that from 2005 through 2010, CHS engaged in a deliberate corporate-driven scheme to increase inpatient admissions of Medicare, Medicaid and the Department of Defense’s (DOD) TRICARE program beneficiaries over the age of 65 who originally presented to the emergency departments at 119 CHS hospitals. The government further alleged that the inpatient admission of these beneficiaries was not medically necessary, and that the care needed by, and provided to, these beneficiaries should have been provided in a less costly outpatient or observation setting.”
Several emergency physicians and emergency nurses were “whistleblowers” in the case.
When a hospital wants to admit you as an “observation” status, keep criminal investigations and settlements like this in mind.
One US Attorney was quoted as saying “We will not allow this type of misconduct to compromise the integrity of our health care system.” Widespread fraud in the VA causing death and disability to our veterans? Who cares? Fraud and waste in creating the healthcare.gov site? No problem. Fail to have a crystal ball to determine how long a patient will need to be admitted? Hey! THAT’s not allowed!

Kanye West experiences “excruciating” migraine after playing basketball before a show in Australia and rushes to the emergency department for treatment. One of my son’s friends thinks he was just losing at his basketball game.

Some plaintiff attorneys pretend that “defensive medicine” doesn’t exist and is some creation of [insert the group you want to demonize here - insurance companies/hospitals/attorneys/physicians] to fleece the patients. What about “defensive lawyering”?
“In defensive lawyering, a list is developed of every document having even marginal relevance, every witness who might know something about a subject and every interrogatory that can be propounded. Lawyers practicing defensively live in mortal fear of the smoking gun buried in the pile of documents or the mystery witness who appears out of nowhere to sink our client’s case.”

Both sides preparing for battle as they take positions on California’s Proposition 46 ballot vote to quadruple limits on noneconomic damages in medical malpractice cases and to require drug and alcohol testing of physicians. This article by a local city council member notes that in voter guide information, attorneys are trying to downplay the increase in damages and the benefit it would have to the malpractice attorneys. The article also notes that many parts of the state already have physician shortages and that passing the proposition would likely worsen those shortages.
“Paving the way for more malpractice lawsuits is not a way to improve health care coverage nor will it help slow the rapidly growing cost of health insurance premiums. But it will certainly be good for the lawyers behind Prop. 46. Unfortunately, getting this message to the voters will surely be more difficult due to some deceptive official voter guide information.”
We can’t sue our way to better health care.

Dog waits outside emergency department as elderly owner undergoing surgical procedure. A lot of people commenting on these pictures express disgust that a dog would be allowed inside of a hospital. On one hand, I suppose there would be a risk of contamination from the animal, but I’m not sure that risk has ever been proven. On the other hand, it would light up my day to see my dogs there with my family if I was in a hospital recuperating from surgery.

Instapundit posts a link regarding how health care costs are taking a bigger bite out of Americans’ budgets, asking “How’s that Hopey-Changey stuff workin’ out for ya?” The commenters to the articles are full of insight. One of my favorites is from a commenter named Carl who initially noted that a large percentage of health care costs are in response to government regulations and liability protection and then stated “the parasites [referring to the government] all think the host should get much more efficient at using what little blood is left to it — so there’s more for them!


Healthcare Update -- 07-28-2014

Patients with “insurance” wonder why they can’t find access to medical care? Here’s a good example of why: Wisconsin pays a pittance to those who care for its Medicaid patients. As in 71% lower for office visits than private insurance payment rates, 76% to 78% lower for hospital care than private insurance rates, and 91% lower for emergency care than private insurance rates. According to the article:

One result of Medicaid’s low payment rates for physicians is a shortage of primary care clinics in low-income neighborhoods in Milwaukee.
That contributes to many people seeking care in high-cost hospital emergency departments. Wheaton Franciscan-St. Joseph estimates that roughly half of the patients in its emergency department — the busiest in the state — could be treated elsewhere.

Letter to the editor about the article from an emergency physician notes that the abysmal payment rates make it difficult to recruit and maintain emergency physicians in Wisconsin.

Oregon hospital notes “record breaking” increases in emergency department visits after Obamacare implemented. Average daily patient volumes in the 60s increased to the mid-70s with some spikes up to 100 patients per day. Wait times also increasing.

BMJ investigation shows that drug manufacturer Boehringer Ingelheim reportedly hid data from regulators regarding safety of Pradaxa [dabigatran].

Some Life Pro Tips from Reddit contributors on how to speak to people who have hearing impairment. Not scientific, but I’ve found that I tend to speak slower and enunciate each word when a patient initially says that he or she cannot hear me. After going back and forth once or twice, I’m usually able to speak in a normal or near-normal voice. Any ENT experts care to chime in? Slowly, of course.
And for all you young whippersnappers out there, here are two related sitcom videos related to auditory issues from Monty Python and Taxi.

More on the $190 million Johns Hopkins settlement after gynecologist found to have taken secret pictures of up to 8000 patients. Hopkins joined an insurance collective with other universities such as Yale, Cornell, Columbia, and the University of Rochester. Now money will be coming out of the pockets of several institutions that had nothing to do with the Hopkins incidents.

Recently-published CDC study based on 2012 data shows that children covered by Medicaid use the emergency departments at a rate nearly double that of patients with private insurance.

Pregnant California woman in labor is unable to cross street to get into hospital for 30 minutes because President Obama’s motorcade was passing through at the time.

Pakistani town organizes protest of 100 people calling for a doctor to be arrested when patient under doctor’s care dies of stroke. Protestors laid patient’s body in road in front of the clinic and initially refuse to leave.

Philadelphia psychiatrist pulls out gun and shoots armed patient who had just shot his case worker. Police admit that the doctor’s actions stopped the patient from going on a rampage and killing others, but police are also “investigating” why the doctor had a gun at work since “bringing guns to work is against the rules at the hospital.”
Those “no gun” zones work so well. Obviously the patient in the incident was playing close attention to the rules. And Chicago is a shining example of how properly implemented gun-free zones save lives.

You know all those fitness wristbands and fitness apps for your phone? They’re a gold mine for advertisers and identity thieves.

Almost 75% of the apps studied sent data to third parties; nearly half shared personal information with advertisers — all without the user’s knowledge. Another analysis found that the top 20 health-related apps transmitted information to as many as 70 third-party organizations.

And the article notes that since the application makers aren’t “covered entities” under HIPAA laws, there is no protection of the information collected in the applications. Your weight, medical problems, and any other information you allow the apps to harvest could be posted anywhere in the universe and you have no say about it once you opt in.


Healthcare Update -- 07-18-2014

More patients gone wild. Texas woman gets trip to the hoosegow after running a red light and colliding with another vehicle, then attacking the emergency department nurse who was trying to help her.

Adding pelvic exercises to a workout may help men as much as it helps women. Kegel exercises for men *may* improve incontinence and erectile dysfunction, and one company actually created a little weight lifting system that fits over the male genitalia. Gives new meaning to the phrase “pump you up.”

Not to be outdone, you can also see this article on weight training with a women’s genitalia using a jade egg. Who wouldn’t want a pelvic floor like a trampoline? Then again, just reading the article makes me think about getting one of these things for Mrs. WhiteCoat.
Hat tip to Instapundit for the link

North Carolina patient with chronic pain experiences an increase in pain for 2-3 weeks then waits until 3PM on a Friday afternoon to seek medical care in the emergency department rather than seeing their primary care physician in the prior 14-21 days. Given two pain shots and a prescription for pain medications but wife is still upset because he “was not adequately treated for his episode of pain,” so she writes letter to the editor of the newspaper.

Speaking about chronic pain … Salix gets approval for its new drug Relistor for treatment of chronic pain in non-cancer patients. Initially approved for opioid induced constipation and is an isomer of the drug naltrexone which is used to treat alcohol dependence and occasionally used to treat opioid dependence.

California’s Grant Union High School in the midst of a tuberculosis outbreak. 116 of 450 students and staff have latent TB while 5 students developed active TB including one who spread the disease to some family members.

New Jersey’s University Hospital cuts emergency department beds and opens “observation unit” to ease emergency department overcrowding. Kind of interesting how state hospitals work that numbers game. Will be interesting to see how much crowding increases in both the ED and the observation unit.

Naval Hospital Bremerton closing its emergency department and ICU and opening an urgent care facility

April 15, 2014 article in Huffington Post by Alexander Kjerulf titled “Top 5 Reasons Why ‘The Customer Is Always Right’ Is Wrong.”
Companies that exhibit this attitude create unhappy employees: “You can’t treat your employees like serfs. You have to value them … If they think that you won’t support them when a customer is out of line, even the smallest problem can cause resentment.”
The “customer is always right” sentiment also creates perverse incentives where “abusive people get better treatment and conditions than nice people.”
When companies enforce this culture, employees feel less valued, feel as if they have no right to respect, and gradually learn to provide “fake” good service where the courtesy is “on the surface only.” One expert noted that “when you put the employees first, they put the customers first.”
The article ends by noting
The fact is that some customers are just plain wrong, that businesses are better of without them, and that managers siding with unreasonable customers over employees is a very bad idea, that results in worse customer service.

FDA trying to regulate tweets. Maybe it should spend more time reviewing the safety profile of drugs so that it doesn’t recall medications for safety concerns after it has approved them for 30+ years … not that something like that would ever happen. Twice. Or more.
Oh, and by the way. Stare at my avatar for 30 seconds 3-4 times per day. I’ve created a pixel pattern so that doing so over the course of several weeks will significantly improve hydrangopenic neurolitis. If you do notice improvement, please send a PayPal payment to my e-mail address. Nice doing business with you!


Healthcare Update -- 07-08-2014

Here’s an easy way to get published … and try to dispel an “urban legend” at the same time. The “Q**** Study.” Researchers went to the emergency department with random envelopes containing the word “Quiet,” “Busy,” or no statement at all. One envelope was opened each shift and the staff repeatedly said the word and then posted the paper in the department for the remainder of the shift. At the end of the study, the researchers found no difference in the number of patient visits regardless of what word was said at the beginning of the shift.
I think the study was flawed. They didn’t measure patient acuity or stress levels during the study periods. Just because there are the same number of patients doesn’t mean that it isn’t less “quiet.” And you could probably cut the tension with a knife when people went around the department saying “quiet” at the beginning of the shift.

Ohio hospital planning to cease inpatient services at the end of the year and focus on outpatient procedures. EMS chief calls the closure a “game changer” for patients if they will have to be transported to hospitals that are farther away.

Interesting story on how the government is trying to sell Obamacare to the masses … including presidential cameos in return for advertising and attempting to get Obamacare placed into the scripts of TV shows and movies.
Hat tip to Instapundit

Cyberhacking of medical health records “only a matter of time” according to internet security experts. The full profile in your medical records can be worth up to $500 on the black market.

“Have you noticed the proliferation of attorney advertisements on television encouraging, advising, goading anyone — with a bruised pinky toe nail to mesothelioma — to sue someone?” Letter to the editor of Connecticut newspaper alleges “greedy human nature” is behind a majority of medical malpractice lawsuits.

Michigan Court rules that patient can’t sue doctor for telling her not to use birth control after patient tells doctor that her fallopian tubes were blocked. Patient argued that the advice was “grossly negligent” when she later had a child and sued for “wrongful conception.”
Why courts even allow a claim of wrongful conception is beyond me. If you’re that burdened by your child, then give him or her up for adoption.

Louisiana hospital sued for woman’s death from sepsis seven days after she had surgery from a cerebral aneurysm repair. Theory is that nausea then emesis of foul smelling fluids and blood six days later should have clued the medical providers into the diagnosis.

Unnecessary testing? Johns Hopkins study shows that by eliminating CPK testing in patients being ruled out for myocardial infarct, they were able to reduce the number of tests by 66% with a decrease in charges of more than $1.25 million over the first year. The number of acute coronary syndrome diagnoses rose by 0.3% during the first year.
I’m not paying $40 to purchase the article, but I would like to see how many times MIs were missed or had diagnosis delayed during this timeframe and would also like to see follow up on whether there were any lawsuits based on care during the study period. Saving $1.25 million only to pay out more than that in a couple of missed MI cases – especially if they occurred during a study to save money – may not be so cost effective.

US veteran collapses while eating in a VA Hospital cafeteria. Instead of wheeling the patient to the emergency department which was about a four minute walk, VA staff members called 911 and waited 20 minutes for an ambulance to arrive and bring the patient to the emergency department. By that time, the patient was dead.
EMTALA violation? Doesn’t matter. Nothing is going to happen to the people who make the policies that kill our veterans.

Intuitively, the number seems high to me, but still significant. Twelve million visits to the emergency department every year for childhood injuries. Consider that if there are 150 million visits per year, then one in every 12.5 patients is a pediatric injury patient. Nevertheless, there are still some good pointers to avoid injuries, including supervising swimming at all times, wearing protective gear, and taking care when playing sports.

Give us free stuff. Now that people can use medical marijuana in California, Berkeley is requiring that medical marijuana dispensaries give indigent patients 2% of their total yearly sales. Just wondering if the City Council forces its members to give 2% of their income to the hospitals to provide care to indigent patients. Or requires pharmacies and grocery stores and gas stations and restaurants and department stores to give away 2% of their products.

Kansas’ Wesley Medical Center tells emergency physician group that has staffed emergency department for 50 years to either join EMCARE or leave. Interesting that according to the article, the group used EMCARE to help audit its books and improve financial efficiency shortly before EMCARE took over the contract.


Healthcare Update -- 06-27-2014

No more donations to the Red Cross for me … Red Cross hires lawyers to block disclosure of how it spent the $300 million it collected to help the victims of Hurricaine Sandy, calling the information “trade secrets.”

Bryan Preston warns that however bad you THINK the VA scandal really is, it’s worse.
Remember … VA Hospitals aren’t included on the federal government’s Hospital Compare web site

Georgia patient charged with stealing discarded needles and medications from a sharps container in the room. Doctor walked into the room to evaluate patient and found “used needles, syringes and vials of medicine were strewn across the floor.” Patient had syringes, used morphine bottles, and various prescription pain relievers in his pockets, states that he was trying to put them back in the broken sharps container.

States need federal money to afford to keep psychiatric hospitals open while feds cut payments. 10% of state psychiatric hospital beds closed between 2009 and 2012. Private hospitals have also reduced their psychiatric beds because Medicare and Medicaid typically pay less for inpatient mental health care than for medical care.
Good read at USA Today on how several patients learned to cope with their psychiatric illness.

Patients overwhelmingly prefer doctors who respond to e-mail, but only 25% of patients would be willing to pay a doctor $25 for the service.
The medical director for one of the groups, Dr. Robert Dickinson, stated that e-mail communications with patients are “like online banking.” I disagree. When a doctor provides advice over the e-mail, it usually amounts to providing free medical care.
I’m sure that more than 93% of employers would prefer employees who do their work via e-mail without getting paid for it, also.

Honey, I’m taking the kids upstairs for a swim in the toilet. Ten percent of all US beaches are “dangerously polluted” and deemed unsafe for swimmers. Most of the pollution is from sewage overflow and stormwater runoff.
There’s an intereactive map at the site so you can figure out whether you need to bring toilet paper to the beach to wipe yourself after taking a swim.

Price transparency in health care is great, but it may cost insurers money when consumers can compare rates … which is probably why Blue Cross lobbied hard to kill price transparency legislation in Washington State.

Opioid use disorders increase significantly in patients prescribed opiates for chronic noncancer pain. Acute dosing raised opioid use disorders about threefold regardless of the dose. Chronic dosing raised risk of opioid use disorders by 15-fold for low average daily dose and by 28-fold for medium average daily dose. Patients chronically prescribed high daily doses of opioids for noncancer pain were 128 TIMES as likely to develop opioid use disorders as those patients not prescribed opioids for chronic pain.
Hat tip to @IrfanDhalla via Twitter.

Artificial blood showing promise. Haem02 project creates blood that can be stored at room temperature for up to 2 years (currently, all blood donations must be refrigerated) and can be administered to anyone, regardless of blood type.
Plus … 4 out of 5 vampires think it tastes great.
I’ve been watching too many Supernatural reruns.

Great summary article about AC Joint Separations at Academic Life in Emergency Medicine

Taking patient satisfaction surveys to a whole new level. American Board of Internal Medicine now wants patients to rate their physicians as one potential prerequisite to the physician sitting for board recertification.
So hospital administrators aren’t the only ones who are clueless about statistical significance and statistical bias.
The ABIM is being run by idiots.

Dear Mr. Smith: You’re gym membership lapsed, you’re buying too many bags of chips at the grocery store, and you spend too much time at McDonalds. Please stop. Hospitals now hooking up with data mining companies to build impressive dossiers on patients’ habits. If you’re deemed “high risk,” you might just get a call from the hospital to change your ways.
Scary that companies such as Acxiom and LexisNexis are tracking all your credit card transactions and all the purchases you make with your store loyalty cards, then turn around and sell that information to health insurers.
“For a patient with asthma, the hospital would be able to score how likely they are to arrive at the emergency room by looking at whether they’ve refilled their asthma medication at the pharmacy, been buying cigarettes at the grocery store and live in an area with a high pollen count.” Medical providers could also judge the likelihood of someone having a heart attack by considering factors such as the type of foods they buy and if they have a gym membership.
Hello George Orwell.

VA nurse stripped of her nursing duties and supervisory role then banished to an office cubicle after reporting abuse in the VA system.
Among the nurse’s revelations were how a patient remained in restraints for 7 hours in violation of CMS guidelines and how another nurse had stolen 5000 vials of morphine, removed the morphine, and refilled the vials with saline before the medicine was given to cancer patients to treat their pain.

Parkland Memorial Hospital psychiatric emergency department accused of patient abuse. Patient spits at staff and is restrained. Continues spitting, so wad of toilet paper is put in his mouth.
Dr. Peter Breggin, a New York psychiatrist, commented in the article, stating that spitting is a “last resort of a terrified human being” and that the staff should have been trained to “back off” at that point. Then, when the patient harmed himself, he could be called as an expert to testify that the staff should have intervened instead.
From his own web site, Dr. Peter Breggin appears to be a professional witness whom I bet has never set foot in an emergency department and whom I also bet has rarely if ever been face to face alone with an out of control spitting patient. His opinions on this matter should carry little weight in real life.


Healthcare Update -- 06-17-2014

Read more healthcare-related news from around the web on my other blog at Whitecoat’s Call Room at EPMonthly.com

Investigative reporting by ProPublica shows that New Jersey ambulance services billing the government a lot of money for nonemergent taxi rides. 37 companies billed Medicare for more than 50 trips per patient while in 33 other states, not a single ambulance company billed for that many rides per patient. Dialysis center transport is big business. Transport to and from dialysis centers increased ninefold between 2002 and 2011 and Medicare spent $24 billion on providing care for dialysis patients in 2011 alone, with $890 million of those expenses going just for ambulance rides.
Would be helpful to know patient demographics before drawing conclusions, but the data do raise some eyebrows.

5’2″ patient weighing 270 lbs sedated with propofol before undergoing upper endoscopy. Patient wakes up during procedure and begins thrashing about, yells in pain for 20-30 seconds, then falls unconscious. She later died. Family wins $7.9 million judgment, successfully arguing that the patient should have been put under general anesthesia for the procedure because she was so obese. Of course, if they had intubated her for the procedure and the patient had a bad outcome, the doctors would have been criticized because they did intubate her.
Fear the bad outcome. They’ll always find something to second guess you about.

Veteran’s Clinic in Coatesville, PA settles four wrongful death claims for total of $1.2 million. Interesting link on the article site shows how patient was “set on fire” during surgery and the VA offered him $30,000 for his injuries before he ended up filing a lawsuit for $1.3 million.

Patients gone wild. In this case, emergency department visitors gone wild. Two family members get into argument in emergency department. One whips out a kitchen knife and stabs the other one. Latter person becomes a patient, former becomes an arrestee.

Impressive story about how University of Arizona surgeons removed a 47 pound tumor from a patient’s stomach. The liposarcoma had invaded multiple spots on the patient’s inferior vena cava and engulfed a kidney, making removal quite difficult. And the surgery was covered by insurance made available through Obamacare.

GOP pushing plan to repeal and replace Obamacare.

Cough up adverse information about the VA … get demoted or suspended. Not only will illegal retaliation chill further episodes of whistleblowing and decrease public inquiry into this dysfunctional system, but I’d be willing to bet that those responsible for the retaliation will suffer no consequences whatsoever.

Nurse has license suspended for ordering ICU patient the wrong type of sandwich. Hospital administrator Dennis Johnson was quoted as saying “We have a zero-tolerance policy for terrible customer service.” With hospital reimbursement based in part on patient satisfaction scores, nursing directors at the facility were in full support stating, “If we don’t suspend these nurses’ licenses, they will never learn what’s truly important.”

Study in the journal Neurology shows that increased protein intake significantly reduces the risk of stroke. A 20 gram increase in dietary protein intake per day was associated with a 26% reduction in stroke risk. That’s as little as a chicken breast fillet or a salmon fillet each day. Unfortunately, red meat is associated with an increased stroke risk.

Impressive story about how University of Arizona surgeons removed a 47 pound tumor from a patient’s stomach. The liposarcoma had invaded multiple spots on the patient’s inferior vena cava and engulfed a kidney, making removal quite difficult. And the surgery was covered by insurance made available through Obamacare.

Four million people will be penalized by Obamacare for not being able to afford, er, um, not purchasing insurance as required under the law. One million of those earn below 200% of the federal poverty level.

Another serendipitous discovery. Drug used to treat leukemia also found to stimulate immune system to fight other cancers. Use of the drug in mice “significantly increased cancer survival rates across a broad range of tumor types, both solid and haematological cancers.” For example, mice with breast cancer survived twice as long and their cancers spread significantly less.

All of you backyard barbequers beware. Something unexpected could send you to the emergency department with an injury that could require surgery to fix.


Older Entries »

Leave a Reply

Your email address will not be published. Required fields are marked *

*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>